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CSU79/2009: CHILD MORTALITY 30 YEARS AFTER ALMA ATA/ COUNTDOWN TO 2015

Monday, 14th of December 2009

CSU 79/2009: CHILD MORTALITY 30 YEARS  AFTER ALMA ATA/ COUNTDOWN TO 2015
 
 These pieces from The Lancet are food for thought. The world has made
 progress since Alma Ata, but has some way to go.
 
 Malaria is widely recognized as a major obstacle to MDG 4. So, in many
 countries are the vaccine preventible diseases, with pneumonia, Hib and
 rotavirus now joining the list of EPI target diseases. Why do short birth
 intervals, the best predictor of U5MR in most countries, rarely make the
 list?
 
 Good reading.
 
 BD
 
 1) CHILD MORTALITY 30 YEARS AFTER THE ALMA ATA DECLARATION
 
 Full text at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736
 (08)61378-1/fulltext
 
 
 The Lancet, Volume 372, Issue 9642, Pages 874 - 876, 13 September 2008
 
 doi:10.1016/S0140-6736(08)61378-1(Embedded image moved to file:
 pic12717.gif)Cite or Link Using DOI
 Child mortality 30 years after the Alma-Ata Declaration
 Original Text
 Edilberto Loaiza a(Embedded image moved to file: pic18696.gif)Email Address
 , Tessa Wardlaw a, Peter Salama a
 The 30th anniversary of Alma-Ata provides a tremendous opportunity to
 galvanise the increasing political commitment and global momentum behind
 meeting the health-related Millennium Development Goals (MDG). MDG 4 calls
 for a two-thirds reduction in mortality of children aged less than 5 years
 between 1990 and 2015. Accurate and timely estimates of childhood mortality
 are needed to help countries set priorities, to design programmes, and to
 monitor progress. Such estimates are challenging to make because data are
 scarce in many developing countries. In response, in 2004, experts at
 UNICEF, WHO, the World Bank, the UN Population Division (UNPD), and members
 of the academic community, formed the Inter-Agency Group for Child
 Mortality Estimation. The IGME aims to produce best estimates on levels and
 trends in child mortality worldwide, to improve and harmonise methods
 across partners, and to source and share new data on child mortality. Each
 year, UNICEF, on the basis of work of the IGME, publishes the latest
 summary data on global mortality in children under 5 years of age as they
 become available. Detailed national estimates of mortality, trend analysis,
 and other indicators are then published in the annual The State of the
 World's Children report. Further analysis along with other policy and
 programme data are also presented every 2—3 years as the Countdown to 2015,
 involving UNICEF, WHO, UN Population Fund (UNFPA) and a range of civil
 society, academic, and donor partners.1
 Current methods for estimation of mortality in children aged less than 5
 years are described in detail elsewhere.2 Because developing countries
 often lack vital registration systems that can provide nationally
 representative estimates, household surveys, such as the UNICEF-supported
 multiple indicator cluster surveys and the USAID-supported demographic and
 health surveys have become the primary sources of data on child mortality.
 On behalf of the IGME, UNICEF and WHO compile national estimates from these
 surveys and other data of sufficient quality and representativeness,
 including reproductive health surveys, vital registration, and population
 censuses. A regression curve is then fitted to these data points and
 extrapolated to a common reference year to produce a smooth trend. Country
 estimates and the child-mortality database are made publicly available as
 the IGME agrees on the estimates.3
 As well as including new data from household surveys, methods have been
 revised to include an adjustment for AIDS-related deaths. Analysis of
 household surveys had indicated that survey-based estimates underestimated
 deaths among children because of under-reporting of child deaths in
 households where mothers are absent due to AIDS-related death or illness.
 By contrast, rapid increases in coverage of HIV prevention and treatment in
 recent years are likely to have positive effects on child survival.4
 Estimates for 11 countries with the highest HIV prevalence, Botswana,
 Lesotho, Malawi, Namibia, Rwanda, South Africa, Swaziland, Tanzania,
 Uganda, Zambia, and Zimbabwe, include adjustments for HIV/AIDS.
 In 1978, when the Alma-Ata Declaration was signed, nearly 15 million
 children aged less than 5 years were dying every year worldwide. In 1990,
 almost 13 million children died. Today, we publish new data indicating that
 around 9·2 million children died in 2007 (www.childinfo.org). Since 1990,
 mortality of children aged less than 5 years has declined by 27% from 93
 per 1000 livebirths to 68 per 1000 livebirths in 2007 (table 1).
 (Embedded image moved to file: pic11585.gif)Click to open table
 Table 1Table image(Embedded image moved to file: pic24041.gif)Opens in a
 new browser window
 Mortality rates and number of deaths in children aged less than 5 years
 Furthermore, high levels of fertility in sub-Saharan Africa, together with
 high levels of mortality in children aged less than 5 years, have led to an
 increase in the absolute number of deaths (from 4·1 million in 1990 to 4·5
 million in 2007). Sub-Saharan Africa now accounts for almost half of the of
 the 9·2 million deaths among children in this age group annually; and 7·5
 million (82 %) occur in sub-Saharan Africa and south Asia combined (figure
 ). Close to one in seven children in sub-Saharan Africa die before age 5
 years (147 per 1000 livebirths). Table 2 lists the ten countries with the
 greatest annual reduction in child mortality since 1990.
