Goals of the World Summit for Children and Their Implications for Health Policy in the 1990s

Anne R.Pebley

INTRODUCTION

With great fanfare and major media coverage, the World Summit for Children was held at the United Nations on September 29–30, 1990. The summit was initially proposed by UNICEF in its State of the World’s Children report published in December 1988. At the invitation of United Nations Secretary General Javier Perez de Cuellar, heads of state from 72 countries and representatives from 88 others attended.

The underlying objective of the summit was to focus the attention of international political leaders on the problems of children, particularly children’s health, at a time when international political alignments and priorities were changing rapidly. The summit was also intended as a public endorsement of and a renewed commitment to a specific approach to health policy in developing countries—the “child survival strategy”—which has been a central component of health programs implemented by UNICEF, the World Health Organization (WHO), private nongovernmental organizations (NGOs), and many developing countries, and funded by many donor countries during the 1980s. The statement in which the summit was announced (UNICEF, 1990b:2) by the six initiating governments explained that

Anne R.Pebley is at the Woodrow Wilson School and Office of Population Research, Princeton University. The author is grateful to Noreen Goldman, James Gribble, and Barry Wolf for their comments and suggestions.



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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings Goals of the World Summit for Children and Their Implications for Health Policy in the 1990s Anne R.Pebley INTRODUCTION With great fanfare and major media coverage, the World Summit for Children was held at the United Nations on September 29–30, 1990. The summit was initially proposed by UNICEF in its State of the World’s Children report published in December 1988. At the invitation of United Nations Secretary General Javier Perez de Cuellar, heads of state from 72 countries and representatives from 88 others attended. The underlying objective of the summit was to focus the attention of international political leaders on the problems of children, particularly children’s health, at a time when international political alignments and priorities were changing rapidly. The summit was also intended as a public endorsement of and a renewed commitment to a specific approach to health policy in developing countries—the “child survival strategy”—which has been a central component of health programs implemented by UNICEF, the World Health Organization (WHO), private nongovernmental organizations (NGOs), and many developing countries, and funded by many donor countries during the 1980s. The statement in which the summit was announced (UNICEF, 1990b:2) by the six initiating governments explained that Anne R.Pebley is at the Woodrow Wilson School and Office of Population Research, Princeton University. The author is grateful to Noreen Goldman, James Gribble, and Barry Wolf for their comments and suggestions.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings the purpose of the World Summit for Children is to bring attention and promote commitment, at the highest political level, to goals and strategies for ensuring the survival, protection, and development of children as key elements in the socio-economic development of all countries and human society…. Experience in recent years with the approaches known generally as the Child Survival and Development Revolution has demonstrated that dramatic progress can be achieved in reducing child deaths and improving child health and well-being. The necessary mobilization of multiple sectors of government and society to achieve this progress invariably requires the personal and active involvement of national leaders. It has also been demonstrated that this improvement in the survival of children through the involvement of parents contributes to a subsequent voluntary reduction in births. The summit issued a “World Declaration on the Survival, Protection and Development of Children,” which included specific goals that the summiteers endorsed “for implementation by all countries where they are applicable…” prior to the year 2000. Because some of the wording used in the original text is open to varying interpretation, I have reproduced the goals as they are stated in the declaration in the appendix to this paper. They are summarized in Table 1 according to the type of outcome sought through each goal. I have intentionally placed mortality reduction goals first because they are the principal subjects of this paper. Nonetheless, it is important to recognize that the summit goals themselves are not limited to mortality reduction, but include substantial reductions in morbidity and improvements in health-related conditions (such as nutritional status and dietary deficiency diseases) and health-related services (such as access to safe drinking water and to prenatal care). The summit goals address most of the major health problems afflicting children in developing countries, and many of these conditions have a far greater effect numerically on children’s morbidity than they do on mortality. As Mosley and Gray (this volume) have shown, reduction in childhood morbidity or malnutrition may also improve the health and survival chances of adults later in life. Despite the broad reach of the summit goals, they may or may not constitute the optimal and most realistic approach for all developing countries to improving children’s health in the next decade, for a variety of other reasons. This paper is a brief assessment of the implications and consequences of pursuing and/or achieving the goals of the summit. In the first section of the paper, I consider whether the magnitude of the mortality reduction goals proposed seems feasible in light of past experience and whether achievement of these goals is likely to lead to substantial additional population growth. The second section of the paper is a discussion of the methods proposed in the summit document for implementing the goals, and the implications of governments and donors pursuing some goals but not others.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings MAGNITUDE OF THE SUMMIT GOALS Proposed Mortality Reductions in Light of Past Experience One striking characteristic of the summit goals is that most are very specific with regard to desired numerical targets, and the targets chosen are often quite ambitious. There are at least two advantages of clear numerical targets. First, the success (or lack of success) that programs make toward achievement of the goals can be evaluated more effectively. Second, as those involved in business and program development have known for years, the target number itself provides a strong motivational force for fund raising, program planning, and program implementation. Some of the goals appear to be intended more as motivational targets—in the sense of what can be accomplished under ideal conditions—than as realistic goals that are likely to be accomplished. As a UNICEF (1990b:4) publication issued on the eve of the summit explains: The goal of 80% child immunization by the end of 1990 has undoubtedly helped to lift coverage from 10% in the late 1970s to over 70% at the time of writing. It may therefore now be useful to adopt specific goals for the year 2000…. The following list of child-related goals are considered to be both technically feasible and financially affordable over the course of the next decade. A potential disadvantage of specific numerical targets is that the attention of public health workers, government officials, and the donor community may be so strongly focused on achieving the targets themselves that they lose sight of the general objectives of improving children’s health, sustaining health improvements, and strengthening public health care systems (Unger, 1991). There is also the potential for considerable frustration on the part of government officials and donors if the goals are not achieved. How realistic are the child mortality goals in light of the experience of the last several decades? The goals adopted at the summit for infant and child mortality (see Table 1) for individual countries depend on the level of those mortality rates in 1990. It is not clear from the language used in the declaration whether infant mortality, for example, is to be reduced either by one-third or to 50 per 1,000 live births, whichever produces the lower mortality rate in the year 2000, or whether the reference is to whichever reduction is less. The difference between these two interpretations is substantial: if the objective is to achieve the lowest rate, then the proposed mortality reductions, particularly in those parts of the world in which mortality is very high such as sub-Saharan Africa, will be considerably more than one-third. If, for simplicity, we assume that the goal is to reduce both under-5 mortality rates and infant mortality rates by one-third in the 10 years

