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
redesigning child care: survival, growth and development 107 clearly a need for a more comprehensive view of the needs of the child, one that would correspond to problems as they were encountered in the field (4)and would offer a wider range of responses than the existing programmes. These had been designed to target the most important causes of death and, partly as a result of their success, the profile of mortality was changing. Diarrhoea, for example, now causes 18% of child hood deaths, as opposed to 25% in the 1970s(see Box 6.1) he response to this new situation was to package a set of simple, affordable and effective interventions for the combined management of the major childhood illnesses and malnutrition, under the label of"Integrated Management of Childhood Ilness (IMCI). IMCI combines effective interventions for preventing death and for improving healthy growth and development: oral rehydration therapy for diarrhoea; antibiotics fo sepsis, pneumonia, and ear infection; antimalarials and insecticide-treated bednets vitamin A, treatment of anaemia, promotion of breastfeeding and complementary feeding for healthy nutrition and for recovery from illness, and immunization. Some countries have included guidelines to treat children with HIV/AIDS, others for dengue fever, wheezing, or sore throat, or for the follow-up of healthy children Dealing with children, not just with diseases The second justification for a more comprehensive approach was the recognition that the health of children is not merely a question of targeting a limited number of dis eases that are immediate causes of mortality □ Packaging simple, affordable and effective interventions. Here, a vietnamese boy is vaccinated
redesigning child care: survival, growth and development 107 clearly a need for a more comprehensive view of the needs of the child, one that would correspond to problems as they were encountered in the field (4) and would offer a wider range of responses than the existing programmes. These had been designed to target the most important causes of death and, partly as a result of their success, the profile of mortality was changing. Diarrhoea, for example, now causes 18% of childhood deaths, as opposed to 25% in the 1970s (see Box 6.1). The response to this new situation was to package a set of simple, affordable and effective interventions for the combined management of the major childhood illnesses and malnutrition, under the label of “Integrated Management of Childhood Illness” (IMCI). IMCI combines effective interventions for preventing death and for improving healthy growth and development: oral rehydration therapy for diarrhoea; antibiotics for sepsis, pneumonia, and ear infection; antimalarials and insecticide-treated bednets; vitamin A, treatment of anaemia, promotion of breastfeeding and complementary feeding for healthy nutrition and for recovery from illness, and immunization. Some countries have included guidelines to treat children with HIV/AIDS, others for dengue fever, wheezing, or sore throat, or for the follow-up of healthy children. Dealing with children, not just with diseases The second justification for a more comprehensive approach was the recognition that the health of children is not merely a question of targeting a limited number of diseases that are immediate causes of mortality. Packaging simple, affordable and effective interventions. Here, a Vietnamese boy is vaccinated. WHO
108 The World Health Report 2005 As appropriate technologies became more widely available, a gradual evolution also took place in the content and methods of communication between health workers and parents. Previously, a family who brought a child for curative care had generally received basic treatment with minimal instruction and explanation for use of pre treatments at home. The introduction of oral rehydration therapy, however, new element to the relationship between the family and the clinic. During t isit, families now learnt how to prepare and give oral rehydration salts solution (9-11), to recognize signs of illness, and to treat their children without delay at home; they also learnt to make use of fluids available in the home to make treatment more accessible This led to the development of a systematic process of advising and counselling, and to new partnerships between health workers and households Child health programmes see many malnourished children. Some of these children may be malnourished as a result of lack of access to food, but more often it is because of infection and poor feeding practices, or a combination of the two(4, 12). Counselling on feeding practices naturally became an element of IMCI. As with oral rehydration therapy, this forced health workers to enter into a different kind of partnership with mothers. It was no longer a matter of asking a few simple questions and prescribing a treatment: feeding problems had to be identified and acceptable solutions negotiated with the mother. Counselling carried out in this way requires specific training for the health worker, and the right kind of environment, but it is more effective(13, 14) The next logical step was to pay more attention to the physical and psychosocial development of children. A child's health and development is strongly influenced by the relationship between child, parents and other caregivers. The key is for the caregiver to be receptive to the child's state and needs, to interpret them correctly and be quick to react appropriately (15). This is a critical factor in healthy growth (16-19 ); the absence of sensitive, responsive care is associated with malnutrition and failure to thrive(20-22). The influence of such care on healthy cognitive and social development