child health problems global

7/26/2019 Child Health Problems Global

http://slidepdf.com/reader/full/child-health-problems-global 1/86

Child Health, Part 1:Overview of Problems, Trends,

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Learning Objectives

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F

Why focus on child health?

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See Note A



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Scope of the Problem

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Of course being healthy* means more than merely surviving but as a

starting point for discussion it is hard to avoid the fact that 13 children underthe age of five years die every minute.

* WHO Definition of health "Health is a state of complete physical, mental

and social well-being and not merely the absence of disease or infirmity." [2]



J

Indicators of childhoodmortality

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See Note B



U

U5MR, IMR, NMR: Some differences in theproblem and approaches to tackling the problem

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a

Neonatal care is receiving more attention as greater progress

is made in reducing the burden of disease among olderchildren and as more information is available on the burden ofneonatal disease and interventions that can effectively reduce

this burden.

Most interventions aimed at decreasing neonatal mortality are

linked to prenatal and maternal care interventions. The

interventions that are aimed at reducing childhood mortalitybeyond the neonatal period are typically delivered via public

health programs that we generally think of as more classic

public health delivery methods (e.g. immunization clinics).

U5MR, IMR, NMR: Some differences… (cont.)



A

Reminder -- Morbidity

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V

Millennium Development Goal #4 (MDG4):Reduce Child Mortality

The Millennium Development Goals (MDG) are a set of time-bound targets to

guide countries around the world in a framework for improving health, increasing

development, and reducing poverty. Many of the 8 goals relate to improving thehealth of children—e.g. improving educational opportunities, providing healthenvironments, decreasing poverty and hunger. Recognizing the important role

that child health plays in the overall health of societies, the MDGs include a goal

explicitly aimed at reducing child mortality by two-thirds, between 1990 and 2015.This is MDG #4.



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The world is not on track to meet MDG4

See Note D

Source: (2012). Levels & trends in child mortality report 2012: Estimates developed by the

UN Inter-Agency Group for Child Mortality Estimation. New York, United Nations Children's

Fund.



Slowing trends in improvements in child mortality

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See Note E



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Inequitable distribution of child deaths

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Source: You, D., et al., Levels and trends in under-5 mortality,1990-2008. Lancet, 2009.

See also: http://www.alertnet.org/thenews/newsdesk/

LA609360.htm



EF

Inequitable distribution of child mortality:Under-5 mortality rates in 6 countries

Carl Haub and Diana Cornelius, 2000 World Population DataSheet (Washington, DC: Population Reference Bureau, 2000)



U5MR: Inequities withincountries

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Source: WHO Report 2005: Make Every Mother and Child Count



Causes of Child Mortality



EU

POP QUIZ: What are the leading causes ofchildhood mortality in the U.S.?

Source: WHO 2000-2003 data



Ea

POP QUIZ: What are the leading causes of

childhood mortality in the U.S.?

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Global causes of child mortality

Source: http://www.childinfo.org/mortality.html



EV

Leading causes of child mortality, globally

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Undernutrition isan Important

Underlying Causeof Death

20

Source: USAID Nutrition module

See Note F



Regional variations in proportional mortality rates

Source: Liu L et al. Global, regional, and

national causes of child mortality:

an updated systematic analysis for 2010 with

time trends

since 2000. Lancet 2012; 379: 2151–61



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Causes of death also vary from region to region, country to country (and even

among subnational units). For example, malaria is responsible for 7% of childhooddeaths globally; however, it can be the leading cause of childhood deaths in some

endemic African countries.

Proportional mortality data can be misleading if caution is not used in interpretation.

We often use pie charts to visually display causes of death as percentages—i.e.proportional mortality. Remember, proportional mortality only tells you what percent

of deaths are due to a certain cause—it does not tell you about disease incidence or

prevalence and it is not the same as cause specific mortality rates. For example,more than 50% of childhood deaths in the United States are due neonatal causes

compared to Africa where <1/3 of all childhood deaths are due to neonatal causes.However, the number of children who die from neonatal causes per every 1,000

children (i.e. the cause specific mortality rate) is ~3fold in Africa compared to the

US. A disease can kill as many people, but may result in a lower proportionalmortality rate because there are so many deaths due to other causes.

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Regional variations in cause-specific mortality rates

Source: WHO. The Global Burden of Disease: 2004 update (2008)



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Underlying Causes orDeterminants of Disease and

Malnutrition

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Absolute Poverty

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Relative Poverty

http://www.paris21.org/betterworld/infant.htm



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Poverty is defined as either absolute or relative poverty. Both are important

determinants of health.

