78(10)1234

The evolution of child health programmes indeveloping countries: from targeting diseasesto targeting peopleMariam Claeson1 & Ronald J. Waldman2

Mortality rates among children and the absolute number of children dying annually in developing countries havedeclined considerably over the past few decades. However, the gains made have not been distributed evenly:childhood mortality remains higher among poorer people and the gap between rich and poor has grown. Several poorcountries, and some poorer regions within countries, have experienced a levelling off of or even an increase inchildhood mortality over the past few years. Until now, two types of programmes — short-term, disease-specificinitiatives and more general programmes of primary health care — have contributed to the decline in mortality. Bothtypes of programme can contribute substantially to the strengthening of health systems and in enabling householdsand communities to improve their health care. In order for them to do so, and in order to complete the unfinishedagenda of improving child health globally, new strategies are needed. On the one hand, greater emphasis should beplaced on promoting those household behaviours that are not dependent on the performance of health systems. Onthe other hand, more attention should be paid to interventions that affect health at other stages of the life cycle whileefforts that have been made to develop interventions that can be used during childhood continue.

Keywords: child welfare; child health services, trends; communicable diseases, prevention and control; delivery ofhealth care; infant mortality, trends; models, theoretical.

Bulletin of the World Health Organization, 2000, 78: 1234–1245.

Voir page 1243 le resume en francais. En la pagina 1244 figura un resumen en espanol.

Introduction

For the past 35 years, the steep decline in deathsamong infants and children has provided evidence ofan important success story in international develop-ment. Mortality has declined steadily at an average ofabout 1% per year. The absolute number of childrenunder the age of 5 years dying has fallen from anestimated 15million in 1980 to about 11million at theend of the 1990s (1). Remarkably, this decline hasoccurred in the face of increased births, spreadingresistance to commonly used antibiotics and anti-malarial drugs and, most menacingly, the growth ofthe AIDS pandemic.

A closer look at this favourable trend,however, reveals that progress has been distributedunevenly. Recently, the decline in mortality amongchildren under 5 years has stalled in a number ofcountries and in some the trend has reversed andmortality seems to be rising. In 1998, in more than

50 countries the mortality for children under 5 yearswas greater than 100 deaths per 1000 live births. In12 countries (11 of them in Africa), one in everyfive children born alive did not survive to the age offive years (1). Of the nearly 11 million children whowill die before their fifth birthday this year, 70% willdie from a disease, a combination of a few diseases,or a condition for which safe and effectiveinterventions are readily available in industrializedcountries: acute respiratory infections, diarrhoea,measles, malaria, and malnutrition (2).

Better access to basic health services —including vaccinations, oral rehydration therapy,and antibiotics for pneumonia — together withimprovements in social conditions — includinghigher standards of living and smaller families livingon larger incomes — have been important factors inimproving the survival rate of children. As deathsamong children under 5 years have declined in manydeveloping countries, contributing to both demo-graphic and epidemiological transitions, the propor-tional mortality accounted for by some conditionshas increased: this problem has been relativelyignored by the international health community. Forexample, the greatest decline in childhood mortalityrates has occurred among children in the post-neonatal period; this has led to a relative increase inthe importance of neonatal and perinatal mortality.Also, gender-specific issues have emerged in some

1 Principal Public Health Specialist, Health, Nutrition, and Population,Human Development Department, World Bank, Washington, DC,20433, USA (email: [email protected]). Correspondenceshould be addressed to this author.2 Professor of Clinical Public Health and Director, Program onForced Migration and Health, Center for Population and Family Health,Joseph L. Mailman School of Public Health, Columbia University,New York, USA.

Ref. No. 00-0762

Special Theme — Child Mortality

1234 # World Health Organization 2000 Bulletin of the World Health Organization, 2000, 78 (10)

parts of the world, notably on the Indian subconti-nent where girls aged between 1 month and 5 yearsstill experience considerably higher mortality andmorbidity than boys (3, 4). And, although this paperdoes not deal with it specifically, increases in deathsfrom AIDS in Africa are already slowing or reversingthese downward trends. Without a major assault onAIDS throughout local health systems and in thecommunity, childhood mortality, whether frominfection or from the increased risks associated withbeing orphaned, can be expected to increase in someparts of the world.

In this paper, we examine the roots from whichcurrent child health programmes have grown, some ofthe causes behind the apparent slowing of progress inmany parts of the world, and we suggest ways in whichthe nature of these programmes must change ifcontinued gains are to be made throughout the world.

Trends and milestones

Global strategies for reducing childhood mortalityhave been of two basic types. The first wereambitious disease-specific, technologically depen-dent strategies aimed at achieving dramatic, albeitnarrow, successes in a relatively short time. Thenotable failure of the most ambitious programme ofthis type — the malaria eradication programme (notexclusively a child health programme, but one thatwas expected to make a major contribution toreducing child mortality) launched in the 1950s andabandoned in the 1970s — contributed strongly to ashift in thinking (5).

The more people-centred, community-basedstrategy typified by primary health care, with its goalof health for all by the year 2000, was adopted by theWorld Health Assembly in 1977. Primary health caresought to broaden the focus of health services byemphasizing programmatic areas instead of specificdiseases. Accordingly, the provision of universalservices for maternal and child health, familyplanning, improved water supplies, and environ-mental sanitation became objectives; these were to beachieved through an equitable distribution ofresources, community involvement, an emphasis onprevention instead of clinic-based curative interven-tions, and a multisectoral approach.

Neither strategic approach ever totally eclipsedthe other. Although attempts to eradicate malariafailed, the ensuing smallpox eradication programmeis probably the most successful large-scale publichealth programme in history, with the last case ofsmallpox acquired by human-to-human transmissionhaving occurred in 1977. Important lessons havebeen learnt from both the failed malaria eradicationprogramme and the successful smallpox programme;these lessons have been applied to current attemptsto eradicate dracunculiasis and poliomyelitis, twoprogrammes which are on the verge of success. To animportant degree, the appeal of these programmes isrooted in the acceptance that disease-specific

programmes must, when possible, promote com-munity involvement while contributing to the on-going development and strengthening of nationalhealth systems (6).

Similarly, a debate over the degree to which theobjectives of primary health care can be translatedinto effective programmes resulted in the emergenceof ‘‘selective primary health care’’ (7). This newstrategy, which targeted the control of diseasesidentified as the most important contributors toincreasedmortality, was intended to bemore focusedand more feasible. A number of specific, morevertical programmes (so named because of the self-contained way they appear on organizational chartsand, more importantly, in budget lines of healthministries) were promoted to channel relativelymeagre resources into areas in which demonstrablesuccess could be achieved in the medium-term.Furthermore, the emphasis was clearly put onprogrammes that would contribute to achievingdecreases in mortality among infants and children,since children were considered to be the mostvulnerable segment of the population because theyhave the highest rates of preventable death.

The World Health Organization, for example,first developed the Expanded Programme onImmunization and subsequently the Programmefor the Control of Diarrhoeal Diseases. UNICEFchose four specific interventions on which to focus:growth monitoring, oral rehydration therapy, breast-feeding promotion, and immunization, known by theacronym GOBI. It later added three more (food,family planning, and female education). Bilateraldonors followed, channelling funds into what cameto be called ‘‘child survival’’ programmes; theseretained their roots in community-oriented, popula-tion-based, primary health care, but at the same timehad the appeal of using relatively inexpensive medicaltechnologies to reach specific, stated objectives.

Although the two strategies, at different endsof the intervention spectrum, have been able tocoexist relatively peacefully, they have never quitecoalesced. Currently, several attempts at rapproche-ment are under way. For example, the multi-agencyRoll Back Malaria movement includes componentsaimed at health systems and at the community.Reduced rates ofmorbidity and death frommalaria, itsuggests, should be viewed as markers of improvedhealth systems. Similarly, the IntegratedManagementof Childhood Illness initiative explicitly incorporatesa component of community development; thisprogramme evolved from selective primary healthcare programmes that aimed to control diarrhoealdiseases and acute respiratory infections in childhoodby working with health workers and strengtheninghealth systems. Both of these efforts, and manyothers currently being implemented (including thepoliomyelitis and dracunculiasis eradication pro-grammes) emphasize the need for communityparticipation, for strong and effective partnershipsbetween public and private sectors, for intersectorallinks, and the need to combine medical technology

1235Bulletin of the World Health Organization, 2000, 78 (10)

The evolution of child health programmes in developing countries

with behavioural interventions. That is, they recog-nize these needs in rhetoric, if not in practice. Thisreflects current thinking as to how programmes toimprove children’s health should be implemented,not necessarily how resources are being invested.Although emphasis on community-level interven-tions is generally recognized to be a desirable andeffective approach to implementing successfulprogrammes, activities still tend to focus on improv-ing the delivery of services through an organizedhealth system, rather than on effecting behaviouralchange.

The past: research and action

The recognition that there were multiple technicaland operational challenges to the implementation ofchild health and nutrition programmes over the past20 years led to an evolution of research priorities (8).Before 1985, microbiological, epidemiological, im-munological, and clinical research contributed to thedevelopment of both preventive and therapeuticinterventions for the control of common diseases inchildhood. A prototypical example is the finding thattreatment of acute, watery diarrhoea did not dependon the etiological agent and that oral rehydrationtherapy with a single, standard solution is safe andeffective in almost all cases; this finding shaped globaltreatment policies for childhood diarrhoeal diseases.Similarly, the identification of Streptococcus pneumoniaeand Haemophilus influenzae as the leading bacterialcauses of mortality from pneumonia led to thedevelopment of a universal case-management strat-egy based on symptomatic diagnosis and standar-dized antibiotic treatment. After the development ofthese technical approaches, research priorities shiftedfrom focusing on incidence, etiology, and otherdescriptive research to focusing on analytical researchthat was directed at designing, monitoring, andevaluating the impact of priority interventions.

For example, in the mid-1980s, the WorldHealth Organization commissioned a review ofresearch that might contribute to determining thepotential effectiveness, feasibility, and cost of 18 sug-gested preventive interventions for childhood diar-rhoea (9). The most promising were found to bepromoting breastfeeding, improving water supplies,modifying sanitation and hygiene behaviours, in-creasing measles vaccination coverage and, afterdevelopment of the appropriate technologies wasensured, vaccinating against rotavirus infections andcholera. Similar reviews were done for the Pro-grammeonAcuteRespiratory Infections in the 1990s(10). This process identified eight potential interven-tions, each with the ability to prevent at least 5% ofdeaths from pneumonia. These were vaccinatingchildren against measles, S. pneumoniae, H. influenzaetype B, and respiratory syncytial virus; minimizingindoor air pollution; reducing the rates of childrenborn at low birth weight; and exclusively breastfeed-ing until the child was aged 4–6 months. These

reviews influenced the direction of global efforts inpreventing and controlling childhood acute respira-tory infections and diarrhoea.

In the 1990s, research priorities have evolvedas efforts to develop a more integrated approach tocase management both in the home and within thehealth system have intensified. The success of case-management strategies depends only in part uponthe availability of services provided by trained healthcare workers. Equally important, if not more so, arethe behaviours of the carer in the home and in thecommunity. Case management in the home, care-seeking practices (including the extent to whichavailable health services are used), and compliancewith counselling provided by health workers all havean important impact on children’s health. Researchpriorities have therefore focused increasingly onpromoting and maintaining household and commu-nity support for the home management of childhoodillnesses (with appropriate referral when indicated)through interventions designed to encourage com-munication and change behaviour. Ethnographicresearch, participatory rural appraisal, and otherqualitative methods have been the tools that haveguided the development, local adaptation, and imple-mentation of many of these effective, community-level interventions (11).

To a considerable extent, the progress inreducing childhood mortality rates is the result ofefficient interactions between research, analysis,policy development, and programme evaluation.The cycle — which includes the dissemination ofresearch findings, implementation of programmesbased on those findings, and feedback regardingsuccesses and failures — has involved the researchcommunity, bilateral and international donors, healthministries, and nongovernmental organizations indeveloped and developing countries. WHO hasplayed a critical part in the analysis and formulationof policy and has provided guidance in implementingand evaluating efforts in various countries.

The present: new initiativesand programmatic approaches

For much of the past few decades, the internationalhealth agenda has been dominated by strategies andprogrammes aimed at reducing mortality in child-hood. Reich proposes a number of reasons why thiswas the case. For one, it was important that children’shealth problems were being addressed by large,influential organizations, including UNICEF, WHO,and public–private coalitions, such as the Task Forcefor Child Survival and Development. They also hadsymbolic power in the emotional appeal of being ableto save children’s lives with simple, cheap interven-tions. Also, with the exception of the infant formulaindustry, children’s health issues posed no competi-tion to vested corporate interests. Additionally,science was on its side: the use of infant mortalityrates as a proxy for national health status and

1236 Bulletin of the World Health Organization, 2000, 78 (10)


development called attention to the causes of earlydeaths and to the interventions that could be aimed atthem. Finally, for the most part, the agenda setters—that is, the politicians — found that child health is areadily accepted cause that meets with little opposi-tion when proposed as a subject for social investment(12). It should also be mentioned that childhoodillnesses make a substantial contribution to the globalburden of disease (the Integrated Management ofChildhood Illness strategy alone, at the time it wasformulated, addressed conditions that accounted foras much as 14% of disability-adjusted life years) (13),and high mortality rates in children under 5 years ofage are an important contributor to reduced lifeexpectancy in developing countries.

Recently, however, the primacy of child healthconcerns has been challenged, although mostadvocates of adolescent and adult health pro-grammes agree that it is not useful to promotecompetition between intiatives that target other agegroups and and those aimed at child health problems(14). Yet, unless careful attention is paid toconsolidating the gains made to date and to reversingemerging negative trends in some parts of the world,the gap in life expectancy between richer and poorernations, and between rich and poor within nations,may continue to grow. Preventing this situation willrequire continued emphasis on controlling commu-nicable diseases, especially those diseases that affectchildren disproportionately (15).

Health sector reforms

Even if resources for child health are maintained atcurrent levels or increased, strategies will have to beadapted to current trends. Presently, many healthactivities in a large number of developing countriesare unfolding in an environment of health sectorreform. Donor support seems to have shifted fromspecific programmes to the development of leanerand potentially more efficient administrative andmanagerial structures. Typical features ofmost healthreform efforts are the decentralization of budgetaryand, sometimes, programmatic authority to provin-cial or district levels and the administrative integra-tion of centralized programmes. These reformprocesses and sectorwide approaches can provideopportunities to identify priority problems and morecost-effective and affordable interventions. Addi-tionally, they may aid the development of sustainablehealth systems that are capable of devising localsolutions for local problems. However, there hasbeen less emphasis put on maintaining the quality ofthe more traditional, technically dependent pro-grammes such as those dealing with childhooddiseases, including the Expanded Programme onImmunization, the Control of Diarrhoeal Diseasesprogramme, the Programme on Acute RespiratoryInfections, and nutrition. For example, decentraliza-tion has often been accompanied by a reduction insupport for essential programme activities such as

supervision, monitoring, training, and supplyingdrugs or vaccines. Without the technical andprogrammatic support to which they have becomeaccustomed, and which cannot be made available atthe provincial or district level in most developingcountries, child health services are at risk of levellingoff or even declining in both quantity and quality.

At the same time, child health programmes,especially vaccination programmes, have benefitedfrommajor new funding from non-traditional sources.Although it seems as if some of the activities beingpursued may be contradictory, the potential for eachactivity tohelp reduce childhoodmortality is evident.Afew of the more prominent initiatives currently beingimplemented around the world are discussed below.

Vaccination strategies

Vaccine-preventable diseases are responsible for asignificant proportion of the approximately 11 mil-lion deaths that occur annually among children under5 years of age (Table 1). Yet, nowhere is the contrastbetween short-term disease-specific programmesand long-term developmental programmes moreevident than in the area of childhood vaccination.Two contemporary vaccination strategies havereceived massive support from both the public andprivate sectors. The highest profile public healthprogramme is the initiative to eradicate poliomyelitis.Supported by a 1988 resolution of the World HealthAssembly (16) and by a major coalition of interna-tional agencies and private organizations, the drive toeradicate poliomyelitis is a direct descendant ofprevious eradication programmes. Based on astrategy of multiple national mass immunization daysaccompanied by intensified surveillance, poliomyeli-tis has been eliminated from industrialized countriesand is on the verge of being eradicated worldwide.

