Our Global Responsibilityto the World’s Children by Global Health Council

Our Global Responsibility to the Worldâ&#x20AC;&#x2122;s Children A Global Health Council Position Paper on Child Health www.globalhealth.org

Acknowledgements We wish to thank Robert Black of Johns Hopkins University, Anne Tinker of Save the Children, and George Brockway for their helpful review of this paper, as well as the many contributors to The Lancet series on child and newborn health on which this paper is largely based. We also wish to thank Julie Pudlowski, who took the cover photo of this 16-month-old child on his fatherâ&#x20AC;&#x2122;s lap while waiting to be examined at an International Medical Corps clinic in Ethiopia.

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Table of Contents Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 I.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Why children die . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Underlying causes of child illness and death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

II. Simple, Cost-effective Solutions Can Save Millions of Children . . . . . . . . . . . . . . . . . . . . .6 Why invest in saving childrenâ&#x20AC;&#x2122;s lives? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 III. The Global Health Councilâ&#x20AC;&#x2122;s Position Statements on Improving Child Survival and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Position 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Position 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Position 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Position 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Position 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Position 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 IV. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 V.

Appendices 1. Core interventions to prevent 6.6 million child deaths . . . . . . . . . . . . . . . . . . . . . . . . . .18 2. Percentage of child deaths averted by core interventions . . . . . . . . . . . . . . . . . . . . . . . . .19 3. Global monitoring indicators for tracking child survival . . . . . . . . . . . . . . . . . . . . . . . . .20 4. Sixty high child-mortality countries and their progress toward meeting MDG 4 . . . . . . .21

VI. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

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Executive Summary The Global Health Council, the world’s largest membership alliance dedicated to saving lives by improving health, recognizes that averting the needless deaths of children is one of the core global health priorities of our time. Each year more than 10 million children under the age of five die. Experts agree that at least 6.6 million child deaths can be prevented each year if affordable health interventions are made available to the mothers and children who need them. If this were accomplished, the Millennium Development Goal (MDG) 4 to significantly reduce child mortality by 2015 could be achieved.

The positions that follow articulate the Council’s policy agenda and frame the Council’s recommendations to policy-makers. These positions also serve as rallying points for the Council’s members who work daily to improve child health, and as a platform for the Council’s collaboration with other groups advancing child health. The paper first provides an overview of the state of child health globally, the solutions that have been proposed, and the moral and economic rationale to act on this issue now. The Council then endorses the following positions.

Global Health Council Position Statements on Decreasing Child Mortality

1. Governments, multilateral organizations, private donors and civil society should contribute equitably to partnerships aimed at achieving a two-thirds reduction in the 1990 level of child mortality by 2015. 2. Investment in newborn and child health must increase substantially to achieve the goal of saving an additional 6.6 million children each year. 3. Resources should be targeted to the countries and populations where child mortality is greatest, based on the criteria of severity and magnitude. 4. Priority should be given to interventions of proven effectiveness, implemented according to population-specific assessments of the causes of childhood death and disease. 5. Investments in child health should simultaneously strengthen health capacity for the long term. 6. Progress toward achieving MDG 4 should be scrupulously monitored, regularly reported, and routinely evaluated.

Conclusion

The world can achieve MDG 4 and save an additional 6.6 million children with the information and tools we have today. Only political will is needed to prevent most deaths of children under the age of five, even in the poorest countries.

And saving these children is just the first step toward the goal we all share – creating a world where child survival can be taken for granted and families everywhere will be confident that their children will survive and thrive.

Global Health Council Position Paper on Child Health

I. Introduction Impressive gains have been made in reducing child mortality in the past four decades. Globally, deaths of children under five have declined by an average of nearly 2 percent per year over that period.1 In many parts of the world, widespread introduction of simple, inexpensive interventions have successfully targeted the major killers of infants and children. Highly effective and often “low-tech” solutions, as well as improvements in health delivery systems to make such innovations widely known and accessible, have enabled rapid declines in child mortality to occur, even in poor countries. Cost-effectiveness has been increased through providing packages of interventions that address multiple health issues.2 While the overall trajectory of child survival has been positive, progress remains very uneven. Each year, 10.1 million children worldwide still die from largely preventable causes.3 Neonatal mortality has been very persistent, with the

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result that now 38 percent of all child deaths (4 million) occur in the very first month of life. In at least 15 countries, the child mortality rate has increased in the last 17 years, and in at least 13 other countries, progress toward securing children’s survival has stagnated.4 • •

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The overwhelming majority of child deaths (99 percent) occur in poor countries. One in four of the world’s 600 million children under the age of five live in a country where their risk of death is at least 20 times higher than in the U.S.5 Forty-two percent of all child deaths occur in sub-Saharan Africa and 29 percent in south and southeast Asia, but the leading causes of death vary greatly by region.