 (Embedded image moved to file: pic24423.gif)Click to toggle image size
 (Embedded image moved to file: pic24129.gif)Click to toggle image size
 Figure Full-size image (30K)
 Regional distribution of the 9·2 million children who died in 2007 before
 they reached their fifth birthday
 (Embedded image moved to file: pic24229.gif)Click to open table
 Table 2Table image(Embedded image moved to file: pic04565.gif)Opens in a
 new browser window
 Countries making the greatest progress in reducing mortality in children
 aged less than 5 years, 1990—2007
 The adjustments made for HIV/AIDS, however, indicate that mortality in
 children aged less than 5 years in some high HIV prevalence countries such
 as Botswana, Lesotho, and Swaziland, is beginning to decline. Mortality in
 Botswana is 40 per 1000 livebirths, indicating that it is on track for
 reaching MDG 4. More details on revised methods will be published online
 and in the The State of the World's Children report, 2009.
 Substantial progress has been made towards the achievement of MDG 4;
 indeed, since the Alma-Ata Declaration in 1978, around 5·5 million fewer
 children aged less than 5 years are dying every year. Progress is still
 grossly insufficient, particularly in much of sub-Saharan Africa and south
 Asia. However, even in these regions, there are examples of poor countries,
 such as Eritrea and Bangladesh, proving that MDG 4 is achievable.
 Additionally, countries with high HIV/AIDS prevalence, such as Botswana,
 achieving high population-based coverage with critical HIV interventions
 might provide models for countries with similar epidemiological profiles.
 UNICEF will be investing more time in assessing why some countries are
 progressing well on the health-related MDGs and others are not.
 Analysis of intervention coverage data1, 5 has added further clarity.
 Although findings are positive for interventions that either can be
 delivered through outreach or basic health services (such as immunisation,
 vitamin A supplementation, and insecticide-treated bednets) or part of
 high-profile disease-specific initiatives (eg, prevention of
 mother-to-child transmission and paediatric antiretroviral treatment),
 coverage for other interventions is lagging. Particularly disappointing is
 the low coverage of services for pneumonia and diarrhoea treatment and the
 breakdown of the continuum of care.6 UNICEF and the Countdown 2015 partners
 are working with the Inter-Parliamentary Union to ensure an understanding
 of these data at the national level and to determine the best national
 responses.7
 UNICEF will be focusing its health-related programme investments, now
 approaching US$1·5 billion per year, on the expansion of integrated
 packages particularly focused at the community level to prevent, treat, and
 control moderate and severe acute malnutrition, pneumonia, diarrhoea,
 malaria, and other disorders. Working with WHO, UNFPA, WHO, and The World
 Bank, we will be giving renewed attention to maternal and newborn health,
 the subject of the 2009 The State of the World's Children report. The
 sub-Saharan Africa and South Asia regions will remain priorities. In
 keeping with the original principles of Alma-Ata, more attention will be
 given to ensure equity for the most underserved as intervention coverage
 increases. Furthermore, stronger links are being made between
 UNICEF-assisted health, water and sanitation, nutrition, and HIV
 programmes. Finally, more investments will be made to collect high quality
 data and continue to improve estimation methods.
 Measures of intervention coverage emphasised in Countdown to 2015 will
 continue to be important. However, the ultimate measure of our efforts—on
 health system strengthening, in disease-specific work on measles, tetanus,
 HIV, and malaria, or in the myriad of global health partnerships and
 initiatives—will be a substantial and verifiable reduction in maternal and
 child deaths. We call upon others to join us in redoubling our efforts to
 meet these goals, by translating the laudable aspirations of Alma-Ata into
 the concrete investments and specific evidence-based actions at the country
 level, that will make the principles of primary health care a reality for
 the world's underserved.
 We declare that we have no conflict of interest.
 References
 1 Countdown to 2015, Tracking progress in maternal newborn & child
 survival: the 2008 report.
 http://www.countdown2015mnch.org/index.php?option=com_content&view=article&id=68&Itemid=61
 . (accessed Sept 9, 2008).
 2 UNICEF, WHO, The World Bank, UN Population Division. Levels and trends in
 child mortality 2006: estimates developed by the Interagency Group for
 Child Mortality Estimation. New York: UNICEF, 2007.
 3 UNICEF. Monitoring the situation of children and women.
 http://www.childinfo.org/mortality_underfive.php. (accessed Sept 9, 2008).
 4 UNICEF, UNAIDS, WHO. Towards universal access: scaling up HIV services
 for women and children in the health sector: progress report 2008. New
 York: WHO, 2008.
 5 UNICEF. Progress for children: a world fit for children statistical
 review—New York, Number 6. New York: UNICEF, 2007.
 6 Countdown Coverage Writing Group. Countdown to 2015 for maternal, newborn
 and child survival: the 2008 report on tracking coverage of interventions.
 Lancet 2008; 371: 1247-1258. Summary | Full Text | PDF(488KB) | CrossRef |
 PubMed
 7 Bustreo F, Johnsson AB. Parliamentarians: leading the change for
 maternal, newborn and child survival. Lancet 2008; 371: 1221-1222. Full
 Text | PDF(48KB) | CrossRef | PubMed
 a UNICEF, Three United Nations Plaza, New York, NY 10017, USA
 
