1. Accelerating Progress on the MDGs
Informal Meeting on the Preparation of the 2010 HLPM on the MDGs
8 March 2010
New York

2. MDG 4. Under 5 Mortality has fallen below 9 million, but achieving MDG4 is still far off
Under 5 mortality, i.e. the number of children dying before their 5th birthday has steadily declined in the past decades. In fact, between 1960 and 2008, the number of child deaths has more than halved, from 20 million in 1960 to less than 9 million (8.8m) in 2008.
Since 1990, the baseline year for MDG4, child deaths have decreased by about 30% from 12.7 million to 8.8 million. That is great progress. But it is not enough. MDG4 calls for a 2/3 reduction since 1990, so we are only halfway. To achieve MDG4, we must reduce child deaths with another 50% (compared to 2008 levels), to bring it down to 4.3 million by 2015.

3. Progress has not been evenly distributed among regions
This graph illustrates the progress by region.
Currently (2008 data) about half of the 8.8 million children dying every year live in Africa, while only 22% of worldwide births occur on that continent.
Around 40% of all child deaths occur in Asia.
In Sub-Saharan Africa, 1 child out of every 7 children will die before the age of 5 (U5MR 2008: 144 per 1000)! In South Asia one out of every 13 (U5MR: 76 per 1000). Compare that to the industrialized world, where the same will happen to 1 child in every 165 children (U5MR 6 per 1000). That all goes to say that we have made a lot of progress, but that the progress has not been evenly distributed among countries and regions. And that we must work hard, especially in Africa and South Asia to save more lives if we are to achieve MDG4. 3

4. Equity gaps in under-five mortality, by region of the world
Figure 6. Equity gaps in underfive mortality, by region of the world.
Whereas the progress has not been even between regions, also WITHIN regions and countries, we see large differences in child mortality between rich and poor.
As this slide shows, in all regions, child mortality is far higher among poorer families than among richer ones. On the slide, the blue extreme on each bar indicates the richest quintile of the population, while the red extreme is are the poorest 20%. In all cases so we see that mortality among poor families (red) is far higher than among rich ones, plus that the mortality gap between rich and poor (indicated by the length of each bar) is largest in the regions where overall child mortality is highest: Sub-Saharan Africa and South Asia.
This indicates a double equity issue: children living in South Asia or Africa have a much higher chance of dying before the age of five, and among those, it are the children of the poorest families who will suffer most.
Source: DHS analyzed by World Bank PovertyNet 4

5. Overall progress in reducing under-5 mortality BUT little progress in reducing newborn deaths
There have been significant and continuous reductions in mortality in children under 5 as we can here on this slide looking at the blue line.
Unfortunately there has been much less decrease in newborn deaths – the light blue and yellow bars.
For the early newborn deaths – those occurring the first week of life – the yellow bars in this slide – we can say that there has been virtually no progress.
If we want to achieve MDG 4, however, will have to address newborn health and survival.
Note: newborn deaths are deaths occurring in the first month of life. Early newborn deaths are those in the first week of life (the yellow bars).
Source: Lawn JE et al, Lancet 2005

6. Pneumonia and Diarrhoea together account for more than one third of child deaths (including during the neonatal period)
Globally, more than one third of child deaths are attributable to undernutrition
Source: World Health Organization, 2008
Source: World Health Organization, 2008. 6

7. Measles-related deaths among children decreased from 733,000 in 2000 to 164,000 in 2008
Number of Measles Deaths , by MDG region
Companion handout
The global number of measles-related deaths among children decreased from 733,000 in 2000 to 164,000 in 2008 (WHO, 2009). It goes without saying that this will have a big impact on the progress towards the MDG4.
Africa was by far the biggest contributor to this decline. What happened?
With so many children dying of measles a decade ago due to substandard vaccination coverage and lack of treatment options, countries started introducing a second measles vaccination dose. This was mostly implemented as a campaign, with support from the Global Measles Partnership. The result was that worldwide over 600 million children were vaccinated through measles vaccination campaigns, of which about 400 million in Africa alone, and that hundreds of thousands of lives are being saved. It shows that innovative strategies, implemented in response to an immense need, can have very quick results. But sustainability issues remain: if we cannot keep up the protection through ongoing immunization, the new births cohorts will not enjoy the same levels of protection, and measles-related deaths will soon be on the rise again.
Source: WHO, 2009 7

8. Global Immunization 2000-2008, DPT3 immunization coverage
Immunization coverage, often measured as the proportion of children who received all three doses of DTP vaccine by age 1, has in the last few years climbed just above 80% globally (see red line in the middle). This is mainly due to improvements in coverage in South Asia (pink line), but mainly in Africa (black line). The other 4 regions have been able to maintain coverage above 80% (and in some cases above 90%) since many years.
This progress is due to a number of factors, but reflects a gradual strengthening of the immunization systems. Because DTP is typically NOT given through campaigns, increases in coverage may be the result of efforts made to improve the quality of services, including better planning, monitoring, training etc, implementation of new delivery mechanisms such as Child health Days, or the availability of funding that allows health workers to do more outreach, such as the ISS funds supplied by GAVI. Whereas the reasons for improvements in coverage can be diverse, in all cases the investments that have been made will have to be sustained if we want to prevent coverage rates to drop again.
Source: WHO/UNICEF estimates of immunization coverage, July 2009 8

10. Rapid progress in scaling up insecticide-treated net use
Source: UNICEF Global malaria databases 2009, based on 22 countries with trend data for around 2000 and 2006, covering 53 % of children under age five. 10

11. Global production of mosquito nets has more than tripled since 2004
Global Production of long-lasting insecticidal nets, (millions)
In companion handout
Note: Data for 2007 and 2008 are estimated production capacity.
Source: UNICEF Supply Division data 2009, based on estimates from insecticide-treated net manufacturers. 11

12. Pneumonia: a killer for lack of treatment
                                                          
Care seeking for pneumonia (% of children under five with suspected pneumonia being taken to an appropriate care provider)
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Not only lack of prevention kills children. Lack of treatment is just as much a problem.
Pneumonia is responsible for 17% of all under five deaths worldwide (i.e. out of every 6 children dying before their fifth birthday, 1 will die of pneumonia), that is more than deaths from Malaria, measles and AIDS combined.
Yet, it remains largely untreated when in occurs in Africa. On average, less than half the children with pneumonia symptoms are brought to a health care provider, and in West and Central Africa, it is even less than 40%. This reflects a lack of access to health care systems, be it because caregivers do not understand the danger signs, that providers are not available or too far away, or that treatment is too expensive.
(Note: health care seeking behaviour in pneumonia in ROSA, EAPRO and MENA regions is between 60 and 70%. In industrialized countries, I imagine it would be above 95%, but I do not have a firm number on industrialized countries, nor a global average number)
This can be overcome by focusing on community-based care. Since a large proportion of severe pneumonia cases in children of the developing world are bacterial in origin, they can be effectively treated using inexpensive antibiotics at home, provided that families and caregivers follow the advice they receive and treat the child correctly, including returning for help as necessary. If these conditions are in place, evidence from across the developing world suggests that community-based management of pneumonia can be very effective. An analysis of results from nine studies in seven countriesthat investigated the impact of community-based case management of pneumonia revealed substantial reductions not only in pneumonia mortality but in child mortality more generally. Trials resulted in a reduction of child mortality of 26 per cent and a 37 per cent reduction in mortality from pneumonia.
* Excludes China
Source: UNICEF global databases, 2009. 12

13. Continuum of feeding practices Developing world averages of key indicators (%)
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Note: Graph shows the coverage of feeding practices along a continuum of care. The graph shows low coverage of infant and young child feeding practices.
Among all preventative interventions, infant and young child feeding has the potential to prevent an estimated 19 per cent of all U5 deaths in the developing world.
Complementary feeding is the most effective intervention to reduce stunting during the first 2 years of life.
Need to take advantage of opportunities to counsel women to initiate breastfeeding early such as antenatal care contacts for which coverage is higher.
*: Excluding China due to lack of data
Source: UNICEF Global Database, Nov 2009
Compiled from MICS, DHS and other national surveys 13

