ReviewThe unfinished agenda in child survival
Introduction
In June, 2003, The Lancet published a Series of five papers about child survival that brought together three streams of work.1, 2, 3, 4, 5 The Series was conceived during a meeting in Bellagio, Italy, in 2002. The authors' intent was to encourage rethinking about global child health strategies by assembling new evidence about the causes and distribution of child deaths, and how the interventions available to address those causes could be delivered to achieve high, sustained, and equitable coverage and effects on mortality. At that time, the Child Health Epidemiology Reference Group (CHERG) had been working since the late 1990s to improve estimates of the cause-specific distribution of under-5 deaths,6 the Multi-Country Evaluation of the Integrated Management of Childhood Illness was producing results from countries,7 and the Child Health Equity Working Group was producing new analyses of inequities in service access, coverage, and effect.8 The scientists working in these three areas came together to address what they considered to be a global public health emergency: decreasing priority for child survival and insufficient funding for proven intervention programmes to reduce child mortality. In this Review, we give our insights on progress and missed opportunities in the decade since the original Series was published. We focus on the themes of the five original Series articles: epidemiology; interventions and intervention coverage; strategies of health programmes; equity; and accountability, leadership, and resources. Additionally, we discuss developments in relevant data, methods, and directions for child health in the post-2015 era.
Section snippets
Changes in epidemiology
The absolute number of under-5 deaths has fallen substantially since 2000. The total number of child deaths has decreased from 10·8 million in 2000 to 7·6 million in 2010,9 which is especially remarkable in view of the 7% increase in the number of children younger than 5 years in less developed countries during this period. If mortality rates from 2000 had persisted, nearly 11·6 million children would have died in 2010. More than 99% of these deaths continue to happen in low-income and
Changes in interventions, coverage, and underlying assumptions
In 2003, we examined interventions that were feasible for delivery at high and sustained levels of coverage in low-income settings. We classified them on the basis of evidence available at that time of their effectiveness in reducing child mortality due to diarrhoea, pneumonia, measles, malaria, HIV/AIDS, undernutrition, and a small group of causes of neonatal deaths.2 The results showed that if high-impact interventions were universally available, 63% of under-5 deaths could be prevented.
We
Changes in strategies of health programmes
In 2003, the Bellagio group attributed low coverage levels to weaknesses in both the provision of and demand for services, and to malfunctioning health systems.3 At that time, the prevailing child survival strategy was the Integrated Management of Childhood Illness (IMCI), a gold-standard clinical approach for provision of care for sick children in first-level health facilities in countries where the main causes of death are pneumonia, diarrhoea, and malaria. A scarcity of attention to deaths
Changes in equity
The paper about equity in the original child survival series aimed to heighten awareness of the importance of monitoring and incorporation of equity in policies and programmes.4 Before 2000, concerns about within-country inequalities were almost completely absent from the global scientific literature about child survival, and the MDGs were criticised for ignoring within-country inequalities.57
Much progress has been made in the past 10 years. The various dimensions of inequalities are now
Changes in evidence and methods
One of our key messages in 2003 was the need for more and better data for child health epidemiology, for accurate measures of coverage change and for independent, rigorous evaluations of programmes being implemented at scale.5 What score has the global public health community earned in these areas?
Important progress has been made in country-level estimation of neonatal, infant, and under-5 mortality.64 Methodological work on how to measure under-5 mortality in real-time,65 experience with
Accountability
The commitment to accountability made in the final paper of the 2003 series5 has been realised in Countdown. Countdown has become a supra-institutional movement that brings together a broad range of academics, UN agencies, non-governmental organisations, and Ministries of Health to focus on holding countries and their partners accountable for achievement of equitable gains in coverage for proven interventions. Every 2–3 years since 2005, and now annually, Countdown publishes a set of country
References (105)
- et al.
Where and why are 10 million children dying every year?
Lancet
(2003) - et al.
How many child deaths can we prevent this year?
Lancet
(2003) - et al.
Reducing child mortality: can public health deliver?
Lancet
(2003) - et al.
Applying an equity lens to child health and mortality: more of the same is not enough
Lancet
(2003) - et al.
Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000
Lancet
(2012) - et al.
Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world
Lancet
(2007) - et al.
Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries
Lancet
(2011) - et al.
Maternal and child undernutrition: global and regional exposures and health consequences
Lancet
(2008) - et al.
Maternal and child undernutrition and overweight in low-income and middle-income countries
Lancet
(2013) - et al.
Patterns in coverage of maternal, newborn, and child health interventions: projections of neonatal and under-5 mortality to 2035
Lancet
(2013)
Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis
Lancet
Child survival gains in Tanzania: analysis of data from demographic and health surveys
Lancet
The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach
Lancet
Can the world afford to save the lives of 6 million children each year?
