78(10)1234

Special Theme — Child Mortality

The evolution of child health programmes in
developing countries: from targeting diseases
to targeting people
Mariam Claeson1 & Ronald J. Waldman2

Mortality rates among children and the absolute number of children dying annually in developing countries have
declined 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 poor
countries, and some poorer regions within countries, have experienced a levelling off of or even an increase in
childhood mortality over the past few years. Until now, two types of programmes — short-term, disease-specific
initiatives and more general programmes of primary health care — have contributed to the decline in mortality. Both
types of programme can contribute substantially to the strengthening of health systems and in enabling households
and communities to improve their health care. In order for them to do so, and in order to complete the unfinished
agenda of improving child health globally, new strategies are needed. On the one hand, greater emphasis should be
placed on promoting those household behaviours that are not dependent on the performance of health systems. On
the other hand, more attention should be paid to interventions that affect health at other stages of the life cycle while
efforts 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 of
health 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 50 countries the mortality for children under 5 years
was greater than 100 deaths per 1000 live births. In
For the past 35 years, the steep decline in deaths 12 countries (11 of them in Africa), one in every
among infants and children has provided evidence of five children born alive did not survive to the age of
an important success story in international develop- five years (1). Of the nearly 11 million children who
ment. Mortality has declined steadily at an average of will die before their fifth birthday this year, 70% will
about 1% per year. The absolute number of children die from a disease, a combination of a few diseases,
under the age of 5 years dying has fallen from an or a condition for which safe and effective
estimated 15 million in 1980 to about 11 million at the interventions are readily available in industrialized
end of the 1990s (1). Remarkably, this decline has countries: acute respiratory infections, diarrhoea,
occurred in the face of increased births, spreading measles, malaria, and malnutrition (2).
resistance to commonly used antibiotics and anti- Better access to basic health services —
malarial drugs and, most menacingly, the growth of including vaccinations, oral rehydration therapy,
the AIDS pandemic. and antibiotics for pneumonia — together with
A closer look at this favourable trend, improvements in social conditions — including
however, reveals that progress has been distributed higher standards of living and smaller families living
unevenly. Recently, the decline in mortality among on larger incomes — have been important factors in
children under 5 years has stalled in a number of improving the survival rate of children. As deaths
countries and in some the trend has reversed and among children under 5 years have declined in many
mortality seems to be rising. In 1998, in more than developing countries, contributing to both demo-
graphic and epidemiological transitions, the propor-
1
tional mortality accounted for by some conditions
Principal Public Health Specialist, Health, Nutrition, and Population, has increased: this problem has been relatively
Human Development Department, World Bank, Washington, DC,
20433, USA (email: mclaeson@worldbank.org). Correspondence ignored by the international health community. For
should be addressed to this author. example, the greatest decline in childhood mortality
2
Professor of Clinical Public Health and Director, Program on rates has occurred among children in the post-
Forced Migration and Health, Center for Population and Family Health, neonatal period; this has led to a relative increase in
Joseph L. Mailman School of Public Health, Columbia University, the importance of neonatal and perinatal mortality.
New York, USA.
Also, gender-specific issues have emerged in some
Ref. No. 00-0762

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

The evolution of child health programmes in developing countries

parts of the world, notably on the Indian subconti- programmes must, when possible, promote com-
nent where girls aged between 1 month and 5 years munity involvement while contributing to the on-
still experience considerably higher mortality and going development and strengthening of national
morbidity than boys (3, 4). And, although this paper health systems (6).
does not deal with it specifically, increases in deaths Similarly, a debate over the degree to which the
from AIDS in Africa are already slowing or reversing objectives of primary health care can be translated
these downward trends. Without a major assault on into effective programmes resulted in the emergence
AIDS throughout local health systems and in the of ‘‘selective primary health care’’ (7). This new
community, childhood mortality, whether from strategy, which targeted the control of diseases
infection or from the increased risks associated with identified as the most important contributors to
being orphaned, can be expected to increase in some increased mortality, was intended to be more focused
parts of the world. and more feasible. A number of specific, more
In this paper, we examine the roots from which vertical programmes (so named because of the self-
current child health programmes have grown, some of contained way they appear on organizational charts
the causes behind the apparent slowing of progress in and, more importantly, in budget lines of health
many parts of the world, and we suggest ways in which ministries) were promoted to channel relatively
the nature of these programmes must change if meagre resources into areas in which demonstrable
continued gains are to be made throughout the world. success could be achieved in the medium-term.
Furthermore, the emphasis was clearly put on
programmes that would contribute to achieving
decreases in mortality among infants and children,
Trends and milestones since children were considered to be the most
Global strategies for reducing childhood mortality vulnerable segment of the population because they
have been of two basic types. The first were have the highest rates of preventable death.
ambitious disease-specific, technologically depen- The World Health Organization, for example,
dent strategies aimed at achieving dramatic, albeit first developed the Expanded Programme on
narrow, successes in a relatively short time. The Immunization and subsequently the Programme
notable failure of the most ambitious programme of for the Control of Diarrhoeal Diseases. UNICEF
this type — the malaria eradication programme (not chose four specific interventions on which to focus:
exclusively a child health programme, but one that growth monitoring, oral rehydration therapy, breast-
was expected to make a major contribution to feeding promotion, and immunization, known by the
reducing child mortality) launched in the 1950s and acronym GOBI. It later added three more (food,
abandoned in the 1970s — contributed strongly to a family planning, and female education). Bilateral
shift in thinking (5). donors followed, channelling funds into what came
The more people-centred, community-based to be called ‘‘child survival’’ programmes; these
strategy typified by primary health care, with its goal retained their roots in community-oriented, popula-
of health for all by the year 2000, was adopted by the tion-based, primary health care, but at the same time
World Health Assembly in 1977. Primary health care had the appeal of using relatively inexpensive medical
sought to broaden the focus of health services by technologies to reach specific, stated objectives.
emphasizing programmatic areas instead of specific Although the two strategies, at different ends
diseases. Accordingly, the provision of universal of the intervention spectrum, have been able to
services for maternal and child health, family coexist relatively peacefully, they have never quite
planning, improved water supplies, and environ- coalesced. Currently, several attempts at rapproche-
mental sanitation became objectives; these were to be ment are under way. For example, the multi-agency
achieved through an equitable distribution of Roll Back Malaria movement includes components
resources, community involvement, an emphasis on aimed at health systems and at the community.
prevention instead of clinic-based curative interven- Reduced rates of morbidity and death from malaria, it
tions, and a multisectoral approach. suggests, should be viewed as markers of improved
Neither strategic approach ever totally eclipsed health systems. Similarly, the Integrated Management
the other. Although attempts to eradicate malaria of Childhood Illness initiative explicitly incorporates
failed, the ensuing smallpox eradication programme a component of community development; this
is probably the most successful large-scale public programme evolved from selective primary health
health programme in history, with the last case of care programmes that aimed to control diarrhoeal
smallpox acquired by human-to-human transmission diseases and acute respiratory infections in childhood
having occurred in 1977. Important lessons have by working with health workers and strengthening
been learnt from both the failed malaria eradication health systems. Both of these efforts, and many
programme and the successful smallpox programme; others currently being implemented (including the
these lessons have been applied to current attempts poliomyelitis and dracunculiasis eradication pro-
to eradicate dracunculiasis and poliomyelitis, two grammes) emphasize the need for community
programmes which are on the verge of success. To an participation, for strong and effective partnerships
important degree, the appeal of these programmes is between public and private sectors, for intersectoral
rooted in the acceptance that disease-specific links, and the need to combine medical technology

