Countdown to 2015 for Maternal, Newborn and Child Survival

 

The Countdown report will reveal the latest trends in life-saving interventions critical to reduce maternal and child mortality and reach the Millennium Development Goals on health. The Lancet is holding a Press Conference at the Science Media Centre, London, on Thursday April 10 at 10:30am, to launch a special issue dedicated to Countdown. The Countdown to 2015 Conference then takes place between 17–19 April at the Westin Grand Hotel, Cape Town, with a press conference to launch it at 1PM Cape Town time 16 April at the Cape Town International Convention Centre. Parliamentarians from the 68 Countdown priority countries, global health experts and policy makers will be attending the Countdown Conference, as will The Lancet Editor Dr Richard Horton. The Countdown to 2015 takes place during the 118th Assembly of the Inter-Parliamentary Union, bringing together over 1000 delegates from around the world. Flavia Bustreo, Deputy Director of the Partnership for Maternal, Newborn and Child Health, which is facilitating the Countdown Conference says: "There is an urgent need to mobilize Members of the Parliaments in these 68 priority countries as well as in donor nations. As elected leaders they should represent the voices of women and children and protect their rights. Getting their commitment to do so is the objective of the Countdown Conference. Parliamentarians can lead the change for women and children."

Stephanie Clark, Managing Editor, The Lancet
Ann Starrs, President, Family Care International, New York, USA

Jennifer Bryce, Johns Hopkins School of Public Health, Batlimore, USA

Peter Salama, Associate Director, Programme Division,UNICEF

Flavia Bustreo, Deputy Director, Partnership for Maternal, Newborn & Child Health, WHO

Liz Mason, Director, Department of Child and Adolescent Health and Development, WHO

Giulia Greco, London School of Hygiene and Tropical Medicine

 

 

 

Less than one quarter of 68 priority countries* are on track to reach millennium development goals (MDGs) on maternal and child mortality†. And while some countries, notably China, have made signi.cant progress, many more, mostly in sub-Saharan Africa, have seen no progress or even reversals of progress. But rapid progress in many of these nations is achievable and would get them on track. These are the conclusions of authors of the Countdown Report Article in this week’s Countdown Special Edition of The Lancet.

Peter Salama, (UNICEF, New York, USA) and Jennifer Bryce (Johns Hopkins School of Public Health, USA), and colleagues from the Countdown Core Group say that of the 16 countries on track to meet MDG4, seven were already on track when countdown was launched in 2005, including Brazil, Bangladesh, Mexico, and Indonesia. Six of the 16 were included in the Countdown process for the .rst time in 2008, including Eritrea, Peru, and Morocco. Only three—China, Haiti, and Turkmenistan—had made demonstrable progress to move them from "not on track" in 2005 to on track in 2008. The authors say: "The achievement of China, the world’s largest country, is important, as are encouraging signs that several countries, many of which are in East Africa, have reduced mortality in children under-5 since 2005." While data showing trends for maternal mortality were not available to say definitively whether countries were on track to reach MDG5, actual maternal mortality was high or very high in 56 of 68 countries (82%), suggesting these countries were not on track.

 

The researchers found that interventions that could be routinely scheduled, such as immunisation and antenatal care, had much higher coverage than those that rely on functional health systems and 24-hour availability of clinical services, such as skilled or emergency care at birth and care of ill newborn babies and children. They noted that the most rapid increases in coverage were seen in immunisation, which has received significant investment in recent years. They say: "Priority attention in health-system strengthening should be given to establishment of a functional continuum of care that encompasses women before pregnancy, pregnancy, childbirth, the postnatal period, and the first 24 months of a child’s life."

 

The effects of HIV prevalence—which is some countries has peaked and is beginning to drop—may not have been captured by the most recent estimates of mortality in children under 5 years. But the authors say: "Expanded and sustained e.orts are needed to scale up comprehensive programmes for prevention of mother-to-child transmission of HIV, including treatment for pregnant and postnatal women and treatment for paediatric HIV."

 

The 2008 Countdown report suggests that many factors are in place to accelerate progress towards health-related MDGs—including consensus on priority interventions, commitment from countries and donors, programmes in place, and some increases in funding. The authors suggest a framework to cement agreement on priorities and processes, especially strengthening of health systems. They conclude: "In the seven years until 2015, the next two years before the next Countdown Report will be the most crucial. With strategic decisions and investments, and a focus on partnerships for results, we have the opportunity to see unprecedented progress in these 68 countries. Or will the 2010 report show more of the same gaps and lives lost?"

