Approximately 1 in every 10 children has a disability and in developing countries, fewer than one out of 10 of them go to school (1) (2). Persons with disabilities experience overlapping deprivations that contribute to marginalization, significant discrimination, and ultimately, exclusion in societal participation, perpetrating the vicious cycle of disability and poverty (3) (4).
Early childhood is the time when the impact of disability into adulthood can be maximally mitigated. It is, therefore, crucial for identification to be carried out at the earliest possible instance and appropriate intervention is provided.
In the Philippines, efforts are underway to implement a system on prevention, early identification, referral, and intervention for delays, disorders, and disabilities in early childhood in select subnational areas. This is a project that is being implemented through the national Early Childhood Care and Development Council and the Department of Health with support from UNICEF and Humanity and Inclusion.
Important lessons can be taken forward from the design and initial implementation of this system. First, it was necessary to work around the locally existing Early Childhood Care and Development (ECCD) tool that has been normed for Filipino children ages 0-4 years. This tool is the ECCD Checklist Records 1 and 2 for children ages 0-3 years and 1 month, and those 3 years and 1 month to 4 years and 11 months, respectively. Because the tool targets two separate age bands that can be reached with distinct service delivery platforms, close collaboration between health and early learning services was necessary from design to implementation.
Second, the design of the system had to be responsive to the local health and early learning systems context for the feasibility of implementation throughout the care pathway. This required several stakeholder consultations, the development of simplified tools and referral mechanisms across the care pathway, iterative revisions of these tools based on end-user feedback, and cadre-specific capacity-building activities.
Third, in a middle-income country (MIC) with devolved governance, engagement and buy-in of the local chief executive (mayor or governor) for every town/city or province were critical for both effectiveness and sustainability. The implementation of the system involves more than one sector (health and social services) and local ordinances had to be drafted to support its institutionalization. Buy-in of local chief executives (LCE) also opened the possibility of having budget allocations in the annual local budgeting process.
Finally, it cannot be overemphasized that identification of delays and disabilities is inevitably demand generating. This simply means that the supply side of the system has to be ready to respond to the demand that is being created and provide appropriate services for the children identified with disabilities. Therefore, for the initial implementation of this system, parallel work with service providers and other partners at both primary and referral facilities was necessary to ensure that there was some degree of supply-side readiness before the implementation. The initial gains in the upstream work on health financing that established the four social health insurance packages for children with mobility, hearing, visual, and developmental disabilities complement this downstream work and offers the possibility of eventual scale-up.
Figure 1. System on Prevention, Early Identification, Referral, and Intervention for Delays, Disorders, and Disabilities in Early Childhood (simplified schema for the health sector)
UNICEF, WHO. Assistive Technology for Children with Disabilities: Creating Opportunities for Education, Inclusion and Participation (2015). Geneva : World Health Organization, 2015.
United Nations Children's Fund. State of the World's Children 2013: Children with Disabilities. New York : United Nations Children's Fund, 2013.
Poverty and Disability in Low and Middle Income Countries . Banks LM, Kuper H, Polack S. 12, 2017, PLoS One, Vol. 12, pp. 1-19.
B, Rohwerder. Disability inclusion: Topic Guide. United Kingdom : GSDRC University of Birmingham, November 2015.
World Health Organization and The World Bank. World Report on Disability . Geneva : World Health Organization, 2011.
Ma. Bella P. Ponferrada, MD, MPH
Former Health Specialist, UNICEF Philippines, worked with UNICEF Philippines as Health Specialist for Children with Disabilities and Integrated ECD in the First 1,000 Days, from September 2019 to August 2021.
There has been growing interest and experience of community health workers (CHWs) in recent years, especially with the goal of Universal Health Coverage. Typically, the CHWs have provided combinations of health promotion messages, treatment of childhood illnesses, malaria-control measures, nutrition interventions, family planning, and screening and supervised treatment for HIV and TB. Many CHW programs function semi-autonomously with supplies and supervision coming with varying regularity from health facilities.
For many years, this community-based health care approach included the training of traditional birth attendants (TBAs). TBAs were, for the most part, given short training courses and sent back to their communities with little or no continuing connection with health facilities. The approach was halted twenty years ago when it became clear that trained TBAs were not making any impact on maternal and newborn deaths from complications of pregnancy and childbirth. A Skilled Birth Attendant (SBA) policy, to train and deploy greater numbers of obstetricians and midwives, has subsequently proven very effective. More recently, however, it has become clear that not all communities or all members of communities have benefitted equally, focussing greater attention on the social determinants of health.
Afghanistan’s maternal and newborn health services illustrate these policies and trends. In 2002, the national maternal mortality ratio in Afghanistan was estimated at 1600 per 100,000 births. By 2014, that had been reduced to 660 (Ministry of Public Health). Three factors contributed to this improvement. The first was the end of war in 2002, followed by a time of improving prosperity, education, roads and transportation. The second was a government commitment to a policy of skilled birth attendance and the establishment of rural-based midwifery schools, which trained sufficient midwives to staff the newly established health infrastructure. The third was the training of 28,000 CHWs, a male and female in each community. These CHWs, especially the women, were able to provide health education, family planning methods and other primary care services to women who were still culturally constrained in their ability to reach health facility services.
By 2010, the rate of SBAs had risen rapidly to 50%, but was only 22% in the most remote communities. The modern contraceptive prevalence rate was 20%. Sixty percent of women attended antenatal care at a clinic at least once, but only 18% completed the target of four attendances. National surveys have confirmed that the problems are the same as in so many countries, namely distance and the availability and costs of transport. Since 2010, there has been little improvement in use of these services.
The emphasis on SBAs worldwide has not completely prevented explorations of the potential for community-based interventions by CHWs and TBAs. Field trials have shown successful implementation of presumptive treatment of malaria and provision of iron and folic acid tablets during pregnancy by CHWs. Programmes of preparation for a home delivery and the supply of delivery kits to help ensure a clean delivery and safe cord-cutting have well-recognised track records. In recent years, the supply of Misoprostol tablets to prevent postpartum haemorrhage in home deliveries has been shown to significantly reduce what is still the main cause of maternal death worldwide. Finally, many programmes have demonstrated the ability of CHWs and TBAs to provide basic newborn care, perform resuscitation, and both prevent and treat newborn sepsis.
Recognition of the barriers to maternal care in health facilities for many families, together with the demonstrated potential of CHWs and TBAs to provide essential care suggest the potential of more integrated programs between facility and CHWs. In most countries, this requires removing the bureaucratic barriers between professional obstetric and midwifery care and community-based care programs. This, therefore, for example, is an important goal of the National Reproductive, Maternal, Newborn, Child and Adolescent Health Strategy, 2016 to 2021, for Afghanistan.