The concept of poliomyelitis eradication islaudable. If successful, it will rid the world of a diseasewhich causes permanent disability and it will allow forthe cessation of the production, distribution, andadministration of poliomyelitis vaccine. It will givepublic health workers around the world a tangiblesuccess and, perhaps, provide strong motivation forachieving comparable success in other health pro-grammes. However, poliomyelitis does not contributesubstantially to the global burden of disease, and itseradication will not appreciably affect childhoodmortality rates. Furthermore, despite the heroicmobilization efforts that have been undertaken formass immunization days to be successful, eradicationis ultimately dependent upon the ability of a healthsystem to organize special campaigns for the deliveryof services. A strong partnership between commu-nities and the health system is a fundamentalrequirement but, unless it is made an explicit goal,there is little transfer of responsibility to parents andcommunities. So, in some countries, although im-munization days have been successful, vaccinationcoverage with antigens other than those for polio-



myelitis, delivered through the routine health services,is declining. Additionally, it is apparent that thosecountries with the weakest health systems will be thelast to achieve eradication. As a result, as the deadlinefor eradication approaches, there will be increasedpressure on these countries to focus only on thenarrow goal of eradicating poliomyelitis and toabandon the accompanying objectives related tostrengthening their health systems. Accordingly, thereis a real potential that the gap in the ability of countriesto carry out other programmes that are dependent ontheir health systems, including those directed towardimproving child health, will continue to grow.

As the drive toward poliomyelitis eradicationnears its successful end, plans are being made toembark upon a global initiative to eradicate measles.Unlike poliomyelitis, measles is an important cause ofchildhood mortality, and its eradication would makean important contribution towards reducing child-hood mortality. Technical and programmatic argu-ments have been advanced, both in favour of andagainst devoting major resources to eradicatingmeasles. The potential operational, technical, epide-miological, and financial problems that such aprogramme might face have been discussed (17, 18).

While poliomyelitis eradication efforts havebeen progressing, and while measles elimination isbeing pursued in several regions, vaccination coveragewith the standard six antigens of the WHOExpandedProgramme on Immunization has, in fact, fallen overthe past decade (19). UNICEF estimates that, despitethe proclaimed success of its Universal ChildhoodImmunization programme efforts in the 1980s, whichsought to achieve 80% vaccination coverage with theantigens described in the WHO programme by thesecond half of the 1990s, 44 countries had measlesvaccine coverage of less than 65% for children aged1 year. Populous countries, such as Nigeria, areincluded in this category; India had an estimatedmeasles vaccine coverage of 67% (20). The newGlobal Alliance for Vaccines and Immunizations isresponding to this negative trend and is a majorpromoter of vaccination and immunization. Theorganization seeks to provide more vaccines to morechildren in more countries (21). Like the poliomyelitis

eradication initiative, the global alliance is a public–private consortium whose principal members areWHO, UNICEF, the World Bank, national govern-ments, public health and research institutions, theRockefeller Foundation, the International Federationof Pharmaceutical Manufacturers Associations, andthe Bill and Melinda Gates Foundation.

The global alliance reports that althoughchildren in developing countries are scheduled bytheir national immunization programmes to receive sixor seven antigens as part of their routine series ofvaccination, children in the wealthier countries inEurope and North America can expect to receiveprotection against more than 10 vaccine-preventablediseases. This ‘‘vaccine gap’’ is another example of theinequitable distribution of health services that con-tributes to the growing difference inmortality betweenrich and poor. Incorporating newer, safe, and effectivevaccines into routine immunization programmes andincreasing coverage for all vaccines in a consistent andsustainable manner for all segments of the populationwill require a long-term commitment to developingand implementing programmes. Additionally, thedevelopment and maintenance of the infrastructurerequired to support vaccination programmes will beimportant as new vaccines against diseases that aremajor contributors to both childhood and adultmortality, including malaria, AIDS, and tuberculosis,are developed and marketed.

There is no obvious reason why both types ofprogrammes—shorter-termeradication initiativesandlonger-termdevelopmentalprogrammes—shouldnotcoexist. If funding is available, if personnel and othernon-monetary resources are sufficient to support bothkinds of efforts as well as other programmes for whichhealth ministries are responsible, and if demonstrablebenefits to the target populations can be shown,eradicationprogrammes—whichappeal topoliticians,donors, and the public— could not only contribute toreducingmortality but couldalso serve as a leadingedgeto prepare countries for longer-term programmes.However, it might be important to make develop-mental goals more explicit in order to ensure thateradication-type programmes are held accountable fortheir achievements in all countries, both richer andpoorer. This might be accomplished by setting longer-term goals — for example, by deciding what ought tobe achieved over the next 25 years — and allowingcountries to pursue those globally agreed goals at theirown pace in accordance with their own priorities. Theadvent of public health endowments, such as theGlobal Alliance for Vaccines and Immunization, mayallow for longer-term planning, as the urgency to raisefunding for short-termprogrammesmay be somewhatalleviated in the future.

Case-management: the trend towardsintegrating and packaging services

To conform to the changing characteristics of healthministries, which have undergone substantial reorga-

Table 1. Annual deaths due to vaccine-preventable diseases (21 )

Disease No. of preventableannual deaths

Poliomyelitis 720Diphtheria 5000Pertussis 346 000Measles 888 000Tetanus (including 215 000 neonatal deaths) 410 000Haemophilus influenzae type b 400 000Hepatitis Ba 900 000Yellow fevera 30 000Total 2 979 720

a Most deaths do not occur in childhood.



nization and reform, including a reduction in theemphasis on technical programmes, efforts have beenmade to incorporate disease-control programmes inmore integrated and manageable packages of basicservices. The Integrated Management of ChildhoodIllness programme is one example of this approach.Developed jointly by WHO and UNICEF, thisprogramme has been embraced by more than60 countries and has attracted support from a largenumber of donor agencies, including more than25 projects supported by the World Bank.

The conditions included in the package includemajor communicable diseases (pneumonia, diar-rhoea, malaria, and measles). The package alsoemphasizes addressing malnutrition, which has beenshown to contribute to more than half of allchildhood deaths (22). To a greater extent than manyearlier strategies, this package includes both treat-ment and prevention interventions. In addition totraining health workers in standard case-managementprotocols for treating all five diseases, the packageurges the promotion of breastfeeding, improvementsin feeding practices, the use of micronutrientsupplements, and vaccines.

