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Editorials Child Health Redesign

Redesigning health programmes for all children and adolescents

BMJ 2021; 372 doi: (Published 18 March 2021) Cite this as: BMJ 2021;372:n533

Read our Child Health Redesign collection

  1. Jennifer Requejo, senior adviser1,
  2. Kathleen Strong, scientist2
  3. on behalf of the Child Health Redesign writing team
    1. 1Division of Data, Analytics, Planning and Monitoring, Unicef, New York, New York, USA
    2. 2Maternal, Newborn, Child and Adolescent Health and Ageing Department, WHO, Geneva, Switzerland
    1. Correspondence to: J Requejo jrequejo{at}

    Achieving the sustainable development goals requires a shift in thinking

    The covid-19 pandemic risks reversing the remarkable improvements seen over the past two decades in child and adolescent survival.1 Children and adolescents experience milder symptoms with SARS-CoV-2 infection than adults but have been severely affected by disruptions in essential health, education, and other services and by increasing poverty and inequality,2 with unclear long term repercussions. The pandemic has unfolded against the backdrop of a looming climate crisis, also threatening the health and life opportunities of children and adolescents everywhere.

    These two crises should not divert attention away from long term goals of advancing child and adolescent health and wellbeing globally. Countries and the global community need to continue prioritising child and adolescent health and wellbeing, and to tailor health and multisectoral programmes to meet their diverse needs.

    The sustainable development goal (SDG) framework3 adopted in 2015 includes a holistic approach to improving child and adolescent health, still relevant in the wake of covid-19. The framework is based on recognition of macro level trends, and attaining the SDGs requires a substantial shift in thinking about child and adolescent health. This entails moving on from a focus on survival of children under 5 years old to recognise the interconnectedness of maternal, newborn, child, and adolescent health and understanding how early life events ripple throughout a child’s life into adulthood.8

    A sharp decline globally in child mortality since 1990 has focused attention on the increasing numbers of children and adolescents with chronic disabilities, non-communicable diseases, and poor mental health.4 At the same time, progress in improving child survival and nutrition has been uneven. An increasing proportion of child deaths are now occurring in the neonatal period, in sub-Saharan Africa (the only region where the child population is expected to grow in the coming decades), and among the most disadvantaged population groups in all countries.1 Some countries have high levels of child undernutrition while others grapple with the challenges of overweight and obesity among children and young people. These trends indicate that the child survival agenda and attention to equity, both within and across countries, cannot be forgotten if the world is to achieve the SDGs. Demographic projections suggest that children will increasingly be living in urban centres and in the context of humanitarian crises, with serious implications for health programming efforts to ensure that vulnerable children and adolescents do not slip through the cracks.5

    These changes have forced the issue of how countries should strengthen their health systems to be more responsive to the changing needs of children and adolescents. Consequently, the World Health Organization and Unicef initiated efforts to reorient their child health strategy, shifting attention towards a life course perspective and away from a previous exclusive focus on under 5 survival. Attention also expands from children under 5 towards the needs of those up to the age of 19 as well as addressing health, development, and wellbeing (box 1). The intended outcome is to deliver programmes that support an environment that enables all 19 year olds to be optimally healthy and have been raised in safe and secure environments, well educated, and prepared physically, mentally, emotionally to contribute socially and economically to society.6 The redesign process was informed by the latest empirical evidence on demographic, mortality, and morbidity trends, as discussed in this BMJ collection (

    Box 1

    Principles of child health redesign

    • The design and implementation of child and adolescent health policies and programmes should follow a life course approach and be based on available data on disease burden. This approach includes ensuring good preconception care and maternal health services as well as high quality, age appropriate, and condition specific interventions for children aged 0 to 19 years

    • Programmes should be rights based and equitable. Essential interventions and services must be provided to all, everywhere. Programmes must also be tailored to specific contexts (national and sub-national) and include adequate services for children with long term disabilities and conditions

    • Programmes should include comprehensive integrated family, child, and adolescent centred care that promotes health, growth, and wellbeing; builds resilience; prevents exposure to diseases and the subsequent complications; and minimises vulnerability and the cumulative experience of risk factors, taking into consideration the needs of caregivers as well as children and adolescents

    • Children and adolescents must be at the centre of development policies and programmes. A “whole of government” approach is needed to ensure high level coordination of programmes that can improve child and adolescent health across sectors such as education, nutrition, agriculture, water, sanitation and hygiene, social and child protection, labour, and transportation and energy

    • Communities and families should be empowered to participate in the design of child and adolescent health policies and programmes to help ensure they are responsive to community priorities and foster greater accountability of the health system and local and national governments for the provision of quality services


    WHO and Unicef place a three pronged primary healthcare model at the heart of their new programming strategies.9 These three prongs cover integrated health services based around primary healthcare and essential public health functions; multisectoral policy and action beyond healthcare; and empowered people and communities.

    The covid-19 pandemic has shed light on alarming gaps in national primary healthcare systems and the need for greater investment in them to ensure countries can respond rapidly to emergencies while also maintaining delivery of essential services for all. The recommendations from the WHO-Unicef child health redesign consultation should be part of countries’ covid-19 recovery efforts so that children and adolescents are not left behind. They include building country capacity to design comprehensive child and adolescent health programmes based on epidemiological and demographic profiles and resource levels. Countries will need to scale up essential lifesaving maternal, newborn, child and adolescent services, including immunisations, but also expand care to cover chronic diseases, injuries, and disabilities.

    The recommendations also cover the need to build on new innovations, such as digital technologies, which will improve outreach. Focus is also needed on the quality of paediatric care, multisectoral approaches to address equity and social determinants of child and adolescent health, and the active participation of communities and adolescents in the design and review of healthcare programmes. Finally, greater investment must be made into health information systems to enable countries to design, implement, and monitor child and adolescent health and wellbeing programmes and to make sure every child and adolescent receives the services they need.7


    • The other members of Child Health Redesign writing team are Anshu Banerjee, Bernadette Daelmans, Anne Detjen, Rory Nefdt, and Wilson Were.

    • Competing interests:We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    • This article is part of a series proposed by WHO and Unicef and commissioned by The BMJ, which peer reviewed, edited, and made the decision to publish. Article handling fees, including open access are funded by WHO and Unicef.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License (, which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited.