Countdown 2030: Tracking progress towards universal coverage for women’s, children’s and adolescents’ health
This is the first Countdown report in the context of the 2030 agenda for sustainable development and the Every Woman Every Child Global Strategy for Women’s, Children’s and Adolescent’s Health (2016–2030). It synthesizes data on the current situation and trends in reproductive, maternal, newborn and child health and nutrition from a wide array of sources, including the profiles on the 81 Countdown priority countries, which together account for 95% of maternal deaths and 90% of deaths among children under age 5.
Countdown to 2030 builds off the strengths of Countdown to 2015 and has evolved to best contribute to assessing progress towards universal coverage for women’s, children’s and adolescents’ health. It has retained a partnership-based governance model with three main objectives: monitoring progress in the highest burden countries; improving the measurement of intervention coverage, equity and drivers of coverage; and strengthening capacity to collect, generate and use evidence at the regional and country levels. Countdown’s primary focus is the continuum of care, with some expansion into nutrition, adolescent health (currently limited to adolescent girls’ reproductive health), early childhood development, quality of care and effective coverage, and conflict settings.
Annexes A–H provide more detail on the Countdown structure, the conceptual model guiding its analyses, the technical review process that resulted in the 81 priority countries and the indicators included in the country profiles, the definitions and data sources for those indicators, and the list of Countdown countries considered malaria endemic and included in analyses of the malaria indicators.
The Sustainable Development Goals include ambitious targets—including ending all preventable maternal, newborn and child deaths by 2030. Neonatal and under-five mortality in the 81 Countdown countries rapidly declined during 2000–15. But the rate of decline must substantially accelerate for countries to reach the Sustainable Development Goals targets for neonatal mortality (12 deaths per 1,000 live births) and under-five mortality (25 deaths per 1,000 live births).
The average annual rate of reduction in the 50 Countdown countries with the highest mortality levels will need to more than double for neonatal mortality during 2015–30 and nearly double for under-five mortality compared with 2000–15. Reaching the Sustainable Development Goal global target for maternal mortality (70 maternal deaths per 100,000 live births) will also require accelerating the annual rate of reduction.
Although the prevalence of stunting among children under age 5 has dropped considerably in the past decade, it remains 30% or higher in about half of the Countdown countries with available data. All major population groups have seen improvement, but stunting remains much more common among the poorest children, and the absolute gap between rich and poor children has not changed. More than half of Countdown countries have wasting prevalence of 5% or higher, and in 14 countries, including several affected by conflict, the prevalence is over 10%, which is a level considered a serious public health emergency in need of immediate action. The nutrition transition is well under way in Countdown countries, many of which face the double burden of continued high prevalence of undernutrition and growing rates of overweight and obesity among children, adolescents and women. The median prevalence of low body mass index among women ages 20 and older in the Countdown countries with available data is 8% (with a range of 1–24%). In 25 countries the prevalence of low body mass index is 10% or higher. The median prevalence of obesity among women ages 20 and older is 14% (with a range of 5–41%), and in 22 countries prevalence is 25% or higher.
Most of the intervention coverage indicators that Countdown tracks—which span the continuum of care from pregnancy prevention and planning to pregnancy to childbirth to the postnatal period and infancy to childhood and including environmental factors—showed strong progress in recent years. Coverage increased sharply for new vaccines, use of insecticide-treated nets for malaria prevention, pregnant women living with HIV receiving antiretroviral therapy and postnatal care for mothers and for babies. Indicators that did not show large increases include demand for family planning satisfied with modern methods; four or more antenatal care visits; infant and young child feeding behaviours, including early initiation of breastfeeding and exclusive breastfeeding (used as proxies for indicators of coverage of nutrition programmes); and indicators for the treatment of childhood illnesses (such as careseeking for pneumonia and use of oral rehydration salts and zinc for diarrhoea).
In Countdown countries national coverage of many essential interventions is still far from universal. For example, median national coverage for countries with available data is still below 50% for demand for family planning satisfied with modern methods (48%), exclusive breastfeeding (47%), access to basic sanitation services (44%), treatment of diarrhoea with oral rehydration salts (43%) and postnatal care for babies (36%). And across Countdown countries demand for family planning satisfied was much lower among adolescent girls (ages 15–19) than among women ages 20 and older.Only immunization indicators and continued breastfeeding at one year (12–15 months) have rates that average above 80% across the Countdown countries.
Many of the coverage indicators that Countdown tracks and that countries routinely monitor provide information on contact with health services but provide little information on the quality of care received. Low-quality services are unlikely to result in the expected health improvements.
Assessments of healthcare inputs (such as human resources, supplies and equipment), service delivery processes (that is, the content of care provided), outcomes and impact (effective coverage) indicate major deficiencies in the quality of care in all settings. For example, a set of studies in low- and middle income countries found that coverage of antenatal care visits dropped around 30–45 percentage points when appropriate inputs needed for delivering effective services were considered—and was closer to 50 percentage points lower after factoring in appropriate processes that should take place during antenatal care visits. Addressing missed opportunities such as increasing the delivery of recommended evidence-based interventions during service contacts (such as breastfeeding counselling during postnatal care visits) and improving the quality of care provided at service contacts would help Countdown countries reach high coverage levels for all essential interventions across the continuum of care.
Countdown tracks inequalities in individual interventions for reproductive, maternal, newborn and child health and through the well-tested composite coverage index, which cuts across four intervention areas. Wealth-related and urban– rural inequalities in the composite coverage index are falling in most Countdown countries, yet variations persist. Some countries, such as Angola and Nigeria, have massive inequalities between rich and poor people, while others, such as Malawi, Swaziland and Turkmenistan, have almost none. Data on within-country inequality across geographic regions, which is very large in several Countdown countries, also provide critical information for programmatic action.
Viewed together, these results demonstrate the need for countries to set medium-term coverage targets (such as for 2020 and 2025) for selected indicators and to include an inequality dimension so that progress towards universal health coverage and the Sustainable Development Goal targets can be closely monitored.
Context matters in driving health outcomes.
Governance and political stability directly affect the composite coverage index. Greater women’s empowerment also has a positive association with the coverage of interventions. And based on 17 indicators tracked by Countdown that represent four main drivers of change in intervention coverage along the implementation spectrum, major gaps remain in the adoption of supportive policies and legislation; good governance (such as widescale introduction of costed national health plans or civil society engagement in planning and review processes); sufficient financing for reproductive, maternal, newborn, child and adolescent health and nutrition (including domestic financing); and adequate health system inputs (such as health workers).
Despite the data on interventions for women’s, children’s and adolescents’ health, lack of timely data and major data gaps preclude disaggregation for better targeting of programmes and services to the populations most in need. The gaps are particularly serious for causes of death, quality of care, nutrition programmes, adolescent health, and financial and health system inputs. The complex statistical models that are increasingly being relied on for informing progress are useful for predicting global disease burden trends, but they can mask data scarcity, and their utility for local monitoring, decisionmaking and accountability is limited.
Countdown has prioritized regional initiatives and country case studies to enhance local capacity to generate and use data to improve women’s, children’s and adolescents’ health while still producing regular global analyses on progress.