Even more importantly, the package callsattention to the need not only to train healthprofessionals but also to strengthen existing healthsystems to ensure the availability of drugs andsupplies and widespread access to them. Supervision,monitoring, and evaluation activities are also empha-sized. The third, and essential, component of thepackage is the promotion of improved preventionand care-seeking behaviours in the community andthe family.

Diseases that contribute directly to childhoodmortality are not the only subjects of these newinitiatives. Increased attention is being paid to earlychildhood development, emphasizing the psychologi-cal and intellectual growth of the child. Interventionsin childhood development are traditionally focused onthe family and community and are not deliveredthrough the health system. Nevertheless, certainaspects of the care of young children have recentlybeen added as an option in adapting the IntegratedManagement of Childhood Illness package forcountries that want early childhood development tobe incorporated as an integral part of recovery fromchildhood illness. Similarly, just as early childhooddevelopment programmes combine interventions innutrition, health, and psychology to achieve improvedoutcomes overall, recent interagency efforts (betweenWHO, UNICEF, and the World Bank) combine theteaching of life skills with the provision of appropriatehealth services at schools, including adequate waterand sanitation facilities.

The link between poverty and childhealth outcomes

It is increasingly understood that the relation betweenhealth and poverty is bi-directional. Just as low

income is a contributing factor to ill-health andmalnutrition, so are poor health, malnutrition, andlarge family size key determinants of poverty. Intargeting health interventions at poorer people, thereare two formidable challenges: to lower the incidenceof outcomes associated with adverse health and poornutrition and to protect households against poten-tially impoverishing effects when adverse outcomesdo occur.

It is not only that poor people are in ill-health:ill-health causes poverty. In Voices of the poor, a recentWorld Bank study, ill-health emerged as one of theprincipal reasons why households become poor andremain poor (23). Explanations are numerous: theyinclude the burden of health care expendituresincurred by caring for sick household members(24), the lost income of the sick, and the lost incomeof other household members who care for the sick.Nationally, although data relating the impact ofhealth indicators to poverty rates are scarce, evidenceis emerging about the impact of health on economicgrowth. One study estimated that health anddemographic variables accounted for half of thedifference in growth rates betweenAfrica and the restof the world from 1965 to 1990 (25).

Malnutrition is also known to be an importantdeterminant of poverty through its direct effects onloss of earnings: the chronically malnourished workless and earn less (26, 27). In addition, malnutritionexerts indirect effects on health status, cognitivedevelopment, and the productivity of workers.Numerous examples can be cited: non-breastfedbabies have a 14-fold increased risk of dying fromdiarrhoea (28); iodine deficiency disorder has beenestimated to reduce intelligence quotient (IQ) by anaverage of 13.5 points (29); and in Chile, iron-deficient children who were successfully treatedperformed 10–400% better on standardized teststhan anaemic children (30).

Improving health and nutrition especiallyamong people living in poverty or close to povertyis thus likely to pay dividends by contributing to risesin household income and raising incomes will helplower mortality. Because of the gross health inequal-ities between rich and poor both within and betweencountries it seems reasonable to encourage a changein health programming. If mortality rates, especiallyin childhood, are to be further reduced and stagnatingor reversed trends are to be corrected, it may bemoreimportant in the future to address the needs ofspecific families and households rather than toemphasize the development of programmes aimedat specific diseases, wherever they might occur. Thispeople-oriented approach may be more difficult, andit may entail the development and application ofsociological rather than biomedical research. But it isincreasingly clear that reducing poverty can beachieved by introducing policies and applyingprogrammes that protect households from theimpoverishing effects of ill health, malnutrition, andhigh fertility.



The future of child health effortsin a changing political environment

To a certain extent, the easiest part of achieving lastingreductions in childhood mortality has occurred insome countries. In others, the strategies that have beenused — strengthening health systems and traininghealth care providers in the appropriate use of safe,effective, affordable technologies — have beeninadequate or not sustainable. In these countries,mortality rates have stagnated or are rising. In all cases,further improvements will depend to a large extent onwhat happens in the household and community and towhat extent the health system is responsive and willplay a supportive part. The promotion of a limited setof household behaviours that have direct links to theprevention and cure of common childhood illnessesneeds to become the centrepiece of intensified activity(see Box 1). Since the ability and willingness offamilies to adopt new behaviours are influenced by avariety of factors, it will need to be determined locallyhow best to promote these behaviours. Factorsinfluencing the adoption of new behaviours includethe household’s resources, attitudes in the community;and the price, quality, and availability of services andgoods such as food, energy, transport, water, andsanitation facilities.

A graphical depiction of the relation betweenthe household or the community and the healthsystem is shown in Fig. 1 (31). The Pathway toSurvival is a guide that distinguishes betweenprevention behaviours, such as breastfeeding, thatcan be implemented entirely in the home and those,such as vaccination, that require more direct supportfrom the health system. Similarly, it shows how themanagement of childhood illness can also be carriedout in the home in many instances, with mothersresponsible for making the critical decision of whenexternal support is required. One of the mostattractive features of the pathway is that it can beused as a quantitative tool for measuring problems inhome care, health care-seeking behaviour, thedelivery of primary and secondary health care,counselling patients, and the compliance of carers.In fact, a distribution of causes of death can beestablished on the basis of ‘‘social autopsies’’ takenfrom mothers whose children have recently died.One study in the periurban area of El Alto, near LaPaz, the Republic of Bolivia, where childhoodmortality was high, found that considerably morethan half of the deaths could be ascribed toinadequate knowledge or incorrect behaviour, orboth, occurring in the household or community.Findings such as these support the notion that furtherprogress in child survival can only bemade bymakinggreater investments in communities and families.

