CAH reaching outChild and Adolescent Health and Development ISSUE No.2, December 2005

Seizing opportunities in BangladeshA young man of 18 bursts intoyour clinic, walks towards you. He'svery angry, trembling, tears in hiseyes. "When I saw you last weekyou promised no one would knowabout my problem," he says."Yesterday my mother said sheknew everything. One of the nursesin your clinic, who's a friend, toldher … I'll never trust you peopleagain."

This is one of the many sensitiveissues addressed in the OrientationProgramme on Adolescent Healthfor Health-care Providers, adoptedfor use in Bangladesh under TheGlobal Fund to fight AIDS,Tuberculosis and Malaria (GFATM)HIV project. Given that adolescentsconstitute one third of thepopulation in Bangladesh, and theresults of recent behavioural studiesindicate a need to be concernedabout the imminent emergence ofan HIV/AIDs epidemic among itsyouth, CAH set about creating asystematic approach that could berolled out later to other countries.

"Adolescent Health is a new area ofwork for Bangladesh," saysDr Mahabubul Islam, NationalProfessional Officer (AHD andHIV/AIDS), WHO Bangladesh."Previously, a number of NGOswere working on a much widerdefinition of 'young people', butthere was no coordination."

With its strong network of contactsand the commitment of the WHOcountry representative, CAH took

the opportunity to address the problem.The first step was to get a seriousdiscussion going among a wide range ofstakeholders, including religious leadersand young people, and then to find themoney to do the work. "Generating theresources using the Global Fund was avery important step," saysDr Neena Raina, Regional Adviser, CAH.

A national strategy was developed toinclude HIV and other aspects ofadolescent sexual and reproductivehealth. "Development of NationalStandards for Youth Friendly HealthServices is an important step in the GFproject and is the first document of itskind in Bangladesh," says the Secretary,Ministry of Health and Family Welfare,Government of Bangladesh. WithCAH's continuing commitment toprovide ongoing implementation andmonitoring support, a sound basis isdeveloping for rolling out theprogramme to other countries.

EventsTrackingProgress inChild Survival– Countdownto 2015, 13 – 14 December 2005Beveridge Hall, Senate House,University of LondonThe first of two-yearly rolling reviews ofprogress in child survival. This meetingwill bring together around 300 policy-makers and experts in the field of childsurvival, with speakers from all aroundthe world including: WHO Director-General, LEE Jong-wook, UNICEFExecutive Director, Ann Veneman, andHer Royal Highness, Princess Anne,Patron of the University of London andSave the Children.www.childsurvivalcountdown.com

Great Expectations photo seriesSix mothers from very differentcountries share their experiences ofpregnancy,childbirth andlife with ayoung baby. Inthe nextinstalment,out inDecember, themothers, fromBolivia, Egypt,Ethiopia,India, LaoPeople's Democratic Republic and theUnited Kingdom, report on their babies'progress and the environment in whichthey are growing up. The final part ofthe series is due to be published inMarch when the babies reach their firstbirthday.www.who.int/features/great_expectations/en/

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World HealthOrganization

Countdown to 2015

Child Survival

Dr Yehuda Benguigui

Dr Yehuda Benguigui, aBrazilian, began his PAHO/WHO professional career in1987 as Regional Adviser onAcute Respiratory Infections atthe Organization's headquartersin Washington D.C. In 1996,he became Regional Adviser onIntegrated Management ofChildhood Illness (IMCI) andin 2003 he was appointed headof the Child and AdolescentHealth Technical Unit, withinthe Family and CommunityHealth Area. Hisresponsibilities includecontinued IMCIimplementation as well asimprovement in neonatal, childand adolescent health anddevelopment. We spoke withhim about his work in theRegion of the Americas.

Unit ChiefChild and Adolescent HealthFamily and Community HealthWHO/PAHO

Q&AA

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Tell us about your Region

Much of our work relates to inequities inpopulations and the vulnerable indigenous orpoor populations who have almost no accessto health facilities. In the region we have somevery developed countries and a few with theworst indicators in the world, particularlyhealth indicators – countries such as Haiti andBolivia. About 30% of the people in our regionhave no access to basic health facilities, whichis why an important part of our work involvesour partnerships with countries' ministries ofhealth and other organizations.

