Though the number of children who die before age 5 has declined significantly in the last two decades, the path to ending child mortality is long and hard to navigate. Nearly 7 million young children still die yearly, largely from preventable causes. What works and what doesn't in the fight against child mortality? What will it take to go the last mile, and end preventable child deaths?
On a June morning in 2012, international power brokers, doctors, and at least one Hollywood movie star came together at Georgetown University to make a promise to children around the world.
Their vow: to double-down on efforts to save the millions of children who die each year before age 5 from preventable causes such as pneumonia, diarrhea, and malaria. In doing so, the participants at the gathering kicked off a global campaign called "A Promise Renewed" to accelerate reductions in child mortality across the globe. Key to the effort is that the countries with the most child deaths tackle the problem head on.
More than a year later, as lawmakers in Washington draw out budget debates that threaten global health spending, experts on child mortality fear that without improved coordination and sustained financial backing, the effort could fall short of its goals just as many other well-intentioned initiatives have in the past. And there is still a long way to go in reaching even baseline goals that were set more than a decade ago. According to the group charged with tracking the progress of the United Nations' Millennium Development Goals around child and maternal health, as of 2012 fewer than one-third of the 75 countries where child deaths are highest were on track to meet the goal to reduce child mortality.
This summer, GlobalPost correspondents reported from Bangladesh, India, Myanmar, Uganda, and Zambia in our Special Report, "Step by Step." We found hopeful progress on the road to ending preventable deaths in some nations, and considerable challenges in others. The reporting team focused on what works - and what doesn't - in the global push to ensure all children reach their fifth birthday.
While experts agree it is too early to quantify the precise impact A Promise Renewed has had, officials at USAID and UNICEF, the lead organizers of last year's Washington meeting, said that the campaign has created momentum around child health at a time when the development community is looking beyond the Millennium Development Goals deadline of 2015. And they are not backing down.
"We can imagine a world without children dying for no need," Rajiv Shah, administrator of the US Agency for International Development, told GlobalPost in an interview. "We're going to deliver that."
MAKING PROGRESS ON THE ROAD
It is a mark of progress that the number of children who die before their fifth birthday has fallen substantially in the last two decades - from 12 million in 1990 to 6.9 million in 2011. More recent numbers to be released this month are expected to show an even further decline. But such global reductions have been uneven. Eighty percent of deaths in children under 5 occur in 25 countries, primarily in South Asia and sub-Saharan Africa. More than 40 percent of all under-5 deaths occur during the first month of life, where reductions have been particularly slow to come. Poor nutrition, water, and sanitation, along with poor access to education, health care, and family planning, all continue to contribute to young children dying.
In recognition of the variable progress that has been made in reducing child mortality, world health leaders unveiled a 68-page strategic plan during last year's Washington summit to reduce preventable deaths that emphasized a "new way of doing business." Among the more than 700 global leaders in health and international development at the gathering, called the Child Survival Call to Action, were then-Secretary of State Hillary Clinton, then-Ethiopian Minister of Health Tedros Adhanom Ghebreyesus, and even the American actor Ben Affleck.
The roadmap calls for focused efforts in those countries that have the greatest number of child deaths, like India and Nigeria, and on those areas that could drive the greatest future reductions, like neonatal care. Underscoring those targeted measures is the importance of robust and transparent national data. A country needs to know where its children are dying and what they are dying of in order to determine the highest impact intervention.
The plan sets as its goal not a relative reduction, as is the case with the United Nations' Millennium Development Goals, but a firm number for all countries: By 2035, only 1 in 50 children (or fewer) would die before age 5, a number that would match the current average for developed countries. (In 2011, this global figure was much higher, at 1 in 20 children.)
"We are here because you believe that for the first time in history, we have the tools, the knowledge, and the experience to achieve this remarkable goal," Shah told the group.
A Promise Renewed comes under the banner of the United Nations' "Every Woman Every Child" initiative. The new and ambitious effort is the latest iteration in recent decades of fits and starts on improving the health and wellbeing of children. These endeavors, which date to UNICEF's "child survival revolution" of the 1980s and move up through the UN's millennium goals, have fostered significant progress, but many have ultimately fallen short of their grand objectives.
Past efforts, too, have been driven largely by donors and multilateral organizations. The approach of A Promise Renewed - an approach supported by the 175 countries who have come on board - is on local involvement. Key to the campaign is that developing countries with the most preventable child deaths define the road ahead side-by-side with traditional donors, international aid organizations, and partners newer to the mix, such as the private sector and faith community.
The concept of so-called country ownership so fundamental to A Promise Renewed is not new, but the degree to which the campaign has brought the hardest-hit countries into the fold is. Last year's Washington event, for instance, was co-hosted by the governments of India and Ethiopia.