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


with behavioural interventions. That is, they recog- reviews influenced the direction of global efforts in
nize these needs in rhetoric, if not in practice. This preventing and controlling childhood acute respira-
reflects current thinking as to how programmes to tory infections and diarrhoea.
improve children’s health should be implemented, In the 1990s, research priorities have evolved
not necessarily how resources are being invested. as efforts to develop a more integrated approach to
Although emphasis on community-level interven- case management both in the home and within the
tions is generally recognized to be a desirable and health system have intensified. The success of case-
effective approach to implementing successful management strategies depends only in part upon
programmes, activities still tend to focus on improv- the availability of services provided by trained health
ing the delivery of services through an organized care workers. Equally important, if not more so, are
health system, rather than on effecting behavioural the behaviours of the carer in the home and in the
change. community. Case management in the home, care-
seeking practices (including the extent to which
available health services are used), and compliance
The past: research and action with counselling provided by health workers all have
an important impact on children’s health. Research
The recognition that there were multiple technical priorities have therefore focused increasingly on
and operational challenges to the implementation of promoting and maintaining household and commu-
child health and nutrition programmes over the past nity support for the home management of childhood
20 years led to an evolution of research priorities (8). illnesses (with appropriate referral when indicated)
Before 1985, microbiological, epidemiological, im- through interventions designed to encourage com-
munological, and clinical research contributed to the munication and change behaviour. Ethnographic
development of both preventive and therapeutic research, participatory rural appraisal, and other
interventions for the control of common diseases in qualitative methods have been the tools that have
childhood. A prototypical example is the finding that guided the development, local adaptation, and imple-
treatment of acute, watery diarrhoea did not depend mentation of many of these effective, community-
on the etiological agent and that oral rehydration level interventions (11).
therapy with a single, standard solution is safe and To a considerable extent, the progress in
effective in almost all cases; this finding shaped global reducing childhood mortality rates is the result of
treatment policies for childhood diarrhoeal diseases. efficient interactions between research, analysis,
Similarly, the identification of Streptococcus pneumoniae policy development, and programme evaluation.
and Haemophilus influenzae as the leading bacterial The cycle — which includes the dissemination of
causes of mortality from pneumonia led to the research findings, implementation of programmes
development of a universal case-management strat- based on those findings, and feedback regarding
egy based on symptomatic diagnosis and standar- successes and failures — has involved the research
dized antibiotic treatment. After the development of community, bilateral and international donors, health
these technical approaches, research priorities shifted ministries, and nongovernmental organizations in
from focusing on incidence, etiology, and other developed and developing countries. WHO has
descriptive research to focusing on analytical research played a critical part in the analysis and formulation
that was directed at designing, monitoring, and of policy and has provided guidance in implementing
evaluating the impact of priority interventions. and evaluating efforts in various countries.
For example, in the mid-1980s, the World
Health Organization commissioned a review of
research that might contribute to determining the
potential effectiveness, feasibility, and cost of 18 sug-
The present: new initiatives
gested preventive interventions for childhood diar- and programmatic approaches
rhoea (9). The most promising were found to be For much of the past few decades, the international
promoting breastfeeding, improving water supplies, health agenda has been dominated by strategies and
modifying sanitation and hygiene behaviours, in- programmes aimed at reducing mortality in child-
creasing measles vaccination coverage and, after hood. Reich proposes a number of reasons why this
development of the appropriate technologies was was the case. For one, it was important that children’s
ensured, vaccinating against rotavirus infections and health problems were being addressed by large,
cholera. Similar reviews were done for the Pro- influential organizations, including UNICEF, WHO,
gramme on Acute Respiratory Infections in the 1990s and public–private coalitions, such as the Task Force
(10). This process identified eight potential interven- for Child Survival and Development. They also had
tions, each with the ability to prevent at least 5% of symbolic power in the emotional appeal of being able
deaths from pneumonia. These were vaccinating to save children’s lives with simple, cheap interven-
children against measles, S. pneumoniae, H. influenzae tions. Also, with the exception of the infant formula
type B, and respiratory syncytial virus; minimizing industry, children’s health issues posed no competi-
indoor air pollution; reducing the rates of children tion to vested corporate interests. Additionally,
born at low birth weight; and exclusively breastfeed- science was on its side: the use of infant mortality
ing until the child was aged 4–6 months. These rates 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 early supervision, monitoring, training, and supplying
deaths and to the interventions that could be aimed at drugs or vaccines. Without the technical and
them. Finally, for the most part, the agenda setters — programmatic support to which they have become
that is, the politicians — found that child health is a accustomed, and which cannot be made available at
readily accepted cause that meets with little opposi- the provincial or district level in most developing
tion when proposed as a subject for social investment countries, child health services are at risk of levelling
(12). It should also be mentioned that childhood off or even declining in both quantity and quality.
illnesses make a substantial contribution to the global At the same time, child health programmes,
burden of disease (the Integrated Management of especially vaccination programmes, have benefited
Childhood Illness strategy alone, at the time it was from major new funding from non-traditional sources.
formulated, addressed conditions that accounted for Although it seems as if some of the activities being
as much as 14% of disability-adjusted life years) (13), pursued may be contradictory, the potential for each
and high mortality rates in children under 5 years of activity to help reduce childhood mortality is evident. A
age are an important contributor to reduced life few of the more prominent initiatives currently being
expectancy in developing countries. implemented around the world are discussed below.
Recently, however, the primacy of child health
concerns has been challenged, although most
advocates of adolescent and adult health pro- Vaccination strategies
grammes agree that it is not useful to promote
competition between intiatives that target other age Vaccine-preventable diseases are responsible for a
groups and and those aimed at child health problems significant proportion of the approximately 11 mil-
(14). Yet, unless careful attention is paid to lion deaths that occur annually among children under
consolidating the gains made to date and to reversing 5 years of age (Table 1). Yet, nowhere is the contrast
emerging negative trends in some parts of the world, between short-term disease-specific programmes
the gap in life expectancy between richer and poorer and long-term developmental programmes more
nations, and between rich and poor within nations, evident than in the area of childhood vaccination.
may continue to grow. Preventing this situation will Two contemporary vaccination strategies have
require continued emphasis on controlling commu- received massive support from both the public and
nicable diseases, especially those diseases that affect private sectors. The highest profile public health
children disproportionately (15). programme is the initiative to eradicate poliomyelitis.
Supported by a 1988 resolution of the World Health
Assembly (16) and by a major coalition of interna-
tional agencies and private organizations, the drive to
Health sector reforms eradicate poliomyelitis is a direct descendant of
Even if resources for child health are maintained at previous eradication programmes. Based on a
current levels or increased, strategies will have to be strategy of multiple national mass immunization days
adapted to current trends. Presently, many health accompanied by intensified surveillance, poliomyeli-
activities in a large number of developing countries tis has been eliminated from industrialized countries
are unfolding in an environment of health sector and is on the verge of being eradicated worldwide.
reform. Donor support seems to have shifted from The concept of poliomyelitis eradication is
specific programmes to the development of leaner laudable. If successful, it will rid the world of a disease
and potentially more efficient administrative and which causes permanent disability and it will allow for
managerial structures. Typical features of most health the cessation of the production, distribution, and
reform efforts are the decentralization of budgetary administration of poliomyelitis vaccine. It will give
and, sometimes, programmatic authority to provin- public health workers around the world a tangible
cial or district levels and the administrative integra- success and, perhaps, provide strong motivation for
tion of centralized programmes. These reform achieving comparable success in other health pro-
processes and sectorwide approaches can provide grammes. However, poliomyelitis does not contribute
opportunities to identify priority problems and more substantially to the global burden of disease, and its
cost-effective and affordable interventions. Addi- eradication will not appreciably affect childhood
tionally, they may aid the development of sustainable mortality rates. Furthermore, despite the heroic
health systems that are capable of devising local mobilization efforts that have been undertaken for
solutions for local problems. However, there has mass immunization days to be successful, eradication
been less emphasis put on maintaining the quality of is ultimately dependent upon the ability of a health
the more traditional, technically dependent pro- system to organize special campaigns for the delivery
grammes such as those dealing with childhood of services. A strong partnership between commu-
diseases, including the Expanded Programme on nities and the health system is a fundamental
Immunization, the Control of Diarrhoeal Diseases requirement but, unless it is made an explicit goal,
programme, the Programme on Acute Respiratory there is little transfer of responsibility to parents and
Infections, and nutrition. For example, decentraliza- communities. So, in some countries, although im-
tion has often been accompanied by a reduction in munization days have been successful, vaccination
support for essential programme activities such as coverage with antigens other than those for polio-



