Child Health, Part 1:

Overview of Problems, Trends,

and Strategies for Improvement
DonnaM.Denno,M.D.,M.P.H.
UniversityofWashington
Sea8le,WA

ChrisStewart,M.D.
UniversityofCalifornia
SanFrancisco,CA
2008,updated2013

Learning Objectives
Denemostcommonlyusedmeasuresofchild
mortality
List5leadingcausesofchildhooddeathworldwide
List5underlyingcausesofchildhoodmortality
DenestrategiesfordeliveringintervenKonsto
combatchildhoodmortality
Describemajoractorsinglobalchildhealth
Statepercentofchildhooddeathsthatcanbe
preventedwithintervenKonsthatarecurrently
available
Page 2
2

Why focus on child health?

Children
representthemostvulnerablesegmentofsociety
suerdisproporKonatelyintermsofmortalityrisk
Improvementsinchildhealth
Goodmeasureofasocietalprogress
Childhoodillness
ContributesubstanKallytotheglobalburdenofdisease
Majorityofchildhooddeaths
PreventableortreatablewithcurrentlyavailableintervenKons

See Note A

Page 3
3

Scope of the Problem

6.9millionchildrenunder5years
ofagediedin2011
Of course being healthy* means more than merely surviving but as a
starting point for discussion it is hard to avoid the fact that 13 children under
the age of five years die every minute.
* WHO Definition of health "Health is a state of complete physical, mental
and social well-being and not merely the absence of disease or infirmity." [2]

Page 4
4

Indicators of childhood
mortality
Undervemortalityrate(U5MR)(also
calledchildmortalityrate)=probabilityofdying

betweenbirthandexactly5yearsasexpressedper1000livebirths

Infantmortalityrate(IMR)=probabilityofdying
betweenbirthandexactly1yearasexpressedper1000livebirths

Neonatalmortalityrate(NMR)=probabilityof

dyingbetweenbirthandexactly28daysasexpressedper1000live
births

See Note B

Page 5
5

U5MR, IMR, NMR: Some differences in the

problem and approaches to tackling the problem

Societalvulnerability

Dependenceonadultsforcarewithage

Biologicvulnerability

Immune&developmentalimmaturitywithage

Causesofdeath

Dierbyagegroup

TypesofintervenKonsandmethodsfordelivery

Commonproblemsthatoccurbeyondtheneonatalperiod
tendtobemoreeasilyaddressedbypublichealthstrategies
whileneonatalproblemsmayrequiremoreclinicalbased
intervenKons

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6

U5MR, IMR, NMR: Some differences (cont.)

Neonatal care is receiving more attention as greater progress
is made in reducing the burden of disease among older
children and as more information is available on the burden of
neonatal disease and interventions that can effectively reduce
this burden.
Most interventions aimed at decreasing neonatal mortality are
linked to prenatal and maternal care interventions. The
interventions that are aimed at reducing childhood mortality
beyond the neonatal period are typically delivered via public
health programs that we generally think of as more classic
public health delivery methods (e.g. immunization clinics).

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7

Reminder -- Morbidity
Somecommondiseasesdonothavehighcasefatalityratesbutdocause
signicantdisability.
NotevidentifweonlylookatU5MR,IMR,NMR
Examples
VitaminAdeciencyleadingcauseofpreventableblindnessworldwide
IodinedeciencyleadingcauseofmentalretardaKonwith43million
aected.
Irondeciencyaects>50%ofchildrendecreasedIQandpoor
schoolperformance,anemia
HelminthicinfecFonspoorgrowth,anemia,decreasedlearning

See Note C

Page 8
8

Millennium Development Goal #4 (MDG4):

Reduce Child Mortality

The Millennium Development Goals (MDG) are a set of time-bound targets to

guide countries around the world in a framework for improving health, increasing
development, and reducing poverty. Many of the 8 goals relate to improving the
health of childrene.g. improving educational opportunities, providing health
environments, decreasing poverty and hunger. Recognizing the important role
that child health plays in the overall health of societies, the MDGs include a goal
explicitly aimed at reducing child mortality by two-thirds, between 1990 and 2015.
This is MDG #4.
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9

The world is not on track to meet MDG4

Source: (2012). Levels & trends in child mortality report 2012: Estimates developed by the
UN Inter-Agency Group for Child Mortality Estimation. New York, United Nations Children's
Fund.

See Note D

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10

Slowing trends in improvements in child mortality

Source:WHOReport2005:MakeEveryMotherandChildCount

See Note E

Page 11

Inequitable distribution of child deaths

99%ofchildhooddeathsoccurinLowand
MiddleIncomeCountries
93%ofallchildhooddeathsoccurinAsia(42%)and
Africa(51%).ThehighestburdenofdeathsinAsia
andAfricaareinSouthAsiaandWestandCentral
Africa,respecKvely.

Theunder5mortalityrateinSubSaharanAfricais
>10foldthatoftherateinindustrializedcountries.

Source: You, D., et al., Levels and trends in under-5 mortality,

1990-2008. Lancet, 2009.
See also: http://www.alertnet.org/thenews/newsdesk/
LA609360.htm

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12

Inequitable distribution of child mortality:

Under-5 mortality rates in 6 countries

Carl Haub and Diana Cornelius, 2000 World Population Data

Sheet (Washington, DC: Population Reference Bureau, 2000)
Page 13
13

U5MR: Inequities within

countries
In21developingcountrieswhereU5MRs
decreasedoverallduringthepastdecade,the
gapsinmortalityratesbetweentherichand
thepoorincreased.

Source: WHO Report 2005: Make Every Mother and Child Count
Page 14

Causes of Child Mortality

Page 15

POP QUIZ: What are the leading causes of

childhood mortality in the U.S.?

