Successes and challenges of under five child mortality reduction in West Africa

Niger J Paed 2014; 41 (4): 295 - 301

ORIGINAL

Umar LW

Successes and challenges of

Osinusi K

under-five child mortality

reduction in West Africa

DOI:http://dx.doi.org/10.4314/njp.v41i4,1

Accepted: 10th May 2014

Abstract Background: Under-five

tions still remain the leading

mortality rate is an important in-

causes of death. In spite of a five-

Umar LW

(

)

dex for assessing achievements by

fold rise of average annual rate of

Department of Paediatrics

countries and thus its targeted

reduction of under-five deaths

Ahmadu Bello University Teaching

reduction is adopted as bench-

compared to a 3-fold rise of the

Hospital Shika-Zaria

mark towards realizing the Mil-

global average and a 49.7% reduc-

Email: umarlw@gmail.com

lennium Development Goal num-

tion in under-five mortality rate,

Osinusi K

ber 4 by 2015. With less than 24

the sub-region trails behind other

Department of Paediatrics,

months to the deadline, West Af-

parts of Africa. While only Liberia

UCH Ibadan

rica still contributes significantly

achieved the MDG 4 target, Niger,

to the global burden of child mor-

Cape Verde, Gambia, Guinea and

tality, with over half of the deaths

Burkina Faso are on track. Nige-

caused by infections.

ria’s huge child population, high

Objective: To review the suc-

under-five mortality burden and

cesses and challenges of reducing

slow reduction, weighs down the

under-five mortality in West Af-

sub-region’s averages. Neonatal

rica.

death proportions are rising, with

Sources: A search was made in

four countries ranking amongst the

Pub Med and Google Scholar

world’s top ten. With less than 24

using the key words: Under-five,

months left, the likelihood of

Children, Mortality, West Africa,

achieving the reduction targets for

Successes,

Progress,

Achieve-

under-five mortality in most of the

ments and Challenges . Relevant

countries in the sub-region by the

publications and reports available

end of 2015 remains a mirage.

at WHO, UNICEF and UN web-

Conclusion: Numerous daunting

sites were also consulted. Tables

challenges have contributed to

and charts were drawn from rele-

slow the pace of under-five death

vant data for West African Coun-

reduction in West Africa. Coun-

tries obtained from these sources

tries in the sub-region need to ad-

using Microsoft® Excel® for

dress their challenges while scal-

Mac

2011

Version

14.1.0

ing up proven interventions to ac-

(110310).

celerate progress towards further

Results: Although significant un-

reductions of under-five deaths.

der-five death reductions have

been recorded in countries of

Key words: Children, under-five,

West Africa between 1990 and

mortality, West Africa, progress,

2012, the reduction falls far short

successes, achievements,

of the expected targets and infec-

challenges

Introduction

and achievement of 90% measles immunization cover-

age for children 12-24 months of age by the year 2015 .

At the Millennium Development Summit in September

Other health-related MDGs are one (eradicating poverty

2000, world leaders and development experts made the

and hunger), five (improvement of maternal health), six

famous declaration that committed the global commu-

(combating HIV, malaria and TB), seven (environmental

nity to the eight Millennium Development Goals

sustainability) and eight (forging global partnerships).

(MDGs) to address poverty, hunger, diseases and envi-

The fifteen countries in West Africa cover a vast ex-

ronmental degradation. The MDG 4 seeks to improve

panse of landmass extending from Senegal in the north-

survival of children by reducing under-five mortality

east, to the Gulf of Guinea, the Lake Chad and the high-

aiming at three benchmarks: reduction of under-five and

lands bordering Nigeria and Cameroon to the west. The

infant mortality rates by two-thirds of the 1990 figures

average total population in 2011 was about 316 million

296

with a range from 0.5 million in Cape Verde to 160 mil-

Successes in Under-Five Mortality Reduction

lion in Nigeria. Under-5 child proportions range from

Global ranking

10.3% to 19.9% (average of 16.3) and Nigeria has the

highest under-5 population of nearly 27.2 million, or

There has been a significant reduction of under-five

50.2% of the total in the sub-region .

mortality among West African countries from 1990

The countries belong to the “Lower Income” and

when eight countries had mortality rates above

“Lower Middle Income” groups with the lowest GDP

200/1,000 live births, while the rest had rates above

per Capita range of $290 in Liberia to $2940 in Cape

100/1,000 live births. By the end of 2012 none has a rate

Verde, and half of citizens in eight countries living on

above 200/1,000 live births while seven had rates of less

than 100/1,000 live birth . The sub-region however,

4,5

less than $1/day . All are also among the group of “75

Countdown” countries sharing over 95% of the global

still remains home to eight of the top fifteen in the

maternal and child deaths .

global ranking of under-5 mortality (Table 1).