Why Children Die Globally, 80 percent of all child deaths to children under five are due to only a handful of causes: pneumonia (19 percent), diarrhea (18 percent), malaria (8 percent), neonatal pneumonia or sepsis (10 percent), pre-term delivery (10 percent), asphyxia at birth (8 percent), measles (4 percent), and HIV/AIDS (3 percent).6

Diarrhea: 1.8 Million Deaths

Contaminated water causes 90 percent of diarrheal cases among children. Severe diarrhea can kill quickly if a child becomes dehydrated and goes into shock.10 Many caregivers do not recognize the danger until it is too late.11 Malaria: 850,000 Deaths

Neonatal Causes: 4 Million Deaths

Deaths from all causes in the first four weeks of life claim roughly the same number of children each year as are born annually in the United States or in the 23 largest countries of Western Europe.7 The highest number of deaths occurs on the first day of life. In addition, a quarter of the 3.3 million babies who are stillborn each year, die during the birthing process.8 The majority of births in sub-Saharan Africa (59 percent) and in Asia (62 percent) take place without a skilled attendant present, increasing the risk of death or disability for both mother and newborn.9

The majority of deaths due to malaria occur among young children, and 94 percent occur in Africa.12 Malaria accounts for 18 percent of deaths among African children as compared to 8 percent globally. Measles: 400,000 Deaths

Until recently, measles killed nearly 900,000 children each year. Following a joint WHO and UNICEF plan to expand measles vaccine coverage, deaths have declined by 60 percent since 1999.13 About 60 percent of measles deaths occur in Africa and 25 percent in Asia. HIV/AIDS: 350,000 Deaths

Pneumonia: 2 Million Deaths

Pneumonia kills more children under five than any other single disease. Only one in five caregivers can identify the early signs of pneumonia, and only about half of children in need of care are taken to a health-care provider.2

Only one in 10 HIV-positive pregnant women has access to the antiretroviral drugs that can substantially reduce the risk of transmitting HIV to her child.14 As a result, more than 600,000 children become infected with HIV each year, primarily during delivery or through breast milk.i, 15 Many die within the first two years of life. Nearly 90 percent of child deaths due to AIDS occur in Africa.6

UNAIDS advises, â&#x20AC;&#x153;where replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding is recommended. Otherwise, exclusive breastfeeding is recommended for the first few months of life.â&#x20AC;? Exclusive breastfeeding for six months carries a significantly lower risk of HIV infection than does supplementing breast milk with formula or solid foods.

Global Health Council Position Paper on Child Health

Underlying Causes of Child Illness and Death

Poverty: More than 200 million children under five live in absolute poverty, on less than $1 per day.

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Poor children are more likely than betteroff children to be exposed to disease and diarrhea through unsafe water and poor sanitation. They are more likely to live in overcrowded conditions, or to be unprotected from disease vectors such as mosquitoes that cause malaria. They are more likely to suffer respiratory conditions like pneumonia, aggravated by indoor air pollution from open cooking fires. Infants born to poor families are far more likely to die from preventable causes in the first days and month of life.16

Health services and interventions are not equitably distributed and less likely to reach those who need them most. Thus poor children become ill and die more frequently than children who are better off. Under-nutrition and malnutrition: At least 200 million children under five are malnourished.

In more than half of all child deaths (53 percent), under-nutrition is an underlying cause of death, leaving the child far more vulnerable to severe consequences from common infections.6 But death is the “tip of the iceberg”17 because at least 20 times as many children will never fulfill their development potential due to the effect of malnourishment on physical and brain development. In 79 low- and middle-income countries, the physical and intellectual growth of more than a quarter of all children is stuntedii due to poor nutrition and illness. Africa is the only continent ii

Growth stunting is defined by the National Center for Health Statistics as height for age that is more than two standard deviations (SD) below average for the reference group.

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in which malnutrition among children is rising,18 but child malnutrition remains most pervasive in Asia. Children in poor families are much more likely to be deficient in essential micronutrients such as vitamin A, iron and zinc. The effects of chronic malnutrition in the first two years of life on cognitive ability are largely irreversible.19 High fertility and short birth intervals affect the lives of more than 100 million poor children.

Women in 35 of the countries with highest child mortality have, on average, five or more births each. Children born into a large family compete for scarce resources, including for maternal care. Those born less than two years after a previous birth are especially at risk of premature birth, low birth weight, and death and disease in the first weeks, months and even years of life. A child born 17 months or less after a previous birth is three times more likely to die than a child born three years after a previous birth.20 Parents who fear losing a child are often unaware of the importance to child survival of birth spacing, and they may lack access to contraception to plan or space their births. Thus high fertility and high child mortality reinforce one another in a harmful way.

In Niger, a country with child and maternal mortality rates that are among the highest in the world, mothers have an average of eight births each, 68 percent of births are less than three years apart,21 and nearly three of every 10 children die before the age of five. Giving birth to many children increases the mother’s risk of death. A woman in Niger faces a one in seven chance of dying of pregnancy-related causes during her lifetime.22 A child who loses its mother faces a three- to 10-fold increase in risk of death.23

II. Simple, Cost-effective Solutions Can Save Millions of Children “A limited set of known and effective interventions, if implemented together and at universal coverage, can save over 6 million child lives each year. These interventions…are feasible for implementation at high levels of population coverage in poor countries … to all children who need them.” 24 – Countdown to 2015 Child Survival Partnership 2005

