Featured Journal Content
April 2, 2019, Vol 321, No. 13, Pages 1229-1320
Current and Future Challenges for Children Across the World
Zulfiqar A. Bhutta, MBBS, FRCPCH, PhD; Robert E. Black, MD, MPH
JAMA. 2019;321(13):1251-1252. doi:10.1001/jama.2019.1840
There have been substantial gains in global health in the past decade. Access to energy, communications, and clean water has increased and extreme poverty has continued to decline (from >40% in 1990 to <10% in 2018).1 Child mortality has declined substantially, with approximately 10 million children younger than 5 years dying in 2000 compared with 5.4 million in 2017.2 Gains in the health of children worldwide accelerated in part because of the global compacts made in the Millennium Development Goals. The goals were developed by the United Nations system and signed by 189 countries in September 2000 to reduce maternal and child mortality by 75% and 66%, respectively, from an estimated 0.5 million maternal deaths and 12.4 million child deaths annually in 1990. These global gains were possible because of alignment among development agencies, academia, national governments, and community-based organizations for introducing globally evidence-based and effective interventions, such as vaccines, effective care of sick infants, and other interventions.
Notwithstanding these gains, many challenges remain. The daily toll of nearly 15 000 deaths of children before their fifth birthday, with many of these deaths preventable, is unacceptably high, and progress in reducing newborn deaths and stillbirths is especially inadequate. In addition, the 0.9 million annual deaths among older children (5-9 years) and young adolescents (10-14 years) have received relatively little attention.2 Although ample preventive and curative interventions addressing newborn, child, and adolescent health exist, there is no strategy to integrate planning and health care for children in health systems and their linkage to sectors outside of health, such as education, social safety nets, housing, and environmental health. Inequalities persist and are often associated with poverty, conflict, migration, ethnicity, and urbanization. These challenges are insufficiently highlighted in current global strategies or in action plans for child health and development.
In addition, global child health efforts still mainly focus on survival. The importance of early child development and the effects of poor nutrition on children for long-term outcomes were absent in the Millennium Development Goals. The 17 Sustainable Development Goals adopted by 193 countries in September 20153 are ambitious, advocate for more holistic definitions of health, and include aspirational targets addressing social determinants of health across diverse sectors. The increased recognition that cognitive abilities, health, and productivity in adults are the consequence of exposures and opportunities in childhood has led to calls for investments in improving maternal and child nutrition, nurturing care of children, and involvement of other sectors, such as education, leading to enhanced human capital, defined as the stock of knowledge, skills, attitudes, health, and other personal characteristics that enable individuals to realize their potential as productive and responsible members of society.4
Early exposures of children to violence, stress, and displacement could have serious long-term consequences. These include children and families living in the midst of conflict, in neighborhoods of high crime, as well as refugees and migrants. Such considerations for improving the health of women and children using the basic principles of human rights5 should not be restricted to low- and middle-income countries. The recent episodes of forced separation of children from migrant families seeking asylum at the US-Mexican border and preventable child deaths highlight the importance of these concepts even in the best-developed democracies.
The prioritization of noncommunicable diseases, including cardiovascular disease, cancer, chronic respiratory disease, and diabetes, in the Sustainable Development Goals is welcome but also presents challenges. The prevention of many noncommunicable diseases needs to begin in childhood with healthful diets and exercise and avoidance of risks, such as smoking. Current programs for child health and nutrition are poorly linked to noncommunicable disease prevention but offer an opportunity to address these emerging public health priorities in childhood with benefits for current and future generations. These approaches are integral to optimizing child health and not additional or optional strategies for action.
The current global focus on universal health coverage and primary health care by the World Health Organization should be a cornerstone for accelerating child health and development, yet there are strong signals that attention may be shifting. Concentrating on such issues may lead to a disproportionate allocation of public resources to tertiary health facilities serving urban adult populations, especially in countries with limited national allocations for health and diminishing donor assistance. It is notable that the most recent World Health Organization executive board resolution on universal health coverage adopted for discussion at the World Health Assembly in May 2019 does not mention children or child health—even once.6 Neither do the long-awaited restructuring and new initiatives of the World Health Organization mention mothers and children or child health explicitly.7 One challenge is ensuring a focus on child health without distraction by the large number of strategies involving health issues such as programs to treat noncommunicable diseases affecting older populations.
What is needed to improve child global health in the future?
First, to promote global child health and accelerate progress to eliminate preventable child deaths by 2030 and improve child development, it is imperative to continue to focus on quality and coverage of primary care and preventive programs8 and on reaching marginalized and at-risk populations, especially those living in insecure environments or conflict zones. This will require additional resources and different approaches to delivery of services, including engagement of communities, especially women, and working with a range of lay health workers in community settings.
Second, the move beyond survival to enhance or improve early child development is welcome. Such efforts require developing strategies for implementing nurturing care of children, including health, nutrition, and social protection, and ensuring that interventions linking early child health with the care of school-aged children and adolescents are prioritized.9 Community and outreach programs designed to reach marginalized populations must be prioritized and interventions beyond health services expanded, such as living conditions, environmental exposures, food security, and education.
Third, a revolution in information systems is needed to improve the monitoring, evaluation and population effects of health services. For example, registration of births and deaths, with information on the medical and social causes of death, along with illness surveillance, would enable targeting resources and responses to health threats. Granular information is critical to identify and reach the most vulnerable populations; child mortality is increasingly concentrated in certain hot spots that require focused attention.10 Better data and feedback are critical to optimize coverage and quality of services in both the public and private health sectors and to determine the most cost-effective integrated interventions from birth through adolescence.
The next global challenge is to develop a unifying plan for reducing the gap in child health and development between resource-limited and resource-rich countries as well as gaps within countries. Addressing the social determinants of health in all settings, tackling the needs of children living in adverse conditions, and getting governments to recognize that optimizing child health is a fundamental human right are central to the mission and future of the Sustainable Development Goals.
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