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GLOBAL HEALTH RESEARCH:A PERSPECTIVE FROM THE
SOUTH
David SandersDirector: School of Public Health
University of the Western Cape
Member of Global Steering GroupPeoples Health Movement
Member of WHO Health Systems Research Task Force
Presented at the Conference on Global Health Research inBergen, Norway, 21-22 September, 2004
Outline of Presentation Progress in global health 1980-2004
Role of globalisation, health sector reform and HIV/AIDS in weakening health systems in the South
Refocusing of research to address this context
with examples from South Africa
Key responses required
Progress in Global Health
Life expectancy – increases from 46 years in 1950s to 65 years in 1995
Child deaths – reduced from projected 17.5 to 11m per year
Substantial control of poliomyelitis, diphtheria, measles, onchocerciasis, dracunculiasis through immunisation and disease control programmes
Decline in cardiovascular disease in males in industrialised countries
Growing inequalities in global health
40
60
80
100
120
140
160
1960 1981 1999
IMR decline(Percent
)
1960-1981
1981-1999
World 38.5 26.9
SSA 19.2 15.1
IMR
World
SSA
UNICEF: State of the World’s Children
U5MR in Sub-Saharan Africa
0
50
100
150
200
250
World SA Kenya Swaziland Zimbabwe Botswana
1960 1990 2001
The State of the World’s Children 2003. UNICEF
1980s Mixed progress in
implementing health policies
Progress in Implementing PHC Programme Elements
(Source: WHO 1998)
Selective Primary Health Care“Child Survival and Development Revolution”
Growth MonitoringOral Rehydration TherapyBreast FeedingImmunisation
Family PlanningFood SupplementsFemale Education
1990s: progress reversed Inequitable globalisation, Health sector “reform”, and
HIV/AIDS
result in slow progress and reversals.
The debt crisis & structural adjustment:
A crucial development in the current phase of globalisation…
External debt
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 liberalisation
“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)
The global growth of poverty
Global distribution of income
The Health System, its financing and its human
resources
Health expenditure Expenditure as % of GDP1990
Expenditure as % of GDP1996-1998
46 High income countries (none in Africa)
5.3% 6.4%
93 Middle income countries (22 in Africa)
2.6% 3.2%
34 Low income countries (29 in Africa)
0.9% 0.8%
World 4.7% 5.6%
(Source: UNDP Human Development Report, 2000)
Actual amounts of per capita public health expenditure in Africa Amount in USD Number of countries
> USD 60 6
> USD 34 – USD 60 3
USD 12 – USD 34 10
< USD 12 27
No data 7
(Source: Human Development Report, 2000)
Health system ‘reform’:
Aim : Improving the performance of the civil service decentralisation of management responsibility and/or
provision of health improving functioning of national ministries of health broadening health financing options introducing managed competition between providers of
clinical & support services working with the private sector
Health personnel / population ratios
Doctors 31 of 53 African countries
have < 32 doctors / 100,000 people,
17 countries < 10 doctors / 100,000 people
Nurses 41 countries have < 135
nurses/100,000 people,
17 countries < 50 nurses / 100,000 people.
Source: UNDP, 2000
Doctor/100,000
Nurse/100,000
World 122 248
OECD 222 --
LDCs 70 91
SSA 32 135
Health personnel vital, consume between 60 – 80% of recurrent public health expenditure (WB, 1994).
Health professional migration from Africa
Between 1985 and 1995, 60% of Ghana’s medical graduates left
During the 1990s Zimbabwe lost 840 of 1,200 medical graduates
In 1999, 78% of doctors in South Africa’s rural areas were non-South Africans
2,114 South African nurses left for the UK during 2001
International migration—winners & losers
Using the conservative figure of US$ 20,000 to train a medical doctor, Zimbabwe lost US$ 16.8 million through the loss of 840 doctors.
Using the same conservative estimate Nigeria incurred a loss of US$ 420 million due to the migration of 21,000 physicians to the United States.
However, if the UNCTAD figure of US$ 184,000 per professional is used to calculate savings, the United States saved US$ 3.86 billion.
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
Collapsing public health systems resulting from … