Evolution of the Child Health Day strategy for the integrated delivery of child health and nutrition services
Amanda C. Palmer, Theresa Diaz, Aaltje Camielle Noordam, and Nita Dalmiya Abstract Background. In efforts to meet the Millennium Development Goal for mortality among children under 5 years of age, countries require strategies for covering hard-toreach and older children who are often missed by routine, fixed-site health services. Objective. To document the evolution of Child Health Days (CHDs), designed as regular events for the delivery of health and nutrition services to children under the age of five. Methods. We extracted information on service delivery strategies and codelivered interventions for the period 1999 to 2010 from global monitoring databases for vitamin A and immunization. Results. Our data illustrate a dramatic rise in CHDs over the decade: only two countries held CHDs in 1999; in 2010, 96 CHDs were conducted in 51 countries. Reliance on CHDs has been particularly marked in sub-Saharan Africa, where they are increasingly used to deliver five or more services per event. Whereas early CHDs were largely defined by codelivery of vitamin A, immunizations, and deworming, they have since evolved into diverse packages including services such as water purification tablets and screening for severe malnutrition. Conclusions. The scale-up of CHDs is helping countries to achieve high and equitable coverage of essential health and nutrition services. Future research should consider whether the increasingly diverse services delivered via CHDs are guided by epidemiologic considerations, and whether the rising number of codelivered
Amanda C. Palmer is affiliated with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Theresa Diaz, Aaltje Camielle Noordam, and Nita Dalmiya are affliated with UNICEF, New York. Please direct queries to the corresponding author: Theresa Diaz, UNICEF Programme Division, Health Section, Knowledge Management Implementation Research Unit, 3 U.N. Plaza, New York, NY 10017, USA; e-mail: [email protected].
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interventions is affecting coverage performance or service quality. Guidance is also needed to ensure that CHDs are implemented as part of systematic efforts to improve health systems.
Key words: Campaign, Child Health Day, child survival, integrated event
Introduction It has been almost a decade since the Lancet Child Survival Series drew global attention to the 10 million children dying each year from preventable causes [1]. Even with an arsenal of highly efficacious and costeffective measures [2], weak health systems were largely hindering the ability to deliver services to those with the greatest need [3]. The international community responded to this call for action with substantial investment. A major focus of that investment has been the scale-up of integrated, often campaign-style events to supplement routine, fixed-site primary healthcare service delivery. These events are most commonly referred to as Child Health Days (CHDs), although terminology may vary by country. CHDs developed from the early linkage of vitamin A supplementation with the Expanded Programme on Immunization’s National Immunization Days (NIDs) for polio eradication [4]. As the phase-out of NIDs began, selected countries in sub-Saharan Africa and Southeast Asia began to experiment with another style of integrated service delivery most commonly referred to as Child Health Days. In sub-Saharan Africa, early CHDs generally relied on existing donor-supported campaigns as a platform, such as adding vitamin A supplements and insecticide-treated bednets to a measles campaign in Zambia [5] or adding deworming to Micronutrient Days in many West African countries [6, 7]. CHDs in Southeast Asia, such as Preschoolers’ Health Weeks in the Philippines, functioned more as intense social mobilization efforts to promote existing
Food and Nutrition Bulletin, vol. 34, no. 4 © 2013, The Nevin Scrimshaw International Nutrition Foundation.
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services. More recently, a campaign strategy has been used in South Asia, where vitamin A supplementation and other services have been linked with the region’s continued polio eradication efforts, and in Central Asian countries like Uzbekistan, stand-alone vitamin A supplementation campaigns are now being used as a platform to deliver missed vaccines. Countries in Latin America and the Caribbean have traditionally held “immunization campaigns,” which were essentially health promotion events to which vitamin A supplementation has now been added. Although CHDs have become increasingly common over the past several years [8], neither their scale-up nor their impact has been consistently monitored or evaluated. In November 2009, the UNICEF Programme Division convened a Joint Working Group to develop guidance for countries on the design and implementation of CHDs to maximize their impact on child health and nutrition. The first portion of this work, and the goal of the present article, was to catalogue all CHDs conducted over the period from 1999 to 2010 and to summarize event composition, in terms of both the number of services delivered and specific intervention packages.
Methods For the purposes of this review, we defined CHDs as regular events, i.e., generally conducted every 6 months, organized to deliver two or more health or nutrition services to infants, children under the age of five, and, in some cases, pregnant or lactating women. The term “events” is used, as the actual service delivery strategy may fall anywhere on the spectrum from door-to-door campaigns lasting for a few days to month-long mobilization of communities to visit fixed site health facilities. These were differentiated from stand-alone events to deliver any one commodity, and other integrated events (i.e., with two or more services) scheduled based on disease control priorities, including integrated polio, measles, and tetanus Supplementary Immunization Activities. We compiled data from two existing databases: UNICEF’s vitamin A database and the World Health Organization (WHO)/UNICEF Joint Reporting Form immunization database. UNICEF has collected vitamin A supplementation coverage data annually since 1999. For the period from 1999 to 2004, the forms included fields to capture vitamin A delivery mechanisms (e.g., measles Supplementary Immunization Activities); information regarding codelivered services was provided on an ad hoc basis. Since 2005, forms have captured delivery mechanism (routine only, Supplementary Immunization Activities, CHDs, other) and codelivered services via close-coded questions. Services include immunization; deworming; distribution
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or retreatment of insecticide-treated bednets; growth monitoring and promotion; water, sanitation, and hygiene (WASH); screening and referral for severe malnutrition; behavioral change communication; and other services. Verbatim descriptions of “other” services and behavioral change communication messages were also captured. The Joint Reporting Form database includes one section for supplementary activities, which captures the commodity delivered, round or type of campaign (e.g., NID), date of delivery, and targeted geographic area (national or subnational). Since the Joint Reporting Form is organized by commodity rather than event, we employed the delivery date to link codelivered commodities or to identify those delivered in stand-alone campaigns. Commodities for which the date of delivery was missing were excluded from our analyses. We linked vitamin A and Joint Reporting Form databases by delivery date. When two dates matched, we updated the original vitamin A record with additional information on services delivered, including specific vaccines. When events were unique to the Joint Reporting Form, these were appended to the vitamin A database. We then calculated the total number of codelivered services for each event. Immunization was counted as a single service, regardless of the number of codelivered antigens. Events delivering only one service were classified as stand-alone. Those with two or more services, not including immunization, were classified as CHDs. For events with two or more services, including polio, measles, or tetanus toxoid vaccines, we reviewed the full set of reported events from 1999 to 2010 in order to differentiate between CHDs and integrated Supplementary Immunization Activities. Integrated events including polio, measles, or tetanus toxoid vaccine were coded as CHDs if the country had previously reported at least one CHD via the close-coded list of delivery mechanisms on the vitamin A reporting form, and a CHD was held in the semester either immediately prior to or immediately following the event. Essentially, any integrated event following the country’s first selfreported CHD would be considered a CHD, unless there was a gap in the 6-monthly schedule. Integrated events including polio, measles, or tetanus toxoid vaccine that did not meet these criteria were coded as integrated Supplementary Immunization Activities. The final database was organized so that the event itself served as the unit of analysis. For each event, we had information on the UNICEF region; the date; the total number of codelivered services; binary variables indicating whether or not each of nine specific interventions was delivered; binary variables indicating which antigens were delivered (routine catch-up, polio, measles, tetanus toxoid, other antigens); and, where applicable, verbatim descriptions of “other antigens,” behavioral change communication messages, and/ or “other” services. Finally, we generated a “package”
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indicator variable, taking on random values 1, 2,…n, for each unique combination (e.g., vitamin A, deworming, and insecticide-treated bednets) of codelivered services.
