WHAT IS CHILD MORTALITY child mortality = death of infants under the age of in every 1000 children as recorded in 2010 rates of 180 in 2011 per

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1 WHAT IS CHILD MORTALITY child mortality = death of infants under the age of in every 1000 children as recorded in 2010 rates of 180 in 2011 per 1,000 live births Child mortality had reduced significantly from 12.6 million of under-five deaths in 1990 to 6.6 million in 2012 globally. Out of all the deaths, almost 70% are due to preventable diseases. Child mortality is likely to be more severe in developing countries and especially at rural areas where living conditions are undesirable and food is scarce. Main causes: High child mortality rate is often due to the lack of proper healthcare or the accessibility to immediate health care, the lack of clean drinking water which make people vulnerable to malaria and diarrhoea, malnutrition which can cause children to have stunted growth and not being able to develop to their full potential, as well as the lack of education on antenatal care. The root cause of high child mortality: malnutrition Malnutrition: According to the World Health Organisation, malnutrition is the underlying contributing factor in about 45% of all child deaths. Causes of malnutrition are poverty, poor mothering such as lack of breastfeeding, use of traditional practices, and poor deit habits of mothers. Effects: Malnutrition results in children suffering from early deaths, leading to high child mortality rate in the country or hinders a child s development both physically and mentally. On a long-term basis, malnutrition can even impact the social and economic well-being of the individual and country.

2 BACKGROUND OF SOMALIA Geography country located in the Horn of Africa population of around 10 million Politics Mohamed Siad Barre seized power in 1969 and established the Somali Democratic Republic. In 1991, Barre's government collapsed as the Somali Civil War broke out. Due to the absence of a central government, residents in somalia reverted to local forms of conflict resolution Only in 2012, a newly The Federal Parliament of Somalia was concurrently inaugurated, ushering in the Federal Government of Somalia, the first permanent central government in the country since the start of the civil war This is its 14th attempt to establish a government since 1991 Faced a formidable task in its efforts to bring reconciliation to a country divided into clan fiefdoms. Authority was further compromised in 2006 by the rise of Islamists who gained control of much of the south, including the capital Somalia remains a fragmented region consisting of two effectively independent states (Puntland and Somaliland), a small area governed by transitional authorities and the greater part overseen by Islamist groups Environment after the tsunami of December 2004, emerged allegations that after the outbreak of the Somali Civil War in the late 1980s, Somalia's shoreline was used as a dump site for the disposal of toxic waste. huge waves from the tsunami are believed to have stirred up tons of nuclear and toxic waste that might have been dumped illegally in the country by foreign firms.

3 The European Green Party followed up by presenting before the press and the European Parliament in Strasbourg copies of contracts signed by two European companies the Italian Swiss firm, Achair Partners, and an Italian waste broker, Progresso and representatives of the then "President" of Somalia, the faction leader Ali Mahdi Mohamed, to accept 10 million tonnes of toxic waste in exchange for $80 million the waste has resulted in far higher than normal cases of respiratory infections, mouth ulcers and bleeding, abdominal haemorrhages and unusual skin infections among many inhabitants of the areas around the northeastern towns of Hobyo and Benadir on the Indian Ocean coast diseases consistent with radiation sickness CHILD MORTALITY IN SOMALIA one out of every ten Somali children dies before seeing their first birthday one out of every 12 women dies due to pregnancy related causes Access to maternal services is low with only 9% of births being attended by a skilled birth attendants Modern contraceptive rate is around 1% only Every 1,000 Somali children, 180 of them die before they reach the age of 5 years CAUSES OF HIGH CHILD MORTALITY RATE 1. INCOMPETENT GOVERNMENT: Dependence on aid: (causes malnutrition) Had been self sufficient in food grains until early 70s Now: increasing per capita food consumption, but declining per capita food production Due to govt s failure to provide adequate incentives to producers of food crop: they tax rural grain producers in order to ensure cheap

