South Africa: a cocktail offour colliding epidemics
South Africa: coping with a very high burden of disease Percentage of total 22% 9% 6% 4% 4% 4% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 1% Population: 45 MFigure 2: National burden of diseaseData sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo.DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.
South Africa: coping with a very high burden of disease Percentage of total 22% 9% 6% 4% 4% 4% 3% Population: 153 M 3% Population: 48 M 3% 2% 2% 2% 2% 2% 2% 2% 1% Population: 45 MFigure 2: National burden of diseaseData sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo.DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.
South Africa: coping with a very high burden of disease Percentage of total 22% 9% 6% 4% 4% 4% 3% 3% Population: 48 M 3% 2% 2% 2% 2% 2% 2% 2% 1% Population: 45 M Population: 45 MFigure 2: National burden of diseaseData sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo.DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.
Assessment of S. Africa’sprogress on 6 MDGsMDG Progress in South Africa On track?1. Eradicate extreme Underweight children < 5 years:12% Target ≤5% Reversal of progress poverty & hunger Mean reduction per year: –6% Target 2-6%1. Achieve universal Enrolment in primary school: 87% Target 90% Insufficient progress primary education1. Promote gender Gender parity ratio: 1·0 Target 1·0 On track equality & empower women1. Reduce mortality of <5 mortality 1995-2005 - increasing Target -66% Reversal of progress children <5 years1. Improve maternal Maternal mortality 1995-2005 – no Target -75% No progress health reduction1. Combat AIDS, HIV prev 1995-2005 - increasing Target -50% Insufficient progress malaria, etc
A lack of health improvementdespite major investments The paradox is poor health outcomes despite good policies and relatively high health expenditure 5 main areas where contradictions help explain the discordance between high investments and poor outcomes
Avoidable Causes of Deaths• Clinical Care: poor quality• Administrative Management: shortcomings• Community: avoidable factors-awareness and demand
Family and Managers and Healthcare Community policy makers providers44% of maternal deaths 32% of maternal deaths 54% of maternal deaths had ahad a modifiable factor had a modifiable factor modifiable factor related torelated to related to administrator healthcare provider action atfamily/community action, action, e.g. lack of blood primary level; 48% at secondarye.g. Inadequate or no for transfusion, lack of level; and 37% at tertiary levelantenatal care transport between health e.g. not adhering to standard institutions protocols38% of stillbirths and 19% of stillbirths and early 35% of stillbirths and earlyearly neonatal deaths had neonatal deaths had a neonatal deaths had a modifiablea modifiable factor related modifiable factor related to factor related to healthcareto family/community administrator action, e.g. provider action, e.g. fetal distressaction, e.g. delay in personnel not available or not identified in labour, poorseeking care during not sufficiently trained response to maternallabour hypertension25% of all modifiable 22% of all modifiable 53% of all modifiable factors infactors in child deaths factors in child deaths were child deaths were related towere related to related to administrator healthcare provider action, e.g.family/community action, action, e.g. lack of senior IMCI not used in clinics, and poore.g. caregiver did not doctors and nurses, and assessment and management inrecognise severity of the insufficient paedaitric beds hospitalsillness
