Survival & Health Care for Newborns, Moms, Children

from The Nepal Monitor

UNICEF's annual State of the World's Children is out. This year, it focues on child survival and primary health care. Nepal offers some hope in vitamin A programms.

The following is the executive summary of the "The State of the World's Children 2008" report by UNICEF. Key facts on Nepal are highlighted below:

-= Nepal's under-5 mortality rate in 2006 is ranked 63, up from 54 in 2005. Under-5 mortality rate in 2006 is 59, down from 74 in 2005.

-= The annual child deaths rates in Nepal were reduced by 50 per cent or more since 1990, although under-five mortality rates in these countries remain high.

-= Nepal is among the 7 of some 60 countries (identified in 2005 as accounting for 93 per cent of all deaths of children under five) on track to meet the UN Millennium Development Goal (MDG).

-= In Nepal around 50 percent of women respondents reported that husbands alone make decisions about women’s health care

-= Nepal’s national vitamin A programme is found to be highly cost-effective, with a cost per death averted estimated at US$327–$397, while the cost per disability-adjusted life year (DALY) gained was approximately US$11–$12. In Nepal the national vitamin A campaign has trained community volunteers to build their capacities, creating a respected and credible cadre.

-= Community health workers have been particularly effective in improving child survival outcomes at project level in countries like Nepal and Ecuador, Ethiopia, Colombia, etc.

-= Sustained investment in both time and resources is required over many years to steadily take programmes to scale. Nepal’s long-standing campaigns on micronutrient supplementation is one such example.

The State of the World’s Children 2008 provides a wide-ranging assessment of the current state of child survival and primary health care for mothers, newborns and children. These issues lie at the heart of human progress, serving as sensitive barometers of a country’s development and wellbeing and as telling evidence of its priorities and values. Investing in the health of children and their mothers is not only a human rights imperative, it is also a sound economic decision and one of the surest ways for a country to set its course towards a better future.

UNICEF is calling for concerted action to reach the millions of children still excluded from health interventions. Reducing child mortality requires the achievement of the health-related Millennium Development Goals (MDGs)– especially reducing poverty and hunger (MDG 1), improving maternal health (MDG 5), combating HIV and AIDS, malaria and other major diseases (MDG 6) and improving water and sanitation (MDG 7). Attaining MDG 4 – which requires a two-thirds reduction in the under-five mortality rate between 1990 and 2015 – is still possible, but the challenge is formidable: Reaching the target implies lowering the number of under-five deaths from 9.7 million in 2006 to less than 5 million by 2015. It is clear that meeting all of these goals will require political will, resources and sound strategies on an unprecedented scale.

Much of our efforts will focus on sub-Saharan Africa, which accounts for almost half of all child deaths, and West and Central Africa in particular, where little progress has been made in reducing the aggregate under-five mortality rate since 1990. Attention must also be given to South Asia, which has the second highest number of child deaths, and to countries and communities elsewhere that currently lack essential services.

The lessons learned on child health during recent decades should inform the way forward. The State of the World’s Children 2008 examines these lessons and highlights the most important emerging precepts, including:

• The need to focus on the countries and communities where child mortality rates and levels are highest, and on those that are most at risk of missing out on essential primary health care.
• The merits of packaging essential services together to improve the coverage and efficacy of interventions.
• The vital importance of community partnerships in actively engaging community members as health workers and mobilizing the community in support of improved health practices.
• The imperative of providing a continuum of care across the life cycle, linking households and communities with outreach and extension services and facility-based care.
• The benefits of a strategic, results-oriented approach to health-system development with maternal, newborn and child care as a central part.
• The crucial role of political commitment, national and international leadership and sustained financing in strengthening health systems.
• The necessity for greater harmonization of global health programmes and partnerships.

In order to achieve these objectives the key decision makers –governments and communities, donors and international agencies, non-governmental organizations and private sector collaborators – will need to unite their actions and partnerships in support of maternal and child survival and health. Working together, we can ensure that mothers, newborns and children receive quality essential services, improve their health and nutritional status, and place the survival of children at the heart of global efforts to advance humanity.

1. Child survival: Where we stand
Over the past century there have been marked advances in improving the quality and reach of primary health care, reducing deaths among children under five and improving their health and nutritional status. In 1960, roughly 20 million newborns did not live to see their fifth birthday; by 2006, the most recent year for which firm estimates are available, the annual number of child deaths globally fell below 10 million, to 9.7 million, for the first time since records began.