Major causes of child mortality

Table 1: Global ranking of under-5 mortality rates (per 1000

live births) for West Africa, 2012

Infectious diseases have remained the major cause of

% Reduc-

deaths in children in the sub-region (Figure 1). For in-

U5MR

tion from

U5MR

*AAR

Country

1990

2012

1990

Rank

R(%)

stance, amongst fifteen countries with the highest bur-

den of deaths due to pneumonia and diarrhoea, countries

Sierra Leone

257

182

1.6

Guinea-

in the sub-region had 23% of the 1.3 million deaths

Bissau

206

129

2.1

shared by these countries by the end of 2012 . Nigeria

4,5

Mali

253

128

3.1

alone has 18% while Niger, Mali and Burkina Faso,

Nigeria

213

124

2.5

share 5%. Morbidity and mortality due to malaria have

Niger

326

114

4.8

become largely concentrated in countries of West and

Côte d'Ivoire

152

108

1.6

Central Africa, together being responsible for 65% of

Burkina Faso

202

102

3.1

the mortality burden for the top 10 countries or 3.1 mil-

Guinea

241

101

3.9

lion deaths. Nigeria alone has 46% of this figure while

Togo

143

1.8

Benin

181

3.2

Mali, Cote d’Ivoire, Niger and Burkina Faso together

Liberia

248

5.4

share 19% . Neonatal problems account for 28% of all

4,5

Gambia

170

3.8

under-five deaths, with birth asphyxia and prematurity

Ghana

128

2.6

causing 57% while neonatal sepsis, pneumonia and

Senegal

142

3.9

meningitis together cause 25%. Countries of West

Cape Verde

4.6

Africa that feature prominently among top ten countries

with highest neonatal death rates include Cote d’Ivoire,

*AARR: Average Annual Rate of Reduction of under-5 mortality

Guinea Bissau, Mali and Sierra Leone .

Major contribution to under-five mortality decline

Fig 1: Major causes of under-five mortality in West Africa,

2012

The Major decline in deaths was from reduction of

deaths due to infectious diseases, of which measles

Pneumonia, 17%

deaths reduction by over 80% was the most remarkable.

Others, 20%

The average measles immunization coverage in the sub-

region is however yet to reach the 90% target for

MDG4, improving from an average of 58% to 79% and

Diarrhoea, 11%

only five countries reached the 2015 target of 90% by

end of 2012 .

Neonatal, 28%

The 2013 UNICEF MDG Report revealed that based on

Malaria, 18%

regional group analysis West and Central Africa

achieved average reductions of 23% for neonatal mortal-

HIV, 2%

ity, 33% for infant mortality and 39% for under-five

Injuries, 3%

Measles, 1%

mortality from the 1990 rates . When analyzed sepa-

HIV/AIDS is responsible for 1-4% of deaths across the

rately however, West Africa’s progress still fall short of

the 2/3 MDG4 reduction targets, with average reduc-

countries in the sub-region, and out of the total global

under-five deaths of about 103,000 due to the disease in

tion of 30.4% for neonatal mortality, 42.7% for infant

2012, Nigeria has the highest of 24,000 or 23%. At the

mortality and 49.7%, for under-five mortality between

sub-regional level this burden far outweighs the sum for

1990 and 2013.

other countries put together while at the global level

Nigeria remains the country with the second lowest anti-

Absolute Progress

retroviral therapy coverage for eligible children (12%)

out of the 22 countries with the highest burden of HIV

The MDGs have been argued to be too ambitious for sub

infection. The average prevalence of stunting in West

-Saharan Africa because although they were set in 2000,

Africa is about 40% and under-nutrition is associated

their monitoring was backdated to begin from 1990.

with up to a third of under-five deaths in the sub-region .

This makes progress difficult for these countries since

297

they had poor development indices in the 1990s and

mortality burden, with Nigeria alone responsible for

were confronted by numerous challenges along the line.

827,000 deaths or 13% as at the end of 2013, coming

While the MDG4 measures relative progress or extent of

second to India’s 22%. At the sub-regional level 60% of

death reduction from 1990, absolute progress measures

the burden lies with Nigeria alone, while each of the

the total change made. West African countries fared

other countries have less than 10% of the total under-

five mortality as at the end of 2012 (Figure 3) .

better by absolute progress ranking than by relative

ranking (Table 2)

6,7,8,9,10

With a 2011 population of 162 million, Nigeria’s under-

five population of about 27.2 million is over half the

Table 2: Under-five mortality (U5MR) global absolute and

region’s under-five population , partly accounting for its

relative ranking for West African countries, 1990-2007*

relatively higher burden.

Absolute

Relative

U5MR

Progress

Fig 3: Under-five mortality burden in West Africa, 2012 (% of

Country

1990

2007

Rank

1.5 million)

Niger

304

176

Togo

Cote d’Ivoire

Niger

Liberia

Guinea

231

150

Ghana

Guinea

Liberia

205

133

Mali

Benin

184

123

Guinea-Bissau

Mali

250

196

100

Senegal

Burkina Faso

Togo

150

100

Gambia

153

109

Cape Verde

Guinea-Bissau

240

198

106

Sierra Leone

Nigeria

230

189

104

Gambia

Senegal

149

114

Cape Verde

Benin

Sierra Leone

290

262

113

Côte d'Ivoire

151

127

109

Burkina Faso

206

191

116

Ghana

120

115

113

121

Nigeria

60%

* Modified from:

Overseas Development Institute, 2010. The Millennium Development

Countries with the Most Impressive Progress

Goals Report Card. Measuring Progress Across Countries. September

2010

The countries with the most impressive under-five mor-

The 2013 UNICEF MDG Report that included analysis

tality decline were Niger and Liberia with average an-

of United Nation’s Inter-agency Group for Child Mor-

nual rate of reduction (AARR) of 4.8% and 5.4% and

tality Estimation (IGME) data demonstrated the faster

reductions of 65% and 70% from the 1990 rates respec-

tively . These lower income countries successfully

rate of under-five mortality reduction in West and Cen-

tral Africa by absolute average rate of reduction from

scaled up major interventions that improved universal

1990 to 2012 compared to the global average (Figure 2).

access for the leading killer diseases of children includ-

These sub-regions recorded a five times rise in average

ing malaria, pneumonia, diarrhoea, malnutrition and

HIV

2,3,4,5,11

annual rate of reduction (AARR) compared to only a

tripling of the global average in the period 1990 to

In Niger 22% of under-five death reductions were attrib-

2012 .

4,5

uted to improved care-seeking for pneumonia and diar-

rhoea, 25% due to provision of insecticide treated mos-

Fig 2: West/Central Africa’s Rise of Under-5 Mortality

quito nets (ITN) to under-five children and 19% to nutri-

tion intervention programmes

11,12,13

Reduction*

. In Liberia by the

end of 2010 ITN provision for under-five children was

raised to 73% thereby halving malaria prevalence,

prevalence of severe malnutrition fell to 2.2% due to

enrolment of 50% of severely malnourished children in

a basic care package, PMTCT and ART coverage have

improved to 69% of eligible women and to 44% of eligi-

ble children while neonatal tetanus has also been elimi-

11,12,14

nated by the end of 2010

Nigeria’s under-five mortality burden

Nigeria’s performance in under-five death reduction

apparently weighs down both West Africa’s and sub-

*Modified from:

Saharan Africa’s averages, with a population of about

4. United Nations Children’s Fund, New York (2013). Committing to

51.4% of West Africa’s total as at 2011. While Nigeria’s

Child Survival: A Promise Renewed: Progress Report 2013. Accessed

15 September 2013. Available at, www.apromiserenewed.org.

under-five population of 27.2 million is equivalent to

about half (51.6%) of the total under-five population in

In spite of these achievements West African countries

the sub-region, its under-five mortality proportion of

remain prominent in the global league for under-five

60% by the end of 2012 is disproportionately higher

than the country’s contribution to the total under-five

298

population in the sub-region . The country had a 1990

half of children with suspected pneumonia are taken to a

under-five mortality rate of 213/1,000 live births an

health care provider and there is sub-optimal use of anti-

AARR of 2.0% and its total reduction of 42% from the

biotics among those attended to. Similarly there is poor

1990 rate is amongst the six lowest in the sub-region.

utilization of oral rehydration salts (ORS) and zinc for

Nigeria’s rapid population growth is faster than the pace

children in Nigeria, Mali and Niger that have the highest

of scale-up of services. For instance, as the annual num-

diarrhoeal disease burden and deaths in the sub-

region

11,12

ber of births rose from 4.3 million to 6.1 million be-

tween 1990 and 2008 and the number of births attended

to by skilled providers doubled from 1.3 million to 2.7

Sub-optimal routine immunization

million, the service coverage rose by only 8% (31% to

39%). Had the number of births remained stable the cov-

While routine immunizations coverage improved in Li-

erage could have reached 63%, much higher than the 8%

beria and Niger, sub-optimal routine immunization cov-

rise

2,3,17

erage and inconsistent immunization campaigns in some

parts of Nigeria have contributed to resurgence of out-

breaks of measles . Meanwhile the global annual bur-

The Challenges of Reducing Under-five Mortality in

West Africa

den of measles was reported by WHO to have reduced

from 853,500 cases in 2000 to 355,000 cases in 2011

Several challenges have contributed to slow down the

with a decline of mortality globally by 71% between

2000 and 2011, from 542 000 to 158 000 deaths.