Source: WHO 2000-2003 data

Page 16
16

POP QUIZ: What are the leading causes of

childhood mortality in the U.S.?

NeonatalCauses
Injuries

AcuteRespiratory
InfecFons(including
pneumonia)
Other(e.g.cancer)

58%
10%
2%
30%
Source: WHO 2000-2003 data
Page 17
17

Global causes of child mortality

Source: http://www.childinfo.org/mortality.html

Page 18

Leading causes of child mortality, globally

1. Neonatalcauses

Deathsalertheneonatalperiod:
2. Pneumonia

3. Diarrhea

4. Malaria

5. Injuries

6. HIV/AIDS

7. Measles

1%

40%
14%
10%
7%
5%
2%
19

Undernutrition is
an Important
Underlying Cause
of Death

Source: USAID Nutrition module

See Note F

20

Regional variations in proportional mortality rates

Source: Liu L et al. Global, regional, and

national causes of child mortality:
an updated systematic analysis for 2010 with
time trends
since 2000. Lancet 2012; 379: 215161

Page 21

RegionalvariaFonsinproporFonal
mortalityrates,cont.
Causes of death also vary from region to region, country to country (and even
among subnational units). For example, malaria is responsible for 7% of childhood
deaths globally; however, it can be the leading cause of childhood deaths in some
endemic African countries.
Proportional mortality data can be misleading if caution is not used in interpretation.
We often use pie charts to visually display causes of death as percentagesi.e.
proportional mortality. Remember, proportional mortality only tells you what percent
of deaths are due to a certain causeit does not tell you about disease incidence or
prevalence and it is not the same as cause specific mortality rates. For example,
more than 50% of childhood deaths in the United States are due neonatal causes
compared to Africa where <1/3 of all childhood deaths are due to neonatal causes.
However, the number of children who die from neonatal causes per every 1,000
children (i.e. the cause specific mortality rate) is ~3fold in Africa compared to the
US. A disease can kill as many people, but may result in a lower proportional
mortality rate because there are so many deaths due to other causes.

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22

Regional variations in cause-specific mortality rates

Source: WHO. The Global Burden of Disease: 2004 update (2008)

Page 23
23

Underlying Causes or
Determinants of Disease and
Malnutrition

Poverty
Inequality/RelaKvePoverty
Lackofaccesstocare
LackofmaternaleducaKon
Conict/War/Disaster

Page 24
24

Absolute Poverty
1.3billion,oronein5,arelivinginextremepoverty
worldwide(denedas<$1.25/daytheinternaKonal
povertyline)
AddiKonal1.2billionliveonbetween$1.25$2/day
closertoapracKcalpoverty,especiallyinmiddleincome
countries
Morethan40%ofpeoplelivingindevelopingcountries
liveonlessthan$2/day
Page 25
25

Relative Poverty

http://www.paris21.org/betterworld/infant.htm
Page 26

Relative poverty, cont.

Poverty is defined as either absolute or relative poverty. Both are important
determinants of health.
Absolute poverty is also called abject poverty or destitution and means that basic
needs (e.g. adequate food, shelter, health care) cannot be met.
Relative poverty refers to the inequitable distribution of wealth within a society.
Gaps between rich and poor have increased in many countries over the past two
decades. Data from rich and poor countries where there are large gaps between
rich and poor consistently shows that people living at the bottom economic strata
are more likely to die than those at the top. Living in a setting where some people
are materially deprived compared to others around them is linked to poor health
outcomes. For example, young adult males in Harlem have been shown to have
similar mortality rates compared to their like aged males in Africa. [8]
For more information see WHO Commission on Social Determinants of Health
Final Report[9]
http://www.who.int/social_determinants/thecommission/finalreport/en/index.html
(Discussion of relative vs. absolute poverty is in Part 1 Chapter 2.)
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27

Relative Poverty: Impacts the poor in rich countries toothe

Glasgow example

Page 28
28

Relative Poverty: Increasing gaps between the rich and poor

VictoraCG,etal.Applyinganequitylenstochildhealthandmortality.Lancet2003
Page 29
29

Access to Care
Canbelimitedforavarietyofreasons:

Lackofservices(ex.inruralareaswithlackinghealth
servicesandtransportaKoninfrastructure)
Inabilitytopayforservices
Poverty
WorldBankandInternaKonalMonetaryFundStructural
AdjustmentpoliciesincludedimposiKonofuserfeesfor
healthserviceswhichinmanycountrieshadbeenlargely
beenfreeofcharge

QualityofcareExisKngservicesmaybesubstandard
(orviewedassuchbythepopulaKon)
FormoreinformaKonseeDenno,D.(2011)."Globalchildhealth."PediatrRev32(2):e2538.

Page 30
30

Maternal Education

http://www.paris21.org/betterworld/infant.htm
For more information see Gakidou, E., K. Cowling, et al. (2010). "Increased educational attainment and its effect
on child mortality in 175 countries between 1970 and 2009: a systematic analysis." Lancet 376(9745): 959-974.
Page 31

Armed conflicts have direct and

indirect impacts on child health

90% of conflict-related
deaths since 1990 have
been civilians. 80% of
these have been women
and children.

Source: UNICEF State of the Worlds Children 2005, p. 100

Page 32
32

Armed Conflict, cont.

