Summary Background Several years in advance of the 2015 endpoint for the Millennium Development Goals (MDGs), Malawi was already thought to be one of the few countries in sub-Saharan Africa likely to ...meet the MDG 4 target of reducing under-5 mortality by two-thirds between 1990 and 2015. Countdown to 2015 therefore selected the Malawi National Statistical Office to lead an in-depth country case study, aimed mainly at explaining the country's success in improving child survival. Methods We estimated child and neonatal mortality for the years 2000–14 using five district-representative household surveys. The study included recalculation of coverage indicators for that period, and used the Lives Saved Tool (LiST) to attribute the child lives saved in the years from 2000 to 2013 to various interventions. We documented the adoption and implementation of policies and programmes affecting the health of women and children, and developed estimates of financing. Findings The estimated mortality rate in children younger than 5 years declined substantially in the study period, from 247 deaths (90% CI 234–262) per 1000 livebirths in 1990 to 71 deaths (58–83) in 2013, with an annual rate of decline of 5·4%. The most rapid mortality decline occurred in the 1–59 months age group; neonatal mortality declined more slowly (from 50 to 23 deaths per 1000 livebirths), representing an annual rate of decline of 3·3%. Nearly half of the coverage indicators have increased by more than 20 percentage points between 2000 and 2014. Results from the LiST analysis show that about 280 000 children's lives were saved between 2000 and 2013, attributable to interventions including treatment for diarrhoea, pneumonia, and malaria (23%), insecticide-treated bednets (20%), vaccines (17%), reductions in wasting (11%) and stunting (9%), facility birth care (7%), and prevention and treatment of HIV (7%). The amount of funding allocated to the health sector has increased substantially, particularly to child health and HIV and from external sources, but remains below internationally agreed targets. Key policies to address the major causes of child mortality and deliver high-impact interventions at scale throughout Malawi began in the late 1990s and intensified in the latter half of the 2000s and into the 2010s, backed by health-sector-wide policies to improve women's and children's health. Interpretation This case study confirmed that Malawi had achieved MDG 4 for child survival by 2013. Our findings suggest that this was achieved mainly through the scale-up of interventions that are effective against the major causes of child deaths (malaria, pneumonia, and diarrhoea), programmes to reduce child undernutrition and mother-to-child transmission of HIV, and some improvements in the quality of care provided around birth. The Government of Malawi was among the first in sub-Saharan Africa to adopt evidence-based policies and implement programmes at scale to prevent unnecessary child deaths. Much remains to be done, building on this success and extending it to higher proportions of the population and targeting continued high neonatal mortality rates. Funding Bill & Melinda Gates Foundation, WHO, The World Bank, Government of Australia, Government of Canada, Government of Norway, Government of Sweden, Government of the UK, and UNICEF.
Summary Conceived in 2003 and born in 2005 with the launch of its first report and country profiles, the Countdown to 2015 for Maternal, Newborn, and Child Survival has reached its originally ...proposed lifespan. Major reductions in the deaths of mothers and children have occurred since Countdown's inception, even though most of the 75 priority countries failed to achieve Millennium Development Goals 4 and 5. The coverage of life-saving interventions tracked in Countdown increased steadily over time, but wide inequalities persist between and within countries. Key drivers of coverage such as financing, human resources, commodities, and conducive health policies also showed important, yet insufficient increases. As a multistakeholder initiative of more than 40 academic, international, bilateral, and civil society institutions, Countdown was successful in monitoring progress and raising the visibility of the health of mothers, newborns, and children. Lessons learned from this initiative have direct bearing on monitoring progress during the Sustainable Development Goals era.
Summary Evaluation of large-scale programmes and initiatives aimed at improvement of health in countries of low and middle income needs a new approach. Traditional designs, which compare areas with ...and without a given programme, are no longer relevant at a time when many programmes are being scaled up in virtually every district in the world. We propose an evolution in evaluation design, a national platform approach that: uses the district as the unit of design and analysis; is based on continuous monitoring of different levels of indicators; gathers additional data before, during, and after the period to be assessed by multiple methods; uses several analytical techniques to deal with various data gaps and biases; and includes interim and summative evaluation analyses. This new approach will promote country ownership, transparency, and donor coordination while providing a rigorous comparison of the cost-effectiveness of different scale-up approaches.
Summary Background Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how ...inequalities in maternal, newborn, and child health interventions vary by intervention and country. Methods We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality. Findings Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals. Interpretation We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent. Funding Bill & Melinda Gates Foundation, Norad, The World Bank.
