Approximately two-third so funder-5 deaths could be prevented by universal coverage of a small set of existing interventions that do not require expensive technology. Among these interventions, the promotion of breastfeeding, management and prevention of neonatal conditions, ARIs, diarrhoea, malaria and HIV infection, in addition to improved feeding have the highest impact in reducing child mortality. Reduction in neonatal mortality requires increased effective coverage of interventions during pregnancy, childbirth and in the postnatal period.

Coverage with the key earlier-mentioned interventions remains low. Integrating the interventions into packages of care that are organized along a continuum from pregnancy, birth, neonatal period and childhood and delivered at all levels-from the home and community through the first-level facility and hospital-would contribute to improved efficiency in intervention delivery and to the achievement of high coverage. Strengthening the health system will be key for increasing the coverage and quality of health interventions. 

The development of an operational plan to which programmes can be held accountable, along with a good financing and human resource strategy, will yield long-term benefits for the child and the health system at large and is an essential element to follow the development of a child survival strategy.

Service Delivery 

Despite the fact that effective interventions exist against all major conditions from which children die, the coverage of these interventions generally remains low [1]. The key to achievement of substantial child mortality reduction is quality universal coverage of the interventions previously described. 

Before the mid-1990s, child health programmes in low- and middle-income countries focused on immunization, control of diarrhoeal diseases, ARIs and nutrition. Their implementation led to reduction in under-5 mortality in many countries, but this approach encountered limitations. The narrow focus on single interventions has failed to consider the child in a holistic manner, leading to many missed opportunities for care in contacts with a health practitioner. It was also difficult to resolve upstream health-system constraints such as management or human resource policies using this approach [2]. Solving these problems involves ensuring access to an integrated package of interventions that are organized around the continuum of care. It also means that care should span across the home, community, health centre and hospital. The advantages of delivering interventions as pack- ages include the following: Many interventions go naturally together because they are delivered by the same person at the same time. Packaging is more cost-effective in terms of training, implementation and supervision. Packaging meets the needs of the individual caregiver and the child much better than isolated and uncoordinated single-intervention delivery, thus reinforcing the continuum of care. Potential obstacles to packaging of interventions may be related to policy, programmes and the organizational structure of ministries and health services [3]. For example, managers responsible for single issue-focused programmes may feel that packaging their interventions with other maternal and child health services lessens their delivery efficiency. Another concern about packaging interventions is that vulnerable groups may not get any of the interventions if insufficient attention is given to equitable delivery of the package.

In September 2000, at the United Nations Millennium Summit, 189 national leaders endorsed ‘The Millennium Declaration, aimed at promoting poverty elimination, which includes the development of education, promotion of and respect for human rights and equality and improvement of the environment [4]. The declaration was a commitment to attain eight specific goals by 2015 and to accomplish the aims established. While all the Millennium Development Goals are relevant to child health, MDGs 1, 4, 5 and 6 are directly related to child survival. The fourth MDG has the explicit target of ‘reducing by two-thirds, between 1990 and 2015, the under-5 mortality rate [5]. Based on an U5MR of 90 per 1000 live births in 1990, the global target is to reach a mortality rate of 30 per 1000 live births by 2015.

Overall, substantial progress has been made towards achieving MDG 4. Reductions in under-5 mortality in many regions and countries have diminished the global number of under-5 deaths by more than 47 percent, from 12.6 million in 1990 to an estimated 6.6 million in 2012. The most pronounced falls in U5MRs have occurred in four regions: Latin America and the Caribbean; East Asia and the Pacific; Central and Eastern Europe and the Commonwealth of Independent States; and the Middle East and North Africa. All have more than halved their regional rates of under-5 mortality since 1990. The corresponding decline for South Asia was 53 percent, which in absolute terms translates into 2.6 million fewer under-5 deaths in 2012 than in 1990 - by far the highest absolute reduction among all regions. Sub-Saharan Africa, though lagging behind the other regions, has registered a 45 percent decline in the U5MR [6].

Countries that have rapidly increased coverage for multiple interventions across the continuum of care have accelerated child survival. Their success can mainly be attributed to improvements in service quality-bringing them closer to home and expanding access to essential care.

