Can the world afford to save the lives of 6 million children each year?

Summary

Background

In July, 2003, the Bellagio Study Group on Child Survival estimated that the lives of 6 million children could be saved each year if 23 proven interventions were universally available in the 42 countries responsible for 90% of child deaths in 2000. Here we assess the cost of delivering these interventions, and discuss whether the achievement of the Millennium Development Goal (MDG) for child survival falls within the financial capacities of donors and developing countries.

Methods

All child survival interventions shown to reduce mortality from the major causes of death in children younger than 5 years were incorporated into a delivery timetable comprised of 18 contacts between a child or mother and a health-care provider in the period from before birth until the child reaches 5 years. The running costs of delivering the interventions at universal coverage levels were calculated as the sum of unit costs for drugs and materials, delivery costs, and programme management and support costs, including supervision. We estimated the cost of providing interventions at coverage levels reported for 2000 and the additional costs of providing services at universal coverage levels.

Findings

US$5·1 billion in new resources is needed annually to save 6 million child lives in the 42 countries responsible for 90% of child deaths in 2000. This cost represents $1·23 per head in these countries, or an average cost per child life saved of $887. Sensitivity analyses for salary levels for community delivery agents, drug costs, and coverage rates for 2000 were used to develop uncertainty estimates around the US$ 5·1 billion annual price tag that range from about $3·1 billion to $8·0 billion.

Interpretation

Achieving the MDG for child survival is affordable for donors and developing countries. Scaling up health delivery is the challenge, and, along with the lack of funds, will be the limiting factor in reducing child mortality by two-thirds by 2015.

Introduction

As part of the Millennium Development Goals (MDGs), nations pledged to ensure a reduction of two-thirds in child mortality by 2015 from the base year 1990·¹ An early analysis established that prevention and treatment technologies exist to achieve the child mortality MDG.² However, a prerequisite for achieving this goal is adequate and targeted financial resources.³

Estimates of the cost of delivering comprehensive child survival interventions are overdue. In their best-case scenario for 2007, the Commission on Macro-economics and Health identified limited investments in health services at peripheral levels as one of the most important barriers to improving health worldwide. The Commission estimated that about US$1 billion would be needed annually to scale up vaccinations, $4 billion to scale up the treatment of childhood illnesses, and an additional $2·5 billion for malaria prevention and treatment for all age-groups combined.⁴ This finding represents about 1% of gross national product for low-income and middle-income countries. These estimates, developed in 2000–01, were as precise as possible given the evidence available at that time on the causes of child deaths as well as the effectiveness and cost of health interventions. However, these estimates were restricted to specific interventions for selected diseases rather than including a more complete set of interventions needed to achieve a substantial reduction in overall child mortality.²

Cost estimates for reducing mortality from single diseases, such as HIV/AIDS,⁵ malaria,⁶ and measles⁷ seem to have been associated with increased international support focused on these diseases.7, 8, 9 At country level, the World Bank and others are increasingly requesting cost estimates (usually direct costs to governments) as a basis for providing financial support, and governments need financial data for sector-wide planning and health-system reform.¹⁰ Costing exercises based on disease-specific interventions, however, have little use for decision makers seeking to achieve the broad MDG of reducing child mortality because countries will achieve the goal in different ways on the basis of their epidemiological profile, health-system capability, and opportunities for economies of scope.¹¹ The recent publication of cause-of-death estimates for children younger than 5 years¹² and cause-specific estimates of the number of child lives that could be saved through full implementation of effective preventive and treatment interventions² makes it possible, for the first time, to estimate the global cost of implementing comprehensive child survival programmes.

Here we estimate the additional annual running costs for universal delivery of the child survival interventions capable of preventing 6 million annual deaths among children younger than 5 years. We focus on the 42 countries with 90% of worldwide deaths in children younger than 5 years in 2000, and on proven interventions and levels of implementation feasible for delivery at high levels of population coverage in low-income countries.² We do not cost the scaling up of delivery systems needed to achieve all the health MDGs, such as training and placing thousands of new midwives or building new health facilities; instead, we estimate the costs of child survival service provision after a successful scale up to universal coverage. We consider the cost implications of basic policy choices, including trade-offs between prevention and treatment interventions; integrated versus disease-specific delivery strategies; and the balance between health facility-based and community-based approaches to achieving universal coverage. We know these child survival interventions are effective. If they are also affordable, governments and their partners must step forward to provide the political and financial commitments needed to achieve the child survival MDG.