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    • At a time when child

    2019-04-28

    At a time when child pneumonia mortality has fallen substantially in almost all low-income and middle-income countries, any remaining national inequities, such as disadvantaged communities in which progress has lagged behind, must be identified. Much of our understanding of childhood pneumonia in these countries comes from a relatively limited number of hospitals and research centres. These centres often do not represent the highest mortality settings and the most disadvantaged communities. Routine data collection has to be scaled up to better understand child pneumonia in these settings. In addition to documenting the decrease in case-fatality rate with time (both in children who are HIV-positive and HIV-negative), Colbourn and colleagues point to a number of ongoing challenges: almost half of all deaths occurred within the first 24 h after hospital admission; and the case-fatality rate in children with very severe pneumonia is still very high. If these large-scale data were compared with published or population-based estimates by the Ministry of Health, further important questions could be addressed: (1) what percentage of all cases of severe pneumonia (by age group) were admitted to hospital, (2) what percentage of all child deaths (by age group) from pneumonia happened in hospital, and (3) what percentage of the decrease in child pneumonia mortality was due to the decrease in in-hospital pneumonia deaths?
    On World AIDS Day, Dec 1, we commemorate those who have died, reflect on the state of the epidemic, and reunite for the struggle ahead. The AIDS movement has much to celebrate—new infections are down from 3·1 million to 2·0 million since 2000 and AIDS-related deaths have fallen by more than 40% since 2005. Over 15 million people now access treatment. Yet AIDS remains the leading cause of death among women of reproductive age and the leading cause of death in Africa—including among young people. 17 million people lack access to treatment, and 19 million do not know that they pak1 live with the virus.
    Universal health coverage (UHC)—the availability of quality, affordable health services for all when needed without financial impoverishment—can be a vehicle for improving equity, health outcomes, and financial wellbeing. It can also contribute to economic development. In its report, the Commission on Investing in Health (CIH) set forth an ambitious investment framework for transforming global health through UHC. The CIH endorsed pro-poor pathways to UHC that provide access to services and financial protection to poor people from the beginning and that include people with low income in the design and development of UHC health financing and service provision mechanisms. The CIH argued that pro-poor UHC offers the most efficient way to provide health and financial protection, and proposed pathways through which pro-poor UHC could be achieved.
    In the cluster randomised controlled trial by Marcel Yotebieng and colleagues (August, 2015) the addition of Step 10 of the UNICEF Baby Friendly Hospital Initiative (BFHI)—that is, the provision of additional support for breastfeeding—did not enhance the effects of steps 1–9, and may even have lessened them. Consistent findings were reported for a trial of Step 10 in Scotland between 2005 and 2007. In this large cluster-randomised trial, the BIG (Breastfeeding in Groups) trial, 14 primary care organisations were asked either to set up new breastfeeding support groups to cover their geographical area, or to leave their existing group provision for pregnant and postnatal women unchanged. More than 18 000 babies were followed up and there was no significant difference between the two groups in change from baseline in rates of exclusive, or any, breastfeeding 8 weeks after birth. In December, 2012, new standards for BFHI accreditation were introduced and the UNICEF UK 10 steps were updated. Before the BIG trial, Step 10 read “Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic”. In the new standards this now reads: ”Identify sources of national and local support for breastfeeding and ensure that mothers know how to access these prior to discharge from hospital”. This change removes the expectation that hospitals and primary care organisations should routinely establish breastfeeding support groups, with consequent cost savings to national health services. Findings from Yotebieng and colleagues\' trial and the BIG trial are not consistent with Cochrane systematic review evidence that professional or lay support increases the duration of exclusive breastfeeding at 4–6 weeks (RR 0·74, 95%CI 0·61–0·89). Since 2000, no UK-based large-scale trials of additional support have reported a significant effect on breastfeeding outcomes. However, a pilot trial of intensive, proactive telephone-based care from a feeding team shows promise. This person-centred intervention is consistent with new UNICEF-UK standards that aim to avoid making women feel pressured to breastfeed, or judged to have failed as mothers if race do not breastfeed.