Absolute poverty is also called abject poverty or destitution and means that basicneeds (e.g. adequate food, shelter, health care) cannot be met.

Relative poverty refers to the inequitable distribution of wealth within a society.Gaps between rich and poor have increased in many countries over the past two

decades. Data from rich and poor countries where there are large gaps betweenrich and poor consistently shows that people living at the bottom economic strata

are more likely to die than those at the top. Living in a setting where some people

are materially deprived compared to others around them is linked to poor health

outcomes. For example, young adult males in Harlem have been shown to havesimilar mortality rates compared to their like aged males in Africa. [8]For more information see WHO Commission on Social Determinants of Health

Final Report[9]

http://www.who.int/social_determinants/thecommission/finalreport/en/index.html

(Discussion of relative vs. absolute poverty is in Part 1 Chapter 2.)

Relative poverty, cont.



?A

Relative Poverty: Impacts the poor in rich countries too—theGlasgow example



?V

Relative Poverty: Increasing gaps between the rich and poor

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Maternal Education

http://www.paris21.org/betterworld/infant.htm

For more information see Gakidou, E., K. Cowling, et al. (2010). "Increased educational attainment and its effecton child mortality in 175 countries between 1970 and 2009: a systematic analysis." Lancet 376(9745): 959-974.



F?

Armed conflicts have direct andindirect impacts on child health

90% of conflict-related

deaths since 1990 have

been civilians. 80% of

these have been women

and children.

Source: UNICEF State of the Worlds’ Children 2005, p. 100



FF

Armed Conflict, cont.

Children are always among the most heavily affected by armed

conflict—either directly or indirectly. Even if they survive thebullets, they are often subject to violence or being orphaned.

The destruction wrought by war disrupts social services such as

education and health care. In a typical five-year war, the U5MR

increases by 13% (and adult mortality by even more). The

aftermath is still evident after the conflict ends; during the firstfive years of peace, the average U5MR remains 11% higher than

it corresponding level before the conflict.

For further information see Chapter 3 “Children Caught up in Conflict” in the

UNICEF State of the World’s Children 2005

http://www.unicef.org/sowc05/english/fullreport.html



Photo: Adi Dabestani



FJ

Intervention Delivery

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Examples of Intervention Delivery Methods

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Fa

Examples of Intervention Delivery Methods

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FA

Integrated Management of Childhood Illnesses

(IMCI)

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See Note I



3 Components of IMCI

Capacity, structureand functions ofhealth system

Knowledge,Beliefsand skills

caretakers

ClinicalAssessmentand treatment by

health workers

Health Worker Skills

Care in the Community and

Health Systems

If caretakers do not or

cannot access care

and health systems

are not strengthened

then just training

health workers results

in a incomplete

delivery mechanism

for the IMCI package



IMCI Case Examples: 18-month old with fever and

lethargyCommunity

Provider

Health System

Community

•

Caretaker at home recognizes that health care is needed

• Health care provider is available in community and family can

afford to pay for services if there are fees

•

Health care provider recognizes symptoms/signs of

complicated malaria, initiates treatment and refers to hospital

for further care. Inquires about use of insecticide treated

bednet in household and advises caretaker regarding its use to

prevent malaria

•

Family able to access hospital care (transportation, costs, etc)•

Hospital facility quickly admits child and starts on appropriate

treatment for complicated malaria

•

Caretaker learns about insecticide treated materials and

implements use for the children in the household.

See Note J



T?

IMCI Multicountry Evaluation

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A multicountry evaluation of IMCI programs found that the 11 day IMCI training course did

positively impact health workers performance. However, the health systems and parent/

caretaker care components were not strongly implemented and were impediments to overall

IMCI effectiveness.

For more information on the multicountry evaluation see http://www.who.int/imci-mce/



Photos by Donna Denno and AdiDabestani

Photo: Adi DabestaniPhoto: Donna Denno

Photo: Donna Denno



TT

Actors in International Child Health

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For an excellent overview of the history and activities of the major players in international

child health see Chapter 2 “International health agencies, activities and other actors” in

Anne-Emmanuelle Birn’s Textbook of International Health,3nd edition, 2009. Chapters 17 of

Global Health: Diseases, Programs, Systems, and Policies 3nd ed, by Michael Merson,

Robert Black and Anne Mills, Aspen, 2011, also provides an overview to the world of

multilateral international assistance.



Photos by Kelly Evans and DonnaDenno

Photo: Donna Denno

Photo: Kelly Evans

Photo: Kelly Evans



TU

Conclusion: Is there hope? YES!

