Overview of Childhood Ill-Health in Western Cape and Key Actions to Enhance Wellness

SaSa

A WHO Collaborating Centre for Research and Training in Human Resources for Health

David Sanders Emeritus Professor

School of Public Health University of the Western Cape

Overview of Presentation

• Burden of young child mortality in W Cape

• Major determinants of young child Burden of Disease (BoD) in W Cape

• Key interventions to address young child BoD in W Cape

• Lessons from international experience

• Recommended PHC and Social interventions

Millennium development goal 4

Goal 4: Reduce child mortality

Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate

Photo

: L R

eynold

s

MDG4: SA progress

http://www.thepresidency.gov.za/learning/me/indicators/2009/indicators.pdf

0

20

40

60

80

100

120

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

MRC

ASSA 2002

ASSA 2003

HST

U-5MR projections from various sources

Goal for U-5MR: 20 by 2015

0

10

20

30

40

50

60

70

1995 2000 2003 2015[MDG]

The challenge of MDG 4

Goal 4: Reduce child mortality

Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate

0

10

20

30

40

50

60

70

80

90

W C

G P

L P

N C

N W

M P

F S

K Z

N

E C

39

55.5

56 72

64

75

81

Gauteng: 45

52

Sources: Lagerdien K. Reviewing child deaths in South Africa – a rights perspective. [CI] 2005

The range of U5MR

Under 5 mortality in Western Cape

0

10

20

30

40

50

60

70

Winelands C Karoo Metro Eden Overberg W Coast W Cape

2007

2008

Causes & risk factors

Causes of under-five deaths in South

Africa

• Neonatal causes; pneumonia, diarrhoea and other child illness; and HIV/AIDS each account for 30% of U5 deaths

• According to Child PIP 60% of children were underweight and a third were severely malnourished

Based on SA Burden of Disease estimates for 2000

Lancet Vol 371 April 12, 2008, 1294-1304

Leading causes of U5MR, WC 2000

Bradshaw, et al. SOUTH AFRICAN NATIONAL BURDEN OF DISEASE STUDY

WESTERN CAPE PROVINCE. ESTIMATES OF PROVINCIAL MORTALITY 2000

Key Determinants of Disease and Death

Imagine a stroll by the river …

You notice a movement in the water, it is a baby, drowning!

… then another infant, half-submerged, floats down in the water struggling for life

… followed by 5, 10 more -- and more and more and more

You become very good at saving drowning children, develop new methods & technology, teach others, attend international conferences

but more and more and more and more come struggling down …

Photo: L Reynolds

Structural Societal

Behavioural Biological

Burden of Disease study, PGWC

DOWNSTREAM UPSTREAM

An example of the impact on the health services of failing to address social determinants

RCCH serves children from the poorest parts of Cape Town

Source: Prof A Westwood.

The New Millennium: Annual Admissions to the 2 parts of S11

20522449 2387

2731 2555 26683111 3279

4639

4906

7289

6565

6076

5218

5059

5436

0

2000

4000

6000

8000

10000

12000

2001 2002 2003 2004 2005 2006 2007 2008

Year

Ad

mis

sio

ns

A8

A9

40% increase over 4 years (2005-2008) in A8 versus 28% increase in A9

Non-diarrhoea

Diarrhoea

2001 2002 2003 2004 2005 2006 2007 2008

An increasing child population?

CT population 20.9% since 2001 and 36.4% since 1996 [SA by 8.2% 2001

– 2007]

Overwhelmingly: black African group; informal settlements

27% under-14; 14.4% under-5

Birth rates 10 – 15% per year over past 3 years

PLUS inward migration

Deteriorating child health?

Only 52.6% Black African households had piped water by 2007

In some areas up 90 to 100 households, or 300 to 400 people share a

single standpipe

6.9% of Black African households used bucket toilets, 9.1% had

none

where a water source is distant or shared, water usage declines

Small. 2007 Community Survey Analysis. SDI& G Information Branch, Cape Town. October 2008

Diarrhoea/Worms

The context: Khayelitsha, Cape Town

Children under 5 in South Africa:

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

Children under 5

Height-for-age: percentage below -2 SD

01020304050

No

educ

atio

n

Gra

des

1-5

Gra

des

6-7

Gra

des

8-11

Gra

de 1

2

Hig

her

DHS 2003

Malnutrition & household expenditure SA

Zere & McIntyre 2003

Income inequalities

Gini coefficient:

0.56 in 1995

0.73 in 2005 (0.8 without grants)

Share of income for richest 10% of population: 51% (2005)

Share of income for poorest 10% of population: 0.2% (2005)

Statistics South Africa 2002 & 2008

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 six-fold 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 – 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

Risk factors for diarrhoea

• immediate determinants – breast-feeding and care-giving practices

• underlying determinants – 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

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

Conceptual

frameworks for

Malnutrition

& other conditions

ARI

Impaired

immunity

Increased

exposure

Outcome

Immediate

causes

Resources & control human, economic

& organisational resources

Potential resources

Political & ideological factors, economic structure Basic causes

Inadequate

women & child

care

HIV

infection

Malnutrition

Inadequate

breast feeding

Biomass

smoke exp

Underlying

causes

Inadequate

health & environment

services

Overcrowding

& sanitation Low

birth weight

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 eg on wine farms

• Obstetric

– Poor family spacing, inadequate ANC

– HIV infection

• Poverty

Risk factors for vertical transmission of

HIV

• Immediate

– 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

South Africa’s alarming obesity epidemic • South Africa is now the

world’s third fattest country after the U.S. and U.K. according to results of the GlaxoSmithKline (GSK) national health survey released September 8, 2010

• 61 percent of the adult population is overweight, obese or morbidly obese

• 17 percent of children under the age of nine are overweight.

Source: "Our pot bellies rank with world’s largest." Cape Times. 9 Sept. 2010.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Underweight (BMI ≤ 18.5)

Normal Weight(BMI 18.5-24.9)

Overweight and Obese

(BMI ≥ 25)

Source: Puoane, T, K Steyn, D Bradshaw, EV Lambert, J Fourie, and JA Laubscher. "Anthropometry and obesity in South Africa - the National Demographic and Health Survey." International Journal of Obesity (1998).

Anthropometric patterns of black South African adults, aged 15 to 65+ years (age standardised

against the world population)

Men

Women

Dietary changes

• Dietary intakes of 1751 apparently healthy adults of the staple, maize meal, decreased between the urban middle and upper class strata. Fruit and vegetable consumption was low throughout the sample. Food intakes showed a shift from the traditional high carbohydrate, low fat diet to a diet associated with non-communicable diseases.

MacIntyre et al, Nutrition Research 22 (2002) 239–256

• There is a shortage of healthy

low-fat food and little fresh fruit

and vegetables in the poor

townships.

• The majority of local shops sell

cheap fatty foods. Street

vendors’ stalls sell fatty meat

and sausages.’

• ‘Low-fat milk is not available in

our shops’, stated one of the

CHWs after she had tried to

cut down on the fat in her diet.

Chopra M, Puoane T. Diabetes Voice 2003; 48: 24–6.

Societal Factors in Obesity

34

Structural Factors in Obesity

South Africa: Market Sizes - Historic - Retail Value RSP - R mn - Current

Prices So

Category 2004 2005 2006 2007 2008 2009

Packaged food 69475 74462 78929 84062 92671 101192

Source: Packaged Food: Euromonitor from trade sources/national statistics Source: Packaged Food: Euromonitor from trade sources/national statistics

0

50000000

100000000

150000000

200000000

250000000

300000000

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Value of imports from world in Rand

South Africa: Bread, Pastry, Cakes, Biscuits and Other Baker's Wares

0

10000000

20000000

30000000

40000000

50000000

60000000

70000000

80000000

90000000

1993 2007

Whey imports, rand

Whey imports, rand

Company Shares (by Global Brand Owner) Retail Value % breakdown

Geographies

Categories

Companies

2001 2002 2003 2004 2005 2006 2007 2008

South Africa

Packaged food

Tiger Brands Ltd 17.8 18.0 20.3 20.0 19.5 19.1 16.2 16.8

South Africa

Packaged food

Parmalat Group 4.9 4.9 4.7 4.7 5.2 5.3 5.4 5.3

South Africa

Packaged food

Unilever Group 5.3 5.7 5.7 5.6 5.4 5.2 5.2 5.2

South Africa

Packaged food NestlÈ SA 5.2 5.2 5.2 5.2 5.0 5.0 4.9 4.8

South Africa

Packaged food Clover Ltd 4.1 4.1 4.2 4.1 3.9 3.8 3.9 3.7

South Africa

Packaged food

Pioneer Food Group Ltd 2.5 3.4 2.7 3.0 3.2 3.3 3.2 3.3

South Africa

Packaged food

Dairybelle (Pty) Ltd - - - - - - 3.2 3.2

South Africa

Packaged food AVI Ltd 2.6 2.4 2.4 2.5 2.5 2.6 2.8 2.9

South Africa

Packaged food

Cadbury Plc - - - - - - - 2.8

South Africa

Packaged food

PepsiCo Inc 2.3 2.4 2.4 2.0 2.5 2.5 2.6 2.5

South Africa

Packaged food

Willowton Oil & Cake Mills 0.0 0.8 0.9 1.3 1.7 1.6 1.6 1.6

South Africa

Packaged food

Danone, Groupe 0.9 0.9 1.0 1.0 1.1 1.1 1.2 1.2

Source: Packaged Food: Euromonitor from trade sources/national statistics

Rapid growth of supermarkets in South Africa • Supermarkets now share at

least 50-60% of food sales in South Africa, with the majority of this growth occurring after 1994

• In a recent study, nearly two-thirds of households in a rural area in South Africa were now buying their food at supermarkets

• In 2009 study of supermarkets in rural South Africa, healthier foods typically cost between 10% and 60% more when compared on a weight basis (R per 100g) and between 30% and 110% more when compared based on the cost of food energy (R per 100 kJ)

Number of households in two rural areas in Transkei, Eastern Cape going to supermarkets

Xume Luzie Total

Percent of total

78.4% 50.0% 64.8%

Source: D'Haese, Marijke, and Guido Van Huylenbroeck. "The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area, South Africa." Food Policy 30 (2005): 97-113.

