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THE STATE OF AFRICA’S CHILDREN 2008
Child
Survival
3
Contents
Introduction................................................. 1 Panels
Child survival in Africa: Communities unite to find Eritrea finds ways to reach the goal; Improving and
solutions harmonizing national health plans
Figure
1.1 Subregions and regions of Africa
3 Community partnerships in primary
health care for Africa’s mothers,
newborns and children........................ 28
1 Child survival – Where we stand.......... 3 A multiplicity of community-based approaches;
Success factors in community partnerships;
Child mortality above and below the Sahara; Child
Examples of successful community partnerships in
survival in Africa south of the Sahara; Progress
primary health care in Africa; Integrating community
towards the health-related Millennium Development
partnerships into district services and national policies
Goals in Africa; The main causes of child deaths in
sub-Saharan Africa; New hope for child survival:
Seven key gains of recent years; Accelerating progress Panels
on the health-related MDGs; Creating a supportive
Community partnerships in nutrition in Ethiopia, Malawi
environment for child survival strategies
and Sudan; Gambia, Morocco and Ghana: Expanding
immunization services and saving children’s lives;
Panels Ghana and Malawi: Improving access to clean water and
sanitation facilities; Togo: Integrating interventions to
Malawi: One country and its progress in child survival;
South Africa: Saving children’s lives by scaling up early accelerate progress on child survival; Community care
infant diagnosis; Sierra Leone: A unified plan gives hope boosts child survival in Niger
of reducing maternal and child deaths from the world’s
highest rates; Children of conflict: Helping them survive
4 Strengthening community partnerships,
Figures the continuum of care and health systems
1.2 Progress in reducing child mortality by region in Africa........................................................ 35
1.3 Health and the Millennium Development Goals Scaling up; Packaging interventions by service
delivery mode; National strategic planning for
1.4 Sub-Saharan Africa bears an increasing burden
scaling up services and systems; Developing health
of global under-five deaths
systems for outcomes; Obtaining national political
1.5 Subregional comparisons of under-five mortality commitment
rates in Africa
1.6 West Africa accounted for more than 40 per cent
of Africa’s child deaths in 2006 Panels
1.7 Sub-Saharan Africa is making insufficient or no Making children the ‘absolute priority’ in Angola; The
progress towards all of the health-related MDGs challenge of retaining and training skilled health workers;
1.8 The main causes of child deaths in World Health Egypt: A simple way to save young lives; The investment
Organization’s Africa region, 2000 case for child survival and other health-related MDGs in
1.9 Child nutrition in Africa’s subregions sub-Saharan Africa
1.10 Immunization rates have risen across all of
Africa in recent decades
1.11 Rising antiretroviral treatment for HIV-positive 5 Uniting for child survival in Africa............. 45
pregnant women to prevent mother-to-child Making child survival in Africa a regional and global
transmission imperative
1.12 Educational differences by gender
Panels
2 Lessons learned from evolving Why good governance means great things for Africa’s
children, by Joaquim Alberto Chissano; Mobilizing mobile
health-care systems and practices..... 21 phones to improve health services
Disease control; Comprehensive primary health care;
Selective primary health care; Integrated approaches;
Towards a unified framework for maternal and child References......................................................... 50
health care; Key lessons learned from evidence and
experience
Statistics............................................................ 53
i
Acknowledgements
This report was prepared by The State of the World’s Children team in New York with
contributions and guidance from the UNICEF Regional Offices for West and Central Africa,
Eastern and Southern Africa, and the Middle East and North Africa, and from UNICEF
country offices in those regions. Patricia Moccia was the editor in chief, David Anthony
was the consulting editor and William Lee was the coordinating editor. Kate Rogers and
Hirut Gebre-Egziabher were the principal writers and researchers.
Contributions from the regional and country offices were coordinated by Martin Dawes and
Patricia Lone for West and Central Africa and Eastern and Southern Africa, respectively, and
by Abdel Rahman Ghandour for North Africa. Special thanks to Gaëlle Bausson, Genevieve
Begkoyian, Thierry Delvigne-Jean, Yvonne Duncan, James Elder, Lone Hvass, Sara Johansson,
Macharia Kamau, Melanie Renshaw, Asako Saegusa, Angus Spiers, Abdulai Tinorgah and
MacKay Wolff. Policy guidance and comments on the text were provided by David Alnwick,
Barbara Bentein, Geert Cappelaere, Victor Chinyama, Hoosain Coovadia, Demissie Habte,
Anthony Hodges, Adele Khudr, Rudolf Knippenberg, Ngashi Ngongo, Dorothy Rozga,
Mahendra Sheth, Rumishael Shoo and Henk van Norden.
Editorial support was provided by Amy Lai, Charlotte Maitre, Karin Shankar, Catherine Rutgers,
Emily Goodman, Marilia Di Noia, Michelle Risley, Kristin Moehlmann and Gabrielle Mitchell-
Marell. Regional and subregional aggregate statistical tables were prepared by the Strategic
Information Section of the Division of Policy and Planning, with thanks to Nyein Nyein Lwin
and Priscilla Akwara. Production was led by Jaclyn Tierney and Edward Ying, Jr. Design and
pre-press production was undertaken by Choon Shim and Kaspar Tingley of Creatrix.
Photo credits
Cover photo: © UNICEF/HQ06-0197/Michael Kamber (Djibouti).
Inside photos: p. 1, © UNICEF/HQ04-0556/Mariella Furrer; p. 3, © UNICEF

Uganda/2007/Chulho Hyun; p. 5, © UNICEF/HQ05-1407/Christine Nesbitt; p. 6, © UNICEF/
HQ06-0036/Brendan Bannon; p. 9, © UNICEF Côte d’Ivoire/2007/Parfait Kouassi; p. 13,
© UNICEF Senegal/2007/Nisha Bakker; p. 16, © UNICEF/HQ05-2147/Giacomo Pirozzi; p. 20,
© UNICEF Uganda/2007/Chulho Hyun; p. 21, © UNICEF/HQ02-0264/Giacomo Pirozzi; p. 22,
© UNICEF Côte d’Ivoire/2006/Bruno Brioni; p. 25, © UNICEF/HQ05-2269/Giacomo Pirozzi;
p. 27, © UNICEF Mozambique/2007/Thierry Delvigne-Jean; p. 28, © UNICEF Nigeria/2007/
Abayomi Adeshida; p. 29, © UNICEF Zambia/2007/G. Aubourg; p. 30, © UNICEF/HQ05-0566/
Boris Heger; p. 32, © UNICEF Uganda/2007/Chulho Hyun; p. 33, © UNICEF/HQ04-0830/
Thierry Delvigne-Jean; p. 34, © UNICEF/HQ05-1051/Radhika Chalasani; p. 35, © UNICEF/
HQ06-1367/Giacomo Pirozzi; p. 38, © UNICEF/HQ07-0657/Giacomo Pirozzi; p. 40, ©
UNICEF Nigeria/2007/Adesoji Tayo; p. 43, © UNICEF/Gambia/2006/BDownes Thomas;
p. 44, © UNICEF/HQ06-2336/Courtesy of Fouad Kronfol; p. 45, © UNICEF Egypt/2007/
Shehzad Noorani; p. 46, © UNICEF/HQ04-0897/Shehzad Noorani; p. 49, © UNICEF/
HQ08-0161/Kate Holt; p. 52, © UNICEF Côte d’Ivoire/2006/Bruno Brioni
For an electronic version of this report, with additional multimedia material, please visit
www.unicef.org, and click on The State of World’s Children 2008. This report can be found
under the ‘Full Report’ icon.
ii
United Republic of Tanzania: A village ‘health day’.
Introduction
Child survival in Africa: Communities unite to find solutions
Every year, the United Nations Children’s Fund This year, UNICEF is also publishing the inaugural
(UNICEF) publishes The State of the World’s Children, edition of The State of Africa’s Children. This volume
the most comprehensive and authoritative report on and other forthcoming regional editions complement
the world’s youngest citizens. The State of the World’s The State of the World’s Children 2008, sharpening from
Children 2008, published in January 2008, examines the a worldwide to a regional perspective the global report’s
global realities of maternal and child survival and the focus on trends in child survival and health, and
prospects for meeting the health-related Millennium outlining possible solutions – by means of programmes,
Development Goals (MDGs) – the targets set by the policies and partnerships – to accelerate progress in
meeting the Millennium Development Goals.
world community in 2000 for eradicating poverty,
reducing child and maternal mortality, combating The State of Africa’s Children 2008 highlights the
disease, ensuring environmental sustainability need to position child survival at the heart of Africa’s
and providing access to affordable medicines in development and human rights agenda. It begins by
developing countries. examining the state of child survival and progress
Editor’s Note: Much of the discussion in The State of Africa’s Children 2008 concentrates on sub-Saharan Africa, composed of the 46 countries in the
UNICEF subregions of Eastern, Southern, West and Central Africa. Except where indicated, the trend analyses and data for sub-Saharan Africa do not
cover two countries, Djibouti and Sudan, which, while lying mostly south of the Sahara in continental Africa, are nominally part of UNICEF’s Middle
East and North Africa region. For the purposes of statistical analysis, as in Figures 1.2, 1.6 and 1.9, Djibouti and Sudan are included only in the data
for Eastern Africa. See Figure 1.1 on page 2 for a breakdown of subregions and country classifications. Some countries are included in more than one
subregion. Solutions and recommendations referring to ‘sub-Saharan Africa’ will also be relevant to Djibouti and Sudan.
Introduction 1
towards the health-related MDGs for children • P
rovide a continuum of care for mothers, newborns
and mothers in each of the continent’s five main and children by packaging interventions for delivery
subregions: Eastern, Central, North, Southern at key points in the life cycle and according to their
and West Africa. Although much of the report mode of delivery.
concentrates on Africa south of the Sahara, cases and • S trengthen community partnerships and health
analysis from North Africa are examined as well. systems, with a strong emphasis on results.
• A
dvance the joint international agency framework
The report outlines five broad priorities that are
for child and maternal survival.
required to accelerate progress and then seeks to
examine each of these issues in depth, illustrating A call for unity permeates the report from beginning
them with side panels that provide examples from the to end. The basis for action – data, research,
African experience. The priorities discussed chapter evaluation, frameworks, programmes and partnerships
by chapter are: – is already well established. The report concludes
that it is time to rally behind the goals of maternal,
• F
ocus on the countries and communities where
newborn and child survival and health with renewed
the burden of child mortality is highest.
vigour and sharper vision, to fulfil the tenets of social
• A
pply the lessons learned and evidence collated justice and honour the sanctity of life – especially the
over the past century. life of the African child.
Figure 1.1
Subregions and regions of Africa*
North Africa West Africa South Africa; Swaziland; Togo;
Algeria; Egypt; Libyan Arab Benin; Burkina Faso; Cape Verde; Uganda; United Republic of Tanzania;
Jamahiriya; Morocco; Tunisia Côte d’Ivoire; Gambia; Ghana; Zambia; Zimbabwe
Guinea; Guinea-Bissau; Liberia; Mali; Horn of Africa
Central Africa Mauritania; Niger; Nigeria; Senegal;
Cameroon; Central African Republic; Sierra Leone; Togo Djibouti; Eritrea; Ethiopia; Somalia
Chad; Congo; Democratic Republic of Sahel
the Congo; Equatorial Guinea; Gabon; Sub-Saharan Africa
Sao Tome and Principe Angola; Benin; Botswana; Burkina Burkina Faso; Cape Verde; Chad;
Faso; Burundi; Cameroon; Cape Gambia; Guinea-Bissau; Mali;
Eastern Africa‡ Verde; Central African Republic; Mauritania; Niger; Senegal
Burundi; Comoros; Djibouti; Eritrea; Chad; Comoros; Congo; Côte d’Ivoire;
Ethiopia; Kenya; Madagascar; Malawi; Democratic Republic of the Congo;
Mauritius; Mozambique; Rwanda; Equatorial Guinea; Eritrea; Ethiopia; * Subregional and regional classifications have
Seychelles; Somalia; Sudan; Uganda; Gabon; Gambia; Ghana; Guinea; been compiled for the purposes of this report
United Republic of Tanzania and may not strictly conform to standard UNICEF
Guinea-Bissau; Kenya; Lesotho;
regional groupings.
Liberia; Madagascar; Malawi; Mali;
Southern Africa Mauritania; Mauritius; Mozambique; ‡
UNICEF subregion plus Djibouti and Sudan.
Angola; Botswana; Lesotho; Namibia; Namibia; Niger; Nigeria; Rwanda;
Source: UNICEF classifications for The State of
South Africa; Swaziland; Zambia; Sao Tome and Principe; Senegal; Africa’s Children 2008 based on United Nations
Zimbabwe Seychelles; Sierra Leone; Somalia; regional groupings.
2 THE STATE OF AFRICA’S CHILDREN 2008

Uganda: A mother takes her son to a health outreach station.
1 Child survival – Where we stand

Child mortality above five mortality rate by two thirds between Saharan Africa as a whole (including
1990 and 2015.1 Djibouti and Sudan) lowered its
and below the Sahara under-five mortality rate by little
The contrast with trends for child more than one third during the same
The African continent is divided by survival in sub-Saharan Africa 36-year period.
the Sahara, the world’s largest desert, (including Djibouti and Sudan) could
and this demarcation is more than not be more striking. In 1970, the Although this contrast provides a
geographical. In countries lying mostly average under-five mortality rate in poignant example of the growing gap
north of the Sahara – Algeria, Egypt, North Africa was 215 deaths per 1,000 in child survival between sub-Saharan
the Libyan Arab Jamahiriya, Morocco live births. This was not significantly Africa and other parts of the world, it
and Tunisia – the average under-five, different from the 1970 rates for Eastern also encourages hope in the fact that
or child, mortality rate for 2006 was Africa, at 216 per 1,000 live births, or some African countries have been able
35 per 1,000 live births, meaning that in Southern Africa, 208 per 1,000 live to sustain high annual rates of reduction
that year, approximately 1 in every 29 births. But between 1970 and 2006, in child mortality over the past four
children died before their fifth birthday. North Africa reduced its under-five decades. The experience of North
Since 1990, each of the five countries mortality by 84 per cent, while the Africa shows it is possible to lower
in North Africa has reduced its child corresponding reductions in Eastern child mortality at a sharp pace, even
mortality rate by at least 45 per cent, and Southern Africa were just 43 per from high rates, when concerted action,
at a subregional average annual rate cent and 30 per cent, to 123 and 146 sound strategies, adequate resources
of 5.3 per cent – putting them well on per 1,000 live births, respectively. With and strong political will are consistently
track to meet Millennium Development Central Africa and West Africa also applied in support of child and maternal
Goal 4, which seeks to reduce the under- failing to post strong reductions, sub- health.
Child survival – Where we stand 3

Figure 1.2
Progress in reducing child mortality by region examines progress in the five principal
Average annual rate of reduction (AARR) in the under-five mortality rate (U5MR) observed for African subregions towards each of these
1990–2006 and required during 2007–2015 to achieve MDG 4. goals, with particular attention given to
U5MR AARR (%)* MDG 4.
1990 2006 Observed Required Progress towards
1990–2006 2007–2015 the MDG target
187 160 1.0 10.5 insufficient progress
MDG 4: Reducing child
Sub-Saharan Africa
165 131 1.4 9.6 insufficient progress
mortality
Eastern and
Southern Africa North Africa is on track, but the
Eastern Africa‡ 171 123 2.1 8.5 insufficient progress four main subregions of Africa
Southern Africa 125 146 -1.0 13.9 no progress south of the Sahara lag behind
West and Central Africa 208 186 0.7 11.0 no progress
187 193 -0.2 12.6 no progress
North Africa is on track to meet MDG 4,
Central Africa
having reduced its under-five mortality
West Africa 215 183 1.0 10.4 insufficient progress
rate by 57 per cent since 1990. All five
North Africa 82 35 5.3 2.8 on track countries in the subregion have under-
South Asia 123 83 2.5 7.8 insufficient progress five mortality rates below 40 per 1,000
East Asia/Pacific 55 29 4.0 5.1 on track live births. Egypt, in particular, has made
Latin America/Caribbean 55 27 4.4 4.3 on track striking progress towards MDG 4 during
53 27 4.2 4.7 on track
recent years, posting a 62 per cent
CEE/CIS**
reduction in its under-five mortality rate
Industrialized countries 10 6 3.2 6.6 on track
between 1990 and 2006. Nonetheless,
Developing countries 103 79 1.7 9.3 insufficient progress in part due to its large population of
World 93 72 1.6 9.4 insufficient progress children under five (8.6 million), Egypt
* A negative AARR indicates an increase in the under-five mortality rate since 1990.
has the highest number of under-five
‡
Includes Djibouti and Sudan. deaths in North Africa – 64,000 in
** Central and Eastern Europe/Commonwealth of Independent States.
On track: U5MR is less than 40, or U5MR is 40 or more and the AARR in the under-five mortality
2006, greater than the combined total
rate observed for 1990–2006 is 4.0 per cent or more. of 56,000 for the four other countries
Insufficient progress: U5MR is 40 or more, and AARR is between 1.0 per cent and 3.9 per cent.
No progress: U5MR is 40 or more, and AARR is less than 1.0 per cent. in the subregion.
Source: UNICEF estimates based on the work of the Inter-agency Group for Child Mortality Estimation.
Prospects for child survival in sub-
Saharan Africa are immensely
Child survival in Africa of countries, such major impediments
challenging. Although the aggregate
as deeply entrenched and widespread
south of the Sahara poverty, the onslaught of AIDS and under-five mortality rate for sub-
civil conflict, inadequate physical Saharan Africa has fallen since 1990,
Africa south of the Sahara remains the infrastructure and low health-system the base year for many of the
most difficult place in the world for a capacity have contributed to stagnation Millennium Development Goals,
child to survive until age five. In 2006, in recent decades – or even rising rates the average annual rate of reduction
the latest year for which firm estimates and numbers of child deaths. (AARR) of just 1 per cent between 1990
are available, the under-five mortality and 2006 was far below the 4-plus per
rate for sub-Saharan Africa was 160 per cent annual rate required during that
1,000 live births, meaning that roughly Progress towards the period to keep countries and regions on
1 in every 6 children failed to reach their
fifth birthday. Although this represents
health-related MDGs track for MDG 4 by 2015.
a 14 per cent reduction since 1990, it in Africa A further disturbing trend is the
remains by far the highest rate of under- increase of sub-Saharan Africa’s share of
five mortality in the world (Figure 1.2). Progress on all eight Millennium global under-five deaths during recent
Development Goals is vital to the decades. This is due in part to a higher
In addition to having the highest
survival and well-being of children, average fertility rate than is found in
regional rate of child mortality,
sub-Saharan Africa is the furthest and six of the goals have targets that other regions of the world. Sub-Saharan
behind on most of the health-related relate directly to children’s health Africa’s 2006 fertility rate, for example,
Millennium Development Goals (Figure 1.3). To reduce child mortality was 5.3* compared with 3.0 for South
(Figure 1.7) – particularly MDG 4 and in sub-Saharan Africa, and to sustain Asia, and 2.8 for developing countries
also MDG 5, which seeks to reduce the progress achieved in North Africa, as a whole. The region’s rising share
maternal mortality by three quarters greater effort is needed to meet the of global under-five deaths is also the
between 1990 and 2015. In a number health-related MDGs. This section product of slow advances in providing

Malawi: A community-based care centre for orphans and other vulnerable children.
Figure 1.3
Health and the Millennium Development Goals
Goal Health Targets Health Indicators
Goal 1: Target 2
Eradicate extreme Halve, between 1990 and 2015, the proportion of Prevalence of underweight children under age five
poverty and hunger people who suffer from hunger Proportion of population below minimum level of dietary energy
consumption
Goal 4: Target 5
Reduce child Reduce by two thirds, between 1990 and 2015, Under-five mortality rate
mortality the under-five mortality rate
Infant mortality rate
Proportion of one-year-old children immunized against measles
GOAL 5: Target 6
Improve maternal Reduce by three quarters, between 1990 and Maternal mortality ratio
health 2015, the maternal mortality ratio
Proportion of births attended by skilled health personnel
GOAL 6: Target 7
Combat HIV and Have halted by 2015 and begun to reverse the HIV prevalence among pregnant women aged 15–24 years
AIDS, malaria and spread of HIV
Ratio of school attendance of orphans to school attendance of
other diseases
non-orphans aged 10–14 years
Target 8
Have halted by 2015 and begun to reverse the Prevalence and death rates associated with malaria
incidence of malaria and other major diseases
Proportion of population in malaria-risk areas using effective malaria
prevention and treatment measures
Prevalence and death rates associated with tuberculosis
Proportion of tuberculosis cases detected and cured under the Directly
Observed Treatment, Short-course (DOTS) strategy
GOAL 7: Target 10
Ensure Halve by 2015 the proportion of people without Proportion of population with sustainable access to an improved water
environmental sustainable access to safe drinking water and source, urban and rural
sustainability basic sanitation
Proportion of population with access to improved sanitation,
urban and rural
GOAL 8: Target 17
Develop a global In cooperation with pharmaceutical companies, Proportion of population with access to affordable essential drugs
partnership for provide access to affordable essential drugs in on a sustainable basis
development developing countries
Source: Adapted from World Health Organization, Health and the Millennium Development Goals, 2005, p. 11.

quality primary health care, inadequate Figure 1.4
nutrition, and a lack of improved water Sub-Saharan Africa bears an increasing burden of global
sources and basic sanitation facilities,
among other factors.
under-five deaths
Comparing sub-Saharan Africa’s share

of under-five deaths over the past three
and a half decades with that of the
rest of the world puts its position into
sharper relief (Figure 1.4). In 1970,
sub-Saharan Africa accounted for
11 per cent of the world’s births and
19 per cent of global under-five deaths.
By 2006, while sub-Saharan Africa’s
share of global births doubled to
22 per cent, its share of global under-
five deaths soared to almost 50 per cent.
West and Central Africa’s combined
share of global under-five deaths has
tripled since 1970, from 10 per cent Source: UNICEF estimates based on the work of the Inter-agency Group for Child Mortality Estimation.
to 30 per cent, while the share for
Eastern and Central Africa combined
has more than doubled. When child under-five mortality rate between 1990 Africa, Swaziland, and Zimbabwe – the
deaths for Djibouti and Sudan are and 2006. Southern Africa has posted devastating impact of AIDS has caused
combined with those for sub-Saharan a 17 per cent increase in the under- under-five mortality to soar well beyond
Africa, the combined total accounted five mortality rate over the period, its 1990 rate, inflating the subregional
for 50 per cent of all global under although its absolute numbers of child average.
five deaths in 2006. In contrast, the deaths are still far lower than those
proportion for the rest of the world of the other subregions (Figure 1.6). The countries of the Horn of Africa
has fallen. In a number of countries in Southern have made good progress, managing
Africa – Botswana, Lesotho, South to reduce their under-five mortality
Differences in child mortality
between Central, Eastern, Southern * The total fertility rate equals the number of children who would be born per woman if she lived
to the end of her childbearing years and bore children at each age in accordance with prevailing
and West Africa age-specific fertility rates.
This section examines under-five

mortality rates in four separate
subregions of sub-Saharan Africa. The
purpose is to assess disparities in trends,
rates and levels between subregions, and
to discuss the possible implications for
programmes, policies and partnerships.
The findings are compelling. Of the four

subregions, Central Africa has made the
least progress in reducing its numbers
of under-five child deaths since 1990.
Indeed, its subregional aggregate has
edged upward from 187 per 1,000 live
births in 1990 to 193 per 1,000 live
births in 2006. West Africa, starting
from a higher base rate of 215 per 1,000
live births, managed to reduce its under-
five mortality rate by 15 per cent to 183
per 1,000 live births by 2006.
Eastern Africa has seen steady progress,

with a 28 per cent reduction in the Somalia: A health worker measures a child’s arm to determine her nutritional status.

