our global responsibilityto the world’s children

Our Global Responsibilityto the World’s Children

A Global Health Council Position Paper on Child Health

www.globalhealth.org

Acknowledgements

We wish to thank Robert Black of Johns HopkinsUniversity, Anne Tinker of Save the Children, and GeorgeBrockway for their helpful review of this paper, as well as themany contributors to The Lancet series on child and newbornhealth on which this paper is largely based.

We also wish to thank Julie Pudlowski, who took thecover photo of this 16-month-old child on his father’s lapwhile waiting to be examined at an International MedicalCorps clinic in Ethiopia.

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Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Why children die . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Underlying causes of child illness and death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

II. Simple, Cost-effective Solutions Can Save Millions of Children . . . . . . . . . . . . . . . . . . . . .6

Why invest in saving children’s lives? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

III. The Global Health Council’s Position Statements on Improving Child Survival and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Position 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Position 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Position 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Position 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Position 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Position 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

IV. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

V. Appendices

1. Core interventions to prevent 6.6 million child deaths . . . . . . . . . . . . . . . . . . . . . . . . . .18

2. Percentage of child deaths averted by core interventions . . . . . . . . . . . . . . . . . . . . . . . . .19

3. Global monitoring indicators for tracking child survival . . . . . . . . . . . . . . . . . . . . . . . . .20

4. Sixty high child-mortality countries and their progress toward meeting MDG 4 . . . . . . .21

VI. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

2 Global Health Council Position Paper on Child Health

Global Health Council Position Statements on Decreasing Child Mortality1. Governments, multilateral organizations, private donors and civil society should contribute

equitably to partnerships aimed at achieving a two-thirds reduction in the 1990 level of childmortality by 2015.

2. Investment in newborn and child health must increase substantially to achieve the goal of sav-ing an additional 6.6 million children each year.

3. Resources should be targeted to the countries and populations where child mortality is great-est, based on the criteria of severity and magnitude.

4. Priority should be given to interventions of proven effectiveness, implemented according topopulation-specific assessments of the causes of childhood death and disease.

5. Investments in child health should simultaneously strengthen health capacity for the longterm.

6. Progress toward achieving MDG 4 should be scrupulously monitored, regularly reported, androutinely evaluated.

Conclusion

Executive Summary

The Global Health Council, the world’slargest membership alliance dedicated to savinglives by improving health, recognizes that avert-ing the needless deaths of children is one of thecore global health priorities of our time. Eachyear more than 10 million children under the ageof five die. Experts agree that at least 6.6 millionchild deaths can be prevented each year if afford-able health interventions are made available tothe mothers and children who need them. If thiswere accomplished, the Millennium Develop-ment Goal (MDG) 4 to significantly reduce childmortality by 2015 could be achieved.

The positions that follow articulate theCouncil’s policy agenda and frame the Council’srecommendations to policy-makers. These posi-tions also serve as rallying points for the Council’smembers who work daily to improve child health,and as a platform for the Council’s collaborationwith other groups advancing child health.

The paper first provides an overview of thestate of child health globally, the solutions thathave been proposed, and the moral and econom-ic rationale to act on this issue now. The Councilthen endorses the following positions.

The world can achieve MDG 4 and save anadditional 6.6 million children with the informa-tion and tools we have today. Only political willis needed to prevent most deaths of childrenunder the age of five, even in the poorest countries.

And saving these children is just the first steptoward the goal we all share – creating a worldwhere child survival can be taken for grantedand families everywhere will be confident thattheir children will survive and thrive.


I. Introduction

Impressive gains have been made in reducingchild mortality in the past four decades. Globally,deaths of children under five have declined by anaverage of nearly 2 percent per year over thatperiod.1 In many parts of the world, widespreadintroduction of simple, inexpensive interven-tions have successfully targeted the major killersof infants and children. Highly effective andoften “low-tech” solutions, as well as improve-ments in health delivery systems to make suchinnovations widely known and accessible, haveenabled rapid declines in child mortality tooccur, even in poor countries. Cost-effectivenesshas been increased through providing packagesof interventions that address multiple healthissues.2

While the overall trajectory of child survivalhas been positive, progress remains very uneven.Each year, 10.1 million children worldwide stilldie from largely preventable causes.3 Neonatalmortality has been very persistent, with the

result that now 38 percent of all child deaths (4 million) occur in the very first month of life.In at least 15 countries, the child mortality ratehas increased in the last 17 years, and in at least13 other countries, progress toward securingchildren’s survival has stagnated.4

• The overwhelming majority of child deaths(99 percent) occur in poor countries.

• One in four of the world’s 600 millionchildren under the age of five live in acountry where their risk of death is atleast 20 times higher than in the U.S.5

• Forty-two percent of all child deathsoccur in sub-Saharan Africa and 29 per-cent in south and southeast Asia, but theleading causes of death vary greatly byregion.