A recent adaptation of the strategic frameworkfirst presented by Mosley & Chen in 1984 adds anadditional dimension to the Pathway for Survivalmodel (32). In addition to showing the relationbetween the health system and the household andcommunity, the recent Poverty reduction strategy (health,

nutrition and population) sourcebook of the World Bankincludes the more distal role of government policiesand actions (Fig. 2). The Mosley–Chen frameworkincluded both social and biological variables. Itassumed that all influences on childhood mortalityat the individual, household, and community levelsoperate through a set of common mechanisms, suchas maternal factors, environmental contamination,nutrient deficiency, injury, and control over personalillness; these were the more proximate determinants.In the revised framework, the links between policyformulation and health outcomes have been mademore explicit. The revised framework includes healthsystems interventions and the promotion of appro-priate household and community behaviours asessential intermediate steps between policy andoutcome. It recognizes that integrated packages of

Box 1. A list of key household behaviours forreducing childhood mortality (11)

Reproductive health behavioursWomen of reproductive age should delay age of firstpregnancy, practise birth spacing, limit family size.Pregnant women should seek antenatal care at least twiceduring pregnancy.Women should take iron supplementation duringpregnancy.

Infant and child feeding practicesMothers should breastfeed their children exclusivelyfor about six months.From six months mothers should give children appropriatecomplementary feeding and continue to breastfeed for24 months (if testing positive for human immunodeficiencyvirus, current recommendations should be followed).

Immunization practicesAll infants should be taken for measles vaccination at ninemonths of age.Infants should be taken for routine vaccinations even whensick.Pregnant women and other women of childbearing ageshould seek tetanus toxoid vaccine at every opportunity.

Home health practicesPreventionAll children should sleep under insecticide-treated bednetswhen indicated.Wash hands with soap at appropriate times.All infants and children should consume enough vitamin A,by whatever means available.All families should use iodized salt.

TreatmentContinue feeding and increase fluid intake during illness;increase feeding after illness.Mix and administer oral rehydration salts, or an appropriatehome-available fluid, correctly.Administer treatment and medications according toinstruction.

Care-seeking practicesSeek appropriate care when an infant or child is recognizedas being sick.





interventions, such as the Integrated Management ofChildhood Illness, the Integrated Management ofPregnancy and Childbirth, school health pro-grammes, nutritional interventions, and control ofboth communicable diseases (such as HIV/AIDS,tuberculosis, and malaria) and noncommunicablediseases, constitute one set of influences on house-hold behaviours. Yet policies that determine theavailability of health services and the financing ofthose services and others — such as food supply,water, sanitation, and other related commodities andservices — are equally important. Finally, it explicitlyrecognizes that what happens in the household andcommunity is the most proximate determinant offavourable health outcomes (33).

Implicit in this approach to achieving goodhealth outcomes is the recognition that childhoodmortality, for example, does not depend only oninterventions in childhood. The health of mothersand fathers, siblings, grandparents, and other house-hold members also influences the health of children.Similarly, interventions during childhood can have animportant influence on health in adulthood. It isincreasingly recognized that interventions in onegeneration can affect health outcomes in the next.Ensuring adequate nutrition among girls duringchildhood and adolescence, for example, can reducethe incidence of low birth-weight babies, animportant risk factor for early mortality.

In order to account for thesemultiple and cross-cutting influences, and to organize them in a way thatcan be easily translated into health programmes, theWorld Bank and its partners have participated in theelaboration of a life cycle approach (Fig. 3). Thisframework, which includes interventions to beimplemented throughout life (and gives specialconsideration to the reproductive period for women,which includes pregnancy and the start of a new cycle

for a new generation), takes into account four basicprinciples: that health interventions have a cumulativeimpact — the costs and benefits of interventions laterin life are partially dependent upon those that occurredearlier; that sustaining improved outcomes at any stageof the life cycle depends on interventions occurringduring several stages; that interventions in onegeneration can influence outcomes in later genera-tions; and that clearly identifying the different stages ofthe life cycle facilitates the identification of risks forboth individuals and families.

Identifying the major risks to good health ateach stage of the life cycle allows appropriateinterventions to be selected. These interventionscould be implemented either exclusively within thehealth sector or, consistent with the modifiedMosley–Chen framework, through other mechan-isms for influencing household behaviours (34). Thenotion that interventions throughout the life cyclemust be implemented to achieve the maximumreduction of deaths occurring in childhood willhopefully promote collaboration within the healthsector and between sectors and help ensure thatavailable resources are used more efficiently andeffectively.

A discussion of current approaches to reducingchildhood mortality would not be complete withoutmentioning the legal dimensions of this effort. TheConvention on the Rights of the Child, adopted by theGeneral Assembly of the United Nations in 1989 andsubsequently ratified by all but a small number ofcountries, explicitly recognizes a child’s right to healthand health services. Article 24 of the conventionobligates all ratifying parties to ‘‘pursue full imple-mentation of this right and, in particular, [to] takeappropriate measures...to diminish infant and childmortality.’’ Guidance regarding implementation andmonitoring of the actions called for by the conventionhas been developed and disseminated (35).

Conclusions

We have attempted to present briefly the traditionsfrom which child survival efforts have developed, aconcise description of some of the more prominentcurrent initiatives and a few of the ideas beingproposed for ensuring continued or resumedprogress towards reducing childhood mortality.Although many of the technological tools necessaryto address the principal biomedical causes of child-hood mortality in developing countries are available,they have been used in a patchy and inequitablefashion: access to health services and to these toolshas been restricted for large parts of the population inmany countries. It is increasingly recognized that thehealth of children is integrally related to poverty, andthat there is a strong correlation between highmortality and poverty.