 
 2) COUNTDOWN TO 2015
 
 
 Text is at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736
 (06)69339-2/abstract
 
 
 The Lancet, Volume 368, Issue 9541, Pages 1067 - 1076, 23 September 2006
 Countdown to 2015: tracking intervention coverage for child survival
 Jennifer Bryce EdD a, Nancy Terreri BA b (Embedded image moved to file:
 pic06559.gif)Corresponding Author(Embedded image moved to file:
 pic08932.gif)Email Address, Prof Cesar G Victora MD c, Elizabeth Mason MD d
 , Bernadette Daelmans MD d, Prof Zulfiqar A Bhutta MD e, Flavia Bustreo MD
 f, Francisco Songane MD g, Peter Salama MD b, Tessa Wardlaw PhD h
 Summary
 Background
 The fourth Millennium Development Goal (MDG) calls for a two-thirds'
 reduction between 1990 and 2015 in deaths of children younger than five
 years; achieving this will require widespread use of effective
 interventions, especially in poor countries. We present the first report of
 the Child Survival Countdown, a worldwide effort to monitor coverage of key
 child-survival interventions in 60 countries with the world's highest
 numbers or rates of child mortality.
 Methods
 In 2005, we developed a profile for each of the 60 countries to summarise
 information on coverage with essential child survival interventions. The
 profiles also present information on demographics, nutritional status,
 major causes of death in children under 5 years of age, and the status of
 selected health policies. Progress toward the fourth MDG is summarised by
 comparing the average annual rate of reduction in under-5 mortality in each
 country with that needed to achieve the goal. The profiles also include a
 comparison of the proportions of children in the poorest and richest
 quintiles of the population who received six or more essential prevention
 interventions. Each country's progress (as measured by defined indicators
 of intervention coverage) was put into one of three groups created on the
 basis of international targets: “on track”; “watch and act”; and “high
 alert”. For indicators without targets, arbitrary thresholds for high,
 middle, and low performance across the 60 countries were used as a basis
 for categorisation.
 Findings
 Only seven countries are on track to met MDG-4, 39 countries are making
 some progress, although they need to accelerate the speed, and 14 countries
 are cause for serious concern. Coverage of the key child survival
 interventions remains critically low, although some countries have made
 substantial improvements in increasing the proportion of mothers and
 children with access to life saving interventions by as much as ten
 percentage points in 2 years. Children from the poorest families were less
 likely than those from wealthier families to have received at least six
 essential prevention interventions.
 Interpretation
 Our results show that tremendous efforts are urgently needed to achieve the
 MDG for child survival. Profiles for each country show where efforts need
 to be intensified, and highlight the extent to which prevention
 interventions are being delivered equitably and reaching poor families.
 This first report also shows country-specific improvements in coverage and
 highlights missed opportunities. The “Countdown to 2015” will report on
 progress every 2 years as a strategy for increasing accountability
 worldwide for progress in child survival.