GCID/CA LecturePhil Cotton

MDG 4 – Reduce Child Mortality27 January 2011

2010• Every year nearly 9 million children die before

their fifth birthday• 50% SSA; 93% in Latin America, Africa and

Asia; 99% in developing countries (UNICEF -Lancet)

• Almost 90% of all child deaths are attributable to just six conditions: neonatal causes, pneumonia, diarrhoea, malaria, measles, and HIV/AIDS. (WHO)

• Every year half a million women die from pregnancy-related causes; 99% in developing countries

• Every year, almost five million people die of HIV/AIDS, malaria and tuberculosis. (UN)

• In developing countries, one out of every 10 children dies before the age of five.

• In wealthier nations, this number is only one out of 143.

• Cambodia has an infant mortality rate of 143 deaths per 1000 births

• Australia 4.3 deaths per 1000 births (Business for MDG)

Pause 1

• Is there anyone who would not weep, whelmed in miseries so deep?

• Can the human heart refrain from partaking in her (mother) pain,

• Bruised, derided, cursed, defiled, she beheld her tender Child

(Quis est homo – Stabat Mater dolorosa)

WHO

• During 1960-1990, child mortality in developing regions was halved to one child in 10 dying before age five.

• The aim in MDG4 is to further cut child mortality by two thirds by 2015.

• total number of under-5 deaths in the world has declined from 12.5 million in 1990 to 8.8 million in 2008.

The MDG Report 2010

• ‘child deaths are falling, but not quickly enough to reach the target’

The MDG Report 2010

• 1990 – 12.5 million • 2008 – 8.8 million

• 10,000

• 24,000

9.7 million children died in 2006 before 5th birthday UNICEF

AfGH

• Of the 67 countries with high mortality rates (40 per 1000 or more), only ten are on track to track to meet MDG4.

• For African and Asian countries the rate of decline in child mortality is still largely off track.

AfGH• Many of the causes of under-five mortality in developing

countries could be eliminated by simple interventions:• Access to clean water and sanitation can reduce child

deaths from pneumonia and diarrhoea; leading causes of child mortality which account for 3·5 million child deaths a year.

• Basic, cost-effective measures such as vaccines, antibiotics, micronutrient supplements, insecticide-treated bed nets and improved breastfeeding practices would prevent these deaths.

• Millions still die because they lack access to basic services

business

• 1990 – 106• 2005 - 83 (140 for the Asia Pacific)• At the current rate, the target will be

achieved by 2015 globally although none of the poorest regions of the developing world are individually on track and Asia Pacific is moving too slowly to achieve this vital goal.

• WHAT IS THIS DATA?

‘Health’ MDGs

• 4, 5 and 6• 5: to improve maternal health• 6: to combat HIV/AIDS, malaria and other

diseases

• To reduce U5MR by 2/3 between 1990 and 2015

• MDGs will be reviewed in 2010

UNICEF

• U5MR• Immunisations• Pneumonia• Diarrhoea diseases• Newborn care

• A World Fit for Children Report

Under 5 mortality rate per 1000 births UNICEF

Trends in under 5 mortality rates UNICEFCEE – central and eastern europe/commonwealth of indep states

UNICEF

4 diseases account for 43% deaths

4 diseases account for 43% deaths

• AIDS• Pneumonia• Malaria• Diarrhoea

4 diseases account for 45% deaths

• AIDS 3%• Pneumonia 19%• Malaria 8% • Diarrhoea 17%

Major causes of child mortality UNICEF

Most lives saved through…

Most lives saved through…

• Low-cost prevention and treatment• IT Mosquito nets• ORT (drugs)• Antibiotics• Immunisation• Nutrition

UNICEF

• Pneumonia kills more children than any other illness – more than AIDS, malaria and measles combined.

• Around 2 million children under five die from the disease each year – around one in five child deaths globally.

• Around 1 million more infants perish from severe infections, including pneumonia, during the neonatal period.

U5MR by region UNICEF

Pneumonia kills more children worldwide than any other cause UNICEF

More than half of all children with pneumonia are taken to an Appropriate healthcare provider UNICEF

% children with DD receiving ORT along with usual feeding UNICEF

Sketchy data but coverage of correct Rx for DD increased

UNICEF• Programme recommendations on treating diarrhoeal

diseases have changed over time; they reflect a better understanding of what works at home and in the community. In the 1980s, the World Health Organization recommended treating diarrhoeal episodes with a solution of oral rehydration salts (ORS); subsequent research showed that home-made fluids; particularly those containing sodium and glucose, sucrose or other carbohydrates, like cereal-based solutions; could be just as effective.