Why Children Die

Globally, 80 percent of all child deaths tochildren under five are due to only a handful ofcauses: pneumonia (19 percent), diarrhea (18percent), malaria (8 percent), neonatal pneumo-nia or sepsis (10 percent), pre-term delivery (10percent), asphyxia at birth (8 percent), measles(4 percent), and HIV/AIDS (3 percent).6

Neonatal Causes: 4 Million DeathsDeaths from all causes in the first four weeks

of life claim roughly the same number of chil-dren each year as are born annually in the UnitedStates or in the 23 largest countries of WesternEurope.7 The highest number of deaths occurson the first day of life. In addition, a quarter ofthe 3.3 million babies who are stillborn eachyear, die during the birthing process.8 The major-ity of births in sub-Saharan Africa (59 percent)and in Asia (62 percent) take place without askilled attendant present, increasing the risk ofdeath or disability for both mother and new-born.9

Pneumonia: 2 Million DeathsPneumonia kills more children under five

than any other single disease. Only one in fivecaregivers can identify the early signs of pneu-monia, and only about half of children in need ofcare are taken to a health-care provider.2

Diarrhea: 1.8 Million DeathsContaminated water causes 90 percent of

diarrheal cases among children. Severe diarrheacan kill quickly if a child becomes dehydratedand goes into shock.10 Many caregivers do notrecognize the danger until it is too late.11

Malaria: 850,000 DeathsThe majority of deaths due to malaria occur

among young children, and 94 percent occur inAfrica.12 Malaria accounts for 18 percent ofdeaths among African children as compared to 8percent globally.

Measles: 400,000 Deaths Until recently, measles killed nearly 900,000

children each year. Following a joint WHO andUNICEF plan to expand measles vaccine cover-age, deaths have declined by 60 percent since1999.13 About 60 percent of measles deathsoccur in Africa and 25 percent in Asia.

HIV/AIDS: 350,000 Deaths Only one in 10 HIV-positive pregnant

women has access to the antiretroviral drugs thatcan substantially reduce the risk of transmittingHIV to her child.14 As a result, more than600,000 children become infected with HIVeach year, primarily during delivery or throughbreast milk.i, 15 Many die within the first twoyears of life. Nearly 90 percent of child deathsdue to AIDS occur in Africa.6

i UNAIDS advises, “where replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeed-ing is recommended. Otherwise, exclusive breastfeeding is recommended for the first few months of life.” Exclusive breastfeedingfor six months carries a significantly lower risk of HIV infection than does supplementing breast milk with formula or solid foods.


Poverty: More than 200 million childrenunder five live in absolute poverty, on lessthan $1 per day.• Poor children are more likely than better-

off children to be exposed to disease anddiarrhea through unsafe water and poorsanitation.

• They are more likely to live in over-crowded conditions, or to be unprotectedfrom disease vectors such as mosquitoesthat cause malaria.

• They are more likely to suffer respiratoryconditions like pneumonia, aggravatedby indoor air pollution from open cook-ing fires.

• Infants born to poor families are far morelikely to die from preventable causes inthe first days and month of life.16

Health services and interventions are notequitably distributed and less likely to reachthose who need them most. Thus poor childrenbecome ill and die more frequently than childrenwho are better off.

Under-nutrition and malnutrition: At least200 million children under five aremalnourished.

In more than half of all child deaths (53 per-cent), under-nutrition is an underlying cause ofdeath, leaving the child far more vulnerable tosevere consequences from common infections.6

But death is the “tip of the iceberg”17 because atleast 20 times as many children will never fulfilltheir development potential due to the effect ofmalnourishment on physical and brain develop-ment. In 79 low- and middle-income countries,the physical and intellectual growth of more thana quarter of all children is stuntedii due to poornutrition and illness. Africa is the only continent

in which malnutrition among children is rising,18

but child malnutrition remains most pervasive inAsia. Children in poor families are much morelikely to be deficient in essential micronutrientssuch as vitamin A, iron and zinc. The effects ofchronic malnutrition in the first two years of lifeon cognitive ability are largely irreversible.19

High fertility and short birth intervals affectthe lives of more than 100 million poorchildren.

Women in 35 of the countries with highestchild mortality have, on average, five or morebirths each. Children born into a large familycompete for scarce resources, including formaternal care. Those born less than two yearsafter a previous birth are especially at risk of pre-mature birth, low birth weight, and death anddisease in the first weeks, months and even yearsof life. A child born 17 months or less after a pre-vious birth is three times more likely to die thana child born three years after a previous birth.20

Parents who fear losing a child are often unawareof the importance to child survival of birth spac-ing, and they may lack access to contraception toplan or space their births. Thus high fertility andhigh child mortality reinforce one another in aharmful way.

Underlying Causes of Child Illness and Death

In Niger, a country with child and maternalmortality rates that are among the highest in theworld, mothers have an average of eight birthseach, 68 percent of births are less than threeyears apart,21 and nearly three of every 10 chil-dren die before the age of five. Giving birth tomany children increases the mother’s risk ofdeath. A woman in Niger faces a one in sevenchance of dying of pregnancy-related causesduring her lifetime.22 A child who loses its mother faces a three- to 10-fold increase in riskof death.23ii Growth stunting is defined by the National Center for

Health Statistics as height for age that is more than two stan-dard deviations (SD) below average for the reference group.


For every major cause of child death, there isan affordable solution ready to be implementedand these survival interventions work in a widearray of contexts. Most do not need to be deliv-ered in a health facility and many interventionsare so simple and of low cost that even poorcountries with weak health infrastructures canexpect dramatic reductions in infant and childmortality if these interventions are sufficientlyscaled up.21 For example, a study in UttarPradesh, India demonstrated a 50 percentdecline in neonatal mortality through raisingawareness in the community of such simple sur-vival strategies as cleaning, drying and warmingthe newborn, skin-to-skin contact with themother, and exclusive breastfeeding for the firstsix months.25 In comparison with giving thenewborn milk-based fluids or solids in additionto breast milk, immediate (within an hour ofbirth) and exclusive breastfeeding has been

shown to reduce neonatal deaths from all causesby 22 percent.26 Since the majority of infantdeaths occur at home, educating mothers aboutthe importance of immediate and exclusivebreastfeeding and skin-to-skin contact with thenewborn is perhaps the most cost-effective sur-vival solution known. (See Appendices 1 and 2.)

