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Executive Summary Infant and child mortality rates in many parts of sub-Saharan Africa have been decreasing in recent decades, but remain among the highest in the world. Although the decline in mortality is fairly well documented, it has been difficult to determine the relative importance of various diseases and conditions as causes of death among children of different age groups. Data on causes of death are incomplete and of questionable quality, but virtually all studies report that measles, diarrheal diseases, acute respiratory infections, and malaria are the leading causes of death for children less than 5 years of age. This report reviews programs aimed at preventing and treating these and other leading causes of death in sub-Saharan Africa. It also reviews the evidence of the effects of general health programs on reducing child mortality in the region. Many causes of death can be prevented through vaccination programs. We have reviewed studies of vaccine efficacy and immunization programs in specific locales in sub-Saharan Africa, and have concluded that vaccination programs can have substantial effects on reducing infant and child mortality. However, results from these studies should be extrapolated to different parts of Africa with caution because of ecological and cultural differences, and variations in disease epidemiologies across regions. Moreover, results from small-scale studies are difficult to replicate in large-scale national programs because of differences in program management and logistics. However, not all the leading causes of death can be prevented through
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vaccinations. Other diseases responsible for many infant and child deaths can be prevented or treated through a variety of interventions that can be effective if used correctly and in a timely way. DISEASE- AND INTERVENTION-SPECIFIC FINDINGS Studies indicate that increased measles vaccination coverage has led to lower mortality. Moreover, the incidence of measles decreases as vaccination coverage increases. Even so, research is needed on appropriate case-management strategies for lowering the case-fatality rates among those who become infected. Rates of mortality due to diarrheal diseases peak as children are weaned in the postneonatal period. Most interventions in both hospitals and communities focus on case management of acute dehydrating diarrhea by using oral rehydration therapy (ORT) and continued feeding. ORT is an effective treatment, but it is not used widely enough and is often used incorrectly. Research needs include the development and evaluation of home-based treatment programs, the development of case-management strategies for other forms of diarrheal diseases, and an assessment of the effect of ORT programs on mortality. Malaria is a major health problem in Africa for both children and adults, and is responsible for a large proportion of all child deaths. Programs to combat malaria need to consider the diversity of ecologies, the spread of chloroquine-resistant strains, and the high costs and managerial complexities of many of the available technologies. Presumptive treatment of malaria based on the presence of a fever is common both at clinics and at home, but little research has been done to evaluate the effect of presumptive treatment on mortality. Other increasingly common preventive strategies include providing chemoprophylaxis to pregnant women and the use of insecticide-treated bed nets to prevent mosquito bites. Acute respiratory infections (ARIs), especially pneumonia, can be treated with antibiotics, but few large-scale studies have been conducted to test different strategies for providing treatment. Those studies that have been conducted suggest that appropriate case management can reduce infant mortality by 20 percent and under-5 mortality by 25 percent. Data from the Demographic and Health Surveys suggest that only a small fraction of children thought to have ARIs actually receive antibiotic treatment. Other diseases and conditions contributing to infant and child mortality reviewed in this report include pertussis, tuberculosis, tetanus, and nutrition-related conditions. In addition to the disease-specific interventions that have been initiated in recent years, the expansion of general health services has also contributed to mortality reduction. Studies report declines in mortality as different
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types of health services become available. The effects of health services on mortality are difficult to evaluate because of timing in implementation and the confounding effects of other factors. Research needs include documenting the effects of primary health care on infant and child mortality, and indicating the factors contributing to its different degrees of success. GENERAL CONCLUSIONS In addition to research needs related to specific diseases, this report offers eight observations related to the state of health programs and research in sub-Saharan Africa: Declines in mortality rates should remain the ultimate indicator of the effectiveness of child health interventions in Africa. The goals stated for many programs suggest that program planners often have unrealistic expectations about the feasibility of measuring mortality changes associated with some kinds of interventions. Programs can be classified into three groups: those causing rapid reductions in mortality; those with a more modest potential or that reduce mortality at a slower rate; and those for which direct measurement of mortality effect is not feasible. Misunderstanding the nature of a program can lead to unrealistic expectations of its effects. The trend toward stating program goals in terms of reduction in cause-specific mortality may be setting unrealistic expectations for evaluation. More emphasis should be given to age-specific mortality rates in stating program goals. There is a need for more evaluations of various packages of interventions. It is difficult to evaluate individual components when services are provided in combination. More empirical evaluations of program effects are needed in order to test predictions from models. There is a need for more long-term studies that include regular collection of vital statistics, and routine surveys of service utilization and quality of care. All evaluation studies should include detailed measurement of both the coverage and the promptness of services, as well as compliance with program protocols.
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