Even the poorest countries facing the most difficult circumstances – including poverty, armed conflict, natural disaster or complex emergencies involving displaced populations, food insecurity and disease – can take proactive steps to boost maternal, newborn and child health. While investment is undoubtedly a factor in preventing unnecessary deaths, the examples below offer proof of how much can be achieved using extremely limited resources. The key to all of these victories is community knowledge, involvement and empowerment.
Integrated Management of Neonatal and Childhood illnesses in India
Throughout the 1990s, while India was making marked progress in reducing the under-five mortality rate, this positive trend did not apply to deaths during the neonatal period – or the first 28 days of a child’s life. By 2000, neonatal deaths accounted for two-thirds of all infant deaths in the country, and around 45 per cent of under-five deaths. Many of these deaths could be averted if parents recognized warning signs, adopted appropriate feeding practices or had access to skilled health workers and facility-based care.
In 2000, the Government of India adapted the Integrated Management of Childhood Illnesses (IMCI) strategy to focus greater attention on neonatal care by strengthening the health-system infrastructure, enhancing health workers’ skills and promoting community participation. In practice, this means introducing a number of services – such repeat home visits for newborns, community education and follow-up procedures for low birthweight babies – at minimal cost. Indeed, the additional cost of introducing the newborn component of this programme is just US$0.10 per child.
Diagonal Approaches: The Mexican Way
Between 1980 and 2005, Mexico implemented a number of disease-specific health interventions targeting diarrhoeal diseases, vaccine preventable diseases, vitamin A supplementation and intestinal worms. These so-called vertical interventions were subsequently scaled up to reach the broader population, strengthening the health system and introducing innovative strategies in the process.
The PROGRESA programme is one such example. A conditional cash incentive programme created to engage the country’s poorest families, it provides financial rewards for improved health and nutritional practices and keeping children in school. In order to receive its benefits, parents must regularly bring their children to health clinics supporting essential health and nutrition services.
The Ministry of Health’s launch in 2001 of Arranque Parejo en la Vida (Equal Start in Life), a more comprehensive package offering a continuum of maternal, neonatal and child health, built on the success of programmes like PROGRESA. By promoting social and community participation, expanding antenatal and neonatal care and targeting services to young mothers, this diagonal approach has helped earn Mexico the distinction of being one of only 7 countries out of 60 priority nations to be on track to meet the Millennium Development Goal for child survival.
Preventing Mother-to-Child Transmission of HIV in Eastern and Southern Africa through mothers2mothers
An estimated 530,000 children were newly infected with HIV in 2006, mostly through mother-to-child transmission. Without treatment, half of the infants born with the virus will die before the age of two. Although the risk of mother to child transmission can be greatly reduced by the delivery of antiretroviral regimens during pregnancy, a number of factors – including fear of stigma and limited information – often prevent women from accessing these services when they are available.
Yet a programme launched in 2001 is rapidly expanding to reach expectant mothers through a supportive network they can trust – other mothers within their community. Mothers2mothers (m2m) currently operates in nearly 100 sites throughout South Africa and Lesotho, adopting a mentoring approach that uses education and empowerment to prevent mother-to-child transmission of HIV, combat stigma, and keep mothers alive through treatment adherence. The organization is expanding rapidly, with international partnerships in Botswana and Ethiopia, and new programmes about to begin in Kenya, Rwanda and Zambia.
Leadership brings change for mothers and children in Ethiopia
Ethiopia serves as a powerful example of how strong political leadership can bring about positive change for child survival. In 2004, Prime Minister Meles Zenawi urged the government and its partners to join him in charting a road map for universal health care – a tremendous challenge given the many obstacles Ethiopia faced. At the time, less than 30 per cent of women receive antenatal care and less than half of Ethiopia’s children received a full course of immunization by their first birthday.
Yet through their Health Extension Programme, the government is tackling these challenges head on by promoting community-based child and maternal health services. Under this programme, 30,000 female Health Extension Workers are being deployed to promote 16 proven interventions that protect against the major causes of child and maternal mortality. While community level services are buoyed by the Health Extension Programme, the health ministry is also strengthening its infrastructure and adapting its referral system for those requiring hospital care.
The Ethiopia example provides an important lesson – the value of political leadership. This is vital to identifying problems, setting targets, mobilizing resources and fostering community participation.