"It's one thing saying the right things when you're somebody that sits in Washington," said Stephen Hodgins, senior technical adviser for newborn health at Save the Children. "But it's another thing when the minister of health from Ethiopia, for example, at a public meeting talks in quite strong terms about the need for respecting sovereignty and respecting autonomy."
The campaign's roadmap outlines the need for countries to develop and refine their own national child survival plans, with guidance and support from UNICEF and USAID.
"We try and find that delicate balance between saying, well, here are our ideas of things that could be priorities," said Katie Taylor, deputy assistant administrator for the Bureau for Global Health at USAID. "If you ask our advice, we might suggest you look at X,Y, and Z without becoming a paternalistic, western imposed view of the world."
But this approach of cultivating country ownership, and A Promise Renewed more broadly, face challenges ahead.
PARALLEL AND OVERLAPPING EFFORTS
With its 2035 goal to eliminate preventable child deaths, A Promise Renewed, for one, coincides with roughly a half-dozen other global plans developed in the last few years, all noble efforts to improve children's health but with different aims and different target dates. The UN's Every Woman, Every Child, launched in 2010, is the overarching initiative to ramp up acceleration toward the millennium goals and save 16 million women's and children's lives by 2015. That broad effort has since been followed by not only A Promise Renewed, but also goal-driven campaigns for family planning, nutrition, pneumonia and diarrhea, and vaccination, among others. A global newborn action plan is now in the works as well. Few experts are willing to publicly criticize the impact that such parallel and overlapping agendas have on child health, but many have expressed reservations about their lack of alignment--particularly as the community turns to post-2015 planning.
"This is a confusing time for this kind of an activity to gather traction," said Zulfiqar Bhutta, founding chair of the division of women and child health at Aga Khan University in Pakistan.
Concern about A Promise Renewed was raised early on by a group of independent global experts on women's and children's health that reports to the UN on Every Woman, Every Child's progress. Just two weeks before the Washington event, the so-called independent Expert Review Group wrote to Shah expressing unease that USAID was leading the introduction of yet another goal with a new target, but one without the kind of multilateral process that the millennium goals had. While the experts lauded the increased attention on child survival, they were concerned that such a narrow focus could detract from integrated work on reproductive, maternal, child, and newborn health. They also questioned the feasibility of such an aggressive child mortality reduction goal for 2035.
"While we strongly endorse the idea of challenging aspirational goals, we are anxious that an unfeasible goal will simply be another way to show that Africa has 'failed,'" they wrote. "We do not see this possible result as helpful to making global progress in women's and children's health." Moreover, they wrote, 2035 was "simply too distant to be politically realistic."
The letter's authors - who included Bhutta, a renowned maternal and child health physician, and Richard Horton, editor-in-chief of British medical journal The Lancet - told Shah that others shared their concerns. They suggested two changes: Reframe the meeting to reflect a broader goal that includes issues like mother's health and family planning, and cast it as an opportunity to discuss, rather than impose, post-2015 plans and goals.
USAID confirmed that Shah had a conference call with the group in response to the letter, and Horton said in an email to GlobalPost that Shah said USAID and UNICEF were committed to working together with others in a coordinated way. But, Horton noted, as the independent review group considered last year in its report and will do so again in this year's forthcoming report, "evidence that this commitment is being delivered is weak, especially in countries."
Shah said in an interview with GlobalPost that he does not believe that having so many goals is confusing or problematic to coordinate.
"We felt it was important to define an end state, and the reality is, we can now, for the first time, embrace the vision of ending preventable death," he said. "I think that the great value of these efforts is they bring a rigor and a businesslike focus on delivering the result to the global system."
Kate Rogers, the new head of the campaign's secretariat at UNICEF, said that she saw the 2015 deadline as "the first but important step" toward the 2035 goal.
FUNDING THE PROMISE
Partners in Health cofounder Paul Farmer said that while all campaigns based on sound, evidence-based interventions hold promise, they all have requirements. "A) to be funded; B) to strengthen national and local health systems; and C) to be developed and implemented in close partnership with the affected governments," he wrote in an e-mail to GlobalPost.
A Promise Renewed squarely meets two of Farmer's criteria, but funding is notably missing.
Increased national financial commitments in maternal and child health from some countries, such as India, have come on top of new pledges by global institutions such as the World Bank Group. But a comprehensive picture of what new country financial resources have come in as a result of the campaign is unclear. New figures tracking funding to maternal and child health will be released later this month.
