Greetings, and welcome to a new issue of Child Survival Technical Support’s (CSTS+) Bookmarks! This edition of Bookmarks! features a commentary on Child Survival by WHO Director-General LEE Jong-wook. This is part of a series on the subject in the British medical journal the Lancet.

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http://www.thelancet.com/journal/vol362/iss9380/full/llan.362.9380.child_survival.26656.1

The Lancet

CHILD SURVIVAL: A GLOBAL HEALTH CHALLENGE

The series of papers on child survival that have appeared in The Lancet over the past 5 weeks describes a major public-health challenge: more than 10 million children dying each year because they have not been reached by known and effective interventions.(1) Children are dying because of the neglect of common and preventable childhood illnesses, of health problems in newborn babies, and of the measures needed to protect mothers and infants during pregnancy and childbirth.

The child survival series was written by technical experts who recognised a set of problems, reviewed the evidence, and challenged WHO, UNICEF, other UN agencies, multilateral and bilateral agencies, non-governmental organisations, and health professionals to take appropriate action. Now it is time for policy makers and public-health leaders to respond, and to transform this knowledge into action. Three commitments must be pursued urgently and unremittingly.

First, the health of children and mothers must be re-instated as an important focus of organisational agendas. Monitoring child and maternal mortality is a key measure of progress, reflected in the Millennium Development Goals. The underlying causes of disease must also be monitored. Under-nutrition, for example, is estimated to account for over half the child deaths annually, and improved nutrition must be an integral part of child and maternal health programmes. An integrated approach to the causes of under-nutrition and over-nutrition, which often coexist in the same family, will also contribute to reducing the future burden of obesity, diabetes, and other non-communicable diseases.

Second, more of the children and mothers who are dying must be reached, by scaling up delivery of effective interventions and achieving and maintaining high coverage rates, especially among vulnerable populations. This will require a two-pronged strategy. The efficiency of integrated health systems, based on the foundation of strong primary health-care, needs to be increased to provide preventive and curative services of adequate quality to a greater number of children. Mechanisms need to be put into place to better engage and support families and communities in preventing disease and caring for their sick children.

Third, and most important in the longer term, there must be a commitment to building capacity for public-health programmes at the district level. As shown in the first paper in the series, (1) epidemiological profiles vary across countries, even within regions. More reliable and timely health data are needed at country and district level to inform policy choices and assess the effectiveness of programmes. Capacity must be built to collect, analyse, interpret, and act on these data. Reductions in child mortality are needed at district level to achieve the ambitious Millennium Development Goal of reducing child mortality worldwide by two-thirds by 2015.

Achieving the Millennium Development Goal for child survival demands focused and coordinated action to improve nutrition, to strengthen health systems, and to reduce inequalities in access to and use of effective interventions to prevent and treat pneumonia, diarrhoea, malaria, and the causes of neonatal deaths. It is important to learn from successes as well as failures, and continue to improve the practical outcomes at the district level. Monitoring efforts will focus on the extent to which children and mothers have access to essential services, whether delivered in health facilities or communities. Mortality in children aged under 5 years will remain an important indicator of success.

The global partners for child-health improvement, including WHO, UNICEF, the World Bank, national governments, and non-governmental organisations, have the ability to strengthen capacity for child health at country level. This technical capacity will be strengthened to link research, epidemiology, development, implementation, and evaluation across all relevant organisations. The technical or financial strength of these organisations will increasingly work for child survival at country level, building capacity to assess needs and resources, to focus on child and maternal outcomes. In addition, all partners will support the development of strong policy and planning frameworks for the integration and delivery of effective interventions suited to local epidemiological profiles and levels of health-system strength.

WHO cannot take on this challenge alone. Collaborative partnerships for child survival are needed. These will build on the complementary strengths of ministries of health and education, UNICEF, other UN organisations, the World Bank, bilateral aid agencies, non-governmental organisations, paediatricians, nurses, and other technical experts, professional associations, and the private sector. One important part of leadership is setting the direction, mobilising the forces, and monitoring progress. WHO will play its leadership role and use the opportunity of regular meetings on child survival to monitor progress and hold the broader public-health and development community accountable for reducing child and maternal mortality. (2)

Jong-wook Lee

WHO, CH 1211, Geneva 27, Switzerland

(1) Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226-34.

(2) The Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003; 362: 323-27.