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Child Survival Programmes Revisited

Child Survival Programmes Revisited

The very evident flaws in India`s polio eradication programme launched in the 1980s are indicative of the fact that bodies at the international (UNICEF) and the national level (i e, the Indian government) have failed in their primary task of controlling child mortality rates. Similar experiences have been reported from other countries. The UNICEF needs to rededicate itself anew to the health-related goals that form a vital part of the millennium development goals, by reaching out to groups and organisations operating at the grassroot level.

Child Survival Programmes Revisited

The very evident flaws in India’s polio eradication programme launched in the 1980s are indicative of the fact that bodies at the international (UNICEF) and the national level (i e, the Indian government) have failed in their primary task of controlling child mortality rates. Similar experiences have been reported from other countries. The UNICEF needs to rededicate itself anew to the health-related goals that form a vital part of the millennium development goals, by reaching out to groups and organisations

operating at the grassroot level.


hild survival programmes (CSPs) launched by UNICEF in the 1980s in cooperation with many developing countries focused primarily on ensuring the survival of children by protecting them against what were called vaccine preventable diseases (VPDs) like diphtheria, tetanus, polio and measles. In these programmes, initially mothers were not assigned any significance. But then suddenly WHO and other donor agencies discovered the “forgotten mothers” and launched what was then called reproductive child health (RCH) programmes focusing on the reproductive problems of mothers particularly promoting safe delivery practices and maternal care along with child care. The World Summit for Children in 1990 called for a worldwide reduction in child mortality to below 70 deaths per 1000 live births by the year 2000. This “call” has still not been met. The Lancet – a British medical journal has criticised the UNICEF’s handling of these goals in several issues. It is unfortunate that UNICEF/WHO have not taken these critical global analytical reflections by a premier medical journal like the Lancet seriously. The situation has been further compounded by the explosive spread of HIV/AIDS killing millions of infants through what has been known as mother to child transmission of the HIV virus. In Africa child mortality rates are soaring. Then came the millennium development goals (MDGs).1 Out of the eight goals three goals are directly related to CSPs and they are unlikely to be achieved even by the deadline of 2015 according to all present indications. “Apart from three of the eight goals, eight of the 18 targets and eighteen of the 48 indicators relate to health – so no one can say that development is just about economic growth.”2 Health-related goals, however, are crucial to the overall attainment of MDGs.

The scathing attack of the editor of the Lancet on the leadership of the world’s leading agency – UNICEF – responsible for protecting the lives of mothers and children needs to be examined carefully to know where things have gone wrong “UNICEF has lost its way during Carol Bellamy’s long term of office. A corporate lawyer and financier for many years, Bellamy went on to become a New York politician who was thrust into a position that demanded deep experience of children’s issues – and especially child health – worldwide. It was a role that she was ill equipped for, despite her evident enthusiasm for UNICEF’s ideals. While Bellamy has focused on girls’ education, early childhood development, immunisation, HIV/AIDS and protecting children from violence, abuse exploitation, she has failed to address the essential health needs of children. In contrast, Carol Bellamy’s predecessor, (the) late James Grant during his 15-year tenure, showed an unflagging commitment, vision and dedication to improving the lives of the world’s least advantaged – the mothers and children of the developing world.”3

Many have raised doubts even on the well established polio eradication programme in India. “According to the National Polio Surveillance Project data 60 per cent of those who developed polio in 2001 were administered four or more doses of oral polio vaccine (OPV), 44 per cent in 2002 of those who contracted the disease were administered the vaccine and in 2003 this figure went up to 51 per cent.”4 It is therefore essential that we examine how these CSPs have been managed and what has been the impact of these CSPs on infant mortality, maternal mortality and morbidities even before we talk of child rights. First, mother and child have to survive and their “right to life” has to be ensured before we think of their rights for education and upbringing. The Bellagio Child Survival Study Group in Italy under the auspices of the Rockefeller Foundation in February 2003 critically examined the global scenario of child survival and the Lancet brought out a special issue on matters affecting child survival in the world.5

Why and How Children Die?

The CSPs are basically aimed at reducing infant mortality rate and are closely linked to this, is the maternal mortality rate as indicators in many developing countries have shown in the past. When the infant mortality is higher, it usually leads to multiple pregnancies and that leads to maternal depletion and subsequent mortality of mothers. More than 10 million children die each year, largely because of preventable causes and mostly in poor countries. Six countries account for 50 per cent of worldwide deaths among children younger than five years and 42 countries for 90 per cent. The causes of death differ substantially from one country to another as does the epidemiology. The key factors are undernutrition coupled with infectious diseases and pneumonia and diarrhoea also remain the main causes everywhere. Hence, the universal immunisation of both mother and the child was the weapon used to fight IMR and MMR. Now HIV/AIDS is responsible for more than 10 per cent of deaths in just three of the 42 countries. According to the UNICEF report on meeting the promises of the World Summit for Children, polio is still endemic in 20 countries, less than 50 per cent of children under one year of age in sub-Saharan Africa receive DPT3, in 14 countries measles vaccination coverage is less than 50 per cent, 27 countries account for 90 per cent of all remaining neo-natal tetanus and vertical single focus acute respiratory infection (ARI) programmes seem to have had little