• By the early 1990s, the importance of increasing fluids and continued feeding, and more recently, the use of zinc and low-osmolarity ORS in preventing and treating diarrhoeal episodes, has been emphasized.

Diarrhoeal diseases• Nearly 2 million deaths a year among children under five,

making them the second most common cause of child death worldwide

• For more than two decades, oral rehydration therapy (ORT) has been the cornerstone of treatment programmes for childhood diarrhoeal diseases.

• Recommendations on its use have changed over time so data is limited

• Seems that coverage of treatment for children under five has improved significantly across the developing world (excluding China) over the past decade, including in many parts of sub-Saharan Africa. But coverage still remains too low UNICEF

Measures to prevent childhood diarrhoeal episodes include:

• promoting exclusive breastfeeding, • raising vitamin A supplementation rates, • improving hygiene, • increasing the use of improved sources of

drinking water and sanitation facilities, • promoting zinc intake and • immunizing against rotavirus UNICEF

% women 15-49 who commenced breastfeeding within 1 hour of birth

Neonatal deaths

• Each year, around 4 million children die within the first 28 days of life – the newborn (neonatal) period.

• Given that these newborn deaths account for about 40% of all U5 deaths, improving neonatal survival is essential if MDG 4 –reduce child mortality – is to be reached.

Reducing neonatal deaths• requires improving women’s health during pregnancy• providing appropriate care for both mother and newborn

during and immediately after birth, and• caring for the baby during the first weeks of life. Cost-effective, feasible interventions include: • initiating breastfeeding within one hour of birth• ensuring proper cord care• keeping the baby warm• recognizing danger signs and seeking care, and • giving special care to infants with low birthweight. A continuum of care from pregnancy to early childhood

should link community-based programmes to strengthened health systems

• Efforts to develop a core set of indicators to monitor newborn care interventions are under way.

• More work is needed to finalize these indicators for inclusion in household surveys.

Key neonatal survival interventions in the developing world UNICEF

Every year 4 million children die in first month of life UNICEF

Key interventions

Proportion women who gave birth outside healthcare and had postnatal check within 3 days

Newborns 8x more likely to die in developing countries

Number polio cases declined UNICEF

Measles coverage rose in every region

Number children not immunised with DPT –26m not immunised, 20m live in 10 countries

42 of 47 priority countries completed supplementary measles imms –5 did not

Measles imms increased steadily in 47 priority countries

• Measles is one of the leading causes of vaccine-preventable child mortality, with 95 per cent of deaths occurring in 47 countries.

• Two doses of measles vaccine effectively protect children against the disease – led to 78% reduction in measles deaths from 733,000 in 2000 to 164,000 in 2008

• BUT increase in deaths of 1.7 million between 2010 and 2013 without sustained funding and focus

• improved routine measles immunization coverage and follow-up campaigns providing a second opportunity for immunization has led to a steep reduction in the number of measles deaths: by 60 per cent worldwide and by 75 per cent in sub-Saharan Africa between 1999 and 2005.

• The World Fit for Children target has been met. • The challenge now lies in reducing measles

mortality by 90 per cent by 2010, a goal established by UNICEF and the World Health Organization.

World Fit for Children targets• include immunization of all children against

diphtheria, pertussis and tetanus, polio and maternal/neonatal tetanus – as well as providing access to new vaccines. Globally, coverage of the third dose of combined diphtheria/pertussis/tetanus vaccine (DPT3) remains level, at around 79 per cent, and 80 per cent of newborns are protected against tetanus.

• Targets for eliminating maternal/neonatal tetanus and certifying the global eradication of polio by 2005 were not met

• Increasing number of countries introduced HepB and Hib into infant immunisation schedules

• Inappropriate feeding practices

• 1.5 million lives could be saved by extending duration and exclusivity of BF

End poverty 2015 milleniumcampaign

• One of the darkest characteristics of poverty is that it seems to prey on the vulnerable and defenceless.

