0%

20%

40%

60%

80%

100%

Poorest 2nd 3rd 4th Least poor

Bangladesh Benin Brazil Cambodia Eritrea

Haiti Malawi Nepal Nicaragua Philippines

% <5 children receiving 6+ child survival interventions, by wealth quintile and country

Bottom inequity

Top inequity

Arch. Dis. Child. Fetal Neonatal Ed. 2007;92;F361-F366

Problems with data

• Tendency to apply “spin” to existing data• DHS data of variable quality• Neonatal mortality is systematically under-reported– Impossible to monitor progress– Disincentive to improve data quality• Quintile analysis in Africa (little variation between

low and high income household assets)

• Worldwide measles deaths – mostly children under five – plummeted by 68 per cent, from 757,000 in 2000 to 242 ,000 in 2006. In sub-Saharan Africa, measles deaths fell by more than 91 per cent.

The Millenium Development Goals Report, 2008

Policy - generalEconomics• Reimbursement of transport costs• Allocate resources at district level according to disease

burdenGeography• building housing for rural staff• road improvements• Provision of water favouring the poorEthnicity• Training providers who speak indigenous languages

Wagstaff, A. et al (2004) ‘Child Health: Reaching the Poor’, American Journal of Public Health; 94:5

Policy – health interventions

• Improved service delivery organisation• Supportive financial structures• Cash payments for use of services• Mass campaigns (Ghana and Zambia for ITN)• Social marketing (Tanzania for ITN) • Strong effort to achieve universal coverage

Gwatkin, D. Bhuiya, A. Vitoria,C. (2004) ‘Making Health Systems More Equitable’, Lancet, v364

Conclusions• MDG4 is a major opportunity to improve child

survival, globally• Emphasis on country-level goal achievements

should be discouraged• Africa should not be seen as a failure if significant

progress is being made• Three major risks of the MDG4 process are:– Increasing inequity in child survival– Sudden decline in intensity of efforts at 2015– Generation and perpetuation of poor quality data