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02 Kaseje Hiv Aids And Community Health Dec 3, 09 Sahara

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02 Kaseje Hiv Aids And Community Health Dec 3, 09 Sahara

  1. 1. COMMUNITY HEALTH ASPECTS OF HIV/AIDS Dan Kaseje, MBChB, MPH, PhD Professor of Public Health, December, 2009 GREAT LAKES 98 GREAT LAKES UNIVERSITY OF KISUMU (GLUK) UN U V M I ER SU SI TY KI OF
  2. 2. CONTEXT 9yrs ago, world leaders set goals to free humanity from the shackles of extreme poverty, hunger, illiteracy &disease by 2015 They established quantitative benchmarks for poverty, hunger, education, gender equity, child/maternal mortality, malaria and HIV, environmental sustainability and global partnership for development. But progress has been slow, casting doubts as to the possibility of achieving the goals in Sub-Sahara Africa. Less than 6 yrs away, progress is threatened by unprecedented economic crisis that has led to diminished resources, fewer opportunities for lower income countries, worsening already unacceptable DISPARITY (between and within countries). GREAT LAKES 98 GREAT LAKES UNIVERSITY OF KISUMU (GLUK) UN U V M I ER SU SI TY KI OF
  3. 3. The global economic crisis derails fight against poverty Worldwide, the number of people living in extreme poverty in 2009 is 90 million higher than anticipated before the Global economic crisis Minimal poverty reduction in SS Africa, farthest from target Steady global reduction Proportion of people living on less than $1.25 a day, 1990, 1999 and 2005 (Percentage)
  4. 4. A decrease in international food prices fails to translate into more affordable food at local markets A decrease in international food prices in the second half of 2008 was expected to lower prices in local mkts This has not materialized, and consumer access to food in many developing countries, such as Brazil, India and Nigeria did not improve as expected FOOD PRICE INDEX HIGHEST IN SS AFRICA. International food price index and consumer food price index in selected countries, 2008 (Year 2000=100)
  5. 5. SUPPLY SIDE There is poor preparedness for emerging scenario, inadequate skills mix (particularly leadership and management) to face the context Competing systems of care contribute to delays in care seeking (since available, accessible, acceptable) yet ignored and unregulated (effectiveness unknown). Delayed care seeking leads to COSTLY CONSEQUENCES Solutions which tend to be developed outside the context of the problem (by professionals), too simplistic against complex situations surrounding the households, entrapped in the a vicious cycle of poverty and ill-health, as well as layers of disabling socio-economic realities (culture, stigma, discrimination) GREAT LAKES 98 GREAT LAKES UNIVERSITY OF KISUMU (GLUK) UN U V M I ER SU SI TY KI OF
  6. 6. SUPPLY SIDE CONDOM (less than 50% coverage) MALE CIRCUMSCISION (20%) VCT, PMTCT (only 10% know their status) TREATMENT OF STI (less than 20% access treatment) Home based testing ART, HAART OVC interventions Home based care (all effective yet not reaching hh, individuals enough to change situation) GREAT LAKES 98 GREAT LAKES UNIVERSITY OF KISUMU (GLUK) UN U V M I ER SU SI TY KI OF
  7. 7. THERE IS COMLEX INTERFACE: HH TO CARE Tertiary Hospital Secondary Hospital Primary Hospital Health Centre, Maternity and Nursing Home Dispensary/Clinics Interface: Distance, transport, costs, culture etc Community: Village/Household/Family/Individuals
  8. 8. Demand side: 70%HH IN POVERTY TRAP THE VICIOUS CYCLE TRAPPED ILL HEALTH POVERTY HOUSEHOLDS
  9. 9. Demand: affected by Distance Costs (direct and indirect) Gender and other discriminations Decision making processes Stigma Extreme poverty and hunger Illiteracy Problems are greatest where resources are least (inverse law)
  10. 10. The gender gap increases in secondary school enrolment, girls fall behind due to poverty, hunger and RH issues The gap is wider where overall enrolment is lower, increases in secondary school enrolment tend to be accompanied by reductions in gender disparities. Target to eliminate disparities by 2005 target was missed Girls’ secondary school enrolment in relation to boys’,1998/1999 and 2006/2007 (Girls per 100 boys)
  11. 11. POVERTY IS MAJOR CAUSE OF DISPARITY Gender parity has been reached in urban areas and among the richest 40 per cent of households. In contrast, girls are more likely to be excluded from primary education in rural and when they reside in the poorest households. Secondary school net attendance ratio of boys and girls, by place of residence and household wealth, 1998/2007 (Percentage)
  12. 12. Maternal Death: 2005 6% (28,000) Africa Asia Africa Asia 51% Rest of the 43% world (276,000) (232,000) Source: UNICEF global database 2009 GREAT LAKES 98 GREAT LAKES UNIVERSITY OF KISUMU (GLUK) UN U V M I ER SU SI TY KI OF
