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Measuring Progress

Millennium Development Goals

In 2000, the Millennium Declaration set eight global Millennium Development Goals (MDGs) that provide a framework for confronting poverty, hunger and environmental problems challenging poor countries and for improving health, education and gender equity.¹

MDG 4 calls for reducing the 1990 child mortality rates by 2/3 by 2015.
Of the 60 countries that account for 94 percent of child deaths, only Bangladesh, Brazil, Egypt, Indonesia, Mexico, Nepal and the Philippines are currently on-track to achieve their MDG 4 targets.²
Efforts to achieve the MDGs have fostered the development of bilateral and multilateral partnerships to implement integrated programs.

Countries On Track to Achieve their MDG 4 Target²

Case Study 1: Bangladesh. Bangladesh, a densely populated country of 138 million people, has succeeded in cutting its 1990 child mortality rate of 149 per 1000 live births to 77 in 2004, despite widespread poverty and poor infrastructure.^{2, 3}
In the late 1990s, about half of child deaths were due to pneumonia, diarrhea, measles and malaria.^{4, 5} Nearly half of all children were underweight and 36 percent of newborns had a low birth weight; nutritional deficiencies and growth stunting were common.^{2, 3, 6, 7}
In 1998, Bangladesh introduced the Integrated Management of Childhood Illness (IMCI) strategy to raise health awareness and improve the ability to manage illness at the family, community and health-worker levels, link families and communities to health facilities, and strengthen health systems.^{8, 9}
Over the next several years, training guidelines for health-care workers, case management techniques and breastfeeding counseling, strengthening of health systems, and community-based services were implemented.^{5, 10}
- Oral rehydration salts and zinc supplements to prevent and treat diarrhea were scaled up.^{3, 11-13}
- Antibiotic programs to treat pneumonia, and vitamin A, iron and folic acid supplements for pregnant women and young children were provided.¹⁴
- Immunization rates increased from less than 20 percent in 1987 to 75 percent for measles, 88 percent for three doses of diphtheria, pertussis and tetanus (DPT), and more than 95 percent for tuberculosis by 2005.
- Improved quality of care in health facilities, resulting from IMCI training and case management, led to positive results, including a three-fold increase in the use of health-care services.¹⁵
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Case Study 2: Mexico. Mexico’s 1990 child mortality rate was 46 per 1,000 live births and its progress in reducing the mortality rate to 28 per 1,000 live births in 2004 has been well-documented.^{16, 17}
Mexico conducted surveys to identify the disease burden and assess health systems operations and needs.^{16, 18}
Disease-specific strategies (e.g., expanding immunization) were combined with efforts to strengthen health systems (e.g., insurance and subsidies, improving access to clinics). Incremental scale-up promoted integration of interventions, while ongoing data collection made it possible to track progress.
Over the past 25 years, Mexico has sustained an expanding range of services.
- Oral rehydration therapy, first in hospitals and then in clinical practices, contributed to a 60 percent decrease in deaths due to diarrhea in five years.
A stepwise implementation of universal vaccinations, a clean water program, “national health weeks” focused on child health, anti-parasite treatment, respiratory infection prevention and treatment, and nutrition programs reduced the child mortality rate by 64 percent and the proportion of underweight children by 43 percent.¹⁰
The next challenge for Mexico is to reduce deaths in the neonatal period, as birth asphyxia and trauma, congenital heart anomalies, and low birth weight are the leading causes of death.¹⁶

Other successes of on-track countries include:^{2, 3, 11, 19-21}

In Brazil, skilled attendants are present at 97 percent of all births; immunization rates for tuberculosis, measles, and DPT exceed 90 percent.
In Egypt, skilled attendants are present at 70 percent of all births; ORT therapy is marketed to households through the private sector and the media.
The Philippines has initiated baby-friendly hospital programs and expanded micronutrient supplementation and maternal tetanus vaccination.
In Indonesia, a national, routine immunization plan has been put in place, raising vaccine rates against tuberculosis, diphtheria, tetanus, pertussis and measles to more than 70 percent.
In Nepal, vitamin A distribution to preschool-age children decreased the mortality rate by about half between 1995 and 2000;²² antibiotic treatment for pneumonia, and iron and folic acid supplementation are delivered through community-based programs, resulting in decreases in pneumonia and diarrheal diseases.²³

Other countries, while not on track to achieve MDG 4, have made progress as well:^{2, 3, 11, 19-21}

