Goal Four

Protecting the World's Most Vulnerable

 Meg Bolger

Target: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate

Photo Courtesy of Jason de Pecol

Introduction

Millennium Development Goal 4, the goal to reduce by two-thirds the under-five mortality rate between 1990 and 2015, is one of the more simple goals of the 8 Millennium Development Goals, having only 1 target and 3 indicators.  The indicators used to measure the progress made on Goal 4 are the under-five mortality rate, the infant mortality rate and the proportion of 1 year-old children immunized against measles. As of right now, most of the countries participating in the Millennium Development Goals are not on track to achieve this goal.

Historical Development

Much of the history of Millennium Development Goal 4 goes hand in hand with the history and focus of UNICEF, or the United Nations Children’s Fund.  UNICEF “is a specialized agency of the United Nations, led by an executive director and governed by a 36-member executive board.” (Young, 2010, 1). UNICEF is funded by voluntary donations, giving them a budget of over $3 billion per year, which is used to help children in over 150 developing countries around the world (Young, 2010, 1). UNICEF was established on December 11, 1946 in response to the dangers of World War II on the lives of children. The goal of this organization at the time of its establishment was to help the children affected by the war, specifically focusing on children in Europe and Japan. A few years later the span of the organization was expanded to help children and women in all developing countries. UNICEF continued to develop, eventually reforming its focus. “The agency’s mission was expanded with the landmark Declaration of the Rights of the Child in 1959 that defined children’s rights to protection, education, health care, shelter, and nutrition, and these rights still serve as the major guiding principles for the organization” (Young, 2010, 1). Many of the issues listed above are important factors in the formation of Goal 4 of the Millennium Development Goals, as both of these organizations continue to work towards a common goal.

The late 1970s and 1980s was an important time period in making the rights of children an important global issue, one that since then has only grown in significance. 1979 was declared the International Year of the Child, which raised awareness of the issue, reinforcing commitment to the issue of the rights of children.  “The 1980s, under the leadership of then Executive Director Dr Jim Grant, ushered in the Child Survival and Development Revolution to save the lives of millions of children each year through the provision of 4 simple, low-cost interventions” (Young, 2010, 1). These interventions were growth monitoring, oral rehydration therapy, breastfeeding and immunization, collectively nicknamed as GOBI.  These solutions were simple yet effective; they are solutions that are still being used as a key response to the still ongoing issue of child mortality in developing countries today.

In 1989, the Convention on the Rights of the Child was held. The conference set standards for the quality of the health care, education, and legal, civil and social services that children receive. “This conference…was adopted by the UN General Assembly and became the most widely and rapidly accepted human rights treaty in history” (Young, 2010, 1). The treaty was inspired based on the belief that children are entitled to the same human rights that adults are, and often times need extra help ensuring that they receive those rights. “The Convention on the Rights of the Child is the first legally binding international instrument to incorporate the full range of human rights—civil, cultural, economic, political and social rights” (“Convention on the Rights of the Child.”, 2013). A number of events, similar to this one were held over the next few decades, continually reinforcing the idea that the rights of children is an important global issue that needs to be addressed more seriously. The next event that worked for the rights of children was the World Summit for Children, held in 1990, “which set 10-year goals for children’s health, nutrition, and education” (Young, 2010, 1). In 1996, the Machel Report, which discussed the impact of armed conflict on the lives of children, was released.  This report inspired a debate about this issue, conducted by the UN Security Council.  This was the first event of its kind and was held in 1998 (Young, 2010, 1).

After all of these events, raising awareness of the issue of the rights of children, the International Conference on Population and Development was held in 1994.  This was an essential event in the planning of the health-related MDGs—Goals 4, 5 and 6.  This conference emphasized the role of reproductive health in poverty reduction, with a special focus on fertility and mortality rates, the transmission of HIV/AIDS and sexually transmitted diseases (Obaid, 2009, 2)

Key to this new approach is empowering women and providing them with more choices through expanded access to education and health services and promoting skill development and employment. The Programme advocates making family planning universally available by 2015, or sooner, as part of a broadened approach to reproductive health and rights, provides estimates of the levels of national resources and international assistance that will be required, and calls on Governments to make these resources available” (“ICPD”, 2013).

The guidelines of this program, which are extremely similar to the objectives of the Millennium Development Goals, seemed to work as a framework for the MDGs themselves.

            The Millennium Development Goals were officially developed during the Millennium Summit held in 2000.  Adapted from the previously existing International Development Goals, the decision was made that the Millennium Development Goals would include eight goals based on the wellbeing of the global population and the wellbeing and future of our planet. Of these goals, the health-related goals discussed at the ICPD were each rewarded their own goal within the eight Millennium Development Goals.  In terms of Goal 4, the goal to reduce child mortality, UNICEF has continued to play a big role in its progress, as it accounts for a large amount of the funding and support for this goal. (Young, 2010, 2)

In May of 2002, the UN Special Session on Children was held, and “was devoted exclusively to children, and was the first time that General Assembly delegations included children themselves as official members. It was convened to review progress since the World Summit for Children in 1990 and to re-energize global commitment to children” (“The United Nations Special Session on Children”, 2). Although this conference was held after the beginning of the Millennium Development Goals, the Special Session on Children was essential in the progress of Goal 4.  The conference had a high attendance rate, with over 7,000 people participating.  Those involved included representatives from NGOs from all over the world, country representatives and various other organizations (cultural, academic, business, religious) (“The United Nations Special Session on Children”, 2).   “The Declaration and Plan of Action - A World Fit for Children (WFFC) - adopted at the SSC is the international community’s pledge to act together to put children at the heart of development and to build a better world for children” (“The United Nations Special Session on Children”, 1).  One year after the conference, in 2003, progress was evaluated, showing that progress had been made worldwide, but this progress was uneven.  The regions around the world are not advancing at the same pace, which still proves to be one of the biggest challenges in completing this goal (“The United Nations Special Session on Children”, 2)

Current Status

As of 2013, child mortality has been reduced by 41 percent since 1990. Statistics show that levels of child mortality have been reduced from 87 deaths per 1,000 live births in 1990 to 51 deaths in 2012 (“The Millennium Development Goals Report 2013”, 2013, 26). Although a great amount of progress has been made thus far, there is still a lot more work to be done in order to achieving Goal 4. “While around 17,000 fewer children are dying each day, 6.6 million children under five died in 2012—mostly from preventable diseases” (“GOAL 4: Reduce child mortality”, 2013,1). Although the solution to this issue may be difficult, it is within our reach, although solving it will likely take longer than the 2 years remaining until the Millennium Development Goal deadline. 

            The Millennium Development Goals Report from 2013 shows that the regions that are most on track include Northern Africa, Latin America and the Caribbean and Eastern Asia, some of which have been unexpected successes.  However, two regions—sub-Saharan Africa and Southern Asia—are lagging far behind. “In 2011, these two regions accounted for 5.7 million of the 6.9 million deaths in children under five worldwide. This represents 83 percent of the global total in 2011, up from 69 per cent in 1990” (“The Millennium Development Goals Report 2013”, 2013, 27). Only eight of the 49 countries within sub-Saharan Africa are on track to achieve Goal 4.  This setback between sub-Saharan Africa and Southern Asia follows a trend in progress among the Millennium Development Goals, as these two regions of the world are lagging behind in other goals as well.

            Even with these overwhelming disparities, many countries have made more progress that ever expected.  “…a number of countries with very high rates of child mortality in 1990 have defied the odds, showing that progress for all children is within our grasp” (“The Millennium Development Goals Report 2013”, 2013, 27).  Bangladesh and Liberia have already achieved the two-thirds reduction. These surprising successes are part of the few developing countries that have already achieved Goal 4.  Many other countries, including Ethiopia, Madagascar and Malawi, among others, seem to be right on track, already having made a reduction of 60 percent.

