Childhood Diseases Workgroup

1. Childhood Diseases Workgroup Malnutrition, Final Report: David Sanders & Louis Reynolds Low Birth Weight: Phumza Nongena & Tharina van Heerden HIV/AIDS: Brian Eley and Max Kroon ARI: Heather Zar & Mary-Ann Davies Diarrhoea: Tony Westwood with advice from George Swingler

2. Overview of Presentation • Contribution of Child Mortality to BoD • Human rights and SA’s commitments • Burden of young child mortality in W Cape • Major determinants of young child BoD in W Cape • Key interventions to address young child BoD in W Cape • Inequities between BoD and resource allocation • Lessons from international experience • Recommended PHC and Social interventions

3. 'Gastro-tsunami' 2007 • RXH admissions in Feb highest for > decade • Costly in terms of finance, staff, general standard of care • HHH experienced the same problem • Overwhelmingly from informal settlements • TBH: lower rate of increase – predominantly formal housing in drainage area

4. 'Gastro-tsunami' 2007 • Overall Hospital Occupancy at RCCH rose to 91% in March 2007, the highest recorded in recent years. • “It is clear that in 2007 preventive efforts surrounding diarrhoea in the Metro district were inadequate and too late. The unprecedented size of the epidemic would have been somewhat mitigated if community based work and communication strategies had been implemented in a more coordinated fashion.” • “It is strongly recommended that the partner departments identified by the Burden of Disease project be brought on board early in the planning i.e. DWAF and City for water and sanitation areas identified in 2005/6.” Prof A Westwood, Clinical Co-ordinator, Child Health Services,PGWC, June 2007

5. Where to focus?

6. Health: an 'investment' or a human right? DALYs undervalue children’s lives • They incorporate questionable assumptions about the value of life • They assign different values to years of life lost at different ages: • zero at birth • peak at age 25 • declines with increasing age • The young, the elderly, and disabled people are less likely to contribute to society in economic terms • Fewer DALYs will be saved by health interventions which address their ills • Therefore such interventions are less deserving of public support

7. Caring for childrenWhich values & goals do we share? • National • Constitution • UNCRC • MDGs • Provincial • 2010 • Institutional • Patient related • Staff related • Community related

8. Goal 4: Reduce child mortality • Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate The challenge of MDG 4

9. Age distribution of deaths, Western Cape, 2000 • The great majority occur in infancy (under one year of age) and 1-4 age group • U-5 deaths account for a significant percentage of all deaths • Mainly due to communicable diseases and malnutrition

10. IMR in Cape Town 2001 - 2004 IMR per 1000 live births by sub district, Cape Town 2001 - 2004 Substantial numbers dieoutside health facilities

11. Causes & risk factors

12. Leading causes of U5MR, WC 2000 Bradshaw, et al. SOUTH AFRICAN NATIONAL BURDEN OF DISEASE STUDY WESTERN CAPE PROVINCE. ESTIMATES OF PROVINCIAL MORTALITY 2000

13. malnutrition Leading causes of U5MR, SA 2000 Direct/non-synergistic Bradshaw D, Bourne D, Nannan N. MRC Policy Brief No3, 2003

14. Children under 5: Nutritional Status • Overall, 12 percent of children are underweight, 27 percent are stunted and 5 percent are wasted (DHS 2003). • There are no indications that the nutritional status of children has changed substantially over the past 10 years.

15. Malnutrition in W Cape urban infants • 15 percent of Western Cape children were stunted • Cross-sectional study in disadvantaged WC urban black and 'coloured' communities: • coloured infants: 18% stunted and 7% underweight • black infants: 8% stunted and 2% underweight • micronutrient intake lower in black infants than in coloured infants • Anaemia: 64% of coloured and 83% of black infants • Zinc deficiency: 35% of coloured and 33% of black infants • Vitamin A deficiency: 2% of coloured infants & 23% of black infants • Overall 6% of coloured infants & 42% of black infants were deficient in two or more micronutrients NFCS,1999; Oelofse A et al 2002

16. Outcome malnutrition Immediatecauses Inadequatedietary intake Disease Inadequate carefor children & women Underlyingcauses Inadequate health services& unhealthy environments Inadequate access to food Resources & controlhuman, economic & organisational resources Basic causes Political & ideological factors, economic structure Potential resources Conceptual framework of causality

