The authors of Countdown to 2015 decade report 2000-10, led by Prof Zulfiqar Bhutta of Aga Khan University, and Dr Mickey Chopra, UNICEF, New York, USA, found that nearly three-quarters of the 68 countries in which more than 90 per cent of child under-five deaths occur are showing accelerated progress in reducing child mortality. But maternal mortality remains high and is showing fewer signs of progress. In the report, appearing in the Women Deliver Special Issue of The Lancet, Brazil and China are highlighted as countries on track to meet the targets set out in MDG4 and MDG5.
MDG4 requires reduction of child under-five mortality by two thirds between 1990 and 2015; while MDG5 asks countries to reduce their maternal mortality by three quarters over the same period. Despite three-quarters of the 68 Countdown countries showing accelerated progress, only 19 are on track to meet MDG4 —including Brazil, China, Mexico, Peru, Nepal, Egypt, Malawi, and Turkmenistan. Across the 68 countries child under-5 mortality fell from 90 deaths per 1000 live births in 1990 to 65 in 2008, a 28 per cent reduction.
The report states: “Wide and persistent disparities exist in the coverage of interventions between and within countries, but some regions have successfully reduced long-standing inequities. Coverage of interventions delivered directly in the community on scheduled occasions was higher than for interventions relying on functional health systems.” Examples of such community interventions include vitamin A supplementation, vaccination against tetanus, whooping cough and diphtheria, and complementary feeding.
Services that are on-demand or require health-system strengthening, such as skilled attendant at birth, postnatal visits, antibiotic treatment, continue to be major obstacles to Countdown progress. Latest estimates from 2008 show that only 22 per cent of the 68 Countdown countries met the minimum threshold of 23 physicians, nurses, and midwives per 10 000 people that was established by WHO as necessary to deliver essential health services. Cost-effective ways to overcome this include use of community workers to deliver treatments, and there is promising progress here. In 2010, 29 countries had a policy allowing community-based health workers to manage pneumonia with antibiotics compared with 18 in 2008.
The median per head total health expenditure in 68 countries is a mere 80 dollars (2007 figure based on US dollar value); only five Countdown countries are devoting 15 per cent or more of their national budgets to health, and only five countries have household out-of-pocket expenditures of less than 15 per cent. The report says: “The goal is to move away from out-of-pocket payments through several approaches including development of prepayment and risk-pooling schemes.”
Dr Bhutta says that the global comparative indicators in the Countdown Report suggest that in contrast to many neighboring countries, Pakistan has made very little progress in reducing maternal, newborn and child mortality over the last decade. Coverage rates of key interventions, notably those that address care during pregnancy and childbirth, remain slow. Although Pakistan has ample health care professionals in urban populations, coverage rates and access to care for the rural poor remain abysmally low. Without a concerted focus on making maternal, newborn and child health a national priority and attention to reaching the poor, Pakistan is unlikely to reach the Millennium Development Goal targets and commitments to reduce the burden of maternal and child deaths.
Meanwhile, Brazil has made progress through reducing socioeconomic inequities and improving primary coverage to almost universal levels. Nowadays, almost all pregnant women in Brazil have access to a skilled birth attendant. China’s successful reduction of newborn and child mortality during the past two decades is a remarkable example of progress through steady investments in reproductive health, primary care, and economic development.
The authors say: “In the two years since the last Countdown report, 19 million women of childbearing age and children younger than five years have died because of preventable disorders. Pneumonia, diarrhoea, and malaria still kill more than three million children every year, and our report shows that the long-established treatments for these infections still do not reach half of the children who need them.”
They conclude: “Notwithstanding the limitations of health systems in provision of maternal health services such as family planning, skilled delivery, and emergency obstetric care, social determinants also act as an important barrier to universal coverage. Families need access to rapid transportation to functional facilities when danger signs occur during labour, delivery, and the immediate postpartum period. Increased education of women, improved sex equality, comprehensive family planning services so that women can space or limit births, and strengthening of women’s empowerment in decision making about seeking care are essential elements of strategies to improve maternal health and to reduce neonatal and child deaths.”