MDGS to SDGS: what next for women & children’s health?

www.lshtm.ac.uk

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@joylawn@MARCH_LSHTM

Professor Joy Lawn FRCPCHLondon School of Hygiene & Tropical Medicine

Launch of CICH Imperial29th January 2016, Keynote

Millennium Development Goals

“One of the great successes of human history

especially for the effect on women’s and

children’s health” - Ban Ki-Moon, United Nations Secretary General

No newborn

born to die

3.2 million die303,000 die

No child dying orstunted

2.7 million die

Almost 9 million deaths of women and children, 6 million related to pregnancy and birth

Progress slower than for child or maternal mortality

At the end of the Millennium Development Goals era…

No baby

stillborn2.6 million die

No woman should die

while giving life

No woman should die

while giving life

Data sources: 1) UN U5MR and NMR: The UN Inter-agency Group for Child Mortality Estimation, Levels and Trends in Child Mortality: Report 2014, UNICEF, New York, 2014 (downloaded from

http://data.unicef.org); 2) IHME U5MR and NMR: Global Burden of Disease Study 2013. Global Burden of Disease Study 2013 (GBD 2013) Neonatal, Infant, and Under-5 Mortality 1990-2013. Seattle, United

States: Institute for Health Metrics and Evaluation (IHME), 2014.

0

10

20

30

40

50

60

70

80

90

100

1990 1995 2000 2005 2010 2015

Mo

rtal

ity

pe

r 1

00

0 li

ve b

irth

sUnder-five mortality rate (UN)

Under-five mortality rate (IHME)

Neonatal mortality rate (UN)

Neonatal mortality rate (IHME)

2029

46

MDG 4

target

Progress to MDG 4 for child survival globally, 1990 to 2015

6.4 million fewer child deaths, progress still accelerating

Slower for neonatal deaths, now 44% of under-five deaths

Progress for different causes of child deaths Cause-specific mortality, 2000-2013

Li Liu ... Lawn et al Lancet 2015

Most of the reduction in child mortality worldwide is from INFECTIONS (pneumonia, diarrhoea, measles, malaria)

Li Liu ... Lawn et al Lancet 2015

Progress for different causes of child deaths Average annual rate of reduction, 2000-2013

9 of the 10 fastest reducing causes of child death are INFECTIONS...

But not all due to immunisation coverage... Look at 3 examples

AIDS child deaths reducing 6.7% a yearNow ~100,000 deaths annually

Prevention Mother-to -

Child-Transmission (PMTCT)

• 67% ARV coverage (2013)

• From zero ARV coverage

(2000)

• Still challenges on infant

feeding approaches

Treatment of HIV+

Children

• 34% ARV child

coverage 2013

• Yet 64% ARV adult

coverage

Risks

• New infections in

adolescents ~800,000 new

infections <24 yrs old,

especially girls

• Societal barriers...

Not easy!!

Major health system and societal complexity.

Yet major investment, innovation & leadership

and unprecedented level of ambition....

Countdown to Zero

Malaria child deaths reducing 4.5% a yearNow ~450,000 deaths annually

Prevention with Insecticide

Treated Bednets

• 49% coverage (2013)

• From 3% (2000)

• 214 million bednets (2014)

Treatment of Malaria in

Children

• Rapid Diagnostic Tests

160 million (2013)

• ACT courses 392

million (2013)

Risks and gaps

• Drug / insecticide resistance

• Risk of severe disease with

changing immunity

• Gap still for malaria

prophylaxis in pregnancy

Major investment (USD2.7billion/yr), innovation & leadership

Potential from further innovations (eg vaccines)

Pneumonia & Diarrhoea child deaths reducing by around 5% per year

Prevention

• Water and sanitation

improvements

• Breastfeeding

• Vaccines especially

measles, pneumo and

now rotavirus, BCG

Treatment

• ORS and zinc for diarrhoea

now 49% coverage

• Simpler antibiotic therapy

including community level

• Treatment of TB slower

progress

Risks

• Ongoing low level of

attention and investment

apart from vaccines

• Antimicorbial resistance

• Environmental challenges

Major scope still to reduce deaths and cases

but limited research apart from regarding vaccines

Key to also address to environmental and societal change.

Pneumonia, 13%

Neonatal pneumonia, 2%

Preterm birth complications, 15%

Intrapartum-related events, 11%

Sepsis or meningitis, 7%

Congenital abnormalities, 4%

Other neonatal disorders, 4%

Tetanus, 1%Diarrhoea, 9%Measles, 2%

Injury, 5%

Malaria, 7%

AIDS, 2%

Meningitis, 2%

Pertussis, 2%

Other disorders, 15%

Li Liu, et al. Lancet, 2015

Preterm birth now

top cause of

CHILD deaths

Also important cause

of disability and loss

of human capitalNeonatal

Death

44%

WHAT do children die of?Global causes of child death for 2013

www.lancet.com/series/everynewborn #EveryNewborn

Lawn et al http://www.nature.com/pr/journal/

In low income countries the major challenge is still survivalBUT in middle income countries disability is increasing

