Implementing a Comprehensive Response to Hiv/Aids: the ...

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 Africas 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 Worlds 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 Worlds 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. rowing 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 64 44 48 52 69 75

75 75 75 74 74 74 75 72 71 72 74 71 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 Central Europe, CIS

Industrialized countries East Asia and Pacific Latin America and Caribbean Mid-East and N Africa South Asia 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 Africas 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 Communiqu, 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 Banks 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 in developing their salaries, abetted low level national economies than in corruption as a means of looting the assets of their survival countries (Hanlon, How Northern Amongst worst MNC Donors Promote bribery offenders are those Corruption, The Corner located in G8 countries

House, 2004) (Transparency International) Why should a Japanese cow enjoy a higher income than an African citizen? 0 500 1000 1500 2000 2500

3000 US dollars J apan annual dairy subsidy, per cow E U annual dairy subsidy, per cow Per capita annual income, sub-Saharan Africa Per capita cost of package of essential health interventions Per capita annual health expenditure, 63 low income countries 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$3040 per capita (Save the Children 2003). Countries just dont 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 peoples 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 womens 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 migrationwinners & 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 Aftertasks Gillespie and Jonsson necessary to perform the 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: 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 40 30 20 10 0 Based on 2002 ODA figures from OECD, Big Mac prices from The Economist, April 25, 2002 Canada France Germany Italy Japan U.K.

U.S. Too much of the history of the industrialised worlds 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 TOTAL Tygerberg West 0% Tygerberg

East 20% SPM 40% 60% 50% 40% 30% 20% 10% 0% Oostenberg % 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 Helderberg Infant Mortality Rate

Athlone TOTAL Tygerberg W est Tygerberg East SPM Oostenberg Nyanga Mitchells Plain

Khayelitsha Helderberg Central Blaauwberg Athlone 50 Central Blaauwberg Athlone

Health Need across Cape Town Districts HIV prevalence 2000(estimate) 12% 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 -20,000,000 Tygerberg West Tygerberg East South Peninsula Oostenberg Nyanga Mitchells Plain

Khayelitsha Central METROPOLE -15,000,000 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% Sipetu 25% Holy Cross 45% St Margarets 24% St. Elizabeths 36% Taylor Bequest 21% Mt. Ayliff 34% Greenville 15% St. Patricks 30%

Rietvlei 10% Bambisana 28% 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

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. In the wards, they were not fed for at least 11 hours at

night Hypoglycaemia not diagnosed Lack of knowledge about how to prevent it Shortage of staff especially during the night No supplies for testing for hypoglycaemia 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 District-Level INP Training & Implementation from March 98 to Aug 99 Two formal training workshops for Paeds staff On-site facilitation by nurse-trainer 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 Cear, 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 PEOPLES 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 WHOs strategy of Primary Health Care. www.ghwatch.o Unfair Trade (1) ..drawing the poorest countries into the global economy is the surest way to address their fundamental aspirations (G8 Communiqu, 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).

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