Child survival – a success or failure

in our time?

Dr. Mariam Claeson

Director, MNCH

© 2014 Bill & Melinda Gates Foundation

April 2014

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1990 1995 2000 2005 2010 2015 2020 2025 2030 2035

A PROMISE RENEWED TARGET • 2 million deaths by 2035 • Every country reaches U5MR of

20/1000 • Requires U5M ARR 5.2%

MDG 4

6.9 m child deaths in 2011 3m are neonatal (43%)

U5M current trajectory: ARR 2.5%

Child survival target by 2035 in A Promise Renewed Under 5 mortality = 20/1000

Source: UNICEF State of the World’s Children 2012; The UN Inter-agency Group for Child Mortality Estimation, Levels and Trends in Child Mortality: Report 2011, 2011; Team analysis from 2035 onward based on straight-line ARR reduction from UNICEF numbers 1990-2035

NMR current trajectory: ARR 2.2%

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9.6 m deaths in 2000

Unless we achieve major acceleration for newborn survival, we cannot reach our goal for ending preventable child deaths by 2035

Under-five causes of death, 2000

Source: MCEE/WHO/UNICEF, 2014, in preparation

Under-five causes of death, 2012

Source: MCEE/WHO/UNICEF, 2014, in preparation

How has Niger reduced deaths among children by 40% in a decade?

Landlocked; 80% Sahara desert

Population 15.7 million

World’s highest fertility rate (7.1 per woman)

Poor:

o GDP per capita: US$278

o 59.5% of population below poverty line

o In 2011, ranked186 of 187 countries on the Human Development Index

Three major child survival strategies since 2000

1. Increased access to primary health care for major child killers (malaria, pneumonia, diarrhea, measles)

2. Mass campaigns for rapid scale-up of insecticide-treated nets (ITNs), measles vaccination, and vitamin A supplementation

3. Intensified efforts to address child undernutrition

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1996 1998 2000 2002 2004 2006 2008 2010

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U5MR NNMR

Percent annual rate of decline in U5MR: 5.1%

Under-five mortality declined; no significant change in neonatal mortality

Wasting is down sharply; only small decline in stunting

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

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Moderate or severe stunting Severe wasting

New policies were effectively implemented

Health service indicator 1998 2009

Number of functioning health posts 0 1938

% population living within 5km of health post or health center

48% 80%

CHWs trained in management of childhood illness

0 2308

% of children with fever/cough for whom care was sought outside the home

23% 54%

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Dramatic increases in coverage across the continuum of care, 1998 to 2009

1998 2009

Coverage Estimates for Interventions Across the Continuum of Care in 68 Priority Countries (2000-

06)

Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008 12

Proportion of child lives saved in 2009, by intervention or risk factor reduction

ITN ownership

25%

Others (<2% each)

11%

Reduction in stunting

10%

Reduction in wasting

9%

Careseeking for malaria

9% Vit A supp.

9%

Careseeking for pneumonia

8%

ORS + Zinc 5%

Measles vaccine

5%

Hib vaccine 4%

Changes in BF practices 3%

TT in preg 2%

19% lives saved

Almost 60,000 children’s lives saved in 2009!

Neonatal as a proportion of child mortality

• Despite 40% reduction in child deaths over past two decades, 2.9 million newborns still die each year

• One million newborns die on their birth day, closely linked to 1.2 million intrapartum stillbirths

• Neonatal mortality reduction is still slower than under five and maternal mortality

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50-year mortality trends in children and young people: a study of 50 low-income, middle income and high-income countries. Viner et al, Lancet 2011

Reductions in mortality over time – yet rates of reduction

vary by age strata U5 consistent rapid reduction Adolescent and newborn slower

IMAGINE THE LIFE OF

A TYPICAL

BANGLADESHI

ADOLESCENT GIRL

• Married on average at 16.7

years, first child within 1.7 years

• 82% sexually active => 42% using modern contraception

• ~10% have had their first child by 15 years

• Mean BMI (15-19 years): 20.9; 25-35% BMI < 18.5; 49% anemic

Childhood Newborn/postnatal Pre-pregnancy Pregnancy

Risk of Mortality Peaks Around Childbirth

Birth

Maternal deaths

Stillbirths Newborn deaths

Child Deaths

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Maternal Mortality Rates The Maternal Risk View

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Global Maternal Deaths, 1990-2011

Source: Lozano R et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 2011; 378: 1139-65

Mortality decline: 2.8%/y 273,500

217,400

56,100

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Unless we greatly accelerate newborn survival efforts, the goal to end preventable child deaths by 2035 is unreachable

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1990 1995 2000 2005 2010 2015 2020 2025 2030 2035

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2000-2012 AAR = 2.7%

Proposed NMR target: National NMR of 10 or less Global NMR of 7

2000-2012 AAR = 3.8% Global U5MR

Global NMR

APR target: National U5MR of 20 or less Global U5MR of 15

Business as usual: U5MR

AAR = 4.3%

Business as usual: NMR

Scenario 2035 global NMR 2035 neonatal deaths

If current trends are unchanged 13 1.8 million

Every country to NMR of 10 per 1000 7 0.9 million

From To

No targets and limited data to monitor progress

Global targets for NMR and intervention coverage

Limited in-country political will and resource allocation

High-level political buy-in from high-burden countries to scale-up newborn interventions

Newborns lost between maternal and child health

Global organizations mobilized for newborns (e.g. UNICEF)

A fragmented and uncoordinated in-county civil society voice

A mobilized and active civil society implementing and tracking accountability

Lack of accountability Defined mechanism for accountability and monitoring

Small group of technocratic champions

Champions keep maternal and newborn health on the agenda

21 newborn deaths per 1,000 live births (2012)

7 newborn deaths per 1,000 live births (2035)

The Every Newborn Action Plan (ENAP) is our window of opportunity to accelerate newborn health gains

Every Newborn Action Plan

© 2013 Bill & Melinda Gates Foundation | 22 Confidential

The build up to ENAP launch is galvanizing international and country-level support around evidence-based interventions

April 2013

KMC Consensus Statement

Afrinest results and

dissemination

Solution Pathway for

Preterm Birth

December 2013

CHX and antenatal

steroids added to WHO Essential

Medicines List

Zambia CHX trial results

Newborn Research Funder Consensus

Every Newborn

Action Plan

Policy and

Evidence on

Newborn Health

June 2014 August 2013

Lancet ENAP series

published

ENAP Stakeholder

Meeting

World Health Assembly Geneva

Partners Forum Johannesburg

WHO Executive Board Meeting

Bottleneck Analyses Draft WHA Document Global Outreach

© 2013 Bill & Melinda Gates Foundation |

23

Sept 2014

UN General Assembly

Confidential

BOY DRINKING WATER LETS NOT FORGET WHAT OTHER SECTORS CAN DO FOR CHILD HEALTH

Child Survival – a success

when no more preventable

deaths

THANK YOU