 

 

Despite most Countdown countries having made gradual progress since 1990, coverage gaps for key interventions in maternal and child health remain wide. Further, the pace of progress must be more than doubled to reach levels of coverage needed to reach MDG4 and MDG5. These are the conclusions of an Article in this week’s Countdown Special Edition of The Lancet.

 

Ties Boerma, WHO, Geneva, Switzerland, and colleagues from the Countdown 2008 Equity Analysis Group looked at data from household surveys between 1990 and 2006 for 54 countries in the Countdown initiative to create an aggregate coverage index based on four intervention areas: family planning*, maternal and newborn care†, immunisation‡, and treatment of sick children§—with each given equal weight. They found that the overall size of the coverage gap (the percentage of the population not receiving treatment coverage) ranged from less than 20% in Tajikistan and Peru to more than 70% in Ethiopia and Chad, with a mean of 43% for the most recent surveys in the 54 countries. There were also large di.erences within countries, with a country mean coverage gap of 54% for the poorest quintiles of the population and 29% for the wealthiest. These rich/poor di.erences were largest in the maternal and newborn health intervention area and smallest for immunisation. In 40 countries with more than one survey, the coverage gap has decreased by an average 0·9% per year since the early 1990s. Declines greater than 2% per year were seen in only three countries post-1995: Cambodia, Mozambique, and Nepal. Inequality patterns remained consistent, with the high coverage for rich people in countries with the lower overall coverage, and low coverage for poor people in the countries with higher overall coverage, remaining more or less the same. The authors conclude: "Most countdown countries have made gradual progress in reducing the coverage gap for key interventions since 1990. The coverage gaps, however, are still very wide and the pace of decline needs to be more than doubled to make signi.cant progress in the years between now and 2015 to reach levels of coverage of these and other interventions needed for MDG4 and 5.

Jennifer Bryce, Johns Hopkins School of Public Health, Baltimore, USA. T) +1 607 280 4800 (attending press conference) Jessie Malter, UNICEF Media Relations, New York, USA. T) +1 212 326 7412 / +1 646 732 0047 (mobile)  

 

 

There have been huge increases in donor funding to aid maternal, newborn, and child health in recent years, with a near-doubling of funding per child in the 68 Countdown priority countries. However, funding fell in some of these countries, and work needs to be done to stabilise funding .ows to allow governments to make long term commitments to health improvements. These are the conclusions of authors of an Article in this week’s Countdown Special Edition of The Lancet.

 

To track donor assistance to maternal, newborn, and child health-related activities is necessary to assess progress towards MDGs 4 and 5 and to foster donor accountability. Anne Mills and Giulia Greco, London School of Hygiene and Tropical Medicine, UK, and colleagues, analysed aid in these areas between 2003 and 2006.

 

They found that donor disbursements increased from US$2119 million in 2003 to $3482 million in 2006; funding for child health increased by 63% and for maternal and newborn health by 66%. In the 68 priority countries, child-related disbursements increased from a mean of $4 per child in 2003 to $7 per child in 2006; and those for maternal and neonatal health increased from $7 per livebirth in 2003 to $12 per livebirth in 2006. Of the 68 countries, 52 countries saw increases in official development assistance (ODA) to child health per child between 2003 and 2006, by an average 200% per country. 50 also saw ODA to maternal and newborn health per livebirth rise, on average by 400% per country. The countries that saw falls in ODA in these areas included Brazil, Congo, Ghana, and Burundi. 

 

Furthermore, countries with higher under-.ve mortality received more o.cial developmental assistance per child, but o.cial development assistance did not seem to be well targeted towards countries with the greatest maternal health needs. In terms of actual donation size, the four countries which gave the largest donations in 2006 were World Bank ($725 million), USA ($692 million), Global Fund ($327 million) and UK ($325 million). Only France, Greece and Italy have substantially reduced their donations in these areas in recent years.

 

The authors also comment on the volatile and variable nature of disbursements. They say: "This volatility makes effective planning and provision of appropriate levels of funding for various strategic priorities difficult for developing countries...Donors to maternal, newborn, and child health need to not only to provide long-term commitments but also to coordinate themselves collectively such that funding at the country level does not fluctuate excessively year-on-year."

 

They conclude: "This study demonstrates the value of year on year analysis of donor assistance to maternal, newborn, and child health. These analyses, for example, show that although expenditure is increasing, it is still far from sufficient. Despite the Paris Declaration on Aid Effectiveness, the great bulk of disbursements are still through projects rather than sector or budget support. Analyses, such as those presented here, must continue to be done so that donor commitments can be monitored and assessed to make sure that the most needy countries are benefiting."