26, 27

progress of West African countries towards reduction of

under-five deaths, many of which are common to all the

The WHO has estimated that about 1.7 million out of

countries while a few are unique to each country. Fore-

the 20 million unprotected children live in Nigeria with

most among the common challenges are:

up to 18,843 cases reported in measles outbreaks in the

country in 2011 alone .

Funding constraints

Human resource constraints

Both domestic and external funding (MDG 8 targets) for

the implementation of MDG interventions are falling

The sub-region has the severest shortage of health care

short of expectation. For instance funding from the

personnel with a density of less than two health workers

Overseas Development Assistance (ODA), which com-

per 1,000 persons, much lower than the WHO standard

mits developed countries to set aside 0.7% of their Gross

of 2.3 per 1,000. Health care workers are much fewer in

National Income (GNI) towards MDG funding has been

rural, remote and hard to reach areas and where avail-

dwindling especially due to the global economic crisis in

able, they often have inappropriate skill mix, performing

jobs not suited for their competencies

17,18,19

the last decade. Similarly, commitments made by Afri-

can leaders in the“2001 Abuja Declaration” were not

being fulfilled, with only five of the countries in the sub-

Inadequate water supply and poor environmental sani-

region keeping their promise of setting aside 15% of

tation

their national budgets for health as at 2011

15,20

There is generally poor access to safe potable water re-

Poverty, hunger, malnutrition and poor maternal educa-

sulting in high diarrhoeal disease prevalence and higher

tion

burden of diarrhoeal disease mortality. There is gener-

ally slow progress in realizing the environmental sus-

West African countries are among those with the highest

tainability targets (MDG 7) in most countries in the sub-

under-five death rates in the poorest households. Mortal-

region, with less than 50% of citizens having access to

ity analysis by household wealth quintiles has revealed

supply of safe water. There is also poor environmental

that under-five children of the poorest 20% of house-

sanitation with the effect of contamination of surface

water

4,25

holds have at least a two-fold risk of mortality than

those in the richest quintile . There is also a three times

higher risk of under-five mortality in children of unedu-

High out of pocket expenses for health

cated mothers compared to those of mothers that had

secondary level of education . Countries like Niger,

The countries in West Africa generally have high out of

Mali and Guinea Bissau have serious to alarming levels

pocket expenses for health from family income for their

of hunger as rated on the Global Hunger Index. The

citizens. For instance these expenses make up above

lingering poverty coupled with food insecurity is aggra-

50% in half of the countries and is up to 88% in Guinea

vated by adverse climatic changes, as well as civil un-

and 94% in Cape Verde. The Governments’ per capita

rest, all of which have contributed to high rates of mal-

expenditure on health is also quite low, being less than

15% across the sub-region .

2,6

nutrition and increased vulnerability of children to infec-

tions

11,12

Slow rate of maternal mortality reduction

Poor utilization of health services

Maternal mortality ratio ranks amongst the highest in the

There is generally poor health seeking behaviour for

world due to poor progress in reduction of peripartum

children across the sub-region. For instance, less than

deaths across the sub-region. Nigeria has one of the

299

highest maternal mortality rates in the sub-region, with a

able to reduce their under-five mortality to the expected

level till up to two decades after 2015 (Figure 4) . As a

national average of 545/100,000 live births and nearly

twice this in the north east and north west zones

sub-region therefore, even though West Africa has re-

(1000/100,000). Maternal deaths consequently increases

corded undisputed successes in child death reductions

vulnerability of orphans, further predisposing them to

over the last decade, it is unlikely to achieve the desired

inadequate care and malnutrition, with negative impact

global benchmark for under-five morality reductions in

on their chances of survival

3,4,19

the remaining period to the end of 2015.

Slow rate of neonatal mortality reduction

Fig 4: Year at which West African Countries would Achieve

MDG4

Reduction of neonatal deaths lags behind under-5 mor-

tality decline as a result of which the average share

among total under-5 deaths rose from 36% to 40% from

1990. The absolute number of neonatal deaths rose

above the 1990 figures in some countries like Nigeria

3,4,5

. A large proportion of neonatal deaths are attribut-

able to birth asphyxia following high rates of home de-

liveries that are often unsupervised by skilled attendants.