For every major cause of child death, there is an affordable solution ready to be implemented and these survival interventions work in a wide array of contexts. Most do not need to be delivered in a health facility and many interventions are so simple and of low cost that even poor countries with weak health infrastructures can expect dramatic reductions in infant and child mortality if these interventions are sufficiently scaled up.21 For example, a study in Uttar Pradesh, India demonstrated a 50 percent decline in neonatal mortality through raising awareness in the community of such simple survival strategies as cleaning, drying and warming the newborn, skin-to-skin contact with the mother, and exclusive breastfeeding for the first six months.25 In comparison with giving the newborn milk-based fluids or solids in addition to breast milk, immediate (within an hour of birth) and exclusive breastfeeding has been

shown to reduce neonatal deaths from all causes by 22 percent.26 Since the majority of infant deaths occur at home, educating mothers about the importance of immediate and exclusive breastfeeding and skin-to-skin contact with the newborn is perhaps the most cost-effective survival solution known. (See Appendices 1 and 2.) Table 1 illustrates how inexpensively the major killers of children can be prevented and treated. Life-saving interventions, such as vaccines and oral rehydration salts (ORS), already prevent more than 3 million child deaths each year at a very affordable price. In southern Africa, measles has been nearly eliminated as a cause of child death in just four years through a vaccination campaign costing just $1.10 per child.27 Dramatic impact such as these can be achieved throughout the developing world.

Table 1: Major Causes of Child Deaths and Cost of Treatment per Child Disease

Pneumonia Diarrhea Malaria Measles Birth Asphyxia HIV/AIDS Tetanus

% Deaths under 5

19% 17% 8% 4% 8% 3% 2%

# Deaths annually

Cost to treat/prevent illness for one child

2 million 1.8 million 850,000 400,000 830,000 350,000 250,000

Antibiotic treatment . . . . . . . . . . . . .$ 0.30 Oral rehydration packet . . . . . . . . . .$ 0.20 Insecticide treated bednet . . . . . . . . .$ 5.00 Measles vaccine . . . . . . . . . . . . . . . . .$ 1.10 Resuscitation mask and bag . . . . . . .$10.00 Antiretroviral drug . . . . . . . . . . . . . .$ 5.00 Two tetanus toxoid injections . . . . .$ 0.40

Global Health Council Position Paper on Child Health

Many health interventions are so inexpensive that the barrier that extreme poverty creates is almost inconceivable. A recent study in a squatter settlement of Karachi, Pakistan found that soap and hand-washing reduced pneumonia by 50 percent and diarrhea by 53 percent. Yet half the residents lived on less than $.50 per day and could not afford even the $4 per month for hand soap.28 Most women in a Bangladesh study also said they could not afford to buy soap.29 The cost of scaling up these interventions in the 60 countries with 94 percent of all child deaths has been carefully estimated. More than 60 percent of the 10.1 million deaths â&#x20AC;&#x201C; 6.6 million childrenâ&#x20AC;&#x2122;s lives, including 2.5 million neonates â&#x20AC;&#x201C; could be saved through an additional investment of only $7 billion per year.2, 7, 30, iii To put this level of spending in perspective, it is less than 10 percent of what was spent in 2005 on tobacco products in the United States alone.31 Overall, 80 percent of these costs are for preventing rather than treating disease.32 While some preventive efforts, like vaccines, are easily affordable, others are initially costly but ultimately highly cost-effective. The most expensive, expanding access to safe water and sanitation,

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can reduce long-term disease incidence and treatment costs by about 60 percent.33 In the recent past, the interests of mothers and children have been forced to compete for a very limited pool of financial resources and international attention. Yet, we know that the survival of mothers, newborns and children is intertwined: all benefit from an essential package of care.34 The core interventions to improve child survival (Appendices 1 and 2) form a continuum, from antenatal care and proper nutrition for pregnant women through prevention and treatment of common childhood illnesses. Enabling women to space births and prevent unwanted pregnancies, and assuring that a skilled attendant is present at birth are critically important child survival strategies. Extending contraceptive services to 200 million women with an unmet need for family planning is estimated to cost $3.9 billion per year,35 while providing maternal care to 75 percent of women in the 75 highest maternal mortality countries would require on average an additional $3.9 billion per year.23 Although these additional costs are not insignificant, the combined estimate to provide maternal, newborn and child health as well as family planning is well within global capacity if all actors do their part.

This figure is a new cost estimate by Lawn et al., 2007 representing a combination of the child and newborn cost estimates outlined in The Lancet (365, 2005): $5.1 billion to save 6 million children in 42 countries and $4.1 billion to save 2.7 million neonates in 75 countries. The new figure estimates the running costs for providing 99 percent coverage of 32 interventions for newborn and child health in the 60 priority high mortality countries.30

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Why Invest in Saving Children’s Lives? A visible commitment to child health reflects our most deeply held beliefs and values. A child’s risk of dying before age five was cut in half between 1960 and 1990 due to wide scale-up of child survival strategies in many countries.34 Yet, despite low cost and high cost-effectiveness, coverage of the key child survival interventions remains appallingly low in many countries. Child mortality has actually risen in some of the poorest countries where rapid population growth, poor economic performance, and low priority placed on basic public health services, have hindered efforts to reach a larger portion of the population with key prevention and treatment interventions. High fertility, low productivity and failing economies are all fueled by child death and illness, forming a vicious cycle that can only be broken through concerted action.

Investments in Child Health Have Long-term Economic Payoffs – for Recipient and Donor Countries

It is time to reset our global development priorities and invest according to our highest and most universally shared values.