17. Nutrition and Dietary Intake The National Food Consumption Survey (1999) showed that in a large national sample of children aged 1-3 45% received less than two-thirds of their daily energy requirements 80% received less than two-thirds of their daily iron requirements 65% received less than two-thirds of their daily Vitamin A requirements

18. Exclusive breastfeeding (ie giving nothing but breastmilk to the infant) reduces under-five mortality by 13 percent (Jones et al., 2003). Compared with infants who are exclusively breastfed, infants aged 0-5 months who are not breastfed have six-fold and two-and-a-half-fold increased risks of death from diarrhea and pneumonia respectively (WHO Collaborative Study Team, 2000). Benefits of Breast Feeding

19. Duration of breast feeding The Western Cape has the shortest median duration of breast feeding • median duration of breastfeeding in South Africa varies • 10 months in the Western Cape • 20 months in the Northern Province • other provinces 14-17 months • The duration of breastfeeding varies widely according to population group • African 17 months • Coloured 11 months • Asian 5 months • White less than 1 month SADHS 1998

20. Children under 5Height-for-age: percentage below -2 SD DHS 2003

21. Malnutrition & household expenditure SA Zere & McIntyre 2003

23. The impact & burden of ARI • Global: 1.9 million under-5 deaths each year • SA: 6110 under-5 deaths in 2000 [5.8% of U-5MR] • ARI increases mortality of associated conditions • 30 - 40% of hospital admissions • Case-fatality rate 15 - 28% Impact of HIV/AIDS on ARI • Increases case fatality rate 3 - 6 times • Changes spectrum of pathogens [PCP &c] • Increases complexity of case management • Prolongs hospitalization

24. Outcome Immediatecauses Impairedimmunity Increasedexposure ARI Inadequate health & environmentservices Underlyingcauses Biomasssmoke exp Inadequatewomen & childcare Inadequatebreast feeding Lowbirth weight Malnutrition HIV infection Resources & controlhuman, economic & organisational resources Overcrowding & sanitation Basic causes Political & ideological factors, economic structure Potential resources Conceptual framework for ARI Conceptualframeworks forMalnutrition & other conditions Modified from: Davies & Zar, 2007. Acute Respiratory InfectionW Cape BoD Workgroup

25. Risk factors for Low Birth Weight • Risk-taking behaviour and substance abuse • Drinking alcohol during pregnancy • Smoking during pregnancy • Illicit drugs • Physical labour • Obstetric • Poor family spacing, inadequate ANC • HIV infection • Poverty

26. Risk factors for diarrhoea • immediate determinants • breast-feeding and care-giving practices • underlying determinants • malnutrition • quality of health services including prenatal care • environmental services including water supply, • sanitation and hygiene • handwashing with soap. • basic determinants • Maternal education • Poor socioeconomic status

27. Khayelitsha as example Khayelitsha 2003: • Almost 30% of residents did not have easy access to water and 80% lived in shacks • 14 521 households did not have access to water while the sanitation backlog was around 29 811 households • There were an average of 105 people per toilet in Sites B and C • One toilet per seven households where toilets had been provided • In other areas there were none Anso Thom, 2006. Widening gulf between Khayelitsha and Cape Town. Health-e, 28/2/2006;Stern R, Scott V, 2005. Research action to address inequities: Cape Town Equity Gauge, City of Cape Town 2003/4..

28. Risk factors for vertical transmission of HIV • Immediate • under-utilisation of Family Planning Services • late or no booking for ante-natal care • poor uptake of HIV testing. • Ill-considered and unsafe infant feeding policy • Sub-optimal choice of ARV regimens • Underlying & Basic • as in generalised HIV epidemic

29. Interventions

30. Interventions to improve immunity • Promote breast feeding - • Maternity leave, BF • time at work • Incentives equivalent to formula • Counsellors • Mixed feeding out • Nutrition programmes • INP • CBNP incl GMP • Micronutrients, esp Vit A • Improved PSNP • Appropriate complementary feeding • Immunisation coverage • Extend EPI through increased community coverage • Pneumococcal vaccine?

