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11.3 Child health

11.3 Child health
Oxford Textbook of Public Health

11.3
Child health

Carol Bellamy

The situation of children in the world
Development of the child
The challenge from experience gained

The World Summit for Children

Convention on the Rights of the Child
Mobilizing support for children in the future
Reduction in child mortality and morbidity

Immunization

Prevention and treatment of communicable diseases
Childhood disabilities

Malnutrition and disability

Rehabilitative care

Children and land mines
Role of the mother
Strengthening of child health services
Advocacy and communication for child health programmes
Mobilizing resources for children
Chapter References

The situation of children in the world
There have been major strides made in improving child health since the call for ‘Health for All by the Year 2000’ was first declared at the joint World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) meeting at Alma Ata in 1978 (WHO 1978). The period following the Declaration of Alma-Ata witnessed revolutionary gains in life expectancy. Among today’s high-income countries, life expectancy has increased by 30 to 40 years in the twentieth century. These health gains have transformed quality of life and created conditions favouring sustained fertility reductions and consequent demographic change. In many developing countries, for example, according to the WHO, the total fertility rate—the expected number of children a woman will bear over her lifetime—declined from over six in the late 1950s to about three at present. Life expectancy in developing countries today is greater that it was in any developed country at the start of this century (Murray and Lopez 1996).
The 1980s saw an acceleration of large-scale health projects in developing countries, focusing on immunization, control of diarrhoeal diseases, acute respiratory infections, and nutrition interventions. In the 1990s, clear and ambitious goals were established to reduce infant and child mortality rates and improve the overall well being and status of children in developing countries. Compared with 1990, a million more children now survive annually beyond their fifth birthday, polio is on the verge of elimination, and routine immunization coverage has reduced measles deaths by 85 per cent and deaths associated with neonatal tetanus by two-thirds. Mental retardation is no longer a risk for an estimated 12 million children every year as increasing numbers of people routinely consume iodized salt as part of their diet. In many parts of the world, children’s overall resistance to infectious diseases and debilitating illnesses has been strengthened through increasing vitamin A intake, and blindness related to vitamin A deficiency has declined sharply. Improved breast-feeding practices in numerous countries have increased the chances of survival, growth, and development of millions of children.
Yet, despite this progress, 12 million children under the age 5 years still die annually from easily preventable causes and some 200 million children still suffer from malnutrition. Deaths from communicable diseases are expected to climb from 28.1 million a year in 1990 to 49.7 million in 2020, an increase in absolute numbers of 77 per cent. According to recent studies on the burden of disease among the global poor, communicable diseases caused 59 per cent of the deaths and disability among the world’s poorest 20 per cent. Among the world’s richest 20 per cent, non-communicable diseases caused 85 per cent of death and disability (Gwatkin et al. 1999). Seven million children continue to die every year in developing countries from just four conditions: pneumonia, diarrhoeal diseases, measles, and malaria. Some 1.2 million children under 14 years old are living with HIV/AIDS, approximately 90 per cent of whom have become infected through mother-to-child transmission during late pregnancy, labour, childbirth, or breast feeding. In southern and eastern Africa, HIV/AIDS is the leading cause of death for children. The impact of AIDS in eroding the gains made in infant and child mortality rates in the past 20 years is a serious threat. At the end of 1999, 33.6 million people were living with HIV/AIDS, more than 95 of them in developing countries. HIV/AIDS is the leading cause of death in Africa where more that 23 million people have died. A major obstacle to combating AIDS is that many nations have been slow to acknowledge the extent of the epidemic, which has left millions of children orphaned, with significantly reduced life expectancies, swamped health care services, and crippled economies.
The burden of infectious diseases falls most heavily on people living in poverty. Certain diseases are re-emerging as epidemics such as meningococcal meningitis, dengue fever, and cholera. Nearly one-quarter of the world’s population, 1.3 billion people, continue to live in absolute poverty, earning less than US$41 per day. The 1993 World Development Report Investing in Health estimated loss of healthy life from over 100 of the most common diseases and injuries. Of the total global disease burden, 93 per cent is concentrated in low- and middle-income countries. The State of the World’s Children’s Report 2000 (UNICEF 1999b) noted that, in 1960, the income gap between the richest one-fifth of the world’s population and the poorest one-fifth was 30:1; in 1997, the gap was 74:1.
Children in many nations continue to be victims of war—losing their parents and their homes, losing their childhood and their opportunity for education, losing their limbs and their lives to the machinery of violence. Conflict-induced disruption in the public health system due to lack of adequate services and trained personnel willing to work in areas of conflict can severely affect the community. Interruption of immunization services is one of the most serious consequences of a fractured health system. This leaves children susceptible to rapid onset of diseases such as measles, but also the destruction of medical equipment and records, and lack of provision of services, can severely disrupt communities. To try to reduce the devastation as a result of the complete disruption of services and the impact on children who grow up in such chaos and violence, it is essential to ensure that some semblance of order is returned to their lives.
In the new millennium, more effort needs to be made to develop sustainable approaches to improve child health to reduce both mortality and morbidity if we are to ensure that children not only survive but also grow in a healthy environment with access to basic essential services. This calls for a more integrated approach to tackling child health and ensuring that communities and families are more actively involved in improving the health of their children and empowering them to be able to assist in this process. With the threat that is presently posed by HIV/AIDS and the likelihood that the disease will negate the gains made in child survival in large parts of the world, it is essential to develop a more integrated approach to address major health concerns. The challenge for the next 20 years is to ensure that mothers and children have access to the best health services that are available. This should include access to essential drugs and supplies, vaccines against all immunizable diseases, attendance by well-trained health professionals, access to the most recent and up-to-date health information, and a well-equipped health facility at a reasonable distance from their homes.
The most important and often neglected determinant of whether a child grows well or not is the quality of child care. Whether we are concerned with how well and how frequently a young child is fed, or about the degree of stimulation and interaction with parents, or about disease prevention and domestic hygiene, or use of health services and regular growth monitoring, the issue to which we are constantly returning is how well the child is cared for.
Although greater involvement by fathers in all countries and cultures is one of the most fundamental priorities for improving the care and upbringing of children, it is in practice the mothers who are the principal providers of care. However, regardless of how much a mother may care for her children, it is nearly impossible for her to provide high-quality child care if she herself is poor and oppressed, illiterate and uninformed, anaemic and unhealthy, has five or six other children, lives in a slum or shanty town, has neither clean water nor safe sanitation, and is without the necessary support from health services, from her society, or from the father of her children. We are therefore talking as much about care of the mother as care by the child. The care that is provided to a mother can determine the quality of child care and therefore the health and nutritional well being of children.
For the foreseeable future, hundreds of millions of children will continue to fall ill and will continue to be brought to clinics and health centres throughout the developing world. It is how those clinics, health workers, and families respond that will largely determine whether childhood illnesses will continue to seriously affect poor communities. At the moment, many health centres in developing countries are failing those children. Many die from preventable or treatable diseases even after they have been brought to clinics. And many parents leave without essential drugs and advice on how to prevent or treat the conditions that threaten the life and normal growth of their children. At all levels of primary care, health workers are too often badly trained, poorly supervised, underpaid, or absent from their posts. Parents with sick children may have to queue for hours, only to receive peremptory treatment or be told that no drugs are available. Also, there is often a weak system of referral for those cases where more qualified care is needed. It may be that this is due to cuts in government spending, perhaps as a result of economic adjustment programmes. Whatever the cause, the result is that many families in the developing world are abandoning public health services in favour of private practitioners who, in many cases, offer them the most expensive instead of the most appropriate treatment. Here, the opportunity for making available today’s effective, inexpensive treatments and provision of vital information and advice is lost. Without an improved response from health workers and health clinics throughout the poor world, it will not be possible to finish the job and bring the ordinary diseases of childhood under control.
About 80 per cent of all children are suffering from just one or more of five common conditions—diarrhoea, measles, respiratory infections, malaria, or malnutrition—for which the treatment is relatively inexpensive and the advice needed by parents is relatively straightforward. In addition to the continuing effort to prevent disease and to enable families themselves to protect their children’s health, the great challenge of the years immediately ahead is ensuring that any family taking a child to a clinic or health centre anywhere in the developing world will find a health provider who can examine and diagnose, make a decision on appropriate treatment, give basic drugs for the most common problems, refer the child to hospital if needed, and offer the right advice about how best to prevent and manage illness in the home.
Development of the child
Evidence suggests that early investments in development of the child can bring improvements in the life of a child and provide benefits to the entire society. Cumulative research indicates that most rapid mental growth occurs during infancy and early childhood and that, on the whole, the early years are critical in the formation and development of intelligence, personality, and social behaviour (Bundy 1996). Scientific research indicates that, given the decisive influence of children’s early stimulation on physical, psychological, and social development, primary school and kindergarten programmes (for children 4 to 5 years old) may be too late to counteract some physical, neurological, psychological, and social factors closely associated with early deprivation and lack of adequate stimulation.
Early childhood, here defined as from birth to 8 years, is a particularly crucial period (Bundy 1996) when physical and nutritional elements have their most profound consequences. During the later years of life, even where remediation is possible, the rate of improvement is reduced because of the relative slowing of subsequent development.
The importance of attention to the mother and to the well being of the family, including measures to increase the mother’s capacity to look after her children, building upon existing customs, is essential for early child survival and development. Survival, growth, and psychosocial and cognitive development are three intimately intertwined processes directed toward the overall well being of the child (UNICEF 1998). These processes occur simultaneously and mutually affect each other. The care that is provided to a child—by families, within communities, and/or through services and institutions—affects each of the child development outcomes. Survival is intimately connected with growth and development. The better the child’s quality of life (involving good health, growth, development, and active social participation), the greater the chances of her/his survival. The bigger and stronger the child, the more likely the child is to survive, enjoy good health, and develop well. Conversely, a child who is physically healthy and who is developing well mentally, emotionally, and socially is more likely to grow well because his or her food intake will be better.
Psychosocial and cognitive development is the beginning of a lifelong process of human development in which people (and children) learn to handle increasingly complex levels of moving, thinking, feeling, and relating to others. Such development involves moving from simple to complex and from dependent to autonomous behaviour. The more advanced the development of a child, the greater the potential of that child to participate actively in life’s events and to become empowered to affect others and the world around her. Attention to a child’s development in all its dimensions can help to increase survival and growth, even as it enhances development and the quality of life.
At a conceptual level, recognition is needed that fostering a child’s development affects survival and growth. There is general acceptance that health and nutrition must go together in order to affect survival, growth, and physical development, but we must now learn to include psychosocial (as well as physical) development in the equation (Eming Young 1994).
The challenge from experience gained
The World Summit for Children
The largest ever gathering of world leaders was held for the World Summit for Children (WSC), at the United Nations Headquarters in September 1990. Seventy-one heads of state or government, together with delegations from an additional 88 countries, met to consider the situation of children around the world and to issue a world declaration for children. The World Declaration and Plan of Action established a vision of a ‘first call’ for children by establishing seven major and 21 supporting health goals that were quantifiable and considered achievable by the year 2000 (Table 1 and Table 2).

