Transcript IMPLEMENTING A COMPREHENSIVE RESPONSE TO HIV/AIDS: …

WHAT CIVIL SOCIETY CAN CONTRIBUTE :
RESEARCH, TRAINING AND ADVOCACY TO
ADDRESS CHILD HUNGER AND
UNDERNUTRITION
David Sanders
Director: School of Public Health
University of the Western Cape
Member of Global Steering Group
Peoples Health Movement
A WHO Collaborating Centre for Research and Training in Human
Resources for Health
Outline of Presentation



Trends in child health and nutrition in the era of
Primary Health Care - 1980 to 2004 – with special
emphasis on Africa’s health situation
Impact of globalisation, health sector reform
and HIV/AIDS on poverty, health “determinants”,
health systems and human resources for health
The role of research, training and advocacy in
addressing inequities and capacity weaknesses,
with illustrative examples from Southern Africa
Despite successes, growing inequalities in
global health
widening gap in infant mortality experience
IMR: babies dying before age 1 per thousand born live
160
IMR
decline
(Percent)
1960-1981
1981-1999
140
SSA
120
World
38.5
26.9
100
80
SSA
19.2
World
15.1
60
40
1960
UNICEF: State of the World’s Children
1981
1999
U5MR in Sub-Saharan Africa
250
200
150
100
50
0
World
SA
Kenya
1960
Swaziland
1990
Zimbabwe
Botswana
2001
The State of the World’s Children 2003. UNICEF
Global health inequities
• A woman has a nine in ten chance of reaching the
age of 65 years in a high-income OECD country,
• but a four in ten chance in Malawi.
• In Tanzania, every sixth child born alive will die
before the age of five years,
• while in high income OECD countries, every
167th child dies before the age of five.
Growing inequalities in child health – within countries
Declining Health Systems
Slide Date: Octo
Global Immunization 1980-2002, DTP3 coverage
global coverage at 75% in 2002
100
90
80
70
60
50
40
30
20
10
0
75
69
75 75 75 74
74 74 75
72 71 72 74
71
64
44
48
52
56
37
20
23 25
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Global
Industrialized countries
Central Europe, CIS
East Asia and Pacific
Latin America and Caribbean
South Asia
Mid-East and N Africa
Sub-Saharan Africa
Source: WHO/UNICEF estimates, 2003
Leading global risk factors and contributions
to global burden of disease : % DALYs, World
Rates of childhood stunting
The determinants of child mortality
Conceptual framework of causality
Outcome
Undernutrition
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
2002 FOOD CRISES IN SOUTHERN
AFRICA
ZIMBABWE: food
shortages:
31.4% of pregnant women
in rural areas HIV+
ZAMBIA: second year
of crop failure: few
food stocks: adult HIV
MALAWI: >70% of
population facing
food shortages; adult
HIV prevalence 15%
prevalence 21.5%
LESOTHO: second year of
food shortages: maize prices
high; adult HIV prevalence
31%
MOCAMBIQUE:
severe floods
2000, 2001 and
2007: drought
2002: adult HIV
prevalence 13%
Double Burden
Increased Oil Consumption
Rising Consumption of Poultry
BUT what are the key ‘Basic Causes’ of
Africa’s Health and Health Care Crisis?
Increasing poverty and inequality
worsened by inequitable globalisation,
Selective PHC and Health sector “reform”,
and
HIV/AIDS
….. result in slow progress and reversals.
The debt crisis, structural adjustment and
globalisation:
• A crucial development in the current phase
of globalisation…
External debt grows
External debt
• Between 1970 and 2002, African countries
borrowed $540 billion from foreign sources,
paid back $550 billion (in principal and
interest), but still owe $295 billion (
UNCTAD 2004)
• Africa spends more on debt servicing each
year than on health and education -- “the
building blocks of the AIDS response” (Piot 2004)
Debt Service Payments Dwarf
Development Assistance Inflows
Sub-Saharan Africa
South Asia
Development
assistance
Middle East, North Africa
Debt service
Latin America, Caribbean
East Asia & Pacific
-150
-100
-50
0
50
US $ billion, 2002
(Source: Calculated from World Bank World Development Indicators database )
Structural Adjustment Programmes:
the main components
• Cuts in public enterprise deficits
• Reduction in public sector spending & employment
• Introduction of cost recovery in health and education
sectors
• Phased removal of subsidies
• Devaluation of local currency
• Trade and financial market liberalisation
Impact of SAPs on health
“The majority of studies in Africa, whether theoretical or
empirical, are negative towards structural adjustment and
its effects on health outcomes”
Breman and Shelton, WHO CMH WG6, 2001
Globalisation is primarily about
trade…
Globalization, defined as the process of
increasing economic, political, and social
interdependence and global integration which
takes place as capital, traded goods,
persons, concepts, images, ideas, and values
diffuse across state boundaries, is occurring
at ever increasing rates
(Hurrell, 1995, p.447).
…..unfair trade
Northern
agricultural
subsidies:
Japan, the EU
and the US
Source: UNDP
HDR 2005
Northern
agricultural
subsidies go to
large farms,
not small
Source: UNDP HDR 2005
Unfair Trade (1)
• “..drawing the poorest countries into the global economy is
the surest way to address their fundamental aspirations”
(G8 Communiqué, Genoa, July
22, 2001)
• BUT… many developing countries have destroyed
domestic economic sectors, such as textiles and clothing
in Zambia (Jeter 2002) and poultry in Ghana (Atarah 2005),
by lowering trade barriers and accepting the resulting
social dislocations as the price of global integration
.
Unfair Trade (2)
• In addition industrialized countries apply much
higher tariffs (tariff peaks), sometimes
amounting to more than 100 percent, to the
labour-intensive exports that are of special
importance to developing countries. For
example, the EU tariff on raw cocoa exported
from Ghana is just 0.5 percent, but the tariff
rises to 30.6 percent on chocolate imported
from the same country (Elliott 2004b). Thus,
although 90 percent of cocoa beans are grown in
developing countries, they account for just four
percent of the value of global chocolate
production (IMF, 2002).
The result… unequal growth of wealth within countries
Trends in income inequality, selected Latin American &
Caribbean countries
Uruguay
Venezuela
Argentina
Costa Rica
Chile
El Salvador
Jamaica
Mexico
Brazil
70
60
50
40
Share of
national
income,
ratio of
top to
bottom
decile
30
20
10
Source: de Ferranti
et al, 2004 (Table
A.2)
0
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
The result… unequal growth of wealth between countries
..and unequal distribution of global
income
UNDP 1997
..and growth of poverty
•According to the World Bank’s most recent figures, in sub-Saharan
Africa 313 million people, or almost half the population, live below a
standardized poverty line of $1/day or less (Chen and Ravallion 2004).
•Sub-Saharan Africa is the only region of the world in which the number
of people living in extreme poverty has increased – indeed, almost
doubling between 1981 and 2001.
Governance - Bribery & Corruption
• Superpowers in Africa
• SAPs, by lowering public
“backed venal despots
expenditures and workers’
who were less interested
salaries, abetted low level
in developing their
corruption as a means of
national economies than
survival
in looting the assets of
their countries…”
(Hanlon, How Northern
Donors Promote
• Amongst worst MNC
Corruption, The Corner
bribery offenders are
House, 2004)
those located in G8
countries
(Transparency
International)
Why should a Japanese cow enjoy a higher income
than an African citizen?
0
500
1000
1500
2000
2500
3000
U S dollars
J apan annual dai ry s ubs i dy , per c ow
E U annual dai ry s ubs i dy , per c ow
P er c api t a annual i nc om e, s ub-S aharan A f ri c a
P er c api t a c os t of pac k age of es s ent i al heal t h i nt erv ent i ons
P er c api t a annual heal t h ex pendi t ure, 63 l ow i nc om e c ount ri es
The Health System, its
financing and Health Sector
‘Reform’
Sub-Saharan African Country per capita
expenditures on health (1997-2000)
Recommended expenditure: >$60/capita (Brundtland);
>$34/capita (CMH)
Number of countries
Amount of spending
4
> $60
$34 - $60
$12 - $34
< $12
2
11
18
13
Data not available or population
<1.5 million
World Bank, World Development Report 2004
• For instance, Ethiopia spends 22% of its
national budget on health and education, but
this amounts to only US$1.50 per capita on
health. Even if Ethiopia were to spend its
entire budget on healthcare, it would still
not meet the WHO target of US$30–40
per capita (Save the Children 2003).
• “Countries just don’t have enough money.”
Rt. Hon. Hilary Benn, April 2004,
WFPHA/UKPHA,
Brighton
Health sector ‘reform’
Quest for efficiency
A focus on cost-effective technologies and a neglect of
social and environmental determinants of health has
proposed essential “packages” of interventions –
reminiscent of selective PHC..
Public Health package:

Immunizations

School-based health services

Family planning and
nutrition education

Programs to reduce tobacco
and alcohol consumption

Actions to improve the
household environment
Clinical package:

Pregnancy-related services

Family planning and STD
services

Tuberculosis control, mainly
through drug therapy

Care for the common serious
illnesses of young children IMCI
CEA cannot evaluate the effectiveness of
‘broader’ interventions that may result in
health improvement through numerous direct
and indirect mechanisms
“[C]ost-effectiveness analyses have shown improved water
supply and sanitation to be costly ways of improving people’s
health. …. encouraging people to wash their hands and making
soap available have reduced the incidence of diarrhoeal disease
by 32% to 43%... (Commission on Macroeconomics and Health,2001/02)
For example, water provision can:
Improve hygiene practice and thus reduce incidence of diarrhoeal
disease
Save women’s time for caring and economic activity, thus
improving household income and food security
Contribute to increased agricultural production, thus improving
household income and food security
..subverting the Mission of Public Health

“Ensuring the conditions in which people can
be healthy”
(Institute of Medicine)
Health sector ‘reform’
Quest for efficiency
cont.-
The move from equity and comprehensiveness to efficiency
and selectiveness leads to:



A return to vertical programmes;
Erosion of intersectoral work and community
health infrastructures
Fragmentation of health services and reversal
of health gains
AIDS and Aid may both disrupt health systems…
In 2000, Tanzania was preparing 2,400 quarterly reports on
separate aid-funded projects and hosted 1,000 donor visit
meetings a year.
At last count there were over 90 GHIs (the best known being
GAVI, GFATM, Pepfar), each funding different diseases and
programmes.
Labonte, 2005, presentation to Nuffield Trust
Health systems & personnel in Africa

Health personnel vital, consume between 60
– 80% of recurrent public health expenditure
(WB, 1994).
Burden of disease
Share of population
Share of health workers
Our Common Interest 2005:184
NURSE REGISTRATION IN UK :Increase during a period when a “ban”
on active international recruitment had just come into effect
Buchan et al 2003
The brain drain



In relation to health care professionals, especially nurses …
there are aggressive and targeted international recruitment
initiatives.
The UK government, for example, has stated that international
recruitment is part of the solution to meeting its staffing needs.
This type of active recruitment can have a marked
effect on a sending country, especially because it … is
aimed at getting significant numbers of workers from
the country …
International migration—winners & losers
How much do importing countries gain from
international migration?
UN Conference on Trade and Development
(UNCTAD):
for each professional aged between 25 and 35 years,
US$ $184,000 is saved in training costs by rich
countries
(UNECA, 2000)
Global HIV prevalence




40 million people around the
world live with HIV - more than
the population of Poland.
Nearly two-thirds of them live in
Sub-Saharan Africa, where in the
two hardest hit countries HIV
prevalence is almost 40%.
The global HIV/Aids epidemic
killed more than 3 million people
in 2003
there are emerging and growing
epidemics in China, Indonesia,
Papua New Guinea, Vietnam,
several Central Asian Republics,
the Baltic States, and North
Africa.
The AIDS debate, BBC News
Enhancing Capacity for Public Nutrition
Action
Decentralised health services have
dramatically increased need for public health
skills – for policy, advocacy, planning,
programme design, implementation,
monitoring and evaluation
Implementation Cycle
Policy
Advocacy
Evaluation
Teambuilding
Implementation
and Management
Capacity Development
Situational
Assessment
Planning
Analysis
Components of Capacity to Perform
Tasks




