Child Health
A small number of conditions accounts for most of the (large) differences in health between the poor and the not so poor. Less than 1 percent of all deaths from AIDS, TB, and malaria, for example, occur in the high-income countries. Available technical options—exemplified by but going well beyond immunization—can address most of the conditions that affect children, and can do so with great efficacy and at modest cost. That short list of conditions, including undernutrition, relates directly to achieving the MDGs for health. Public expenditures to address those conditions have, in the past, benefited the relatively well off, albeit within poor countries (although global inequities have decreased because many poor countries have made much progress).
Under-Five Health Problems and Intervention Priorities
MDG-4 for under-five mortality (reducing its level in 2015 by two-thirds relative to what it was in 1990) is highly ambitious. Yet its implication of an average 4.3 percent per year decline is well within recent experience. In the first half of the MDG period (1990-2002), 46 countries achieved rates of decline in under-five mortality greater than 4.3 percent per year. Figure 1.4 displays trends in the rate of decline in under-five mortality relative to the requisite 4.3 percent per year for China, India, Latin America and the Caribbean, and Sub-Saharan Africa. Africa's slowed progress probably stems mostly from HIV/AIDS and the spread of resistance to previously effective and widely used antimalarial drugs. Map 2 (on the inside back cover of this book) shows country-specific progress in reducing under-five mortality:
[Figure
1.4]
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Countries colored in green experienced annual rates of decline greater than 4.3 percent in the first half of the MDG period (1990-2002).
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Countries colored in red saw no decrease (or an increase) in their under-five mortality.
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Countries colored in yellow and orange depict countries in between—with yellow indicating performance in the top half of the range between 0 and 4.3 percent, and orange indicating poorer performance in the bottom half of the range.
Basic knowledge about the cost-effectiveness of interventions to address maternal and child health has been available from the 1980s. DCP2's work provides a reassessment with few surprises but some additions. It makes two important relatively new points. The first results from noting that half of under-five deaths occur at ages less than 28 days, when the substantial but usually neglected problem of stillbirth is considered. DCP2 identifies some highly cost-effective approaches to intervention against stillbirth and neonatal death (chapter 27). The second new point results from the rapid spread of resistance of the malaria parasite to chloroquine and sulfadoxine-pyrimethamine (SP). These inexpensive, highly effective, widely available drugs provided an important partial check on the high levels of malaria mortality in Africa. Their loss is leading to an even greater rise in malaria mortality and morbidity that could be substantial. Figure 1.5 illustrates increases in malaria death rates in under-five children in Sub-Saharan Africa in the period from 1990 to 2001. The design of instruments for financing a rapid transition to effective new treatments—artemisinin combination therapies (ACTs)—is a high priority (chapter 21; Arrow, Gelband, and Jamison 2005).
[Figure
1.5]
The other intervention priorities for addressing under-five mortality are for the most part familiar:
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Expand immunization coverage.
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Expand the use of the simple and low cost but highly effective treatments for diarrhea and child pneumonia through integrated management of childhood illness or other mechanisms.
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Prevent transmission of and mortality from malaria by expanding coverage of insecticide-treated bednets, by expanding use of intermittent preventive treatment for pregnant women, and, particularly, by financing the adoption of ACTs to replace the now widely ineffective drugs chloroquine and SP.
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Ensure widespread distribution of key micronutrients.
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Expand the use of a package of measures to prevent mother-to-child transmission of HIV (further discussed in the next section on HIV/AIDS).
In addition to interventions to reduce under-five mortality, one other priority is clear. The world's most prevalent infections are intestinal helminth (worm) infections, and children of all ages are among the most heavily affected. Chapter 24 discusses these infections, which a low-cost drug (albendazole), taken every six months to a year, can control effectively. Chapter 58 on school health services points to both the importance to children's school progress of taking albendazole where needed and the potential efficacy of school health programs as a vehicle for delivery. In the long run, improved sanitation and water supplies will prevent transmission. Use of albendazole is only an interim solution, but it is one that may be required for decades if the experience of the currently high-income countries is relevant.
Delivering Child Health Interventions
The list of potential interventions is far from exhaustive, and different regions, countries, and communities will face different mixes of the problems these interventions address. However, there can be little dispute that any short list of intervention priorities for under-five mortality in low- and middle-income countries would include many on the list in the preceding section. Why not, then, simply put money into scaling up these known interventions to a satisfactory level?
To greatly oversimplify—and these issues are discussed more substantially in chapter 3—two schools of thought exist. One line of thinking—often ascribed to macroeconomist Jeffrey Sachs and his work as chair of the WHO CMH—concludes that more money and focused effort are the solutions. Although acknowledging dual constraints—of money and of health system capacity—Sachs and his colleagues (WHO CMH 2001; Sachs 2005) contend that money can buy (or develop, or both) relevant system capacity even over a period as short as five years. Major gains are affordable and health system capacity constraints can be overcome. Immunization provides an example of where, even in the short term, money can substitute for system capacity. Adding antigens for Haemophilus influenzae type B (Hib) and hepatitis B (HepB) to the immunization schedule is costly (although still cost-effective). In some environments, however, it proves less demanding of system capacity than expanding coverage does. Money can be effectively spent by adding antigens at the same time as investing in the capacity to extend coverage.
A second school of thought acknowledges the need for more money but asserts that health system capacity is often a binding short- to medium-term constraint on substantial scaling up of interventions. Critical priorities are, therefore, system reform and strengthening while ensuring that such reforms focus clearly on achieving improved health outcomes and financial protection.
Chapter 3, as indicated, discusses these issues further in the context of all the problems facing a health system, and chapter 9 provides a thoughtful assessment of how to overcome the constraints facing achievement of the MDGs for health. From an individual country's perspective, however, if financial resources are available, the question is very much an empirical one: to what extent can those resources be effectively deployed in buying interventions, in buying out of prevailing system constraints, and in investing in relevant system capacity for the future? What needs to be constantly borne in mind throughout this continued controversy is that something works: under-five mortality rates have plunged by more than half since 1960 in the low- and middle-income countries.
