chapter SIX redesigning child care: survival, growth and development The knowledge and effective interventions for reducing child mortality are available and technically appropriate to the countries and areas that need them most. This chapter says that what is now needed is to implement them to scale. Over the last half-century there has been a shift in focus from diseases to children, and from health centres alone to a continuum of care that implicates families and communities, health centres, and referral-level hospitals Our understanding of the underlying skills that mothers need to care adequately for their children has grown and changed. As child health programmes continue to move towards integration, we need to move from small-scale projects to universal implementation that will also reach those children we are currently not reaching. Finally, the chapter provides the additional costs of scaling up that will be needed to reach all children with the appropriate interventions and meet the challenge of the Millennium Development Goal IMPROVING THE CHANCES OF SURVIVAL The ambitions of the primary health care movement were vast. To implement its strategy, resources would The ambitions of the primary health care movement have had to be redistributed, health personnel reoriented During the 1970s, socioeconomic development and improved basic and the whole design, planning and management of the living conditions-clean water, sanitation and nutrition-were seen health system overhauled. This was clearly a long-term as the keys to improving child health. The primary health care move- endeavour that would have required a major increase in ment, with its commitment to tackle the underlying social, economic funds being made available to the sector and political causes of poor health, integrated this notion but outlined a strategy which would also respond more equitably, appropriately and The successes of vertical programmes effectively to basic health care needs. Along with intersectoral action The economic situation at the end of the 1970s, however, for health, community involvement and self-reliance, primary health did not allow for such a development. Setting up primary care stood for universal access to care and coverage on the basis of health care systems in a context of shrinking resources need. Much of the primary health care strategy was designed with the was a daunting task. While countries struggled with the health of children as the priority of priorities complexities of long-term socioeconomic development
103 chapter six redesigning child care: survival, growth and development IMPROVING THE CHANCES OF SURVIVAL The ambitions of the primary health care movement During the 1970s, socioeconomic development and improved basic living conditions – clean water, sanitation and nutrition – were seen as the keys to improving child health. The primary health care movement, with its commitment to tackle the underlying social, economic and political causes of poor health, integrated this notion but outlined a strategy which would also respond more equitably, appropriately and effectively to basic health care needs. Along with intersectoral action for health, community involvement and self-reliance, primary health care stood for universal access to care and coverage on the basis of need. Much of the primary health care strategy was designed with the health of children as the priority of priorities. The ambitions of the primary health care movement were vast. To implement its strategy, resources would have had to be redistributed, health personnel reoriented and the whole design, planning and management of the health system overhauled. This was clearly a long-term endeavour that would have required a major increase in funds being made available to the sector. The successes of vertical programmes The economic situation at the end of the 1970s, however, did not allow for such a development. Setting up primary health care systems in a context of shrinking resources was a daunting task. While countries struggled with the complexities of long-term socioeconomic development, The knowledge and effective interventions for reducing child mortality are available and technically appropriate to the countries and areas that need them most. This chapter says that what is now needed is to implement them to scale. Over the last half-century there has been a shift in focus from diseases to children, and from health centres alone to a continuum of care that implicates families and communities, health centres, and referral-level hospitals. Our understanding of the underlying skills that mothers need to care adequately for their children has grown and changed. As child health programmes continue to move towards integration, we need to move from small-scale projects to universal implementation that will also reach those children we are currently not reaching. Finally, the chapter provides the additional costs of scaling up that will be needed to reach all children with the appropriate interventions and meet the challenge of the Millennium Development Goal