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WHO World Health Report 2005: Making Every Mother and Child Count

Pneumonia, diarrhea, malaria and 3 neonatal disorders (pre-term delivery, sepsis

and lack of oxygen at birth.) Interventions need the vehicle of strong communitiesand health systems to deliver reductions in childhood morbidity and mortality.



Ta

Conclusion: Is there hope? YES!

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Jones G, et al. How many child deaths can we prevent this year? Lancet 2003

7 in 10 of the 10 million annual deaths in children younger than 5 years are attributable to

six causes: Pneumonia, diarrhea, malaria and 3 neonatal disorders (pre-term delivery,

sepsis and asphyxia.)

2/3 of childhood deaths are preventable with interventions that we already know to be

effective and are feasible for implementation. Things like insecticide treated bednets,

appropriate antibiotics for respiratory infections and antimalarials, access to clean waterand sanitation, oral rehydration therapy for treatment of diarrhea, intermittent presumptive

treatment of malaria during pregnancy, attended births with appropriate care of the

neonate. These prevention and treatment interventions are reviewed in detail in the 2nd

GHEC Child Health Module.



TA

Quiz

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TV

1. Approximately how many children die every year around the world?

A.

60-70 million

B.

6-7 million

C.

650,000

D. 65,000

2. What percent of childhood deaths occur in low and middle income

countries?

A. 50%

B. 67%

C. 75%

D.

99%



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3.

T or F Neonatal mortality rate (NMR) is the probability of

dying between birth and one year as expressed per 1000live births

4.

T or F U5MR and child mortality rate (CMR) are

synonyms.

5.

T or F Neonatal deaths are included in child (i.e. under-

five) mortality figures/rates.

6.

T or F Undernutrition and obesity are both forms of

malnutrition.



J?

8. Approximately what percent of global childhood deaths are

preventable and/or treatable with interventions that arecurrently available and feasible for implementation?

A.

10%

B.

25%

C.

50%

D.

67%

E.

90%

9. T or F Interventions aimed at reducing neonatal deaths

are closely linked to maternal health interventions



JF

10. IMCI health provider protocol for assessment of a febrile

child might include (more than one response acceptable):

A. Checking immunization/growth card to see if vaccinations are up to

date

B.

Checking immunization/growth card to see if there is any growth

faltering

C. Assessment for signs of complicated malaria

D.

Checking to see if child is sleeping under an insecticide treated bed

nets

E. All of the above



JT

11. Millennium Development Goal #4 seeks to reduce the

childhood mortality rate between 1990 and 2015 by:

A.

One-fourth

B.

One-third

C.

One-half

D.

Two-thirds

12. T or F Given current trends in child mortality rate

reduction, we are on target to meet Millennium Development

Goal #4.



JJ

13. T or F S Asia and sub Saharan Africa have the greatest

proportions of child deaths compared to other regions in theworld.

14. Which are the 3 most important underlying determinants of

child mortality?

A.

Lack of paternal educationB.

Lack of maternal education

C.

High fertility rates

D.

High levels of poverty

E.

Inadequate access to healthcare



JU

15. T or F Despite improvements in child mortality rates,many countries have experienced increasing gaps in mortality

rates between the rich and the poor.



Ja

16. A multi-country evaluation of IMCI found the following

(multiple responses acceptable):

A.

Training of health providers improved assessment and

treatment practices

B.

Some sites experienced poor utilization of health services

by caretakers of children

C.

Health system infrastructure deficits led to poor supervision

of health providers in the communityD.

Implementation of the community component of IMCI does

not impact child health



JA

And now the answers to the questions



JV

1. Approximately how many children die every year around the world?

A. 60-70 million

B. 6-7 million -- Approximately 6.9 million children died in 2011

C.

650,000

D.

65,000

2. What percent of childhood deaths occur in low and middle income

countries?

A.

50%

B. 67%

C. 75%

D. 99%



U@

3. False Neonatal mortality rate (NMR) is the probability of dying

between birth and one year as expressed per 1000 live births(NMR is the probability of dying between birth and 28 days asexpressed per 1000 live births)

4. True U5MR and child mortality rate (CMR) are synonyms.

5. True Neonatal deaths are included in child (i.e. under-five)

mortality figures/rates, including those in the IMR and NNR.

6. True Undernutrition and obesity are both forms of malnutrition.



UE

7. Which of the following is NOT considered to be a key component of

IMCI?

A. Training health workers at the community level to be able to treat

all sick children at the community level. -- Key components of IMCI

include the 1) caretakers in the community, 2) strong health systems to

supervise health workers and provide referral care, and 3) training of

community based health workers to recognize signs of illness, treat

appropriately and refer children who are severely ill to referral facilities.

