1. Keeping promises, Measuring results: Global overview of progress in achieving MDG 4
Dr Bernadette Daelmans
Coordinator, Policy, Planning and Programmes
Department of Maternal, Newborn, Child and Adolescent Health
Family, Women and Children's Health Cluster
World Health Organization

2. Promises
Adoption of the Millennium Declaration countries endorsing 8 Millennium Development Goals (2000)
2005: Start of Countdown to 2015: Tracking progress in maternal, newborn and child survival & Launch of the Partnership for Maternal, Newborn & Child Health (PMNCH)
G8 Muskoka initiative - commitment of US$ 7.3 billion in new and additional funding for MDGs 4 and 5 (2008)
UN Secretary General's Global Strategy for Women's and Children's Health (2010)
Commitments to implement the strategy of over US$ 40 billion
Commission on Information and Accountability for Women's and Children's Health - 10 recommendations and global oversight (2011)

3. These are silent tragedies that have to be prevented
A great challenge ….
EVERY YEAR:
7.6 million children die before their 5th birthday
3.2 million newborn babies in the first month of life
2.4 million infants between 1 – 12 months
356,000 women die due to complications of pregnancy and childbirth
3 million stillbirths
These are silent tragedies that have to be prevented

4. MDG 4: progress too slow

5. 7.6 million children die from preventable causes every year
On track
Insufficient progress
No progress/reversal
No data
Insufficient progress, particularly in sub-saharan Africa and Asia
Point out that there is still a high number of countries in Africa that are showing no progress or even reversal in progress towards MDG 4
Source: Levels & Trends in Child Mortality, Report 2010 and WHO / UNICEF / UNPD / World Bank, 5 5

6. We know the why …

7. Malnutrition: a major contributing cause

8. We know when.. 75% of neonatal Up to 50% deaths occur in of neonatal
the first week
Up to 50%
of neonatal
deaths occur in
the first 24 hours
Source: Levels and Trends in Child Mortality, UN-IGME Report 2011

9. Maternal mortality in 2008; average annual decline - 1990 to 2008
MDG 5: progress too slow
Maternal mortality in 2008; average annual decline to 2008
MMR (2008)
(uncertainty interval)
Maternal deaths (n) (2008)
Average annual decline (%)
World total
260 (200, 370)
358,000
2.3 (2.1, 2.4)
Developed regions
14 (13, 16)
1700
0.8 (0.6, 1.0)
Countries of the CIS
40 (34, 48)
1500
3.0 (2.8, 3.1)
Developing regions
290 (220, 410)
355,000
2.3 (2.2, 2.5)
North Africa
92 (60, 140)
3400
5.0 (4.8, 5.1)
Sub-Saharan Africa
640 (470, 930)
204,000
1.7 (1.4, 1.9)
Asia
190 (130, 270)
139,000
4.0 (3.9, 4.1)
Latin America and the Caribbean
85 (72, 100)
9200
2.9 (2.6, 3.3)
Oceania
230 (100, 500)
550
1.4 (1.2, 1.3)
MDG TARGET
* Numbers are rounded

10. Effective interventions are available …
Preventive interventions
Skilled care at birth
Postnatal care for all newborns
Early initiation and exclusive breastfeeding for 6 months
Complementary feeding
Immunization
Insecticide treated bed-nets
Prevention of mother to child transmission of HIV
Treatment interventions
Neonatal resuscitation
Extra care of LBW babies
Treatment of neonatal sepsis
ORT and zinc for diarrhoea
Antibiotics for dysentery
Antibiotics for pneumonia
Anti-malarials
Antiretroviral treatment

11. But coverage is low…
Pre-pregnancy  Pregnancy  Birth  Postnatal  Neonatal  Infancy  Childhood
But what is still going wrong?
We know the effective interventions and these interventions are being adopted and promoted by many of the countries in the world.
A key part of the explanation of our inability to be more successful is shown in this slide. Improving maternal and child health requires coverage of high impact interventions all along the continuum of care. The latest report from the Countdown to 2015 shows coverage levels in the 68 high mortality countries monitored by the Countdown. While rates tend to be higher for immunizations, they are very low for newer interventions (insecticide treated bed nets) and for those that depend on curative services (for diarrhoea, pneumonia, and malaria) and 24 hr. access to care (providing emergency child birth services such as caesarean sections). Exclusive breastfeeding rates remain low and less than 40% of mothers receive a postnatal visit.
Median national coverage levels for 19 Countdown interventions and approaches, most recent estimate since 2000

12. And decreasing in many countries
Source: Boschi-Pinto et al. JHPN 2009

13. Inequities are great
The situation gets even clearer in terms of the lack of coverage with interventions when we look at coverage according to quintiles of wealth. The worst case in this analysis is for access to skilled birth attendants. It was 3-fold higher among the families in the highest wealth quintile than in the lowest. Those who need the most often get the least.
Source: 42 countdown countries, survey data

14. The good news …
Good news! 19 of 68 Countdown countries on track to achieve MDG4
17 countries have reduced child mortality by at least 50%
47 countries have accelerated progress since 2000
Bullet 2: Give examples of countries with large declines. 14

15. The good news …
Good news! 5 Countdown countries are on track to achieve MDG 5 and 32 countries are making progress
However, progress is insufficient especially in sub-Saharan Africa
For every woman who dies there are 20 who suffer injuries, infection and disability

16. Driving progress: The continuum of care

17. And working together Maternal mortality Under-5 mortality
Malaria in the World
HIV Global burden I 17

18. From research to action: community care
1. Cluster-RCT in 6 districts of central Ghana: Effect of home visits during pregnancy and postnatal period by CHW
Preliminary results: moderate improvement in early and exclusive breastfeeding; mortality impact 8-14% but not statistically significant
2. Cluster-RCT in Hala, Pakistan: Effect of community-based interventions
Results: 15% reduction in neonatal mortality, 21% reduction in stillbirths

