CHILD SURVIVAL

What is child survival and why does it matter?

Child survival programs are inexpensive, basic interventions that save the lives of children under five from the leading causes of child death and promote healthy and productive families and communities.

Today, almost 25,205 children under age five will die mostly from preventable or treatable causes. This is a loss of over nine million children each year. A majority of these child deaths are from everyday conditions. Pneumonia, treatable with 27 cents’ worth of antibiotics, accounts for almost one of every five deaths among children under age five each year. Diarrhea, treatable with 6 cents’ worth of oral rehydration salts, causes 17 percent of young children’s deaths. And more than one third of child deaths result from complications related to birth, a cluster of causes that includes tetanus, which is preventable with a $1.20 tetanus vaccine for the mother during pregnancy.

The greatest number of under five child deaths in the world occur in Sierra Leone, Angola and Afghanistan, where between 257 and 270 children die for every 1,000 live births. The lowest death rates in the developing world occur in Cuba, Sri Lanka and Syria, where between seven to 14 children die for every 1000 live births.

The need to focus attention on child survival funding and programming was vividly highlighted by a recent Save the Children report entitled State of the World’s Mothers 2008. The report stressed that child survival resource needs are disproportional to the level of funding that these programs receive. In fact, if both rich and poor children received the full grouping of essential health care programs, 6.1 million children’s lives would be saved yearly.

UNICEF also underscored the importance of child survival in their State of the World’s Children 2008 report and explained that child survival matters for a multitude of reasons: beyond the obvious tragedy of a sick child, children who have been raised in physically and emotionally nurturing environments will be more likely to survive and less likely to succumb to illness and disease. They will be more likely to develop intellectually and socially, allowing them to better contribute to society in the future.

What is the current situation?

Every year, more than 200 million children under five do not receive basic health care and, as a result, over nine million children die annually, mostly from preventable and/or treatable diseases. More than 25,000 children die every day, and every minute, a woman dies in childbirth. Contrary to popular belief, the biggest killers of children worldwide are newborn complications, pneumonia, diarrhea, and malaria, although global funding does not reflect this proportionally.

When one examines the data pertaining to the incidence of disease and health expenditure allotted, funding is also disproportional in developing countries versus high-income countries. Health care spending unevenly benefits people living in high-income countries with diseases that are more expensive to treat, whereas people in the developing world carry a larger burden of disease treatable with low-cost remedies. This problem is compounded by the fact that the majority of the money provided for health care for the world’s poor does not target the needs of mothers and children who are at highest risk for disease and death. Further, a large shortfall exists between funds that are needed and the funds that have been committed by the global community.

While large scale programs and reforms are necessary in the long term, the use of existing low-cost tools and knowledge could save more than six million of the nine million who die every year from treatable or preventable causes. These low-cost responses have been in existence for decades, though a lack of funding and essential political will have kept these tools from being delivered to those who need them most.

Child and maternal mortality have many triggers, both direct and indirect. UNICEF outlines the structural causes for maternal and child mortality in their 2008 State of the World’s Children report. Poorly funded and culturally inappropriate health and nutrition services, food insecurity, inaccurate feeding practices and lack of hygiene are direct causes of mortality in both children and mothers. The indirect causes may be less obvious externally, but play just as large a role in mortality statistics. Female illiteracy adversely affects maternal and child survival rates and is also linked to early pregnancy.

In many countries, especially where child marriage is prevalent, the lack of primary education and lack of access to healthcare contribute significantly to child and maternal mortality statistics. In very poor countries, girls are taken out of school in order to perform household chores and are often considered to be a financial burden upon their parents. Some families choose to marry off their young girls in order to receive the largest possible bridal dowry, as younger girls receive a higher bride price.

In the 2006 report, Raising the Age of Marriage for Young Girls in Bangladesh, Pathfinder International noted that "women who have completed their secondary education are more likely to delay pregnancy, receive prenatal and postnatal care, and have their births attended by qualified medical practitioners. Children born to these women are more likely to receive all the necessary childhood vaccinations, stay healthier than children born to women without formal education and be taken to health care facilities when they are sick." UNICEF also notes that discrimination and exclusion of access to health and nutrition services due to poverty, geographic and political marginalization is a factor in mortality rates as well.

What is needed?

What is needed immediately?

Many cost-efficient, effective solutions are readily available to promote child survival and maternal health. They are simple, proven and inexpensive. But while programs such as PEPFAR and the Global Fund have exponentially multiplied the level of U.S. support to fight AIDS, malaria and tuberculosis, child survival programming has suffered from both a lack of political will and a lack of funding. Despite the high incidence of death in children under five in poor countries, U.S. funding for child and maternal health has remained virtually stagnant over the years.