When looking at the progress of Goal 4, it is impossible to ignore the obvious disparities that are affecting the reduction of child mortality around the world.  These disparities include poverty, location and access to education. “Children born into the poorest households are almost twice as likely to die before age five as their wealthiest counterparts” (“The Millennium Development Goals Report 2013”, 2013, 25). Another factor that plays a big part in determining the rate of child mortality is whether a child is born into a rural or urban area.  Those who are born in rural areas are more likely to die before the age of five.  This is also the case when it comes to mothers’ access to education.  The less education that mothers have received, the less likely their child is to survive past five years old (“The Millennium Development Goals Report 2013”, 2013, 28).

An extremely important factor that ties into Goal 4 is political violence within countries.  The presence of violence in a country, or the weaker that a country’s political system is, the higher the rate of child mortality the country is likely to have. “Eight of the 10 countries with the world’s highest under-five mortality rates are marked by conflict or violence or are characterized by weak central governments” (“The Millennium Development Goals Report 2013”, 2013, 28). Until we address this issue of violence and conflict within countries, it is unlikely that significant progress will be made on reducing child mortality in these areas. 

            Despite the various successes that have been made in reducing child mortality, it is very unlikely that Goal 4 will be achieved by all of the countries participating in the Millennium Development Goals. “Ninety countries, 53 of them from developing nations, should be able to meet the 2015 Goal of reducing child mortality by two-thirds, if they maintain their current annual reduction rate.  But 91 developing countries lag far behind” (“Goal: Reduce child mortality”, 2013, 1). Although improvements in child survival have been seen throughout every region of the globe, the improvements have not been significant enough to globally reach the two-thirds reduction by 2015.

Successes

The UN Fact Sheet on Goal 4 highlights numerous success stories from various countries around the world that have made considerable progress towards achieving Goal 4, highlighting a few different strategies that have proven to be successful in reducing child mortality. 

·         Bangladesh—In Bangladesh, UNICEF has worked closely with many communities, providing education and training to community healthcare workers.  This program has not only provided jobs for Bangladeshi people, but has also had a significant affect on the child mortality rate. “Infant mortality declined from 100 deaths per 1,000 live births in 1990 to 33 deaths per 1,000 live births in 2012. In the same period, under-five mortality dropped by 72 per cent from 144 deaths per 1,000 live births in 1990 to 41 in 2012” (“GOAL 4: Reduce child mortality”, 2013, 1).  This program in Bangladesh shows the importance of having access to healthcare in reducing child mortality.

·         Peru—In Peru, progress has been made in some of the most remote, hard to reach regions.  The indigenous population of Peru is extremely disadvantaged in terms of services, infrastructure and education, all of which play an important role in child mortality rates. The Millennium Development Goals Fund for Farmers Field Schools is now providing funding and training to Peruvian families.  Through this program, farmers learn agricultural and management techniques, with a specific emphasis on the health and nutrition of their children. 

·         Chad—Chad, which has been shown to have one of the lowest vaccination rates around the world, is confronting this issue head-on. With the help of UNICEF, Chad is working on expanding its immunization program. They have used a variety of community outreach techniques, including radio broadcasts and other campaigns in order to reach as many children as possible.

·         Nigeria—In Nigeria, a new program called ‘Saving One Million Lives’ has proven to be very successful.  This program was launched by the Nigerian government in 2012, with its main goal being to save one million Nigerian lives by 2015.  They are doing so by expanding access to health care, specifically among women and children.  They are providing more telephone lines for health care workers, and important equipment including the equipment necessary to prevent mother-to-child HIV transmission and bed nets to prevent against diseases.

·         Cambodia—Cambodia has progress by targeting one of the major causes of child mortality in their country—measles.  They are confronting this issue by expanding access to immunizations, with a specific focus on the children in the most remote areas of the country.

The number of children under 1 year of age immunized against measles in Cambodia between 2000 and 2012 went up by 71 per cent, but 7 per cent were still not being reached. In 2011, the World Health Organization helped the national immunization programme identify communities at high risk of missing out on vaccines (“GOAL 4: Reduce child mortality, 2013, 2).

These immunizations are distributed in fairly public places, such as market places or in the homes of village leaders.  Once focus was shifted to the most marginalized communities, Cambodia went 12 months without a single case of measles in 2012, a significant decrease from the 722 cases in 2011. 

