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  1. 1. Special Theme — Child MortalityThe evolution of child health programmes indeveloping countries: from targeting diseasesto targeting peopleMariam Claeson1 & Ronald J. Waldman2 Mortality rates among children and the absolute number of children dying annually in developing countries have declined considerably over the past few decades. However, the gains made have not been distributed evenly: childhood mortality remains higher among poorer people and the gap between rich and poor has grown. Several poor countries, and some poorer regions within countries, have experienced a levelling off of or even an increase in childhood mortality over the past few years. Until now, two types of programmes — short-term, disease-specific initiatives and more general programmes of primary health care — have contributed to the decline in mortality. Both types of programme can contribute substantially to the strengthening of health systems and in enabling households and communities to improve their health care. In order for them to do so, and in order to complete the unfinished agenda of improving child health globally, new strategies are needed. On the one hand, greater emphasis should be placed on promoting those household behaviours that are not dependent on the performance of health systems. On the other hand, more attention should be paid to interventions that affect health at other stages of the life cycle while efforts that have been made to develop interventions that can be used during childhood continue. Keywords: child welfare; child health services, trends; communicable diseases, prevention and control; delivery of health care; infant mortality, trends; models, theoretical. Bulletin of the World Health Organization, 2000, 78: 1234–1245. Voir page 1243 le resume en francais. En la pagina 1244 figura un resumen en espanol. ´ ´ ¸ ´ ˜ Introduction 50 countries the mortality for children under 5 years was greater than 100 deaths per 1000 live births. In For the past 35 years, the steep decline in deaths 12 countries (11 of them in Africa), one in every among infants and children has provided evidence of five children born alive did not survive to the age of an important success story in international develop- five years (1). Of the nearly 11 million children who ment. Mortality has declined steadily at an average of will die before their fifth birthday this year, 70% will about 1% per year. The absolute number of children die from a disease, a combination of a few diseases, under the age of 5 years dying has fallen from an or a condition for which safe and effective estimated 15 million in 1980 to about 11 million at the interventions are readily available in industrialized end of the 1990s (1). Remarkably, this decline has countries: acute respiratory infections, diarrhoea, occurred in the face of increased births, spreading measles, malaria, and malnutrition (2). resistance to commonly used antibiotics and anti- Better access to basic health services — malarial drugs and, most menacingly, the growth of including vaccinations, oral rehydration therapy, the AIDS pandemic. and antibiotics for pneumonia — together with A closer look at this favourable trend, improvements in social conditions — including however, reveals that progress has been distributed higher standards of living and smaller families living unevenly. Recently, the decline in mortality among on larger incomes — have been important factors in children under 5 years has stalled in a number of improving the survival rate of children. As deaths countries and in some the trend has reversed and among children under 5 years have declined in many mortality seems to be rising. In 1998, in more than developing countries, contributing to both demo- graphic and epidemiological transitions, the propor- 1 tional mortality accounted for by some conditions Principal Public Health Specialist, Health, Nutrition, and Population, has increased: this problem has been relatively Human Development Department, World Bank, Washington, DC, 20433, USA (email: mclaeson@worldbank.org). Correspondence ignored by the international health community. For should be addressed to this author. example, the greatest decline in childhood mortality 2 Professor of Clinical Public Health and Director, Program on rates has occurred among children in the post- Forced Migration and Health, Center for Population and Family Health, neonatal period; this has led to a relative increase in Joseph L. Mailman School of Public Health, Columbia University, the importance of neonatal and perinatal mortality. New York, USA. Also, gender-specific issues have emerged in some Ref. No. 00-07621234 # World Health Organization 2000 Bulletin of the World Health Organization, 2000, 78 (10)
  2. 2. The evolution of child health programmes in developing countriesparts of the world, notably on the Indian subconti- programmes must, when possible, promote com-nent where girls aged between 1 month and 5 years munity involvement while contributing to the on-still experience considerably higher mortality and going development and strengthening of nationalmorbidity than boys (3, 4). And, although this paper health systems (6).does not deal with it specifically, increases in deaths Similarly, a debate over the degree to which thefrom AIDS in Africa are already slowing or reversing objectives of primary health care can be translatedthese downward trends. Without a major assault on into effective programmes resulted in the emergenceAIDS throughout local health systems and in the of ‘‘selective primary health care’’ (7). This newcommunity, childhood mortality, whether from strategy, which targeted the control of diseasesinfection or from the increased risks associated with identified as the most important contributors tobeing orphaned, can be expected to increase in some increased mortality, was intended to be more focusedparts of the world. and more feasible. A number of specific, more In this paper, we examine the roots from which vertical programmes (so named because of the self-current child health programmes have grown, some of contained way they appear on organizational chartsthe causes behind the apparent slowing of progress in and, more importantly, in budget lines of healthmany parts of the world, and we suggest ways in which ministries) were promoted to channel relativelythe nature of these programmes must change if meagre resources into areas in which demonstrablecontinued gains are to be made throughout the world. success could be achieved in the medium-term. Furthermore, the emphasis was clearly put on programmes that would contribute to achieving decreases in mortality among infants and children,Trends and milestones since children were considered to be the mostGlobal strategies for reducing childhood mortality vulnerable segment of the population because theyhave been of two basic types. The first were have the highest rates of preventable death.ambitious disease-specific, technologically depen- The World Health Organization, for example,dent strategies aimed at achieving dramatic, albeit first developed the Expanded Programme onnarrow, successes in a relatively short time. The Immunization and subsequently the Programmenotable failure of the most ambitious programme of for the Control of Diarrhoeal Diseases. UNICEFthis type — the malaria eradication programme (not chose four specific interventions on which to focus:exclusively a child health programme, but one that growth monitoring, oral rehydration therapy, breast-was expected to make a major contribution to feeding promotion, and immunization, known by thereducing child mortality) launched in the 1950s and acronym GOBI. It later added three more (food,abandoned in the 1970s — contributed strongly to a family planning, and female education). Bilateralshift in thinking (5). donors followed, channelling funds into what came The more people-centred, community-based to be called ‘‘child survival’’ programmes; thesestrategy typified by primary health care, with its goal retained their roots in community-oriented, popula-of health for all by the year 2000, was adopted by the tion-based, primary health care, but at the same timeWorld Health Assembly in 1977. Primary health care had the appeal of using relatively inexpensive medicalsought to broaden the focus of health services by technologies to reach specific, stated objectives.emphasizing programmatic areas instead of specific Although the two strategies, at different endsdiseases. Accordingly, the provision of universal of the intervention spectrum, have been able toservices for maternal and child health, family coexist relatively peacefully, they have never quiteplanning, improved water supplies, and environ- coalesced. Currently, several attempts at rapproche-mental sanitation became objectives; these were to be ment are under way. For example, the multi-agencyachieved through an equitable distribution of Roll Back Malaria movement includes componentsresources, community involvement, an emphasis on aimed at health systems and at the community.prevention instead of clinic-based curative interven- Reduced rates of morbidity and death from malaria, ittions, and a multisectoral approach. suggests, should be viewed as markers of improved Neither strategic approach ever totally eclipsed health systems. Similarly, the Integrated Managementthe other. Although attempts to eradicate malaria of Childhood Illness initiative explicitly incorporatesfailed, the ensuing smallpox eradication programme a component of community development; thisis probably the most successful large-scale public programme evolved from selective primary healthhealth programme in history, with the last case of care programmes that aimed to control diarrhoealsmallpox acquired by human-to-human transmission diseases and acute respiratory infections in childhoodhaving occurred in 1977. Important lessons have by working with health workers and strengtheningbeen learnt from both the failed malaria eradication health systems. Both of these efforts, and manyprogramme and the successful smallpox programme; others currently being implemented (including thethese lessons have been applied to current attempts poliomyelitis and dracunculiasis eradication pro-to eradicate dracunculiasis and poliomyelitis, two grammes) emphasize the need for communityprogrammes which are on the verge of success. To an participation, for strong and effective partnershipsimportant degree, the appeal of these programmes is between public and private sectors, for intersectoralrooted in the acceptance that disease-specific links, and the need to combine medical technologyBulletin of the World Health Organization, 2000, 78 (10) 1235
  3. 3. Special Theme — Child Mortality with behavioural interventions. That is, they recog- reviews influenced the direction of global efforts in nize these needs in rhetoric, if not in practice. This preventing and controlling childhood acute respira- reflects current thinking as to how programmes to tory infections and diarrhoea. improve children’s health should be implemented, In the 1990s, research priorities have evolved not necessarily how resources are being invested. as efforts to develop a more integrated approach to Although emphasis on community-level interven- case management both in the home and within the tions is generally recognized to be a desirable and health system have intensified. The success of case- effective approach to implementing successful management strategies depends only in part upon programmes, activities still tend to focus on improv- the availability of services provided by trained health ing the delivery of services through an organized care workers. Equally important, if not more so, are health system, rather than on effecting behavioural the behaviours of the carer in the home and in the change. community. Case management in the home, care- seeking practices (including the extent to which available health services are used), and compliance The past: research and action with counselling provided by health workers all have an important impact on children’s health. Research The recognition that there were multiple technical priorities have therefore focused increasingly on and operational challenges to the implementation of promoting and maintaining household and commu- child health and nutrition programmes over the past nity support for the home management of childhood 20 years led to an evolution of research priorities (8). illnesses (with appropriate referral when indicated) Before 1985, microbiological, epidemiological, im- through interventions designed to encourage com- munological, and clinical research contributed to the munication and change behaviour. Ethnographic development of both preventive and therapeutic research, participatory rural appraisal, and other interventions for the control of common diseases in qualitative methods have been the tools that have childhood. A prototypical example is the finding that guided the development, local adaptation, and imple- treatment of acute, watery diarrhoea did not depend mentation of many of these effective, community- on the etiological agent and that oral rehydration level interventions (11). therapy with a single, standard solution is safe and To a considerable extent, the progress in effective in almost all cases; this finding shaped global reducing childhood mortality rates is the result of treatment policies for childhood diarrhoeal diseases. efficient interactions between research, analysis, Similarly, the identification of Streptococcus pneumoniae policy development, and programme evaluation. and Haemophilus influenzae as the leading bacterial The cycle — which includes the dissemination of causes of mortality from pneumonia led to the research findings, implementation of programmes development of a universal case-management strat- based on those findings, and feedback regarding egy based on symptomatic diagnosis and standar- successes and failures — has involved the research dized antibiotic treatment. After the development of community, bilateral and international donors, health these technical approaches, research priorities shifted ministries, and nongovernmental organizations in from focusing on incidence, etiology, and other developed and developing countries. WHO has descriptive research to focusing on analytical research played a critical part in the analysis and