Critical Subsystems

Economic hardship and financial crises have eroded the health sector in many countries over the past two decades. Many national health systems are in disarray, with a deteriorating infrastructure and a public health sector subject to the resource restrictions con- sequent to structural adjustment and macroeconomic ceilings [7]. As a result, human resources working in the health sector have been destabilized and undermined. In many countries, households spend considerable amounts on healthcare and out-of-pocket expenditures for health services can be between two and three times greater than the total health expenditure by governments and donors.

The higher the proportion of user payments in the total finance for heath, the greater the relative share of financial burden on the poor and thus they are unable to afford necessary healthcare. Household expenditure surveys suggest that more than 150 million individuals globally face severe financial hardship each year due to healthcare costs [8]. Prepayment systems involve advance collection of funds through tax-based insurance or social health insurance schemes and should be used to promote fair access to health services. Both provide financial risk protection and promote equity through prepayment of healthcare costs and pooling of health risks. Out-of-pocket expenditures should be gradually converted into prepayment schemes, including community finance programmes. Unfortunately, rectifying the current state of healthcare services could take many years.

Health workers are ‘all people engaged in actions whose primary intent is to enhance health’. This includes health service providers such as doctors, nurses, midwives, pharmacists and community health workers. It also includes health management and support workers who dedicate all or part of their time to improving health’ [9]. The availability of a competent workforce is key to successfully delivering child healthcare and services. Critical shortages, inadequate skill mix and uneven geographical distribution of the health workforce are major barriers to achieving glob- ally set child health goals and targets [10]. The minimum threshold necessary to deliver essential maternal and child health services is estimated as 23 doctors, nurses and midwives per 10,000 population. Countries that fall below this threshold struggle to provide skilled care at birth to significant numbers of pregnant women, as well as emergency and specialized services for new-born and young children, impacting the burden of women and children mortality.

Child Rights

Efforts to ensure effective accountability for children’s health are further enhanced by the recognition that availability of and access to health information and services for children and their caregivers are basic human rights. Recognition of need for legal entitlements of every child, regardless of his/her status or situation, elevates associated responsibilities and political commitments to legal obligations. This paradigm shift thus enables the establishment of not merely a normative but indeed legal foundation for addressing the health needs of children. 

The UN Convention on the Rights of the Child, adopted in 1989 and ratified by all but two UN Member States, is the principal legal instrument for the protection of children’s well-being and outlines the core obligations of States in relation to children’s health. Article 24 directly addresses the child’s right to health and healthcare, while other provisions refer to the many underlying determinants of children’s health. The CRC thus provides a valuable holistic blueprint of all essential needs and legal entitlements of entitlements of children needed to ensure their survival, health, and optimal development.

States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services. 

States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures:
 

• To diminish infant and child mortality

• To ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary care

• To combat disease and malnutrition, including within the framework of primary health care, though, inter alia, the application of readily available technology and through the provision of adequate nutritious foods and clean drinking-water, taking into consideration the dangers and risks of environmental pollution

• To ensure appropriate pre-natal and post-natal health care for mothers

• To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation and the prevention of accidents 

• To develop preventive health care, guidance for parents and family planning education and services

States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children. 

States Parties undertake to promote and encourage international co-operation with a view to achieving progressively the full realization of the right recognized in the present article. In this regard, particular account shall be taken of the needs of developing countries.

Poor health and survival are linked to social and economic dis-advantages. Child deaths are unequally distributed in the world. Within countries, child morbidity and mortality tend to be higher in the rural areas and within the poorer and least educated families. Poorly nourished, LBW, sick and disabled children all are at particular risk of adverse outcomes and have special needs for care. Global progress in child health is attributable to a broad range of factors that include high coverage of good quality effective interventions, development programming and strategic delivery of health services, along with improvements in education, child protection, respect for human rights and economic gains in developing countries.

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10. Lamberti, L. et al. "Breastfeeding and the Risk for Diarrhoea Morbidity and Mortality." BMC Public Health, vol. 11, Suppl. 3, 2011, Article ID S15.