Saul S. Morris

Where and why are 10 million children dying every year

More than 10 million children die each year, most from preventable causes and almost all in poor countries. Six countries account for 50% of worldwide deaths in children younger than 5 years, and 42 countries for 90%. The causes of death differ substantially from one country to another, highlighting the need to expand understanding of child health epidemiology at a country level rather than in geopolitical regions. Other key issues include the importance of undernutrition as an underlying cause of child deaths associated with infectious diseases, the effects of multiple concurrent illnesses, and recognition that pneumonia and diarrhoea remain the diseases that are most often associated with child deaths. A better understanding of child health epidemiology could contribute to more effective approaches to saving childrens lives.

How many child deaths can we prevent this year

This is the second of five papers in the child survival series. The first focused on continuing high rates of child mortality (over 10 million each year) from preventable causes: diarrhoea, pneumonia, measles, malaria, HIV/AIDS, the underlying cause of undernutrition, and a small group of causes leading to neonatal deaths. We review child survival interventions feasible for delivery at high coverage in low-income settings, and classify these as level 1 (sufficient evidence of effect), level 2 (limited evidence), or level 3 (inadequate evidence). Our results show that at least one level-1 intervention is available for preventing or treating each main cause of death among children younger than 5 years, apart from birth asphyxia, for which a level-2 intervention is available. There is also limited evidence for several other interventions. However, global coverage for most interventions is below 50%. If level 1 or 2 interventions were universally available, 63% of child deaths could be prevented. These findings show that the interventions needed to achieve the millennium development goal of reducing child mortality by two-thirds by 2015 are available, but that they are not being delivered to the mothers and children who need them.

Vitamin A supplementation in northern Ghana: effects on clinic attendances, hospital admissions, and child mortality

Although most studies on the effect of vitamin A supplementation have reported reductions in childhood mortality, the effects on morbidity are less clear. We have carried out two double-blind, randomised, placebo-controlled trials of vitamin A supplementation in adjacent populations in northern Ghana to assess the impact on childhood morbidity and mortality. The Survival Study included 21,906 children aged 6-90 months in 185 geographical clusters, who were followed for up to 26 months. The Health Study included 1455 children aged 6-59 months, who were monitored weekly for a year. Children were randomly assigned either 200,000 IU retinol equivalent (100,000 IU under 12 months) or placebo every 4 months; randomisation was by individual in the Health Study and by cluster in the Survival Study. There were no significant differences in the Health Study between the vitamin A and placebo groups in the prevalence of diarrhoea or acute respiratory infections; of the symptoms and conditions specifically asked about, only vomiting and anorexia were significantly less frequent in the supplemented children. Vitamin-A-supplemented children had significantly fewer attendances at clinics (rate ratio 0.88 [95% CI 0.81-0.95], p = 0.001), hospital admissions (0.62 [0.42-0.93], p = 0.02), and deaths (0.81 [0.68-0.98], p = 0.03) than children who received placebo. The extent of the effect on morbidity and mortality did not vary significantly with age or sex. However, the mortality rate due to acute gastroenteritis was lower in vitamin-A-supplemented than in placebo clusters (0.66 [0.47-0.92], p = 0.02); mortality rates for all other causes except acute lower respiratory infections and malaria were also lower in vitamin A clusters, but not significantly so. Improving the vitamin A intake of young children in populations where xerophthalmia exists, even at relatively low prevalence, should be a high priority for health and agricultural services in Africa and elsewhere.