Table 1 illustrates how inexpensively themajor killers of children can be prevented andtreated. Life-saving interventions, such as vac-cines and oral rehydration salts (ORS), alreadyprevent more than 3 million child deaths eachyear at a very affordable price. In southernAfrica, measles has been nearly eliminated as acause of child death in just four years through avaccination campaign costing just $1.10 perchild.27 Dramatic impact such as these can beachieved throughout the developing world.

II. Simple, Cost-effective Solutions Can Save Millions of Children

“A limited set of known and effective interventions, if implemented together and at univer-sal coverage, can save over 6 million child lives each year. These interventions…are feasiblefor implementation at high levels of population coverage in poor countries … to all childrenwho need them.” 24

– Countdown to 2015 Child Survival Partnership 2005

Table 1: Major Causes of Child Deaths and Cost of Treatment per Child

% Deaths # DeathsDisease under 5 annually Cost to treat/prevent illness for one childPneumonia 19% 2 million Antibiotic treatment . . . . . . . . . . . . .$ 0.30Diarrhea 17% 1.8 million Oral rehydration packet . . . . . . . . . .$ 0.20Malaria 8% 850,000 Insecticide treated bednet . . . . . . . . .$ 5.00Measles 4% 400,000 Measles vaccine . . . . . . . . . . . . . . . . .$ 1.10 Birth Asphyxia 8% 830,000 Resuscitation mask and bag . . . . . . .$10.00HIV/AIDS 3% 350,000 Antiretroviral drug . . . . . . . . . . . . . .$ 5.00Tetanus 2% 250,000 Two tetanus toxoid injections . . . . .$ 0.40


Many health interventions are so inexpensivethat the barrier that extreme poverty creates isalmost inconceivable. A recent study in a squat-ter settlement of Karachi, Pakistan found thatsoap and hand-washing reduced pneumonia by50 percent and diarrhea by 53 percent. Yet halfthe residents lived on less than $.50 per day andcould not afford even the $4 per month for handsoap.28 Most women in a Bangladesh study alsosaid they could not afford to buy soap.29

The cost of scaling up these interventions inthe 60 countries with 94 percent of all childdeaths has been carefully estimated. More than60 percent of the 10.1 million deaths – 6.6 mil-lion children’s lives, including 2.5 millionneonates – could be saved through an additionalinvestment of only $7 billion per year.2, 7, 30, iii Toput this level of spending in perspective, it is lessthan 10 percent of what was spent in 2005 ontobacco products in the United States alone.31

Overall, 80 percent of these costs are for pre-venting rather than treating disease.32 Whilesome preventive efforts, like vaccines, are easilyaffordable, others are initially costly but ulti-mately highly cost-effective. The most expensive,expanding access to safe water and sanitation,

can reduce long-term disease incidence andtreatment costs by about 60 percent.33

In the recent past, the interests of mothers andchildren have been forced to compete for a verylimited pool of financial resources and interna-tional attention. Yet, we know that the survival ofmothers, newborns and children is intertwined:all benefit from an essential package of care.34 Thecore interventions to improve child survival(Appendices 1 and 2) form a continuum, fromantenatal care and proper nutrition for pregnantwomen through prevention and treatment ofcommon childhood illnesses. Enabling women tospace births and prevent unwanted pregnancies,and assuring that a skilled attendant is present atbirth are critically important child survival strate-gies. Extending contraceptive services to 200 mil-lion women with an unmet need for family plan-ning is estimated to cost $3.9 billion per year,35

while providing maternal care to 75 percent ofwomen in the 75 highest maternal mortalitycountries would require on average an additional$3.9 billion per year.23 Although these additionalcosts are not insignificant, the combined estimateto provide maternal, newborn and child health aswell as family planning is well within globalcapacity if all actors do their part.

iii This figure is a new cost estimate by Lawn et al., 2007 representing a combination of the child and newborn cost estimates out-lined in The Lancet (365, 2005): $5.1 billion to save 6 million children in 42 countries and $4.1 billion to save 2.7 million neonatesin 75 countries. The new figure estimates the running costs for providing 99 percent coverage of 32 interventions for newborn andchild health in the 60 priority high mortality countries.30


Why Invest in Saving Children’s Lives?

A visible commitment to child health reflectsour most deeply held beliefs and values. A child’srisk of dying before age five was cut in halfbetween 1960 and 1990 due to wide scale-up ofchild survival strategies in many countries.34 Yet,despite low cost and high cost-effectiveness, cov-erage of the key child survival interventionsremains appallingly low in many countries.Child mortality has actually risen in some of thepoorest countries where rapid populationgrowth, poor economic performance, and lowpriority placed on basic public health services,have hindered efforts to reach a larger portion ofthe population with key prevention and treat-ment interventions. High fertility, low productiv-ity and failing economies are all fueled by childdeath and illness, forming a vicious cycle thatcan only be broken through concerted action.

The loss of a child is emotionally devastatingfor any parent, but for those privileged to livewhere the death of a child is a rare event, the fre-quency of loss in the developing world is almostbeyond comprehension. Why should a childborn in Ethiopia today be 20 times as likely todie before age five as a child born in NorthAmerica or Western Europe? Losing 28,000 chil-dren per day when the tools and knowledge toprevent more than half of these deaths are readi-ly available, is neither morally acceptable nor inthe best interests of any individual, nation or theglobal community. Action to improve childhealth reflects deeply held moral beliefs andbasic humanitarian values, including equity, fair-ness and justice. We can, with political will andsound investments, create a world where childdeaths will no longer be considered routine andinevitable.

