January 21, 2015 — Günther Fink, a health economist with expertise in child health and development, thinks that all countries should aim to reduce neonatal mortality by 70% by the year 2030. In a recent paper for the Copenhagen Consensus, he argues that this goal should be part of the new UN Sustainable Development Goals, which will be set in September 2015.
Why do you think it’s critical that the world focus on reducing neonatal mortality?
It is depressing that about 2.8 million babies continue to die in the first month of their lives every year. Those deaths account for more than 40% of total mortality of children under age five globally, and most of those deaths—70% or 80%—can be prevented relatively easily. The large majority of these deaths are due to three main causes: prematurity, interpartum-related complications, and sepsis. There is no reason why so many babies have to die. To me, saving neonatal lives is a more tangible and more real objective than more general things like ending poverty—which we also want to do and we also agree on—because this objective is more concrete and more achievable than many other objectives currently being considered for the new Sustainable Development Goals.
You wrote in your paper that the best way to reduce deaths among the very young is to improve health systems in developing countries. What are the impediments to achieving this?
To save these babies you need a functioning health system, which of course is not easy to achieve. One issue is funding—improving health systems requires substantial investment. Currently, in my view, many developing countries focus too much on what people call “vertical programs”—programs that focus on single diseases such as HIV or malaria. These programs are good and have improved health a lot, but they often generate parallel health systems, which is not really what countries need. Fundamentally, countries need well-functioning overall health systems, which will help children survive and which are also good for the general population. So rather than fixing one disease at a time—which we have been very successful at over the past 20 years—I think we should change the mindset going forward and really focus on getting health systems right. If the systems are right, more infants would survive—and many other health-related problems would also be solved.
The main challenge is that improving health systems is hard. Building health systems is expensive and takes time. We would need to train nurses, doctors, community health workers. We would need to make sure they work in areas that are underserved. We would need to make sure they get the supplies they need. So—as the word “systems” suggests—it’s much more complex than running, for instance, a malaria program.
You did a cost-benefit analysis of the effect of what would happen if each country around the world saved 70% of neonatal lives by 2030. What did you find?
I found that the ratio of benefits to costs is roughly 15 to 1. The calculations underlying this number are relatively simple. The best current cost estimate we have suggests that an annual investment of about $20 billion would be needed annually to achieve the health system improvements required for a 70% reduction in neonatal mortality by 2030. Offsetting that cost would be the estimated economic value each surviving child would bring to society. Any kind of cost-effectiveness calculation has to start, unfortunately, with a number assigned to the cost of a “life year.” The question of what a person’s life is worth is, of course, a separate ethical question, but for policy we need to use numbers. The Copenhagen Consensus assigns a value of $5,000 to each life year in a developing country, which roughly corresponds to the average income per capita in low and middle-income countries today. So, if each surviving child lives on average at least 30 years in expected terms, that corresponds to a value of $150,000 per child; multiplying this by the two million lives saved every year yields an annual benefit of $300 billion—about 15 times the annual investment required.
Some economists are concerned that, in the short run, improving survival a lot may lead to rapid population growth and therefore be harmful for economic development. I am quite confident that such effects would be reversed within 20 or 30 years. That’s because all the evidence we have in studies of global populations shows that any mortality reduction is eventually followed by fertility reduction. Once parents realize that all of their children are surviving, they tend to have fewer children. So, even with excessive population growth for a decade or two, it’s good in the long run, because it would bring us to where we want to be—with fewer kids, but healthier kids.