Results Our database included information on 954 events conducted in 83 countries over the period from 1999 to 2010. These were highly concentrated in sub-Saharan Africa and Southern Asia. Fifty-seven percent of events were classified as CHDs, while the remaining 43% were either integrated polio or measles campaigns. After excluding the 412 integrated NIDs and Supplementary Immunization Activities, we were left with a total of 542 CHDs. As noted above, complete information on event composition was available only from 2005 to 2010, limiting our sample to 474 CHDs.
No. of countries or CHDs
100
Countries
Child Health Days, 1999–2010
A total of 542 CHDs were carried out from 1999 to 2010 in 72 countries. The total number held per year has risen dramatically, from only two events held in 1999 to 96 in 2010 (fig. 1). Countries that held CHDs in 2010 are depicted in figure 2. Sub-Saharan Africa accounts for the majority of CHDs (61%), followed by countries in East Asia and the Pacific (20%) and South Asia (9%). The remaining UNICEF regions have averaged two or fewer CHDs per year. Zambia, Tanzania, and the Philippines have had the most extensive experience, each with 20 or more CHDs conducted between 1999 and 2010. Services delivered
We had complete information on event composition for 474 CHDs. Vitamin A, deworming, and immunization
CHDs
80 60 40 20 0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
FIG 1. Number of countries holding Child Health Days and total number of events by year, 1999 to 2010
FIG. 2. Countries reporting one or more Child Health Days in 2010 based on reports of 136 supplementary activities (i.e., nonroutine service delivery) from 57 countries
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Vitamin A supplementation were the most common services (fig. 3), delivered in 99.6%, 80.8%, and 79.5% Deworming of CHDs, respectively. Polio vaccine Immunization was the most common antigen (35% Growth monitoring of CHDs), followed by measles vacBehavioral change communication cine, tetanus toxoid vaccine, and routine Bednets Expanded Program on Immunization (EPI) antigens. Other antigens, primarOther services ily yellow fever, were included in less Water, sanitation, and hygiene than 5% of CHDs. Although the rankNutrition screening ing of interventions did not vary by 0 20 40 60 80 100 year, there has been a dramatic increase % CHDs in the diversity of services offered. For instance, no WASH interventions (e.g., FIG. 3. Proportion of Child Health Days that included any of nine categories distribution of aquatabs) were delivered of key child health and nutrition interventions, 2005 to 2010. Estimates are in 2005/06 events, but they were incor- based on 474 CHDs conducted in 70 countries from 2005 to 2010 for which porated into 20% to 30% of events from complete data on event composition were available 2007 onwards. Inclusion of nutrition screening and referral to therapeutic services became more common (18% in 2005 and feeding centers has also increased sharply, primarily 27% in 2010). This was most marked in sub-Saharan in Eastern and Southern Africa: prior to 2010, fewer Africa: the proportion of CHDs including only two than five events annually included nutrition screening, services decreased from 51% in 2005 to 9% in 2010, whereas 31% of CHDs (n = 30) included this service in while the proportion delivering five or more services 2010. Roughly 20% of CHDs included “other” services. more than tripled (from 9% to 31%). We found signifiMaternal iron–folic acid supplementation was, by far, cant regional variation in the number of codelivered the most common of these (47%), followed by birth interventions. The numbers were highest in Eastern registration (7%). Where behavioral change commu- and Southern Africa, where 45% of events included nication messages were specified, these were largely five or more services, and East Asia and the Pacific, nutrition-themed (e.g., breastfeeding). where 23% of events included five or more services. In contrast, less than 20% of CHDs in South Asia, Western and Central Africa, or other UNICEF regions Composition of Child Health Days, 2005–2010 (combined due to small sample size) codelivered five Overall, CHDs included a median of four and a or more interventions. maximum of nine interventions. From 2005 to 2010, the proportion of countries codelivering two or three Intervention packages interventions remained roughly the same (53% in 2005 and 48% in 2010); however, codelivery of five or more From 2005 to 2010, CHDs could be classified into 82
TABLE 1. Most common service packages delivered during Child Health Days conducted from 2005 to 2010a Interventions included
Rank
n (%)b
1 2 3 4 5
117 (25) 93 (20) 63 (13) 40 (8) 38 (8)
Vitamin A supplementation X X X X X
Immunization X X X X
Insecticidetreated Deworming bednets X X X X
Otherc X
X
X X
a. Estimates are based on 474 CHDs conducted in 70 countries from 2005 to 2010 for which complete data were available on event composition. b. Number and proportion of all CHDs conducted from 2005 to 2010; these data yielded 83 unique service packages. c. E.g., antenatal iron–folic acid supplementation. This category has been collapsed for illustrative purposes only. Data analysis considered all of the following as independent categories: growth monitoring and promotion; water, sanitation, and hygiene (WASH); screening and referral for severe malnutrition; behavioral change communication; and other interventions.
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different intervention packages, although the top five most common packages accounted for roughly 50% of CHDs (table 1). Overall, codelivery of vitamin A, immunization, and deworming was most prevalent (20%) and ranked either first or second every year. The second most common package overall was vitamin A plus deworming (9%), followed by vitamin A plus immunization (8%), and vitamin A, immunization, deworming, and distribution of insecticide-treated bednets (5%). No other packages accounted for more than 5% of events. Intervention packages are increasingly diverse. In 2005, there were only 19 unique packages. This number climbed to 35 packages in 2010. With regard to regional variation, Eastern and Southern Africa had the most types of packages (53 combinations), followed by Western and Central Africa (33), East Asia and the Pacific (28), and South Asia (9). The combination of vitamin A, immunization, and deworming remained first or second ranked across all four of these UNICEF regions.
Discussion Our analysis documents a dramatic increase in the reliance on CHDs for delivering key child health and nutrition interventions. The increases are particularly marked in Africa, which accounts for roughly 60% of all CHDs conducted during the decade from 1999 to 2010. These events serve as the delivery platform for an increasing number of services as well. Almost one-third of events held in 2010 included five or more interventions. While CHDs originated as events largely defined by the codelivery of vitamin A, immunization, and deworming, they have evolved into diverse packages. In the most recent reporting years, these have included an increasing number of nontraditional services, such as distribution of water purification tablets or screening and referral services for severe acute malnutrition. Even with their growing diversity, the continued emphasis of CHDs is on delivering interventions such as vaccinations and vitamin A (i.e., commodities). Evidence shows that these have fared better in terms of coverage in that they are low discretionary interventions, requiring less specific information and little variability in their delivery [9]. Services such as nutrition screening, birth registration, growth monitoring, and behavioral change communication have been included in only about one-quarter of all events. This may be due to their highly discretionary nature, requiring providers to have specific and often unique information for each client. Such interventions may be more effectively delivered on an individual level or through group-based strategies (e.g., women’s groups), as opposed to high-volume events like CHDs. Our review has found nutrition screening to be included in a small number of events. Experience from Ethiopia using the
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Enhanced Outreach Strategy shows that large numbers of children could be successfully screened using midupper-arm circumference in drought-prone woredas of the country and then referred for follow-up [10]. Other countries in sub-Saharan Africa, specifically those with a high burden of severe acute malnutrition, are increasingly considering and testing the integration of nutrition screening in CHDs in an effort to strengthen the link between preventive and curative services [11]. The ability to tailor CHDs for specific populations, driven by the needs assessments and planning at the subnational level, has been cited as one of the strategy’s major strengths [6, 7]. Yet, there is some criticism that the choice of codelivered services may be driven largely by convenience [12]. Given our reliance on global reporting system data, we were unable to assess contextual factors driving the choice of interventions or the appropriateness of packages to given settings. However, our data do suggest that packages may be influenced somewhat by historical trends. For instance, the evolution of CHDs from events such as Micronutrient or Vitamin A Days [6, 7, 10] may account for the common inclusion of maternal iron–folic acid distribution and the largely nutrition-themed behavioral change communication messages. We also found an increasing diversity in service packages. It is possible that this reflects tailoring by countries to meet specific needs. Alternatively, it may be the result of the increasing number and diversity of services. Future studies should closely monitor at what point the absolute number of codelivered services becomes burdensome. This is likely to have an effect on the ability of CHDs to maintain high coverage, as well as the quality of service delivery for components like behavioral change communication messages or the nutrition counseling that accompanies growth monitoring. There is a general consensus in the literature that CHDs and other integrated events have improved coverage of key interventions such as vitamin A supplementation [4, 13–18], deworming [19–21], insecticide-treated bednets [22–26], and measles vaccine [27]. Pre- and postevent coverage surveys have also highlighted improvements in coverage equity [23–25, 28–30], leading the World Bank to rank integrated events, including CHDs, as pro-poor [31]. Despite these promising data, there are a number of concerns. Documented coverage gains have been largely restricted to commodities (e.g., vitamin A capsules, insecticide-treated bednets) as opposed to indicators reliant on behavioral change, such as exclusive breastfeeding rates [8, 32]. Furthermore, these analyses have tended to focus on one commodity. Our data show that countries are increasingly codelivering five or more services during the same event. It remains unclear whether there are diminishing returns with regard to coverage or service quality as countries expand the package of codelivered interventions. Finally, until CHDs are
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able to reach and sustain universal or near-universal coverage, we may be concentrating services among a subset of children and thus significantly increasing inequity [33]. Improvements in coverage are largely based on the fact that, without these efforts, there would be no effective mechanism for reaching children under 5 years of age, and particularly those more than 1 year of age. Routine delivery remains weak, especially in sub-Saharan Africa, where our data show the greatest reliance on CHDs. Some authors cite concerns that coverage gains through CHDs may actually be at the expense of routine, facility-based health service delivery. For instance, one investigation found “widespread evidence that primary healthcare (PHC) staff were being diverted from their usual PHC functions” [8] and pointed to disproportionate remuneration for CHD compared with routine activities. Other challenges include a disconnect between the free distribution of commodities during CHDs versus the fee-for-service primary healthcare model, a limited impact from commodities delivered without sufficient behavioral change communication (e.g., distribution of insecticide-treated bednets leads to high coverage but does not always increase the proportion of children sleeping under insecticide-treated bednets), unequal resource allocation (e.g., investments in campaigns far exceed those in routine services), and poor integration of data management (e.g., event coverage may not be captured by the health management information system or there may be difficulties in reconciling routine and event coverage data) [8, 34]. However, some evidence suggests that the effect of CHDs on routine primary healthcare activities may be modified by baseline health system functionality. Among more developed health systems in Eastern and Southern Africa, for example, there was a large degree of integration, so that CHDs functioned as an extension of routine service delivery [8]. In areas with weaker health systems, the impact depended on efforts expended in coordination, management, and capacitybuilding of staff through training and supervision. Similarly, work in Madagascar suggested that CHDs were able to increase routine EPI coverage in areas where health facilities were better at tracking infants and pregnant women who had missed contacts [35]. Where facilities were less adept at identifying missed contacts, routine coverage was boosted only during the event, subsiding afterwards [35]. Given the increasing reliance on CHDs, clear guidance is urgently needed to ensure that CHDs are implemented as part of systematic efforts to improve health systems. As noted, CHDs play an indispensable role in service delivery where health systems are weakest [4]. Due to the lack of regular and predictable funding, however, the periodicity of CHDs in these settings is not always guaranteed and may be dependent upon disease-specific campaigns. There may also be appeals
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to deliver a large service package, with inadequate consideration of staff burden and detrimental effects on coverage or service quality. As health information systems are inadequate, service delivery tends to be monitored based solely on marking tally sheets, rather than consistent recording of services in registers and on child health cards. Yet numerous prospects for strengthening of health systems exist [36]. These include building the capacity of health managers to design and execute multiyear strategic plans, ensuring a semiannual CHD schedule, identifying an appropriate package of interventions based on the epidemiologic situation of the country, and using monitoring data to inform program management. There are also opportunities for training health workers, e.g., to strengthen injection safety and waste management or to emphasize the importance of child-centered monitoring. In addition, providing a regular and reliable supply of essential health and nutrition services can be an effective means of building the trust of local populations in health systems and state-provided services [37]. In the context of more developed health systems, CHDs should be included in national and subnational health plans on a 6-monthly schedule as a means to supplement facility-based primary healthcare services. These plans would ideally include budget lines for CHD operational costs and commodities, supported by Poverty Reduction Strategies or Sector-Wide Approaches. CHDs in this context would rely on a combination of health facilities, outreach by primary healthcare staff and volunteers (door-to-door or mobilization to a central site), and approaches such as contracting with nongovernmental organizations. Intervention packages also vary according to the setting to include services that are not reaching coverage targets. Although funding streams may still be separate, every attempt should be made to work synergistically with routine services, not only to avoid drawing health staff away from their essential responsibilities, but also to strengthen those activities. For instance, routing CHD commodities through the essential medicines supply system can be used as a means to reinforce supply management capacity. Tracking CHD performance using Health Management Information System registers and child health cards can bolster the use of these tools for following up missed contacts and referrals, although the feasibility of child-centered monitoring in the context of large-scale events remains a challenge. Ultimately, CHDs can transition from a special event toward an enhanced form of primary healthcare extension services. At this level, they gain recognition as part of the primary healthcare worker’s job responsibilities and are conducted without any additional incentives. Instead of every 6 months, this enhanced outreach is done periodically for those populations with poor access to facility-based primary healthcare services. Although we benefited from a rich database of
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information, both from systematized monitoring of vitamin A and from open-ended reporting via the WHO/UNICEF Joint Reporting Form, there were several limitations. Most notably, the lack of standardized reporting of codelivered services prior to 2005 forced us to exclude these data from some analyses. Our work was initially limited to the vitamin A database; however, we were concerned that vitamin A reporting might have missed information on codelivered commodities or CHDs without a vitamin A component. We therefore endeavored to merge in information from the WHO/UNICEF Joint Reporting Form database. Yet, the different database structures and the open-ended nature of the Joint Reporting Form supplementary reporting section forced us to match records solely by the month that campaigns occurred. It is therefore possible that we incorrectly linked some commodities, or that we failed to identify certain codelivered interventions. Even with these combined data sources, some important aspects of CHDs were still not adequately captured. For instance, we were unable to determine the primary social mobilization strategies (e.g., doorto-door, mobilization to a central site) employed during CHDs, or any variability in delivery strategy or intervention packages at the subnational level. To our knowledge, the data presented here provide the most comprehensive picture to date of CHD scaleup and service packages. Many countries, especially in sub-Saharan Africa, are relying on CHDs to increase coverage of key health and nutrition interventions for children. However, there are several unanswered questions. More in-depth analyses are needed regarding their ability to deliver services to the poorest and
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most underserved populations, costs and comparative cost-effectiveness, and effective integration of CHDs with routine service delivery. Future research should consider whether the increasingly diverse services delivered via CHDs are guided by epidemiologic considerations, and whether the rising number of codelivered interventions is affecting coverage performance or service quality. Further evaluation at the national and subnational levels is also needed to document and disseminate best practices with regard to planning, training, logistics, community awareness and social mobilization, record-keeping, supervision, monitoring, and evaluation.
Authors’ contributions Amanda C. Palmer and Aaltje Camielle Noordam generated the CHD database. Amanda C. Palmer conducted analyses and drafted the manuscript. All authors contributed to the manuscript. All authors read and approved the final manuscript and are responsible for the final content. Amanda C. Palmer’s contribution to this publication was as a paid consultant to UNICEF.
Acknowledgments We thank Mickey Chopra, Nicholas Oliphant, and Amy Rice for their comments on early versions of this manuscript. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or stated policy of UNICEF.
References 1. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361:2226–34. 2. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet 2003;362:65–71. 3. Bryce J, el Arifeen S, Pariyo G, Lanata C, Gwatkin D, Habicht JP. Reducing child mortality: can public health deliver? Lancet 2003;362:159–64. 4. Goodman T, Dalmiya N, de Benoist B, Schultink W. Polio as a platform: using national immunization days to deliver vitamin A supplements. Bull World Health Organ 2000;78:305–14. 5. CORE Group. Partnership in Action: an integrated approach to combining a measles campaign with a bed net, vitamin A and mebendazole campaign in Zambia. Washington, DC: CORE Group, 2004. 6. UNICEF. Results from the Child Health Days assessments: preliminary findings: Ethiopia, Tanzania and Uganda. Presentation at the Global Immunization Meeting, 13–15 February 2007. New York: UNICEF, 2007. 7. Micronutrient Forum. Proceedings of the First Meeting of the Micronutrient Forum, 16–18 April 2007. Istanbul,
2007. 8. Doherty T, Chopra M, Tomlinson M, Oliphant N, Nsibande D, Mason J. Moving from vertical to integrated child health programmes: experiences from a multicountry assessment of the Child Health Days approach in Africa. Trop Med Int Health 2010;15:296–305. 9. Chopra M, Sharkey A, Dalmiya N, Anthony D, Binkin N; UNICEF Equity in Child Survival, Health and Nutrition Analysis Team. Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition. Lancet 2012;380:1331–40. 10. Fiedler JL, Chuko T. The cost of Child Health Days: a case study of Ethiopia’s Enhanced Outreach Strategy (EOS). Health Policy Plan 2008;23:222–33. 11. Nyirandutiye DH, Ag Iknane A, Fofana A, Brown KH. Screening for acute childhood malnutrition during the National Nutrition Week in Mali increases treatment referrals. PLoS One 2011;6:e14818. 12. Haws RA, Thomas AL, Bhutta ZA, Darmstadt GL. impact of packaged interventions on neonatal health: a review of the evidence. Health Policy Plan 2007; 22:193–215.
419
Global expansion of Child Health Days
13. Acharya K, Sanghvi T, Diene S, Stapleton V, Seumo E, Srikantiah S, Aminu F, Ly C, Dossou V. Using ‘Essential Nutrition Actions (ENA)’ to accelerate coverage with nutrition interventions in high mortality settings. Arlington, Va, USA: Basic Support for Institutionalizing Child Survival Project (BASICS II), 2004. 14. Aguayo VM, Garnier D, Baker SK. Drops of life: vitamin A supplementation for child survival. Progress and lessons learned in West and Central Africa. Dakar, Senegal: UNICEF Regional Office for West and Central Africa, 2007. 15. Khan MA, Ahmad M, Munir MA, Nazir A, Shams N, Hussain O, Ahmed R. Evaluation of vitamin A supplementation piloting in Pakistan. Ottawa: Micronutrient Initiative, 2006. 16. United Nations Children’s Fund. Vitamin A supplementation: a decade of progress. New York: UNICEF, 2007. 17. Deitchler M, Mathys E, Mason J, Winichagoon P, Tuazon MA. Lessons from successful micronutrient programs. Part II: program implementation. Food Nutr Bull 2004;25:30–52. 18. Best Practices in Nutrition: Summary Report. BoboDioulasso, Burkina Faso: West African Health Organization, 2006. 19. REACH. Acting at scale: implementation case studies— deworming. New York: REACH Partnership, 2009. 20. Soil-transmitted helminthiasis. Number of children treated 2007–2008: update on the 2010 global target. Wkly Epidemiol Rec 2010;85:141–7. 21. Soil-transmitted helminthiasis. Progress report on number of children treated with anthelminthic drugs: an update towards the 2010 global target. Wkly Epidemiol Rec 2008;82:237–52. 22. Grabowsky M, Nobiya T, Ahun M, Donna R, Lengor M, Zimmerman D, Ladd H, Hoekstra E, Bello A, BaffoeWilmot A, Amofah G. Distributing insecticide-treated bednets during measles vaccination: a low-cost means of achieving high and equitable coverage. Bull World Health Organ 2005;83:195–201. 23. Terlouw DJ, Morgah K, Wolkon A, Dare A, Dorkenoo A, Eliades MJ, Vanden Eng J, Sodahlon YK, Ter Kuile FO, Hawley WA. Impact of mass distribution of free longlasting insecticidal nets on childhood malaria morbidity: The Togo National Integrated Child Health Campaign. Malar J 2010;9:199. 24. Thwing J, Hochberg N, Vanden Eng J, Issifi S, Eliades MJ, Minkoulou E, Wolkon A, Gado H, Ibrahim O, Newman RD, Lama M. Insecticide-treated net ownership and usage in Niger after a nationwide integrated campaign. Trop Med Int Health 2008;13:827–34. 25. Distribution of insecticide-treated bednets during a polio immunization campaign—Niger, 2005. MMWR Morb Mortal Wkly Rep 2006;55:913–6. 26. Distribution of insecticide-treated bednets during an integrated nationwide immunization campaign—Togo,
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
West Africa, December 2004. MMWR Morb Mortal Wkly Rep 2005;54:994–6. World Health Organization/UNICEF. WHO/UNICEF joint annual measles report 2007: strengthening immunization services through measles control. Geneva: WHO, 2008. Grabowsky M, Farrell N, Hawley W, Chimumbwa J, Hoyer S, Wolkon A, Selanikio J. Integrating insecticidetreated bednets into a measles vaccination campaign achieves high, rapid and equitable coverage with direct and voucher-based methods. Trop Med Int Health 2005;10:1151–60. Kulkarni MA, Vanden Eng J, Desrochers RE, Cotte AH, Goodson JL, Johnston A, Wolkon A, Erskine M, Berti P, Rakotoarisoa A, Ranaivo L, Peat J. Contribution of integrated campaign distribution of long-lasting insecticidal nets to coverage of target groups and total populations in malaria-endemic areas in Madagascar. Am J Trop Med Hyg 2010;82:420–5. Skarbinski J, Massaga JJ, Rowe AK, Kachur SP. Distribution of free untreated bednets bundled with insecticide via an integrated child health campaign in Lindi Region, Tanzania: lessons for future campaigns. Am J Trop Med Hyg 2007;76:1100–6. Gwatkin DR, Wagstaff A, Yazbeck AS, eds. Reaching the poor with health, nutrition, and population services: what works, what doesn’t, and why. Washington, DC: World Bank, 2005. Bryce J, Gilroy K, Jones G, Hazel E, Black RE, Victora CG. The Accelerated Child Survival and Development programme in West Africa: a retrospective evaluation. Lancet 2010;375:572–82. Victora CG, Fenn B, Bryce J, Kirkwood BR. Co-coverage of preventive interventions and implications for childsurvival strategies: evidence from national surveys. Lancet 2005;366:1460–6. Wallace A, Dietz V, Cairns KL. Integration of immunization services with other health interventions in the developing world: what works and why? Systematic literature review. Trop Med Int Health 2009;14:11–9. Ralaivao JS, Rabemanantena J, Shimp L. Community involvement in maternal and child health in Madagascar. Available at: http://www.immunizationbasics. jsi.com/Docs/IMMbasics_Madagascar_Community_ mobilization_experience_(English).pdf. Accessed 10 September 2013. World Health Organization/UNICEF. WHO/UNICEF joint annual measles report: strengthening immunization services through measles control. Geneva: WHO, 2009. Mogedal S, Stenson B. Disease eradication: friend or foe to the health system. Synthesis report from field studies in Tanzania, Nepal and Lao PDR. Geneva: World Health Organization, 1999.
Amanda C. Palmer, Theresa Diaz, Aaltje Camielle Noordam, and Nita Dalmiya Abstract Background. In efforts to meet the Millennium Development Goal for mortality among children under 5 years of age, countries require strategies for covering hard-toreach and older children who are often missed by routine, fixed-site health services. Objective. To document the evolution of Child Health Days (CHDs), designed as regular events for the delivery of health and nutrition services to children under the age of five. Methods. We extracted information on service delivery strategies and codelivered interventions for the period 1999 to 2010 from global monitoring databases for vitamin A and immunization. Results. Our data illustrate a dramatic rise in CHDs over the decade: only two countries held CHDs in 1999; in 2010, 96 CHDs were conducted in 51 countries. Reliance on CHDs has been particularly marked in sub-Saharan Africa, where they are increasingly used to deliver five or more services per event. Whereas early CHDs were largely defined by codelivery of vitamin A, immunizations, and deworming, they have since evolved into diverse packages including services such as water purification tablets and screening for severe malnutrition. Conclusions. The scale-up of CHDs is helping countries to achieve high and equitable coverage of essential health and nutrition services. Future research should consider whether the increasingly diverse services delivered via CHDs are guided by epidemiologic considerations, and whether the rising number of codelivered
Amanda C. Palmer is affiliated with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Theresa Diaz, Aaltje Camielle Noordam, and Nita Dalmiya are affliated with UNICEF, New York. Please direct queries to the corresponding author: Theresa Diaz, UNICEF Programme Division, Health Section, Knowledge Management Implementation Research Unit, 3 U.N. Plaza, New York, NY 10017, USA; e-mail: [email protected].
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interventions is affecting coverage performance or service quality. Guidance is also needed to ensure that CHDs are implemented as part of systematic efforts to improve health systems.
Key words: Campaign, Child Health Day, child survival, integrated event
Introduction It has been almost a decade since the Lancet Child Survival Series drew global attention to the 10 million children dying each year from preventable causes [1]. Even with an arsenal of highly efficacious and costeffective measures [2], weak health systems were largely hindering the ability to deliver services to those with the greatest need [3]. The international community responded to this call for action with substantial investment. A major focus of that investment has been the scale-up of integrated, often campaign-style events to supplement routine, fixed-site primary healthcare service delivery. These events are most commonly referred to as Child Health Days (CHDs), although terminology may vary by country. CHDs developed from the early linkage of vitamin A supplementation with the Expanded Programme on Immunization’s National Immunization Days (NIDs) for polio eradication [4]. As the phase-out of NIDs began, selected countries in sub-Saharan Africa and Southeast Asia began to experiment with another style of integrated service delivery most commonly referred to as Child Health Days. In sub-Saharan Africa, early CHDs generally relied on existing donor-supported campaigns as a platform, such as adding vitamin A supplements and insecticide-treated bednets to a measles campaign in Zambia [5] or adding deworming to Micronutrient Days in many West African countries [6, 7]. CHDs in Southeast Asia, such as Preschoolers’ Health Weeks in the Philippines, functioned more as intense social mobilization efforts to promote existing
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services. More recently, a campaign strategy has been used in South Asia, where vitamin A supplementation and other services have been linked with the region’s continued polio eradication efforts, and in Central Asian countries like Uzbekistan, stand-alone vitamin A supplementation campaigns are now being used as a platform to deliver missed vaccines. Countries in Latin America and the Caribbean have traditionally held “immunization campaigns,” which were essentially health promotion events to which vitamin A supplementation has now been added. Although CHDs have become increasingly common over the past several years [8], neither their scale-up nor their impact has been consistently monitored or evaluated. In November 2009, the UNICEF Programme Division convened a Joint Working Group to develop guidance for countries on the design and implementation of CHDs to maximize their impact on child health and nutrition. The first portion of this work, and the goal of the present article, was to catalogue all CHDs conducted over the period from 1999 to 2010 and to summarize event composition, in terms of both the number of services delivered and specific intervention packages.
Methods For the purposes of this review, we defined CHDs as regular events, i.e., generally conducted every 6 months, organized to deliver two or more health or nutrition services to infants, children under the age of five, and, in some cases, pregnant or lactating women. The term “events” is used, as the actual service delivery strategy may fall anywhere on the spectrum from door-to-door campaigns lasting for a few days to month-long mobilization of communities to visit fixed site health facilities. These were differentiated from stand-alone events to deliver any one commodity, and other integrated events (i.e., with two or more services) scheduled based on disease control priorities, including integrated polio, measles, and tetanus Supplementary Immunization Activities. We compiled data from two existing databases: UNICEF’s vitamin A database and the World Health Organization (WHO)/UNICEF Joint Reporting Form immunization database. UNICEF has collected vitamin A supplementation coverage data annually since 1999. For the period from 1999 to 2004, the forms included fields to capture vitamin A delivery mechanisms (e.g., measles Supplementary Immunization Activities); information regarding codelivered services was provided on an ad hoc basis. Since 2005, forms have captured delivery mechanism (routine only, Supplementary Immunization Activities, CHDs, other) and codelivered services via close-coded questions. Services include immunization; deworming; distribution
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or retreatment of insecticide-treated bednets; growth monitoring and promotion; water, sanitation, and hygiene (WASH); screening and referral for severe malnutrition; behavioral change communication; and other services. Verbatim descriptions of “other” services and behavioral change communication messages were also captured. The Joint Reporting Form database includes one section for supplementary activities, which captures the commodity delivered, round or type of campaign (e.g., NID), date of delivery, and targeted geographic area (national or subnational). Since the Joint Reporting Form is organized by commodity rather than event, we employed the delivery date to link codelivered commodities or to identify those delivered in stand-alone campaigns. Commodities for which the date of delivery was missing were excluded from our analyses. We linked vitamin A and Joint Reporting Form databases by delivery date. When two dates matched, we updated the original vitamin A record with additional information on services delivered, including specific vaccines. When events were unique to the Joint Reporting Form, these were appended to the vitamin A database. We then calculated the total number of codelivered services for each event. Immunization was counted as a single service, regardless of the number of codelivered antigens. Events delivering only one service were classified as stand-alone. Those with two or more services, not including immunization, were classified as CHDs. For events with two or more services, including polio, measles, or tetanus toxoid vaccines, we reviewed the full set of reported events from 1999 to 2010 in order to differentiate between CHDs and integrated Supplementary Immunization Activities. Integrated events including polio, measles, or tetanus toxoid vaccine were coded as CHDs if the country had previously reported at least one CHD via the close-coded list of delivery mechanisms on the vitamin A reporting form, and a CHD was held in the semester either immediately prior to or immediately following the event. Essentially, any integrated event following the country’s first selfreported CHD would be considered a CHD, unless there was a gap in the 6-monthly schedule. Integrated events including polio, measles, or tetanus toxoid vaccine that did not meet these criteria were coded as integrated Supplementary Immunization Activities. The final database was organized so that the event itself served as the unit of analysis. For each event, we had information on the UNICEF region; the date; the total number of codelivered services; binary variables indicating whether or not each of nine specific interventions was delivered; binary variables indicating which antigens were delivered (routine catch-up, polio, measles, tetanus toxoid, other antigens); and, where applicable, verbatim descriptions of “other antigens,” behavioral change communication messages, and/ or “other” services. Finally, we generated a “package”
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indicator variable, taking on random values 1, 2,…n, for each unique combination (e.g., vitamin A, deworming, and insecticide-treated bednets) of codelivered services.