Summary 80% of the world's undernourished children live in just 20 countries. Intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal (MDG) ...and greatly increase the chances of achieving goals for child and maternal mortality (MDGs 4 and 5). Despite isolated successes in specific countries or for interventions—eg, iodised salt and vitamin A supplementation—most countries with high rates of undernutrition are failing to reach undernourished mothers and children with effective interventions supported by appropriate policies. This paper reports on an assessment of actions addressing undernutrition in the countries with the highest burden of undernutrition, drawing on systematic reviews and best-practice reports. Seven key challenges for addressing undernutrition at national level are defined and reported on: getting nutrition on the list of priorities, and keeping it there; doing the right things; not doing the wrong things; acting at scale; reaching those in need; data-based decisionmaking; and building strategic and operational capacity. Interventions with proven effectiveness that are selected by countries should be rapidly implemented at scale. The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing undernutrition and its adverse effects. Programme efforts, as well as monitoring and assessment, should focus on this segment of the continuum of care. Nutrition resources should not be used to support actions unlikely to be effective in the context of country or local realities. Nutrition resources should not be used to support actions that have not been proven to have a direct effect on undernutrition, such as stand-alone growth monitoring or school feeding programmes. In addition to health and nutrition interventions, economic and social policies addressing poverty, trade, and agriculture that have been associated with rapid improvements in nutritional status should be implemented. There is a reservoir of important experience and expertise in individual countries about how to build commitment, develop and monitor nutrition programmes, move toward acting at scale, reform or phase-out ineffective programmes, and other challenges. This resource needs to be formalised, shared, and used as the basis for setting priorities in problem-solving research for nutrition.
Summary The Countdown to 2015 for Maternal, Newborn, and Child Survival monitors coverage of priority interventions to achieve the Millennium Development Goals (MDGs) for child mortality and maternal ...health. We reviewed progress between 1990 and 2010 in coverage of 26 key interventions in 68 Countdown priority countries accounting for more than 90% of maternal and child deaths worldwide. 19 countries studied were on track to meet MDG 4, in 47 we noted acceleration in the yearly rate of reduction in mortality of children younger than 5 years, and in 12 countries progress had decelerated since 2000. Progress towards reduction of neonatal deaths has been slow, and maternal mortality remains high in most Countdown countries, with little evidence of progress. Wide and persistent disparities exist in the coverage of interventions between and within countries, but some regions have successfully reduced longstanding inequities. Coverage of interventions delivered directly in the community on scheduled occasions was higher than for interventions relying on functional health systems. Although overseas development assistance for maternal, newborn, and child health has increased, funding for this sector accounted for only 31% of all development assistance for health in 2007. We provide evidence from several countries showing that rapid progress is possible and that focused and targeted interventions can reduce inequities related to socioeconomic status and sex. However, much more can and should be done to address maternal and newborn health and improve coverage of interventions related to family planning, care around childbirth, and case management of childhood illnesses.
Summary Background Urgent calls have been made for improved understanding of changes in coverage of maternal, newborn, and child health interventions, and their country-level determinants. We ...examined historical trends in coverage of interventions with proven effectiveness, and used them to project rates of child and neonatal mortality in 2035 in 74 Countdown to 2015 priority countries. Methods We investigated coverage of all interventions for which evidence was available to suggest effective reductions in maternal and child mortality, for which indicators have been defined, and data have been obtained through household surveys. We reanalysed coverage data from 312 nationally-representative household surveys done between 1990 and 2011 in 69 countries, including 58 Countdown countries. We developed logistic Loess regression models for patterns of coverage change for each intervention, and used k -means cluster analysis to divide interventions into three groups with different historical patterns of coverage change. Within each intervention group, we examined performance of each country in achieving coverage gains. We constructed models that included baseline coverage, region, gross domestic product, conflict, and governance to examine country-specific annual percentage coverage change for each group of indicators. We used the Lives Saved Tool (LiST) to predict mortality rates of children younger than 5 years (henceforth, under 5) and in the neonatal period in 2035 for Countdown countries if trends in coverage continue unchanged (historical trends scenario) and if each country accelerates intervention coverage to the highest level achieved by a Countdown country with similar baseline coverage level (best performer scenario). Results Odds of coverage of three interventions (antimalarial treatment, skilled attendant at birth, and use of improved sanitation facilities) have decreased since 1990, with a mean annual decrease of 5·5% (SD 2·7%). Odds of coverage of four interventions—all related to the prevention of malaria—have increased rapidly, with a mean annual increase of 27·9% (7·3%). Odds of coverage of other interventions have slowly increased, with a mean annual increase of 5·3% (3·5%). Rates of coverage change varied widely across countries; we could not explain the differences by measures of gross domestic product, conflict, or governance. On the basis of LiST projections, we predicted that the number of Countdown countries with an under-5 mortality rate of fewer than 20 deaths per 1000 livebirths per year would increase from four (5%) of the 74 in 2010, to nine (12%) by 2035 under the historical trends scenario, and to 15 (20%) under the best performer scenario. The number of countries with neonatal mortality rates of fewer than 11 per 1000 livebirths per year would increase from three (4%) in 2010, to ten (14%) by 2035 under the historical trends scenario, and 67 (91%) under the best performer scenario. The number of under-5 deaths per year would decrease from an estimated 7·6 million in 2010, to 5·4 million (28% decrease) if historical trends continue, and to 2·3 million (71% decrease) under the best performer scenario. Interpretation Substantial reductions in child deaths are possible, but only if intensified efforts to achieve intervention coverage are implemented successfully within each of the Countdown countries. Funding The Bill & Melinda Gates Foundation.
