Ann Starrs

Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival

The Countdown to 2015 for Maternal, Newborn, and Child Survival monitors coverage of priority interventions to achieve the Millennium Development Goals (MDGs) for child mortality and maternal health. We reviewed progress between 1990 and 2010 in coverage of 26 key interventions in 68 Countdown priority countries accounting for more than 90% of maternal and child deaths worldwide. 19 countries studied were on track to meet MDG 4, in 47 we noted acceleration in the yearly rate of reduction in mortality of children younger than 5 years, and in 12 countries progress had decelerated since 2000. Progress towards reduction of neonatal deaths has been slow, and maternal mortality remains high in most Countdown countries, with little evidence of progress. Wide and persistent disparities exist in the coverage of interventions between and within countries, but some regions have successfully reduced longstanding inequities. Coverage of interventions delivered directly in the community on scheduled occasions was higher than for interventions relying on functional health systems. Although overseas development assistance for maternal, newborn, and child health has increased, funding for this sector accounted for only 31% of all development assistance for health in 2007. We provide evidence from several countries showing that rapid progress is possible and that focused and targeted interventions can reduce inequities related to socioeconomic status and sex. However, much more can and should be done to address maternal and newborn health and improve coverage of interventions related to family planning, care around childbirth, and case management of childhood illnesses.

Continuum of care for maternal, newborn, and child health: from slogan to service delivery

The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths. The continuum for maternal, newborn, and child health usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). We define a population-level or public-health framework based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children. These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one. The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes. Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care. Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.

Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions.

BACKGROUND The Countdown to 2015 for Maternal, Newborn, and Child Survival initiative monitors coverage of priority interventions to achieve the Millennium Development Goals (MDG) for reduction of maternal and child mortality. We aimed to report on 68 countries which have 97% of maternal and child deaths worldwide, and on 22 interventions that have been proven to improve maternal, newborn, and child survival. METHODS We selected countries with high rates of maternal and child deaths, and interventions with the most potential to avert such deaths. We analysed country-specific data for maternal and child mortality and coverage of selected interventions. We also tracked cause-of-death profiles; indicators of nutritional status; the presence of supportive policies; financial flows to maternal, newborn, and child health; and equity in coverage of interventions. FINDINGS Of the 68 priority countries, 16 were on track to meet MDG 4. Of these, seven had been on track in 2005 when the Countdown initiative was launched, three (including China) moved into the on-track category in 2008, and six were included in the Countdown process for the first time in 2008. Trends in maternal mortality that would indicate progress towards MDG 5 were not available, but in most (56 of 68) countries, maternal mortality was high or very high. Coverage of different interventions varied widely both between and within countries. Interventions that can be routinely scheduled, such as immunisation and antenatal care, had much higher coverage than those that rely on functional health systems and 24-hour availability of clinical services, such as skilled or emergency care at birth and care of ill newborn babies and children. Data for postnatal care were either unavailable or showed poor coverage in almost all 68 countries. The most rapid increases in coverage were seen for immunisation, which also received significant investment during this period. INTERPRETATION Rapid progress is possible, but much more can and must be done. Focused efforts will be needed to improve coverage, especially for priorities such as contraceptive services, care in childbirth, postnatal care, and clinical case management of illnesses in newborn babies and children.Background The Countdown to 2015 for Maternal, Newborn, and Child Survival initiative monitors coverage of priority interventions to achieve the Millennium Development Goals (MDG) for reduction of maternal and child mortality. We aimed to report on 68 countries which have 97% of maternal and child deaths worldwide, and on 22 interventions that have been proven to improve maternal, newborn, and child survival.

Safe motherhood initiative: 20 years and counting

The global campaign to reduce maternal mortality was launched in February 1987 when three UN agencies-- UNFPA the World Bank and WHO--sponsored the international Safe Motherhood Conference in Nairobi Kenya. The event aimed to raise awareness about the numbers of women dying each year from complications of pregnancy and childbirth and to challenge the world to do something. The origins of the conference dated from 1985 when two critical events focused the attention of public-health specialists on the horrific risks pregnancy posed for women in developing countries. In that year Allan Rosenfield and Deborah Maine pointed out that maternal and child health programmes in developing countries were almost exclusively for the benefit of the child with almost no attention to the factors that were causing women to die. That same year during the conference marking the end of the UN Decade for Women womens advocates from around the world heard WHO announce that half a million women were dying each year from obstetric complications. (excerpt)