as well as on survival has been well documented (18, 23) New evidence accumulated during the 1990s shows that mothers can be helped to communicate better with and to stimulate their young children(24). The skills needed for appropriate feeding, psychosocial care and care-seeking are closely linked (24), and improving one of these positively influences the others. Sensitivity and responsiveness can be effectively promoted and taught to caregivers, even in difficult social and economic conditions, or when a mother' s ability to care for her child is compromised by depression(24 ). Specific efforts are required to work with foster parents, or with children who are heads of households. The challenge is to integrate these new findings into public health programming Parents are naturally concerned about the growth and psychosocial development of their children; however, health workers who operate in resource-constrained environments have long considered this more of a luxury or something that they could not influence IMCI changed that: in doing so it created new challenges for what was no longer just a technical programme but became a partnership between parents and health workers ORGANIZING INTEGRATED CHILD CARE The notion of integration has a long history. Integration is supposed to tackle the need for complementarity of different interdependent services and administrative struc- tures, so as to better achieve common goals. In the 1950s these goals were defined in terms of outcome, in the 1960s of process and in the 1990s of economic impact
108 The World Health Report 2005 As appropriate technologies became more widely available, a gradual evolution also took place in the content and methods of communication between health workers and parents. Previously, a family who brought a child for curative care had generally received basic treatment with minimal instruction and explanation for use of prescribed treatments at home. The introduction of oral rehydration therapy, however, added a new element to the relationship between the family and the clinic. During the clinic visit, families now learnt how to prepare and give oral rehydration salts solution (9–11), to recognize signs of illness, and to treat their children without delay at home; they also learnt to make use of fluids available in the home, to make treatment more accessible. This led to the development of a systematic process of advising and counselling, and to new partnerships between health workers and households. Child health programmes see many malnourished children. Some of these children may be malnourished as a result of lack of access to food, but more often it is because of infection and poor feeding practices, or a combination of the two (4, 12). Counselling on feeding practices naturally became an element of IMCI. As with oral rehydration therapy, this forced health workers to enter into a different kind of partnership with mothers. It was no longer a matter of asking a few simple questions and prescribing a treatment: feeding problems had to be identified and acceptable solutions negotiated with the mother. Counselling carried out in this way requires specific training for the health worker, and the right kind of environment, but it is more effective (13, 14). The next logical step was to pay more attention to the physical and psychosocial development of children. A child’s health and development is strongly influenced by the relationship between child, parents and other caregivers. The key is for the caregiver to be receptive to the child’s state and needs, to interpret them correctly and be quick to react appropriately (15). This is a critical factor in healthy growth (16–19); the absence of sensitive, responsive care is associated with malnutrition and failure to thrive (20–22). The influence of such care on healthy cognitive and social development as well as on survival has been well documented (18, 23). New evidence accumulated during the 1990s shows that mothers can be helped to communicate better with and to stimulate their young children (24). The skills needed for appropriate feeding, psychosocial care and care-seeking are closely linked (24), and improving one of these positively influences the others. Sensitivity and responsiveness can be effectively promoted and taught to caregivers, even in difficult social and economic conditions, or when a mother’s ability to care for her child is compromised by depression (24). Specific efforts are required to work with fosterparents, or with children who are heads of households. The challenge is to integrate these new findings into public health programming. Parents are naturally concerned about the growth and psychosocial development of their children; however, health workers who operate in resource-constrained environments have long considered this more of a luxury or something that they could not influence. IMCI changed that: in doing so it created new challenges for what was no longer just a technical programme but became a partnership between parents and health workers. ORGANIZING INTEGRATED CHILD CARE The notion of integration has a long history. Integration is supposed to tackle the need for complementarity of different interdependent services and administrative structures, so as to better achieve common goals. In the 1950s these goals were defined in terms of outcome, in the 1960s of process and in the 1990s of economic impact
