One million children with a chance to live / James P. Grant ; interviewed by Jack Ling

One million children ·with a .chance to· live, 10 Mr )ames P~ Grant, Executive Director of the UN Children's FundjuNICEF) was ihter- viewed for World Health by Mr Jack Ling, Visiting Professor of Communications, Uni- versity of Southwestern Louisiana, USA JL: At the World Health Assembly in 1978, the interna- tional community adopted a resolution setting a specific target for WHO's Expanded Pro- gramme on Immunization (EPI). This was to protect all children, by 1990, against polio, diphtheria, per- tussis, tetanus, measles, and tuber- culosis. As a close collaborator with W,HO in primary health care (PHC), including immunization, what is UNICEF's support towards this goal? JPG: We try to support it on sev- eral different fronts. One is to add credibility to the goal and commit UNICEF's resources to achieving it by that date. Secondly by advocacy -and advocacy at a number of different levels- telling the world loudly that universal immunization for all children by 1990 is an achievable goal, and persuading top leadership to support ministries of health in their efforts. Thirdly, we provide financial assistance for vac- cines, syringes, transport, the cold chain and other aspects. Finally, we are very active in providing the "software," particularly mobilis- ing the whole range of ministries and NGO that are required for a successful end result. Universal Child Immunization, UCI, can be achieved only when immunization as part of PHC is accepted as a goal of all sectors in society, and is not just left to the responsibility of the ministries of health. JL: You mention UCI while WHO's programme is called the Expanded Programme on Immunization. Is there a difference between them? JPG: Absolutely none. EPI is the instrument for UCI. JL: How crucial is immunization to the overall UNICEF programme of collaboration with governments? JPG: It's an increasingly important part of our collaboration with de- veloping countries, primarily be- cause in recent years we have seen this potential to accelerate EPI and achieve dramatic results through social communication to a degree . that we had scarcely anticipated before 1982. The PHC concept, as enunciated in the 1978 Alma-Ata Declaration, worked! It was possi- ble to treat health care as an effort embracing all sectors, and to mobil- ise these sectors at very low cost to support immunization. So this ac- tivity moved higher on the UNICEF WoRLD HEALTH, Jan./Feb. 1987 list of pi-iorities for support and funding. Vaccine use alone trebled between 1983 and 1985. At the moment, expenditures have in- creased to about 11 per cent of UNICEF's budget and can be expected to increase further until 1990, after which expenditures should decrease as EPI shifts more to maintenance. It is noteworthy, however, that the "twin engines" of immuniza- tion and oral rehydration therapy (ORT) which propel and accelerate PHC and child survival take only about half as much money as we are spending on water supply activities. And our expenditures on PHC, ex- clusive of EPI and ORT, are larger today than they were in the early 1980s. JL: You are saying that financial input is not necessarily an accurate measure of UNICEF's contribution? JPG: That's right. What we are seeing are greatly increased inputs by government into these areas, either in absolute amounts for PHC or through a restructuring of their budgets. For example, in Pakistan they delayed the building of the big, new capital hospital in Islamabad for several years, and took the savings from there to finance their national immunization programme, the oral rehydration programme, and the retraining of tens of thousands of traditional birth atten- dants over a three-year period. Expenditure by bilateral agencies is also going up substantially in this arena. The United States Agency for International Development (USAID) has received from Congress an extra $80 to $100 million a year over the past three years to support PHC, including these child survival activities and, of course, UCI. And the Italian Government has made $100 million available to us for Africa, primarily to be devoted to advancing Immunization and oral rehydration-but particularly UCIIEPI-in 26 African countries. · JL : How do you assess the progress so far and what are the problems between now and 1990? JPG: I would say that we-meaning the world community, WHO and UNICEF and the governments con- Inadequate sanitation breeds diseases. UNICEF, like WHO, sees immunization as an integral part of primary health care : a global strategy for better health. Photo W HO/Zafar W ORLD HEALTH, Jan./Feb. 1987 cerned-are more or less on track towards achieving that goal, pro- vided that the present level of polit- ical commitment can be sustained and backed up with the right kind of assistance for implementation. JL: Is there any hard evidence that the immunization coverage has contributed directly to reducing in- fant mortality? If X number of children are immunized, theoreti- cally there should be a correspond- ing reduction in infant mortality? Are there any countries where this has actually happened? JPG: These are obviously difficult things to measure. It has been easier to measure the impact of oral rehy- dration because that impact is seen almost immediately, so that in a country such as Egypt you can ob- serve a decrease in diarrhoea cases. In the hospitals it's possible to talk of scores of thousands of children's lives being saved. In immunization we, in consultation with WHO, have come up with a general estimate that the number of deaths from these six diseases has dropped from the early 1980s level of about four and a half million to something like three and a half million today. That is, nearly one million child lives a year are being saved as a result of the immunization programmes of the 1980s. JL: What other