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  1. 1
    182223
    Peer Reviewed

    Applying an equity lens to child health and mortality: more of the same is not enough.

    Victora CG; Wagstaff A; Schellenberg JA; Gwatkin D; Claeson M

    Lancet. 2003 Jul 19; 362(9379):233-241.

    Gaps in child mortality between rich and poor countries are unacceptably wide and in some areas are becoming wider, as are the gaps between wealthy and poor children within most countries. Poor children are more likely than their better-off peers to be exposed to health risks, and they have less resistance to disease because of undernutrition and other hazards typical in poor communities. These inequities are compounded by reduced access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Experience and evidence about how to reach poor populations are growing, albeit largely through small-scale case studies. Successful approaches include those that improve geographic access to health interventions in poor communities, subsidised health care and health inputs, and social marketing. Targeting of health interventions to poor people and ensuring universal coverage are promising approaches for improvement of equity, but both have limitations that necessitate planning for child survival and effective delivery at national level and below. Regular monitoring of inequities and use of the resulting information for education, advocacy, and increased accountability among the general public and decision makers is urgently needed, but will not be sufficient. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels must be developed. (author's)
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  2. 2
    182213
    Peer Reviewed

    Management of severely ill children at first-level health facilities in sub-Saharan Africa when referral is difficult. [La prise en charge au niveau des installations sanitaires de premier niveau des enfants gravement malades, en Afrique sub-saharienne, en cas de difficulté d'orientation vers d'autres structures]

    Simoes EA; Peterson S; Gamatie Y; Kisanga FS; Mukasa G

    Bulletin of the World Health Organization. 2003 Jul; 81(7):522-531.

    Objectives: To quantify the main reasons for referral of infants and children from first-level health facilities to referral hospitals in sub- Saharan Africa and to determine what further supplies, equipment, and legal empowerment might be needed to manage such children when referral is difficult. Methods: In an observational study at first-level health facilities in Uganda, the United Republic of Tanzania, and Niger, over 3–5 months, we prospectively documented the diagnoses and severity of diseases in children using the standardized Integrated Management of Childhood Illness (IMCI) guidelines. We reviewed the facilities for supplies and equipment and examined the legal constraints of health personnel working at these facilities. Findings: We studied 7195 children aged 2–59 months, of whom 691 (9.6%) were classified under a severe IMCI classification that required urgent referral to a hospital. Overall, 226 children had general danger signs, 292 had severe pneumonia or very severe disease, 104 were severely dehydrated, 31 had severe persistent diarrhoea, 207 were severely malnourished, and 98 had severe anaemia. Considerably more ill were 415 young infants aged one week to two months: nearly three-quarters of these required referral. Legal constraints and a lack of simple equipment (suction pumps, nebulizers, and oxygen concentrators) and supplies (nasogastric tubes and 50% glucose) could prevent health workers from dealing more appropriately with sick children when referral was not possible. Conclusion: When referral is difficult or impossible, some additional supplies and equipment, as well as provision of simple guidelines, may improve management of seriously ill infants and children. (author's)
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