1. Meeting Unmet Needs in Child Survival USAID Bureau for Global Health

2. 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

3. Slowing Reduction in Under 5 Mortality Source: UNICEF Time Series Estimates, 2000.

4. Objectives of Analysis Are we investing in the correct areas? Is there a need for any strategic program changes?

5. 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?

6. Methodology Review of literature Special study of services and health behaviors using DHS data Consultation with experts in child survival interventions

7. Are there additional technical areas that need to be addressed?

8. HIV 4% ARI 20% Others 28% Diarrhea 12% Malaria 8% 22% Measles 5% Main Causes of U5M: 1990 and 2000 Measles 11% Neo-natal tetanus 6% Malaria 7% Diarrhea 28% Others 29% ARI 15% Whooping cough 4% 19902000 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

9. HIV 4% ARI 20% Others 28% Diarrhea 12% Malaria 8% 22% Measles 5% Main Causes of U5M: 1990 and 2000 Measles 11% Neo-natal tetanus 6% Malaria 7% Diarrhea 28% Others 29% ARI 15% Whooping cough 4% 19902000 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%

10. Increasing Proportion of Neonatal Mortality Based on State of the World’s Newborns, State of the World’s Children 2001, WHO Publications

11. 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.

12. Water and Sanitation Access to safe drinking waterAccess to sanitary means of excreta disposal Source: UNICEF, The state of world’s children, 2002

13. Are there identifiable geographic areas of greatest unmet need?

14. High Infant Mortality Countries Source: IMR data from UNICEF

15. U5M Rate Changes 1990-2000

16. Within Country Differences in U5 Mortality Rates (India) Source: NFHS 1998-99

17. Urban Slums: Among the most deprived Source: DHS and Urban Health Study, 2001

18. Are there particular characteristics of children or their families that help predict or identify unmet need?

19. U5 Mortality Rates by Wealth Quintiles Source: World Bank and DHS

20. EPI Immunization* Coverage b y Wealth Quintiles Source: World Bank and DHS * Coverage in children 12-23 months old

21. Percent Children Underweight* by Wealth Quintiles * Below -2 sd z-score, weight for age, children under 5 years Source: World Bank and DHS

22. Differences in U5 Mortality by Gender, Caste & Religion (India) GenderCasteReligion Source: NFHS 1998-99

23. Differences in U5 Mortality by Mother’s education Source: Demographic and Health Surveys for indicated year

24. Correlation Among Various 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?

25. Target Unmet Need Poor Rich Program Coverage Current Coverage Additional investments in current approach Equity Enabling Efforts

26. 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:

27. Resource Allocation Allocate resources more strategically

28. Target Unmet Need Map and identify unmet need Learn how to best target programs to reduce disparities Monitor effectiveness of targeting

29. 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

30. Health Seeking Behavior Among 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%)

31. Include Poverty Approach Develop and monitor disparity indicators Develop new tools and strategies to address health of urban poor

32. 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:

33. Strategic Approaches Place more emphasis on neonatal health and nutrition Link new child health interventions to existing programs

34. Strategic Approaches Look for intersectoral synergies Protect basic child health services in HIV endemic areas and prevent MTCT

35. Conclusions Impressive gains but daunting challenges remainImpressive gains but daunting challenges remain Progress has slowed in recent yearsProgress has slowed in recent years To accelerate mortality declines, key actions are:To accelerate mortality declines, key actions are:

36. 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