Rapid population growth

West African countries have about the highest popula-

tion growth rates constituting a huge challenge for ade-

quacy of health service coverage. The rate of population

Some development experts have disputed the current

growth is faster than the rate of scale up of services as

methodology for the measurement of success in achiev-

typified by Nigeria where there was marginal increase in

ing reduction of under-five mortality, proposing that

births attended by skilled personnel despite a two-fold

measurement is more objective when made by assessing

increase in number of skilled birth attendants over the

for pace of progress than by achievement of fixed tar-

gets . The official reports of the UNDP, World Bank,

period from 1990 to 2008

2,3,17

UNICEF and other UN agencies on successes of MDGs

Armed conflicts

placed much emphasis on achieving set targets and these

have portrayed sub-Saharan Africa as either being “off-

Most countries of the sub-region have had their share of

track”, “missing the target” or having a “grossly insuffi-

one type of conflict or another ranging from civil wars

cient rate of reduction”. It is further argued that as per-

and sectarian/ethnic clashes to military take-over of

formance measures, MDG success should equally focus

power in coup d’états, which has disrupted equitable

on pace or acceleration of progress relative to pre-2000

period rather than achieving projected targets . They

service delivery. Civil wars were fought in Sierra Leone,

Liberia, Guinea-Bissau and Cote d’Ivoire, Coups d’états

further observed that the current reported MDG achieve-

occurred in Gambia, Niger and Guinea while ethnic and

ments do not differentiate between background non-

sectarian clashes occurred frequently in Nigeria, Mali,

MDG

country

developmental

performance

from

Benin since 1990. These have caused displacement of

achievements solely attributed to MDG efforts, and so

populations and movements of people across borders

any observed progress could as well have been at least

leading to vulnerable refugee settlements where child

partly as a result of efforts unrelated to MDG. In this

malnutrition and infectious disease incidence contribute

context, a proposed alternative method of analysis of

data from the period preceding 1990 , revealed empiri-

to increased morbidity and mortality especially amongst

under-five children .

cal findings suggesting that Africa’s MDG progress is

even faster than the global average , Other findings in

The Outlook for Reduction of Under-five Mortality

this regard include:

in West Africa

A 63% acceleration (post-2000) of Africa’s under-5

With less than 24 months to the end of 2015, up to nine

mortality reduction against a global average of 32%.

countries including the most populous are unlikely to

Nigeria, Burkina Faso and Senegal emerged among

achieve significant under-five death reductions, and

the world’s top 10 for under-5 mortality reduction

therefore may not be able to reach their 2/3 reduction

and among the top 15 improvers of reduction by

targets at their current average annual rates of under-five

absolute pace of improvement.

mortality reduction (AARR). Although up till the end of

When rated by AARR and comparing progress from

2013 only Liberia has attained the 2/3 under-5 mortal-

1970 to 2010, 75% of sub-Saharan Africa had ac-

ity reduction from the 1990 rate, but with sustained pro-

celerated its AARR in the period between 2001 and

2010 over previous rates .

gress at the current AARR of 3.8-4.8% Niger, Cape

Verde, Senegal, Guinea and Gambia are likely to attain

their two-thirds reduction targets. At their current

Recommendations for the Way Forward

AARR counties like Togo and Sierra Leone may not be

With obscure prospects for achieving global reduction

300

goals and targets, West African countries need to focus

Conclusion

on strategies to further accelerate their progress beyond

just a focus on 2015 targets, specifically to:

West Africa continues to have a huge burden of under-

Improve political will and commitment to adopt and

five mortality in spite of considerable successes that

implement innovative health policies, strategies and

were achieved by absolute progress a disadvantaged

interventions

4,19,21,23

status in 1990 and daunting challenges along the line.

Review terms of development partnerships with

By the current MDG benchmarks, realizing the two-

stakeholders through country-led selection of needs,

thirds under-5 mortality reduction target is unlikely for

taking the lead in setting their own national goals

West Africa. Countries in the sub-region would need to

and targets and channeling partner support towards

further strengthen and scale up successful strategies and

the most essential interventions .

interventions, address the challenges, and take more

Implement strategies to further address poverty alle-

ownership and responsibility towards combating

viation and reduce family out-of-pocket expenses

infectious diseases and neonatal deaths.

for health

4,19

Increase universal access to basic services and sup-

plies (drugs, vaccines) and rehabilitate physical

Conflict of interest: None

infrastructure by increase in budgets for the health

Funding: None

sector

13,14,15,20

Accelerate efforts to address human resource gaps

through task shifting, mentoring and deployment of

skilled personnel to under served areas

3,4,11,17

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