Meeting Unmet Needs in Child Survival
USAID
Bureau for Global Health
Introduction
• Substantial progress over past few decades in reducing infant and child mortality
• During the 1990’s, decline in child mortality began to decelerate or plateau in many regions
20
70
120
170
220
270
1960 1965 1970 1975 1980 1985 1990 1995 2000
Year
U5M
R (
dea
ths
per
100
0 b
irth
s)
Sub-Saharan AfricaMiddle East and North AfricaSouth AsiaEast Asia and PacificLatin America and CaribbeanCEE/CIS and Baltic StatesWorld
Slowing Reduction in Under 5 Mortality
Source: UNICEF Time Series Estimates, 2000.
Objectives of Analysis
• Are we investing in the correct areas?
• Is there a need for any strategic program changes?
Questions• Are there additional technical areas that need to be
addressed?• Are there identifiable geographic areas of greatest
unmet need?• Are there particular characteristics of children or
their families that help predict or identify unmet need?
• What are the programmatic implications of these findings?
Methodology
• Review of literature• Special study of services
and health behaviors using DHS data
• Consultation with experts in child survival interventions
Are there additional technical Are there additional technical areas that need to be addressed?areas that need to be addressed?
HIV
4%
ARI 20%
Others
28%
Diarrhea
12%
Malaria
8%
22%
Measles
5%
Main Causes of U5M:1990 and 2000
Measles11%
Neo-natal tetanus
6%
Malaria7%
Diarrhea28%
Others29%
ARI 15%
Whooping cough
4%
1990 2000
Source: Protecting the world’s children, A call for action, 1990; Evidence and information for Policy/WHO, Child Adolescent Health and Development, 2001 WHO, Child and Adolescent Health and Development. On line www.who.int/child-adolescent-health/inegr.htm
Perinatal
HIV
4%
ARI 20%
Others
28%
Diarrhea
12%
Malaria
8%
22%
Measles
5%
Main Causes of U5M:1990 and 2000
Measles11%
Neo-natal tetanus
6%
Malaria7%
Diarrhea28%
Others29%
ARI 15%
Whooping cough
4%
1990 2000
Source: Protecting the world’s children, A call for action, 1990; Evidence and information for Policy/WHO, Child Adolescent Health and Development, 2001 WHO, Child and Adolescent Health and Development. On line www.who.int/child-adolescent-health/inegr.htm
Perinatal
Malnutrition(underlying factor)
60%
0
10
20
30
40
50
60
70
80
90
100
1983 1999
Post-neonatal mortality rateNeonatal mortality rate
Increasing Proportion of Neonatal Mortality
Based on State of the World’s Newborns, State of the World’s Children 2001, WHO Publications
Percentage of Children with Unmet Need
Unmet need for child survival is the percentage of children whose families do not practice healthy behaviors or use services such as
immunizations, ORT, breastfeeding, etc.
26 28
40
58
25
52
32
0
10
20
30
40
50
60
70
80
90
100
DPT3Immunization
ORT ARI Treatment Exclusive BreastFeeding
Nutrition(Underw eight)
Vitamin ASupplementation
Iodized Salt
Immunization data for 12-23 months children and exclusive breastfeeding for children under 4 months only.Source: DHS, ACC/SCN, Unicef
Per
cent
of c
hild
ren
who
did
not
rec
eive
ch
ild s
urvi
val i
nter
vent
ions
Water and Sanitation
0
10
20
30
40
50
60
70
80
90
100
World sub-SaharanAfrica
South Asia
Per
cen
t
1990 2000
Access to safe drinking water
0
10
20
30
40
50
60
70
80
90
100
World sub-SaharanAfrica
South Asia
Per
cen
t
1990 2000
Access to sanitary means of excreta disposal
Source: UNICEF, The state of world’s children, 2002
Are there identifiable geographic Are there identifiable geographic areas of greatest unmet need?areas of greatest unmet need?
High Infant Mortality Countries
Infant mortality rates (2000)
72 to 180 (49)28 to 72 (42)13 to 28 (46)
3 to 13 (48)
Source: IMR data from UNICEF
U5M Rate Changes 1990-2000
180
135
76
5753
40
9
94
172
101
62
4438
34
6
81
0
20
40
60
80
100
120
140
160
180
200
Sub-SaharanAfrica
South Asia Middle Eastand North
Africa
East Asia andP acific
Latin Americaand Carribean
CEE/CIS andBaltic States
Industrializedcountries
World
Source: The State of the World's Children, 2002, UNICEF
U5M
R (
death
s p
er
1,0
00 liv
e b
irth
s)
1990
2000
Within Country Differences in U5 Mortality Rates (India)
Source: NFHS 1998-99
19
47
58
63
70
85
86
105
115
123
138
0 20 40 60 80 100 120 140 160
Kerala
Goa
Maharashtra
Tamil Nadu
Karnataka
Gujarat
Andhra Pradesh
Bihar
Rajasthan
U.P.
M.P.