Table 1. Annual deaths due to vaccine-preventable diseases (21 ) eradication initiative, the global alliance is a public–
private consortium whose principal members are
Disease No. of preventable WHO, UNICEF, the World Bank, national govern-
annual deaths ments, public health and research institutions, the
Rockefeller Foundation, the International Federation
Poliomyelitis 720 of Pharmaceutical Manufacturers Associations, and
Diphtheria 5000 the Bill and Melinda Gates Foundation.
Pertussis 346 000 The global alliance reports that although
Measles 888 000
children in developing countries are scheduled by
Tetanus (including 215 000 neonatal deaths) 410 000
their national immunization programmes to receive six
Haemophilus influenzae type b 400 000
or seven antigens as part of their routine series of
Hepatitis Ba 900 000
vaccination, children in the wealthier countries in
Yellow fevera 30 000
Total 2 979 720 Europe and North America can expect to receive
protection against more than 10 vaccine-preventable
a
Most deaths do not occur in childhood. diseases. This ‘‘vaccine gap’’ is another example of the
inequitable distribution of health services that con-
tributes to the growing difference in mortality between
myelitis, delivered through the routine health services, rich and poor. Incorporating newer, safe, and effective
is declining. Additionally, it is apparent that those vaccines into routine immunization programmes and
countries with the weakest health systems will be the increasing coverage for all vaccines in a consistent and
last to achieve eradication. As a result, as the deadline sustainable manner for all segments of the population
for eradication approaches, there will be increased will require a long-term commitment to developing
pressure on these countries to focus only on the and implementing programmes. Additionally, the
narrow goal of eradicating poliomyelitis and to development and maintenance of the infrastructure
abandon the accompanying objectives related to required to support vaccination programmes will be
strengthening their health systems. Accordingly, there important as new vaccines against diseases that are
is a real potential that the gap in the ability of countries major contributors to both childhood and adult
to carry out other programmes that are dependent on mortality, including malaria, AIDS, and tuberculosis,
their health systems, including those directed toward are developed and marketed.
improving child health, will continue to grow. There is no obvious reason why both types of
As the drive toward poliomyelitis eradication programmes — shorter-term eradication initiatives and
nears its successful end, plans are being made to longer-term developmental programmes — should not
embark upon a global initiative to eradicate measles. coexist. If funding is available, if personnel and other
Unlike poliomyelitis, measles is an important cause of non-monetary resources are sufficient to support both
childhood mortality, and its eradication would make kinds of efforts as well as other programmes for which
an important contribution towards reducing child- health ministries are responsible, and if demonstrable
hood mortality. Technical and programmatic argu- benefits to the target populations can be shown,
ments have been advanced, both in favour of and eradication programmes — which appeal to politicians,
against devoting major resources to eradicating donors, and the public — could not only contribute to
measles. The potential operational, technical, epide- reducing mortality but could also serve as a leading edge
miological, and financial problems that such a to prepare countries for longer-term programmes.
programme might face have been discussed (17, 18). However, it might be important to make develop-
While poliomyelitis eradication efforts have mental goals more explicit in order to ensure that
been progressing, and while measles elimination is eradication-type programmes are held accountable for
being pursued in several regions, vaccination coverage their achievements in all countries, both richer and
with the standard six antigens of the WHO Expanded poorer. This might be accomplished by setting longer-
Programme on Immunization has, in fact, fallen over term goals — for example, by deciding what ought to
the past decade (19). UNICEF estimates that, despite be achieved over the next 25 years — and allowing
the proclaimed success of its Universal Childhood countries to pursue those globally agreed goals at their
Immunization programme efforts in the 1980s, which own pace in accordance with their own priorities. The
sought to achieve 80% vaccination coverage with the advent of public health endowments, such as the
antigens described in the WHO programme by the Global Alliance for Vaccines and Immunization, may
second half of the 1990s, 44 countries had measles allow for longer-term planning, as the urgency to raise
vaccine coverage of less than 65% for children aged funding for short-term programmes may be somewhat
1 year. Populous countries, such as Nigeria, are alleviated in the future.
included in this category; India had an estimated
measles vaccine coverage of 67% (20). The new
Global Alliance for Vaccines and Immunizations is Case-management: the trend towards
responding to this negative trend and is a major
promoter of vaccination and immunization. The
integrating and packaging services
organization seeks to provide more vaccines to more To conform to the changing characteristics of health
children in more countries (21). Like the poliomyelitis ministries, which have undergone substantial reorga-



