Western Cape Province Burden of Disease Reduction Project: The approach taken Prof Jonny Myers

1. Western Cape Province Burden of Disease Reduction Project: The approach takenProf Jonny Myers Symposium 25 – 26 June 2007

2. History of Project • Approach from Prof Househam 9/2005 • Nature of the Mandate/conceptual model • Project Reference Group established 9/2005 • 6 Proposals identified • Formation of a Project Management Team • 2 Workteams and 5 Expert Groups

3. The Project Mandate: looking upstream for risk and intervention Sex Age STIs Viral load Gender Older partners Violent crime Social systems Structural Societal Behavioural Biological Method of sex No of partners Substance abuse Indicators of poverty Migration / Urbanisation Education Institutions Infrastructures

4. It must be said • Very atypical request • Amounting to a PH Professionals dream in its far-sightedness • Not the usual Health Sx or systems Mx request or even clinical request • But directed at the primary end of the prevention hierarchy, and • Intrinsically inter-sectoral in approach

5. History of Project • Approach from Prof Househam 9/2005 • Nature of the Mandate/conceptual model • Project Reference Group estab 9/2005 • 6 Proposals identified • Formation of a Project Management Team • 2 Workteams and 5 Expert Groups

6. History of Project • Approach from Prof Househam 9/2005 • Nature of the Mandate • Project Reference Group established 9/2005 • 6 Proposals identified • Formation of a Project Management Team • 2 Workteams and 5 Expert Groups

7. The six original proposals

8. History of Project • Approach from Prof Househam 9/2005 • Nature of the Mandate • Project Reference Group established 9/2005 • 6 Proposals identified • Formation of a Project Management Team • 2 Workteams and 5 Expert Groups

9. Project Structure PRG

10. PMT • Project Leader • DOH Representative • WT 1 Champion • WT2 Champions (5) Function: Project Management to deliver high quality product within budget and timelines

11. The 2 Work Teams • Work Team 1: Proposal 1 -4 Surveillance • Work Team 2: Proposal 5 -6 • Preventive interventions • Evidenced based upstream recommendations

12. Ranked BoD components provided focus for Work Team 2

13. Principal components of the BOD PLUS hidden burden of Mental Health Disorders not captured by mortality

14. 5 Expert Groups

15. 5 Expert Groups • Structure and function • each group with specific champion • Authors identified • Multi stakeholder expert group assembled–including many members of PRG • examined evidence for intervention effectiveness (where this existed or was possible) or promise (where more complex causally). • Peer review (incl. international review) where possible given time constraints

16. The Report: March 2007 and as edited June 2007 Volume 1 - You have been given hardcopy of the June 2007 version Foreword by Prof C Househam, Head of Health Overview chapter by Jonny Myers and Tracey Naledi and executive summaries from Volumes 2 to 7 from other authors There is a CD Rom in your pack containing electronic copy of everything from Volume 1 through Volume 7 June 2007 version Volume 2:Mortality surveillance Executive summary with appendices • Paper 1: Cape Town Mortality by authors • Paper 2: Boland/Overberg Mortality by authors • Paper 3: Western Cape overall Mortality by authors

17. The Report (2) Volumes 3,4,5,6 • Order of appearance follows the degree of contribution to the overall burden of disease • Each has an executive summary. • Authored by Champions plus authors’ groups • Incorporating where appropriate Reviewers’ comment Volume 3: Major Infectious Diseases (HIV/AIDS and TB) Volume 4: Mental Health Volume 5: Injury – intentional/violence and unintentional/RTI Volume 6: Cardivascular Diseases - IHD and stroke

18. The Report (3) Volume 7 Overview of Childhood Diseases with 5 appendices: HIV/AIDS in children Diarrhoea Low birth weight Acute Respiratory Infections Malnutrition

19. The 7 Volumes Constitute a rich source of outputs with useful information about interventions against the major risk factors for the top 5 BoD components for which there is either • Evidence • Or which are agreed to be promising

20. Fidelity to mandate • Maintained faithfulness of mandate to look upstream in terms of • The conceptual model focussing on societal and structural risk factors and levels of intervention • and beyond the health department to other sectors and relevant government departments • While retaining focus on “downstream” health sector based interventions with recursive preventive effects at the primary level eg ARVs, Mental Health Services

21. The Project Mandate: looking upstream for risk and intervention Sex Age STIs Viral load Gender Older partners Violent crime Social systems Structural Societal Behavioural Biological Method of sex No of partners Substance abuse Indicators of poverty Migration / Urbanisation Education Institutions Infrastructures

22. Main Points: 1. Surveillance is crucial • Whatever we do with interventions into the future we need to know where we are at any one time, and what the impact measurable at the population level could be. • So we need improved and institutionalised mortality surveillance systems sensitive to rapid change at the most disaggregated level

23. 2. Upstream risks and upstream interventions for all risksare critical for reduction of BoD • Have highlighted the role of behavioural factors (alcohol, road use, sexual and health-seeking) in contributing to the BoD • And how these link to even more upstream infrastructural risks of material and social deprivation • And how upstream interventions have multiple direct and indirect impacts on all risks

24. Used global and local evidence • To provide highlights of upstream interventions that have been: • shown to be effective • or are considered by consensus to be promising

25. Value of the output • Study has not broken entirely new ground • Overlap with WCPPoA 07/08 – provincial strategic objectives • Our recommended interventions can provide detail and more concrete proposals for the achievement of these strategic policy objectives • Provides a menu of interventions for policy makers – and a guide to feasibility and practicability

26. Value of the output (2) • Our recommendations can help assessment of current, consideration of new, and dropping of existing interventions that have been shown not to work. • The devil is in the detail • some interventions are nominally present but not implementable any time soon and • others are inadequately targeted to high risk groups who could benefit most

27. Tasks ahead for 2007/8

28. Principal tasks as seen by the project team • Institutionalisation of mortality surveillance should continue • Intersectoral engagement with other non-health government departments on upstream interventions to mitigate risk, involving: • Identification of optimal intersectoral structures and vehicles for reducing the BoD • Making specific Public Health contributions to this work including assistance with design of intervention implementation and monitoring systems and data analysis and interpretation for evaluating these interventions over time

29. Structure of Symposium • Presentations in some detail • Lots of time for input from the floor