B. Teaching caretakers to recognize signs of illness so they will know when

to seek care

C.

Continued monitoring and training of health workers

D. Health infrastructures having systems in place to assure availability

necessary medications



U?

8. Approximately what percent of global childhood deaths are

preventable and/or treatable with interventions that arecurrently available and feasible for implementation?

A.

10%

B.

25%

C.

50%

D.

67%

E.

90%

9. True Interventions aimed at reducing neonatal deaths are

closely linked to maternal health interventions



UF

10. IMCI health provider protocol for assessment of a febrile child might

include (more than one response acceptable):

A.

Checking immunization/growth card to see if vaccinations are up to date

B. Checking immunization/growth card to see if there is any growth faltering

C. Assessment for signs of complicated malaria

D.

Checking to see if child is sleeping under an insecticide treated bed nets

E.All of the above -- IMCI health provider protocol for assessment of a febrile childincludes: checking immunization history and growth chart, evaluating for signs of

complicated malaria (and referring for further care if needed), asking the caretakersif the child is sleeping under an insecticide treated bednet in order to prevent further

episodes of malaria.



UT

11. Millennium Development Goal #4 seeks to reduce the

childhood mortality rate between 1990 and 2015 by:

A.

One-fourth

B.

One-third

C.

One-half

D.

Two-thirds

12. False -- Given current trends in child mortality ratereduction, we are on target to meet Millennium Development

Goal #4. (Few countries are on track to meet MDG4.)



UJ

13. True S Asia and sub Saharan Africa have the greatest

proportions of child deaths compared to other regions in theworld. – About 80% of child deaths occur in these regions.

14. Which are the 3 most important underlying determinants of

child mortality?

A.

Lack of paternal educationB.

Lack of maternal education

C.

High fertility rates

D.

High levels of poverty

E.Inadequate access to healthcare



UU

15. True Despite improvements in child mortality rates,many countries have experienced increasing gaps in mortality

rates between the rich and the poor.



Ua

16. A multi-country evaluation of IMCI found the following

(multiple responses acceptable):

A.

Training of health providers improved assessment and

treatment practices

B.

Some sites experienced poor utilization of health

services by caretakers of children

C.

Health system infrastructure deficits led to poor

supervision of health providers in the communityD.

Implementation of the community component of IMCI does

not impact child health



UA



UV

References

1. World Development Report 1993--Investing in health1993, Washington DC:

Oxford University Press for the World Bank.

2. Preamble to the Constitution of the World Health Organization as adopted by

the International Health Conference, New York , 1946.

3. Lawn, J.E., Newborn Survival , in Disease Control Priorities, J.G.B. Dean T.Jamison, Anthony R. Measham, George Alleyne, Mariam Claeson, David B.

Evans, Prabhat Jha, Anne Mills, Philip Musgrove, Editor 2006, Oxford University

Press: New York.

4. Levels & trends in child mortality report 2012: Estimates developed by the UNInter-Agency Group for Child Mortality Estimation, ed. Unicef, et al.2012, New

York: United Nations Children's Fund.

5. World Health Report: Make Every Mother and Child Count , 2005, World Health

Organization: Geneva.



a@

References6. Denno, D., Global child health. Pediatr Rev, 2011. 32(2): p. e25-38.

7. Black, R.E., et al., Maternal and child undernutrition: global and

regional exposures and health consequences. Lancet, 2008.

371(9608): p. 243-60.

. McCord, C. and H.P. Freeman, Excess mortality in Harlem. N Engl J

Med, 1990. 322(3): p. 173-7.

9. WHO, Commission on Social Determinants of Health Final Report ,

2008, World Health Organization: Geneva.



aE

Recommended resources:

•

2003 Lancet Child Survival series including 1st of 5 articles--Black RE, Morris

SS, Bryce J. Where and why are 10 million children dying every year? Lancet2003;361(9376):2226-34.

• World Health Report: Make Every Mother and Child Count . World Health

Organization; Geneva; 2005.

• Denno, D., Global child health. Pediatr Rev, 2011. 32(2): p. e25-38.

•

UNICEF’s annual State of the World’s Children Report includes latest statistics

on child health and development. Each report also covers a special theme. The2009 report, for example, focused on maternal and newborn health.

• UNICEF ChildInfo website http://www.childinfo.org/index.html

• Closing the gap in a generation: health equity through action on the social

determinants of health. Final Report of the Commission on Social determinantsof Health. World Health Organization; Geneva; 2008.



a?

