Academic journal article Bulletin of the World Health Organization

The Evolution of Child Health Programmes in Developing Countries: From Targeting Diseases to Targeting People

Academic journal article Bulletin of the World Health Organization

The Evolution of Child Health Programmes in Developing Countries: From Targeting Diseases to Targeting People

Article excerpt

Voir page 1243 le resume en francais. En la pagina 1244 figura un resumen en espanol.


For the past 35 years, the steep decline in deaths among infants and children has provided evidence of an important success story in international development. Mortality has declined steadily at an average of about 1% per year. The absolute number of children under the age of 5 years dying has fallen from an estimated 15 million in 1980 to about 11 million at the end of the 1990s (1). Remarkably, this decline has occurred in the face of increased births, spreading resistance to commonly used antibiotics and anti-malarial drugs and, most menacingly, the growth of the AIDS pandemic.

A closer look at this favourable trend, however, reveals that progress has been distributed unevenly. Recently, the decline in mortality among children under 5 years has stalled in a number of countries and in some the trend has reversed and mortality seems to be rising. In 1998, in more than 50 countries the mortality for children under 5 years was greater than 100 deaths per 1000 live births. In 12 countries (11 of them in Africa), one in every five children born alive did not survive to the age of five years (1). Of the nearly 11 million children who will die before their fifth birthday this year, 70% will die from a disease, a combination of a few diseases, or a condition for which safe and effective interventions are readily available in industrialized countries: acute respiratory infections, diarrhoea, measles, malaria, and malnutrition (2).

Better access to basic health services -- including vaccinations, oral rehydration therapy, and antibiotics for pneumonia -- together with improvements in social conditions -- including higher standards of living and smaller families living on larger incomes -- have been important factors in improving the survival rate of children. As deaths among children under 5 years have declined in many developing countries, contributing to both demographic and epidemiological transitions, the proportional mortality accounted for by some conditions has increased: this problem has been relatively ignored by the international health community. For example, the greatest decline in childhood mortality rates has occurred among children in the post-neonatal period; this has led to a relative increase in the importance of neonatal and perinatal mortality. Also, gender-specific issues have emerged in some parts of the world, notably on the Indian subcontinent where girls aged between 1 month and 5 years still experience considerably higher mortality and morbidity than boys (3, 4). And, although this paper does not deal with it specifically, increases in deaths from AIDS in Africa are already slowing or reversing these downward trends. Without a major assault on AIDS throughout local health systems and in the community, childhood mortality, whether from infection or from the increased risks associated with being orphaned, can be expected to increase in some parts of the world.

In this paper, we examine the roots from which current child health programmes have grown, some of the causes behind the apparent slowing of progress in many parts of the world, and we suggest ways in which the nature of these programmes must change if continued gains are to be made throughout the world.

Trends and milestones

Global strategies for reducing childhood mortally, have been of two basic types. The first were ambitious disease-specific, technologically dependent strategies aimed at achieving dramatic, albeit narrow, successes in a relatively short time. The notable failure of the most ambitious programme of this type -- the malaria eradication programme (not exclusively a child health programme, but one that was expected to make a major contribution to reducing child mortality) launched in the 1950s and abandoned in the 1970s -- contributed strongly to a shift in thinking (5). …

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