31. Interventions to reduce exposure • PMTCT • EBF, rapid deployment of new mid-level & community workers • Smoking & alcohol control programmes, incl pricing & legislation • Control indoor and outdoor air pollution • Insulation & electrification, energy efficiency • Increase basic allocation of free water • Sanitation • Handwashing with soap and water

32. Examples of interventions for ARI • To address specific risk factors • Malnutrition, LBW, breastfeeding • Immunisation: improve coverage of EPI • Zn supplementation • Smoking control programmes [successful in 4/18 studies] • Air pollution at household level: electrification, insulation • Handwashing [soap & water] • Broader interventions • IMCI [pneumonia deaths cut by 42% in neonates & 36% in children 1-5] • Comprehensive community-based programmes • Maternal education • Poverty alleviation: eliminate obstacles to existing grants

33. Inequity demands targeting

34. Inequity demands targeting WC Index of Multiple Deprivation • Domains: • Income & material deprivation • Employment deprivation • Health deprivation • Education deprivation • Living environment deprivation • Most deprived areas are in Beaufort West, Breede Valley, City of Cape Town [Khayelitsha], George & Knysna

35. Infant Mortality % households below poverty line HIV prevalence (estimated) % unemployed The metro: determinants and health Cape Town Equity Gauge, UWC SOPH, 2002

36. Equity requires a balance between resources and needs NEEDS Resources Health District Geographic Area

37. Distance to Equity in Resource Allocation for Primary Care (Health Centres and Clinics)

38. Ceará, Brazil • Early 1980s IMR >100 per 1,000 and malnutrition very common 1986 statewide survey new health policies, including GOBI plus vitamin-A supplementation • Coverage improvement through CHWs and TBAs, health services decentralised to rural municipalities with worst health indicators • social mobilisation campaign using media and small radio stations • 1990 and 1994 surveys repeated, and results incorporated into health policy. This process was sustained by four consecutive state governors

39. Ceará, Brazil Improved outputs By 1994: • ORS use increased to more than 50 per cent • nearly all children had a growth chart • half had been weighed within the previous three month • immunisation coverage was 90 per cent or higher • median breastfeeding duration increased from 4.0 to 6.9 months. • Improved outcome indicators • low W/A fell from 12.7% to 9.2%; low H/A from 27.4% to 17.7% • reduced diarrhoea from 26.1% to 13.6% • IMR fell from 63 per 1,000 live births in 1987 to 39 per 1,000 in 1994 • diarrhoea deaths fell from 48% to 29% • perinatal deaths increased as a proportion from 7 per cent to 21 per cent and • respiratory infections from 10 per cent to 25 per cent. (Victora et al, 2000)).

40. PHC interventions in WC • Rapidly increase coverage through CHWs of key interventions eg ORT, vaccination, Vit A, exclusive breast feeding, GMP, handwashing • Improve support and QOC at health centres and clinics • Improve intersectoral collaboration esp. water, sanitation, housing • Massively increase HR numbers and competence - ? HRH fund • Develop integrated multi-level Academic Health Service Complexes to improve service and training

41. Oportunidades, Mexico • Progresa-Oportunidades, now known as Oportunidades • Principal anti-poverty program of Mexican government • Comprehensive focus on human capital through nutrition, health, education and evaluation • Being considered for replication in other countries and cities • Monetary educational grants to participating families for each child under 22 years of age who is enrolled in school between the third grade of primary and the third grade of high school • Cash transfers are also linked to regular health clinic visits more than 5 million poor families break out of poverty since 1997 World Bank; Brookings Institution. 2007.

42. Key elements for success • Large & growing in scale • operates in more than 70000 localities, • financial allocation almost half (46,5%) of Mexico’s annual anti-poverty budget • only 6% of its budget goes to operating costs • Strong government commitment ensures sustainability • Targets poor and marginalised communities • 96% of its localities are in marginalised rural areas • In urban areas it focuses on smaller cities with significant levels of marginalisation. • Strong gender focus - improvement of the condition of women a priority • About 98% of heads of households that get cash benefits are women • Strategic focus on youth: monetary value of scholarships increases as learners enter higher grades where school dropout rates are higher • Effective review mechanism • regular evaluation of management, results and impact with clear indicators UNICEF: State of the World's Children 2005. [pp 32-33]

43. Social interventions in WC • Target education at vulnerable groups esp poor women • Old age pensions, esp to women-headed households • Increased WFH by 1.9 SD in U5 girls [Duflo] • CSG • ‘significantly boosted child height’ • Projected to increase adult earning by up to 230% [Agüero et al 2004] • Generate employment • Expand and professionalize EPWP for health infrastructure

44. Conclusions • BoD estimates undervalue children’s lives • Although W Cape ‘better’ than other provinces, unacceptable mortality/morbidity and major inequalities exist • Health services are under immense strain • Major causes of BoD are rooted in social and economic inequalities and eminently preventable by non- health sector interventions • International experience provides a guide to success factors