What are the major concerns andachievements of your region?

Infant and child health is a major concern.Neonatal problems represent about 60% ofinfant mortality for which we have developeda very successful technical approach in thecontext of IMCI (which was adopted by20 countries in the region). The LatinAmerican and Caribbean population coveredby these 20 countries represents 75% of theRegional LAC population. In relation to themost recently implemented "Neonatal IMCI",10 countries are in the process of adopting thisstrategy.

We are also working in partnership withministries of health and NGOs in our region touse our 500,000 community health workers toreach people with virtually no access to healthfacilities. A high priority has been the region'sinfant and child under-five mortality, for whichwe've developed a manual and strategy forneonatal intervention at community level andpractical materials to promote key familypractices.

"Forty mothers, 320 babies and800 children have died in the past40 minutes," said Dr DoyinOluwole, AFRO Director,Reproductive Health (DRH/AFRO), calling for a minute'ssilence of remembrance.

Dr Oluwole was speaking inEthiopia at a special session tointroduce the Partnership forMaternal, Newborn and ChildHealth to the participants of threemajor regional meetings: TheReproductive Health Task Force;The Special Session on Newborn

Newborn and child survival

And what about adolescents?

We've created a unique approach we callIMAN (Integrated Management ofAdolescent Needs). The issues here are not ofdisease but of needs. We have a focal point ofchild and adolescent health in all thecountries of our region and we are workingtogether with other agencies on AIDSprevention. Our current projects include:Sexual and reproductive health, pregnancyprevention in adolescents and young people,financed by Project ASDI in seven countries;HIV/AIDS Prevention in adolescents andyoung people, financed by NORAD in ninecountries; and Juvenile DevelopmentPromotion and Violence Prevention, financedby GTZ in six countries.

What of the MDGs?

National authorities in some of the countriesin our region feel that the MillenniumDevelopment Goals belong to the UN systemand are not really meant for them, so we areconstantly promoting ownership of the goalsand encourage their incorporation intocountries' policies and strategies. As aninstitution at regional and global levels, weare working more closely in terms ofinternational goals and mandates. I also seethe MDGs as a wonderful opportunity toincrease advocacy and mobilization ofresources for our activities – a greatopportunity for interaction between manytechnical units such as CAH, MakingPregnancy Safer, Nutrition, and HIV/AIDSetc. Working in partnership is the future forChild and Adolescent Health.

www.paho.org

One of theTask Force’smainachievementshas been thedevelopmentof a regionalroad map tospeed up thereduction ofmaternal and newborn mortality in Africa.Within one year it has been initiated in31 countries in Africa and 15 have agreednational plans.

www.intranet.afro.who.int/drh/index.html

Health; and the Child Survival Consultation.The aims of the meetings were to buildpartnerships, improve maternal, newborn andchild health, and promote the integratedcontinuum of care.

Dr Tedros Adhanom, Minister of Health forEthiopia, stressed the importance of aninnovative package of community-based healthpromotion and preventive health care to reach95% of women and children currently notaccessing health services. "Today I met the firstgraduates of our health extension package,designed to reach mothers, newborns andchildren with care at home. These women haveinspired me! … I have new hope for our nation."

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Imagine climbing the coldest mountainsin Afghanistan, or paddling thetreacherous waters of the Amazon, oreven peddling your bicycle through thehot and sparsely populated areas ofNiger … and always with your pack ofvaluable vaccines at your side. This isthe work of the health workersdelivering immunization to the hard-to-reach areas of the world.

Added to these challenges, introducingnew and more costly vaccines,strengthening management andmonitoring also need to be addressed bynational health systems. In response,WHO and UNICEF have developedthe Global Immunization Vision andStrategy (GIVS) for the period 2006 –2015. GIVS spells out the contributionof immunization to MDG 4 – a twothirds or greater reduction in globalchildhood deaths and illness due tovaccine-preventable diseases by 2015compared with 2000.

One of the four GIVS Strategic Areas is”Linking with others”. Seeking a morerapid reduction in child mortality andstrengthening of the overall healthsystem means that integratingimmunization with other life-savinghealth interventions opens the way, and– perhaps most importantly – theimagination, to the enormous potentialof routine health contacts to address theneeds of infants and children,particularly the hard-to-reach.