  13. 13. Giving birth safely is still largely a privilege of the Rich Maternal deaths per 100,000 live births, 1990 and 2005 7
  14. 14. Maternal Health “Maternal death rate is the largest health disparity in the world”
  15. 15. Who is dying? Ronsmans C, Graham WJ. Maternal mortality: who, when, where and why. Lancet 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69380-X.
  16. 16. Why are they dying? • Direct Causes: – Hemorrhage – Htn of Pregnancy – Infections – Obstructed Labor – Unsafe Abortion • Indirect Causes: – HIV/AIDS – Malaria – Violence Ronsmans C, Graham WJ. Maternal mortality: who, when, where and why. Lancet 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69380-X.
  17. 17. Less than half of pregnant women in developing countries have the benefit of adequate prenatal care Only 40% of women receive four or more antenatal visits in sub-Saharan Africa to benefit from PMTCT, less still deliver in health facility Proportion of women (15-49 years old) attended four or more times during pregnancy by skilled health personnel, 2003/2008 (Percentage)
  18. 18. New HIV infections and AIDS deaths have peaked 1996, 2005 but 33 million people are still living with HIV, two thirds in s-s Africa, majority are women Number of people living with HIV, number of people newly infected with HIV and number of AIDS deaths in the world (Millions), 1990-2007
  19. 19. Urgent innovations needed to address the interface complexities to accelerate progress
  20. 20. Collaborative in Action Research, focusing on the interface Many studies show benefits of collaborative action research (providers, users, researchers and decision-makers), (Ross, 2003; Kogan et al, 2006; Lomas, 2000) in improving policy and practice. Is this an opportunity for SAHARA to engage, facilitate knowledge generation linked to actions to address problems of uptake of effective technologies? Partners engage in an iterative process of joint assessment, dialogue, planning and action (ADPA) for improvement Findings fed into dialogue enabling all parties to contribute to questions and solutions based on own expertise. GREAT LAKES 98 GREAT LAKES UNIVERSITY OF KISUMU (GLUK) UN U V M I ER SU SI TY KI OF
  21. 21. Collaborative research process Dialogue promotes radical thinking, ability to search for new models, innovations, more likely to succeed. Dialogue synergizes efforts and motivation through ADPA cycle for continuous improvement. Actions taken to address barriers around households, that have to do with the social fabric, context in which they live The approach links action to available evidence, demonstrates progress towards the goals, which justifies continued action, in areas of influence/responsibility. GREAT LAKES 98 GREAT LAKES UNIVERSITY OF KISUMU (GLUK) UN U V M I ER SU SI TY KI OF
  22. 22. Community Dialogue for cont. Improvement What is the situation from evidence? Why? What improvement can we accomplish in 1 year? What can we do to improve the situation? How will we measure the improvement? Act Assess Plan Dialogue GREAT LAKES 98 GREAT LAKES UNIVERSITY OF KISUMU (GLUK) UN U V M I ER SU SI TY KI OF
  23. 23. Leverage Intellectual Resources and Knowledge To Develop New Approaches across the interface Drive Strategy Problem Idea Solution Problem Characterization Generation Development Innovation Leadership Invest in Research | Challenge Develop Vision | Mentor Talent | Thinkers | “Connect the Dots” Transition to Execution Knowledge Management Consolidate Learnings | Cross-fertilize Ideas | Educate/Train | Guide Investments | Create a Knowledge Community
  24. 24. Support Execution: Clear the Way for Entrepreneurs to Succeed Support Execution Planning Implementation Scale Up IMPACT Network Capital/resourcing PHASA Skills | Provide Leadership | Commercial | Non-Profit | Enhanced Human Capacity Government Partnership Platform Planning | Organizing | Implementing | Assessing | Reporting Advocating | Social mobilization for change
  25. 25. Key messages 1. Scale up community-based strategies, partnerships, to address both demand and supply, supported by evidence 2. Promote collaborative action research, to drive policy reforms aimed at accelerated continuous improvement (successful local models embedded into policy and practice) 3. Move beyond Afro-Pessimism to concrete action to continuously improve starting at your own area of responsibility and influence, increasing in ever expanding concentric circles. GREAT LAKES 98 GREAT LAKES UNIVERSITY OF KISUMU (GLUK) UN U V M I ER SU SI TY KI OF
  26. 26. Moving beyond Afro-pessimism, for the future of Africa THANK YOU JICA Nyanza Health Management Project

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