Countdown to 2015 and beyond: fulfilling the health agenda for women and children

The end of 2015 will signal the end of the Millennium Development Goal era, when the world can take stock of what has been achieved. The Countdown to 2015 for Maternal, Newborn, and Child Survival (Countdown) has focused its 2014 report on how much has been achieved in intervention coverage in these groups, and on how best to sustain, focus, and intensify efforts to progress for this and future generations. Our 2014 results show unfinished business in achievement of high, sustained, and equitable coverage of essential interventions. Progress has accelerated in the past decade in most Countdown countries, suggesting that further gains are possible with intensified actions. Some of the greatest coverage gaps are in family planning, interventions addressing newborn mortality, and case management of childhood diseases. Although inequities are pervasive, country successes in reaching of the poorest populations provide lessons for other countries to follow. As we transition to the next set of global goals, we must remember the centrality of data to accountability, and the importance of support of country capacity to collect and use high-quality data on intervention coverage and inequities for decision making. To fulfill the health agenda for women and children both now and beyond 2015 requires continued monitoring of country and global progress; Countdown is committed to playing its part in this effort.

Human resources for health and universal health coverage: fostering equity and effective coverage

Achieving universal health coverage (UHC) involves distributing resources, especially human resources for health (HRH), to match population needs. This paper explores the policy lessons on HRH from four countries that have achieved sustained improvements in UHC: Brazil, Ghana, Mexico and Thailand. Its purpose is to inform global policy and financial commitments on HRH in support of UHC. The paper reports on country experiences using an analytical framework that examines effective coverage in relation to the availability, accessibility, acceptability and quality (AAAQ) of HRH. The AAAQ dimensions make it possible to perform tracing analysis on HRH policy actions since 1990 in the four countries of interest in relation to national trends in workforce numbers and population mortality rates. The findings inform key principles for evidence-based decision-making on HRH in support of UHC. First, HRH are critical to the expansion of health service coverage and the package of benefits; second, HRH strategies in each of the AAAQ dimensions collectively support achievements in effective coverage; and third, success is achieved through partnerships involving health and non-health actors. Facing the unprecedented health and development challenges that affect all countries and transforming HRH evidence into policy and practice must be at the heart of UHC and the post-2015 development agenda. It is a political imperative requiring national commitment and leadership to maximize the impact of available financial and human resources, and improve healthy life expectancy, with the recognition that improvements in health care are enabled by a health workforce that is fit for purpose.

A global fund for the health MDGs

The world is off track to achieve the health-related targets of the Millennium Development Goals (MDGs) by 2015. Maternal mortality has stagnated for two decades child mortality is not declining fast enough HIV/AIDS still infects people faster than the pace of antiretroviral treatment roll-out and inequalities are widening within and across countries. Addressing these crises will require increased funding and more efficient spending. The next Board meetings of the Global Fund to Fight AIDS Tuberculosis and Malaria and the GAVI Alliance scheduled for May and June respectively present an opportunity to tackle these issues. We propose that the exceptional approach created for the fight against AIDS should be expanded: the entire global health agenda must adopt a rights-based approach which in some countries requires challenging the model of national financial autonomy. We therefore recommend that the Global Fund and the GAVI Alliance gradually move towards becoming a global fund for all the health MDGs which will require substantially greater resources to address the broader mandate. As a first step the next Global Fund and GAVI Alliance board meetings should expand the review of their architecture to provide greater support to national health plans including co-financing non-disease-specific human resources for health. A global fund for the health MDGs would eventually allow the delivery of prevention and treatment services for specific diseases through revamped general health services reducing transaction costs and streamlining the global health architecture. Such radical yet rational action is our best chance of meeting-or at least making significant progress toward-the health-related MDG targets by 2015.

Delivering for women

20 years ago the global health community came together to highlight the most striking inequity in public health: half a million women 99% of them in the developing world were dying every year in pregnancy and childbirth. High fertility inadequate and inaccessible health services and womens low status meant that women in the poorest regions of the world were 500 times more likely to die from pregnancy-related complications (one in 20 risk) than women in northern Europe (one in 10 000 risk). The global Safe Motherhood Initiative was launched to generate political will identify effective interventions and mobilise resources that would rectify this horrifying injustice. Today 20 years into the initiative maternal mortality has declined in some regions especially in middle-income countries in Latin America and northern Africa as documented by Ken Hill and colleagues in todays Lancet. But dismally we are nowhere near the goals of reduction of global maternal mortality by 50% (the target setin 1987) or 75% (the target set by Millennium Development Goal [MDG] 5 accepted by the UN and heads of state in 2000). Progress has been achieved in other areas including much greater awareness of the issue and an enormous increase in knowledge about what works and what does not. But without substantial decreases in maternal mortality what is there to celebrate in 2007? As the 20th anniversary approached this dilemma was faced by the agencies organisations donors and individuals who helped launch the initiative. (excerpt)

Making the Countdown count

The 2008 Countdown report comes at a particularly important time-the midpoint for achieving the Millennium Development Goals (MDGs) in 2015. This issue of The Lancet focuses on the 2008 results of the Countdown to 2015 for Maternal Newborn and Child Survival initiative and coincides with the Countdown meeting in Cape Town South Africa held jointly with the Inter-Parliamentary Union. Countdown a collaboration of individuals and institutions aims to stimulate country action by tracking coverage for interventions that are essential for the attainment of MDGs 4 and 5 as well as elements of the other health-related MDGs. In 2006 we reported on coverage of child survival interventions for 60 countries in the first international Countdown conference held in London in December 2005. The Countdown 2008 report tracks progress in 68 countries that account for more than 97% of maternal and child deaths and includes indicators across the continuum of care for reproductive maternal newborn and child health. The coverage results are complemented by tracking of relevant policies health system performance measures equity patterns in coverage and financial flows to maternal newborn and child health and nutrition. (excerpt)

Survival convergence: bringing maternal and newborn health together for 2015 and beyond

When WHO published the Mother-Baby Package in 1996, mothers and newborn babies were viewed as a dyad, and it was assumed that what was good for the mother was good for the baby. Basic interventions to deal with newborn complications were included, but neonatal mortality received little attention from the broader public health community, or even from the maternal health and child health communities. Although global attention to newborn health began in 2000 with the launch of the Saving Newborn Lives initiative, and accelerated with the publication of the Lancet Series on Neonatal Survival in 2005, reductions in neonatal mortality lagged behind maternal and under-5 mortality. Worldwide, 44% of deaths in children younger than 5 years now occur in the fi rst month of life, a huge and highly inequitable burden. The Every Newborn Series in The Lancet highlights many of the future opportunities and challenges in forging true integration between the maternal and newborn health communities. The fi rst opportunity is in defi ning new goals and targets. As we shift from the Millennium Development Goals (MDGs) to the post-2015 era, there will probably be a single overarching health goal, with measurable targets relating both to the unfi nished agenda of the health MDGs and to major new challenges in responding to the burden of non-communicable diseases. As noted by Elizabeth Mason and colleagues in this Series, targets for ending preventable newborn deaths and stillbirths must be included in the post-2015 agenda, along with targets for ending preventable maternal and child deaths, as well as for sexual and reproductive health. Ideally a cohesive set of targets on reproductive, maternal, newborn, and child health will be clustered in the agenda so that their linkages across the continuum of care are clear. The second opportunity is the emerging expansion of country ownership in setting priorities, designing programmes, and defi ning goals. As countries adopt more integrated approaches to designing, implementing, and funding health services and health systems, there is less appetite for externally driven initiatives that promote dealing with health challenges in vertical silos. In keeping with country preferences, the Every Newborn Action Plan calls for including or strengthening a specifi c newborn focus within maternal, child, and reproductive health plans. The third opportunity is increased clarity on the most eff ective technical interventions for saving the lives of newborn babies, and what is needed to deliver those interventions. Maternal and newborn health need strong, functional health systems with an educated, enabled workforce in suffi cient numbers; functioning commodity systems; attention to quality of care; and eff ective mechanisms for recording, analysing, and using data. However, interventions and technologies specifi c to newborn babies must also be available to improve newborn health and survival. Experience shows that health-worker training programmes or commodity systems for maternal or child health will not automatically include those interventions and technologies—they must be explicitly and consciously included in planning and budgeting. To achieve optimum integration of maternal and newborn health requires that we must recognise and respond to the remaining challenges, especially in the political realm. The fi rst is the centrality of reproductive health to maternal and newborn health and wellbeing. The newborn and child health communities have recently begun to acknowledge that access to quality, comprehensive contraceptive services is important for For the Lancet 2005 Series on neonatal survival see http://www.thelancet.com/ series/neonatal-survival