MDG 4 & 5: ‘All ten fast-track countries did work outside health as well’

While a majority of low- and middle-income countries (LMICs) are struggling to meet the Millennium Development Goal 4 and 5 of reducing child mortality and improving maternal health, in 2012 ten countries with similar resources were on the “fast-track” of achieving the targets, notes a June 30, 2014 Partnership for Maternal, Newborn and Child Health, WHO report.

These countries (in alphabetical order) — Bangladesh, Cambodia, China, Egypt, Ethiopia, Lao PDR, Nepal, Peru, Rwanda, and Vietnam — “deployed tailored strategies and adapted quickly to change” to achieve the desired results. “Each country had a unique pathway but had certain commonalities like family planning and immunisation,” said Dr. Shyama Kuruvilla, Senior Technical Officer, Knowledge for Policy, Partnership for Maternal, Newborn and Child Health, WHO, Geneva. She is also a coordinating author of the “Success Factors for Women and Children’s Health” report.

The reason why these 10 countries are doing better than other low- and middle income countries turns the spotlight on the core issue – it was not the amount of money they spent but how they spent it that mattered. “These countries identified evidence-based high-impact interventions like immunisation, family planning and quality care at the time of birth. And these were carried out the interventions in a novel way and adapted to suit the particular country’s conditions,” she said.

As a result, the immunisation coverage shot up from 2 per cent to 85 per cent between 1985 and 2010. “They have a very good monitoring system. You need to focus on the results of investment and not just how much money is put in. These [10] countries have, what we call, a triple planning — investment, investing to sustain progress and identifying the challenges that require change,” Dr. Kuruvilla explained.

These countries did work outside health as well, like girl’s education; women’s participation in labour force and politics; rapid increase in safer water availability and sanitation; and economic development and good governance. “All the 10 countries are doing better than other countries in all these areas. We need combined progress in all areas, not just health. That’s the challenge for India,” Dr. Kuruvilla stressed.

China made universal primary education compulsory in 2000. It made nine years education compulsory for eliminating illiteracy among young people. And in 2011, the net enrolment of primary school-age children was 99.8 per cent. It achieved universal education in 2011, much ahead of 2015. “So the strongest population point is China. It achieved 99.8 per cent enrolment of children [although] the population is 1.37 billion,” she said dismissing the excuse of a large population in India standing in the way of vastly and quickly improving the health indicators.

Between 1990 and 2013, India reduced maternal mortality by 65 per cent (569 to 190 per 100,000 live births). But it still accounts for 17 per cent (50,000) of the global maternal deaths, the highest in the world. Though it brought down under-five mortality from 2.5 million to 1.4 million between 2001 and 2012, 22 per cent (the highest in the world) of deaths took place inIndia in 2012. Of the three million neonatal (0-27 days) deaths in 2012, 779,000 happened in India. Also, globally there were 2.6 million stillbirths the same year, of which 600,000 were in India.

In the case of Nepal, increased provision of maternal and neonatal services like free delivery scheme and cash incentives for antenatal care visits have ensured that women deliver safely and babies have a better start to life. The number of skilled birth attendance has shot up from less than 10 per cent in 2001 to 36 per cent in 2011.

Many government strategies and policies connected to safer motherhood, neonatal health, nutrition and gender are “underpinned by principles of human rights.” Reproductive, maternal, newborn, and child health have become a political priority. Between 1991 and 2011, Nepal witnessed a 66 per cent reduction in under-five mortality (from 162 to 54 per 1,000 live births) and 80 per cent reduction in maternal mortality (from 850 to 170 per 100,000 live births). Nepal has shown that political instability is not a limiting factor. “Despite severe economical and political challenges, all these [10] countries have done well,” she added

“There is greater participation and ownership by community and female health volunteers in Nepal,” Dr. Kuruvilla said. In the case of Bangladesh, the co-ordinated efforts by community workers and NGOs helped save the lives of many under-five children. “In Bangladesh and Nepal somebody takes leadership. We must have leadership from somewhere. The only problem [inIndia] is we need a critical mass. There are hundreds of NGOs but all do different things,” she highlighted.

The widespread use of mobile phone technology is playing a pivotal role in strengthening the health system in Bangladesh. Collection of real-time data on pregnant women and under-five children, text messages offering advice to registered pregnant women are sent out every week and online registration of births and deaths are driven by information and communication technology.

“The use of mobile phones has increased birth registration [in Bangladesh] from 10 per cent in 2006 to 50 per cent in 2009,” said Dr. Kuruvilla. The country is striving to make government health services fully digital by 2016; rural areas, where 75 per cent of the population lives, got connected by wireless broadband in 2012.

Between 1990 and 2011, Bangladesh witnessed a 65 per cent reduction in under-five mortality (from 151 to 53 per 1,000 live births) and 66 per cent fall in maternal mortality (from 574 to 194 per 100,000 live births).

“Bangladesh and Vietnam adopted economic programmes to employ women,” said Dr. Kim Dickson, Co-Chair of “Every Newborn Action Plan” report and Senior Adviser for Maternal and Newborn Health, UNICEF. “They [women] have more money… can help take decisions.”

Stressing on the importance of breast feeding, Dr. Dickson cited the example of Cambodia where it increased from 11 per cent in 2000 to 74 per cent in 2010. “There was a campaign focussed on media awareness, including TV soap operas,” Dr. Dickson said.

In many countries, breast feeding not being done as recommended is not unusual. “Early initiation [in facilities immediately after birth] and exclusive breast feeding for first six months are an issue,” Dr. Kuruvilla said.