A U.S. Coalition for Child Survival report cited findings from a 2007 Lake Research Partners survey on various aspects of child survival. According to this survey, almost all Americans (95 percent) believe the issue of child survival is an important problem facing the world today; 93 percent of Americans feel child survival should be a priority in terms of U.S. international aid priorities; 64 percent say it should be a very important priority.

There are strong allies of child survival in the U.S. Congress as well. Representative Betty McCollum (D-MN) and others have worked for years to increase funding for these efforts. Recently, the Senate Foreign Operations Subcommittee has also pushed for higher funding. But more must be done if these preventable child deaths are to be halted.

Save the Children listed a handful of proven, inexpensive child survival interventions in their State of the World’s Mothers 2008 report:

• Mosquito Prevention and Treatment - In sub-Saharan Africa, one in six deaths is caused by malaria. Indoor spraying, insecticide treated nets and anti-malarial drugs are essential and can be provided in a cost-effective manner. Although indoor insecticide spraying and insecticide-treated bed nets cost only $2.80 to $4 per child per year, only eight percent of children under five in sub-Saharan Africa sleep under treated nets and only one in three children are treated with anti-malarial drugs.
• Immunizations - There is a great need to scale up immunization of children. Life-saving measles vaccinations are only 33 cents per dose. Pneumococcal and rotavirus vaccines are now available to GAVI-eligible countries and prevent the leading cause of the two main child-killers - pneumonia and diarrhea. Despite significant progress in immunizing children, however, 24 million children - almost 20 percent of all children born in 2007 - did not receive the complete regimen of vaccinations for their first year.
• Vitamin A - Supplements given two to three times per year can prevent blindness and lower the risk for death from diarrhea, malaria and measles. Each capsule costs only two cents, yet 28 percent of children in poor countries are not receiving this treatment. Zinc supplements are also essential.
• Promotion of Breastfeeding - Babies not exclusively breastfed for the first six months of life are at an elevated risk for under-nutrition and disease; exclusive breastfeeding for the first six months has the capability to prevent 13 percent of all under five deaths in developing countries.
• Prenatal Care, Skilled Care During Childbirth, Postnatal Care - 61 percent of maternal deaths occur in the first six weeks after birth, and nearly half of those occur in the first day after delivery. Postnatal care costs half the amount of skilled care during childbirth and has potential to save 20 to 40 percent of newborn lives.

According to Save the Children, the use of existing, low-cost tools and knowledge could save more than six million of the nine million children who die every year from easily preventable or treatable causes.

What are the goals for the future?

In September 2000 world leaders came together at the United Nations to create a blueprint for global development with a target date of 2015, producing eight Millennium Development Goals (MDGs). These goals range from halving extreme poverty to providing universal education. The current focus of child survival and development advocates is Millennium Development Goal 4: Reduce the global rate of under-five mortality by two thirds between 1990 and 2015. According to UNICEF, in order to reach the 2015 goal, the number of child deaths must be cut in half - to less than 13,000 child deaths per day and fewer than five million per year. Additionally, the majority of the efforts will have to be focused upon the poorest, most isolated and marginalized communities in order to make an impact. UNICEF underscored the fact that "business as usual will be grossly insufficient to meet the health-related Millennium Development Goals for Children." [1]

Other health-related Millennium Development Goals must garner the attention of the international community as well in order to holistically address child survival. These goals are MDG 1: Eradicate extreme poverty and hunger; MDG 5: Improve maternal health; MDG 6: Combat HIV and AIDS, malaria and other diseases; MDG 7: Increase use of safe water and basic sanitation.

Progress has been made in reducing child deaths in every region of the world over the past two decades, and three regions - Latin America and the Caribbean, East Asia and the Pacific, and Central and Eastern Europe - have reduced children mortality substantially. Regions that are not on track to meet the fourth Millennium Development Goal include the Middle East and Africa.

Although progress has been made, the global goals still have not changed. Since 1990, deaths of children under age five have decreased steadily worldwide, despite population growth. Two key interventions in child mortality rates have proven especially effective in the hard-hit region of sub-Saharan Africa - the distribution of insecticide-treated bed nets to reduce the toll of malaria and "second chance" immunizations to prevent measles, both major killers of children. The MDGs must still provide the focus for global efforts, and the promises of equity and social justice must be kept.   

UNICEF and Save the Children both outlined a similar set of steps that must be followed to improve child and maternal health around the world. First, a global commitment to and investment in child and maternal health programming is essential. Also, both organizations stress the need for community-based development and programs designed around the needs of those who will be served. As Save the Children noted, good care in the home is an essential starting point to treat and prevent minor sicknesses, provision of community-based clinic care is the next step and hospital care for only the most serious of ailments because, the sad reality is that children in the developing world rarely see the inside of a hospital. This idea ties into the need for building local capacity and investment in health care systems and community healthcare workers are essential in order to provide sustainability, better coverage and a sense of ownership. An increase in the number of health care workers who live in the communities where the need is the greatest will serve as a first line defense against the common causes of childhood mortality.