Investments in Child Health Have Long-termEconomic Payoffs – for Recipient and Donor Countries

While saving children’s lives is a moral issue,the money spent on child health is probably themost cost-effective investment the developedand developing world can jointly make. It wouldprovide more stability and prosperity amongdeveloping nations, and a more equitable worldeconomy.

“Robust findings indicate that more attentionshould be paid to poor health as a mechanism

for the intergenerational transmission ofpoverty ... as [poor children] earn less as

adults which in turn affects the nextgeneration of children who will thus be born

into poorer families.” 36

Health has long been recognized as animportant determinant of human capital andproductivity.37 Poor health, and its attendantphysical and intellectual stunting, hinder theability of a child to attend school or to learn asmuch as a healthy child is capable of learning.Limited education and poor learning have adirect bearing on job potential and earnings.Ultimately, poor child health undermines socie-tal development, while improved health is thefirst step toward enabling children to break outof a cycle of ill-health and poverty that may oth-erwise continue for generations.38 A study quan-tifying this relationship found that for each onepoint decrease in infant mortality, domesticproduct per capita grew by 0.145 percent.39

Childhood illness and death contribute tothe impoverishment of families through expendi-tures on medical care they can ill afford, throughreduced income for other necessities such asfood and education, and through economic pro-ductivity lost in caring for a sick child. The eco-nomic cost of child mortality on lost productivi-

It is time to reset our global development priorities and invest

according to our highest and most universally shared values.


ty has been estimated for Senegal and Uganda,two of the world’s poorest countries, at $1,200per death for each of the 14,000 annual childdeaths in Senegal and the 33,000 in Uganda.38

Comparing this with the average cost of saving achild’s life,30, 32 illustrates that preventing andtreating childhood illness is far less costly in eco-nomic terms and an immeasurable benefit tofamilies and societies.

The Effects of Childhood Illness and Malnutrition Can Last a Lifetime

The first years of life, beginning before birthand continuing to age two, are critically impor-tant, as growth stunting due to malnutrition hasan irreversible effect on the child’s brain andphysical development.19 Unable to reach theirintellectual or physical potential, affected chil-dren are destined to be less productive and lesseconomically successful as adults. Compared tochildren who are neither stunted nor grow up inabsolute poverty, these children face a 20 percentdeficit in income as adults.17

A clear example of the economic cost of failingto safeguard child health is evident among themore than half a million African children who arestricken with cerebral malaria each year. Survivorsoften experience severe anemia and neurologicalcomplications that can permanently impair cogni-tive ability and economic productivity.40 Althoughit is well-documented that providing treatment formalaria before age six has lasting cognitive bene-fits,41 as few as 8 percent of affected children areseen by a health professional.40

The long-term individual, familial, commu-nity and societal costs of child illness and deathshould be taken into account when the price ofinterventions to improve child health are consid-ered.17 Interventions to prevent stunting and itslong-term after-effects are, in fact, simple andhighly cost effective, have long-term benefits onschooling and intelligence tests in adulthood,42

and return up to $3 in additional wages for every$1 invested in improving child nutrition.36

Community-based programs promoting betterchild-feeding practices can reduce stunting andcognitive impairment by 1-2 percentage pointsper year for an annual cost of just $5 to $10 perchild.33

Investments in Child Health Often Pay for Themselves Over Time43

In short, it is difficult to identify a moresound or well-described investment that can bemade in the interest of global development thanto improve child health and survival.

PolioSince 1988, the number of polio casesworldwide has fallen by 99 percent. By2002, the WHO had certified 124 countriespolio-free, and predicts global savings reach-ing $3 billion annually by the year 2015.

Other infectious diseases of childhood For every dollar spent on the diphtheria/tetanus/pertussis vaccine, economists esti-mate a savings of $29; for the measles/mumps/rubella vaccine, $21.


The Global Health Council, the world’slargest membership alliance dedicated to savinglives by improving health, has long recognizedthat the needless death of children is one of thecore global health priorities of our time. TheCouncil supports the rights of all children andfamilies to have access to essential primaryhealth care that is responsive to their core healthneeds. Many organizations and coalition partner-ships throughout the world share this goal withthe Council and are pursuing various efforts tosecure child survival and achieve better healthfor children. Affordable and effective interven-tions for the most common causes of child

deaths must be made accessible to all families,especially those in countries with high childmortality.

The positions that follow articulate theCouncil’s policy and advocacy agenda forimproving child survival and health. These posi-tions are set forth as recommendations to con-cerned policy-makers, as rallying points for theCouncil’s members who work daily to improvechild health, and as a platform for collaborationwith other organizations and coalitions advanc-ing child health.

III. Global Health Council Positions on Improving Child Survival and Health


In 2000, 187 UN member states signed theMillennium Declaration, endorsing eight achiev-able goals to advance global health and develop-ment. Millennium Development Goal (MDG) 4pledged countries to reduce their 1990 child mor-tality rate by two-thirds by 2015.4 Child healthexperts have determined that it is entirely feasibleto save at least 6.6 million children each year byexpanding coverage of existing health interven-tions. The Lancet has published two series on childhealth and neonatal health by these experts, whichprovide a roadmap for what must be done andwhere.iv Several countries are translating the rec-ommendations into concrete actions.v Many moreneed to follow suit if they are to achieve MDG 4.

