M illennium Development Goals and Child Health: where do we stand? - PowerPoint PPT Presentation

M illennium Development Goals and Child Health: where do we stand? Zulfiqar A. Bhutta Noordin Noormahomed Endowed Professor & Founding Chair Division of Women & Child Health The Aga Khan University Karachi, Pakistan

Outline • M DGs and Global Burden of M ortality • Causes & social determinants • What can be done? • Can this be done effectively? • Funding Gaps for M aternal and Child Survival • What role, if any, for CAPGAN?

The numbers “ Not everything that can be counted counts, and not everything that counts can be counted ” Albert Einstein

The Millennium Development Goals (MDGs) Goal 2: Goal 1: Eradicate Extreme Hunger Achieve Universal and Poverty Primary Education Goal 3: Goal 4: Promote Gender Equality and Reduce Child Mortality Empower Women Goal 5: Goal 6: Improve Maternal Combat HIV/AIDS, Malaria and other diseases Health Goal 7: Goal 8: Ensure Environmental Develop a Global Partnership Sustainability for Development

Specific targets for MDGs 4 & 5 MDG 5 MDG 4 a. Reduce by three quarters, Reduce by two thirds, between 1990-2015, the between 1990-2015, the maternal mortality ratio under-five mortality rate b. Achieve, by 2015, universal access to reproductive health Source: http:/ / www.un.org/millenniumgoals/childhealth.shtml

Risk of mortality peaks around childbirth Stillbirths Newborn deaths M aternal deaths Child Deaths Pre-pregnancy Newborn/ postnatal Childhood Pregnancy Birth

Top 10 countries for numbers of stillbirths, neonatal and maternal deaths Ranking for neonatal Ranking for Ranking for deaths maternal deaths stillbirths India 1 1 1 Nigeria 2 2 3 Pakistan 3 2.4 million 8 2 340,000 1.77 neonatal maternal China 4 13 8 million deaths deaths stillbirths DR Congo 5 3 6 Ethiopia 6 Approx 5 5 Approx Approx 67% 65% 63% Bangladesh 7 6 4 of global of global of global Indonesia 8 7 7 total total total Afghanistan 9 4 12 Tanzania 10 9 11 Ref: Lawn JE et al BJOG sept 2009. Data sources: Estimates of maternal (2005) and neonatal (2008) deaths from WHO. Stillbirths from Cousens et al 2010 Updated Aug 2010

2 million deaths at the time of birth Maternal deaths Stillbirths (>1000 g) Neonatal deaths 358,000 per year 2.65 million per year 3.6 million per year Intrapartum-related Intrapartum stillbirths (2009) Intrapartum-related Fetal death during labour maternal deaths (2008) neonatal deaths (2009) (fresh stillbirths) Death during labour, Previously called “birth birth and first 24 hrs asphyxia” + + 261,000 1,200,000 814,000

Timing of Neonatal Deaths 10 Up to 50% of neonatal deaths are Daily risk of death (per 1,000 survivors) in the first 24 hours 8 6 75% of neonatal deaths (nearly 3 million) occur in the first week 4 2 0 0 10 20 30 Day of life Lawn et al. Lancet 2005; 365: 891–900.

M DG 4 progress 8.3 million under 5 deaths annually Progress towards MDG 4, with countries classified according to the following thresholds: On track: U5MR is less than 40, or U5MR is 40 or No progress: U5MR is 40 or more and more and the average annual rate of reduction AARR is less than 1.0 per cent (AARR) in the under-five mortality rate observed for 1990-2007 is 4.0 percent or more Bhutta et al Insufficient progress: U5MR is 40 or more and Data not available AARR is between 1.0 per cent and 3.9 per cent Lancet 2010

Global Progress to M DG 4 M DG 4 target (32) Ref: Lawn, Kerber et al BJOG 2009 updated with data for 2008 from UN Child Mortality Group, WHO//CHERG and IHME (Rajaratnam J eta l 2010)

The Causes

Distribution of Causes of Child Deaths: Global Source: Black RE, et al. Lancet 2010

Childhood Diarrhea • 1.34 million deaths • Over half of all 1 diarrhea deaths are in only 5 countries of Asia & Africa • Rate of reduction of diarrhea deaths appears to have slowed

Time trends in diarrhea deaths 5 Snyder & M erson 1982 4 3 Bern et al, 1992 GBD 1990 2 EIP 2000 1 CHERG 2010 0 1975 1980 1985 1990 1995 2000 2005 2010 Source: Boschi-Pinto C, T omaskovic L. For CHERG (2006) & Black et al (CHERG 2010)