Have the knowledge and skills to perform the
tasks
Accept responsibility to carry out the tasks
Have the authority to carry out the tasks
Have access to and control of resources
necessary to perform the tasks
After Gillespie and Jonsson
Household and Community Capacities
Potter and Brough (2004).
The Challenge in Research and Training



Need to train personnel from different backgrounds
to facilitate process of change
Short to medium term priority is to upskill those
already in the field
Needs to be as least disruptive, both to the
participants and the health services, as possible
Key focus areas for public health research

Research and advocacy on health determinants
(local and global) with an equity lens

Participatory research on health systems,
particularly on effectiveness - operational
aspects and evaluation, and on human resources

Case studies of comprehensive, communitybased approaches
Sanders et al, Bull WHO 2004, 82(10)
1. Examples of Priority Research and
Advocacy

Research on health determinants and equity – at
a global level
“Determinants”
research: a global
example
Available from University of
Cape Town Press, 2004.
Online ordering and
prepublication proofs
available at:
http://web.idrc.ca/ev.php?ID=45682_201&ID2=DO_TOPIC
What We Did

Identified health-related commitments made at 1999,
2000, 2001 summits



Updated to 2002, 2003 and 2004 summits
Commitments either relate directly to health, or
Have implications for policy areas that affect the determinants
of population health (e.g. macroeconomic policy, trade and
market access, environment)
Assessed Commitments with Respect to
Three Criteria:



Have the G8 lived up to the commitment?
Was the commitment adequate, when measured
against the need addressed?
Was the commitment appropriate, or was it, e.g., rooted
in an economic model that may actually undermine
determinants of health?
What We Found (1999 – 2001):
Promises kept:
Promises broken:
8 or 9*
17 or 18*
* Depends on whether one regards the 2003 TRIPS
Council ruling on parallel imports as a kept or broken
promise
Development assistance as % of Gross National
Income
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Anglo-American
FY 2003
Source: OECD/DAC Annual Report 2004
Norway
Denmark
Luxembourg
Netherlands
Sweden
Belgium
France
Ireland
UK
Australia
Canada
New Zealand
US
Annual cost of meeting the 0.7 percent of GNI
ODA target, in Big Macs/capita
90
80
70
60
50
Canada
France
40
Germany
30
Italy
Japan
20
10
0
Based on 2002 ODA figures from OECD, Big Mac prices from The
Economist, April 25, 2002
U.K.
U.S.
“Too much of the history of the industrialised world’s
involvement in Africa is a miserable history of broken
promises.”
Report of the Commission for Africa, 2005, p.18
2. Examples of Priority Research


Research on health determinants and
equity – at a local level
The Cape Town Equity Gauge
Part of a global movement:
Global Equity Gauge Alliance (GEGA)
14 initiatives:
11 country initiatives
3 city initiatives
Funded by Rockefeller Foundation
Equity requires a balance between resources
and needs
NEEDS
Resources
Health District
Geographic Area
Example: Resource allocation in Primary Care



To assess health need
To assess primary care resources and
compare to need
To develop a resource allocation tool to rectify
the inequities
0%
40%
20%
60%
50%
40%
30%
20%
10%
0%
Oostenberg
TOTAL
Tygerberg
West
Tygerberg
East
SPM
%
households below the poverty line
60%
Nyanga
0%
Mitchells
Plain
0
Khayelitsha
2%
Helderberg
10
Central
Tygerberg
West
Tygerberg
East
South
Peninsular
Oostenberg
Nyanga
Mitchells
Plain
Khayelitsha
Helderberg
Central
20
Blaauwberg
30
Blaauwberg
40
Athlone
Region
Tyg. West
Tyg. East
SPM
Oostenberg
Nyanga
Mitchells
Plain
Khayelitsha
Infant Mortality Rate
Athlone
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
Helderberg
Central
Blaauwberg
Athlone
50
He lde rbe rg
Ce ntral
Blaauw be rg
Athlone
Health Need across Cape Town Districts
12%
HIV prevalence 2000(estimate)
10%
8%
6%
4%
% unemployed
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
3. Examples of Priority Research