Table 1 Major goals for child survival and protection

Table 2 Major supporting goals for child survival and protection

Convention on the Rights of the Child
The most widely ratified human rights treaty in history is the 1989 Convention on the Rights of the Child. The General Assembly of the United Nations adopted the text of the United Nations Convention, without modifications, on 20 November 1989. It entered into force as international law on 2 September 1990 after its ratification by the required 20 states. Today it is the most widely ratified human rights treaty in the world with all but two countries having ratified. The Convention is the most universally accepted human rights instrument in history—it has been ratified by every country in the world except two—and therefore it uniquely places children at the centre in the quest for the universal application of human rights. By ratifying this instrument, national governments have committed themselves to protecting and ensuring children’s rights and they have agreed to hold themselves accountable for this commitment before the international community.
Built on varied legal systems and cultural traditions, the Convention on the Rights of the Child is a universally agreed set of non-negotiable standards and obligations. It spells out the basic human rights that children everywhere—without discrimination—have. These are the right to survival; to develop to the fullest; to protection from harmful influences, abuse, and exploitation; and to participate fully in family, cultural, and social life. The Convention protects children’s rights by setting standards in health care, education, and legal, civil, and social services. These standards are benchmarks against which progress can be assessed. States that are party to the Convention are obliged to develop and undertake all actions and policies in the light of the best interests of the child.
The 54 articles of the Convention can be divided into four main parts. The key principles of the Convention are:
Box 1 Convention on the Rights of the Child

The Convention incorporates the full spectrum of human rights—civil, political, social, cultural, and economic—and the ways that these should be made available to children:

The definition of children as all persons less than 18 years of age, unless the legal age of majority in a country is lower.

Civil rights and freedoms, including the rights to a name and nationality; to freedom of expression, thought, and association; to access to information; and the right not to be subjected to torture.

Family environment and alternative care, including the right to live with parents, to be reunited with parents if separated from them, and to the provision of appropriate alternative care where necessary.

Basic health and welfare, including the rights of disabled children, the right to health and health care, social security, child-care services and an adequate standard of living.

The right to education, the aims of education, and the rights to play, leisure, and participation in cultural life and the arts.

Special protection measures covering the rights of refugee children, those caught up in armed conflicts, children in the juvenile justice system, children deprived of their liberty and children in the juvenile justice system, children deprived of their liberty, and children suffering economic, sexual, or other exploitation.

the right to survival and development

respect for the best interests of the child as a primary consideration

the right of the child to express his or her views freely

the right of all children to enjoy the rights of the Convention without any discrimination.
The Convention has been a major catalyst to the development of a children’s rights movement across the world. It has provided a shared vision of the fulfilment of children’s rights that has been accepted everywhere. However, deepening poverty, proliferating conflicts, the impact of HIV/AIDS, and rampant discrimination and disparities have stalled progress and further pose serious challenges to the improvement of the well being of children and the realization of their rights. Ten years after the World Summit, we should ensure that future actions for children are based on the commitments, unfinished business, and lessons of the past decade.
Mobilizing support for children in the future
Global health actions for children need to focus more on the reduction of child mortality, morbidity, and disability through the prevention and treatment of disease and illness in a more integrated way. The overarching aim of development co-operation for children should be to break the chains of disadvantage, impoverishment, and failed human development through actions that converge to promote capacities at critical times in the life of the mother and child.

In pregnancy, since women’s special reproductive health needs, especially in pregnancy, and child birth, have to be met if they are to fulfil their roles, especially with regard to family responsibilities, child care, and development—and if their children are to be born capable of achieving their full potential.

In infancy and early childhood, since food, health, care, socialization, stimulation, and education in the earliest years of a child’s life lay the foundation for subsequent human capabilities and development.

In early adolescence, since children at this age are innovative, energetic, and are already contributing significantly to the care and well being of their families and the life of their communities. Yet these are the years of childhood when millions of children are abandoned by the formal education system, have no recognized role or status, and are exposed to forms of violence, exploitation and high-risk behaviours that threaten both their own lives and the lives of others. And these are the years that heavily influence when and how well they will assume their responsibilities as the next generation of adults and parents.
At the operational level, through programmes of co-operation, the world needs to continue to focus on protecting children from various forms of preventable death. In addition, it should place new emphasis on developing policies, institutional capacities, and social practices that will enable poor children to have access to further opportunities and to overcome barriers to their healthy growth, emotional well being, and intellectual development.
Reduction in child mortality and morbidity
The world’s poorest populations live in the shadow of a group of old enemies—malnutrition, childhood infections, poor maternal and perinatal health, and high fertility. Approximately 65 per cent of all child deaths are from three causes (WHO 1999c).

Acute respiratory tract infection now kills 3.6 million children each year.

Diarrhoeal diseases are responsible for 3 million child deaths every year.

Immunization-preventable diseases: measles, tuberculosis, tetanus, diphtheria, polio, and pertussis are responsible for some 2.1 million child deaths every year. Of these, almost 1 million are attributed to measles.
Two hundred million children under the age of 5 years still suffer from malnutrition. Every year 7.5 million children die during the perinatal period, primarily due to poor maternal health care, and 30 per cent of the world is still without safe water and sanitation. One in every 48 women dies from pregnancy-related causes in low- and middle-income countries (585 000 deaths per year) compared with 1 in 4000 in higher-income countries (UNICEF 2000).
Early childhood exposure to undernutrition, micronutrient malnutrition (iron, iodine, vitamin A), or infection (diarrhoea, malaria) often results in long-term or irreversible retardation of physical and cognitive development. These conditions are particularly devastating to the poor, whose children enter adulthood and the workforce handicapped by early life experiences.
Effective large-scale health interventions, such as immunization, the use of oral rehydration for treatment of diarrhoea, and early recognition and proper case management for pneumonia, have had a greater impact on mortality in the age group 1 to 4 years than in the first year of life. The number of deaths due to neonatal tetanus has been cut by a third since 1990, and measles as well as polio cases by over 80 per cent. The replacement and transport of cold-chain supplies and the purchase of vaccines are becoming more difficult due do the current economic crises in many countries. In countries with weak health systems, the Extended Programme for Immunization coverage is not very stable and is dependent on outreach, mobile teams, and conducting national immunization days. Measles epidemics still occur in most countries outside South America, despite high coverage rates. Routine reporting of measles cases is still weak in many countries, making accurate assessment of progress very difficult. Elimination of neonatal tetanus is constrained by low tetanus toxoid coverage in some countries such as China. Child mortality due to diarrhoeal dehydration has globally been reduced by about 25 per cent, but in many countries and also in marginal groups within low-income countries, diarrhoea, acute respiratory infections, and malaria still cause high numbers of deaths in children under 5 years old.
Protein-energy malnutrition affects 30 per cent of children globally, which amounts to more than 160 million children. The vast majority of these children are found in Asia. South Asia has the highest level (nearly 50 per cent) followed by East Asia and Africa each having levels of around 30 per cent in their children under 5 years of age. China displays large differences between geographical areas and population groups. In Asia the levels of malnutrition are generally decreasing, and severe malnutrition is becoming rare. However, the rate of improvement is slow and does not match the corresponding rates of global economic development. In Africa the reported rates are actually increasing.
Levels of maternal malnutrition (chronic energy deficiency) are also very high but show large variations. Incidence of low birth weight is equally significant suggesting a close relationship between maternal health and nutrition factors and infant and child malnutrition. The promotion and certification of ‘baby friendly’ hospitals advocating for improved breast-feeding practices has continued successfully in some countries. Despite very high rates for initiating breast feeding, exclusive breast-feeding rates remain low in many countries. Many countries have improved their high vitamin A supplementation coverage rates, especially of young children, often to over 90 per cent. Despite the capacity to iodize all edible salt in most countries, the key remaining challenge is to ensure that iodized salt is used by families in a sustainable way and to monitor the quality of iodization.
Immunization
Although vaccines are one of the most cost-effective ways in which to reduce child mortality, many children in the poor areas of the world do not have access to childhood vaccines. In some countries, only 30 per cent of children may be vaccinated (Fig. 1). Even fewer children have access to the recently licensed and expensive vaccines that are likely to have a major additional impact on decreasing child mortality such as vaccine for Haemophilus influenzae type B. This type has been shown to be a major cause of bacterial pneumonia in children and a significant cause of childhood meningitis. It is estimated to cause at least 3 million cases of serious disease and 400 000 to 700 000 deaths worldwide each year, in young children (WHO 1998).

Fig. 1 Vaccines licensed since 1900.

Immunization has been one of the greatest public health success stories. Between 1980 and 1990, a massive effort raised coverage rates worldwide from 5 to 80 per cent. Deaths from six major childhood diseases (measles, tetanus, whooping cough, tuberculosis, polio, and diphtheria) have been slashed by 3 million a year. At least 750 000 fewer children are left blind, paralysed, or mentally disabled. Due to a successful global eradication campaign, polio is expected to follow smallpox into extinction by the year 2005, eliminating the need for vaccination and saving the governments of the world US$1.5 billion in vaccines, treatment, and rehabilitation costs every year. The campaign against polio has not only reduced the threat of the disease, but has also galvanized political commitment, brought in extra funding, and has increased awareness of the importance of routine immunization and other basic child health measures. For instance, countries are using National Immunization Days as an opportunity to distribute vitamin A supplements widely. Immunization and high-quality surveillance need to continue for a number of years after the last polio case has been detected before a region, and then eventually the world, is certified free of polio, and viruses are contained. The target date for certification of the world as polio free is 2005.
Box 2 World Summit for Children Goals for Immunization

The World Summit for Children set an end 1999 goal of achieving 90 per cent immunization coverage for children under 1 year of age against the six major child hood diseases as well as against tetanus for women of child-bearing age. The mid-decade goal of 80 per cent coverage has been reached and sustained. About 89 countries had achieved the end 1999 goal of 90 per cent by 1995. While overall coverage rates have been good, there is wide disparity between countries and several sub-Saharan countries have coverage rates below 50 per cent. Lessons learned include the following.