SPECIALIST OBSTETRIC AND GYNAECOLOGICAL SPECIALIST NEONATAL AND PAEDIATRIC CARERegionalhospital CARE Connecting places of caregiving REPRODUCTIVE EMERGENCY PREGNANCY AND EMERGENCY NEWBORN AND CHILD CARE CARE CHILDBIRTH CARE Care for sick children including those with HIV&AIDS, basedhospitalDistrict Termination of pregnancy Care for high risk pregnancies and Post-abortion care on Integrated Management of Childhood Illness principles Treatment of complicated immediate newborn care including Extra care of preterm babies including kangaroo mother care sexually transmitted resuscitation Emergency care for sick newborns infections REPRODUCTIVE ANTENATAL BASIC CHILDBIRTH POSTNATAL CARE CHILD CARE HEALTH CARE CARE CARE •Early detection & Immunisations •Family planning Basic antenatal Care for normal referral of complications Growth monitoring andOutpatient and •Prevention and care care package with deliveries and immediate nutritionmaternity unit •Support for infant of sexually prevention of HIV newborn care including feeding choices Integrated Management of transmitted infections mother-to child resuscitation •HIV testing for infants at Childhood Illness integrated and HIV&AIDS transmission and prevention of mother- with care of children with HIV 6 weeks •Preconception folic care for women to child transmission of including cotrimoxazole acid HIV •Adolescent and pre- •Healthy behaviours eg maternal nutrition, •Appropriate home care of babies: appropriate feeding, avoiding pregnancy nutrition reduced work load hypothermia, hygienic cord/skin care, extra care for preterm babies •Prevention of HIV •Danger sign recognition, and emergency •Good nutrition, including complementary feeding •Demand for key preventive services such as immunisationscommunity and sexually preparednessFamily and transmitted infections •Recognition of danger signs and appropriate care-seeking Intersectoral Improved living conditions – housing , water and sanitation, nutrition Education and empowerment Pre-pregnancy Pregnancy Birth Postnatal Childhood
Need to address key structuraland health systems bottlenecksImproving capacity and stewardship of health systemto institute fundamental changes such as:improving levels of morale and commitment amongsthealth workers;scaling up of mid-level workers;task-shifting;standardization, expansion and strengthening ofcommunity health worker programmes;and re-orientation of pre-service training, acceleratedproduction of such graduates and enhancing capacityof public health managers.
Violence and injuriesDistribution of injury mortality by cause, 2000(A) Worldwide. (B) South Africa.
Examples of innovation in the system Examples of innovationMaternal, • Audits of deaths of mothers and children26;Newborn and • Twinning of hospitals and clinics;Child Health • On-site mentoring within health system27; • Development of ‘mothers to mothers’ support groups28; • Use of participatory research to improve malnutrition management29HIV/TB • Widespread implementation of lay counsellors and community workers30; • Universal use of rapid HIV test kits; • Shift towards nurse driven treatment and care; • Development and introduction of electronic clinical information systems31 • Outreach support for nurses in TB programmes32Chronic disease • Development of simplified clinical protocols33;and mental health • Inclusion of adult health indicators in national health survey to monitor the prevention and control of chronic diseases and their risk factors34 • Outreach support from hospital to clinicsViolence and • Development of Family Courts;injury • Establishment of peace committees; • Use of group interventions and micro-credit to reduce violence35 36; • Settings based approach (schools and cities) towards improving environmental determinants;
Key Messages– HIV/AIDS and poor implementation of existing packages of care are the main reasons for the lack of progress towards the MDGs on MNCH.– Full coverage of key packages of interventions would put South Africa on track to achieve MDG 4 and make substantial progress towards MDG 5.
Key messages High coverage of priority care forMNCH is financially feasible,requiring a 24% increase inexpenditure. Strengthening of leadership,accountability mechanisms, andhigh quality of care interventions are required
4 million newborns dieannually withinthe first monthof life, and their fate is intimately linked to their mothers’ health.
HIV AND MATERNALMORTALITY King Edward Vlll Hospital, Durban., South Africa Hypertension Other Causes (24%) (35%) AIDSPre-existing Med (15%) Conditions Pregnancy-related Haemorrhage Sepsis (7%) Under-reporting of AIDS Deaths HIV Status unknown in 75.8%
Why do mothers die in South Africa? Other, 16% Non- pregnancy related infections Sepsis, 8% sucAIDS, TB, Pre-existing pneumonia, medical 38% disease, 6% Haemorrhag e, 13% Hypertensio n, 19% Source: Saving mothers report, DOH.
