Each year, 5.6 million children die before their fifth birthday, while millions more fail to reach their full development potential. While global strategies like Integrated Management of Childhood Illness (IMCI) and integrated Community Case Management (iCCM) have contributed to significant reductions in child deaths, what can we learn from 20 years’ implementation about the state of the art in delivering child health interventions? How can we save more lives and best promote children’s healthy growth and development?
These are the questions addressed in a new BMJ online collection titled “A Strategic Review of Child Health.” The fruit of nearly three years’ collaboration between WHO, UNICEF, and independent child health experts worldwide, the review is introduced by M. Merson and M. Jacobs. The methodology draws on data points from over 90 countries, comprehensive literature reviews, interviews with leading global experts, in-depth country case studies, and more, to distill key messages about how to end preventable newborn and child mortality, promote each child’s healthy growth, and reach objectives under the Sustainable Development Goals (SDGs) and Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030).
Two decades ago, WHO and UNICEF introduced IMCI as a strategy to “reach all children” with prevention, diagnosis and treatment interventions for common childhood illnesses, with iCCM later released as a complementary strategy to increase access for under-served populations using community health workers. To date, IMCI has been adopted in over 100 countries and iCCM has also been widely adopted, mainly in sub-Saharan Africa, as detailed by Boschi-Pinto et al. However, the implementation of IMCI and iCCM has not provided a seamless continuum of care between the home, community and healthcare system. Rather, a focus on improving health worker skills operated to the exclusion of health systems strengthening and community engagement, say S. Patel et al. This lopsided implementation limited IMCI and iCCM’s potential impact by undermining built-in synergies, for example between demand creation at community level and improved service delivery.
The Strategic Review identified several obstacles to the successful implementation of integrated child health strategies – and some potential solutions. T. Doherty et al. argue that district health teams have not been equipped to engage in effective operational planning and implementation, and must be supported by improved management training, decentralised planning and budgeting, and systems-wide health systems improvements. Similarly, current training and supervision strategies fail to enable and support health workers. A. Rowe et al. suggest a pragmatic approach, using best practices to outline an initial performance improvement strategy, reinforced by monitoring and continual adjustment.
One clear finding of the Strategic Review was the need to look beyond the health facility. Increasingly strong, high-quality evidence supports the effectiveness of community engagement strategies such as home visits, women’s groups, community dialogues and health committees, which should have a larger place in child health strategies, say A. Prost et al. Furthermore, current child health strategies largely fail to collaborate with the private sector, where a majority of children seek care in many countries. P. Awor et al. evaluate approaches for strengthening these collaborations. And while past strategies to “reach every child” have reduced systematic inequities, much more emphasis is needed on intersectoral interventions to address the social determinants of health, financing to reduce the burden on poor families, and targeted program planning to reach the neediest, argue S. Dalglish et al.
How will WHO, UNICEF and other global agencies respond to these challenges? One of the first steps will be to redesign child health guidance and guidelines to create a single set of flexible, adaptable and user-friendly tools, using a life-course approach and covering children aged 0-18 years, a process that is currently underway, according to J. Simon et al. Concurrent work to harmonize and integrate monitoring and evaluation systems will reduce the burden on health workers by prioritising a small number of indicators, according T. Diaz et al.
While in the past, a lack of unified global leadership at WHO and UNICEF has limited the effectiveness of child health strategies and led to uncoordinated policies and disorganized implementation, a final commentary by child health leaders at WHO and UNICEF acknowledges these insufficiencies and lays out a five-point plan to provide harmonized support to countries and fulfill global commitments. These leaders ask to be held accountable to their commitments – a call that Jacobs & Merson take up in their commentary, saying they await “strong, intrepid action … to translate this knowledge into action.”
In this spirit of accountability, we invite discussion about our process, methods and findings. How can we better design and implement strategies to safeguard the health and well-being of every child? Tell us what you think on Twitter using the hashtag #FutureOfChildHealth. The world’s children deserve the best we can do.
Full online collection at BMJ: https://www.bmj.com/child-health