4 food for urban consumers: results in increased dependence on imported food not self sufficient: do not have a reliable agricultural sector: frequent food shortages: malnutrition 43% children underweight: at risk of stunting LACK OF GOVERNMENT (!!!V IMP) Somalia was without a formal parliament for more than two decades after the overthrow of President Siad Barre in Years of political instability(anarchy) followed the downfall of President Barre, and it was not until 2012 that a new internationally-backed government was installed. impacted the economy and development of the country Corruption--political instability : (causes misuse of funds) ranked 4th in corruption perception index in 2012, 0 being the most corrupt, 100 being the least corrupt: most corrupted country in the world lack of transparency and mutual accountability bribery in access to clean water and seeing professional doctors Britain, the European Union and the U.S. committed more than $350 million in May to finance the bulk of Somalia's federal budget. However, much of the funds transferred into the bank not traceable at all. 80% of withdrawals from Somalia's central bank was made for private purposes rather than running government programs. A cashier at the Finance Ministry withdrew $20.5 million in his name between 2010 and 2013: to make untracked payments for ministry officials government never had the political will to promote and deliver the interventions necessary for child survival, there never has been a national action plan to end child deaths that are preventable

5 millions of dollars donated to improve child and maternity health services are misused or misdirected Collaboration with the global health stakeholders e.g. campaigns The Millennium Development Goals, Every Women Every Child, and The Child Survival Call to Action, has been poor as the result of the two and half decades old civil war 2. DROUGHT PRONE Somalia experiences recurrent droughts 2 year drought( ) has caused record food inflation o Maize prices increase by about 80% in Juba region Somalia was hit by an extreme drought in 2011 that affected millions-causing famine and worsening child malnutrition 2.4 million people (up from 2 million people 2 years ago) (1/3 of Somalia s population) require humanitarian aid Thousands leaving the countryside to the capital in search of food and water over the past 2 months 3. POLITICAL INSTABILITY Problem further worsened by lack of access to many of the worst affected areas NGO- initiated programmes do not have full coverage across the entire country because of the political instability. o Al-Shabaab Islamist Group which controls much of south and central Somalia has ideology of self-sufficiency and rejects outside aid NGO (e.g. World Food Programme has suspended distribution in many areas since Jan 2011 Including central Hiraan region, where 70% of population are in crisis o Food prices in Mogadishu, where the weak Somali government exercises some control, are lower than elsewhere Due to availability of food aid

6 Internal conflict spanning more than two decades has resulted in the disintegration of Somalia s infrastructure and significantly weakened the government s capacity to respond to the basic needs of the population, such as access to clean water and appropriate sanitation facilities, adequate healthcare and effective security services. Lack of food: lack of nutrients for pregnant mother: child is malnourished 3. ILLNESSES pneumonia (25%), diarrhoea, malaria, neonatal disorders lack access to maternal services / basic health services preterm birth complications 80% lack access to basic services only 9% of births are attended by skilled attendants lack family planning lack sanitation facilities poor indoor air pollution lack prenatal care only 9% of babies are breastfed exclusively malnutrition (20% are acutely, malnourished recorded in 2010) About 40% o children suffer from malnutrition in Somalia; 33% eeat once a day Agriculture is their main source of income, but droughts and floods, as well as war, do not allow for sufficient crop production Almost ⅓ of newborns suffer from low birth weight. The lack of prenatal care and education for mothers is often the cause. drought prone --> extreme food insecurity (43% underweight) no safe drinking water poor healthcare very few hospitals in Somalia, which lack medical equipment and trained staff

7 4. POVERTY 60% of Somalis live below the poverty line--they earn less than 2 dollars per day. Half of Somali children have to work in order to provide for themselves and their families. (in the form of agriculture) 5. CIVIL WAR(!!) For many years, Somalia has been ravaged by a particularly violent civil war children are a large part of the victims. In Mogadishu, the capital, there are still armed conflicts and terrorist attacks every day. SOLUTIONS 1. End government conflicts (anti-corruption): Britain, the European Union and the U.S. committed more than $350 million in May to finance the bulk of Somalia's federal budget o much of the funds transferred into the bank not traceable at all 80% of withdrawals from Somalia's central bank was made for private purposes rather than running government programs A cashier at the Finance Ministry, Shir Axmed Jumcaale, withdrew $20.5 million in his name between 2010 and 2013: to make untracked payments for ministry officials With a less corrupted government, more money can be spent on improving healthcare instead of spending on private purposes o Currently, Somalia has 300 doctors, which is 0.35 per 10,000 people, compared to Cambodia: 2.27 per 10,000 o Cambodia currently 6 dollars per capita government spending on health reduce indoor air pollution introduce clean energy increase use of mosquito nets improve drinking water

