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Child and adolescent health

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This analytical profile on child and adolescent health is structured as follows:

Contents

Analytical summary

Sub-Saharan Africa has the lowest rate of improvement in child survival in the past 20 years, despite the highest rate of reduction in under-five mortality. To meet Millennium Development Goal 4, child mortality must be reduced by 8% per year, whereas the present rate is 1.4%. The leading causes of childhood deaths, in order, are neonatal conditions, diarrhoea, pneumonia, malaria, measles and HIV/AIDS. A total of 25% of under-fives are underweight and one third are stunted.

Percentage of infants exclusively breastfed for the first 6 months of life in the WHO African Region, 2000–2010

The challenges in nutrition faced by most African countries include:

  • the need to meet the energy needs and strengthen the immune systems of people with infectious diseases such as HIV/AIDS and tuberculosis;
  • increasing household food security and increasing dietary intake across the life cycle;
  • addressing the high consumption of sugars and fats that contribute to diet-related disorders.

Insufficient countries are making adequate progress on services such as skilled birth attendance, exclusive breastfeeding, and treatment of pneumonia, diarrhoea, and malaria.

However, good progress has been made on immunization and vitamin A supplementation. Measles vaccination has been successful, although recent gains are threatened by funding shortages.

Antiretroviral therapy access for children is low at only 35%. Postnatal care programmes are the weakest intervention of all, reflected in the high neonatal mortality rates.

All interventions need to be understood in the context of persistently poor environmental health conditions, with lack of drinking water and sanitation, and high rates of open defecation, occurring throughout sub-Saharan Africa. These represent particular threats to infants and young children and negate the benefits of many medical interventions.

The number of countries with child survival strategies has increased rapidly from only 11 in 2007 to 27 in 2009. However, the distribution of interventions remains low and inequitable, and does not operate across a continuum of care. Policies and action in the water and sanitation, education and transport sectors and revisions in national legal frameworks need to be combined with effective health interventions coverage to ensure sustained improvements in child health and survival and equitable access to services.

More attention is needed to putting in place health social insurance schemes to facilitate and encourage attendance at health services. It is clearly a disincentive for those in poor communities to make an effort to reach health facilities that cost them significant out-of-pocket sums, while these services are frequently inadequately staffed and poorly supplied.



Disease burden

Although child survival has improved globally, sub-Saharan Africa has seen the smallest rate of improvement over the last 20 years. Deaths in children under five years of age have decreased globally from 12.5 million in 1990 to 8.8 million in 2008. However, sub-Sahara’s contribution to the global under-five mortality rate increased from 34% in 1990 to 50% in 2008. It is estimated that 4.2 million children under five years of age died in the African Region in 2008, mainly concentrated in sub-Saharan Africa and South Asia.

The fourth Millennium Development Goal (MDG 4) requires countries to reduce under-five mortality rate by two thirds by 2015. In the WHO African Region, under-five mortality rates have dropped from 180:1 000 live births in 1990 to 142:1 000 in 2008[1], the highest rate of any region in the world. Child mortality is currently decreasing at an average rate of 1.4% per year[2]. In order to meet the goal, countries need to reduce mortality by at least 8% each year until 2015.

Currently only six countries in the African Region are estimated to be on track to achieve MDG 4 (Botswana, Cape Verde, Eritrea, Malawi, Mauritius and Seychelles). Twenty-seven countries are estimated to be making insufficient progress, while the remaining 13 are making no progress[3],[4].


Most prevalent diseases and conditions

There are a small number of diseases and conditions that directly cause more than 80% of childhood deaths in Africa. These are neonatal conditions, diarrhoea, pneumonia, malaria, measles, and HIV/AIDS. Figure 1 shows the main causes of under-five mortality in the region.