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings TABLE 1 Summary of Specific Goals of the World Summit for Children by 2000 (except as noted) Mortality Reduction Goals Infant mortality rates reduced by one-third or to 50 per 1,000 live births, whichever is less; Under-5 mortality rates reduced by one-third or to 70 per 1,000 live births, whichever is less; Maternal mortality rate reduced by half; Deaths due to measles reduced by 95 percent compared to preimmunization levels by 1995; Deaths due to diarrhea reduced by half; Deaths due to acute respiratory infections reduced by one-third. Diseasea Elimination or Eradication Poliomyelitis eradication; Neonatal tetanus elimination by 1995; Iodine deficiency (virtual) elimination;b Vitamin A deficiency (virtual) elimination;b Guinea-worm disease (dracunculiasis) elimination. Disease Condition Reduction Severe and moderate malnutrition among children under-5 reduced by half of 1990 levels; Low birthweight (2.5 kilograms or less) reduced to less than 10 percent; Iron deficiency anemia in women reduced by one-third of 1990 levels; Measles cases reduced by 90 percent compared to preimmunization levels; Diarrhea incidence rate reduced by 25 percent; Health Service Provision-Related Goals Universal access to safe drinking water and to sanitary means of excreta disposal; Access to contraceptive information and contraception for spacing, delaying, and terminating childbearing; Access to prenatal care and trained childbirth attendants; Institutionalization of growth promotion and regular monitoring. Other Goals Universal access to basic education and completion of primary school by at least 80 percent of primary school-age children; Reduction of adult illiteracy and emphasis on female literacy; Dissemination of knowledge and supporting services to increase food production to ensure household food security; Use of mass media and social action to impart skills for better living to families and individuals; Protection of children in especially difficult circumstances. NOTES: aAs used here, “disease” includes nutritional deficiency diseases. bThe goals do not give a specific year by which iodine deficiency and vitamin A deficiency are to be eliminated. The year 2000 is assumed because these goals are intended to be accomplished during the 1990s.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings between 1990 and 2000, we can compare this goal with previous experience in mortality reduction in developing countries. Table 2 presents estimates of the percentage decline in under-5 mortality rates (5q0) (i.e., deaths of children less than 5 years of age per 1,000 live births) for 10-year periods since the 1960s from an article by Hill and Pebley (1989), updated with more recent data from Sullivan (1991). Table 2 includes only countries that have data judged to be reliable for at least two periods of time 10 years apart. Nonetheless, caution should be exercised in interpreting the magnitude of the changes because of remaining problems with data quality. In Latin America, Asia, and the Middle East, many countries have been able to achieve reductions in under-5 mortality of at least one-third in at least one decade since 1960–1965. In four Latin American countries (Chile, Colombia, Costa Rica, and Cuba), Puerto Rico, three Asian countries (Hong Kong, Singapore, and Thailand), and one Middle Eastern country (Kuwait), mortality declined by 33 percent or more in at least three of the four decades. Such reduction was most likely also the case for China and Korea, and may also have been true for Jamaica, although data for the last time period are unavailable. However, there are also a number of countries outside of sub-Saharan Africa in which estimates are available for three or four decades but in which declines of 33 percent or more were not achieved in any of these decadelong periods, including Brazil, Guatemala, Mexico, Peru, Indonesia, the Philippines, and Turkey. Several of the poorest countries in each region, with data available for only one or two decades, also failed to achieve declines of 33 percent in under-5 mortality in any of the decades for which data are available. This group includes Bangladesh, Haiti, Nepal, and Pakistan. The case of Africa is much harder to assess because of the lack of data for many countries and time periods. To the extent that there is a correlation between the availability of reliable mortality data and the likelihood of major mortality declines on the order of those experienced by China, Chile, or Costa Rica, it is less likely that especially large declines occurred in many of the countries for which data are unavailable. Despite the relative lack of data on under-5 mortality change for African countries, the data that are available make it clear that declines of 33 percent or more were rare: only Botswana, Kenya, and Zimbabwe experienced under-5 mortality declines of this magnitude, in at least one of the decades shown. It is important to note that several major public health programs, such as WHO’s Expanded Programme of Immunizations (EPI), were initiated in sub-Saharan Africa in the early 1980s. These efforts are likely to have had their greatest effect on under-5 mortality by the late 1980s and early 1990s, the period for which the least information is currently available. Unfortunately, the effects of these programs on child mortality may have been reduced by the economic crises suffered by African economies during this period.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings TABLE 2 Decline in Under-5 Mortality Rates (5q0) in Developing Countries with Reliable Data by Country, Region and Time Period (percent) Country 1960–1965 to 1970–1975 1965–1970 to 1975–1980 1970–1975 to 1980–1985 1975–1980 to 1985–1990 Latin America Argentina 19.4 29.4 27.6 — Bolivia — — 34.8 — Brazil 17.8 23.0 31.2 — Chile 41.9 53.6 64.5 — Colombia 34.1 46.2 52.8 — Costa Rica 42.9 60.2 62.5 — Cuba 41.6 54.1 53.3 — Dominican Republic — — 33.3 — Ecuador 22.3 25.6 33.8 29.3 Guatemala — 28.0 27.2 20.9 Haiti — — 18.5 — Jamaica 37.7 48.4 — — Mexico 21.3 23.0 23.0 29.9 Panama 29.9 42.7 45.6 — Peru 27.1 24.2 29.6 — Puerto Rico 46.3 43.6 34.5 — Trinidad and Tobago 30.2 36.0 24.3 — Uruguay 1.9 9.3 34.6 — Asia Bangladesh — 3.1 5.7 — China 48.8 48.7 — — Hong Kong 55.3 50.0 42.9 — Indonesia 22.2 27.4 30.3 30.8 Republic of Korea 38.4 36.8 — — Malaysia 31.9 36.1 33.9 — Nepal 17.2 — — — Pakistan — 16.3 — — Philippines 21.1 21.9 17.8 — Singapore 45.2 48.4 47.8 — Sri Lanka 21.8 24.1 — 47.0 Thailand 33.1 40.7 39.6 35.7 Middle East Egypt — 32.1 35.4 46.3 Jordan 38.7 30.3 — — Kuwait 48.6 42.5 50.9 — Syria — 39.3 — — Tunisia 26.5 38.1 — 50.0 Turkey 23.0 22.8 23.4 —