The unfinished agenda in child survival Bryce, Jennifer, EdD; Victora, Cesar G, Prof; Black, Robert E, Prof
The Lancet (British edition),
09/2013, Volume:
382, Issue:
9897
Journal Article
Peer reviewed
10 years ago, The Lancet published a Series about child survival. In this Review, we examine progress in the past decade in child survival, with a focus on epidemiology, interventions and ...intervention coverage, strategies of health programmes, equity, evidence, accountability, and global leadership. Knowledge of child health epidemiology has greatly increased, and although more and better interventions are available, they still do not reach large numbers of mothers and children. Child survival should remain at the heart of global goals in the post-2015 era. Many countries are now making good progress and need the time and support required to finish the task. The global health community should show its steadfast commitment to child survival by amassing knowledge and experience as a basis for ever more effective programmes. Leadership and accountability for child survival should be strengthened and shared among the UN system; governments in high-income, middle-income, and low-income countries; and non-governmental organisations.
Summary Background WHO and UNICEF launched the Integrated Management of Childhood Illness (IMCI) strategy in the mid-1990s to reduce deaths from diarrhoea, pneumonia, malaria, measles, and ...malnutrition in children younger than 5 years. We assessed the effect of IMCI on health and nutrition of children younger than 5 years in Bangladesh. Methods In this cluster randomised trial, 20 first-level government health facilities in the Matlab subdistrict of Bangladesh and their catchment areas (total population about 350 000) were paired and randomly assigned to either IMCI (intervention; ten clusters) or usual services (comparison; ten clusters). All three components of IMCI—health-worker training, health-systems improvements, and family and community activities—were implemented beginning in February, 2002. Assessment included household and health facility surveys tracking intermediate outputs and outcomes, and nutrition and mortality changes in intervention and comparison areas. Primary endpoint was mortality in children aged between 7 days and 59 months. Analysis was by intention to treat. This study is registered, number ISRCTN52793850. Findings The yearly rate of mortality reduction in children younger than 5 years (excluding deaths in first week of life) was similar in IMCI and comparison areas (8·6% vs 7·8%). In the last 2 years of the study, the mortality rate was 13·4% lower in IMCI than in comparison areas (95% CI −14·2 to 34·3), corresponding to 4·2 fewer deaths per 1000 livebirths (95% CI −4·1 to 12·4; p=0·30). Implementation of IMCI led to improved health-worker skills, health-system support, and family and community practices, translating into increased care-seeking for illnesses. In IMCI areas, more children younger than 6 months were exclusively breastfed (76% vs 65%, difference of differences 10·1%, 95% CI 2·65–17·62), and prevalence of stunting in children aged 24–59 months decreased more rapidly (difference of differences −7·33, 95% CI −13·83 to −0·83) than in comparison areas. Interpretation IMCI was associated with positive changes in all input, output, and outcome indicators, including increased exclusive breastfeeding and decreased stunting. However, IMCI implementation had no effect on mortality within the timeframe of the assessment. Funding Bill & Melinda Gates Foundation, WHO's Department of Child and Adolescent Health and Development, and US Agency for International Development.
Summary Politicians, policymakers, and public-health professionals make complex decisions on the basis of estimates of disease burden from different sources, many of which are “marketed” by skilled ...advocates. To help people who rely on such statistics make more informed decisions, we explain how health estimates are developed, and offer basic guidance on how to assess and interpret them. We describe the different levels of estimates used to quantify disease burden and its correlates; understanding how closely linked a type of statistic is to disease and death rates is crucial in designing health policies and programmes. We also suggest questions that people using such statistics should ask and offer tips to help separate advocacy from evidence-based positions. Global health agencies have a key role in communicating robust estimates of disease, as do policymakers at national and subnational levels where key public-health decisions are made. A common framework and standardised methods, building on the work of Child Health Epidemiology Reference Group (CHERG) and others, are urgently needed.
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