Immunization efforts were sustained where there was planning and implementation at the local level with active support from national and subnational programme managers.

The efforts made in the late 1980s to reach universal childhood immunization (UCI) goals led to coverage in the 1990s being at a much higher level than it would have been without such a global effort.

Effective partnerships were developed between public and private sectors, between non-governmental organizations and governments as well as donors, and these were instrumental in raising the programme profile and committing everyone to a common outcome.

The immunization programme strengthened primary health care programmes in many countries and became the vehicle for providing further child health interventions.

However, despite the low cost of the existing immunization package, many of the world’s poorest children are not being reached, especially in sub-Saharan Africa. Many developing countries made spectacular progress throughout the 1980s but are finding it difficult to keep the momentum and to go the extra mile needed to reach the remaining children.
The Children’s Vaccine Initiative, launched in 1990 (Fig. 2), aimed to improve the world’s supply of existing vaccines. It was the idea of five sponsoring agencies: WHO, UNICEF, UNDP, the Rockefeller Foundation, and the World Bank. The initiative stimulated a global dialogue among governments, donors, and vaccine manufacturers, researchers, and immunization programme managers. The initiative encouraged governments to assume responsibility for their own vaccine needs. Many developing countries now procure more than half the vaccines used for national immunization programmes.

Fig. 2 The widening gap immunization gap: number of vaccines used in industrialized and developing countries (GAVI 2000).

Newer vaccines, such as those for hepatitis B, Haemophilus influenzae type B, and yellow fever are now widely used in developed countries. While children in developing countries may have access to six or seven vaccines, children in industrialized countries can now expect to receive 11 or 12. Thus the gap between rich and poor children is widening.
In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was formed. Members of GAVI include the WHO, UNICEF, the World Bank, representatives from bilateral agencies, the Rockefeller Foundation, the Bill and Melinda Gates Children’s Vaccine Programme, and representatives from industry. The aim is to go beyond the goals of the Children’s Vaccine Initiative to provide support to the poorest countries for the introduction of new vaccines and stimulate the necessary research and finance for the development of new vaccines. GAVI has established five strategic objectives: improve access to sustainable immunization services; expand the use of all existing, safe, and cost-effective vaccines where they address a public health problem; accelerate the development and introduction of new vaccines and technologies; accelerate research and development efforts for vaccines needed primarily in developing countries; make immunization coverage a centrepiece in development efforts.
Box 3 Global Alliance of Vaccines and Immunization (GAVI) milestones, 2000

During 2000, GAVI presented an analysis of current market and policy failures concerning levels of research, development, and commercialization of candidate vaccines for HIV/AIDS, malaria, and tuberculosis and made recommendations to overcome these problems

By 2005, 80 per cent of developing countries will have routine immunization coverage of at least 80 per cent in all districts

By 2002, 80 per cent of all countries with adequate delivery system will introduce hepatitis B vaccine and all countries by 2007

By 2005, 50 per cent of the poorest countries with a high burden of disease and adequate delivery systems will have introduced Haemophilus influenzae type B vaccine

Strengthening of immunization services—as part of a comprehensive strategy to reduce child mortality and morbidity—will continue to play a major role in the promotion of early childhood care for child survival, growth, and development. However, governments need to ensure that strategies for immunization are informed by the lessons learned from the successes and shortcomings of programmes in the 1980s and 1990s, and are designed to contribute to strengthening health systems and overall health reform processes. It is also essential to ensure that immunization services are integrated with other important interventions such as improved breast-feeding practices, provision of micronutrients, and control of infectious diseases.
Prevention and treatment of communicable diseases
Until sufficient high-quality vaccines are available to protect against all major fatal diseases, countries must continue to exert efforts to prevent and treat communicable diseases seriously affecting children such as HIV/AIDS, malaria, diarrhoeal diseases, acute respiratory infections, and tuberculosis.
HIV/AIDS (see also Chapter 9.14)
HIV/AIDS is today the world’s most rapidly spreading infectious disease for which science still has no cure. HIV/AIDS has reversed the survival, health, and wider human development gains of many countries and will continue to negatively affect all aspects of community life and children’s well being in the regions most heavily affected for decades to come. Some 5.8 million people are newly infected each year. Nearly 12 million children have already been orphaned, mostly in Africa, and 50 per cent of all new infections are among young people aged 10 to 24 years. By the end of 1999, 33.6 million people worldwide were living with HIV, a 10 per cent increase over just a year before. According to UNAIDS/WHO estimates (UNAIDS/WHO 1999), 11 men, women, and children around the world were infected per minute during 1998, or 16 000 a day and close to 6 million people in all. Almost half of the new infections were in young people aged 15 to 24 years, and the epidemic is increasingly affecting women, young people, and children. Ninety-five per cent of HIV infections occur in developing countries.
In 1998, 43 per cent of all people over 15 years of age living with HIV/AIDS were women, up from 41 per cent the previous year. Mortality in infants and children under 5 years of age is expected to increase exponentially in the worst affected countries over the next years. Nearly 4.5 million children below the age of 15 years have been infected with HIV since the AIDS epidemic began, and more than 3 million of them have already died of AIDS. Today, on a global scale, children are becoming infected at about the rate of one child every minute of every day. In 1998, one in ten of all new infections was a child, and the vast majority of them acquired the virus from their infected mothers. Though Africa accounts for only 10 per cent of the world’s population, it is home to 90 per cent of the world’s HIV-infected children, largely as a consequence of high fertility rates combined with very high levels of HIV infection among women. However, the number of cases in India, China, and South-East Asia is rising rapidly.
The effects of the epidemic among young children are serious and far-reaching. AIDS threatens to reverse years of steady progress in child survival achieved through such measures as the promotion of breast feeding, immunization, and oral rehydration. UNAIDS believes that, by the year 2010, AIDS may have increased mortality of children under 5 years of age by more than 100 per cent in regions most affected by the virus. In Harare, Zimbabwe, for example, the death rate among infants in their first year of life increased from 30 to 60 per 1000 between 1990 and 1996. Deaths among 1- to 5-year-olds, the age group in which the bulk of child AIDS-related deaths are concentrated, rose even more sharply—from eight to 20 per 1000—in the same period. In a growing number of countries, AIDS is now the greatest single cause of child death.
Mother-to-child transmission is by far the largest source of HIV infection in children below the age of 15 years (De Cock et al. 2000). In countries where blood for transfusion and blood products are regularly screened, and where clean syringes and needles are widely available in health centres and hospitals, mother-to-child transmission is virtually the only source of infection in young children. Therefore the extremely high rate of HIV infection among women of child-bearing age in some parts of the world—and the increasing risk of infection among women everywhere—is doubly concerning.
According to data from UNAIDS, there are very few places outside sub-Saharan Africa in which the prevalence of HIV infection among pregnant women has reached 10 per cent, let alone the extremely high figures seen in this region. However, this is partly because the epidemic in other badly affected countries is younger and less advanced than in sub-Saharan Africa.
The virus is spreading fastest among young people below the age of 24 years—at the peak of fertility. In places where the virus is spread predominantly through heterosexual intercourse—notably sub-Saharan Africa—young women outnumber young men among those becoming infected. Studies sponsored by UNAIDS show that in western Kenya nearly one girl in four between the ages of 15 and 19 years is living with HIV compared with one in 25 boys in the same age group. In Zambia in this age range, 16 times as many girls as boys are infected. Among 20- to 24-year-olds in rural Uganda, there are six young women who are HIV positive for every infected young man. It is these high rates of infection, coupled with high rates of pregnancy among women, that explain why Africa is also currently home to the vast majority of HIV-positive children.
The virus may be transmitted during pregnancy, childbirth, or breast feeding. Where no preventive measures are taken, the risk of a baby acquiring the virus from an infected mother ranges from 15 to 25 per cent in industrialized countries (most estimates are below 20 per cent), and from 25 to 45 per cent in developing countries (most estimates are between 30 and 35 per cent) (De Cock et al. 2000). Evidence suggests that the risk of transmission increases when the mother has a higher viral load (this is the case when a person is newly infected with HIV or is in an advanced stage of disease), or if the baby is highly exposed to the mother’s infected body fluids during birth.
The difference in risk between developing and developed countries is due largely to feeding practices. Breast feeding is more common and usually practised for a longer period in developing countries than in the industrialized world. It is estimated that a child born uninfected to an HIV-positive mother has a 20 per cent chance of acquiring the virus from her milk if he or she is breast fed. In places where breast feeding is the norm, this route may account for more than one-third of mother-to-child transmissions of the virus.
Since there is a possibility of transmitting HIV through breast feeding, replacement feeding is an option for mothers. If an HIV-infected mother has access to an adequate supply of breast-milk substitutes, knows how to use them, has access to fuel and clean water, and the time to prepare breast-milk substitutes safely, refraining from breast feeding will reduce the risk of transmitting HIV through breast feeding. In countries where families live in poverty, have limited education, and poor access to the resources required to provide safe feeding alternatives to breast feeding, including counselling, the risk of death from diarrhoea, respiratory, and other infections associated with replacement feeding can be as great or greater than the risk of transmitting HIV through breast feeding.
Even if a mother has the means to feed her baby safely with a breast-milk substitute, she may face other dilemmas. In cultures where breast feeding is the norm, the very fact that she chooses not to breast feed may draw attention to her HIV status and invite discrimination or even violence and abandonment by her family and community.
In August 1997, the WHO, UNICEF, and UNAIDS issued a Joint Policy Statement on HIV and infant feeding. They subsequently prepared guidelines to help national authorities to implement the policy. These documents emphasize that it is the individual mother’s right to decide how she will feed her child. The responsibility of health or social work professionals, who counsel HIV-positive women about infant feeding, is to give them the fullest available information on the risks associated with breast feeding. They should discuss breast feeding’s feasibility and alternative feeding methods in the light of personal circumstances and give appropriate support to these women, for the course of action they choose. Women should have easy access to voluntary and confidential counselling and testing for HIV. Since the majority of pregnant and lactating women attending clinics are likely to be HIV negative, information on how to protect themselves from infection is also a vital component of routine care.
Breast feeding has been the cornerstone of child health and survival strategies for the past two decades and has played a pivotal role in reducing infant mortality in many countries. Even in the era of AIDS, breast feeding remains the best possible nutrition for the great majority of babies and it is important that the practice by women who are HIV negative or whose HIV status is unknown continues actively to be promoted, protected, and supported.
The recent study conducted in South Africa by Coutsoudis et al. (1999) suggested that children of HIV-infected mothers who are exclusively breast fed in their first 3 months of life are at no greater risk of contracting HIV than children fed solely on breast-milk substitutes. The Coutsoudis study looked at infant feeding in 549 women for 3 months after birth. At 3 months, there was no significant difference between the proportion of infants who became infected between the group which received any breast feeding (21.3 per cent) and those who were never breast fed (18.8 per cent). When the breast-fed group was divided according to whether the breast feeding was exclusive or partial, the infants who were exclusively breast fed from birth to 3 months had a significantly lower rate of infection (14.6 per cent) than those who received partial breast feeding along with other drinks or foods. Most of the experts that UNICEF has consulted regarding this study concede that it is very important, and that it certainly gives an indication that exclusive breast feeding may be protective. They caution, however, that because of limitations in the study design, notably the danger that the group of women who exclusively breast fed were not strictly comparable to the women who used formula, further studies are needed before the present policy adopted by the WHO, UNAIDS, and UNICEF is changed.
There are three complementary strategies for preventing mother-to-child transmission of HIV.

