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This officially licensed Toy Story Woody costume includes a yellow checked shirt with cow print waistcoat attached and a pair of denim effect trousers with an elasticated waist. Also included is a gun holster, red neckerchief and a cowboy hat for that perfect Woody look!
There is a tremendous success story in Sub-Saharan Africa that has only barely been recognized. The under-5 mortality (U5MR) measure captures the number of children per 1000 live births who die before their 5th birthday.
In the 20 countries for which recent data is available, 12 show rates of decline above this “MDG rate.” In particular, Senegal, Rwanda, Kenya, Uganda, and Ghana have experienced extremely large drops at a rate of more than 6 percent per year.
The acceleration in the decline of child mortality in Sub-Saharan Africa was evident in a 2010 Lancet article, but that article was completed before much of the recent data showing the most dramatic declines was available. One of us (Ritva) used to work on post-conflict Uganda in the 1990s analyzing household survey data on under-5 mortality.
In a recent co-authored working paper, one of us (Gabriel) explores what may have driven part of this decline in Kenya, which had the fastest rate of infant (under age 1) mortality, with a drop of 7.6 percent per year between recent Demographic and Health Surveys. The infant mortality decline took place chiefly in malaria high-risk zones and was entirely confined to postneonatal mortality (deaths after the 1st month.) Postneonatal mortality is much higher in malaria high-risk zones and much lower among households that own an ITN in malaria high-risk zones (both unconditionally and controlling for a wide variety of other factors). In the Kenya decomposition analysis, the growth in ITN ownership explains just over half of the infant mortality decline. Has anyone spotted that the big fall in infant mortality in Africa over the last five years has coincided with the period when more and more African governments removed user fees for health services - especially for pregnant women and children?
2012 marks an important anniversary in this area, as it is 25 years ago since a number of influential development agencies started encouraging African governments to charge user fees - including for young children. Is there any evidence from other countries, apart from Kenya, showing the importance of ITN for the IMR? Robert: I haven't seen any research that examines the influence of ITNs for IMR using national data.

Swati: I share your enthusiasm for recognizing that the widespread decline in infant mortality is a substantial achievement, for which the citizens and governments of the countries in questions deserve congratulations. Yes, treated bed nets are likely contributing to these incremental declines; yes, improving access to health services works.
Having worked in Sudan, Angola and parts of Africa over the past 30 years on malaria control, it is gratifying to see your attribution of lower Infant Mortality to decreases in malaria. The good news is that a more sustainable approach, which we demonstrated in the Gezira Irrigation System in central Sudan in the 1980's, is improving the irrigation and drainage system in ways which reduce malaria mosquito breeding.
So in construction of new irrigation systems, and in rehab of existing ones, malaria control can be made sustainable and economical, as we showed with the $100 million World Bank loan we received in 1984 for the Gezira Rehabilitation Program. While there's certainly some good news in those trends, we can't lose site of the fact that millions of children still die each year before the age of five. Infant and under-5 mortality has plummeted in many countries in the region in recent years.
One of the Millennium Development Goals is a two-thirds decline in U5MR between 1990 and 2015, which would require an annual decline of 4.4 percent per year. A decomposition analysis suggests that the huge increase in ownership of insecticide-treated bednets (ITNs) played a substantial role, by reducing malaria deaths. ITN ownership skyrocketed in Kenya between 2003 and 2008, going from 8 to 60 percent of households nationally and reaching 75 percent of households in high-risk zones.
The Kenyan example is illustrative because bed net use only sky-rocketed post 2003 when the Government started distributing them free of charge. Following these excellent recent results one really thinks that these agencies owe it to the developing world to acknowledge that this policy was wrong. I am not deeply familiar with the history and research on user fees for health, and I look forward to learning more.
They are steeper than the sub-Saharan average -- but graphing them produces trends that, for half of the "top-8" (Mozambique, Ethiopia, Ghana, Senegal) seem to be an extension of the "long slog" of broad, incremental improvements in public health, in education (particularly for women), income and urbanization that promoted declines in under-5 mortality elsewhere.

Zambia, Uganda and Kenya seem to be declining from upsurges in Q5 during the 1990s, likely the influence of mother-to-child transmission of HIV. But, while I am no expert in this, it is my understanding that as the rates get lower further declines get to be harder to achieve and that for each decrease of 10% different factors are responsible. According to the latest mortality statistics, 44 percent of those children don't even make it through the first month of life.
But it does tell us that the African Renaissance is bringing tangible benefits to the continent’s citizens.
The paper applies some statistical machinery to the question, but the basic logic is simple. In future work, we will examine the broader story of infant and under-5 mortality declines across many countries in the region, which allow us to consider the role of country-wide factors like the broad improvement in living standards that have come with renewed economic growth. Because of this miracle, hundreds of thousands of parents will be spared the agony of the loss of a child.
This collection of facts suggests that ITNs played an important role in the decline of infant mortality in Kenya. This conclusion is also compatible with the findings of small-scale experimental and panel studies on the effects of ITNs on malaria prevalence and mortality. On the other hand, can you imagine a journalist picking up the news of ongoing secular declines and transforming it into the newspaper headline, "Sub-Saharan Africa: Long-term childhood mortality declines continue, even after disruptions" ?

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