African children in the spotlight
Authors: Zoë Mullan
Journal: The Lancet Global Health (2015)

June 16 is the Day of the African Child—an African Union initiative to commemorate the hundreds who died during the 1976 protests by black schoolchildren against racially biased educational practices in Soweto, South Africa. Today the anniversary is an opportunity to highlight the rights of all African children to a quality education, and to a healthy childhood. The theme for 2015's Day of the African Child is ending child marriage—ie, marriage before 18 years—a practice that affects 40% of girls in sub-Saharan Africa. Child brides are more likely than older women to have a lower level of education and to become pregnant while physically and emotionally immature. They are also less likely to receive adequate medical care while pregnant, and are at greater risk of maternal death. However, it is not just the young mothers themselves who are damaged by early childbearing: the consequences extend to the next generation, as an Article in this month's issue shows. Caroline Fall and colleagues' cohort study of 22 000 mothers from Brazil, Guatemala, India, the Philippines, and South Africa found that the offspring of those aged 19 years and younger were more likely than those of mothers aged 20–24 years to be born preterm or low birthweight, to be stunted in infancy, to have poor schooling, to be short as adults, and to have higher adult fasting glucose concentrations. These disadvantages were independent of the mother's socioeconomic status, height, breastfeeding duration, and parity. As Haroon Saloojee and Hoosen Coovadia note in their linked Comment, “Maternal age matters: for a lifetime, or longer”. The prevention of child marriage and early pregnancy is thus a priority for child rights and health in Africa and elsewhere, with a multitude of downstream benefits. In a further Article in this month's issue, Karen Devries and colleagues address another aspect of African children's rights: the right not to be physically attacked in their classrooms. It sounds astonishing to those of us in countries where corporal punishment of children by adults in positions of authority makes headlines, but such violence in schools is commonplace in many countries. Recent national surveys in Kenya and Tanzania indicate that about half of adolescents report physical violence from school staff. Devries and colleagues' study in 42 primary schools in Uganda shows that such figures are unlikely to represent reporting bias: baseline data revealed that more than 40% of the staff themselves admitted that they had carried out physical violence against a pupil in the past week. Encouragingly, however, implementation of a complex behavioural intervention that engaged teachers, administrative staff, students, and parents, was shown to reduce past-week violence by 60% after 18 months. Starting from such a high baseline, however, meant that even a 60% relative decrease left an unacceptable absolute prevalence. The tolerance of violence as a means of control or punishment pervades many sectors of society, and tackling ingrained attitudes will require similarly imaginative interventions to Devries and colleagues' in other settings. Finally, some good news for African children, in the form of progress on Millennium Development Goal 4 (MDG4) in Tanzania. In a third Article in this month's issue, Hoviyeh Afnan-Holmes and colleagues present a country case study as part of the Countdown to 2015 process. Tanzania in fact met its MDG4 target in 2013, with an under-5 mortality rate of 54 deaths per 1000 livebirths. Afnan-Holmes and colleagues find that the country is also on track to meet the proposed target for 2030 (14 deaths per 1000 livebirths). Critical analysis of changes in intervention coverage, equity, and financing, as well as health system and policy changes, showed that the drivers of Tanzania's dramatic success, particularly since 2000, were consistent political attention to the issue since the mid-1980s, large funding increases, and a steady focus on high-impact interventions at primary care level, particularly immunisations, bednets, and the prevention and treatment of HIV. Unfortunately, the same successes could not be extended to family planning and maternal and neonatal survival, which have suffered from more recent political prioritisation, lower funding, changes of strategic direction (maternal health), and limited scale-up (neonatal health). The analysis presents an extraordinarily rich and incisive assessment of one country's successes and failures in reproductive, neonatal, child, and maternal health, and draws lessons with easy parallels to many other countries struggling to make or maintain traction in this crucial area as we move into the post-2015 age.