 

 

Many priority Countdown countries have policy gaps hindering their progress towards MDGs for maternal and child mortality. Coupled with formidable challenges in health .nancing and human resources, lack of policy measures poses a serious threat to rapid scaling-up of effctive maternal, newborn, and child health interventions. These are the conclusions of Dr Elizabeth Mason, WHO, Geneva, Switzerland and colleagues from the Countdown Working Group, who discuss the issues in a Health Policy paper in this week’s Countdown Special Issue of The Lancet.

 

The authors say: "To have a broader understanding of the environment in which health services are delivered and health outcomes are produced is essential to increase intervention coverage. Programmes to address maternal, newborn, and child health rely on health systems to generate information needed for e.ective decisions and to achieve the expected outcomes. Governance and leadership are needed throughout the process not only to create policies and implement them but also to assure quality and e.ciency of care, to .nance health services su.ciently and in an equitable way, and to manage the health workforce."

 

They looked at 13 separate indicators of health policy and systems under .ve categories—evidence and information; leadership and governance; service delivery; .nancing; and health workforce. There was a huge variation in the status of these indicators both between and within countries. In terms of the health workforce, 54 of the 68 priority Countdown countries have fewer than 2·5 physicians, nurses and midwives per 1000 population, a benchmark that has been assessed internationally as a critical threshold for countries to achieve adequate coverage rates—notably those crucial to MNCH. For service delivery, one intervention—use of community health workers to treat childhood pneumonia—was only authorised in 18 of the 68 countries. However another intervention under the same category—use of oral hydration salts and zinc to prevent diarrhoea—has seen substantial progress in many of these countries.

 

Under the financing category, the authors looked at, among other issues, out-of-pocket expenditure for health services at point of use—and propose that where this expenditure is more than 15% of the total health expenditure, this can cause households big problems and lead to them not seeking the care they need. Unfortunately, this payment burden is above 15% for 60 of the 68 priority countries. The authors also identify three potential conflicts that prevent policy uptake—commercial interests, professional interests, and product availability. For commercial interests, they found that policies which require intersectoral action and involve employment, trade, and financial interests can be the hardest to adopt.

 

For professional interests, they found that, for example, policies that promote task delegation and support task shifting to less quali.ed (eg, nurses) of health workers can be resisted by those who are more highly quali.ed (eg, doctors). And for product availability, the effectiveness of a new policy can obviously be hindered by lack of product availability—for example the zinc supplementation policy mentioned above has been troubled by lack of a suitable product.

 

The authors conclude: "If governments are to exert leadership to promote the maternal, newborn, and child health agenda, policies need to be in place to create a facilitating environment and direct the use of scare resources...The Countdown initiative will continue to monitor the status of indicators of health policy and health and health systems as a complement to coverage indicators, will seek to work with partners to improve the measurement methods, and will facilitate the integration of policy and health system considerations into the e.orts to rapidly scale-up maternal, newborn and child health interventions."

 

Whilst many African nations have made little or no progress towards meeting the Millennium Development Goal for reducing Child Mortality (MDG4), Tanzania is on target to meet the goal thanks to a combination of key interventions in child health. These are the conclusions of an Article in this week’s Countdown Special Edition of The Lancet.

 

MDG4 for Tanzania means a reduction from its under-5 child mortality rate of 141 per 1000 live births in 1990 to 47 per 1000 by 2015—ie, a reduction of two thirds. Between 2000 and 2004, this mortality rate reduced by 24%, with most of this gain occurring after 1999. Dr Hassan Mshinda, Ifakara Health Research and Development Centre, Tanzania, and colleagues analyse how Tanzania achieved this remarkable progress and ask if it can be sustained in order for the country to meet MDG4.

 

The authors found that between 1999 and 2004, Tanzania more than doubled its public expenditure on health. They say: "Such increased expenditure has been strongly correlated with increased survival in children younger than five years in developing countries, especially in poor people." Further, the government implemented policy shifts towards greater decentralisation in 2000, by introducing grants that gave individual districts substantial .nancial resources. This opened opportunities for local problem solving and allowed districts to selectively increase resources for key interventions.

 

These funding improvements worked in unison with increased coverage of key child-survival interventions, such as integrated management of childhood illness, insecticide-treated nets to prevent malaria, vitamin A supplementation, immunisation, and exclusive breastfeeding. Together these funding changes and interventions reduced mortality in children under-5-years in Tanzania by 24% between 2000 and 2004.

