CHILD HEALTH PRIORITIES CONFERENCE

3 DECEMBER 2015

MRC* StatsSA CoMMiC#

IMR 29.0 25.0 26.8

U5MR 41.0 37.0 36.2

* Correction for underreporting # Uncorrected but able to disaggregate to Province & District

2009 2010 2011 2012 2013

Births (Registered) 995 791 990 775 985 727 1 090 893 1 018 398

Deaths (Reported)

Newborn 37 974 34 431

11 002 11 256 10 438

Post newborn 16 979 15 335 15 555

Child (1 – 4 years) 12 497 12 987 9 927 10 324 9 101

Under-5 50 471 47 418 37 908 36 915 35 094

Mortality rate

NNMR 12.5 12.0 11.2 10.3 10.8

IMR 38.1 35.5 28.4 24.4 26.8

U5MR 50.7 48.9 38.5 33.8 36.2

StatsSA Birth & Death Notification

StatsSA Death Notification

Rapid Mortality Surveillance Report 2013

StatsSA Vital Registration 2011

Neonatal 29%

Post neonatal

45%

Child 26%

UNDER 1 1 - 4 YRS

CAUSE NO % CAUSE NO %

Neonatal 9605 34.3 Neonatal 2 0.0

Congenital Abnormality 1334 4.8 Congenital Abnormality 149 1.5

Non-natural 900 3.2 Non-natural 1470 14.8

Diarrhoea 3954 14.1 Diarrhoea 1748 17.6

Flu / ARI / LRTI 3554 12.7 Flu / ARI / LRTI 1310 13.2

Ill defined 3562 12.7 Ill defined 1888 19.0

Malnutrition 799 2.9 Malnutrition 666 6.7

TB 316 1.1 TB 450 4.5

HIV 244 0.9 HIV 137 1.4

Other Bacterial 475 1.7 Other Bacterial 147 1.5

StatsSA Death Notification

UNDER 5 CAUSE NO %

Neonatal 9608 25.3 Congenital Abnormality 1483 3.9 Non-natural 2370 6.3 Diarrhoea 5702 15.0 Flu / ARI / LRTI 4888 12.9 Ill defined 5511 14.5 Malnutrition 1468 3.9 TB 767 2.0 HIV 440 1.2 Other Bacterial 625 1.6

StatsSA Death Notification

Neonatal 34%

Congenital Abnormality

5% Non-natural 3%

Diarrhoea 14%

Pneumonia 13%

Ill defined 13%

Malnutrition 3%

TB 1%

HIV 1% Other

13%

StatsSA Death Notification

Neonates 25%

Ill defined 16%

Diarrhoea 15%

Pneumonia 13%

Non-natural 6%

Malnutrition 4%

Congenital Abnormality

4%

TB 2%

Other 16%

StatsSA Death Notification

StatsSA Death Notification

0

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40

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EC FS GP KZN LP MP NW NC WC RSA

NNMR

IMR

U5MR

StatsSA Death Notification

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

EC FS GP KZN LP MP NC NW WC RSA

2009

2010

2011

2012

2013

StatsSA Death Notification

0.0

20.0

40.0

60.0

80.0

100.0

120.0

EC FS GP KZN LP MP NC NW WC RSA

2009

2010

2011

2012

2013

NMR* IMR* U5MR* % in

Hosp# %

SAM# % HIV#

% <24 hrs#

CFR **

GE ARI SAM

E Cape 5.5 18.6 27.7 41.3 29.7 31.9 37.5 6.9 5.4 14.7

F State 16.9 43.4 56.9 55.1 35.1 37.3 38.8 4.2 3.6 11.2

Gauteng 12.8 27.8 35.0 49.2 15.5 29.5 28.8 3.5 2.8 7.5

KZN 7.0 16.4 22.1 58.2 28.7 42.5 30.5 3.6 2.9 10.8

Limpopo 8.0 23.9 36.1 45.2 39.2 41.2 31.0 5.7 4.7 16.7

M'langa 9.5 23.6 33.2 49.9 28.8 46.9 35.5 6.1 5.9 13.1

N West 17.5 46.0 61.6 65.9 43.5 40.8 31.6 5.4 5.1 11.1

N Cape 14.8 38.2 49.8 49.2 44.8 30.2 40.8 3.0 3.8 11.7

W Cape 9.5 18.9 20.6 55.9 14.0 20.7 35.4 0.1 0.4 3.4

RSA 10.5 26.8 36.2 49.6 31.2 39.1 33.6 4.0 3.7 12.0

* StatsSA Death Notification

# Child PIP

** DHIS

2009 2010 2011 2012 2013

HIV associated # 48.3 49.9 43.0 39.9 39.1

Severe Acute Malnutrition # 33.2 33.0 30.9 27.9 31.2

In health service* 50.0 49.5 45.5 47.9 49.6

Within 24 hrs # 33.0 30.5 34.2 33.6

ARI Case Fatality Rate** 6.7 6.3 4.3 4.1 3.7

AGE CFR** 7.4 7.0 5.2 4.2 4.0

SAM CFR** 18.9 19.2 13.5 12.2 12.0

* StatsSA Death Notification

# Child PIP

** DHIS

PLACE MOST FREQUENT MODIFIABLE FACTORS

Wards

Lack of High Care and/or ICU facilities for children in own and higher level facility

Insufficient notes on clinical care in ward (assess, manage, monitor) Inadequate investigations in ward