redesigning child care: survival, growth and development 109 (25-27) Integration has different meanings at different levels(28). At the patient level it means case management. At the point of delivery it means that multiple interven tions are provided through one delivery channel- for example where vaccination is used as an opportunity to provide vitamin a and insecticide-treated bednets during EPl-plus"activities, boosting efficiency and coverage(29, 30). At the system level integration means bringing together the management and support functions of differ- ent sub-programmes, and ensuring complementarity between different levels of care IMCI is now the only child health strategy that aims for improved integration at these three levels simultaneously IMCI has successfully integrated case management and tasks in first-level facilities by providing health workers with guidelines, tools and training. Progress towards integration between different levels is facilitated by the complementary guidelines for case management at first-level and referral facilities. Health workers at first-level facilities have guidelines for referring severely ill newborns and children, as well those with complex problems. Health workers at the district hospital in turn get the guidelines and training to manage these referred children. MCI has gone a step further. More than just adding more programmes to a single delivery channel, it has sought to transform the way the health system looks at child care. IMCI retained its original name, but with the ambition of going beyond the management of illness (3, 5, 31, 32). Based on experience from single-issue programmes, IMCl designed an approach with three components: improving the skills of health workers, strengthening the support of health systems, and helping families and communities to bring up their children healthily and deal with ill-health when it occurs. In doing so, IMCI had to move beyond the traditional notion of a health centre's staff providing a set of technical interventions to their target population Households and health workers As they increasingly entered into dialogue with households, health workers in child programmes realized how crucial what happens in the household is for the health of a child. Food, medicine and a stimulating environment are all necessarily mediated by what households and communities do or do not do. When a child is ill, for example someone in the household must recognize that there is a problem, provide appropri- ate care, identify signs indicating that the child needs medical care, take the child a health worker, work out a proper course of action with the health worker(which may be to obtain medication and comply with the instructions on how to use it, or to take the child to hospital), provide support during convalescence, and return to the health worker if necessary. Households and communities thus determine whether the health system's intervention can make a difference. Without all this, even the best health centre will get poor results. To look at child health from this perspective may seem obvious today, but for the vertical programmes of the 1980s this was a radical change. It stimulated a flurry of interest in how households can contribute to the improvement of the health of their children: the so-called "key family practices ummarized in Box 6.2 These family practices tackle behaviour that promotes physical growth and mental development, and prevents illness. The importance of this is obvious and has long been recognized. What is new is that seeking care from health services is also considered to be one of the ways households contribute to the health of their children Poor or delayed care-seeking contributes to up to 70%of child deaths(33). Most children die at home, and many without prior contact with competent medical care
redesigning child care: survival, growth and development 109 (25–27). Integration has different meanings at different levels (28). At the patient level it means case management. At the point of delivery it means that multiple interventions are provided through one delivery channel – for example where vaccination is used as an opportunity to provide vitamin A and insecticide-treated bednets during “EPI-plus” activities, boosting efficiency and coverage (29, 30 ). At the system level integration means bringing together the management and support functions of different sub-programmes, and ensuring complementarity between different levels of care. IMCI is now the only child health strategy that aims for improved integration at these three levels simultaneously. IMCI has successfully integrated case management and tasks in first-level facilities by providing health workers with guidelines, tools and training. Progress towards integration between different levels is facilitated by the complementary guidelines for case management at first-level and referral facilities. Health workers at first-level facilities have guidelines for referring severely ill newborns and children, as well as those with complex problems. Health workers at the district hospital in turn get the guidelines and training to manage these referred children. IMCI has gone a step further. More than just adding more programmes to a single delivery channel, it has sought to transform the way the health system looks at child care. IMCI retained its original name, but with the ambition of going beyond the management of illness (3, 5, 31, 32). Based on experience from single-issue programmes, IMCI designed an approach with three components: improving the skills of health workers, strengthening the support of health systems, and helping families and communities to bring up their children healthily and deal with ill-health when it occurs. In doing so, IMCI had to move beyond the traditional notion of a health centre's staff providing a set of technical interventions to their target population. Households and health workers As they increasingly entered into dialogue with households, health workers in child programmes realized how crucial what happens in the household is for the health of a