8 provide education and clinical skills needed to identify respiratory infections raise awareness among mothers to health, hygiene and maternal feeding practices ending conflicts with governance anti corruption policies rely on sources and partner with the world sufficient and sustainable food source improves access and quality of health care especially in rural areas and port-natal care scale up vaccinations expand basic infrastructure Case Study 1 - Successful Child Health Days Strategy (Somalia) immunization services reaches remote areas, covering disparity between urban and rural areas (bribery) infants able to receive third dose of vaccine 51% coverage in 2009 and 66% in 2010 Periodic intensification of routine immunization (PIRI) services Supplemental Immunization Activities (SIAs) Accelerated Young Child Survival Initiative (2008) designed by UNICEF and WHO reduce maternal, neonatal and child mortality to contribute to Millennium Development Goal 4 (reduce child mortality) Somalia embarked on CHD since 2008 December, twice a year to reach as many children through equitable delivery strategy targets children below 5 and women of childbearing age took health services out of facilities and deliver directly to community through teams of vaccinators and health workers reduce access barriers (transport, security, cost) creates bridge between health facilities and communities CHD methods

9 implementation of 5 days in each district considering access, insecurity, authorization by authorities, operational capacity, manpower provided by existing health centers, temporary outreach sites and mobile units in remote areas (1-2 days per village) infants screened for malnutrition and provided with vaccines and vitamins, along with follow up rounds of vaccination mothers given 3 sachets of water purification tablets for use in case of diarrhea CHD results 84% more infants with measles vaccination vaccine coverage disparity between rural and urban reduced from 17% (42% urban and 25% rural) to 10% (50% urban and 60% rural) more than 60% infants received vitamin A supplementation facilities now accessible to 30% of Somalia Why is it not successful? Permission for access is not granted by local control in some areas, resulting in CHD not conducted since 2008 in highly populated areas. facilities below minimum standards and suffer irregular supplies, insufficient staffing -- range of services limited low trust among population reduced demand for utilization linked and integrated to health systems to strengthen capacity disease surveillance system under development --> measuring impact of CHD in terms of reduction affected lack post campaign evaluation data use of ORS in surveys to access success and coverage private sector involved in monitoring and ensuring quality and equity

10 expensive and require a lot of input (staff and resources) only deliver small range of promotional and preventive services not providing access to services required by population Case Study 2: Somalia Red Crescent Society Delivery of key health services to prevent maternal and child mortality forms the core of the Somali Red Crescent Society s health programming. Immunization is one of the best, most cost-effective services available to prevent childhood illness. Through its network of 58 maternal and child health/out-patients clinics, 23 mobile health units and 4,600 volunteers, the Somali Red Crescent Society in Somaliland and Puntland provides critical health service to vulnerable populations, including routine immunization. Trained volunteers, who live in the same community as the local population and speak the same language, helped reach the most inaccessible, poor and marginalized communities. They made door-to-door visits to sensitize parents on the benefits of immunization. The five-day campaign saw 3,450 children receive polio immunization through the mobile clinics. Of these, 140 had not been vaccinated in previous rounds. Why is it not as successful? There is political instability in the country; there are fights going on, especially in Central and Southern Somalia. Al-Shabaab Islamist Group which controls much of south and central Somalia has ideology of self-sufficiency and rejects outside aid and NGO (e.g. World Food Programme has suspended distribution in many areas since Jan 2011). Insecurity and lack of access to certain parts of Somalia has, rendered it impossible to immunize many children for over three years. This has resulted in the re-emergence of the wild poliovirus in south and central Somalia in 2013, with the total cases reaching 190. In central and south Somalia, the militant group fighting the federal government does not allow house-to-house visits or mass public campaign activities, thus