Children are always among the most heavily affected by armed
conflicteither directly or indirectly. Even if they survive the
bullets, they are often subject to violence or being orphaned.
The destruction wrought by war disrupts social services such as
education and health care. In a typical five-year war, the U5MR
increases by 13% (and adult mortality by even more). The
aftermath is still evident after the conflict ends; during the first
five years of peace, the average U5MR remains 11% higher than
it corresponding level before the conflict.
For further information see Chapter 3 Children Caught up in Conflict in the
UNICEF State of the Worlds Children 2005
http://www.unicef.org/sowc05/english/fullreport.html
Page 33
33

Photo: Adi Dabestani

Page 34

Intervention Delivery
WhatisanintervenKon?
DeniKonbiologicagentoracKonintendedto
reducemorbidityormortality*
Targeted

UsuallyatdirectcausesofmortalityandmalnutriKon
Notolentargetedatunderlyingdeterminantsofhealth
butincreasinglythisneedisbeingrecognized

ExamplesinsecKcidetreatedbednetstoprevent
malaria,vitaminAsupplementaKon,measles
vaccinaKon,accesstocleanwaterandsanitaKon,
treatmentwithoralrehydraKontherapyfordiarrhea
*Jones,G.,etal.,Howmanychilddeathscanwepreventthisyear?Lancet,2003.362(9377):p.
6571.

Page 35
35

Examples of Intervention Delivery Methods

PrimaryHealthCarecomprehensiverangeofbasicprevenKve
andcuraKvehealthservicesavailabletoallanddeliveredatthe
communitylevel
AsarKculatedin1978AlmaAtaDeclaraKonHealthCarefor
AllbytheYear2000signedby138ministersofhealth
Addressesunderlyingsocial,economicandpoliKcalcausesof
poorhealthaswellasmedicalcauses

See Note G

Page 36
36

Examples of Intervention Delivery Methods

VerKcalPrograms
Focusoncontrolofonediseaseornarrowsetof
diseaseswithtargetedintervenKons
ImplementaKonolenseparatefromexisKnghealth
system

See Note H

Page 37
37

Integrated Management of Childhood Illnesses

(IMCI)
Integratedapproach
Aimstoreducedeath,illnessanddisability,andto
promoteimprovedgrowthanddevelopment
IncludesbothprevenKveandcuraKveelements
Implementedbyfamilies,communiKesandhealth
faciliKes

See Note I

Page 38
38

IMCI Addresses Most

Causes of Death

Pneumonia
Diarrhea
Malaria
SevereMalnutriKon
Sepsis
MeningiKs

Measles
DehydraKon
Anemia
EarinfecKon
HIV/AIDS
Wheezing

If a child presents with fever, cough and tachypnea IMCI algorithms address treatment
of malaria, pneumonia as well as nutritional and growth concerns. IMCI protocols take
into account comorbidities and underlying conditions leading to disease.
Page 39

3 Components of IMCI
Health Worker Skills
Care in the Community and
Health Systems
If caretakers do not or
cannot access care
and health systems
are not strengthened
then just training
health workers results
in a incomplete
delivery mechanism
for the IMCI package

Clinical
Assessment
and treatment by

health workers

Knowledge,
Beliefs
and skills

caretakers
Capacity, structure
and functions of

health system

Page 40

IMCI Case Examples: 18-month old with fever and

lethargy
Community
Provider

Health System
Community

See Note J

Caretaker at home recognizes that health care is needed

Health care provider is available in community and family can
afford to pay for services if there are fees
Health care provider recognizes symptoms/signs of
complicated malaria, initiates treatment and refers to hospital
for further care. Inquires about use of insecticide treated
bednet in household and advises caretaker regarding its use to
prevent malaria
Family able to access hospital care (transportation, costs, etc)
Hospital facility quickly admits child and starts on appropriate
treatment for complicated malaria
Caretaker learns about insecticide treated materials and
implements use for the children in the household.

Page 41

IMCI Multicountry Evaluation

Traininghealthworkersimproved
performancebut..
DistrictandnaKonalhealthsystemslacksucientmanagementstructure,
funding,coordinaKon,supervision,andmanpower
LowuKlizaKonratesofhealthservicesIMCIcannotimpactchild
mortality
Diculttomaintain&expandexisKngIMCIsites
IMCIhasnotreachedthosemostinneedpoorerandmorerural
communiKes
A multicountry evaluation of IMCI programs found that the 11 day IMCI training course did
positively impact health workers performance. However, the health systems and parent/
caretaker care components were not strongly implemented and were impediments to overall
IMCI effectiveness.
For more information on the multicountry evaluation see http://www.who.int/imci-mce/

Page 42
42

Photos by Donna Denno and Adi

Dabestani

Photo: Donna Denno

Photo: Adi Dabestani

Photo: Donna Denno

Page 43

Actors in International Child Health

UNagencies:UNICEF,WHO
NaKonalDevelopmentAgencies:USAID,UKDepartment
forInternaKonalDevelopment(DFID)
PhilanthropicFoundaKons:e.g.,Gates,Rockefeller
InternaKonalBanks:WorldBank,IMF
NongovernmentalOrganizaKons:Oxfam,CARE,MSF
IndividualCountryGovernments
For an excellent overview of the history and activities of the major players in international
child health see Chapter 2 International health agencies, activities and other actors in
Anne-Emmanuelle Birns Textbook of International Health,3nd edition, 2009. Chapters 17 of
Global Health: Diseases, Programs, Systems, and Policies 3nd ed, by Michael Merson,
Robert Black and Anne Mills, Aspen, 2011, also provides an overview to the world of
multilateral international assistance.

Page 44
44

Photos by Kelly Evans and Donna

Denno

Photo: Kelly Evans

Photo: Kelly Evans

Photo: Donna Denno

Page 45

Conclusion: Is there hope?