The protection of children and women from HIV infection. This will minimize the risk that women of child-bearing age are carrying the virus in the first place. The strategy is sometimes referred to as ‘primary prevention’. It involves promoting safe and responsible sexual behaviour in couples, providing them with knowledge about HIV/AIDS and how to prevent infection. It also means providing good-quality user-friendly prevention and treatment programmes for other sexually transmitted diseases, the presence of which increases the risk of HIV transmission up to 10-fold. Crucially, it means taking steps to deal with the cultural, legal, and economic factors that make girls and women especially vulnerable to HIV infection by limiting their autonomy and power to protect themselves.

The provision of efficient and accessible family planning services to enable women to avoid unwanted pregnancies and births. The aim is to ensure informed reproductive choice.

An integrated package of measures consisting of voluntary and confidential HIV counselling and testing, the provision of antiretroviral drugs for HIV-positive pregnant women (and sometimes their babies), counselling on infant feeding, and support for the feeding method(s) chosen by the mother. This package is often referred to as the antiretroviral drug strategy.
Until recently primary prevention measures and the provision of family planning were virtually the only options for limiting the number of HIV-infected children. However, in 1994, researchers in France and the United States reported the results of a major collaborative study (Connor et al. 1994) of mother-to-child transmission of HIV that offers a complementary strategy for HIV-positive women who want to give birth. The scientists found that when the antiretroviral drug zidovudine is given to HIV-positive women orally five times daily from the 14th week of pregnancy onwards, and intravenously during labour, and administered to their infants for 6 weeks after birth, the risk of transmitting HIV from mother to child is reduced by over two-thirds if breast feeding is avoided. However, the regimen is costly (approximately US$1000 per mother and child pair), and it is long and complicated to administer, which means that it is unsuitable for widespread use in developing countries.
Early in 1998, trials in Thailand sponsored by the country’s Ministry of Public Health and the US Centres for Disease Control and Prevention (Shaffer et al. 1999) showed that a shorter and simpler course of zidovudine is able to cut the rate of mother-to-child transmission of HIV by at least half if the baby is not breast fed. The infection rate was just above 9 per cent compared with a rate of 19 per cent for babies of infected mothers who did not take antiretrovirals, but who also avoided breast feeding.
A study sponsored by the HIV Prevention Trials Network, supported through the American government, was conducted in Uganda to investigate the effectiveness of oral nevirapine and oral zidovudine administered to pregnant HIV-infected women during labour and to their infants during the first week of life (Guay et al. 1999). The study measured the number of new HIV infections in the infant. At 6 to 8 weeks of age, 11.9 per cent of infants in the nevirapine group were HIV infected compared with 21.3 per cent of infants in the zidovudine group. At 14 to 16 weeks of age, 13 per cent of infants in the nevirapine group were infected compared with 25 per cent in the zidovudine group. Ninety-five per cent of infants were breast fed to 14 weeks or longer.
The results of the study indicate that nevirapine is a low-cost drug that can achieve a superior reduction of transmission with only a single dose to the mother and a single dose to the baby within 3 days of birth. The nevirapine regimen costs around US$4 for each mother and child, and the drug can be easily stored in hot climates. Long-term follow-up of both the mothers and babies remain a high priority to assess any late drug toxicities as well as long-term survival (NIH 1999).
Box 4 Zambia needs more help to tackle HIV/AIDS

Zambia, like its neighbours in sub-Saharan Africa, is grappling to cope with the devastating impact of the HIV/AIDS pandemic. It is estimated that one in five adults in Zambia is HIV positive and that by 1997, there were already 360 000 children under the age of 15 years who had lost their mother or both their parents to AIDS. The number of orphans is likely to increase, as more parents become ill and die

A country already crippled by poverty and debt, Zambia is facing overwhelming challenges, as a generation of young people prepare to grow up without the love and support of their parents. Furthermore, many children experience the pain of watching their parents die one after the other. Although the majority of orphans are still being absorbed by the extended family, the number of children living or working on the streets is estimated at more than 90 000 and growing. UNICEF is working with the Zambian Government and non-governmental organizations to tackle the crisis. Efforts are underway to develop policies and strategies to increase the ability to cope with the disease. But preventing the further spread of HIV/AIDS and finding sustainable support for these children requires a dramatic increase in resources and political will from the international community

Programming needs to focus more on increasing youth participation in decision-making, promoting their rights and access to appropriate information and services, and creating supportive environments to reduce risk and vulnerability to HIV/AIDS. Voluntary and confidential counselling and testing are key elements in HIV prevention programmes targeting young people, and are services to which young people have a right to regular access. A number of priority actions are recommended for improving and accelerating the use of HIV counselling and testing with young people in the region, including improving understanding of the impact of HIV/AIDS on young people and expanding key services.
It is important to focus on identifying approaches that enable orphans with AIDS to remain within the community, especially approaches that strengthen families’ capacity to cope and to find alternative models of care. Particular emphasis should be given to monitoring the impact of HIV/AIDS by identifying vulnerable children and improving orphan registration schemes, ensuring that children and families have access to essential health and social services, and co-ordinating the efforts of local organizations to provide practical support to children affected by AIDS.
Many countries, especially in Africa, are supporting the development of life skills and health education curricula, training of teachers and the production of materials for children with HIV/AIDS and children from families affected by HIV/AIDS, and to ensure that pregnant schoolgirls remain in school in a safe non-discriminatory environment. It becomes increasingly important to understand the socioculturally constructed gender roles of men and women in order to combat the causes and consequences of HIV/AIDS.
Communication is a critical tool for strengthening HIV/AIDS prevention and care, tackling stigma and discrimination, and addressing the social and cultural norms that influence sexual behaviour. Communication programming includes policy dialogue at global and national levels, to ‘break the conspiracy of silence’, emphasize the concerns of children, youth and women, and promote the rights of children and young people.
Malaria
This formidable tropical parasitic disease kills at least a million people annually, three-quarters of them children. Between 300 million and 500 million people suffer acute episodes of malaria in 100 developing countries each year. Of the more than a million people who die of malaria-related causes each year, 90 per cent are in Africa. This is a disease that is a major factor in Africa’s high rate of infant and maternal mortality, the single largest cause of low birth weight among newborns, and the leading cause of school absenteeism, as well as low productivity in farming and other industries. The spread of chloroquine resistance in many countries, especially in Africa, has diminished the effectiveness of treatment with the most widely used drug leading to the risk of persistent parasitaemia and anaemia in young children (Shapira et al. 1993).
Malaria during pregnancy is a major public health problem in endemic areas, where pregnant women are the main adult risk group. Plasmodium falciparium infection during pregnancy has adverse health consequences for both the mother and her newborn. Non-immune pregnant women are at increased risk of severe malaria and death, spontaneous abortions, and stillbirths. In highly endemic areas where adults have a relatively high level of acquired antimalarial immunity, the risk of malaria is greatest during first and second pregnancies, with a gradual decrease in risk with subsequent pregnancies except in the presence of HIV infection. In these areas, malaria infection contributes to (severe) anaemia during pregnancy, putting the woman at risk of haemorrhage and death. Maternal anaemia and P. falciparum infection of the placenta increase the risk of low birth weight, the single greatest risk factor for neonatal mortality. Malaria in Africa is estimated to cause up to 15 per cent of maternal anaemia and 35 per cent of preventable low birth weight. HIV-infected pregnant women suffer from higher malaria parasite prevalence and densities at all parities, and infant mortality is increased. More detailed discussion of malaria in pregnancy can be found in Brabin (1991), Menendez (1995), Steketee et al. (1996), Nahlen (2000), USAID (2000), and WHO (2000b), and in Annals of Tropical Medicine and Parasitology, Vol. 93, Supplement 1, 1999.
For children, wherever malaria is common and access to diagnostic facilities scarce, it is important to treat any fever as if it were malaria. A full course of a recommended antimalarial drug should be given to the child immediately, even if the fever disappears rapidly. If treatment is not completed, malaria could recur and become more difficult to treat. Children with severe malaria symptoms such as fever or convulsions should be taken to a health facility as their case may be becoming complicated and they should be given extra liquids and food. Someone suffering from malaria should have prompt access to correct and affordable treatment within 8 hours of the onset of symptoms and should have access to a well-supplied and properly functioning health centre. Where this is not possible, governments will need to balance carefully the benefits against the risks of making good first-line malaria treatment readily available through shops or community organizations, which may be more accessible and less likely to run out of supplies.
Several field trials have evaluated the effectiveness of bed nets as a malaria prevention strategy. A meta-analysis of published reports of field trials that measured the incidence of infections was performed to provide a measure of the effectiveness of insecticide-treated bednets in preventing clinical malaria. Subset analyses were performed on 10 field trials to calculate pooled incidence rate ratios of infection among the study groups. The results showed that insecticide-impregnated bednets are effective in preventing malaria, decreasing the incidence rate ratio by approximately 50 per cent in field trails performed to date (Choi et al. 1995).
The WHO standard protocol was developed specifically for the testing of the therapeutic efficacy of antimalarial drugs against clinical infections with P. falciparum in infants and young children in areas of intense transmission (WHO 1996). It is based on the practical evaluation of a draft protocol, carried out in May 1996 by an international group of malaria workers in a district of Tanzania through a consensus of participants of meetings, intercountry workshops, and of several international malaria experts. It should be applied wherever a drug policy needs to be developed or revised with the intention of effective implementation and evaluation, and it implies the availability of appropriate antimalarial drugs at all levels of the health care system.
The impact of HIV/AIDS has compounded the crisis of malaria. Malaria affects most of the same desperately poor countries that are also reeling from the HIV/AIDS pandemic. Indeed, in many ways, Africa’s future development is inextricably linked to the success of malaria and HIV/AIDS prevention and control. Malaria is a disease of poverty. It afflicts primarily the poor, who tend to live in malaria-prone areas, in dwellings that offer few, if any, barriers against mosquitoes. By sapping peoples’ health, strength, and productivity, malaria generates still more poverty.
There is also a growing consensus on the need to expand malaria prevention and treatment programmes beyond the health infrastructure into communities and homes. The Roll Back Malaria Initiative, led by the WHO, the UNDP, the World Bank, and UNICEF, emphasizes the importance of forming strong partnerships—an objective to which UNICEF is committed. In recent years, there has been increasing involvement by a wider range of sector ministries and non-governmental and community organizations—and the pledging of more national and international financial resources.
Governments are helping by encouraging the commercial sector to make quality nets and insecticide more affordable and more available. They do this through a combination of incentives, such as exempting materials and manufacturing equipment from taxes and import duties, through tax credits for industries that wish to expand, and by creating demand for nets and insecticide through effective communication strategies.
Diarrhoea
Despite many advances, diarrhoeal diseases and the resulting dehydration continue to be responsible for 3 million child deaths every year. Approximately 50 per cent of these deaths are due to watery diarrhoea (WHO 1999a). This occurs either because of lack of access to oral rehydration solution and/or health facilities, or because of incorrect case management (home or health facility). Persistent diarrhoea (approximately 35 per cent) and dysentery (approximately 15 per cent) account for the remainder. While there are numerous diarrhoea-causing organisms, studies have shown that there are five organisms (WHO 1999a) primarily responsible: rotavirus was shown to be the only frequently isolated viral enteropathogen, Escherichia coli, Shigella, and Campylobacter jejuni were the most frequently isolated bacteria, and Cryptosporidium was the most frequent protozoan cause of diarrhoea.
It is most practical to base treatment of diarrhoea on the clinical type of the illness, which can easily be determined when a child is first examined. Laboratory studies are not needed. Four clinical types of diarrhoea can be recognized, each reflecting the basic underlying pathology and altered physiology (WHO 1999a).