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings Country 1960–1965 to 1970–1975 1965–1970 to 1975–1980 1970–1975 to 1980–1985 1975–1980 to 1985–1990 Africa Benin — 15.7 — — Botswana 19.4 32.3 47.4 49.5 Burkina Faso 5.0 — — — Burundi 8.2 — — — Cameroon 19.7 — — — Central African Republic 24.9 — — — Ghana 20.2 23.5 8.1 −3.3 Kenya 20.6 39.6 — 16.8 Lesotho 7.1 — — — Liberia 6.5 12.9 20.0 — Malawi 6.2 — — — Mali — — 16.3 17.2 Nigeria 17.9 11.5 — — Rwanda −2.2 −3.6 — — Senegal 2.5 14.2 23.6 21.1 Sudan — 25.5 — 14.0 Tanzania 7.6 — — — Togo — 10.6 — 22.2 Uganda 15.6 11.5 −3.6 −5.3 Zimbabwe 6.5 10.5 — 45.3   SOURCE: Hill and Pebley (1989: Table A–1); Sullivan (1991). Achievement of a specific percentage of mortality reduction may be considerably easier for countries with lower initial mortality rates. This observation may account for part of the difference in size of the percentage change between African countries and those in other parts of the world. For example, a reduction of one-third in a relatively low-mortality country with an initial infant mortality rate of 30 per 1,000 live births means preventing 10 additional deaths per 1,000 live births each year. However, in a country with an initial infant mortality rate of 90, a one-third reduction in infant mortality would require the prevention of 30 additional deaths per 1,000 live births1 each year, three times as many deaths as in the low-mortality country. 1   On the other hand, it may be easier to bring about large mortality declines in high-mortality countries because the causes of childhood death that predominate in these countries (e.g., infectious diseases) are easier to prevent and treat than the causes of death that predominate in lower-mortality countries (e.g., perinatal problems). Previous experience shown in Table 2, however, suggests that high-mortality countries have not generally experienced the greatest mortality declines in the past several decades.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings The pattern of changes in infant mortality rates (not shown) during decades between 1960–1965 and 1985–1990 is very similar to that shown in Table 2 for under-5 mortality. This is not surprising because deaths in infancy constitute a substantial part of all deaths before the fifth birthday.2 In summary, a number of countries have been able to achieve reductions in under-5 and infant mortality of 33 percent or more over a 10-year period. Thus, the goal of a one-third reduction in mortality rates for children seems plausible in light of previous experience. However, it is important to recognize that many of the countries that have been most successful at achieving declines of this magnitude either have unusually well-organized health care systems (e.g., Cuba and China, and perhaps Costa Rica), and/or are economically well-off relative to other countries in their region (e.g., Chile, Korea, Hong Kong, Singapore, Thailand, Kuwait, Zimbabwe, Kenya, and Botswana). The evidence is not in yet on whether infant and child mortality can be reduced by as much as one-third in a 10-year period in poorer, high-mortality countries, with less well-organized health systems, through the type of program adopted at the summit. The summit goals also include the reduction of maternal mortality rates by half. Reliable data on past reductions in maternal mortality on a national basis over a 10-year period are even more scarce than information on childhood mortality reductions. Thus, it is difficult to determine whether reductions of 50 percent appear feasible in light of previous experience, and I have not attempted to do so here. Compared with deaths in infancy, deaths due to maternal mortality are relatively uncommon even in countries that have high maternal mortality rates by international standards. Nonetheless, reduction in maternal mortality rates is an important goal because the institution of practices to reduce these rates will also reduce the incidence of nonlethal maternal injury, illness, and infection connected with pregnancy, which affect a substantially larger number of women in developing countries. Reductions in maternal mortality and morbidity are also an essential part of programs designed to improve the health of children. In most developing countries, mothers continue to play the key role in care for children, and children whose mothers have died have much lower survival rates and are also likely to be sicker. Mothers who have suffered serious but nonfatal birth injuries are also likely to be considerably less effective in caring for their newborn children. 2   In fact, from a demographer’s point of view, it would make considerably more sense to specify goals for infant mortality and for 1- to 5-year-old mortality. Focusing on both infant and under-5 mortality seems like a form of double counting because infant mortality is included in rates for both age groups. However, “1- to 5-year-old mortality” is not a particularly memorable phrase for purposes of publicity and promotion, and the term “childhood mortality” is presumably too vague.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings Despite the importance of reducing maternal morbidity and mortality, this goal may be considerably more difficult to achieve than some of the others because of the nature of measures required. Unlike measles immunization, for example, which requires one contact for each child, the provision of adequate prenatal care (even if it is limited to one prenatal visit), safe delivery, and postpartum care for each pregnancy, or contraceptive services to prevent unsafe abortions to all women, is a monumental task in many poor countries. Potential Demographic Consequences During the 1960s and 1970s, there was considerable debate in the public health community about whether reducing infant and child mortality rates, in the absence of strong fertility reduction efforts, would add to the rapid population growth already being experienced by many countries in the world. The controversy has recently been raised again (see Kalish, 1992). Would implementing the goals of the summit dramatically increase population growth rates? In the absence of other demographic changes, mortality declines generally have three demographic consequences: (1) an increase in population growth rates, (2) a change in the age structure, and (3) a change in the relative importance of different causes of death. A 33 percent reduction in infant and child mortality rates in developing countries between 1990 and 2000 would increase population size (particularly the size of the population under age 10). However, it would clearly not affect the annual number of births (at least directly) until after the year 2000, because the additional children who survived because of the mortality reduction would generally not yet have reached their childbearing years by 2000. If mortality rates for children under 5 decreased faster than rates at other ages, the population would be “younger” on average than it would be otherwise—an effect that would subsequently be compounded when additional surviving children reached childbearing ages and gave birth to a larger total number of children. The cause-of-death structure would obviously also change to some degree as well because of the reduction of mortality for diseases that specifically affect children. The amount of increased population growth that might actually be produced by a one-third reduction in infant and child mortality in a particular population between 1990 and 2000 will depend on three factors: (1) demographic trends in 1990 (including fertility and infant and child mortality rates), (2) the timing of the mortality decline, and (3) the level of fertility rates between 1990 and 2000. The initial level of infant and child mortality is important because a one-third decline from a lower mortality rate adds fewer survivors to the population. For example, if the infant mortality rate