YES!
7in10ofthe10millionannualdeathsinchildren
youngerthan5yearsarea8ributabletosixcauses
EecKveintervenKonsexist
EecKveintervenKonsneedtobeavailabletothe
poorestpopulaKons
Pneumonia, diarrhea, malaria and 3 neonatal disorders (pre-term delivery, sepsis
and lack of oxygen at birth.) Interventions need the vehicle of strong communities
and health systems to deliver reductions in childhood morbidity and mortality.
WHO World Health Report 2005: Making Every Mother and Child Count
Page 46
46

Conclusion: Is there hope? YES!

Twothirdsofchilddeathscouldbepreventedby
intervenKonsthatareavailabletodayandarefeasible
forimplementaKoninlowincomecountriesathigh
levelsofpopulaKoncoverage.
7 in 10 of the 10 million annual deaths in children younger than 5 years are attributable to
six causes: Pneumonia, diarrhea, malaria and 3 neonatal disorders (pre-term delivery,
sepsis and asphyxia.)
2/3 of childhood deaths are preventable with interventions that we already know to be
effective and are feasible for implementation. Things like insecticide treated bednets,
appropriate antibiotics for respiratory infections and antimalarials, access to clean water
and sanitation, oral rehydration therapy for treatment of diarrhea, intermittent presumptive
treatment of malaria during pregnancy, attended births with appropriate care of the
neonate. These prevention and treatment interventions are reviewed in detail in the 2nd
GHEC Child Health Module.

Jones G, et al. How many child deaths can we prevent this year? Lancet 2003
Page 47
47

Quiz
Nowweinviteyoutotakethemodulequizand
testyourrecentlearning.
Thismodulequizincludes16quesKonsreviewing
someofthekeypointsofthismodule.
Noteyouranswersonpaperandthenreviewthe
answersthatfollowthelastquesKon.Aler
compleKngyourquizyoucanreviewthe
conclusionandsuggestedreferencesforthis
modulepresentaKon.

48

1. Approximately how many children die every year around the world?
A.
B.
C.
D.

60-70 million
6-7 million
650,000
65,000

2. What percent of childhood deaths occur in low and middle income

countries?
A.
B.
C.
D.

50%
67%
75%
99%

Page 49
49

3. T or F Neonatal mortality rate (NMR) is the probability of

dying between birth and one year as expressed per 1000
live births
4. T or F U5MR and child mortality rate (CMR) are
synonyms.
5. T or F Neonatal deaths are included in child (i.e. underfive) mortality figures/rates.
6. T or F Undernutrition and obesity are both forms of
malnutrition.

Page 50
50

7. Which of the following is NOT considered to be a key

component of IMCI?
A. Training health workers at the community level to be able
to treat all sick children at the community level.
B. Teaching caretakers to recognize signs of illness so they
will know when to seek care
C. Continued monitoring and training of health workers
D. Health infrastructures having systems in place to assure
availability necessary medications
Page 51
51

8. Approximately what percent of global childhood deaths are

preventable and/or treatable with interventions that are
currently available and feasible for implementation?
A.10%
B.25%
C.50%
D.67%
E.90%
9. T or F Interventions aimed at reducing neonatal deaths
are closely linked to maternal health interventions

Page 52
52

10. IMCI health provider protocol for assessment of a febrile

child might include (more than one response acceptable):
A. Checking immunization/growth card to see if vaccinations are up to
date
B. Checking immunization/growth card to see if there is any growth
faltering
C. Assessment for signs of complicated malaria
D. Checking to see if child is sleeping under an insecticide treated bed
nets
E. All of the above
Page 53
53

11. Millennium Development Goal #4 seeks to reduce the

childhood mortality rate between 1990 and 2015 by:
A.One-fourth
B.One-third
C.One-half
D.Two-thirds
12. T or F Given current trends in child mortality rate
reduction, we are on target to meet Millennium Development
Goal #4.

Page 54
54

13. T or F S Asia and sub Saharan Africa have the greatest

proportions of child deaths compared to other regions in the
world.
14. Which are the 3 most important underlying determinants of
child mortality?
A.
B.
C.
D.
E.

Lack of paternal education

Lack of maternal education
High fertility rates
High levels of poverty
Inadequate access to healthcare
Page 55
55

15. T or F Despite improvements in child mortality rates,

many countries have experienced increasing gaps in mortality
rates between the rich and the poor.

Page 56
56

16. A multi-country evaluation of IMCI found the following

(multiple responses acceptable):
A. Training of health providers improved assessment and
treatment practices
B. Some sites experienced poor utilization of health services
by caretakers of children
C. Health system infrastructure deficits led to poor supervision
of health providers in the community
D. Implementation of the community component of IMCI does
not impact child health

Page 57
57

And now the answers to the questions

Page 58
58

1. Approximately how many children die every year around the world?
A.
B.
C.
D.

60-70 million
6-7 million -- Approximately 6.9 million children died in 2011
650,000
65,000

2. What percent of childhood deaths occur in low and middle income

countries?
A.
B.
C.
D.

50%
67%
75%
99%
Page 59
59

3. False Neonatal mortality rate (NMR) is the probability of dying

between birth and one year as expressed per 1000 live births
(NMR is the probability of dying between birth and 28 days as
expressed per 1000 live births)
4. True U5MR and child mortality rate (CMR) are synonyms.
5. True Neonatal deaths are included in child (i.e. under-five)
mortality figures/rates, including those in the IMR and NNR.
6. True Undernutrition and obesity are both forms of malnutrition.

