A Price Tag for Newborn and Child Survival Dr. Joy Lawn BM BS MRCP (Paeds) MPH Saving Newborn Lives/Save the Children-USA and MRC, Cape Town South Africa and Institute of Child Health London

The Team Child series costing Neff Walker Jennifer Bryce Joy Lawn Zulfiqar Bhutta Saul Morris Bob Black Newborn series costing Neff Walker Joy Lawn Simon Cousins Zulfiqar Bhutta Luc de Bernis Gary Darmstadt Combining the newborn and child costings All the above plus Saul Morris and Gareth Jones THE LANCET Can the world afford to save 6 million children?

Outline 1.Countdown context 2.Combining The Lancet Price Tags for newborn & child survival 3.Costs for lives saved – the bottom line 4.Comparison with other costings 5.Consequences

Countdown context The majority of newborn, child and maternal deaths are preventable with existing interventions Some countries or some single interventions have been successful in rapid scaling up, but overall we need to accelerate progress $Accelerated progress will require investment – how much will the essential interventions cost? $Donor investment in child health has increased but seems to be most focussed on “vertical” programmes $What is the financial gap? Where will the money come from for MNCH health systems and how will it get to where it is needed most in countries? How can the poor be protected?

Full coverage (99%) with 23 proven interventions could reduce under-five mortality by 66%, saving 6 million child deaths/year The Lancet Child Survival series: Key findings LIVES Additional cost of providing these interventions is US$ 5.1 billion annually or $1.23 per capita COST

Coverage (90%) with 16 proven interventions delivered through packages could reduce neonatal mortality by up to 67% equivalent to 2.7 million deaths/year The Lancet Neonatal Survival series: Key findings LIVES Additional cost of providing these interventions is US$ 4.1 billion annually or $0.96 per capita 70% of the costs also benefit mothers and older children COST

Methods & assumptions Combining newborn and child survival costing Bellagio seriesNeonatal seriesCountdown combined Countries Interventions23 8 neonatal 16 7 of the 8 neonatal in Bellagio series 32 Current coverage 2000 Updated with Countdown data Target coverage 99%90%99%

To estimate the running costs at 99% coverage for selected essential interventions for newborn and child health in the 60 priority countries Current running costs based on current coverage (updated from Countdown report) Additional cost to provide these interventions to those currently unreached Combined costing Objective

Does NOT include costs to expand infrastructure (new hospitals) produce new human resources (pre-service training of new midwives) Combined costing Methods & assumptions Current running costs Intervention-specific cost –Cost of commodities (ORS, antibiotics, vaccines) –Cost of service delivery (community health worker time, staff time and clinic's running costs, theatre time) Programme cost associated –Staff and support inputs (training, supervision, monitoring and evaluation etc) –Amortised costs for buildings, equipment and transport Incorporates the increasing costs required to reach the unreached at higher levels of coverage based on assumptions from the WHO CHOICE model

Approximate child age in months Measles vaccine Vitamin A Complementary Zinc Hib vaccine Insecticide-treated Breastfeeding Neonatal interventions* replacement feeding Tetanus Toxoid preventive treatment Preventive interventions Before birth Nevirapine& Antimalarialintermittent Birth antenatal steroids * Includes clean delivery with skilled attendant, temperature management, antibiotics for premature rupture of membranes and neonatal sepsis, steroids Weeks 1-2 Water & sanitation feeding materials Contact with trained health care worker Birth Integrated service delivery timetable for preventive child survival interventions included (adaptation needed for countries)

Outreach/outpatient services Tetanus toxoid immunization Intermittent presumptive therapy for malaria Family- community Breastfeeding promotion, Case management for pneumonia Clinical care Antibiotics for preterm rupture of membranes # Corticosteroids for preterm labour # Neonatal sepsis treatment Clean delivery and neonatal resuscitation Lancet Neonatal Survival series Skilled obstetric and immediate newborn care (hygiene, warmth, breastfeeding) & resuscitation Emergency obstetric care to manage complications eg obstruction, hemorrhage Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies including Kangaroo Mother Care Counseling and preparation for newborn care and breastfeeding, emergency preparedness Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care Extra care of low birth weight babies Case management for pneumonia Clean delivery by traditional birth attendant (if no skilled attendant is available) Simple early newborn care Infancy Neonatal period Pre- pregnancy Pregnancy Birth # For health systems with higher coverage and capacity Folic acid # Focused 4-visit antenatal package tetanus immunisation, management of syphilis/STIs pre-eclampsia, etc Malaria intermittent presumptive therapy* Detection and treatment of bacteriuria # Postnatal care to support healthy practices Early detection and referral of complications

