Policy Brief Success Stories: Reaching the Child Survival Millennium Development Goal Overview It is tragic that more than 10 million children under age five will die this year, particularly since most of these deaths will result from preventable and treatable causes. Although individual countries have undertaken efforts to reduce child mortality, improved child survival became a global aspiration in 2000 through the Millennium Development Goals (MDGs).1 MDG 4 calls for countries to reduce their 1990 under-five child mortality rate by two-thirds by 2015. Of the 60 countries that account for 94 percent of all child deaths, only seven are currently on track to achieve their MDG target for child survival: Bangladesh, Brazil, Egypt, Indonesia, Mexico, Nepal and the Philippines.2 This brief will describe how two countries – Bangladesh and Mexico – have succeeded. It will highlight some of the lessons learned that may be helpful for other countries trying to achieve MDG 4. Under-5 Child Mortality Rate (per 1,000 live births)
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Countries On Track to Achieve MDG 4 Target
Countries on Track to Achieve MDG 4 Target
180 160 140 120 100 80 60 40 20 0 Bangladesh
Brazil
Egypt Eqypt
U5MR 1990
Indonesia U5MR 2004
Mexico
Nepal
Philippines
U5MR Target for 2015
Background Globally, most deaths to children under five are due to neonatal causes (38 percent), pneumonia (19 percent), diarrhea (17 percent), and malaria (8 percent).3 However, large geographic differences exist: malaria, for example, causes 18 percent of child deaths in sub-Saharan Africa but less than 1 percent in Southeast Asia.4 Malnutrition contributes to more than half of all child deaths.3 Regional variability, risk factors, and the need for coordination of interventions necessitate a multifaceted approach tailored to the country’s disease burden.3-5 Cost-effective prevention and treatment interventions that can be readily implemented in low-
income countries have been identified to address the major causes of death.5 Such interventions include many low-tech solutions, including vitamin A supplementation, oral rehydration therapy (ORT) for diarrhea, insecticide-treated bednets to prevent malaria, and promoting full and exclusive breastfeeding for the first 6 months.
Case Study #1: Bangladesh Bangladesh, a low-income country of 138 million people, spends 3 percent of GDP and $14 per capita on health expenditures.6 Despite widespread poverty and poor infrastructure, Bangladesh has succeeded in cutting its 1990
Percent Coverage
Coverage of Child Health Intervention in Bangladesh and South Asia, 2004 Coverage of Child Health Interventions in Bangladesh and South Asia, 2004
100 90 80 70 60 50 40 30 20 10 0 V itamin A
E xclus ive B reas tfeeding
Iodized S alt
Pneumonia T reatment
Oral R ehydration T herapy
B anglades h
child mortality rate of 149 per 1,000 live births to 77 in 2004.2, 7 In the late 1990s, about half of child deaths were due to pneumonia, diarrhea, measles and malaria.4, 8 Nearly half of all children were underweight and 36 percent of newborns had a low birth weight; nutritional deficiencies and growth stunting were common.2, 7, 9, 10
may 2007
In response to this burden of disease, Bangladesh introduced the Integrated Management of Childhood Illness (IMCI) strategy in a few locations in 1998, and extended the program in a stepwise progression over the next several years.11 IMCI aims to raise health awareness and improve the ability to manage illness at the family, community and health-worker levels, link families and communities to health facilities, and strengthen health systems.12 In 2001, training guidelines for health-care workers were implemented; by 2004, 94 percent had been trained in case management techniques and breastfeeding counseling.8 In 2002, strengthening of health systems was undertaken. In 2003, the community component was implemented and health workers received additional training in nutrition.8, 13
2
Improved quality of care in health facilities, resulting from IMCI training and case management, led to positive results, including a three-fold increase in the use of health-care services.14 Community-based services included: ORT and zinc supplements to prevent and treat diarrhea,7, 15-17 antibiotic programs to treat pneumonia, and vitamin A, iron and folic acid supplements for pregnant women and young children.18 Immunization rates increased from less than 20 percent in 1987 to 75 percent for measles, 88 percent for three doses of diphtheria, tetanus and pertussis (DTP), and more than 95 percent for tuberculosis.