Page 60
60

7. Which of the following is NOT considered to be a key component of

IMCI?
A.Training health workers at the community level to be able to treat
all sick children at the community level. -- Key components of IMCI
include the 1) caretakers in the community, 2) strong health systems to
supervise health workers and provide referral care, and 3) training of
community based health workers to recognize signs of illness, treat
appropriately and refer children who are severely ill to referral facilities.
B.Teaching caretakers to recognize signs of illness so they will know when
to seek care
C.Continued monitoring and training of health workers
D.Health infrastructures having systems in place to assure availability
necessary medications
Page 61
61

8. Approximately what percent of global childhood deaths are

preventable and/or treatable with interventions that are
currently available and feasible for implementation?
A.10%
B.25%
C.50%
D.67%
E.90%
9. True Interventions aimed at reducing neonatal deaths are
closely linked to maternal health interventions

Page 62
62

10. IMCI health provider protocol for assessment of a febrile child might
include (more than one response acceptable):
A.Checking immunization/growth card to see if vaccinations are up to date
B.Checking immunization/growth card to see if there is any growth faltering
C.Assessment for signs of complicated malaria
D.Checking to see if child is sleeping under an insecticide treated bed nets
E.All of the above -- IMCI health provider protocol for assessment of a febrile child
includes: checking immunization history and growth chart, evaluating for signs of
complicated malaria (and referring for further care if needed), asking the caretakers
if the child is sleeping under an insecticide treated bednet in order to prevent further
episodes of malaria.

Page 63
63

11. Millennium Development Goal #4 seeks to reduce the

childhood mortality rate between 1990 and 2015 by:
A.One-fourth
B.One-third
C.One-half
D.Two-thirds
12. False -- Given current trends in child mortality rate
reduction, we are on target to meet Millennium Development
Goal #4. (Few countries are on track to meet MDG4.)

Page 64
64

13. True S Asia and sub Saharan Africa have the greatest
proportions of child deaths compared to other regions in the
world. About 80% of child deaths occur in these regions.
14. Which are the 3 most important underlying determinants of
child mortality?
A.Lack of paternal education
B.Lack of maternal education
C.High fertility rates
D.High levels of poverty
E.Inadequate access to healthcare
Page 65
65

15. True Despite improvements in child mortality rates,

many countries have experienced increasing gaps in mortality
rates between the rich and the poor.

Page 66
66

16. A multi-country evaluation of IMCI found the following

(multiple responses acceptable):
A. Training of health providers improved assessment and
treatment practices
B. Some sites experienced poor utilization of health
services by caretakers of children
C. Health system infrastructure deficits led to poor
supervision of health providers in the community
D. Implementation of the community component of IMCI does
not impact child health

Page 67
67

Page 68
68

References
1. World Development Report 1993--Investing in health1993, Washington DC:
Oxford University Press for the World Bank.
2. Preamble to the Constitution of the World Health Organization as adopted by
the International Health Conference, New York, 1946.
3. Lawn, J.E., Newborn Survival, in Disease Control Priorities, J.G.B. Dean T.
Jamison, Anthony R. Measham, George Alleyne, Mariam Claeson, David B.
Evans, Prabhat Jha, Anne Mills, Philip Musgrove, Editor 2006, Oxford University
Press: New York.
4. Levels & trends in child mortality report 2012: Estimates developed by the UN
Inter-Agency Group for Child Mortality Estimation, ed. Unicef, et al.2012, New
York: United Nations Children's Fund.
5. World Health Report: Make Every Mother and Child Count, 2005, World Health
Organization: Geneva.

69

References
6. Denno, D., Global child health. Pediatr Rev, 2011. 32(2): p. e25-38.
7. Black, R.E., et al., Maternal and child undernutrition: global and
regional exposures and health consequences. Lancet, 2008.
371(9608): p. 243-60.
. McCord, C. and H.P. Freeman, Excess mortality in Harlem. N Engl J
Med, 1990. 322(3): p. 173-7.
9. WHO, Commission on Social Determinants of Health Final Report,
2008, World Health Organization: Geneva.

70

Recommended resources:
2003 Lancet Child Survival series including 1st of 5 articles--Black RE, Morris
SS, Bryce J. Where and why are 10 million children dying every year? Lancet
2003;361(9376):2226-34.
World Health Report: Make Every Mother and Child Count. World Health
Organization; Geneva; 2005.
Denno, D., Global child health. Pediatr Rev, 2011. 32(2): p. e25-38.
UNICEFs annual State of the Worlds Children Report includes latest statistics
on child health and development. Each report also covers a special theme. The
2009 report, for example, focused on maternal and newborn health.
UNICEF ChildInfo website http://www.childinfo.org/index.html
Closing the gap in a generation: health equity through action on the social
determinants of health. Final Report of the Commission on Social determinants
of Health. World Health Organization; Geneva; 2008.
71

Credits
DonnaM.Denno,M.D.,M.P.H.

UniversityofWashington
Sea8le,WA
ChrisStewart,M.D.

UniversityofCalifornia
SanFrancisco,CA
2013

Page
7272

The Global Health Education Consortium gratefully acknowledges the support

provided for developing these teaching modules from:

Sponsors

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73

Supplementary Notes

74

NOTE A -- Why focus on child health?