Credits

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J;%.: 8+$@,%+B 2?T?,#-.(/0-12 "3 ;$9-3"/#-$

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Sponsors

The Global Health Education Consortium gratefully acknowledges the supportprovided for developing these teaching modules from:

Margaret Kendrick Blodgett Foundation

The Josiah Macy, Jr. Foundation

Arnold P. Gold Foundation

This work is licensed under aCreative Commons Attribution-Noncommercial-No Derivative Works 3.0

United States License.



aT

Supplementary Notes



NOTE A -- Why focus on child health?

1) Children represent the most vulnerable societal group for a number ofreasons: a) biologic immaturity—for example, immunologic immaturity putthem at increased risk of infectious diseases, b) they are at risk of insults

which can arrest or retard their physical and mental development, c) theyare dependant on adults for their optimal development and in fact survival. As a result of their vulnerability and dependence on society and adults fortheir care, the UN Convention on the Rights of the Child (UNCRC) wasdrafted and presented in 1989 with all countries signing the Conventionand all but 2 countries’ governments (US and Somalia) ratifying theConvention. At the time of this writing, the new US Presidential

Administration has indicated that they will review the document forratification reconsideration. However, ratification requires Congressionalapproval in the US as well. For more information seehttp://www.unicef.org/ceecis/overview_1583.html for an overview and

http://www.crin.org/docs/resources/treaties/uncrc.asp for the full text.

2) Improvements in child health are a good measure of societal progress—hence the Millennium Development goals (described later in Note F)contains a specific goal explicitly stating the need to reduce childhoodmortality as well as other goals relating to children as well (i.e. improvingeducation rates, reducing poverty rates). Infant and child mortality rates(discussed in later slide and note C) have traditionally been (and still are)used as sensitive markers for the overall health of nations as a whole.

3) GHEC Module 21 reviews the Global Burden of Disease* and commonways to measure that burden including life expectancy and disability-adjusted life years (DALYs)1. Childhood illness, disability, and death areimportant components of the global burden of disease; death duringchildhood substantially contributes to reduced life expectancy indeveloping countries. Furthermore, childhood illness is an importantcontributor to the global burden of disease. For example, the key causesof childhood morbidity are estimated to account for 14% of DALYs [1].

4) 2/3 of childhood deaths are preventable and/or treatable with interventionsthat are currently available! Read on for more information!

*For more information about the Global Burden of Disease Project see:

Return to Slide 3

1 DALY is a weighted index that takes into account loss of life, morbidity and disability.



NOTE B -- Indicators of childhood mortality

DEFINITIONS, DEFINITIONS—LET’S GET A HANDLE ON THE LINGO USEDTO MEASURE CHILD HEALTH OR LACK THEREOF

An indicator is a commonly used term in public health that refers to a measureof health or disease. Incidence and prevalence rates and different types ofmortality rates are commonly used indicators. For example:

o Proportional mortality = number of deaths due to a specific cause in adefined population over a year / total number of deaths occurring in thatpopulation during the same year

o Mortality rate = number of deaths due to a specific cause in a definedpopulation over a year/ total number in the defined population at themidpoint of the same year = probability of dying due to a specific cause

in a given populationo Note that proportion dying and probability of dying from a given cause are

very different! For example, 3% of childhood deaths in developingcountries are due to injuries vs. 10% in developed countries. So, areinjuries an important problem in developing countries? Doesn’t seem likeit if you just look at proportional mortality of 3%. However, the risk orprobability of a child dying from injuries is greater in developing countriesthan it is in developed countries!! In other words, more children/population are at risk of fatal injuries in developing countries than indeveloped countries. It’s just that they are also dying from other causes athigher rates, so the importance of injuries as a contributor to mortality ismasked if you just look at proportional mortality.

In child health the 3 most used common mortality indicators are:

• Under five mortality rate (U5MR) is also referred to as child mortalityrate (CHR) = number of deaths under five years of age in a definedpopulation over a year / number of live births occurring in that populationduring the same year

• Infant mortality rate (IMR) = number of deaths under one year of age in adefined population over a year / number of live births occurring in thatpopulation during the same year

• Neonatal mortality rate (NMR)= number of deaths under 28 days of agein a defined population over a year / number of live births occurring in thatpopulation during that same year

Note the differences in the definitions of the denominators between the childmortality rates and general mortality rate. Note also that NMR is encompassedwithin IMR and U5MR, and NMR and IMR are encompassed within U5MR.