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings is 21 per 1,000, a one-third reduction will mean an additional 7 survivors per 1,000 live births. A one-third reduction in an initial rate of 210, however, implies an additional 70 survivors per 1,000 live births. This effect is compounded by the fact that fertility would likely remain high in many high-mortality countries; thus the number of live births annually (the denominator of the infant mortality rate) per size of the population is much larger than in the lower-mortality countries.3 Thus, if the summit’s goal of reducing all infant and child mortality rates by one-third were achieved, the potential for increased population growth would be greatest in high-mortality countries. However, note that these are exactly the countries in which, as I argued earlier, complete achievement of the summit’s mortality reduction goals over the next several years is likely to be the most difficult. The second factor, the timing of the reduction, would also help to determine the extent of the actual increase in population growth. If, for example, all the efforts proposed as part of the summit declaration were introduced immediately and effectively in 1990, the potential effect on population growth would be greater than if the efforts were phased in over 10 years. Although many countries began EPI, oral rehydration salts (ORS), and related programs during the 1980s, it seems doubtful that all of the proposed interventions would be in place until the end of the decade, at earliest, in many countries. Even in those countries that do achieve infant and child mortality rates in 2000 of one-third less than their 1990 rates, the change is likely to be a gradual one. In some countries, it may even be true that much of the change achieved occurs at the end of the decade as governments and NGOs increase their efforts to achieve the goals by 2000. The third factor, the trend in fertility rates between 1990 and 2000, is especially important to any estimate of potential population growth rates. Clearly, if fertility rates decline quickly enough, this change can outweigh any increase in population growth rates due to mortality reductions. Even in countries with currently high levels of fertility and mortality, however, a reduction by one-third in under-5 mortality that occurs evenly over 1990–2000 would not bring about a great change in population growth rates by the year 2000. Take, for example, the case of Senegal. The 1988 United Nations projection for Senegal for 1990–2000 was that infant mortal- 3   For example, in a population with 1,810 births annually and an under-5 mortality rate of 210 deaths per 1000 live births, a one-third reduction in this rate would mean 70 additional survivors per 1,000 live births, or about 127 additional survivors every year. As the text indicates, another population with an initial rate of 21 deaths per 1,000 live births would have 7 additional survivors per 1,000 live births if mortality rates were reduced by one-third. If the annual number of births were the same as in the first population, this would mean an addition of only about 13 survivors annually. If the annual number of births were halved in each of the populations, the total number of additional survivors from a one-third reduction in under-5 mortality would be about 63 and 6, respectively.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings ity would decline by about 16 percent, under-5 mortality by about the same amount, and the annual population growth rate during this period would be about 2.80 percent. If we assume that fertility rates remain constant4 and that both infant and age 1–4 mortality rates decline by 33 percent—instead of 16 percent—between 1990 and 2000, the annual population growth rate for this period would increase only about 2.9 or 3.0 percent, depending on how the decline occurred.5 The longer-term consequences of the proposed reduction in under-5 mortality for population growth will be somewhat greater as additional survivors move into the childbearing years. However, fertility rates in high-fertility countries are also more likely to fall in the long term than in the next decade. Child Mortality Decline and Fertility Decline Many in the public health community—including UNICEF in its materials prepared for the summit—have argued that increased child survival itself will motivate parents to reduce their fertility. The logic of this argument is twofold: (1) that parents in high-mortality settings feel they must have as many children as possible (or perhaps simply a large number of children) to minimize the risk of ending up with very few or no children surviving to adulthood, and (2) that, for the same reason, parents try to replace children who have died as rapidly as possible. Among demographers, the former hypothesis has been known as the “insurance effect” and the latter as the “replacement effect.” These ideas originated with demographers studying the “demographic transition” in the 1930s through 1950s. Early demographers, including Walter Willcox and especially Frank Notestein argued that fertility change would not occur until mortality was reduced. Notestein explained that “any society having to face the heavy mortality characteristics of the premodern era must have high fertility to survive” (Notestein, 1945:39, as quoted in Caldwell, 1986:32) and hence had in place social incentives for families to maintain high fertility. In the 1970s, renewed interest was focused on the more specific issue of whether parents changed their fertility behavior based on their perceptions of child mortality levels. The basic conclusion of many studies is that there is a significant biological effect, especially in popula- 4   That is, fertility rates decline gradually as in the United Nations projection from a crude birth rate of 45.7 in 1990–1995 to 44.5 in 1995–2000. 5   The growth rate by assuming zero decline in mortality rates between 1990 and 2000 (i.e., assuming that the 1985–1990 rate would prevail for the entire period) would be 2.6 percent. The comparison is made in the text with the United Nations assumption of a 16 percent decline in under-5 mortality because a decline in mortality rates would be expected even in the absence of effective implementation of the summit goals.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings GOBI and CSDR programs, is also included in the summit goals as one of the program strategies. However, experience with growth monitoring as a diagnostic and educational tool has been mixed (Gadomski and Black, 1990; Ruel, in press). Gadomski and Black (1990:106) conclude that even if the interaction in the growth monitoring session “is a positive one, the returns on implementing nutritional advice are slow to materialize and therefore less tangible, and involve more of a leap of faith for the individual mother. Additionally, the other constraints on a mother’s time and resources may limit her ability to implement the advice she receives.” Based on their observational study in Zaire, Gerein and Ross (1991:667) conclude that “the case for including growth monitoring in child health programmes remains unproven either on theoretical grounds or in practice.” In summary, among the components of SPHC programs implemented during the 1980s, immunization programs appear to have had the most success, at least in achieving relatively high coverage levels. Experience has shown that the difficult task in the case of immunization is to sustain the high level of social mobilization and high coverage levels that are often achieved in the initial campaign, while not absorbing all available health care resources in the process (Unger, 1991). Other programs, such as diarrheal disease control, malaria control, and ARI control, have had more mixed results and at least in some settings, may be limited in their effectiveness in the future if they are not implemented as part of a more comprehensive primary health care program. Finally, experience with other SPHC components, such as growth monitoring (as distinguished from other nutritional programs), has led to doubts about their cost-effectiveness. Implications of Pursuing Some Goals and Not Others What are the implications for child health of pursuing some of the summit goals and not others? The answer to this question is clearly related to the debate outlined above about the relative merits of the SPHC and the CPHC approaches. To use its resources most effectively, even a CPHC program must make choices about which causes of morbidity are and are not most important in its population. However, unlike a package of programs aimed at specific diseases (or based on a particular set of medical technologies), the potential advantage of an effective CPHC system is its ability to attend to patients with other health problems that are not part of its main objectives, as well as to adapt to changes in the causes of morbidity.9 An SPHC-type program that concentrates on immunization and ORT distribution, for example, clearly offers nothing to patients with respiratory 9   Of course, the potential disadvantage of a CPHC program is that its goals are so general that effective implementation is impossible.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings infections or to their family members who are trying to avoid contracting ARI themselves. The point here is that any health program must choose a limited set of goals, but the choice of a subset of summit goals is likely to have quite different and perhaps more serious implications in “child survival” programs (as they were implemented during the 1980s) than in an effective CPHC program. In terms of criteria for choosing among health interventions, Ewbank and Zimicki (1990:142) have argued persuasively that it is time to move beyond the “very focused, short-term and generalized approach” that characterized SPHC programs during the 1980s, and move on to “successor programs” that are considerably less generalized and are based on the major health problems of each country or region. Specifically, they propose that these programs should be based on a “more careful consideration of local cause structures of mortality, that is, the relative importance of causes of death.” The thrust of their argument is that to use the limited funds available for health during the 1990s, developing countries and, especially, donor and international agencies will have to move away from fairly uniform intervention packages, which are implemented in all parts of the world, toward a much greater diversity in programs. For example, they argue that in West Africa, the most effective use of additional funds would be “substantially increased efforts to vaccinate children against measles.” In many poor Latin American countries, on the other hand, measles are comparatively less important than in West Africa, and diarrheal diseases and ARI are relatively more important. Thus, the most cost-effective use of funds in these countries might be prevention and treatment of these two groups of diseases. Ewbank and Zimicki argue that the basis for determining what health conditions should be the focus of a program in a given country or region is an analysis of causes of death, not because health programs should concentrate primarily on reducing mortality, but because death and its causes are somewhat easier to measure accurately than morbidity. Although reliable measurement of cause of death is unavailable from the vital statistics systems in many countries, Zimicki (1988), Garenne and Fontaine (1988), and others have been developing and testing new methods of assessing causes of death, which provide much more useful information for setting priorities in health programs. A topic of considerable concern to health personnel, especially those involved in SPHC programs, has been that attacking some diseases and not others may be a waste of time and money because children saved from one disease may go on to die of another shortly thereafter. A large body of previous research has shown that there are important interactions among infectious diseases, and between these diseases and malnutrition. In general, an intervention targeted at a particular disease has one of three pos-

