The Drum Beat 224 - Child Survival

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"Child survival is the most pressing moral dilemma of the new millennium". Motivated by that belief, a group of global child health experts met several times in 2003 to figure out how to galvanise available effective low-cost interventions to prevent children's deaths. This process of dialogue culminated in a 6-day February 2003 workshop in Bellagio, Italy that was sponsored by the Rockefeller Foundation and arranged by The Lancet.

On the basis of these meetings, the Bellagio Child Survival Study Group (hereafter, BCSSG) produced a series of 5 articles. These articles explore the causes of child deaths, evaluate current levels of intervention coverage, question current global health strategies, address inequalities in child health, and urge shifts in policy and funding at country and global levels. The papers are preceded by an editorial by The Lancet.

This issue of the Drum Beat focuses on the content of these articles as a context and foundation for communicators addressing child survival.

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THE ARTICLES

From The Lancet - click here for website.

Summarised and reprinted with permission from Elsevier.

1. The world's forgotten children

2. Where and why are 10 million children dying every year?

3. How many child deaths can we prevent this year?

4. Reducing child mortality: can public health deliver?

5. Applying an equity lens to child health and mortality: more of the same is not enough

6. Knowledge into action for child survival

THE SCOPE

"...while the world's attention has understandably been focused on the growing HIV/AIDS pandemic and the resurgence of such diseases as tuberculosis and malaria, progress in reducing child mortality has in many of the world's poorest countries slowed, stopped, and in some cases reversed".

• In 2003, 10.8 million children will die before they reach the age of 5.
• Roughly 6 million of them will die of diseases that "could have easily been prevented or treated".
  
  • 2 million will die from diarrhoea, which is usually treatable with simple oral rehydration therapy.
  • Pneumonia - for which antibiotics are available - will claim the lives of an additional 2.1 million.
  • Another 1 million will die from malaria, which can be prevented by insecticide-treated bed nets or treated with anti-malarials.
  • Hundreds of thousands will die from measles, a disease for which there is a cheap, effective vaccine.
• Worldwide, 26% of children under the age of 2 do not receive diphtheria, pertussis, and tetanus immunisation; 28% do not receive oral rehydration therapy; 40% do not receive antibiotic treatment for pneumonia; 58% are not breastfed exclusively during the first 4 months of life; 52% do not receive vitamin A supplementation; 32% do not have access to iodised salt; and 25% are malnourished (contributing to 60% of child deaths).
• In 2000, the average worldwide child morality rate was 67 deaths per 1000 live births. However, in Africa the average rate was 150 deaths per 1000 live births, a rate 8 times that of Europe. In Burundi, Lesotho, Madagascar, Mauritania, Nigeria, Sierra Leone, and Tanzania, there has been little or no change in child mortality rates over the past 50 years.

[from: The world's forgotten children]

"6 countries account for 50% of worldwide deaths in children younger than 5 years, and 42 countries for 90%. The causes of death differ substantially from one country to another, highlighting the need to expand understanding of child health epidemiology at a country level rather than in geopolitical regions. Other key issues include the importance of undernutrition as an underlying cause of child deaths associated with infectious diseases, the effects of multiple concurrent illnesses, and recognition that pneumonia and diarrhoea remain the diseases that are most often associated with child deaths. A better understanding of child health epidemiology could contribute to more effective approaches to saving children's lives."

[from: Where and why are 10 million children dying every year?]

Poor children die earlier. In high-income countries, 6 of every 1000 children die before their 5th birthday; in the developing world, the rate is 88 per 1000; and in the world's poorest countries, the rate is 120 per 1000. Poorer children are exposed to risks for disease in the form of inadequate water and sanitation, indoor air pollution, crowding, poor housing, and high exposure to disease vectors. They are also more likely to have lower resistance to infectious diseases because they are undernourished. Further, their health is compromised by low coverage levels for preventive interventions. Once sick, they are not as likely to be taken to a health care facility; if they are, they are less likely to receive proper care.

[from: Applying an equity lens to child health and mortality: more of the same is not enough]

THE STRATEGIES

Some of the most promising interventions can be delivered at the household level - and with limited need for external materials:

• Breastfeeding and oral rehydration therapy alone are estimated to be able to prevent 13% and 15% of all under-5 deaths, respectively.
• 6 other interventions could each further prevent a significant percentage of under-5 deaths:
  1. insecticide-treated materials: 7%
  2. complementary feeding (providing food in addition to breastmilk): 6%
  3. antibiotics for sepsis: 6%
  4. antibiotics for pneumonia: 6%
  5. antimalarials: 5%
  6. zinc to reduce diarrhoea and pneumonia deaths: 5%

[from: How many child deaths can we prevent this year?]

