Countdown initiative is a global collaborative effort of individuals and institutions, aimed at stimulating country action by tracking coverage for interventions that are essential for the attainment of Millennium Development Goals (MDGs). There are a total of 8 MDGs designated by numbers 1 to 8, and Goals 4 and 5 deal with ‘child survival’ (reducing under-5 mortality rate by two-third) and ‘maternal health’ (reducing maternal mortality by three quarters and achieve universal access to reproductive health), respectively. The first report on MDGs 4 and 5 was published in 2005 and the second of this series based on country progress till 2006 is released in 2008. The 2008 report tracks progress in 68 countries that account for more than 97% of maternal and child deaths, and include indicators across the continuum of care for reproductive, maternal, newborn, and child health. The coverage results are complemented by tracking of relevant policies, health system performance measures, equity patterns in coverage, and financial flows to maternal, newborn, child health, and nutrition. The countdown tracks coverage data for 22 health interventions including immunization rates, vitamin A supplementation, improved drinking water, complementary feeding, access to reproductive health care, treatment of major killer diseases of children, etc, which have been acclaimed to reduce mortality among mothers and children(1).

The 2008 Countdown results reflect extreme diversity(1-3). A cursory glance of the report reveals that there have been reasonable progress made by many countries in the field related to child survival (MDG 4), however, the progress made in the field of reproductive health (MDG 5) is far from satisfactory. The major success is in the field of achieving targeted immunization coverage.

Only 16 of the 68 countdown priority countries were on track to reach the MDG 4 on child survival, 26 countries made insufficient progress and another 26 made no progress at all. Twelve African nations have seen an increase in child mortality since 1990, mostly as a result of HIV epidemics and conflict. On MDG 5, good progress was made by only 12 countries. Progress is made in child survival by several East African countries, whereas sub-Saharan Africa suffered a reversal in child survival. Slow progress is noted in many countries of South Asia.

Fifty-six of the 68 countries still had high or very high maternal mortality, while only 3 countries had low maternal mortality ratios(1). China, Brazil, Egypt, Mexico, and Bangladesh have made significant progress in last couple of years. Half of all maternal deaths take place in sub-Saharan Africa which constitutes only 11% of world’s population, while South Asia accounts for 45% (1).

In conclusion, only 10 countries have shown good progress towards both MDG 4 and 5, six showed progress towards 4 but not 5, and only two showed good progress towards 5 but not towards 4(1).

A thorough analysis of the entire report shows that coverage is improving for interventions that can be routinely scheduled such as immunization, vitamin A supplementation and antenatal care. However, coverage is low for interventions that require clinical skills such as optimal care during delivery, postnatal visits, and treatment of common childhood illnesses including pneumonia, diarrhea and malaria(1,3). Further, patterns of inequity show that people in the poorest economic echelon receive less care and have higher mortality rates than their wealthier peers(4). Urban versus rural disparities are also striking for certain interventions such as access to cesarean sections.

Analysis of funding for these two MDGs reveals that the total volume of official development assistance to this initiative has increased by 64% between 2003 to 2006(1). Yet, these programs are still grossly under-funded in relative and absolute terms and 95% of such aid is provided in the form of projects that can change with little notice, which makes it difficult for countries to plan effectively(5).

There are several shortcomings to the Countdown initiative as indicated above. To make this program more effective and to achieve the target within stipulated time limit, certain issues must be vigorously pursued.

Progress in India is far from spectacular but it is also not as bad as in sub-Saharan Africa. India is moving slowly towards achieving targets of MDGs, but to achieve them within the stipulated time limit, it will need to accelerate pace of interventions to reduce both child and maternal mortality. Our spending on health is still 0.9% of total gross domestic product (GDP), which is far below the predicted level of at least 2-3% by the National Health Policy (NHP)(8). However, performance of few states like Madhya Pradesh in reducing maternal mortality by intelli-gently using few innovative schemes like ‘Janani Express’, ‘Matri Shakti’ and better utilization of existing schemes of National Rural Health Mission (NRHM) like ‘Janani Suraksha’ should show way to other states to emulate its success.

The overall analysis of the Countdown report indicates that despite isolated examples of progress, national and global attention to maternal and child health is still quite inadequate. Paradoxically, there is more money and greater political will for global health than ever before. We need to capitalize on these resources to strengthen health systems and close the huge gap for maternal and child health related services. The next Countdown meeting will be in 2010. With concerted efforts, a major turnaround in progress could rewrite the outcome in many countries.

Funding: None.

Competing interests: None stated.

Vipin M Vashishtha,
Pediatric Generalist and Neonatologist,
Mangla Hospital, Shakti Chowk,
Bijnor 246 701, UP, India.
Email: [email protected]