Lives saved in the 60 countries Combined costing results Proportion of deaths averted at 99% coverage Number of lives that could be saved in the 60 countries All under 5 child deaths 67%6.6 million Two thirds of newborn and child deaths are preventable with existing interventions 6.6 million lives a year

Combined costing results Cost in 60 countries  US$ 7 billion annually in new resources or US$ 1.62 per capita in the 60 countries  US$ 4.3 billion is already being spent  US$ 25 per child under 5 per year for the total cost all the essential interventions

Combined costing results Cost in 60 countries Sensitivity analysis was performed by varying the following inputs: Coverage estimates Drug costs Community worker costs Results in a range of US$ 4.6 to 10.7 billion

Combined costing results Costs by service delivery approach

Combined costing results Costs saved in treatment by preventive care Estimated annual running costs of delivering treatment interventions at current (2004) coverage levels, with and without savings from expanded prevention, in millions of 2004 US$ Savings: US$ 700 million

Combined costing results Costs saved by integrated delivery Estimated annual cost per child life saved comparing integrated and parallel delivery of preventive interventions in millions of 2004 US$

1. Cost-effective packages within the continuum of care 2. Delivery at all levels through outreach, family-community care, and facility-based clinical care – synergistic effect 3. Initial focus on outreach and health education to families and communities which is feasible even in weak health systems and gives economic benefits through prevention in reducing treatment costs Economical policy choices

Comparison with other relevant costings World Health Report 2005 reaching MDGs 4 & 5 –Inputs: 75 countries with similar interventions –Results: $52 billion over 10 years $7.8 billion per year once at coverage of 95% Per capita cost of $1.50 Commission for Macroeconomics and Health –Inputs: Includes the cost of new infrastructure and human resources and running costs related to malaria, maternal and child health components of the total CMH costing –Results: $21.8 billion (14 to 25.5) out of total of $46 billion Specific MNCH per capita costs of $4.5

Is US$ 7 billion/year to save 6.6 million children and newborns “affordable”? About half of the US$12 to US$20 billion committed annually to the fight against HIV/AIDs Less than 10% of what was spent on tobacco products in the US in 2003 Less than 10% global Overseas Development Aid estimated total of US$78 billion Less than the annual subsidisation of the Japanese cow Only a little more than the US$4 billion lost to poor countries in migrating skilled professionals

Commitments…. few poor countries deliver Low income countries must spend more and prioritise reaching the poor as per Abuja target of 15% of government spending on health TanzaniaZambiaEthiopia

Commitments…. few donor countries deliver Donor countries must meet their commitment of 0.7% of GDP

Not just more money – spending better and reaching the poor Some low income countries halved their neonatal mortality rates in the 1990s (Sri Lanka, Nicaragua, Honduras, Peru, Indonesia) Success is possible in low-income countries with leadership and systematic investment to provide essential interventions to the poor women and children Source: Martines J et al Lancet 2005

 Move to MNCH – incorporate costs for further maternal interventions  Approaches to identify the financing gap at country level and simplification of current tools  More long term efforts to improve the input data:  Disability outcomes (eg by preventing birth asphyxia) not included  Coverage data for specific interventions not routinely available  Almost no data on societal and opportunity costs Costing – the future

Conclusion Commitment and leadership US $ 7 billion or $1.64 per capita per year would save 6.6 million babies and children and also reduce maternal deaths Current spending is not enough - limited information on resource flows suggests donor inputs for most MNCH essential interventions is a very low proportion More investment is required alongside strategic, phased planning - rapid gains can be made and many lives saved especially by starting at community level The leaders of both rich and poor countries have a responsibility to the mothers and children of the world

WHO, Rivers of life Thank you!

Comparison with WHO cost estimates Model element/ Approach Lancet Child/ Neonatal Survival Combined WHO World Health Report Relative to Bryce et al, WHO estimate is likely to be: What is costed? Running costs Scale-up & running costs Countries 6075 Interventions 3216 “sets” Target coverage 99%95% Delivery strategy Integrated delivery timetable Some vertical; some combined.