Figure 1: Main causes of Neonatal and under-five mortality, African Region, 2008

Fig18section45CAHfig1.png

Source: WHO, World Health Statistics, 2010 and www.who.int/child_adolescent_health/media/CAH_death_u5_neonates_afro_2008.pdf

Diarrhoea

After neonatal conditions, diarrhoea is the leading cause of death in children under five in the WHO African Region, with 748 000 annual deaths. Nearly one in every five child deaths (17%) is due to diarrhoea. Only 37% of African children with diarrhoea receive the recommended treatment of low-osmolarity oral rehydration salts (ORS) and zinc, which would prevent most diarrhoea deaths. Limited trend data suggest that little progress has been made in this regard since the year 2000, and in some places the situation is worsening. Zinc supplements are largely unavailable in most African countries, while low-osmolarity ORS have been rolled out more slowly than expected, even five years after WHO and UNICEF recommended their use[5],[6].

Malaria

Malaria causes an estimated 16% of under-five deaths in the WHO African Region, or 704 000 deaths annually. At present, fewer than 20% of children in sub-Saharan Africa sleep under insecticide treated bednets (ITNs). Ethiopia, Mali, Niger, Rwanda, Sao Tome and Principe, and Zambia have distributed ITNs to between 68% and 100% of the vulnerable population, with recorded usage rates of between 44% and 63%.

In these six countries, only one third to two thirds of all fever cases are being treated. Although there has been dramatic improvement over the last six years, these countries still fall short of the agreed target of 80% coverage[7] Ten countries in the African Region, namely Botswana, Cape Verde, Eritrea, Namibia, Rwanda, Sao Tome and Principe, South Africa, Swaziland, United Republic of Tanzania (Zanzibar) and Zambia, have succeeded in reducing malaria cases by at least 50% between 2000 and 2008.

Pneumonia

Pneumonia causes an estimated 14% of deaths in children under five in the African Region, or 616 000 annual deaths[8]. Many countries are implementing innovative strategies to identify and manage pneumonia closer to home[9]. The antibiotics to treat pneumonia cost less than US $ 1 per child per treatment, and community health workers have been trained for as little as US$ 100 per trainee to diagnose and treat pneumonia. Malawi has begun to roll out community case management for pneumonia, soon to be followed by Rwanda, Uganda and Zambia.

HIV/AIDS

Four percent of child deaths in the Region are caused by HIV/AIDS, with 176 000 deaths annually. Antiretroviral drug therapy (ART) can greatly reduce mother-to-child transmission of HIV, and is essential for tackling AIDS-related child mortality in Africa. Kenya, Nigeria, South Africa and Zimbabwe account for nearly half (146 000) of all HIV-related deaths in children under five in the Region. For most African countries, access to ART for infants with HIV/AIDS remains a challenge. Opportunistic infections, including pneumonia, are the main cause of early death in HIV-infected infants. Cotrimoxazole prophylaxis coverage to prevent opportunistic infections among HIV-infected or exposed infants is low. In 2008, only 8% of HIV exposed infants are reported to have initiated this prophylaxis by two months of age.

Nutrition

Only nine countries on the continent are on track to reach MDG Target 1 of halving hunger and malnutrition by 2015. Africa has high levels of maternal and child undernutrition and poor feeding practices. Today, 25% of children under 5 years of age in Africa are underweight[10]. More than one third of children under five in Africa are stunted.1 And despite some recent progress, only 31% of infants in the Region are exclusively breastfed for their first six months. Complementary feeding frequently begins too early or too late, and foods are often nutritionally inadequate and unsafe.

A lack of certain key micronutrients can also damage the health of the mother and child, and increase the risk of maternal and child mortality. For example, anaemia affects 42% of pregnant women globally, ranging from 24% in the Americas to 57% in Africa, raising the risk of premature birth, low birth weight, haemorrhage and sepsis[11]. Zinc deficiency in children is associated with increased risk of pneumonia, diarrhoea and malaria. However, the national prevalence of zinc is high in most countries of sub-Saharan Africa[12]. Vitamin A supplementation to children is implemented by 72% of countries, while salt iodization is implemented by 61%.2

The nutritional challenges faced by most African countries are well known. They include meeting the energy needs and strengthening the immune systems of people with communicable diseases such as HIV/AIDS and tuberculosis; increasing household food security through improved food availability and affordability; increasing dietary intake across the life cycle through appropriate feeding practices and debunking of food taboos; and addressing the high consumption of sugars and fats that contribute to diet-related disorders.