Economic and Political Weekly January 7, 2006

impact.6 Similarly, there is no world-wide evidence that MMR has declined over the last decade. 5,15,000 women still die every year as a result of pregnancy and child birth. The reach of delivery care is only 36 per cent in south Asia and 42 per cent in sub-Saharan Africa and available evidence shows little change during 1990s in the prevalence of anaemia among pregnant women.

Who is responsible for this dismal situation? National/local governments across the world who plan and monitor the CSP programmes or is it the lead agency for overseeing the lot of the world’s children – UNICEF? Has vaccine technology failed or has the management of VPDs failed? What is the role of WHO in rendering technical advice on controversial vaccines like oral polio vaccine or injectible vaccines? What has been the leadership role of bodies like UNICEF/ WHO in mobilising global resources and global leadership for tackling these CSPs? These questions come to the fore when we attempt to analyse the causes and consequences and look for remedial strategies and actions for better outcomes and results.

Impact of Immunisation

Universal Immunisation Programme (UIP) the world over was the sheet anchor of CSPs and its coverage and impact is still not visible on children across the world although it has contributed significantly to the reduction of VPDs. UIP has to be judged on what is called ACLIVE principle.7 A stands for administration and organisation, C for continuous enumeration (census) of newborns to catch them for vaccination , L for logistics and cold chain for vaccine storage and movement, I for information education and communication, V for vaccines and vaccination strategies and E for evaluation of coverage and impact. The father of small pox eradication programme Donald Henderson used the administration, logistics, information, vaccine, evaluation (ALIVE) principle. Unlike small pox vaccine which was just one dose, in CSR, a range of vaccines are used and their proper storage is very crucial to maintain their potency. Hence as a part of UIP, cold chain and tracking of newborns (census) becomes critical. Unlike small pox which was a one shot affair, UIP is long term and continuous. However, despite the massive coverage of polio immunisation programme its complete eradication remains elusive even in developed countries. The GoI launched the national immunisation days which were also termed as Pulse Polio Immunisation (PPIs) in 1995 and over the last 10 years no one knows how effectively these PPIs have been conducted and what have been the gains and losses in the entire campaign.8 The most serious problem not just in PPIs but in the entire UIP is the way in which the cold chain has been maintained to keep the vaccine potent by maintaining the required temperature (see Chart on temperature requirement in vaccine storage).

Basically there are four partners in the UIP programme – the mother, the child (mother has to bring the child for immunisation), the vaccine administrator and the vaccine itself (how potent is it and how is it preserved). Unless all the four are synchronised the impact of the UIP is not felt. It was February 23, 2003 in a Bangalore suburb when the national immunisation day and the pulse polio drive was inaugurated with fanfare. It was noon when I interviewed the mother, the vaccine administrator and saw the vaccine carrier to see how well it was kept. I discovered that there was no ice in the ice pack, and the vaccine vial was half-empty; the vaccine administrator was not sure for how long the vial had been open. Such pulse polio centres immediately raise doubts on matters of vaccine efficiency and the potency of the polio vaccine.

Bangalore boasts of a flagship publicprivate partnership called Bangalore Agenda Task Force (BATF). The Karnataka health department should have joined hands with them to conduct lot quality assurance sampling (LQAS) as per the WHO mandate to see how effectively the polio vaccine is stored.

How Cold Is the Cold Chain?

Besides, the vaccine technology itself is changing fast since the launch of PPIs. There is now a section of scientists advocating the use of inactivated polio vaccine (IPV) than the OPV. The OPV in some areas has led to what is termed as vaccine associated paralytic polio (VAPP) “Jacob John – a leading virologist in CMC Vellore is a strong advocate of IPV and according to him IPV evokes a strong immune response and also generates immunity in the inner lining of the digestive tract (which was supposed to be one of OPV’s advantages) and creates a herd effect by reducing transmission of the virus to others. These were all the qualities of a good vaccine according to Jacob John.”9 WHO – the global health leader – is still not able to decide on the future of polio vaccine technology, whether to switch to IPV or continue with the OPV. The global certification of polio eradication would be confined only to the elimination of wild polio virus and this is an important difference between small pox and polio eradication. OPV has created uncertainty whether the polio virus will ever be eliminated. After more than ten years of being polio-free, the Carribbean island of Hispaniola reported outbreak of the disease in the summer of 2000.