Further, packaging of services for mothers and newborns that takes into account the realities of impoverished communities is important in order to provide appropriate care and access to care for the largest number of people. Access to care is an immense problem in the poorest countries. Millions of families have no access to health care due to economic and geographic boundaries. Closing the health care coverage gaps could save more than six million children per year. Globally, there is a need to coordinate an effort to train, equip and supply more community health workers who can reach the poorest and most marginalized populations. Moreover, increased government support for proven strategies that save children’s lives is necessary as well. Affordable solutions are already in existence and are currently being refined and improved. What has been lacking is the political will and funding needed to deliver these proven solutions to the children who need them most.

UNICEF may have found the answer: it has pioneered a highly effective child survival strategy called the Accelerated Child Survival and Development Initiative (ACSD) in a handful of West African Countries. ACSD focuses on scaling up access to a package of integrated, high-impact interventions for communities and families. The package of interventions depends on a community’s needs, and may include insecticide-treated bed nets for malaria prevention, vitamin A tablets to strengthen a child’s immune system, oral rehydration salts to combat diarrheal dehydration, immunizations, anti-retroviral drugs for HIV-infected mothers and children, antibiotics to treat opportunistic AIDS-related illnesses, and drugs to prevent transmission of the HIV virus from mothers to children during birth. In communities where UNICEF piloted this initiative, child mortality rates dropped by an average of 30 percent in three years, at a cost of only $500 to $1,000 per child life saved. The African Union has endorsed this child survival strategy, and UNICEF plans to expand this initiative to other countries in Africa and Asia - but these countries will need targeted funding in order to scale up this integrated, community-level approach. Investing in the scale up of ACSD would be a good use of precious U.S. foreign aid resources, as every additional $100 million invested in this approach would save up to 100,000 kids’ lives.

How You Can Act

The U.S. government needs a new strategy. The United States has joined 188 countries in supporting the Millennium Development Goals and has already contributed to a 50 percent reduction in the mortality of children under the age of five between 1960 and 1990. The world, however, has reached a stage where current and stand-alone programs are not enough. The U.S. government needs a new integrated and comprehensive strategy for reducing mortality and improving newborn, child, and maternal health. The Newborn, Child, and Mother Survival Act of 2009 (H.R. 1410) does just that.

This bill, sponsored by Representative Betty McCollum (D-MN), strengthens the U.S. government’s role in improving the health of newborns, children, and mothers in poor countries. The Newborn, Child, and Mother Survival Act requires the U.S. government to:

• Develop and implement an integrated, comprehensive strategy for reducing mortality and improving health with a focus on the 60 countries with the highest newborn, child, and maternal mortality rates;
• Establish guidelines to help strengthen local capacity and self-sufficiency and improve partnerships with non-governmental organizations and local communities;
• Continue investments in proven, cost-effective programs such as UNICEF and the Global Vaccine Initiative, which recently developed the life-saving rotavirus vaccine;
• Expand the Child Survival and Health Grants Program created by Congress to further American commitment to the issue;
• Create an Interagency Newborn, Child, and Maternal Health Task Forces which would coordinate U.S. Government activities; and
• Require the President to submit an annual report to Congress detailing United States’ efforts to reduce mortality and promote the health of newborns, children, and mothers in developing countries.

By authorizing the Newborn, Child, and Mother Survival Act of 2009, the United States could act on nearly unanimous public opinion and start on the path to help save more than six million of the nine million children who die every year from easily preventable or treatable causes. For more information on the Newborn, Child, and Mother Survival Act, click here.

Take Action Now

You can help! Urge your member of Congress to support this critical piece of legislation. A list of current cosponsors can be found here. If your representative is not already a supporter, take action now! Call or write their office and urge them to support this important issue by cosponsoring the Newborn, Child and Mother Survival Act of 2009, H.R. 1410. By cosponsoring this bill, your representative could take an essential step in saving the lives of millions of children and mothers.

Perhaps Melinda Gates explained the need for child survival programming best when speaking of her many trips to developing countries. "On my side of the mat, when my kids are sick, they get antibiotics. On the other side of the mat, when their children get sick, they may be receiving a death sentence. Those of us in wealthy countries must try to put ourselves on the other side of the mat…We must remember that these mothers love their children just as much as we love ours."

Additional Resources:

UNICEF and Child Survival

Save the Children and Child Survival

USAID and Child Health

US Coalition for Child Survival

Bill & Melinda Gates Foundation and Maternal, Newborn, and Child Health

RESULTS and Child Survival

CARE

GAVI Alliance

Read UNICEF’s State of the World’s Children 2008 report

Read Save the Children’s State of the World’s Mothers Report 2008

My Own Monsters: Designed by children to benefit children