Concerted efforts on the part of governments, donors, international agencies and health professionals have led to the eradication of smallpox and marked reductions in other major diseases such as measles and polio. Increased emphasis on ensuring that children are adequately nourished has resulted in sharp reductions of undernutrition in many countries. Improved water, sanitation and hygiene practices have helped reduce the incidence of diarrhoeal diseases.

In recent years, significant advances in providing essential services and promoting healthy practices and behaviours give the grounds for optimism. For example, coverage of children aged 6–59 months with at least one dose of vitamin A supplementation per year has risen by 50 per cent since 1999. Increased coverage of measles vaccination and follow-up campaigns contributed to a 60 per cent fall in global measles deaths and a 75 per cent reduction in sub-Saharan Africa between 1999 and 2005. Exclusive breastfeeding has risen notably in many
sub-Saharan African countries over the past 10 years.

In addition, there have been noteworthy advances in efforts to prevent mother-to-child transmission of HIV; provide paediatric treatment of AIDS; prevent and treat malaria through expanded coverage of insecticide-treated mosquito nets and adoption of artemisinin-based combination therapy; and increase household consumption of iodized salt, among other interventions. Such measures are proven, effective and affordable. The challenge is to scale up coverage rates of these and other essential interventions even further, especially in those countries – notably in sub-Saharan Africa and in South Asia –and communities where provision is still limited.

There has been less progress in increasing coverage rates for effective treatments against childhood illness. Although pneumonia kills more children worldwide than any other single cause – accounting for almost 20 per cent of all deaths among children under age five – only 56 per cent of the children who suffer from suspected pneumonia are taken to appropriate health-care providers. Only about 1 in every 4 caregivers knows the key symptoms of pneumonia in children: rapid or difficult breathing. Diarrhoeal diseases account for almost 2 million deaths a year among children under five, and though coverage of the recommended treatment – oral rehydration therapy or increased fluids with continued feeding – increased significantly between 1995 and 2005, only around one third of children in the developing world with this condition receive the appropriate treatment. Tackling undernutrition remains a key concern, as this condition is associated with up to 50 per cent of child deaths.

Another challenge is to scale up the provision of essential services to mothers and children during pregnancy and delivery, in the postnatal period and into early childhood. Across developing countries and territories, 1 in every 4 pregnant women receives no antenatal care, and more than 40 per cent give birth without the assistance of a skilled attendant. Almost 40 per cent of all under-five deaths occur during the neonatal period, the first 28 days of life, from a variety of complications.

On balance, therefore, and despite many achievements, the problem of child mortality is no less poignant today than it was 25 years ago when the ‘child survival revolution’ was launched by the United Nations Children’s Fund. Every day, on average, more than 26,000 children under age five die around the world, mostly from preventable causes. Nearly all of them live in the developing regions or, more precisely, in 60 developing countries. Although half of the world’s regions are on track to meet MDG 4 (see page 7), many countries have fallen behind and will need to accelerate progress considerably to meet the goal.

Achieving MDG 4 at the global level will require greater efforts on multiple fronts, including meeting the other health-related MDGs through scaling up quality primary-health-care services. It will also necessitate a re-examination of strategies to reach the poorest, most marginalized communities.

The remarkable advances in reducing child deaths achieved by many developing countries during recent decades provide reason for optimism. The causes of and solutions to child deaths are well known and accepted. Simple, reliable and affordable interventions with the potential to save two thirds of the children currently at risk are readily available. The challenge is to ensure that these remedies – along with quality primary health services and a continuum of maternal, newborn and child health care – reach the millions of children and families who, so far, have been passed by.

2. Lessons learned from evolving health-care systems and practices
An examination of different approaches to the delivery of essential services from the beginning of the 20th century to the present demonstrates that a range of effective interventions and policies holds the most potential for accelerated progress. These span from initiatives targeted towards a single disease or condition, such as malaria or undernutrition, to the ideal of providing a continuum of comprehensive primary-health-care services that integrate hospital and clinical facilities, outpatient and outreach services, and household and community-based care.

Disease control: Efforts to control specific diseases began early in the 20th century and escalated markedly in the 1950s, 1960s and 1970s with the advent of ‘mass campaigns’ focusing on the reduction or eradication of a specific disease using a particular technology. The success of several of these ‘vertical’ mass campaigns, particularly smallpox, paved the way for the design of possibly the most successful public health programme in history: the Expanded Programme on Immunization, launched in 1974. Efforts to control specific diseases such as measles are still in operation today and are continuing to register notable gains.

Comprehensive primary health care: Successful innovations in community health in countries as diverse as China, Indonesia and Nigeria developed after World War II showed the potential for delivering a range of health-care services beyond those targeted towards specific diseases. The comprehensive primary-health-care approach, consolidated at a landmark International Conference in Alma-Ata in 1978, broadened the concept of health-care provision beyond the control of specific diseases to include the tenets of community involvement, equity, health promotion, integrated approaches to health-service delivery and intersectoral collaboration. These and other primary-health-care precepts have become guiding principles
in the development of health systems during recent decades.

Selective primary health care: Economic constraints and other factors impeded implementation of the primary-health-care approach during the 1980s. An alternative framework, selective primary health care, focused on a defined subset of key diseases and conditions and addressed them by employing relatively inexpensive medical technologies to reach specific objectives. Selective primary health care received strong donor support, and the ‘child survival revolution’ spearheaded by UNICEF in 1982 was based on this framework. It focused on four low-cost interventions collectively referred to as GOBI – growth monitoring for undernutrition, oral rehydration therapy to treat childhood diarrhoea, breastfeeding to ensure the health of young children and immunization against six deadly childhood diseases. GOBI, together with the Expanded Programme on Immunization and programmes to control diarrhoeal diseases and acute respiratory infections led by the World Health Organization, made an undeniable contribution to reducing child deaths in the 1980s.

Integrated approaches: The 1990s and the early years of the current decade have seen a renewed focus on integrated approaches to health-service delivery, which seek to combine a strong emphasis on cost-effective solutions to address specific health challenges with community participation, intersectoral collaboration and incorporation into general health-system delivery. One such approach included the Bamako Initiative, sponsored by UNICEF and WHO and adopted by African ministers of health in 1987, which sought to deliver integrated
minimum health-care packages through health centres, with a firm emphasis on community partnerships and providing access to drugs.

The dominant framework for integration is the Integrated Management of Childhood Illness (IMCI), which adopts a broad, cross-cutting approach to case management of childhood illness. IMCI strategies, which aim to improve health worker performance, strengthen health systems and enhance community and family practices, have been adopted by more than 100 countries since their introduction in 1992.

A more recent example of an integrated approach is the Accelerated Child Survival and Development initiative. Initiated in 2001 by the Canadian International Development Agency, UNICEF and national governments in West and Central Africa, it now covers more than 16 million people in 11 countries that have high rates of under-five mortality. Accelerated Child Survival and Development concentrates on community-based promotion of family health, nutrition and hygiene practices; outreach efforts and campaigns to provide essential services and products; and facility-based delivery of an integrated minimum-care package. It builds on the strengths of existing approaches, such as the ‘plus’ programmes for Antenatal Care, the Expanded Programme on Immunization and the Integrated Management of Childhood Illness.

Towards a unified framework: Distilling the lessons of the past century, experts in maternal, newborn and child health are increasingly coalescing around a set of strategic principles:
• A renewed recognition of the principles of primary health care, which emphasize the primacy of family and community partnership in the survival, growth and development
of children.
• The ‘health systems development for outcomes’ approach to health-service delivery, which combines the strengths of selective/vertical and comprehensive/horizontal approaches
through scaling up cost-effective intervention packages and integrating them into a continuum of care for mothers and children. This approach defies the long-standing dichotomy
between vertical approaches to achieve specific outcomes and integrated approaches to strengthen systems and improve general health, arguing that both aims can be realized by adapting health systems to achieve results.
• Enhanced ways of working at the national and international levels, with a strong focus on coordination, harmonization and results – most prominently, the achievement of the health-related Millennium Development Goals. One overarching principle that has emerged from the review of a century of approaches to health-service delivery is that no single approach is applicable in all circumstances. The organization, delivery and intervention orientation of health-care services must be tailored to meet the constraints of human and financial resources, socioeconomic context, existing capacity of the health system and urgency of achieving results. A focus on results requires strategies that build on the collective knowledge of maternal, newborn and child survival and health in order to identify the solutions that work best for each country and community.