The UN has also been working to make more progress worldwide.  In 2010, Secretary-General Ban Ki-moon launched the ‘Every Woman Every Child’ program.  The goal of this program is to “to mobilize and intensify global action to save the lives of 16-million women and children around the world and improve the health and lives of millions more” (“GOAL 4: Reduce child mortality”, 2013, 2).  More that 280 public and private partners and 70 governments have signed on to this program, committing to a renewed effort to reducing child mortality.  These programs implemented in local communities all over the world, provide a number of ideas that are proven to be successful, which other countries could use as a starting point when confronting the issue within their own communities.

Challenges

One of the biggest challenges holding back the reduction of child mortality in general is the neonatal mortality rate, or the rate of children dying within their first month of life. This challenge is one that continues to be a problem in all regions of the world and has been considered by many to be the biggest challenge concerning the reduction of child mortality.  The under-five mortality rate is decreasing at a much faster rate than the neonatal mortality rate, meaning that between the two measurements, as they both decrease at different rates, the proportion of child deaths that are considered neonatal deaths continues to increase.Many of these deaths are due to under nutrition of the mother, in addition to a lack of health care and skilled birth attendants, creating an unsafe birthing situation for both the mother and her child (“The Millennium Development Goals Report 2013”, 2013, 28). 

Another challenge that has had a significant effect on child mortality is death caused by preventable diseases.  “The main killers are pneumonia, preterm birth complications, diarrhea, intrapartum-related complications and malaria” (“GOAL 4: Reduce child mortality”, 2013, 1). These infectious diseases account for almost two thirds of all child deaths, many of which can be prevented with increased access to immunizations and/or clean water (“Accountability for Maternal, Newborn & Child Survival”, 2013, 10). Measles vaccines have been fairly successful in preventing under-five deaths, however future progress using these vaccines is questionable. Measles vaccines have prevented over 10 million under-five deaths since 2000 (“The Millennium Development Goals Report 2013”, 2013, 29). However, cases of measles continue to appear, especially in sub-Saharan Africa and Southern Asia, where measles cases are most highly concentrated.  The issue that has caused the measles vaccine effort to lose its momentum is a lack of consistency and regulation in its distribution.

Some 20.1 million infants—many of whom are among the poorest, most marginalized children on earth—did not receive even a first-dose of measles vaccine in 2011. Measles immunization remains a key strategy in reducing child mortality. Stronger political and financial commitment is needed to control and prevent this deadly disease, in accordance with the 2010 World Health Assembly (“The Millennium Development Goals Report 2013”, 2013, 29).

Measles prevention through this two-dose vaccination has huge potential, however it seems as though it is not being taken as seriously as it should be.

HIV transmission from mothers to their babies is yet another problem that is holding us back our success on Goal 4. “Every year, almost 330,000 babies become infected with HIV because they are born to mothers living with HIV. Preventing this is not just a moral imperative but one of the best investments that the world can make to address HIV” (“A progress report on the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive”, 2012, 3). This aspect of Goal 4 goes hand in hand with Goal 6, the reduction of HIV/AIDS, malaria and other preventable diseases.  By working to prevent the reduction of HIV transmission from mothers to children, we will not only make progress on Goal 6, but also make significant progress on reducing child mortality.  “Without treatment, up to 40% of babies born to HIV- positive mothers will start life infected, and almost half of them will die before they are two years old” (“A progress report on the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive”, 2012, 3). Eliminating transmission of HIV from mothers to children is absolutely essential in achieving Goal 4.

Monitoring of progress and child mortality rates in some areas of the world has provided extremely valuable information, allowing us to look at the goal’s progress overall.  However, monitoring of the progress of this goal has also proved to be a barrier in harder to reach areas of the world. 

Monitoring through the MDGs has drawn global attention to the problem of child mortality, established targets for its reduction, and informed policymakers about the impact of their actions. Yet in many developing countries, complete vital registration systems, the best source of monitoring data, are lacking. Continued efforts are needed by countries and international agencies to strengthen statistical capacity and to fill data gaps through a wide variety of household surveys (“The Millennium Development Goals Report 2013”, 2013, 28).

