Developing Leadership in Global Child Health
Twenty years ago, when I (the author, K.C.) was a young medical student, a little girl asked the group of us who were working in rural Malawi, “Why can you who have so much not help us who have so little?” Twenty years ago, the challenge was identifying health as an issue. I remember speaking at a meeting of leaders in Malawi in the late 1990s about the specter of HIV/AIDS affecting both men and women, and was told that the disease was something seen only in Western countries.
Around the world, we have seen a large transformation occurring in the attitudes toward health, with a significant push made by governments and leading philanthropic organizations, such as the Bill and Melinda Gates Foundation and the One Foundation, led by the rock star Bono. These visible leaders have put global health into the conversation of important priorities, especially in developing countries.
Yet despite a 30% decline in childhood deaths around the world from 1990 to 2009, the United Nations Children’s Emergency Fund (UNICEF) still reports 8.1 million deaths in children under the age of 5 in 2009 [1]. Approximately 70% of these deaths are preventable by available knowledge and technology [2]. Therefore, 5.5 million deaths in children can be prevented by what we know and have available to us. These simple questions still exist: Why do these deaths occur when we know how to prevent them? How can we reduce the gap between our knowledge base and our actions leading to these poor health outcomes?
Obviously there is a large gap between what is known and what is done to improve global child health. One of the issues is how do we make these solutions, visible, viable, and acted upon? The challenge is not just to review the state of where global child health is, but to provide fresh, new insight into possible solutions. The missing gap is something that is not discussed in many medical or public health schools, but something we find in business and management schools: leadership. My belief is that the major weakness is a lack of global child health leadership globally, nationally, and locally that prohibits faster improvements in morbidity and mortality.
What is known about global child health leadership? The unfortunate answer is: not very much.
This article looks at the realm of global child health leadership and examines prior attempts to reduce mortality and morbidity. The philosophy and outlook at building global child health leadership currently being developed between sub-Saharan Africa and the Hospital for Sick Children in Toronto is highlighted. Examples are provided of concrete programs and efforts being worked upon to develop this global child health leadership capacity. The author hopes to inspire more participation in building global child health leadership.
First, a brief survey is given of global child health programs: Primary Health Care, the Integrated Management of Childhood Illnesses, and Millennium Development Goal #4.
Primary health care
In 1978, Primary Health Care (PHC) was launched at Alma Ata with the slogan “Health for All by the Year 2000” [3]. PHC aimed to create national health systems, based on the economic abilities of each country [4]. The type of health care employees would be dependent on each country’s goals and resources available.
The specific Alma Ata declaration aimed to increase the participation of community members in the development of health care, and aimed to decentralize health care to individuals at a local level [3].
The key principles can be summarized as follows: (1) PHC aimed to promote equity within health care; (2) community participation was paramount at all decision-making points; (3) prevention was highlighted over cure; (4) available technology should be used; (5) other sectors should be involved in health care (such as education, agriculture and housing); (6) decentralization of decision-making was important; and (7) leadership was needed to achieve the goals of PHC [5].
Therefore, as far back as 1978 it was clear that global health leadership was a basic requirement to achieving health for all people. However, although there were programs to “train” health leaders, there was little systematic development that targeted national or local leaders effectively.
The integrated management of childhood illnesses
In the mid 1990s, the World Health Organization (WHO) and UNICEF adopted the Integrated Management of Childhood Illnesses (IMCI). IMCI builds on the concept of PHC, using the community health worker (CHW) as the cornerstone of assessing a child’s well-being. If a sick child presents to the CHW, the CHW decides how to best treat a child, using a color-coded system with red (danger), yellow (caution), or green (safe) to determine whether a child should be managed at home or in hospital.
IMCI has other foci including improving the training of CHWs, strengthening preventive health care measures, and upgrading existing health care services. It provides a first-line approach to treating child health problems. Although IMCI has been a standard of care, its proper adoption has been a challenge.
The Millennium Development Goal #4: reducing child mortality
The fourth Millennium Development Goal (MDG #4) is to reduce the under-5 mortality rate by two-thirds from 1990 to 2015 [6]. We have seen the number of children dying from developing countries decrease from 100 (1990) to 72 (2008) deaths per 1000 live births, with only 10 of 67 countries with high child mortality on track to meet the MDG target [7]. The continuing challenge, however, has been the slow decline in childhood deaths in sub-Saharan Africa, with high fertility rates and a slow reduction in under-5 mortality rates (Fig. 1).
Fig. 1 Mortality rate in children younger than 5 years by WHO region.
(Reprinted from www.who.int/whosis/whostat/EN_WHS10_Part1.pdf, p. 13; copyright The World Health Organization; with permission.)
Other associated MDG #4 objectives include reducing the infant mortality rate, and increasing the proportion of 1-year-old children immunized against measles (Fig. 2).
Fig. 2 Measles immunization coverage among 1-year-olds by WHO region.
(Reprinted from www.who.int/whosis/whostat/EN_WHS10_Part1.pdf, p. 14; copyright The World Health Organization; with permission.)
There are obvious trends downward in the number of childhood deaths. There have been large falls in under-5 mortality rates across all areas of the world, but because of high fertility rates, there has been little progress in overall numbers of childhood deaths in sub-Saharan Africa [7].
Why are we failing to reduce child deaths faster?
As far back as David Morley’s classic textbook on global child health, Paediatric Priorities in the Developing World, there was widespread recognition that improvements in children’s health were not strictly rooted in medical answers [8]. The challenge is that many of the underlying root causes of child deaths are not simple and straightforward medical causes that health professionals tackle on a daily basis. For example, poverty, poor female education, and poor water and sanitation remain barriers to successfully reducing childhood mortality.
The challenge in children’s health is but one small portion of a government’s list of competing priorities. Child health competes with adult health; health competes with other departments, such as defense, industry, education, transportation, and agriculture for limited government resources. Improving children’s health requires both technological improvements in tackling children’s diseases, and providing enough funding and resources to deliver proper services.
Regarding the solution to global child health mortality, the technical aspects are not the problem as much as access to health care. For example, one area where there has been little reduction in global child mortality in the past decade has been on perinatal mortality. The challenge remains in identifying mothers who will run into trouble, getting access to the right level of care, and ensuring the quality of care once they arrive at the facility [9].
Our current global child health leaders continue to face a combination of economic, policy and political challenges to improve health systems and health outcomes for children. In particular, a cadre of child health leaders who can advocate for children and policy change should be developed in the existing health care system. Leveraging existing collaborative networks, such as the Program for Global Pediatric Research, can bring together child health leaders from Africa and around the world to forward the global child health agenda [10].
It is with this in mind that the author now looks at leadership as an integral part of developing global child health programs.
What is leadership?
There is great difficulty in defining what leadership is. Is it experience? Is it logic? Is it vision? Pulitzer Prize winner James MacGregor Burns, in his influential book Transforming Leadership, aptly states: “I have come to see leadership not only as a field of study but as a master discipline that illuminates some of the toughest problems of human needs and social change” [11]. The reality is that leadership occurs at various levels, both from positions of power and from individuals at the grassroots level.
Leaders such as Gandhi in India, Mao Tse-Tung in China, and Alexander the Great are well-known leaders who helped transform countries and societies. The question is whether the intrinsic characteristics of an individual, the “Great Man” theory proposed by Sidney Hook, “creates” leadership through the natural intellect and strength of character [12]. Countervailing ideas suggest that leadership may be a product of time and circumstances, and by decisions made at opportune times. This idea was championed by Karl Marx [13] and later by the philosopher, Herbert Spencer [14]. In particular, Spencer championed the concept that complex influences were what created the conditions by which leaders, through a Darwinian process, would succeed through the creation of wealth and power. So the concept of a great leader was hypothesized either to be intrinsic to the leader oneself, or a concept dependent on the circumstances and the situation. Thus, leadership can also occur at local levels around specific issues that lead to direct activism, such as protecting women from being sexually exploited or by protecting a local park or forest from being harmed.
The development of the program for global child health leadership comes from a perspective that leadership qualities, characteristics, and traits can be maximized, and specific situational opportunities identified to improve global child health.
Leadership begins with “vision”: what is the purpose and goal we seek? Leadership provides purpose to an idea or goal. However, vision is insufficient. Leadership should bring components such as logic and pragmatic approaches that can be performed in a systematic fashion. There are also some basic characteristics that are important for a leader to bring to the fore, such as integrity, adherence to principles and values, humility and respect for others, communication, and the ability to persuade people and demonstrate commitment to the vision. Experience often helps in leadership, but it may act as a barrier if preconceived notions limit the capacity to invoke change.
What does leadership in global child health mean?
Before 2000, global child health leadership was provided internationally by UNICEF and the WHO. There were many local champions of child health, but little systematic training of these leaders.
