Determinants (Pillars) of Child

Survival, MDGs and SDGs

Dr B. Osano
Paediatrics and Child Health
CHS - UoN

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 Objectives
1. Introduction/Definition

2. To discuss various determinants of health

3. Introduction to MDGs and SDGs

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 Outline
• Determinants of Child Health

• Kenya’s Child survival & Development strategy

• High impact interventions

• MDGs

• SDGs

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 Pillars of Health services delivery
1. Leadership and Governance
2. Health Infrastructure (physical infrastructure,
equipment, transport, ICT)
3. Health Human resource
4. Health information system
5. Procurement and supplies (Health Products)
6. Monitoring and evaluation
7. Health Financing

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Infant and Under-five Mortality Rates,
Kenya 1990/2009 (KDHS and KIHBS)

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 Introduction
• Currently emphasize in diagnostic and
treatment services to individuals.

• We need to focus on those factors

(DETERMINANTS) which have the most
influence on the health of the population.

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Determinants of child health

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Determinants of health framework

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Determinants of Health

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 Contemporary Concept of Health
• Health has multiple determinants.
• Factors important to health, illness, and injury are
social, economic, genetic, perinatal, nutritional,
behavioral, infectious, and environmental.
• Biologic or host factors include:
– genetics
– behaviors that determine the susceptibility of the
individual to disease
– other factors related to susceptibility

Omenn 1998 12
 Genetics and Gender
• Genetic predisposition
– SCD, Haemophiliacs, Immune-deficiency

• Gender:
– different sexes suffer from different ailments at
different times (Ca Cx, prostate ca etc)

• Age:
– Extremes of ages suffer from different ailments
(cancer, infections etc)
1. Davis et al. Race, Genetics, and Health Disparities. American
Journal of Public Health, 2005, Vol 95, No. 12 13
 Social
• Social support networks1

• Availability of harmful products/services such

as alcohol, cannabis, prostitution2

1. Uchino, B. N., 2006. Social Support and Health: A Review of Physiological Processes Potentially
Underlying Links to Disease Outcomes. Journal of Behavioural Medicine, 29(4), pp. 377-387.
2. Davis et al. Race, Genetics, and Health Disparities. American Journal of Public Health, 2005, Vol
95, No. 12
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 cultural
• Lifestyle, diet and stress are areas of human
behavior shaped by cultural differences 1
• Beliefs about disease
– etiology,
– appropriate treatments,
– proper self-care and preventive treatment,
– human physiology, and
– appropriate doctor and patient conduct.
1. Shaw, SJ., et al 2009,’ The role of culture in health literacy and chronic disease screening and management’,
Journal of immigrant and minority health, vol.11, no.6, pp. 460-467

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 Cultural
• Food types and malnutrition

• Practices
– FGM, incision of gums, cutting of epiglottis

• Etiology and/or explanation of illnesses

– No need for treatment if there is no pain
– Hypertension, DM, Cancer screening etc
– Be-witched “Chira”, “bad eye”, “Ebiriri” etc
Beiersmann, C., Sanou, A., Wladarsch, E., De Allegri, M., Kouyate, B. &
Muller, O. 2007, "Malaria in rural Burkina Faso: local illness concepts,
patterns of traditional treatment and influence on health-seeking
behaviour", Malaria journal, vol. 6, pp. 106
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 Political/Security
• Political stability and wars
– Availability /supply of pillars of service delivery
– Post election violence in Kenya
– North Eastern/Coast province

Roberts, B. et al., 2009. An exploration of social determinants of health amongst internally displaced
persons in northern Uganda. Conflict and Health, 3(10), pp. 1752-1505.

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 Economic
• Affordability
• The well off
– Seek medical care in health facilities
– Tend to get better services

Ahmed, S.M., Tomson, G., Petzold, M. & Kabir, Z.N. 2005, "Socioeconomic status
overrides age and gender in determining health-seeking behaviour in rural
Bangladesh", Bulletin of the World Health Organization, vol. 83, no. 2, pp. 109-117.

