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The world has witnessed a remarkable achievement –
under-five child mortality has decreased from about 200 per 1000 live births
in the early 1960s to 80 per 1000 live births in 2003. Effective public
health interventions delivered to large numbers of children are responsible
for a major part of this success.
Nonetheless, the prevailing situation is unacceptable. In
the year 2000, 10.6 million children under-five years of age died globally;
over half of them due to just five preventable communicable diseases
compounded by malnutrition. The countries of the South-East
Asia region accounted for 3.1 million child deaths. In many
countries, the progress in reducing deaths has slowed and in some areas past gains
have been reversed. Failure to effectively address neonatal mortality is one
important reason for these trends. Other reasons include the limited impact
that has been made in addressing determinants of ill health such as
malnutrition, unhealthy environments, and low levels of access to and
utilization of quality health care services. Knowledge about the management and prevention of disease and injuries
has increased, but coverage of essential interventions is modest and is not
sufficiently expanding. At the same time, many of the children who survive
are held back from reaching their full potential by poor health and
inadequate care for their intellectual and social development.
Under-five mortality
currently averages 6 per 1000 live births in the high-income countries but is
as high as 175 per 1000 in low-income countries. Within countries, child
health also tends to be worse among the poor. In some countries children in the poorest third of the population
are six times more likely to die before age five years than those among the
richest ten per cent. These inequalities are ethically indefensible, and they
extend far beyond survival to documented inequities in exposure to risks
through the physical and social environment, and access to information and services.
A series of activities in the recent past have highlighted
the need to re-visit the unfinished child survival agenda. These include the
Global consultation on child and adolescent health and development
(Stockholm, March 2002), the United Nations General Assembly Special Session
on Children (May 2002), and the Team Residency: “Knowledge into Action:
Improving Equity in Child Health” (Bellagio,
February 2003) that brought together experience from the Child Health
Epidemiology Research Group, the ongoing Multi-Country Evaluation of
Integrated Management of Childhood Illness strategy and the WHO/World Bank/
UNICEF Working Group on Child Health and Poverty. The major conclusion of
these and other international events like the Lancet Series on Child Survival
(2003) and the recent (2005) series on Neonatal Survival highlights the fact
that we already have the tools to attack the problem. What is needed is the
resolve to provide resources to ensure equitable access to the known
effective interventions to all children.
The 11 Member Countries of the WHO South-East Asia Region
are home to about a quarter of the world population. The Region accounts for
almost one-third of the global child deaths. Many of the Member States in the
WHO South-East Asia Region have a significantly higher under-five mortality
rate than the global under-five mortality rate.
Forty two countries from all over the world contribute to
90% of the annual child deaths. From the South-East Asia Region India (with 2,402,000 deaths), Bangladesh (with 343,000 deaths), Indonesia (with 218,000 deaths) Myanmar (with 132.000 deaths) and Nepal
(with 76,000 deaths) figure on the list.
ISSUES IN
CHILD HEALTH IN THE REGION
Based on the current evidence,
certain areas call for focused attention. The risks in these areas not only
affect physical well-being, but also limit the intellectual development of
children and adolescents, and effectively undermine the economic development
of their communities.
Mother and newborn:
Further reductions in childhood deaths and long-term disabilities cannot be
achieved without making the health of
mothers and newborns a higher priority. Forty percent of child deaths
take place in the neonatal period. Decline in neonatal deaths over recent
decades has been much smaller than for the older children. Among the 7
million infants who die each year all over the world, approximately 4 million
deaths occur within the first month of life. Of the 38 million babies born
every year in the South- Asia region 1.4 million lose their lives in the
first month after life. An additional 1 million are still-born. A large
proportion of women each year deliver with no skilled birth attendants, and
many more mothers and newborns go without any post-natal care during the most
vulnerable days and weeks after birth. Children born to unhealthy mothers are
also more likely to be under weight and to have difficulty combating illness.
They face an environment that is less able to provide safe and nurturing
conditions that are necessary for their healthy growth and development.
Nutrition: The
importance of nutrition as a foundation for healthy development is
underestimated. Poor nutrition leads to ill health and ill health causes
further deterioration of nutritional status. These effects are observed most dramatically
in infants and young children, who carry the brunt of the onset of
malnutrition, and the highest risks of death and disability associated with
it. Sixty per cent of all child deaths in 2000 were associated with
malnutrition. But the children who die represent only a small part of the
total disease burden due to nutritional deficiencies. Maternal malnutrition
and inadequate breastfeeding and complementary feeding represent huge risks
to the health of those children who survive. Vitamin A, iodine, iron, and
zinc deficiencies are still widespread and are a common cause of excess
morbidity and mortality, particularly among young children. In the region
about half the under-five children are underweight; 15% are wasted; and, in
low-income countries one in every three children at age five is stunted. The
effects of poor nutrition and stunting continue over the child's life,
contributing to poor school performance, reduced productivity, and other
measures of impaired intellectual and social development.
Communicable Diseases:
Preventable communicable diseases
(pneumonia, diarrhoea, malaria, measles and HIV infection) account for over
60% of childhood deaths. The fact that over 99 per cent of these deaths in
2000 occurred in low-income countries demonstrates that they can and should
be prevented. Communicable diseases also lead to considerable morbidity and
in some cases long-term disability. Helminth
infections, represent a significant public health burden, particularly among
children aged five to fourteen. These intestinal parasites harm health and
nutritional status, contributing to severe outcomes from measles, malaria,
pneumonia and other diseases. Repeated bouts of illness prevent the young
child from learning through exploration and interaction with the world. For
older children, illness limits their opportunities for further development
and affects school attendance and performance. The devastating consequences
of the HIV pandemic on children, adolescents and their families are felt
worldwide. In addition to the children with HIV who must be cared for, many
more children are indirectly affected through the loss of one or both parents
or the overwhelming emotional and financial burden of the disease on their
families. However, even where HIV is prevalent, attention should not be
diverted from the pressing need to attain and maintain high levels of
coverage with basic child survival interventions.
Injuries: Globally,
each year injuries account for almost 1 million deaths of children and
adolescents up to the age of 14 years. Although most of these deaths occur in
the low- and middle-income countries, injuries are among the leading causes
of child and adolescent mortality in high-income countries. In the European
Region, for example, three to four
out of every 10 deaths that occur in children less than 15 years of age are
due to injury. Many of those who survive suffer life-long disability. For
instance, victims of child sexual abuse are twice as likely in later life to
become depressed and four times as likely to attempt suicide.
Environment: Preliminary global estimates suggest that up to one third of the
global disease burden can be attributed to threats in the physical environment. Over 40 per cent of this
burden falls on children under 5 years of age. Inadequate drinking water and
sanitation, indoor air pollution, and injuries and other environmental risk
factors are the root cause for almost half (4.7 million) of the 10.6 million
deaths a year in this age group. More than half of the 2.1 million annual
deaths in children under-five years caused by acute lower respiratory
infections may be associated with indoor air pollution. Interventions to
improve water supply, sanitation and hygiene alone are estimated to reduce
child mortality by 65 per cent. These environmental factors also contribute
to life-long illness and disability triggered by the risks encountered in
childhood.
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