The Alliance for Maternal, Newborn and Child Health: An example of Evidence-Based Policy Health

By Anibal Velásquez

At the beginning of the 1980’s child health continued to be in a state emergency since 15 million children under 5 were dying every year. In those circumstances a proposal was made to modify the Alma Ata Primary Health Care model[1] [2] by developing effective interventions for groups at high risk with the implementation of few technological applications irrespective of social and economic development and the participation of the community[3]. This new plan was called ‘selective health primary care’ and involved implementing vertical programs focused on the diseases causing the high mortality rates among infants under 1 year of age and young children.
On the basis of this model the strategy ‘Revolution of Child Survival’ was developed, led by UNICEF and set up in1982. This strategy was based on four low cost interventions, known jointly as the GOBI strategy[4] [5]: monitoring of growth to evaluate nutritional status, oral rehydration therapy to treat infant diarrhea, breastfeeding to ensure the health of young children and immunization against six fatal childhood diseases. The GOBI strategy received the support of the main MDG-led initiatives such as the Extended Immunization Program and other programs for the control of diarrheic diseases and acute respiratory infections[6]. Later, three other components were added – complementary foods, spacing between births and maternal literacy. The selective primary health care received the support of the donors who were in favor of investing resources in ‘child survival’ programs. Those efforts helped to decrease the mortality rate of the under 5’s around the world[7]: from 115 per 1000 live births in 1980 to 93 in 1990, a reduction of 19% in 10 years.
From 1990, when the MDG’s were established[8], efforts were concentrated on improving maternal and child health around the world because with these objectives it was possible to link health with development. This MDG approach was based on evidence showing that health is a pre-condition for economic growth and conversely economic development, if it is properly managed can achieve huge improvements to the health and life expectancy of women and children[9]. Accordingly, health in itself is a development goal to be linked to the welfare of the individual.

This MDG focus, to link health with development, has resulted in an important political commitment and great motivation on the part of the international community to make the reforms and investment necessary to reach the health MDG’s and those which allow improvement to health (education, sanitation, nutrition and gender equality) in particular among the less favored and/or excluded groups.

The methodology employed by the MDGs consists of selecting priorities, establishing goals and monitoring progress. Therefore, commitments are established and responsibility assigned for accountability in respect of progress made on reforms, implementation of policies and programs and their achievements in helping to reach the MDG’s. Consequently, with the inclusion of MDG 4 and MDG 5 the MDG’s are in themselves a way to improve maternal and child health.

This is not the first time that child health goals have been proposed. In 1980, UNICEF and the WHO proposed the reduction by half of child deaths within a certain time, for which solutions and strategies were put forward to reduce child mortality and improve child health. However, these initiatives did not have the impact that the MDG’s are now having. The last UNICEF report on the state of world infancy and childhood 2008 mentioned that ‘Unlike the 1980’s, when UNICEF was often waging a solitary war for child survival, today it has the support of numerous allies in this endeavor’.

The Lancet series in 2003 on Child Survival[10] [11] [12] [13] [14] helped to increase the awareness that each year worldwide more than 10 million children under 5 die and that more than half of these lives could be saved with the implementation of simple measures[15]. As an example, 2 million children die of diarrhea and the majority of those cases could be treated with oral rehydration therapy. Another 2.1 million die of pneumonia (more than the number of those dying of HIV, tuberculosis and malaria). A further million die of malaria but could have been protected through the use of antimalarial drugs or bed nets treated with insecticides. And hundreds of thousands of children die of measles which could be prevented by cheap and effective vaccine. In this series it was pointed out that despite the existence of these simple and effective measures the world has been paying more attention to the AIDS pandemic and the resurgence of tuberculosis and malaria, to the point that progress made in reducing child mortality had been slowed or halted in the poorest countries, and in some cases reversed.

In 2005, the Lancet series focused on neonatal mortality[16] [17] [18] [19], showing that almost 40% of the deaths of children under 5 occur in the first month of life, and reviewed evidence regarding the most effective, feasible and low-cost interventions.

These two series provided the necessary evidence to revitalize efforts to reduce deaths among children and the newly born and to achieve MDG 4. Since 2003 we have seen notable progress in the advocacy for child and neonatal survival. Under the leadership of the OMS and UNICEF public commitments have been made to reduce child mortality. To this end important alliances have been made around the world and from 2005 forces joined for maternal and neonatal health, expanding the group known as Partnership for Maternal, Newborn and Child Health - PMNCH)[20]. This group focuses on advocacy for accelerating action on the national level and strengthening global accountability mechanisms, including recent evidence and proposals outlined in the Lancet series on maternal survival[21] and the link between child survival and maternal and child nutrition[22].

