What is the state of child health?

ANDY YOUNG: Hi. I’m Andy Young. I’m a paediatrician with an interest in understanding how health services can best help improve child survival and development. In this section, I will be setting the scene for the Child Health Week by answering a question. How many children die? Where? And what from? We will also look at how the answer to this question is changing over time by looking at the progress we have made since the Millennium Development Goal era and what we need to do to achieve the Sustainable Development Goal targets for 2030. So to the first part of our question, how many children die? UNICEF estimates that in 2015, globally, 5.6 million children under the age of five died.

Each of these deaths is a tragedy affecting an individual, a family, and a community. What is more, many of these 5.6 million tragedies are preventable. The scale of the task is huge. However, there is cause for optimism, as this number is a significant decrease from 1990, when 12.6 million children under the age of five died.

We have made some remarkable progress. But this is what we had hoped to achieve. Millennium Development Goal 4 was to reduce by 2/3 between 1990 and 2015 the number of deaths under five per 1,000 live births– the under-5 mortality rate. The UN estimates this rate was 92 in 1990, and by 2015, it had reduced to 40. This is a 57% reduction, which is not quite 2/3. So as a global community, we missed this goal, but made significant progress. Before moving on from child-mortality rates, I want to make a technical but important point about where this data comes from. If you look at these two different lines, the line that starts slightly higher is the United Nations estimate.

And the next is from the international Health Metrics and Evaluation unit in Seattle. Many countries do not have comprehensive vital registration systems that allow us to use the actual number of births and deaths to calculate the under-5 mortality rate. For these places, the rate is estimated from what we do know from censuses and parts of the population that have been monitored more closely. The type of data that is used and the statistical methods for estimating the final numbers are different for the UN for the IHME, but on a global level, as you can see, the numbers agree quite closely.

At country level, the estimates can be very different, which can make it difficult to know where to focus our efforts and to accurately monitor progress. This highlights the importance of good, quality data. If you are interested in learning more about the process of generating estimates for metrics like under-5 mortality and neonatal mortality, there is an appendix to the section which goes into more detail on this topic. Now, looking forwards at sustainable development goals– Sustainable Development Goal 3 is to ensure healthy lives and promote well-being for all at all ages. Within this goal, there is a target to end preventable deaths of newborns and children under five years of age by 2030.

This has been equated to an under-5 mortality rate of 25 or below. Taking a crude look at our progress from 1990 to 2015, and plotting where we need to be in 2030, it looks like at a global level, we are already on the right track. And if we just keep doing what we’ve been doing, we will achieve Sustainable Development Goal 3. At global level, this is broadly true. And one model has suggested that the global under-5 mortality rate will be as low as 19 by 2030. However, there is an important difference between the Millennium Development Goals and Sustainable Development Goals targets for child health. This is that the SDG target of under-5 mortality is for each individual country to achieve.

This is an important statement on global inequities in child health– that it is not acceptable to make up for poor progress in child survival in some countries by particularly good progress in others. It makes it clear that we cannot leave any child behind. This leads us on to the next part of our question. Where do children die? This map of the world showed the size of each country relative to the absolute number of deaths of children under five in 2015. You can see that the world looks very different when we take this perspective. The majority of child deaths are now in sub-Saharan Africa, southern Asia, and East Asia.

Looking at trends over time for different regions of the world, you can start to see that it is not just the absolute numbers, but the rates of child mortality have been and continue to be vastly divergent in different regions. The green-dotted line shows the SDG target under-5 mortality rate of 25. Large parts of the world have already reached the target, and the Western Asia and Northern Africa region is almost there. The progress needs to be made in Central and southern Asia and in sub-Saharan Africa. Looking to the future, this graph shows the projected under-5 mortality rate for 2030, with each blue dot representing a different country. You can see there are many countries with projected under-5 mortality rates over 25.

With current progress, some of these countries will come close. For example, Djibouti and Myanmar will get to within one or two of the goal. However, some countries will still be a long way behind, with South Sudan, Chad, and the Central African Republic projected to still have an under-5 mortality rate above 75, three times the target rate. These countries represent a significant part of the world population and are projected in 2030 to be home to 1.8 billion people. We have talked about which countries have been left behind, but which specific populations have been left behind within and across countries? There are three key groups. First is the poorest.

The under-5 mortality is 1.9 times higher in the poorest households compared to the richest. Second are rural populations. Under-5 mortality is 1.7 times higher in rural populations than urban populations. Thirdly, there are neonates. Progress has been slower through the MDG era in neonates than in the under-5 age group as a whole, with a 48% reduction in neonatal mortality versus a 56% reduction in under-5 mortality. Now that we know how many children die and where they die, the final part of our question is, what do children die from? To find the answer, we turn the Global Burden of Disease Study.

This is a huge piece of work that estimates the causes of death around the world, for adults as well as children, on an annual basis. The whole area of the chart represents all the deaths of children under five in 2015. The size of each rectangle represents the proportion of those total deaths due to each cause. This is split into three overarching categories– in red– communicable, maternal, neonatal, and nutritional diseases, the largest group; in blue– the non-communicable diseases; and in green– injuries. That’s the answer to our question, how Many children die, where, and what from? It is an important and urgent question, but child health is about so much more than survival.

The World Health Organisation’s Global Strategy for Women’s Children’s and Adolescent Health for 2016 to 2030 recognises this and describes the agenda as survive, thrive, and transform. Let’s focus on thrive. What do we mean by thriving? This means that every child and adolescent can reach their full potential. If we can achieve this, it will result in enormous social, demographic, and economic benefits. But how will we achieve it? Two key strategic areas on the road to success will be nutrition, ending malnutrition, and meeting broader nutritional needs, and ensuring good-quality early childhood development. We will touch on these themes more throughout this week. During this session, we have answered the questions. How many children die?

Around 5.6 million every year, but many fewer than in 1990. Where do they die? Largely in sub-Saharan Africa and southern and East Asia. And what do they die from? Communicable diseases, neonatal causes, and an increasing number of non-communicable and injury-related causes. We have also learned that we need to look beyond this question of survival to the question of how to enable every child to not just survive, but to also thrive.