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
Overview of Presentation
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•
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•
•
•
•
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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
'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
March
April
2007
3941
3188
2006
3344
3190
18% increase
No change
'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
Where to focus?
CONTRIBUTOR TO THE BURDEN OF
DISEASE
MEASURED AS PREMATURE
MORTALITY (% YLL)
HIV/AIDS/ TB
22.0
Homicide/Violence/Road Traffic Accidents
19.8
Mental disorders
~ 0 but high morbidity burden
Ischaemic Heart Disease/Stroke
10.5
Childhood diseases
6.0 minimum
Total
58.3%
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
Caring for children
Which values & goals do we share?
• National
– Constitution
– UNCRC
– MDGs
• Provincial
– 2010
• Institutional
– Patient related
– Staff related
– Community related
The challenge of MDG 4
Goal 4: Reduce child mortality
Reduce by two-thirds, between 1990 and 2015, the
under-five mortality rate
70
60
50
40
30
20
10
0
199 5
200 0
200 3
201 5[MDG]
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
IMR in Cape Town 2001 - 2004
60
IMR per 1000 live births by sub district, Cape Town 2001 - 2004
2001
2002
2003
2004
50
40
Substantial numbers die
outside health facilities
30
20
10
0
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w
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ya
bg
a
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n
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Pl
rg
g
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aa
Bl
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ne
lo
th
W
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Causes & risk factors
Leading causes of U5MR, WC 2000
Bradshaw, et al. SOUTH AFRICAN NATIONAL BURDEN OF DISEASE STUDY
WESTERN CAPE PROVINCE. ESTIMATES OF PROVINCIAL MORTALITY 2000
Leading causes of U5MR, SA 2000
Direct/non-synergistic
PEM
Birth Trauma
& asphyxia
Other
LRTI
Diarrhoea
malnutrition
LBW
HIV/AIDS
Bradshaw D, Bourne D, Nannan N. MRC Policy Brief No3, 2003
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.
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
Conceptual framework of causality
Outcome
malnutrition
Disease
Immediate
causes
Inadequate health services
& unhealthy environments
Underlying
causes
Inadequate
dietary intake
Inadequate
access to food
Inadequate care
for children & women
Resources & control
human, economic
& organisational resources
Political & ideological factors, economic structure
Potential resources
Basic causes
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
Benefits of Breast Feeding
•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 sixfold and two-and-a-half-fold increased risks of death
from diarrhea and pneumonia respectively (WHO
Collaborative Study Team, 2000).
Duration of breast feeding
The Western Cape has the shortest median duration of breast feeding
• median duration of breastfeeding in South Africa varies
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–
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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
Children under 5
Height-for-age: percentage below -2 SD
he
r
Hi
g
12
de
G
ra
G
ra
de
s
81
1
67
de
s
G
ra
de
s
G
ra
No
ed
uc
a
tio
15
n
50
40
30
20
10
0
DHS 2003
Malnutrition & household expenditure SA
Zere & McIntyre 2003
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
Conceptual framework for ARI
Outcome
ARI
Impaired
immunity
Increased
exposure
HIV
infection
Biomass
smoke exp
Malnutrition
Inadequate
breast feeding
Low
birth weight
Inadequate
health & environment
services
Inadequate
women & child
care
Overcrowding
& sanitation
Immediate
causes
Underlying
causes
Resources & control
Conceptual
frameworks for
Malnutrition
& other conditions
human, economic
& organisational resources
Political & ideological factors, economic structure
Potential resources
Basic causes
Modified from:
Davies & Zar, 2007.
Acute Respiratory Infection
W Cape BoD Workgroup
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
Risk factors for diarrhoea
• immediate determinants
– breast-feeding and care-giving practices
• underlying determinants
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–
–
–
–
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
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..
Risk factors for vertical transmission of HIV
• Immediate
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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
Interventions
Interventions to improve immunity
• Promote breast feeding –
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Maternity leave, BF
time at work
Incentives equivalent to formula
Counsellors
Mixed feeding out
• Nutrition programmes
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INP
CBNP incl GMP
Micronutrients, esp Vit A
Improved PSNP
Appropriate complementary feeding
• Immunisation coverage
– Extend EPI through increased community coverage
– Pneumococcal vaccine?
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
Examples of interventions for ARI
• To address specific risk factors
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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
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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
Inequity demands targeting
Inequity demands targeting
WC Index of Multiple Deprivation
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Domains:
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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
Athlone
4%
2%
0%
Cape Town Equity Gauge, UWC SOPH, 2002
TOTAL
Tygerberg
West
Tygerberg
East
SPM
6%
Nyanga
8%
60%
50%
40%
30%
20%
10%
0%
Oostenberg
HIV prevalence (estimated)
Mitchells
Plain
12%
Khayelitsha
0%
Helderberg
0
Blaauwberg
% unemployed
TOTAL
Tyge rbe rg
We s t
Tyge rbe rg
Eas t
SPM
Oos te nbe rg
Nyanga
M itche lls
Plain
Khaye lits ha
He lde rbe rg
Ce ntral
20
Athlone
30
Blaauw be rg
Infant Mortality
Central
10%
Region
Tyg. West
Tyg. East
SPM
Oostenberg
Nyanga
Mitchells
Plain
Khayelitsha
Helderberg
Central
Blaauwberg
Athlone
50
Athlone
Tygerberg
West
Tygerberg
East
South
Peninsular
Oostenberg
Nyanga
Mitchells
Plain
Khayelitsha
Helderberg
Central
Blaauwberg
The metro: determinants and health
60%
% households below poverty line
40
40%
10
20%
Equity requires a balance between
resources and needs
NEEDS
Resources
Health District
Geographic Area
Distance to Equity in Resource Allocation for Primary
Care (Health Centres and Clinics)
20,000,000
15,000,000
10,000,000
5,000,000
-15,000,000
-20,000,000
METROPOLE
Tygerberg
West
Tygerberg
East
South
Peninsula
Oostenberg
Nyanga
Mitchells Plain
Khayelitsha
Central
Helderberg
-10,000,000
Blaauwberg
-5,000,000
Athlone
0
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
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social mobilisation campaign using media and small radio stations
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1990 and 1994 surveys repeated, and results incorporated into health policy.
This process was sustained by four consecutive state governors
Ceará, Brazil
Improved outputs
By 1994:
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ORS use increased to more than 50 per cent
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nearly all children had a growth chart
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half had been weighed within the previous three month
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immunisation coverage was 90 per cent or higher
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median breastfeeding duration increased from 4.0 to 6.9 months.
Improved outcome indicators
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low W/A fell from 12.7% to 9.2%; low H/A from 27.4% to 17.7%
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reduced diarrhoea from 26.1% to 13.6%
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IMR fell from 63 per 1,000 live births in 1987 to 39 per 1,000 in 1994
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diarrhoea deaths fell from 48% to 29%
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perinatal deaths increased as a proportion from 7 per cent to 21 per cent and
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respiratory infections from 10 per cent to 25 per cent. (Victora et al, 2000)).
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
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.
Key elements for success
1. 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
2. Strong government commitment ensures sustainability
3. 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.
4. Strong gender focus - improvement of the condition of women a priority
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•
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
5. Effective review mechanism
•
regular evaluation of management, results and impact with clear indicators
UNICEF: State of the World's Children 2005. [pp 32-33]
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
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