WHO is currently collaborating with Member States on the development of a comprehensive plan on infant and young child nutrition. This is a critical component of a global multisectoral nutrition framework to address the challenges outlined above.

Intervention coverage

In nearly all cases, the diseases and conditions that cause child deaths are preventable, and are treatable with proven interventions. But these interventions remain unavailable or inaccessible to many children in the African region.

The 2010 report, "Countdown to 2015", shows data from the 68 countries where more than 95% of global maternal and child deaths occur. Of these, 39 countries are in the African region. The report indicates that most countries have high or increasing coverage for preventive interventions such as vaccinations, with measles immunization at 80%, and vitamin A supplementation (2 doses) at 73%[1]. However, it also shows that very few countries are making progress in reaching women and children with clinical care services such as skilled attendants at delivery (47%), treatment of pneumonia (43%), diarrhoea (37%) and malaria (35%)[2]. Implementation of interventions that require behavioural and social change, such as exclusive breastfeeding up to the age of six months (31%), is also low.

In sub-Saharan Africa, antiretroviral coverage for preventing mother-to-child transmission of HIV currently stands at 45%, while access to ART for children needing treatment is only 35%[13]. Postnatal care programmes are among the weakest of all interventions for maternal and child health in the African Region. Where there is least contact with the health system, 870 000 newborns die annually in their first week of life[14]. Figure 2 shows coverage rates of some key child survival interventions.

Figure 2: Coverage of Child Survival Interventions, AFRO 2008 Fig19section45CAHfig2.jpg

Source: WHO World Health Statistics 2010, UNICEF SOWC, 2011

Immunization coverage

Although overall progress on improving child survival in Africa has been inadequate, there have been some key successes. The adoption of effective measles mortality reduction strategies in Africa has resulted in a 92% reduction in the number of deaths of children under five years from this cause between 2000 and 2008 – a reduction from over 395 000 to less than 32 000 [3]. Botswana, Malawi, Namibia, and South Africa have reduced measles deaths to near zero. However, reduction in funding available for measles prevention activities in countries has led to recent outbreaks in several African countries that threaten the gains achieved.

Progress has also been made on preventive interventions such as vitamin A supplementation. But in other areas, much work remains. Rotavirus and pneumococcal vaccine for preventing diarrhoea and pneumonia respectively are not available in most African countries. Thirty-one percent of the people in sub-Saharan Africa lack access to improved sanitation facilities, and 28% still practise open defecation. Forty-two percent of people in sub-Saharan Africa lack access to improved drinking-water sources.

Newborn health

Deaths in the first month of life account for more than a quarter of child mortality in sub-Saharan Africa, taking an annual toll of 1.2 million cases. While a number of countries have seen recent gains in child survival, neonatal mortality has, for the most part, remained stagnant over the last decade. Deaths in the first month of life are primarily due to birth asphyxia (not breathing at birth), complications of preterm birth, and severe infections such as sepsis and pneumonia. Neonatal tetanus causes about 24 000 deaths annually, despite the availability of tetanus toxoid immunization during pregnancy that costs less than US $ 0.50 US cents[15].

Approximately one third of newborn deaths could be prevented through improved family and community care alone, such as better hygiene standards at birth, both in health facilities and in homes, early and exclusive breastfeeding, better recognition of signs that the child is seriously ill, timely and appropriate care-seeking, and treatment for newborn infections.7 A range of known and affordable interventions exists, which if implemented fully, could prevent 63% of current childhood mortality.

Case management

The Integrated Management of Childhood Illness strategy (IMCI) remains key to reducing child mortality. The strategy includes improving case management of sick children at first-level health facilities, strengthening health systems and improving family and community practices to promote child health. In the African Region, 22 countries are now implementing IMCI in over 75% of districts, compared with only 10 countries in 2007.

Equity

National data on coverage levels often hide important disparities among population subgroups. Equity analyses, including systematic breakdowns of key coverage indicators by wealth quintiles, have been done by the "Countdown to 2015" initiative, in which WHO plays a major role.