M eas les Immunization
DT P Immunization
S killed B irth A ttendant
A ntenatal C are
S outh A s ia
Case Study #2: Mexico Mexico, a much wealthier country than Bangladesh, spends 6.2 percent of GDP and $372 per capita on health expenditures.9 Mexico’s 1990 child mortality rate was 46 per 1,000 live births and its progress in reducing the mortality rate to 28 per 1,000 live births in 2004 has been well-documented.19, 20 Through a series of surveys, Mexico identified the disease burden and assessed health systems operations and needs.19, 21 The systematic response to reducing child mortality combined disease-specific strategies (e.g., expanding immunization) and strengthening of health systems (e.g., insurance and subsidies, improving access to clinics). Incremental scale-up promoted integration of interventions, while ongoing data collection made it possible to track progress. Over the past 25 years, Mexico has sustained an expanding range of services. During the 1980s, when diarrheal disease was the leading cause of under-five deaths, ORT was implemented in hospitals and then in clinical practice, contributing to a 60 percent decrease in deaths due to diarrhea in five years. This was followed by stepwise implementation of universal vaccinations, a clean water program, “national health weeks� focused on child health, anti-parasite treatment, respiratory infection prevention and treatment, and nutrition programs. The combined impact is reflected in a 64 percent decline in the child mortality rate since 1980 and a 43 percent decline in the proportion of underweight children since 1990.13 The next challenge for Mexico is to reduce deaths in the neonatal period, as birth asphyxia and trauma, congenital heart anomalies, and low birth weight are the leading causes of death.19 A program was initiated in 2001 to improve maternal and perinatal health services and provide nutritional supplements to pregnant women. Programs to combat pneumonia, malnutrition and improve maternal
and newborn care must be expanded to further reduce child mortality.
Successes in the 60 priority countries For the other countries on track to achieve the MDG for child health:2, 7, 15, 22-25 • In Brazil, skilled attendants are present at 97 percent of all births; immunization rates for tuberculosis, measles and DTP exceed 90 percent. • In Egypt, skilled attendants are present at 70 percent of all births; ORT therapy is marketed to households through the private sector and the media. • The Philippines has initiated baby-friendly hospital programs and expanded micronutrient supplementation and maternal tetanus vaccination. • In Indonesia, immunization rates for tuberculosis, DTP and measles exceed 70 percent. • In Nepal, antibiotic treatment for pneumonia is delivered through community-based programs. Of the 60 priority countries, 10 are on track to achieve their breastfeeding targets, 10 had greater than 90 percent coverage for measles and DTP, and 56 have established vitamin A supplementation programs. • Between 1990 and 2004, China, Guinea and Mozambique had average annual declines in the child mortality rate of at least 3 percent. • Tanzania has been recognized for implementing the IMCI approach, which contributed to a 13 percent decline in child mortality in two years. • Efforts to achieve the MDGs have fostered the development of bilateral and multilateral partnerships to implement integrated programs.
General Lessons Learned How do countries make progress on multifaceted issues like child mortality? Through their review of success stories
in global health, the Center for Global Development identified six key elements that contribute to achieving goals:26 • Predictable, adequate, and long-term funding from both international and local sources. • Political leadership and champions to maintain the high profile needed for adherence and success. • Technical innovation within an effective delivery system, at a sustainable price, to ensure that new and effective products are distributed to where they are needed. • Technical consensus among experts on the appropriate biomedical or public health approach fostering advocacy efforts to increase support. • Good management on the ground so that the services and materials reach those who need them. • Effective use of monitoring and evaluating information so that accomplishments and problems are documented and mid-course corrections can be made.
Much more effort is needed While progress is being made, considerable challenges remain before even high-performing countries will reach child mortality rates that approach those of high-income countries (about 7 per 1,000 live births).2, 4 • Of the seven on-track priority countries, only two are among the poorest countries; none are in sub-Saharan Africa, where 42 percent of child deaths occur. • Eleven priority countries had higher child mortality rates in 2004 than in 1990. • In 23 countries, exclusive breastfeeding rates are lower than 20 percent. • Six countries have immunization rates lower than 50 percent and three had a decline in immunization rates. • In 11 countries, skilled attendants are present at less than 30 percent of births. • No country is close to the MDG 6 malaria target of 80 percent coverage for insecticide-treated bednets.
The Global Health Council Supports the Following Measures • Increasing international support by $7 billion to meet the goal of saving 6.6 million children’s lives in highest mortality countries.27 The U.S. contribution should be $2 billion.
• Country-led plans, including fulfillment of commitments made by African nations in the Abuja Declaration to target at least 15 percent of annual national budgets to the improvement of the health sector.28
• Expanding coverage of evidence-based policies and interventions as promoted by the Countdown to 2015 Child Survival Partnership and The Partnership for Maternal, Newborn and Child Health.
• The United States Commitment to Global Child Survival Act of 2007 that provides assistance to improve the health of newborns, children and mothers in developing countries. may 2007
3
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