Eshetu, E. B. & Woldesenbet, S. A., 2011. Are there particular social determinants
of health for the world’s poorest countries?. African Health Sciences , 11(1), pp.
108-115. 18
 Income & Health
• Poor neighborhoods
– often dangerous • Offer residents, no
– high crime rates matter what their race,
– substandard housing income or education,
– few or no decent medical little chance to improve
services nearby their lives and engage in
– low-quality schools health-promoting
– little recreation behaviors.
– almost no stores selling
wholesome food

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Diez et al. 2001
 Education level
• Low education:
– Poor health,
– more stress and
– lower self-confidence.
• Means of communication
• Proxy for socio-economic status
KDHS 2008
Pignone, M.P. & DeWalt, D.A. 2006, "Literacy and health outcomes: is adherence the
missing link?", Journal of general internal medicine, vol. 21, no. 8, pp. 896-897.

Saha, S. 2006, "Improving literacy as a means to reducing health disparities", Journal of

general internal medicine, vol. 21, no. 8, pp. 893-895

Shaw, S. J. et al., 2009. The Role of Culture in Health Literacy and Chronic Disease
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Screening and Management. Journal of immigrant and minority health, 11(6), pp. 460-467.
 Religion
• Some religion do not believe in conventional
medicine/ blood and blood products
– “Kabonokia”
– Jehovah Witnesses,
– Some Jews

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 Environmental
• Built environment
– Transportation: access, accidents
– Buildings: aeration, warmth
– Street design

• Natural environment
– Pollution
– Air, water,

• Informational environment
– Advertising
– Health information

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 Environmental Quality
• Hazardous Wastes
• Air Pollution
• Water Pollution
• Ambient Noise
• Residential Crowding
• Housing Quality
• Educational Facilities
• Work Environments
• Neighborhood Quality

Lee, et. al 2003 23

 Physical environment
• WASH: safe water, Sanitation, Hygiene,
• healthy workplaces/homes/schools,
• safe houses, communities and roads
• Play area(s)

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MoH: Child Survival and Development
Strategy 2008-2015
• Guided by the National Health Sector Strategic
Plan II: 2005–2010 (NHSSP II)
• Targets anticipated in achieving the MDGs and
Vision 2030
• use the lifecycle approach and focus on
mother and child from pregnancy to postnatal
period, early childhood and adolescent period
• Strengthening of the level 1&2 health system
that focus on the community and
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Child Survival & Development Strategy
• Increasing the coverage of several available,
simple, key evidence-based and cost effective
child survival interventions (Lancet 2003) will
have a significant impact on under five
mortality

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 Child survival and development strategic
framework
GOAL.
• To support the Ministry of Health to achieve the
health and nutrition MDGs.
PURPOSE.
• To raise national awareness, understanding and
commitment to maternal and child survival and
development and support a coherent and budgeted
framework to achieve the MDGs.

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 The objectives of the Child Survival
strategy are:
• To provide a framework that all partners will
support to scale up and accelerate Child
Survival and Development in Kenya;

• To advocate for increased political will and

financial commitment for Child Survival and
Development in Kenya.

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 Universal coverage with a few interventions can
prevent over 6 million deaths in a year
Deaths Deaths
Prevented as Prevented as
Prevention proportion of Treatment proportion of
Intervention All child deaths Intervention All child deaths
Breastfeeding 13% Oral rehydration 15%
Insecticide-treated materials 7% Antibiotics for 6%
pneumonia
Complimentary feeding 6% Antimalarials 5%

Zinc 5% Zinc 4%
Hib vaccine 4% Antibiotics for 3%
dysentery
Water, sanitation, hygiene 3%

Vitamin A 2%

Simple cost effective interventions can reduce U5 mortality by 60%.