nization and reform, including a reduction in the income is a contributing factor to ill-health and
emphasis on technical programmes, efforts have been malnutrition, so are poor health, malnutrition, and
made to incorporate disease-control programmes in large family size key determinants of poverty. In
more integrated and manageable packages of basic targeting health interventions at poorer people, there
services. The Integrated Management of Childhood are two formidable challenges: to lower the incidence
Illness programme is one example of this approach. of outcomes associated with adverse health and poor
Developed jointly by WHO and UNICEF, this nutrition and to protect households against poten-
programme has been embraced by more than tially impoverishing effects when adverse outcomes
60 countries and has attracted support from a large do occur.
number of donor agencies, including more than It is not only that poor people are in ill-health:
25 projects supported by the World Bank. ill-health causes poverty. In Voices of the poor, a recent
The conditions included in the package include World Bank study, ill-health emerged as one of the
major communicable diseases (pneumonia, diar- principal reasons why households become poor and
rhoea, malaria, and measles). The package also remain poor (23). Explanations are numerous: they
emphasizes addressing malnutrition, which has been include the burden of health care expenditures
shown to contribute to more than half of all incurred by caring for sick household members
childhood deaths (22). To a greater extent than many (24), the lost income of the sick, and the lost income
earlier strategies, this package includes both treat- of other household members who care for the sick.
ment and prevention interventions. In addition to Nationally, although data relating the impact of
training health workers in standard case-management health indicators to poverty rates are scarce, evidence
protocols for treating all five diseases, the package is emerging about the impact of health on economic
urges the promotion of breastfeeding, improvements growth. One study estimated that health and
in feeding practices, the use of micronutrient demographic variables accounted for half of the
supplements, and vaccines. difference in growth rates between Africa and the rest
Even more importantly, the package calls of the world from 1965 to 1990 (25).
attention to the need not only to train health Malnutrition is also known to be an important
professionals but also to strengthen existing health determinant of poverty through its direct effects on
systems to ensure the availability of drugs and loss of earnings: the chronically malnourished work
supplies and widespread access to them. Supervision, less and earn less (26, 27). In addition, malnutrition
monitoring, and evaluation activities are also empha- exerts indirect effects on health status, cognitive
sized. The third, and essential, component of the development, and the productivity of workers.
package is the promotion of improved prevention Numerous examples can be cited: non-breastfed
and care-seeking behaviours in the community and babies have a 14-fold increased risk of dying from
the family. diarrhoea (28); iodine deficiency disorder has been
Diseases that contribute directly to childhood estimated to reduce intelligence quotient (IQ) by an
mortality are not the only subjects of these new average of 13.5 points (29); and in Chile, iron-
initiatives. Increased attention is being paid to early deficient children who were successfully treated
childhood development, emphasizing the psychologi- performed 10–400% better on standardized tests
cal and intellectual growth of the child. Interventions than anaemic children (30).
in childhood development are traditionally focused on Improving health and nutrition especially
the family and community and are not delivered among people living in poverty or close to poverty
through the health system. Nevertheless, certain is thus likely to pay dividends by contributing to rises
aspects of the care of young children have recently in household income and raising incomes will help
been added as an option in adapting the Integrated lower mortality. Because of the gross health inequal-
Management of Childhood Illness package for ities between rich and poor both within and between
countries that want early childhood development to countries it seems reasonable to encourage a change
be incorporated as an integral part of recovery from in health programming. If mortality rates, especially
childhood illness. Similarly, just as early childhood in childhood, are to be further reduced and stagnating
development programmes combine interventions in or reversed trends are to be corrected, it may be more
nutrition, health, and psychology to achieve improved important in the future to address the needs of
outcomes overall, recent interagency efforts (between specific families and households rather than to
WHO, UNICEF, and the World Bank) combine the emphasize the development of programmes aimed
teaching of life skills with the provision of appropriate at specific diseases, wherever they might occur. This
health services at schools, including adequate water people-oriented approach may be more difficult, and
and sanitation facilities. it may entail the development and application of
sociological rather than biomedical research. But it is
increasingly clear that reducing poverty can be
The link between poverty and child achieved by introducing policies and applying
programmes that protect households from the
health outcomes impoverishing effects of ill health, malnutrition, and
It is increasingly understood that the relation between high fertility.
health and poverty is bi-directional. Just as low



The future of child health efforts Box 1. A list of key household behaviours for
in a changing political environment reducing childhood mortality (11 )

To a certain extent, the easiest part of achieving lasting Reproductive health behaviours
reductions in childhood mortality has occurred in Women of reproductive age should delay age of first
some countries. In others, the strategies that have been pregnancy, practise birth spacing, limit family size.
used — strengthening health systems and training Pregnant women should seek antenatal care at least twice
health care providers in the appropriate use of safe, during pregnancy.
effective, affordable technologies — have been Women should take iron supplementation during
inadequate or not sustainable. In these countries, pregnancy.
mortality rates have stagnated or are rising. In all cases, Infant and child feeding practices
further improvements will depend to a large extent on Mothers should breastfeed their children exclusively
what happens in the household and community and to for about six months.
what extent the health system is responsive and will From six months mothers should give children appropriate
play a supportive part. The promotion of a limited set complementary feeding and continue to breastfeed for
of household behaviours that have direct links to the 24 months (if testing positive for human immunodeficiency
prevention and cure of common childhood illnesses virus, current recommendations should be followed).
needs to become the centrepiece of intensified activity
Immunization practices
(see Box 1). Since the ability and willingness of
All infants should be taken for measles vaccination at nine
families to adopt new behaviours are influenced by a months of age.
variety of factors, it will need to be determined locally Infants should be taken for routine vaccinations even when
how best to promote these behaviours. Factors sick.
influencing the adoption of new behaviours include Pregnant women and other women of childbearing age
the household’s resources, attitudes in the community; should seek tetanus toxoid vaccine at every opportunity.
and the price, quality, and availability of services and
goods such as food, energy, transport, water, and Home health practices
Prevention
sanitation facilities.
All children should sleep under insecticide-treated bednets
A graphical depiction of the relation between
when indicated.
the household or the community and the health
Wash hands with soap at appropriate times.
system is shown in Fig. 1 (31). The Pathway to All infants and children should consume enough vitamin A,
Survival is a guide that distinguishes between by whatever means available.
prevention behaviours, such as breastfeeding, that All families should use iodized salt.
can be implemented entirely in the home and those,
such as vaccination, that require more direct support Treatment
from the health system. Similarly, it shows how the Continue feeding and increase fluid intake during illness;
management of childhood illness can also be carried increase feeding after illness.
Mix and administer oral rehydration salts, or an appropriate
out in the home in many instances, with mothers
home-available fluid, correctly.
responsible for making the critical decision of when
Administer treatment and medications according to
external support is required. One of the most
instruction.
attractive features of the pathway is that it can be
used as a quantitative tool for measuring problems in Care-seeking practices
home care, health care-seeking behaviour, the Seek appropriate care when an infant or child is recognized
delivery of primary and secondary health care, as being sick.
counselling patients, and the compliance of carers.
In fact, a distribution of causes of death can be
established on the basis of ‘‘social autopsies’’ taken nutrition and population) sourcebook of the World Bank
from mothers whose children have recently died. includes the more distal role of government policies
One study in the periurban area of El Alto, near La and actions (Fig. 2). The Mosley–Chen framework
Paz, the Republic of Bolivia, where childhood included both social and biological variables. It
mortality was high, found that considerably more assumed that all influences on childhood mortality
than half of the deaths could be ascribed to at the individual, household, and community levels
inadequate knowledge or incorrect behaviour, or operate through a set of common mechanisms, such
both, occurring in the household or community. as maternal factors, environmental contamination,
Findings such as these support the notion that further nutrient deficiency, injury, and control over personal
progress in child survival can only be made by making illness; these were the more proximate determinants.
greater investments in communities and families. In the revised framework, the links between policy
A recent adaptation of the strategic framework formulation and health outcomes have been made
first presented by Mosley & Chen in 1984 adds an more explicit. The revised framework includes health
additional dimension to the Pathway for Survival systems interventions and the promotion of appro-
model (32). In addition to showing the relation priate household and community behaviours as
between the health system and the household and essential intermediate steps between policy and
community, the recent Poverty reduction strategy (health, outcome. It recognizes that integrated packages of