child. Food, medicine and a stimulating environment are all necessarily mediated by what households and communities do or do not do. When a child is ill, for example, someone in the household must recognize that there is a problem, provide appropriate care, identify signs indicating that the child needs medical care, take the child to a health worker, work out a proper course of action with the health worker (which may be to obtain medication and comply with the instructions on how to use it, or to take the child to hospital), provide support during convalescence, and return to the health worker if necessary. Households and communities thus determine whether the health system’s intervention can make a difference. Without all this, even the best health centre will get poor results. To look at child health from this perspective may seem obvious today, but for the vertical programmes of the 1980s this was a radical change. It stimulated a flurry of interest in how households can contribute to the improvement of the health of their children: the so-called “key family practices” summarized in Box 6.2. These family practices tackle behaviour that promotes physical growth and mental development, and prevents illness. The importance of this is obvious and has long been recognized. What is new is that seeking care from health services is also considered to be one of the ways households contribute to the health of their children. Poor or delayed care-seeking contributes to up to 70% of child deaths (33). Most children die at home, and many without prior contact with competent medical care
110 The World Health Report 2005 Promoting appropriate care-seeking and ensuring that health facilities are accessible are therefore crucial. The potential of appropriate home care, whether by the caregiver or by a lay community worker, is also increasingly recognized. For example, home management of malaria can reduce the incidence of severe malaria and malaria mortality, as experience in Burkina Faso and Ethiopia has shown (34, 35). Prompt antibiotic treatment of pneumonia by well-trained and supervised community health workers can substantially reduce pneumonia-related mortality (36) Recognizing the importance of what households do is one thing, identifying how they can be helped to do so is another (37). One approach is to improve the communication skills of health workers. Experiences in Brazil and the United Republic of Tanzania show that this results in improved care by families in the home(13). Another approach is to work through community development programmes. In Bangladesh, for example, training of health workers in combination with community activities tripled the uptake of services from 0.6 to 1.8 visits per child per year (38). While households carry the primary responsibility for what they do or do not do at home, the health system needs to enable households to meet these responsibilities. This is not a simple question of health education, but a more complex process of empowerment, for which the health worker also needs to change his or her way of working (38) With the support of a responsive health system, much can be done. In Makwanpur Nepal, for example, women's groups supported by a facilitator discussed what factors contributed to perinatal mortality in their own living environment and formulated rategies to deal with them. This improved the way newborns were cared for at home and the appropriate use of health services, leading to a reduction of neonatal mortality ( 39) Box 6.2 How households can make a difference Households can promote physical growth and Households can improve care for sick to levels of particulate matter that are 100 times mental and social development by ensuring children at home by continuing to feed and higher than typical outdoor air concentrations exclusive breastfeeding for six months, by offer more fluids (including breast milk) to in European cities. With little ventilation, the starting complementary feeding at six months children when they are sick, by giving them smoke makes breathing difficult, burns the of age and continuing breastfeeding until the appropriate home treatment for infections, and eyes and covers the dwelling in black soot. child is aged two years or more. They can by taking appropriate action in case of injury Young children, often carried on their mothers ensure that children receive adequate amounts or accidents. backs during cooking, are most exposed of micronutrients either in their diet or through Households can prevent illness by Moreover, women and children often spend upplementation. They can also respond to a disposing of faeces safely, and by washing many hours collecting fuel -time that co child s needs for care through talking, playing hands after defecation, before preparing be spent on education, child care or income and providing a stimulating environment. The meals and before feeding children. They generation. Lack of a good source of lighting entire household, including men, has a role can bring their children for vaccination. In limits educational activities beyond daylight malaria-endemic areas they can ensure that hours. Households and communities can help children sleep under insecticide-treated bed- In the short term, well-designed stoves with prevent child abuse and neglect, and can nets Households and communities can take chimneys can significantly reduce emissions take appropriate action when it has occurred. measures to prevent injuries and accidents. and help protect children. But to reduce indoor Households can improve adequate uptake Much depends, though, on the environment air pollution drastically, it is necessary to switch of health care services by recognizing when in which members households live. to cleaner and more efficient fuels: liqu troleum gas, electricity or solar power. Poor and seeking timely care from appropriate world's population rely on dung, wood, crop households often do not have the resources to providers. It is important for households to take waste or coal to meet their most basic energy do so, and this situation will continue until the children as scheduled to complete a full course needs. In the highlands of western Guatemala, roots of poverty are tackled. of immunizations before their first birthday. for example, most households use an open and to follow health workers' advice about fire, fuelled by wood, for cooking and heating treatment, follow-up and referral. Cooking with these so-called solid fuels leads
