MILLENNIUM DEVELOPMENT GOALS

In 2000, the members of the UN adopted eight millennium development goals (MDGs) to be completed by 2015. The fourth goal is to "reduce by two-thirds, between 1990 and 2015, the under-five mortality rate."

data sources

The information visualised here is aggregated from four recent papers related to child mortality published by the World Health Organization (WHO) over the last 10 years.

Levels and Trends in Child Mortality Report 2011

Global, regional, and national causes of child mortality in 2008: a systematic analysis

Methodology and Assumptions used to estimate the Cost of Scaling Up selected Child Health Interventions, 2005

WHO estimates of the causes of death in children, 2005

Estimation of Costs

These costs are the most recent estimates of the total investment required to scale up 16 key health interventions to universal coverage, beginning in 2006 and ending in 2015. 75 countries with the highest burden of mortality are included in the study, together accounting for almost 95% of deaths of children under five annually.

The cost estimates take into consideration both patient and programme costs across a continuum of care from local communities to national infrastructure and policy.

Costs are presented in 2004 US dollars, and assume 3% inflation.

WHY DO COSTS VARY FROM REGION TO REGION?

WHO member states are grouped into epidemiological regions based on the global burden of disease (GBD) classification system. These regions are further classified according to mortality:

Very low: Very low child, very low adult
Low: Low child, low adult
Moderate: Low child, high adult
High: High child, high adult
Very High: High child, very high adult

The Commission on Macroeconomics in Health (CMH) index was also used to group countries into quartiles based on the current constraints on their health infrastructure. The interplay between burden of disease and strength of infrastructure account for the variability in scale up costs from region to region. In countries with very high mortality and weak infrastructure, costs are high due to basic needs such as drugs and facilities. In countries with less infrastructure constraints and lower mortality, labour and supply costs are relatively high.

Programme Costs

The $52.4bn total cost to achieve health outcomes includes both the patient cost at the point of delivery for each intervention, as well as the programme costs incurred at administrative levels. These include:

• Programme management
• Honoraria for community health workers delivering child health interventions only
• Training
• Supervision
• Externally funded technical assistance
• Information, education and communication
• Monitoring and evaluation
• Infrastructure
• Advocacy
• Laws, policy, regulation
• Programme costs for immunisation

Key Medical Interventions

The 16 key medical interventions included in the visualisation are grouped into delivery categories, each targeting a specific cause of child mortality.

1. Infant feeding
2. Vital vaccines
3. Combating diarrhoea
4. Combating pneumonia and sepsis
5. Combating malaria
6. Prevention and care for HIV

Descriptions of all medical interventions are adapted from Annex 3 of Methodology and assumptions used to estimate the cost of scaling up selected child health interventions

Interventions: Infant Feeding

Case management of severe malnutrition. All severely malnourished children with weight-for-height below three standard deviations (SD) and/or oedema are hospitalised during the initial phase of their treatment. After the medical complications associated with severe malnutrition are under control and initial stabilisation has occurred, all severely malnourished children receive a highly fortified, therapeutic diet, high in energy and protein, to allow rapid catch up growth until full recovery.

Promotion of breastfeeding. Mothers are counselled to exclusively breastfeed for six months after delivery, followed by appropriate complementary feeding and continued breastfeeding for two years or beyond. Costs were included for three counselling visits: one session within the first week after birth; one session at six weeks; and one session between five and six months of life.

Improvement of complementary feeding. Costs are included for one care giver per child to be given intensive counselling (two full sessions: one at nine months and the second at 12 months) on the importance of continued breastfeeding after six months of age along with appropriate complementary feeding practices.

Vitamin A supplementation. Vitamin A is supplemented to all children aged three, nine, and 15 months, with subsequent doses every six months up to the age of five years.

Universal Salt Iodisation. The costs for implementing this intervention mainly reside in the category of programme costs. The patient costs included account for the cost of adding iodine to salt. Programme costs include a legislative and policy process, the purchase of industry equipment for iodising salt, as well as monitoring visits to producing factories.

Regulation of Baby Formula. National governments take steps to implement the International Code of Marketing of Breast Milk Substitutes, including the enactment of legislation and introduction of measures to control the marketing of breast milk substitutes. This intervention includes only programme costs and no patient costs.

Interventions: Vital Vaccines

Immunisation. The cost estimate includes vaccination with BCG, measles, yellow fever, three doses of Diptheria-Tetanus-Pertussis (DTP), oral polio, Haemophilus influenza type-b (Hib), and Hepatitis B.

Deworming. Regular treatment with anthelminthics (as from WHO list of essential medicines) of any child over the age of 12 months in areas where soil-transmitted helminths are of public health relevance.

Interventions: Combating Diarrhoea

Case management of diarrhoea. Treatment also varies by the point of delivery, but is based on standard recommendations on diarrhoea management with ORS and zinc, and in the case of very severe dehydration, rehydration by intravenous injection.

Antibiotic treatment for dysentery. Trained health workers use an algorithm for the assessment and management of bloody diarrhoea in children under five years of age. If bloody diarrhoea is present, the children will be provided with a three day course of ciprofloxacin and re-evaluated after two days. It is assumed that around 5% of diarrhoea cases need to be treated with antibiotics due to presence of bloody diarrhoea or shigellosis.

Interventions: Combating Pneumonia and Sepsis

Case management of pneumonia. Treatment varies depending on the estimated point of treatment (family, community health worker, health facility, or hospital), but in general involves a trained health worker administering children diagnosed with mild or moderate pneumonia with an eight day course of oral amoxycillin and paracetamol to treat fever. Drugs for the treatment of wheezing cough are administered in some cases.

Treatment of measles and measles complications. Health facility workers manage non-complicated measles with vitamin A therapy, 69 70 and paracetamol in case of fever. It is assumed that 10% of cases will develop severe complicated measles with pneumonia complications and need to be treated at the first referral level (no other complications were included in this model).

Community based case management of suspected sepsis. Community health workers, assumed to be trained in neonatal care and diagnosis and management of sepsis, identify sick newborns through a combination of home visits and care-seeking by families. Neonates suspected to have sepsis are treated with antibiotics.

Interventions: Combating Malaria

Insecticide treated bednets and anti-malarials. Patient costs include costs for long lasting insecticide treated bed nets (ITNs, with an assumed useful life of three years), costs for treatment with first and second line drugs, and treatment diagnostics. Long lasting ITNs are assumed to be distributed to children in conjunction with routine post-natal care, and especially in conjunction with vaccine administration.

Interventions: Prevention and care for HIV

Prevention of mother-to-child transmission prevention of HIV (PMTCT). Prevention of mother-to-child transmission prevention of HIV (PMTCT). To calculate the cost of anti-retroviral prophylaxis and infant feeding counselling we used a costing model developed by the Futures Institute. The model assumes that 10-50% of women attending ante-natal clinics are tested. Using country-specific prevalence data, costs have been based on the assumption that 90% of HIV-positive mothers accept treatment and that 50% decide to use replacement feeding.