Building on these efforts, the Countdown to2015 Child Survival Partnership, (CSP) an interna-tional reference group of child health experts hasformed to further and monitor progress to achieveMDG 4. CSP includes the governments of partnercountries, UNICEF, the World Health Organization(WHO), World Bank, the Canadian InternationalDevelopment Agency (CIDA), the United KingdomDepartment for International Development (DFID),the Bill & Melinda Gates Foundation, the U.S.Agency for International Development (USAID),professional associations, academic, research andtechnical institutions and a growing number ofbilateral partners and non-governmental organiza-tions such as Save the Children. The partnershipdoes not disburse funds but encourages all partiesto contribute to improved child health and to makeoptimal use of existing resources to make essentialservices widely available.24

At present, few countries are on track toachieve the two-thirds reduction in 1990 child

mortality by 2015. However, this goal remainsachievable with concerted global investment toreduce child deaths in high mortality countries.

Recommendations:• Donor countries, multilateral assistance

agencies, developing country govern-ments and civil society should support theglobal resource need of an additional $7billion per year as identified by the CSP,and cooperate fully to achieve its goals.

• The widespread shortfall in resources andprogress should be addressed throughcountry-specific partnerships committedto national strategies for achieving MDG 4.

• Partnerships that increase resources forevidence-based programming, sustainstrong political commitment, and encour-age monitoring of results to spur rapidimprovement in child survival should beencouraged and replicated.

A model of leadership and partnership that oth-ers can follow is provided by Norway, which hasbeen a major contributor to the Global Alliance forVaccination and Immunization (GAVI), supportingimmunization coverage for childhood diseases. TheNorwegian aid program, NORAD, is developingpartnerships with select countries to reduce partic-ularly high numbers of children deaths. The firstcollaboration is with India, the country with thegreatest annual number (2.4 million) of childdeaths. The strong political commitment by theNorwegian and Indian prime ministers is viewed asessential to the success of the partnership.44

Position #1Governments, multilateral organizations, private donors and civil society should contributeequitably to partnerships aimed at achieving a two-thirds reduction in the 1990 level ofchild mortality by 2015.

MDG 4 to reduce child mortality [is the] litmustest for our common determination to do businessin a different way and achieve results… Childmortality is a sensitive indicator of economicdevelopment and social inclusion and the distri-bution of resources and services in society.44

iv The Lancet, Volume 361, 2003, and Volume 365, 2005.

v Cambodia, China, Ethiopia, India, Mozambique, Pakistanand Tanzania. Countdown to 2015. Tracking Progress inChild Survival: The 2005 Report.


Presently, all donor spending on child, newbornand maternal health combined ($1.99 billion in2004)vi represents just 2 percent of gross aid dis-bursements to developing countries.46 These exter-nal sources represent only 20 percent of total healthexpenditures in developing countries. By way ofcontrast, twice as many deaths due to preventablecauses occur to children under age five each year ascompared to AIDS, malaria and TB deaths for allages. Yet, far fewer global resources are devoted tochild health than to AIDS and malaria.

Improving the effectiveness of assistancerequires not just more money but “long-term con-sistency in aid commitments.”18 This has not beenthe historical pattern, particularly in Africa.Programs in the 1970s and 1980s that focused onprimary health care and food security were aban-doned as USAID and World Bank assistance toAfrican agriculture dropped by 90 percent duringthe 1990s. The loss of these programs contributedto the present state of famine and food insecurity.18

Developing countries afflicted with high childmortality must both increase their investment inchild health and use their limited resources wisely.For many, this will require a doubling or tripling ofcurrent domestic expenditures for child health.34

India, where nearly 30 percent of all neonatal deathsworldwide take place, has tripled spending on pub-lic heath over four years, from less than 1 percentGDP to nearly 3 percent, emphasizing reducedmaternal and neonatal mortality in rural areas.7

Recommendations:• Donor countries and multilateral assistance

organizations should commit to anincreased and equitable share of meeting theadditional $7 billion per year needed to save6.6 million lives.

• The U.S. government (USG) should be asubstantial partner in this global effort.

Leading by example, the USG should immedi-ately increase its current bilateral programinvestments by $300 million to $660 million,and commit to placing funding for child healthprograms on par with U.S. spending in otherareas of global health. Ultimately, the USGshould increase its contribution to $2 billion per year.

• Private sector donors, including foundationsand corporations, should prioritize increasingaccess to proven, cost-effective interventionsthat will save children’s lives, while sustaininginvestment in new technologies for the mediumto long term.

• Developing country governments shouldincrease domestic child health expenditures tolevels consistent with their commitments toapplicable international agreements, includingto achieve MDG 4 and, for African countries, tomeet the Abuja target of expending 15 percentof the national budget on health.47

• Donors should encourage such investments,especially efforts to improve health among thepoor, through technical assistance, policy dia-logue, and constructive incentives for gains inchild health.

• National governments have responsibility andauthority over strategies for achieving MDG 4.Funding from all sources must be coordinatedat the national level to assure that child healthassistance is effective and streamlined.48 All part-ners should coordinate country efforts underthe aegis of national authority and consistentwith the Three Ones Principle – one countryplan, one coordinating mechanism, and onemonitoring and evaluation strategy.

• Donors, including the United States, shouldcommit stable and secure funding through 2015in order to achieve and sustain targeted reduc-tion in child mortality as developing countriesstrengthen their internal child health deliverysystems.