formulation that was directed at designing, monitoring, and of policy and has provided guidance in implementing evaluating the impact of priority interventions. and evaluating efforts in various countries. For example, in the mid-1980s, the World Health Organization commissioned a review of research that might contribute to determining the potential effectiveness, feasibility, and cost of 18 sug- The present: new initiatives gested preventive interventions for childhood diar- and programmatic approaches rhoea (9). The most promising were found to be For much of the past few decades, the international promoting breastfeeding, improving water supplies, health agenda has been dominated by strategies and modifying sanitation and hygiene behaviours, in- programmes aimed at reducing mortality in child- creasing measles vaccination coverage and, after hood. Reich proposes a number of reasons why this development of the appropriate technologies was was the case. For one, it was important that children’s ensured, vaccinating against rotavirus infections and health problems were being addressed by large, cholera. Similar reviews were done for the Pro- influential organizations, including UNICEF, WHO, gramme on Acute Respiratory Infections in the 1990s and public–private coalitions, such as the Task Force (10). This process identified eight potential interven- for Child Survival and Development. They also had tions, each with the ability to prevent at least 5% of symbolic power in the emotional appeal of being able deaths from pneumonia. These were vaccinating to save children’s lives with simple, cheap interven- children against measles, S. pneumoniae, H. influenzae tions. Also, with the exception of the infant formula type B, and respiratory syncytial virus; minimizing industry, children’s health issues posed no competi- indoor air pollution; reducing the rates of children tion to vested corporate interests. Additionally, born at low birth weight; and exclusively breastfeed- science was on its side: the use of infant mortality ing until the child was aged 4–6 months. These rates as a proxy for national health status and1236 Bulletin of the World Health Organization, 2000, 78 (10)
  4. 4. The evolution of child health programmes in developing countriesdevelopment called attention to the causes of early supervision, monitoring, training, and supplyingdeaths and to the interventions that could be aimed at drugs or vaccines. Without the technical andthem. Finally, for the most part, the agenda setters — programmatic support to which they have becomethat is, the politicians — found that child health is a accustomed, and which cannot be made available atreadily accepted cause that meets with little opposi- the provincial or district level in most developingtion when proposed as a subject for social investment countries, child health services are at risk of levelling(12). It should also be mentioned that childhood off or even declining in both quantity and quality.illnesses make a substantial contribution to the global At the same time, child health programmes,burden of disease (the Integrated Management of especially vaccination programmes, have benefitedChildhood Illness strategy alone, at the time it was from major new funding from non-traditional sources.formulated, addressed conditions that accounted for Although it seems as if some of the activities beingas much as 14% of disability-adjusted life years) (13), pursued may be contradictory, the potential for eachand high mortality rates in children under 5 years of activity to help reduce childhood mortality is evident. Aage are an important contributor to reduced life few of the more prominent initiatives currently beingexpectancy in developing countries. implemented around the world are discussed below. Recently, however, the primacy of child healthconcerns has been challenged, although mostadvocates of adolescent and adult health pro- Vaccination strategiesgrammes agree that it is not useful to promotecompetition between intiatives that target other age Vaccine-preventable diseases are responsible for agroups and and those aimed at child health problems significant proportion of the approximately 11 mil-(14). Yet, unless careful attention is paid to lion deaths that occur annually among children underconsolidating the gains made to date and to reversing 5 years of age (Table 1). Yet, nowhere is the contrastemerging negative trends in some parts of the world, between short-term disease-specific programmesthe gap in life expectancy between richer and poorer and long-term developmental programmes morenations, and between rich and poor within nations, evident than in the area of childhood vaccination.may continue to grow. Preventing this situation will Two contemporary vaccination strategies haverequire continued emphasis on controlling commu- received massive support from both the public andnicable diseases, especially those diseases that affect private sectors. The highest profile public healthchildren disproportionately (15). programme is the initiative to eradicate poliomyelitis. Supported by a 1988 resolution of the World Health Assembly (16) and by a major coalition of interna- tional agencies and private organizations, the drive toHealth sector reforms eradicate poliomyelitis is a direct descendant ofEven if resources for child health are maintained at previous eradication programmes. Based on acurrent levels or increased, strategies will have to be strategy of multiple national mass immunization daysadapted to current trends. Presently, many health accompanied by intensified surveillance, poliomyeli-activities in a large number of developing countries tis has been eliminated from industrialized countriesare unfolding in an environment of health sector and is on the verge of being eradicated worldwide.reform. Donor support seems to have shifted from The concept of poliomyelitis eradication isspecific programmes to the development of leaner laudable. If successful, it will rid the world of a diseaseand potentially more efficient administrative and which causes permanent disability and it will allow formanagerial structures. Typical features of most health the cessation of the production, distribution, andreform efforts are the decentralization of budgetary administration of poliomyelitis vaccine. It will giveand, sometimes, programmatic authority to provin- public health workers around the world a tangiblecial or district levels and the administrative integra- success and, perhaps, provide strong motivation fortion of centralized programmes. These reform achieving comparable success in other health pro-processes and sectorwide approaches can provide grammes. However, poliomyelitis does not contributeopportunities to identify priority problems and more substantially to the global burden of disease, and itscost-effective and affordable interventions. Addi- eradication will not appreciably affect childhoodtionally, they may aid the development of sustainable mortality rates. Furthermore, despite the heroichealth systems that are capable of devising local mobilization efforts that have been undertaken forsolutions for local problems. However, there has mass immunization days to be successful, eradicationbeen less emphasis put on maintaining the quality of is ultimately dependent upon the ability of a healththe more traditional, technically dependent pro- system to organize special campaigns for the deliverygrammes such as those dealing with childhood of services. A strong partnership between commu-diseases, including the Expanded Programme on nities and the health system is a fundamentalImmunization, the Control of Diarrhoeal Diseases requirement but, unless it is made an explicit goal,programme, the Programme on Acute Respiratory there is little transfer of responsibility to parents andInfections, and nutrition. For example, decentraliza- communities. So, in some countries, although im-tion has often been accompanied by a reduction in munization days have been successful, vaccinationsupport for essential programme activities such as coverage with antigens other than those for polio-Bulletin of the World Health Organization, 2000, 78 (10) 1237
  5. 5. Special Theme — Child Mortality Table 1. Annual deaths due to vaccine-preventable diseases (21 ) eradication initiative, the global alliance is a public– private consortium whose principal members are Disease No. of preventable WHO, UNICEF, the World Bank, national govern- annual deaths ments, public health and research institutions, the Rockefeller Foundation, the International Federation Poliomyelitis 720 of Pharmaceutical Manufacturers Associations, and Diphtheria 5000 the Bill and Melinda Gates Foundation. Pertussis 346 000 The global alliance reports that although Measles 888 000 children in developing countries are scheduled by Tetanus (including 215 000 neonatal deaths) 410 000 their national immunization programmes to receive six Haemophilus influenzae type b 400 000 or seven antigens as part of their routine series of Hepatitis Ba 900 000 vaccination, children in the wealthier countries in Yellow fevera 30 000 Total 2 979 720 Europe and North America can expect to receive protection against more than 10 vaccine-preventable a Most deaths do not occur in childhood. diseases. This ‘‘vaccine gap’’ is another example of the inequitable distribution of health services that con- tributes to the growing difference in mortality between myelitis, delivered through the routine health services, rich and poor. Incorporating newer, safe, and effective is declining. Additionally, it is apparent that those vaccines into routine immunization programmes and countries with the weakest health systems will be the increasing coverage for all vaccines in a consistent and last to achieve eradication. As a result, as the deadline sustainable manner for all segments of the population for eradication approaches, there will be increased will require a long-term commitment to developing pressure on these countries to focus only on the and implementing programmes. Additionally, the narrow goal of eradicating poliomyelitis and to development and maintenance of the infrastructure abandon the accompanying objectives related to required to support vaccination programmes will be strengthening their health systems. Accordingly, there important as new vaccines against diseases that are is a real potential that the gap in the ability of countries major contributors to both childhood and adult to carry out other programmes that are dependent on mortality, including malaria, AIDS, and tuberculosis, their health systems, including those directed toward are developed and marketed. improving child health, will continue to grow. There is no obvious reason why both types of As the drive toward poliomyelitis eradication programmes — shorter-term eradication initiatives and nears its successful end, plans are being made to longer-term developmental programmes — should not embark upon a global initiative to eradicate measles. coexist. If funding is available, if personnel and other Unlike poliomyelitis, measles is an important cause of non-monetary resources are sufficient to support both childhood mortality, and its eradication would make kinds of efforts as well as other programmes for which an important contribution towards reducing child- health ministries are responsible, and if demonstrable hood mortality. Technical and programmatic argu- benefits to the target populations can be shown, ments have been advanced, both in favour of and eradication programmes — which appeal to politicians, against devoting major resources to eradicating donors, and the public — could not only contribute to measles. The potential operational, technical, epide- reducing mortality but could also serve as a leading edge miological, and financial problems that such a to prepare countries for longer-term programmes. programme might face have been discussed (17, 18). However, it might be important to make develop- While poliomyelitis eradication efforts have mental goals more explicit in order to ensure that been progressing, and while measles elimination is eradication-type programmes are held accountable for being pursued in several regions, vaccination coverage their achievements in all countries, both richer and with the standard six antigens of the WHO Expanded poorer. This might be accomplished by setting longer- Programme on Immunization has, in fact, fallen over term goals — for example, by deciding what ought to the past decade (19). UNICEF estimates that, despite be achieved over the next 25 years — and allowing the proclaimed success of its Universal Childhood countries to pursue those globally agreed goals at their Immunization programme efforts in the 1980s, which own pace in accordance with their own priorities. The sought to achieve 80% vaccination coverage with the advent of public health endowments, such as the antigens described in the WHO programme by the Global Alliance for Vaccines and Immunization, may second half of the 1990s, 44 countries had measles allow for longer-term planning, as the urgency to raise vaccine coverage of less than 65% for children aged funding for short-term programmes may be somewhat 1 year. Populous countries, such as Nigeria, are alleviated in the future. included in this category; India had an estimated measles vaccine coverage of 67% (20). The new Global Alliance for Vaccines and Immunizations is Case-management: the trend towards responding to this negative trend and is a major promoter of vaccination and immunization. The integrating and packaging services organization seeks to provide more vaccines to more To conform to the changing characteristics of health children in more countries (21). Like the poliomyelitis ministries, which have undergone substantial reorga-1238 Bulletin of the World Health Organization, 2000, 78 (10)
  6. 6. The evolution of child health programmes in developing countriesnization and reform, including a reduction in the income is a contributing factor to ill-health andemphasis on technical programmes, efforts have been malnutrition, so are poor health, malnutrition, andmade to incorporate disease-control programmes in large family size key determinants of poverty. Inmore integrated and manageable packages of basic targeting health interventions at poorer people, thereservices. The Integrated Management of Childhood are two formidable challenges: to lower the incidenceIllness programme is one example of this approach. of outcomes associated with adverse health and poorDeveloped jointly by WHO and UNICEF, this nutrition and to protect households against poten-programme has been embraced by more than tially impoverishing effects when adverse outcomes60 countries and has attracted support from a large do occur.number of donor agencies, including more than It is not only that poor people are in ill-health:25 projects supported by the World Bank. ill-health causes poverty. In Voices of the poor, a recent The conditions included in the package include World Bank study, ill-health emerged as one of themajor communicable diseases (pneumonia, diar- principal reasons why households become poor andrhoea, malaria, and measles). The package also remain poor (23). Explanations are numerous: theyemphasizes addressing malnutrition, which has been include the burden of health care expendituresshown to contribute to more than half of all incurred by caring for sick household memberschildhood deaths (22). To a greater extent than many (24), the lost income of the sick, and the lost incomeearlier strategies, this package includes both treat- of other household members who care for the sick.ment and prevention interventions. In addition to Nationally, although data relating the impact oftraining health workers in standard case-management health indicators to poverty rates are scarce, evidenceprotocols for treating all five diseases, the package is emerging about the impact of health on economicurges the promotion of breastfeeding, improvements growth. One study estimated that health andin feeding practices, the use of micronutrient demographic variables accounted for half of thesupplements, and vaccines. difference in growth rates between Africa and the rest Even more importantly, the package calls of the world from 1965 to 1990 (25).attention to the need not only to train health Malnutrition is also known to be an importantprofessionals but also to strengthen existing health determinant of poverty through its direct effects onsystems to ensure the availability of drugs and loss of earnings: the chronically malnourished worksupplies and widespread access to them. Supervision, less and earn less (26, 27). In addition, malnutritionmonitoring, and evaluation activities are also empha- exerts indirect effects on health status, cognitivesized. The third, and essential, component of the development, and the productivity of workers.package is the promotion of improved prevention Numerous examples can be cited: non-breastfedand care-seeking behaviours in the community and babies have a 14-fold increased risk of dying fromthe family. diarrhoea (28); iodine deficiency disorder has been Diseases that contribute directly to childhood estimated to reduce intelligence quotient (IQ) by anmortality are not the only subjects of these new average of 13.5 points (29); and in Chile, iron-initiatives. Increased attention is being paid to early deficient children who were successfully treatedchildhood development, emphasizing the psychologi- performed 10–400% better on standardized testscal and intellectual growth of the child. Interventions than anaemic children (30).in childhood development are traditionally focused on Improving health and nutrition especiallythe family and community and are not delivered among people living in poverty or close to povertythrough the health system. Nevertheless, certain is thus likely to pay dividends by contributing to risesaspects of the care of young children have recently in household income and raising incomes will helpbeen added as an option in adapting the Integrated lower mortality. Because of the gross health inequal-Management of Childhood Illness package for ities between rich and poor both within and betweencountries that want early childhood development to countries it seems reasonable to encourage a changebe incorporated as an integral part of recovery from in health programming. If mortality rates, especiallychildhood illness. Similarly, just as early childhood in childhood, are to be further reduced and stagnatingdevelopment programmes combine interventions in or reversed trends are to be corrected, it may be morenutrition, health, and psychology to achieve improved important in the future to address the needs ofoutcomes overall, recent interagency efforts (between specific families and households rather than toWHO, UNICEF, and the World Bank) combine the emphasize the development of programmes aimedteaching of life skills with the provision of appropriate at specific diseases, wherever they might occur. Thishealth services at schools, including adequate water people-oriented approach may be more difficult, andand sanitation facilities. it may entail the development and application of sociological rather than biomedical research. But it is increasingly clear that reducing poverty can beThe link between poverty and child achieved by introducing policies and applying programmes that protect households from thehealth outcomes impoverishing effects of ill health, malnutrition, andIt is increasingly understood that the relation between high fertility.health and poverty is bi-directional. Just as lowBulletin of the World Health Organization, 2000, 78 (10) 1239
  7. 7. Special Theme — Child Mortality The future of child health efforts Box 1. A list of key household behaviours for in a changing political environment reducing childhood mortality (11 ) To a certain extent, the easiest part of achieving lasting Reproductive health behaviours reductions in childhood mortality has occurred in Women of reproductive age should delay age of first some countries. In others, the strategies that have been pregnancy, practise birth spacing, limit family size. used — strengthening health systems and training Pregnant women should seek antenatal care at least twice health care providers in the appropriate use of safe, during pregnancy. effective, affordable technologies — have been Women should take iron supplementation during inadequate or not sustainable. In these countries, pregnancy. mortality rates have stagnated or are rising. In all cases, Infant and child feeding practices further improvements will depend to a large extent on Mothers should breastfeed their children exclusively what happens in the household and community and to for about six months. what extent the health system is responsive and will From six months mothers should give children appropriate play a supportive part. The promotion of a limited set complementary feeding and continue to breastfeed for of household behaviours that have direct links to the 24 months (if testing positive for human immunodeficiency prevention and cure of common childhood illnesses virus, current recommendations should be followed). needs to become the centrepiece of intensified activity Immunization practices (see Box 1). Since the ability and willingness of All infants should be taken for measles vaccination at nine families to adopt new behaviours are influenced by a months of age. variety of factors, it will need to be determined locally Infants should be taken for routine vaccinations even when how best to promote these behaviours. Factors sick. influencing the adoption of new behaviours include Pregnant women and other women of childbearing age the household’s resources, attitudes in the community; should seek tetanus toxoid vaccine at every opportunity. and the price, quality, and availability of services and goods such as food, energy, transport, water, and Home health practices Prevention sanitation facilities. All children should sleep under insecticide-treated bednets A graphical depiction of the relation between when indicated. the household or the community and the health Wash hands with soap at appropriate times. system is shown in Fig. 1 (31). The Pathway to All infants and children should consume enough vitamin A, Survival is a guide that distinguishes between by whatever means available. prevention behaviours, such as breastfeeding, that All families should use iodized salt. can be implemented entirely in the home and those, such as vaccination, that require more direct support Treatment from the health system. Similarly, it shows how the Continue feeding and increase fluid intake during illness; management of childhood illness can also be carried increase feeding after illness. Mix and administer oral rehydration salts, or an appropriate out in the home in many instances, with mothers home-available fluid, correctly. responsible for making the critical decision of when Administer treatment and medications according to external support is required. One of the most instruction. attractive features of the pathway is that it can be used as a quantitative tool for measuring problems in Care-seeking practices home care, health care-seeking behaviour, the Seek appropriate care when an infant or child is recognized delivery of primary and secondary health care, as being sick. counselling patients, and the compliance of carers. In fact, a distribution of causes of death can be established on the basis of ‘‘social autopsies’’ taken nutrition and population) sourcebook of the World Bank from mothers whose children have recently died. includes the more distal role of government policies One study in the periurban area of El Alto, near La and actions (Fig. 2). The Mosley–Chen framework Paz, the Republic of Bolivia, where childhood included both social and biological variables. It mortality was high, found that considerably more assumed that all influences on childhood mortality than half of the deaths could be ascribed to at the individual, household, and community levels inadequate knowledge or incorrect behaviour, or operate through a set of common mechanisms, such both, occurring in the household or community. as maternal factors, environmental contamination, Findings such as these support the notion that further nutrient deficiency, injury, and control over personal progress in child survival can only be made by making illness; these were the more proximate determinants. greater investments in communities and families. In the revised framework, the links between policy A recent adaptation of the strategic framework formulation and health outcomes have been made first presented by Mosley & Chen in 1984 adds an more explicit. The revised framework includes health additional dimension to the Pathway for Survival systems interventions and the promotion of appro- model (32). In addition to showing the relation priate household and community behaviours as between the health system and the household and essential intermediate steps between policy and community, the recent Poverty reduction strategy (health, outcome. It recognizes that integrated packages of1240 Bulletin of the World Health Organization, 2000, 78 (10)
  8. 8. The evolution of child health programmes in developing countriesBulletin of the World Health Organization, 2000, 78 (10) 1241
  9. 9. Special Theme — Child Mortality interventions, such as the Integrated Management of for a new generation), takes into account four basic Childhood Illness, the Integrated Management of principles: that health interventions have a cumulative Pregnancy and Childbirth, school health pro- impact — the costs and benefits of interventions later grammes, nutritional interventions, and control of in life are partially dependent upon those that occurred both communicable diseases (such as HIV/AIDS, earlier; that sustaining improved outcomes at any stage tuberculosis, and malaria) and noncommunicable of the life cycle depends on interventions occurring diseases, constitute one set of influences on house- during several stages; that interventions in one hold behaviours. Yet policies that determine the generation can influence outcomes in later genera- availability of health services and the financing of tions; and that clearly identifying the different stages of those services and others — such as food supply, the life cycle facilitates the identification of risks for water, sanitation, and other related commodities and both individuals and families. services — are equally important. Finally, it explicitly Identifying the major risks to good health at recognizes that what happens in the household and each stage of the life cycle allows appropriate community is the most proximate determinant of interventions to be selected. These interventions favourable health outcomes (33). could be implemented either exclusively within the Implicit in this approach to achieving good health sector or, consistent with the modified health outcomes is the recognition that childhood Mosley–Chen framework, through other mechan- mortality, for example, does not depend only on isms for influencing household behaviours (34). The interventions in childhood. The health of mothers notion that interventions throughout the life cycle and fathers, siblings, grandparents, and other house- must be implemented to achieve the maximum hold members also influences the health of children. reduction of deaths occurring in childhood will Similarly, interventions during childhood can have an hopefully promote collaboration within the health important influence on health in adulthood. It is sector and between sectors and help ensure that increasingly recognized that interventions in one available resources are used more efficiently and generation can affect health outcomes in the next. effectively. Ensuring adequate nutrition among girls during A discussion of current approaches to reducing childhood and adolescence, for example, can reduce childhood mortality would not be complete without the incidence of low birth-weight babies, an mentioning the legal dimensions of this effort. The important risk factor for early mortality. Convention on the Rights of the Child, adopted by the In order to account for these multiple and cross- General Assembly of the United Nations in 1989 and cutting influences, and to organize them in a way that subsequently ratified by all but a small number of can be easily translated into health programmes, the countries, explicitly recognizes a child’s right to health World Bank and its partners have participated in the and health services. Article 24 of the convention elaboration of a life cycle approach (Fig. 3). This obligates all ratifying parties to ‘‘pursue full imple- framework, which includes interventions to be mentation of this right and, in particular, [to] take implemented throughout life (and gives special appropriate measures...to diminish infant and child consideration to the reproductive period for women, mortality.’’ Guidance regarding implementation and which includes pregnancy and the start of a new cycle monitoring of the actions called for by the convention has been developed and disseminated (35). Conclusions We have attempted to present briefly the traditions from which child survival efforts have developed, a concise description of some of the more prominent current initiatives and a few of the ideas being proposed for ensuring continued or resumed progress towards reducing childhood mortality. Although many of the technological tools necessary to address the principal biomedical causes of child- hood mortality in developing countries are available, they have been used in a patchy and inequitable fashion: access to health services and to these tools has been restricted for large parts of the population in many countries. It is increasingly recognized that the health of children is integrally related to poverty, and that there is a strong correlation between high mortality and poverty. Perinatal, neonatal, and early childhood mor- tality have become relatively more important in areas where reductions in mortality have already been1242 Bulletin of the World Health Organization, 2000, 78 (10)
  10. 10. The evolution of child health programmes in developing countriessubstantial. More effective technical interventions order for substantial new reductions in mortality toand strategies for implementing them still need to be be made, disease-specific programmes and those thatdeveloped for many of the potentially fatal conditions address the determinants of common causes ofthat occur earlier in life. But technological advances mortality should be designed to complement eachnotwithstanding, an increased emphasis on improv- other. Research into new technologies and into newing health behaviours in households and in commu- ways of influencing household behaviours should benities must occur if sustainable improvement in strongly and effectively managed, and solutions tooutcomes related to children’s health is to be problems of implementation should be disseminated,achieved across all segments of society. Research, widely applied, and evaluated. Strategic approaches,and especially social science research, can contribute such as the Pathway to Survival model, the modifiedto the development of appropriate behavioural Mosley–Chen framework, and the life cycle ap-interventions but only if the close collaboration proach, should be further developed to providebetween the research and the programmatic com- guidance to policy-makers, health service providers,munities can be strengthened. and community leaders. These approaches that are Poverty is an important contributing factor to more community-driven are necessary because thechildhood mortality, and economists and international pattern and trends of childhood mortality havefinancial institutions are beginning to recognize that changed. Although impressive in some places, theadverse health outcomes are an important contributor apparent reductions over the past 20 years sometimesto poverty. Accordingly, it is important that strategies mask the fact that the rate of decline has stalled foraimed at reducing poverty take into account the many people and especially for those who are poor.determinants of poor health outcomes at all stages of Improving children’s survival is an unfinished task,the life cycle. The formulation of policies and but by using innovative multisectoral approaches thatprogrammes that use a broad range of interventions recognize that health outcomes can be influenced inimplemented in an integrated manner can result both ways that have not yet been adequately explored, andin improved health and improved standards of living. especially by moving the centre of attention from the The future of child health programmes in health system to the household, additional gains candeveloping countries depends upon bridging gaps. In be made rapidly and effectively. nResume ´ ´L’evolution des programmes de sante infantile dans les pays en developpement : ´ ´ ´on cesse de cibler les maladies pour cibler les gensAu cours des 30 dernieres annees, les taux de mortalite ` ´ ´ subsaharienne et en Asie du Sud-Est, comprometchez les nourrissons et les enfants ont baisse dans ´ serieusement la poursuite des progres. ´ `presque tous les pays. En outre, le nombre de deces ´ ` Le present article examine les tendances observees ´ ´d’enfants est passe d’environ 15 millions a environ ´ ` dans les programmes visant a promouvoir la sante des ` ´11 millions, malgre une augmentation du nombre des ´ enfants au cours des dernieres decennies et avance des ` ´naissances, une resistance croissante aux antibiotiques ´ propositions sur la meilleure facon de concevoir les ¸et antipaludiques courants et la propagation – difficile a ` programmes futurs. Il passe en revue les differentes ´enrayer – du syndrome d’immunodeficience acquise ´ approches adoptees dans le passe : les initiatives a court ´ ´ `(SIDA) dans une grande partie du monde. Plusieurs terme et a objectifs etroits, dirigees contre des maladies ` ´ ´maladies et problemes de sante, dont les infections ` ´ determinees, comme les premieres campagnes d’eradi- ´ ´ ` ´respiratoires aigues, les maladies diarrheiques, le ¨ ´ cation du paludisme (un echec) et de la variole (un ´paludisme, la rougeole et la malnutrition, ont toujours succes), et les strategies de grande envergure, axees sur ` ´ ´ete les principales causes d’une mortalite infantile ´ ´ ´ le developpement a long terme et sur les communautes, ´ ` ´elevee, bien qu’il existe contre chacun d’eux des ´ ´ comme les soins de sante primaires. Les programmes ´interventions sans danger et efficaces. modernes d’eradication de maladies telles que la ´ Nul ne peut garantir que les progres continueront. ` poliomye lite et la dracunculose et les strate gies ´ ´D’abord, les succes enregistres a ce jour n’ont pas ete ` ´ ` ´ ´ « selectives » de soins de sante primaires, comme le ´ ´uniformes. Beaucoup de pays pauvres et de regions ´ programme de prise en charge integree des maladies de ´ ´pauvres de nombreux pays n’ont pas obtenu les memes ˆ l’enfant, essaient de combiner des elements de chacune ´ ´resultats que les pays prosperes. Ensuite, a mesure que ´ ` ` de ces demarches. ´les taux de mortalite baissent, differentes affections ´ ´ Le role traditionnellement preponderant des ˆ ´ ´jouent un role plus determinant : les maladies peri- ˆ ´ ´ programmes de sante infantile semble s’amenuiser. Cela ´natales et neonatales, contre lesquelles des interventions ´ peut s’expliquer, entre autres, par le fait que leappropriees pouvant etre appliquees sur une grande ´ ˆ ´ mouvement de reforme du secteur de la sante s’est ´ ´echelle n’ont pas encore ete mises au point, sont ´ ´ ´ davantage preoccupe de considerations administratives ´ ´ ´desormais la cause d’une proportion plus elevee de deces ´ ´ ´ ´ ` et financieres que des programmes techniques ou `chez les enfants de moins de cinq ans. Les questions ensembles de programmes. La de centralisation a ´sexospecifiques doivent aussi etre abordees et la ´ ˆ ´ entraıˆne dans de nombreux pays une deterioration des ´ ´ ´propagation continue du SIDA, notamment en Afrique fonctions d’appui aux systemes de sante, telles que la ` ´Bulletin of the World Health Organization, 2000, 78 (10) 1243
  11. 11. Special Theme — Child Mortality formation et l’encadrement du personnel et le suivi et Quatre modeles sont examines. Le guide de la ` ´ l’evaluation des programmes. Toutefois, les strategies ´ ´ survie et une adaptation du cadre de Mosley-Chen techniques, comme celles qui sont appliquees dans le ´ illustrent la relation entre la communaute et le systeme ´ ` cadre des programmes de vaccination et des initiatives de sante, mais sous un angle different. La nouvelle ´ ´ de prise en charge des cas, continuent de s’affiner pour approche du cycle biologique decrit au moyen de ´ ameliorer la prestation des services, renforcer les ´ graphiques comment la sante de l’enfant depend des ´ ´ systemes de sante et, par-dessus tout, favoriser la ` ´ risques et des interventions sanitaires a des ages ` ˆ participation communautaire. differents et des influences entre generations. Enfin, il ´ ´ ´ L’accent est mis de sormais sur la relation ´ est fait mention de la Convention relative aux droits de bidirectionnelle entre la pauvrete et la sante. De grandes ´ ´ l’enfant, et notamment du droit a la sante et aux services ` ´ inegalites en matiere de sante existent entre riches et ´ ´ ` ´ de sante. ´ pauvres, entre pays, au sein des pays et au sein des Bien que l’on dispose dans une large mesure des communaute s. A l’avenir, il peut e tre important ´ ˆ outils technologiques permettant de reduire davantage ´ d’accorder plus d’attention aux menages et aux familles ´ la mortalite infantile, les strategies de mise en œuvre ´ ´ dans lesquels, a cause de la pauvrete ou d’autres ` ´ doivent s’adapter au contexte local. La recherche en facteurs, les enfants sont davantage exposes au risque de ´ sciences sociales, qui vise a trouver des moyens ` mourir. Le message essentiel contenu dans cet article est d’atteindre les communautes et les familles a haut ´ ` que la reduction de la mortalite infanto-juvenile pourrait ´ ´ ´ risque, en particulier celles dont l’acces aux services de ` bien dependre davantage de ce qui se passe dans les ´ sante est entrave par la pauvrete, devient de plus en plus ´ ´ ´ communautes et les menages que de ce qui se passe a ´ ´ ` importante. l’interieur d’un systeme de sante. ´ ` ´ Resumen La evolucion de los programas de salud infantil en los paıses en desarrollo: el punto ´ ´ de mira se desplaza de las enfermedades a las personas Durante los 30 ultimos anos, las tasas de mortalidad de ´ ˜ pasado, a saber: iniciativas a corto plazo y con objetivos lactantes y ninos han disminuido en casi todos los paı´ses. ˜ muy concretos contra enfermedades especı´ficas, como Ademas, el numero de defunciones infantiles ha ´ ´ las primeras iniciativas de erradicacion del paludismo (un ´ descendido de unos 15 millones a cerca de 11 millones fracaso) y de la viruela (un exito), y estrategias amplias, a ´ a pesar del aumento del numero de nacimientos, de ´ largo plazo, de desarrollo, orientadas hacia la comuni- la resistencia creciente a antibioticos y antipaludicos ´ ´ dad, como la de atencion primaria de salud. Los ´ comunes y de la propagacion relativamente incontrolada ´ programas modernos de erradicacion de enfermedades ´ del SIDA en gran parte del mundo. Un numero limitado ´ como la poliomielitis y la dracunculosis y las estrategias de afecciones medicas, como las infecciones respiratorias ´ «selectivas» de atencion primaria, como la de lucha ´ agudas, las enfermedades diarreicas, el paludismo, el integrada contra las enfermedades de la infancia, tratan sarampion y la malnutricion, han constituido sistemati- ´ ´ ´ de combinar diversos elementos de cada uno de esos camente las principales causas de mortalidad infantil enfoques. pese a que existen intervenciones seguras y eficaces La importante funcion que han desempenado ´ ˜ contra cada una de ellas. tradicionalmente los programas de salud infantil parece El progreso continuo no esta asegurado. Primero, ´ estar disminuyendo. Una de las razones podrı´a ser que el hasta la fecha el exito no ha sido uniforme. Muchos ´ impulso hacia la reforma del sector de la salud se ha paı´ses pobres, y zonas pobres de muchos paı´ses, no han centrado mas en consideraciones administrativas y ´ conseguido resultados tan buenos como los mas ricos. ´ financieras que en programas o conjuntos de programas Ademas, a medida que disminuyen las tasas de ´ tecnicos. La descentralizacion ha dado lugar en muchos ´ ´ mortalidad, otras afecciones adquieren mas importancia; ´ paı´ses a un deterioro de las funciones de apoyo a los la mortalidad perinatal y neonatal, para la cual todavı´a sistemas, como la capacitacion, la supervision y la ´ ´ no se han desarrollado intervenciones que puedan vigilancia y la evaluacion de los programas. Sin embargo, ´ implantarse de forma generalizada, contribuye aun mas ´ ´ las estrategias tecnicas, como las de los programas de ´ que antes al numero de defunciones de menores de ´ vacunacion y las iniciativas de gestion de casos, siguen ´ ´ 5 anos. Tambien es necesario abordar las cuestiones ˜ ´ evolucionando para mejorar la prestacion de servicios, ´ relacionadas con la paridad entre los sexos, y la fortalecer los sistemas de salud y, lo que es mas ´ propagacio n continua del sı´ ndrome de inmuno- ´ importante, promover la participacion comunitaria. ´ deficiencia adquirida (SIDA), especialmente en el Africa´ Se destaca la relacionbidireccional entre la pobreza y ´ subsahariana y en Asia Sudoriental, amenaza seriamente la salud. Existen grandes desigualdades de salud entre ricos la continuidad de los progresos. y pobres, entre los paı´ses, dentro de los paı´ses y dentro de En este artı´culo se examinan las tendencias de los las comunidades. En el futuro quiza sea importante dirigir ´ programas de promocion de la salud de los ninos en los ´ ˜ los esfuerzos hacia los hogares y familias en los que, debido ultimos decenios y se formulan sugerencias sobre la ´ a la pobreza u otros factores, los ninos corren mayor peligro ˜ mejor manera de disenar programas en el futuro. Se ˜ de morir. El mensaje clave de este artı´culo es que los futuros analizan los diferentes enfoques adoptados en el avances en la reduccion de la mortalidad de lactantes y ´1244 Bulletin of the World Health Organization, 2000, 78 (10)
  12. 12. The evolution of child health programmes in developing countriesninos bien pueden depender de lo que suceda en las ˜ la Convencion sobre los Derechos del Nino, que reconoce ´ ˜comunidades y los hogares, y no tanto de lo que suceda en el derecho a la salud y a servicios de salud.el sistema de salud. Aunque en gran medida se dispone de herra- Se examinan cuatro modelos. El modelo «La Vı´a mientas tecnologicas para seguir reduciendo la morta- ´de la Supervivencia» y una adaptacion del marco de ´ lidad infantil, es necesario adaptar las estrategias deMosley-Chen muestran la relacion entre la comunidad y ´ aplicacion a los contextos locales. Las investigaciones ´el sistema de salud, pero de forma diferente. 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