The WHO is responsible for promoting and assisting all countries in the effort to increase coverage of all effective interventions, strengthen health systems and follow up on interim progress and affects on nutrition and mortality.

In 2005, in response to the World Health Report of that year, the World Assembly of Health Ministries passed a resolution to place maternal and child survival at the top of the list of priorities. Accordingly, from 2005 on, a progress follow-up will be done every two years on maternal, neonatal and child survival in countries with high mortality rates with the aim of achieving DGM 4 (child survival) and DGM 5 (maternal health) [23]. “Countdown to 2015” is the name for this collaborative effort highlighting the progress, obstacles and solutions towards achieving the DGMs.

Within this global framework strategies and interventions for maternal, neonatal and child survival are being developed in Central America and the Caribbean and therefore many of the initiatives, strategies and interventions are the same. Yet more so as consensus has grown among co-operating agencies to combine and complement efforts and align the co-operation agenda with the DGMs and national priorites. The differences found underlie the political and economic situation within the country, the features of the national health system, the capacity to offer services, the availability of technical and financial resources, the technical capacity to implement interventions and the decision and commitment of governments to make the necessary reforms and allocate resources to fulfill these priorities.

[1] Declaración de Alma Ata, 12 septiembre 1978. Conferencia Internacional sobre Atención Primaria de Salud. OMS y UNICEF
[2] Schuftan C. (1990). The Child Survival Revolution: A Critique. Family Practice, 7(4): 329
[3] Werner D, Sanders D, Weston J, Babb S, Rodríguez B. (2000). Cuestionando la solución: Las Políticas de Atención Primaria de Salud y Supervivencia Infantil con una crítica detallada de la Terapia de Rehidratación Oral. HealthWrights
[4] WHO (2002). The world health report 2002 - Reducing Risks, Promoting Healthy Life. Geneva: World Health Organization
[5] UNICEF (2007). The State of the World's Children 2008. Child Survival. New York: United Nations Children’s Fund (UNICEF)
[6] Claeson M, Waldman R. (2000). The evolution of child health programmes in developing countries: from targeting diseases to targeting people. Bulletin of the World Health Organization, 78: 1234–1245
[7] UNICEF (2007). Op. cit
[8] Los ODM fueron adoptados por 189 países en 2000 y que deberán cumplirse para el año 2015
[9] Freedman L, Wirth M, Waldman R, Chowdhury M, Rosenfield A. (2003). Child Health and Maternal Health.Background Paper. New York: Columbian University
[10] Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361:2226-34.
[11]Jones G, Steketee R, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003; 362:65-71.
[12] Bryce J, Arifeen S, Pariyo G, Lanata CF, Gwatkin D, Habicht JP and the Multi-Country Evaluation of IMCI Study Group. Reducing child mortality: Can public health deliver? Lancet 2003; 362:159-64.
[13] Victora CG, Wagstaff A, Armstrong-Schellenberg J, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: More of the same is not enough. Lancet 2003; 362:233-41.
[14] The Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003; 362:323-7.
[15] The Lancet (2003). The world’s forgotten children. The Lancet Volume 361, Number 9351:1
[16] Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet 2004; 365:891-900.
[17] Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based,cost-effective interventions: how many newborn babies can we save? Lancet 2004; 365:977-988.
[18] Knippenberg R, Lawn JE, Darmstadt GL, Begkoyian G, Fogstad H, Walelign N, Paul VK. Systematic scaling up of neonatal care in countries. Lancet 2004; 365:1087-1098.
[19] Martines J, Paul VK, Bhutta ZA, Koblinsky M, Soucat A, Walker N, Bahl R, Fogstad H, Costello A. Neonatal Survival: a call for action. Lancet 2004;365:1189-1197.
[20] Countdown Working Group. Taking Progress in Child Survival: The 2005 Report. New York: UNICEF
[21] Ronsmans C, Graham W. Maternal mortality: who, when, where, and why. Lancet 2006; 368: 1189–200
[22] Black R, Allen L, Bhutta Z, Caulfield L, Onis M, Ezzati M, Mathers C, Rivera J. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008; 371: 243–60
[23] Countdown to 2015. Traking Progress in Maternal, newborn & Child Survival: The 2008 Report. Available at: http://www.countdown2015mnch.org/

Photo credits: Anibal Velasquez. Montana Hotel. Port au Prince