11 hampering access of the population to immunization services despite their high knowledge of the importance of vaccinating children to prevent diseases. Delivery of immunization activities, in this area is limited to ten of the 30 static clinics. Malnutrition rates in Somalia are still among the highest in the world, with one in seven children under five acutely malnourished. Two thirds of these children are in southern Somalia and need medical assistance. Aid organizations say they have been unable to reach millions of children in the Galgaduud, Hiraan and Middle Juba regions of the south due to lack of funding and limited access. CASE STUDY ( NEPAL) The Nepal National Vitamin A Program (NVAP) was begun in 1993 in eight of the country's 75 districts. By the end of 1997, the programme covered 32 districts. The Nepal NVAP is considered by many to be a highly successful, model programme. CASE STUDY ( INDIA) What does it solve: Overcome the lack of financial support, lack of immunization Government worked closely with World Health Organisation and UNICEF Universal Immunization Programme (UIP) Provide free vaccines at different stages of a child s life depending on the type of vaccine Provide protection against diseases such as pertussis, tetanus, polio, tuberculosis etc aimed to immunize all eligible children by 1990 Programme targets: immune 26 million new born each year with primary doses 100 million of children of 1-5 year age with booster doses of UIP vaccines Results: 89.8% of vaccination in India provided through public sector government can provide support for its people

12 61% of all children in india are fully immunized with all vaccines UIP lowered the child mortality rates by a huge amount over the years and will continue to ensure kids are immunized over the years Since it was implemented, the child mortality rate in India has been decreasing 140 out of 1000 children under 5 dying in out of 1000 children under 5 dying in 2009 Shows relation between the provision of immunization and the child mortality rates of the country When immunization is provided, child mortality will be reduced as more children protected against diseases Factor: child mortality can be reduced if it is within the government s means to provide free immunization for its citizens May not work in Somalia due to corrupt government misuse of funds for immunization / health facilities no actual government will to improve child mortality Hence, it will only work if corrupt government are eradicated completely. Factor: political instability Solution: delivering healthcare services to them Cambodia html

13 e.aspx Somalia EN_LR.pdf Profile.pdf some websites show stats; some show talk about food insecurity but the main point i wanted to highlight is political instability affecting the coverage of voluntary healthcare service Cambodia Context: During the Khmer Rouge rule from , the health infrastructure in Cambodia was severely affected, to the extent that less than 50 health professionals can be found in the country. As a result, child mortality has been high with the poor health systems available in the country. However, according to a report by WHO, Cambodia is one of the top five countries who have shown commendable progress in reducing child mortality. Although child mortality in Cambodia is still considered high in its region, it has been reduced from 116 to 40 per 1000 live births from 1990 to At the rate child mortality is reducing in Cambodia, she will be able to meet the Millennium Development Goal 4 (MDG 4), which is to reduce child mortality in her country by two-thirds before the year Nearly 70 per cent of child deaths in Cambodia are due to diarrhoea, pneumonia or neonatal conditions.

14 Causes: Inadequate accessibility, quality and utilization of health services There is a widespread shortage of skilled health personnel, particularly midwives, decreasing the chances of the child surviving birth complications only 71% had access to a skilled birth attendant a little over ½ of births took place in a health facility insufficient supply of some essential drugs and equipment inadequate linkages between communities and health facilities Many Cambodians living in rural areas need to travel more than 100 miles to reach the hospital (J.D. Heather, 2012), causing them to be unable to seek treatment in time, resulting in death. There are high transportation costs; some families even need to sell their cow or homes to pay for a trip to hospital or hospital fees Uneducated mothers Many common illnesses such as diarrhoea are treatable and preventable if the mothers are adequately educated Few visit clinics for routine yet potentially life-saving health check-ups for their babies (unaware of benefits) Do not breastfeed exclusively for first 6 months of baby s life and children older than 6 months get too little or not the right complementary food: parents lack knowledge/cannot afford nutritious food, resulting in malnutrition 40% of children <5 y/o are too small for their age 28% underweight Illnesses eg. Malnutrition Solutions