104 The World Health Report 2005 child health- and particularly child survival- was such an obvious emergency that pressure for immediate action mounted. Therefore, by the early 1980s, many coun tries shifted their focus from primary health care systems to vertical, " single-issue programmes that promised cheaper and faster results The most visible illustration of this shift was the child survival revolution of the 1980s, spearheaded by the United Nations Children,s Fund(UNICEF), and built around a package of interventions grouped under the acronym GoBi(growth monitoring, oral rehydration therapy for diarrhoea, breastfeeding, and immunization). Donors and ministries of health responded enthusiastically, particularly to initiatives prioritizing immunization and oral rehydration therapy. Many countries set up programmes for this purpose. Like the malaria and smallpox programmes of the 1950s and 1960s, each ne had its own administration and budget and a large amount of autonomy from the conventional health care delivery system These programmes benefited from the support of dedicated programmes within WHO: the Expanded Programme on Immunization of the mid-1970s, and, later, those created to reinforce national programmes for Control of Diarrhoeal Disease and Acute Respiratory Infections. At country level these vertical programmes successfully tackled a number of priority diseases. The Expanded Programme on Immunization started in 1974 and widened the range of vaccines routinely provided, from smallpox, BCG and DTP to include polio and measles. It set out to increase coverage in line with the intemational commitment to achieve the universal child immunization goal of 80% coverage in every country. The 1980s did indeed see a huge increase in coverage(see Figure 2.2 in Chapter 2). In 1988, when the World Health Assembly resolved to eradicate polio, there were some 350 000 cases worldwide; by January 2005 there were only 1185 cases reported Thanks to sustained efforts to promote immunization, deaths from measles decreased by 39% between 1999 and 2003(1); compared to levels in 1980, measles mortality has declined by 80%. Efforts continue to increase coverage and widen the range of vaccines provided. The vaccination schedule is under constant revision as new vaccines become available, for example those against Hepatitis B and Haemophilus fluenzae type b, and, in the near future, rotavirus(diarrhoea) and pneumococcus These vertical programmes used a combination of state-of-the-art management and simple technologies based on solid research. The prototype for this was oral rehydration therapy, the"medical discovery of the century"(2, 3)-a cheap and effective way to tackle mortality from diarrhoea. Widespread introduction of oral rehydration therapy largely contributed to reducing the number of deaths due to diarrhoea from 4.6 million per year in the 1970s to 3. 3 million per year in the 1980s and 1. 8 million in 2000 As mortality from diarrhoea and vaccine-preventable diseases decreased, pneumonia came to the foreground as a cause of death, and in the early 1980s programmes were developed around simplified diagnostic and treatment techniques. In the meantime promotion of breastfeeding continued, backed up by international initiatives such as the International Code of Marketing of Breast-milk Substitutes (adopted by the World Health Assembly in 1981)and the Global Strategy for infant and Young child Feeding(endorsed by the World Health Assembly and by the UNICEF Executive Board in 2002). Advances were made possible by new insights into the optimal duration of exclusive breastfeeding and feeding for babies born to HIv-infected women. Countries idely implemented the Baby-Friendly Hospitals initiative to support promotion of
104 The World Health Report 2005 child health – and particularly child survival – was such an obvious emergency that pressure for immediate action mounted. Therefore, by the early 1980s, many countries shifted their focus from primary health care systems to vertical, “single-issue”, programmes that promised cheaper and faster results. The most visible illustration of this shift was the Child Survival Revolution of the 1980s, spearheaded by the United Nations Children’s Fund (UNICEF), and built around a package of interventions grouped under the acronym GOBI (growth monitoring, oral rehydration therapy for diarrhoea, breastfeeding, and immunization). Donors and ministries of health responded enthusiastically, particularly to initiatives prioritizing immunization and oral rehydration therapy. Many countries set up programmes for this purpose. Like the malaria and smallpox programmes of the 1950s and 1960s, each one had its own administration and budget and a large amount of autonomy from the conventional health care delivery system. These programmes benefited from the support of dedicated programmes within WHO: the Expanded Programme on Immunization of the mid-1970s, and, later, those created to reinforce national programmes for Control of Diarrhoeal Disease and Acute Respiratory Infections. At country level these vertical programmes successfully tackled a number of priority diseases. The Expanded Programme on Immunization started in 1974 and widened the range of vaccines routinely provided, from smallpox, BCG and DTP