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings sible effects, if it is at least minimally effective (Foster, 1984:124). It may (1) reduce mortality from the specific disease and from other related diseases, so that overall mortality declines more than would be expected from cause-specific mortality alone; (2) reduce mortality from the disease alone and therefore lower that cause-specific mortality and overall mortality by a corresponding amount; and (3) save weaker children from dying only to have them die later on from the same or other causes (i.e, reduce mortality by less than would be expected). The third outcome would presumably be avoided by an effective CPHC program because it would provide prevention or treatment for a wide range of illnesses. But is the effectiveness of single intervention programs diminished by this “negative synergism” or “replacement mortality”? Mosley and Becker (1990) suggest that the answer depends on the type of intervention. If the intervention prevents the incidence of disease, such as immunization against measles and other childhood diseases, it is likely to reduce mortality not only from that disease but also from other diseases as well. However, the effect of interventions that are “curative,” such as ORT treatment for diarrhea, may be diminished somewhat because children who survive are left weakened by the effects of the disease. Mosley and Becker also indicate that “broad based preventive measures like water programs, personal hygiene, and breastfeeding promotion which reduce the incidence of multiple diseases simultaneously will show a substantial demographic impact on overall survival, even if the direct effects on individual diseases are modest” (Mosley and Becker, 1990:172). Empirical research on the effects of measles immunization supports Mosley and Becker’s conclusions about interventions that reduce the incidence of a specific disease. A study in eastern Zaire in the 1970s (Kasongo Project Team, 1981) suggested that immunization against measles would save the lives of both strong children (most of whom would have survived measles anyway) and weak children, but that many of the weak children would die quickly of other diseases (known as “replacement mortality”). However, this study has been severely criticized by others (Aaby et al., 1981; Manshande and De Caluwe, 1981) because the results were ambiguous and did not appear to support the authors’ conclusions. More recent work (Stephens, 1984; Hull et al., 1983; Holt et al., 1990; World Health Organization, 1987) indicates that measles immunization seems to reduce child mortality by a greater amount than might be expected from reducing measles-related mortality alone. The evidence in the case of malaria—a very different disease requiring a very different control approach—is similar (Hill and Pebley, 1989). Mosley and Becker’s conclusion about programs designed to treat infections makes sense in terms of previous research (see, for example, Mata, 1978; Martorell and Ho, 1984), but there is less clear-cut evidence on the

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings extent of the diminished effectiveness of these intervention programs because of subsequent “replacement mortality.” Gadomski and Black (1990) report, for example, that several of the studies of ARI interventions that they reviewed “demonstrate a reduction in total mortality, a reduction that is sometimes larger than that due to ARI alone. The reduction in overall mortality is surprising because it implies that replacement mortality is not overriding the impact of this particular intervention.” SUMMARY AND CONCLUSIONS The World Summit for Children played an important role in focusing media and political attention on the continuing high mortality and morbidity rates for young children in developing countries, and on the availability of measures to improve child health. The increased attention in and of itself was a significant accomplishment in a rapidly changing international political and economic climate. Rather than assessing political consequences of the summit, this paper has concentrated on the specific goals approved by the Summit as a guide for international- and national-level health programs directed toward children during the 1990s. There are four general characteristics of these goals: (1) many of them include very specific numerical targets; (2) taken as a whole, they are very ambitious; (3) they are pragmatic in the sense that many are based on existing public health technology and at least a decade of experience with implementation; and (4) they are philosophically grounded in the ideas underlying what has come to be known as “selective primary health care.” The goals include mortality reduction, reduction of mortality from specific diseases, eradication of certain diseases, and reduction in the incidence of specific health conditions, as well as improved public services such as water, sewage disposal, and education. In this paper, I have concentrated primarily on mortality reduction-related goals. An examination of previous mortality declines in developing countries since the 1960s shows that the goal of a one-third reduction in mortality rates for children seems plausible in light of previous experience. However, many of the countries that have been most successful at achieving declines of this magnitude either have unusually well-organized health care systems (e.g., Cuba, China, and perhaps Costa Rica) or are relatively well-off for their region (e.g., Chile, Korea, Hong Kong, Singapore, Thailand, Kuwait, and Botswana). Results presented in this paper also show that although population growth rates would be increased slightly, especially in high-fertility and high-mortality countries, by a one-third reduction in infant and child mortality, the increases over the next decade would be very small and could well be wiped out by fertility declines. Thus, concern that implementation of the summit