Acute watery diarrhoea (including cholera) which lasts for several hours or days: the main danger is dehydration; weight loss also occurs if feeding is not continued.

Acute bloody diarrhoea, which is also called dysentery: the main dangers are intestinal damage, sepsis, and malnutrition; other complications, including dehydration, may also occur.

Persistent diarrhoea which lasts 14 days or longer: the main danger is malnutrition and serious non-intestinal infection; dehydration may also occur.

Diarrhoea with severe malnutrition (marasmus or kwashiorkor): the main dangers are severe systemic infection, dehydration, heart failure, and vitamin and mineral deficiency.
Diarrhoea is the passage of watery stools, usually more than three times in a 24-h period. However, it is the consistency of the stools rather than the number that is most important. Frequent passing of formed stools is not diarrhoea. Babies fed only breast milk often pass loose ‘pasty’ stools; this also is not diarrhoea. Mothers usually know when their children have diarrhoea and may provide useful working definitions in local situations. The management of each type of diarrhoea should prevent or treat the main danger(s) that each presents. Diarrhoea causes rapid depletion of water and sodium—both of which are necessary for life. If the water and salts are not replaced fast, the body starts to ‘dry up’ or become dehydrated. If more than 10 per cent of the body’s fluid is lost, death occurs.
Diarrhoea can be prevented by pursuing multisectoral efforts: improving access to clean water and safe sanitation, promoting hygiene education, exclusive breast feeding, improved complementary feeding practices, immunizing all children especially against measles, using latrines, keeping food and water clean, washing hands with soap before touching food, and sanitary disposal of stools. The common thread that links these infectious diseases is the nutrition of the mother and child. Malnutrition predisposes children to disease, and diseases often result in worse nutritional status, and consequently a vicious circle of cause and effect is established.
Acute respiratory infections
Most children have about four to eight acute respiratory infections each year. Children with respiratory infections account for a large proportion of patients seen by health workers in health centres. These infections tend to be even more frequent in urban communities than in rural areas. Respiratory infections are infections in any area of the respiratory tract, including the nose, middle ear, throat (pharynx), voice box (larnyx, windpipe, trachea), air passages (bronchi or bronchioles), and lungs. Many areas of the respiratory tract can be involved, and there can be a wide variety of signs and symptoms of infection. These include cough, difficult breathing, sore throats, runny nose, and ear problems. Fever is also common in acute respiratory infections. Fortunately, most children with these respiratory symptoms have only a mild infection, such as a cold or bronchitis (WHO 1995).
A systematic and comprehensive study was carried out from 1991 to 1995 to identify interventions likely to be effective, feasible, and affordable for the prevention of childhood pneumonia. This study was also conducted in collaboration with the London School of Hygiene and Tropical Medicine, building on the methodological experience gained earlier (Kirkwood et al. 1995). Four interventions were found to be highly effective: reducing the prevalence of underweight and low birth weight, increasing measles immunization coverage, increasing breast feeding, and reducing indoor pollution. Improved breast-feeding practices are considered effective for prevention of childhood pneumonia. Breast feeding has long been believed to protect against acute respiratory illness in infants but studies have not consistently demonstrated that there is protection against infection. Victora et al. (1998) found that, in all regions except Latin America, interventions to prevent malnutrition and low birth weight appeared more promising than breast-feeding promotion. In Latin America, breast-feeding promotion appeared to have a similar effect to that of increasing birth weight. However, other more recent studies (Cushing et al. 1998) have indicated that breast feeding can reduce the severity of illness due to acute respiratory infection. One study (Cesar et al. 1999) found that breast feeding protects young children against pneumonia, especially in the first months of life. These results may be used for targeting intervention campaigns at the most vulnerable age groups.
Box 5 Outcome of review of interventions to prevent childhood deaths from pneumonia (1991–1995)

High effectiveness (potential impact more than 10 per cent)

Pneumococcal vaccines

Respiratory syncytial virus vaccines

Reduction of indoor pollution

Reduction of low birth weight

Reduction of underweight
Medium effectiveness (potential impact 5–10 per cent)

Increase in measles immunization

Haemophilus influenzae type B vaccine

Increase in breast feeding (Latin America only)

Some interventions showed no evidence of impact on pneumonia mortality or morbidity including:

use of antibiotics for upper respiratory tract infections (although such use is widespread)

prophylactic use of antibiotics in severely malnourished children

vitamin A supplementation (except in relation to measles-associated pneumonia)

treatment of helminth infections

reduction of environmental tobacco smoke (although this is clearly implicated in other acute respiratory infections and childhood asthmas in developed countries).
Tuberculosis
Tuberculosis is a contagious disease. Like the common cold, it spreads through the air. Only people who are ill with pulmonary tuberculosis (tuberculosis of the lungs) are infectious. When infectious people cough, sneeze, talk, or spit, they propel tuberculosis germs known as bacilli into the air. A person needs only to inhale these to be infected. Left untreated, each person with active tuberculosis will infect on average between 10 and 15 people in each year. But people infected with tuberculosis will not necessarily become ill with the disease. The immune system ‘walls off’ the tuberculosis bacilli which, protected by a thick waxy coat, can lie dormant for many years. When someone’s immune system is weakened, the chances of becoming ill are greater. Sputum smear microscopy is the most cost-effective method of screening pulmonary tuberculosis suspects referred to health services. It identifies sputum smear positive, highly infectious tuberculosis cases. Tuberculosis is diagnosed using patient history, clinical examination, and diagnostic tests. A sputum sample is submitted to the laboratory and the results of the microscopic examination are entered into the laboratory register. The goal is for all suspects to have a sputum smear microscopy examination and for all patients diagnosed with tuberculosis to be registered and treated (WHO 2000a).

Someone in the world is newly infected with tuberculosis every second.

Nearly 1 per cent of the world’s population is infected with tuberculosis each year.

Overall, one-third of the world’s population is infected with the tuberculosis bacillus.