3. Community partnerships in primary health care for mothers, newborns and children
Reaching the health-related Millennium Development Goals will necessitate strengthening health systems at all levels –facility-based services, formal public health programmes and community partnerships. A growing body of evidence shows that improved health practices in the community and household, combined with opportunities for health-system referrals, can have a powerful impact on reducing under-five mortality. As a result, integrated health systems and community-based primary health care are once again receiving greater attention and emphasis in national policies and international health partnerships and programmes.

Community partnerships and participation show great potential to improve health, nutrition and environmental conditions, especially in countries with low health-system capacity, and particularly for the most marginalized and the poorest populations. Experience shows that successful community partnerships are based on several common factors:
• Cohesive and inclusive community organization and participation: Programmes that build on established structures within a community, are socially inclusive and include community members in the planning and evaluation as well implementation are among the most successful in developing countries.
• Support and incentives for community health workers: Community health workers, the main agents of community-based treatment, education and counselling, require incentives and support to prevent attrition, meet their obligations and sustain motivation.
• Adequate programme supervision and support: Supervision is required to sustain community members’ interest and motivation and lower the risk of attrition. Other important types of support include logistics, supplies and equipment.
• Effective referral systems to facility-based care: Hospitals and clinics are essential complements to successful community partnerships, providing services that cannot be safely replicated elsewhere, such as emergency obstetric care. District health systems also serve as a focal point for public health programme coordination.
• Cooperation and coordination with other programmes and sectors: An integrated approach to maternal, newborn and child health necessitates collaborative action between programmes and sectors addressing health, nutrition, hygiene, major diseases and food security, as well as intersectoral collaboration to address transportation infrastructure and access to water and sanitation facilities.
• Secure financing: To be successful over the longer term, financing for community partnerships should address considerations of sustainability and equity, including such issues as cost-sharing and financial incentives for community health workers.
• Integration with district and national programmes and policies: Consultative multi-stakeholder processes are needed to develop strategies and ensure that maternal and child survival feature prominently in national and decentralized plans and budgets, with clear goals and concrete benchmarks. Many countries, including some of the poorest in the world, have implemented successful community-based health programmes. The large-scale community health worker initiatives undertaken in Bangladesh (BRAC), India (Jamkhed and others) and Pakistan (Lady Health Workers) have all been led by local organizations – often women’s groups. These groups build on the established structures within communities that extend to other areas of development, including education and credit as well as health.

In the Philippines, the success of health workers at the barangay level, the smallest political unit in the country, has been encouraged by the Barangay Health Workers’ Benefits and Incentives Act of 1995, which includes such provisions as subsistence allowances, career enrichment, special training programmes and preferential access to loans. Through cooperation and coordination with other programmes, organizations have shared best practices from around the world. The ‘Care Group’ approach to reducing under-five mortality, for example, trains community educators through group interaction, and its methods are being used successfully in Cambodia, Malawi, Mozambique and Rwanda.

There are numerous examples of succesful community partnerships in primary health care for mothers and children in Central and Eastern Europe and the Commenwealth of Independent States, East Asia and Pacific, Latin America and the Caribbean, Middle East and North Africa, South Asia, and, increasingly, in Sub-Saharan Africa. The challenge is now to learn from these experiences, take the programmes to scale and reach the millions of children whom the health system, so far, has passed by.

Scaling up essential health-care interventions and approaches requires a comprehensive understanding of both the strategies that accelerate progress and the challenges that hinder it. A health worker weighs a baby for growth monitoring, the Philippines.

4. Strengthening community partnerships, the continuum of care, and health systems
Accelerating progress on child survival will require applying the lessons learned from a century of health-sector development and taking effective approaches to strengthen community partnerships, the continuum of care and health systems. Based on the joint framework developed by leading international agencies, including the World Bank, the World Health Organization and UNICEF, The State of the World’s Children 2008 has identified five distinct yet related actions to building up health systems across developing countries and territories through programmes, policies and partnerships during the coming decade.

Action I: Realign programmes from disease-specific interventions to evidence-based, high-impact, integrated intervention packages to ensure a continuum of care. This involves specifying intervention packages, establishing benchmarks and targets for coverage and delivery, and providing a mix of services by the three key delivery modes: family-oriented, community-based services with periodic oversight from skilled professionals; population-oriented scheduled services provided by skilled or semi-skilled health staff; and individually oriented clinical services requiring health workers with advanced skills.