Health has long been recognized as an important determinant of human capital and productivity.37 Poor health, and its attendant physical and intellectual stunting, hinder the ability of a child to attend school or to learn as much as a healthy child is capable of learning. Limited education and poor learning have a direct bearing on job potential and earnings. Ultimately, poor child health undermines societal development, while improved health is the first step toward enabling children to break out of a cycle of ill-health and poverty that may otherwise continue for generations.38 A study quantifying this relationship found that for each one point decrease in infant mortality, domestic product per capita grew by 0.145 percent.39

The loss of a child is emotionally devastating for any parent, but for those privileged to live where the death of a child is a rare event, the frequency of loss in the developing world is almost beyond comprehension. Why should a child born in Ethiopia today be 20 times as likely to die before age five as a child born in North America or Western Europe? Losing 28,000 children per day when the tools and knowledge to prevent more than half of these deaths are readily available, is neither morally acceptable nor in the best interests of any individual, nation or the global community. Action to improve child health reflects deeply held moral beliefs and basic humanitarian values, including equity, fairness and justice. We can, with political will and sound investments, create a world where child deaths will no longer be considered routine and inevitable.

While saving children’s lives is a moral issue, the money spent on child health is probably the most cost-effective investment the developed and developing world can jointly make. It would provide more stability and prosperity among developing nations, and a more equitable world economy. “Robust findings indicate that more attention should be paid to poor health as a mechanism for the intergenerational transmission of poverty ... as [poor children] earn less as adults which in turn affects the next generation of children who will thus be born into poorer families.” 36

Childhood illness and death contribute to the impoverishment of families through expenditures on medical care they can ill afford, through reduced income for other necessities such as food and education, and through economic productivity lost in caring for a sick child. The economic cost of child mortality on lost productivi-

Global Health Council Position Paper on Child Health

ty has been estimated for Senegal and Uganda, two of the worldâ&#x20AC;&#x2122;s poorest countries, at $1,200 per death for each of the 14,000 annual child deaths in Senegal and the 33,000 in Uganda.38 Comparing this with the average cost of saving a childâ&#x20AC;&#x2122;s life,30, 32 illustrates that preventing and treating childhood illness is far less costly in economic terms and an immeasurable benefit to families and societies. The Effects of Childhood Illness and Malnutrition Can Last a Lifetime

The first years of life, beginning before birth and continuing to age two, are critically important, as growth stunting due to malnutrition has an irreversible effect on the childâ&#x20AC;&#x2122;s brain and physical development.19 Unable to reach their intellectual or physical potential, affected children are destined to be less productive and less economically successful as adults. Compared to children who are neither stunted nor grow up in absolute poverty, these children face a 20 percent deficit in income as adults.17 A clear example of the economic cost of failing to safeguard child health is evident among the more than half a million African children who are stricken with cerebral malaria each year. Survivors often experience severe anemia and neurological complications that can permanently impair cognitive ability and economic productivity.40 Although it is well-documented that providing treatment for malaria before age six has lasting cognitive benefits,41 as few as 8 percent of affected children are seen by a health professional.40

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The long-term individual, familial, community and societal costs of child illness and death should be taken into account when the price of interventions to improve child health are considered.17 Interventions to prevent stunting and its long-term after-effects are, in fact, simple and highly cost effective, have long-term benefits on schooling and intelligence tests in adulthood,42 and return up to $3 in additional wages for every $1 invested in improving child nutrition.36 Community-based programs promoting better child-feeding practices can reduce stunting and cognitive impairment by 1-2 percentage points per year for an annual cost of just $5 to $10 per child.33 Investments in Child Health Often Pay for Themselves Over Time43 Polio

Since 1988, the number of polio cases worldwide has fallen by 99 percent. By 2002, the WHO had certified 124 countries polio-free, and predicts global savings reaching $3 billion annually by the year 2015. Other infectious diseases of childhood

For every dollar spent on the diphtheria/ tetanus/pertussis vaccine, economists estimate a savings of $29; for the measles/ mumps/rubella vaccine, $21. In short, it is difficult to identify a more sound or well-described investment that can be made in the interest of global development than to improve child health and survival.

III. Global Health Council Positions on Improving Child Survival and Health The Global Health Council, the worldâ&#x20AC;&#x2122;s largest membership alliance dedicated to saving lives by improving health, has long recognized that the needless death of children is one of the core global health priorities of our time. The Council supports the rights of all children and families to have access to essential primary health care that is responsive to their core health needs. Many organizations and coalition partnerships throughout the world share this goal with the Council and are pursuing various efforts to secure child survival and achieve better health for children. Affordable and effective interventions for the most common causes of child

deaths must be made accessible to all families, especially those in countries with high child mortality. The positions that follow articulate the Councilâ&#x20AC;&#x2122;s policy and advocacy agenda for improving child survival and health. These positions are set forth as recommendations to concerned policy-makers, as rallying points for the Councilâ&#x20AC;&#x2122;s members who work daily to improve child health, and as a platform for collaboration with other organizations and coalitions advancing child health.

Global Health Council Position Paper on Child Health

Position #1 Governments, multilateral organizations, private donors and civil society should contribute equitably to partnerships aimed at achieving a two-thirds reduction in the 1990 level of child mortality by 2015.