UNICEF Leadership Failure

Next in significance to vaccine and its storage, the vital partner is the motherchild partnership for getting the vaccine inserted/injected. Dropout rates in UIP are a bad sign and according to UNICEF, health systems in countries where the dropout rate is more than 10 per cent are considered flawed.10 Drop outs could reflect lower motivation among mothers

Chart: Temperature Requirement in Vaccine Storage

Vaccine Level Central Store Regional Healthcare Transport Maximum Storage Time Up to 8 Months Up to 3 Months Up to 1 Month Up to 1 Week Measles Yellow Fever –150 to –250 Oral Polio DPT Tetanus Toxoid 20C to –80C IPV DT BCG Note: – Never freeze DPT, IPV or Tetanus (all of which freeze at temperatures below 30 C) – Storage times are recommended maximum figures. Remember to check expiry dates. (Adapted from Manage the Cold Chain, WHO, February 1985).

Economic and Political Weekly January 7, 2006 to bring back their kids for completing the shots or unresponsive vaccine administrators that do not augur well for the health of the young children and present a challenge for local health delivery system. The Bellagio Child Survival Study Group makes “a distinction between intervention and delivery strategies. Reducing child mortality and achieving the millennium development goals for child survival depend on whether effective and sustainable interventions can be delivered to high proportion of children and mothers. The distinction between interventions and delivery strategies is essential. The knowledge base for designing, implementing and sustaining effective delivery strategies is scattered and in most cases, context specific. A major research priority is how to effectively scale up the successful experience of many local projects, this area of research has unfortunately received much less attention than the development or smallscale implementation of new interventions.”11 The WHO’s choosing interventions that are cost effective (CHOICE) project is examining various combinations of interventions and their cost effectiveness. But UNICEF has better knowledge on this than WHO because of UNICEF’s vast network of field offices and its grassroot experience in and around 165 countries of the world with a rich knowledge pool. It is here where the global leadership of UNICEF during Carol Bellamy for a decade failed miserably. This poor leadership of UNICEF stands out in sharp contrast to the towering personality and leadership of late Jim Grant who touched the conscience of world leaders when he organised the first ever World Summit of Leaders on Children in 1990. Jim Grant’s strategy of setting specific, measurable goals, lobbying tirelessly for their achievements, monitoring and publicising progress towards them was remarkable in the history of world development. In the decade and half he spent as head of UNICEF, he personally met more than 100 heads of state to enlist their personal and political support for the achievement of specific goals for children. He would meet them carrying iodised salt and an ORS packet in his coat to demonstrate to the heads of states how simple and powerful techniques can prevent childhood deaths.

The present millennium development goals were actually conceived by Jim Grant when he organised the First World Summit on Children in 1990. The world leaders need to be reminded of their broken promises now, not just by UN bodies but by private foundations like the Bill Gates Foundation, Bellagio Child Survival Group, drug companies, civil society groups, professional societies, ministries of health, education and finance of developing countries who have to steer their ministries into action. These alliances for child survival are in bad shape now and they must be forged at global, regional, national and local levels. HIV/AIDS is now a big threat and we need to think of new vaccines, new infant feeding practices to save both mothers and newborns suffering from HIV/AIDS. UNICEF estimated that 7,20,000 infants were born with HIV worldwide in 2001 and till the HIV vaccine is found, we have to save these infants with costly anti-retrovirals which have to be subsidised if we care for the infants.

Misplaced emphasis on child rights by the present leadership of UNICEF is not only unfortunate but tragic. Preoccupation with rights ignores the fact that children will have no opportunity for development at all unless they survive. The most fundamental right of all is the right to survive and in the words of Lancet “child survival must sit at the core of UNICEF’s advocacy and country work. Currently and shamefully it does not.”




[This note is dedicated to the memory of late James Grant, head of UNICEF from 1978 to 1995 under whose inspiration the author worked for UNICEF.]

1 ‘Informed Choices for Attaining the MDGs’,

Lancet, September 11, 2004.

2 Andy Haines and Andrew Cassels, ‘Can

Millenium Development Goals Be Attained’

British Medical Journal, August 14, 2004.

3 Lancet, December 11, 2004.

4 Yash Paul, ‘Check the Vaccine: Why Are

Children Developing Polio even after Inocula

tion’? Down to Earth, February 15, 2005.

5 Lancet, Vol 361, 2003,

6 UNICEF, ‘We the Children’ New York, 2001,

p 20.

7 Manu N Kulkarni, ‘UIP in India – Issues of

Sustainability’, Economic and Political

Weekly, July 4, 1992.

8 Manu N Kulkarni, ‘How Useful Is Pulse

Strategy for Polio Eradication’, Economic and

Political Weekly, March 15, 1997.

9 N Gopal Raj, ‘Eradicating Polio’, The Hindu, Chennai, November 23, 2004. 10 UNICEF, ‘The Progress of Nations’, 2000, New York, p 22. 11 The Lancet, Vol 362, July 12, 2003.

Economic and Political Weekly January 7, 2006

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