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

]]> https://www.internationalhealthpolicies.org/strategic-orientations-for-the-future-of-child-health-in-a-new-online-collection-at-bmj/feed/ 0 https://www.internationalhealthpolicies.org/operationalizing-power-in-a-study-of-health-policymaking-in-niger/#respond Mon, 22 Feb 2016 08:02:23 +0000 http://www.internationalhealthpolicies.org/?p=2394 The number one cause of ill health is poverty, and power is the underlying dynamic determining why the poor are poor, and – let us not forget – why the rich are rich. That’s how I see things, and that’s why I’m interested in understanding power as a distal but pervasive determinant of health, notably at the level of health policy. However while analyses of health policymaking in low- and middle-income countries frequently evoke power and power dynamics, these concepts are rarely explicitly defined or explored.

Niger is a low-income West African country that recorded precipitous drops in child mortality (1998-2009) thanks in part to a policy called integrated Community Case Management (iCCM) providing care for pneumonia, malaria and diarrhea to large numbers of poor children. To understand why a pro-poor child survival policy succeeded in Niger, we relied on a political economy outlook to operationalize the concept of power and identify three relevant dimensions: 1) political authority, 2) financial resources and 3) technical expertise.

The policy analysis showed that manifestations of power during iCCM policymaking were multiform, combining Nigerien forms of political authority (Niger is a neo-patrimonial, multi-party democracy) with hard cash from various sources and smart policies appropriate for local health infrastructure. The Nigerien President at the time, Mamadou Tandja, laid the groundwork for iCCM starting in 2001 by launching a campaign to build over 2,500 “health huts” using funds from the Heavily Indebted Poor Countries initiative (HIPC), simultaneously building up his rural constituencies and supporting client networks charged with construction. Community health workers staffing the “health huts” were undertrained, however, until the advent in 2007 of a nationwide iCCM training campaign paid for by funds from Unicef and the Canadian development agency under the Catalytic Initiative, alongside support for supply of essential medicines. The demand-side piece fell into place around the same time when the World Bank strong-armed the Tandja administration into declaring fee exemptions for health services for children under five (without consulting health officials), leading to a well-documented jump in care-seeking.

Power dynamics were perhaps best understood as an ongoing dialogue between actors, who used the leverage available to them while for various reasons maintaining the interests of the poor at heart.  President Tandja’s pro-poor outlook emerged from his political ambitions; he would later cite his rural development works (and even the fee exemptions) in his 2009-2010 campaign to revise the constitution to extend his rule (known as Tazartché, continuation).  For World Bank negotiators in Washington, the conditionality on fee exemptions was motivated by adherence to recent statements and evidence on abolishing user fees, in a turnaround for the organization following on the backlash to structural adjustment in the 1990s and early 2000s.  For technical experts at national and international levels, the emphasis on the poor was based on prioritization of equity, access and perhaps above all impact.

The Nigerien case sheds light on dimensions of power in health policymaking, particularly in neo-patrimonial African regimes, and provides insights on how external actors can work within these contexts to promote pro-poor policies. With national elections in Niger last weekend, and the machine of international health and development grinding on, keeping the attention of the powerful focused on the poor is both an ethical imperative and a programmatic one, if the goal is to meet the greatest need.  While a growing body of work examines how power shapes health policy processes in low- and middle-income countries, more research and practical guidance is needed on how to apply such a profound, multi-faceted and contested theoretical concept. Our article presents one attempt at operationalizing the concept of power in policy-making that we hope will spark conversation on this critical topic.

Full article: “Power and pro-poor policies: the case of iCCM in Niger,” Health Policy & Planning (2015)