Worldwide, 12 million children under age 5 years die each year. 70% of these deaths are due to diarrhea, pneumonia, measles, malaria, or malnutrition, often to a combination of these conditions. A single diagnosis for a sick child is therefore often inappropriate since the signs and symptoms of several major childhood diseases overlap substantially and often more than one disease may be present. Responding to only the most apparent problem may lead to an associated, and potentially life-threatening, condition being overlooked. Combined therapy may be needed to effectively treat the presenting conditions. Some World Health Organization (WHO) and UNICEF programs provide for the integrated management of the sick child. Program efforts have been coordinated by the WHO Division of Diarrheal and Acute Respiratory Disease Control. Many other agencies, institutions, and individuals are contributing to this initiative. It is expected that the integrated management of the sick child will result in the more accurate identification of illnesses in outpatient settings, ensure more appropriate and, where possible, combined treatment of all the major illnesses, and speed the referral of severely ill children. The approach also emphasizes the importance of preventive interventions such as immunization, vitamin A supplementation when necessary, and improved infant feeding, including exclusive breast feeding.
The World Health Organization (WHO) Maternal Health and Safe Motherhood Programme developed the Mother-Baby package to facilitate the development of national strategies and plans of action. It was presented at an international meeting in Geneva in April 1994. The goals of the package are by the year 2000 to reduce maternal mortality by half and perinatal and neonatal mortality by 30-40% of 1990 levels. The package comprises: 1) a section on the technical basis and underlying strategies, 2) a section describing intervention before and during pregnancy, and during and after delivery, and 3) detailed recommendations on operating the program. The underlying strategy aims to reduce the number of high-risk and unwanted pregnancies; the number of obstetric complications; and the case fatality rate in women with complications. Interventions are based on a fourfold approach of family planning, quality antenatal care, clean and safe delivery, and access to essential obstetric care for high-risk pregnancies and complications. The district health system is the basic unit for planning and implementing the interventions. Midwives who live in the community are best equipped to provide appropriate community-based care to pregnant women. Pregnancy and obstetric complications requiring surgery and anesthesia should be available in the district hospital with an adequate referral system. Upgrading the skills of traditional birth attendants is also essential. National authorities should undertake a series of steps to carry out the interventions. A basic infrastructure, the upgrading of peripheral facilities, the development of human resources for safe motherhood, the effective delegation of responsibility, information, education, and communication (IEC), the involvement of nongovernmental organizations and women's groups, and the monitoring of results are other important elements in carrying out the interventions.
Gender refers to differences in behavior, cultural expectations, and the social roles of males and females within particular social structures. A gender approach to health and illness includes not only biological aspects, but also the social, cultural, and economic contexts of those affected. A gender approach to the impact of HIV and AIDS therefore must take into account female and male roles in terms of factors which affect the risk of exposure and infection, responsibility for preventive actions, responsibility for caring for people with AIDS, and access to health care and treatment. A gender analysis of health is concerned with the well-being of individuals as human beings with personal needs, priorities, and preferences within the context of everyday experience. The gender and tropical diseases framework incorporates the three following principal dimensions: economic/production, social reproduction, and personal. This framework applies to the impact of HIV and AIDS on men and women as described in the case presented in the text of a man and woman in Africa infected with HIV. The man became ill with what clinically appeared to be AIDS. He refused, however, to have his blood tested for the presence of antibodies to HIV and would not tell anyone, especially his family, about his condition. The ongoing illness crippled the man and his family financially, and ultimately killed him. After his death, his wife was confirmed HIV-seropositive. She now travels by bus to work and lies in bed despondent at night.
The Plan of Action approved at the 1994 International Conference on Population and Development seeks to ensure access to reproductive health care services to all couples through a process of female empowerment. However, this goal conflicts with current social and economic policies in many countries as well as with hegemonic international development strategies based on structural adjustment. The full realization of the goals outlined in Cairo and Beijing will depend on the willingness of the international community to ensure the development of broader conceptualizations of human rights as well as the strengthening of community-based initiatives. Critical will be implementation of a multisectoral approach and coordinated networking at the peripheral level. Channels to express needs and demands must be developed in countries burdened with cultural obstacles or disrupted by political strife. If health care systems are to achieve targeted improvements in maternal mortality, they must both demonstrate an interest in mothers as women with needs of their own and seek to involve men in reproductive health decisions. Although the development of a broader range of contraceptive options remains critical, the most important reproductive technology issue concerns improvements in the quality of the user-provider interaction.
The concept of primary health care (PHC) generally refers to eight technical components related to health and health care. The author proposes making income generating activities (IGA) for women the ninth element of PHC. Although it would be a major move to add the non-health component to PHC, requiring different new technical and organizational inputs, income derived from women's IGAs could have a significant effect upon individual health and nutritional status in low-income households. Disposable household income is known to correlate positively with health and nutrition indicators. Women's IGAs affect that income which then tends to be added to cover routine household expenditures. The author stresses that IGAs for women can be promoted as a technical PHC element to address the key determinants of morbidity and malnutrition, and ultimately organize and empower women in a way which prepares them to take more active roles in health care and other important community decision-making and action.
