Empowering communities and women

Primary health care and child survival:

Dr. Henry PERRY

In 2000, world leaders came together at the United Nations Headquarters in New York to adopt the UN Millennium Declaration. Committing to a new global partnership to reduce extreme poverty, they set out a series of time-bound targets, with a deadline of 2015, that have become known as the Millennium Development Goals (MDG').

MDG 4 calls for a two-thirds reduction in the mortality rates of children in their first five years of life, based on the 1990 rates. 1 There are 68 countries in which 97 percent of the annual deaths of under-five children take place; at present, only 16 are on track to reach MDG 4. 2 We have now passed the halfway point between the Declaration and the year for reaching these goals. Why are we so far behind on child health?

Simple approaches save lives

Although the number of children dying each year around the world has fallen from 18.9 million in 1960 to 9.2 million in 2007, 3 the great majority of these deaths are from readily preventable or treatable conditions such as pneumonia, diarrhea, malnutrition, measles and neo-natal infections and tetanus.

In the 68 priority countries, the coverage of key interventions for improving child survival shows that much progress can be made through simple approaches.

Immunisation and vitamin A supplementation reach at least 78 percent of mothers and children in these countries. But only one third are receiving appropriate treatment for the two leading killers of children: pneumonia and diarrhea.

If all mothers practised exclusive breastfeeding during the first six months of life, we would be able to prevent the deaths of 1.5 million children each year. 4 However, only 28 percent of mothers do this. 5 Exclusive breastfeeding is the single most important preventive intervention against child mortality, 6 providing optimal nutrition during early infancy and protection from diarrhea-causing pathogens in food and liquids to which the infant would otherwise be exposed.

And the other benefits of breastfeeding are numerous and significant as well: prevention of hypothermia in the infant, empowering women, reducing household expenses and many more.

Promoting appropriate complementary feeding, by frequently providing nutritious foods at six months of age, can prevent another 6 percent of child deaths. 7 Improving the quality of water, hand washing and sanitation can each prevent the number of cases of diarrhea by one third. 8 Diarrhea treatment by mothers using oral dehydration fluids is life saving. So is the early treatment of childhood pneumonia (which can be diagnosed by simply counting the number of breaths per minute) by properly trained and supervised community health workers administering oral antibiotics costing only pennies. 9 Home-based neo-natal care, in which community health workers educate pregnant women and assist them in the care of their newborn, can reduce neo-natal mortality by one third or more.10

Treatment close to home

We are learning that community-based programs, that reach every household with health education and that provide services as close to the home as possible, are the key to high levels of coverage with proven child survival interventions and to having maximum impact on reducing under-five mortality. Many organizations around the world are helping to empower communities to be able to provide these key services themselves and to link communities with existing health services.

Government health programs often focus on facility-based curative services and give little emphasis to community partnerships and empowerment.

Engagement, empowerment

Empowering communities and women to adopt healthier behaviours for themselves and their children, teaching mothers about the symptoms of childhood illness that indicate the need for treatment by a trained health worker and about the importance of obtaining preventive services such as immunisations, will save the lives of children who otherwise would die.

Training and supervising community health workers to be able to diagnose and treat childhood pneumonia, malaria and severe dehydration from diarrhea will also save lives, by bringing effective treatment closer to home.

For decades, many non-governmental organizations around the world have been engaged in these community-based child survival programs that have saved the lives of thousands and thousands of children.

Unfortunately, community-based approaches that focus on community empowerment and women's empowerment have not always been embraced by formal government health programs, which often remain focused on facility-based curative services.

Health Ministries in most countries have not been able to develop programs that encourage strong community collaboration.

However, UNICEF, the World Health Organization, the World Bank and other leading development organizations are now coming to the realization that stronger partnerships with communities - partnerships that engage communities as a valued resource rather than as a target for health programs - are needed in order to reach MDG 4, especially in the poorest countries with the highest under-five mortality rates.

Formation of participatory groups in which women can obtain practical and sound advice and in which women can learn from and support each other, is perhaps one of the most effective strategies that we know for implementing these simple child survival interventions. The effectiveness of this strategy for reducing under-five mortality is now well documented. 11

One of my friends once remarked that the greatest injustice in the world is the 'lottery' of where a child is born. Millions of children have suffered the injustice of being born into poverty without access to basic health care services and have died from an avoidable cause.

We must not forget them, or our collective responsibility as a global family for their deaths. But we cannot undo the past. Instead, we must redouble our efforts on behalf of those who have suffered and who will suffer this injustice of being born into poverty. We must do all we can on their behalf.

We must work hard to implement what we know works. And we must increase efforts to support those who have the expertise and the capacity to build partnerships between governments, communities and health ministries that will strengthen community-based primary health programs.

References:

(1) United Nations, Resolution adopted by the General Assembly: 55/2 United Nations Millennium Declaration, 2000

(2) UNICEF, Tracking progress in maternal, newborn and child survival, 2008, p 17, http://www. childinfo.org/files/Countdown20l5Publication.pdf

(3) UNICEF, ibid.; OB Ahmad, AD Lopez, M Inoue, 'The decline in child mortality: A reappraisal', Bulletin of the World Health Organization, 78(10), 2000, pp 1175-91

(4) UNICEF, 'Infant and young child feeding', see http://www.unicef.org/nutrition/ index breastfeeding.html

(5) UNICEF, Tracking progress in maternal, newborn and child survival, op. cit.

(6) N Bhandari, et al., 'Mainstreaming nutrition into maternal and child health programmes: Scaling up of exclusive breastfeeding', Maternal & Child Nutrition,4 Suppl I, April 2008, pp 5-23

(7) G Jones, et al., 'How many child deaths can we prevent this year?', The Lancet, 362(9377), 5 July 2003, pp 65-71

(8) BF Arnold, J M Colford Jr, 'Treating water with chlorine at point-of-use to improve water quality and reduce child diarrhea in developing countries', American Journal of Tropical Medicine and Hygiene, 76(2), 2007, pp 354-64; R I Ejemot, et al., 'Hand washing for preventing diarrhea', Wiley, 2008, see http://www.ehproiect.org/ PDF/ehkm/elemot2008-handwashing review. pdf ; L Fewtrell, et al., 'Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries', The Lancet Infectious Diseases, 5(l), January 2005, pp 42-52

(9) S Sazawal, RE Black, 'Effect of pneumonia case management on mortality in neonates, infants, and preschool children: A meta-analysis of community-based trials', The Lancet Infectious Diseases, 3(9), September 2003, pp 547-56

(10) AT Bang, et al., 'Home-based neonatal care: Summary and applications of the field trial in rural Gadchiroli, India (1993 to 2003)', Journal of Perinatology, 25 Suppl 1, March 2005, S108-22; AH Baqui, et al., 'Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: A cluster-randomised controlled trial', The Lancet, 371(9628), June 2008, pp 1936-44

(11) D S Manandhar, et al., 'Effect of a participatory intervention with women's groups on birth outcomes in Nepal: Cluster-randomised controlled trial', The Lancet, 364(9438), September 2004, pp 970-9; A Edward et al., 'Examining the evidence of under-five mortality reduction in a community-based program in Gaza, Mozambique', Transactions of the Royal Society of Tropical Medicine and Hygiene, 101(8), August 2007, pp 814-22. - Third World Network Features