Ending Preventable Child Death in a Generation
Authors: Roger I. Glass, Alan E. Guttmacher, Robert E. Black
Journal: JAMA (2012)

DURING THE PAST 20 YEARS, THERE HAS BEEN A SUBstantial decline in mortality among children younger than 5 years from 12.0 million deaths in 1990 to 7.6 million in 2010. In these decades alone, global health and development efforts have saved the lives of more than 50 million children, half of them by preventing deaths due to pneumonia, diarrhea, and measles. This improvement in child survival was catalyzed in part by setting aspirational global targets such as the Millennium Development Goals (MDGs). As 2015 approaches, and with it a final assessment of progress toward MDG 4 on reducing child mortality, it is appropriate to consider a post-2015 vision for child health. A new common vision for a global commitment to end all preventable child deaths is needed. Such a vision will not be compelling unless it can be tied to concrete and measurable benchmarks at the global and country levels that are both ambitious and plausible. In this Viewpoint, a new benchmark is detailed: that all countries achieve a national under-5 mortality rate (U5MR) of no more than 20 deaths per 1000 live births by 2035 and that the global average U5MR should decline to 15 deaths per 1000 in 2035. Of 195 countries, 98 already have U5MRs of 20 per 1000 or fewer; 43 countries would be expected to reach this goal by 2035 at current annual rates of reduction (ARRs), and 54 countries would have to accelerate progress above the 2000-2010 ARRs. The proposed U5MR benchmark of 20 deaths per 1000 live births is supported by modeling analyses by UNICEF as well as similar exercises at Johns Hopkins Bloomberg School of Public Health and the Institute for Health Metrics and Evaluation at the University of Washington. The consensus of a consultation at the National Institutes of Health’s Fogarty International Center in May 2012 was that this benchmark, while ambitious, could be achieved for most countries. In addition, for countries in which the U5MR is already near or below 20 deaths per 1000, the focus could be on ensuring that all subpopulations (defined in local terms of geography, socioeconomic groups, or other equity measures) have a U5MR of fewer than 20 deaths per 1000. The global average of 15 deaths per 1000 in 2035 would be within the current range of U5MRs in industrialized countries of 3 deaths per 1000 to 18 deaths per 1000 (FIGURE). Achieving these benchmarks would require a global ARR in U5MR of 5.3% over the period 2010 to 2035, more than doubling the ARR of the last decade of 2.5%. Clearly, significant accelerations in progress will be required in many countries, including those that are among the largest contributors to global child deaths—India, Nigeria, Pakistan, the Democratic Republic of the Congo, and Ethiopia. For instance, India, which accounts for nearly a quarter of all child deaths, has had an ARR of 3.1% for the last decade. It would need to increase this ARR to 4.6% to reach the U5MR of 20 deaths per 1000 by 2035. Pneumonia, diarrhea, and malaria remain significant global causes of death, but recent progress against these diseases means an increasing proportion of under-5 deaths are due to neonatal conditions (40% of the total currently), including preterm birth complications, intrapartum complications, and severe neonatal infections. Preventing these deaths will require different interventions such as safe deliveries, chlorhexidine cord care, or antibiotics for treatment of sepsis, meningitis, and pneumonia. The Lives Saved Tool estimates the improvements in mortality rates that can be achieved in 2035 by scaling up current interventions to provide full and equitable coverage. Such modeling provides insights into the individual value of each intervention, but preliminary results indicate that a major effort will be required on many fronts— from malaria control in endemic areas to the prevention of neonatal deaths in all settings. Success in bending the curve of child mortality is predicated on renewed commitment and political will as well as continued innovation in health technology and implementation science to scale solutions in a sustainable manner, including harnessing the power of such modern tools as mobile phones. Continued gains in reducing poverty, improving education for girls, and strengthening health systems and family planning would also help improve child survival. Ending preventable child deaths will not be due only to tradi-