1) Children represent the most vulnerable societal group for a number of
reasons: a) biologic immaturityfor example, immunologic immaturity put
them at increased risk of infectious diseases, b) they are at risk of insults
which can arrest or retard their physical and mental development, c) they
are dependant on adults for their optimal development and in fact survival.
As a result of their vulnerability and dependence on society and adults for
their care, the UN Convention on the Rights of the Child (UNCRC) was
drafted and presented in 1989 with all countries signing the Convention
and all but 2 countries governments (US and Somalia) ratifying the
Convention. At the time of this writing, the new US Presidential
Administration has indicated that they will review the document for
ratification reconsideration. However, ratification requires Congressional
approval in the US as well. For more information see
http://www.unicef.org/ceecis/overview_1583.html for an overview and
http://www.crin.org/docs/resources/treaties/uncrc.asp for the full text.
2) Improvements in child health are a good measure of societal progress
hence the Millennium Development goals (described later in Note F)
contains a specific goal explicitly stating the need to reduce childhood
mortality as well as other goals relating to children as well (i.e. improving
education rates, reducing poverty rates). Infant and child mortality rates
(discussed in later slide and note C) have traditionally been (and still are)
used as sensitive markers for the overall health of nations as a whole.
3) GHEC Module 21 reviews the Global Burden of Disease* and common
ways to measure that burden including life expectancy and disabilityadjusted life years (DALYs)1. Childhood illness, disability, and death are
important components of the global burden of disease; death during
childhood substantially contributes to reduced life expectancy in
developing countries. Furthermore, childhood illness is an important
contributor to the global burden of disease. For example, the key causes
of childhood morbidity are estimated to account for 14% of DALYs [1].
4) 2/3 of childhood deaths are preventable and/or treatable with interventions
that are currently available! Read on for more information!
*For more information about the Global Burden of Disease Project see:
Return to Slide 3

DALY is a weighted index that takes into account loss of life, morbidity and disability.

NOTE B -- Indicators of childhood mortality

DEFINITIONS, DEFINITIONSLETS GET A HANDLE ON THE LINGO USED
TO MEASURE CHILD HEALTH OR LACK THEREOF
An indicator is a commonly used term in public health that refers to a measure
of health or disease. Incidence and prevalence rates and different types of
mortality rates are commonly used indicators. For example:
o Proportional mortality = number of deaths due to a specific cause in a
defined population over a year / total number of deaths occurring in that
population during the same year
o Mortality rate = number of deaths due to a specific cause in a defined
population over a year/ total number in the defined population at the
midpoint of the same year = probability of dying due to a specific cause
in a given population
o Note that proportion dying and probability of dying from a given cause are
very different! For example, 3% of childhood deaths in developing
countries are due to injuries vs. 10% in developed countries. So, are
injuries an important problem in developing countries? Doesnt seem like
it if you just look at proportional mortality of 3%. However, the risk or
probability of a child dying from injuries is greater in developing countries
than it is in developed countries!! In other words, more children/
population are at risk of fatal injuries in developing countries than in
developed countries. Its just that they are also dying from other causes at
higher rates, so the importance of injuries as a contributor to mortality is
masked if you just look at proportional mortality.
In child health the 3 most used common mortality indicators are:

Under five mortality rate (U5MR) is also referred to as child mortality

rate (CHR) = number of deaths under five years of age in a defined
population over a year / number of live births occurring in that population
during the same year
Infant mortality rate (IMR) = number of deaths under one year of age in a
defined population over a year / number of live births occurring in that
population during the same year
Neonatal mortality rate (NMR)= number of deaths under 28 days of age
in a defined population over a year / number of live births occurring in that
population during that same year

Note the differences in the definitions of the denominators between the child
mortality rates and general mortality rate. Note also that NMR is encompassed
within IMR and U5MR, and NMR and IMR are encompassed within U5MR.

For more information about these and other indicators see:

SOWC 2007 p.137 (http://www.unicef.org/sowc07/report/report.php )
Specific indicators by country can be found on the UNICEF
http://www.unicef.org/infobycountry/index.html or WHO
http://www.who.int/whosis/en/ websites
Return to Slide 5

NOTE C -- Reminder -- Morbidity

IODINE Deficiency is the single most important cause of preventable brain
damage and mental retardation. It significantly raises the risk of stillbirth and
miscarriage in pregnant women. 43 million people worldwide suffer from varying
degrees of brain damage and physical impairment due to iodine deficiency
there is a spectrum of associated disability. The primary intervention for the
control of IDD is through salt iodization. For more information on IDD see
http://www.childinfo.org/idd.html
VITAMIN A Deficiency is a contributing factor in 2.2 million deaths each year
from diarrhea and 1 million deaths from measles among preschool children under
five. Severe deficiency can also cause irreversible corneal damage, leading to
partial or total blindness. Vitamin A deficient children face a 23% greater risk of
dying from ailments such as measles, diarrhea or malaria . Vitamin A
supplementation of children with can reduce deaths from diarrhea and measles
by 35-50% and 50%, respectively. Treatment with high dose vitamin A is an
important component of measles case management. For more information on
vitamin A deficiency see http://www.childinfo.org/vitamina.html
IRON Deficiency is the most common nutritional disorder in the world. It lowers
resistance to disease and weakens a child's learning ability and physical stamina.
It is a significant cause of maternal mortality, increasing the risk of hemorrhage
and infection during childbirth. Nearly 2 billion people are estimated to be
anemic and millions more are iron deficient, the vast majority are women and
children. For more information see
http://www.unicef.org/nutrition/23964_iron.html
HELMINTHIC infections are an important cause of poor growth and anemia
worldwide. Hookworm infection, for example, is an important cause of anemia in
many settings with clinical manifestations similar to that of iron deficiency
anemia. Periodic presumptive treatment among schoolchildren can lead to
control in endemic settings. For more information on helminthiasis see
http://www.who.int/topics/helminthiasis/en/
Furthermore, many common causes of child mortality can leave survivors with
long term disabilities: for example, reduced cognitive function post cerebral
malaria, intestinal malabsorption as a result of prolonged or recurrent diarrheal
infections leading to poor nutrient absorption, disabilities secondary to injuries.
Return to Slide 8