Participatory research on health systems, particularly
on effectiveness - operational aspects and
evaluation, and on human resources
More focus on Health Systems Research
to improve coverage and quality of care
As well as researchers asking “what, why, where, and
who?”
 We should be asking “How?”
ie increase research on health systems, particularly on
effectiveness - operational aspects and evaluation

Berg A Sliding toward nutrition malpractice: time to reconsider and redeploy
Am J Clin Nutr 1993
AN EXAMPLE OF EFFECTIVENESS
RESEARCH: MT. FRERE HEALTH DISTRICT





Eastern Cape Province,
South Africa
Former apartheid-era
homeland
Estimated Population:
280,000
Infant Mortality Rate:
99/1000
Under 5 Mortality Rate:
108/1000
STUDY SETTING:
PAEDIATRIC WARDS
Nurses have the main
responsibility for malnourished
children
Per Ward:

2-3 nurses and 1-2 nursing
assistants on day duty, and
2 nurses on night duty

10-15 general paediatric beds
and 5-6 malnutrition beds

Implementation Cycle
Policy
Advocacy
Evaluation
Teambuilding
Implementation
and Management
Capacity Development
Situational
Assessment
Planning
Analysis
CASE FATALITY IN RURAL HOSPITALS
PRE-INTERVENTION CFRs
Mary Terese 46%
Holy Cross 45%
St. Elizabeth’s 36%
Mt. Ayliff 34%
St. Patrick’s 30%
Bambisana 28%
Sipetu 25%
St Margaret’s 24%
Taylor Bequest 21%
Greenville 15%
Rietvlei 10%
Implementation Cycle
Policy
Advocacy
Evaluation
Teambuilding
Implementation
and Management
Capacity Development
Situational
Assessment
Planning
Analysis
WHO 10-STEPS PROTOCOL – Nutrition component of
hospital level IMCI
Step 1 Treat/prevent hypoglycaemia
Step 2: Treat/prevent hypothermia
Step 3: Treat/prevent dehydration
Step 4: Correct electrolyte imbalance
Step 5. Treat/prevent infection
Step 6. Correct micronutrient deficiencies
Step 7. Cautious feeding
Step 8. Catch-up growth
Step 9. Stimulation, play and loving care
Step 10. Preparations for discharge
Comparison of recommended and actual practices
SITUATIONAL ANALYSIS
IMPLEMENTATION
Recommended
practice
Practice prior to
intervention
Perceived barriers to
quality care
Programme
intervention
Changes
reported at
follow up
visits
Step 1:
Treat/prevent
hypoglycaemia
Children were left
waiting in the queue
in the outpatient
department and
during admission
procedures.
Lack of knowledge
about risks of
hypoglycaemia
Training to explain
why malnourished
children are at
increased risk
In the wards, they
were not fed for at
least 11 hours at
night
Shortage of staff
especially during the
night
Malnourish
ed children
fed
straightawa
y and 3
hourly
during day
and night.
Feed every 2
hours during the
day and night.
Start straight
away.
Lack of knowledge
about how to prevent it
No supplies for testing
for hypoglycaemia
Hypoglycaemia not
diagnosed
Training on how to
prevent and treat
hypoglycaemia
Motivated for more
night staff in paediatric
wards
Motivated the
Department of Health
to provide resources
(10% glucose and
Dextrostix.)
The
number of
night staff
was
increased
Dextrostix
and 10%
glucose
obtained
WHO 10-STEPS TRAINING – Mt. Frere District,
Eastern Cape





Developed as part of a DistrictLevel INP
Training & Implementation from
March 98 to Aug 99
Two formal training workshops
for Paeds staff
On-site facilitation by nursetrainer
Adaptation of protocols –
Now have Eastern Cape
Provincial Guidelines
Evaluation of Implementation

Major improvements:






Separate HEATED wards
3 hourly feedings with appropriate special formulas and
modified hospital meals
Increased administration of vitamins, micronutrients and
broad spectrum antibiotics
Improved management of diarrhea & dehydration with
decreased use of IV hydration
Health education & empowerment of mothers
Problems still existed:




Intermittent supply problems for vitamins and micronutrients
Power cuts – no heat
Poor discharge follow-up
Staff shortage, of both doctors and nurses, and resultant low
morale
Ashworth et al, Lancet 2004; 363:1110-1115
CHANGES IN CFRs IN RURAL HOSPITALS
50
45
40
35
1998-1999
30
2000-2001
25
2002
20
2003
15
10
5
0
Holy-cross
St. Patricks
Mt. Ayliff
St. Elizabeth
Educational Strategies




Based on assessed
training needs
Problem-oriented
Adult education
techniques
Linked to systems
development





Distance learning
materials
Training guides
Location should be as
close to workplace as
possible
Training of teams
Follow-up support
4. Case studies of comprehensive,
community-based approaches
Ceará, Brazil



Early1980s IMR over100 per 1,000 and malnutrition very common
1986 statewide survey of child health and nutrition resulted in new health
policies, including GOBI plus vitamin-A supplementation.
Coverage improvement through large new programmes of community
health workers and traditional birth attendants.
health services decentralised to rural municipalities with worst health
indicators
social mobilisation campaign for child health implemented using media and
small radio stations to broadcast educational messages
surveys repeated in 1990 and 1994, and results incorporated into health
policy. This process was sustained by four consecutive state governors
Improved outputs
By 1994
ORS use increased to more than 50 per cent
nearly all children had a growth chart and half had been weighed
within the previous three months
immunisation coverage was 90 per cent or higher; and median
breastfeeding duration increased from 4.0 to 6.9 months.
Improved outcome indicators
low W/A fell from 12.7% to 9.2%; low H/A from 27.4% to 17.7%
reduced diarrhoea from 26.1% to 13.6%
IMR fell from 63 per 1,000 live births in 1987 to 39 per 1,000 in 1994
diarrhoea deaths fell from 48% to 29%
perinatal deaths increased as a proportion from 7 per cent to 21 per cent and
respiratory infections from 10 per cent to 25 per cent. (Victora et al, 2000)).
Conclusions
Main actions required from Public Nutrition Community:


Challenge unfair globalisation and ill-considered health sector reforms
through research and advocacy
Advocate for increased investment in enhancing capacity of
and reorientating Southern institutions (incl. equitable
collaboration/partnerships with Northern institutions)

Develop capacity through health systems research, practice-based
and problem-oriented training.

Improve quality of interventions and develop well-managed
comprehensive programmes

Involve other sectors and communities

Support with better management systems

Focus on health centres

Rapidly (re)train CHWs

Provide resources to and develop partnerships with
progressive civil society
PEOPLE´S HEALTH
MOVEMENT
The Peoples Health Movement (PHM) is a large
global civil society network of health activists
supportive of the WHO policy of Health for All and
organised to combat the economic and political
causes of deepening inequalities in health
worldwide and revitalise the implementation of
WHO’s strategy of Primary Health Care.
www.phmovement.org
www.ghwatch.org
Unfair Trade (1)
• “..drawing the poorest countries into the global economy is the surest way to
address their fundamental aspirations”
(G8 Communiqué, Genoa, July 22, 2001)
• BUT… many developing countries have destroyed domestic economic sectors,
such as textiles and clothing in Zambia (Jeter 2002) and poultry in Ghana
(Atarah 2005), by lowering trade barriers and accepting the resulting social
dislocations as the price of global integration
• Import liberalization was a key element of structural adjustment programs; a recent
study found that PRSPs may include “trade-related conditions that are more
stringent, in terms of requiring more, or faster, or deeper liberalization, than WTO
provisions to which the respective country has agreed”(Brock and McGee 2004)
.
The Notion of “Capacity”
Potter and Brough (2004).
Household and Community Capacities
Potter and Brough (2004).
Household and Community Capacities
Potter and Brough (2004).