CDReport 2015 front cover web‘Ten years from now, in 2015,’ said the opening line of Countdown’s first report in 2005, ‘the governments of the world will meet to assess if we have achieved the Millennium Development Goals (MDGs), the most widely ratified set of development goals ever, signed onto by every country in the world.’ Now that day of reckoning has come.

For MDGs 4 and 5, the verdict is mixed. Countdown’s findings, consistently from 2005 through the final Countdown to 2015 report, have always combined good news with bad, progress with unfinished business, lives saved with the many lives still needlessly being lost. Countdown’s 2015 Report highlights country progress—and obstacles to progress— in efforts to reduce child mortality and improve maternal health. It focuses, like previous Countdown reports, on evidence-based solutions—health interventions proven to save lives—and on contextual factors that affect the equitable delivery of these interventions to women and children. Country Profiles for 75 Countdown countries were published as a core part of the report, and updated Equity Profiles for 62 countries were simultaneously posted online. 

This is the last Countdown to 2015 Report: a final accounting of progress and remaining gaps in the 75 countries that account for more than 95% of all maternal, newborn and child deaths. The 2015 Report’s headline messages include the following:

There is good news on maternal and child survival, but MDGs 4 & 5 have mostly not been achieved.

  • Maternal and child survival have improved markedly during the MDG era: Both maternal and under-five mortality have been reduced by about half since 1990, and the rate of improvement has accelerated after 2000.
  • table 1b thumbtable 1a thumbMany countries have ‘graduated’ from Countdown: More than half of the 68 countries that were included in Countdown because they exceeded specified ‘threshold’ levels of child or maternal mortality have succeeded in reducing mortality levels below those thresholds.
  • MDGs 4 and 5 remain mostly unfulfilled: Fifty Countdown countries will fail to achieve the child mortality reductions promised in MDG 4, and 69 of 75 countries will not achieve the maternal mortality reductions required to fulfill MDG 5. Only 4 of the 75 Countdown countries – Cambodia, Eritrea, Nepal, and Rwanda – will achieve both MDGs 4 and 5. 

 

Newborn survival and child nutrition are two key, continuing challenges that must be addressed.

  • Newborns account for 45% of all under-5 deaths: Neonatal conditions cause an increasing share of all child deaths as interventions are successful in reducing deaths of older children
  • figure 1 thumbNutrition is crucial – and far too many children are still hungry: In more than half of all Countdown countries, stunting (a sign of inadequate diet and repeated illness) affects at least 30%, and wasting (a marker of acute malnutrition) 5% or more, of all children under age 5. Undernutrition, which is most prevalent among the poor and in rural areas, is an underlying cause of almost half of all child deaths.

 

 

 

Coverage of key interventions is still unacceptably low, and varies greatly across countries.

  • figure 3 thumbHigher intervention coverage means lower mortality: New analysis confirms the clear association of increased coverage of essential interventions with reduced child mortality, even when adjusted for economic growth and other factors.
  • figure 2 thumbUniversal coverage remains a distant target for most interventions in most countries:  Vaccines and many malaria and HIV interventions have been prioritized and achieved significant improvements, but most other interventions still fail to reach a third or more of the women and children who need them.
  • table 3 thumbServices requiring contact with a working health system have lagged the most: Family planning, pregnancy and childbirth services, and childhood disease management still have large coverage gaps.

 

Equity has improved, but not nearly enough.

  • box 2 thumbAcross the Countdown countries, there are systematic pro-rich inequalities for virtually all coverage indicators: These equity gaps are widest for interventions requiring access to health facilities.
  • figure 4 thumbbox 8 figure 1 thumbGlobally, coverage has increased more for the poor than for the rich, so the equity gap is gradually shrinking: Coverage equity is improving in both absolute and relative terms, but it remains a pressing challenge in virtually every Countdown country.
  • box 8 figure 2 thumbCountries succeed in improving overall coverage when they focus on reducing inequity: Rapid progress in coverage came when countries effectively reached the poorest families.

 

High, equitable coverage requires financial investment, supportive policies, and strengthened health systems.

  • box 12 figure 1 thumbDonor funding has increased, but countries’ reliance on out-of-pocket spending is a concern: Aid for MNCH tripled from 2003 to 2012, and recent attention to neonatal survival has led to increased newborn health commitments.
  • figure 5 thumbMany countries have made progress in adopting supportive policies: More research is needed to better understand the strength of countries’ implementation after policies are adopted.
  • Most Countdown countries have a severe shortage of skilled health workers: Countdown countries have a median of 10.2 skilled health workers per 10,000 population, and ¾ are below the WHO benchmark of 22.8 per 10,000.

More data are now available; more and better data are still needed.

  • box 5 thumbMore countries are conducting more frequent household surveys: Countries can use this data to support evidence-based decision making about policies and programs.
  • box 7 table thumbbox 7 figure thumbBetter data are needed for assessing quality of care: Coverage data often measure service contacts, but don’t tell what occurred during that service contact.

 

The Countdown to 2015 experience offers important lessons learned that are relevant to the Sustainable Development Goals era. Countdown’s insights and recommendations for monitoring and accountability in the SDG era, detailed on pages 42-44 of the 2015 Report, include the following:

  • Establish clear, consistent baseline data
  • Solve the modelled mortality problem, particularly in regard to the maternal mortality ratio
  • Improve measurement and data collection
  • Ensure that common standards of measurement and reporting are used
  • Set relative targets to complement fixed targets for assessing country progress
  • Set targets that are aspirational but also achievable
  • Track specific coverage indicators and a composite coverage index
  • Choose indicators carefully and balance focus with breadth

Countdown’s experience over the past 10 years has established the importance and feasibility of a vibrant multi-stakeholder initiative with independence and a strong technical component in accelerating progress for the world’s women and children. The launch and growth of Every Woman Every Child under the auspices of the UN Secretary-General, further supported by a new Global Financing Facility, increase the relevance of Countdown’s work, challenging it to rise to the occasion by continuing its independent monitoring role and innovative technical work at the global and country levels, with the ultimate aim of holding all to account for saving women’s and children’s lives over the next 15 years.

Countdown stands ready to begin.