In 2000, 187 UN member states signed the Millennium Declaration, endorsing eight achievable goals to advance global health and development. Millennium Development Goal (MDG) 4 pledged countries to reduce their 1990 child mortality rate by two-thirds by 2015.4 Child health experts have determined that it is entirely feasible to save at least 6.6 million children each year by expanding coverage of existing health interventions. The Lancet has published two series on child health and neonatal health by these experts, which provide a roadmap for what must be done and where.iv Several countries are translating the recommendations into concrete actions.v Many more need to follow suit if they are to achieve MDG 4.

mortality by 2015. However, this goal remains achievable with concerted global investment to reduce child deaths in high mortality countries. Recommendations:

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• Building on these efforts, the Countdown to 2015 Child Survival Partnership, (CSP) an international reference group of child health experts has formed to further and monitor progress to achieve MDG 4. CSP includes the governments of partner countries, UNICEF, the World Health Organization (WHO), World Bank, the Canadian International Development Agency (CIDA), the United Kingdom Department for International Development (DFID), the Bill & Melinda Gates Foundation, the U.S. Agency for International Development (USAID), professional associations, academic, research and technical institutions and a growing number of bilateral partners and non-governmental organizations such as Save the Children. The partnership does not disburse funds but encourages all parties to contribute to improved child health and to make optimal use of existing resources to make essential services widely available.24 At present, few countries are on track to achieve the two-thirds reduction in 1990 child iv

The Lancet, Volume 361, 2003, and Volume 365, 2005.

Cambodia, China, Ethiopia, India, Mozambique, Pakistan and Tanzania. Countdown to 2015. Tracking Progress in Child Survival: The 2005 Report.

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Donor countries, multilateral assistance agencies, developing country governments and civil society should support the global resource need of an additional $7 billion per year as identified by the CSP, and cooperate fully to achieve its goals. The widespread shortfall in resources and progress should be addressed through country-specific partnerships committed to national strategies for achieving MDG 4. Partnerships that increase resources for evidence-based programming, sustain strong political commitment, and encourage monitoring of results to spur rapid improvement in child survival should be encouraged and replicated.

A model of leadership and partnership that others can follow is provided by Norway, which has been a major contributor to the Global Alliance for Vaccination and Immunization (GAVI), supporting immunization coverage for childhood diseases. The Norwegian aid program, NORAD, is developing partnerships with select countries to reduce particularly high numbers of children deaths. The first collaboration is with India, the country with the greatest annual number (2.4 million) of child deaths. The strong political commitment by the Norwegian and Indian prime ministers is viewed as essential to the success of the partnership.44 MDG 4 to reduce child mortality [is the] litmus test for our common determination to do business in a different way and achieve results… Child mortality is a sensitive indicator of economic development and social inclusion and the distribution of resources and services in society.44

Position #2 Investment in newborn and child health must increase substantially to achieve the goal of saving an additional 6.6 million children each year.

Presently, all donor spending on child, newborn and maternal health combined ($1.99 billion in 2004)vi represents just 2 percent of gross aid disbursements to developing countries.46 These external sources represent only 20 percent of total health expenditures in developing countries. By way of contrast, twice as many deaths due to preventable causes occur to children under age five each year as compared to AIDS, malaria and TB deaths for all ages. Yet, far fewer global resources are devoted to child health than to AIDS and malaria. Improving the effectiveness of assistance requires not just more money but “long-term consistency in aid commitments.”18 This has not been the historical pattern, particularly in Africa. Programs in the 1970s and 1980s that focused on primary health care and food security were abandoned as USAID and World Bank assistance to African agriculture dropped by 90 percent during the 1990s. The loss of these programs contributed to the present state of famine and food insecurity.18 Developing countries afflicted with high child mortality must both increase their investment in child health and use their limited resources wisely. For many, this will require a doubling or tripling of current domestic expenditures for child health.34 India, where nearly 30 percent of all neonatal deaths worldwide take place, has tripled spending on public heath over four years, from less than 1 percent GDP to nearly 3 percent, emphasizing reduced maternal and neonatal mortality in rural areas.7 Recommendations:

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• vi

Donor countries and multilateral assistance organizations should commit to an increased and equitable share of meeting the additional $7 billion per year needed to save 6.6 million lives. The U.S. government (USG) should be a substantial partner in this global effort.

Leading by example, the USG should immediately increase its current bilateral program investments by $300 million to $660 million, and commit to placing funding for child health programs on par with U.S. spending in other areas of global health. Ultimately, the USG should increase its contribution to $2 billion per year. • Private sector donors, including foundations and corporations, should prioritize increasing access to proven, cost-effective interventions that will save children’s lives, while sustaining investment in new technologies for the medium to long term. • Developing country governments should increase domestic child health expenditures to levels consistent with their commitments to applicable international agreements, including to achieve MDG 4 and, for African countries, to meet the Abuja target of expending 15 percent of the national budget on health.47 • Donors should encourage such investments, especially efforts to improve health among the poor, through technical assistance, policy dialogue, and constructive incentives for gains in child health. • National governments have responsibility and authority over strategies for achieving MDG 4. Funding from all sources must be coordinated at the national level to assure that child health assistance is effective and streamlined.48 All partners should coordinate country efforts under the aegis of national authority and consistent with the Three Ones Principle – one country plan, one coordinating mechanism, and one monitoring and evaluation strategy. • Donors, including the United States, should commit stable and secure funding through 2015 in order to achieve and sustain targeted reduction in child mortality as developing countries strengthen their internal child health delivery systems.

Most recent data available specifically for child, newborn and maternal health. Includes assistance to 150 developing countries by the 22 high income donor countries and the European Union represented in the Development Assistance Committee (DAC) of the Organization of Economic Cooperation and Development, (OECD) as well as the World Bank, UNICEF, UNFPA, the Global Alliance for Vaccines and Immunization (GAVI), and the Global Fund to Fight AIDS, TB and Malaria.45 Global Health Council Position Paper on Child Health

Position #3 Resources should be targeted to the countries and populations where child mortality is greatest, based on the criteria of severity and magnitude.

