Elsevier

The Lancet

Volume 382, Issue 9897, 21–27 September 2013, Pages 1049-1059
The Lancet

Review
The unfinished agenda in child survival

https://doi.org/10.1016/S0140-6736(13)61753-5Get rights and content

Summary

10 years ago, The Lancet published a Series about child survival. In this Review, we examine progress in the past decade in child survival, with a focus on epidemiology, interventions and intervention coverage, strategies of health programmes, equity, evidence, accountability, and global leadership. Knowledge of child health epidemiology has greatly increased, and although more and better interventions are available, they still do not reach large numbers of mothers and children. Child survival should remain at the heart of global goals in the post-2015 era. Many countries are now making good progress and need the time and support required to finish the task. The global health community should show its steadfast commitment to child survival by amassing knowledge and experience as a basis for ever more effective programmes. Leadership and accountability for child survival should be strengthened and shared among the UN system; governments in high-income, middle-income, and low-income countries; and non-governmental organisations.

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

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