Five to ten per cent of people who are infected with tuberculosis become ill or infectious at some time during their life.
Tuberculosis is the single largest killer of young women in the world, taking the lives of 750 000 each year as well as 250 000 children (UNICEF 2000). In addition to being a deadly killer, the stigma of tuberculosis often results in women being ostracized by their families and communities, which in turn has a devastating impact on the well being of their children. The result is that many thousands of upwardly mobile families are driven back into poverty, while those families that were already impoverished must struggle even harder just to survive. Children are especially vulnerable to the effects of tuberculosis, which is often difficult to diagnose in young children and therefore difficult to treat effectively. Children also suffer serious social consequences when someone in their family has tuberculosis. In India, for example, over 300 000 children are withdrawn from school each year either to go to work or to help their families bear the costs of tuberculosis care.
The method of directly observed treatment—short course (DOTS) has proved to be a successful, innovative approach to tuberculosis control in countries such as China, Bangladesh, Vietnam, Peru, and countries of West Africa (WHO 1999b). However, new challenges to the implementation of DOTS include health sector reforms, the worsening HIV epidemic, and the emergence of drug-resistant strains of tuberculosis. Short-course chemotherapy refers to a process treatment regimen lasting 6 to 8 months and uses a combination of powerful antituberculosis drugs. Standardized regimens are based on whether the patient is classified as a new case or a previously treated case. The most common antituberculosis drugs used are isoniazid, rifampicin, pyrazinamide, streptomycin, and ethambutol. Drug treatment of each patient needs to be observed for at least the first 2 months (WHO 1999b).
DOTS has been heralded as a breakthrough, and the achievements of such programmes in a wide range of settings are undoubtedly impressive. Globally, however, it is estimated that only 15 per cent of smear-positive tuberculosis cases are treated under a DOTS programme as recommended by the WHO. Coverage remains low because ‘short-course’ treatment is nonetheless protracted, and the burden of DOTS on patients and health services is quite substantial. Moreover, because marginalized groups such as women and migrant workers have difficulty in complying with DOTS, and incomplete treatment facilitates the spread of drug resistance. There is a danger that concerns about the spread of resistance and a desire to maintain high cure rates might lead to the exclusion of the poorest from tuberculosis programmes, which would exacerbate inequalities in health
Malnutrition
Malnutrition plays a very significant direct or indirect role in more than half of the nearly 12 million deaths each year of children under five in developing countries. It has multiple causes, including a lack of food, common and preventable infections, inadequate care, and unsafe water. In turn, malnutrition itself also exacerbates the symptoms of preventable illnesses. Strategies and interventions to improve the nutritional status of women and children aim to overcome many of the major health challenges posed by malnutrition.
About 20 per cent of babies born in developing countries weigh less than 2.5 kg (UNICEF 1997) which is an important factor contributing to the burden of malnutrition in developing countries. Few specific actions in developing countries have been supported to reduce the prevalence of low birth weight (Alnwick 1998). The lack of specific actions reflects the lack of any scientific consensus on the nature of effective interventions. The most effective interventions (Gulmezoglu et al. 1997) are considered to be smoking cessation, antimalarial chemoprophylaxis, and balanced protein-energy supplementation for the mother. Zinc, folate, iron, and magnesium supplementation in gestation and probably the reduction of teenage pregnancies merit further study.
Protecting, promoting, and supporting exclusive breast feeding for 4 to 6 months from birth and continued breast feeding with adequate complementary foods for 2 years or beyond is crucial in developing countries (Fig. 3). The cost of infant formula is often beyond the means of poor families, even when it is widely available. Besides, many families lack easy access to the knowledge, safe water, and fuel needed to prepare feeds safely, or simply have no time to prepare them. If used incorrectly—mixed with unsafe unboiled water, for example, or overdiluted—a breast-milk substitute can cause infections, malnutrition, and even death. Virtually all of the community-based programmes that have resulted in reductions in malnutrition have focused on improvements in infant feeding, especially the protection, promotion, and support of breast feeding. While community-based support for breast feeding is a major achievement, larger economic and institutional pressures can foil even the efforts of communities well aware of the central importance of breast feeding. Infant formula is an important product for the minority of children who for medical reasons cannot be breast fed. However, commercial pressures have often resulted in artificial feeding of children who would otherwise benefit from breast feeding.

Fig. 3 Continued breast feeding.

Promotional activities, such as providing free or subsidized supplies of infant formula, bottles, and teats in maternity wards, have also undermined the best intentions and the confidence of new mothers to breast feed. In 1981, the World Health Assembly (WHA), which consists of the health ministers of almost all countries, responded vigorously to inappropriate promotional efforts of the infant-food industry by adopting the International Code of Marketing of Breastmilk Substitutes, drafted by the WHO, UNICEF, non-governmental organizations, and representatives of the infant-food industry. The Code and subsequent WHA resolutions establish minimum standards to regulate marketing practices by setting out the responsibilities of companies, health workers, governments, and others, and provides standards for the labelling of breast-milk substitutes. Among its provisions are that health facilities must never be involved in the promotion of breast-milk substitutes and that free samples should not be provided to pregnant women or new mothers.
Two global conferences which took place at the beginning of the last decade (World Summit for Children in 1990 and the International Conference on Nutrition in 1992) established for the first time specific global goals and targets for reducing micronutrient deficiencies and improving child nutrition. Only in the last decade has the world begun to realize the importance of micronutrients in saving and protecting children’s lives. Foods and vitamin supplements in industrialized countries have been fortified with micronutrients like vitamin A and iodine for many years. However, it is only in recent years that their impact on child development in developing countries has been discovered. Some of the knowledge on the importance of micronutrients is now well established, like the effect of vitamin A on child survival, iodine’s effect on learning ability, and iron’s effect on productivity. Others, like the importance of vitamin A for reducing maternal mortality and of multiple micronutrient supplements for women and children’s health, are beginning to emerge.
In areas where vitamin A deficiency exists, improving children’s vitamin A status can increase their chances of survival by as much as 25 per cent. It is important to ensure that vitamin A capsules and fortified foods are available to women and children who need them. Ensuring that children consume enough vitamin A is a simple and effective child survival strategy. Adequate intake of vitamin A keeps children well; it is essential for the proper functioning of the body’s immune system. In the past, vitamin A deficiency has been recognized as the leading cause of preventable childhood blindness. Recently, the international community has recognized that even so-called mild or moderate vitamin A deficiency, which does not result in eye damage or blindness, can impair children’s ability to resist illness and can cause death.
Until recently, iodine deficiency was still the world’s single greatest preventable cause of mental retardation. Even mild iodine deficiency can cause significant mental and physical retardation. In many parts of the world, people lack adequate amounts of iodine in their diet. The consequences of deficiency are most serious in pregnant women and young children. During pregnancy, iodine deficiency results in retarded fetal development, and severe iodine deficiency may result in fetal death or severe physical and mental growth retardation—a condition known as cretinism. In childhood, iodine deficiency can result in speech and hearing defects, delayed motor development, and impaired physical growth. In both adults and children, chronic iodine deficiency causes the disease known as goitre—a swelling of the thyroid gland. Grouped together, goitre, cretinism, and delayed physical and mental development due to iodine deficiency are known as iodine deficiency disorders.
Milder forms of goitre will disappear, and the mental and physical development of children mildly affected by iodine deficiency disorder will improve when iodine intake increases. But the severest forms of iodine deficiency disorder, such as cretinism, cannot be reversed; they must be prevented. The World Summit for Children set the goal of virtual elimination of iodine deficiency disorder by the year 2000. At the time of the Summit, 1.6 billion people—30 per cent of the global population—were still at risk of physical and mental retardation. Goitre affected 750 million people; 43 million have brain damage each year. Less than 20 per cent of those in affected countries had access to iodized salt. Currently about 70 per cent of the world’s population has access to iodized salt, protecting millions of people from the negative impact of iodine deficiency.
Fifty per cent of all iron-deficiency anaemia occurs among pregnant women and preschool children. This condition greatly heightens women’s risk of death during childbirth, and their newborns face a high risk of low birth weight, as well as poor growth and physical development. Pregnant women can receive a low-cost iron folate supplement that can reduce anaemia and contribute to improved maternal and infant health.
Iron-deficiency anaemia is perhaps one of the most prevalent global nutritional problems, affecting more than half of all women in developing countries and a large percentage of young children (Alnwick 1998). Worldwide, some 500 to 600 million people now suffer from iron-deficiency anaemia. Since it reduces work capacity and adversely affects productivity, iron-deficiency anaemia can have a profound impact on a family’s ability to feed and care for its children. Children affected by iron-deficiency anaemia can also suffer from impaired cognitive abilities and reduced resistance to disease, impairing their right to achieve their fullest potential. The use of a simple, low-cost iron tablet could prevent these problems. Ensuring that pregnant women receive this dietary supplement can help prevent both maternal and infant deaths.
Measures to prevent iron deficiency should be part of an overall strategy to control anaemia and should be based on a combination of iron supplementation, dietary approaches including food fortification, and more general public health measures to address other causes of anaemia (WHO 2000a). It is encouraging to observe that more and more countries are embarking on iron fortification programmes.
Childhood disabilities
The rights of children with disabilities are clearly articulated in the Convention on the Rights of the Child. Article 2 calls on state parties ‘to respect and ensure the rights set forth in the Convention to each child within their jurisdiction without discrimination of any kind, irrespective of the child’s or his or her parent’s race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status’. Article 23 goes on to state that all children should have access to rehabilitation services and the right to special care and assistance, appropriate to the child’s condition.
It is estimated that between 300 to 500 million people live with a significant disabling condition. Of these, up to 120 million are children (WHO 2000a). According to the United Nations, 80 per cent of all individuals with a disability live in developing countries. More affluent countries may report higher rates of disability, both because of increased survival rates after a disability occurs and because census reports include individuals with mild or moderate disabling conditions. In many developing countries, some disabilities may not even be recorded due to poor data availability or, for example, poor recognition of milder disabilities such as dyslexia (UNICEF 1999d).
Developing countries often report higher disability rates for boys than girls. This may be due to work-related injuries. However, it is more likely to be due to the cultural preference for boys, and therefore the survival rate for disabled males will be higher than that for girls. For example in Nepal, the long-term survival rate for boys who suffered from polio was twice that for girls, although the chances of girls and boys being infected was equal.
Disability is more often considered a medical concern. However, it is increasingly being realized that most of the problems faced by the disabled are social, cultural, and economic rather than medical. Disabled people need to live in environments that are safe and supportive; they require education, health, and other basic services, and access to sports and recreation. They also need to develop skills that will allow them to earn a living.
Malnutrition and disability
The impact of malnutrition extends to the millions of survivors of malnutrition, who are left physically and psychologically crippled, chronically vulnerable to illness, and intellectually disabled. Child malnutrition is not only a problem of developing countries. In industrialized countries, widening income disparities, coupled with reductions in social protection, are resulting in increased vulnerability of children to malnutrition. In infancy and early childhood, iron-deficiency anaemia can delay psychomotor development and impair cognitive development.
Rehabilitative care
In industrialized countries, where long-term rehabilitative care is available, there is often a lack of comprehensive rehabilitative programmes that deal with both psychological and physical problems encountered. Hundred sof thousands of disabled children live in institutions. There, they are usually at greater risk of physical and emotional neglect and social isolation. They can also be at greater risk of abuse.
The most prominent unmet medical need identified for adolescents and youth with disabilities is the continuing lack of rehabilitation services. The United Nations estimates that, of those worldwide who need rehabilitation, only 5 per cent receive any sort of care. Moreover, rehabilitative services tend to be concentrated in urban areas and are often very expensive. Programmes that require long-term residency are also often unavailable to girls in societies where females are not allowed to travel unescorted or live on their own.
Prosthetic devices (artificial limbs, wheelchairs, hearing aids, spectacles, etc.) are often difficult and expensive to acquire, and a growing young person needs frequent replacements. A poorly fitting artificial limb has profound psychological and social implications for an already marginalized adolescent. A wheelchair that has become too small limits the ability of a young person to leave the house to attend school, do chores, or establish any measure of autonomy.
Children and land mines
Children face dangers form all sorts of weapons. However, the most dangerous is the threat of land mines. The 1997 international convention on banning land mines was a major step toward ridding the world of these terrible weapons. Children in 64 countries live amidst the contamination of 60 to 70 million land mines. Antipersonnel land mines kill or maim at least 2000 people each month with most of the victims being poor. In Cambodia, around 20 per cent of all children injured by mines die from their injuries. The rest have serious medical problems related to amputation. Around half of the world’s mine-affected countries have had mine awareness programmes. It is important not only to tell the participants about the issues but also to try to involve them in the learning process. Programmes should address the specific needs of children, incorporating mine awareness into school curricula and providing teacher training.
UNICEF is the lead agency for mine awareness, and in co-operation with other partners has prepared international guidelines and developed a comprehensive package of mine awareness training materials and modules.
The damage caused by land mines stimulated an international campaign to ban their manufacture and use. In 1992, a global coalition of more than 1000 organizations in 60 countries formed the international campaign to ban land mines. The momentum triggered by this campaign led in 1997 to the Ottawa Convention related to the prohibition of the use, stockpiling, production, and transfer of antipersonnel mines and on their destruction. The Convention is now part of international law, and far fewer land mines are being produced and deployed. However, children continue to be killed and maimed by land mines each day, and resources for mine clearance and for the support and rehabilitation of victims are inadequate. Given sufficient determination and resources, countries should be able to eliminate all land mines in their territories within a decade, the timeframe set by the Ottawa Convention following ratification of the treaty.
Role of the mother
Every year, 1.4 million infants are stillborn and between 1.5 and 2.5 million infants die in the first week of life from complications related to their mothers’ pregnancy or delivery—and those who survive their mother’s death are at greater risk of malnutrition and death. These deaths constitute two-thirds of all the deaths of children under 1 year of age in developing countries (Fig. 4).