15 NGOs Voluntary healthcare workers voluntary healthcare workers from Non-Governmental Organisations (NGOs) eg. RACHA (Reproductive and Child Health Alliance), a Cambodian-based NGO, are sent out to inaccessible rural communities, where they identify ill children so that they can be sent for medical treatment, and they train the adults how to identify and treat common preventable illnesses, such as diarrhea, which is one of the top causes of child mortality. When such preventable illnesses are spotted earlier, treatment can be given to the children earlier, hence increasing the chances of the children recovering without any complications, and as a result, reducing child mortality. Health workers deliver vaccines to these inaccessible communities. Immunisations play a huge part in reducing child mortality too, as many illnesses such as tetanus, polio, measles etc, can result in child mortality too. Health workers also educate the expectant and new mothers on the benefits of breastfeeding, especially in the first 6 months of the child s life, proper nutrition and hygiene. This outreach was proved effective, which can be seen through the reduced rate of child mortality in the past years. Role of the Government In addition to the help from NGOs, the Cambodian government plays a huge part too. For a programme to last long enough to bring visible, positive changes to a community, funding from the government is extremely important. The government works with many NGOs, such as the one mentioned above. The Cambodian government has also set up the Health Equity Fund. The fund was set up to give the poor in Cambodia free access to healthcare. Sometimes, representatives from the Health Equity Fund also go to these inaccessible areas to explain to the users how to access their funds and prove their eligibility to access health services for free. Without worrying about the expensive costs of healthcare, more mothers are willing to send their children to seek treatment, before their condition worsens, thus reducing child mortality. Improved the rate of access to improved sanitation facilities: 2000 <10%; 2010 >25%

16 hygienic toilets prevent children from coming into contact with faeces: reduce risk of infections via the faecal-oral route >70% Cambodian children still live in households without improved sanitary facilities Subsidies in the form of vouchers Payment of hospital fees Support for transportation: effective for improving access for poor pregnant women By 2013, vouchers: implemented in 27 health districts Limitations: financial sustainability: scheme is currently funded by external subsidies 2000: 32%; 2010: 71% sought help from a skilled birth attendant Increase number of skilled health personnel (initiated and funded by Cambodian government) Aimed at motivating skilled birth attendants (including midwives, doctors) to promote deliveries in public health facilities Became operational nationwide in late 2007 after Ministry of Health and the Ministry of Economy and Finance allocated government budget to the payment of an incentive for skilled birth attendants US$ 15 for each live birth attended in health centres and US$ 10 in hospitals Incentives are shared with other health personnel in the facility and with Village Health Support Groups, village chiefs and traditional birth attendants (TBAs) who refer women to the facility for deliver Encouraged communities to refer women to facilities for delivery By 2009, all health centres had at least one primary midwife (with one year s training) >1/2 had a secondary midwife (with three years training). By 2011, Cambodia met the minimum global benchmark for provision of midwives: 6/1000 births/year. By % of health facilities had at least one secondary midwife All these measures or programmes can only work out if the government is willing to spend more money on health expenditure. According to the Annual Health

17 Financing Report 2012 by the Cambodian government, the National budget allocation for health has consistently increasing over the last decade. The Total Health Expenditure (THE) too, has substantially increased over the last five years, from USD 564 Million in 2008 to USD 763 Million in 2012, representing more than 5% of the GDP. The success of these measures were largely possible because the Cambodian government has increased her health expenditure, and is willing to increase it further, thus reducing child mortality in the country. /Why it was successful?/ Cambodia has long been one of the poorest countries in Southeast Asia, but thirty years of war, totalitarian government, and natural disaster has raised the country s malnutrition rates to among the highest in Southeast Asia as well. During the Khmer Rouge rule from , the health infrastructure in Cambodia was severely affected, to the extent that less than 50 health professionals can be found in the country. As a result, child mortality has been high with the poor health systems available in the country. The Cambodians have also gone through four coups in the last 30 years. There were protests in 1998, but after both parties reached an agreement, the political situation of Cambodia stayed fairly stable. During the past five years, Cambodia has enjoyed much more political stability and territorial unity than for decades. stable until the last election, which was held last July. In the recent years, the government worked together with many different NGOs to further improve the access to healthcare services, reducing child and maternal mortality. They are more politically stable, as compared to Somalia, and hence they are willing to allocate more money to healthcare instead of focusing more on military spending to defend themselves in the internal conflict, like somalia.