Integrated management of childhood illness (IMCI) is a delivery strategy adopted by over 100 low-income and middle-income countries by the end of 2002; fewer than half of those countries have moved into the phase of scaling-up to higher levels of coverage. IMCI involves the creation of guidelines meant to help manage the care of a sick child at a first-level health care facility, as well as at household, community, and referral levels. Although "[t]raining of health workers in countries with IMCI implementation has been shown to have positive effects if training includes clinical practice, sufficient facilitators, and use of materials relevant to local culture and language", most evidence suggests that "the effort devoted to implementation has not been sufficient, especially in relation to strengthening health systems and changing key behaviours at the family and community level".

Here are 5 proposed strategies for achieving and maintaining high and equitable coverage:

1. Acquiring local data on epidemiology, health-system capacity, and community preferences - and presenting this data in a useful format for programme planners. (This may require that health managers be trained in data collection and analysis.)
2. Basing community or health-facility interventions on locally-defined key criteria, and combining delivery and technical integration of interventions.
3. Assessing alternative delivery strategies, and building capacity for making strategic decisions at the country level and below.
4. Tailoring supply to meet demand and respond to needs by, for example, fostering coordination between programmes and monitoring the extent to which the population being addressed is really being reached.
5. Strengthening national health systems as a medium- to long-term goal and integrating community-based strategies (such as pre-packed single-dose injection devices) with health-system-based efforts to increase their capacity.

[from: Reducing child mortality: can public health deliver?]

2 strategies for increasing child survival intervention coverage in poor communities include "targeting" (direct or indirect) and rapid, universal coverage. An example of the latter approach is immunising an entire community against infectious disease, without developing ways of ensuring that the poor are vaccinated first. While there is a worry that universal coverage initiatives may lose momentum before reaching poor people, the pitfall of differential service quality is avoided here. The decision of which strategy to pursue must be made, according to BCSSG, on a case-by-case basis.

Poverty-oriented approaches like these are more likely to succeed in settings in which programme managers and policymakers are committed to health as a basic human right. Providing these personnel - along with poor people, NGOs, and health professionals - with accurate information about health inequities, BCSSG suggests, is key. They review 3 ways of communicating this information: measurement of health status and programme use according to socioeconomic status, gender, or ethnic group; establishment and monitoring of health objectives in terms of health status or service use among the poor; and development of tools to track progress among those groups.

BCSSG also urges change at the international level. They say that agencies such as WHO and UNICEF must work to build knowledge and competency among their staff on poverty and equity issues, advise governments on what they can do, and categorise health data according to socioeconomic, gender, and geographic categories (rather than just presenting national averages). Multilateral and bilateral agencies, they urge, must ensure that equity considerations are integral to the design of all new projects, address equity issues in dialogue with countries, and ensure that impact evaluations provide data on equity.

[from: Applying an equity lens to child health and mortality: more of the same is not enough]

THE NEED FOR MORE RESEARCH

BCSSG points to gaps in evidence that demand the following actions:

1. Epidemiology - countries need to seek out and apply available information to programming efforts, while carrying out new data collection and monitoring initiatives.
2. Child survival interventions - existing interventions need to be aggressively applied - and continually assessed - and progress needs to be made on developing interventions not yet available, such as vaccines for pneumonia, diarrhoea, and malaria.
3. Delivery strategies - in order to ensure that interventions begin reaching the children and mothers who need them, country-level programme personnel must conduct in-depth field research and develop monitoring methods (and build the capacity to use them).
4. Inequities - indicators, methods, and guidelines must be developed; capacity must be built in equity measurement and monitoring at all levels.

[from: Knowledge into action for child survival]

THE CALL TO ACTION

The following prerequisites, BCSSG claims, are required in order to transform knowledge into effective action to reduce child mortality:

1. Leadership - at international, national, and subnational levels.
2. Strong (public) health systems "that are capable of defining needs, generating resources, managing programmes and people, delivering cost-effective services, and gathering and using data to improve the effect of their efforts."
3. Adequate and targeted resources (human and financial) - "New ways must be identified to build local capacity, and counteract the brain drain that is depriving low-income and middle-income countries of many of their most capable citizens." Further, mechanisms must be developed to track child survival investments.
4. Awareness and a commitment to action that goes beyond the public health community to mobilise all citizens. Messages should be clear and simple, and should be communicated consistently through all available channels.

For their part, BCSSG pledges to convene a series of meetings every 2 years to provide opportunities for those concerned about child survival to exchange experiences, monitor progress, and ensure accountability.

In conclusion, they state, "We hope readers will respond to this call to action by advocating for change within their institutions, countries, and communities. In addition, we welcome open discussion in a forum established by The Lancet and open to all at The Lancet (debate@lancet.com)."

[from: Knowledge into action for child survival]

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This issue written by Kier Olsen DeVries.

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[For context, please see The Drum Beat #222]

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