Fig. 4 The death of a child: percentage of women aged 15 to 49, married or previously married, who have had at least one child die.

The toll of injury and disability from pregnancy-related causes is arguably the most neglected health problem in the world. For every woman who dies in childbirth, probably about 30 incur injuries and infections—many of which are often painful, disabling, embarrassing, and lifelong. Therefore it is likely that more than 15 million women a year fall victim to ‘maternal morbidity’, and that there are several hundred million women in the world today who have suffered or are suffering from the untreated and uncared-for consequences of injuries arising during pregnancy and childbirth. The percentage of women in developing countries who lose at least one child is still very high which has psychological and social consequences.
Each day worldwide some 1600 women die in pregnancy and childbirth—one death every minute—making complications of pregnancy and delivery the leading cause of death among reproductive-age women in developing countries. In addition to those who die, each year over 60 million women suffer acute complications from pregnancy. Most maternal deaths could be prevented if women had access to basic medical care during pregnancy, childbirth, and the postpartum period. This implies strengthening health systems and linking communities, health centres, and hospitals to provide care when and where women need it (UNICEF 1999c). Good-quality health care during the critical period of labour and delivery is the single most important intervention for preventing maternal and newborn mortality and morbidity. Lack of safe delivery care, late referral of complications, and low access to essential mother and child health services remain serious problems. Low accessibility and poor quality of emergency obstetric care, other reproductive health services, as well as treatment and prevention of general women’s health problems (e.g. malaria, urinary tract infections, etc.), are some challenges that have to be addressed.
Distance and lack of transport is a great problem. In most rural areas, one in three women lives more than 5 km from the nearest health facility, and 80 per cent of rural women live more than 5 km from the nearest hospital. The scarcity of vehicles, especially in remote areas, and poor road conditions can make it extremely difficult for women to reach even relatively nearby facilities. Walking is the primary mode of transportation, even for women in labour.
Eighty per cent of maternal deaths all over the world are directly attributable to haemorrhage, sepsis, eclampsia, obstructed labour, and unsafe abortion. These direct factors are similar in all settings. However, multiple factors underlie women’s capacity to survive pregnancy and childbirth. They include women’s health and nutritional status, their access to and use of health services, household practices, and community behaviours with regard to women’s health. The status of girls and women in society underlie all of the above.
Common barriers contributing to the low utilization of health services include the lack of compliance of services with defined standards, the shortage of supplies, infrastructure problems, deficiency in detection and management of complications or emergency cases, and poor client–provider interaction. Furthermore, services are also underutilized when they are perceived to be disrespectful of women’s rights and needs, or are not adapted to the cultural contexts.
Women-friendly health services should provide accessible high-quality health care, be respectful of cultural and social norms, and empower users and motivate providers by involving them in decision-making, thereby enhancing all-around satisfaction. This approach builds upon existing concepts and recent experiences of countries, including all stakeholders involved in planning and implementing long-term country programmes. This is a rights-based approach to maternal and neonatal health care, which will enable governments and international agencies to monitor women’s access to quality maternal and reproductive health services.
Vital to making maternal care accessible (prenatal, delivery, and postpartum care) is to ensure that no woman is denied care, even if she is unable to pay for it. The indicator for measuring affordability against the standard can be the proportion of women refused urgent essential obstetric care for financial reasons. Cultural barriers to health care relating to the lack of autonomy and decision-making power of women often constrain their access to health care. In some areas, for example, women are not allowed to leave home unaccompanied, while in others women are not permitted to be attended by male health care providers. Sometimes, the fear of not having her cultural values respected inhibits a woman from accessing the services she needs. To eliminate these barriers, health services should be organized in a way to respect women and their culture, religion, and beliefs.
Men often hold the financial as well as other assets. They are the decision-makers who determine what women can and cannot do, and consequently how they will be treated. Therefore, in order to improve women’s health, men must be targeted with sufficient information on pregnancy and childbirth to make them more aware of their role and responsibilities.
Strengthening of child health services
The experience gained through dialogue on child survival programmes and the promotion and implementation of the Convention on the Rights of the Child has provided the necessary opportunities to review health policy issues with governments. The goal is to create health systems that can:

improve health status

reduce health inequalities

enhance responsiveness to legitimate expectations

increase efficiency

protect individuals, families, and communities from financial loss

enhance fairness in the financing and delivery of health care.
One of the keys to building more equitable and essential health services is the development of adequate financial mechanisms. Governments need to maintain an active dialogue with private health insurance companies and community-based insurance systems to ensure that they adhere to the principles of equity, non-discrimination, protection of women and children, and approaches to a better health status and lifestyle. In many countries where private health care providers are people’s contact of choice, it is important to develop partnerships with these important actors. The role of the private sector is also crucial since they tend to focus more on purely curative care, and can sometimes neglect prevention, health education and promotion, and monitoring.
Box 6 Child health services

Strengthening of child health services should be considered at the following levels.

Policy level: advocacy with governments and major donors for child-friendly movements, including national health systems management and financing strategies that ensure equitable access and quality of essential health care for marginal groups (including social safety nets/health insurance systems for the poor), especially in the context of privatization and decentralization, as well as review of policies on decentralization, cost-sharing, and co-management of health systems

District level: improving access, quality, sustainability, and equity of health systems through child- and women-friendly movements can be instrumental to efforts being made in the regional context of privatization, decentralization, and economic crisis

Community level: strengthening community links, which are essential to facilitate family care, referrals of obstetric complications and sick children, and increase health staff accountability for quality care and equity of access. This includes improving the capacity and motivation of primary health care staff (especially midwives), community health and social volunteers, teachers, and mass organizations to support family care. Improve capacities and motivation to identify limiting factors in family care practices and resources and develop appropriate communication and intersectoral support strategies to improve care and empower families

Family level: improving family care practices, especially breast feeding, household-level integrated management of childhood illness, promotion of hygiene practices, use of bednets, and women’s empowerment and psychosocial stimulation (which are not only essential for prevention of protein-energy malnutrition and sanitation but also for maternal mortality reduction and child mortality goals). This implies identifying limiting factors in family care practices and resources as well as developing appropriate communication and intersectional support strategies to improve care and to empower families

The rationale for health policy reform is based on the fact that, despite dramatic improvement in the health status of their population, life expectancy in the world’s developing countries continues to be low and will continue to decrease in countries stricken with HIV/AIDS. Inadequate financial resources available for public health, combined with poor use of already scarce resources, have contributed to chronic drug shortages, inconsistent services, and a deterioration in health infrastructure.
The WHO and UNICEF have drawn up a list of the essential drugs required to deal with most of the common diseases of childhood. They include oral antibiotics for pneumonia, dysentery, and ear infections, an oral antimalarial drug, paracetamol for fever, oral rehydration salts for diarrhoeal dehydration, vitamin A for prevention of vitamin A deficiency and treatment of measles, mebendazole for intestinal parasites, tetracycline ointment for eye infections, and gentian violet for mouth ulcers and bacterial skin infections. The average cost for a full course of each treatment is approximately 15 cents. So even if every single child under 5 years of age in the developing world had to be given a course of drugs twice a year every year, the total annual cost would still be considerably less than US$200 million.
High-income countries now commit vast sums (over US$55 billion per year) to research and development efforts. But only a fraction of that amount is directed to solving the particular problems of poor and disadvantaged groups. Greater research and development can contribute significantly to improving the health status of children and should be an integral element of health system development. Focused investments by health systems on specific problems of the poor can generate major short- to medium-term gains in health; however increased investment in research and development can sustain medium- to long-term gains.
For strengthening of child health services, there are several remaining challenges which need to be overcome.
Box 7 Bamako Initiative

The Bamako Initiative, launched in 1987, has been recognized as the most cost-effective sustainable approach to revitalizing health systems in countries with poor primary health care structures. The strategy of the initiative was to revitalize public health systems by decentralizing decision-making from the national to the district level, reorganizing health care delivery, instituting community financing, and providing a minimum package of essential health services at the level of basic health units. By late 1994, the Initiative had been implemented in 33 countries, 28 in sub-Saharan Africa. Funds have been used mainly for the purchase of drugs to set up community revolving drug funds, for institution building at local levels and for the development of management capacity and logistic systems. The lessons learned from the actual experience confirm all the premises on which it was founded.

