MDG4: Reduce child mortality - Professor Kim Mulholland, LSHTM Tue, 2009-06-30 02:05

The intensity of international efforts to reduce child mortality has varied since global child mortality data became available. During the 1980s UNICEF spearheaded a ?Child Survival Revolution? focused on simple, mainly vertical, interventions, yet in the 1990s interest waned as UNICEF focused on other issues and child survival seemed to disappear from WHO?s agenda. The MDGs have given renewed energy to the child survival movement, especially MDG4?s target to reduce under-five mortality by two-thirds. This is meant to be a global and regional goal, not a country-level goal. It may be particularly unfair for Africa, which starts from a much higher baseline. There is an irresistible trend with donors towards country-level vertical strategies and the inevitable result is growing inequity in child survival. Like all quantitative goals, the MDGs are likely to lead to distortions in reported data, particularly in the neonatal mortality field, where existing data are notoriously unreliable.

Read on to read a full report of the presentation.

Millennium Development Goal 4: Reduce child mortality

Focusing on equity

Professor Kim Mulholland, of the London School of Hygiene and Tropical Medicine (LSHTM), focused at LIDC’s conference on the issue of equity and poor quality data relating to child mortality. He reviewed MDG4, which aims to reduce by two-thirds the under-five mortality rate by 2015, at the event called No Goals at Half-time: What Next for the MDGs?

Child mortality: A serious concern
Mulholland began his presentation by setting out the history of interventions targeting child morality. UNICEF spearheaded a “Child Survival Revolution” after its 1980 figures showed that 12 per cent of all children worldwide, and 20 per cent of children in sub-Saharan Africa, died before their fifth birthday. However, in the 1990s interest waned as UNICEF focused on other issues and child survival seemed to disappear from the agenda of the World Health Organization.

Mulholland continued by illustrating how the situation is most serious in Africa and how the aim of a two-thirds reduction in child mortality by 2015 in Africa is optimistic. The Countdown group, formed by UNICEF and others, has identified 68 priority countries where most child deaths occur. In total, 26 of these nations are making no progress and 84 per cent of the countries making no progress are from Africa. The only country on track to meet MDG4 in Africa is Eritrea. Yet Mulholland also emphasised, along with other speakers, that the MDGs were conceived as global targets rather than country targets, and that it may be “wrong and unfair” to criticise individual countries for not meeting the targets, especially as African countries started from a higher baseline than countries in other regions.

Eritrea: A case study
Given Eritrea’s status as the only priority country on track to meet MDG4 in Africa, Mulholland analysed its environment, history and health programmes to find an explanation for its reported progress. He acknowledged the success of increased immunisation coverage in the area, which has risen from 50 to 90 per cent since 1990 (although Eritrea only became a country in 1993, data for the area exists for 1990), and the growth of the use of bed-nets to prevent malaria. However, Mulholland also highlighted its isolated rural communities, two recent wars with Yemen and Ethiopia, the expulsion of bilateral donors and NGOs, and internal problems, including the drafting of youths into the army for indefinite periods. He said: “It is hard in some ways to see how Eritrea could be the most successful country in Africa”. Mulholland continued by showing the low figure of reported neonatal mortality in Eritrea is far below what would be expected in a poor African country. He said this illustrated problems with the data, how neonatal mortality is systematically under-reported and how there is a disincentive to improve data quality if the figures available demonstrate a country is on track to meet the MDGs.

Wealthiest benefit most
Mulholland observed that the wealthiest quintile benefit most from child mortality intervention in developing countries. He stressed that targets encourage policies designed to secure the quick-wins or “low hanging fruit” and that unless equity is considered when a new intervention is introduced, it will lead to increasing inequity so long as coverage is less than 100 per cent.

Conclusions
Despite certain reservations about data quality and concerns about the issue of equity, Mulholland broadly welcomed MDG4 as an opportunity to improve child survival globally. He also warned against country-level targets and said Africa should not be seen as a failure if significant progress is being made.

Professor Kim Mulholland is a paediatrician working at the Infectious Diseases Epidemiology Unit at LSHTM. From 1989 to 1995 he worked with the Medical Research Council unit in The Gambia, where he established a programme of research focused on clinical pneumonia and prevention of pneumonia by vaccination. He also worked for five years at the World Health Organization and his interests are child survival, childhood pneumonia and the use of new vaccines in developing countries.