Results Our database included information on 954 events conducted in 83 countries over the period from 1999 to 2010. These were highly concentrated in sub-Saharan Africa and Southern Asia. Fifty-seven percent of events were classified as CHDs, while the remaining 43% were either integrated polio or measles campaigns. After excluding the 412 integrated NIDs and Supplementary Immunization Activities, we were left with a total of 542 CHDs. As noted above, complete information on event composition was available only from 2005 to 2010, limiting our sample to 474 CHDs.
No. of countries or CHDs
100
Countries
Child Health Days, 1999–2010
A total of 542 CHDs were carried out from 1999 to 2010 in 72 countries. The total number held per year has risen dramatically, from only two events held in 1999 to 96 in 2010 (fig. 1). Countries that held CHDs in 2010 are depicted in figure 2. Sub-Saharan Africa accounts for the majority of CHDs (61%), followed by countries in East Asia and the Pacific (20%) and South Asia (9%). The remaining UNICEF regions have averaged two or fewer CHDs per year. Zambia, Tanzania, and the Philippines have had the most extensive experience, each with 20 or more CHDs conducted between 1999 and 2010. Services delivered
We had complete information on event composition for 474 CHDs. Vitamin A, deworming, and immunization
CHDs
80 60 40 20 0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
FIG 1. Number of countries holding Child Health Days and total number of events by year, 1999 to 2010
FIG. 2. Countries reporting one or more Child Health Days in 2010 based on reports of 136 supplementary activities (i.e., nonroutine service delivery) from 57 countries
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Vitamin A supplementation were the most common services (fig. 3), delivered in 99.6%, 80.8%, and 79.5% Deworming of CHDs, respectively. Polio vaccine Immunization was the most common antigen (35% Growth monitoring of CHDs), followed by measles vacBehavioral change communication cine, tetanus toxoid vaccine, and routine Bednets Expanded Program on Immunization (EPI) antigens. Other antigens, primarOther services ily yellow fever, were included in less Water, sanitation, and hygiene than 5% of CHDs. Although the rankNutrition screening ing of interventions did not vary by 0 20 40 60 80 100 year, there has been a dramatic increase % CHDs in the diversity of services offered. For instance, no WASH interventions (e.g., FIG. 3. Proportion of Child Health Days that included any of nine categories distribution of aquatabs) were delivered of key child health and nutrition interventions, 2005 to 2010. Estimates are in 2005/06 events, but they were incor- based on 474 CHDs conducted in 70 countries from 2005 to 2010 for which porated into 20% to 30% of events from complete data on event composition were available 2007 onwards. Inclusion of nutrition screening and referral to therapeutic services became more common (18% in 2005 and feeding centers has also increased sharply, primarily 27% in 2010). This was most marked in sub-Saharan in Eastern and Southern Africa: prior to 2010, fewer Africa: the proportion of CHDs including only two than five events annually included nutrition screening, services decreased from 51% in 2005 to 9% in 2010, whereas 31% of CHDs (n = 30) included this service in while the proportion delivering five or more services 2010. Roughly 20% of CHDs included “other” services. more than tripled (from 9% to 31%). We found signifiMaternal iron–folic acid supplementation was, by far, cant regional variation in the number of codelivered the most common of these (47%), followed by birth interventions. The numbers were highest in Eastern registration (7%). Where behavioral change commu- and Southern Africa, where 45% of events included nication messages were specified, these were largely five or more services, and East Asia and the Pacific, nutrition-themed (e.g., breastfeeding). where 23% of events included five or more services. In contrast, less than 20% of CHDs in South Asia, Western and Central Africa, or other UNICEF regions Composition of Child Health Days, 2005–2010 (combined due to small sample size) codelivered five Overall, CHDs included a median of four and a or more interventions. maximum of nine interventions. From 2005 to 2010, the proportion of countries codelivering two or three Intervention packages interventions remained roughly the same (53% in 2005 and 48% in 2010); however, codelivery of five or more From 2005 to 2010, CHDs could be classified into 82
TABLE 1. Most common service packages delivered during Child Health Days conducted from 2005 to 2010a Interventions included
Rank
n (%)b
1 2 3 4 5
117 (25) 93 (20) 63 (13) 40 (8) 38 (8)
Vitamin A supplementation X X X X X
Immunization X X X X
Insecticidetreated Deworming bednets X X X X
Otherc X
X
X X
a. Estimates are based on 474 CHDs conducted in 70 countries from 2005 to 2010 for which complete data were available on event composition. b. Number and proportion of all CHDs conducted from 2005 to 2010; these data yielded 83 unique service packages. c. E.g., antenatal iron–folic acid supplementation. This category has been collapsed for illustrative purposes only. Data analysis considered all of the following as independent categories: growth monitoring and promotion; water, sanitation, and hygiene (WASH); screening and referral for severe malnutrition; behavioral change communication; and other interventions.
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different intervention packages, although the top five most common packages accounted for roughly 50% of CHDs (table 1). Overall, codelivery of vitamin A, immunization, and deworming was most prevalent (20%) and ranked either first or second every year. The second most common package overall was vitamin A plus deworming (9%), followed by vitamin A plus immunization (8%), and vitamin A, immunization, deworming, and distribution of insecticide-treated bednets (5%). No other packages accounted for more than 5% of events. Intervention packages are increasingly diverse. In 2005, there were only 19 unique packages. This number climbed to 35 packages in 2010. With regard to regional variation, Eastern and Southern Africa had the most types of packages (53 combinations), followed by Western and Central Africa (33), East Asia and the Pacific (28), and South Asia (9). The combination of vitamin A, immunization, and deworming remained first or second ranked across all four of these UNICEF regions.
