The Epidemiological Transition Policy and Planning Implications for Developing Countries (1993) / Chapter Skim
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GOALS OF THE WORLD SUMMIT FOR CHILDREN AND THEIR IMPLICATIONS FOR HEALTH POLICY IN THE 1990s
GOALS OF THE WORLD SUMMIT FOR CHILDREN AND THEIR IMPLICATIONS FOR HEALTH POLICY IN THE 1990s
Pages 170-196
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From page 170... ...
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)
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From page 171... ...
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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From page 172... ...
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.
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From page 173... ...
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.
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From page 174... ...
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)
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From page 175... ...
175 1960- 1965 to 1965- 1970 to1970- 1975 to 1975- 1980 to Country 1970-1975 1975-19801980-1985 1985-1990 Latin America Argentina 19.4 29.427.6 Bolivia -34.8 Brazil 17.8 23.031.2 Chile 41.9 53.664.5 Colombia 34.1 46.252.8 Costa Rica 42.9 60.262.5 Cuba 41.6 54.153.3 Dominican Republic 33.3 Ecuador 22.3 25.633.8 29.3 Guatemala 28.027.2 20.9 Haiti 18.5 Jamaica 37.7 48.4 Mexico 21.3 23.023.0 29.9 Panama 29.9 42.745.6 Peru 27.1 24.229.6 Puerto Rico 46.3 43.634.5 Trinidad and Tobago 30.2 36.024.3 Uruguay 1.9 9.334.6 Asia Bangladesh 3.15.7 China 48.8 48.7 Hong Kong 55.3 50.042.9 Indonesia 22.2 27.430.3 30.8 Republic of Korea 38.4 36.8 Malaysia 31.9 36.133.9 Nepal 17.2 Pakistan 16.3 Philippines 21.1 21.917.8 Singapore 45.2 48.447.8 Sri Lanka 21.8 24.1 47.0 Thailand 33.1 40.739.6 35.7 Middle East Egypt - 32.135.4 46.3 Jordan 38.7 30.3 Kuwait 48.6 42.550.9 Syria 39.3 Tunisia 26.5 38.1 50.0 Turkey 23.0 22.823.4 continued
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From page 176... ...
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. 1On 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)
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From page 177... ...
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.
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From page 178... ...
. 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.
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From page 179... ...
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.
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From page 180... ...
However, fertility rates in highfertility 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.
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From page 181... ...
So what is the bottom line of the relationship between achieving the summit's infant and child mortality goals and the potential for substantial increases in population growth? Without any change in fertility rates a onethird reduction in under-5 mortality rates will certainly cause some additional population growth.
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From page 182... ...
Many agencies, donors, and governments subsequently adopted the selective primary health care approach, including WHO's Expanded Program of Immunization, UNICEF's program based on growth monitoring, oral rehydration therapy, breastfeeding, and immunizations (GOBI) , and U.S.A.I.D.'s Control of Childhood Communicable Diseases program.
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From page 183... ...
For the most part, advocates of "interim approaches" now acknowledge "that the greatest weakness of current CSDR fUNICEF's child survival and development revolution] efforts has been that generally insufficient attention has been paid to long-range objectives in the pressure to get something/anything started fast" and that "overly circumscribed activities have tended to leave countries with entrenched bureaucracies that resist eventual integration into PHC Eprimary health care]
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From page 184... ...
There are also several goals toward which SPHC programs have been directed in the past that are likely to be implemented more successfully in a primary health care setting, such as reduction in the incidence of and case-fatality rates from acute respiratory infections and diarrhea! diseases.
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From page 185... ...
note in the case of acute respiratory infection control in particular, "it will be difficult to implement case management in areas where this infrastructure is poor or lacking, since effective case management depends on a reliable supply of antibiotics, adequate training and supervision of CHWs [community health workers] and on an operative referral network." Growth monitoring, which has been an important feature of UNICEF's 8Ironically, the cholera epidemic in several Latin American countries may significantly increase awareness of ORT and its use among the general public in these countries.
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From page 186... ...
Other programs, such as diarrhea! 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.
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From page 187... ...
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 l990s, 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.
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From page 188... ...
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.
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From page 189... ...
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.
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From page 190... ...
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)
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Smits 1981 Measles vaccination and child mortality. Lancet 2:93.
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1985 Will primary health care reduce infant and child mortality?
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From page 193... ...
Warren 1979 Selective primary health care: An interim strategy for disease control in developing countries. New England Journal of Medicine 301:18.
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From page 194... ...
Between 1990 and the year 2000, reduction of severe and moderate malnutrition among under-5 children by half ~d' T ~ · ~ , r I ~ · , ~ u Averse access to sate drinking water and to sanitary means of excrete disposal (e) By the year 2000, universal access to basic education and completion of primary education by at least 80 percent of primary schoolage children (f)
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From page 195... ...
Growth promotion and its regular monitoring to be institutionalized in all countries by the end of the l990s (viii) Dissemination of knowledge and supporting services to increase food production to ensure household food security C
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From page 196... ...
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
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