Perinatal, neonatal, and early childhood mor-tality have become relatively more important in areaswhere reductions in mortality have already been



substantial. More effective technical interventionsand strategies for implementing them still need to bedeveloped formany of the potentially fatal conditionsthat occur earlier in life. But technological advancesnotwithstanding, an increased emphasis on improv-ing health behaviours in households and in commu-nities must occur if sustainable improvement inoutcomes related to children’s health is to beachieved across all segments of society. Research,and especially social science research, can contributeto the development of appropriate behaviouralinterventions but only if the close collaborationbetween the research and the programmatic com-munities can be strengthened.

Poverty is an important contributing factor tochildhoodmortality, and economists and internationalfinancial institutions are beginning to recognize thatadverse health outcomes are an important contributorto poverty. Accordingly, it is important that strategiesaimed at reducing poverty take into account thedeterminants of poor health outcomes at all stages ofthe life cycle. The formulation of policies andprogrammes that use a broad range of interventionsimplemented in an integrated manner can result bothin improved health and improved standards of living.

The future of child health programmes indeveloping countries depends upon bridging gaps. In

order for substantial new reductions in mortality tobemade, disease-specific programmes and those thataddress the determinants of common causes ofmortality should be designed to complement eachother. Research into new technologies and into newways of influencing household behaviours should bestrongly and effectively managed, and solutions toproblems of implementation should be disseminated,widely applied, and evaluated. Strategic approaches,such as the Pathway to Survival model, the modifiedMosley–Chen framework, and the life cycle ap-proach, should be further developed to provideguidance to policy-makers, health service providers,and community leaders. These approaches that aremore community-driven are necessary because thepattern and trends of childhood mortality havechanged. Although impressive in some places, theapparent reductions over the past 20 years sometimesmask the fact that the rate of decline has stalled formany people and especially for those who are poor.Improving children’s survival is an unfinished task,but by using innovativemultisectoral approaches thatrecognize that health outcomes can be influenced inways that have not yet been adequately explored, andespecially by moving the centre of attention from thehealth system to the household, additional gains canbe made rapidly and effectively. n

Resume

L’evolution des programmes de sante infantile dans les pays en developpement :on cesse de cibler les maladies pour cibler les gensAu cours des 30 dernieres annees, les taux de mortalitechez les nourrissons et les enfants ont baisse danspresque tous les pays. En outre, le nombre de decesd’enfants est passe d’environ 15 millions a environ11 millions, malgre une augmentation du nombre desnaissances, une resistance croissante aux antibiotiqueset antipaludiques courants et la propagation – difficile aenrayer – du syndrome d’immunodeficience acquise(SIDA) dans une grande partie du monde. Plusieursmaladies et problemes de sante, dont les infectionsrespiratoires aigues, les maladies diarrheiques, lepaludisme, la rougeole et la malnutrition, ont toujoursete les principales causes d’une mortalite infantileelevee, bien qu’il existe contre chacun d’eux desinterventions sans danger et efficaces.

Nul ne peut garantir que les progres continueront.D’abord, les succes enregistres a ce jour n’ont pas eteuniformes. Beaucoup de pays pauvres et de regionspauvres de nombreux pays n’ont pas obtenu les memesresultats que les pays prosperes. Ensuite, a mesure queles taux de mortalite baissent, differentes affectionsjouent un role plus determinant : les maladies peri-natales et neonatales, contre lesquelles des interventionsappropriees pouvant etre appliquees sur une grandeechelle n’ont pas encore ete mises au point, sontdesormais la cause d’une proportion plus elevee de deceschez les enfants de moins de cinq ans. Les questionssexospecifiques doivent aussi etre abordees et lapropagation continue du SIDA, notamment en Afrique

subsaharienne et en Asie du Sud-Est, comprometserieusement la poursuite des progres.

Le present article examine les tendances observeesdans les programmes visant a promouvoir la sante desenfants au cours des dernieres decennies et avance despropositions sur la meilleure facon de concevoir lesprogrammes futurs. Il passe en revue les differentesapproches adoptees dans le passe : les initiatives a courtterme et a objectifs etroits, dirigees contre des maladiesdeterminees, comme les premieres campagnes d’eradi-cation du paludisme (un echec) et de la variole (unsucces), et les strategies de grande envergure, axees surle developpement a long terme et sur les communautes,comme les soins de sante primaires. Les programmesmodernes d’eradication de maladies telles que lapoliomyelite et la dracunculose et les strategies« selectives » de soins de sante primaires, comme leprogramme de prise en charge integree des maladies del’enfant, essaient de combiner des elements de chacunede ces demarches.

Le role traditionnellement preponderant desprogrammes de sante infantile semble s’amenuiser. Celapeut s’expliquer, entre autres, par le fait que lemouvement de reforme du secteur de la sante s’estdavantage preoccupe de considerations administrativeset financieres que des programmes techniques ouensembles de programmes. La decentralisation aentraıne dans de nombreux pays une deterioration desfonctions d’appui aux systemes de sante, telles que la



formation et l’encadrement du personnel et le suivi etl’evaluation des programmes. Toutefois, les strategiestechniques, comme celles qui sont appliquees dans lecadre des programmes de vaccination et des initiativesde prise en charge des cas, continuent de s’affiner pourameliorer la prestation des services, renforcer lessystemes de sante et, par-dessus tout, favoriser laparticipation communautaire.

L’accent est mis desormais sur la relationbidirectionnelle entre la pauvrete et la sante. De grandesinegalites en matiere de sante existent entre riches etpauvres, entre pays, au sein des pays et au sein descommunautes. A l’avenir, il peut etre importantd’accorder plus d’attention aux menages et aux famillesdans lesquels, a cause de la pauvrete ou d’autresfacteurs, les enfants sont davantage exposes au risque demourir. Le message essentiel contenu dans cet article estque la reduction de la mortalite infanto-juvenile pourraitbien dependre davantage de ce qui se passe dans lescommunautes et les menages que de ce qui se passe al’interieur d’un systeme de sante.