NOTE D -- The world is not on track to meet MDG4

Progress is being made in reducing childhood mortality. Between 1980 and 2008
annual child deaths worldwide decreased from 13.5 million to 8.8 million. Latin
America, the Caribbean, Eastern Europe, the Pacific and East Asia are on track
for meeting MDG4.
Worldwide, there has been a 41% reduction in U5MR from1990-2011. In some
countries progress had stalled or even reversed in the 1990s (e.g. Kenya, South
Africa, Zimbabwe, Rwanda, Swaziland)often due to conflict, political instability
leading to reduced focus on public health infrastructure, and/or the HIV/AIDS
epdemic.
However, of 66 countries with child mortality rates of at least 40 per 1,000 live
births, 20 have reduced their under-five mortality rates by at least half between
1990 and 2011, and 4 of them have achieved at least a two-thirds decline (in
Lao Peoples Democratic Republic, Timor-Leste, Liberia and Bangladesh) [4].
For more information see http://www.childinfo.org/mortality_underfive.php .
Return to Slide 10

NOTE E -- Slowing trends in improvements in child mortality

Reductions in mortality rates during the 1960s-1970s and into 1980s provided
optimism that MDG #4 could be realistically met by 2015. However, progress
slowed in the 1980s and 1990s [5, 6], picking up at a somewhat better pace
during the first decade of this centurybut not at a pace fast enough to meet
MDG4 by 2015 at current rates. Globally, rates of reduction in under-five
mortality decreased by an average of 1.8 percent per year between 19902000.
Progress improved over the next decade with an average 3.2 percent decrease
per annum from 20002011. However, in order to meet MDG4 an annual rate of
reduction in child mortality of 14.2% would be needed.
Of 66 countries with the highest mortality rates, only 15 are on track to meet
MDG4.
Meeting the target will require serious commitments to implementing life-saving
interventions and tackling the social determinants of health. But it can be done,
even in the poorest of environments. The following are examples of high mortality
countries have made great strides forward in reducing under-5 mortality: Nepal,
Timor Leste, Bangladesh, Eritrea, Lao Peoples Democratic Republic, Mongolia,
Bolivia, and Malawi.
For further information on the progress being made toward meeting MDGs see:
http://www.childinfo.org/mortality_underfive.php
http://www.un.org/millenniumgoals/
www.countdown2015mnch.org
Rajaratnam JN, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer
L, Costa M, Lopez AD, Murray CJL. Neonatal, postneonatal, childhood,
and under-5 mortality for 187 countries, 19702010: a systematic analysis
of progress towards Millennium Development Goal 4. Lancet 2010; 375:
19882008.
Return to Slide 11

NOTE F -- Undernutrition is an Important Underlying Cause of Death

Undernutrition* typically is not directly responsible as a cause of death, more
often it is a very important underlying cause of death. Altogether undernutrition
contributes to 35% of childhood deaths [7]. Undernutrition puts children at
increased risk of illness (e.g. increased risk of contracting pneumonia, diarrhea,
malaria) and once they are sick puts them at even greater risk of dying.
Undernutrition can take many forms. While poor caloric and macronutrient
(protein, fat, carbohydrate) intake is an obvious cause of undernutrition (defined
as low weight for age), micronutrients also play an important role in promoting
growth and micronutrient deficiencies can also lead to low weight for age. In
addition, micronutrient deficiencies can be present in children who are not
underweight. Micronutrient deficiencies are associated with increased risk of
morbidity and mortalityfor example increased risk of getting ill with diarrhea
and increased risk of dying from measles, respiratory infections, and diarrhea.
The most common micronutrient deficiencies are vitamin A, zinc, iron and iodine.
Breastfeeding also plays an important role in health promotion and disease
prevention. Infants less than six months who have not been breastfed have a 7fold and a 5-fold risk of dying from diarrhea and pneumonia, respectively,
compared to children who have been exclusively breastfed. Those who have
been breastfed but not exclusively, face a 2-fold increased risk compared to
those who have been exclusively breastfed. For more information on
breastfeeding see http://www.childinfo.org/breastfeeding.html
Undernutrition also inhibits physical and mental development. It is also a major
cause of neonatal morbidity and mortality as malnourished girls and women with
stunted growth have increased risk of obstructed labor as well as low birth weight
babies.
The term malnutrition encompasses overweight, obesity and undernutrition. The
term undernutrition refers to calorie/macronutrient deficiency, micronutrient
deficiency and lack of exclusive breastfeeding. Infants 6 months and older also
benefit from breastmilk in their diet in terms of protection from mortality.
For more information on malnutrition see GHEC Module 48, Part 2 of the GHEC
Child Health Module (Module 12) and Black, R. E., L. H. Allen, et al.
(2008). "Maternal and child undernutrition: global and regional exposures
and health consequences." Lancet 371(9608): 243-260.
Return to Slide 20

NOTE G -- Examples of Intervention Delivery Methods

Primary Health Care (PHC) refers to a specific movement originating in the late
1970s which defined a goal of Health for All by the year 2000 via the Alma Ata
Declaration which was signed by 134 health ministers from around the world and
endorsed by WHO, UNICEF and major funding organizations. The goal was to
be realized via the provision of essential health care (e.g. access to care for
treatment of common conditions) and basic public health services (e.g.
immunizations, clean water, sanitation facilities) as well as tackling underlying
causes of death such as poverty and illiteracy. PHC involves an integrated
approach to the delivery of services at the community level but as a part of a
comprehensive national health system.
To read the 1978 Alma Ata declaration on PHC and Health Care for all by 2000
see http://www.paho.org/english/dd/pin/alma-ata_declaration.htm
Return to Slide 36

NOTE H -- Examples of Intervention Delivery Methods

Following the Alma Ata declaration, there was concern (for example among
governments with a vested political interest in preserving inequities as well as
among influential US international health experts) that PHC was too ambitious a
project, and that there needed to be a focus on delivering specific selective
interventionsreferred to as selective cost effective interventions (SPHC).
SPHC movement focused on the technological aspects of the interventions. The
roles of communities, socio economic development and addressing underlying
determinants of health are not by SPHC. In the 1980s UNICEF adopted a
SPHC child survival strategy termed GOBI (growth monitoring, oral rehydration
therapy and immunization). This was expanded to include family planning, food
supplements and female education (GOBI-FFF). SPHC programs are often
delivered as vertical programsi.e. not an integral part of the health care and
public health system in developing communities but rather as isolated and
independent programs.
Vertical programming often results in human resources being diverted from dayto-day management of PHC operations in order to devote time and attention to
the vertical intervention being promoted at that time. Vertical programming is
difficult to sustain without continued carry-through via a functioning health
system.
For more information on PHC its revitalization 21st century see GHEC Module 30
PHCNow More than Ever
Return to Slide 37

NOTE I -- Integrated Management of Childhood Illnesses (IMCI)

In the 1990s UNICEF and WHO started promoting the Integrated Management
of Childhood Illnesses (IMCI) approach which might be viewed as a pendulum
partial swing back toward PHCcommunity involvement is emphasized although
underlying social, political and economic causes of poor health are not well
addressed. IMCI is an integrated approach to child health that focuses on the
well-being of the whole child. IMCI aims to reduce death, illness and disability,
and to promote improved growth and development among children under 5 years
of age. IMCI includes both preventive and curative elements that are
implemented by families and communities as well as by health facilities. In
health facilities, the IMCI strategy promotes the accurate identification of
childhood illnesses in outpatient settings, ensures appropriate combined
treatment of all major illnesses, strengthens the counselling of caretakers, and
speeds up the referral of severely ill children. In the home setting, it promotes
appropriate care-seeking behaviours, improved nutrition and preventative care,
and the correct implementation of prescribed care.
There are 3 components to IMCI:
improving health worker skills
o IMCI trainings are structured 11 day courses aimed at teaching health
care workers in the community (i.e. primarily the non-physician
providers (e.g. nurses) who provide the majority of care in many
developing countries.
o The courses cover IMCI protocols in identifying the common
presentations of the sick child as well as appropriate treatment, followup and referral for these conditions.
o The courses and IMCI protocols also have components on assessing
well child issues--growth, nutrition, development, and immunizations.
The protocols encourage health workers to check immunization/growth
chart cards during sick visits to assess for and growth faltering, gaps in
immunizations or routine vitamin A doses, delays in development
(developmental milestones are included on these cards. Appropriate
treatment and referral are included in guidelines.
improving home and community based care and practices to ensure that:
o appropriate prevention strategies such as exclusive breastfeeding for 6
months, appropriate nutrition, use of insecticide treated materials are
being practiced
o home based care is appropriate for both the sick child (e.g. appropriate
antimalarials for the febrile child in a malaria endemic setting, oral
rehydration therapy for the child with diarrhea and no dehydration)
o children are taken promptly to a health worker when symptoms and
signs of illness warrant health care (e.g. symptoms of complicated
malaria--fever and poor feeding, fever and lethargy or diarrhea with
signs of dehydration (poor ability to drink, lethargy, etc)

o children are given full courses of prescribed treatments (e.g. full course
of appropriate antibiotics prescribed by health worker for respiratory
infection, full course of appropriate anti-malarials
improving health systems
o appropriate supervision of and continued training for health workers
o procurement systems with adequate supplies of medications, vaccines
and supplies
o referral facilities (i.e. hospitals) that respond to referrals from the
community level. Mechanisms must be in place to efficiently respond
to the sick child who is referred from the community.

Standard IMCI protocols share common features (e.g. identification of child

needing antibiotics for treatment of respiratory infection and symptoms/signs
requiring hospital referral), but protocols are also setting specific (e.g. includes
assessment and treatment for dengue fever in endemic settings)
Return to Slide 38

Note J -- IMCI Case Examples: 18-month old with fever and lethargy
Preliminary Data from 5 countries that where an evaluation of IMCI is taking
place are encouraging in regards to training of health workers but the health
systems component of IMCI is just not strong enough to deliver an effective total
IMCI package. Access to care presents another significant impediment to IMCI
effectiveness.
Case example: An 18 month old presents with fever and lethargy. In order for
IMCI to be effective in helping this child, the caretaker needs to identify that the
child is ill and seek care. The community health worker must be trained to
recognize severe malaria based on clinical presentation and initiative immediate
treatment and referral to a health care facility. The family must then be able to
access the facility and the facility must recognize the condition and treat the child
appropriately.
Case example: An 8 month old presents cough and fever. Again, the family
must recognize that this is a condition for which care should be sought and care
within the community should be accessible. The community health worker
should not only be able to follow clinical algorithm leading to a clinical diagnosis
of pneumonia but should also assess the growth and immunization record and
give nutrition advice and update immunizations accordingly. The community
health worker should also document developmental progress on the growth chart
and intervene if there is developmental delay. If the child is from a malaria
endemic setting treatment for potential concomitant malaria is included in the
clinical care guidelines as well.
In IMCI care is more comprehensive. Community education regarding healthy
practices is important and encompassed in 16 key family practices for healthy
growth and development that fall into 4 categories: promote physical growth
and mental development, promote disease prevention, promote appropriate
home care, and promote health care seeking behavior. For a full list of the 16
key community IMCI family practices see
http://www.paho.org/english/ad/fch/ca/GSIYCF_keyfam_practices.pdf
Return to Slide 41