Efforts to reduce child mortality have been especially disappointing in sub-Saharan Africa. Among the 30 countries with the highest rates of child mortality, 27 are in this region, as are 11 of the 15 countries with higher child mortality in 2006 than in 1990.49 The decline in mortality for the entire sub-Saharan region is half that in Southeast Asia and about a fifth that in Latin America.50 The disparity in child mortality between rich and poor is large and increasing, both between and within countries.51 The urgency is to deliver the right interventions to children who need them most. Health programs aiming to reach the population at large tend to first reach those who are better off to start with. Demographic and health surveys indicate that health interventions reaching 60-80 percent of those in the highest income quintile may reach less than 10 percent of the poorest children.2 In Ethiopia, for example, only one percent of poor women had a skilled attendant at birth compared to 25 percent of women in the highest income group.34 Because child deaths are concentrated among the poor, attending to the poorest will have the greatest impact on overall child mortality reduction. While reaching the poor, particularly in rural areas, is challenging, the poorest 40 percent of households are much more likely to benefit if programs are strategically pro-poor.51 An explicit “equity focus” on the poor and disadvantaged can improve health coverage by reaching people where they live, creating incentives to encourage demand for services, and including their viewpoints in program design and implementation.52

vii

The extreme challenge of lowering child mortality in the poorest countries is aggravated by rapid population growth and low access to family planning. In the 60 countries with highest child mortality rates, the numbers of children under five grew by 37 million (13 percent) between 1996 and 2006. Niger has 34 percent more children under five than it did just 10 years ago. The number of women of reproductive age in these countries has also grown by a staggering 26 percent.vii These countries should be the focus of far greater attention to improve maternal, child and reproductive health. Recommendations:

•

All partners in this effort should commit to reaching those most in need through a focus on countries or regions with the highest rates of death and reaching the highest risk groups, including the poorest and those in rural and hard-to-reach areas. All partners should demonstrate accountability for reaching the poor through regular monitoring and reporting of equity indicators to the public and decisionmakers.53 In countries experiencing rapid population growth, investments to improve child health should reflect the need for expanded access to high quality family planning and reproductive health programs.

Global Health Council calculation based on U.S. Census Bureau data of countries with populations of more than 1 million and child mortality rates of 50 or more deaths per 1,000 live births.

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Position #4 Priority should be given to interventions of proven effectiveness, implemented according to population-specific assessments of the causes of childhood death and disease.

The core interventions outlined in Appendices 1 and 2 have been demonstrated to be effective in reducing child mortality. Disease burden varies by country and region and full coverage of all interventions cannot be instantly achieved, nor may all be equally needed. The order in which interventions are scaled up in individual countries should be determined through a priority-setting exercise based on the local, national and regional disease burden, and in consideration of pro-poor policies to improve health equity. The significant reduction in mortality that can be achieved simply through immediate and exclusive breastfeeding has already been highlighted. Yet in 23 high child mortality countries, less than 20 percent of babies are fully breastfed for the first six months. These countries should be considered on “high alert” for expanding breastfeeding awareness and practice. 2 Expanding the practice of breastfeeding in these countries can be expected to have a large pay-off in reduced neonatal deaths, as well as in significantly reducing diarrhea and growth stunting, for a minimal investment.54 Through such priority-setting and focus on effective interventions, even very poor countries have made remarkable progress. Child mortality has declined 30 percent in Tanzania in the last five years following a decision by district health managers to base their budget priorities on local patterns of death and to increase spending on maternal health and Integrated Management of Childhood Illnesses (IMCI). The Countdown to 2015 Child Survival Partnership has tracked the 60 countriesviii with

the highest child mortality rates and numbers of deaths. (Appendix 4) It is in these countries that 94 percent of all deaths to children under age five occur.55 Although none of these countries have achieved minimum coverage for all or even most of the 19 indicators for tracking child survival, six poor countries (Senegal, Nepal, Bolivia, Tanzania, Pakistan and Zambia) are showing progress.56 In addition, Tanzania and five other African countries with per capita GNI below $400 – Malawi, Uganda, Eritrea, Burkina Faso and Madagascar – have succeeded in reducing newborn deaths by an average of 29 percent over 10 years through expanding evidence-based practices according to national needs.57 Recommendations:

•

Donors should immediately increase support to country-led efforts to develop strategic plans addressing maternal, neonatal and child mortality. These strategies should be cost effective, use integrated delivery of services rather than parallel delivery of disease-specific interventions, and aim to expand communitybased coverage to complement facilitybased services. Because nearly 40 percent of deaths take place in the neonatal period, all plans should include specific attention to assure that mothers and newborns receive appropriate care during the anteand post-natal period.

Pneumonia and diarrhea are the two largest killers of children under five and, in most countries, far more attention should be given to preventing and treating these illnesses.11

viii The 60 CSP countries include six large countries with under-five mortality rate less than 40 per 1,000 live births (Brazil, China, Egypt, Indonesia Mexico and the Philippines), but large numbers of death due to large populations of children under five.

Global Health Council Position Paper on Child Health

Position #5 Investments in child health should simultaneously strengthen health capacity for the long term.

Although many of the proven child health interventions can be effective even where health systems are weak, it is clear that saving more childrenâ&#x20AC;&#x2122;s lives and sustaining a downward trend in child mortality will require substantial investments to strengthen health systems. The process of expanding many of these services is an opportunity to build human resource capacity and improve health systems. For example, the WHO estimates that 344,000 new skilled birth attendants are needed by 2015 to provide universal coverage in the 75 high mortality countries.58 Comprehensive human resource plans addressing training, retraining, staff retention and geographical distribution of health personnel need to be included in the national strategic plan. Strengthening health systems, particularly drug and vaccine supply and logistics support, is one of the three components of the Integrated Management of Childhood Illness package (IMCI) which aims to reduce gaps in knowledge among providers, parents and communities and improve child health practices. In Tanzania, a 13 percent decline in under-five mortality was achieved in only two years through improving the supply of essential drugs; training health

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workers to improve the quality of IMCI care at facilities; and educating parents to recognize illness, manage the sick child at home, and seek care when appropriate.57 Recommendations:

â&#x20AC;˘

Partners should ensure that as coverage of the core child health interventions is scaled up, efforts to improve the broader health system, encompassing personnel, facilities, commodities, information, financing and health insurance or protection from catastrophic illness, are incorporated to the fullest extent possible. Routine collection of meaningful data requires that health information systems and trained personnel are also in place. It is in the interest of all parties to invest in strengthening national strategic health information systems to collect standardized, accurate data. Such investment will build internal capacity for governments to measure their progress in all aspects of development, identify obstacles, and enable donors to determine whether their efforts are contributing to such progress.

Position #6 Progress toward achieving MDG 4 should be scrupulously monitored, regularly reported, and routinely evaluated.

On a global scale, capacity to measure indicators of health is weak. Tracking progress toward meeting the Millennium Development Goals provides an imperative to improve measurement and evaluation. Deaths to newborns, for example, are thought to be significantly underestimated, and must be counted. Better morbidity and mortality data are needed if progress is to be meaningfully assessed. Measurement indicators must go beyond numerical targets to assess and evaluate outcomes and impact of investments over time. At the 2005 World Health Assembly, the Health Metrics Network (HMN) was launched to help countries generate data for decision-making. HMN is the first global partnership comprised of government ministries of health, multilateral, bilateral and private donors, and statistical and technical experts, to focus on strengthening health information systems. The goal of the HMN is to “increase the availability, quality, value and use of timely and accurate health information by catalyzing the joint funding and development of core country health information systems.”59 This network has the potential to assist in tracking progress toward MDG 4 as well as all other aspects of health at the national and global level.

Competing donor demands for data collection and analysis currently impose a huge burden within countries and programs – a burden that undermines the quality, efficiency and effectiveness of country programs. HMN partners are selecting a rational set of core health indicators that meet international technical standards and are harmonized with the indicators used in international and global initiatives. Recommendations:

•

All parties making efforts to improve child survival and health should agree on a rational set of key indicators, including neonatal mortality. Rigorous benchmarks to provide timely and accurate data for decision-making should be established and all parties held accountable for their contributions. All partners should strive to harmonize resources, avoid duplication of effort, and reduce administrative burden by supporting a unified monitoring and evaluation plan and using the agreed-upon indicators to track and report upon on their progress.

Global Health Council Position Paper on Child Health

IV Conclusion

We have all the evidence we need to save more childrenâ&#x20AC;&#x2122;s lives. Let us begin.

The world can achieve MDG 4 and save an additional 6.6 million children with the information and tools we have today. We have affordable and effective solutions, and the indicators to measure progress. We have sound estimates of the costs. In the global context, the level of investment required is not only entirely feasible, but so easily within current capacity that there is little cause for debate. Already, creative partnerships and coalitions like the Countdown to 2015 Child Survival Partnership and the Partnership for Maternal, Newborn and Child Health have

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begun to mark out road maps to success. It is in our best interests as a global society to make the most of this opportunity. Only political will is needed to prevent most deaths to children under the age of five, even in the poorest countries. And saving at least 6.6 million children is just the first step toward the goal we all share â&#x20AC;&#x201C; creating a world where child survival can be taken for granted and families everywhere are confident that their children will survive and thrive.

Appendix 1 Core Interventions to Prevent 6.6 Million Child Deaths 60, 61

Preventive interventions

Folic acid supplementation Tetanus toxoid Syphilis screening and treatment Pre-eclampsia and eclampsia prevention (calcium supplementation) Intermittent presumptive treatment for malaria in pregnancy Antibiotics for premature rupture of membranes Detection and management of breech (caesarian section) Labor surveillance (including partograph) for early diagnosis of complications Clean delivery practices Breastfeeding Prevention and management of hypothermia Kangaroo mother care (skin-to-skin contact) for low birth-weight newborns Newborn temperature management Insecticide-treated materials Complementary feeding Zinc Hib vaccine Water, sanitation, hygiene Antenatal steroids Vitamin A Nevirapine and replacement feeding to prevent HIV transmission Measles vaccine Treatment interventions

Detection and treatment of asymptomatic bacteriuria Corticosteroids for preterm labor Newborn resuscitation Community-based pneumonia case management, including antibiotics Oral rehydration therapy Antibiotics for sepsis Antimalarials Zinc for diarrhea Antibiotics for dysentery Vitamin A

Global Health Council Position Paper on Child Health

Appendix 2 Percentage of Child Deaths Averted by Core Interventions

Percent of Total Deaths Averted by Single Interventions â&#x20AC;&#x201C; Prevention 0%

10%

Breastfeeding (post-NN impact) Early BF, thermal care & NN hygiene ITM Complementary feeding Skilled maternal & Immed. NN care Zinc Measles vaccine Hib vaccine Water/San/Hygiene Vitamin A Antiretroviral treatment Extra care for LBW infants Antenatal steroids Tetanus toxoid ANC: exam, eclampsia, syphilis Rx/Tx aymptomatic bacteriuria Antibiotics: PRoM IPT malaria in pregnancy Periconceptual folic acid suppl.