110 The World Health Report 2005 Promoting appropriate care-seeking and ensuring that health facilities are accessible are therefore crucial. The potential of appropriate home care, whether by the caregiver or by a lay community worker, is also increasingly recognized. For example, home management of malaria can reduce the incidence of severe malaria and malaria mortality, as experience in Burkina Faso and Ethiopia has shown (34, 35). Prompt antibiotic treatment of pneumonia by well-trained and supervised community health workers can substantially reduce pneumonia-related mortality (36). Recognizing the importance of what households do is one thing, identifying how they can be helped to do so is another (37). One approach is to improve the communication skills of health workers. Experiences in Brazil and the United Republic of Tanzania show that this results in improved care by families in the home (13). Another approach is to work through community development programmes. In Bangladesh, for example, training of health workers in combination with community activities tripled the uptake of services from 0.6 to 1.8 visits per child per year (38). While households carry the primary responsibility for what they do or do not do at home, the health system needs to enable households to meet these responsibilities. This is not a simple question of health education, but a more complex process of empowerment, for which the health worker also needs to change his or her way of working (38). With the support of a responsive health system, much can be done. In Makwanpur, Nepal, for example, women’s groups supported by a facilitator discussed what factors contributed to perinatal mortality in their own living environment and formulated strategies to deal with them. This improved the way newborns were cared for at home and the appropriate use of health services, leading to a reduction of neonatal mortality (39). Households can improve care for sick children at home by continuing to feed and offer more fluids (including breast milk) to children when they are sick, by giving them appropriate home treatment for infections, and by taking appropriate action in case of injury or accidents. Households can prevent illness by disposing of faeces safely, and by washing hands after defecation, before preparing meals and before feeding children. They can bring their children for vaccination. In malaria-endemic areas they can ensure that children sleep under insecticide-treated bednets. Households and communities can take measures to prevent injuries and accidents. Much depends, though, on the environment in which members of poor households live. An example is indoor air pollution. Half of the world’s population rely on dung, wood, crop waste or coal to meet their most basic energy needs. In the highlands of western Guatemala, for example, most households use an open fire, fuelled by wood, for cooking and heating. Cooking with these so-called solid fuels leads Households can promote physical growth and mental and social development by ensuring exclusive breastfeeding for six months, by starting complementary feeding at six months of age and continuing breastfeeding until the child is aged two years or more. They can ensure that children receive adequate amounts of micronutrients either in their diet or through supplementation. They can also respond to a child’s needs for care through talking, playing and providing a stimulating environment. The entire household, including men, has a role to play. Households and communities can help prevent child abuse and neglect, and can take appropriate action when it has occurred. Households can improve adequate uptake of health care services by recognizing when sick children need treatment outside the home and seeking timely care from appropriate providers. It is important for households to take children as scheduled to complete a full course of immunizations before their first birthday, and to follow health workers’ advice about treatment, follow-up and referral. to levels of particulate matter that are 100 times higher than typical outdoor air concentrations in European cities. With little ventilation, the smoke makes breathing difficult, burns the eyes and covers the dwelling in black soot. Young children, often carried on their mothers' backs during cooking, are most exposed. Moreover, women and children often spend many hours collecting fuel – time that could be spent on education, child care or income generation. Lack of a good source of lighting limits educational activities beyond daylight hours. In the short term, well-designed stoves with chimneys can significantly reduce emissions and help protect children. But to reduce indoor air pollution drastically, it is necessary to switch to cleaner and more efficient fuels: liquid petroleum gas, electricity or solar power. Poor households often do not have the resources to do so, and this situation will continue until the roots of poverty are tackled. Box 6.2 How households can make a difference
redesigning child care: survival, growth and development 111 In Haryana, India, health workers provided counselling during immunization sessions and curative care consultations, while community health workers did the same during weighing sessions and home visits. This increased exclusive breastfeeding at three months, reduced rates of diarrhoea (40), improved complementary feeding practices at nine months of age(41), and increased uptake of curative and preventive health IMCI has focused much of its training and capacity-building efforts on the first contact level: the health centre, and the nurse or doctor who first sees the sick child or IMCI to work optimally, it has to build the continuum of care in two direction towards facilitating referral, and towards bringing care closer to households, and thus to children(see Figure 6.1) Referring sick children The focus on primary health care and more recently, on the role of households Figure 6.1 An integrated approach to child health themselves has often meant that child health programmes have overlooked how important it is to be able to refer a sick child to a well-functioning hospital This is important for the child and the child's family, but also for the front-line health workers: it can have a substantial impact on child mortality (43) Facilitating referral is straightforward, at least in principle, if a district system has been put in place. It does, however, depend on removing delays and obstacles that are Newtom careNutrtiancaunselling not always considered to be part of the lealth worker's responsibilities. Deaths in hospital often occur within 24 hours of admission. Many of these Manageme Antibiotics for deaths could be prevented if good of diamox quality care were provided in good time HEALTH FACILITIES To achieve this, dangerous delays must be avoided: first, by helping mothers or M C other caregivers identify early the sign which show that children need medical attention; second, by ensuring that publi health services are open when they are from the fields or from work. and when Integrated approaches are children feel ill(often in the evening) hild centred and tackle the third, by making sure that health problems comprehensively workers refer promptly when there is an indication to do so. Implementation of MCI guidelines should result in referral of 10% of children aged between two months and five years(44, 45 In many of the countries that have made little or Isolated vertical approaches only tackle part of the problem
redesigning child care: survival, growth and development 111 In Haryana, India, health workers provided counselling during immunization sessions and curative care consultations, while community health workers did the same during weighing sessions and home visits. This increased exclusive breastfeeding at three months, reduced rates of diarrhoea (40), improved complementary feeding practices at nine months of age (41), and increased uptake of curative and preventive health care services (42). IMCI has focused much of its training and capacity-building efforts on the first contact level: the health centre, and the nurse or doctor who first sees the sick child. For IMCI to work optimally, it has to build the continuum of care in two directions: towards facilitating referral, and towards bringing care closer to households, and thus to children (see Figure 6.1). Referring sick children The focus on primary health care and, more recently, on the role of households themselves, has often meant that child health programmes have overlooked how important it is to be able to refer a sick child to a well-functioning hospital. This is important for the child and the child’s family, but also for the front-line health workers; it can have a substantial impact on child mortality (43). Facilitating referral is straightforward, at least in principle, if a district system has been put in place. It does, however, depend on removing delays and obstacles that are not always considered to be part of the health worker’s responsibilities. Deaths in hospital often occur within 24 hours of admission. Many of these deaths could be prevented if goodquality care were provided in good time. To achieve this, dangerous delays must be avoided: first, by helping mothers or other caregivers identify early the signs which show that children need medical attention; second, by ensuring that public health services are open when they are needed, such as when parents are home from the fields or from work, and when children feel ill (often in the evening); third, by making sure that health workers refer promptly when there is an indication to do so. Implementation of IMCI guidelines should result in referral of 10% of children aged between two months and five years (44, 45). In many of the countries that have made little or HEALTH FACILITIES Seek vaccination Exclusive breastfeeding Warmth, care seeking HOME I M C I Outreach / Community activities Use of insecticide treated bednets Safer infant-feeding practices for HIV-positive mothers Home treatment of diarrhoea Care seeking Treatment of pneumonia Outreach for delivering vaccines Deliver essential Nutrition counselling vaccines Newborn care Promote exclusive breastfeeding Antimalarials Counselling on safer infant feeding practices Routine postnatal care Promote ORT for diarrhoea Promote HIV prevention, use of PMTCT services Insecticide treated bednet distribution COMMUNITY Key family behaviours Antibiotics for pneumonia and neonatal sepsis Isolated vertical approaches only tackle part of the problem Management of diarrhoea Management of diarrhoea Home treatment of diarrhoea Promote ORT for diarrhoea Integrated approaches are child centred and tackle the problems comprehensively Figure 6.1 An integrated approach to child health