U5MR (deaths per 1000 births)
U5MR
Urban Slums:Among the most deprived
Source: DHS and Urban Health Study, 2001
Ahmedabad Slums (India)
68
73
108.9
47
76
123
020406080100120140
India (Total)
India (Rural)
India (Rural PoorestQuintile)
India (urban)
Ahmedabad City
Ahmedabad Slums
IMR (death per 1,000 births)
1997 Report onslums incounterpart studyNFHS 1998-99
Manila Slums (Philippines)
27.1
44.3
38.4
72
0 20 40 60 80 100 120 140
Manila Slums
Manila City
Philippines Rural
Philippines Total
IMR (deaths per 1000 births)
DHS 1993DOH 1993
Are there particular Are there particular characteristics of children or their characteristics of children or their
families that help predict or families that help predict or identify unmet need?identify unmet need?
U5 Mortality Rates by Wealth Quintiles
0
25
50
75
100
125
150
175
200
Poorest Second Middle Fourth Richest
Wealth Quintiles
U5M
R (
dea
ths
per
100
0 b
irth
s)
Brazil, 1996Peru, 1996Bolivia, 1998Egypt, 1996Bangladesh, 1997India, 1993Zimbabw e, 1994Uganda, 1995Tanzania, 1996
Source: World Bank and DHS
EPI Immunization* Coverage by Wealth Quintiles
0
10
20
30
40
50
60
70
80
90
100
Poorest Second Middle Fourth Richest
Wealth Quintiles
Per
cen
t
Brazil PeruBolivia EgyptBangladesh IndiaZimbabwe UgandaTanzania
Source: World Bank and DHS
* Coverage in children 12-23 months old
Percent Children Underweight* by Wealth Quintiles
* Below -2 sd z-score, weight for age, children under 5 yearsSource: World Bank and DHS
0
10
20
30
40
50
60
70
Poorest Second Middle Fourth Richest
Wealth Quintiles
Per
cen
t
Brazil, 1996Peru, 1996Bolivia, 1998Egypt, 1996Bangladesh, 1997India, 1993Zimbabwe, 1994Uganda, 1995Tanzania, 1996
Differences in U5 Mortality by Gender, Caste & Religion (India)
0
20
40
60
80
100
120
140
ScheduledTribes
ScheduledCastes
OtherBackwardCastes
ForwardCastes
0
20
40
60
80
100
120
140
Male Female
Dea
ths
per
100
0 b
irth
s
0
20
40
60
80
100
120
140
Hindu Muslim Christian Sikh
Gender Caste Religion
Source: NFHS 1998-99
Differences in U5 Mortality by Mother’s education
Source: Demographic and Health Surveys for indicated year
0
25
50
75
100
125
150
175
200
225
No Education Primary Complete Secondary +
U5
MR
(d
ea
ths
pe
r 1
,00
0 b
irth
s)
Kenya, 1998Uganda, 2000Zimbabwe, 1999Egypt, 2000Gabon, 2000Ethiopia, 2000Cambodia, 2000India, 1998Bangladesh, 2000
Correlation AmongVarious Unmet Needs
• Is there a correlation among various unmet needs of child survival?
• Can we use a few indicators to predict the children with highest unmet need for child survival?
Target Unmet Need
Poor Rich
Pro
gram
C
over
age
Current Coverage
Additional investments in current approach
Equity Enabling Efforts
Programmatic Implications
• address the deceleration of progress in child survival?
• deal with equity issues which are widening?
What changes are needed in child survival programs to:
Resource AllocationAllocate resources more strategically
Target Unmet Need
• Map and identify unmet need
• Learn how to best target programs to reduce disparities
• Monitor effectiveness of targeting
Reach Families and Communities
• Reach families directly with information and behavior change messages
• Emphasize community-based approaches
• Improve quality and supply of services by private providers
Health Seeking BehaviorAmong ARI & Diarrhea Deaths (El Alto, Bolivia)
Source: Basics Project, 1997
Did not get appropriate home care (90%)
Failed timely recognition (60%)
Died without reaching any care provider (42%)
Used community providers (39%)
Received quality care from any provider (5%)
Include Poverty Approach
• Develop and monitor disparity indicators
• Develop new tools and strategies to address health of urban poor
Strategic Approaches
• Increase overall coverage rates for cost-effective child survival programs
• Select interventions with highest impact in high mortality populations
Use strategic approaches to reaching those with unmet need:
Strategic Approaches• Place more
emphasis on neonatal health and nutrition
• Link new child health interventions to existing programs
Strategic Approaches
• Look for intersectoral synergies
• Protect basic child health services in HIV endemic areas and prevent MTCT
ConclusionsConclusions
• Impressive gains but daunting Impressive gains but daunting challenges remainchallenges remain
• Progress has slowed in recent yearsProgress has slowed in recent years
• To accelerate mortality declines, key To accelerate mortality declines, key actions are:actions are:
Conclusions
• Expand current programs, increase attention to neonatal health, and HIV/AIDS and malaria in some regions
• Identify and target groups with unmet need and reduce disparities
• Factor in geographic, poverty and social exclusion dimensions
• Allocate resources more strategically
