—from Epidemiological Bulletin, Vol. 20
No. 4, December 1999—
"Healthy Children: Goal 2002"
Introduction
Prospects for reducing mortality from communicable diseases
in children
Interventions
General guidelines for implementation
Coordination and Participation
Steps to be taken
Introduction
The new initiative “Healthy Children: Goal 2002” was officially launched
on the 1st of December, 1999, with the objective of preventing the death
of 100,000 children under 5 years of age in the Americas by the year 2002,
through the use of the Integrated Management of Childhood Illness (IMCI)
strategy elaborated by the Pan American Health Organization/World Health
Organization and the United Nations Children’s Fund.
The latest United Nations population and mortality figures, corresponding to the 5-year period 1995-2000, estimate that over half a million deaths will occur each year in children under 5 in the countries of the Region of the Americas with more than 10,000 births annually. According to PAHO/WHO estimates, over one-third of those deaths are due to communicable diseases, which shows that these causes are still a significant child health problem.
Although mortality from communicable diseases has declined in all the countries in recent decades, the percentage of decline has varied. Developing countries that have achieved lower infant mortality rates (IMR) are those that have shown a steeper decline in mortality from communicable diseases.
Similarly, in all countries of the Region of the Americas that currently have an estimated IMR of under 30 per 1,000 live births, communicable diseases represent at most 25% and generally less than 20% of deaths in children under 5. In contrast, in all the countries with an IMR of over 30 per 1,000 live births, communicable diseases account for over 30% of deaths and are, in some countries, the cause of over half of all deaths in children under 5.
Prospects for Reducing Mortality from Communicable
Diseases in Children
The possibility of reducing mortality from communicable diseases is
confirmed by the significant decline in the number of deaths from these
causes observed in many countries of the world, and of the Region of the
Americas in particular. Numerous factors related, on the one hand, to
the general development of populations and the improvement of their living
conditions and, on the other, to the availability of effective interventions
for the prevention, early diagnosis, and successful treatment of communicable
diseases in children, played a role in that drop.
If the rate of decline in mortality from communicable di-seases were to increase, based on the declines observed, 100,000 deaths of children under 5 could be prevented just in terms of deaths from communicable diseases. In the 14 countries of the Region of the Americas where the IMR still exceeds 30 per 1,000 live births, 95,000 deaths would be prevented, which would increase the drop in mortality due to communicable diseases to the level reached by other countries when they had a similar IMR.
Interventions
Although achieving this impact would be contingent upon a series of
factors in addition to the implementation of adequate prevention, early
diagnosis, and treatment interventions, such interventions can have a
significant impact, particularly on mortality, for the following reasons:
- Access to basic measures to prevent diarrheal diseases, such as exclusive breast-feeding during the first 4 to 6 months of life, the use of potable water, and better food hygiene, can help reduce the incidence and severity of bouts of diarrhea, even in population groups that still do not have access to running water, with the consequent impact of reducing deaths from this cause.
- Access to and use of oral rehydration therapy (ORT) to manage diarrhea in the home, and knowledge of the war-ning signs for seeking early consultation can reduce the number of cases of serious dehydration and the number of deaths from diarrhea.
- Proper management of diarrhea by health workers, including adequate case evaluation, classification, and management, can help prevent cases from worsening, cure them more quickly and effectively, and reduce the number of deaths from this cause in children.
- Early detection and proper treatment of bouts of acute respiratory infections (ARI), particularly pneumonia, also help bring down the frequency of severe cases and prevent a large number of deaths from this cause.
- Reducing the number and severity of cases of diarrhea and ARI, as well as their early detection and proper treatment, will help reduce the incidence of septicemia and meningitis associated with these causes, with the consequent impact on mortality from these illnesses.
The examples cited above, which refer only to the prevention and proper management of diarrhea and ARI, are very important since these illnesses are the cause of 80 to 90% of deaths from communicable diseases in children under 5. Controlling other illnesses and health problems, including vaccine-preventable diseases (measles, diphtheria, whoo- ping cough, tuberculous meningitis) or malnutrition, will also help to reduce the number of deaths in childhood.
In order to reduce mortality in children under 5 in the Region of the Americas, it is essential to put this information and the care needed for the prevention, early diagnosis, and proper treatment of these health problems within the reach of the population, particularly the most vulnerable groups.
The interventions mentioned above, as well as others that contribute to the improvement of the overall health conditions of children under 5 and their families, are currently included in the Integrated Management of Childhood Illness (IMCI) strategy prepared by PAHO/WHO and UNICEF during the first five years of the 1990s. For this reason, the IMCI strategy is the main intervention proposed to achieve a significant reduction in the number of deaths from communicable diseases in children under 5.
The IMCI strategy includes a basic set of prevention, early diagnosis, and treatment measures that covers the illnesses and health problems that most frequently affect the health of children under 5. Moreover, the strategy not only includes actions to be carried out through the health structure, but also a community component aimed at improving the capacity of families and the community to care for children at home. Thus, the IMCI strategy acts not only through palliative actions to reduce the risk children face when they become ill, but also through prevention and promotion actions aimed at improving the health status of children, making them less susceptible to disease and reducing their risk of contracting those diseases.
Implementation of the IMCI strategy in a community makes it possible to:
- Give the population access to basic measures for prevention, early diagnosis, and proper treatment of children under 5, as well as information on care for children when they are healthy and when they are ill (including recognition of warning signs to seek early consultation outside the home), through all health workers (institutional and non-institutional, public or private, etc.)
- Include other people who participate in the care of children under 5 in the dissemination of the knowledge needed to improve care for children in the home. These include institutional personnel (governmental and non-governmental) and volunteers, as well as the families themselves.
