In PSI’s latest issue of Impact magazine, the organization explores the importance of giving children a healthy start to life. PSI is one of our crucial partners in improving the health and lives of people living in the developing world, focusing on family planning, HIV, maternal health and, critically, addressing threats to children including diarrhea and malaria.

As part of the online issue, PSI’s Nutrition Research Advisor Dr. Abel Irena talks with Saul Morris, Senior Program Officer here at the Gates Foundation, about progress that has been made in child health and the next steps toward achieving the Millennium Development Goals by 2015.  For the full interview, visit PSI's blog, Healthy Lives.

Abel Irena: Pneumonia is the biggest single killer of children in the world, and yet, it is reasonably cheap and simple to treat with antibiotics. Why then has it become the biggest killer? What needs to be improved to change the situation?

Saul Morris: We are not yet seeing quite the same enthusiasm and energy rallying behind the issue of pneumonia as we have seen in some other health areas have recently. I think at a higher level, one could say this is partly because there’s still a real lack of familiarity with the importance of pneumonia as a killer. I often find that when I mention that pneumonia is the largest single killer of children in high-burden countries, it’s met with amazement at policy level.

At a more technical level, one of the challenges with pneumonia is that it’s not a disease that can be dealt with simply through commodities. It requires major outreach to households, in part to make them aware of the significance of the symptoms, around difficult breathing – which is not recognized in the way that fever is recognized as an obvious sign that the child is in danger. But there are also complicated negotiations around household dynamics about who is allowed to make decisions about the care of the sick child or seek outside help. In the case of pneumonia, these issues really can’t be skirted; they have to be dealt with explicitly.

At the provider level, pneumonia requires a certain degree of provider skills and changing the way that providers work. Particularly in the private sector – where mothers prefer to seek care in many countries around the world – it’s very difficult to incentivize providers toward practicing behaviors that would be most effective in dealing with pneumonia.

AI: What is the progress on increasing access to zinc for diarrhea treatment, and what are the bottlenecks to further progress? What is the Gates Foundation’s strategy for encouraging promotion for ORS and zinc together?

SM: We’re at the beginning of a rather long road. We have a strong evidence base now around what zinc would do when added to the clinical protocols for treatment of diarrhea. It will shorten the duration of the index illness; it will prevent subsequent episodes of illness over the following couple of months; and it will also reduce the likelihood that the child will become severely ill and hospitalized over the subsequent couple of months. It also improves alertness and appetite.

We’re also beginning to know what it would take to for scale up. We have a few good country case studies –Bangladesh, and parts of Nepal or Benin, where we know that it’s possible to bring about a major change in utilization levels in a relatively short period of time.  There are very strong lessons learned from those studies. We have the pieces; now we need to introduce them in whole countries through high levels of coverage and in some of the bigger countries as well.

AI: Public, private and community-based health delivery systems all have their strengths and weaknesses but seem to largely operate independently. How can the global health community better capitalize on the strengths, mitigate the weaknesses and coordinate these sectors better to ultimately improve access to health care for the population as a whole?

SM:  I think there are two points where these multiple systems come together, and we’ve failed to give both of them adequate attention. The first one – and this applies to many but perhaps not all countries – would be the district health management team. This is a critical element of the health system which has not received the amount of attention that it merits. Ultimately these two or three or four people who constitute district health management teams in many countries are the ones who are supposed to be the stewards of all public, private and community-based health delivery systems. And they are really struggling to generate some relevant information which would enable them to manage more efficiently; they often don’t have management skills or training or management tools to help them to bring that together in one place. They are often supposed to have huge responsibility for managing these things but very little budget authority to actually have any moveable funds that they can allocate to overcome bottlenecks.  I think that if we concentrate on strengthening district health management teams, we would come a long way to help bring better coordination to these multiple health systems.

The other point where all of these converge is at the family level. Families effectively integrate public, private and community-based health systems because they negotiate their way between all three separate systems. So if we engage effectively with families and help them to make effective decisions based on sound information about their options, I think we could go a long way to improve the coordination of these elements.

AI: What is your vision for reducing child mortality through appropriately integrated case management services for pneumonia, diarrhea and malaria? And what are the key steps to making that a reality?

SM: The kind of comprehensive sectoral planning that has been made has not really tackled these areas around providing case management services across the range of different illnesses in a very comprehensive way. So I think the first thing to do is know what it is that you want to do. In that respect, it’s very encouraging that in the course of the last half year we’ve seen major efforts through huge groups of stakeholders in a dozen or so countries, come together and develop comprehensive plans. These plans do tend to identify the kinds of things that would really make a big difference, and in many ways, these are shared elements across numerous countries. They’ve singled out both public providers in terms of increasing awareness and looking at the incentive systems that need to be put in place. The same around private providers – how can you actually both increase their awareness but also change their practices through appropriate incentives? Then look at the regulators’ space and what needs to be done there, look at the market place for the commodities needed to improve these services, and look at interacting directly with families and generating demand, which has been an incredibly overlooked area of activity in the field and that really needs readdressing urgently.