Gareth Jones

How many child deaths can we prevent this year

This is the second of five papers in the child survival series. The first focused on continuing high rates of child mortality (over 10 million each year) from preventable causes: diarrhoea, pneumonia, measles, malaria, HIV/AIDS, the underlying cause of undernutrition, and a small group of causes leading to neonatal deaths. We review child survival interventions feasible for delivery at high coverage in low-income settings, and classify these as level 1 (sufficient evidence of effect), level 2 (limited evidence), or level 3 (inadequate evidence). Our results show that at least one level-1 intervention is available for preventing or treating each main cause of death among children younger than 5 years, apart from birth asphyxia, for which a level-2 intervention is available. There is also limited evidence for several other interventions. However, global coverage for most interventions is below 50%. If level 1 or 2 interventions were universally available, 63% of child deaths could be prevented. These findings show that the interventions needed to achieve the millennium development goal of reducing child mortality by two-thirds by 2015 are available, but that they are not being delivered to the mothers and children who need them.

Levels and trends in child mortality, 1990–2009

This article looks at the levels and trends in child mortality from 1990-2009. It tracks the progress that has been made in this area and states that removing financial and social barriers to accessing welfare services innovations to make supply of critical services more available to the poor and increasing local accountability of the health systems are examples of policy interventions that have allowed health systems to improve equity.

WHO and UNICEF estimates of national infant immunization coverage: methods and processes

WHO and the United Nations Childrens Fund (UNICEF) annually review data on immunization coverage to estimate national coverage with routine service delivery of the following vaccines: bacille Calmette-Guérin; diphtheria-tetanus-pertussis, first and third doses; either oral polio vaccine or inactivated polio vaccine, third dose of either; hepatitis B, third dose; Haemophilus influenzae type b, third dose; and a measles virus-containing vaccine, either for measles alone or in the form of a combination vaccine, one dose. The estimates are based on government reports submitted to WHO and UNICEF and are supplemented by survey results from the published and grey literature. Local experts, primarily national immunization system managers and WHO/UNICEF regional and national staff, are consulted for additional information on the performance of specific immunization systems. Estimates are derived through a country-by-country review of available data informed and constrained by a set of heuristics; no statistical or mathematical models are used. Draft estimates are made, sent to national authorities for review and comment and modified in light of their feedback. While the final estimates may not differ from reported data, they constitute an independent technical assessment by WHO and UNICEF of the performance of national immunization systems. These country-specific estimates, available from 1980 onward, are updated annually.

Levels and trends in under-5 mortality, 1990–2008

As global momentum and investment for accelerating maternal and child survival grows, monitoring of progress at the global and country level has become even more needed. Millennium Development Goal 4 (MDG 4) calls for a two-thirds reduction in the mortality rate among children under the age of 5 years between 1990 and 2015. Generating accurate estimates of under-5 mortality poses a considerable challenge because of the limited data available for many developing countries. In response, experts at UNICEF, WHO, the World Bank, the UN Population Division (UNPD), and members of the academic community formed the Inter-agency Group for Child Mortality Estimation (IGME).1 The IGME aims to source and share data on child mortality, to improve and harmonise estimation methods across partners, and to produce consistent estimates on the levels and trends in child mortality worldwide.

The Accelerated Child Survival and Development programme in west Africa: a retrospective evaluation

BACKGROUND UNICEF implemented the Accelerated Child Survival and Development (ACSD) programme in 11 west African countries between 2001 and 2005 to reduce child mortality by at least 25% by the end of 2006. We undertook a retrospective evaluation of the programme in Benin, Ghana, and Mali. METHODS We used data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys to compare changes in coverage for 14 ACSD interventions, nutritional status (stunting and wasting), and mortality in children younger than 5 years in the ACSD focus districts with those in the remainder of every country (comparison areas), after excluding major metropolitan areas. FINDINGS Mortality in children younger than 5 years decreased in ACSD areas by 13% in Benin (absolute decrease 18 deaths per 1000 livebirths, p=0.12), 20% in Ghana (21 per 1000 livebirths, p=0.10), and 24% in Mali (63 per 1000 livebirths, p<0.0001), but these decreases were not greater than those in comparison areas in Benin (25%; absolute decrease 36 deaths per 1000 livebirths, p=0.15) or Mali (31%; 76 per 1000 livebirths, p=0.30; comparison data not available for Ghana). ACSD districts showed significantly greater increases than did comparison areas in coverage for preventive interventions delivered through outreach and campaign strategies in Ghana and Mali, but not Benin. Coverage in ACSD areas for correct treatment of childhood pneumonia, diarrhoea, and malaria did not differ significantly from before to after programme implementation in Benin and Mali, but decreased significantly in Ghana for malaria (from 78% to 53%, p<0.0001) and diarrhoea (from 39% to 28%, p=0.05). We recorded no significant improvements in nutritional status attributable to ACSD in the three countries. INTERPRETATION The ACSD project did not accelerate child survival in Benin and Mali focus districts relative to comparison areas, probably because coverage for effective treatment interventions for malaria and pneumonia were not accelerated, causes of neonatal deaths and undernutrition were not addressed, and stock shortages of insecticide-treated nets restricted the potential effect of this intervention. Changes in policy and nationwide programme strengthening may have benefited from inputs by UNICEF and other partners, making an acceleration effect in the ACSD focus districts difficult to capture. FUNDING UNICEF, Canadian International Development Agency, Coordenação de Aperfeiçoamento de Pessoal do Nível Superior (Brazil), and Fulbright Fellowship.

Comparing modelled to measured mortality reductions: applying the Lives Saved Tool to evaluation data from the Accelerated Child Survival Programme in West Africa

Background The Lives Saved Tool (LiST) projects the magnitude of mortality reduction based on baseline coverage, demographic characteristics and coverage targets. As a validation exercise, we compared neonatal, post-neonatal, infant, child and under-5 mortality reductions as projected by LiST to changes in mortality measured through demographic surveys in Ghana and Mali as part of a recently completed, retrospective evaluation of a child survival programme. Methods Using coverage and other information collected during the evaluation, we modelled the predicted mortality reduction, using logical assumptions to fill gaps if no data were available. We performed a sensitivity analysis on several indicators for which we used a proxy, using the results to examine model sensitivity and readdress our assumptions. Results In Ghana, the modelled mortality reductions were within the 95% confidence boundaries of the measured reduction. In Mali LiST significantly underestimated the reduction. Several coverage indicators were found to influence the projection, specifically case management of serious neonatal illness in both countries and pneumonia treatment, vitamin A measles treatment and breastfeeding promotion in Mali. Conclusions We consider LiST to be a useful tool given the limitations of the available data. Although the model was a good match in Ghana, we identified several limiting factors with the input data in the Mali projection. This exercise highlights the importance of continually improving the availability of sound demographic, epidemiological and intervention coverage data at district and national levels. More comparative studies are needed to fully assess the strengths and weaknesses of LiST.

A response to criticism of our estimates of under-5 mortality in Iraq, 1980–98

According to estimates published in this journal, the number of deaths of children under 5 in Iraq in the period 1991–98 resulting from the Gulf War of 1991 and the subsequent imposition of sanctions by the United Nations was between 400,000 and 500,000. These estimates have since been held to be implausibly high by a working group set up by an Independent Inquiry Committee appointed by the United Nations Secretary-General. We believe the working groups own estimates are seriously flawed and cannot be regarded as a credible challenge to our own. To obtain their estimates, they reject as unreliable the evidence of the 1999 Iraq Child and Maternal Mortality Survey—despite clear evidence of its internal coherence and supporting evidence from another, independent survey. They prefer to rely on the 1987 and 1997 censuses and on data obtained in a format that had elsewhere been rejected as unreliable 30 years earlier.

Real-Time Monitoring of Under-Five Mortality: Lessons for Strengthened Vital Statistics Systems.

Bryce and colleagues, reflect on lessons that can be learned from the Real-Time Monitoring of Under-Five Mortality Collection.

Retrospective evaluation of UNICEF's ACSD programme – Authors' reply

1522 www.thelancet.com Vol 375 May 1, 2010 which are akin to treatment eff ects, and in table 3 (coverage) these may be obtained by subtraction. We do agree with Chen and Fan that the presence of other programmes in the com parison areas has aff ected our results, as mentioned in our conclusions. However, given that the ACSD programme was aimed at accelerating progress, we stand by our main policy conclusions that there was no evidence of such acceleration.