interventions, such as the Integrated Management of for a new generation), takes into account four basic
Childhood Illness, the Integrated Management of principles: that health interventions have a cumulative
Pregnancy and Childbirth, school health pro- impact — the costs and benefits of interventions later
grammes, nutritional interventions, and control of in life are partially dependent upon those that occurred
both communicable diseases (such as HIV/AIDS, earlier; that sustaining improved outcomes at any stage
tuberculosis, and malaria) and noncommunicable of the life cycle depends on interventions occurring
diseases, constitute one set of influences on house- during several stages; that interventions in one
hold behaviours. Yet policies that determine the generation can influence outcomes in later genera-
availability of health services and the financing of tions; and that clearly identifying the different stages of
those services and others — such as food supply, the life cycle facilitates the identification of risks for
water, sanitation, and other related commodities and both individuals and families.
services — are equally important. Finally, it explicitly Identifying the major risks to good health at
recognizes that what happens in the household and each stage of the life cycle allows appropriate
community is the most proximate determinant of interventions to be selected. These interventions
favourable health outcomes (33). could be implemented either exclusively within the
Implicit in this approach to achieving good health sector or, consistent with the modified
health outcomes is the recognition that childhood Mosley–Chen framework, through other mechan-
mortality, for example, does not depend only on isms for influencing household behaviours (34). The
interventions in childhood. The health of mothers notion that interventions throughout the life cycle
and fathers, siblings, grandparents, and other house- must be implemented to achieve the maximum
hold members also influences the health of children. reduction of deaths occurring in childhood will
Similarly, interventions during childhood can have an hopefully promote collaboration within the health
important influence on health in adulthood. It is sector and between sectors and help ensure that
increasingly recognized that interventions in one available resources are used more efficiently and
generation can affect health outcomes in the next. effectively.
Ensuring adequate nutrition among girls during A discussion of current approaches to reducing
childhood and adolescence, for example, can reduce childhood mortality would not be complete without
the incidence of low birth-weight babies, an mentioning the legal dimensions of this effort. The
important risk factor for early mortality. Convention on the Rights of the Child, adopted by the
In order to account for these multiple and cross- General Assembly of the United Nations in 1989 and
cutting influences, and to organize them in a way that subsequently ratified by all but a small number of
can be easily translated into health programmes, the countries, explicitly recognizes a child’s right to health
World Bank and its partners have participated in the and health services. Article 24 of the convention
elaboration of a life cycle approach (Fig. 3). This obligates all ratifying parties to ‘‘pursue full imple-
framework, which includes interventions to be mentation of this right and, in particular, [to] take
implemented throughout life (and gives special appropriate measures...to diminish infant and child
consideration to the reproductive period for women, mortality.’’ Guidance regarding implementation and
which includes pregnancy and the start of a new cycle monitoring of the actions called for by the convention
has been developed and disseminated (35).

Conclusions
We have attempted to present briefly the traditions
from which child survival efforts have developed, a
concise description of some of the more prominent
current initiatives and a few of the ideas being
proposed for ensuring continued or resumed
progress towards reducing childhood mortality.
Although many of the technological tools necessary
to address the principal biomedical causes of child-
hood mortality in developing countries are available,
they have been used in a patchy and inequitable
fashion: access to health services and to these tools
has been restricted for large parts of the population in
many countries. It is increasingly recognized that the
health of children is integrally related to poverty, and
that there is a strong correlation between high
mortality and poverty.
Perinatal, neonatal, and early childhood mor-
tality have become relatively more important in areas
where reductions in mortality have already been



substantial. More effective technical interventions order for substantial new reductions in mortality to
and strategies for implementing them still need to be be made, disease-specific programmes and those that
developed for many of the potentially fatal conditions address the determinants of common causes of
that occur earlier in life. But technological advances mortality should be designed to complement each
notwithstanding, an increased emphasis on improv- other. Research into new technologies and into new
ing health behaviours in households and in commu- ways of influencing household behaviours should be
nities must occur if sustainable improvement in strongly and effectively managed, and solutions to
outcomes related to children’s health is to be problems of implementation should be disseminated,
achieved across all segments of society. Research, widely applied, and evaluated. Strategic approaches,
and especially social science research, can contribute such as the Pathway to Survival model, the modified
to the development of appropriate behavioural Mosley–Chen framework, and the life cycle ap-
interventions but only if the close collaboration proach, should be further developed to provide
between the research and the programmatic com- guidance to policy-makers, health service providers,
munities can be strengthened. and community leaders. These approaches that are
Poverty is an important contributing factor to more community-driven are necessary because the
childhood mortality, and economists and international pattern and trends of childhood mortality have
financial institutions are beginning to recognize that changed. Although impressive in some places, the
adverse health outcomes are an important contributor apparent reductions over the past 20 years sometimes
to poverty. Accordingly, it is important that strategies mask the fact that the rate of decline has stalled for
aimed at reducing poverty take into account the many people and especially for those who are poor.
determinants of poor health outcomes at all stages of Improving children’s survival is an unfinished task,
the life cycle. The formulation of policies and but by using innovative multisectoral approaches that
programmes that use a broad range of interventions recognize that health outcomes can be influenced in
implemented in an integrated manner can result both ways that have not yet been adequately explored, and
in improved health and improved standards of living. especially by moving the centre of attention from the
The future of child health programmes in health system to the household, additional gains can
developing countries depends upon bridging gaps. In be 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 gens
Au cours des 30 dernieres annees, les taux de mortalite
` ´ ´ subsaharienne et en Asie du Sud-Est, compromet
chez les nourrissons et les enfants ont baisse dans ´ serieusement la poursuite des progres.
´ `
presque tous les pays. En outre, le nombre de deces ´ ` Le present article examine les tendances observees
´ ´
d’enfants est passe d’environ 15 millions a environ
´ ` dans les programmes visant a promouvoir la sante des
` ´
11 millions, malgre une augmentation du nombre des
´ enfants au cours des dernieres decennies et avance des
` ´
naissances, une resistance croissante aux antibiotiques
´ propositions sur la meilleure facon de concevoir les
¸
et antipaludiques courants et la propagation – difficile a ` programmes futurs. Il passe en revue les differentes ´
enrayer – du syndrome d’immunodeficience acquise
´ approches adoptees dans le passe : les initiatives a court
´ ´ `
(SIDA) dans une grande partie du monde. Plusieurs terme et a objectifs etroits, dirigees contre des maladies
` ´ ´
maladies et problemes de sante, dont les infections
` ´ determinees, comme les premieres campagnes d’eradi-
´ ´ ` ´
respiratoires aigues, les maladies diarrheiques, le
¨ ´ cation du paludisme (un echec) et de la variole (un
´
paludisme, la rougeole et la malnutrition, ont toujours succes), et les strategies de grande envergure, axees sur
` ´ ´
ete les principales causes d’une mortalite infantile
´ ´ ´ le developpement a long terme et sur les communautes,
´ ` ´
elevee, bien qu’il existe contre chacun d’eux des
´ ´ comme les soins de sante primaires. Les programmes
´
interventions sans danger et efficaces. modernes d’eradication de maladies telles que la
´
Nul ne peut garantir que les progres continueront.
` poliomye lite et la dracunculose et les strate gies
´ ´
D’abord, les succes enregistres a ce jour n’ont pas ete
` ´ ` ´ ´ « selectives » de soins de sante primaires, comme le
´ ´
uniformes. Beaucoup de pays pauvres et de regions ´ programme de prise en charge integree des maladies de
´ ´
pauvres de nombreux pays n’ont pas obtenu les memes ˆ l’enfant, essaient de combiner des elements de chacune
´ ´
resultats que les pays prosperes. Ensuite, a mesure que
´ ` ` de ces demarches.
´
les taux de mortalite baissent, differentes affections
´ ´ Le role traditionnellement preponderant des
ˆ ´ ´
jouent un role plus determinant : les maladies peri-
ˆ ´ ´ programmes de sante infantile semble s’amenuiser. Cela
´
natales et neonatales, contre lesquelles des interventions
´ peut s’expliquer, entre autres, par le fait que le
appropriees pouvant etre appliquees sur une grande
´ ˆ ´ mouvement de reforme du secteur de la sante s’est
´ ´
echelle n’ont pas encore ete mises au point, sont
´ ´ ´ davantage preoccupe de considerations administratives
´ ´ ´
desormais la cause d’une proportion plus elevee de deces
´ ´ ´ ´ ` et financieres que des programmes techniques ou
`
chez les enfants de moins de cinq ans. Les questions ensembles de programmes. La de centralisation a ´
sexospecifiques doivent aussi etre abordees et la
´ ˆ ´ entraıˆne dans de nombreux pays une deterioration des
´ ´ ´
propagation continue du SIDA, notamment en Afrique fonctions d’appui aux systemes de sante, telles que la
` ´



formation et l’encadrement du personnel et le suivi et Quatre modeles sont examines. Le guide de la
` ´
l’evaluation des programmes. Toutefois, les strategies
´ ´ survie et une adaptation du cadre de Mosley-Chen
techniques, comme celles qui sont appliquees dans le
´ illustrent la relation entre la communaute et le systeme
´ `
cadre des programmes de vaccination et des initiatives de sante, mais sous un angle different. La nouvelle
´ ´
de prise en charge des cas, continuent de s’affiner pour approche du cycle biologique decrit au moyen de
´
ameliorer la prestation des services, renforcer les
´ graphiques comment la sante de l’enfant depend des
´ ´
systemes de sante et, par-dessus tout, favoriser la
` ´ risques et des interventions sanitaires a des ages ` ˆ
participation communautaire. differents et des influences entre generations. Enfin, il
´ ´ ´
L’accent est mis de sormais sur la relation
´ est fait mention de la Convention relative aux droits de
bidirectionnelle entre la pauvrete et la sante. De grandes
´ ´ l’enfant, et notamment du droit a la sante et aux services
` ´
inegalites en matiere de sante existent entre riches et
´ ´ ` ´ de sante. ´
pauvres, entre pays, au sein des pays et au sein des Bien que l’on dispose dans une large mesure des
communaute s. A l’avenir, il peut e tre important
´ ˆ outils technologiques permettant de reduire davantage
´
d’accorder plus d’attention aux menages et aux familles
´ la mortalite infantile, les strategies de mise en œuvre
´ ´
dans lesquels, a cause de la pauvrete ou d’autres
` ´ doivent s’adapter au contexte local. La recherche en
facteurs, les enfants sont davantage exposes au risque de
´ sciences sociales, qui vise a trouver des moyens
`
mourir. Le message essentiel contenu dans cet article est d’atteindre les communautes et les familles a haut
´ `
que la reduction de la mortalite infanto-juvenile pourrait
´ ´ ´ risque, en particulier celles dont l’acces aux services de
`
bien dependre davantage de ce qui se passe dans les
´ sante est entrave par la pauvrete, devient de plus en plus
´ ´ ´
communautes et les menages que de ce qui se passe a
´ ´ ` importante.
l’interieur d’un systeme de sante.
´ ` ´