A mean coverage index, consisting of an unweighted average of four intervention areas across the continuum of care, has been developed. Each area includes selected indicators for eight reproductive, maternal, newborn and child interventions:

1. family planning: need for family planning satisfied;
2. maternal and newborn health: at least one antenatal visit and skilled attendant at delivery;
3. immunizations: measles, BCG and DPT3; and
4. curative child care: diarrhoea and pneumonia management (ORS + zinc and continued feeding, and care-seeking for pneumonia).

To give an example, according to the "Countdown to 2015" report, the mean coverage index of the eight interventions in Benin is 73% among children in the richest wealth quintile, compared with 41% in the poorest wealth quintile.

This report also indicates that countries in the African Region with the lowest gap in coverage for the eight interventions are Rwanda, South Africa, Swaziland and Zambia. Countries with the largest gap in coverage are Chad, Madagascar and Nigeria. Countries with the lowest coverage – below 25% in the poorest population groups – are Chad, Ethiopia and Nigeria.

In most countries with Demographic and Health Survey data, intervention coverage is substantially higher among mothers and children from better-off households than among those from poor households.

The equity analysis gaps are markedly larger for maternal and newborn interventions than interventions delivered to older children. Interventions that are most frequently delivered in fixed health facilities, for example antenatal, delivery, or postnatal care, tend to show greater disparities than those delivered at the community level, such as vaccinations, vitamin A supplementation or ITNs).

Policies

The year 2006 saw the development by WHO, UNICEF and the World Bank of a Regional Child Survival Strategy[16]. It aims to scale up a defined set of effective child survival interventions in African countries, including antenatal care, newborn care, appropriate infant feeding, immunization, management of common childhood illnesses and the use of ITNs. By the end 2009, 27 countries had developed or updated national child survival policies, strategies or plans, compared to only 11 in 2007.

Systems

Beyond the negative impact of HIV/AIDS and conflict, coverage of effective health and nutrition interventions and practices in many countries remains low and inequitable. Key obstacles are found in public policies regarding budget allocations, and the development, deployment and retention of human resources.

The majority of child mortality causes can be correlated with economic, social and environmental factors. Dramatic declines in child mortality are attributable both to control of communicable diseases, and to policies ensuring better nutrition, improved standards of living, and social protection.

While macroeconomic policies and poverty reduction strategies address the underlying causes of high child mortality, they do not affect the supply, demand and access to health care among families and communities. Policies and action in the water and sanitation, education, and transport sectors — and in the national legal framework — need to be combined with scaling up effective health interventions to ensure sustained improvements in child health and survival, and equitable access to services.


Health Financing

Maternal, newborn and child health services should be available, of good quality, and free at the point of delivery in order to remove financial barriers to access and utilization.

An important obstacle to the uptake of services is the expected cost of care. To reach universal coverage, financial barriers to service utilization need to be removed, and families protected against catastrophic expenditures on health care. Therefore, user fees need to be phased out and replaced by policies that promote a shift from out-of-pocket payments to pre-payment and pooling.

Catastrophic payments and fairness in financial contributions for health care are of increasing concern to many governments[17]. Out-of-pocket financing for health care is common in many African countries. It is generally agreed that above 15% out-of-pocket financing for health care makes households more vulnerable to catastrophic payments[18].

A key step towards universal coverage is therefore to move away from out-of-pocket payments through prepayment and risk-pooling schemes. Several countries are moving in this direction. In Mali and Rwanda, social health insurance schemes are achieving high coverage and showing a positive effect on access to priority health services, including maternal, newborn and child health. Uganda has succeeded in increasing essential health service coverage, particularly among the poor, by removing user fees.

Median per capita government expenditure on health in the African Region is US$ 34 (in 2007 international dollars), with only six countries devoting the recommended level of at least 15% of their national budgets to health. However, these six still have low indicators in one or more MDG categories, principally due to low per capita investment in health and social determinants[19]. Commitment by African countries to increasing government expenditure on health to at least 15% therefore remains a challenge.

Access to maternal and child care

A series of intermediate factors makes some children more likely to fall prey to disease or medical conditions, limiting their chances of recovery. These factors include the absence of essential health care or the inability of mothers and their children to access it. At minimum, health systems should be equipped, staffed and organized to deliver proven interventions, effectively and equitably, to those mothers, newborns and children who need them, particularly those from the poorest and most marginalized communities.