By combining provision ofimmunization together with provisionof insecticide-treated bed nets, de-worming treatments, nutritionmanagement and vitamin Asupplements, GIVS is optimizing everyeffort in reaching more … introducing newand … linking with others.

www.who.int/vaccines/GIVS/english/GIVS_Final_17Oct05.pdf

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es"Educate a mother and you educate futuregenerations." So the age-old saying goes and itis as relevant today as it always was.

WHO recently completed the developmentof a new comprehensive training course onInfant and Young Child Feeding (IYCF).The course combines and condenses threeseparate counselling courses on:breastfeeding, complimentary feeding, andHIV and infant feeding. In October thecourse was conducted for the first time byWPRO/CAH in Manila for representativesfrom 10 countries.

The two-week activity prepared regionalfacilitators and provided initial training forfuture trainers. It also identified approaches

for how the course could be introduced androlled out in countries in the WesternPacific Region.

"The course has been very helpful in thedevelopment of our Plan of Action on IYCFin China," said Dr Yaohua Dai, Professorand Chairman, Department of ChildHealth, Capital Institute of Paediatrics,Beijing, People's Republic of China. Thiswas typical of the positive response ofparticipants.

Like many other country representatives onthe course, Dr Dai plans to incorporate itinto her work in China. "We are nowtranslating training materials, which will beused for future training courses for IMCIimplementation. Based on the messagesprovided by the course we are developingthe new Mother's Card for improvingfeeding practices."

In the majority of countries represented inthe training course, more than 30% ofchildren under the age of five areunderweight. In these circumstancesimproved feeding practices could reallymake a difference.

http://www.who.int/child-adolescent-health/publications/pubnutrition.htm

Improving infant feeding practices Linking with others

Effective teaching: A guide for educating health-care providersThis learning package aims to help educators in child and adolescent health anddevelopment become more effective teachers. The package is designed for teachers andtutors of students, including senior students, clinical instructors and clinical staff, whoassist with teaching at clinical practice sites. It includes a reference manual, learner's guideand facilitator's guide.http://www.who.int/child-adolescent-health/publications/IMCI/ISBN_92_4_159380_6.htm

Pocket book of hospital care for children: Guidelines for the managementof common illnesses with limited resourcesPart of a series, supporting IMCI, for doctors, senior nurses andsenior health workers responsible for the first referral-level care ofyoung children in developing countries. Offers up-to-date guidelinesfor both inpatient and outpatient care in hospitals with basicfacilities. It focuses on the inpatient management of major causes ofchildhood mortality and covers neonatal problems and manageablesurgical conditions.http://www.who.int/child-adolescent-health/publications/CHILD_HEALTH/PB.htm

New publications

WHO/UNICEF/GIVS

InternetPapers prepared for the recent High Level Forum on MDGsQuality papers on cross-cutting issues and principles. www.hlfhealthmdgs.org

(See November 2005 Paris meeting, background materials – Best Practices Principles forHealth Partnerships at Country Level)

Fixing Health Systems by Don de Savigny, Harun Kasale, Conrad Mbuya and Graham Reid,International Development Research Centre, 2004. www.idrc.ca/tehip

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June 5, 2006, willmark 25 years sinceCDC's Morbidityand MortalityWeekly Reportpublished adescription of fiveLos Angeles men

with Pneumocystis carinii pneumonia,drawing attention to the pandemic ofHIV/AIDS. An astonishing amount hashappened since, including most recentlythe establishment of treatmentprogrammes such as WHO's "3by5"initiative, the President's EmergencyPlan for AIDS Relief (PEPFAR), and thecommitment by the G8 nations in July2005 to strive for universal access toprevention, treatment and care by 2010.

As we celebrate lives saved throughantiretroviral (ARV) treatment scale-up(for example, in Kenya, more than55,000 people receive ARVs comparedto less than 10,000 two years ago), wealso must focus on gaps and disparitiesin treatment and prevention efforts.Areas in need of enhanced attentioninclude the prevention of mother-to-child transmission (PMTCT) of HIV,treatment of HIV-infected children, andthe HIV prevention and reproductivehealth needs of adolescents.