Multi-country analysis of the effects of diarrhoea on childhood stunting

Diarrhoea is an important cause of death and illness among children in developing countries; however, it remains controversial as to whether diarrhoea leads to stunting. We conducted a pooled analysis of nine studies that collected daily diarrhoea morbidity and longitudinal anthropometry to determine the effects of the longitudinal history of diarrhoea prior to 24 months on stunting at age 24 months. Data covered a 20-year period and five countries. We used logistic regression to model the effect of diarrhoea on stunting. The prevalence of stunting at age 24 months varied by study (range 21-90%), as did the longitudinal history of diarrhoea prior to 24 months (incidence range 3.6-13.4 episodes per child-year, prevalence range 2.4-16.3%). The effect of diarrhoea on stunting, however, was similar across studies. The odds of stunting at age 24 months increased multiplicatively with each diarrhoeal episode and with each day of diarrhoea before 24 months (all P < 0.001). The adjusted odds of stunting increased by 1.13 for every five episodes (95% CI 1.07-1.19), and by 1.16 for every 5% unit increase in longitudinal prevalence (95% CI 1.07-1.25). In this assembled sample of 24-month-old children, the proportion of stunting attributed to >or=5 diarrhoeal episodes before 24 months was 25% (95% CI 8-38%) and that attributed to being ill with diarrhoea for >or=2% of the time before 24 months was 18% (95% CI 1-31%). These observations are consistent with the hypothesis that a higher cumulative burden of diarrhoea increases the risk of stunting.

Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis.

Summary Background The annual number of hospital admissions and in-hospital deaths due to severe acute lower respiratory infections (ALRI) in young children worldwide is unknown. We aimed to estimate the incidence of admissions and deaths for such infections in children younger than 5 years in 2010. Methods We estimated the incidence of admissions for severe and very severe ALRI in children younger than 5 years, stratified by age and region, with data from a systematic review of studies published between Jan 1, 1990, and March 31, 2012, and from 28 unpublished population-based studies. We applied these incidence estimates to population estimates for 2010, to calculate the global and regional burden in children admitted with severe ALRI in that year. We estimated in-hospital mortality due to severe and very severe ALRI by combining incidence estimates with case fatality ratios from hospital-based studies. Findings We identified 89 eligible studies and estimated that in 2010, 11·9 million (95% CI 10·3–13·9 million) episodes of severe and 3·0 million (2·1–4·2 million) episodes of very severe ALRI resulted in hospital admissions in young children worldwide. Incidence was higher in boys than in girls, the sex disparity being greatest in South Asian studies. On the basis of data from 37 hospital studies reporting case fatality ratios for severe ALRI, we estimated that roughly 265 000 (95% CI 160 000–450 000) in-hospital deaths took place in young children, with 99% of these deaths in developing countries. Therefore, the data suggest that although 62% of children with severe ALRI are treated in hospitals, 81% of deaths happen outside hospitals. Interpretation Severe ALRI is a substantial burden on health services worldwide and a major cause of hospital referral and admission in young children. Improved hospital access and reduced inequities, such as those related to sex and rural status, could substantially decrease mortality related to such infection. Community-based management of severe disease could be an important complementary strategy to reduce pneumonia mortality and health inequities. Funding WHO.

Good Care Practices Can Mitigate the Negative Effects of Poverty and Low Maternal Schooling on Children’s Nutritional Status: Evidence from Accra

This study uses data from a representative survey of households with preschoolers in Accra, Ghana to (1) examine the importance of care practices for childrens height-for-age z-scores (HAZ); and (2) identify subgroups of children for whom good maternal care practices may be particularly important. Good caregiving practices related to child feeding and use of preventive health services were a strong determinant of childrens HAZ, specially among children from the two lower income terciles and children whose mothers had less than secondary schooling. In this population, good care practices could compensate for the negative effects of poverty and low maternal schooling on childrens HAZ. Thus, effective targeting of specific education messages to improve child feeding practices and use of preventive health care could have a major impact on reducing childhood malnutrition in Accra.