Emergency Department

Inadequate notes on clinical care (assessment, management, monitoring at A&E

Inadequate history taken at A&E Inadequate investigations (blood, x-ray, other) at A&E

Referring Facility & Transit

No or delayed referral to higher level Severity of child`s condition incorrectly assessed at referring facility Inadequate referral letter from referring facility

Clinic/OPD

Child`s growth problem (severe malnutrition, not growing well) inadequately identified or classified

Inadequate assessment for HIV (IMCI not used) at clinic/OPD Delayed referral for severe malnutrition, weight loss, or growth faltering

from clinic/OPD

Home

Caregiver delayed seeking care Caregiver did not recognise danger signs/severity of illness Child not provided with adequate (quality and/or quantity) food at home

Nutrition

Household food security

Growth monitoring

Delay referral for faltering

Incomplete implementation of 10 steps

Emergency care

Failure to recognise severity of illness

Delayed entry

Poor use of IMCI

Poor assessment – in transit, on arrival & in ward

Record keeping

Road-to-Health Booklet

Referral notes

Clinical records

Under reporting E Cape, KZN, Limpopo & Mpumalanga

NW - births

Wide range of mortality Provincial 20 62

District 15 105

Rising U5MR Only 1 district vs 14 last year

Community deaths RSA 54.5%

Range 44.9% 59.7%

Plateau 2012 – 2013 All sources show slower rate of reduction

Cause of death Unchanging NNMR

Non-natural deaths

Role of nutrition

Decline in underlying factors HIV

49.9% in 2010

39.1% in 2013

Reduction in case fatality rates (CFR)

2008 2013

Severe Acute Malnutrition 19.6% 12.0%

Acute Respiratory Illness 9.3% 3.7%

Gastroenteritis 9.2% 4.0%

Fully implemented 1. National Health Strategy

MNCWH & Nutrition Strategic Plan

Mid-term review completed

Not implemented 2. Framework for an essential package of care (EPOC)

Essential package

Norms & Standards

Partially implemented

Adopted but coverage incomplete

3. Strengthen Community Based services Ward Based Outreach Teams (CHWs / CCGs)

Integrated School Health Programme

District Clinical Specialist Team

4. Strengthen priority programmes HIV – PMTCT & ART

Integrated management of acute malnutrition

TB geneXpert & Mx

IMCI chart booklet

5. Training

Post graduate – national core curriculum

In-service – related to DCST

NOT Undergraduate or nursing

6. Geographically defined, population focussed oversight

District Clinical Specialist Teams

Provincial Paediatrician

7. Strengthen data systems

Death notification form

Standardised ward register

Child PIP

8. Identify key drivers

Child health forums

MNCWH Dashboard

Accountability

Connected Household

Capacitated Health worker

Essential Health system

Support

Standard

No new magic bullet

Continue existing programmes

Strengthen Quality of care & implementation

A-ccountability for an Adequate standard of living and safe environments for All children.

C-onnected easily with health systems in proportion to need.

C-apacitated parents, caregivers and families, able to provide a safe and stimulating environment.

E-ssential care must be comprehensive care wherever it is delivered to children.

S-upport for ECD activities and services for babies and young children - in homes, health services and communities.

S-tandard package of routine, as well as specialised, care close to their homes.

A-ccountability with empowerment.

C-onnected to the systems and communities in which they work and to the children they serve.

C-apacitated for the job.

E-ssential Package of Care understood and delivered.

S-upport in all that they do.

S-tandard, Sufficient Staffing establishments.

A-ccountability to the community.

C-onnected with all who carry responsibility for the health and wellbeing of children.

C-apacitated to ensure systems of Care for children with long term health conditions.

E-ssential Package of Care developed and delivered.

S-upport for frontline staff.

S-tandard data Sets for children.

A-ccountability for an adequate standard of living and a safe environment for all children: Ongoing health education through Mom-Connect and other

media channels.

WBOT support to households for health education, promotion and prevention activities.

C-onnected easily between households and the health system:

Ensure lodger mother facilities in all hospitals and birthing units.

C-apacitated front line health care workers:

Pre- and post-basic training on all flagship programmes, ECD and EPOC.

Non-rotation of staff.

E-ssential Package of Care (EPOC):

Finalise development, including equitable access to all levels of care.

Train health workers around the EPOC.

Progressive roll out of the EPOC.

S-upport: Early child development and the first 1,000 days.

Frontline health workers through outreach programme.

S-tandard data sets and tools: Standard data sets for children for monitoring, evaluation and

feedback.

Implement the Road to Health Booklet as the standard record of a child’s health care.

1 in 26 (vs 20) children die before their 5th birthday 44 549 childhood lives saved since 2009

Of these… 25% die in the newborn period

45% of children die inside the health service

In the health service…. Entry to the service is late

Care on arrival is poor

General inability to assess severity of condition & growth

Access to high care beds is limited

30% of deaths occur within 24 hours of admission

39% of deaths occur in association with HIV

31% of deaths have underlying severe malnutrition

N McKerrow KZN

M Mulaudzi GP

G Boon EC

A Ferris NC

B Gaede KZN

FN Mabuza MP

S Matela FS

F Mothebe FS

V Mubaiwa KZN

A Njie NW

A Robertson LP

H Saloojee GP

G Thabapelo NC

A Venter FS

A Westwood WC

NDoH / Secretariate

L Bamford

S Ngake

E Maseti

A Ngqaka

L Slade

K Moodley