Reducing child mortality: can public health deliver?

Abstract:

"...This paper highlights the importance of separating biological or behavioural interventions from the delivery systems required to put them in place, and the need to tailor delivery strategies to the stage of health-system development. We review recent initiatives in child health and discuss essential aspects of delivery systems..."

This article begins by presenting data to support the claim that child survival interventions are not reaching those who need them most. The authors explore in detail what integrated management of childhood illness (IMCI), a delivery strategy adopted by over 100 low-income and middle-income countries by the end of 2002, entails and why fewer than half of those countries have moved into the phase of scaling-up to higher levels of coverage. IMCI involves the creation of guidelines meant to help manage the care of a sick child at a first-level health care facility, as well as at household, community, and referral levels. Although "[t]raining of health workers in countries with IMCI implementation has been shown to have positive effects if training includes clinical practice, sufficient facilitators, and use of materials relevant to local culture and language", most evidence suggests that "the effort devoted to implementation has not been sufficient, especially in relation to strengthening health systems and changing key behaviours at the family and community level".

There have been some successful delivery strategies, though, and the authors provide a few case studies to draw out what works, and why. To cite only one, a small-scale, cost-efficient project in Guatemala resulted in a drop in infant mortality from 139 to 28 deaths per 1000 births, and in age 1-4 mortality from 28 to 6 deaths per 1000 births - all in a 3-year period. Health workers received on-the-job training in the management of common childhood illnesses with locally-adapted protocols. Supervision by more experienced health workers was tailored, in frequency and content, to the needs of each worker. The success of the project was attributed to its adaptation to the local epidemiological and community circumstances, to continued training and encouragement of the workers, and to the increases it engendered in the use of health services. In general, the authors suggest that very different approaches can be effective and sustainable, provided that they fit well within the setting in which they are implemented and that they are managed competently.

Drawing on these case studies, the authors then highlight 5 strategies for achieving and maintaining high and equitable coverage:

1. Acquiring local data on epidemiology, health-system capacity, and community preferences - and presenting this data in a useful format for programme planners. (This may require that health managers be trained in data collection and analysis.)
2. Basing community or health-facility interventions on locally-defined key criteria, and combining delivery and technical integration of interventions.
3. Assessing alternative delivery strategies, and building capacity for making strategic decisions at the country level and below.
4. Tailoring supply to meet demand and respond to needs by, for example, fostering coordination between programmes and monitoring the extent to which the population being addressed is really being reached.
5. Strengthening national health systems as a medium- to long-term goal and integrating community-based strategies (such as pre-packed single-dose injection devices) with health-system-based efforts to increase their capacity.

In conclusion, the authors urge that, while global delivery strategies and evidence-based technical guidelines have an important role, "we must couple them with expanded capacity to develop, implement, monitor, and assess better combinations of interventions provided through locally-designed delivery strategies".

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This paper is part of a 5-part series on child survival published by The Lancet. Click here to access an overview of that series.

Source:

Summarised and reprinted with permission from Elsevier (The Lancet, 2003, Vol No 362, pages 159-64). Click here for the Lancet Home Page.