International developments

1
International developments

• Millennium Developmental
• Goals (MDG)

2
MDGs - where do they come from?

• In September 2000, Millennium Summit (189
  countries)
• Millennium Declaration describes 7 areas for
  national leaders commitment
• Road Map towards the implementation of the UN
  Millennium Declaration (specific goals to be
  achieved for the 7 areas)
• Millennium Development Goals (endorsed by the UN
  General Assembly)

3
The Millennium Declaration
Millennium General AssemblySeptember 2001
Secretary Generals Millennium Report
4
MDGs - how are they structured?
8 GOALS
16 TARGETS
48 INDICATORS
5
MDGs - what are the 8 MDG Goals?

• Halving extreme poverty and hunger
• Achieving universal primary education
• Promoting gender quality
• Reducing under 5 mortality by 2/3 from 1990
  levels
• Reducing maternal mortality by 3/4
• Reversing the spread of HIV/AIDS, malaria, and TB
• Ensuring environmental sustainability
• Developing a global partnership for development,
  with targets for aid, trade and debt relief

6
MDGs - how is health represented?
High prominence given to health
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Millennium Development Goals
To reduce under 5 mortality by 2/3 of 1990 levels
by the year 2015
8
Global trends in under-five mortality, 1960-2000,
with projections to 2015
200
175
150
125
Under-five mortality per 1000
If recent trends continue
100
75
50
To achieve
Millennium Development Goals
25
0
60
65
70
75
80
85
90
95
00
05
10
15
Source
Data from
Ahmad
OB, Lopez AD Inoue M. The decline in child
mortality A reappraisal.
Bull WHO,
2000, 70(10), with trend extended through

2015 and linear trend needed to achieve 2/3
reduction from 1990 levels.
9
MDGs matter in all regions
Share of countries on/off track to achieve 2/3
reduction in child mortality by 2015
10
Infant mortality by region and income level
11
MDGs relevance

• Importance of health for sustainable development,
  including economic development (CMH)
• Several efforts ongoing to cost the achievement
  of the MDGs
• The World Bank has adopted the MDGs as corporate
  priorities

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Child Health Determinants

• Proximate Determinants
• Feeding and nutrition
• Hygiene and indoor air pollution
• Other preventive activities
• Care during illness

Socio-economic differences For each of
these determinants The poor are disadvantaged

• Underlying Determinants
• Financial barriers
• Health care provision
• Maternal education
• Water, sanitation, and the home environment
• Other underlying determinants

Source Wagstaff, Bryce, Bustreo, Claeson. Child
health reaching the poor. AJPH forthcoming
13
Focus on child mortality reduction goal
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What are children dying of?
Determinants of Child Mortality
Outcomes

• Nutrition
• Immunization
• Care
• Malaria prevention

Reduce child mortality by 2/3 by 2015
Malnutrition 541
Health Outcomes
Perinatal causes 22
Sources EIP/WHO 2000, based on 1999 data 1
Pelletier et al, J Nut 1994 1242.
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What are the major (proximate) determinants of
child mortality?

• At population level, at least
• nutrition
• care
• malaria prevention
• care-seeking

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What set of interventions are most likely to
reduce child mortality?

• Access to appropriate case management, at home
  and in communities
• Interventions to improve nutrition and
  appropriate care seeking
• Regular use of insecticide-treated nets
• Immunization against major endemic diseases
• Interventions to improve neonatal care, e.g.,
  skilled attendants at birth

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Intermediate determinants Nutrition
Determinants of Child Mortality
Indicators
Household/ Community
Proportion of infants under 6 months of age who
are exclusively breastfed 1 Proportion of
infants aged 6-9 months receiving breast milk and
complementary food Low height for age

• Nutrition

Sources of data
MICS DHS Other population-based surveys
1 Reflecting change in global policy for duration
of exclusive breastfeeding.
18
Intermediate determinants Immunization
Determinants of Child Mortality
Indicator
Household/ Community
Proportion of surviving infants who have received
a dose of measles vaccine on their first birthday.

• Nutrition
• Immunization

Sources of data
MICS DHS Other population-based surveys EPI
programme data
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Intermediate determinants Care
Determinants of Child Mortality
Indicator
Household/ Community
Proportion of children with fast or difficult
breathing in past two weeks who received an
appropriate antibiotic Proportion of children
with diarrhoea in the past two weeks who received
ORT Proportion of children with fever in past two
weeks who received an appropriate antimalarial

• Nutrition
• Immunization
• Care

Sources of data
MICS DHS Other population-based surveys
20
Intermediate determinants Malaria prevention
Determinants of Child Mortality
Indicator
Household/ Community
(to be used in malarious areas) Proportion of
children under five who slept under an
insecticide-treated net the previous night.

• Nutrition
• Immunization
• Care
• Malaria prevention

Sources of data
MICS DHS Other population-based surveys
21
Safe, effective treatments are available...
Determinants of Child Mortality
Intermediate Determinants
Health system other sectors

• Nutrition
• Immunization
• Care
• Malaria prevention

High coverage of the target population with
effective interventions
Health service provision
Health finance
Supply in related sectors
22
and IMCI offers a combined service delivery
strategy
Determinants of Child Mortality
Intermediate Determinants
Health system other sectors

• Nutrition
• Immunization
• Care
• Malaria prevention

High coverage of the target population with
effective interventions
Health service provision
Health finance
Supply in related sectors
23
Intermediate determinantsAccess to quality care

Determinants of Child Mortality
Proposed areas for measurement
Intermediate Determinants
Health system other sectors
Presence of skilled attendance at birth

• Nutrition
• Immunization
• Care
• Malaria prevention

High coverage of the target population with
effective interventions
Health service provision
Sources of data
Health finance
Health facility surveys Population-based coverage
surveys
Supply in related sectors
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Conclusions

• The focus on MDGs provides an opportunity to
  improve child health
• The effort may translate in concrete financial
  support to countries
• The implementation of a limited set of effective
  interventions will lead to achievement of the MDG
  for child mortality
• Achieving high coverage levels among poor
  children is critical
• A joint effort to monitor intermediate indicators
  and report progress toward the MDGs is needed

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MDGs - global level dimensions

• Millennium Report annual monitoring of progress
  towards the achievement of the goals
• Millennium Project 10 task forces (TF4 is on
  maternal and child health)
• Global Millennium Campaign advocacy

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MDGs - country level dimensions

• MDG reports link countries development
  priorities and policies with aid trade debt
  relief and investment flows of OECD countries
• Country studies on strategies, investment and
  financing develop proposals to achieve MDGs
  through policy dialogue, CCA, UNDAF, PRSPs etc.
• National Millennium Campaigns coalition building

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The framework to accelerate action on the MDGs
Guiding Principles

• Building on existing mechanisms
• Tackling critical implementation constraints
• Harmonizing donor efforts within poverty
  reduction strategies
• Applying a multisectoral approach potential to
  obtain synergies across MDGs
• A results based approach to achieving the MDGs

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Issues to consider

• For the MDG of Child Mortality Reduction
• Harmonization of efforts can maximize results
• Country focus is a must
• The actions need to be multiple and
  multi-sectorial to address inequalities
• The health system constraints need to be tackled

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MDGs - WHO Commitment

• WHO commitment to MDG reaffirmed at WHA 55
• Report to the 111th Executive Board (Jan 2003) on
  MDGs included
• WHO commitment on tracking progress and measuring
  achievements
• Operationalisation of MDG at country level
  (capacity building, advocacy, policy)
• WHO work on MDG is on WHA 56 agenda (May 03)
• DG has taken MDGs into account for preparation of
  Proposed Programme Budget 2004-2005