For more information about these and other indicators see:• SOWC 2007 p.137 (http://www.unicef.org/sowc07/report/report.php )

Specific indicators by country can be found on the UNICEFhttp://www.unicef.org/infobycountry/index.html or WHOhttp://www.who.int/whosis/en/ websites

Return to Slide 5



NOTE C -- Reminder -- Morbidity

IODINE Deficiency is the single most important cause of preventable braindamage and mental retardation. It significantly raises the risk of stillbirth and

miscarriage in pregnant women. 43 million people worldwide suffer from varyingdegrees of brain damage and physical impairment due to iodine deficiency—there is a spectrum of associated disability. The primary intervention for thecontrol of IDD is through salt iodization. For more information on IDD seehttp://www.childinfo.org/idd.html

VITAMIN A Deficiency is a contributing factor in 2.2 million deaths each yearfrom diarrhea and 1 million deaths from measles among preschool children underfive. Severe deficiency can also cause irreversible corneal damage, leading topartial or total blindness. Vitamin A deficient children face a 23% greater risk ofdying from ailments such as measles, diarrhea or malaria . Vitamin A

supplementation of children with can reduce deaths from diarrhea and measlesby

35-50% and 50%, respectively. Treatment with high dose vitamin A is animportant component of measles case management. For more information onvitamin A deficiency see http://www.childinfo.org/vitamina.html

IRON Deficiency is the most common nutritional disorder in the world. It lowersresistance to disease and weakens a child's learning ability and physical stamina.It is a significant cause of maternal mortality, increasing the risk of hemorrhageand infection during childbirth. Nearly 2 billion people are estimated to beanemic and millions more are iron deficient, the vast majority are women andchildren. For more information seehttp://www.unicef.org/nutrition/23964_iron.html

HELMINTHIC infections are an important cause of poor growth and anemiaworldwide. Hookworm infection, for example, is an important cause of anemia inmany settings with clinical manifestations similar to that of iron deficiencyanemia. Periodic presumptive treatment among schoolchildren can lead tocontrol in endemic settings. For more information on helminthiasis seehttp://www.who.int/topics/helminthiasis/en/

Furthermore, many common causes of child mortality can leave survivors withlong term disabilities: for example, reduced cognitive function post cerebralmalaria, intestinal malabsorption as a result of prolonged or recurrent diarrhealinfections leading to poor nutrient absorption, disabilities secondary to injuries.

Return to Slide 8



NOTE D -- The world is not on track to meet MDG4

Progress is being made in reducing childhood mortality. Between 1980 and 2008annual child deaths worldwide decreased from 13.5 million to 8.8 million. Latin

America, the Caribbean, Eastern Europe, the Pacific and East Asia are on track

for meeting MDG4.

Worldwide, there has been a 41% reduction in U5MR from1990-2011. In somecountries progress had stalled or even reversed in the 1990’s (e.g. Kenya, South

Africa, Zimbabwe, Rwanda, Swaziland)—often due to conflict, political instabilityleading to reduced focus on public health infrastructure, and/or the HIV/AIDSepdemic.

However, of 66 countries with child mortality rates of at least 40 per 1,000 livebirths, 20 have reduced their under-five mortality rates by at least half between1990 and 2011, and 4 of them have achieved at least a two-thirds decline (in

Lao People’s Democratic Republic, Timor-Leste, Liberia and Bangladesh) [4].For more information see http://www.childinfo.org/mortality_underfive.php .

Return to Slide 10



NOTE E -- Slowing trends in improvements in child mortality

Reductions in mortality rates during the 1960s-1970s and into 1980s providedoptimism that MDG #4 could be realistically met by 2015. However, progressslowed in the 1980s and 1990s [5, 6], picking up at a somewhat better pace

during the first decade of this century—but not at a pace fast enough to meetMDG4 by 2015 at current rates. Globally, rates of reduction in under-fivemortality decreased by an average of 1.8 percent per year between 1990–2000.Progress improved over the next decade with an average 3.2 percent decreaseper annum from 2000–2011. However, in order to meet MDG4 an annual rate ofreduction in child mortality of 14.2% would be needed.

Of 66 countries with the highest mortality rates, only 15 are on track to meetMDG4.

Meeting the target will require serious commitments to implementing life-saving

interventions and tackling the social determinants of health. But it can be done,even in the poorest of environments. The following are examples of high mortalitycountries have made great strides forward in reducing under-5 mortality: Nepal,Timor Leste, Bangladesh, Eritrea, Lao People’s Democratic Republic, Mongolia,Bolivia, and Malawi.

