Child survival in the SDG world: what next?

JOY LAWN: So child survival, what next? To understand that, we need to look back at the last 25 years of the Millennium Development Goal era. And we have had the so-called child survival revolution. But that is not just one revolution. We actually had two revolutions with a gap in between. So in the 1980s, we had the first child survival revolution, led very clearly with global direction from UNICEF, the director of UNICEF then, Jim Grant, real primary health care focus. The acronym was GOBIFFF, so G for Growth monitoring, O for Oral rehydration, B for breastfeeding, and I for immunisation. Those are the bits that everybody remembers and that we’ve heard about throughout this week in the course as well.

But there was an FFF that got lost. And that was Female education, Family planning, and Food, the wider nutrition context. So that first child survival revolution really started the global focus with the architecture within the UN, but also national leaders at presidential level paying attention to child survival. That was the 1980s. Then during the 1990s we had a non-revolution. Child survival and health generally wasn’t so high on the agenda, particularly in Africa with economic, structural readjustment, the start of the AIDS epidemic, and many other challenges. Child survival wasn’t high on the agenda. Health wasn’t high on the agenda. And the progress really stagnated.

If we look at global child deaths during the 1990s, almost a flat line in many countries, and particularly in Africa. And yet then we came to the Millennium Development Goal push when they were announced in 2000, and then particularly the second half of that decade, after 2005, so the last 10 years of the MDGs. And what we’ve seen is leadership came again, and this time in many cases from countries, leaders who wanted to see child survival change. And this is true in Latin America, in southeast Asia, but also in Africa, the African Union discussing this. We’ve seen a doubling of funding. We’ve seen many of the things we’ve learnt about in this course, dramatic reductions in infectious diseases.

We’ve seen real progress that is speeding up. So even the last three years of the Millennium Development Goals, the rate of change for under-five mortality has increased. So what we learn from this 25 years of progress for child survival is that it’s easier sometimes to do these more vertical primary health care things. But even those things only really work if we’re paying attention to leadership, to politics, to the economics, and to wider shifts. So as we move forward, what are the wider shifts that will also influence the health of the child and families and women and children?

So as we move forward into the Sustainable Development Goal era, there are shifts beyond health care provision that have a big effect on women and on children. So looking at child survival, there will be four critical shifts that affect children. The first of those is economic growth and the shift of the world into middle-income countries. The second one is urbanisation and the shift into cities. The third one is population growth. Where are the biggest populations going to be? And the fourth is the epidemiological transition. What diseases are affecting families?

So if we start with economic growth, at the beginning of the Millennium Development Goals when we thought about poor people, it was poor rural people, mainly in Sub-Saharan Africa, South Asia, and also Latin America. But during this era, more than 40 countries have graduated from low-income to middle-income. Now most of the world is born in a middle-income country. And in fact, most of the world’s poor are in middle-income countries, because of the equity divide there.

So what we do still has to take into account the rural poor, particularly in Africa, but also needs to take into account the urban poor, particularly in south Asia, Latin America, but also in parts of Africa, so urbanisation changes what we do for women and children. Secondly– so middle-income economic growth changes, but secondly also so does urbanisation, that similar shift. So just in the last few years the world has tipped from being predominantly rural to being predominantly urban. Now, around 55% percent of the world is urban. By the end of the Sustainable Development Goals, at least 2/3, maybe more will be urban. So these two shifts, the economic growth, the urbanisation, go together. What about population growth and change?

So at the moment, the bulge of adolescents that will go through and will have children, even with the most optimistic scenarios for meeting unmet need for family planning, we’re going to see sustained population growth. And that will particularly be in Africa, so Africa currently is one in four of the world’s births. By the end of this period of the Sustainable Development Goals, the projections suggest that will be one in three births. So this is critical, the focus on Africa. And it’s particularly critical for child survival, because unless we change what we do now, not only will Africa have one in three of the world’s births by 2030, but they will have almost 2/3 of the world’s child deaths.

So the focus of where we look and what we look at and how we deliver care has to take into account these shifts, but also what people are dying of. So the fourth shift is the epidemiological transition. And as we have seen throughout this course and particularly on the newborn and child sections and what children die of, we have tipped from the majority of deaths being infections to the majority being in the neonatal period, and including things like preterm birth. And this is similar to the transition we’ve seen in adults, where infectious diseases have tipped into non-communicable diseases. And with this we have to think about what we do. Primary health care still has to continue.

But we must shift to also being able to provide more long-term care and looking at these conditions. So as we look at child survival, what next, we need to also look at the bigger world and how these shifts will affect what do we do, where do we do it, and especially how do we reach the poorest, who don’t look the same as we sometimes maybe think they do? So what next for child survival? The first thing to remember here is that we still have around six million child deaths. We still have an unfinished child survival agenda. We must end these preventable deaths. And what will that take?

Taking into account what we’ve learnt, what’s changing in the world, and the data we have, there are critical differences in what we need to do. First of all, we really need to pay attention to newborn health. I’m not just saying that because that’s what I work on. The data show us that. So around the world, almost half of child deaths are in the neonatal period. And what we have to do for them is different and totally links to maternal health and what we do for women, and really needs to integrate with that. Secondly, we must finish the unfinished agenda for child infections. We have many of the solutions that we need.

But we need to be much more innovative in how we deliver those, and especially to the poor, bearing in mind where the poor are and how to reach them. And then we need to really take into account that the single biggest slice in the child cause of death pie is now “other.” “Other” includes non-communicable diseases in children. It includes injuries. It includes a shift that we’re seeing especially in middle-income countries. And we need to be pushing on this, including congenital disorders. So these are areas that we need to start to pay more attention to. So that’s the things that we need to do. But how do we do that?

One very fundamental difference that we need to take forward as we go forward is that we need to put the child together again. A lot of what we’ve done for child survival has been about immunisation, malaria, HIV, targeting different parts. We’ve subspecialised so much, whether that’s in global public health or what we do in clinical care. As a paediatrician, I know this. People become so specialised they’re just seeing a kidney. They’re just seeing one part of a child. What we need to do is to put the child together. And that leads us very much beyond child survival into child development, the child in the family, and that context. So as we go forward, this is critical.

What do we invest in? How do we do that? However we do that, we need to keep the actual child in mind and we need to remember especially the poorest and the most vulnerable to make sure that we intentionally reach those and close huge equity gaps for children around the world today.