interesting, success- ful national experiences are worthy of attention? JPG: A country such as Colombia (one of the first to undertake an · accelerated EPI programme) gives a good illustration of both sustain- ability and expansion. The first year, the emphasis was really on alerting people to get children im- munized, using many thousands @f radio spots, television spots , having the president himself giving vacci- nations, and the like. Then atten- 11 One million children with a chance to live tion turned almost immediately to how to keep this drive sustained and how to broaden it. Several elements were quickly identified. One, of course, was that the health system itself, in carrying forward the successful 1984 effort, placed a whole new priority on immuniza- tion. So that within the health struc- ture there was a shift in emphasis. With success, there was a new spirit in the health ministry about what could be done. Then, there was a revamping of the primary school curriculum to include basic materials on immuniz- ation and on the other major ele- .ments of PHC. The other partners in the initial crusade also sought ways to institutionalise their works. The church set up a regular training programme for all parish priests, so that premarital counselling now in- cludes several minutes underlining that responsible parenthood in- cludes knowing about immunizing your children, how to prevent diar- rhoea, how to do oral rehydration therapy. Groups like the Red Cross included this whole broad range of PHC activities into their training programmes. So you see in Colom- bia an illustration of how a country went from a crusade into these other elements and on a more sus- tainable basis. In India, Prime Minister Rajiv Gandhi announced in May of 1985 that they would make "Universal Child Immunization by 1990" a living memorial to the late Mrs Indira Gandhi, a very worthy one indeed since about one million chil- dren a year have been dying in India from these six diseases. This was launched on Indira Gandhi's birthday of November 19, and seems to be proceeding well in India. Virtually all major countries in the world over the last 18 months have accelerated their programmes substantially towards the 1990 goal. China is dedicating itself to reaching it in all provinces by 1988. Nigeria has a well-developed pro- gramme to achieve UCI by 1990. Brazil in some ways ante-dated Colombia in social mobilisation, but it was focused initially just on polio and then they broadened it to cover the other major diseases. JL: How does UNICEF's child sur- vival and development revolution fit in with WHO's goal of Health for all by the year 2000, through PHC? 12 JPG: A historic watershed for health was Alma-Ata, when the concept of PHC was legitimised for the first time; and the subsequent vigorous pushing by WHO and UNICEF helped add to this legitimacy so that it now seems the proper thing to do. The country-by-coun- try follow up that WHO pursued with its Director-General Halfdan Mahler in the lead, and with Prime Minister Indira Gandhi and other leaders signing these PHC state- ments, gave a new legitimacy and urgency to the shift of attention towards preventing disease, to- Polio victim in Mexico. UNICEF and WHO are working hand-in-hand to prevent such tragedies. Photo WHO/L. Solmssen wards involving other sectors in health, and towards the need to find financially feasible ways for the health service delivery system to reach the village. So we saw the appearance of literally millions of auxiliary health workers after Alma-Ata as an extremely major development. The problem that we faced in the early 1980s was the impact of the global recession. Most governments began to restrict their investments on the social side. Education and health were cut back and this made it increasingly difficult to expand PHC and the more traditional medi- cal infrastructure at the same time. In many countries there was a real drying up of supplies, of financing. The Child Survival Revolution was designed to highlight the fact that there was a new capacity for social organization to make drama- tic progress in Health for all; so dramatic that it would become good politics for national leaders to in- vest significant amounts of their own leadership time in making it work, and in providing leadership and guidance to all sectors of so- ciety. The potentials for progress were also sufficiently great so that it was possible to energise non-health sectors of society, to excite non- governmental organizations about what could be accomplished, and to encourage community participation in immunization and oral rehydra- tion therapy. The Center for Disease Control in Atlanta, Georgia, points out that to add another year to male lives in the United States through curative means would take tens of millions of dollars, but that one could add at least ten years to the life of the average American male if through education he would stop smoking, watch the quality and quantity of his food intake, exercise regularly, and drink moderately. This pro- cess of change is already occurring. We see people stopping smoking, adopting different eating habits, taking up exercise, drinking much less-encouraged and motivated through different social channels. Now we are seeing in developing countries the same sort of motiva- tion against the old risks, and I look forward to the day when· the indus- trial countries will look at the ex- perience of Colombia and say 'that is the kind of total social mobilisa- tion we ought to apply in our coun- try against the problem of smoking, against the problem of alcohol.' These ought to be treated exactly as we are now attacking the six dis- eases through EPI and diarrhoea through oral rehydration therapy and health education. JL: You are saying that to get to Health for all, there is a need to mobilise all for health. Thank you, Mr Grant. • WoRLD HEALTH, Jan./Feb. 1987