GLOBAL HEALTH RESEARCH: A PERSPECTIVE FROM THE SOUTH

1. GLOBAL HEALTH RESEARCH:A PERSPECTIVE FROM THE SOUTH David SandersDirector: School of Public HealthUniversity of the Western Cape Member of Global Steering GroupPeoples Health Movement Member of WHO Health Systems Research Task Force Presented at the Conference on Global Health Research in Bergen, Norway, 21-22 September, 2004

2. Outline of Presentation • Progress in global health 1980-2004 • Role of globalisation, health sector reform and HIV/AIDS in weakening health systems in the South • Refocusing of research to address this context with examples from South Africa • Key responses required

3. Progress in Global Health • Life expectancy – increases from 46 years in 1950s to 65 years in 1995 • Child deaths – reduced from projected 17.5 to 11m per year • Substantial control of poliomyelitis, diphtheria, measles, onchocerciasis, dracunculiasis through immunisation and disease control programmes • Decline in cardiovascular disease in males in • industrialised countries

4. Growing inequalities in global health IMR SSA World UNICEF: State of the World’s Children

5. U5MR in Sub-Saharan Africa The State of the World’s Children 2003. UNICEF

6. 1980s Mixed progress in implementing health policies

7. Progress in Implementing PHC Programme Elements (Source: WHO 1998)

8. Selective Primary Health Care“Child Survival and Development Revolution” Growth Monitoring Oral Rehydration Therapy Breast Feeding Immunisation Family Planning Food Supplements Female Education

9. 1990s: progress reversed • Inequitable globalisation, • Health sector “reform”, and • HIV/AIDS • result in slow progress and reversals.

10. The debt crisis & structural adjustment: • A crucial development in the current phase of globalisation…

11. External debt

12. Structural Adjustment Programmes: the main components • Cuts in public enterprise deficits • Reduction in public sector spending & employment • Introduction of cost recovery in health and education sectors • Phased removal of subsidies • Devaluation of local currency • Trade liberalisation “The majority of studies in Africa, whether theoretical or empirical, are negative towards structural adjustment and its effects on health outcomes” (Breman and Shelton, WHO CMH WG6, 2001)

13. The global growth of poverty

14. Global distribution of income

15. The Health System, its financing and its human resources

16. Health expenditure (Source: UNDP Human Development Report, 2000)

17. Actual amounts of per capita public health expenditure in Africa (Source: Human Development Report, 2000)

18. Health system ‘reform’: Aim : Improving the performance of the civil service • decentralisation of management responsibility and/or provision of health • improving functioning of national ministries of health • broadening health financing options • introducing managed competition between providers of clinical & support services • working with the private sector

19. Health personnel / population ratios Health personnel vital, consume between 60 – 80% of recurrent public health expenditure (WB, 1994). • Doctors • 31 of 53 African countries have < 32 doctors / 100,000 people, • 17 countries < 10 doctors / 100,000 people • Nurses • 41 countries have < 135 nurses/100,000 people, • 17 countries < 50 nurses / 100,000 people. Source: UNDP, 2000

20. Health professional migration from Africa • Between 1985 and 1995, 60% of Ghana’s medical graduates left • During the 1990s Zimbabwe lost 840 of 1,200 medical graduates • In 1999, 78% of doctors in South Africa’s rural areas were non-South Africans • 2,114 South African nurses left for the UK during 2001

21. International migration—winners & losers • Using the conservative figure of US$ 20,000 to train a medical doctor, Zimbabwe lost US$ 16.8 million through the loss of 840 doctors. • Using the same conservative estimate Nigeria incurred a loss of US$ 420 million due to the migration of 21,000 physicians to the United States. • However, if the UNCTAD figure of US$ 184,000 per professional is used to calculate savings, the United States saved US$ 3.86 billion.

22. Global HIV prevalence • 40 million people around the world live with HIV - more than the population of Poland. • Nearly two-thirds of them live in Sub-Saharan Africa, where in the two hardest hit countries HIV prevalence is almost 40%. • The global HIV/Aids epidemic killed more than 3 million people in 2003 • there are emerging and growing epidemics in China, Indonesia, Papua New Guinea, Vietnam, several Central Asian Republics, the Baltic States, and North Africa. The AIDS debate, BBC News

23. Collapsing public health systems resulting from … • Declining per capita health spending reducing • Health personnel numbers and morale • Drug availability • Transport for outreach & supervision • Promotion of the private sector through “health sector reform” • HIV/AIDS affecting and infecting health personnel • … reversing previous gains in PHC implementation

24. Global Immunization 1980-2002, DTP3 coverageglobal coverage at 75% in 2002 Source: WHO/UNICEF estimates, 2003

25. Collapsing public health systems need to implement more complex interventions and programmes

27. Key focus areas for health research • Research on health systems, particularly on operational aspects and on evaluation • Research on health determinants (local and global) with an equity lens • Case studies of comprehensive, community-based approaches

28. How well are researchers meeting the challenge?

29. Describe the problem Identify risk factors Explore the contextual factors Select possible interventions Test interventions Formulate public health interventions Assess efficacy public health interventions Assess effectiveness public health interventions Research steps in the development and evaluation of public health interventions De Zoysa et al, Bull WHO 1998, 76:127-133

