Current status of child health in SA

1. Children’s BillDepartment of Health presentation to the portfolio committee on Social Development25 August 2004

2. Current status of child health in SA

3. Infant and under 5 mortality

5. Source: Bradshaw D, Bourne D, Nannan N. What are the leading causes of death among South African children? MRC Policy Brief No. 3, December 2003. Bradshaw D, Groenewald P, Laubscher R et al. Initial Burden of Disease Estimates for South Africa, 2000. Cape Town: SAMRC, 2003.

6. Mortality: Comment • Large inter and intra- provincial variation in U5MR and IMR • Average IMR higher than countries with comparable economies e.g. Cuba • Main causes of deaths are preventable: • Infants: diarrhoea, chest infections, malnutrition • under-5: trauma, diarrhoea, chest infections, malnutrition and HIV • 5-14 years: violent intentional trauma and accidental trauma HIV Diarrhoea, pneumonia, malnutrition

7. Morbidity: Comment • Mostly preventable causes e.g. diarrhoea, malnutrition and chest infections • Disabilities often the result of: • delayed recognition / management or • inappropriate management e.g. birth asphyxia

8. MULTIFACTORIAL FACTORS associated with freq. & severity (incl. death) of child health conditions e.g. diarrhoea, chest infections, malnutrition, HIV, abuse, accidents To improve Child health: ALL national , provincial district & local organs of govt. and all sectors must be guided by The best interest of the child when making policy legislative budgetary and administrative decisions Bacterial / Viral load; Availability of and access to health services incl. PHC package, hospital / institutional care, home care / protection Immediate Causes Feeding pattern / household food security (poverty), Unhygienic conditions; Smoking; Pollution; Access to safe water, sanitation, environments; Education (esp maternal) Underlying Causes Allocation and distribution of resources; Intersectoral planning; Gender issues; Budgeting and prioritisation of children Basic Causes

9. INTERNATIONAL AND NATIONAL CONTEXT

10. International Context • CRC: “Putting children first” • African charter on the health and welfare of children • MDG • UNGASS • A World Fit for children • Global Strategy on Infant and Young Child Feeding • NEPAD • WHA Resolution (54.19), May 2001, on Schistosomiasis and STH infections

11. International Context: CRC • right to survival and development (6) • protection from all forms of violence / abuse (19, 25,34) • special consideration for all mentally or physically disabled children (23) • right to health and facilities for the treatment of illness and rehabilitation of health (24) • rehabilitation (39) As a country we need to further define these rights and provide a supportive milieu to realise them • In all actions the best interests of the child shall be a primary consideration (3) • State parties shall undertake all appropriate legislative, administrative and other measures for the implementation…(4)

12. International Context Millennium Development Goals: 3/7 goals are directly related to health By 2015: • Reduce by 2/3 the U5MR • Reduce maternal mortality by 3/4 • Combat HIV/AIDS, malaria and other dx How far are we?

13. International Context NEPAD Health Strategy • Focus on poorest and most marginalised incl. women and children • Reduce IMR and U5MR by 2/3 by 2015 • Targets: • Effective implementation of IMCI and EPI; • Polio eradication • Consolidation of: • IMCI • Progr. on HIV and AIDS, TB and malaria • Immunisation • EBF and appropriate nutrition

14. International Context National Context Legislation Policy Strategies Programmes

15. National Health Act • As it relates to children will be presented by my colleague at the end of this presentation

16. Legislation • Other health-related legislation that impact on children exist, including, inter alia: • food fortification • tobacco Control These will not be presented

17. Health sector strategic plans / frameworks

18. The Health Sector Strategic Framework, 1999-2004 (10 point plan) • aims to • improve access to health care for all (and build on achievements since 1994); • reduce inequities in health care, and • improve the quality of care at all levels of the health care system

19. The Health Sector Strategic Framework, 1999-2004 (10 point plan) • Prioritises: • improving the quality of care, • speeding up delivery of an essential package of PHC through the district health system, • decreasing morbidity and mortality through strategic interventions, • improving resource mobilisation and the management of resources bearing in mind “equity” issues

20. The Strategic Plan for HIV / AIDS 2000-2005 • 4 priority areas: • prevention; • treatment, care and support; • research and • human and legal rights. • translates into: • preventing primary HIV infection, • preventing unwanted / unintended pregnancies in HIV+, • PMTCT; • preventing common illnesses, and ensuring ongoing care and support for mothers and children infected or affected by HIV and AIDS within a human rights paradigm.

21. Policies / Programmes / Strategies currently offered by the DoH

22. Child Health Policies and Guidelines • Policies • Draft: Child Health Policy and Implementation Guidelines • Draft: Infant and Young Child Feeding Policy • Draft: Policy Framework for non-communicable chronic conditions in children • Policy Guidelines for the Management and Prevention of Genetic Disorders, Birth Defects, and Disabilities • Draft: National Policy Framework for Child Abuse • National Health Policy Guidelines for Improved Mental health in South Africa • Policy Guidelines for Child and Adolescent Mental Health • National Rehabilitation Policy • Strategies and Guidelines (excluding training packages) • Comprehensive Primary Health Care Package + Norms and Standards • District Hospital Service Package for South Africa • Draft Maternal and Neonatal Strategy • SA Breastfeeding Guidelines for Health Workers • Guidelines for Nutrition Interventions at Health Facilities to Manage and Prevent Child Malnutrition • PMTCT Protocol for Pilot Sites • Expanded Programme on Immunisation (South Africa) – Immunisation Schedule and Fact Sheets • Integrated Management of Childhood Illness Strategy: Case Management Guidelines • National Guidelines on Palliative Care for Children • Draft: Guidelines for health care providers managing suspected child abuse, neglect and exploitation • HIV and / or AIDS: Strategic Plan of the National Department of Health: 2000-2005 • Comprehensive Treatment Plan for HIV and AIDS • Management of Diabetes Type I in children (<18 years) at hospital level • Management of Asthma in Children • National Guidelines on Primary Prevention and Prophylaxis of Rheumatic Fever and Rheumatic Heart Disease for Health Professionals at primary level

