Jennifer Bryce

WHO estimates of the causes of death in children

BACKGROUNDnChild survival efforts can be effective only if they are based on accurate information about causes of deaths. Here, we report on a 4-year effort by WHO to improve the accuracy of this information.nnnMETHODSnWHO established the external Child Health Epidemiology Reference Group (CHERG) in 2001 to develop estimates of the proportion of deaths in children younger than age 5 years attributable to pneumonia, diarrhoea, malaria, measles, and the major causes of death in the first 28 days of life. Various methods, including single-cause and multi-cause proportionate mortality models, were used. The role of undernutrition as an underlying cause of death was estimated in collaboration with CHERG.nnnFINDINGSnIn 2000-03, six causes accounted for 73% of the 10.6 million yearly deaths in children younger than age 5 years: pneumonia (19%), diarrhoea (18%), malaria (8%), neonatal pneumonia or sepsis (10%), preterm delivery (10%), and asphyxia at birth (8%). The four communicable disease categories account for more than half (54%) of all child deaths. The greatest communicable disease killers are similar in all WHO regions with the exception of malaria; 94% of global deaths attributable to this disease occur in the Africa region. Undernutrition is an underlying cause of 53% of all deaths in children younger than age 5 years.nnnINTERPRETATIONnAchievement of the millennium development goal of reducing child mortality by two-thirds from the 1990 rate will depend on renewed efforts to prevent and control pneumonia, diarrhoea, and undernutrition in all WHO regions, and malaria in the Africa region. In all regions, deaths in the neonatal period, primarily due to preterm delivery, sepsis or pneumonia, and birth asphyxia should also be addressed. These estimates of the causes of child deaths should be used to guide public-health policies and programmes.

Estimates of world-wide distribution of child deaths from acute respiratory infections.

Acute respiratory infections (ARI) are among the leading causes of childhood mortality. Estimates of the number of children worldwide who die from ARI are needed in setting priorities for health care. To establish a relation between deaths due to ARI and all-cause deaths in children under 5 years we show that the proportion of deaths directly attributable to ARI declines from 23% to 18% and then 15% (95% confidence limits range from +/- 2% to +/- 3%) as under-5 mortality declines from 50 to 20 and then to 10/1000 per year. Much of the variability in estimates of ARI in children is shown to be inherent in the use of verbal autopsies. This analysis suggests that throughout the world 1.9 million (95% CI 1.6-2.2 million) children died from ARI in 2000, 70% of them in Africa and southeast Asia.

Reducing deaths from diarrhoea through oral rehydration therapy

In 1980, diarrhoea was the leading cause of child mortality, accounting for 4.6 million deaths annually. Efforts to control diarrhoea over the past decade have been based on multiple, potentially powerful interventions implemented more or less simultaneously. Oral rehydration therapy (ORT) was introduced in 1979 and rapidly became the cornerstone of programmes for the control of diarrhoeal diseases. We report on the strategy for controlling diarrhoea through case management, with special reference to ORT, and on the relationship between its implementation and reduced mortality. Population-based data on the coverage and quality of facility-based use of ORT are scarce, despite its potential importance in reducing mortality, especially for severe cases. ORT use rates during the 1980s are available for only a few countries. An improvement in the availability of data occurred in the mid-1990s. The study of time trends is hampered by the use of several different definitions of ORT. Nevertheless, the data show positive trends in diarrhoea management in most parts of the world. ORT is now given to the majority of children with diarrhoea. The annual number of deaths attributable to diarrhoea among children aged under 5 years fell from the estimated 4.6 million in 1980 to about 1.5 million today. Case studies in Brazil, Egypt, Mexico, and the Philippines confirm increases in the use of ORT which are concomitant with marked falls in mortality. In some countries, possible alternative explanations for the observed decline in mortality have been fairly confidently ruled out. Experience with ORT can provide useful guidance for child survival programmes. With adequate political will and financial support, cost-effective interventions other than that of immunization can be successfully delivered by national programmes. Furthermore, there are important lessons for evaluators. The population-based data needed to establish trends in health service delivery, outcomes and impact are not available in respect of diarrhoea, as is true for malaria, pneumonia and other major childhood conditions. Standard indicators and measurement methods should be established. Efforts to change existing global indicators should be firmly resisted. Support should be given for the continuing evaluation and documentation activities needed to guide future public health policies and programmes.

Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions.

BACKGROUNDnThe Countdown to 2015 for Maternal, Newborn, and Child Survival initiative monitors coverage of priority interventions to achieve the Millennium Development Goals (MDG) for reduction of maternal and child mortality. We aimed to report on 68 countries which have 97% of maternal and child deaths worldwide, and on 22 interventions that have been proven to improve maternal, newborn, and child survival.nnnMETHODSnWe selected countries with high rates of maternal and child deaths, and interventions with the most potential to avert such deaths. We analysed country-specific data for maternal and child mortality and coverage of selected interventions. We also tracked cause-of-death profiles; indicators of nutritional status; the presence of supportive policies; financial flows to maternal, newborn, and child health; and equity in coverage of interventions.nnnFINDINGSnOf the 68 priority countries, 16 were on track to meet MDG 4. Of these, seven had been on track in 2005 when the Countdown initiative was launched, three (including China) moved into the on-track category in 2008, and six were included in the Countdown process for the first time in 2008. Trends in maternal mortality that would indicate progress towards MDG 5 were not available, but in most (56 of 68) countries, maternal mortality was high or very high. Coverage of different interventions varied widely both between and within countries. Interventions that can be routinely scheduled, such as immunisation and antenatal care, had much higher coverage than those that rely on functional health systems and 24-hour availability of clinical services, such as skilled or emergency care at birth and care of ill newborn babies and children. Data for postnatal care were either unavailable or showed poor coverage in almost all 68 countries. The most rapid increases in coverage were seen for immunisation, which also received significant investment during this period.nnnINTERPRETATIONnRapid progress is possible, but much more can and must be done. Focused efforts will be needed to improve coverage, especially for priorities such as contraceptive services, care in childbirth, postnatal care, and clinical case management of illnesses in newborn babies and children.Background The Countdown to 2015 for Maternal, Newborn, and Child Survival initiative monitors coverage of priority interventions to achieve the Millennium Development Goals (MDG) for reduction of maternal and child mortality. We aimed to report on 68 countries which have 97% of maternal and child deaths worldwide, and on 22 interventions that have been proven to improve maternal, newborn, and child survival.

Achieving universal coverage with health interventions

Cost-effective public health interventions are not reaching developing country populations who need them. Programmes to deliver these interventions are too often patchy, low quality, inequitable, and short-lived. We review the challenges of going to scale, building on known, effective interventions to achieve universal coverage. One challenge is to choose interventions consistent with the epidemiological profile of the population. A second is to plan for context-specific delivery mechanisms effective in going to scale, and to avoid uniform approaches. A third is to develop innovative delivery mechanisms that move incrementally along the vertical-to-horizontal axis as health systems gain capacity in service delivery. The availability of sufficient funds is essential, but constraints to reaching universal coverage go well beyond financial issues. Accurate estimates of resource requirements need a full understanding of the factors that limit intervention delivery. Sound decisions need to be made about the choice of delivery mechanisms, the sequence of action, and the pace at which services can be expanded. Strong health systems are required, and the time frames and funding cycles of national and international agencies are often unrealistically short.

Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study

BACKGROUNDnWe report the preliminary findings from a continuing cluster randomised evaluation of the Integrated Management of Childhood Illness (IMCI) strategy in Bangladesh.nnnMETHODSn20 first-level outpatient facilities in the Matlab sub-district and their catchment areas were randomised to either IMCI or standard care. Surveys were done in households and in health facilities at baseline and were repeated about 2 years after implementation. Data on use of health facilities were recorded. IMCI implementation included health worker training, health systems support, and community level activities guided by formative research.nnnFINDINGSn94% of health workers in the intervention facilities were trained in IMCI. Health systems supports were generally available, but implementation of the community activities was slow. The mean index of correct treatment for sick children was 54 in IMCI facilities compared with 9 in comparison facilities (range 0-100). Use of the IMCI facilities increased from 0.6 visits per child per year at baseline to 1.9 visits per child per year about 21 months after IMCI introduction. 19% of sick children in the IMCI area were taken to a health worker compared with 9% in the non-IMCI area.nnnINTERPRETATIONn2 years into the assessment, the results show improvements in the quality of care in health facilities, increases in use of facilities, and gains in the proportion of sick children taken to an appropriate health care provider. These findings are being used to strengthen child health care nationwide. They suggest that low levels of use of health facilities could be improved by investing in quality of care and health systems support.

Co-coverage of preventive interventions and implications for child-survival strategies: evidence from national surveys

BACKGROUNDnIn most low-income countries, several child-survival interventions are being implemented. We assessed how these interventions are clustered at the level of the individual child.nnnMETHODSnWe analysed data from Bangladesh, Benin, Brazil, Cambodia, Eritrea, Haiti, Malawi, Nepal, and Nicaragua. A co-coverage score was obtained by adding the number of interventions received by each child (including BCG, diphtheria-pertussis-tetanus, and measles vaccines), tetanus toxoid for the mother, vitamin A supplementation, antenatal care, skilled delivery, and safe water. Socioeconomic status was assessed through principal components analysis of household assets, and concentration indices were calculated.nnnFINDINGSnThe percentage of children who did not receive a single intervention ranged from 0.3% (14/5495) in Nicaragua to 18.8% (1154/6144) in Cambodia. The proportions receiving all available interventions varied from 0.8% (48/6144) in Cambodia to 13.3% (733/5495) in Nicaragua. There were substantial inequities within all countries. In the poorest wealth quintile, 31% of Cambodian children received no interventions and 17% only one intervention; in Haiti, these figures were 15% and 17%, respectively. Inequities were inversely related to coverage levels. Countries with higher coverage rates tended to show bottom inequity patterns, with the poorest lagging behind all other groups, whereas low-coverage countries showed top inequities with the rich substantially above the rest.nnnINTERPRETATIONnThe inequitable clustering of interventions at the level of the child raises the possibility that the introduction of new technologies might primarily benefit children who are already covered by existing interventions. Packaging several interventions through a single delivery strategy, while making economic sense, could contribute to increased inequities unless population coverage is very high. Co-coverage analyses of child-health surveys provide a way to assess these issues.

Can the world afford to save the lives of 6 million children each year

BACKGROUNDnIn July, 2003, the Bellagio Study Group on Child Survival estimated that the lives of 6 million children could be saved each year if 23 proven interventions were universally available in the 42 countries responsible for 90% of child deaths in 2000. Here we assess the cost of delivering these interventions, and discuss whether the achievement of the Millennium Development Goal (MDG) for child survival falls within the financial capacities of donors and developing countries.nnnMETHODSnAll child survival interventions shown to reduce mortality from the major causes of death in children younger than 5 years were incorporated into a delivery timetable comprised of 18 contacts between a child or mother and a health-care provider in the period from before birth until the child reaches 5 years. The running costs of delivering the interventions at universal coverage levels were calculated as the sum of unit costs for drugs and materials, delivery costs, and programme management and support costs, including supervision. We estimated the cost of providing interventions at coverage levels reported for 2000 and the additional costs of providing services at universal coverage levels.nnnFINDINGSnUSD 5.1 billion in new resources is needed annually to save 6 million child lives in the 42 countries responsible for 90% of child deaths in 2000. This cost represents 1.23 dollars per head in these countries, or an average cost per child life saved of 887 dollars. Sensitivity analyses for salary levels for community delivery agents, drug costs, and coverage rates for 2000 were used to develop uncertainty estimates around the USD 5.1 billion annual price tag that range from about 3.1 billion dollars to 8.0 billion dollars.nnnINTERPRETATIONnAchieving the MDG for child survival is affordable for donors and developing countries. Scaling up health delivery is the challenge, and, along with the lack of funds, will be the limiting factor in reducing child mortality by two-thirds by 2015.

Improving antimicrobial use among health workers in first-level facilities: results from the Multi-Country Evaluation of the Integrated Management of Childhood Illness strategy

OBJECTIVEnThe objective of this study was to assess the effect of Integrated Management of Childhood Illness (IMCI) case management training on the use of antimicrobial drugs among health-care workers treating young children at first-level facilities. Antimicrobial drugs are an essential child-survival intervention. Ensuring that children younger than five who need these drugs receive them promptly and correctly can save their lives. Prescribing these drugs only when necessary and ensuring that those who receive them complete the full course can slow the development of antimicrobial resistance.nnnMETHODSnData collected through observation-based surveys in randomly selected first-level health facilities in Brazil, Uganda and the United Republic of Tanzania were statistically analysed. The surveys were carried out as part of the multi-country evaluation of IMCI effectiveness, cost and impact (MCE).nnnFINDINGSnResults from three MCE sites show that children receiving care from health workers trained in IMCI are significantly more likely to receive correct prescriptions for antimicrobial drugs than those receiving care from workers not trained in IMCI. They are also more likely to receive the first dose of the drug before leaving the health facility, to have their caregiver advised how to administer the drug, and to have caregivers who are able to describe correctly how to give the drug at home as they leave the health facility.nnnCONCLUSIONSnIMCI case management training is an effective intervention to improve the rational use of antimicrobial drugs for sick children visiting first-level health facilities in low-income and middle-income countries.

Effect of Integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-Brazil

A multi-country evaluation is being carried out in Brazil and four other countries to determine the effectiveness, cost, and impact of the Integrated Management of Childhood Illness (IMCI). We examine the effect of IMCI on the quality of health care provided to children under five visiting health facilities. A health facility survey was conducted at 24 facilities (12 with IMCI) in each of four States in the Northeast. We assessed the quality of care provided to children between 2 months and 5 years attending the facilities. Health workers trained in IMCI provided significantly better care than those not trained. Significant differences between health workers who were trained or not trained in IMCI were found in the assessment of the child, disease classification, treatment, and caretaker communication. Nurses trained in IMCI performed as well as, and sometimes better than, medical officers trained in IMCI. We conclude that while there is room for further improvement, IMCI case management training significantly improves health worker performance, and that parts of Brazil that have not yet introduced IMCI should be encouraged to do so.