These systems need to operate across the ‘continuum of care’. Services must be provided to women of reproductive age, through pregnancy, birth, and the early days and years of a child’s life. There must also be links between care provided in the home, locally in the community, and in hospitals and other health facilities.

Yet in many poor countries and communities, strong health systems operating across the continuum of care simply do not exist. Health facilities are often too far away or too expensive to access. In many cases, those that do exist are inadequately staffed and lack essential medicines and equipment. Poor people are therefore reluctant to invest precious time, effort and money in seeking care that may be unavailable or of poor quality.

Human Resources

Among the 39 African countries monitored by the ‘Countdown process’, only four (10%) meet the critical threshold of 23 doctors, nurses and midwives per 10 000 people generally considered necessary to deliver essential health services. The shortage is compounded by uneven geographic distribution within countries. Increased investment in education of health workers, strategies for motivating health workers to remain in underserved areas, and effective regulatory frameworks (including those for skills substitution) are among the effective policy options for addressing critical workforce shortages and maldistribution.

Ethiopia, Ghana, Malawi and Rwanda are among the countries addressing workforce shortages and maldistribution challenges through comprehensive strategies, including deployment of health service providers at the community level. The United Republic of Tanzania and Zambia have authorized non-physician clinicians to carry out certain specialized tasks. More than 90% of caesarean sections in rural areas of Malawi and Mozambique are successfully performed by surgical technicians, with low rates of morbidity and mortality.

State of surveillance

Monitoring and evaluation in relation to child survival in the African Region is mainly based on indicators to assess inputs such as implementation of appropriate policies and strategies, and the availability of human resources. It also relies on output and outcome indicators such as the number of health workers trained in IMCI, supervisory visits completed as planned, the availability of drugs, supplies and equipment, the quality of case-management of sick children, caretaker knowledge and practices, and the level of coverage of key interventions. It relies, finally, on health status indicators such as mortality and nutritional status. Disease surveillance is well developed for malaria, HIV/AIDS and vaccine-preventable diseases, but much less so for diarrhoea and pneumonia.

Endnotes: sources, methods, abbreviations, etc.

List of Tables/Figures

Atlas Figure 84: Under 5 mortality rate per 1 000 live births in the African Region by country, 2009 and 1990.

Figure 1: Main causes of Neonatal and under-five mortality, African Region, 2008 Figure 2: Coverage of Child Survival Interventions, AFRO 2008

References

1. World Health Statistics 2009. WHO, Geneva.

2. The State of Africa’s Children 2010. UNICEF, New York.

3. Countdown Coverage Writing Group on behalf of the Countdown to 2015 Core Group: Countdown to 2015 for maternal, newborn and child survival: the 2008 report on tracking coverage of interventions, Lancet 317:1247-58.

4. The State of Africa’s Children, 2010. Celebrating 20 Years of the Convention on the Rights of the Child. UNICEF, New York (Table 10. The rate of progress).

5. Joint statement: clinical management of acute diarrhoea. WHO and UNICEF, 2004. http://www.who.int/child_adolescent_health/documents/who_fch_cah_04_7/en/index.html (accessed April 2, 2010).

6. World Malaria Report 2008. WHO, Geneva. available at http://malaria.who.int/wmr2008/malaria2008.pdf

7. World Health Statistics 2009. WHO, Geneva.

8. Marsh, DR et al., 2008. Community case management of pneumonia: at a tipping point? Bull. World Health Org., 86 (5):381-9.

9. Briefing for the Day of the African Child Reaching Millennium Development Goal 4: What progress has Africa made and what more needs to be done? UNICEF, New York 2009

10. de Benoist B, McLean E, Egli I, and Cogswell M (eds), 2008. Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia, World Health Organization and the Centers for Disease Control and Prevention. Accessed 06 April 2010 http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf

11. Black, RE et al., 2008. Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet, 371:243-260

12. Towards Universal Access: Scaling up priority HIV and AIDS interventions in the health sector, progress report 2009. WHO, UNAIDS, and UNICEF.

