Post-2015 Consensus: Health Perspective, Fink

Perspective Paper

Summary

Eliminating all infant and child deaths is the ultimate long-term goal, but we need to look at more achievable targets for the relatively short period 2015-2030. The UN High Level Panel has suggested that this should be to aim for “… an upper threshold of 20 deaths per 1000 live births in all income quintiles of the population”. We argue that this target is not nearly ambitious enough for some middle income countries and rather unreasonable for some of the poorest country; instead of aiming for a uniform target, we argue that all countries should target a reduction of 70% in neonatal mortality between 2015 and 2030.

In 1970, close to 18 million children died before the age of five; by 2013 the figure was less than 7 million. Because of the greater number of children being born, this represents a 70% fall in the global under-5 mortality rate, from 142 per 1,000 to 44.2 per 1,000. 32% of these deaths are in the first seven days of a baby’s life. The single most common cause of deaths among under-5 children today globally is prematurity, accounting for an estimated 17% of the total global burden. Pneumonia, diarrhea and malaria, the most common infectious diseases, account for 15%, 9% and 7%, respectively, which means that neonatal complications account for more deaths than the three major infectious diseases combined

Infant mortality rates decline by about 5 deaths for every $1000 of income per capita; the overwhelming majority of children today die in in countries where the average is about $2500; even if these countries should develop well economically in the period 2015-2030, large improvements in the average resources locally available do not seem likely.

We focus here on neonatal mortality, where 75% of deaths are caused by prematurity, interpartum-related complications and neonatal sepsis. Eight countries, with a combined population of 3.5 billion, account for about two-thirds of all neonatal deaths. Although prematurity can be reduced by providing better diets for mothers, major progress in all three categories can only be made by delivering improved health services, to ensure that skilled staff are available to support mothers before, during and after births in a safe and clean environment.

Ante-natal care can be delivered at a relatively low cost – less than $1.5 billion per year globally – but ensuring safe deliveries and post-natal care is more complicated and costly. The marginal cost for the 75 countries with the highest burden of infant death has been estimated as $5.65 billion per year, but this rises to around $10 billion when the cost of building capacity is taken into account. In practice, this is also likely to be an underestimate because of the need to improve the broader health system, for example by employing more doctors. Not accounting for training, employing the additional 1.3 million doctors needed today would cost about $7.7 billion.

This and other improvements would obviously provide broader benefits, beyond neonatal care. Accounting for this, the total cost of necessary improvements to child and maternal healthcare is about $17.3 billion annually, or $10.9 billion for running costs and infrastructure only. Assuming a $5,000 value for a DALY and the higher of the costs, the benefit-cost ratio is 18.2 at a 3% discount rate. For all scenarios, including a 5% discount rate, BCRs are positive and returns to investment high.

However, this level of investment required to reach this target likely goes well beyond the financial and institutional capacities of many of the poorest countries, and definitely also goes beyond the scope and budget of international institutions like the Global Fund; major shifts in global health financing will likely be needed if ambitious targets are to be reached for neonatal mortality within the next 15 years.