Constraints to the potential impact of child survival in developing countries

The direct interventions for child survival in developing countries include oral rehydration therapy and diarrhoeal disease control, immunizations, acute respiratory infection control, malaria control and nutrition programmes. Although these interventions targeted the leading causes of infant and childhood mortality in developing countries, they have not had as great an impact on child mortality as was anticipated at the beginning of the 1980s. While effective in more controlled settings, the largescale implementation of these interventions in communities is fraught with problems of limited access, lack of effective targeting, inadequate training of health professionals, lack of ceordination with other programmes, poor community acceptance, and lack of effective use of services. A conceptual framework to describe how a direct intervention may operate to produce health impacts in a population is discussed. For example, the impact of the more specific interventions may be undermined by replacement mortality. Interventions that ameliorate but do not prevent disease may be undermined by increased frailty following the disease episode which increases the individual's chance of dying from another disease. This retrospective view on the direct interventions was undertaken in order to conceptualize what changes in implementation are needed in the 1990s.