Reducing Under-Five Mortality in Mozambique through Community-Based Care
Recent successes with community-based care in Mozambique offer both evidence and hope. Evidence that the strategy is effective to reduce under-five mortality and hope to other impoverished countries that child survival rates do not need to be a reflection of a nation’s economic status.
Mozambique is one of the world’s poorest countries, with an under-five mortality rate of 138 deaths per 1,000 live births in 2006 and a life expectancy of just 42 years. More than 40 per cent of children under five suffer from moderate to severe stunting – a result of inadequate nutrition – and with two-thirds of the population living in rural areas, access to essential health-care services is limited.
Using a “Care Group” approach to address the needs of Mozambique’s largely rural population, the government and international partners aimed to: improve partnerships between the health system and the community; increase accessible care for community-based providers; and promote essential household practices for child health. They pursued these goals by training community educators that offer peer-to-peer health education to households about low-cost, life-saving practices, such as exclusive breastfeeding, use of oral rehydration therapy and insecticide-treated mosquito nets, which were provided by UNICEF and the International Committee of the Red Cross, along with free vitamin A supplements. As a result of these efforts, community-based registries showed a 66 per cent drop in infant morality, and a 62 per cent drop in under-five mortality.
Scaling Up Adequate Nutrition for Mothers, Newborns and Children in Benin
Undernutrition is the underlying factor in up to 50 per cent of under-five deaths, and evidence links the mother’s nutritional status and evidence suggests a mother’s poor nutritional status elevates the risk of maternal and infant death.
Undernutrition stems from a variety of factors, including inappropriate feeding and care practices, inadequate sanitation, diarrhoeal diseases, and poor access to health services.
Ten years ago in the Borgou Region of Benin, only 14 per cent of infants under four months old benefited from exclusive breastfeeding – the single most effective intervention to save young lives. To address this gap and other problems linked with the region’s high rates of malnutrition, the Essential Nutrition Actions programme was introduced in 1997 to reinforce: exclusive breastfeeding for infants up to six months; appropriate complementary feeding with continued breastfeeding from 6- 24 months; vitamin A supplementation; iron and folic acid supplementation for pregnant women; iodized salt supplementation and counseling and support for undernourished and sick children.
In the process, this partnership also strengthened the health system by training health workers within the community and launching a communications campaign tailored to the conditions of the undernourished populations. These campaigns involved volunteers in the form of youth singers, community theater groups and women’s groups, who spread the messages through song, drama or word of mouth. This vast community mobilization led to a genuine change in breastfeeding behaviour among mothers. In 2001, nearly 50 per cent of mothers with infants under four months old reported their babies were exclusively breastfed.
Scaling-up Safe Water and Adequate Sanitation in Southern Sudan and Bangladesh
More than any other group, young children are vulnerable to the risks posed by contaminated water, poor sanitation and inadequate hygiene. Together, the lack of these services account for about 1.5 million child deaths a year due to diarrhoeal diseases. One third of these deaths could be averted by better sanitation, and together with better hygiene behaviour – such as hand-washing – up to two-thirds of these diarrhoeal-related deaths could be prevented. The first step toward saving these lives is providing communities with the knowledge and resources they need to improve water sources, basic sanitation, and proper hygiene.
Against a backdrop of ongoing conflict and natural disaster, a community-based programme is beating the odds in Southern Sudan to increase access to safe water and sanitation. Involving local teams with members selected by the community, the programme enables the teams to hand-drill for water and maintain handpumps. This low-cost, low tech means of supplying water also has the added advantage of being easily portable – an important feature for displaced communities in flux. By working together with communities, this project has extended tube wells across large areas of northern Bahr el Ghazal.
Improving sanitation in South Asia involves a number of factors – not the least of which requires investing in toilet construction. Yet equally important for public health purposes are raising community awareness about the importance of adequate sanitation and changing longstanding behaviours. Toward this end, a unique community mobilization effort in Bangladesh focused on “total sanitation.” Launched in 2001 in the Rajshahi district, this pilot project aimed to help communities understand the negative effects of defecating openly and empower them to collectively find solutions. The result of this pilot project was a total ban on defecation within the village – an achievement earned without any external subsidies.