23. HIV and AIDS VCT PMTCT ART HBC STIs TB Prevention Treatment DOTS Programmes or Strategies offered MCWH ANC, ATT Genetics services KMC Oral health EPI +ATT INP: BFHI; Code,, growth monitoring, PSNP IMCI PMTCT ART SHS Services for abused incl. ARV PEP IMCI Child survival and improved quality of life in children Malaria (RBM) / cholera / other VBD Prevention Case management Outbreak response Health Promotion HPSI Healthy environment for children Anti tobacco Mental Health Victim empowerment FAS Counselling Rehabilitation School health services

24. IMCI Components and Intervention areas Improving case management Strengthening the health system Improving household, community and family behaviours Targets: 80% of district must have 60% of health workers trained in IMCI by 2005 HHCC must be implemented in ALL districts by end 2005

25. Programme Implementation

26. IMCI Expansion in SA Shortage of funding for training Shortage of facilitators, course directors NC: no training this year No transport for supervision ** no data; P planning; --not started and no plans yet

27. Fully Immunised (annualised) by District - 2003 Target: 80% Key : Yellow : 60-79% Green : ≥80%

28. Fully Immunised (annualised) in Gauteng Province - 2003 Mestweding DM City of Tswane West Rand DM Ekurhuleni Metro Sedibeng DM Key: Red : 0-59% Yellow : 60-79% Green : ≥ 80% City of Johannesburg

29. INP • >25% health facilities are baby friendly PMTCT • At >1260 facilities • 99% of HIV exposed infants receive nevirapine • >2800 health care providers trained in PMTCT and IF IMCI

30. Infrastructure for these services • District Health System • Local authorities

31. Human / Material Resources available Child and Youth Health: EPI Child Youth and Adolescent (National ) Chief Directorate: MCWHN No dedicated structures or budget for child health at district levels or in LSAs Provincial District

32. Challenges and Gaps: • Children still die of preventable conditions • Socio-economic issues impact negatively on health e.g. poverty • Inequitable distribution of resources • Competing priorities at local levels • Services for children not prioritised

33. Challenges and Gaps: • Sub-optimal implementation of programmes e.g. Immunisation / SHS • Poor inter-sectoral collaboration resulting in poor / non-existing implementation e.g. SHS • Data on progress needed (addressed through NHA) • Ineffective child protection

34. The Children’s Bill

35. Addressing challenges through the Bill Education Sanitation Social Welfare System Healthy children Water Safe environments Refuse removal Protection by Justice system and SAPS

36. Children’s Bill • Provides unique opportunity to legislate in favour of one of the most vulnerable groups of society:CHILDREN • If properly developed Children’s Bill, can accelerate and improve implementation of health services for children

37. Children’s Bill • Currently adopts a piece-meal approach:- • Needs to go one step further and state that: “The Minister, after consultation with the Ministers of Justice, Education, Health, Correctional services and Safety and Securty, develop a national policy framework to ensure a uniformed and coordinated approach by all Government departments in dealing with matters pertaining to children to guide the implementation and enforcement and administration of this Act” • This will facilitate implementation of Health Programmes that optimise the growth and development of our children

38. Current intersectoral response • Falling short • Not bound / guided / obligated by law • Participation often inadequate / delegated to junior officials • Faces numerous internal challenges which has hindered its function and achievements • Needs to be re-energised

39. Bill needs to elaborate on rights • It currently is a re-statement of section 28 of the Constitution • Needs to include the ffg: • Basic health care and information about health – (part of PHC package and IMCI)* • Basic nutrition and appropriate information about nutrition (part of PEM scheme and IMCI)* • Water and sanitation – stated in chapter 6 (83) – minimum norms and standards for partial care – needs to be mainstreamed to prevent disease in general • Safe environments • Leisure and recreation • Education • Social security • * would not necessitate policy shifts but would assist with implementation of policy

40. Cont…/ elaboration of rights • Protection from abuse, neglect, maltreatment, degredation and other harmful practices • Protection from economic exploitation • Unfair discrimination – with specific reference to disability; ethnicity, pregnancy • Family / safe alternate care • Property and possessions • Shelter • Social services

41. Cont…/ elaboration of rights • Children with special needs deserve recognition and special mention in relation to their rights: • Long-term health conditions: diabetes, epilepsy, asthma • Disabilities • Born to parents who are HIV+ / debilitated • Orphans • Child-headed households • Living on street • Care centres • Refugee / unaccompanied minors

42. Cost Implications

43. Cost • Would require integrated planning, budgeting and prioritisation for children at district level • Cost of ARVs covered by Conditional grants • Cost of school health services: R71 646 505 for full coverage over 5 years (policy already accepted by Health MINMEC and PHRC) • Cost of IMCI implementation to ensure 100% coverage still has to be done but plans underway for full implementation