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings goals would bring about a significant increase in population growth is not well justified. To my mind, more well-founded concerns about specific summit goals include (1) whether pursuit of these particular numerical targets will lead public health workers, government officials, and the donor community to lose sight of the general objectives of improving children’s health, sustaining health improvements, and strengthening public health care systems; (2) whether a continuation of the “child survival” approach, which was important and effective during the 1980s (and is implicit in the summit goals), is the best strategy for improving children’s health in the 1990s; and (3) whether some of the goals (e.g., prenatal and delivery assistance, ARI and malaria prevention and treatment, and diarrheal disease prevention and control) can be implemented effectively without major, long-term work on strengthening the health care infrastructure. Child health programs in developing countries during the 1990s, and more specifically efforts to implement the summit goals, will face at least two major challenges if they are to be successful. First, greater diversity in the focus of health programs among countries will be required if funds and human resources are to be used most effectively. Experience with health interventions and data collected in the past 10 years makes it clear that there is considerable variation in the types of health problems faced by countries, and that this variation will likely grow over the next decade as mortality declines. Generalized health intervention packages, while easier to implement on an international level, are likely to be increasingly less cost-effective in this changing environment. Second, many observers of the experience of the 1980s have concluded that governments, donors, and international agencies are going to have to face the issue of institution building (i.e., strengthening or building a primary health care system) head-on during the 1990s if gains in children’s health are to continue. The route to building a primary health care system may be through institutionalization of SPHC-type interventions, but the experience of the 1980s shows that simply having SPHC programs in place does not automatically guarantee institutional strengthening (Gadomski et al., 1989; Unger, 1991). The need to face the issue of institution building does not arise either because EPI and other SPHC have been ineffective (in fact, many SPHC programs have been quite effective) or because of the problem of “replacement mortality” (which for many diseases is probably much less of a concern that many previously thought). Rather, efforts to build an effective primary health care system are important because of the difficulty of sustaining effective SPHC interventions and of dealing with important health conditions such as ARI, pregnancy, and diarrhea, in the absence of such a system.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings REFERENCES Aaby, P., J.Bukh, I.M.Lisse, and A.J.Smits 1981 Measles vaccination and child mortality. Lancet 2:93. Caldwell, J. 1986 The role of mortality decline in theories of social and demographic transition. Consequences of Mortality Trends and Differentials. Population Studies No. 95, ST/ ESA/SER.A/95. New York: United Nations, Department of International Economic and Social Affairs. Ewbank, D., and S.Zimicki 1990 The interim is over: Implications of the changing cause-structure of mortality for the design of health interventions. In K.Hill, ed., Child Survival Programs: Issues for the 1990s. Baltimore, Md.: Institute for International Programs, School of Hygiene and Public Health, Johns Hopkins University. Foster, S. 1984 Immunizable and respiratory diseases and child mortality. In W.H.Mosley and L. Chen, eds., Child Survival: Strategies for Research. Supplement to Population and Development Review 10:119–140. Gadomski, A., and R.E.Black 1990 Impact of direct interventions. In K.Hill, ed., Child Survival Programs: Issues for the 1990s. Baltimore, Md.: Institute for International Programs, School of Hygiene and Public Health, Johns Hopkins University. Gadomski, A., R.Black, and W.H.Mosley 1989 Constraints to the potential impact of the direct intervention for child survival in developing countries. Health Transition 2. Gareaballah, E.-T., and B.P.Loevinsohn 1989 The accuracy of mothers’ reports about their children’s vaccination status. Bulletin of the World Health Organization 67(6):669–674. Garenne, M., and O.Fontaine 1988 Enquete sur les causes probables de deces en milieu rural au Senegal. In J.Vallin, S.D’Souza, and A.Palloni, eds., Mesure et Analyse de la Mortalite: Nouvelles Approches. Paris: Presses Universitaires de France. Gerein, N.M., and D.A.Ross 1991 Is growth monitoring worthwhile? An evaluation of its use in three child health programs in Zaire. Social Science and Medicine 32(6):667–675. Goldman, N., and A.R.Pebley 1992 Health cards, maternal recall, and immunization coverage in Guatemala. Mimeo. Grodos, D., and X.de Bethune 1988 Les interventions sanitaires selectives: Un piege pour les politiques de sante du tiers monde. Social Science and Medicine 26(9):879–889. Habicht, J.-P., and P.A.Berman 1980 Planning primary health services from a body count? Social Science and Medicine 14C:129–136. Hill, K., and A.R.Pebley 1989 Child mortality in the developing world. Population and Development Review 15(4):657–687. Holt, E.A., R.Boulos, N.A.Halsey, L.M.Boulos, and C.Boulos 1990 Childhood survival in Haiti: The protective effect of measles vaccination. Pediatrics 85(2):188–194. Hull, H.F., P.Williams, and F.Oldfield 1983 Measles mortality and vaccine efficacy in rural West Africa. Lancet 1:972–975.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings Kalish, S. 1992 Child survival and the demographic “trap.” Population Today 20(2):8–9. Kasongo Project Team 1981 Influence of measles vaccination in developing countries. Lancet 4 (April):764–767. Knodel, J. 1982 Child mortality and reporductive behavior in german villages in the past: A micro-level analysis of the replacement effect. Population Studies 36(2):177–200. Manshande, J.P., and P.De Caluwe 1981 Measles vaccination and survival. Lancet 6 (June):1271. Martorell, R., and T.J.Ho 1984 Malnutrition, morbidity, and mortality. In W.H.Mosley and L.Chen, eds., Child Survival: Strategies for Research. Supplement to Population and Development Review 10:119–140. Mata, L.J. 1978 The Children of Santa Maria Cauque: A Prospective Field Study of Health and Growth. Cambridge, Mass.: MIT Press. Mensch, B.S. 1985 The effects of child mortality on contraceptive use and fertility in Colombia, Costa Rica, and Korea. Population Studies 39(2):309–328. Molineaux, L. 1985 The impact of parasitic diseases and their control with an emphasis on malaria and Africa. Pp. 103–137 in J.Vallin and A.D.Lopez, eds., Health Policy, Social Policy and Mortality Prospects. Liège: Ordina Editions. Morgan, L.M. 1990 International politics and primary health care in Costa Rica. Social Science and Medicine 30(2):211–219. Mosley, W.H. 1985 Will primary health care reduce infant and child mortality? In J.Vallin and A.D. Lopez, eds., Health Policy, Social Policy and Mortality Prospects. Liège: Ordina Editions. 1988 Is there a middle way? Categorical programs for PHC. Social Science and Medicine 26(9):907–908. Mosley, W.H., and S.Becker 1990 Demographic models for child survival: Implications for program strategy. Health Policy and Planning 6(3):218–233. Newell, K.W. 1988 Selective primary health care: The counter revolution. Social Science and Medicine 26(9):903–906. Notestein, F. 1945 Population: The long view. In T.W.Schultz, ed., Food for the World. Chicago: University of Chicago Press. Rifkin, S., and G.Walt 1986 Why health improves: Defining issues concerning “Comprehensive Primary Health Care” and “Selective Primary Health Care.” Social Science and Medicine 23:559–566. Ruel, M. (in press) Growth monitoring as an educational tool, an integrating strategy and a source of information: A review of experience. In P.Pinstrup-Anderson, D.Pelletier, and H.Alderman, eds., Beyond Child Survival. Ithaca, N.Y.: Cornell University Press.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings Stephens, P.W. 1984 Morbidity and mortality from measles in Ngayokheme: A case study of risks and their associated factors. University Microfilms: Ph.D. dissertation, University of Pennsylvania. Sullivan, J.M. 1991 The pace of decline in under-five mortality: Evidence from the DHS surveys. Paper presented at the DHS World Conference, Washington, D.C., August 5–7. Taylor, C., and R.Jolly 1988 The straw men of primary health care. Social Science and Medicine 26(9):971–977. Unger, J.-P. 1991 Can intensive campaigns dynamize front line health services? The evaluation of an immunization campaign in the Thies health district, Senegal. Social Science and Medicine 32(3):249–259. Unger, J.-P., and J.Killingsworth 1986 Selective primary health care: A critical view of methods and results. Social Science and Medicine 20:1001–1012. UNICEF 1990a First Call for Children: World Declaration and Plan of Action from the World Summit for Children. New York: UNICEF. 1990b The World Summit for Children: A UNICEF Contribution to the World Summit for Children. New York: UNICEF. Van Lerberghe, W., and K.Pangu 1988 Comprehensive can be effective: The influence of coverage with a health centre network on the hospitalisation patterns in the rural area of Kasongo, Zaire. Social Science and Medicine 26(9):949–955. Walsh, J.A., and K.S.Warren 1979 Selective primary health care: An interim strategy for disease control in developing countries. New England Journal of Medicine 301:18. Warren, K.S. 1988 The evolution of selective primary health care. Social Science and Medicine 26(9):891–898. World Health Organization 1987 Key Issues in Measles Research: A Review of the Literature. Expanded Programme on Immunization Global Advisory Group Meeting. November. EPI/GAG/87/Wp.10. Zimicki, S. 1988 L’enregistrement des causes de deces par des non-medecins: Deux experiences au Bangladesh. In J.Vallin, S.D’Souza, and A.Palloni, eds., Mesure et Analyse de la Mortalite: Nouvelles Approches. Paris: Presses Universitaires de France.