The campaign comes at an important juncture in US budget discussions. After having just worked out a continuing resolution for the 2013 fiscal year, the US government, the world's largest funder for global health, does not yet have a budget for 2014. The Republican-led House is seeking to eliminate US contributions to UNICEF as well as UNFPA, the global agency for family planning and reproductive health programs. As for USAID, the House has proposed moderately cutting funding for global health programs within the organization's budget over enacted 2012 levels, whereas the Senate has increased it. Both houses of Congress, however, have boosted the budget for maternal and child health. And overall, USAID estimates that its funding to end preventable child and maternal deaths has risen from $984 million in 2006 to $2.1 billion in 2012.
"The US government is the biggest funder, and we want that to continue," said Amie Batson, chief strategy officer of PATH, a nongovernmental organization that focuses on technology-based global health solutions. "But we're missing the whole picture if we say that it's all about the donors, and that nothing else matters."
In fact, UNICEF's Rogers said, A Promise Renewed was never intended to raise money.
"The whole thinking is there's already a lot of money that's out there within the world of global public health," she said. "What we're proposing is that we can make better use of the resources that are out there."
The hope, Rogers said, is that as countries sharpen their plans to reduce child mortality at the same time that donors coordinate their own investments, "we can get greater bang for the buck."
But when there is no clear financial commitment in a global campaign, it can be hard for countries without resources to know what they are supposed to do, said Carol Presern, director of the Partnership for Maternal, Newborn & Child Health at the World Health Organization. The problem may be particularly acute for a country like Myanmar, which has only recently opened up to the international community.
"The government cannot do it alone, they need help from outside agents," said Cynthie Tin-Oo, a public health consultant with Myanmar Research International. But that influx of aid ushers in unique problems with donors that have their own agendas.
"The government says, 'Yes. Yes. Yes,'" Tin-Oo said. "So many 'yeses,' and then they cannot get anything done because all the different programs are overlapping and they don't have enough resources to manage them."
Save the Children's Hodgins said that without additional funding, large-scale endeavors risk stalling to some extent. But with the buy-in from other countries and UNICEF, he said, the outcome for A Promise Renewed could be different.
IN THE RIGHT DIRECTION
Since last June, leaders of A Promise Renewed said that the campaign has gained political momentum. They hail as success the 175 nations that signed a pledge introduced at the meeting to "recommit the efforts of our respective governments to give every child the best possible start in life." India, Ethiopia, Bangladesh, Zambia, and the Democratic Republic of the Congo are among the eight countries that also have hosted A Promise Renewed celebratory launches and revised their national plans. Ethiopia and India are among the handful of countries that have developed new "scorecards" to publicly track their progress on child mortality. And these numbers are "changing constantly," said a USAID spokesperson. Even President Obama gave a nod to "saving the world's children from preventable deaths" in his latest State of the Union address.
"We all understand no single entity, no single government, no single person, organization, you name it, donor, NGO, we can't do this alone," said USAID's Taylor. "It will require not just international participation but in-country social mobilization at the grassroots level for this to work."
In a world where there are so many efforts to improve the lot of children, however, it is hard to tease apart the effect of A Promise Renewed.
Still, global health experts said, the campaign has made a difference in drawing attention to child health as a broad, integrated issue. Hodgins called it an "advocacy pitch" and a "useful rhetorical tool" that brings together a number of different technical health areas - malaria, HIV, family planning, diarrhea, respiratory infections, immunization, and newborn, for example - and grouping them together in a package.
And this is having an impact on the ground in some countries.
"Sometimes you need a push from high levels," said Kaosar Afsana, director of the health, nutrition and population program at BRAC, a large nonprofit organization in Bangladesh. "Sometimes the people are working in a way they think is normal, and then we set new goals. It shakes the country." That was the case in Bangladesh, which initiated a flurry of child survival activities following A Promise Renewed, Afsana and other child health experts in the country said.
"A Promise Renewed is a step in the right direction," Bhutta said. But apart from select countries that have become involved like Bangladesh, he said, it is hard to say if the effort has gained wide traction.
"It seems as if we did all of this last year, and then after that, it's been cast adrift for lack of a better term," he said. Still, he said, it's too early to declare the campaign a victory or failure.
For now, WHO's Presern offered her own way of viewing progress.
"I think you have to look at the counterfactual," she said. "What if they had not done it?"
This post is part of a series produced by The Huffington Post and the NGO alliance InterAction around the United Nations General Assembly's 68th session and its general debate on the Millennium Development Goals (MDGs), "Post-2015 Development Agenda: Setting the Stage" (September 24-October 2, 2013). The session will feature world leaders discussing progress made on the MDGs and what should replace them when they expire in 2015. To read all the posts in the series, click here; to follow the conversation on Twitter, find the hashtag #No1Behind. For more information about InterAction, click here.
Additional reporting for this article contributed by Emily Judem and Elizabeth Stuart in Boston, Sasha Chavkin in Uganda, and Harman Boparai in India.