14. MDG 5 - Maternal Mortality Half a million women continue to die annually from childbirth-related causes Another 10 million are left with lifelong debilitating effects
Similar as with the newborn deaths, little progress is being achieved to reduce maternal deaths. This is in particular the case for Sub-Saharan Africa, where maternal mortality rates remain unacceptably high and where virtually no progress has been noted over the last decades.
The reasons for the lack of progress in in area of maternal and early newborn health are due to the fact childbirth care is a 24/7 relatively sophisticated services, that at unlike vaccination for example can not be scheduled.
One of the areas that need to strengthened, in particular in rural Africa is Emergency Obstetric Care, to ensure women receive the care and life-saving interventions they need during a complicated delivery.
Source: UNICEF: Progress for Children 2008 14

15. In the developing world, thirty-five per cent of women aged years entered into marriage/union by the age of 18 Percentage of women aged years who were married/in union by the age of 18, by region ( ).
Link to maternal mortality issue; rights, gender, power relations etc
Source: UNICEF Global Database, Nov 2009
Compiled from MICS, DHS and other national surveys 15

16. Whilst we know what works, there are important coverage gaps2
GAP 1
GAP 3
GAP 4
The interventions with the highest coverage can be scheduled and organized once or twice a month, such as for example during vaccination activities.
A first gap on the continuum, is in terms of contraceptive use – family planning being an important intervention for mothers but also their children.
A second gap is around the time of delivery. As a delivery can not be planned, it requires a much stronger health system to deliver these services. The same is valid for the 4th gap – treatment of pneumonia and other diseases, that again can not be scheduled and require the 24/7 services.
The 3rd gap is around exclusive breastfeeding and in general the interventions that require a behavioral change achieve less higher coverage (another example would be hand-washing with soap).
Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008 16

17. Although ANC coverage is high, less than half of women in developing world receive recommended minimum of four visits
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18. Rural Africa lacks proper access to emergency obstetric care
Caesarean section rates in urban and rural areas, selected countries in Africa, DHS
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Source: UNICEF Global Database, Nov 2008 18

19. Skilled attendant at delivery coverage has increased in all regions since 1990
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20. Skilled health workers are in short supply
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21. MDG 1: Reduction in underweight prevalence by half (1990 – 2015) 63 countries are on track to meet the MDG 1 target Progress is insufficient in 34 countries and 20 countries have made no progress
ARCHANA – Saad would like the “data not available” caption replaced
Source: UNICEF Global Database, Nov 2009
Compiled from MICS, DHS and other national surveys 21

22. 195 Million under-fives in the developing world are stunted
Close to 200 million U5 children are stunted – or one in three. Africa and Asia carry the burden of stunted children with 40% and 36%. More than 90% of the world’s stunted children live on these two continents.
A reduction of 28% in stunting prevalence in the developing world.
Progress notable in Asia where prevalence dropped from 44% to 30% mainly influenced by declines in China.
Decline in Africa modest mainly due to population growth – overall number of African children U5 increased from 43 to 52 million.
Progress has been made in a number of countries showing that progress is possible with integrated programmes covering pregnancy through 2 years.
Six of the 10 countries which contribute most to the global burden of stunting are in Asia – Bangladesh, China, India, Indonesia, Pakistan and Philippines. India alone has 61 million stunted children. 22

23. MDG 7: DRINKING WATER (2008 status) World ON TRACK for MDG target
Progress towards the MDG drinking water target, 2008
Let’s start with the good news - The world is on track to meet the MDG drinking water target. Since 1990, 1.6 billion people gained access to an improved drinking water source and for the first time since than the number of people without access has fallen below 1 billion
However, this map shows some clear regional disparities – in particular, Sub Saharan Africa is lagging behind.
In the light of population growth another xxx million people need to gain access to safe water to meet the MDGs.
Not on track
Progress but insufficient
On track
Source: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2010