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 High Impact interventions for MNCH
Period Level of Care
Community Facility
ANC Create demand for early ANC, 4 ANC visits with Focused
Birth and emergency preparedness Antenatal Care (FANC)
HIV testing and counseling package, Referral ,PMTCT
Use of LLITNS ART for mothers
Delivery Community actions to promote skilled care Emergency Obstetric and
Newborn Care (EmONC)
Postnatal care Behaviour Change Communication (BCC) Skilled attendance within 24-
for FP and postnatal care and skilled 48 hrs of delivery
attendance within 24-48 hrs of delivery Long and permanent FP
methods
Maternal and perinatal death
reviews
Newborn Hand washing, Hand washing, temperature
temperature management , management , early initiation
early initiation and exclusive and exclusive BF,
breastfeeding (BF) resuscitation, antibiotics for
infections, PMTCT
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 MDGs
• Eight international development goals
• Established following the Millennium Summit
of the United Nations in 2000, baseline year
1990
• Followed the adoption of the United Nations
Millennium Declaration
• Goals to be achieved by the year 2015
• Each goal had specific targets and dates for
achieving them
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 MDGs
• The MDGs were built on the recognition that problems
of poverty, hunger, poor health, lack of education,
social and economic discrimination and environmental
degradation are commonly interconnected and must
be addressed in concert if sustainable improvements in
the poor’s health and well being are to be achieved

• Together they aimed to create well nourished, healthy,

educated populations with adequate and equitable
access to basic goods and services, live and work in
safe and secure environments

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The 8 MDGs had:
• 21 quantifiable
targets and

• 61 indicators

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MILLENNIUM DEVELOPMENT GOALS

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MILLENNIUM DEVELOPMENT GOALS

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 TARGETS AND INDICATORS
MDG 4 REDUCE CHILD MORTALITY
• TARGET: Reduce by two-thirds, between 1990
and 2015, the under-five mortality rate
INDICATORS
• Under-five mortality rate
• Infant mortality rate
• Proportion of 1 year-old children immunised
against measles
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 TARGETS AND INDICATORS
MDG 5 IMPROVE MATERNAL HEALTH
• TARGET: Reduce by three quarters, between
1990 and 2015, the maternal mortality ratio
and Achieve, by 2015, universal access to
reproductive health
INDICATORS
• Maternal mortality ratio
• Proportion of births attended by skilled health
personnel
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 TARGETS AND INDICATORS
MDG 6 COMBAT HIV/AIDS, MALARIA AND OTHER
DISEASES
• TARGET: Halt by 2015 and begun to reverse the spread of
HIV/AIDS
INDICATORS
• HIV prevalence among population aged 15-24 years
• Condom use at last high-risk sex
• Proportion of population aged 15-24 years with
comprehensive correct knowledge of HIV/AIDS
• Ratio of school attendance of orphans to school
attendance of non-orphans aged 10-14 years

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 State of MDGs in Kenya
• Population below the poverty
– 56% in 2000
– 45.9% in 2006.
– Close to 60% as of 2015!

• Basic education: Primary school

– Net enrollment: 77:7% in 2002 to 92.9% in 2009
– Completion: 62.8% in 2002 to 83.2% in 2009

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What helped?

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 What helped?
• Immunization
• Water, Sanitation and Hygiene
• Breastfeeding/Nutrition (IYCF)
• Growth monitoring
• Proper case management: Malaria, diarrhoea,
pneumonia, sepsis
– Antibiotic treatment
• HIV/AIDS care
• Free primary education
• Free maternity services
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 To follow details
• Tracking the global process of MDG

www.undp.org/mdg/progress.shtml

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 MDGs gaps by 2015
• High levels of extreme poverty and hunger.

• Many children who are denied the right to primary education.

• Gender inequality persists

– Discrimination in education, work, economic assets and
decision making.