Position #2Investment in newborn and child health must increase substantially to achieve the goal ofsaving an additional 6.6 million children each year.

vi Most recent data available specifically for child, newborn and maternal health. Includes assistance to 150 developing countries bythe 22 high income donor countries and the European Union represented in the Development Assistance Committee (DAC) of theOrganization of Economic Cooperation and Development, (OECD) as well as the World Bank, UNICEF, UNFPA, the GlobalAlliance for Vaccines and Immunization (GAVI), and the Global Fund to Fight AIDS, TB and Malaria.45


Efforts to reduce child mortality have beenespecially disappointing in sub-Saharan Africa.Among the 30 countries with the highest rates ofchild mortality, 27 are in this region, as are 11 ofthe 15 countries with higher child mortality in2006 than in 1990.49 The decline in mortality forthe entire sub-Saharan region is half that inSoutheast Asia and about a fifth that in LatinAmerica.50

The disparity in child mortality between richand poor is large and increasing, both betweenand within countries.51 The urgency is to deliverthe right interventions to children who needthem most. Health programs aiming to reach thepopulation at large tend to first reach those whoare better off to start with. Demographic andhealth surveys indicate that health interventionsreaching 60-80 percent of those in the highestincome quintile may reach less than 10 percentof the poorest children.2 In Ethiopia, for exam-ple, only one percent of poor women had askilled attendant at birth compared to 25 percentof women in the highest income group.34

Because child deaths are concentrated amongthe poor, attending to the poorest will have thegreatest impact on overall child mortality reduc-tion. While reaching the poor, particularly inrural areas, is challenging, the poorest 40 percentof households are much more likely to benefit ifprograms are strategically pro-poor.51 An explicit“equity focus” on the poor and disadvantagedcan improve health coverage by reaching peoplewhere they live, creating incentives to encouragedemand for services, and including their view-points in program design and implementation.52

The extreme challenge of lowering childmortality in the poorest countries is aggravatedby rapid population growth and low access tofamily planning. In the 60 countries with highestchild mortality rates, the numbers of childrenunder five grew by 37 million (13 percent)between 1996 and 2006. Niger has 34 percentmore children under five than it did just 10 yearsago. The number of women of reproductive agein these countries has also grown by a staggering26 percent.vii These countries should be the focusof far greater attention to improve maternal,child and reproductive health.

Recommendations:• All partners in this effort should commit

to reaching those most in need through afocus on countries or regions with thehighest rates of death and reaching thehighest risk groups, including the poor-est and those in rural and hard-to-reachareas.

• All partners should demonstrate account-ability for reaching the poor through reg-ular monitoring and reporting of equityindicators to the public and decision-makers.53

• In countries experiencing rapid popula-tion growth, investments to improvechild health should reflect the need forexpanded access to high quality familyplanning and reproductive health pro-grams.

Position #3Resources should be targeted to the countries and populations where child mortality isgreatest, based on the criteria of severity and magnitude.

vii Global Health Council calculation based on U.S. Census Bureau data of countries with populations of more than 1 million andchild mortality rates of 50 or more deaths per 1,000 live births.


The core interventions outlined inAppendices 1 and 2 have been demonstrated tobe effective in reducing child mortality. Diseaseburden varies by country and region and fullcoverage of all interventions cannot be instantlyachieved, nor may all be equally needed. Theorder in which interventions are scaled up inindividual countries should be determinedthrough a priority-setting exercise based on thelocal, national and regional disease burden, andin consideration of pro-poor policies to improvehealth equity.

The significant reduction in mortality thatcan be achieved simply through immediate andexclusive breastfeeding has already been high-lighted. Yet in 23 high child mortality countries,less than 20 percent of babies are fully breastfedfor the first six months. These countries shouldbe considered on “high alert” for expandingbreastfeeding awareness and practice.2

Expanding the practice of breastfeeding in thesecountries can be expected to have a large pay-offin reduced neonatal deaths, as well as in signifi-cantly reducing diarrhea and growth stunting,for a minimal investment.54

Through such priority-setting and focus oneffective interventions, even very poor countrieshave made remarkable progress. Child mortalityhas declined 30 percent in Tanzania in the lastfive years following a decision by district healthmanagers to base their budget priorities on localpatterns of death and to increase spending onmaternal health and Integrated Management ofChildhood Illnesses (IMCI).

The Countdown to 2015 Child SurvivalPartnership has tracked the 60 countriesviii with

the highest child mortality rates and numbers ofdeaths. (Appendix 4) It is in these countries that94 percent of all deaths to children under agefive occur.55 Although none of these countrieshave achieved minimum coverage for all or evenmost of the 19 indicators for tracking child sur-vival, six poor countries (Senegal, Nepal, Bolivia,Tanzania, Pakistan and Zambia) are showingprogress.56 In addition, Tanzania and five otherAfrican countries with per capita GNI below$400 – Malawi, Uganda, Eritrea, Burkina Fasoand Madagascar – have succeeded in reducingnewborn deaths by an average of 29 percent over10 years through expanding evidence-basedpractices according to national needs.57

Recommendations:• Donors should immediately increase sup-

port to country-led efforts to developstrategic plans addressing maternal,neonatal and child mortality. Thesestrategies should be cost effective, useintegrated delivery of services rather thanparallel delivery of disease-specific inter-ventions, and aim to expand community-based coverage to complement facility-based services.

• Because nearly 40 percent of deaths takeplace in the neonatal period, all plansshould include specific attention toassure that mothers and newbornsreceive appropriate care during the ante-and post-natal period.

Pneumonia and diarrhea are the two largestkillers of children under five and, in most coun-tries, far more attention should be given to pre-venting and treating these illnesses.11

Position #4Priority should be given to interventions of proven effectiveness, implemented accordingto population-specific assessments of the causes of childhood death and disease.

viii The 60 CSP countries include six large countries with under-five mortality rate less than 40 per 1,000 live births (Brazil, China,Egypt, Indonesia Mexico and the Philippines), but large numbers of death due to large populations of children under five.


Although many of the proven child healthinterventions can be effective even where healthsystems are weak, it is clear that saving morechildren’s lives and sustaining a downward trendin child mortality will require substantial invest-ments to strengthen health systems. The processof expanding many of these services is an oppor-tunity to build human resource capacity andimprove health systems. For example, the WHOestimates that 344,000 new skilled birth atten-dants are needed by 2015 to provide universalcoverage in the 75 high mortality countries.58

Comprehensive human resource plans address-ing training, retraining, staff retention and geo-graphical distribution of health personnel needto be included in the national strategic plan.

Strengthening health systems, particularlydrug and vaccine supply and logistics support, isone of the three components of the IntegratedManagement of Childhood Illness package(IMCI) which aims to reduce gaps in knowledgeamong providers, parents and communities andimprove child health practices. In Tanzania, a 13percent decline in under-five mortality wasachieved in only two years through improvingthe supply of essential drugs; training health

workers to improve the quality of IMCI care atfacilities; and educating parents to recognize ill-ness, manage the sick child at home, and seekcare when appropriate.57

Recommendations:• Partners should ensure that as coverage

of the core child health interventions isscaled up, efforts to improve the broaderhealth system, encompassing personnel,facilities, commodities, information,financing and health insurance or protec-tion from catastrophic illness, are incor-porated to the fullest extent possible.

• Routine collection of meaningful datarequires that health information systemsand trained personnel are also in place. Itis in the interest of all parties to invest instrengthening national strategic healthinformation systems to collect standard-ized, accurate data. Such investment willbuild internal capacity for governmentsto measure their progress in all aspects ofdevelopment, identify obstacles, andenable donors to determine whether theirefforts are contributing to such progress.

Position #5Investments in child health should simultaneously strengthen health capacity for the long term.


On a global scale, capacity to measure indi-cators of health is weak. Tracking progresstoward meeting the Millennium DevelopmentGoals provides an imperative to improve meas-urement and evaluation. Deaths to newborns, forexample, are thought to be significantly underes-timated, and must be counted. Better morbidityand mortality data are needed if progress is to bemeaningfully assessed. Measurement indicatorsmust go beyond numerical targets to assess andevaluate outcomes and impact of investmentsover time.

At the 2005 World Health Assembly, theHealth Metrics Network (HMN) was launched tohelp countries generate data for decision-mak-ing. HMN is the first global partnership com-prised of government ministries of health, multi-lateral, bilateral and private donors, and statisti-cal and technical experts, to focus on strengthen-ing health information systems. The goal of theHMN is to “increase the availability, quality, valueand use of timely and accurate health informa-tion by catalyzing the joint funding and develop-ment of core country health information sys-tems.”59 This network has the potential to assistin tracking progress toward MDG 4 as well as allother aspects of health at the national and globallevel.

Competing donor demands for data collec-tion and analysis currently impose a huge bur-den within countries and programs – a burdenthat undermines the quality, efficiency and effec-tiveness of country programs. HMN partners areselecting a rational set of core health indicatorsthat meet international technical standards andare harmonized with the indicators used in inter-national and global initiatives.

Recommendations:• All parties making efforts to improve

child survival and health should agree ona rational set of key indicators, includingneonatal mortality. Rigorous benchmarksto provide timely and accurate data fordecision-making should be establishedand all parties held accountable for theircontributions.

• All partners should strive to harmonizeresources, avoid duplication of effort, andreduce administrative burden by sup-porting a unified monitoring and evalua-tion plan and using the agreed-uponindicators to track and report upon ontheir progress.

Position #6Progress toward achieving MDG 4 should be scrupulously monitored, regularly reported,and routinely evaluated.


The world can achieve MDG 4 and save anadditional 6.6 million children with the informa-tion and tools we have today. We have affordableand effective solutions, and the indicators tomeasure progress. We have sound estimates ofthe costs. In the global context, the level ofinvestment required is not only entirely feasible,but so easily within current capacity that there islittle cause for debate. Already, creative partner-ships and coalitions like the Countdown to 2015Child Survival Partnership and the Partnershipfor Maternal, Newborn and Child Health have

begun to mark out road maps to success. It is inour best interests as a global society to make themost of this opportunity.

Only political will is needed to prevent mostdeaths to children under the age of five, even inthe poorest countries. And saving at least 6.6million children is just the first step toward thegoal we all share – creating a world where childsurvival can be taken for granted and familieseverywhere are confident that their children willsurvive and thrive.

IV Conclusion

We have all the evidence we need to save more children’s lives. Let us begin.


Appendix 1

Core Interventions to Prevent 6.6 Million Child Deaths60, 61

Preventive interventionsFolic acid supplementationTetanus toxoidSyphilis screening and treatmentPre-eclampsia and eclampsia prevention (calcium supplementation)Intermittent presumptive treatment for malaria in pregnancyAntibiotics for premature rupture of membranesDetection and management of breech (caesarian section)Labor surveillance (including partograph)

for early diagnosis of complicationsClean delivery practicesBreastfeedingPrevention and management of hypothermiaKangaroo mother care (skin-to-skin contact)

for low birth-weight newborns Newborn temperature managementInsecticide-treated materialsComplementary feedingZincHib vaccineWater, sanitation, hygieneAntenatal steroidsVitamin ANevirapine and replacement feeding to prevent HIV transmissionMeasles vaccine

Treatment interventionsDetection and treatment of asymptomatic bacteriuriaCorticosteroids for preterm laborNewborn resuscitationCommunity-based pneumonia case management, including antibioticsOral rehydration therapyAntibiotics for sepsisAntimalarialsZinc for diarrheaAntibiotics for dysenteryVitamin A


Appendix 2

Percentage of Child Deaths Averted by Core Interventionsix

ix Morris S, Black RE, Shibuya K, Cousens S, and Bryce. How many child deaths can we prevent? 2003 update, poster, 2007.

