This is a joint post with Julia Goldberg.
The newly released new child mortality data by UNICEF has findings that are encouraging yet still worrisome: the world has made progress in reducing child deaths globally; yet each day some 19,000 children die every day largely from preventable causes. USAID highlighted this new publication to remind the world of its “Child Survival Call to Action: Ending Preventable Child Deaths,” co-hosted by USAID, India, Ethiopia, and others on June 14 and 15. Before we completely forget what happened in mid-June, we revisit the event and its desired goals by taking a closer look at the event’s “Roadmap”.
Bottom line: The Child Survival Call to Action does not bring much new money or knowledge, but it brings some laudable political attention and a promising emphasis on delivery and accountability. But without more systematic attention from countries and donors, the new child survival agenda risks being another same-old global-health flavor-of-the-month, potentially crowded out by competing priorities in global health.
The Roadmap declares a new and laudable goal for every country to reduce child deaths to a maximum of 20 per 1,000 live births by 2035 (p. 6). The latest UNICEF report indicates that child mortality is 51 per 1,000 live births worldwide, but is as high as 185 in Sierra Leone, 101 in Afghanistan, and 70 in Haiti, for example. According to the Roadmap, the current annual rate of reduction in child mortality is 2.5 percent. To reach the new goal by 2035, almost every developing country will need to at least double their rates of reduction in child mortality to reach a 5.2 percent annual decline. Though ambitious, this goal is possible.
Yet we know from the MDG experience that the mere setting of a goal—even if a more realistic goal, with regular reporting of achievements on defined indicators—is not, by itself, sufficient to reach that goal. The Roadmap suggests that the plan for accelerating child survival consists of a focus on (1) geography, (2) high-burden populations, (3) high-impact solutions, (4) 'supportive environment' including education, empowerment, economy, environment, and (5) mutual accountability. Does this plan pave a new path for countries to reach such an ambitious goal?
The aspect of the Roadmap celebrated as the most ‘new’ is knowledge of effective interventions. In April 2012, USAID Administrator Rajiv Shah introduced the Child Survival Call to Action at a Kaiser Family Foundation event, stating “for the first time in history, we really do have the tools and know-how to change this brutal fact of life.” But is knowledge of effective interventions really so revolutionary?
Similar tools and know-how were at the core of Jim Grant’s child-survival revolution in the 1980s. Knowledge and new tools developed since the 1980s have helped worldwide child mortality decline by nearly one-half, from 112 deaths per 1000 live births in the 1980s to 58 today.
Despite this knowledge, major deficiencies remain. For example, just 30% of children in sub-Saharan Africa who had diarrhea received oral-rehydration solution. Is knowledge of effective interventions enough to “accelerate progress” within the hardest-to-reach populations?
If not new knowledge, could new funding pave the way for accelerating child survival efforts? Joy Lawn and colleagues estimate that additional funding of $7 billion each year would be required to achieve universal coverage of 32 maternal and child health interventions in 60 priority countries. In the current economic climate, development assistance for health is expected to decline.
Of the eight partnership commitments made as part of the Child Survival Conference, only one partnership was accompanied by any financial commitment (the Declaration on Scaling Up Treatment of Childhood Diarrhea and Pneumonia). That commitment of $20 million is a paltry 0.3 percent of the estimated amount needed for maternal and child survival and is small relative to contributions for other diseases, i.e. for HIV/AIDS. Additional funding will be needed to scale up efforts to save children’s lives.
A new approach?
To nearly double the rate of decline in child mortality, new funding must be combined with a new and better approach. Of all the different aspects of the Roadmap, here are two aspects that we think are most promising to achieve its goals: (1) increasing knowledge to deliver; and (2) giving ‘teeth’ to accountability.
- Knowledge to deliver: The global health community may know which interventions are effective, but it has to learn how to deliver those interventions more effectively. The Roadmap touches on this in saying that the global health community needs to “invest in innovation (including operations research) to accelerate results”. After decades of having cost-effective solutions that fail to reach children who need them, a new emphasis on learning how to deliver effective interventions could fuel acceleration of child survival efforts. Rigorous research is needed on suitable methods of program delivery, financing, and incentive structures for patients, health-care providers, and organizations within countries.]
- Give “teeth” to accountability: Hillary Clinton spoke at the conference of giving “teeth” to accountability. The Roadmap declares that “each year, UNICEF and partners will release global progress reports to stimulate public dialogue and sustain the political commitment to child survival” (p. 10) and that “in September of each year, a child mortality report will be issued under the banner of A Promise Renewed, with country profiles that track progress at the national and sub-national levels” (p. 17). If you’re having a moment of déjà vu, it’s understandable. The MDGs and other donors with various scorecards have long been tracking results and progress.
Accountability requires measurement, ownership, and enforcement, but also clarity about who has the authority to enforce accountability, and with what consequences. While accountability in the Roadmap refers mainly to high-level accountability in measurement between countries and donors, performance-based financing is a key tool to “give teeth” to accountability between countries and donors. Donors should seriously consider enhancing accountability through performance-based financing and Cash-on-Delivery.
Moreover, greater accountability of governments to the citizens is needed. In one randomized trial in Uganda, citizens received regular report cards on the performance of their local health facility and participated in exercises to hold the staff of health facilities accountable. Child mortality declined by one-third in these districts—quite an acceleration—in comparison to control districts. Countries and donors should work together to share performance indicator with citizens.
Will the agenda for child survival survive?
Given the limited financial commitment to this agenda, one wonders if the Child Survival agenda will survive an Administration change or new budget realities. Will the political attention serve as a lever for future commitments? Some may argue, perhaps optimistically, that child survival is serving as a political, system-wide slogan to re-orient global-health priorities in the US government. It is true that US government's priorities on child health are minimally channeled through a line-item for 'maternal and child health', and instead largely channeled through disease-specific priorities i.e. malaria and HIV/AIDS. Could it be that child survival is a slogan to re-orient US global-health priorities more systematically, even if under other more familiar line items? We shall wait and see.
The authors thank Amanda Glassman, Lawrence MacDonald, and Jenny Ottenhoff for excellent comments.
CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.