• Economic gaps: poorest and richest households, rural/urban

• Sanitation facilities

• Mortality rate for children under five

– Child deaths continue to be increasingly concentrated in
the poorest regions and in the first month of life
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 Sustainable development goals
(SDGs)
• 17 goals
– 169 targets
• Start on 1 January 2016 and to be achieved by
31 December 2030.
• However, some targets that build on preset
international agreements are expected to be
achieved even earlier than the end of 2030

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 Six Elements of the SDGs
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THE 17 SUSTAINABLE DEVELOPMENT GOALS
TARGETS

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 Goal 3: Ensure healthy lives and
promote well-being for all
• Maternal mortality ratio to less than 70 per 100,000
live births
• End preventable deaths of newborns and children
under 5
– NMR to at least as low as 12 per 1,000 live births
and
– U5MR to at least as low as 25 per 1,000 live births
• End the epidemics of AIDS, TB malaria and neglected
tropical diseases and combat hepatitis, water-borne
diseases and other communicable diseases
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 Goal 3: Ensure healthy lives and
promote well-being for all
• Reduce by one third premature mortality from
NCDs through prevention and treatment and
promote mental health and well-being

• Strengthen the prevention and treatment of

substance abuse, including narcotic drug
abuse and harmful use of alcohol

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 Goal 3: Ensure healthy lives and
promote well-being for all
• By2020, halve the number of global deaths
and injuries from road traffic accidents

• Ensure universal access to sexual and

reproductive health-care services, including
for family planning and the integration of
reproductive health into national strategies
and programs

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 Goal 3: Ensure healthy lives and
promote well-being for all
• Achieve universal health coverage

• Reduce the number of deaths and illnesses

from hazardous chemicals and air, water and
soil pollution and contamination

• Strengthen the implementation of the WHO

Framework Convention on Tobacco Control in
all countries, as appropriate
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 Goal 3: Ensure healthy lives and
promote well-being for all
• Support the research and development of vaccines and
medicines for the communicable and non-communicable
diseases, and, in particular, provide access to medicines for all

• Substantially increase health financing and the recruitment,

development, training and retention of the health workforce
in developing countries, especially in least developed
countries and small island developing States

• Strengthen the capacity of all countries, in particular

developing countries, for early warning, risk reduction and
management of national and global health risks

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 Goal 6:Ensure availability and sustainable
management of water & sanitation (targets)
• Achieve universal and equitable access to safe,
quality and affordable WASH, and end open
defecation,
– Special attention women and girls & vulnerable
– Improve water quality globally by:
• Reducing pollution,
• Eliminating dumping and
• Minimizing release of hazardous chemicals and materials,
• Halving the proportion of untreated wastewater and
• Substantially increasing recycling and safe reuse

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Goal 2: End hunger, achieve food security, improve
nutrition and promote sustainable agriculture
• End hunger and ensure access by all people to
safe, nutritious and sufficient food all year
round

• End all forms of malnutrition,

– including achieving, by 2025, agreed targets on
• Stunting and wasting in children under 5 years of age,
• Address the nutritional needs of adolescent girls,
pregnant and lactating women and older persons

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 Where to get information?
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❑http://sustainabledevelopment.un.org/
Questions

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 Summary
• Health determinants include:
– Health systems in place
– genetics,
– environment,
– socio-cultural/Religious,
– economic,
– Literacy/Education
– Security/Politics
• Child survival strategy and vision 2030 address some of
these
• MDGs/SDGs are aimed at addressing the determinants
• Health workers need to be aware of them to intervene
appropriately

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THANK YOU 59
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Impacts of Various Domains on Early Deaths in the United
States

Genetic Predisposition (30%)

30%
40% Social Circumstances (15%)

Environmental Exposure (5%)

Shortfalls in Medical Care (10%)

15% Behavioral Patterns (40%)

10% 5%

Adapted from McGinnis JM, Williams-Russo P, Knichman JR. The

case for more active policy attention to health promotion. 62
Health Aff (Millwood) 2002;21(2):78-93.
Tuberculosis

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Lienhardt 2001 64
 Environmental Determinants
• Environment includes:
– physical environment
– conditions of living
– toxic agents
– infectious agents

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 Social Determinants
• Social factors of importance include:
– poverty
– education
– cultural environments (including isolation)

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 The determinants of health include:
• The social and economic environment,
• the physical environment, and
• the person’s individual characteristics and
behaviour

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