to include polio and measles. It set out to increase coverage in line with the international commitment to achieve the universal child immunization goal of 80% coverage in every country. The 1980s did indeed see a huge increase in coverage (see Figure 2.2 in Chapter 2). In 1988, when the World Health Assembly resolved to eradicate polio, there were some 350 000 cases worldwide; by January 2005 there were only 1185 cases reported. Thanks to sustained efforts to promote immunization, deaths from measles decreased by 39% between 1999 and 2003 (1); compared to levels in 1980, measles mortality has declined by 80%. Efforts continue to increase coverage and widen the range of vaccines provided. The vaccination schedule is under constant revision as new vaccines become available, for example those against Hepatitis B and Haemophilus influenzae type b, and, in the near future, rotavirus (diarrhoea) and pneumococcus (pneumonia). These vertical programmes used a combination of state-of-the-art management and simple technologies based on solid research. The prototype for this was oral rehydration therapy, the “medical discovery of the century” (2, 3) – a cheap and effective way to tackle mortality from diarrhoea. Widespread introduction of oral rehydration therapy largely contributed to reducing the number of deaths due to diarrhoea from 4.6 million per year in the 1970s to 3.3 million per year in the 1980s and 1.8 million in 2000. As mortality from diarrhoea and vaccine-preventable diseases decreased, pneumonia came to the foreground as a cause of death, and in the early 1980s programmes were developed around simplified diagnostic and treatment techniques. In the meantime promotion of breastfeeding continued, backed up by international initiatives such as the International Code of Marketing of Breast-milk Substitutes (adopted by the World Health Assembly in 1981) and the Global Strategy for Infant and Young Child Feeding (endorsed by the World Health Assembly and by the UNICEF Executive Board in 2002). Advances were made possible by new insights into the optimal duration of exclusive breastfeeding and feeding for babies born to HIV-infected women. Countries widely implemented the Baby-Friendly Hospitals initiative to support promotion of
redesigning child care: survival, growth and development breastfeeding in maternities. In 1990, less than one fifth of mothers gave exclusive breastfeeding for four months; by 2002 that figure had doubled to 38% Some countries had impressive successes with such programmatic approaches, and went beyond the small number of priority programmes that had international attention Tunisia, for example, used the managerial experience gained in its first successful programmes to expand the range of health problems addressed, organizing delivery of these programmes through its network of health centres and hospitals. The country reduced the under-five mortality rate by 50% between 1970 and 1980, 48% between 1980 and 1990 and 46% between 1990 and 2000 TIME FOR A CHANGE OF STRATEGY Combining a wider range of interventions For all their impressive results, the inherent limitations of these vertical approaches soon became apparent. In their daily practice health workers have to deal with a large range of situations and health problems. a feverish and irritable child that has difficulty eating can be suffering from a single illness, such as dysentery, or from a combination of diseases, such as malaria and pneumonia (3-8 ) Single-issue programmes were not designed to provide guidance on how to deal with such situations. There was
redesigning child care: survival, growth and development 105 breastfeeding in maternities. In 1990, less than one fifth of mothers gave exclusive breastfeeding for four months; by 2002 that figure had doubled to 38%. Some countries had impressive successes with such programmatic approaches, and went beyond the small number of priority programmes that had international attention. Tunisia, for example, used the managerial experience gained in its first successful programmes to expand the range of health problems addressed, organizing delivery of these programmes through its network of health centres and hospitals. The country reduced the under-five mortality rate by 50% between 1970 and 1980, 48% between 1980 and 1990 and 46% between 1990 and 2000. TIME FOR A CHANGE OF STRATEGY Combining a wider range of interventions For all their impressive results, the inherent limitations of these vertical approaches soon became apparent. In their daily practice health workers have to deal with a large range of situations and health problems. A feverish and irritable child that has difficulty eating can be suffering from a single illness, such as dysentery, or from a combination of diseases, such as malaria and pneumonia (3–8). Single-issue programmes were not designed to provide guidance on how to deal with such situations. There was In 1988 when the World Health Assembly resolved to eradicate polio, there were some 350 000 cases worldwide; by January 2005 there were only 1185 cases reported. J.M. Giboux/WHO