Must track and minimise disability as we scale up more complex neonatal care

Beyond survivalThe world you are born into determines your survival and your risk of disability

www.lancet.com/series/everynewborn #EveryNewborn

Every Newborn Series

5 papers

6 comments

55 authors from 18+ countries

60+ partner organisations

Every Newborn Action PlanBased on the evidence from the Series

Co-led by UNICEF & WHO, Launch June 2014

Consultation >60 country governments

>80 organisations, >1000 individuals

World Health Assembly 2014 resolution

One year after, already policy and programme change in at least 20 high burden countries

Main funders: Bill & Melinda Gates Foundation, USAID, Children’s Investment Fund Foundation

Ending preventable

maternal mortality

Born Too Soon: The Global Action Report on Preterm Birth

www.lancet.com/series/everynewborn #EveryNewborn

PRIORITIES

@joylawn

Li Liu ...Lawn et al Lancet 2015

WHERE? Africa carries the heaviest burden

Births Child deaths

By 2030

Africa will have one third of

the world’s births

(assuming ongoing

increases in family

planning use)

BUT

Over 60% of the

world’s child deaths

www.lancet.com/series/everynewborn #EveryNewborn

WHERE?

12

Countries with highest neonatal mortality rates

Cen African Rep (40.9)

Mali (41.5)

DR Congo (43.5)

Lesotho (45.3)

Angola (45.4)

Guinea Bissau (45.7)

Somalia (45.7)

Sierra Leone (49.5)

Countries with biggest numbers of neonatal deaths

1. India (779,000)2. Nigeria (267,000)3. Pakistan (202,400)4. China (157,400)5. DR Congo (118,100)6. Ethiopia (87,800)7. Bangladesh (75,900)8. Indonesia (72,400)9. Angola (41,200)10. Kenya (40,000) Source Lawn et al Lancet Every Newborn series, paper 2

As many

newborn deaths

in 1 day as all

Ebola deaths so

far this epidemic

Countries with highest neonatal mortality rates & those with biggest numbers

www.lancet.com/series/everynewborn #EveryNewborn

Countries making progress for newborn survival?

12

Countries in dark red are making slowest progress for newborn survival, 29 countries need to at least double progress to meet post 2015 targets

BUT in every region there are countries with rapid progress

Peru

Financial protection measures, health insurance, & linking data to action.

Nepal

Dynamic leadership, innovative interventions at community level, plus family planning

Malawi

Workforce planning increased numbers and specific skills

Source Lawn et al Lancet Every Newborn series, paper 2

Born Too Soon: The Global Action Report on Preterm Birth

17

www.lancet.com/series/everynewborn #EveryNewborn

PRIORITISING WHAT TO

DO FIRST

@joylawn

Born Too Soon: The Global Action Report on Preterm Birth

www.lancet.com/series/everynewborn #EveryNewborn

Source: Lawn et al Lancet Every Newborn series, paper 2

1.2 million intrapartum stillbirths

>1 million neonatal deaths

~113,000 maternal deaths

75% neonatal deaths

Birth day

WHEN? For women, stillbirths, newborns, highest risk is at same time

“The two most important days

in your life are the day you

are born ...and the day you

find out why.”Mark Twain (1835-1910)

Analysis: Shefali Oza et al Lancet Global Health

Source: Lawn et al Lancet Every Newborn series, paper 2

Birth is the time of greatest risk of death and disability

TRIPLE return on investment – quadruple if count development outcomes

Risk of dying on your birth day... Industrialized countries (37 with high quality data)

In rich countries, the first day is proportionately even

more important ... especially with a high preterm birth

rate

USA ranked 34th

UK ranked 26th

< 0.5Per 1000

2.6Per 1000

www.lancet.com/series/everynewborn #EveryNewborn

What return on investment? 3 million lives could be saved per year with universal coverage

Source: The Lancet Every Newborn series, paper 3

2 of the 3 MILLION

POTENTIAL LIVES SAVED / YEARRunning cost $1.15 per person

Born Too Soon: The Global Action Report on Preterm Birth

www.lancet.com/series/everynewborn #EveryNewborn

Could save 2 million lives a year by closing this quality gap

for births already in facilities

Health system change especially midwives and neonatal nurses

Important to better measure and address hospital acquired infections

QUALITY gap for facility births

Source: Lancet Every Newborn series, paper 3 and 4

Bold text = high quality evidence

Immediate care for every newborn:

Essential newborn care

Cord care• Delayed cord clamping (15 RCTs)

• Cord care including chlorhexidine cleansing if appropriate (3 large RCTs from Asia, WHO guidance context specific)

• Handwashing and hygienic practices (multiple studies)

Breastfeeding • Exclusive breastfeeding (multiple studies, multiple positive outcomes)

• Immediate breastfeeding (analyses of descriptive data)

Thermal protection for term infants• Skin to skin care, delayed bathing etc (limited low quality evidence)

Mis-match of evidence with action for “simple” things

Eg handwashing, breastfeeding

What works in community settings?

www.lancet.com/series/everynewborn #EveryNewborn

POTENTIAL (AND RISK) POST

2015

@joylawn

Learning from the MDGs

Health at the

heart of the

MDGs

4,5,6

Progress for every goal at

least at global level

Accelerating especially last

5 years

Improved data, with at

least 79 countries having

time series data for 18 or

more of 22 core indicators

RESULT HEADLINES

BUT….