• Coined as ‘preferential option for the poor’

• http://www.endpoverty2015.org/en/africa/news/odi-releases-seven-new-case-studies-showcasing-concrete-mdg-progress-africa-and-asia/21/dec/10

• http://www.mdgmonitor.org/story.cfm?goal=4• http://www.gapminder.org/downloads/mdg-4-

reducing-child-mortality/• http://www.unfpa.org.br/lacodm/arquivos/mdg4.p

df

• http://www.one.org/blog/2010/11/10/fighting-pneumonia-a-key-to-achieving-mdg-4/

• GAVI alliance – US charity• http://www.who.int/pmnch/events/2010/2010092

0_unicef_mdg4/en/index.html• http://www.ilo.org/travail/info/fs/lang--

en/docName--WCMS_141550/index.htm• www.un-

ngls.org/.../Amnesty_International_NGLS_Briefing_4_Oct_2010_-_Moving_Forward_MDG_Summit.doc

GAVI

• mission of the GAVI Alliance is to save children’s lives and protect people’s health by increasing access to immunization in poor countries. GAVI Campaign mobilizes resources and engages private individuals and organizations in support of GAVI'swork.

GAVI• New studies show vaccines against rotavirus are a

powerful tool in the battle against child mortality. Yet half a million children under 5 still die from this particularly lethal, and preventable, form of diarrhea – every year.

• Support from GAVI is what is needed to make good on the WHO's strong recommendation that use of rotavirus vaccines be expanded to the poorest nations.

• With vaccine, the lives of more than 2 million children at risk from rotavirus can be protected over the next decade. The greatest impact these vaccines stand to make is in Africa and Asia where more than 85 percent of rotavirus deaths occur.

• http://en.wikipedia.org/wiki/Millennium_Development_Goals

• How do you measure any of this?• Countries that have made most progress

are those with greatest economic growth –China and India. Bangladesh bucked trend by introducing cheap and effective immsstrategy

• Gender discrimination is a real barrier to development

• Mozhttp://www.undg.org/archive_docs/261-Mozambique_MDG_Report_-_Millenium_Development_Goa.pdf

• http://www.undp.org/africa/documents/mdg/mozambique_september2010.pdf

• Jeffrey sachs

Bangladesh

• Will achieve U5MR by 2015• 1991 146/1000 live births – target 48,

projected 28• National integrated programmes including

breastfeeding and immunisation• Challenge of natural disasters, geography• http://www.undp.org.bd/mdgs.php

Deaths 39% higher in rural areas;Maputo 138 – Zambezia 322;3 x more likely to die before 5 in CD than Maputo;88% urban children immunised –59% rural (43% in Zambezia)HIV 12% - if lose both parents before 5th birthday doesn’t bode well;Malaria 30-40% of U5 deaths –severe anaemia in pregnant women and LBW;50% population have access to health unit (20% units staffed by unqualified);Z – lowest spend and healthcare workers; lack information and community workers;

*

Mozambique UNDP

• Newborn mort rate decreased from 55/1000 to 35 in urban areas but 57 to 53 in rural ones despite the increasing threat of AIDS and causes of child mortality, such as malaria, acute respiratory infections, diarrhoeas and malnutrition.

National measles imms campaign now covers 94% children by 14 years

• focus on the following areas: • readoption of mobile team services• supervision• liaison with the community• monitoring and record-keeping• resource planning and management.

WHO interventions• require universal coverage with key effective, affordable

interventions: • care for newborns and their mothers; • infant and young child feeding; • vaccines; • prevention and case management of diarrhoea,

pneumonia and sepsis; • malaria control; and • prevention and care of HIV/AIDS. • In countries with high mortality, these interventions could

reduce the number of deaths by more than half.

WHO strategies

• appropriate home care and timely treatment of complications for newborns

• integrated management of childhood illness for all children under five years old

• expanded programme on immunization • infant and young child feeding (complemented by interventions for maternal

health, in particular, skilled care during pregnancy and childbirth)

UNDP – indicators for monitoring progress

• Target 4a: reduce by 2/3 the mortality rate among children under 5

• 4.1 U5MR• 4.2 Infant (1 year) MR• 4.3 proportion of 1 year old children

immunised against measles

http://www.unicef.org/progressforchildren/2007n6/index_41799.htm

Action for Global Health • underlying shortfalls of weak health systems; inadequate

financing of the health sector in developing countries, and inequitable access to health services.

• action to deliver universal access to primary health care, including preventative services with rapid scaling up of efforts to address the weaknesses in health service delivery caused by huge shortages of human resources, drug stock-outs and inadequate funding, alongside more concerted efforts to remove the social, cultural and financial barriers that prevent many people in low and middle-income countries from accessing the healthcare that they need.