Figure 1.5 occur in Central Africa. The countries
of the Sahel and the Horn of Africa
Subregional comparisons of under-five mortality rates
account for 12 per cent and 10 per cent,
in Africa respectively, of the entire continent’s
Central Africa
Eastern Africa under-five deaths. Three countries – the
300 Southern Africa Democratic Republic of the Congo,
under-five deaths per 1,000 live births
West Africa Ethiopia and Nigeria – account for more

North Africa
250 than 43 per cent of total under-five
deaths in all of Africa.
200
Of the 46 countries in sub-Saharan
150 Africa, only Cape Verde, Eritrea,
Mauritius and Seychelles are on track
100 to attain MDG 4, according to the
December 2007 special edition of
50 Progress for Children: A world fit for
children statistical review, UNICEF’s
0 flagship report card on progress towards
1970 1980 1990 2000 2006
internationally agreed targets for
Source: UNICEF estimates based on the work of the Inter-agency Group for Child Mortality Estimation. children. Of greatest concern are the
24 countries in the region registering
no progress, or increases, in under-five
rates by 39 per cent since 1990. More 6 infants is exclusively breastfed during
mortality rates since 1990. Both Djibouti
rapid advances are possible if key issues, the first six months of life – would
and Sudan are making insufficient
particularly the poor nutritional status contribute to improving children’s
progress towards MDG 4, and will
of children under age five – with nearly nutritional status.
need to increase their annual rate of
half moderately or severely stunted –
An examination of the distribution of reduction of under-five mortality from
are addressed. Any advances will also
child deaths among Africa’s subregions, 1.9 per cent in 1990–2006 to 8.9 per cent
depend on an end to the conflict in
including Djibouti and Sudan, reveals in 2007–2015 to meet the goal.
Somalia, where women and children
have borne the brunt of a debilitating that despite posting the sharpest
Sub-Saharan Africa faces an immense
combination of conflict, natural disaster increase in under-five mortality rates
and unprecedented challenge to meet
and outbreaks of disease that have since 1990, Southern Africa accounts
Millennium Development Goal 4 on
produced a growing humanitarian for only 8 per cent of child deaths
time. Achieving MDG 4 will require
crisis. The countries of the Sahel have in the region as whole. The bulk of
reducing the number of child deaths
made less progress, with the under-five child deaths is borne by West Africa
between 2007 and 2015 at more than
mortality rate declining by just 11 per (42 per cent), followed by Eastern Africa
10 times the rate recorded between
cent since 1990. Heightening rates of (30 per cent). Just less than 20 per cent
of child deaths in sub-Saharan Africa 1990 and 2006. If current trends persist,
exclusive breastfeeding – only 1 in every
2.8 million children under five in sub-
Saharan Africa will die in the MDG
Figure 1.6 target year of 2015 whose lives could
West Africa accounted for more than 40 per cent of have been saved in that year alone if
Africa’s child deaths in 2006 MDG 4 had been met.
Southern Africa 8%
Sub-Saharan Africa also lags on the
(0.4 million) other health-related MDGs (Figure 1.7).
Central Africa18%
According to Progress for Children,
(0.9 million)
North Africa 2% sub-Saharan Africa is:
(0.1 million)
• Making insufficient progress towards
eradicating extreme poverty and
hunger (MDG 1).
Eastern Africa 30% • Displaying rates of maternal mortality
(1.5 million) West Africa 42%
(MDG 5) classified as very high.
(2.1 million) • Yet to halt and begin to reverse the
spread of HIV (MDG 6).
• Making no progress towards ensuring
Source: UNICEF estimates based on the work of the Inter-agency Group for Child Mortality Estimation. environmental sustainability (MDG 7).

The main causes of standard classification for sub- and services that have been identified as
Saharan Africa only in that it includes the most basic, yet important, include:
child deaths in sub- Algeria and omits Somalia. The next
Saharan Africa major killer is pneumonia, which is • Skilled attendants at birth and follow-
responsible for more than one fifth of up care after delivery.
The major causes of death among child deaths. Malaria and diarrhoeal • Prevention of mother-to-child
children under five in sub-Saharan diseases account for 18 per cent and transmission of HIV and paediatric
Africa are well known (Figure 1.8). 17 per cent, respectively, of child deaths. treatment of AIDS.
Other significant causes are AIDS,
According to the latest figures published • Adequate nutrition, particularly
particularly in the countries of Southern
in the World Health Organization’s in the form of early and exclusive
Africa, and measles.
World Health Statistics 2007, neonatal breastfeeding during the first six
diseases account for more than one The essential interventions and practices months of life.
quarter of deaths in the WHO Africa required to avert most child deaths in • Complementary feeding combined
region, which differs from UNICEF’s Africa are also well known. Practices with continued breastfeeding for at
least two more years.
• Micronutrient supplementation to
Figure 1.7 boost immune systems.
Sub-Saharan Africa is making insufficient or • Immunization to protect children
no progress towards all of the health-related MDGs against the six major vaccine-
preventable diseases.
indicatorS of Latest firm average Progress
progress in estimate Annual rate towards the
• Oral rehydration therapy and zinc to
meeting Millennium of reduction MDG target combat diarrhoeal diseases.
Development Goals (1990–2006) • Antibiotics to fight pneumonia.
MDG 1 • Insecticide-treated mosquito nets and
Underweight prevalence 28% (2000–2006) 1.1 Insufficient effective medicines to prevent and
in children under five progress treat malaria.
MDG 4 • Hygiene promotion, including hand
washing with soap, point-of-use water
Under-five mortality rate 187 per 1,000 live 1.0 Insufficient
births (1990); 160 per progress
treatment and excreta disposal.2
1,000 live births (2006)
Although coverage rates of many
MDG 5 of these interventions remain low
Maternal mortality ratio, 920 per 100,000 live n/a ‘Very high’* across much of the region, there
adjusted births (2005) have been significant advances in
providing preventive measures against
MDG 6
childhood illness, as outlined in
Malaria, under-fives 8% (2003–2006) n/a Yet to halt and the next section, New hope for child
sleeping under an reverse the spread survival. There has been less progress,
insecticide-treated net of malaria
however, in increasing coverage rates
Paediatric HIV infections 2.0 million (2005) n/a Yet to halt and for effective treatment of childhood
(children aged 1–14) reverse the spread illness – particularly of pneumonia and
of HIV
diarrhoeal diseases, which together
HIV prevalence among 9.7% (2005) n/a Yet to halt and account for 38 per cent of child
young pregnant women reverse the spread deaths in the WHO Africa region. Of
(aged 15–24) in capital city of HIV
those children younger than five in
MDG 7 sub-Saharan Africa with suspected
Use of improved sources 48% (1990); 55% (2004) n/a No progress pneumonia, only 40 per cent are taken
of drinking water to an appropriate health-care provider.
Use of improved sanitation 32% (1990); 37% (2004) n/a No progress Coverage of treatment for diarrhoeal
facilities diseases is even lower, with fewer than
one third of under-fives with diarrhoea
* ‘Very high’ indicates a maternal mortality ratio of 550 or more deaths of women from
pregnancy-related causes per 100,000 live births. in sub-Saharan Africa receiving
the recommended treatment: oral
Source: UNICEF, Progress for Children: A World Fit for Children statistical review, Number 6,
December 2007; and The State of the World’s Children 2008; Joint United Nations Programme rehydration therapy or increased fluids
on HIV/AIDS, 2006 Report on the Global AIDS Epidemic, UNAIDS, Geneva, 2006. with continued feeding.

Côte d’Ivoire: A mother breastfeeds her child as a community health worker looks on.
Figure 1.8 The four subregions of sub-Saharan

The main causes of child deaths in the World Health Africa, including Djibouti and Sudan
within Eastern Africa, have high rates
Organization’s Africa region, 2000* of undernutrition, as measured by rates
of moderate or severe underweight,
Neonatal diseases
Other wasting and stunting (Figure 1.9).
25%
6%
Undernutrition is most acute in the
Injuries Sahel and in the Horn of Africa, owing
2% in part to food insecurity. In addition,
AIDS rates of exclusive breastfeeding up to
7% six months remain low, particularly
in Central, Southern and West Africa.
Pneumonia Southern Africa has fallen behind on
21%
vitamin A supplementation, with only
Diarrhoeal diseases half of children aged 6–59 months
17% receiving full coverage, or two doses,
of this micronutrient, while less than
Malaria half of households in Eastern Africa
Measles
18% 4%
consume iodized salt.
* WHO’s Africa region differs from UNICEF’s regional grouping for sub-Saharan Africa in that it Although North Africa has far lower
includes Algeria and excludes Somalia. For a list of the countries in UNICEF’s regional grouping
for sub-Saharan Africa, see Figure 1.1, p. 2. rates of undernutrition as measured
by underweight and wasting, challenges
Source: World Health Organization, World Health Statistics 2007, p. 31.
in child nutrition remain. Roughly
1 in every 6 children under five in
Tackling undernutrition and improving child nutrition is a prerequisite to North Africa is moderately or severely
environmental health are also urgent achieving MDG 4. stunted, and more than 1 in every 4
concerns in sub-Saharan Africa. households do not consume iodized
More than one third of child deaths Adequate nutrition must begin during salt. Contrastingly, among wealthier
are attributable to maternal and child pregnancy. Maternal undernutrition can households, obesity and overnutrition
have lifelong consequences for children, are emerging as key health issues for
undernutrition. Achieving MDG 1,
including impaired prenatal growth, low young children and adolescents.
which aims to reduce poverty and
birthweight birth and increased risk of
hunger, would help avert child deaths developmental disabilities later in life. Enhancing environmental health
from diarrhoea, pneumonia, malaria, Indeed, the nutritional status of women remains particularly challenging for
HIV and measles and reduce neonatal is a telling indicator of the health and sub-Saharan Africa. Around 45 per
mortality. In other words, improving nutrition of children.3 cent of sub-Saharan Africa’s population

Figure 1.9
Child nutrition in Africa’s subregions
% of infants % of children (2000–2006*) who are: % of under-fives (2000–2006*) suffering from: Vitamin A supplementation % of
with low coverage rate (6–59 months) households
birthweight 2005 consuming
iodized salt
underweight wasting stunting
1999–2006* exclusively breastfed with still moderate severe moderate moderate at least one full 2000–2006*
breastfed complementary breastfeeding and severe and severe and severe dose (%) coverage** (%)
food
(<6 months) (6–9 months) (20–23 months)
Central Africa 13 21 75 47 29 9 12 37 93 86 65
Eastern Africa 16 42 69 56 30 8 8 41 79 71 47
North Africa 12 31 61 29 6 1 5 16 - - 71
Southern Africa 12 17 66 41 23 - 6 41 56 50 -
West Africa 15 21 58 46 28 8 10 36 82 80 74
The Sahel 18 16 55 66 34 11 13 37 89 85 45
Horn of Africa 19 45 50 - 38 11 11 45 59 58 20
* Data refer to the most recent year available doing the period specified.
** Refers to the percentage of childen reached with two doses.
Source: UNICEF estimates based on data from Demographic and Health Surveys, Multiple Indicator Cluster Surveys, World Health Organization, UNICEF,
other national household surveys and data from routine reporting systems.
does not use improved drinking-water population growth. Rapid population Running taps and decent toilets have the
sources, and more than 60 per cent expansion in sub-Saharan Africa potential to transform children’s lives.
remain without access to improved translates to 54 million children under Better sanitation alone could reduce
sanitation facilities as of 2004, the most five without access to an improved worldwide diarrhoea-related morbidity
recent year for which firm estimates are drinking-water source; in Eastern and by more than a third; improved
available (Figure 1.7). Southern Africa, the number of people sanitation combined with hygiene
without basic sanitation increased by awareness and behaviour change could
Some progress has been achieved since one third between 1990 and 2004.5 reduce it by two thirds.
1990 in increasing access to improved
drinking-water sources throughout The repercussions of inadequate While several African countries have
Africa. Progress towards improved environmental health facilities are made substantial progress in improving
sanitation, however, has been grossly often deadly. Recent estimates of water and sanitation, none can afford
insufficient, with only eight countries the number of children under five to rest on its achievements. Among the
– the five North African nations plus dying from diarrhoea stand at nearly largest disparities in safe water and basic
Djibouti, Malawi and Senegal – on track sanitation are those between urban
2 million a year worldwide, and in
to meet the MDG7 target of halving the and rural populations. The urban-
some countries the proportion of child
proportion of people without access to rural divide in drinking water is at its
deaths due primarily to diarrhoea is
basic sanitation by 2015.4 widest among the world’s regions in
as high as 20 per cent. An estimated
sub-Saharan Africa, where 81 per cent
In West and Central Africa combined, 88 per cent of global diarrhoeal deaths
of people in urban areas are served,
the number of people without access are attributed to lack of water for
compared with 41 per cent in
to improved water sources and basic hygiene, unsafe drinking-water supplies
rural areas.6
sanitation facilities was higher in and poor access to sanitation.
2004 than in 1990. In Eastern and
Southern Africa combined, the Equally unacceptable is the fact that New hope for child
70 per cent of children with diarrhoea in
proportions were 56 per cent with
sub-Saharan Africa do not receive oral
survival: Seven key
access to improved water sources
(up from 48 per cent in 1990) and rehydration therapy, a simple salt and gains of recent years
38 per cent with access to basic sugar solution that treats dehydration
sanitation (a slight improvement from from diarrhoea and prevents possible Sub-Saharan Africa’s lack of progress
35 per cent in 1990), but the increase death – and costs less than five U.S. towards many of the health-related
in coverage has not kept pace with cents per dose. MDGs is a cause for concern at

the midway point between the uniting around frameworks, • Rising rates of exclusive breastfeeding
establishment of the goals in 2000 at programmes and policies to expand up to six months.
the Millennium Summit and the 2015 quality health care rapidly to mothers
• Expanded distribution and use of
deadline for their completion. However, and children through a continuum
micronutrient supplementation.
faster progress may ensue during the of care across time and location.
coming years as a result of recent • A growing consensus on the
reductions in children’s deaths Seven key gains in child survival within framework and strategies required
from measles – by a remarkable sub-Saharan Africa during recent to accelerate progress.
91 per cent between 2000 and 2006 years indicate that faster advances
– and notable increases in rates of are possible. These include: 1. Rapid progress in child
exclusive breastfeeding, vitamin survival in several countries
A supplementation, the use of • Rapid progress in child survival in
insecticide-treated mosquito nets, several sub-Saharan African Gains in child survival are evident even
and improvements in identifying countries since 1990. in some of Africa’s poorest countries.
HIV-positive pregnant women and • A remarkable reduction in measles Furthermore, the examples of several
interventions to prevent mother-to- deaths among children between countries in the region that have made
child transmission of HIV, among 2000 and 2006. significant advances in reducing child
other interventions. There is also mortality rates since 1990 inspire
• Advances in malaria prevention hope. Statistics show that dramatic
cause for optimism in the fact that
and treatment. improvements in child mortality
national governments, international
agencies, donors, non-governmental • Increased access to antiretroviral and health can be attained rapidly.
organizations, national administrations treatment for HIV-positive mothers According to data from The State of the
and communities are increasingly and children. World’s Children 2008, the under-five
Malawi: One country and 86 per cent received the full Goal 4 target for reducing child
two-dose coverage. mortality will be reached.
and its progress in child
survival At 56 per cent, exclusive breast- A 2005 UNICEF report reaffirms
feeding for children up to six months the success of the IMCI strategy:
is also relatively high by regional “In 2000, following an initial pilot
ALTHOUGH child mortality in Malawi standards. About 73 per cent of phase, Malawi started scaling up
remains high by global standards, households use an improved water the implementation of intermittent
the country has achieved significant source. The Government of Malawi preventive treatment (IPT) for
progress in reducing child deaths. reported that more than 1 million pregnant women, and distribution
From 1990 to 2005, the under-five of subsidized insecticide-treated
insecticide-treated mosquito nets
mortality rate fell from 221 to 125 per mosquito nets to mothers during
had been distributed by December
1,000 live births. Its 2006 under-five visits to antenatal care and child-
2006 – exceeding the Abuja target of welfare clinics. The high antenatal
mortality rate of 120 per 1,000 live 60 per cent by reaching 65 per cent coverage, development of a clear
births is the same as or lower than of pregnant women and children policy on IPT in pregnancy, and
that of 30 other countries in Africa under age five. The government the active and positive support
south of the Sahara. also claimed that polio had been from partners (particularly UNICEF,
eliminated in Malawi in 2002, with WHO, USAID, Population Services
Factors contributing to this rapid no new cases reported since then. International and Roll Back Malaria)
reduction in child mortality include have all contributed significantly to
very high immunization coverage According to the Government’s the positive results attained by this
and vitamin A supplementation. 2006 ‘A World Fit for Children’ strategy.”
Among Malawian children aged one report, the reduction in under-five
year or younger, 99 per cent receive mortality can also be attributed to One factor that has not changed
tuberculosis, polio and hepatitis B the expansion of high-impact health since the 1990s is the prevalence of
vaccines, as well as three doses of undernutrition, which remains the
interventions under the Integrated
diphtheria/pertussis/tetanus and three underlying cause of almost half of
Management of Childhood Illness child deaths in Malawi. Nineteen
doses of Haemophilus influenzae (IMCI) approach, which focuses on per cent of children under five are
type b vaccines, and 85 per cent are parental care and targets malaria, moderately or severely underweight,
immunized against measles. In undernutrition, anaemia, pneumonia, and 46 per cent are moderately or
2006, 94 per cent of Malawian measles and diarrhoea. If this severely stunted.
children aged 6–59 months received reduction rate continues, the report
at least one dose of vitamin A, states, the Millennium Development See References, page 50.

mortality rate has fallen by 40 percent in several ways – for example, through cent), Guinea-Bissau (39 per cent) and
or more since 1990 in Eritrea, Ethiopia, the promotion of safe injection practices, Togo (38 per cent). Other countries
Malawi and Mozambique – countries enhanced cold chain capacity for are on the brink of registering much
whose per capita gross national income vaccination storage and the development higher figures for distribution and usage
is below US$350 a year. of a global public health laboratory of insecticide-treated mosquito nets.
network. In addition, vaccination For instance, since its last household
campaigns are being combined with survey in 2005, Ethiopia has distributed
2. Remarkable reduction in such other essential interventions as more than 18 million nets, and Kenya
measles deaths vitamin A supplementation, deworming has distributed more than 10 million
medicines and insecticide-treated since its last survey in 2003.8 Across
After slipping back during the 1990s, mosquito nets. sub-Saharan Africa, local production of
particularly in Central and West Africa,
insecticide-treated mosquito nets more
immunization rates in the region have
than doubled, from 30 million to 63
edged steadily upward for all major 3. Advances in malaria million a year, between 2004 and 2006.
vaccines, including the third dose of prevention and treatment
diphtheria, pertussis and tetanus (DPT3)
Recent data from Kenya indicate that
and the measles vaccine – the latter In much of sub-Saharan Africa, the
coverage and socio-economic equity are
is one of the three indicators used to region hardest hit by malaria-related
both enhanced when insecticide-treated
measure progress towards MDG 4. disease and death, notable progress
mosquito nets are delivered at highly
has been made in the distribution of
Increased coverage of routine measles subsidized prices through routine health
insecticide-treated mosquito nets.
immunization and follow-up campaigns services or free through mass campaigns.
Recent evidence from the region
giving a second opportunity for children More than 10 million nets have been
shows that all countries with trend distributed in Kenya since 2003 through
to be vaccinated have contributed to a data available have expanded their use
91 per cent decrease in measles deaths integrated child and maternal health
among children under five, with 16 of 20 services that include immunization and
in Africa between 2000 and 2006. countries at least tripling coverage since
This represents a major breakthrough antenatal care. A recent survey in four
2000. The latest comprehensive regional Kenyan districts shows this increased
because it implies that the challenge of
figures, however, indicate that only distribution resulted in 67 per cent of
reducing global measles mortality by
15 per cent of children in sub-Saharan children younger than five sleeping
90 per cent by 2010 compared with
2000 rates, a goal established at the 2005 Africa sleep under any type of mosquito under an insecticide-treated net.
World Health Assembly, has been met net, while only 8 per cent sleep under an
ahead of schedule in the African region.7 insecticide-treated net. Several countries Treatment for malaria has also increased
have surpassed the regional average in sub-Saharan Africa, and around one
Measles control activities are contributing usage rate: Gambia (49 per cent around third of children with fever are treated
to health-system development in Africa 2005), Sao Tome and Principe (42 per with antimalarial drugs. Despite recent
Figure 1.10
Immunization rates* have risen across all of Africa in recent decades
100 %
80 %
60 %
Central Africa
Eastern Africa
40 %
North Africa
Southern Africa
20 %
West Africa
0%
84 86 88 90 92 94 96 98 00 02 04 06
19 19 19 19 19 19 19 19 20 20 20 20
* Percentage of infants receiving three doses of diphtheria, pertussis and tetanus vaccine (DPT3). DPT3 is used as the benchmark indicator of annual routine
immunization coverage by UNICEF and the World Health Organization.
Source: UNICEF estimates based on data from UNICEF and World Health Organization.

Senegal: Schoolgirls bring their mosquito nets in for insecticide treatment.
gains in prevention and treatment, countries have adopted artemisinin- if positive, to put free antibiotics into the
however, overall levels of coverage based combination therapy as their first parents’ hands, has had a marked effect
remain low, particularly considering treatment against malaria. in treating affected children promptly.
that the region accounts for 80 per
cent of worldwide deaths from malaria In childhood, malaria and another
among children under five. One major child-killing disease, pneumonia, 4. Increased access to
potential breakthrough is artemisinin- have major overlaps in terms of antiretroviral treatment for
based combination therapy, which is symptoms. Once a child develops HIV-positive mothers and
safe, effective and fast-acting against pneumonia, a caregiver must recognize
the symptoms and seek appropriate care
children
strains of malaria that are multi-drug
resistant. It also has the advantage of immediately. In Senegal, for example, a The AIDS epidemic is a major threat
preventing recurrence of the disease. programme to teach health workers and to child survival in sub-Saharan Africa:
Nearly all sub-Saharan African parents to identify these early signs and, Nearly 90 per cent of global paediatric
cases of HIV-infection and most
Figure 1.11 deaths from AIDS occur in this region.
Rising rates of antiretroviral coverage for HIV-positive Southern Africa has been particularly
affected, seeing its under-five mortality
pregnant women to prevent mother-to-child transmission rate rise from 125 per 1,000 live births
in 1990 to 146 per 1,000 live births in
35 2006. Although the burden of death
West and Central Africa
Eastern and Southern Africa
has been highest in Southern Africa,
receiving antiretrovirals for PMTCT
% of HIV-positive pregnant women
30 Total low and middle income the other subregions have also been
affected.
25
More than 400,000 children under 15
20 were newly infected with the virus in
2007, mostly through mother-to-child
15
transmission.9 Once a pregnant woman
is infected, there is a 35 per cent chance
10
that, without intervention, she will pass
5
the virus on to her newborn during
pregnancy, birth or breastfeeding.10
0
Preventing mother-to-child
2004 2005 2006
transmission of HIV, and identifying
Source: UNICEF estimates based on preliminary data from Joint United Nations Programme
and providing treatment for infected
on HIV and AIDS. mothers and children are among the

