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Improving the Chances of Survival
The ambitions of the primary health care movement
During the 1970s, socioeconomic development and improved basic living conditions – clean water, sanitation and nutrition – were seen as the keys to improving child health. The primary health care movement, with its commitment to tackle the underlying social, economic and political causes of poor health, integrated this notion but outlined a strategy which would also respond more equitably, appropriately and effectively to basic health care needs. Along with intersectoral action for health, community involvement and self-reliance, primary health care stood for universal access to care and coverage on the basis of need. Much of the primary health care strategy was designed with the health of children as the priority of priorities.
The ambitions of the primary health care movement were vast. To implement its strategy, resources would have had to be redistributed, health personnel reoriented and the whole design, planning and management of the health system overhauled. This was clearly a long-term endeavour that would have required a major increase in funds being made available to the sector.
The successes of vertical programmes
The economic situation at the end of the 1970s, however, did not allow for such a development. Setting up primary health care systems in a context of shrinking resources was a daunting task. While countries struggled with the complexities of long-term socioeconomic development, child health – and particularly child survival – was such an obvious emergency that pressure for immediate action mounted. Therefore, by the early 1980s, many countries shifted their focus from primary health care systems to vertical, "single-issue", programmes that promised cheaper and faster results.
The most visible illustration of this shift was the Child Survival Revolution of the 1980s, spearheaded by the United Nations Children’s Fund (UNICEF), and built around a package of interventions grouped under the acronym GOBI (growth monitoring, oral rehydration therapy for diarrhoea, breastfeeding, and immunization). Donors and ministries of health responded enthusiastically, particularly to initiatives prioritizing immunization and oral rehydration therapy. Many countries set up programmes for this purpose. Like the malaria and smallpox programmes of the 1950s and 1960s, each one had its own administration and budget and a large amount of autonomy from the conventional health care delivery system.
These programmes benefited from the support of dedicated programmes within WHO: the Expanded Programme on Immunization of the mid-1970s, and, later, those created to reinforce national programmes for Control of Diarrhoeal Disease and Acute Respiratory Infections. At country level these vertical programmes successfully tackled a number of priority diseases.
The Expanded Programme on Immunization started in 1974 and widened the range of vaccines routinely provided, from smallpox, BCG and DTP to include polio and measles. It set out to increase coverage in line with the international commitment to achieve the universal child immunization goal of 80% coverage in every country. The 1980s did indeed see a huge increase in coverage (see Figure 2.2 in Chapter 2). In 1988, when the World Health Assembly resolved to eradicate polio, there were some 350 000 cases worldwide; by January 2005 there were only 1185 cases reported. Thanks to sustained efforts to promote immunization, deaths from measles decreased by 39% between 1999 and 2003 (
); compared to levels in 1980, measles mortality has declined by 80%. Efforts continue to increase coverage and widen the range of vaccines provided. The vaccination schedule is under constant revision as new vaccines become available, for example those against Hepatitis B and
Haemophilus influenzae type b, and, in the near future, rotavirus (diarrhoea) and pneumococcus (pneumonia).
These vertical programmes used a combination of state-of-the-art management and simple technologies based on solid research. The prototype for this was oral rehydration therapy, the "medical discovery of the century" (
) – a cheap and effective way to tackle mortality from diarrhoea. Widespread introduction of oral rehydration therapy largely contributed to reducing the number of deaths due to diarrhoea from 4.6 million per year in the 1970s to 3.3 million per year in the 1980s and 1.8 million in 2000.
As mortality from diarrhoea and vaccine-preventable diseases decreased, pneumonia came to the foreground as a cause of death, and in the early 1980s programmes were developed around simplified diagnostic and treatment techniques. In the meantime promotion of breastfeeding continued, backed up by international initiatives such as the International Code of Marketing of Breast-milk Substitutes (adopted by the World Health Assembly in 1981) and the Global Strategy for Infant and Young Child Feeding (endorsed by the World Health Assembly and by the UNICEF Executive Board in 2002). Advances were made possible by new insights into the optimal duration of exclusive breastfeeding and feeding for babies born to HIV-infected women. Countries widely implemented the Baby-Friendly Hospitals initiative to support promotion of breastfeeding in maternities. In 1990, less than one fifth of mothers gave exclusive breastfeeding for four months; by 2002 that figure had doubled to 38%.
Some countries had impressive successes with such programmatic approaches, and went beyond the small number of priority programmes that had international attention. Tunisia, for example, used the managerial experience gained in its first successful programmes to expand the range of health problems addressed, organizing delivery of these programmes through its network of health centres and hospitals. The country reduced the under-five mortality rate by 50% between 1970 and 1980, 48% between 1980 and 1990 and 46% between 1990 and 2000.
1 Progress in reducing global measles deaths: 1999–2002. Weekly Epidemiological Record, 2004, 79:20–21.
2 Water with sugar and salt [editorial]. Lancet, 1978, 2:300–301.
3 Wolfheim C. From disease control to child health and development, World Health Forum, 1998, 19:174–181
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