Action II: Make maternal and child health a central tenet of integrated national planning processes for scaling up essential services. Key measures required in national strategic plans to scale up the packaged interventions include: identifying and removing health-system bottlenecks; monitoring progress and problems in coverage; phasing in intervention packages and health-system strengthening; addressing the human resource crisis in health care in many developing countries; establishing a results-oriented approach for health-system development; and strengthening district health systems.

Action III: Improve the quality and consistency of financing for health-system strengthening. A consensus is emerging on five principles for financing plans to scale up health systems: using ‘compacts’ to reward performance in a sustainable way; aligning development assistance to country systems; promoting results-based financing; establishing benchmarks and outcome indicators for health-system development; and developing innovative and equitable financing strategies.

Action IV: Obtain national political commitment. Time and again it has been shown that when governments take the lead and are committed to expanding pilot and small-scale projects, these initiatives can rapidly gain nationwide coverage. Brazil’s community health worker programme and the Bolsa Familia initiative; Mexico’s health, nutrition and education programme, PROGRESA, and Seguro Popular de Salud health insurance scheme; Indonesia’s community health workers; Egypt’s oral rehydration initiatives; and Ethiopia’s Health Extension Program are just some examples that show the potential for scale-up when governments are willing to commit even scarce funding to health and social welfare programmes. In addition to increasing funding for human resources dedicated to primary health care, governments must be committed to sustaining and creating the required technical and administrative capacity.

Action V: Create conditions for greater harmonization of global health programmes and partnerships. The rapid proliferation of new programmes and partnerships in health is proving to be challenging for developing countries to keep track of, let alone manage and coordinate. The OECD Development Assistance Committee has produced a ‘Good Practice Guidance for aligning global programs at the country level’. This guidance aims to enhance governance and implementation of global programmes and partnerships in order to improve country ownership, harmonization and alignment, and to promote mutual accountability for the health of children and mothers.

For governments, donors, international agencies and global health partnerships effective scale-up will require a new way of working in primary health care among the key stakeholders. The central theme of this paradigm is unity. Initiatives and partnerships directed towards improving aspects of maternal and child health abound and continue to proliferate, but they will require greater coherence and harmonization to meet the health-related Millennium Development Goals for mothers and children.

Meeting the health-related MDGs will require unified actions and partnerships in support of maternal, newborn and child survival and health. Children wait in line at a vaccination site, Bangladesh.

5. Uniting for child survival
The Millennium Development Goals are not a series of utopian targets but the product of tough thinking and hard calculations by some of the world’s leading politicians, development specialists, economists and scientists, and they currently represent our best hope to accelerate human progress.

Achieving the goals will mean that the lives of around 30 million children and 2 million mothers will have been spared between 2005 and 2015. It will result in hundreds of millions of children, men and women being relieved of hunger, utilizing safe water and basic sanitation, obtaining an education, and enjoying the same economic advantages and political
opportunities that are available to others.

Although several regions and countries are lagging, the targets are all reachable in time if the political will, necessary resources and required strategies are put in place. Six pivotal actions urgently need a unified response:
• Create a supportive environment for maternal, newborn and child survival and health by ensuring that health systems and programmes are rights based – and by supporting peace, security, child protection, non-discrimination, gender equality and the empowerment of women.
• Develop and strengthen the continuum of care across time and location. The continuum must deliver essential services at key points during the life cycle of mothers and children. Strong links are also required between the household, the community, and quality outreach and clinical services at primary health facilities and district hospitals.
• Scale up packages of essential services by strengthening health systems and community partnerships through initiatives to train health workers, extend outreach services, overcome bottlenecks and exploit new technologies.
• Expand the data, research and evidence base. Although the evidence base on maternal and child health is being provided by a rich array of resources, there is still a demand for more rigorous data collection and dissemination, research and evaluation.
• Leverage resources for mothers, newborns and children. Donor assistance is rising, but not fast enough to meet the goals. National governments must also fulfil promises to boost health spending.
• Make maternal, newborn and child survival a global imperative. Accelerating progress will necessitate positioning these objectives at the heart of the international agenda in the run-up to the 2015 deadline for the Millennium Development Goals. The challenge is to build on the progress achieved across the developing world, particularly during recent years, in preventive interventions delivered by outreach services. The basis for action – data, research, evaluation – is already well established. The frameworks – community partnerships, the continuum of care and health-system strengthening for outcomes – are well defined. In effect, the means are in our hands. It is now a question of will and action, and there is no enterprise more noble or reward more precious than saving the life of a child.