Increased funding,

particularly for women’s &

children’s health

www.lancet.com/series/everynewborn #EveryNewborn

22%

Donor funding for MNCH (tracked by Countdown to 2015)Major mis-match with burden

0.00

1,000.00

2,000.00

3,000.00

4,000.00

5,000.00

6,000.00

7,000.00

2003 2004 2005 2006 2007 2008 2009 2010

Mil

lio

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SD

(co

ns

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01

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ODA for Child Health

ODA for Maternal Health

10% of ODA for MNCH

mentions

“newborn”

2003: $52 million67 projects mentioning newborn

Source: Lancet Every Newborn series, paper 1

2010: $ 613 million 1,573 projects mentioning newborn

The word “Stillbirth” or “fetal” occurred < 5 times in 250 million donor disbursements, 2003 – 2010, despite 2.6 million stillbirths

Over 2/3rds for immunisation, HIV

and malaria

From 8 MDGs to …17 SDGs (Sustainable Development Goals)

Making the case for health will have to be smarter – economic, environmental

www.lancet.com/series/everynewborn #EveryNewborn

ENDING

PREVENTABLE CHILD AND

MATERNAL DEATHS BY 2030

(and being able to measure!)

@joylawn

www.lancet.com/series/everynewborn #EveryNewborn

Ending preventable child and newborn deathsMortality targets in Every Newborn Action Plan and A Promise Renewed

Source: Lancet Every Newborn series, paper 2

From 2.8 to 0.8 million neonatal deaths ~100 countries have already met the target – focus on equity gaps

About 29 countries will have to more than double their rates of progress

EVERY NEWBORN TARGET BY 2030:

National neonatal mortality rate of 12 or fewer

www.lancet.com/series/everynewborn #EveryNewborn

Lancet GH Sept 2013 : The Lancet Global Health 2013; 1:e176-e177 (DOI:10.1016/S2214-109X(13)70059-7)

Ending preventable maternal deaths Maternal mortality target also included in Every Newborn Action Plan

Global average MMR of 70 per 100,000 with different targets for different countries

Also targets for sexual and reproductive health

www.lancet/series/ending-preventable-stillbirths #EndStillbirthswww.lancet.com/series/ending-preventable-stillbirths

Source: Lawn et al. Lancet 2016.

From 2.6 to 1.1 million stillbirthsAligned with neonatal mortality target but more ambitious change needed

56 countries need to at least double their rate of progress… BUT still not mentioned in any SDG document

Also ending preventable stillbirths

EVERY NEWBORN TARGET BY 2030:

National stillbirth rateof 12 or fewer

32 |www.lancet.com/series/everynewborn #EveryNewborn

WHAT DO WE NEED TO DO

DIFFERENTLY?

WHAT DO WE NEED TO DO

DIFFERENTLY?

@joylawn

www.lancet/series/ending-preventable-stillbirths #EndStillbirths

Increase implementation and investment

Address health system bottlenecks, integrate and

invest in Quality of Care

Increase the voice of women

Promote women’s rights, support them to raise their voices for

accountability; increase attention to respectful care

Intentional leadership development

Emphasize leadership in countries with highest burden

Improve indicators & metrics

Ensure sufficient data and monitoring to meet 2030

Targets, measure progress and impact

What to do differently?

Investigate critical knowledge gaps

Collaborate and build the evidence base

Source: de Bernis et al. Lancet 2016.

Adolescents & young people... Healthy transitions especially for girls

..... Reducing risks, providing services

Births... Family planning, reproductive health

..... Care at birth for women and babies

.......Healthy start

Children ... Survive and thrive

..... Optimal nutrition and growth

....... Child development

A healthy life course

Integrated care and also integrated science along the research pipeline Epidemiology & epigentics, social science & implementation

march.lshtm.ac.uk

LSHTM MARCH Centre

Massive Open Online Course - Free

Improving the Health of Women, Children & Adolescents

2nd Cycle opens Feb 29th 20161st cycle in late 2015 had >10,500 participants

@joylawn

@LSHTM_MARCH march.lshtm.ac.uk

www.lancet.com/series/everynewborn #EveryNewborn

We have the potential to transform

survival and health for

EVERY woman EVERY baby EVERY child

including for the world’s poorest families –

What will CICH do?

How can we in LSHTM

MARCH work with you?

march.lshtm.ac.uk@joylawn