As more children survive, can health systems cope?

UNICEF reports that, “Fewer children under the age of five are dying today than in past years, according to the latest data from UNICEF. Globally, the number of young children who died in 2007 dropped to 9.2 million, compared to 12.7 million deaths in 1990.”

UNICEF explained that, “As we are more successful in some ways, the task is a little harder. As coverage of basic services gets higher, the most underserved populations are sometimes the most difficult to access. To ensure further declines in child mortality in the future, UNICEF is calling for a greater focus on newborn and maternal health, as well as strengthening basic health systems in areas where young children are at risk.”

bednet-drawing-on-clinic.JPGReduced malaria deaths are part of the scenario. “Malaria in these parts (high burden) of Africa could however be substantially reduced using currently available tools. Examples of successful control are occurring in Africa where areas previously known for their high endemicity have become areas of relatively low transmission over about 10 years, including The Gambia, Zanzibar and some parts of Kenya. This reduction in malaria is often unrecognized by public health services or clinicians yet is a practical reality.”

Likewise Chambers et al. noted in April 2008 that, “Last month, WHO reported that cases of malaria in Rwanda decreased by 64% and deaths by 66% between 2005 and 2007 among children aged less than 5 years.2 Ethiopia, meanwhile, saw reductions of 51% in deaths and 60% in cases in the same age group. These remarkable outcomes were achieved through expanded access to malaria control, primarily long-lasting insecticide-treated bednets and artemisinin-based combination therapies.” The head of WHO’s Global Malaria Program was quoted as saying, “This is the first time we have seen these results with the new tools.”

Questions arise – how will the health system respond if large scale donor interventions in high burden areas continue to make improvements as seen in Rwanda, Ethiopia, Kenya, the Gambia and Zanzibar? Below are some possibilities. What do you think will happen?

  • Replacement mortality will claim children if health systems do not address malnutrition and unsafe water supplies
  • More surviving children may influence fertility decisions assuming the health system makes family planning commodities more readily available
  • The health system will become complacent and relax malaria control efforts before achieving elimination, leading to rebound malaria mortality

Our recent discussions about health systems issues require that health system strengthening must be taken seriously if gains against malaria are to be sustained.

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