Discussion Our analysis documents a dramatic increase in the reliance on CHDs for delivering key child health and nutrition interventions. The increases are particularly marked in Africa, which accounts for roughly 60% of all CHDs conducted during the decade from 1999 to 2010. These events serve as the delivery platform for an increasing number of services as well. Almost one-third of events held in 2010 included five or more interventions. While CHDs originated as events largely defined by the codelivery of vitamin A, immunization, and deworming, they have evolved into diverse packages. In the most recent reporting years, these have included an increasing number of nontraditional services, such as distribution of water purification tablets or screening and referral services for severe acute malnutrition. Even with their growing diversity, the continued emphasis of CHDs is on delivering interventions such as vaccinations and vitamin A (i.e., commodities). Evidence shows that these have fared better in terms of coverage in that they are low discretionary interventions, requiring less specific information and little variability in their delivery [9]. Services such as nutrition screening, birth registration, growth monitoring, and behavioral change communication have been included in only about one-quarter of all events. This may be due to their highly discretionary nature, requiring providers to have specific and often unique information for each client. Such interventions may be more effectively delivered on an individual level or through group-based strategies (e.g., women’s groups), as opposed to high-volume events like CHDs. Our review has found nutrition screening to be included in a small number of events. Experience from Ethiopia using the
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Enhanced Outreach Strategy shows that large numbers of children could be successfully screened using midupper-arm circumference in drought-prone woredas of the country and then referred for follow-up [10]. Other countries in sub-Saharan Africa, specifically those with a high burden of severe acute malnutrition, are increasingly considering and testing the integration of nutrition screening in CHDs in an effort to strengthen the link between preventive and curative services [11]. The ability to tailor CHDs for specific populations, driven by the needs assessments and planning at the subnational level, has been cited as one of the strategy’s major strengths [6, 7]. Yet, there is some criticism that the choice of codelivered services may be driven largely by convenience [12]. Given our reliance on global reporting system data, we were unable to assess contextual factors driving the choice of interventions or the appropriateness of packages to given settings. However, our data do suggest that packages may be influenced somewhat by historical trends. For instance, the evolution of CHDs from events such as Micronutrient or Vitamin A Days [6, 7, 10] may account for the common inclusion of maternal iron–folic acid distribution and the largely nutrition-themed behavioral change communication messages. We also found an increasing diversity in service packages. It is possible that this reflects tailoring by countries to meet specific needs. Alternatively, it may be the result of the increasing number and diversity of services. Future studies should closely monitor at what point the absolute number of codelivered services becomes burdensome. This is likely to have an effect on the ability of CHDs to maintain high coverage, as well as the quality of service delivery for components like behavioral change communication messages or the nutrition counseling that accompanies growth monitoring. There is a general consensus in the literature that CHDs and other integrated events have improved coverage of key interventions such as vitamin A supplementation [4, 13–18], deworming [19–21], insecticide-treated bednets [22–26], and measles vaccine [27]. Pre- and postevent coverage surveys have also highlighted improvements in coverage equity [23–25, 28–30], leading the World Bank to rank integrated events, including CHDs, as pro-poor [31]. Despite these promising data, there are a number of concerns. Documented coverage gains have been largely restricted to commodities (e.g., vitamin A capsules, insecticide-treated bednets) as opposed to indicators reliant on behavioral change, such as exclusive breastfeeding rates [8, 32]. Furthermore, these analyses have tended to focus on one commodity. Our data show that countries are increasingly codelivering five or more services during the same event. It remains unclear whether there are diminishing returns with regard to coverage or service quality as countries expand the package of codelivered interventions. Finally, until CHDs are
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able to reach and sustain universal or near-universal coverage, we may be concentrating services among a subset of children and thus significantly increasing inequity [33]. Improvements in coverage are largely based on the fact that, without these efforts, there would be no effective mechanism for reaching children under 5 years of age, and particularly those more than 1 year of age. Routine delivery remains weak, especially in sub-Saharan Africa, where our data show the greatest reliance on CHDs. Some authors cite concerns that coverage gains through CHDs may actually be at the expense of routine, facility-based health service delivery. For instance, one investigation found “widespread evidence that primary healthcare (PHC) staff were being diverted from their usual PHC functions” [8] and pointed to disproportionate remuneration for CHD compared with routine activities. Other challenges include a disconnect between the free distribution of commodities during CHDs versus the fee-for-service primary healthcare model, a limited impact from commodities delivered without sufficient behavioral change communication (e.g., distribution of insecticide-treated bednets leads to high coverage but does not always increase the proportion of children sleeping under insecticide-treated bednets), unequal resource allocation (e.g., investments in campaigns far exceed those in routine services), and poor integration of data management (e.g., event coverage may not be captured by the health management information system or there may be difficulties in reconciling routine and event coverage data) [8, 34]. However, some evidence suggests that the effect of CHDs on routine primary healthcare activities may be modified by baseline health system functionality. Among more developed health systems in Eastern and Southern Africa, for example, there was a large degree of integration, so that CHDs functioned as an extension of routine service delivery [8]. In areas with weaker health systems, the impact depended on efforts expended in coordination, management, and capacitybuilding of staff through training and supervision. Similarly, work in Madagascar suggested that CHDs were able to increase routine EPI coverage in areas where health facilities were better at tracking infants and pregnant women who had missed contacts [35]. Where facilities were less adept at identifying missed contacts, routine coverage was boosted only during the event, subsiding afterwards [35]. Given the increasing reliance on CHDs, clear guidance is urgently needed to ensure that CHDs are implemented as part of systematic efforts to improve health systems. As noted, CHDs play an indispensable role in service delivery where health systems are weakest [4]. Due to the lack of regular and predictable funding, however, the periodicity of CHDs in these settings is not always guaranteed and may be dependent upon disease-specific campaigns. There may also be appeals
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to deliver a large service package, with inadequate consideration of staff burden and detrimental effects on coverage or service quality. As health information systems are inadequate, service delivery tends to be monitored based solely on marking tally sheets, rather than consistent recording of services in registers and on child health cards. Yet numerous prospects for strengthening of health systems exist [36]. These include building the capacity of health managers to design and execute multiyear strategic plans, ensuring a semiannual CHD schedule, identifying an appropriate package of interventions based on the epidemiologic situation of the country, and using monitoring data to inform program management. There are also opportunities for training health workers, e.g., to strengthen injection safety and waste management or to emphasize the importance of child-centered monitoring. In addition, providing a regular and reliable supply of essential health and nutrition services can be an effective means of building the trust of local populations in health systems and state-provided services [37]. In the context of more developed health systems, CHDs should be included in national and subnational health plans on a 6-monthly schedule as a means to supplement facility-based primary healthcare services. These plans would ideally include budget lines for CHD operational costs and commodities, supported by Poverty Reduction Strategies or Sector-Wide Approaches. CHDs in this context would rely on a combination of health facilities, outreach by primary healthcare staff and volunteers (door-to-door or mobilization to a central site), and approaches such as contracting with nongovernmental organizations. Intervention packages also vary according to the setting to include services that are not reaching coverage targets. Although funding streams may still be separate, every attempt should be made to work synergistically with routine services, not only to avoid drawing health staff away from their essential responsibilities, but also to strengthen those activities. For instance, routing CHD commodities through the essential medicines supply system can be used as a means to reinforce supply management capacity. Tracking CHD performance using Health Management Information System registers and child health cards can bolster the use of these tools for following up missed contacts and referrals, although the feasibility of child-centered monitoring in the context of large-scale events remains a challenge. Ultimately, CHDs can transition from a special event toward an enhanced form of primary healthcare extension services. At this level, they gain recognition as part of the primary healthcare worker’s job responsibilities and are conducted without any additional incentives. Instead of every 6 months, this enhanced outreach is done periodically for those populations with poor access to facility-based primary healthcare services. Although we benefited from a rich database of
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information, both from systematized monitoring of vitamin A and from open-ended reporting via the WHO/UNICEF Joint Reporting Form, there were several limitations. Most notably, the lack of standardized reporting of codelivered services prior to 2005 forced us to exclude these data from some analyses. Our work was initially limited to the vitamin A database; however, we were concerned that vitamin A reporting might have missed information on codelivered commodities or CHDs without a vitamin A component. We therefore endeavored to merge in information from the WHO/UNICEF Joint Reporting Form database. Yet, the different database structures and the open-ended nature of the Joint Reporting Form supplementary reporting section forced us to match records solely by the month that campaigns occurred. It is therefore possible that we incorrectly linked some commodities, or that we failed to identify certain codelivered interventions. Even with these combined data sources, some important aspects of CHDs were still not adequately captured. For instance, we were unable to determine the primary social mobilization strategies (e.g., doorto-door, mobilization to a central site) employed during CHDs, or any variability in delivery strategy or intervention packages at the subnational level. To our knowledge, the data presented here provide the most comprehensive picture to date of CHD scaleup and service packages. Many countries, especially in sub-Saharan Africa, are relying on CHDs to increase coverage of key health and nutrition interventions for children. However, there are several unanswered questions. More in-depth analyses are needed regarding their ability to deliver services to the poorest and
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most underserved populations, costs and comparative cost-effectiveness, and effective integration of CHDs with routine service delivery. Future research should consider whether the increasingly diverse services delivered via CHDs are guided by epidemiologic considerations, and whether the rising number of codelivered interventions is affecting coverage performance or service quality. Further evaluation at the national and subnational levels is also needed to document and disseminate best practices with regard to planning, training, logistics, community awareness and social mobilization, record-keeping, supervision, monitoring, and evaluation.
Authors’ contributions Amanda C. Palmer and Aaltje Camielle Noordam generated the CHD database. Amanda C. Palmer conducted analyses and drafted the manuscript. All authors contributed to the manuscript. All authors read and approved the final manuscript and are responsible for the final content. Amanda C. Palmer’s contribution to this publication was as a paid consultant to UNICEF.