Percent of Total Deaths Averted by Single Interventions â&#x20AC;&#x201C; Treatment 0%

10%

12%

Oral rehydration therapy Antibiotics: pneumonia + sepsis Emergency neonatal care Antimalarials Zinc Emergency obstetric care Antibiotics: dysentery Vitamin A Antibiotics: PRoM ix

Morris S, Black RE, Shibuya K, Cousens S, and Bryce. How many child deaths can we prevent? 2003 update, poster, 2007.

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Appendix 3 Global Monitoring Indicators for Tracking Child Survival 56

Nutrition

1. 2. 3.

Exclusive breastfeeding for six months Breastfeeding and appropriate complementary feeding at six-nine months Continued breastfeeding at 20-23 months

Vaccination

4. 5. 6.

Measles immunization coverage DPT2 immunization coverage Hib immunization coverage

Prevention

7. 8. 9. 10.

Vitamin supplementation coverage with at least one dose in last six months Access to safe drinking water Access to sanitation facilities Use of insecticide-treated bed net

Newborn Health

11. 12. 13. 14. 15.

Skilled attendance at birth Tetanus toxoid protection at birth Timely initiation of breastfeeding (within one hour) Postnatal visit within three days after delivery Prevention of mother-to-child transmission of HIV

Case Management

16. 17. 18. 19.

Care seeking for pneumonia Antibiotic treatment of pneumonia Oral rehydration therapy and continued feeding received Anti-malarial treatment

Global Health Council Position Paper on Child Health

Appendix 4 Sixty High Child Mortality Countries and their Progress Toward Meeting MDG 4 STATUS

Afghanistan Angola Azerbaijan Bangladesh Benin Botswana Brazil Burkina Faso Burundi Cambodia Cameroon Central African Rep Chad China Congo Congo, Dem Rep Côte d’Ivoire Djibouti Egypt Equatorial Guinea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Haiti India Indonesia Iraq Kenya Liberia Madagascar Malawi Mali Mauritania Mexico Mozambique Myanmar Nepal Niger Nigeria Pakistan Papau New Guinea Philippines Rwanda Senegal Sierra Leone Somalia South Africa Sudan Swaziland Tajikistan Tanzania, United Rep Togo Turkmenistan Uganda Yemen Zambia Zimbabwe www.globalhealth.org

TARGET

Under-5 mortality rate 1990

Under-5 mortality rate 2004

Estimated average annual rate of reduction 1990-2004

MDG target under-5 mortality rate 2015

Average annual rate of reduction needed between 2004 and 2015 to meet target

260 260 105 149 185 58 60 210 190 115 139 168 203 49 110 205 157 163 104 170 204 92 154 122 240 253 150 123 91 50 97 235 168 241 250 133 46 235 130 145 320 230 130 101 62 173 148 302 225 60 120 110 128 161 152 97 160 142 180 80

257 260 90 77 152 116 34 192 190 141 149 193 200 31 108 205 194 126 36 204 166 91 122 112 155 203 117 85 38 125 120 235 123 175 219 125 28 152 106 76 259 197 101 93 34 203 137 283 225 67 91 156 118 126 140 103 138 111 182 129

0.1 0.0 1.1 4.7 1.4 -5.0 4.1 0.6 0.0 -1.5 -0.5 -1.0 0.1 3.3 0.1 0.0 -1.5 1.8 7.6 -1.3 1.5 0.1 1.7 0.6 3.1 1.6 1.8 2.6 6.2 -6.5 -1.5 0.0 2.2 2.3 0.9 0.4 3.5 3.1 1.5 4.6 1.5 1.1 1.8 0.6 4.3 -1.1 0.6 0.5 0.0 -0.8 2.0 -2.5 0.6 1.8 0.6 -0.4 1.1 1.8 -0.1 -3.4

87 87 35 50 62 19 20 70 63 38 46 56 68 16 37 68 52 54 35 57 68 31 51 41 80 84 50 41 30 17 32 78 56 80 83 44 15 78 43 48 107 77 43 34 21 58 49 101 75 20 40 37 43 54 51 32 53 47 60 27

9.9 10.0 8.6 4.0 8.2 16.3 4.8 9.2 10.0 11.8 10.6 11.2 9.8 5.8 9.8 10.0 11.9 7.7 0.3 11.6 8.1 9.9 7.9 9.2 6.0 8.0 7.7 6.6 2.1 18.3 11.9 10.0 7.2 7.1 8.8 9.4 5.5 6.0 8.1 4.1 8.1 8.6 7.7 9.2 4.5 11.4 9.3 9.4 10.0 11.0 7.5 13.2 9.2 7.8 9.2 10.5 8.6 7.8 10.1 14.3 21

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Global Health Council Position Paper on Child Health

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Notes

Global Health Council Position Paper on Child Health

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