However, this barrier is not going unaddressed.  The UNICEF and USAID run program, ‘A Promise Renewed’, focuses on increasing intensity of Goals 4 and 5, extending the time frame until 2035. The organization also does not plan on stopping at just a two-thirds reduction of under-five deaths, but going a step further and ending all preventable child deaths by 2035. A Promise Renewed takes pride in its use of advanced technologies and monitoring strategies to reach the world’s most marginalized children.“As part of their pledge, governments and partners from civil society, the United Nations and the private sector are working together to strengthen the monitoring and reporting of child survival within and among countries” (“The Millennium Development Goals Report 2013”, 2013, 28). National governments of the participating countries are aided by the organization in developing an individualized strategy in reducing child mortality and are required to report their progress every 5 years using the program’s strict monitoring system.  Although, through the work of this program, the goal will not likely be completed before the Millennium Development Goal’s completion date of 2015, it will still likely be effective in increasing the rate of reduction until the goal is completed.

If the U.S. were an MDG country

Although the US is not one of the countries that is working towards achieving the two-thirds reduction of child mortality that Goal 4 calls for, it has reduced its child mortality rate over the years. In 1990, the US had a mortality rate of 11 child deaths per 1000 live births and by 2012, had reduced this number to 7 child deaths per 1000 live births.  This reduction, however, does not show a two-thirds reduction (“Mortality rate, under-5”, 2013). This low-level of progress compared to that of developing countries is understandable, as many of the deaths in the US are not caused by preventable diseases. “In 2007, unintentional injuries, birth defects, homicide, cancer, and heart disease were the top five leading causes of death of children aged 1-4, accounting for two-thirds of all deaths in 2007” (Singh, 2010, 1). These diseases are much harder to solve, as many of them are unpreventable. The US has passed the stage that many of the developing countries are in—preventing deaths caused by curable diseases due to a lack of infrastructure, sanitation and health care. 

Where do we go from here?

In order to make more progress on Goal 4, we are going to have to reevaluate the way that we have confronted this goal thus far.  In determining which steps we need to take from this point on in achieving the reduction of child mortality, it is important to consider the interconnectedness of the eight the Millennium Development Goals.  The work that we do and the progress that we make on individual goals often simultaneously facilitates the progress of other goals. “If one considered each of the eight MDGs on their own in the year 2000, when they were proposed, they would have all seemed hard, or even impossible, to reach. However, these goals are very intertwined” (Kolcic, 2013, 1).  This idea absolutely applies to Goal 4, which is closely affected by almost all of the other goals.  A few issues that we need to address in order to make significant progress on Goal 4, among other goals, include access to healthcare, access to education and family planning services and increased access to water and sanitation. 

An increased emphasis on healthcare is necessary in addressing almost all of the barriers faced by Goal 4 efforts, including preventable disease, HIV-transmission and the risk during the neonatal period of a child’s life. Increased access to vaccines is a simple solution, which yields significant results in preventing disease when distributed consistently and correctly, as shown with many of the success stories previously mentioned. This is just one of a number of necessary changes. 

At the same time, systematic action is required to target the main causes of child death (pneumonia, diarrhea, malaria and under nutrition) and the most vulnerable children. This includes a stronger focus on neonatal mortality, which is now a driving factor in child mortality overall. Simple, cost-effective interventions such as postnatal home visits have proven effective in saving newborn lives” (“The Millennium Development Goals Report 2013 2013, 28).

Access to more advanced infrastructure and skilled healthcare workers would also significantly reduce HIV-transmission from mothers to their children.  Both of these solutions are directly connected with Goal 6, to combat HIV/AIDS, malaria and other diseases.  Increased healthcare access would also prevent neonatal deaths as the assistance provided during delivery would give both the mother and child will have a better chance of survival. 

One of the most challenging parts of Goal 4, is that part of the solution lies in the hands of cultural norms. “Progress will require not only funding, but advances in ‘health-related behavior change’ and decision-making—changes in human behavior in both poor and rich countries” (Buttenhiem, 2012, 1). However, cultural norms are often the most difficult things to change. These changes could most easily be influenced through increased access to education and family planning, which would promote healthy practices for both the mother and child, while also serving as a preventative strategy for reducing child mortality.  These services would also be productive in working on Goal 5, to improve maternal health and Goal 3, to promote gender equality and empower women.  Through education, with a specific focus on the education of women, people will be exposed to various strategies of raising a healthy baby and therefore decreasing the likelihood of child mortality.  These strategies include the importance of breastfeeding and use of bed nets to prevent access to disease transmitted by insects.  Over time, education would also most likely lead to a decreased birth rate, as women become more educated, the more likely they are to wait to have children and have less children. 

Another necessary strategy in addressing Goal 4 is increasing access to potable water and sanitation, which would simultaneously work towards solving Goal 1, to eradicate extreme poverty and hunger and Goal 7, to ensure environmental sustainability (which includes access to an improved water source).  Increasing access to water and sanitation would make progress in eliminating under nutrition as a major contributor to child mortality.  Under nutrition, which is a factor in about 45 percent of deaths of children under 5, can be reduced through breastfeeding. Breastfeeding ties into this strategy as a solution to the lack of access to potable water, while also improving nutrition.  “Breastfeeding within 1 hour of birth, exclusive breastfeeding for the 1st 6 months of life and micronutrient supplementation with complementary feeding between 6 and 24 months have been shown to improve children’s overall nutritional status” (Keating, 2011, 1).  Breastfeeding also eliminates the issue of children becoming exposed to preventable diseases such as diarrhea or typhoid, which can be caused simply by the exposure to contaminated water.

Another obvious shift that has to be added to our plan of action is a specific focus on reduction of child mortality in the regions of Southern Asia and sub-Saharan Africa.  The progress of these two regions, which has lagged behind the most out of all areas of the world, needs to be addressed before we can consider goal 4 to be completed. In fact, this goal has been criticized for not being ambitious enough, in the sense that if completed, it will still be leaving one third of the children left to die and often these are the children in the most marginalized communities. Achieving this goal, without ignoring the population that is suffering the most is going to take an intensified effort, with an updated strategy and increased international funding, as progress is needed most in the areas that are the hardest to reach.

With the help of organizations such as ‘Countdown to 2015’, we will accelerate our efforts to make progress until the year 2015, which marks the end of the Millennium Development Goals.  A benefit of this organization is that it focuses on the most marginalized areas and incorporates many of the simple solutions that are essential in making progress on this goal.  “Countdown to 2015 is committed to supporting the accountability agenda by providing evidence on progress for each of the 75 countries where more than 95% of all maternal and child deaths occur” (“Accountability for Maternal, Newborn & Child Survival”, 2013, 7).  The core missions of ‘Countdown to 2012’ are mainly focused on making progress on Millennium Development Goals 4 and 5, including access to family planning, prevention of HIV mother-to-child transmission and promotion of health care both during and after birth.  The organization also promotes strategies essential for the health of babies after birth, including exclusive breast-feeding for the first six months of life and immunizations to prevent disease. 

Conclusion

Millennium Development Goal 4 strives to reduce by two-thirds child mortality between 1990 and 2015, looking at three key indicators—the under-five mortality rate, the infant mortality rate and the proportion of 1 year-old children immunized against measles. Although a great deal of progress has been made on this goal, there is still has a long way to go before its completion. The barriers that are being faced in making progress to this goal, many of which have simple solutions, are harder to overcome on such a large-scale project. The biggest challenge that we have seen is the challenge of regional disparities, as sub-Saharan Africa and Southern Asia are lagging behind all of the other regions.  Even with these various challenges, a number of countries have been surprisingly successful on this goal, including Bangladesh, Peru and Nigeria. If we are determined to complete Millennium Development Goal 4 worldwide, we are going to have to take the effort to make the simple solutions a reality in all regions of the world.  These include the solutions of access to healthcare, access to education and family planning services and increased access to water and sanitation. The completion of Goal 4 is within our reach with an increased effort, although doing so by the Millennium Development Goal deadline of 2015 is unlikely