Since a paediatric AIDS epidemiccannot occur without an HIV epidemicin women of childbearing age, the firstpriorities are the prevention of HIVinfection in adolescent and youngwomen, and the prevention ofunintended pregnancies. PMTCTprogrammes, incorporating universalHIV screening with the "opt-out"approach, optimal drug regimens forinfected women, and rational adviceabout safe infant feeding, must bevigorously expanded.

Although children account for about15% of global AIDS deaths, theyaccount for not more than 5% of globalARV recipients. The reasons for thisdisparity are legion – many childrensicken and die before HIV diagnosis,staff trained in paediatric treatment arescarce, diagnosis is technicallychallenging in younger children,paediatric ARV formulations areexpensive and suboptimal, etc.Fundamentally, however, children havebeen forgotten until recently.

A neglected priority is adolescent health,especially HIV prevention. In heavilyaffected countries such as in southernAfrica, vulnerability is demonstrated bythe steep increase in serial HIVprevalence in the teens and early 20s.Girls are especially at risk. In ruralNyanza Province, Kenya, the HIVprevalence in males and females aged15 –19 years were, respectively, 0.7%and 8.4%. Our understanding of the

dynamics of such epidemics is limited –who is infecting whom, under whatcircumstances, how much young femalesexual behaviour is coerced, why doesthis public health disaster not generatemore outrage?

As always, we need expansion andintensification of programmes but wealso need more research. Evaluations ofbehavioural interventions involvingparents and families and of biomedicalinterventions have immense relevanceto adolescent health. Adolescent sexualbehaviour has never been easy toaddress, neither by adults nor byadolescents themselves. In the case ofHIV/AIDS, how we meet preventionneeds of youth – the future of anycountry – is a litmus test of ourcommitment and honesty.

Dr Kevin M De Cock

In early 2006, Dr De Cock will assume thedirectorship of the WHO HIV/AIDS Department

WHO, UNICEF and SCN to reviserecommendations for themanagement of severe malnutrition.Globally more than 10 million childrensuffer from severe malnutrition. Untilrecently it was recommended they betreated in hospital with fortified milk-based diets.Recent studieshave shownthat most ofthese childrencan be safelytreated at homefed with newlydevelopedready-to-usetherapeutic

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foods (RUTF). Also, good results can beobtained with specially prepared familyfoods fortified with vitamins and minerals.A WHO/UNICEF/SCN meeting on 21 –23 November 2005 examined thesedevelopments and recommended a newcommunity-based approach.

The Adolescent Health andDevelopment team supported AFROand SEARO in a series of regionaland subregional workshops onstrengthening the health sectorresponse to the prevention and careof HIV/AIDS among young people.The workshops took place in Abuja,Dakar, Harare, and Chiang Mai. Theylooked at developing a good

OPINION

understanding of the HIV situation in theregion/subregion, similarities and differences,and the rationale for linking HIV responseswith responses to other adolescent sexual andreproductive health problems. Key tools forWHO's SSSS (Strategic information, Services,Supportive policies and Strengthening othersectors) approach to strengthening healthsector response were outlined and examined.The ADH team in Geneva is developingsystematic orientation and support based onthese workshops for regional offices andcountries.

CAH address: 20 Avenue Appia, 1211 Geneva 27, Switzerland, Tel: +41 22 791 32 81 Fax: +41 22 791 48 53 E-mail: cah@who.int Web site: www.who.int/child-adolescent-health

Send your comments, suggestions andquestions to cah@who.int

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Dr De Cock is currently CountryDirector for the US Centers for DiseaseControl and Prevention (CDC),Department of Health and HumanServices, Nairobi, Kenya. He is a Fellowof the United Kingdom’s Royal Collegeof Physicians and has over 25 years ofacademic and field research experience.He was previously Director, Division ofHIV/AIDS Prevention, Surveillance andEpidemiology, CDC, Atlanta, USA, andProfessor of Medicine and InternationalHealth at the London School ofHygiene and Tropical Medicine, and is along-term adviser to WHO.

UNICEF