For further information on the progress being made toward meeting MDGs see:• http://www.childinfo.org/mortality_underfive.php • http://www.un.org/millenniumgoals/ • www.countdown2015mnch.org • Rajaratnam JN, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer

L, Costa M, Lopez AD, Murray CJL. Neonatal, postneonatal, childhood,and under-5 mortality for 187 countries, 1970–2010: a systematic analysisof progress towards Millennium Development Goal 4. Lancet 2010; 375:1988–2008.

Return to Slide 11



NOTE F -- Undernutrition is an Important Underlying Cause of Death

Undernutrition* typically is not directly responsible as a cause of death, moreoften it is a very important underlying cause of death. Altogether undernutritioncontributes to 35% of childhood deaths [7]. Undernutrition puts children at

increased risk of illness (e.g. increased risk of contracting pneumonia, diarrhea,malaria) and once they are sick puts them at even greater risk of dying.

Undernutrition can take many forms. While poor caloric and macronutrient(protein, fat, carbohydrate) intake is an obvious cause of undernutrition (definedas low weight for age), micronutrients also play an important role in promotinggrowth and micronutrient deficiencies can also lead to low weight for age. Inaddition, micronutrient deficiencies can be present in children who are notunderweight. Micronutrient deficiencies are associated with increased risk ofmorbidity and mortality—for example increased risk of getting ill with diarrheaand increased risk of dying from measles, respiratory infections, and diarrhea.The most common micronutrient deficiencies are vitamin A, zinc, iron and iodine.

Breastfeeding also plays an important role in health promotion and diseaseprevention. Infants less than six months who have not been breastfed have a 7-fold and a 5-fold risk of dying from diarrhea and pneumonia, respectively,compared to children who have been exclusively breastfed. Those who havebeen breastfed but not exclusively, face a 2-fold increased risk compared tothose who have been exclusively breastfed. For more information onbreastfeeding see http://www.childinfo.org/breastfeeding.html

Undernutrition also inhibits physical and mental development. It is also a majorcause of neonatal morbidity and mortality as malnourished girls and women withstunted growth have increased risk of obstructed labor as well as low birth weight

babies.!The term malnutrition encompasses overweight, obesity and undernutrition. The

term undernutrition refers to calorie/macronutrient deficiency, micronutrientdeficiency and lack of exclusive breastfeeding. Infants 6 months and older alsobenefit from breastmilk in their diet in terms of protection from mortality.

For more information on malnutrition see GHEC Module 48, Part 2 of the GHECChild Health Module (Module 12) and Black, R. E., L. H. Allen, et al.(2008). "Maternal and child undernutrition: global and regional exposuresand health consequences." Lancet 371(9608): 243-260.

Return to Slide 20



NOTE G -- Examples of Intervention Delivery Methods

Primary Health Care (PHC) refers to a specific movement originating in the late1970’s which defined a goal of “Health for All by the year 2000” via the Alma Ata

Declaration which was signed by 134 health ministers from around the world andendorsed by WHO, UNICEF and major funding organizations. The goal was tobe realized via the provision of essential health care (e.g. access to care fortreatment of common conditions) and basic public health services (e.g.immunizations, clean water, sanitation facilities) as well as tackling underlyingcauses of death such as poverty and illiteracy. PHC involves an integratedapproach to the delivery of services at the community level but as a part of acomprehensive national health system.

To read the 1978 Alma Ata declaration on PHC and Health Care for all by 2000see http://www.paho.org/english/dd/pin/alma-ata_declaration.htm

Return to Slide 36



NOTE H -- Examples of Intervention Delivery Methods

Following the Alma Ata declaration, there was concern (for example amonggovernments with a vested political interest in preserving inequities as well asamong influential US international health experts) that PHC was too ambitious a

project, and that there needed to be a focus on delivering specific selectiveinterventions—referred to as selective cost effective interventions (SPHC).SPHC movement focused on the technological aspects of the interventions. Theroles of communities, socio economic development and addressing underlyingdeterminants of health are not by SPHC. In the 1980’s UNICEF adopted aSPHC child survival strategy termed GOBI (growth monitoring, oral rehydrationtherapy and immunization). This was expanded to include family planning, foodsupplements and female education (GOBI-FFF). SPHC programs are oftendelivered as vertical programs—i.e. not an integral part of the health care andpublic health system in developing communities but rather as isolated andindependent programs.

Vertical programming often results in human resources being diverted from day-to-day management of PHC operations in order to devote time and attention tothe vertical intervention being promoted at that time. Vertical programming isdifficult to sustain without continued carry-through via a functioning healthsystem.