South Africa: Saving prolonging medicines through the By the end of 2006, the national
Operational Plan for Comprehensive services had established eight DNA
children’s lives by scaling HIV and AIDS Care, Management PCR laboratories with capacity to
up early infant diagnosis and Treatment for South Africa. perform more than 300,000 tests
per year.
The Government of South Africa
SOUTH Africa has the highest identified children’s access to care Impact: From 2004 to 2006,
AIDS burden in the world, with an and treatment for AIDS as a priority the number of DNA PCR tests
estimated 5.5 million people living in its national response. As early as performed increased from less than
with HIV, around a quarter of a April 2004, it recommended early 20,000 to more than 140,000 per
million children younger than 15 are year – contributing to a remarkable
diagnosis of infection in infants born
HIV-positive (as of 2005). As many boost in access to paediatric
to women who were infected with
as 64,000 newborns contract HIV antiretroviral therapy. The number of
HIV, using the preferred virological
each year through mother-to-child eligible children receiving treatment
method for diagnosing HIV in infants
transmission. About half of HIV- increased from fewer than 3,000 in
at six weeks of age called ‘DNA PCR’.
positive infants who do not receive 2004 to 25,000 by September 2006
Prior to this, the test was not widely
treatment die before their second and 32,000 by December 2007. This
available in the public sector and
birthday, making AIDS the biggest has contributed to saving the lives
National Health Laboratory Services
killer of children – accounting for of hundreds of young children who
half of under-five deaths in South capacity was limited to fewer than
60,000 tests per year – despite the would have died without these
African hospitals. medicines.
estimated annual required capacity
The high mortality rate stems partly of at least 400,000 DNA PCR tests.
AIDS remains the primary challenge
from the fact that access has been to child survival in South Africa.
limited for pregnant women seeking Action: In 2004, the National
Department of Health initiated a To achieve MDG 4 will first require
services for prevention of mother-to- accelerated scaling up of PMTCT
child transmission (PMTCT), and for programme to expand DNA PCR
testing capacity in three laboratories services to prevent as many new
children who need paediatric AIDS infections as possible and reduce
care and treatment. in three provinces: Gauteng,
KwaZulu-Natal and Western Cape. the demand for care and treatment.
As one of the most rural provinces In addition, it will require scaling up
In 2005, only 30 per cent of pregnant
challenged by long distances access to early infant diagnosis, care
women who were infected with HIV
and treatment for those who are
received single-dose nevirapine, between health facilities, KwaZulu-
infected despite PMTCT. Through
26 per cent of HIV-exposed infants Natal introduced dried blood spot
the ‘HIV and AIDS and STI National
received cotrimoxazole prophylaxis, technology, with support from
Strategic Plan 2007–2011’, the
and 18 per cent of eligible children UNICEF, to facilitate specimen
Government and people of South
received antiretroviral therapy. One transportation between health
Africa have committed to achieving
of the major challenges has been facilities and the laboratory.
universal access to PMTCT, care
that children’s HIV status was rarely
and treatment services for children
diagnosed at the ideal age, four to By 2005, the three laboratories
by 2011.
six weeks after birth. Subsequently, were able to perform more than
most infected babies were not 5,000 tests per month. In 2005,
See References, page 50.
given antiretroviral therapy, despite National Health Laboratory Services
the increasing availability of life- began to expand testing capacity.
most pressing health-care needs in Nonetheless, given the scale of the infants exclusively breastfed for the
Africa. Antiretroviral drug therapy problem, these levels are still strikingly first six months of life rising from
can greatly reduce the chances that low, and much more needs to be done to 22 per cent in 1996 to around
transmission will occur and is essential expand access rapidly. 30 per cent in 2006. Several countries,
to stemming the rise in child mortality including Benin, Ghana, Madagascar
in countries where AIDS has reached and Malawi, managed to raise their
5. Rising rates of exclusive
epidemic levels. There are signs that rates of exclusive breastfeeding above
coverage levels are improving, albeit breastfeeding 50 per cent over the 10-year period.
from a low base. Preliminary estimates Immediate and exclusive breastfeeding
for 2006 indicate a marked rise in the is the best source of nutrition for The potential of exclusive breastfeeding
coverage of antiretroviral therapy in newborns, providing physical warmth as a child survival strategy should not be
sub-Saharan Africa (Figure 1.11). In and strengthening immune systems. underestimated: It has the potential to
Eastern and Southern Africa combined, While still low, rates of exclusive avert around 13 per cent of all under-
access to antiretroviral treatment for breastfeeding in sub-Saharan Africa five deaths in developing countries.
children under 15 increased to 17 per have seen significant improvement in Countries in sub-Saharan Africa have
cent in 2006 from 12 per cent in 2005. recent years, with the percentage of already shown it is possible to elevate

rates, and the challenge is to ensure that growing consensus on the framework fact that maternal, newborn and child
others make rapid progress in this area. required to deliver essential services deaths share a number of similar and
and commodities. In recent years, interrelated structural causes along with
partnerships and programmes undernutrition. Delivering interventions
6. Expanded distribution addressing maternal, newborn across the life cycle, in packages and
and use of micronutrient and child health have increasingly in dynamic health-care systems that
supplementation integrated their efforts around the integrate home-, community-, outreach-
‘continuum of care’ framework, which and facility-based care, can increase
Micronutrients such as iodine, iron
has emerged in recognition of the their efficiency and cost-effectiveness.
and vitamin A can have a profound
impact on a child’s development
and a mother’s health. Despite their
proven benefits and cost-effectiveness,
many infants and mothers in sub-
Sierra Leone: A unified and Child Health Strategic Plan
Saharan Africa are still missing out 2008–2010 has been developed
on micronutrient supplementation. plan gives hope of by the Ministry of Health and
reducing maternal and Sanitation in collaboration with key
A telling statistic is that 10 million
partners. Several key UN agencies
newborns in sub-Saharan Africa child deaths from the – UNICEF, World Food Programme,
remain without protection from iodine world’s highest rates World Health Organization and
deficiency, which is the principal cause the United Nations Population
Fund – have developed a joint
of preventable mental retardation. The devastating impact of conflict programme in support of the Plan.
on maternal and child survival is The programme covers basic
Rising coverage of vitamin A perhaps most evident in Sierra and comprehensive emergency
supplementation in recent years Leone, a war-ravaged country obstetric care, immunization, and
provides a source of hope for scaling up with the world’s highest rates of prevention and management of
under-five and maternal mortality. undernutrition. The venture is one
other micronutrient supplementation. of several collaborative initiatives
Of every 1,000 live births in 2006,
Sub-Saharan Africa, along with other 270 children will die before the related to the Reproductive
developing areas, has seen a marked age of five – around 1 in every and Child Strategic Health Plan
rise in coverage of children aged 4 children. Maternal mortality is that draw on the input of the
the highest in the world, with the government and a variety of
6–59 months with at least one dose international partners, including
maternal mortality ratio at 2,100
of vitamin A per year. Of the regions per 100,000 live births in 2005, the Wold Bank and the United
assessed by UNICEF in The State of the and the lifetime risk of maternal Kingdom’s Department for
International Development. The
World’s Children 2008 for which there death at 1 in 8, compared to the
overarching aim of these initiatives
were sufficient data to form a regional sub-Saharan Africa average of 1 in
is to reduce the 2005 rates of
22 and an average of 1 in 8000 in
aggregate, West and Central Africa has maternal, under-five and infant
industrialized countries.
the highest combined rate of vitamin A mortality by 30 per cent by 2010.
coverage, along with East Asia and the The latest estimates for 1999–2006
The Reproductive and Child
Pacific. show that almost one quarter of Health Strategic Plan represents
infants have low birthweight and a significant shift in addressing
only 8 per cent are exclusively
The expansion of vitamin A breastfeeding during the first
maternal and child survival,
supplementation has been achieved because it prioritizes integration
six months of life, 30 per cent of and the involvement of all key
through a combination of strategies, children under five are moderately partners. It uses the continuum
encompassing advocacy and the or severely underweight, and of care framework, delivering
packaging of vitamin A with other 40 per cent are moderately or health services first to women
severely stunted. Over one third before, during and after pregnancy
high-impact health and nutrition of infants are missing out on and then to newborns and
interventions, such as immunization. essential vaccines, such as three young children. To maximize aid
National health days and child health doses of diphtheria, pertussis and effectiveness, the plan emphasizes
days have often been the instruments tetanus (DPT3) and polio. Access to ownership, alignment, managing
improved drinking water sources in for results, mutual accountability
used to deliver the supplementation.
2004 (the latest year for which firm and harmonization among key
estimates are available), at 57 per stakeholders – with the aim of
cent, and adequate sanitation, at bringing a unified approach to
7. Growing consensus on 39 per cent, remain low. support Sierra Leone’s efforts
the framework required to improve maternal and child
In order to better address the survival and health.
to accelerate progress devastatingly high rates of
maternal and child death in Sierra See References, page 50.
The seventh source of hope for Leone, a national Reproductive
accelerating progress on child
survival in sub-Saharan Africa is the

Accelerating progress Strengthening health laden health system. And it is
systems through essential for reaching those who are
on the health-related the most isolated or excluded. As the
community involvement
MDGs following chapters in this report will
Delivering comprehensive health show, many countries in Africa have
care for children requires preventive implemented successful community-
The challenges facing North Africa and
measures, as well as treatment of illness. based programmes addressing health,
sub-Saharan Africa related to achieving
Prevention typically requires behaviour nutrition, AIDS and environmental
the MDGs are divergent. North Africa
changes that start in the household and health. The challenge is to learn from
has a firm foundation on which to push these experiences, formulate strategies
ahead – not only to reach the MDG 4 gain support through the community.
As an integral part of the larger health to take successful programmes to scale,
target but to go beyond it, particularly and reach the millions of mothers and
system, community partnerships in
through addressing socio-economic children whom the health system has
support of maternal and child health
inequalities in health-care provision. passed by.
care can serve a dual function: actively
Sub-Saharan Africa will need to engaging community members as
undergo a radical transformation of health workers and mobilizing the
its health systems in the coming years, community in support of improved Establishing the continuum
with several key priorities forming the health practices. They can also stimulate of care across time and
basis of change. These priorities include demand for quality health services from location
strengthening health systems through governments.
community partnerships, establishing An effective continuum of care
continuums of care across time and Community involvement can foster connects essential maternal, newborn
location, and developing health systems local ownership of child survival efforts and child health services through
for outcomes. and add vitality to a bureaucracy- pregnancy, childbirth, postnatal and
Democratic Republic of the Congo: A community religious leader administers a polio vaccination to a child.

newborn periods and into childhood Creating a supportive The legacy of conflict and
and adolescence. Each stage builds instability
on the success of the previous stage. environment for child
Providing integrated services to survival strategies Civil conflict poses one of the biggest
adolescent girls, for example, results obstacles to maternal and child survival
in fewer unintended or poorly timed Prospects for child survival are shaped in Africa. Of the 10 African countries
pregnancies. Visits to a health-care by the institutional and environmental where 20 per cent or more of children
practitioner can prevent problems context in which children and their die before age five – Angola, Burkina
during pregnancy and make it more families live, as well as by the provision Faso, Chad, the Democratic Republic of
likely that mothers will get appropriate of essential services and practices. the Congo, Equatorial Guinea, Guinea-
care during delivery. Skilled care before, Infant and child mortality rates in Bissau, Liberia, Mali, Niger and Sierra
during and immediately after birth Africa, as elsewhere, are highest in the Leone – more than half have suffered
reduces the risk of death or disability poorest countries, among the most a major armed conflict since 1989. In
for both the mother and the baby. impoverished, isolated, uneducated the Democratic Republic of the Congo,
Continued care for children supports and marginalized districts and four years of conflict have driven more
their right to health. communities, and in countries ravaged than 1 million people, mostly women
by civil strife, AIDS, food insecurity, and children, from their homes, forcing
A continuum of care also addresses weak governance and chronic them into makeshift villages where
the gaps in care, whether in the home, underinvestment in public health child-killing diseases such as cholera
community, health centre or hospital. systems and physical infrastructure. and measles can spread like wildfire.
For instance, newborns with birth Similarly, fragile states, characterized The struggle to restore essential
asphyxia, sepsis or complications from by weak institutions with high levels services continues long after conflicts
a preterm birth can die within hours of corruption, political instability and end, particularly for children and
or even minutes if appropriate care is a shaky rule of law, are often incapable families whose homes and communities
not provided. Because the majority of providing basic services for their were destroyed by war.
of African mothers deliver at home, citizens.
it is critical that a skilled attendant be Despite their desperate circumstances,
present at birth with strong backup by Institutional and environmental factors African countries in post-conflict
a local health clinic or other first-level can sometimes be the dominant factor situations are rising to the monumental
facility.11 Quality of care at all points in in child survival. In those countries
challenge of rebuilding their war-torn
in Eastern and Southern Africa where
the continuum is crucial. societies. Stronger national leadership
AIDS reaches high levels, for example,
in support of maternal and child health,
combating the disease has presented
Strengthening health assisted by international partners, is
the main challenge for child survival.
systems with results- resulting in Angola, Côte d’Ivoire,
The scale and nature of the epidemic
based strategies, and is such that all other interventions Ethiopia, Liberia, Rwanda, Sierra Leone
unified programmes and will prove ineffective unless AIDS and other countries taking courageous
partnerships is addressed. Countries that suffer action to reverse war’s toll on essential
from food insecurity or are prone to services.
Accelerating progress on child survival drought, such as those in the Horn of
will require applying the lessons Africa, are also at risk of having weaker At the same time, efforts must be taken
learned from a century of health-sector child survival outcomes. The inability to ensure that the children of war-torn
development and taking effective to diversify diets can lead to chronic societies have the opportunity to grow
approaches to strengthen community undernutrition for children, increasing up in a safe and stable environment.
partnerships, the continuum of care their vulnerability to ill health and, Many states remain fragile long after
and health systems. Based on the ultimately, death. the cessation of conflict. Durable peace
joint framework developed by leading requires social and political structures
international agencies, including the The challenge of reaching children that address both the root causes and
World Bank, WHO and UNICEF, and in countries with such intractable consequences of violent conflict. This
presented to the African Union, The problems is substantial. Nevertheless, is a long-term process that requires
State of Africa’s Children 2008 lays out a with committed, concerted and the full participation of all members of
framework in Chapter 4 for building up sustained actions, there are steps society and the sustained commitment
health systems across Africa through these countries can take to create a of international partners.
programmes, policies and partnerships supportive environment for child
in the coming decade. survival and development.

Children of conflict: At each of 12 refugee camps, 10 litres children to eat it. Children showing
of water are provided per person signs of acute undernutrition are
Helping them survive per day and the same coverage is transferred to a therapeutic feeding
extended to communal latrines. centre.
ACROSS Africa, civilian populations Teams of camp youth are assigned
are caught in the crossfire of conflict, to clear out stagnant water that Outside the refugee camp, native
and women and children are all too threatens to flow into a nearby Chadians live a different kind of life.
often among the casualties. Of the feeding centre. The same group also They are reluctant to work in this
estimated 3.6 million people affected cleans rubbish from the common part of the country, where life is hard
by the ongoing crisis in the western areas of the camp. and unstable. Chadian teachers,
Sudan region of Darfur, for example, already paid irregularly by the state,
1.8 million are children. Children attend temporary schools have left their posts to work in the
and prepare for exams. Given their refugee camps, where salaries are
The conflict in Darfur continues number, two teaching sessions better. Meanwhile, five doctors and
to displace large segments of the are held every day, in the morning midwives staff the only hospital in
indigenous population, and more and afternoon. Teachers are mainly Abéché town.
than 240,000 Sudanese – 85 per cent
volunteers who have completed one
of them women and children – have International and local support
month of training. A parent-teacher
found refuge in neighbouring Chad. for both the internally displaced
association takes responsibility for
working with the children to clean and the host communities has
What the world may not be hearing been growing. The population’s
about are the 173,000 Chadians who and maintain the schools.
essential survival needs – water,
have also been displaced as a result food, health care, protection,
of internal conflict and violence in In camp discussion groups,
mothers talk about the importance shelter and education – are being
their country – 30,000 of them in covered. Here, as elsewhere in
the closing months of 2007. Funding of breastfeeding their newborns
for the first six months, while Africa, there is a concerted effort
to support the internally displaced by all humanitarian actors to
and the communities that have health workers remind them of a
forthcoming measles vaccination recognize a critical link between
borne the cost of hosting them has
campaign for children six months these emergency interventions
been much harder to come by than
to four years old. Children play and development support for
assistance for Darfurian refugees.
affected local communities. This,
At the beginning of 2008, more than in places set aside for them.
in turn, may allow the internally
100 international non-governmental Community-based networks have
displaced to become self-sufficient
organizations and United Nations been set up to look after the welfare
and integrated into the host
agencies were working on behalf of of Sudanese and Chadian children in
communities, as well as provide all
the Sudanese in and around Abéché, both the camp and the community.
those affected – displaced and host
in eastern Chad. Much of their work
A high-protein, high-energy communities alike – better access to
focused on public health and other
peanut paste is distributed to life-saving services and support.
interventions that enhance the
chances for child survival among undernourished children under five,
the refugees and displaced. and mothers say it is easy to get their
The education factor during pregnancy and childbirth. Rights of the Child, which explicitly
Women who have acquired some formal calls in Article 7 for the registration
Low levels of education, particularly education are more likely to delay of a child immediately after birth.
among women and girls, represent a marriage and childbirth, to ensure that Yet the births of around 51 million
major obstacle to child and maternal their children are immunized, to be children worldwide went unregistered
survival throughout much of sub- better informed about their own and
in 2006. The right to be registered
Saharan Africa. Several African their children’s nutritional requirements,
is a fundamental human right and
countries are making tremendous and to adopt improved birth-spacing
practices. As a result, their children a prerequisite to fulfilling other rights
strides in girls’ education. Much of
have higher survival rates and tend to and practical needs. These include
this progress is recent, however, and
illiteracy remains relatively high be healthier and better nourished. access to health care and education,
among women. as well as protection from child labour,
Birth registration: An child marriage, underage military
The consequences of female illiteracy important step towards service or conscription, separation
can be devastating. Compared to from family members after conflict
accessing essential services
women with relatively high levels of or natural disaster, trafficking, and
education, uneducated women are less The right to a name and a nationality harassment by police or other law
likely to have a skilled attendant present is established by the Convention on the enforcement officers.

Figure 1.12 to registration centres often act as
powerful deterrents.
Educational differences by gender
Primary school net enrolment/ Youth (15–24 years) High cost in particular was revealed
attendance ratio* literacy rate** by a recent UNICEF analysis to be the
(%, 2000–2006‡) (2000–2006‡) primary reason for the lack of birth
Total Male Female Male Female registration in as many as 20 developing
countries across the world, resulting in
Central Africa 58 61 54 76 60
large registration disparities between
Eastern Africa 66 66 66 74 63 rich and poor children. In the United
Republic of Tanzania, where overall
North Africa 93 95 91 90 78
birth registration is very low, there is a
Southern Africa 77 77 78 - - wide disparity between rich and poor,
West Africa 64 67 59 76 65 with only 2 per cent of the poorest fifth
of children being registered compared to
* rimary school net enrolment/attendance ratio: Number of children enrolled in or attending
P 25 per cent of the richest fifth.
primary school, expressed as a percentage of the total number of children of primary school
age. This indicator is either the primary school net enrolment ratio or the primary school net
attendance ratio. In general, if both indicators are available, the primary school net enrolment Achieving universal birth registration
ratio is preferred unless the data for primary school attendance is considered to be of
superior quality.
in Africa will require governments,
** Youth (15–24 years) literacy rate: Number of literate persons aged 15–24, expressed as a parents and communities to work
percentage of the total population in the age group.
‡ Data refer to the most recent year available during the period specified.
together to make it a priority. An
integrated approach, such as combining
Sources: UNICEF estimates based on UNESCO Institute of Statistics, Demographic and Health
Surveys and Multiple Indicator Cluster Surveys.
national immunization campaigns with
birth registration campaigns, often
provides the best strategy. Fulfilling a
child’s right to acquire a name and a
In 2006, 19.7 million children in sub- by a skilled attendant, only 28 per cent nationality is a tangible goal, as well as
Saharan Africa were not registerd at were registered. Furthermore, the data an essential step towards ensuring that
birth. Indeed, sub-Saharan Africa has also suggest that birth registration all children have access to the care and
the highest proportion, 66 per cent, or levels tend to increase with the number protection they deserve.
more than 33.6 million children not of vaccinations received and with the
registered at birth. The challenges are provision of vitamin A supplements,
particularly felt in some countries, such as well as with the level of medical Empowering women
as the United Republic of Tanzania care available. In Chad, for example,
Empowering women socially and
and Zambia, where birth registration 38 per cent of children receiving
economically is central to improving
rates are very low due to the absence of vitamin A supplements have been
child survival. It is well known that
effective and functioning registration registered, compared to 15 per cent
when women have influence in
systems. UNICEF estimates that in of those not receiving supplements. household decision-making, including
the 1999–2006 period, only 10 per cent over household finances, they tend
of births were registered in Zambia, In the absence of birth registration,
to direct a large portion of household
while in the United Republic of children in many countries may be
resources towards food and other
Tanzania the registration rate was denied access to vital interventions
necessities for children. For the same
just 8 per cent. or programmes. The challenges
reasons, giving women the means to
encountered by parents in registering
become more economically self-reliant
Birth registration and access to health the birth of their children often signal
will likely have positive spin-offs for
care are closely linked, especially for an overlap with broader patterns of children.
children under five. For example, social exclusion and lack of access to
data from several African countries social services. Particularly in remote Analysis of the data from recent
suggest a close correlation between the areas, parents often do not see the Demographic and Health Surveys in
presence of a skilled birth attendant benefits of their own citizenship, let 30 countries suggests that in many
during delivery and birth registration. alone the benefits that birth registration households, especially in South Asia
In Benin, for example, 74 per cent of would confer on their children. and sub-Saharan Africa, women
children who were delivered by a skilled Furthermore, even when parents have little influence in health-related
attendant were registered at birth; do plan to register a birth, the high decisions, whether about their own
among children who were not delivered cost of registration and long distances health or that of their children. In

Burkina Faso, Mali and Nigeria, for disparities in child survival prospects during recent years from emergencies
example, almost 75 per cent of women between poor and better-off children ranging from drought and floods to
respondents reported that husbands is stark, not only among countries but outbreaks of disease, such as Ebola
alone make decisions about their within them. In every country with haemorrhagic fever. Sub-Saharan Africa
partners’ health care.12 available data, children living in the has also been at the epicentre of the
poorest 20 per cent of households are AIDS epidemic, and its toll on families
Initiatives that enhance women’s far less likely to reach the age of five and children has been enormous. A
empowerment and leadership at the than children from the richest quintile five-year retrospective study in Zambia
community level have been important of the population. Poor children, from 2001, of 232 urban and 101 rural
in improving the health status of compared to those born to better-off families affected by AIDS, reported that
women and children. In Ghana, Guinea families, are more exposed to the risk the monthly disposable income of more
worm disease – a painful disease that of disease through inadequate water
than two thirds of the families had fallen
is spread by water and can incapacitate and sanitation, indoor air pollution,
by more than 80 per cent.14
an infected person for months – was crowding, poor housing conditions and
sufficiently prevalent to require a high exposure to disease vectors.
In the absence of risk prevention and
comprehensive eradication campaign.
Policy interventions to eliminate mitigation strategies, households must
Women volunteers, who were more
socio-economic inequalities – that is, often cope by decreasing investment
familiar with the improved water
bringing child mortality rates in the in child nutrition, especially for boys,
sources than their male counterparts,
poorest 80 per cent of the population on and in education, particularly for girls.
conducted door-to-door surveillance,
distributing filters, identifying par with those of the richest 20 per cent There is considerable evidence that
potentially contaminated water sources – would have a dramatic effect on the AIDS has worsened already weak coping
and educating the community. As a under-five mortality rate for a country mechanisms, with affected households
result, incidence of the disease fell by as a whole. In sub-Saharan Africa, about resorting to unsustainable selling of
36 per cent between 2002 and 2003. 35 per cent of under-five deaths could vital assets such as livestock, resulting
be prevented in this way.13 in lower income levels and increased
poverty.
Promoting social equity African countries are particularly
vulnerable to macro-level factors, Successful approaches used to tackle
Millions of women and children have ranging from armed conflict to social inequities can include removing
been excluded from social and economic natural disaster to weak governance user fees in health-care programmes
progress in recent decades because and economic shock. Many countries that bring health interventions to
they are poor and disenfranchised. The in sub-Saharan Africa have suffered those who are hardest to reach, and
subsidizing health care for the poor and
those who have been excluded.
Rising to the challenge

The main challenge for child survival is
less about determining the proximate
causes of, or solutions to, child
mortality than it is about ensuring
that the services and education
required for these solutions reach
the most marginalized countries and
communities. Many countries, including
some of the poorest in the world, have
made significant strides in reaching
large numbers of children and families
with essential services. Effectively
scaling up these services, however,
requires that we learn from the lessons
of recent decades, with a particular
emphasis on strengthening integrated
approaches to child health at the
Uganda: A day-old child being vaccinated outside a village clinic. community level.

Mali: A traditional birth attendant explaining the dangers of tetanus.
2 Lessons learned from evolving health-care

systems and practices
An examination of diverse approaches for health-care systems and public Disease control
to the delivery of essential services from health-care practices on the continent
the beginning of the 20th century to can provide important perspectives on
the present demonstrates that a range Efforts to control specific diseases in
the current situation and help guide the
of effective interventions and policies Africa began early in the 20th century.
way forward. This review focuses on five In the first half of that century, mass
holds the most potential for accelerating major stages in public health care: mass
progress in Africa – especially sub- disease control efforts centred on
disease control; comprehensive primary malaria programmes, linking research
Saharan Africa. These span from
health care; selective primary health care; with control of the disease on the
initiatives targeted towards a single
integrated approaches; and the unified African continent. These preliminary,
disease or condition, such as malaria or
undernutrition, to the ideal of providing health-care framework that is emerging fragmented efforts were undertaken
a continuum of comprehensive primary- from the lessons learned. by colonial governments. Despite their
health-care services that integrates narrow focus, some of the initiatives
hospital and clinical facilities, outpatient Each of these stages is covered in detail – for example, malaria control from
and outreach services, and household- in The State of the World’s Children 2008, 1930–1950 in and around copper mines
and community-based care. the international report on which this in what is present-day Zambia – were
and other regional editions are based. quite successful. However, malaria
A brief review of the accomplishments The main points of that review are control was never seriously attempted
in child health in Africa during the past summarized here, together with specific across Africa, which still accounts for the
century and the remaining challenges examples of how they relate to Africa. vast majority of global cases and deaths.
Lessons learned from evolving health-care systems and practices 21

Mass disease control programmes continuing to advance. The remarkable child survival, health and well-being.
were expanded markedly in the 1950s 91 per cent reduction in measles Another key lesson drawn from these
to 1970s with the advent of mass deaths in Africa between 2000 and experiences is the need for disease-
campaigns focusing on the reduction 2006, recently reported by the Measles specific programmes to promote
or eradication of a specific disease by Initiative, is testimony to the merits community involvement, whenever
using a particular technology. Such of vertical approaches – as are gains possible, while contributing to the
campaigns addressed diseases, including noted in the opening chapter of ongoing development and strengthening
Guinea worm, smallpox, leprosy, this report in such interventions as of national health systems.2
trachoma, yaws, elephantiasis, and other exclusive breastfeeding, micronutrient
conditions affecting the ability to work. supplementation and insecticide-treated Successful innovation in community
Several of these campaigns were highly mosquito nets in sub-Saharan Africa. health in Nigeria and such countries as
effective, most notably smallpox, which China and Indonesia after World War
was eradicated from the continent and II showed the potential for delivering
elsewhere in 1977. Onchocerciasis, or
Comprehensive a range of health-care services beyond
river blindness, was defeated in West primary health care those targeting specific diseases. The
Africa and significantly reduced in comprehensive primary-health-care
the rest of sub-Saharan Africa.1 The One of the key lessons learned from the approach, consolidated at a landmark
success of several of these ‘vertical’ mass malaria eradication of the 1950s and international conference in Alma-Ata
campaigns, particularly smallpox, paved 1960s campaign is that without basic (now Almaty), Kazakhstan, in 1978,
the way for the most successful health services to support and consolidate broadened the concept of health-
programme in history: the Expanded vertical approaches to disease care provision beyond the control of
Programme on Immunization, launched eradication, it is difficult to promote specific diseases to include the tenets of
in 1974. improved health-care practices over the community involvement, equity, health
longer term. Accordingly, clean water, promotion, integrated approaches to
Efforts to control specific diseases basic sanitation facilities and adequate health-service delivery and intersectoral
and conditions such as measles are nutrition are now viewed as critical to collaboration. These and other primary-
Côte d’Ivoire: Immunization day at a health centre.

health-care precepts have become meeting of African health ministers in Saharan Africa. A study conducted in
guiding principles in the development of Bamako, Mali. This strategy focused on rural districts of the United Republic
health systems in recent decades. increasing access to primary health care of Tanzania, for example, finds that
and meeting basic community needs those districts implementing a health-
Selective primary in sub-Saharan Africa by delivering system-strengthening initiative and
an integrated minimum health-care IMCI demonstrated a 13 per cent
health care package through health centres. A greater reduction in child mortality
strong emphasis was placed on access than control districts.3 Survey results in
Economic constraints, notably the debt to drugs and regular contact between Malawi, South Africa, Uganda and the
crisis experienced by many countries health-care providers and communities. United Republic of Tanzania indicate
during the 1980s, and low health-system
capacity, impeded the implementation that wide-scale implementation of
The emphasis on integrating essential community-based IMCI – known as
of primary health care in sub-Saharan services that was a central feature of the
Africa. An alternative framework, Community Integrated Management
Bamako Initiative was to become the
selective primary health care, focused of Childhood Illness, or C-IMCI – can
driving force of approaches to health
on a defined subset of key diseases yield improved results in some of the
care in the 1990s. Integrated approaches
and conditions and addressed them key family practices, such as nutrition
sought to combine the merits of
by employing relatively inexpensive and early survival, disease prevention,
selective primary care and primary
medical technologies to reach specific home care or care seeking for the sick
health care. Like selective approaches,
objectives. Selective primary health child, and provision of a supportive
integrated approaches placed a strong
care received strong donor support, environment for child growth and
emphasis on providing a core group of
and ‘the child survival revolution’ development.4
cost-effective solutions in a timely way
spearheaded by UNICEF in 1982 was
to address specific health challenges;
based on this framework. It focused on
like primary health care, they also Accelerated Child Survival
four low-cost interventions collectively
focused attention on community
known as GOBI – growth monitoring and Development
participation, intersectoral collaboration
for undernutrition, oral rehydration
and integration in the general health- A more recent example of an integrated
therapy to treat childhood diarrhoea,
delivery system. approach to primary health care is
breastfeeding to ensure the health of
young children and immunization the Accelerated Child Survival and
against six deadly childhood diseases. Development (ACSD) programme.
Integrated Management of Initiated by the Canadian International
GOBI, together with the Expanded Childhood Illness Development Agency, UNICEF and
Programme on Immunization and national governments in West and
The dominant framework for
programmes to control diarrhoeal and Central Africa, ACSD aims to reduce
integration is Integrated Management of
acute respiratory diseases, made an infant (under-one), under-five and
Childhood Illness (IMCI), which adopts
undeniable contribution to reducing maternal mortality rates. Since its
a broad, cross-cutting approach to
global child deaths in the 1980s. In introduction in 2002, ACSD has grown
case management of childhood illness, rapidly and currently focuses on more
Africa, immunization rates increased acknowledging that there is usually
steadily, albeit from very low levels, than 16 million people in selected
more than one contributing cause. districts in 11 countries of West and
during the decade. The other three In many cases, sick children exhibit
interventions were not adopted with Central Africa that have high rates of
overlapping signs and symptoms of under-five mortality. 5
such vigour, with coverage falling far
disease, complicating efforts to arrive at
behind that of other regions.
a single diagnosis even in communities ACSD concentrates on three service-
with adequate first-level examination delivery strategies to augment coverage
Integrated approaches facilities, let alone those facing more for women and children:
challenging circumstances.
The 1990s and the early years of the • Community-based promotion
current decade have seen a renewed IMCI strategies, which aim to improve of a package of family health and
focus on integrated approaches to health-worker performance, strengthen nutrition practices, employing mostly
health-service delivery. health systems and enhance community volunteers.
and family practices, have been adopted • Outreach and campaigns to provide
by most African countries since their essential services and commodities,
The Bamako Initiative
introduction in 1992. such as immunization, vitamin
One approach used by many countries A supplementation, anthelmintic
in Africa was the Bamako Initiative, Positive outcomes for IMCI have been treatment and selected prenatal
launched in 1987 at a WHO-sponsored noted in several countries in sub- services.

Eritrea finds ways to action through volunteers had the journey takes at least a day and costs
potential to reduce child mortality families 120 nakfa (US$8) for the
reach the goal and that bringing care to the rent of a camel. Eight dollars is a lot
community might remove some of money in a country where more
ERITREA is one of the few countries barriers to seeking care in health than 60 per cent of the population
in sub-Saharan Africa currently facilities, thereby increasing health- lives on US$16 a month. Another
on track to meet Millennium care coverage. It was observed way of reaching the most vulnerable
Development Goal 4. Its under-five that enthusiasm on the part of children in very remote villages has
mortality rate fell by roughly 50 per community health workers was been to send out teams from health
cent, from 147 per 1,000 live births high, and that workers who provided centres with enough equipment
in 1990 to 74 per 1,000 in 2006. curative care had a higher level of to treat common illnesses, refer
The decline can be attributed to a motivation than those who were severe cases, and provide essential
number of factors. Chief among limited to health promotion. Monthly immunization and vitamin A
them is increased immunization refresher training in health facilities – supplementation. Health staff from
coverage, leading to a decreased and with it the opportunity to follow Foro in the Northern Red Sea region,
prevalence of vaccine-preventable up on the work of community health where an estimated 40 per cent of
diseases. Eritrea is polio free, workers – also proved successful. the population does not have access
maternal and neonatal tetanus have to health services, explain how they
Based on ‘lessons learned’, it was use camels to reach the most remote
been eliminated, and there have
decided to launch C-IMCI in another and mountainous villages – rides
been no measles deaths during
63 villages in 2007. Adi-Rosso is that sometimes take up to five days.
the past two years. There has also
one of those villages, and the Although implementation is very
been a sharp reduction in malaria
community health workers – one recent, it looks as if the outreach
morbidity, from 125,750 cases in
for every 75 children – selected by
2001 to 34,100 cases in 2005, and in initiative, coupled with campaigns,
each village committee were being
malaria mortality, from 129 deaths in has boosted immunization coverage.
sent on training courses according
2001 to 38 deaths in 2005.
to the village plan. By the end of the Vitamin A campaigns: Since 2006,
process they will be able to identify the Eritrean Government has been
Since independence in 1993, and
and, if necessary, prescribe drugs committed to reaching all children
after a 30-year-long conflict with
for the most common childhood aged 6 to 59 months with vitamin A
neighbouring Ethiopia, Eritrea has
illnesses, and to refer severe cases
made great efforts to ensure access supplementation. This is especially
to appropriate health facilities.
to health-care services by investing important because undernutrition
Because half of all under-five deaths
in reconstruction of destroyed rates are high in most regions
occur when children are less than
facilities, training for health and there is a strong chance that
one month old – and a majority of
workers, and increased provision children already weakened by
those deaths occur during the first
of drugs and equipment. As part undernutrition will have severe
week after birth – the Government
of its strengthening of the health complications due to other illnesses;
has decided to add a neonatal
system, the Ministry of Health has thus a boost to the immune system
component to the Integrated
used campaigns to protect children can become a life-saving measure.
Management of Childhood Illness at
from such illnesses as polio and Vitamin A-plus campaigns in 2006
both facility and community levels.
measles and to provide vitamin A were complemented by measles
supplements to boost the immune Community-based therapeutic vaccination and a hand-washing
system and avoid nyctalopia, or feeding: Based on successful campaign in elementary schools
night blindness. However, many community participation in and kindergartens. In May 2007,
children living along the Red Sea addressing threats against children’s the activity was combined with a
coast miss out on health care, and, health and survival, community- catch-up campaign in 16 subregions
not surprisingly, child mortality is based therapeutic feeding was to increase routine child vaccination
higher in the two coastal regions introduced in Eritrea in 2006. Still to at least 80 per cent and increase
than in the other four regions. early in the implementation phase, coverage of two doses of tetanus
it is evident that this intervention toxoid vaccine among pregnant
Community Integrated Management may be able to reach those children women to at least 50 per cent.
of Childhood Illness (C-IMCI): who cannot access facility-based Screening of undernutrition
This approach was introduced in therapeutic feeding. Community- among children under age five
2005 in 17 villages or clusters of based feeding is allowing children was included in the Anseba region
villages. Equipped with information, and their caregivers to stay in their campaign. Coverage of vitamin A
education and communication community and family while being supplementation is more than
materials, timers, thermometers, treated – thus addressing women’s 95 per cent in the campaigns –
scales, medicines, registers and workloads, one of the main obstacles reaching children in even the
medical cards, 37 community to facility-based treatment. most remote areas through the
health workers assisted more than use of donkeys, camels and boats.
2,000 children and gave advice to Outreach: Families in Adi-Rosso
caregivers. In 2006, the first C-IMCI take their children to a health centre See References, page 50.
evaluation revealed that community in Nefasit for immunization. The

• Facility-based delivery of an integrated exclusive breastfeeding and wide approaches, poverty reduction
minimum-care package consisting of complementary feeding. strategies – including Poverty Reduction
all the selected priority interventions. Strategy Papers – and associated
This delivery and intervention medium-term expenditure frameworks,
These priority interventions are also framework is supported by cross- basket funding and budget support. It
organized around three areas that build cutting strategies to address behavioural, also underscores building capacity at
on the strengths of existing programmes institutional and environmental regional, district and community levels.
and approaches: constraints. These strategies include:
ACSD has a strong community-
• Antenatal Care plus (ANC+), which • Advocacy, social mobilization and based component and is considered
provides intermittent preventive communication for behaviour change. a ‘behaviour-centred’ programme
treatment of malaria during because the majority of interventions
pregnancy, iron and folic acid • A results-based approach to service – such as utilizing insecticide-
supplementation, tetanus vaccine delivery at the community level. treated nets in communities where
and prevention of mother-to-child malaria is endemic, improving care
• District-based monitoring and of sick children and newborns,
transmission of HIV.
micro-planning. and encouraging breastfeeding and
• Expanded Programme on
complementary feeding – aim to
Immunization plus (EPI+), which • Integrated training.
promote behaviour change. ACSD also
includes immunization, vitamin A supports active outreach and mobile
• Improved supply systems.
supplementation and deworming. strategies that are essential to reaching
• Integrated Management of Childhood Accelerated Child Survival and the most remote areas.
Illness plus (IMCI+), which covers Development strongly emphasizes
promotion of insecticide-treated bringing its integrative framework The ACSD partners, which include
mosquito nets, oral rehydration into the mainstream of national policies national governments and donors,
therapy, antimalarial drugs, and programmes, such as health sector- have set targets of increasing coverage of
Morocco: Carefully monitoring child growth.

Improving and 100 per cent among children aged delivery, monitoring health-system
6 to 59 months. Polio vaccination performance, results-based financing,
harmonizing national coverage rose to 100 per cent. No and synthesizing experience on
health plans measles deaths have been recorded aid effectiveness and health.
since 2004, and more than half of
Ghanaian children and pregnant • Supporting countries to leverage
IN November 2007, at the Second women now sleep under insecticide- predictable and sustained resources
Pan-African Forum on Children, treated mosquito nets. Another lesson for the health sector, developing
held in Cairo, the African Union to be drawn from the experience investment cases and providing
endorsed the ‘Strategic Framework in Ghana is that much can be a platform for bringing together
for Reaching the Millennium accomplished when governments, funding from all global mechanisms.
Development Goals on Child Survival donors and UN agencies work in
in Africa’, which had been developed harmony towards a common goal. • Ensuring accountability and
by UNICEF, the World Health assisting in monitoring performance
Organization and the World Bank. ‘Harmonization for Health in Africa’ of national health systems, aid
Even before that, however, ministries effectiveness and the performance of
of health throughout the continent Facing various degrees of progress the International Health Partnership.
had been revisiting and revising their in African health-care systems, UN
national health plans along the lines agencies, including UNICEF, have • Enhancing coordination in support
of the Strategic Framework. chosen to utilize their strengths by of nationally-owned plans and
creating a consultative structure implementation processes, and
In Benin, for example, the president called Harmonization for Health in helping countries to address the
announced in early 2007 the abolition Africa (HHA). Coordinated by WHO country-level bottlenecks arising
of all user fees for health services and the World Bank, and growing out from constraints within international
provided to pregnant women and of a 2003 meeting of development agencies.
to children under age five. National agencies and developing countries
health and financial specialists in Canada, three ‘High Level Forums’ The agencies provide support to
worked with UNICEF, the World Bank, have been held since 2004. countries within existing national
the United Nations Population Fund development and financing
and the World Health Organization At these forums, discussions focused frameworks – including Poverty
(WHO) to refashion the state budget on resources, aid effectiveness Reduction Strategy Papers,
to reflect this new reality. Both and harmonization, global health multi-budget support and sector-
domestic and foreign assistance partnerships and monitoring progress wide approaches, medium-term
funds were shifted to cover shortfalls towards the MDGs. The forums expenditure frameworks and sector
the change engendered. As a result, recommended the establishment of a investment plans. The following
the poverty reduction strategy for regional mechanism to facilitate and are identified as initial critical
Benin, particularly as it relates to coordinate country-led development interventions:
maternal and neonatal health and of evidence-based policies, plans
child survival, is much more child- and budgets – with the aim of ■ Support identified country-level
friendly – and more likely to help strengthening health systems and action by mobilizing expertise from
Benin reach the MDGs. service delivery to reach the poor across the participating agencies
and vulnerable. and beyond.
Certain national health plans in Africa
have been in existence for so long, The objective of the HHA action ■ Produce evidence-based reports for
and accumulated such extensive framework is to coordinate the efforts boards and global decision makers
bases of data and lessons learned, of international health agencies and that influence health development
that achieving harmony with the other stakeholders as they work in Africa.
Strategic Framework is more a to overcome the grave challenges
matter of fine-tuning than major Africa faces in its progress towards ■ Provide all stakeholders with
overhaul. Mali presents one such achieving the MDGs and increasing a comprehensive assessment of
example. The nation’s Programme de health outcomes. The six focus progress and country needs and
Développement Sanitaire et Social areas are: demands in achieving the health-
(PRODESS) has advanced to the related MDGs.
stage where the 2008–2012 strategy • Supporting countries to identify,
for child survival presents detailed plan and address health-system ■ Serve as a broker and, where
interventions appropriate to the constraints to improve outcomes in a appropriate, provide support in
smallest administrative district. This sustainable and effective manner. facilitating resource mobilization
meticulous planning enables districts and grant proposal preparation
in Mali to understand their needs and • Developing national capacity for countries.
constraints better, and consequently through training in relevant areas
manage their local health systems and stimulating peer exchange, ■ Facilitate exchange of experience
responsively. establishing a roster of technical across countries and regional
expertise in the region and institutions to develop regional
In 2007, Ghana launched a High developing partnerships with Africa- centres of excellence.
Impact Rapid Delivery strategy based academic institutions.
for health care that has generated The partnering international agencies
impressive results. Fully 100 per cent • Promoting the generation and have started to implement the HHA
of Ghanaian newborns and 78 per dissemination of knowledge, action framework, and 23 countries
cent of pregnant women have been guidance and tools in specific will be supported by 2010.
reached by basic preventive actions. technical areas – focusing on
Vitamin A supplementation rose to strengthening health-service See References, page 50.

ANC+, EPI+ and IMCI+ to 80 per cent strengths of selective/vertical and Key lessons learned
within two years and reducing under- comprehensive/horizontal approaches
five mortality rates in the districts where through scaling up cost-effective from evidence and
the programme is operating by 15 per intervention packages and integrating
cent within three years and 25 per cent them into a continuum of care for
experience
within five years. mothers and children. This approach,
which is being advanced by a joint One overarching principle that has
Based on preliminary evaluation and international agency framework in emerged from the review is that no
data presented by district health teams Africa (see Chapter 4), defies the single approach is applicable in all
in Ghana, this approach is already long-standing dichotomy between circumstances. The organization,
having a positive impact. Coverage vertical approaches to achieve specific delivery and intervention orientation
levels of routine immunization among outcomes and integrated approaches to of health-care services must be tailored
districts have increased by 10–20 strengthen health systems and improve to meet the constraints of human
per cent, and there have been major general health, arguing that both aims and financial resources, the socio-
gains in the proportion of children can be realized by adapting health economic context, the existing capacity
sleeping under insecticide-treated systems to achieve results. of the health system and the urgency
nets, antenatal care coverage, and the
of achieving results. A focus on results
expansion of oral rehydration therapy • Enhanced ways of working at the
requires strategies that build on the
and vitamin A usage. In addition, national and international levels,
subsidized insecticide-treated nets with a strong focus on coordination, collective knowledge of maternal,
are being distributed in conjunction harmonization and results, most newborn and child survival and
with immunization-plus activities. prominently the achievement of health in order to identify the
The challenge in West and Central the health-related Millennium solutions that work best for each
Africa, which have among the highest Development Goals. country and community.
incidence of maternal, newborn and
child mortality in the world, is to scale
up effective but sustainable approaches
rapidly. ACSD partners are carefully
examining the evaluations, with a view
to expanding the approach to many
more districts and countries in Africa.
Towards a unified
framework for
maternal and child
health care
Distilling the lessons of the past century
of public health care in Africa, experts
in maternal, newborn and child health
are coalescing around a set of strategic
principles that have a strong general
application to developing countries and
a specific focus on reducing maternal
and child survival in Africa. The three
core principles are:
• A renewed recognition of the

principles of primary health care,
which emphasize the importance of
family and community partnerships in
the survival, growth and development
of children.
• The health-system development
for outcomes approach to health-
service delivery, which combines the Mozambique: A young mother and her baby.

Nigeria: Mothers wait their turn at a primary health-care centre.
3 Community partnerships in primary health care

for Africa’s mothers, newborns and children
The household is the front line of health environmental services are lacking. as the communities they are designed
care and treatment of childhood illness In marginalized and impoverished to serve. Not only are there marked
in Africa. Recent data from 24 countries areas, in both rural and urban settings, differences among communities in
in sub-Saharan Africa show that 42 per community participation can be crucial a particular country or district, but
cent of children who took antimalarial for households and families to obtain there are likely to be disparities within
medicines received treatment at home.1 the food, health and caregiving needed them as well. Even though members
Across the region, fewer than 40 per cent by mothers and children to ensure of communities may share common
of women give birth with the assistance their health and nutritional status. In heritage, assets and interests, or suffer
of a skilled attendant.2 In Eritrea, for most cases, this involves the support similar deprivations and disadvantages,
example, 72 per cent of women give of trained, motivated workers to attend different members will have specific
birth at home with no skilled personnel to their health-care needs. needs, concerns and expectations
to help them.3 regarding health care.
Empowering African households and A multiplicity of Nevertheless, there are some common
communities to participate in the health community-based factors associated with successful
and nutrition of mothers, newborns community partnerships in Africa and
and children is a logical and practical approaches elsewhere in the developing world.
way to enhance the provision of care – An overarching objective is that these
especially in countries and communities Community partnerships in maternal, programmes aim to increase the local
where basic primary health care and newborn and child health are as diverse population’s access to health services

and interventions. Evidence shows that and evaluation as
such programmes can help accelerate well implementation
advances in behaviour change, care are among the most
practices and care seeking, successful in developing
and empower communities and countries.
households to demand quality health • Adequate programme
care, nutrition, and water and sanitation supervision and support:
services. Supervision is required
to sustain community
The importance of community members’ interest and
participation goes beyond the direct motivation and reduce
health benefits to family and community the risk of attrition.
members, and indeed lies at the heart Other important types
of a rights-based approach to human of support programmes
progress. Participation is essential include logistics, supplies
to enabling people to achieve their and equipment.
full capabilities, exercise their rights • Effective referral systems
to engage in public and community to facility-based care:
affairs, and foster equity, equality Hospitals and clinics are Zambia: Caring for an infant suffering from malnutrition.
and empowerment. To be effective, essential complements
community-based programmes and to successful community
approaches must be owned by the partnerships, providing Examples of
services that cannot be safely
community and adapted to local needs
replicated elsewhere, such as
successful community
and context.
emergency obstetric care. District partnerships in
Success factors
health systems also serve as focal primary health care
points for public health programme
in community coordination. in Africa
• Cooperation and coordination with
partnerships other programmes and sectors: An Africa provides rich examples of
integrated approach to maternal, community-based programmes in a
Experience shows that successful newborn and child health necessitates broad spectrum related to maternal
community partnerships are based on collaborative action between and child health and survival. Although
several common factors. These factors programmes and sectors related to these cases differ in terms of their goals
are explored in detail in Chapter 3 of health, nutrition, hygiene, major and methods, they all demonstrate
The State of the World’s Children 2008 diseases and food security, as well that engaging community members
and are summarized here: as intersectoral collaboration to in programme design is crucial to the
address the lack of transportation success of each initiative. This section
• Support and incentives for community infrastructure and access to water will examine community partnerships
health workers: Community and sanitation facilities. in health, nutrition, HIV and AIDS,
health workers, the main agents and environmental health in Africa and
• Secure financing: To be successful
of community-based treatment, over the longer term, financing for highlight the factors that have made
education and counselling, require community partnerships should them successful.
incentives and support to avert address sustainability and equity,
attrition, meet their own commitments including such issues as user fees Nutrition
and obligations, and sustain and financial incentives for
worker motivation. They have been community health workers. Adequate nutrition benefits children,
particularly effective in improving • Integration with district and their families and communities as
child survival outcomes in countries national programmes and policies: a whole. Just as important as the
across Africa. Consultative, multi-stakeholder availability of food in ensuring
• Cohesive and inclusive community processes are needed for developing nutrition are the decisions households
organization and participation: sound strategies and ensuring make about food storage, preparation
Programmes that build on established that maternal and child survival and feeding. For infants and young
structures within the community, feature prominently in national and children, proper nutrition starts with
are socially inclusive, and include decentralized plans and budgets, with exclusive breastfeeding from birth to
community members in planning clear goals and concrete benchmarks. six months. Continued breastfeeding is
Community partnerships in primary health care for Africa’s mothers, newborns and children 29
recommended for two years or longer,
Community partnerships between 2001 and 2005 achieved with age-appropriate complementary
recovery rates of 78.1 per cent feeding to sustain growth and
in nutrition in Ethiopia, and reduced mortality rates to
development. In countries where
Malawi and Sudan 4.3 per cent. Coverage rates
mortality among young children is high,
reached 73 per cent, while
Evidence from Ethiopia, Malawi
74 per cent of the severely ensuring that children 6–59 months of
undernourished children who age receive enough vitamin A is one of
and Sudan shows that community- presented were treated solely as
based management of severe outpatients. Initial data indicate the most cost-effective child survival
acute undernutrition can be both these programmes are cost- interventions. Another cost-effective
successful and cost-effective. effective, with costs varying
Where severe acute undernutrition measure is fortifying staple foods that
between US$12 and US$132
is common, case fatality rates for each year of life gained. most of the population consumes,
are typically 20–30 per cent and such as oils or flour.4
treatment coverage is commonly The high cost-effectiveness of these
less than 10 per cent. Recent community-based therapeutic care
evidence shows that programmes programmes is due to the precise Care for mothers and
of community-based therapeutic targeting of resources towards newborns
care can substantially reduce case severely undernourished children
fatality rates and increase coverage who are at a high risk of dying,
rates. These programmes use new, and compares favourably with
Close to 40 per cent of all under-five
ready-to-use therapeutic foods and other mainstream child survival deaths occur in the first month of life,
are designed to increase access to interventions such as vitamin the neonatal period, with two thirds
services, reduce opportunity costs, A supplementation. Wherever
encourage early presentation and possible, programmes build
occurring during the first week of life,
compliance, and increase coverage on local capacity and existing and approximately two thirds of those
and recovery rates. structures and systems, helping within 24 hours of birth.5 Prenatal care
to equip communities to deal with
and skilled birth attendants significantly
Community-based programmes future periods of vulnerability.
implemented in Ethiopia, Malawi, increase the odds of newborn survival
and northern and southern Sudan See References, page 51. during this critical period. Yet more
than half of mothers throughout the
developing world give birth at home,
and nearly half are cared for by family
members, neighbours or untrained
attendants.6 Equipping communities
with the skills and knowledge for safe
motherhood and newborn care is
therefore crucial, particularly in the
absence of accessible and affordable
health facilities.
Evidence shows that community-based

strategies for maternal and newborn
survival can make a powerful difference.
Up to 72 per cent of newborn deaths
could be avoided with simple, cost-
effective interventions, such as maternal
immunization for tetanus toxoid,
nutritional support, birth planning,
counselling on breastfeeding, skilled
attendants at delivery, immediate
postnatal care for the baby, and
continued and routine visits with a
trained health-care provider.7 Various
trials at the community level in Africa
have shown substantial reductions
in child mortality, particularly with
case management of sick children by
Ethiopia: A proud mother with her just-vaccinated child. community health workers.

Preventive interventions of illnesses, community engagement can access to sanitation together contribute
maximize the effectiveness of low-cost, to more than 1.5 million of the 1.9
The evidence in favour of community- affordable interventions. million deaths of children under age
based approaches to child survival five each year that are due to diarrhoeal
and comprehensive health care for diseases.9
children is perhaps strongest in the area Hygiene and sanitation
of disease prevention and treatment. Better sanitation alone could reduce
Through such initiatives as the More than any other group, young
diarrhoea-related morbidity by more
distribution and increased utilization children are vulnerable to the risks
than one third; improved sanitation
of insecticide-treated mosquito nets to posed by contaminated water and poor combined with hygiene awareness
protect children and pregnant women sanitation and hygiene.8 Unsafe drinking and behaviour change could reduce
from malaria, prevention and treatment water, inadequate availability of water it by two thirds. Improved household
of HIV, or immunization against a range for washing and cooking and lack of practices would include consistent use
Gambia, Morocco Morocco’s immunization rates for gaps can be targeted through
five of the six preventable childhood disparities in vaccination rates
and Ghana: Expanding diseases have risen impressively correlated to the disadvantages of
since 1990. In 2006, more than 95 infants born in rural versus urban
immunization services per cent of Moroccan children were areas, levels of maternal education
and saving children’s lives immunized against the six major and economic status.
vaccine-preventable diseases by
age one. High rates of coverage Bringing immunization services
Vaccinating children against for the third dose of the combined closer to children in Ghana’s rural
Haemophilus influenzae type b diphtheria-pertussis-tetanus (DPT3) communities: An immunization
(Hib) meningitis in the Gambia: vaccine have been found to be campaign in rural Ghana
Experience in the Gambia representative of a country’s capacity demonstrates that comprehensive
disproves the notion that integrated to succeed with its immunization and inclusive local-level planning
approaches must struggle to programme, as well as an indicator can lead to positive results for
function in resource-poor countries of the effectiveness of health- children’s health – even in remote
with weak health systems. In spite of service delivery overall. Since 1990, communities where resources
its very limited health and physical Morocco’s national coverage rates are scarce. The Reaching Every
infrastructure – the country had for DPT3 have improved from District campaign delivers
only 19 telephone lines per 100 81 per cent to 97 per cent, according integrated services in remote
people in 2005, and only 11 doctors to WHO-UNICEF estimates recorded communities hindered by weak
for every 100,000 people in 2004 in 2006.
health infrastructure and inadequate
– and frequent breakdowns in the understanding of immunization by
vaccination supply chain, the Gambia Dissemination of the third dose of
families and communities.
managed to improve its Hib vaccine hepatitis B vaccine rose even more
sharply, from 43 per cent to 84 per
cold chain with the use of solar Adopted in 2003, Reaching Every
cent between 2000 and 2001, and has
power, decentralized vaccine storage, District empowers local districts
continued to improve, with estimated
and health-care management to to plan, implement and monitor
coverage of 95 per cent in 2006.
provide vaccines where and when activities through on-site training
they are needed. Compared with the Morocco’s advancement towards by supervisors, regular meetings
children who received no vaccine, polio eradication has been between community and health
the Hib-immunized group had 95 commendable, with vaccination rates staff, and community monitoring
per cent fewer cases of invasive reaching 97 per cent, while rates for systems. By 2004, half of the 10
Hib disease, confirming that the the measles-containing vaccine stand participating districts recorded an
vaccine was as highly protective as at 95 per cent. In 2002, Morocco increase in the number of children
it is in industrialized countries. The became the first country in WHO’s immunized over previous years,
trial also helped reduce all types of Eastern Mediterranean Region to representing a 12 per cent increase.
pneumonia in Gambian infants by demonstrate attainment of neonatal Community involvement is crucial
21 per cent. tetanus elimination. In 2006, the to the success of the programme –
Ministry of Health budget devoted particularly the participation of local
Immunization as a key to enhancing to the acquisition of vaccines was religious leaders. The decision to
child survival in Morocco: Steady doubled, and inoculation against conduct immunization campaigns
advances in immunization coverage Haemophilus influenzae type b close to markets on active days
have been the key to Morocco’s was introduced into the national ensures that children taken to the
success in reducing its under-five vaccination calendar. market by their mothers do not
mortality rate by 58 per cent between have to miss out on vaccination.
1990 and 2006 – from 89 to 37 per Near-universal immunization
1,000 live births, for an average coverage for Morocco’s children is See References, page 51.
annual reduction rate of 5.5 per cent. attainable. Many of the remaining
of a toilet or latrine by each person in
the household, safe disposal of young
children’s faeces, hand washing with
soap or ash after defecation and before
eating, and the installation of public
standpipes, tube wells or boreholes
in households and communities.10
Providing communities with the
knowledge and resources to implement
these basic household practices is a vital
first step towards improving sanitation
and hygiene.
HIV and AIDS

The urgency of preventing mother-to-
child transmission (PMTCT) of HIV is
clear. More than 400,000 children under
15 were newly infected in 2007, mostly
through mother-to-child transmission.
Without treatment, half of the infants
born with the virus will die before they
Uganda: Women collect water from a community water point. are two years old.
Significant reductions in mother-to-

child transmission can be achieved
Ghana and Malawi: In Malawi, sanitation coverage for through implementation of basic but
rural communities is estimated to critical actions, such as identifying
Improving access be 30 per cent or less, and water HIV-infected pregnant women by
to clean water and coverage stands at 62 per cent,
offering routine testing, enrolling them
although this figure may mask
sanitation facilities a significant percentage of non- in PMTCT programmes, ensuring that
functioning facilities. In many health systems are fully able to deliver
In Ghana, a sweeping water reform communities, sanitation facilities effective antiretroviral regimens both
programme introduced by the consist of traditional pit latrines,
for prophylaxis and for treatment,
Government in the early 1990s led which are often inadequate to
to a dramatic overhaul of a top- protect against faecal-oral disease and supporting women in adhering to
down system that was unresponsive transmission. Cholera, typhoid fever optimal and safe infant feeding.
and failed to deliver, especially and other water-related diseases
in rural areas. As a result of the remain prevalent.
reform process, responsibilities for Integrating community
Water for People is a North
water supplies were transferred
to local governments and rural America-based non-governmental partnerships into
communities, and new political organization working with
communities to provide more than
district services and
structures for water governance
have been developed. Village 150,000 people with improved
sanitation and access to water. The
national policies
structures are now part of the
organization partners with local
system. To apply for capital
non-governmental organizations Two key elements that can help
grants, communities must form
village water committees and
and district governments to sustain and support community-
support community-based efforts based initiatives are active support for
draw up plans detailing how to enhance the quality of water and
they will manage their systems, sanitation facilities. Typical water provincial and central governments, and
contribute the cash equivalent projects include borehole wells, integration of community programmes
of 5 per cent of the capital costs hand-dug shallow wells, rainwater into government policies and planning.
and meet maintenance costs. This catchment tanks, community tap Child survival, health and nutrition
participatory approach has resulted stands and simple pit latrines
in a dramatic increase in access
should feature prominently in national
covered with sanitary platforms.
to an improved water source, from Each project benefits 200 to 1,000 and district health policies, with clear
55 per cent in 1990 to 75 per cent people, the organization says. goals and concrete benchmarks.11
in 2004, and access continues Strategies for child survival are best
to expand. See References, page 51. formulated through consultative

processes involving representatives introduction of a decentralized health other fundamental challenges, such
from the community, district and system based on broad consultations as mosquito nets not being treated
national levels, as well as the donor with all stakeholders – especially with insecticide.15
community. community leaders and women – led
to a near doubling of the number of Donors need to rally behind national
Evidence from a wide variety of national community-based health centres, from strategies for improved child survival,
programmes and smaller-scale projects 370 in 1998 to more than 700 in 2004. health and nutrition. Both the short-
confirms that when adapted to suit local Of these health centres, 30–51 per cent term, disease-specific eradication
conditions and managed by supportive can provide a minimum package of initiatives – firmly supported by new
communities and governments, preventive and curative services.13 international donor partnerships – and
integrated community-based approaches longer-term, health-sector development
can produce effective, efficient and Understanding variations in programmes can, and should, continue
sustainable results.12 In Mali, the epidemiological profiles within a to coexist.
country is an essential first step towards
developing a targeted strategy. Equally The ultimate responsibility for ensuring
important are detailed assessments of children’s right to health and nutrition
Togo: Integrating financial realities and existing levels lies with national governments.
interventions to of infrastructure at the community, Governments have a pivotal role in
accelerate progress district and national levels of health- developing and implementing policies
care delivery. These aspects are vital to to lower the barriers to child health care,
on child survival improving the quality and efficiency of
the successful execution of a national
strategy for child and maternal health, service providers and increasing public
In 2004, Togo conducted the and must be considered at the outset of accountability.16 At the same time, health
first ever national distribution policies must be accountable to the
any planning exercise.
of insecticide-treated mosquito
nets. The campaign utilized the
communities and districts they serve.
infrastructure and personnel National strategies must lend priority
already in place for an ongoing attention to the removal of obstacles to Developing strong, child-focused health
measles mortality reduction effective scale-up and implementation policies and building strong linkages
strategy to provide an at different levels of the health system. between communities and health
integrated package of health- Well known bottlenecks include systems are critical; in many countries,
care interventions. The package irregular immunization sessions, increases in health expenditures will
included measles vaccine, need to be accompanied by substantial
negative experiences with the health
oral polio vaccine, one treated
system, distance to health centres or improvements in governance, economic
mosquito net and one tablet
of mebendazole deworming lack of information.14 At the family and stability and health-care administration,
medication per child, with the community level, effective coverage among other factors, to achieve
aim of reaching more than is often impeded by a poor supply significant progress towards the health-
95 per cent of children. of affordable drugs, low demand and related MDGs for children.
An evaluation of the planning,

implementation and results
demonstrated the feasibility of
integrating delivery of these
services. One month after the
campaign began, evaluators
found that 93.1 per cent of
children had been reached
with measles vaccine and 94
per cent with mebendazole,
and household ownership of
treated nets increased from
8 per cent to 63 per cent. The
campaign still had a long way
to go, however, particularly in
changing behaviour: The night
before the survey only 44 per cent
of children under five had slept
under their nets.

Togo: Women registering their children during an immunization campaign.
Community care boosts community health posts. They low-cost interventions produce
have been trained in the Integrated high-impact results in reducing
child survival in Niger Management of Childhood Illness child mortality.
(IMCI) in order to identify and
FIFTY-SIX per cent of Niger’s nearly treat effectively the most common Although nascent, and with many
14 million inhabitants live more diseases among children under five. challenges to overcome, Niger’s
than five kilometres from a health Malaria, pneumonia and diarrhoea community health post initiative
facility. To increase child survival are responsible for almost 60 per has opened doors to skilled health
cent of under-five deaths in Niger, care for thousands of children. The
by bringing health care closer to
and timely and effective treatment availability of trained community
underserved rural communities,
significantly reduces child mortality. health workers is making a
the Government of Niger in 2000
Community health workers refer difference and providing hope for
began implementing an ambitious
patients with severe illnesses the 1.8 million children who live far
strategy to use funds from a debt
to integrated health centres and from integrated health centres and
reduction programme to finance the hospitals. Accessing the next level of
construction of 2,000 community hospitals. The Government of Niger’s
care, however, can present serious recent decision to make health care
health posts. This is a major step challenges, and lack of transportation
towards ensuring the availability of available free to children under
is one of the barriers encountered in five is another promising move. It
one health facility per 5,000 people the referral system.
in rural areas. eliminates yet another barrier to
health services for the 61 per cent
Prevention is key to the strategy’s
Construction of 30 community of Niger’s population who live on
success
health posts in southern Niger’s less than a dollar a day.
Madarounfa District more than Along with providing basic
doubled access to health care. The treatment, community health More needs to be done, however,
proportion of people living within workers promote disease prevention. to build on this programme’s initial
five kilometres (or a 60-minute walk) They assess children’s growth, success. Ideally, health posts should
of a health facility increased from monitor vaccination status and offer be upgraded to integrated health
34 per cent to 72 per cent. Children follow-up care. Community health centres in order to make all services
especially benefit. Since the opening workers also advise households and available to children at reasonable
of additional community health posts communities as they communicate distances from their homes. In the
in the district, the number of annual life-saving information on early meantime, community health posts
contacts per child per year has initiation of breastfeeding, exclusive provide a cost-effective way to save
nearly doubled. breastfeeding for newborns up to the lives of many children who
six months, age-appropriate feeding might otherwise die of preventable
Trained community health workers practices, hygiene and use of diseases each year in Niger.
offer a minimum package of curative insecticide-treated mosquito nets for
and preventive interventions at children and pregnant women. These See References, page 51.
Niger: A woman and her baby head home with a sack of millet.

South Africa: A mother and child receive nutrition counselling.
4 Strengthening community partnerships, the

continuum of care and health systems in Africa
The lessons learned from evidence and For governments, donors, international • Action I: Realign programmes
experience in health-care provision and agencies and global health partnerships, from disease-specific interventions
taking effective approaches to scale are effective scale-up will require a new way to evidence-based, high-impact,
steadily being applied in an increasingly of working in primary health care among integrated intervention packages to
unified and consistent manner. The the key stakeholders. The central theme ensure a continuum of care across
key international agencies working for of this paradigm is unity. Initiatives and time and location.
maternal and child survival and health – partnerships directed towards improving • Action II: Ensure that maternal,
UNICEF, the World Health Organization, aspects of maternal and child health newborn and child health care form
the United Nations Population Fund abound and continue to proliferate, a central part of an improved and
and the World Bank – are uniting with but without greater coherence and integrated national strategic planning
donors, governments and other leading harmonization, these disparate efforts process for scaling up services and
international organizations, such as risk falling short of achieving the health- systems.
the African Union, around common related MDGs during the coming years.
frameworks and strategies to scale up • Action III: Develop country plans
access to primary health care. Scaling The following distinct yet related actions to strengthen health systems for
up involves a complex range of actions, will be required to align programmes, outcomes.
many of which are interrelated, both to policies and partnerships in the coming • Action IV: Foster and sustain
achieve breadth and to ensure long-term decade for the purpose of uniting for political commitment, national and
sustainability of the expansion. maternal, newborn and child survival: international leadership, and sustained
Strengthening community partnerships, the continuum of care and health systems in Africa 35
financing necessary for guaranteeing the past, safe motherhood and child Packaging
access to the continuum of care.1 survival programmes often operated
• Action V: Create conditions for separately, leaving disconnections in interventions by
greater harmonization of global health care that affected both mothers and service delivery mode
programmes and partnerships. newborns. It is now recognized that
delivering specific interventions at Prevention and cure are equally vital
The continuum of maternal, newborn pivotal points in the continuum has in combating disease and fostering
and child health care is a relatively multiple benefits. Linking interventions maternal, newborn and child health.
new paradigm that emphasizes in packages can also increase their Packaging a range of evidence-based,
the interrelationship between efficiency and cost-effectiveness. cost-effective interventions has the
undernutrition and the death of Integration of services can encourage potential to be among the most effective
mothers, newborns and children. their uptake and provide opportunities methods to achieve the desired aims.
The continuum provides packages of to enhance coverage. The primary focus Scaling up requires that countries
essential primary-health-care services is on providing universal coverage of identify a continuum of care based
across two dimensions: essential interventions throughout the on a context-specific mix of three
life cycle in an integrated primary- components:
• Time: The need to ensure essential health-care system.
services for mothers and children • Family-oriented, community-based
during pregnancy, childbirth, the The projected impact of achieving a services, which can be provided on a
postpartum period, infancy and high rate of coverage with a continuum regular basis by community health and
early childhood, recognizing that the of health care could be profound. In sub- nutrition promoters, with periodic
birth period – before, during and Saharan Africa, achieving a continuum oversight from skilled professionals.
after – is the time when mortality and of care that covered 90 per cent of • Population-oriented scheduled services,
morbidity risks are highest for both mothers and newborns could avert including scheduled services provided
mother and child. two thirds of newborn deaths, saving by skilled or semi-skilled health staff,
• Location: Linking the delivery 800,000 lives each year.2 such as auxiliary nurses or birth
of essential services in a dynamic attendants and other paramedical staff,
primary-health-care system that through outreach or in facilities.
integrates home, community, outreach
Scaling up
• Individually-oriented clinical services,
and facility-based care, recognizing i.e., interventions requiring health
that gaps in care are often most Scaling up to achieve a continuum
workers with advanced skills, such
prevalent at the locations – the home of care across time and location is
as registered nurses and midwives or
and community – where it is most increasingly viewed as one of the physicians, available on a permanent
required. most promising ways to accelerate basis.
progress towards the health-related
The continuum of care framework has MDGs. However, the evidence base Combining the delivery of interventions
emerged in recognition that maternal, on the effectiveness and feasibility of according to age-specific contacts
newborn and child deaths share a the continuum of care is much less with health and nutrition services can
number of similar and interrelated developed than for disease-specific generate economies of scale in terms
structural causes with undernutrition. interventions, and there is a growing of both cost and time, and enhance the
These causes include such factors as need to gather evidence on how the number of services that are accessible to
food insecurity, female illiteracy, early continuum approach can function in children and mothers. If, for instance,
pregnancy and poor birth outcomes, practice. It will require new frameworks insecticide-treated mosquito nets are
including low birthweights; inadequate and processes, especially with regard distributed in a community on one
feeding practices; lack of hygiene day, vitamin A is provided on another
to programme organization. It will
and access to safe water or adequate day and immunization campaigns take
also necessitate adapting programme
sanitation; exclusion from access place on yet a different day, children
management structures to reflect
to health and nutrition services as are less likely to benefit from all three
a result of poverty, geographical or integration of the various components
interventions than they would be if these
political marginalization; and poorly of the intervention packages and to
were made available on a single day.
resourced, unresponsive and culturally embed them within health-system
Conversely, by combining such low-cost
inappropriate health and nutrition development. This will, in turn, call interventions as vaccines, antibiotics,
services. for enhancement of institutional and insecticide-treated mosquito nets and
individual capacities, overcoming vitamin A supplementation, and adding
The continuum of care also reflects resistance to change, and integrating the promotion of improved feeding
lessons learned from evidence and and coordinating fragmented funding and hygiene practices, the packaged
experience in maternal, newborn and streams, particularly those coming from approach can markedly increase service
child health during recent decades. In international donors and partnerships.3 coverage.4

A number of programmes have been
scaled up successfully. The Accelerated Making children the council is at the level of vice-minister
or national director, and members
Child Survival and Development ‘absolute priority’ in include 16 ministries, the National
(ACSD) programme is a promising Angola Institute for the Angolan Child and
recent effort that has grown rapidly 18 civil society representatives.
in West and Central Africa. ACSD The National Council of Children
ANGOLA has now seen six years of is responsible for monitoring
concentrates on three service-delivery stability following a prolonged civil implementation of 11 commitments
strategies to augment coverage for war that left much of the country’s to children made at the 2007 national
children, newborns and pregnant health infrastructure in need of forum that address their survival,
rebuilding. To revitalize health and development, education, protection
women and bundles them in an other basic services is the main goal and participation – which the forum
integrated, cost-effective package. of current Government-led efforts to declared to be “the absolute priority.”
Based on preliminary data presented address child survival. An investment
by district health teams in Ghana, this plan, covering the period 2007– Building on this momentum for
2013, has been developed by the children, the Ministry of Health has
integrated approach, which includes Angolan Government, in partnership identified an essential package of
immunization, infant and young child with UNICEF, the World Health mother and child health care and
feeding, integrated management of Organization and the United Nations services to be delivered through
childhood illnesses, and antenatal care, Population Fund, to put this strategy three main channels: the fixed
into effect. network of public health services;
is already having a positive impact
outreach and mobile services; and
on routine immunization coverage. A first priority is data collection community-based activities. The
Subsidized insecticide-treated mosquito in this large country of nearly first phase (2007–2009) focuses
nets are being distributed in conjunction 17 million people. Existing statistics on five provinces – Bie, Cunene,
on mother and child health date Huila, Luanda and Moxico –
with immunization-plus activities. mostly from before the end of covering approximately a third of
civil conflict in 2002, and they do the population. The government is
not reflect the considerable effort
National strategic made since then to target individual
already using the experience of
these provinces with a view to scaling
planning for scaling diseases. Even as new surveys are
being carried out, new policies have
up the plan to cover all of Angola’s
18 provinces. Its UN-system partners
up services and been put in place to address needs have elaborated an Accelerated Child
and capacity challenges in child and Survival and Development (ACSD)
systems maternal health. strategy that can be used to leverage
government and donor funding for
Angola’s under-five mortality rate the national roll-out.
Scaling up services and systems will is the second highest in the world,
require practical, effective strategies at at 260 deaths for every 1,000 live Data on current coverage of health
the national level that take into account births. Of all under-five deaths, interventions and projections of
the potential for expansion, describe 18 per cent are due to diarrhoea, and coverage levels that will be achieved
nearly 90 per cent of those deaths in the intervention areas have been
the constraints and obstacles that might are attributable to a lack of water used to calculate the maternal,
impede advances, and propose ways for hygiene, unsafe drinking water, neonatal and under-five mortality
these can be overcome. and poor access to sanitary waste reductions that may be expected
disposal. Nearly 9 million Angolans, over the five-year period. Results
Key actions required in national more than half the population, will be measured using baseline
strategic plans for scaling up packaged do not have access to safe water, surveys in each of the five target
and 11.4 million have no access to provinces, and in three or four
interventions include: adequate sanitation facilities. Only provinces where the integrated
30–40 per cent of the population has package is not being offered.
• Identifying and removing health- access to fixed health installations.
system bottlenecks. To address the fact that few Angolans
To ensure that Angola reaches the have direct access to health posts, a
• Monitoring progress and problems in Millennium Development Goals, the cadre of community health workers
coverage. deaths of children under five must be is being developed. Their role is to
reduced by two thirds and maternal motivate the population, to ensure
• Phasing in intervention packages and mortality by more than three quarters that the package is known and
health-system strengthening. in the period between 1990 and 2015. adopted at the household level,
• Addressing the human and financial Investment will be needed to add and to provide families with basic
6.7 million new water users and 8.1 medical assistance. Field visits to
resources crisis in health care. million new sanitation users by 2015. municipalities have shown there is a
• Strengthening health systems at the common agenda and understanding
district level. The newly established National of the revitalization process at
Council of Children, engendered by different levels of government,
• Developing health systems for the third National Forum on Children and that systems are in place and
outcomes. in June 2007, is one example of working well.
the Government of Angola’s drive
• Obtaining national political to address the challenges to child See References, page 52.
commitment. survival. Representation on the
Identifying and removing slept under a mosquito net that had under five) and antenatal care (at least
health system bottlenecks been recently treated with insecticide. three visits) from 40 per cent in 2002 to
This bottleneck to protection against 70 per cent two years later.
Functional service delivery networks malaria was addressed through the free
are necessary for providing a continuum treatment of all existing nets, combined Many bottlenecks will demand a specific
of care based on three levels of service with heavily subsidized distribution of solution that involves addressing
delivery: family-oriented, community- insecticide-treated nets, and focused constraints at one or more levels of
based services; close-to-client primary on reaching pregnant women who service delivery. For example, low
services; and facility-based referral care were utilizing antenatal care and had demand for quality health services
and specialized preventive services. An completely immunized their children. among community members or the
initial step involves gathering data and By 2004, this integrated approach limited capacity of health facilities and
qualitative information on all existing to removing bottlenecks increased extension workers to deliver essential
service providers – public, private and the effective coverage of insecticide- services may restrict the coverage of
informal – and organizations, including treated nets by 40 per cent, while also intervention packages, as may financial,
non-governmental organizations, that expanding the effective coverage of social and physical barriers to access.
can be mobilized in support of the immunization (full course for children Here, appropriately, the community
scaling-up effort.
One example of this process is provided

in upper eastern Ghana, where many
non-governmental organizations are
actively supporting different health
interventions. Collaboration between
the Ghana Red Cross Mothers Club, the
national health services and UNICEF
under the Accelerated Child Survival
and Development (ACSD) programme
has succeeded in integrating the efforts
of all these organizations and focusing
their support on scaling up an evidence-
based package of high-impact, low-cost
interventions.
Another important step is to identify

and analyse system-wide bottlenecks
and constraints and to formulate
strategies to remove or overcome
them.5 These may originate at the
level of facilities, outreach services, or
communities and households, or from
the strategic and bureaucratic apparatus
that sets policies, controls logistics and
supplies, and drafts and implements
regulations.
In Guinea, for example, 70 per cent

of villages in the districts where
ACSD was under way in 2002 had
a community health and nutrition
promoter, 50 per cent of families owned
a mosquito net, and 25 per cent of
pregnant women slept under a net.
However, levels of effective coverage
(quality) were found to be far lower than
levels of adequate coverage (quantity);
fewer than 5 per cent of individuals Liberia: A woman and her child, newly recovered from malaria, under a bed net.

partnerships elaborated in Chapter households and communities that are and to provide services for many
3 can play a unique and vital role in currently lacking essential interventions. health interventions that require more
enhancing contact between dedicated But facility-based care and outreach specialized assistance.6
health workers – including community workers will be required both to
health workers – and services, and support community health workers
Monitoring progress and
problems in coverage
The challenge of retaining areas, where shortages are often Improving the performance and
most severe. Incentive packages
and training skilled health to retain health workers or reverse
motivation of health workers and
workers migration have been devised ensuring that facilities are adequately
in several countries. In Mali, for equipped and drugs are readily available
example, the Ministry of Health are essential second-line requirements
ACCELERATING progress for child encourages newly graduated doctors
survival and providing a continuum to support community partnerships in
to serve in rural areas by offering
of care for mothers, newborns and training, accommodation, equipment health and nutrition and to enhance
children will require a vast increase and transportation. the quality of service delivery. Part
in the number of health workers, of the solution to improving service
especially at the community level. Training focused on local conditions delivery involves increasing resources –
It is estimated that almost 860,000 can also help limit workforce attrition.
additional health staff, more than Long-standing efforts to expand the
human, financial and managerial – and
half of them health and nutrition number of health workers in rural providing training, but other incentives
promoters, will need to be recruited areas suggest that training local and better human resource management
and deployed by 2015 to meet the workers – in local languages and in may also be needed.
health-related MDGs in Africa. skills relevant to local conditions –
facilitates retention. Such approaches
At the same time they are facing Higher-level determinants of health-
to training often lead to credentials
massive shortages of health that do not have international system performance – policy and
personnel, African countries are recognition, which further limits strategic management, multisectoral
steadily losing health professionals migration. Success, however, is public policies and environmental and
to industrialized countries that offer contingent on providing incentives
better economic opportunities.
contextual change – are among the
and support at the local level.
The International Development most complex challenges for health-
Research Centre, sponsored by the There is growing concern that system development because they form
Government of Canada, estimates affluent countries are benefiting from part of a political and institutional
that developing countries invest the brain drain at Africa’s expense. context that may not change readily or
about US$500 million each year in In response, a movement has
training health professionals who easily.7 Nonetheless, sound leadership,
emerged that calls for an end to the
are then recruited or move, in effect recruitment of health workers from advocacy, technical assistance and
subsidizing health systems in more Africa, or only to do so in a way that partnerships can help to prompt change.
affluent countries. Among personnel is mutually beneficial. Some voices in
trained in Africa, 1 in every 4 doctors this discussion call on industrialized
and 1 in every 20 nurses are now countries to compensate Africa’s Phasing in intervention
working in the 30 most industrialized health systems for the damage
countries of the world. For example, caused by their recruitment. In packages and health-system
29 per cent of Ghana’s physicians are the past five years, about a dozen strengthening
working abroad, as are 34 per cent of international instruments have
Zimbabwean nurses. In the absence emerged from national authorities, A phased approach to health-service
of significant investment in their professional associations and
health systems, developing countries
delivery will allow individual countries
international bodies that have set
will have very limited options for norms for behaviour among the key to define and implement an initial
stopping this ‘brain drain’. stakeholders in the international package of interventions that can
recruitment of health workers. be expanded over time. Both the
Adapting medical training to country
packaging and the delivery of the
needs and providing incentives Similar concerns have been the focus
priority interventions will depend on
of bilateral agreements, such as the
To address the loss of health accord between South Africa and the the country’s health-system capacity.
personnel, at least in the short United Kingdom, signed in 2003, that The gradual removal of bottlenecks
to medium term, national health aims to create partnerships on health will facilitate the expansion of service
systems must build incentives for education and workforce issues. The
practising health care at home. While
delivery, even during complex
pact has reportedly been successful
this remains an ongoing challenge, in managing migration of health
emergencies. Since the packaged
a number of countries have been workers. approach is results-oriented, the
successful in recruiting and retaining implementation of priority interventions
health workers, including in rural See References, page 52. at scale can be planned and monitored
in a phased manner.
Longer term: Tackling the health worker
crisis will demand massive increases
in education and training for health-
care professionals. Without improved
training for medical professionals
and increased funding, the crisis may
worsen, with devastating implications
for maternal, newborn and child
survival and health.
The scale of this challenge should not be

underestimated. Addressing the health
worker crisis in sub-Saharan Africa
alone will require an unprecedented
surge in staffing levels during the
coming decade. Of the 860,000
Nigeria: A community health worker gets a lift to her next destination.
estimated additional workers needed,
more than half will be community
The three phases recommended for Phase three: The third phase involves health and nutrition promoters.
expanding service delivery coverage introducing and scaling up innovative Efforts are under way to expand the
for countries with low health-system interventions, such as rotavirus and number of community health workers
capacity are as follows. pneumococcal vaccines, and enhancing in many developing countries, as well
the supply and demand for this as to devise incentive packages that
Phase one: The initial phase focuses maximum package. will decrease attrition rates. Several
on reducing system-wide bottlenecks countries, including Kenya, South Africa
for family- and community-based care and Uganda, are currently considering
and population-oriented outreach Addressing the human and national programmes for community
services, fostering demand for and financial resources crisis in health workers, while Ethiopia is
the supply of quality clinical services health care training 30,000 community-based,
and providing a minimum package of In many countries, economic hardship female health-extension workers to
high-impact, low-cost interventions and financial crises have destabilized focus on maternal, newborn and child
that can be implemented given the and undermined health staff, creating health, malaria, and HIV and AIDS.8
current policy, human resources and a vicious cycle of demotivation, low Programmes to increase the number of
capacity conditions. Operational productivity and underinvestment in community health workers have also
strategies include the training and human resources. Tackling the health been launched in countries as diverse as
deployment of community health and worker crisis in developing countries Burkina Faso, Egypt and Mozambique.
nutrition promoters for improved will require a mix of measures across
family care practices. The minimum various time frames. Upgrading the skills of existing health
package of interventions typically workers is an integral part of effective
includes the following components: Short term: An immediate priority scale-up. Improved supervision and
anti-malaria interventions; nutrition; is to ensure that expanding national monitoring, in addition to results-based
hygiene promotion; immunization and global initiatives for maternal and performance incentives and contracts,
complemented by measles mortality child health do not result in further have the potential to motivate health
reduction campaigns; Integrated disruptions to the health system or workers employed in sub-Saharan
Management of Neonatal and further significant loss of personnel. Africa.
Childhood Illnesses; skilled delivery,
newborn care and emergency obstetric Short to medium term: The productivity Investment in human resources and
care; HIV and AIDS prevention and and morale of health-care professionals health-system development requires
treatment; facility-based care. need to be restored, including through significant resources. Countries where
such incentives as increased pay and donor support plays a critical role in
Phase two: The second phase comprises improved supervision. The health funding these programmes cannot plan
an expanded package that includes workforce – including community for long-term activities unless financing
additional neonatal and maternal health workers – also needs to be is secure. Yet, research tracking donor
interventions, improved water supplies expanded within the confines of the assistance to maternal, newborn and
and basic sanitation through national country’s overall macroeconomic child health found that the 60 priority
policies, and the mobilization of framework and poverty-reduction countries worldwide that account for
additional funding. strategies. more than 90 per cent of child deaths

received only US$1.4 billion in official lost fee revenue, maintain quality without risks: It can have unintended
development assistance in 2004, or just and respond to increased demand. It consequences, such as deepening
US$3.10 per child.9 While some experts also needs clear communication with existing inequalities in communities
estimate that, theoretically, it is possible a broad stakeholder buy-in, careful based on factors such as poverty, gender,
to fill the gap between present levels and monitoring to ensure that official language and ethnicity.12 Furthermore,
near-universal coverage by 2015, scaling fees are not replaced by informal fees, even where decentralization efforts have
up interventions will not be possible and appropriate management of the been successful, experience suggests that
without massively increased investment alternative financing mechanisms which transforming an administrative district
in maternal, newborn and child health.10 are replacing user fees. into a functional health system takes
time. In 2000, for example, only 13 of
Ensuring universal access to a When the above conditions are not Niger’s district hospitals had appropriate
continuum of quality maternal, met, fee removal is unlikely to benefit facilities to perform a Caesarean section.
newborn and child health care is not the poor. Under such circumstances This was also the case for only 17 of
merely a question of finding money to alternative policy options for reaching the 53 district hospitals in Burkina
expand the supply of services or to pay the poor more effectively should be Faso 10 years after districts had been
providers. Reaching the health-related considered. established; moreover, only 5 of those
MDGs will require that financing 17 hospitals had the three doctors
strategies focus on overcoming financial There is a growing consensus that required to ensure continuity of care
barriers to women’s and children’s access resources for the health sector should throughout the year.13
to services and give users predictable be channelled through institutions
protection against the financial hardship that aim to provide universal coverage, Nevertheless, the experience of
that may result from paying for care. rather than through projects and decentralization over the past decade
programmes. Maternal, newborn and suggests that, on balance, health districts
This has important implications. child health services must be part of remain a rational way for governments
User fees are an important barrier to the basket of core health interventions to roll out primary health care through
accessing health services, especially for that are covered in any benefit package networks of health centres, family
poor people. They also have a negative funded through these institutions. practices or equivalent decentralized
impact on adherence to long-term Enhancing resources spent on maternal, structures, backed by referral hospitals.
expensive treatments. This is offset newborn and child health may require Where districts have reached the
to some extent by potentially positive trade-offs in government expenditures, critical point of becoming stable and
impacts on quality. either within the health budget itself viable structures, they have shown
or within the national budget. Such credible and visible results, sometimes
User fees, though, are not the only trade-offs need to be negotiated in the in very adverse circumstances, as
barrier that the poor face. Other cost context of the overall macroeconomic in the Democratic Republic of the
barriers include informal fees, the cost environment, which can allow for Congo and Guinea. Similarly, Mali
of drugs, laboratory and radiology tests incremental sector spending if health has managed to expand health centre
not supplied in public health facilities, care requirements are well argued. networks and services for mothers
travel costs, food and accommodation At the country level, resources also and children.14 In countries where
costs, as well as charges in private health need to be mobilized from outside the decentralization has been accompanied
care facilities. These costs generally public sector through the involvement by reforms of public administration
make up a significant proportion of of the private sector, civil society there has been significant progress
the total costs that households face, organizations, communities and within a few years. Examples include
and affect disproportionately the households. Mozambique, Rwanda and Uganda, all
poor. In addition, a number of quality, countries that experienced many years
information and cultural barriers must of conflict and economic collapse but
also be overcome before the poor can Strengthening health have since made noteworthy advances
access adequate health services. The systems at the district level in reforming government institutions
evidence indicates that the poor are and performance, including their health
disproportionately affected by these Strengthening health systems remains a systems.15
non-cost barriers. challenging and complex task, especially
in many of the priority countries. The Work on the district approach to
Removing user fees has the potential decentralization of health systems and delivering the continuum of maternal,
to improve access to health services, an increasing focus on the district level newborn and child health care requires
especially for the poor. For this to can be seen as an effective vehicle for a new impetus and more rigorous
happen, fee removal needs to be part delivering effective care to marginalized systematization. In particular, a key
of a broader package of reforms that children and families at the community focus of research should be on the
includes increased budgets to offset level.11 But decentralization is not reorientation of national health systems
Egypt: A simple way to including WHO and UNICEF. In not survive to age five, and child-
1984, the programme became fully mortality rates in Upper Egypt
save young lives operational. It began with a pilot – the poorer, mostly rural part of
study to test various approaches the country south of the fertile
EGYPT is one African country that and gather baseline information and urbanized Nile Delta – remain
has made remarkable progress in relevant to all the interventions; it glaringly inconsistent with those in
reducing the number of children was then scaled up based on this the rest of the country and in North
dying before age five. In 1970, the information. Africa as a whole.
country had an under-five mortality
rate of 235 per 1,000 live births, The main components of the Even in countries where ORT has
meaning that almost 1 in every project were strengthening local been promoted, there are obstacles
4 children did not reach their fifth production, establishing an to increasing coverage to prevent
birthday. By 1990, however, that extensive distribution network, deaths resulting from diarrhoeal
rate had been reduced to 91 per training health-care providers, disease. Most private clinics still do
1,000 live births, and in subsequent developing product design not prescribe ORS and instead use
years, Egypt reduced child mortality and branding, and carrying intravenous therapy. Doctors and
by more than two thirds, to 35 per out promotion and marketing. other health-care providers in the
1,000 live births. Now, the country Television was chosen as the key private sector must be encouraged
is on track to cut this number to mass-education medium after to use ORT. The underlying causes
30 per 1,000 live births and meet research showed that 90 per cent of diarrhoea, including poor access
the Millennium Development Goal of households owned a television to education, limited empowerment
target by 2015. set. Public-service advertisements of mothers, and the lack of safe
brought awareness of ORT to rural water and improved means
One reason for Egypt’s outstanding communities with high illiteracy of sanitation, also need to be
success in increasing child survival rates. Rehydration training centres addressed.
is its pioneering adoption of oral were established at all levels, from
rehydration therapy (ORT) to local health centres to universities Egypt boasts rates of more than
treat infant diarrhoeal diseases. and central hospitals. Extensive 98 per cent in use of clean water
In the late 1970s, diarrhoea was training was provided to doctors sources and 70 per cent in use
responsible for at least half of and nurses, and oral rehydration of improved sanitation; its rates
infant deaths in the country and therapy was included in basic for immunization against six
accounted for more than 30 per cent nursing and medical training. main childhood diseases are above
of children’s hospital admissions. In 98 per cent overall. It lags, however,
1977, the Egyptian Ministry of Health Good results came quickly. By in the prevalence of exclusive
introduced a simple solution of 1986, nearly 99 per cent of Egyptian breastfeeding, as does the North
salt, sugar and clean water, known mothers were aware of ORS, use of Africa subregion as a whole.
as oral rehydration salts (ORS), the solution was widespread, and According to most recent estimates,
in public clinics and commenced most women could correctly mix 14 per cent of Egyptian newborns
local production of ORS packets. the solution. The number of children are underweight at birth, and
At first, usage of the treatment brought into clinics for treatment only 38 per cent are exclusively
was slow to pick up. By 1982, of diarrhoea rose from 630,000 in breastfed in the crucial first six
only 10–20 per cent of diarrhoea 1983 to 1.4 million in 1985. Infant months of life. This figure is the
cases were treated with ORS, and mortality was reduced by 36 per exact average for developing
most of the salts lay untouched in cent and under-five mortality by countries as a whole but stands out
warehouses and clinics. Instead, 43 per cent between 1982 and in a subregion where most other
the most widespread treatments 1987. Diarrhoea-related mortality child-health indicators are much
were ineffective antidiarrhoeal during this same period fell better than the global norm.
medicines, and physicians 82 per cent among infants and
commonly recommended that 62 per cent among children under Despite the remarkable success
mothers withhold fluids and food five. It was estimated that the ORT of ORT in Egypt, the programme’s
and suspend breastfeeding. campaign prevented the deaths sustainability could be threatened
of 300,000 children between 1982 by inadequate financing.
Building on the success of and 1989. Experience shows that when
community trials the previous funding for oral rehydration
year, in 1981 Egypt established The intervention was cost-effective, programmes is cut, rates of ORT
the National Control of Diarrhoeal too. The average cost per child usage fall sharply. Such rapid
Diseases Project with financial treated with oral rehydration declines indicate that behaviour
support from external donors and therapy was estimated at less change is still far from widespread,
consultants. The project involved than US$6, and the cost per death even among health professionals,
the Ministry of Health and other averted was US$100–$200. Today, and that further education and
branches of government, the private most Egyptian children enjoy their training are still needed.
sector, professional societies most basic right to survival. Still,
and international organizations, 1 out of 28 children in Egypt does See References, page 52.

to create the conditions in which This linkage between systems and Establishing benchmarks
district health and nutrition systems outcomes has been stressed in the and outcome indicators for
that provide a continuum of care can African Union’s Strategic Framework health-system development
thrive. Systematic analysis and case for Reaching the Millennium
studies from countries that have tried Development Goals in Africa, Indicators associated with the health-
this approach could yield important prepared jointly by UNICEF, WHO related MDGs can serve as appropriate
insights into the ways current policy and the World Bank and presented tracers or proxy measures for the
processes function and might be to the African Union in November performance of health systems. New
improved. Some significant problems – 2007. The framework analyses system initiatives can support governments
such as building institutional capacity bottlenecks for 16 countries and in achieving their agreed outcomes in
and obtaining strategic intelligence simulates the potential impact on the selected target areas through results-
for steering and monitoring resource MDGs of removing these bottlenecks based financing and appropriate
incentive frameworks. The objective
flows and health-system performance country by country. Based on this
is to achieve defined output targets for
– are already well recognized by framework, more than 10 countries in
coverage of services that are strongly
practitioners. There is also ample Africa are currently revising plans and
correlated with positive maternal,
consensus that effective methods of budgetary mechanisms such as Poverty
newborn and child health and survival
monitoring and evaluating progress are Reduction Strategy Papers, health- outcomes – for example, the proportion
vital for proper system governance. sector development plans, sector- of deliveries in an accredited facility,
wide approaches and medium-term immunization coverage of three
A results-oriented, evidence-based expenditure frameworks to strengthen doses of diphtheria, tetanus toxoid
approach to formulating a continuum health systems with the aim of concrete and pertussis vaccine, or coverage of
of quality primary health care for outcomes for mothers and children. insecticide-treated mosquito nets in
mothers, newborns and children
necessitates reviewing the best
information, data and analysis to
arrive at the most useful lessons that
can inform current and future actions.
It is clear that there is much work to
be done in gathering evidence and
knowledge on ways to build capacities
for policy formation, regulation and
steering that can inform governance
of the health sector as a whole, as well
as the organization of a continuum of
maternal, newborn and child care at the
district level.
Developing health
systems for outcomes
Efforts to improve harmonization
of aid and to scale up activities,
particularly in Africa, have increasingly
focused on utilizing the health-related
Millennium Development Goals and
other indicators as the benchmark for
outcomes. The emphasis on outcomes
is intended to create a synergy between
the outcomes and inputs. Health-
system development is increasingly
being framed as part of the process
of achieving the MDGs, not distinct
from them. Gambia: An affectionate moment for a mother and child.
malaria endemic areas. These outputs when governments take the lead and are health systems and nutrition services.
and targets would be selected based on committed to expanding successful pilot Many of the countries struggling to
the risk factors contributing to mortality and small-scale projects, these initiatives meet the MDGs, particularly in sub-
and morbidity for each country. can rapidly gain nationwide coverage. Saharan Africa, do not enjoy political
Governments can provide the capacity or economic stability. Under such
and will to creating a national network
Obtaining national based on community health.
circumstances, it is important to
political commitment mobilize all forms of effective leadership
Sound budgeting and political in society, whether at the national level,
Country ownership and public-sector and macroeconomic stability are where broad sectoral decisions are made,
leadership can vastly increase the prerequisites for mobilizing the or at various subnational levels, e.g., the
prospects for successful scaling up. institutional, human and financial province or district, where interaction
Time and again it has been shown that resources required to strengthen with communities takes place.
The investment case for an incremental estimated annual cost The cost is for commodities, drugs
between US$2 and US$3 per capita, and supplies. Insecticide-treated
child survival and other or around US$1,000 per life saved. mosquito nets represent a very
health-related MDGs in sizeable share of this cost, as do
In Phase two, implementation at drugs. The cost is apportioned to
sub-Saharan Africa scale of an expanded package would human resources, health facilities
lead to an estimated reduction in and equipment, and for promotion,
The strategies outlined in ‘A the region’s under-five mortality rate demand creation, monitoring and
Strategic Framework for Reaching the in excess of 45 per cent and would evaluation.
Millennium Development Goals on diminish maternal mortality by 40
Child Survival in Africa’ – prepared per cent and neonatal mortality by In the context of the Strategic
for the African Union in July 2005 – around 30 per cent. The incremental Framework, the following co-
are expected to create, in a relatively annual economic cost is estimated financing scenario is proposed: In
short time frame, the minimal at around $5 per capita, or less than all three phases, almost half of the
conditions needed to increase $1,500 per life saved. additional funding to scale up the
effective coverage of primary health minimum package would come from
care in sub-Saharan Africa. In Phase three, it is estimated that national budgets, including budget
reaching the effective coverage support, with 15 per cent coming
These will include a minimum frontiers with the maximum package from out-of-pocket expenditures, and
package of evidence-based, high- of interventions would allow one third from the Global Fund to
impact, low-cost services that can countries to meet or approach key Fight AIDS, Tuberculosis and Malaria,
be delivered through family and targets for MDGs 1, 4, 5 and 6 by UNICEF, the World Bank, WHO and
community-based care and through reducing the under-five mortality other donors.
population-oriented services and and maternal mortality rates by
clinical care. more than 60 per cent, cutting the See References, page 52.
neonatal mortality rate by 50 per cent
The key interventions are expected to and halving the incidence of malaria
be: antibiotics to combat pneumonia and undernutrition. The incremental
and neonatal infections; antimalarial annual economic cost to achieve
combination drugs; infant phase three is estimated at $12–$15
feeding and hygiene promotion; per capita, or around $2,500 per life
insecticide-treated mosquito nets; saved.
oral rehydration therapy; skilled
attendance at birth; vitamin A Assuming an incremental pace
supplementation; prevention and care of implementation, the additional
of paediatric AIDS; and emergency annual funding required for the
obstetric and neonatal care. proposed phased acceleration will
increase between $2 and $3 per
These strategies and interventions are capita and per year to take the
expected to have a substantial impact minimum package to scale in Phase
on improving child nutrition, maternal one; it will increase by more than
mortality, women’s status and $12–$15 per capita and per year
poverty reduction through women’s to take the maximum package to
empowerment. scale by 2015 in Phase three. It is
noteworthy that these additional
In Phase one, it is estimated that this costs have recently been estimated
strategy could reduce Africa’s under- using different costing tools, each
five mortality rate by more than 30 of which has generated similar
per cent and provide initial reductions projections, suggesting that the Morocco: A 1984 postage stamp heralds
of 15 per cent in maternal mortality at estimates are robust. the theme of ‘child survival’.

Egypt: A community health worker pays a postnatal visit to a mother in a Nile Valley village.
5 Uniting for child survival in Africa
The marked progress in reducing child At the subregional level, North Africa’s treatment of childhood illness will risk
deaths in North Africa during recent main challenges are to sustain the foundering. Eastern Africa (including
decades, significant achievements in progress made in recent decades and Djibouti and Sudan) and West Africa
several sub-Saharan countries, rapid to reduce inequalities and disparities. face the task of building on the moderate
scaling up of several key preventive The four main subregions of sub- progress achieved in reducing child
interventions, and the joint international Saharan Africa face a formidable task – deaths since 1990.
agency framework for maternal and child particularly Central Africa and Southern
health in Africa provide grounds for Africa, which have registered increases Meeting the challenge of child survival
optimism in the ongoing struggle against in under-five mortality since 1990. In facing sub-Saharan Africa is not beyond
death and disease on the continent. both of these subregions, the challenge the realm of possibility. The Millennium
But a mighty push is required to turn is to halt, and then reverse, the rise in Development Goals were not dreamed up
sanguinity into action and rhetoric under-five mortality by tackling factors by a group of utopians but are the result
into reality. The challenge for child that affect the supportive environment of tough thinking and hard calculations
survival must not be underestimated: – notably civil conflict in Central Africa by some of the world’s leading political
Simply put, sub-Saharan Africa faces the and the AIDS epidemic in Southern leaders, development specialists,
unprecedented task of lowering child Africa. Without rapid and sustainable economists and scientists, and they can
mortality at an annual average rate of improvements in these areas, efforts to represent a new hope for accelerating
more than 10 per cent over the next eight reduce child mortality by increasing progress on human development in
years if it is to meet MDG 4 on time. coverage of preventive and curative Africa. This report has already described
Uniting for child survival in Africa 45

some of the many success stories in of care and develop health systems The State of Africa’s Children 2008
child and maternal survival and health for results. It also calls for large-scale underscores six pivotal, macro-level
in Africa that have been made possible investment in all areas of the health actions that require unified engagement:
by combining committed leadership, system – from the community and
political will, adequate resources, sound household levels to outreach services • Create a supportive environment for
strategies and concerted action among and facility-based care – and especially maternal, newborn and child survival
stakeholders. in those countries lagging furthest and health by ensuring that health
behind. For the goals to be met, the systems and programmes are rights
Meeting the health-related Millennium survival of mothers, newborns and based – and by supporting peace,
Development Goals in Africa will children must become a regional security, child protection, birth
require a redoubling of efforts to scale imperative and be placed at the heart of registration, non-discrimination,
up community partnerships in primary the international agenda for Africa at gender equality and the empowerment
health care, create sustainable continua the very highest levels. of women.
• Develop and strengthen the continuum
of care across time and location. The
continuum must deliver essential
services at key points during the life
cycle of mothers and children. Strong
links are also required between the
household, the community, and
quality outreach, outpatient and
clinical services at primary health-care
facilities and district hospitals.
• Scale up packages of essential services
by strengthening health systems and
community partnerships through
initiatives to train health workers,
extend outreach services, overcome
bottlenecks and exploit new
technologies and paradigms.
• Expand the data, research and
evidence base. Although the evidence
base on maternal and child health
is being provided by a rich array of
resources, there is still a demand for
more rigorous data collection and
dissemination, and research and
evaluation.
• Leverage resources for mothers,
newborns and children. Donor
assistance is rising, but not fast enough
to meet the goals in Africa. National
governments must also fulfil promises
to boost health spending.
• Make maternal, newborn and child
survival in Africa a global and regional
imperative.
What needs to be done for progress

in child survival in Africa is clear.
The basis for action – data, research,
evaluation – is already well established.
The time frame for results is set by the
Sudan: Mother and child in the western Darfur region. Millennium Development Goals. The

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surprenante présence d'esprit. La réalité de l'attaque dissipait la
terreur imprécise qui l'anéantissait tout à l'heure.
Souple et nerveuse, attentive et adroite, malgré sa fragilité, elle
échappa dix fois aux mains affolées, à l'étreinte de l'ivrogne qui
grommelait des imprécations sourdement et soufflait comme un ours
traqué...
Cependant, elle eut tout à coup l'affre de sentir ses jambes
immobilisées par les genoux du géant...
En vain, elle essaya de s'arracher à son enlacement, les chairs
meurtries, les os rompus par son effort désespéré: son buste seul
s'agitait.
Ce fut alors que, sentant sa défaite imminente, fatale, elle aperçut,
solide et brillant, l'instrument de suprême défense.
A terre, presque sous la chaise longue, auprès du plat retourné et
des débris du souper piétinés, gisait un couteau de cuisine, au
manche de bois noir cerclé de cuivre, à la lame très large à la base,
très effilée de la pointe.
Muette et exaspérée, elle s'empara de l'arme. Et, comme l'homme se
courbait sur elle, s'arc-boutant d'une main contre lui, elle enfonça de
toute sa force la lame dans la chair résistante, un peu au-dessous du
cou, à l'endroit de la clavicule que l'effort du Russe creusait.
Ce fut instantané.
Un cri rauque fusa de la gorge de Lénine et la jeune fille sentit le
corps de l'homme peser sur elle, mais devenu mou, incapable
d'étreinte ou de volonté, tel qu'un matelas qui l'eût étouffée sous sa
masse inerte.
Elle se libéra, d'un élan qui la fit glisser et s'étaler sur le tapis. Lénine
s'affaissa sur la chaise longue avec des gémissements.
D'un bond, Cady fut sur ses pieds et elle contempla le blessé avec
curiosité, toute frayeur enfuie, emplie d'une sensation intense de
triomphe et d'orgueil, toute au bonheur d'être sauvée.
Elle ne songeait pas le moins du monde à la gravité possible de son
geste.
Georges surgit effaré.
—Nom de Dieu! est-ce que tu l'as tué?...
Déjà, Lénine reprenait ses sens, son vertige passé, son ivresse
alcoolique et passionnelle complètement dissipée.
Il se redressa, s'assit et porta la main à sa blessure, peu profonde,
mais qui saignait assez abondamment.
—Bougre de gamine! proféra-t-il presque allégrement, en tournant
ses yeux vers Cady, qui l'étudiait avidement, sans songer à rectifier
le désordre de ses vêtements.
Georges apportait une serviette mouillée d'eau fraîche.
—Tenez, monsieur, fit-il tout tremblant.
—Merci, petit.
Le Russe essuya, tamponna sa coupure sans cesser d'examiner la
fillette.
—Je ne sais toujours pas comment tu te trouves ici, Cady? dit-il.
Elle avait repris son aplomb habituel.
—Ça ne vous regarde pas, dit-elle délibérément. Est-ce que je vous
demande pourquoi vous y êtes, vous? Tenez, écoutez-moi, monsieur
Lénine, vous allez me jurer que vous ne direz pas un mot chez moi...
Et moi, je vous promets de ne rien révéler de ce qui s'est passé ici...
Il jeta à terre la serviette ensanglantée et en prit une seconde qui
fut aussitôt maculée.
—En vérité? s'écria-t-il avec une indignation à demi jouée. Tu es
vraiment trop bonne, petit serpent!... Elle m'assassine et c'est elle
qui fait la magnanime!...
Elle riposta vertement:
—Tiens, c'est vous qui y gagnez, je pense!... Si papa savait!
Il hocha la tête, réfléchit, rassembla ses souvenirs et fronça les
sourcils, soucieux, évitant le regard hardi de la jeune fille.
—Après tout, tu as raison, concéda-t-il.
Ces paroles suffirent à Cady. Prompte, elle détala, sans s'arrêter
auprès du lit de Charlotte de Montigny, qui, effrayée par le bruit,
implorait inutilement qu'on la renseignât sur ce qui se passait.
—Débrouille-toi, avait jeté la fillette à Georges en s'enfuyant.
Elle ouvrit prestement la porte de service de son appartement,
traversa la cuisine déserte, fila le long du corridor et rentra à pas
feutrés dans la chambre où Mlle Armande dormait pesamment.
Elle se coucha et demeura longtemps—la plus grande partie de la
nuit—sans parvenir à s'assoupir, brûlante, énervée, les membres
tourmentés de crampes, les reins douloureux. Elle conservait avec
horreur sur sa peau l'impression du contact étranger de l'homme nu.
Et elle croyait sentir sur ses lèvres, dans sa bouche, un fade goût de
sang.
Cependant elle regrettait de n'avoir pas gardé le couteau auquel elle
avait dû son triomphe.
Elle ne reconquit un peu de calme qu'en se forçant à chasser de son
esprit le souvenir de la fin de cette nuit, en rappelant de toutes ses
forces le commencement de la soirée, tout plein de gaîté et de claire
tendresse.
Et Cady finit par s'endormir, apaisée, le nom de son ami sur les
lèvres:
—Mon petit... Mon cher petit Georges...
XXVII
Pour célébrer la guérison de Baby, Mme Darquet donnait un dîner
sans cérémonie où figuraient ses deux filles et leurs cousines Alice et
Marie-Annette.
Les autres convives étaient Mme Serveroy, les deux secrétaires,
Listonnet et Malifer, Jacques Laumière, Victor Renaudin, le jeune
juge suppléant, et trois personnes qui, depuis peu, s'étaient faufilées
dans l'intimité de Noémi Darquet avec cette ténacité et cette
hardiesse que donnent l'intérêt et l'ambition sans scrupules.
Mme Durand de l'Isle, d'une laideur apoplectique qui la classait à
quarante-quatre ans parmi les grand'mères, avait pour fille une
assez jolie créature, mince, d'une grâce câline, visiblement affectée,
néanmoins attachante à force d'exagération, et pour fils un coquebin
parfaitement nul, le sachant, mais ne s'en troublant point, comptant
avec raison sur l'entregent de sa mère et de sa sœur pour lui trouver
une situation que son mérite ne saurait lui procurer.
Mme Durand de l'Isle était veuve d'un chef de bureau des Finances,
et sa fille Fernande, à vingt-quatre ans, avait déjà divorcé d'avec un
avocat qui la battait, prétendait sa mère. D'ailleurs, la jeune femme
refusait avec obstination de révéler les causes de sa prompte
séparation d'avec son époux et se contentait de sourire
énigmatiquement lorsqu'il y était fait allusion.
Le but de la veuve, sans fortune, intrigante et avide, était de caser
son fils comme secrétaire du député et de glaner un second mari
avantageux pour Fernande, aux côtés et sous l'égide de la femme
influente qu'était Noémi Darquet.
Il va sans dire que celle-ci lisait clairement dans le jeu des deux
femmes et n'était point dupe de leur comédie d'empressement,
d'admiration et d'affection; mais, leurs flagorneries lui plaisaient.
Elle adorait être entourée, complimentée, flattée avec outrance.
Cependant, comme elle n'était point sotte et qu'elle ne fermait les
yeux que volontairement sur l'hypocrisie de ses commensaux, elle se
dégoûtait vite de ceux-ci. Le règne de ses favoris n'était jamais de
longue durée. Tels qui fréquentaient assidûment pendant six mois
disparaissaient brusquement de l'atmosphère de Mme Darquet pour
ne plus y jamais reparaître.
Du reste, à part quelques exceptions, la femme du député ne les
renvoyait que pourvus de ce qu'ils étaient venus quêter près d'elle,
et qu'ils avaient payé d'avance en courbettes, lâchetés et adulations.
Sitôt le dîner terminé, la petite Jeanne, qui méditait de rafler le reste
du dessert avant que les domestiques desservissent, obtint la
permission de se retirer, en simulant une fatigue excessive.
Lorsqu'on quitta la salle à manger, ainsi qu'il arrive fréquemment
dans une société intime, les groupes se scindèrent immédiatement,
sans souci de la politesse qui élargit le cercle des convives moins
familiers.
Le bridge accapara Cyprien Darquet, Renaudin, M. Durand de l'Isle
et la jeune divorcée, que sa mère rallia vivement dès qu'il fut certain
que le juge serait de la partie.
C'était le gendre en vue, et la veuve manœuvrait avec d'autant plus
d'audace qu'elle sentait que la maîtresse de la maison approuvait
son dessein.
Cette dernière, plongée en des réflexions personnelles touchant son
prochain départ pour le Midi, décidé pour consolider la
convalescence de Baby, demeurait en tiers, assez distraite, dans la
conversation qu'avaient sa belle-sœur, Mme Serveroy et Jacques
Laumière.
La mère d'Alice et de Marie-Annette gardait de jolis traits à quarante
ans. C'était en elle un singulier mélange d'apparente jeunesse, de
lassitude et de grâce fanée.
Extrêmement avaricieuse et parfois hantée de snobisme, elle avait
mis dans sa tête d'obtenir son portrait par Laumière, sachant que
celui-ci ne faisait point payer ses toiles et que, grâce à l'originalité du
peintre, elles avaient un grand succès à l'exposition annuelle de la
Société Nationale.
Tout de suite, Jacques devina la raison des cajoleries de la dame, et
son premier mouvement avait été de se dérober. Néanmoins, sans
laisser deviner son impression, il l'étudiait, pesant dans sa tête les
avantages et les inconvénients de son acceptation.
Evidemment, la tête de cette névrosée offrait de l'intérêt et pouvait
donner lieu à une œuvre curieuse. Mais les séances seraient
mortelles.
D'un autre côté, sous ses dehors d'indifférence et de détachement,
Jacques Laumière, arriviste prudent et dissimulé, ambitionnait
vivement la croix. Or, Mme Serveroy, certaine avec l'aide de son frère
de l'obtenir pour son peintre, la promettait carrément sous ses
discrètes allusions.
Cady s'était montrée sombre, taciturne et préoccupée durant tout le
dîner. Et, refusant de jouer avec ses cousines et les deux secrétaires
au ping-pong installé sur la table de la salle à manger promptement
débarrassée, elle demeura pendant quelques instants auprès des
joueurs, visiblement absorbée par d'autres pensées que celles qui
animaient si vivement et si joyeusement les deux camps adverses.
Enfin, lorsque les jeunes gens, tout à leur exercice, ne la regardèrent
plus, elle s'esquiva sans bruit et gagna la galerie, d'où elle inspecta
soigneusement les convives.
Dans le cabinet-fumoir du député, les bridgers s'enfonçaient
complètement dans les péripéties du jeu. Au bout du grand salon,
Noémi Darquet, étendue dans un fauteuil, semblait installée pour
toute la soirée en face de sa belle-sœur et de Jacques Laumière
engagés à fond dans leur petite lutte de diplomatie particulière.
La fillette pénétra dans la chambre de Mme Darquet à peine éclairée.
Lentement, elle s'approcha du chiffonnier où Noémi serrait ses
bijoux et elle l'examina avec attention.
Dans sa tête, deux idées ressassées depuis le commencement de la
soirée s'agitaient, la troublant profondément.
Là-bas, dans l'appartement de Charlotte de Montigny, la demi-
mondaine souffrait—en réalité, malade d'une grave fausse-couche—
abandonnée par le Russe ainsi que par tous ses autres amis, sans le
sou, menacée d'être expulsée, car elle devait plusieurs termes, et le
gérant de l'immeuble, peu flatté d'avoir une «cocotte» pour
locataire, lui avait signifié que l'on ne tolérerait désormais aucun
retard dans les paiements.
Pendant la journée, venu secrètement auprès de Cady, Georges lui
avait conté sa détresse en pleurant à chaudes larmes. Il demeurait
seul avec sa mère pour la soigner, mourant presque de faim, tandis
que Paul s'évertuait sans succès à glaner un peu d'argent, dans une
déveine noire également.
Et Georges ayant supplié Cady de lui venir en aide, celle-ci n'avait pu
que mêler ses larmes à celles de son ami. Elle possédait bien des
économies, mais ces fonds étaient placés et elle ne pouvait y
toucher.
Quant à demander de l'argent à qui que ce fût, c'était impraticable.
Alors, le petit garçon avait insinué que les parents de Cady étaient
riches... qu'il y avait certainement dans l'appartement beaucoup
d'argent, en tout cas, des bijoux de grande valeur...
—Le moindre bracelet, une bague de diamants, une broche nous
sauverait... Paul ne serait pas embarrassé pour laver l'objet,
murmurait-il câlin, ses beaux yeux bleus tout brillants de larmes.
Cady n'avait ni tressailli ni protesté. Elle-même songeait à ce que le
petit lui suggérait.
Cependant, elle secoua la tête négativement.
—C'est impossible.
Il n'avait pas insisté et s'était retiré, le dos courbé, pâle, laissant
dans le cœur de Cady une véritable blessure saignante.
Voir Georges souffrir, et ne pas pouvoir le soulager!...
C'était cette pensée lancinante qui la hantait là, debout, devant le
chiffonnier qui contenait tant de richesses!...
Les bijoux de Mme Darquet étaient justement célèbres. Provenant de
sa mère. ils n'avaient jamais été remontés; ils étaient démodés, mais
d'une beauté qui défait la critique.
Cady connaissait trois rivières de diamants dont la plus petite valait
certainement une fortune... Le collier tiendrait dans le creux de sa
main... Mme Darquet ne s'apercevrait de rien, au moins pendant très
longtemps, car elle ne portait ses parures que très rarement...
Ce serait aussitôt le soulagement des peines qu'enduraient la malade
et son fils...
Et, s'interrogeant, la jeune fille constatait que l'idée de voler sa mère
ne lui inspirait pas plus de répugnance que d'effroi. Elle ressentait
peut-être, au contraire, tout au fond d'elle-même, une espèce de
joie rancuneuse à léser Mme Darquet...
Pourtant certains gestes lui étaient pénibles. Elle eût voulu que le
tiroir s'ouvrît de lui-même, que le collier se trouvât transporté dans
sa main. Il lui coûtait d'accomplir le nécessaire pour s'en emparer.
C'était cependant fort simple. Il y avait beau temps que, furetant en
cachette chez Noémi, pendant les absences de celle-ci, elle avait
découvert le ressort secret qui ouvrait une petite boîte en
marqueterie, dans laquelle Mme Darquet déposait son trousseau de
clefs.
Elle avait parfois fait usage de celles-ci pour d'insignifiants larcins,
surtout pour avoir le plaisir de constater qu'elle était à même
d'ouvrir et de visiter armoires, secrétaire, chiffonnier...
Jamais l'idée ne lui était venue de dérober de l'argent pour elle;
mais, une fois, elle s'était plu à déchirer un billet de cent francs en
menus morceaux et à le fourrer au fond d'une bottine... attendant
avec anxiété le résultat de son acte, qui lui était suggéré par des
impulsions assez complexes. Il n'avait eu aucune suite et elle avait
cessé de songer à cet incident, après quelque déception de son peu
de retentissement.
Elle revint dans la galerie sans avoir pu prendre un parti.
Justement, Mme Darquet répondait à une question que Mme Durand
de l'Isle lui adressait du fumoir, pendant le loisir des comptes d'une
première manche:
—Non, non, je n'emmène point Cady au Cap d'Ail! s'écriait Noémi...
Il n'en a jamais été question... C'est exclusivement pour la santé de
Baby que je me résous à quitter Paris à cette époque, et il ne faut
pas que les études de ma fille aînée soient interrompues.
Le sang monta aux joues de Cady. Elle eut une sorte
d'éblouissement.
Jusqu'alors, elle n'avait point mis en doute qu'elle fît, avec sa mère
et sa sœur, le voyage décidé après la maladie de Baby. Elle s'en était
follement réjouie et entassait silencieusement en elle-même mille
projets radieux, que la phrase sèche de sa mère venait de culbuter...
Elle serra les dents et les poings, touchée comme par la douleur
physique la plus aiguë, murmurant éperdue, exaspérée:
—Sale bête, va!...
Et, mue par un irrésistible besoin de vengeance, elle courut vers la
chambre de sa mère, où elle se saisit de la boîte à secret dont elle fit
jouer le ressort brutalement. Si les clefs ne s'y fussent pas trouvées,
elle eût été capable d'essayer de briser la serrure du meuble, sans
souci du bruit, du scandale possible...
Le trousseau était à sa place. Elle s'approcha du chiffonnier, ouvrit le
tiroir sans hésitation, le cœur tout bouillant de colère et de haine.
Elle connaissait l'écrin, qu'elle négligea de prendre, attachant avec
une folle témérité le collier de diamants autour de son cou.
Elle referma le tiroir, remit les clefs dans leur cachette, et, la rivière
dansant sur sa poitrine, elle se précipita dans son appartement.
Mlle Lavernière, ayant congé pour la soirée, ne s'y trouvait
naturellement point.
Cady ouvrit la fenêtre du cabinet de toilette et se mit à siffler
bruyamment.
Au troisième appel, Georges parut.
—C'est toi, Cady.
Elle répondit haut, sa voix résonnant entre les murs rapprochés:
—Oui, j'ai un collier... pour toi.
Georges poussa un cri Joyeux:
—Oh! Cady, mignonne Cady!
Penchée à la croisée, la fillette mesura le vide.
—Si je le jette, il va tomber dans la cour, sûr!...
Il dit précipitamment:
—Ne le jette pas!... Attends!
Et il disparut.
Peu après, Cady se redressa avec un sursaut de contrariété. Auprès
de Georges, elle apercevait le buste et la tête équivoque de Paul, le
jeune homme fripé, aux cheveux teints au henné.
—Ne t'en va pas, Cady! s'écria Georges alarmé de son geste.
Paul sourit d'un air engageant.
—Tenez, mademoiselle, voilà qui fera l'affaire.
Il tendit par la fenêtre le long manche d'une tête de loup, à
l'extrémité duquel il avait fixé un mouchoir noué en forme de sac.
—Mettez l'objet dans le mouchoir. N'ayez crainte, il ne tombera pas.
Mais Cady, révoltée, recula.
—Ce n'est pas à vous que je le donne! s'écria-t-elle frémissante et
hautaine.
Le jeune homme sourit avec contrainte.
—Ne parlez pas si haut!... et ne vous fâchez pas. Charlotte est
malade, vous savez bien, et Georges n'a pas le bras assez long.
Le petit garçon se penchait, inquiet.
—Voyons, Cady, fais donc pas de magnes!...
La jeune fille se saisit brusquement du mouchoir que Paul maintenait
à sa portée, le roula en boule et le lança à toute volée dans la
direction du jeune homme. Il vint briser un carreau derrière sa tête.
—Zut! cria-t-elle, outrée.
Et, le collier à la main, elle reprit le galop vers la chambre de sa
mère, où elle le lança brutalement sur la cheminée, dans une coupe.
Puis, sans s'occuper de l'étonnement, des commentaires auxquels
donnerait lieu la présence inexpliquée du bijou à cette place, elle
revint dans la salle à manger, où s'agitaient et piaillaient les jeunes
filles et les secrétaires.
—Monsieur Malifer, donnez-moi votre place! s'écria Cady
impérieusement. Vite, vite!... je veux jouer!...
Et, bousculant tout le monde, elle fit voler les balles légères avec
une virtuosité sans pareille.
—Hein? c'est exécuté cela? s'écria-t-elle avec triomphe, tandis que
les jeunes gens applaudissaient à son adresse.
Alice grogna, maussade:
—Oh! dès que tu es là, il faut que tu éclipses les autres...
Cady lui fit une grimace:
—Il y a des gens près de qui ça n'est pas difficile!...
Puis, comme Valentin apportait le thé, elle planta là le jeu et courut
à Mme Darquet.
—Maman, me permettez-vous de servir le thé? fit-elle d'une voix
étudiée.
Etonnée, Noémi acquiesça.
—Si tu veux.
Alors, la fillette rejoignit le domestique dans la galerie en
gambadant, les yeux flambant d'une joie dont elle eût été bien
embarrassée de déterminer la cause.
—Grande andouille, dit-elle bas. Pose ton plateau et fous le camp, je
suis la demoiselle de la maison et je fais tout le turbin!...
Les dames servies, elle expédia les hommes, et se délivra de ses
cousines en leur confiant les assiettes de petits fours, pour apporter
une tasse à Renaudin, avec l'impayable singerie des minauderies
auxquelles se livrent la plupart des jeunes filles en cette occupation.
—Eh bien, cher ange, glissa-t-elle bas au jeune magistrat. A quand
le mariage?
Renaudin sourit à ses mines, sans saisir le sens de sa question.
—Avec qui?... Avec toi?
Cady haussa les épaules.
—Fais donc le malin!... Avec mademoiselle-madame, là-bas!...
Et, d'un clin d'œil furtif, elle désignait Fernande, que, tout bas, sa
mère admonestait vertement pour son manque de vivacité pendant
le bridge et ses fautes impardonnables à un jeu où Renaudin était de
première force et paraissait se complaire.
Cette fois, le jeune homme dut comprendre.
—Oh! tu crois? fit-il, frappé par mille ressouvenirs de petits faits.
—Pardi!...
Il rit de bon cœur.
—Oh! bien, tu sais!
Elle l'examinait curieusement.
—Oui, j'imagine que toi, tu n'es pas pour les divorcées.
Il fit la grimace.
—En effet.
Elle poursuivit, péremptoire et sérieuse:
—Toi, tu épouseras une jeune fille... très jeune... beaucoup plus
jeune que toi, avec qui tu seras content de faire le papa.
Il haussa les épaules avec un certain embarras:
—Tu dis des bêtises, Cady!
Elle partit d'un éclat de rire clair.
—Veux-tu que je te dise?... Eh bien, c'est toi qui en feras, des
bêtises... Au moins une... Tu m'épouseras, quand je serai sortie de
nourrice!... Tu ne penses qu'à ça...
Renaudin devint pourpre.
—Cady, tu passes les bornes!... Tu es vraiment trop mal élevée!...
balbutia-t-il.
Et, réellement furieux, il tourna le dos à la terrible gamine et s'en fut
ostensiblement rejoindre le groupe Durand de l'Isle.
—Faisons-nous un second tour de bridge? demanda-t-il empressé.
Le visage de Mme Durand s'illumina:
—Comment donc!... C'est-à-dire, ma fille jouera; elle a une telle
passion pour le bridge!... Madame Darquet, c'est votre tour, vous me
permettrez de suivre votre jeu?... Vous êtes si supérieure!... Je
prendrai une bonne leçon.
Les secrétaires, prétextant un travail pressé, avaient pris congé. Les
deux Serveroy, désœuvrées, retombèrent sur Cady.
—Viens avec nous dans la galerie... Dis donc, quelle chance tu as de
voir ces deux jeunes gens tous les jours, ils sont charmants!
—Zut! zut et zut!... répondit Cady, agacée. Vous ne croyez pas que
je vais vous écouter chanter les louanges de Listonnet et de
Malifer!... un grand jackdale et un pisse-vinaigre!...
—Qu'est-ce que tu dis? s'esclaffa Marie-Annette, dont le visage se
tordit.
Cady répondit majestueusement:
—C'est des mots à ma nourrice!
Et, brusquement, une tristesse, une mélancolie sans nom,
l'envahirent. Elle s'absorba si bien en elle-même qu'elle n'eût pu
dire, le lendemain, comment les hôtes étaient partis, quand elle avait
regagné sa chambre, s'était couchée et était tombée dans le profond
sommeil qui la conduisit d'une traite jusqu'au lendemain matin, sans
que la rentrée de Mlle Armande troublât son repos.
XXVIII
Quelques jours avaient passé, durant lesquels les fenêtres de
Charlotte de Montigny demeurant obstinément closes, Cady n'avait
pu avoir de nouvelles du petit Georges.
Du reste, il restait assez d'enfance en elle pour qu'elle se persuadât
que tout avait dû s'arranger; et sa propre déconvenue au sujet du
voyage escompté et manqué l'absorbait complètement.
Bien qu'elle cachât orgueilleusement sa déception, elle ne pouvait en
prendre son parti, et les préparatifs que l'on faisait, la joie banale de
la petite Jeanne, la jetaient dans un sombre désespoir.
Pendant trois jours, Mlle Armande, surprise et ravie, n'entendit pas
une note de musique.
Cependant, le matin du départ de Mme Darquet et de Baby, que le
député accompagnait pour quarante-huit heures, Cady se composa
une attitude si habilement indifférente que nul n'eût pu deviner le
désarroi, la souffrance, la désespérance, que masquaient cette
apparence correcte et naturelle.
Maria suivait sa maîtresse. Valentin fila un quart d'heure après les
patrons. Clémence apprêta un déjeuner sommaire, en bougonnant,
et demanda d'un tel ton de menace à Mlle Armande si elle ne se
contenterait pas d'un dîner froid, qui permettrait à la cuisinière des
courses urgentes, que l'institutrice se hâta de l'assurer qu'elle
pouvait agir comme il lui conviendrait le mieux.
Après le déjeuner, Cady ayant refusé obstinément de sortir, Mlle
Lavernière s'octroya un congé et ne revint qu'à la nuit tombante.
Les sons du piano frappèrent son oreille, et, malgré son
incompétence musicale, elle eut l'intuition de la fougue, de la
passion, de l'espèce de maîtrise du jeu de la fillette enfiévrée,
énervée par le chagrin, qu'exaspérait encore l'exaltation de la
musique, rouée par la fatigue corporelle d'un exercice musculaire qui
durait depuis plusieurs heures.
Arrachée à son rêve, Cady, silencieuse, maussade, mangea du bout
des dents un peu de viande froide, et se coucha pour s'endormir
presque instantanément.
Elle n'entendit point Mlle Armande se mettre au lit.
Quand elle fut réveillée en sursaut, il était environ une heure du