- Identify other health problems of mothers and families that can affect the health of children and of the community in general.
Through the use of prevention, early diagnosis, and proper treatment of the leading causes of mortality in children under 5, IMCI is a suitable strategy to increase the rate at which mortality from communicable diseases is reduced. In addition, since one of the components of the IMCI strategy is aimed at improving child feeding practices and knowledge, including exclusive breast-feeding during the first four to six months and proper feeding thereafter, implementing the IMCI strategy can reduce the number of cases and deaths from malnutrition in children. Finally, by looking into other health problems of children and their families, the IMCI strategy can also reach more pregnant women, give them access to prenatal check-ups, and advise them on the most appropriate place for delivery and on proper care during delivery. It thus contributes to the improvement of coverage and quality of perinatal care and affects mortality from this cause, which accounts for a high percentage of deaths in children.
Implementation of the IMCI strategy can therefore be the main tool for achieving the desired reduction in the number of deaths in childhood. Even if the drop does not reach the levels observed in other countries (which are also associated with other interventions that improved the overall living conditions of the population), it is estimated that by affecting other causes of death of children under 5, the strategy will reduce by at least 100,000 the number of deaths of children in this age group in the Region of the Americas.
General Guidelines for Implementation
The above impact on infant mortality can only be achieved if the entire
population, particularly the most vulnerable groups, is guaranteed access
to the IMCI strategy and if knowledge and implementation of the recommendations
to improve the care of children during the first years of life are promoted
among the population. To this end, government commitment to this initiative
and broad intersectoral participation will be required in support of the
activities.
Emphasis on the most vulnerable population groups
In order to have the fastest impact, it will be essential to gear
implementation efforts toward areas where the most vulnerable population
lives.
Bearing in mind the general characteristics of the Region of the Americas, specific plans will have to be developed and implemented for the areas with the highest mortality, both in relative (mortality and percentage of deaths from communicable diseases), and absolute terms (number of deaths from communicable diseases). These population groups will certainly include more or less scattered rural populations and urban fringe populations.
The initial steps in implementing the initiative will therefore be aimed at identifying, within each country, the areas with the greatest population concentration and high infant mortality.
In this first stage of identifying priority areas, different actors who could participate in the implementation effort will also be identified, and available data will be adjusted in order to have an adequate baseline for monitoring and evaluating the proposed goal.
Identification of higher priority areas for immediate implementation of the IMCI strategy will not preclude development and execution of activities in other areas of each country.
Implementation of the IMCI strategy in areas with lower mortality will have the additional advantage of increasing the areas available for training and the number of people available to support the implementation processes in areas with fewer resources.
Preparation of local plans of operations for implementation
The design of plans of operations will include, among others,
the following activities essential for implementation of the IMCI strategy:
- Training of all persons involved in child health care to implement the IMCI strategy, both at the institutional and non-institutional level. This will include not only health workers in charge of children’s health care (institutional, non-institutional, volunteers), but also other personnel involved in caring for children under 5, including day-care teachers and assistants, community food kitchen workers, social workers, etc.
- On-going provision of essential supplies for treatment, especially drugs, including oral rehydration salts, vaccines, basic antibiotics, and malaria pills.
- Regular supervision of trained staff to support the effective implementation of the IMCI strategy.
-· Information, education, and communication to broadly disseminate the knowledge, skills, and practices that improve the health status of children and contribute to disease prevention, early detection of warning signs, and seeking care from the appropriate personnel.
- Continuous monitoring and periodic evaluation of activities and results to promptly identify problems, and design and implement appropriate solutions.
Coordination and Participation
Given the importance of the task to be carried out and the various
factors involved in achieving the proposed goal of reducing by 100,000
the number of deaths in children under 5 from the diseases included in
the IMCI strategy, internal and external coordination mechanisms will
be established that make it possible to strengthen the different efforts
towards better child health already under way.
In this regard, coordination with other units, programs, and divisions will be strengthened, including not only those that control disease and health problems but also those that promote conditions favorable to health. This includes efforts aimed at promoting and generating healthy spaces, work in educational institutions to achieve healthy schools, and actions designed to improve sanitary conditions and reduce the risk of disease transmission, among others.
Ties will be strengthened for joint work at the country level between the health and education sectors, in order to achieve the active participation of children and adolescents in the activities that will help improve the health status of children under 5.
The participation of non-governmental organizations (NGOs) will be also promoted in order to incorporate the IMCI strategy into their work agenda, both to expand its implementation and contribute to the transfer of knowledge and practices favorable to child health that also protect children from diseases.
At the regional and national levels, closer ties with universities and scientific associations will be forged in order to produce an environment favorable to the implementation of the IMCI strategy and to support its gradual incorporation into teaching. This will be directed not only at undergraduate and graduate health worker education but also at other personnel that participates in actions related to caring for children and families, such as social workers, educators, etc.
Taking advantage of the experience gained in the countries in incorporating the IMCI strategy within health sector reform processes, coordination with other care sectors, such as social security and private health care, will be also pro-moted in order to help quickly increase the population’s access to the IMCI strategy.
Steps to Be Taken
Achieving universal access of the population to the IMCI strategy
and thus preventing deaths in childhood will require joint efforts among
the different governmental and non-governmental sectors, as well as a
call for broad participation from the entire population in order to dedicate
the efforts and resources of the entire community to children. PAHO/WHO,
in coordinating this effort, will support the countries in developing
general and specific intervention plans aimed at incorporating the IMCI
strategy as a basic tool for child health care throughout the health structure,
and in establishing the coordination ties needed to expand its implementation,
through community personnel to reach the community.