Elsevier

The Lancet

Volume 385, Issue 9966, 31 January–6 February 2015, Pages 466-476
The Lancet

Review
Countdown to 2015 and beyond: fulfilling the health agenda for women and children

https://doi.org/10.1016/S0140-6736(14)60925-9Get rights and content

Summary

The end of 2015 will signal the end of the Millennium Development Goal era, when the world can take stock of what has been achieved. The Countdown to 2015 for Maternal, Newborn, and Child Survival (Countdown) has focused its 2014 report on how much has been achieved in intervention coverage in these groups, and on how best to sustain, focus, and intensify efforts to progress for this and future generations. Our 2014 results show unfinished business in achievement of high, sustained, and equitable coverage of essential interventions. Progress has accelerated in the past decade in most Countdown countries, suggesting that further gains are possible with intensified actions. Some of the greatest coverage gaps are in family planning, interventions addressing newborn mortality, and case management of childhood diseases. Although inequities are pervasive, country successes in reaching of the poorest populations provide lessons for other countries to follow. As we transition to the next set of global goals, we must remember the centrality of data to accountability, and the importance of support of country capacity to collect and use high-quality data on intervention coverage and inequities for decision making. To fulfill the health agenda for women and children both now and beyond 2015 requires continued monitoring of country and global progress; Countdown is committed to playing its part in this effort.

Introduction

At the end of 2015 the period of the Millennium Development Goals (MDGs) will end, and the 189 signatory countries will take stock of what has been achieved. The focus is already shifting to proposals for a new global framework for after 2015, centered on sustainable development. Now is therefore the time to take a hard look at how far women's and children's health has come, and at what more can and must be done. Efforts must not slow in the transition from the Millennium Development Goals to what will follow. The 2014 report1 from Countdown to 2015 for Maternal, Newborn and Child Survival (Countdown), released on June 30, 2014, has focused on the unfinished business of the MDGs and how best to sustain, focus, and intensify efforts for women and children as we move forward.

The MDGs, fixed in 2000, committed the global community to reduce extreme poverty and achieve a set of targets by 2015, relative to a starting point in 1990. At the heart of the MDGs are MDG4, which calls for a reduction of child mortality by two-thirds, and MDG5, which focuses on improvement of maternal health through a reduction of maternal mortality by three-quarters and universal access to reproductive health. Countdown tracks and stimulates progress toward these targets in the 75 countries that represent more than 95% of maternal and child deaths, and has published country-specific profiles at least every 2 years since 2005. Each profile features data on intervention coverage, equity in coverage, and policy, health systems, and financial factors that can affect whether every woman and child receives interventions that can save their lives (appendix pp 1–2).

We summarise Countdown results for 2014, examine the data supporting evidence-based decisions in women's and children's health, describe elements of the Countdown process that might inform ongoing efforts to hold the world to account for progress, and list concrete steps that can be taken now to ensure continued progress for women and children.

Key messages

  • Achievement of high, sustained, and equitable coverage of life-saving interventions for women and children is insufficient.

  • Although most countries will not achieve Millennium Development Goals (MDGs) 4 and 5, progress has accelerated in recent years, suggesting that further gains are possible with continued, intensified actions.

  • Some of the most important coverage gaps are in family planning, interventions addressing newborn mortality, and case management of childhood diseases.

  • Massive inequalities in intervention coverage and health outcomes, including stunting, must be tackled for progress to continue.

  • Progress has occurred in country adoption of evidence-based policies and strategies to improve women's and children's health.

  • Accountability cannot exist without data. Countries must continue to be supported to build capacity to collect high-quality data on intervention coverage and inequities, and to use it as a basis for decisions about how best to reach women and children with interventions. Baseline data must be collected now for the post-2015 era.

  • Countdown will continue to monitor country-specific coverage and inequalities over the final days of the MDG era and into the future, to ensure that attention and focus are maintained during this transition period.

Section snippets

Data

The compilation of recent, relevant, quality-controlled data to drive action is a hallmark of Countdown work (panel 1). We summarise selected findings for 2014, with an emphasis on our core focus of intervention coverage and equity. The full results are available at www.countdown2015mnch.org.

Reduction of mortality and undernutrition

Progress in reduction of mortality and undernutrition is accelerating, but not quickly enough. Only a few Countdown countries will reach MDG4 in 2015,6 and even fewer will reach MDG5.7 However, child

Intervention coverage: the core of Countdown monitoring

Intervention coverage is closely related to maternal, newborn, and child survival. Figure 1 shows that countries with higher levels of intervention coverage (as captured in the composite coverage index [CCI]), a measure of performance in achievement of coverage along the continuum of care, defined in panel 1) tend to have lower levels of child mortality, and vice versa. A strong correlation exists between coverage levels and child mortality (Pearson r=−0·74; P<0·001), and this association is

Equity: no women and children left behind

Focusing on coverage at the national level alone can mask large differences in access to services between different population groups within a country. A large part of the unfinished business in Reproductive, Maternal, Newborn, and Child Health (RMNCH) is addressing of pervasive inequities, to ensure that all women and children receive the services they need, regardless of wealth, gender, ethnic group, or geography.

Figure 4 shows achievement of coverage of eight preventive and curative

Policy and health systems supports

Health systems characteristics and policies can set the stage for reaching all women and children with the interventions they need. Country progress in family planning shows how these factors can be determinants of coverage and ultimately fertility and mortality outcomes (appendix p 10).

Countdown provides a snapshot of the number of priority countries with available data that have adopted ten key tracer policies that support delivery of proven interventions across the RMNCH continuum of care (

The state of the data

Accountability cannot exist without data. Countdown therefore puts a special focus on availability, quality, and use of data. Working closely with the independent Expert Review Group of the Commission,28 Countdown advocates for efforts to ensure all countries have adequate data to make informed decisions about programme priorities for women and children, and to monitor the implementation of those programmes. These data include, but are not limited to, high-quality household surveys. Continued

The Countdown process: what we have learned

As the original time horizon of Countdown approaches, we look both back and forward to draw lessons that might inform the future landscape for women's and children's health. Many of the same challenges exist; some, including broadening of the goals to encompass a more holistic agenda and the explosion of methods and initiatives for monitoring, will be new.

Countdown was conceived in a 2003 meeting at the Rockefeller Foundation's Bellagio Center, resulting in the publication of a series on child

Countdown speaks: priorities for the next 500 days and beyond

What do the 2014 findings mean for women and children, both immediately for the period until the end of the MDG era, and for the process of definition of the post-2015 framework? What actions must be taken?

Looking to after 2015, the Countdown experience and findings point to four absolute necessities related to accountability. First, now is the time to build a foundation of baseline data that can be used to track progress—a crucial omission in the MDGs. Second, we must work to define an

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