Acknowledgments We thank Mickey Chopra, Nicholas Oliphant, and Amy Rice for their comments on early versions of this manuscript. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or stated policy of UNICEF.
References 1. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361:2226–34. 2. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet 2003;362:65–71. 3. Bryce J, el Arifeen S, Pariyo G, Lanata C, Gwatkin D, Habicht JP. Reducing child mortality: can public health deliver? Lancet 2003;362:159–64. 4. Goodman T, Dalmiya N, de Benoist B, Schultink W. Polio as a platform: using national immunization days to deliver vitamin A supplements. Bull World Health Organ 2000;78:305–14. 5. CORE Group. Partnership in Action: an integrated approach to combining a measles campaign with a bed net, vitamin A and mebendazole campaign in Zambia. Washington, DC: CORE Group, 2004. 6. UNICEF. Results from the Child Health Days assessments: preliminary findings: Ethiopia, Tanzania and Uganda. Presentation at the Global Immunization Meeting, 13–15 February 2007. New York: UNICEF, 2007. 7. Micronutrient Forum. Proceedings of the First Meeting of the Micronutrient Forum, 16–18 April 2007. Istanbul,
2007. 8. Doherty T, Chopra M, Tomlinson M, Oliphant N, Nsibande D, Mason J. Moving from vertical to integrated child health programmes: experiences from a multicountry assessment of the Child Health Days approach in Africa. Trop Med Int Health 2010;15:296–305. 9. Chopra M, Sharkey A, Dalmiya N, Anthony D, Binkin N; UNICEF Equity in Child Survival, Health and Nutrition Analysis Team. Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition. Lancet 2012;380:1331–40. 10. Fiedler JL, Chuko T. The cost of Child Health Days: a case study of Ethiopia’s Enhanced Outreach Strategy (EOS). Health Policy Plan 2008;23:222–33. 11. Nyirandutiye DH, Ag Iknane A, Fofana A, Brown KH. Screening for acute childhood malnutrition during the National Nutrition Week in Mali increases treatment referrals. PLoS One 2011;6:e14818. 12. Haws RA, Thomas AL, Bhutta ZA, Darmstadt GL. impact of packaged interventions on neonatal health: a review of the evidence. Health Policy Plan 2007; 22:193–215.
419
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13. Acharya K, Sanghvi T, Diene S, Stapleton V, Seumo E, Srikantiah S, Aminu F, Ly C, Dossou V. Using ‘Essential Nutrition Actions (ENA)’ to accelerate coverage with nutrition interventions in high mortality settings. Arlington, Va, USA: Basic Support for Institutionalizing Child Survival Project (BASICS II), 2004. 14. Aguayo VM, Garnier D, Baker SK. Drops of life: vitamin A supplementation for child survival. Progress and lessons learned in West and Central Africa. Dakar, Senegal: UNICEF Regional Office for West and Central Africa, 2007. 15. Khan MA, Ahmad M, Munir MA, Nazir A, Shams N, Hussain O, Ahmed R. Evaluation of vitamin A supplementation piloting in Pakistan. Ottawa: Micronutrient Initiative, 2006. 16. United Nations Children’s Fund. Vitamin A supplementation: a decade of progress. New York: UNICEF, 2007. 17. Deitchler M, Mathys E, Mason J, Winichagoon P, Tuazon MA. Lessons from successful micronutrient programs. Part II: program implementation. Food Nutr Bull 2004;25:30–52. 18. Best Practices in Nutrition: Summary Report. BoboDioulasso, Burkina Faso: West African Health Organization, 2006. 19. REACH. Acting at scale: implementation case studies— deworming. New York: REACH Partnership, 2009. 20. Soil-transmitted helminthiasis. Number of children treated 2007–2008: update on the 2010 global target. Wkly Epidemiol Rec 2010;85:141–7. 21. Soil-transmitted helminthiasis. Progress report on number of children treated with anthelminthic drugs: an update towards the 2010 global target. Wkly Epidemiol Rec 2008;82:237–52. 22. Grabowsky M, Nobiya T, Ahun M, Donna R, Lengor M, Zimmerman D, Ladd H, Hoekstra E, Bello A, BaffoeWilmot A, Amofah G. Distributing insecticide-treated bednets during measles vaccination: a low-cost means of achieving high and equitable coverage. Bull World Health Organ 2005;83:195–201. 23. Terlouw DJ, Morgah K, Wolkon A, Dare A, Dorkenoo A, Eliades MJ, Vanden Eng J, Sodahlon YK, Ter Kuile FO, Hawley WA. Impact of mass distribution of free longlasting insecticidal nets on childhood malaria morbidity: The Togo National Integrated Child Health Campaign. Malar J 2010;9:199. 24. Thwing J, Hochberg N, Vanden Eng J, Issifi S, Eliades MJ, Minkoulou E, Wolkon A, Gado H, Ibrahim O, Newman RD, Lama M. Insecticide-treated net ownership and usage in Niger after a nationwide integrated campaign. Trop Med Int Health 2008;13:827–34. 25. Distribution of insecticide-treated bednets during a polio immunization campaign—Niger, 2005. MMWR Morb Mortal Wkly Rep 2006;55:913–6. 26. Distribution of insecticide-treated bednets during an integrated nationwide immunization campaign—Togo,
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
West Africa, December 2004. MMWR Morb Mortal Wkly Rep 2005;54:994–6. World Health Organization/UNICEF. WHO/UNICEF joint annual measles report 2007: strengthening immunization services through measles control. Geneva: WHO, 2008. Grabowsky M, Farrell N, Hawley W, Chimumbwa J, Hoyer S, Wolkon A, Selanikio J. Integrating insecticidetreated bednets into a measles vaccination campaign achieves high, rapid and equitable coverage with direct and voucher-based methods. Trop Med Int Health 2005;10:1151–60. Kulkarni MA, Vanden Eng J, Desrochers RE, Cotte AH, Goodson JL, Johnston A, Wolkon A, Erskine M, Berti P, Rakotoarisoa A, Ranaivo L, Peat J. Contribution of integrated campaign distribution of long-lasting insecticidal nets to coverage of target groups and total populations in malaria-endemic areas in Madagascar. Am J Trop Med Hyg 2010;82:420–5. Skarbinski J, Massaga JJ, Rowe AK, Kachur SP. Distribution of free untreated bednets bundled with insecticide via an integrated child health campaign in Lindi Region, Tanzania: lessons for future campaigns. Am J Trop Med Hyg 2007;76:1100–6. Gwatkin DR, Wagstaff A, Yazbeck AS, eds. Reaching the poor with health, nutrition, and population services: what works, what doesn’t, and why. Washington, DC: World Bank, 2005. Bryce J, Gilroy K, Jones G, Hazel E, Black RE, Victora CG. The Accelerated Child Survival and Development programme in West Africa: a retrospective evaluation. Lancet 2010;375:572–82. Victora CG, Fenn B, Bryce J, Kirkwood BR. Co-coverage of preventive interventions and implications for childsurvival strategies: evidence from national surveys. Lancet 2005;366:1460–6. Wallace A, Dietz V, Cairns KL. Integration of immunization services with other health interventions in the developing world: what works and why? Systematic literature review. Trop Med Int Health 2009;14:11–9. Ralaivao JS, Rabemanantena J, Shimp L. Community involvement in maternal and child health in Madagascar. Available at: http://www.immunizationbasics. jsi.com/Docs/IMMbasics_Madagascar_Community_ mobilization_experience_(English).pdf. Accessed 10 September 2013. World Health Organization/UNICEF. WHO/UNICEF joint annual measles report: strengthening immunization services through measles control. Geneva: WHO, 2009. Mogedal S, Stenson B. Disease eradication: friend or foe to the health system. Synthesis report from field studies in Tanzania, Nepal and Lao PDR. Geneva: World Health Organization, 1999.