24. Urban/Rural disparities, 2008
Urban drinking water
Rural drinking water
Drinking water coverage, 2008
And there is further worrying news – there are also urban and rural disparities in drinking water coverage
84% of the almost 900 million population without access to an improved drinking water source live in rural areas.
Less than 50%
50 – 75% % %
Source: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2010

26. MDG 7. Sanitation World not on track for MDG target
Progress towards the MDG sanitation target, 2006
Here you can see the global situation regarding sanitation. The regions and countries off-track are in red, and easily identified.
On track
Progress but insufficient
Not on track
Source: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2010 26

27. 1.1 billion people still practise open defecation, 2008
Countries where more than 10 million people practise open defecation, 2008
Source: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2010

28. Hygiene: Hand washing with soap…..
can reduce diarrhoea rates by 42-47%
can reduce Acute Respiratory Infections by up to 23%
by mothers and birth attendants can reduce neonatal mortality rates by 44%
Cost-effectiveness of hygiene promotion as a health intervention: US $ 3.35/ Disability Adjusted Life Year
Why handwashing with soap?
Infectious diseases affect the world unequally. Sixty-two percent of all deaths in Africa and 31% of all deaths in SE Asia are caused by infections (Global Health Council, 2005). At the same time only 5% of all deaths in Europe are from infectious causes. Reducing this disparity in rates of infection and mortality is a priority for the global community. However, the two biggest killers of children, the diarrhoeal diseases and the Acute Respiratory Infections remain relatively neglected by a public health fraternity engaged in combating HIV/AIDS, malaria and TB.
A half of all child deaths each year are due to diarrhoea and ARIs, both of which are transmitted from person to person during everyday interaction, through the air, through skin contact and through contamination of the environment1.
One of the most important ways of preventing these infections is handwashing with soap (HWWS). This is because handwashing can remove the agents of infection both at the time that they are emitted from the primary host and prevent them reaching secondary hosts. Regular handwashing with soap is thus an excellent way of preventing the transmission of microbes from one person to another. 28 28

29. Children (<15 years) estimated to be living with HIV, 2008
2.1 million children under 15 years are living with HIV globally
Children (<15 years) estimated to be living with HIV, 2008
Total: 2.1 million (Range: 1.2 million million)
Source: UNAIDS and WHO, AIDS Epidemic Update, 2009. 29

30. Percentage of pregnant women with HIV receiving antiretrovirals for preventing mother-to-child transmission of HIV in low- and middle-income countries, 2004–2008
Status
1. In 2008, 19 countries reached the 2010 PMTCT target coverage rates of 80 per cent
2. 45% of estimated HIV+ pregnant women received ARV in 2008; as compared to 24% in 2006
Constraint
-Weak integration of HIV with MNCH, family planning and sexual/reproductive health
-Men and boys are not fully engaged
Accelerated scale-up of PMTCT and paediatric HIV and AIDS treatment, care and support will require a decentralized approach, in which national programmes transfer the planning and implementation of services to sub-national levels and establish clear mechanisms for coordination, financing and accountability, including engaging the broader community.
Engaging men through PMTCT services has been successful in Rwanda. Couples testing grew to over 90% in some facilities in 2008 accompanying an overall increase in HIV testing coverage among pregnant women which reached 73% in 2008. 30

31. Percentage of children receiving antiretroviral therapy in low- and middle-income countries, 2005–2008
Status
1. 38% pediatric ARV coverage in 2008; as compared to 18% in 2006
Constraints
Loss to follow-up and slow roll-out of early infant diagnosis
Accelerated scale-up of PMTCT and paediatric HIV and AIDS treatment, care and support will require a decentralized approach, in which national programmes transfer the planning and implementation of services to sub-national levels and establish clear mechanisms for coordination, financing and accountability, including engaging the broader community.
Source: Towards Universal Access: Scaling up priority HIV/AIDS interventions
in the health sector, 2009, UNICEF, WHO, UNAIDS 31