 

There is optimism among the authors that Tanzania can maintain this mortality reduction, since there are a number of child health interventions that have recently been implemented whose e.ects will have barely shown up in the latest estimates, if at all. Firstly the increased funding to the nation from the Global Fund to .ght HIV/AIDS, Tuberculosis and Malaria—grants were announced in 2002 but only took effect in late 2004. Secondly, the scaling up of the Prevention of Mother to Child Transmission (HIV) programme and antiretroviral therapy started in 2005. Thirdly, programmes for Zinc Supplementation and oral rehydration therapy started in 2007 which will reduce deaths due to diarrhoeal illness; and finally access to improved antimalarial treatment through artemisinin combination therapy also started in 2007. All of these factors are expected to substantially reduce child mortality in the remaining years of Countdown to 2015. However, the authors note that there has been no signi.cant reduction in neonatal deaths (deaths in the .rst month of life) and that these now account for almost one third of child deaths in Tanzania. In addition there is no measurable change in maternal mortality ratio, so MDG 5 is not on track. More systematic attention to maternal and neonatal interventions is vital.

 

The authors conclude: "Broad, multifaceted progress in stewardship, public expenditure on health, decentralised .nancing, resource allocation, and better coverage of essential child-survival services can work synergistically to effect important progress towards MDG4 in low-income countries such as Tanzania. Increased health resources combined with strengthening of decentralised health systems to ensure that life-saving interventions reach those in need is a key child-survival strategy."

 

 

The authors of three South African health reports on maternal, neonatal, and child deaths have come together to launch a new report entitled Every Death Counts, which analyses this data and puts forward key strategies to reduce this terrible burden in the country. The detail is contained in a Public Health paper in this week’s Countdown Special Issue of The Lancet.

 

Joy Lawn, Saving Newborn Lives/Save the Children-US, and colleagues from the South Africa Every Death Counts Writing Group say: "All indications are that maternal and child mortality has increased since the baseline for Millennium Development Goals in 1990." The figures are disturbing—each year in South Africa, at least 1 600 mothers die due to complications of pregnancy and childbirth. Some 20,000 babies are stillborn and another 22 000 die before they reach on month of age. And in total, at least 75 000 children die before their fifth birthday. This terrible toll is due to .ve major health challenges—pregnancy and childbirth complications, newborn illness, childhood illness, HIV and AIDS, and malnutrition. 

 

South Africa is one of just 12 counties globally in which the child mortality rate has increased instead of falling since 1990. As a result, the country now has to achieve a yearly rate of reduction of 14% to meet MDG4 by 2015.

 

The authors say: "This toll is too high in view of South Africa’s status as a middle-income country and capacity to provide services...The existing high coverage of many key interventions presents an opportunity to save lives by focussing on high-quality services and integration of HIV/AIDS care, while addressing inequity by reach the poorest and marginalised populations." Many of these lives could be saved—over 40 000 babies and children each year—if high-impact interventions reached all families in South Africa. A high proportion of women’s lives could also be saved with more investment in the same solutions that saves babies and children. There are success stories—individual clinicians and hospitals that have made a big di.erence in a short time using local data. But national progress requires national leadership.

 

They conclude: "National mortality audits for mothers, babies, and children are an achievement and present recommendations and strategies to save lives. The new Every Death Counts report brings these aims together as one harmonised set of recommendations. However, if South Africa is to see a reduction in maternal, neonatal, and child mortality, these recommendations need to be fully implemented to turn mortality data into action. This goal needs accountability at all levels. Then every death will truly count."

 

See also  Editorial

 

 

A call to reduce maternal and child mortality rates is made by The Lancet Editor Dr Richard Horton in his Comment which opens this week’s Countdown Special Edition of The Lancet.

 

Dr Horton praises the evolution of the Countdown process from its creation in 2003 through its rapid evolution "into a scienti.c and social movement to prevent the needless deaths of millions of mothers and children." He says: "At the half-way stage towards the Millennium Development Goals, Countdown symbolises a model for collaboration, evaluation, and action that has valuable lessons for many other domains in public health." 

 

He discusses the deliberate and significant choice of Cape Town, South Africa for the Countdown Conference from April 17–19, which will help highlight the plight of various countries in sub-Saharan Africa which have seen increased rather than decreased under-5 mortality rates. He says: "It signals the determination of all Countdown partners to do more to mobilise political commitment and .nancing for maternal, newborn, child, and reproductive health across the continent."

Issued by Tony Kirby, Press Officer, The Lancet Press Office. T) +44 (0) 20 7424