Service delivery: experience demonstrates that utilization of health services increases once the quality of care improves. In Guinea, by mid-1994, 7 years after the launching of the Bamako Initiative, community co-financing and co-management had boosted the number of health centres to 295, covering approximately 80 per cent of the population and immunization coverage reached 74 per cent in the area

Resources for basic health services: in areas where the Initiative has been implemented, it has contributed to making low-cost high-quality drugs accessible to the majority of the population. Community-managed health services have been able to generate sufficient resources to cover total essential drug costs and some small local expenses

Capacity building and empowerment: the Bamako Initiative has contributed to developing managerial and organizational skills at all levels. Local decentralized management systems and district management capacity have been strengthened in many countries. At the national level, UNICEF has trained public health policy-makers and planners in Africa, Asia, and Latin America in health financing analysis and costing of services
Many countries in West and Central Africa are moving ahead to extend revitalization of health services nationally. This is largely due to the positive lessons of the Bamako Initiative

Many health reform programmes continue to focus on user fees as an objective, with insufficient emphasis on conditions, management reform for efficiency, or co-management for accountability and empowerment. The best practices in community co-management need to be further documented and extended to other areas to improve the participation of health committee members and health centre users in monitoring and micro-planning. To make this possible, increasing emphasis should be placed on the training of communities and community health workers.

The motivation of health professionals in public health centres is often poor due to low or unpaid salaries, insufficient supervision, and poor relationships with the communities where they are assigned. Rewards for good performance provide an impetus for hard work and good ethics.

Although quality of care has improved in many health centres, there is still room for improvement. Improved drug policies and autonomous drug procurement units with associated distribution networks could vastly improve logistics and supply in most countries.
Since 1992 UNICEF and the WHO have been working on developing a strategy for reducing childhood mortality and morbidity associated with five major causes: acute respiratory tract infections, diarrhoeal diseases, measles, malaria, and malnutrition. This Initiative for the Integrated Management of Childhood Illness (IMCI) focuses on the prevention, early detection, and treatment of the leading childhood fatal diseases, recognizing that when children become ill they often have more than one illness. The initiative aims to improve the skills of health workers, the health system, including the availability of drugs, and family and community practices. Community-based actions to promote and protect child health and nutrition are complemented by improved management of childhood illness at health facilities.
The IMCI initiative incorporates many elements of diarrhoeal disease control and acute respiratory tract infection and some of the child-oriented aspects of malaria control and nutrition promotion. It also depends on the effective functioning of the Extended Programme for Immunization. In addition, it should also be noted that, as IMCI activities expand, single-disease programmes focusing on childhood diarrhoea and acute respiratory tract infection have been phased out.
Advocacy and communication for child health programmes
Communication strategies have provided a powerful means of accelerating action towards child health achievements and have proved effective in mobilizing social and individual change. Communication through news, entertainment, marketing and distribution of popular goods and services, community-level communication, interpersonal interactions, and awards programmes provide national scale channels that are compelling and influential. The development and implementation of skills-based health education in early childhood education and in primary and secondary schools should be supported. This includes strengthening the capacities of teachers to enable them to communicate better about health issues. In many countries, assistance is provided for training adolescents to become peer educator trainers. A continuing priority is to strengthen the capacities of community- and workplace-based women’s organizations for health promotion activities. This includes support for the incorporation of essential health information into organizations’ activities and the creation of peer support mechanisms to motivate health action.
Box 8 Family and community practices

The following practices are promoted through the IMCI Initiative at the family and community level to improve child survival, growth and development.
Growth

Breast feed infants exclusively for at least 6 months (taking into account WHO/UNICEF/UNAIDS policy and recommendations on HIV and infant feeding)

Starting at about 6 months of age, feed children freshly prepared energy- and nutrient-rich complementary foods, while continuing to breast feed up to 2 years or longer

Provide children with adequate amounts of micronutrients (vitamin A and iron, in particular) either in their diet or through supplementation

Promote child’s mental and social development by being responsive to the child’s needs for care, and stimulating the child through talking, playing, and other appropriate physical and affective interactions
Disease prevention

Dispose of faeces (including children’s faeces) safely, and wash hands with soap after defecation, and before preparing meals and feeding children

In malaria-endemic areas, ensure children sleep under recommended insecticide-treated mosquito nets

Prevent child abuse/neglect and take appropriate action when it has occurred

Adopt and sustain appropriate behaviour regarding prevention and care for people affected with HIV/AIDS, including orphans
Home care

Continue to feed and offer more fluids to children when they are sick

Give sick children appropriate home treatment for illness

Take appropriate actions to prevent and manage child injuries and accidents
Care seeking

Take children as scheduled to complete a full course of immunization (BCG, DPT, OPV, and measles)

Recognize when sick children need treatment outside the home and take them to the appropriate providers for health care

Ensure that every pregnant woman receives the recommended four antenatal visits, recommended doses of tetanus toxoid vaccination, and is supported by family and community in seeking appropriate care, especially at the time of delivery and during the postpartum/lactation period

Ensure that men actively participate in provision of child care, and are involved in reproductive health initiatives

One of the prime examples of effective communication strategies has been the worldwide mobilization of all levels of society for child immunization. UNICEF was the driving force behind the social mobilization that led to the vast increase in vaccination coverage. The building blocks that led to the process of social mobilization were social marketing, advocacy, and forming strategic alliances. Social mobilization first came into prominence in connection with the Universal Child Immunization campaign, which was launched in 1984 with the objective of fully immunizing 80 per cent of the world’s children by 1990. UNICEF was successful in generating political will for Universal Child Immunization in many countries, which was instrumental to the success of the programme. The success of Universal Child Immunization further led to the Global Polio Eradication Initiative with the goal of eradicating polio by the end of the twentieth century. The initiative has been largely successful with mass immunization campaigns such as National Immunization Days. The Days held in December 1998 and January 1999 in India constituted the largest public health campaign ever undertaken in a single country, immunizing about 134 million children. Such events require monumental co-ordination on the part of the government and public health authorities and the greatest challenge is to identify children who have not been reached by routine immunization.
Social mobilization and communication play an essential role in creating a demand for change. Through repeated messages such as speeches by political and religious leaders, messages from well-known personalities, media campaigns, slogans printed on caps and tee-shirts, radio and television spots, puppet shows, training sessions for village leaders, and conversations among neighbours, individuals and communities come to understand strategies that will improve their lives. Social mobilization and communication has been responsible for much of the dramatic success in efforts to improve child health in the past decade. Mobilizing people requires a thorough understanding of the local culture and the creativity to develop innovative strategies to respond to people’s legitimate concerns.
Mobilizing resources for children
To achieve improved health outcomes for all children, development strategies and programmes need to focus far more on building the capacities of families and communities to provide for and protect the physical, emotional, and cognitive development of children. It is important to ensure universal access to good-quality basic social services for every child, and creating the national legal, policy, and budget framework to facilitate and promote the realization of children’s rights to high-quality health services.
The challenges facing societies and the unfulfilled rights of children require broad participation and the commitment of many actors. Building an alliance of influential actors, governmental and non-governmental, who have the power to shape national laws, policies, budgets, institutions, and programmes, or who influence how societies behave towards children and adolescents, is essential.
UNICEF supports programmes to protect the rights and improve the health and welfare of children in over 160 countries. The leading international advocate for child survival and development, UNICEF works closely with other United Nations agencies such as the WHO, the World Food Programme, and the Joint United Nations Programme on HIV/AIDS. For more than 50 years, UNICEF has been helping governments, communities, and families make the world a better place for children. Part of the United Nations system, UNICEF has an enviable mandate and mission to advocate for children’s rights and help meet their needs. UNICEF works in 161 countries, areas, and territories on solutions to the problems plaguing poor children and their families and on ways to realize their rights. Its activities are as varied as the challenges it faces, encouraging the care and stimulation that offer the best possible start in life, helping prevent childhood illness and death, making pregnancy and childbirth safe, combating discrimination, and co-operating with communities to ensure that girls as well as boys attend school.
Since the early 1980s UNICEF has been voicing its concern about the plight of children in the world’s heavily indebted countries (UNICEF 2000), which are being driven by very high debt burdens to spend more on servicing their external debt than on basic health and other services. Unsustainable debt has implications for economic growth and equity as well as social sector financing. Debt, especially in the most heavily indebted countries, remains one of the greatest barriers to improving child health globally. UNICEF and Oxfam (UNICEF 2000) have developed a possible strategy for absorbing debt relief into the national poverty reduction strategy. The aim of this plan would be to provide a broad indication of expenditure plans, with special focus on longer-term development goals. It would be developed with bilateral donors, United Nations agencies, and the World Bank, and presented to national consultative groups.
The financial resources for child health are primarily within countries and therefore responsibility for success lies ultimately with governments. Only a fraction of resources for health in low- and middle-income countries originates in the international system—development banks, bilateral development assistance agencies, international non-governmental organizations, and foundations. According to the WHO, health spending in low- and middle-income countries in 1994 totalled about US$250 billion, of which only 2 or 3 billion dollars was from development assistance.
In recent years there has been growing pressure on donors to say how much of their aid goes to meet obvious basic needs—adequate nutrition, safe water and sanitation, basic health care, and primary education. At present, it is thought that only about 10 per cent of Official Development Assistance (ODA) is allocated to these basics. Five United Nations agencies—the UNDP, UNESCO, the UNFPA, UNICEF, and the WHO—have called for this to be increased to at least 20 per cent. An indicative target of 20 per cent of national budgets and 20 per cent of ODA was set to ensure universal access to basic social services. The purpose of the 20/20 Initiative is to provide adequate funding for universal access to basic social services for the achievement of the social goals that were set at the World Summit for Children, the International Conference for Population and Development and the World Summit for Social Development. The universal provision of basic social services is viewed as one of the most effective and cost-effective methods to address the worst manifestations of poverty. The initiative calls for greater collaboration among developing countries and their development partners in the financing of basic social services. This indicative allocation is not the only means to improve well being; the 20/20 Initiative also recognizes that better efficiency and more equity are required, which requires public action and entails adequate resources. Without universal coverage, the virtuous circle of social and economic development will remain elusive.
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