Lancet
Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost?
Lancet
Understanding careseeking for child illness in sub-Saharan Africa: a systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria
Soc Sci Med
Maternal and child undernutrition: consequences for adult health and human capital
Lancet
Universal health care and the removal of user fees
Lancet
H_pe for mHealth: more “y” or “o” on the horizon?
Int J Med Inform
The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015 Lancet and London International Development Centre Commission
Lancet
Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition
Lancet
Stillbirths: Where? When? Why? How to make the data count?
Lancet
Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis
Lancet
National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications
Lancet
Gaps in policy-relevant information on burden of disease in children: a systematic review
Lancet
How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys
Lancet
Measuring impact in the Millennium Development Goal era and beyond: a new approach to large-scale effectiveness evaluations
Lancet
Getting it right for children: a review of UNICEF joint health and nutrition strategy for 2006–15
Lancet
The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015 Lancet and London International Development Centre Commission
Lancet
The politics of reducing malnutrition: building commitment and accelerating progress
Lancet
The case for a new Global Fund for maternal, neonatal, and child survival
Lancet
Knowledge into action for child survival
Lancet
Child Health Epidemiology Reference Group Available
Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness
Health Policy Plan
Child health: reaching the poor
Am J Public Health
Under-five mortality dashboard
Trends in under-five mortality rates, 1960–2011
World development report 2005: a better investment climate for everyone
A framework for action
A global review of the key interventions related to reproductive, maternal, newborn and child health (RMNCH)
Evaluation of long-lasting insecticidal nets after 2 years of household use
Trop Med Int Health
Cost and cost effectiveness of long-lasting insecticide-treated bed nets - a model-based analysis
Cost Eff Resour Alloc
Field issues related to effectiveness of insecticide-treated nets in Tanzania
Med Vet Entomol
Evidence for a useful life of more than three years for a polyester-based long-lasting insecticidal mosquito net in Western Uganda
Malar J
Rotavirus vaccine and diarrhea mortality: quantifying regional variation in effect size
BMC Public Health
LiST as a catalyst in program planning: experiences from Burkina Faso, Ghana and Malawi
Int J Epidemiol
Accountability for maternal, newborn & child survival: the 2013 update
Social, economic, political and health system and program determinants of child mortality reduction in China between 1990 and 2006: a systematic analysis
J Glob Health
Strategies for integrating primary health services in middle- and low-income countries at the point of delivery
Cochrane Database Syst Rev
Strategies for integrating primary health services in low- and middle-income countries at the point of delivery
Cochrane Database Syst Rev
Cited by (53)
Effect of a mass radio campaign on family behaviours and child survival in Burkina Faso: a repeated cross-sectional, cluster-randomised trial
2018, The Lancet Global HealthCitation Excerpt :Scenario-based projections suggest that, to achieve the Sustainable Development Goal (SDG) target of 25 or fewer under-5 deaths per 1000 livebirths by 2030, about two-thirds of all sub-Saharan African countries will need to accelerate progress in reducing under-5 deaths.1 Poor coverage of effective interventions for preventing child deaths has been attributed to weaknesses in both provision of and demand for services.2 While much effort towards achieving the Millennium Development Goals has focused on health systems and the supply side,3 including community case management of childhood illnesses,4,5 less attention has been paid to increasing demand for services.
Sources of variation in under-5 mortality across sub-Saharan Africa: a spatial analysis
2016, The Lancet Global HealthCitation Excerpt :Nevertheless, the relative contribution of within-country and between-country differences in explaining under-5 mortality remains unknown. Improved understanding of the relative contribution of national and sub-national factors could provide insight into the drivers of mortality levels and declines in mortality, as well as improve the targeting of interventions to the areas where they are most needed.16 Evidence before this study
Determinants and morbidities of multiple anthropometric deficits in southwest rural Ethiopia
2016, NutritionCitation Excerpt :Nevertheless, this finding was similar to the study conducted in India [23], indicating that experiencing two or more anthropometrical failures is the key challenge in developing countries. Factors contributing to the high occurrence of anthropometrical failures in developing countries are low utilization of health services, poor sanitation, and lack of commitment and accountability to address child nutrition [26–29]. Global and regional nutrition programs should design strategies to create awareness in the scientific communities and policymakers about classification of undernutrition and multiple anthropological failures.
Countdown to 2030 for reproductive, maternal, newborn, child, and adolescent health and nutrition
2016, The Lancet Global HealthPredictors of stillbirths and neonatal deaths in rural western Uganda
2016, International Journal of Gynecology and ObstetricsPrevalence of neonatal near miss in Africa: a systematic review and meta-analysis
2023, International Health