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings APPENDIX Goals for Children and Development in the 1990s (From UNICEF, 1990a:31–35) I. Major goals for child survival, development and protection Between 1990 and the year 2000, reduction of infant and under-5 mortality rate by one-third or to 50 and 70 percent per 1,000 live births, respectively, whichever is less Between 1990 and the year 2000, reduction of maternal mortality rate by half Between 1990 and the year 2000, reduction of severe and moderate malnutrition among under-5 children by half Universal access to safe drinking water and to sanitary means of excreta disposal By the year 2000, universal access to basic education and completion of primary education by at least 80 percent of primary school-age children Reduction of the adult literacy rate (the appropriate age group to be determined in each country) to at least half its 1990 level with emphasis on female literacy Improved protection of children in especially difficult circumstances II. Supporting/sectoral goals A. Women’s health and education Special attention to the health and nutrition of the female child and to pregnant and lactating women Access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late, or too many Access by all pregnant women to prenatal care, trained attendants during childbirth, and referral facilities for high-risk pregnancies and obstetric emergencies Universal access to primary education with special emphasis for girls and accelerated literacy programs for women B. Nutrition Reduction in severe, as well as moderate, malnutrition among children under 5 by half of 1990 levels Reduction of the rate of low birthweight (2.5 kilograms or less) to less than 10 percent Reduction of iron deficiency anemia in women by one-third of the 1990 levels

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings Virtual elimination of iodine deficiency disorders Virtual elimination of vitamin A deficiency and its consequences, including blindness Empowerment of all women to breastfeed their children exclusively for four to six months and to continue breastfeeding, with complementary foods, well into the second year Growth promotion and its regular monitoring to be institutionalized in all countries by the end of the 1990s Dissemination of knowledge and supporting services to increase food production to ensure household food security C. Child health Global eradication of poliomyelitis by the year 2000 Elimination of neonatal tetanus by 1995 Reduction by 95 percent in measles deaths and reduction by 90 percent of measles cases compared to preimmunization levels by 1995, as a major step toward the global eradication of measles in the longer run Maintenance of a high level of immunization coverage (at least 90 percent of children under 1 year of age by the year 2000) against diphtheria, pertussis, tetanus, measles, poliomyelitis, and tuberculosis and against tetanus for women of childbearing age Reduction by 50 percent in the deaths due to diarrhea in children under the age of 5 years and 25 percent reduction in the diarrhea incidence rate Reduction by one-third in the deaths due to acute respiratory infections in children under 5 years D. Water and sanitation Universal access to safe drinking water Universal access to sanitary means of excreta disposal Elimination of guinea-worm disease (dracunculiasis) by the year 2000 E. Basic education Expansion of early childhood development activities, including appropriate low-cost family- and community-based interventions Universal access to basic education, and achievement of primary education by at least 80 percent of primary school-age children through formal schooling or nonformal education of comparable learning standard, with emphasis on reducing the current disparities between boys and girls Reduction of the adult literacy rate (the appropriate age group to be

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The Epidemiological Transition: Policy and Planning Implications for Developing Countries - Workshop Proceedings determined in each country) to at least half its 1990 level, with emphasis on female literacy Increased acquisition by individuals and families of knowledge, skills, and values required for better living, made available through all educational channels, including mass media, other forms of modern and traditional communication and social action, with effectiveness measured in terms of behavioral change F. Children in difficult circumstances Provide improved protection of children in especially difficult circumstances and tackle the root causes leading to such situations