For more information on PHC its revitalization 21st century see GHEC Module 30PHC—Now More than Ever

Return to Slide 37



NOTE I -- Integrated Management of Childhood Illnesses (IMCI)

In the 1990’s UNICEF and WHO started promoting the Integrated Managementof Childhood Illnesses (IMCI) approach which might be viewed as a pendulumpartial swing back toward PHC—community involvement is emphasized although

underlying social, political and economic causes of poor health are not welladdressed. IMCI is “an integrated approach to child health that focuses on thewell-being of the whole child. IMCI aims to reduce death, illness and disability,and to promote improved growth and development among children under 5 yearsof age. IMCI includes both preventive and curative elements that areimplemented by families and communities as well as by health facilities.” Inhealth facilities, the IMCI strategy promotes the accurate identification ofchildhood illnesses in outpatient settings, ensures appropriate combinedtreatment of all major illnesses, strengthens the counselling of caretakers, andspeeds up the referral of severely ill children. In the home setting, it promotesappropriate care-seeking behaviours, improved nutrition and preventative care,

and the correct implementation of prescribed care.

There are 3 components to IMCI:• improving health worker skills

o IMCI trainings are structured 11 day courses aimed at teaching healthcare workers in the community (i.e. primarily the non-physicianproviders (e.g. nurses) who provide the majority of care in manydeveloping countries.

o The courses cover IMCI protocols in identifying the commonpresentations of the sick child as well as appropriate treatment, follow-up and referral for these conditions.

o The courses and IMCI protocols also have components on assessing“well child issues”--growth, nutrition, development, and immunizations.The protocols encourage health workers to check immunization/growthchart cards during sick visits to assess for and growth faltering, gaps inimmunizations or routine vitamin A doses, delays in development(developmental milestones are included on these cards. Appropriatetreatment and referral are included in guidelines.

• improving home and community based care and practices to ensure that:o appropriate prevention strategies such as exclusive breastfeeding for 6

months, appropriate nutrition, use of insecticide treated materials arebeing practiced

o home based care is appropriate for both the sick child (e.g. appropriateantimalarials for the febrile child in a malaria endemic setting, oralrehydration therapy for the child with diarrhea and no dehydration)

o children are taken promptly to a health worker when symptoms andsigns of illness warrant health care (e.g. symptoms of complicatedmalaria--fever and poor feeding, fever and lethargy or diarrhea withsigns of dehydration (poor ability to drink, lethargy, etc)



o children are given full courses of prescribed treatments (e.g. full courseof appropriate antibiotics prescribed by health worker for respiratoryinfection, full course of appropriate anti-malarials

• improving health systemso appropriate supervision of and continued training for health workerso

procurement systems with adequate supplies of medications, vaccinesand supplieso referral facilities (i.e. hospitals) that respond to referrals from the

community level. Mechanisms must be in place to efficiently respondto the sick child who is referred from the community.

Standard IMCI protocols share common features (e.g. identification of childneeding antibiotics for treatment of respiratory infection and symptoms/signsrequiring hospital referral), but protocols are also setting specific (e.g. includesassessment and treatment for dengue fever in endemic settings)

Return to Slide 38



Note J -- IMCI Case Examples: 18-month old with fever and lethargy

Preliminary Data from 5 countries that where an evaluation of IMCI is takingplace are encouraging in regards to training of health workers but the healthsystems component of IMCI is just not strong enough to deliver an effective total

IMCI package. Access to care presents another significant impediment to IMCIeffectiveness.

Case example: An 18 month old presents with fever and lethargy. In order forIMCI to be effective in helping this child, the caretaker needs to identify that thechild is ill and seek care. The community health worker must be trained torecognize severe malaria based on clinical presentation and initiative immediatetreatment and referral to a health care facility. The family must then be able toaccess the facility and the facility must recognize the condition and treat the childappropriately.

Case example: An 8 month old presents cough and fever. Again, the familymust recognize that this is a condition for which care should be sought and carewithin the community should be accessible. The community health workershould not only be able to follow clinical algorithm leading to a clinical diagnosisof pneumonia but should also assess the growth and immunization record andgive nutrition advice and update immunizations accordingly. The communityhealth worker should also document developmental progress on the growth chartand intervene if there is developmental delay. If the child is from a malariaendemic setting treatment for potential concomitant malaria is included in theclinical care guidelines as well.

In IMCI care is more comprehensive. Community education regarding healthypractices is important and encompassed in 16 “key family practices for healthygrowth and development” that fall into 4 categories: promote physical growthand mental development, promote disease prevention, promote appropriatehome care, and promote health care seeking behavior. For a full list of the 16key community IMCI family practices see http://www.paho.org/english/ad/fch/ca/GSIYCF_keyfam_practices.pdf

Return to Slide 41

child health problems global

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