Working Women in an Urban Setting: Traders, Vendors and Food Security in Accra

Data collected from a 1997 household survey carried out in Accra, Ghana, are used to look at the crucial role that women play as income earners and in securing access to food in urban areas. The high number of female-headed households and the large percent of working women in the sample provide a good backdrop for looking at how women earn and spend income differently than men in an urban area. Livelihood strategies for both men and women are predominantly labor based and dependent on social networks. For all households in the sample, food is still the single most important item in the total budget. Yet, important and striking differences between men and womens livelihoods and expenditure patterns exist. Compared to men, women are less likely to be employed as wage earners, and more likely to work as street food vendors or petty traders. Women earn lower incomes, but tend to allocate more of their budget to basic goods for themselves and their children, while men spend more on entertainment for themselves only. Despite lower incomes and additional demands on their time as housewives and mothers, female-headed households, petty traders, and street food vendors have the largest percentage of food secure households. This paper explores differences in income, expenditure, and consumption patterns in an effort to answer this question, and suggests ways that urban planners and policymakers can address special concerns of working women in urban areas.

To Retain or Remove User Fees?: Reflections on the Current Debate in Low- and Middle-Income Countries

Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care.It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option.Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.

Socio-economic differentials in child stunting are consistently larger in urban than rural areas

Iron deficiency is the world’s most common nutritional disorder and is predominantly responsible for anaemia in human populations. Its management and control involve iron supplementation and fortification of foods and, in developing countries, the control of parasitic infections as well. It is also important to formulate foodbased strategies to improve the bioavailability of dietary iron, for example, by promoting culturally acceptable changes in food choices, processing, and preservation. These require sound scientific data from nutritional research and the participation of women scientists who are familiar with the local and sociocultural preferences of the target communities. Research has shown that the major effects of processing on iron availability are associated with the separation, dehulling, and cooking procedures. The magnitude of losses varies with the food type and processing technique. Blanching and homogenization of vegetables may account for up to 28% and 40% of soluble iron loss, respectively. Moreover, the traditional practice of adding kanwa (an alkaline salt) to soften beans and to impart a green colour to vegetables during cooking results in reduced iron availability. In contrast, germination and fermentation have been shown to enhance the availability of iron from foods. Thus, traditional-food processing methods, such as fermentation, should be encouraged, actively promoted, and preserved.Urban-rural comparisons of childhood undernutrition suggest that urban populations are better-off than rural populations. However, these comparisons could mask the large differentials that exist among socioeconomic groups in urban areas. Data from the Demographic and Health Surveys (DHS) for 11 countries from three regions were used to test the hypothesis that intra-urban differentials in child stunting were greater than intra-rural differentials, and that the prevalence of stunting among the urban and the rural poor was equally high. A socioeconomic status (SES) index based on household assets, housing quality, and availability of services was created separately for rural and urban areas of each country, using principal components analysis. In most countries, stunting in the poorest urban quintile was almost on par with that of poor rural dwellers. Thus, malnutrition in urban areas continues to be of concern, and effective targeting of nutrition programs to the poorest segments of the urban population will be critical to their success and cost-effectiveness.

Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomised trial

BACKGROUND Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of demand. In Latin America, some governments have been trying to increase demand for health interventions by making direct payments to poor households contingent on them keeping up-to-date with preventive health services. We undertook a public health programme effectiveness trial in Honduras to assess this approach, contrasting it with a direct transfer of resources to local health teams. METHODS 70 municipalities were selected because they had the countrys highest prevalence of malnutrition. They were allocated at random to four groups: money to households; resources to local health teams combined with a community-based nutrition intervention; both packages; and neither. Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later. Pregnant women and mothers of children younger than 3 years old were asked about use of health services (primary outcome) and coverage of interventions such as immunisation and growth monitoring (secondary outcome). Reports were supplemented with data from childrens health cards and government service utilisation data. Analysis was by mixed effects regression, accounting for the municipality-level randomisation. FINDINGS The household-level intervention had a large impact (15-20 percentage points; p<0.01) on the reported coverage of antenatal care and well-child check-ups. Childhood immunisation series could thus be started more opportunely, and the coverage of growth monitoring was markedly increased (15-21 percentage points; p<0.01. Measles and tetanus toxoid immunisation were not affected. The transfer of resources to local health teams could not be implemented properly because of legal complications. INTERPRETATION Conditional payments to households increase the use and coverage of preventive health care interventions.