106 The World Health Report 2005 Box 6.1 What do children die of today? Despite the substantial reductions in the num- ber of deaths observed in recent decades, The causes of death of children under five, 2000-2003 around 10.6 million children still die every year efore reaching their fifth birthday. Alme Under-5 causes of death Neonatal causes of death all of these deaths occur in low-income and middle-income countries. a global picture of Acute respiratory Other what these children die from has emerged during the past few years in a collaborative effort between WHO, UNICEF, and a group of ent technical experts, the Child Heal demology Reference Group(CHE Most deaths among children under five years are still attributable to just a handful of condi ns and are avoidable through existing inter- ventions. Six conditions account for 70 to over 90% of all these deaths These are: acute lower respiratory infections, mostly pneumonia (post-nean (19%), diarrhoea (18%), malaria(8%),measles (4%) HIV/AIDS (3%), and neonatal conditions mainly preterm birth, birth asphyxia, and infec 3% others, including a Totals are more than 100% due to rounding Malnutrition increases the risk of dying from these diseases. Over half of all child death occur in children who are underweight. The relative importance of the various causes of Major causes of death among children under five from diarhoea and many of the vaccine-pre. by WHO region, 2000-2003 ventable diseases. The relative contribution of HIV/AIDS to the total mortality of children under five years of age, especially in sub-Saharan Africa, has been increasing steadily: in 1990 it counted for around 2% of under-five mortal- ty in the African Region, but in 2003 the figur had reached about 6. 5%6 Summarizing data across regions and coun-250 tries masks substantial differences in the distri bution of causes of death. Approximately 90% 240 of all malaria and HIV/AIDS deaths in children, 30 more than 50% of measles deaths and about 40% of pneumonia and diarrhoea deaths are in the African Region. On the other hand, deaths from injuries and noncommunicable diseases ther than congenital anomalies account fo 0 World Africa Americas South-East Europe Eastem Westem 0-30% of under-five deaths in the Region of Mediterranean pacific the Americas and in the European and Western Pacific Regions HIV/AIDS MAlayi □ Diarrhoeal diseases □ Measles noncommunicable diseases Neonatal causes
106 The World Health Report 2005 Despite the substantial reductions in the number of deaths observed in recent decades, around 10.6 million children still die every year before reaching their fifth birthday. Almost all of these deaths occur in low-income and middle-income countries. A global picture of what these children die from has emerged during the past few years in a collaborative effort between WHO, UNICEF, and a group of independent technical experts, the Child Health Epidemiology Reference Group (CHERG). Most deaths among children under five years are still attributable to just a handful of conditions and are avoidable through existing interventions. Six conditions account for 70% to over 90% of all these deaths. These are: acute lower respiratory infections, mostly pneumonia (19%), diarrhoea (18%), malaria (8%), measles (4%), HIV/AIDS (3%), and neonatal conditions, mainly preterm birth, birth asphyxia, and infections (37%). Malnutrition increases the risk of dying from these diseases. Over half of all child deaths occur in children who are underweight. The relative importance of the various causes of death has changed with the decline in mortality from diarrhoea and many of the vaccine-preventable diseases. The relative contribution of HIV/AIDS to the total mortality of children under five years of age, especially in sub-Saharan Africa, has been increasing steadily: in 1990 it accounted for around 2% of under-five mortality in the African Region, but in 2003 the figure had reached about 6.5%. Summarizing data across regions and countries masks substantial differences in the distribution of causes of death. Approximately 90% of all malaria and HIV/AIDS deaths in children, more than 50% of measles deaths and about 40% of pneumonia and diarrhoea deaths are in the African Region. On the other hand, deaths from injuries and noncommunicable diseases other than congenital anomalies account for 20–30% of under-five deaths in the Region of the Americas and in the European and Western Pacific Regions. Box 6.1 What do children die of today? Acute respiratory infections 19% Neonatal causes 37% Injuries 3% Others, including noncommunicable diseases 10% HIV/AIDS 3% Diarrhoeal diseases (post-neonatal) 17% Measles 4% Malaria 8% Other neonatal 7% Neonatal tetanus 7% Severe infections 26% Birth asphyxia Diarrhoeal 23% diseases 3% Congenital anomalies 8% Preterm birth 28% Under-5 causes of death Neonatal causes of death The causes of death of children under five, 2000–2003a % of all under-5 deaths World Injuries Measles 100 Major causes of death among children under five, by WHO region, 2000–2003 Malaria Others, including noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Neonatal causes 0 HIV/AIDS 90 80 70 60 50 40 30 20 10 Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific a Totals are more than 100% due to rounding