Resumen
La evolucion de los programas de salud infantil en los paıses en desarrollo: el punto
´ ´
de mira se desplaza de las enfermedades a las personas
Durante los 30 ultimos anos, las tasas de mortalidad de
´ ˜ pasado, a saber: iniciativas a corto plazo y con objetivos
lactantes y ninos han disminuido en casi todos los paı´ses.
˜ muy concretos contra enfermedades especı´ficas, como
Ademas, el numero de defunciones infantiles ha
´ ´ las primeras iniciativas de erradicacion del paludismo (un
´
descendido de unos 15 millones a cerca de 11 millones fracaso) y de la viruela (un exito), y estrategias amplias, a
´
a pesar del aumento del numero de nacimientos, de
´ largo plazo, de desarrollo, orientadas hacia la comuni-
la resistencia creciente a antibioticos y antipaludicos
´ ´ dad, como la de atencion primaria de salud. Los
´
comunes y de la propagacion relativamente incontrolada
´ programas modernos de erradicacion de enfermedades
´
del SIDA en gran parte del mundo. Un numero limitado
´ como la poliomielitis y la dracunculosis y las estrategias
de afecciones medicas, como las infecciones respiratorias
´ «selectivas» de atencion primaria, como la de lucha
´
agudas, las enfermedades diarreicas, el paludismo, el integrada contra las enfermedades de la infancia, tratan
sarampion y la malnutricion, han constituido sistemati-
´ ´ ´ de combinar diversos elementos de cada uno de esos
camente las principales causas de mortalidad infantil enfoques.
pese a que existen intervenciones seguras y eficaces La importante funcion que han desempenado
´ ˜
contra cada una de ellas. tradicionalmente los programas de salud infantil parece
El progreso continuo no esta asegurado. Primero,
´ estar disminuyendo. Una de las razones podrıá ser que el
hasta la fecha el exito no ha sido uniforme. Muchos
´ impulso hacia la reforma del sector de la salud se ha
paı´ses pobres, y zonas pobres de muchos paı´ses, no han centrado mas en consideraciones administrativas y
´
conseguido resultados tan buenos como los mas ricos.
´ financieras que en programas o conjuntos de programas
Ademas, a medida que disminuyen las tasas de
´ tecnicos. La descentralizacion ha dado lugar en muchos
´ ´
mortalidad, otras afecciones adquieren mas importancia;
´ paı´ses a un deterioro de las funciones de apoyo a los
la mortalidad perinatal y neonatal, para la cual todavıá sistemas, como la capacitacion, la supervision y la
´ ´
no se han desarrollado intervenciones que puedan vigilancia y la evaluacion de los programas. Sin embargo,
´
implantarse de forma generalizada, contribuye aun mas
´ ´ las estrategias tecnicas, como las de los programas de
´
que antes al numero de defunciones de menores de
´ vacunacion y las iniciativas de gestion de casos, siguen
´ ´
5 anos. Tambien es necesario abordar las cuestiones
˜ ´ evolucionando para mejorar la prestacion de servicios,
´
relacionadas con la paridad entre los sexos, y la fortalecer los sistemas de salud y, lo que es mas ´
propagacio n continua del sı´ ndrome de inmuno-
´ importante, promover la participacion comunitaria.
´
deficiencia adquirida (SIDA), especialmente en el Africa´ Se destaca la relacionbidireccional entre la pobreza y
´
subsahariana y en Asia Sudoriental, amenaza seriamente la salud. Existen grandes desigualdades de salud entre ricos
la continuidad de los progresos. y pobres, entre los paı´ses, dentro de los paı´ses y dentro de
En este artıćulo se examinan las tendencias de los las comunidades. En el futuro quiza sea importante dirigir
´
programas de promocion de la salud de los ninos en los
´ ˜ los esfuerzos hacia los hogares y familias en los que, debido
ultimos decenios y se formulan sugerencias sobre la
´ a la pobreza u otros factores, los ninos corren mayor peligro
˜
mejor manera de disenar programas en el futuro. Se
˜ de morir. El mensaje clave de este artıćulo es que los futuros
analizan los diferentes enfoques adoptados en el avances en la reduccion de la mortalidad de lactantes y
´



ninos bien pueden depender de lo que suceda en las
˜ la Convencion sobre los Derechos del Nino, que reconoce
´ ˜
comunidades y los hogares, y no tanto de lo que suceda en el derecho a la salud y a servicios de salud.
el sistema de salud. Aunque en gran medida se dispone de herra-
Se examinan cuatro modelos. El modelo «La Vı´a mientas tecnologicas para seguir reduciendo la morta-
´
de la Supervivencia» y una adaptacion del marco de
´ lidad infantil, es necesario adaptar las estrategias de
Mosley-Chen muestran la relacion entre la comunidad y
´ aplicacion a los contextos locales. Las investigaciones
´
el sistema de salud, pero de forma diferente. El nuevo sociologicas encaminadas a identificar maneras de llegar
´
enfoque del ciclo de vida ilustra graficamente la manera
´ a las comunidades y familias de alto riesgo, especial-
en que la salud de los ninos depende de los riesgos e
˜ mente aquellas cuyo acceso a los servicios de salud se
intervenciones sanitarios a distintas edades y de halla limitado por la pobreza, estan cobrando una
´
influencias intergeneracionales. Por ultimo se menciona
´ importancia creciente.

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