Why do newborns and children die in South Africa? Pneumonia, 1% Other child, 2% Injuries, 5% Diarrhoea, 1% Neonatal infections, 7% Preterm, 13% Neonatal HIV & Birth asphyxia, AIDS, 8% 35% Congential, 4% Other neonatal, 2%Source: UN estimates and South African data for 2008
WHY DO WHY DO AFRICAN NEWBORNS AND CHILDREN UNDER CHILDREN DIE IN THE AGE OF 5 SOUTH AFRICA? YEARS DIE? Pneumonia, 1% Other child, 2% Injuries, 5%Diarrhoea, 1% Neonatal infections, 7% Preterm, 13% Neonatal HIV & Birth asphyxia, AIDS, 8% 35% Congential, 4% Other neonatal, 2% Source: UN estimates and South African data for 2008
Number of Children on Comprehensive HIV and AIDS Treatment Plan Source of data: Monitoring and Evaluation, DoH, SA 21
Mortality trend in selected countries Brazil * 5646 21 17 IMR U5MR 1990 2009 South Africa * 62 62 48 43 IMR U5MR 1990 2009 Source: : UN Inter-agency Group for Child Mortality Estimation,2010 23
WHY DO WHY DO AFRICAN MOTHERS DIE MOTHERS IN SOUTH DIE? AFRICA? Why do mothers die in South Africa? Other, 16% Other, 16% Non- pregnan related infectio Sepsis, 8% Sepsis, 8% Non- sucAID pregnancy TB, related infections Pre-existing pneumon sucAIDS, TB, pneumonia, medical Pre-existing medical disease, 6% 38% 38% disease, 6% Haemorrhag Haemorrhage, 13% e, 13% Hypertension, 19% Hypertensio n, 19% Source: Saving mothers report,Source: Khan KS et al. Lancet 2006 Source: Saving mothers report. DoH.
TOTAL MATERNALPOPULATION MORTALITY BURDEN SASI Group and M. Newman 2006
HIV/AIDS BURDEN Source: SASI Group and M. Newman 2006
Family and HIVFirst steps to healing the South African Family.Lucy Holborn and Gail Eddy. SAIRRFractured families: a crisis for South Africa“In South Africa, the “typical” child is raised by theirmother in a single-parent household. Most childrenlive in households with unemployed adults”
Orphans and child-headed households:There are 860 000 double-orphans in this country, 624 000maternal orphans and 2 400 000 paternal orphans. More thanhalf had lost parents due to AIDS.Single-parent households:23% of children were living with neither biological parent; 35%were living with both biological parents.Absent fathers:Living but absent fathers 48% and present 36% in 2009.
Broken families breakingyouth.Family breakdown impactson: education, employmentopportunities, teenagepregnancies, attitudes to sex,HIV, violence and crime,mental health
WHAT NEEDS TO BE DONE AT FAMILY LEVEL? NOW!1. Support children through families2. Develop comprehensive & integrated family-centered services3. Create social protection for the poorest families4. Expand income transfers to poor families Linda Richter. Mexico IAS Conference 2008
NOT ONLY ORPHANS ARE AFFECTED• AIDS Orphans ??• Children infected and affected• Few differences between “orphans” and very poor children• A massive social problem<10% of children orphaned or made vulnerable by AIDS currently receive public support and services. UNAIDS . 2007 AIDS EPIDEMIC UPDATE
TREATMENT: WAYS FORWARD• Each infection can and should be prevented• Early diagnosis prior to disease progression• Earlier initiation of ART• Expand screening for HIV in health care facilities
TREATMENT:IMPROVING EFFECTIVENESS OF ARV THERAPY AMONG HIV-INFECTEDCHILDREN IN SUB-SAHARAN AFRICA“..findings emphasise the need for: **low-cost diagnostic tests that allow for earlier identification of HIV infection in infants **improved access to antiretrovirals, including expansion into rural areas **integration of antiretroviral treatment programmes with other health-care services, such as nutritional support”. Sutcliffe et al, Lancet Infectious Diseases, 2008; 8:477-89
All children, including those affected by HIV and AIDS are best cared for in functional families with basic income security, access to health care and education, and support from kin and communityOur work is to ensure these conditions for children and families