WHAT WE HAVE LEARNED: A CENTURY OF EVOLVING HEALTH SYSTEMS AND PRACTICES
With the target date for Millennium Development Goal 4, – which aims to reduce child mortality by two thirds between 1990 and 2015– drawing near and many countries making insufficient progress to achieve it, critical questions arise, namely: How can momentum on maternal, newborn and child survival be recaptured and progress accelerated in the next eight years? What frameworks, strategies and resources are required to achieve the goal? How should countries set priorities in maternal, newborn and child health?
In answering these questions, there is much to be learned from initiatives for child health and survival over the past century. These have ranged from mass campaigns targeting a single disease or condition such as measles or polio, to initiatives aimed at providing a continuum of maternal, newborn and child health care across the life cycle that encompasses hospital and clinical facilities, outpatient and outreach services, and household and community-based care.
Today, the case for an integrated approach to health service provision for mothers and children is becoming more convincing. This approach entails providing a core group of cost-effective solutions in a timely way to address specific health challenges. It also emphasizes community participation, intersectoral collaboration and integration of approaches with the general health-delivery system.
Milestones in health service provision
Efforts to control specific diseases began early in the 20th century, and escalated markedly in the 1950s, 1960s and 1970s with the advent of ‘mass campaigns’ focusing on the reduction or eradication of a specific disease using a particular technology. The success of several of these ‘vertical’ mass campaigns, particularly smallpox, paved the way for the design of possibly the most successful public health programme in history – the expanded programme on immunization, which was launched in 1974. Successful innovations in community health in countries as diverse as China, Indonesia and Nigeria in the 1970s showed the potential for delivering a range of health care services beyond those targeted at specific diseases. The comprehensive primary health care approach, consolidated at a landmark International Conference in Alma Ata in 1978, broadened the concept of health-care provision beyond the control of specific diseases to include the tenets of community involvement, equity, health promotion, and intersectoral collaboration. Economic constraints and other factors impeded implementation of the primary health care approach during the 1980s. An alternative framework, selective primary health care, based on focusing on a defined subset of key diseases and conditions and addressing them by employing relatively inexpensive medical technologies to reach specific objectives, received strong donor support. The ‘child survival revolution’ spearheaded by UNICEF in 1982 was based on this framework. It focused on four low-cost interventions collectively known as GOBI – growth monitoring for undernutrition, oral rehydration therapy to treat childhood diarrhoea, breastfeeding to ensure the health of young children and immunization against six deadly childhood diseases.
Despite the gains of selective primary health care, by the late 1980s, health systems in many developing countries were under severe stress. Population growth, the debt crisis in many Latin American and sub-Saharan African countries, and political and economic transition in the former Soviet Union and Central and Eastern Europe were but three of the contributing factors. In response, a number of countries embarked on efforts to reform deteriorating, under-resourced health systems, raise their effectiveness, efficiency and financial viability, and increase their equity.
One such approach used by many countries was the Bamako Initiative, which was launched in 1987 at the World Health Organization meeting of African health ministers in Bamako, Mali. The Bamako Initiative sought to deliver integrated minimum health-care packages through health centres, with a strong emphasis on access to drugs and community partnerships.
Examples of the greater emphasis on integrated approaches during the 1990s and into the first decade of the new millennium are provided by the Integrated Management of Childhood Illness (IMCI) and the Accelerated Child Survival and Development (ACSD) strategies. Developed in 1992 by UNICEF and WHO, and employed in more than 100 countries since then, IMCI strategies have three primary components, each of which requires adaptation to the country context: improving health worker performance, improving health systems and improving community and family practices.
Similarly, the ACSD strategy, initiated in 2002 by the Canadian International Development Agency (CIDA), UNICEF and governments in West and Central Africa, covered more than 16 million people in 11 countries with high rates of under-five mortality as of 2004. ACSD concentrates on community-based promotion of a package of family health, nutrition and hygiene practices; outreach efforts and campaigns to provide essential services and products; and facility-based delivery of an integrated minimum-care package. It builds on the strengths of existing programmes such as Antenatal Care plus, Extended Programme of Immunization plus and Integrated Management of Childhood Illness plus.
Accelerating progress on the health-related MDGs
Based on the lessons of the past decades, experts in maternal, newborn and child health are increasingly coalescing around a set of strategic principles for child health and survival. These principles could provide the impetus needed to achieve the health-related MDGs. They include:
- Recognizing the need for community partnerships to support families in improving their care practices for children, especially in countries with weak health systems.
- Providing a continuum of care for mothers, newborns and children by packaging interventions for delivery at key points in the life cycle.
- Strengthening health systems by providing stronger support to developing countries in national planning, policy and budgeting frameworks for the health-related MDGs.
- Enhancing ways of working at the national and international levels with a strong focus on coordination, harmonization and results.
Finally, one overarching principle that has emerged from the review of a century of evolving health systems and practices is that no single approach is applicable in all circumstances. Health-care provision must be tailored to meet the constraints of human and financial resources, the socio-economic context, the existing capacity of a country’s health system and, finally, the urgency of achieving results. The public health community is continually learning and evolving. An examination of these strategies provides important perspectives on the current situation and helps guide the way forward in the drive for child survival.