32. Comprehensive correct knowledge of HIV among young women aged 15-24 remains low in most countries
Percentage of women aged with comprehensive correct knowledge of HIV,
Percentage
Less than 30 per cent
30-49 per cent
50 per cent or more
Data not available
Source: UNICEF global databases, 2010
Compiled from MICS, DHS and other national surveys

33. Action for acceleration
Focus on the main killers of children
Scale up essential live-saving interventions
Services and care through the life cycle
Expand community-based approaches
Strengthen health systems
Significantly increase the investments (both national and external) in health systems
Strengthen partnerships (private, CSO, professional associations, research institutions)
Health System strengthening
Supplies
Human Resources
Financing
Management capacities 33

34. Essential interventions
Skilled attendants at birth and emergency obstetric care
Immunization
Early and exclusive breastfeeding during the first six months of life
Complementary feeding
Micronutrient supplementation
Insecticide-treated mosquito nets, effective medicines to prevent and treat malaria 34

35. Essential interventions
Antibiotics to fight pneumonia
Oral rehydration therapy and zinc to combat diarrhoeal diseases
Treatment of severe acute malnutrition
Prevention of mother-to-child transmission of HIV and paediatric treatment of AIDS
• Hand washing with soap
Sanitation 35

36. Progress towards MDG 2: Achieve universal primary education
In more than 60 developing countries, at least 90 per cent of primary-school-age children are in school
Primary school net enrolment rate or net attendance rate (2003–
Global gross pre-primary enrollment at 41%, some national policy and standards setting
Global net primary enrollment at 87%, gender parity at 0.97, and decrease in children not in school to 72 million (more than 80% in SSA and ROSA)
Increased attention to enhancing quality, reducing disparities and responding to emergencies
Source: UNICEF global databases, 2009, and UNESCO Institute for Statistics Date Centre, March 2009 36

37. 84 per cent of primary-school-age children attend school Primary school enrolment/attendance rate,
Net (%, )
Source: UNICEF Global Database, Nov 2009 37

38. MDG 3: Eliminate gender disparity in education
Many countries have reached gender parity in primary education Gender parity index (GPI) in primary education (2003–2008)
Four years after the target date of 2005, gender parity in education has yet to be achieved. In the developing regions as a whole, 95 girls were enrolled in primary school for every 100 boys in 2007, compared to 91 in 1999.
Source: UNICEF global databases, 2009 38

39. Progress towards MDG 3: Eliminate gender disparity in education
Fewer countries are near parity in secondary education Gender parity index (GPI) in secondary education (2003–2008)
The gender gap is more evident in secondary school enrolment. In Southern Asia, 75 girls per 100 boys were enrolled in secondary school in 1998/9, and 85 girls per 100 boys were enrolled in secondary school in 2006/7
Source: UNICEF global databases, 2009 39

40. Acceleration agenda
Education main tool to break cycle of inter-generational poverty
Investing in data
Adequate, equitable and sustainable financing
Exploiting IT to reach the unreached
Engaging non-traditional partners – private sector, foundations, NGOs – to increase and enhance funding of basic education
Focus on systems strengthening
Revitalization of community-based approaches and social mobilization
Concerted support to fragile contexts
Political mobilization on priority human development issues . We would pitch for:
Maternal Health (may bring up the gender, sexual and reproductive health rights agenda here)
Infant and Young Child interventions
Pneumonia, diarrhoea, neonatal death
- Undernutrition
- Access to water and sanitation
- education
Focus on systems strengthening
Adequate human resources
Quality of services
Equitable outreach
Concerted support to fragile contexts – specific challenges to progress on human development; here the climate change issues can be mentioned
Affordable commodities and application of innovations where most needed
Support social mobilization and community-based approaches
Invest in data; evidence-driven approaches 40