UN: 'We've broken through the glass ceiling of under-five child mortality'

Countries around the world have made historic and unprecedented gains in reducing under-five child mortality, according to a new report by UNICEF and its partners in the UN Inter-agency Group for Child Mortality Estimation. The number of children under five around the world who die annually has fallen by 51% since 2000.

What’s more, a handful of low- and middle-income countries, including Cambodia, Malawi, Mongolia, Rwanda, Sao Tome and Principe, and Uzbekistan, have achieved even more pronounced declines – cutting childhood deaths by more than 75% since 2000. These reductions are well beyond of the declines expected given the economic growth these countries.

These outliers offer lessons on how health leaders can accelerate progress, experts say. “They demonstrate that even though resources are a constraint, and they will always be a constraint in many countries, rapid and robust progress is possible if the right investments are made and interventions are taken to scale,” said Dr. Gagan Gupta, a senior adviser and lead for the Maternal and Newborn Health team at UNICEF headquarters in New York. “We can deploy human and financial resources more effectively to achieve progress and save lives.”

These rapid gains were achieved despite challenges posed by climate change, COVID, and increasing conflict around the world. “We have broken through the glass ceiling of under-five mortality,” added Dr. Gupta. “Finally, fewer than five million children each year are dying. Now we must accelerate progress to achieve our Sustainable Development Goals. We must reduce under-five mortality by another 50% over the next six years.”

Malawi demonstrates a potential pathway toward achieving such an ambitious goal. The country has invested across the spectrum of evidence-based, essential health services for women and children, including pre-pregnancy care for women, prenatal care, institutional delivery, skilled birth attendants, postnatal care, care for small and sick newborns, childhood vaccinations, and treatment for children with diarrhea, malaria, and pneumonia, all with an emphasis on community-based care. And, importantly, Malawi’s health leaders have labored to align the work of partners with government priorities.

“The provision of health care in Malawi was previously vertical,” said Texas Zamasiya, a health specialist with UNICEF Malawi. “This evolved from stand-alone programming such as malaria, immunization, nutrition programming. These were mainly siloed. Now, the government of Malawi continues succeeding in coordinating and integrating programming at both the facility and community levels.”

Zamasiya identified three key investments by Malawi’s health leaders that have delivered outsized impact: skilled birth attendants; the provision of an evidence-based package of essential care for newborns; and growing and supporting key human resources for health, including community health workers (CHWs), midwives, and staff nurses.

The country’s community health worker cadre, called Health Surveillance Assistants (HSAs), have been particularly instrumental in helping this Southern Africa country – where about 80% of the population is rural – connect communities with the formal health system and achieve its health goals. “They are one major reason for Malawi’s progress,” said Zamasiya. “Access to primary health care is paramount.”

The HSAs started in the 1960s as smallpox vaccinators and shifted in the 1970s to combat cholera. Since then, the cohort has been continually expanded and professionalized to meet the evolving needs of rural communities. Most recently, the government increased the cohort’s training requirements from three months to one year.

Today, about 14,000 HSAs provide a range of services including immunization, family planning, and the diagnosis and treatment of malaria, acute respiratory infections, diarrhea, and malnutrition. Ultimately, the government hopes to recruit and train another 4,000, for a total of about 20,000 HSAs – one for every 1,000 people.

Malawi’s approach to training of HSAs is worth noting, said Zamasiya. Recruits undergo two weeks of training in health promotion before starting work in their communities. Ultimately, they undergo a full year of training – all but the first two weeks of it while they are already working and serving their communities.

“Other countries can learn from this,” said Zamasiya. “The HSA’s key role initially is health care promotion. That is basic, it is not difficult. Once they have this training, they can have an immediate and critical impact in their assignment with communities. Then they can go for more training to increase their capacity and increase their impact. We are so very proud of them. They are reducing congestion at health facilities and saving lives.”

As the report noted, “In low- and middle-income countries where children are dying from readily preventable or treatable conditions, community health workers play a pivotal role in promoting and/or delivering this essential care at critical touch points during a child’s growth and development, including providing guidance on nutrition, immunization and basic treatment for sick children. Studies show that if these community-based child survival interventions were scaled up to reach 90 per cent of those in need, child deaths could drop by one third.”

Exemplars in Global Health research has documented the transformational impact of well trained, supervised, equipped, and compensated CHWs on health outcomes from Bangladesh to Brazil and Ethiopia to Liberia.

Malawi’s CHWs are supported both by professional supervisors within the national and district formal health system and by local community health structures like Community Health Action Groups and committees that hold the health providers accountable. And the CHWs are equipped by the ministry of health’s procurement and distribution system for their supplies.

Together, these investments, along with the work of communities, professional health staff, and partners have helped strengthen the health system and improve health outcomes for women and children in Malawi.

Today, for example, 96% of women are assisted by skilled birth attendants, up from just 54% in 2000. And institutional delivery is now nearly universal. The percent of children who receive their DTP immunization has increased from 75% in 2000 to 86% in 2022. And Malawi has become a leader in the delivery of family planning.

The impact of these investments across the board have been amplified by Malawi’s focus on data. Today, data collected in real time allows, for example, for live dashboards that track neonatal admissions and deaths by birthweight in every facility and can show each facility’s strength and weakness as well as national gaps.

“By collecting data, governments have the information they need to identify and address subnational challenges, areas where impact was lagging,” said Dr. Gupta. “We always say that local action is critical to national success.”

As the report notes: “These inspiring outcomes demonstrate the high returns when investments are made in maternal, newborn and child health and survival. They also provide important proof that if sustained and strategic action is taken – even in resource constrained settings … lives will be saved.”

In Malawi and beyond, experts say, there’s still much progress to be made. In particular, global progress has slowed or stagnated on neonatal mortality and maternal mortality.