Turning the World Upside Down. Nigel Crisp

Health• Improvements on

MDGs• Life expectancy up• Vaccine development

Global structures• Little progress on

trade• Low foreign

investment• Top down economic

and health structures

Crisp – picking up some themes

• International development or co-development?• Apply own values and prejudices to work

overseas• Countries can’t afford doctors and nurses, so

what might the solutions be?• Development experts or wider group of people –

teachers, farmers, engineers, nurses?• Poor national leadership• Need to explore fact that the poor define

poverty as lacking control over their lives

• Baby born to Bolivian mother with no education has 10% chance of dying

• If mother has secondary education, chance drops to 0.4%

• 25-fold difference

• Baby born to Indian mother with 5 years’education has 40% better chance of living to 5 years age than if mother has no education

Crisp

Pause 2

• I pray for my mercy for my sufferances. I pray for mercy. Let me weep over my cruel fate, And that I long for freedom! And that I long, and that I long for freedom!

(Lashia Ch’io pianga – Rinaldo. Handel)

Crisp

• Thinking in fresh ways:• Rather than doctors empowering patients,

doctors need to be empowered by patients to work on behalf of their communities

• Sub-Saharan Africa• 10% of world popn• 25% of burden of

disease• 3% of healthcare

resources • 1% of healthcare

workers

North America• 5% of world popn• 3% of burden of

disease• 25% of healthcare

resources• 30% of healthcare

workers

Crisp

Pause 3

7 seconds

• ‘And when a child is born into this worldIt has no conceptOf the tone the skin is living in

And there's a million voicesAnd there's a million voicesTo tell you what she should be thinking’

• ‘7 Seconds’ is about the first positive 7 seconds in the life of a child just born not knowing about the problems and violence in our world. And before the reality of life into which they have been born becomes apparent.

A few notes

• Mulevala – hospital has no water• Tanzania – diabetes care after 18 years

age• Curfews - sensitivity to local culture

• 3 countries that have reduced child mortality most Niger, Guinea and Angola started with very high rates and are in conflict zones. But still have some of highest rates in world

• 6 countries have worsened U5MR over period – CAR, Zambia, Chad, Cameroon, Congo, Kenya

Summary

• U5MR worse in lower income communities• Worse in rural communities within those

countries

Summary

• Largest burden of disease is communicable disease – most cases treated or prevented by local health workers. Need highly trained specialists but also local workers.

• Orientation to health and community work – Marropino Project

Grameen

• Role of microfinance• Microfinance organisations moving into

health – funding and expertise (logistics, procurement) Crisp

Role of business (Aus)

• Playing a key role in establishing strong health systems Provide community health workers, facilities with essential newborn care that are easily accessible, a good referral system, immunisation programs, supervision and support

• Promoting health educationEducation, especially for girls and mothers, is essential in the reduction of child mortality

Role of business• Can you develop new products that combat

nutritional deficiencies and are affordable to low-income families?

• Can you provide affordable diagnostic tools for early detection of illness?

• Can you prioritise research and development efforts around diseases that disproportionately affect poor communities?

• Can you provide affordable infant vaccinations? • Can you support programs to improve child

nutrition?

UN every woman every child

• Dec 2010: 16 million lives saved by 2015 if pledges followed through

• Accountability framework

http://www.undispatch.com/some-accountability-on-the-way-for-every-woman-every-child-pledges

Accountability framework (UN)• Track results and resource flows at global and

country levels;• Identify a core set of indicators and

measurement needs for women’s and children’s health

• Propose steps to improve health information and registration of vital events — births and deaths — in low-income countries

• Explore opportunities for innovation in information technology to improve access to reliable information on resources and outcomes.

Tanzania • Malaria control – biological – Cuba• HIV is an epidemic but not handled as

such (WHO)• Bottom-up planning at district level but

slowed by political reform

• 2.5 billion have no access to basic sanitation (dfid)

• 900 million have no clean water (dfid) Mullevalla

• Under-nourishment plays a part in more than half of all child deaths

• Over 960 million are malnourished

• If you believe the way the world is …..

• Best cure for poverty is empowerment for women

For I am going to do something in your days that you would not believe

Preferential option for the poor

• Preying on the most vulnerable• Praying for the most vulnerable