19. From research to action: IMNCI
3. Cluster-RCT in one district in India to evaluate mortality impact of IMNCI
Preliminary results: 18% reduction in IMR, 13% in NMR
4. Country-wide evaluation on mortality impact of IMCI implementation in Egypt
Preliminary results: Annual rate of mortality decline 6.3% after IMCI implementation compared with 3.3% before IMCI

20. From research to action; Diarrhoea, Pneumonia and Fever
5. Cluster-RCT in Pakistan to evaluate community management of severe pneumonia
Preliminary results: CHW can effectively treat severe pneumonia (chest indrawing) with oral amoxycillin
6. Multi-country RCT to evaluate short-course treatment for meningitis in children
Preliminary results: 5-day treatment of meningitis is as effective as 10-day treatment
7. Cluster-RCT in India to evaluate effectiveness of zinc plus ORS for diarrhoea in infants aged less than 6 months
Results: Zinc and ORS use for treatment of acute diarrhoea reduced prevalence of diarrhoea and pneumonia by about 40%

21. The way forward By 2015: Saving 16 million lives of women and children
Preventing 33 million unwanted pregnancies
Protecting 88 million children from stunting
Protecting 120 million children from pneumonia

22. action is urgently needed
Key areas where
action is urgently needed
Support to country-led health plans
Integrated delivery of quality health services and life-saving interventions
Stronger health systems, with sufficient skilled health workers at their core
Innovative approaches to financing, product development and the efficient delivery of health services
Promoting human rights, equity and gender empowerment
Improved monitoring and evaluation to ensure the accountability of all actors for resources and results
First product to examine the nature of Global Strategy commitments
-launched at high-level EWEC panel session at UNGA in Sept 2011 and now distributed to all PMNCH members and via website
-launched with dedicated media campaign that resulted in more than 250 articles, including in the Washington Post Guardian and scientific journals such as Nature
2011 Report:
Reports on implementation of financial, policy and service delivery commitments, incl. by the business community
Successfully launched in September 2011 on 1st anniversary of Global Strategy, at the UN General Assembly with extensive media coverage
Detailed description of commitments (e.g. start date, content, and anticipated milestones) to:
Provide a “baseline” for future tracking
Document early “success stories”
Content analysis at aggregate level of 90+ commitments to:
Analyze geographic focus & focus across continuum of care
Identify constraints related to implementation to date and areas for increased effort and mobilization
Support country-led health plans and financing
Promote essential interventions, strengthen systems, and improve integration across the MDGs
Innovative approaches to financing, product development and the efficient delivery of health services
Promote human rights and equity
Strengthen accountability for results and resources for women's and children's health 22 22

23. MNCAH CORE PACKAGES ALONG THE TWO CONTINUA OF CARE
GUIDELINES & POLICIES
Guideline products: critical for policy adoption of the new guideline
Technical update: specific changes needed in implementation tools in response to the new guideline
STRATEGIC PLANNING
PROGRAMME MANAGEMENT CAPACITY
HEALTH FACILITY
COMMUNITY LEVEL CAPACITY
M & E
CAPACITY
REFERRAL LEVEL CAPACITY
FIRST LEVEL CAPACITY
MATERNAL
Strategic planning tool for MNCAH including rights
(IT* 1)
Programme managers course for MNCAH including nutrition
(IT* 2)
Managing Complications of Pregnancy and Childbirth (IMPAC) (IT* 3)
PCPNC training package (IMPAC)
(IT* 6)
CHW training package for MNCH, including community mobilization and participation (IFC) (IT* 10)
Short programme reviews (M,C,A including rights)
(IT* 12)
Household Survey for MNCAH (IT* 13)
MNCAH Health facility Survey (IT* 14)
MNCAH SARA (IT* 15)
NEWBORN
Pocketbook for managing newborn problems (IT* 4)
Essential Newborn Care Course
(including NR and Young Infant IMCI)
(IT* 7)
CHILD
Pocketbook for hospital care of children (IT* 5)
IMCI training package (IT* 8)
ADOLESCENT X
Orientation Programme (IT* 9)
Counselling materials for teachers, parents etc (IT* 11)
IT* = Implementation tool to be used as the primary delivery mechanism in countries
Green font: Does not require an immediate update
Blue font: Requires moderate work for update/merging
Red font: Requires major work for update/development

24. Academic /research institutions
All have a role to play
Govt / Policy makers
Parlia-mentarians
UN agencies
Women and children
Health care workers
Business community
Academic /research institutions
Donors
Civil society 24

25. Commitments made
93 commitments made in 2010 amounting to over US$ 40 billion
39 Low-income countries; 21 NGOs; 15 high income countries;
14 foundations; 14 business community
Many new commitments were announced at the Every Woman Every Child first –year anniversary.
29 Low-income countries; 4 high income countries; 12 UN and partnerships; 2 philanthropic institutions; 40 NGOs & civil society; 15 business community; 11 HCW and academic institutions
Graphs of commitments:

26. Accountability
Commission established by UN Secretary General in Jan 2011
Co-chaired by President of Tanzania and Prime Minister of Canada
Supported by 2 working groups: results and resources
Commission's report released in May 2011
Ten recommendations to monitor results and track resources
Unprecedented opportunity to strengthen national health information systems and to hold each other to account

27. Action can be taken now
Strengthen health systems and improve quality of health services
Bring health services closer to homes
Improve measurement and use of data

28. Together, we must do better