13. Lawn J, Kerber K, and Eds, Opportunities for Africa’s Newborns: practical data, policy and programmatic support for newborn care in Africa. 2006, Cape Town: PMNCH, Save the Children, UNFPA, UNICEF, USAID, WHO.

14. WHO/IVB estimates, October 2009, based on Wolfson et al, Lancet 2007:369: 191-200

15. Africa Public Health Alliance and 15%+ Campaign, 2010 Africa Health Financing Scorecard, URL:http://www.hoffmanpr.com/world/PMNCH/InvestmentinAfrica/A3 MDGs%20Health%20Financing%20Scorecard-First%20Quarter%202010..pdf

16. Child Survival: A Strategy for the African Region, 2006. WHO Regional Office for Africa (AFR/RC56/13), World Health Organization.

17. Manzi F, Schellenberg JA, Adam T, Mshinda H, Victoria CG, Bryce J, 2005. Out-of-pocket payments for under-five health care in rural southern Tanzania. Health Policy and Planning. Vol. 20 Supp. 1:185-193

18. Countdown Coverage Writing Group on behalf of the Countdown to 2015 Core Group: Countdown to 2015 for maternal, newborn and child survival: the 2008 report on tracking coverage of interventions, Lancet 317:1247-58.

References

  1. World Health Statistics 2009. WHO, Geneva.
  2. The State of Africa’s Children 2010. UNICEF, New York.
  3. Countdown Coverage Writing Group on behalf of the Countdown to 2015 Core Group: Countdown to 2015 for maternal, newborn and child survival: the 2008 report on tracking coverage of interventions, Lancet 317:1247-58.
  4. The State of Africa’s Children, 2010. Celebrating 20 Years of the Convention on the Rights of the Child. UNICEF, New York (Table 10. The rate of progress).
  5. Joint statement: clinical management of acute diarrhoea. WHO and UNICEF, 2004. http://www.who.int/child_adolescent_health/documents/who_fch_cah_04_7/en/index.html (accessed April 2, 2010).
  6. WHO/IVB estimates, October 2009, based on Wolfson et al, Lancet 2007:369: 191-200
  7. World Malaria Report 2008. WHO, Geneva. Available at http://malaria.who.int/wmr2008/malaria2008.pdf
  8. World Health Statistics 2009. WHO, Geneva.
  9. Marsh, DR et al., 2008. Community case management of pneumonia: at a tipping point? Bull. World Health Org., 86 (5):381-9.
  10. Briefing for the Day of the African Child Reaching Millennium Development Goal 4: What progress has Africa made and what more needs to be done? UNICEF, New York 2009
  11. de Benoist B, McLean E, Egli I, and Cogswell M (eds), 2008. Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia, World Health Organization and the Centers for Disease Control and Prevention. Accessed 06 April 2010 http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf
  12. Black, RE et al., 2008. Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet, 371:243-260
  13. Towards Universal Access: Scaling up priority HIV and AIDS interventions in the health sector, progress report 2009. WHO, UNAIDS, and UNICEF.
  14. Lawn J, Kerber K, and Eds, Opportunities for Africa’s Newborns: practical data, policy and programmatic support for newborn care in Africa. 2006, Cape Town: PMNCH, Save the Children, UNFPA, UNICEF, USAID, WHO.
  15. World Health Statistics 2009. WHO, Geneva.
  16. Africa Public Health Alliance and 15%+ Campaign, 2010 Africa Health Financing Scorecard, URL:http://www.hoffmanpr.com/world/PMNCH/InvestmentinAfrica/A3MDGs%20Health%20Financing%20Scorecard-First%20Quarter%202010.pdf
  17. Child Survival: A Strategy for the African Region, 2006. WHO Regional Office for Africa (AFR/RC56/13), World Health Organization.
  18. Manzi F, Schellenberg JA, Adam T, Mshinda H, Victoria CG, Bryce J, 2005. Out-of-pocket payments for under-five health care in rural southern Tanzania. Health Policy and Planning. Vol. 20 Supp. 1:185-193
  19. Countdown Coverage Writing Group on behalf of the Countdown to 2015 Core Group: Countdown to 2015 for maternal, newborn and child survival: the 2008 report on tracking coverage of interventions, Lancet 317:1247-58.