matin.
L'on était en plein drame.
La chambre était obscure; pourtant, la porte donnant sur le corridor,
ouverte, se découpait, faiblement éclairée par une lueur lointaine.
Et Cady perçut des cris étouffés, un râle, un bruit de chute... et
encore un râle, un râle affreux.
Elle sauta à terre, éperdue, et courut au lit de son institutrice qu'elle
tâta, sans rencontrer celle-ci.
—Mademoiselle Armande! cria-t-elle d'une voix altérée.
Elle avait compris que le lit était vide avant que ses mains eussent
rencontré les draps ouverts, l'oreiller froissé, déjà froid.
Mais le râle s'éteignit... Elle courut à la porte, en chemise, cria
encore:
—Mademoiselle Armande!... Où êtes-vous?
Des pas précipités retentirent sourdement dans le corridor. Une
ombre d'homme s'abattit sur elle, se découpant sur le reflet d'une
lampe qui vacillait là-bas.
Deux mains vigoureuses saisirent la fillette, rabattirent ses bras
instinctivement levés en une défense.
—Pas de musique, nom de Dieu! souffla une voix qu'elle reconnut.
—C'est vous, voleur, assassin! s'écria-t-elle avec une prescience du
drame que, néanmoins, elle n'imaginait point clairement.
La lumière se rapprochait. Cady aperçut Georges qui portait une
lampe Pigeon. Elle vit que Paul qui la maintenait fortement était sans
veston ni gilet, les manches de sa chemise mauve relevées jusqu'au
coude. Il n'avait que des chaussettes aux pieds.
Il la repoussait dans sa chambre.
—Vous allez vous taire, sale moucheron? fit-il d'un accent colère. Ou
bien, on vous fera votre affaire!
Georges s'élança, tout pâle.
—Ne lui fais pas de mal, cochon!
Le jeune homme ricana.
—On ne lui fera rien si elle reste bouche cousue!...
Le petit garçon affirma vivement:
—Elle ne dira rien!... Cady, jure que tu ne diras rien?
Paul enleva la fillette, l'étendit sur son lit, et rapidement, il l'attacha
avec une corde prise dans la poche de son pantalon.
Anéantie—d'ailleurs persuadée qu'elle ne courait aucun danger—elle
n'opposait aucune résistance, ses yeux allant de Georges au jeune
homme, son cerveau reconstituant presque à l'insu de sa volonté, la
genèse de cette scène.
Evidemment, Georges, mis au courant par elle du départ des
Darquet, connaissant l'appartement, sachant la quantité
considérable de bijoux que possédait Noémi avait renseigné l'ami de
sa mère... A la nuit close, ils s'étaient introduits par l'escalier de
service... Les serrures n'étaient pas pour les embarrasser...
Mais Mlle Lavernière?... Sans doute, la malheureuse avait entendu du
bruit, s'était levée... et trouvée face à face avec l'homme!
Cady cria involontairement:
—Mademoiselle Armande?...
Georges avait disparu, laissant la lampe sur une table.
Paul se pencha sur la fillette, menaçant.
—Son compte est réglé!... Toi, ma petite, comprends que ton intérêt
est de te taire!... D'abord, nos affaires terminées ici, nous filons à
l'étranger et bien malin qui se lancera sur notre piste... Si tu nous
dénonçais, réfléchis bien que tout le monde dirait que c'est toi qui
nous as fait entrer dans l'appartement. Donc, écoute-moi bien et
rappelle-toi ce que tu diras à tout le monde... à tes parents, aux
domestiques... au commissaire... au juge... Tu dormais, tu n'as rien
vu, rien entendu... Tout à coup, tu t'es sentie bâillonnée,—car, je
vais te mettre une serviette sur ta bouche—ligottée, et tu ne sais pas
ce qui est arrivé... Tu m'entends?
Les regards de Cady se posèrent fermes et sombres sur le jeune
homme.
—Oui, dit-elle la gorge sèche, articulant difficilement.
Il ricana.
—Tu es un bijou! Ça serait dommage de faire du bobo à un petit
ange comme toi... Et puis, Georges t'aime bien et, moi aussi j'ai de
l'amitié pour toi. Alors, tout est bien convenu?
Cady ne fit aucun mouvement.
—Oui.
Il prit une serviette dans le cabinet de toilette.
—Donne ta bouche que je te musèle... Ne crains rien, je ne serrerai
pas... Là, comme cela, ça suffit. Et maintenant, on file... Merci des
indications, mon petit rat, il y a gros!...
Cady demeura seule, les membres immobilisés, la serviette lui
causant une pénible sensation de chaleur.
Son effroi du premier instant avait fui. Son impression générale était
une intense mortification.
Elle s'était laissé jouer!... Georges avait tenu un rôle d'indicateur,
d'espion!...
Peut-être feignait-il la tendresse envers elle pour mieux l'abuser,
pour obtenir d'elle les renseignements nécessaires à
l'accomplissement du cambriolage... Et elle, pauvre sotte, elle avait
aimé, chéri ce petit traître?... Elle était humiliée, elle souffrait
cruellement... Pour la première fois de sa vie, elle sentait une
solidarité avec ses parents. Le vol dont ils étaient l'objet l'indignait et
elle enrageait d'en être la cause indirecte.
Elle songeait peu à son institutrice, toute à sa déconvenue
personnelle, à la chute douloureuse de la seule affection qui eût
réchauffé son existence glacée.
Georges avait eu la lâcheté de l'abandonner!... de la laisser à la
merci de cet homme qui pouvait l'assassiner!... Il avait fui, sans un
regard pour son amie, sans un mot.
Les yeux de Cady s'emplirent soudain de larmes et sa poitrine se
souleva, gonflée de sanglots.
Un léger bruit la fit tressaillir. Elle essaya de se soulever, saisie d'une
épouvante... sentant la mort approcher.
L'homme s'était ravisé, revenait pour la tuer!... Elle eut l'affre atroce
de doigts posés sur sa gorge, l'étranglant. A son cri inarticulé,
poignant, la voix douce du petit Georges répondit:
—N'aie pas peur, Cady, c'est moi... Je suis seul, Paul est parti...
D'ailleurs, il ne te ferait pas de mal, c'était promis, tu comprends.
Et soudain, la faible lueur de la petite lampe électrique que le
garçonnet portait toujours sur lui jaillit. Il se pencha, caressa le front
de Cady de ses lèvres avec effusion.
—Cady, ma loute!... Ma pauvre chérie, tu as eu bien peur!...
Rapidement, il défaisait le bâillon, coupait la corde avec un couteau
affilé.
—Cady, parle-moi; tu n'es pas fâchée? On avait absolument besoin
de galette... Faut pas en vouloir à Paul... Il aime tant maman!...
La fillette s'était redressée, les yeux attachés sur Georges, les idées
bouleversées.
Il multipliait les paroles câlines, et doucement, avec précaution, il
risquait des caresses qu'elle ne repoussait pas.
—Dis que tu me pardonnes, Cady?... Moi, c'est pas ma faute!... C'est
Paul qui a voulu... Il m'aurait zigouillé si j'avais refusé de le
conduire...
Cady frissonna tout à coup et pointa du doigt vers le corridor.
—Elle!... Il l'a tuée, n'est-ce pas?...
Georges détourna la tête avec embarras.
—Dis donc! cria-t-elle violemment.
—Ben oui, je crois... Dame, elle s'est jetée à crier... elle aurait fait
venir du monde...
Cady frémit.
—Elle est là?
—Oui, dans le couloir.
—Par terre?
—Oui.
—Comment l'a-t-il tuée?
—Avec ses mains... Oh! il n'y a pas de sang, c'est propre.
Cady sauta à bas de son lit, tout à coup résolue.
—Viens avec moi!... Elle n'est peut-être pas encore morte...
Georges recula avec effroi.
—Oh! non, j'ai peur!
Elle avança sur lui, indignée.
—Tu as peur? Tu n'as pas eu peur tout à l'heure quand il l'a tuée!...
Georges protesta.
—J'étais pas là!... J'étais dans le petit salon... J'ai rien vu...
Cady alluma une bougie et le poussa.
—Marche!...
Pourtant, dans le corridor, quand elle aperçut à terre la masse
blanche de l'institutrice vêtue de sa chemise de nuit, elle eut une
défaillance...
Georges la tirait en arrière.
—Laisse-la donc, va... Paul n'a pas manqué son coup, je t'en
réponds!...
La fillette vainquit son émoi, et à pas précipités arriva devant le
corps. Mlle Armande était étendue sur le dos, livide, le visage
convulsé, les bras levés et crispés comme pour une lutte.
Cady, agenouillée, la souleva, essaya d'effacer l'affreux rictus avec sa
main.
—Elle n'est pas morte, elle est chaude! s'écria-t-elle avec un singulier
sentiment d'effroi et de répulsion.
Confusément, malgré toute son horreur pour le crime, elle préférait
au fond d'elle-même que son institutrice ne fût plus, dans sa terreur
que la vérité apparût, que ses parents apprissent toute l'histoire
cachée de ses relations avec l'enfant de la demi-mondaine.
Pourtant, elle ordonna:
—Apporte-moi de l'eau.
Georges lui ayant donné un verre plein, elle essaya de desserrer les
dents de l'étranglée, parvint à faire tomber un peu de liquide dans
sa bouche.
Puis elle essaya des frictions sur le cou, sur la poitrine.
Au bout de quelques instants, elle reposa le corps, courbaturée,
écœurée.
—Elle se refroidit, murmura-t-elle.
Georges insista.
—Je te l'avais bien dit. Laisse-la où elle est.
Cady hésitait.
—Si j'appelais?... Peut-être qu'un médecin la ferait revenir.
Mais Georges lui montra le visage verdissant de Mlle Armande,
l'espèce d'éclat vitreux qui se répandait sur ses yeux grands ouverts,
l'indéfinissable aspect de l'ensemble, qui prenait l'aspect d'un
cadavre!...
—Elle est morte, Paul ne l'a pas manquée, affirma-t-il de nouveau.
Cette fois, la conviction de Cady était faite. Elle se détourna et fuit à
pas précipités.
Georges l'avait suivie, préoccupé.
—Cady, écoute-moi, j'ai quelque chose à te dire...
Et, tendrement, il enlaça la fillette qui s'abandonna machinalement.
—Cady, il faut que je m'en aille... Nous partirons tout à l'heure... Je
ne te verrai plus... Maintenant, du moins, parce que je te jure que,
plus tard, quand je serai grand, je reviendrai te trouver.
—Tu pars? s'écria-t-elle avec vivacité, oubliant presque le drame.
—Oui, on va prendre le bateau à Marseille... je ne sais pas où nous
allons, mais ça doit être très loin. Mais écoute, Cady, ce que j'ai à te
dire... Pendant que Paul, il fouillait, moi, j'ai pris aussi quelque
chose... mais, si tu ne dis pas que tu me le donnes, je le laisserai...
—Tu as pris quoi?
Le garçonnet tira de sa poche une petite chose grise. Cady y jeta un
coup d'œil et s'écria:
—Le diamant de Maurice Deber!...
Il reprit, suppliant:
—J'en ai bien envie, Cady?
Elle se saisit de la pierre et regarda le petit garçon, profondément.
—Tu le veux?...
—Oui, je voudrais... Mais si tu désires le garder, toi, Cady?...
Personne n'en saura rien... Tu le cacheras et on croira qu'il est parti
avec le reste...
Cady reporta ses regards sur le diamant, hésita; puis, lentement, le
tendit à Georges.
—Tiens.
Il le saisit avidement.
—Tu me le donnes?
—Oui.
Ivre de joie, il lui sauta au cou.
Elle le repoussa.
—Va, puisqu'il faut que tu partes! dit-elle avec une certaine dureté.
—Cady!... embrasse-moi, toi?
Elle se pencha, et embrassa longuement la joue veloutée du petit
garçon.
—Adieu.
Elle se rejeta dans son lit, ferma les yeux et se boucha les oreilles
pour ne pas entendre les pas de Georges qui s'éloignaient.
Et, l'affolante veillée commença pour elle, avec l'idée obsédante du
cadavre grimaçant, tombé là-bas... si près!...
Enfin, au jour, elle s'assoupit, et ce ne fut que vers huit heures que,
réveillée brusquement, elle comprit que, puisqu'elle ne voulait ni ne
pouvait révéler la vérité de ce qui s'était passé, il lui faudrait jouer
une lugubre comédie.
XXIX
Les jours avaient passé. Les jours rapides et niveleurs de l'existence
parisienne, où tout s'oublie, tout s'efface, disparaît si promptement.
A l'heure où la foule est le plus dense à l'Exposition de tableaux du
Grand-Palais, Mme Darquet fit son apparition dans les salles,
accompagnée de Mme Durand de l'Isle, et poussant triomphalement
devant elle Cady, dont le portrait était le succès—presque le
scandale—du Salon de cette année-là.
—Ecarte donc ton manteau! s'écriait la mère avec impatience. C'est
absurde, tu auras trop chaud tout à l'heure.
Affectant une candide incompréhension, Cady qui s'esclaffait
intérieurement, répondait en boutonnant plus étroitement son long
pardessus:
—Mais non, maman, au contraire, je gèle... Il fait humide, ici.
Elle savait que la sollicitude de sa mère n'avait pour but que de
permettre au public de remarquer le costume gris du portrait et de
provoquer la reconnaissance de l'original de la toile en vogue.
Depuis l'ouverture du Salon de la Société nationale, Mme Darquet y
venait pour la troisième fois, emmenant toujours Cady avec elle. En
ce moment, la faveur de Baby avait une éclipse.
Arrivée à la salle où le tableau de Jacques Laumière se révélait de
loin par la foule compacte qui se pressait devant lui. Mme Darquet,
affectant une lassitude extrême, se laissa tomber sur le canapé
central.
—Je suis déjà brisée! déclara-t-elle haut. Ma foi, je vais attendre ici
Laumière qui nous fera visiter les autres salles.
Mme Durand de l'Isle approuva avec son obséquiosité ordinaire.
—Oh! ce sera délicieux!... Quelle bonne fortune pour moi que vous
me permettiez de vous accompagner!...
Mme Darquet ne l'écoutait pas, rappelant durement sa fille qui
s'écartait.
—Cady! où vas-tu?... Assieds-toi près de nous, tout de suite!
La fillette essaya de regimber.
—Mais, maman, je peux bien regarder les tableaux de l'autre salle!...
Ici, je les connais par cœur.
—Assieds-toi, je te dis! ordonna Noémi, et ouvre ton pardessus. Tu
es grotesque, emmitouflée comme pour sortir en auto... Défais-toi,
tu entends?
Cady obéit avec tant de mauvaise humeur et de brusquerie que deux
boutons du pardessus sautèrent.
Puis, elle se jeta sur le divan, repoussant son chapeau en arrière et
croisant ses jambes gainées de soie noire.
—Là! marmotta-t-elle entre ses dents, la pose y est!... N'y a
maintenant qu'à passer faire la quête parmi tous ces types qui vont
me zieuter!
Mme Darquet ne l'entendit point, adressant des paroles quelconques
à son amie, avec un air de détachement, radieuse parce que
plusieurs personnes avaient reconnu la fillette et se la montraient en
chuchotant. Peu après, un revirement se produisait dans la salle. On
délaissait le portrait pour se repaître de la vue du modèle vivant, que
l'on appréciait tout bas, ou même tout haut.
Une envie folle démangeait Cady de contorsionner son visage en une
série de grimaces hideuses, ou de se livrer à des cabrioles, ou de
simuler une attaque d'épilepsie.
Elle eut un soupir d'aise en apercevant Victor Renaudin qui fendait la
foule et s'approchait, le chapeau à la main.
Mme Darquet se leva avec empressement, enchantée de cette
diversion. Elle avait assez de tact pour comprendre que la scène
qu'elle avait provoquée, si elle se prolongeait, risquait de sombrer
dans le ridicule.
—C'est vous, Renaudin?... Enchantée de vous rencontrer... Vous avez
vu le portrait de Cady?... Oh! Jacques Laumière a fait une œuvre
vraiment curieuse avec ma petite fille!... Nous l'attendions
précisément pour continuer notre promenade... Et même, il se fait
bien attendre...
Le jeune juge sourit, point du tout dupe de la comédie que jouait la
dame pour la galerie.
—Je crains que vous ne l'attendiez longtemps... Je l'ai aperçu tout à
l'heure, à la sculpture...
Et, se tournant vers Mme Durand de l'Isle.
—Il était justement avec madame votre fille et deux autres dames,
en train de conférencier...
—Vous avez vu ma fille? Vous lui avez parlé? demanda la grosse
dame avec précipitation, la respiration écourtée par une subite
émotion.
Cady, qui s'était levée pour serrer la main du jeune homme, lui
donna une bourrade sournoise. Il pinça les lèvres pour dissimuler un
sourire.
—Je l'ai vue, oui, madame, mais de très loin.
—Il fallait aller la retrouver!... Vous lui auriez fait tant de plaisir!...
Précisément, elle me disait ce matin qu'elle serait si heureuse de
visiter le Salon en votre compagnie.
Renaudin salua respectueusement, et répondit avec une nuance
d'ironie qui passa inaperçue de la veuve, mais que Mme Darquet
remarqua:
—Je suis extrêmement flatté, madame, mais, madame votre fille est
en bien meilleures mains avec Laumière, qui est artiste. Moi, je ne
suis qu'un amateur... un ignorant.
Noémi coupa avec irritation les protestations louangeuses où son
amie allait s'embourber.
—Pas de fausse modestie, Renaudin. Vous êtes un connaisseur en
peinture et une véritable encyclopédie pour tout ce qui touche aux
artistes... Venez avec nous et servez-nous de guide, puisque
Laumière nous délaisse!... Allons, Cady, marche devant... Et vous,
chère amie, accompagnez-nous.
Mme Durand se récusa avec vivacité.
—Chère madame, voulez-vous me permettre d'aller chercher ma
fille?... Elle sera charmée de vous voir, et nous vous rejoindrons dans
dix minutes.
Mme Darquet jeta un coup d'œil sur le jeune juge qui demeurait
impassible.
—Bien, allez... Nous suivrons les salles de gauche.
Mais, lorsque la veuve eut disparu, de toute la vitesse que lui
permettait son extrême corpulence, Noémi Darquet s'arrêta au seuil
de la première salle.
—Dites-moi, Renaudin... Je me sens extraordinairement lasse...
Voulez-vous que nous allions prendre une tasse de thé en bas?
Le jeune homme s'inclina.
—A vos ordres.
Comme ils se dirigeaient vers l'escalier, elle le questionna en
souriant.
—Alors, c'est non?
Il feignit de ne point la comprendre, quoiqu'il saisît parfaitement le
sens de cette brève demande.
—Quoi donc?
—Vous refusez d'épouser cette pauvre Fernande de l'Isle?... Elle est
délicieuse, cependant.
Il hocha la tête.
—Ecoutez!... Je suis doux de caractère, pourtant je me soucie fort
peu d'être battu par ma femme... et il paraît qu'elle rossait son
premier époux!
—Quelle calomnie et quelle sottise! c'est bien plutôt lui qui se livrait
à des sévices sur elle!
Renaudin prit un air naïf.
—Ah! c'est possible, après tout, je croyais que c'était l'inverse. Et
puis, tenez, je crois que cela me déplairait encore davantage... L'idée
que ma femme a pu être corrigée par un autre me serait
insupportable.
Mme Darquet eut un léger éclat de rire.
—Vous aimez mieux que ce soit vous qui vous livriez à cet exercice?
—Non, mais je préfère un corps indemne... à tous points de vue,
d'ailleurs.
Mme Darquet redevint sérieuse.
—Tout cela, ce sont des plaisanteries ou de méchants potins...
Fernande n'a eu que des démêlés d'intérêts avec son mari, qui était
un triste sire.
—Ah! oui, fit Renaudin avec détachement. C'est lui qui avait la
fortune... et le mauvais goût de vouloir la garder après la séparation.
Mme Darquet ne put s'empêcher de rire de nouveau.
—Mon Dieu, que vous êtes devenu rosse depuis que vous êtes
Parisien!
Le jeune homme s'inclina avec une gratitude sincère.
—Grâce au poste inespéré que je vous dois, madame, je ne l'oublie
pas, croyez-le bien!... Mais il serait peu généreux de votre part et
pas du tout dans votre caractère d'exiger de ma reconnaissance que
j'épouse une femme qui, je vous le dirai très franchement, m'inspire
une aversion tout à fait insurmontable, toute séduisante, et
probablement tout honnête et charmante qu'elle soit!...
Mme Darquet pinça les lèvres, vexée.
—Voilà qui est on ne peut plus net, j'espère!...
Il la regarda hardiment.
—J'ai une assez haute opinion de vous, madame, pour être certain
que ma sincérité—ma brutalité même—ne me nuira pas près de
vous.
Elle se rasséréna, ne sachant pas résister à un compliment, sous
quelque forme qu'il se présentât.
Et le sourire revenu sur ses lèvres, elle jeta ses amies par-dessus
bord avec désinvolture.
—Ecoutez, j'en suis désolée pour ces dames aux yeux de qui vous
étiez le mari rêvé!... Mais, je vous aime trop pour vous en vouloir...
Après tout, vous êtes libre de choisir une femme à votre gré!...
Il eut un geste.
—Oh! je vous assure qu'actuellement le mariage c'est le dernier de
mes soucis!
Mme Darquet réfléchissait.
—D'ailleurs, Mme de l'Isle aura une compensation... Malifer nous
quitte, pourvu d'une sous-préfecture, je déciderai Cyprien à donner
sa place au frère de Fernande.
Renaudin s'inclina avec une gravité impeccable.
—Pour M. Darquet, ce sera une excellente acquisition.
Mme Darquet le menaça du doigt.

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State of the World s Children 2008 The Child

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The Nation in Children s Literature Nations of

Facts for Life Fourth Edition United Nations Children'S

Child Friendly Schools Manual United Nations

Children s Personal and Social Development Child

Bridges to Understanding Envisioning the World through

From Children s Services to Children s Spaces Public

From Children s Services to Children s Spaces Public

Children s Illustrated Animal Atlas Children s

Inside photos: p. 1, © UNICEF/HQ04-0556/Mariella Furrer; p. 3, © UNICEF

2 THE STATE OF AFRICA’S CHILDREN 2008

1 Child survival – Where we stand

Child survival – Where we stand 3

4 THE STATE OF AFRICA’S CHILDREN 2008

Child survival – Where we stand 5

Comparing sub-Saharan Africa’s share

This section examines under-five

The findings are compelling. Of the four

Eastern Africa has seen steady progress,

6 THE STATE OF AFRICA’S CHILDREN 2008

West Africa Ethiopia and Nigeria – account for more

Child survival – Where we stand 7

8 THE STATE OF AFRICA’S CHILDREN 2008

Figure 1.8 The four subregions of sub-Saharan

Child survival – Where we stand 9

10 THE STATE OF AFRICA’S CHILDREN 2008

Child survival – Where we stand 11

12 THE STATE OF AFRICA’S CHILDREN 2008

Child survival – Where we stand 13

14 THE STATE OF AFRICA’S CHILDREN 2008

Child survival – Where we stand 15

16 THE STATE OF AFRICA’S CHILDREN 2008

Child survival – Where we stand 17

18 THE STATE OF AFRICA’S CHILDREN 2008

Child survival – Where we stand 19

Rising to the challenge

20 THE STATE OF AFRICA’S CHILDREN 2008

2 Lessons learned from evolving health-care

Lessons learned from evolving health-care systems and practices 21

Côte d’Ivoire: Immunization day at a health centre.

22 THE STATE OF AFRICA’S CHILDREN 2008

Lessons learned from evolving health-care systems and practices 23

24 THE STATE OF AFRICA’S CHILDREN 2008

Morocco: Carefully monitoring child growth.

Lessons learned from evolving health-care systems and practices 25

26 THE STATE OF AFRICA’S CHILDREN 2008

• A renewed recognition of the

Lessons learned from evolving health-care systems and practices 27

3 Community partnerships in primary health care

28 THE STATE OF AFRICA’S CHILDREN 2008

Evidence shows that community-based

30 THE STATE OF AFRICA’S CHILDREN 2008

HIV and AIDS

Significant reductions in mother-to-

32 THE STATE OF AFRICA’S CHILDREN 2008

An evaluation of the planning,

See References, page 51.