Ten had greater than 90 percent coverage for measles and DTP, and 56 have established vitamin A supplementation programs.
China, Guinea and Mozambique had average annual declines in child mortality rate between 1990 and 2004 of at least three percent.
Tanzania has been recognized for implementing the IMCI approach, which contributed to a 13 percent decline in child mortality in two years.
While progress is being made, considerable challenges remain before even high performing countries will reach child mortality rates that approach those of high-income countries (six per 1,000 live births).^{2, 4}
Of the seven on-track priority countries, only two are among the poorest countries; none are in sub-Saharan Africa, where 42 percent of child deaths occur.
In 23 countries, exclusive breastfeeding rates are lower than 20 percent.
Six countries have immunization rates lower than 50 percent and three had a decline in immunization rates.
In 11 countries, skilled attendants are present at less than 30 percent of births.
No country is close to the MDG 6 target for malaria of 80 percent coverage for insecticide-treated bednets.
Fourteen of the 60 countries have lost ground, as their 2004 child mortality rate is higher than their 1990 rate. Most of these countries have experienced either armed conflict or high generalized levels of HIV/AIDS.

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Success Stories: Reaching the Child Survival Millennium Development Goal

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¹	The International Bank for Reconstruction and Development, The World Bank. Global monitoring report 2006 Millennium Development Goals: Strengthening mutual accountability, aid, trade, and governance. Washington, DC: The World Bank. 2006.
²	Bryce J, Terreri N, Victora CG, et al. Countdown to 2015: tracking intervention coverage for child survival. Lancet, 368:1067-76. 2006.
³	UNICEF. The state of the world's children 2007. Available from: http://www.unicef.org/publications/index_36587.html. (accessed April 23, 2007).
⁴	Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet, 361:2226-34. 2003.
⁵	El Arifeen S, Blum LS, Hoque DME, et al. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study. Lancet, 364:1595-602. 2004.
⁶	The World Bank. Country classification. Available here. (accessed April 19, 2007).
⁷	Editorial. Global childhood malnutrition. Lancet, 367:1459. 2006.
⁸	Gwatkin DR. Integrating the management of childhood illness. Lancet, 364:1557-58. 2004.
⁹	World Health Organization. Country situation: stepwise progress of IMCI in Bangladesh. Available from: http://www.whoban.org/imci.html. 2007.
¹⁰	UNICEF. Progress for children: a report card on nutrition. New York, NY: UNICEF. 2006.
¹¹	Wardlaw T, Salama P, Johansson EW, et al. Pneumonia: the leading killer of children. Lancet, 368:1048-50. 2006.
¹²	Rudan I, El Arifeen S, Black RE, Campbell H. Childhood pneumonia and diarrhoea: setting our priorities right. Lancet Infec Dis, 7:56-61. 2007.
¹³	Kinder M. Preventing diarrheal deaths in Egypt. In: Levine R, editor. Case studies in global health: millions saved. Sudbury, MA: Jones & Bartlett Publishers. 2007.
¹⁴	Victora CG, Fenn B, Bryce J, Kirkwood BR. Co-coverage of preventive interventions and implications for child-survival strategies: evidence from national surveys. Lancet, 366:1460-6. 2005.
¹⁵	World Health Organization. Goal 4: WHO's work. Available from: http://www.who.int/mdg/goals/goal4/whowork/en. (accessed April 25, 2007).
¹⁶	Sepulveda J, Bustreo F, Tapia R, et al. Improvement of child survival in Mexico: the diagonal approach. Lancet, 368:2017-27. 2006.
¹⁷	Levine R. Improving the health of the poor in Mexico. In: Levine R, editor. Case studies in global health: millions saved. Sudbury, MA: Jones & Bartlett Publishers. 2007.
¹⁸	Gakidou E, Lozano R, Gonzalez-Pier E, et al. Assessing the effect of the 2001-06 Mexican health reform: an interim report card. Lancet, 368:1920-35. 2006.
¹⁹	Veneman AM. Achieving Millennium Development Goal 4. Lancet, 368:1044-7. 2006.
²⁰	WHO/UNICEF. WHO-UNICEF estimates on immunization coverage, 1980-2005. Available from: http://www.childinfo.org/areas/immunization/database.php. (accessed April 24, 2007).
²¹	UNICEF. At a glance: Philippines. Available from: http://www.unicef.org/infobycountry/philippines_1657.html. (accessed April 30, 2007).
²²	Gottlieb J. Reducing child mortality with vitamin A in Nepal. In: Levine R, editor. Case studies in global health: millions saved. Sudbury, MA: Jones & Bartlett Publishers. 2007.
²³	Tielsch JM, Khatry S, Stoltzfus RJ, et al. Effect of routine prophylactic supplementation with iron and folic acid on preschool child mortality in southern Nepal: community-based, cluster-randomised, placebo-controlled trial. Lancet, 367:144-52. 2006.

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