Oral rehydration therapy

Antibiotics: pneumonia + sepsis

Emergency neonatal care

Antimalarials

Zinc

Emergency obstetric care

Antibiotics: dysentery

Vitamin A

Antibiotics: PRoM

0% 2% 6%4% 8% 10% 12%

Breastfeeding (post-NN impact)

Early BF, thermal care & NN hygiene

ITM

Complementary feeding

Skilled maternal & Immed. NN care

Zinc

Measles vaccine

Hib vaccine

Water/San/Hygiene

Vitamin A

Antiretroviral treatment

Extra care for LBW infants

Antenatal steroids

Tetanus toxoid

ANC: exam, eclampsia, syphilis

Rx/Tx aymptomatic bacteriuria

Antibiotics: PRoM

IPT malaria in pregnancy

Periconceptual folic acid suppl.

0% 2% 6%4% 8% 10%

Percent of Total Deaths Averted by Single Interventions – Prevention

Percent of Total Deaths Averted by Single Interventions – Treatment


Nutrition1. Exclusive breastfeeding for six months2. Breastfeeding and appropriate complementary feeding at six-nine months3. Continued breastfeeding at 20-23 months

Vaccination4. Measles immunization coverage5. DPT2 immunization coverage6. Hib immunization coverage

Prevention7. Vitamin supplementation coverage with at least one dose in last six months8. Access to safe drinking water9. Access to sanitation facilities10. Use of insecticide-treated bed net

Newborn Health11. Skilled attendance at birth12. Tetanus toxoid protection at birth13. Timely initiation of breastfeeding (within one hour)14. Postnatal visit within three days after delivery15. Prevention of mother-to-child transmission of HIV

Case Management16. Care seeking for pneumonia17. Antibiotic treatment of pneumonia18. Oral rehydration therapy and continued feeding received19. Anti-malarial treatment

Appendix 3

Global Monitoring Indicators for Tracking Child Survival56


STATUS TARGET

Under-5 Under-5 Estimated MDG target Average annual ratemortality mortality average annual under-5 of reduction needed

rate rate rate of reduction mortality rate between 2004 and1990 2004 1990-2004 2015 2015 to meet target

Afghanistan 260 257 0.1 87 9.9Angola 260 260 0.0 87 10.0Azerbaijan 105 90 1.1 35 8.6Bangladesh 149 77 4.7 50 4.0Benin 185 152 1.4 62 8.2Botswana 58 116 -5.0 19 16.3Brazil 60 34 4.1 20 4.8Burkina Faso 210 192 0.6 70 9.2Burundi 190 190 0.0 63 10.0Cambodia 115 141 -1.5 38 11.8Cameroon 139 149 -0.5 46 10.6Central African Rep 168 193 -1.0 56 11.2Chad 203 200 0.1 68 9.8China 49 31 3.3 16 5.8Congo 110 108 0.1 37 9.8Congo, Dem Rep 205 205 0.0 68 10.0Côte d’Ivoire 157 194 -1.5 52 11.9Djibouti 163 126 1.8 54 7.7Egypt 104 36 7.6 35 0.3Equatorial Guinea 170 204 -1.3 57 11.6Ethiopia 204 166 1.5 68 8.1Gabon 92 91 0.1 31 9.9Gambia 154 122 1.7 51 7.9Ghana 122 112 0.6 41 9.2Guinea 240 155 3.1 80 6.0Guinea-Bissau 253 203 1.6 84 8.0Haiti 150 117 1.8 50 7.7India 123 85 2.6 41 6.6Indonesia 91 38 6.2 30 2.1Iraq 50 125 -6.5 17 18.3Kenya 97 120 -1.5 32 11.9Liberia 235 235 0.0 78 10.0Madagascar 168 123 2.2 56 7.2Malawi 241 175 2.3 80 7.1Mali 250 219 0.9 83 8.8Mauritania 133 125 0.4 44 9.4Mexico 46 28 3.5 15 5.5Mozambique 235 152 3.1 78 6.0Myanmar 130 106 1.5 43 8.1Nepal 145 76 4.6 48 4.1Niger 320 259 1.5 107 8.1Nigeria 230 197 1.1 77 8.6Pakistan 130 101 1.8 43 7.7Papau New Guinea 101 93 0.6 34 9.2Philippines 62 34 4.3 21 4.5Rwanda 173 203 -1.1 58 11.4Senegal 148 137 0.6 49 9.3Sierra Leone 302 283 0.5 101 9.4Somalia 225 225 0.0 75 10.0South Africa 60 67 -0.8 20 11.0Sudan 120 91 2.0 40 7.5Swaziland 110 156 -2.5 37 13.2Tajikistan 128 118 0.6 43 9.2Tanzania, United Rep 161 126 1.8 54 7.8Togo 152 140 0.6 51 9.2Turkmenistan 97 103 -0.4 32 10.5Uganda 160 138 1.1 53 8.6Yemen 142 111 1.8 47 7.8Zambia 180 182 -0.1 60 10.1Zimbabwe 80 129 -3.4 27 14.3

Appendix 4

Sixty High Child Mortality Countries and their Progress Toward Meeting MDG 42


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9 Bernstein S, Hansen CJ. Public choices, private decisions:sexual and reproductive health and the MillenniumDevelopment Goals. New York: U.N. Millennium Project.2006.

10 Jamison DT, Breman JG, Measham AR, et al, editors.Priorities in health. Washington D.C.: The World Bank.2006.

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Notes

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