Quatre modeles sont examines. Le guide de lasurvie et une adaptation du cadre de Mosley-Chenillustrent la relation entre la communaute et le systemede sante, mais sous un angle different. La nouvelleapproche du cycle biologique decrit au moyen degraphiques comment la sante de l’enfant depend desrisques et des interventions sanitaires a des agesdifferents et des influences entre generations. Enfin, ilest fait mention de la Convention relative aux droits del’enfant, et notamment du droit a la sante et aux servicesde sante.

Bien que l’on dispose dans une large mesure desoutils technologiques permettant de reduire davantagela mortalite infantile, les strategies de mise en œuvredoivent s’adapter au contexte local. La recherche ensciences sociales, qui vise a trouver des moyensd’atteindre les communautes et les familles a hautrisque, en particulier celles dont l’acces aux services desante est entrave par la pauvrete, devient de plus en plusimportante.

Resumen

La evolucion de los programas de salud infantil en los paıses en desarrollo: el puntode mira se desplaza de las enfermedades a las personasDurante los 30 ultimos anos, las tasas de mortalidad delactantes y ninos han disminuido en casi todos los paıses.Ademas, el numero de defunciones infantiles hadescendido de unos 15 millones a cerca de 11 millonesa pesar del aumento del numero de nacimientos, dela resistencia creciente a antibioticos y antipaludicoscomunes y de la propagacion relativamente incontroladadel SIDA en gran parte del mundo. Un numero limitadode afecciones medicas, como las infecciones respiratoriasagudas, las enfermedades diarreicas, el paludismo, elsarampion y la malnutricion, han constituido sistemati-camente las principales causas de mortalidad infantilpese a que existen intervenciones seguras y eficacescontra cada una de ellas.

El progreso continuo no esta asegurado. Primero,hasta la fecha el exito no ha sido uniforme. Muchospaıses pobres, y zonas pobres de muchos paıses, no hanconseguido resultados tan buenos como los mas ricos.Ademas, a medida que disminuyen las tasas demortalidad, otras afecciones adquieren mas importancia;la mortalidad perinatal y neonatal, para la cual todavıano se han desarrollado intervenciones que puedanimplantarse de forma generalizada, contribuye aun masque antes al numero de defunciones de menores de5 anos. Tambien es necesario abordar las cuestionesrelacionadas con la paridad entre los sexos, y lapropagacion continua del sındrome de inmuno-deficiencia adquirida (SIDA), especialmente en el Africasubsahariana y en Asia Sudoriental, amenaza seriamentela continuidad de los progresos.

En este artıculo se examinan las tendencias de losprogramas de promocion de la salud de los ninos en losultimos decenios y se formulan sugerencias sobre lamejor manera de disenar programas en el futuro. Seanalizan los diferentes enfoques adoptados en el

pasado, a saber: iniciativas a corto plazo y con objetivosmuy concretos contra enfermedades especıficas, comolas primeras iniciativas de erradicacion del paludismo (unfracaso) y de la viruela (un exito), y estrategias amplias, alargo plazo, de desarrollo, orientadas hacia la comuni-dad, como la de atencion primaria de salud. Losprogramas modernos de erradicacion de enfermedadescomo la poliomielitis y la dracunculosis y las estrategias«selectivas» de atencion primaria, como la de luchaintegrada contra las enfermedades de la infancia, tratande combinar diversos elementos de cada uno de esosenfoques.

La importante funcion que han desempenadotradicionalmente los programas de salud infantil pareceestar disminuyendo. Una de las razones podrıa ser que elimpulso hacia la reforma del sector de la salud se hacentrado mas en consideraciones administrativas yfinancieras que en programas o conjuntos de programastecnicos. La descentralizacion ha dado lugar en muchospaıses a un deterioro de las funciones de apoyo a lossistemas, como la capacitacion, la supervision y lavigilancia y la evaluacion de los programas. Sin embargo,las estrategias tecnicas, como las de los programas devacunacion y las iniciativas de gestion de casos, siguenevolucionando para mejorar la prestacion de servicios,fortalecer los sistemas de salud y, lo que es masimportante, promover la participacion comunitaria.

Sedestaca la relacionbidireccional entre lapobrezayla salud. Existengrandesdesigualdadesdesaludentre ricosy pobres, entre los paıses, dentro de los paıses y dentro delas comunidades. En el futuro quiza sea importante dirigirlos esfuerzos hacia los hogares y familias en los que, debidoa la pobreza u otros factores, los ninos corren mayor peligrode morir. El mensaje clave de este artıculo es que los futurosavances en la reduccion de la mortalidad de lactantes y



ninos bien pueden depender de lo que suceda en lascomunidades y los hogares, y no tanto de lo que suceda enel sistema de salud.

Se examinan cuatro modelos. El modelo «La Vıade la Supervivencia» y una adaptacion del marco deMosley-Chen muestran la relacion entre la comunidad yel sistema de salud, pero de forma diferente. El nuevoenfoque del ciclo de vida ilustra graficamente la maneraen que la salud de los ninos depende de los riesgos eintervenciones sanitarios a distintas edades y deinfluencias intergeneracionales. Por ultimo se menciona

la Convencion sobre los Derechos del Nino, que reconoceel derecho a la salud y a servicios de salud.

Aunque en gran medida se dispone de herra-mientas tecnologicas para seguir reduciendo la morta-lidad infantil, es necesario adaptar las estrategias deaplicacion a los contextos locales. Las investigacionessociologicas encaminadas a identificar maneras de llegara las comunidades y familias de alto riesgo, especial-mente aquellas cuyo acceso a los servicios de salud sehalla limitado por la pobreza, estan cobrando unaimportancia creciente.

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