Diarrheal Disease Occurs Worldwide… ..but 35 Countries Account for 90% M ortality Burden These 35 Countries Account for 90% of Worldwide Burden Estimated Annual Deaths Due to Diarrhea of Mortality from Diarrhea 50% Deaths 500 1.8M Deaths 450 Rank M ortality Adjusted for Population Size Total 400 350 Nepal (thousands) 300 India 250 Bangladesh 200 Niger 150 Burka Fasino 100 50 0 India Nigeria Pakistan DR Congo China Bangladesh Ethiopia Angola Afghanistan Indonesia U Rep, Tanzania Uganda Mozambique Niger Myanmar Kenya Mali Burkina Faso Malawi Sudan Yemen Madagascar Brazil Nepal Côte d'Ivoire Somalia Zambia Cameroon Iraq South Africa Rwanda Egypt Sierra Leone Philippines Cambodia Bold = DHS data available 50% of 1.34M Diarrheal Disease Deaths Occur in Only 5 Countries 50% of 1.34M Diarrheal Disease Deaths Occur in Only 5 Countries Notes: For subsequent analyses in this presentation, FSG selected top 35 highest mortality burden, plus highest burden countriesfrom Latin America (Haiti, Mexico and Peru). Of the top 35, only countries with DHS data were included for analysis, excluding: DR Congo, China, Angola, Afghanistan, Myanmar, Somalia, Iraq and Sierra Leone. Sources: WHO Global Burden of Disease Estimates 2004; Lopez et al, Global and regional burden of disease, Lancet (367) May 27, 2006: FSG Analysis

The causes of the causes

The health workforce: critical shortages in 57 countries Source: World Health Report 2006

Tertiary Referral Hospital University Hospital Secondary District General Hospital Sub-district Hospitals 35-40% Primary 5-10% Rural Health Center Village Health Units 50-60%

“Know-do Gap”

“Don’t know- Don’t do Gap”

The Lancet & M aternal/ Child Health Stillbirth series 2011 Child 2003 Alma Ata series 2008 Newborn 2005 Repro- Child Under M aternal ductive develop Nutrition Series Health ment series 2006 Series series 2008 2006 2007 36 key interventions can make a huge difference if delivered in primary care settings Lawn UNAPSA SAP A 2008

“Top seven” prevention interventions for children less than five years of age No. of Deaths prevented deaths as proportion of Preventive Intervention prevented all child deaths (‘000s) Breastfeeding 1301 13% Insecticide -treated materials 691 7% Complementary feeding 587 6% Zinc 459 5% Hib vaccine 403 4% Antiseptic delivery 411 4% Water, sanitation, hygiene 326 3% Source: Jones G, Steketee R, Bhutta Z, Morris S. and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003.

“Top seven” treatment interventions for children less than five years of age No. of Deaths prevented deaths as proportion of Treatment Intervention prevented all child deaths (‘000s) Oral rehydration therapy 1477 15% Antibiotics for neonatal sepsis 583 6% Antibiotics for pneumonia 577 6% Antimalarials 467 5% Zinc for diarrhea 394 4% Newborn resuscitation 467 5% Antibiotics for dysentery 310 3% Source: Jones G, Steketee R, Bhutta Z, Morris S. and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003.

Evidence based policies for M NCH in 68 Countdown countries Bhutta et al (Lancet 2010)

Slipping in and out of care! M edian national coverage levels for 19 Countdown interventions and approaches, most recent estimates since 2000. Bhutta et al, Lancet 2010 Pre-pregnancy  Pregnancy  Birth  Postnatal  Neonatal  Infancy  Childhood

M agnitude of inequities by intervention in 38 countries Poorest Richest ORT and continued feeding Care seeking for pneumonia Vitamin A administration (child) BCG vaccine M easles vaccine DPT3 vaccine Insecticide-treated net use (child) Postnatal visit Skilled attendant at delivery Antenatal care (4+ visits) Family planning needs satisfied 0% 20% 40% 60% 80% 100% Coverage

Global Funding Needs for M NCH M ore money for health

DAH for MNCH and other areas, 1990-2010 Source: Institute for Health Metrics and Evaluation (2010) Financing Global Health 2010

Funding Gap Funding Gap is significant Across three distinct categories Gap for health MDGs in 49 lowest- income countries: Billions (2005 US$) US$26 billion (US$19 per capita) 42 – additional in 2011. 37 33 US$42 billion (US$27 per capita) Other costs for scaling up – 31 20 to meet the health MDGs additional in 2015 26 18 16 15 Almost half of these costs are related 12 Health systems costs of to women and children programs targeting 15 13 women and children 12 12 10 Direct costs for programs 7 targeting women and 6 5 4 4 children 2011 2012 2013 2014 2015

Commitments… . few poor countries can deliver Tanzania Zambia Ethiopia Low income countries must spend more and prioritise reaching the poor as per Abuja target of 15% of government spending on health

Commitments… . few donor countries deliver Donor countries must meet their commitment of 0.7% of GDP

More money for health: At MDG Summit in 2010, $40 billion USD committed as policy, service delivery and financial commitments