30. Nutrition Engineers • As well as researchers asking “what, why, where, and who?” • We should be asking “How?” • Berg A Sliding toward nutrition malpractice: time to reconsider and redeploy Am J Clin Nutr 1993

31. Food Science Nutrition Science Efficacy Policy Clinical Population (includes surveys) Number of Articles 5 81 54 25 25 10 9 Percentage of Articles 2% 31.3% 20.8% 9.7% 29% 4% 4% Total Articles 259 Classification of Articles in PUBMED 1994-2002, SAJCN 1998 – 2002 (Keywords: Nutrition, South Africa) Effectiveness Operational Evaluation

32. EXAMPLES OF EFFECTIVENESS RESEARCH

33. Research for Service Development and Health Promotion MT. FRERE HEALTH DISTRICT • Eastern Cape Province, South Africa • Former apartheid-era homeland • Estimated Population: 280,000 • Infant Mortality Rate: 99/1000 • Under 5 Mortality Rate: 108/1000

35. STUDY SETTING:PAEDIATRIC WARDS • Nurses have the main responsibility for malnourished children Per Ward: • 2-3 nurses and 1-2 nursing assistants on day duty, and 2 nurses on night duty • 10-15 general paediatric beds and 5-6 malnutrition beds

36. Implementation Cycle Policy Advocacy Evaluation Capacity Development Teambuilding Implementation and Management Situational Assessment Planning Analysis

37. CASE FATALITY IN RURAL HOSPITALS (Former Region E) PRE-INTERVENTION CFRs Mary Terese 46% Sipetu 25% Holy Cross 45% St Margaret’s 24% St. Elizabeth’s 36% Taylor Bequest 21% Mt. Ayliff 34% Greenville 15% St. Patrick’s 30% Rietvlei 10% Bambisana 28%

38. WHO 10-STEPS PROTOCOL – Nutrition component of hospital level IMCI

39. Implementation Cycle Policy Advocacy Evaluation Capacity Development Teambuilding Implementation and Management Situational Assessment Planning Analysis

40. SITUATIONAL ANALYSIS IMPLEMENTATION Recommended practice Practice prior to intervention Perceived barriers to quality care Programme intervention Changes reported at follow up visits Step 1: Treat/prevent hypoglycaemia Feed every 2 hours during the day and night. Start straight away. Children were left waiting in the queue in the outpatient department and during admission procedures. In the wards, they were not fed for at least 11 hours at night Hypoglycaemia not diagnosed Lack of knowledge about risks of hypoglycaemia Lack of knowledge about how to prevent it Shortage of staff especially during the night No supplies for testing for hypoglycaemia Training to explain why malnourished children are at increased risk Training on how to prevent and treat hypoglycaemia Motivated for more night staff in paediatric wards Motivated the Department of Health to provide resources (10% glucose and Dextrostix.) Malnourished children fed straightaway and 3 hourly during day and night. The number of night staff was increased Dextrostix and 10% glucose obtained Comparison of recommended and actual practices in Mary Theresa and Sipetu hospitals and perceived barriers to quality of care of malnourished children

41. WHO 10-STEPS TRAINING – Mt. Frere District, Eastern Cape • Developed as part of a District-Level INP • Training & Implementation from March 98 to Aug 99 • Two formal training workshops for Paeds staff • On-site facilitation by nurse-trainer • Adaptation of protocols – Now have Eastern Cape Provincial Guidelines

42. 10-STEPS EVALUATION RESULTS • Major improvements in the care of severely malnourished children: • Separate HEATED wards • 3 hourly feedings with appropriate special formulas and modified hospital meals • Increased administration of vitamins, micronutrients and broad spectrum antibiotics • Improved management of diarrhea & dehydration with decreased use of IV hydration • Health education & empowerment of mothers

43. 10-STEPS EVALUATION RESULTS • Problems still existed: • Intermittent supply problems for vitamins and micro-nutrients • Power cuts – no heat • Poor discharge follow-up • Staff shortage, of both doctors and nurses, and resultant low morale

44. CHANGES IN CFRs IN RURAL HOSPITALS

46. Follow-up research seeks to answer the following questions: • Why, with the same in-service training, do some hospitals achieve improved care in the management of severe childhood malnutrition, and others do not? • What are the key factors that constrain and facilitate successful implementation of the WHO treatment guidelines? • What are the most effective actions necessary to replicate successful performance in poorly performing hospitals or new settings? • How can training and/or support be improved to overcome potential constraints and allow facilitating factors to flourish?

47. EVALUATION OF FEASIBILITY OF IMPLEMENTING 10 STEPS STEP 10 OF THE IMCI MALNUTRITION PROTOCOL • Giving Nutrition Education to caregivers by health staff • Planning Follow- up of the child at regular intervals post discharge

48. OBJECTIVES • To determine Household Food Security(HHFS), caregiver knowledge & factors associated with malnutrition • To look at the rate of recovery & health status at 1 month & 6 month post discharge

49. STUDY POPULATION POST DISCHARGE HOME VISITS(HV) • At 1 month (n) = 30 • At 6 month (n) = 24

50. DEMOGRAPHIC & SOCIO-ECONOMIC FACTORS