0%

10%

20%

30%

40%

Japan U.S. South Africa

Percent increase:

1999- 2005

Source: Euromonitor International, 2007

Growth in Supermarket Food Sales

Interventions

Interventions to improve immunity • Promote breast feeding -

– Maternity leave, BF

– time at work

– Incentives equivalent to formula

– Counsellors

– Mixed feeding out

• Nutrition programmes – 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

Inequity demands targeting

Inequity demands targeting

WC Index of Multiple Deprivation

• Domains:

– 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

0%

2%

4%

6%

8%

10%

12%

Ath

lon

e

Bla

au

wb

erg

Ce

ntr

al

He

lde

rbe

rg

Kh

ay

eli

tsh

a

Mit

ch

ell

s

Pla

in

Ny

an

ga

Oo

ste

nb

erg

So

uth

Pe

nin

su

lar

Ty

ge

rbe

rg

Ea

st

Ty

ge

rbe

rg

We

st

HIV prevalence (estimated)

0%

10%

20%

30%

40%

50%

60%

Ath

lone

Bla

auw

be

rg

Ce

ntr

al

He

lde

rbe

rg

Kha

ye

lits

ha

Mitche

lls

Pla

in

Nya

ng

a

Oo

ste

nb

erg

SP

M

Tyg

erb

erg

Ea

st

Tyg

erb

erg

We

st

TO

TA

L

% unemployed

Cape Town Equity Gauge, UWC SOPH, 2002

The metro: determinants and health

0

10

20

30

40

50

Ath

lon

e

Bla

au

wb

erg

Ce

ntr

al

He

lde

rbe

rg

Kh

ay

elits

ha

Mit

ch

ells

Pla

in

Ny

an

ga

Oo

ste

nb

erg

SP

M

Ty

g. E

as

t

Ty

g. W

es

t

Re

gio

n

Infant Mortality

0%

20%

40%

60%

Ath

lon

e

Bla

au

wb

erg

Ce

ntral

He

lde

rb

erg

Kh

aye

lits

ha

Mit

ch

ells

Pla

in

Nyan

ga

Oo

ste

nb

erg

SP

M

Tyg

erb

erg

Eas

t

Tyg

erb

erg

We

st

TO

TA

L

% households below poverty line

RWANDA Increase in the coverage of family planning services

RWANDA Professional assistance at delivery has increased

significantly in the rural areas

Nearly 60% of the existing Human Resources are either nurses or paramedical workers while

doctors contributed to less than 7%

Rwanda now has 60,000 CHWs

RWANDA

Total health personnel in publicly funded facilities has almost doubled in 3 years …

6961

13133

0

2000

4000

6000

8000

10000

12000

14000

2005 2008

Total staff

Total staff

Linear (Total staff)

Linear (Total staff)

RWANDA

Infant and Under-five mortality on the decrease over

the last years …

Trends in infant and under five mortality according to different surveys (1975-2007)

107

233

176

84

129141

219

121

198

217

62

173

1038695

151

110

107

85

225

167

196

86

118

152

95

0

50

100

150

200

250

1975 (77)-

1979(81)

1980(82)-

1984(86)

1985(87)-

1989(91)

1990-94 1995-99 1998(00)-

2000(04)

2003-07

Mo

rtali

ty p

er

1,0

00

DHS 1992 IMR DHS 1992 U5MR DHS 2000 IMR DHS 2000 U5MR

DHS 2005 IMR DHS 2005 U5MR DHS 2007 IMR DHS 2007 U5MR

Source: IDHS 2007.

Brazil Intersectoral action Between 1991 and 2008, Brazil’s gross domestic product doubled and its Gini coefficient decreased by 15% from 0·637 to 0·547 The poverty index decreased from 68% in 1970 to 31% in 2008.

This improvement can be attributed to a combination of social policies:

School attendance has increased since 1990, and illiteracy rates have decreased from 33·7% in 1970 to 10·0% in 2008.

Bolsa Família conditional cash transfer programme (which, in 2008, distributed R$13 billion [about US$7·2 billion] among 10·5 million families)

increases in the legal minimum wage.

In 1970, only 33% of households had indoor water, 17%

had access to sewerage, and less than half had electricity

By 2007, 93% of households had indoor water,

60% had access to sewerage, and most had access to electricity

Paim et al, Lancet, 2011; 377

Time trends in the prevalence of stunting according to family income in four Brazilian surveys, 1974/5 to 2006/7.

Monteiro et al, Bull WHO (in press)

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

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

• 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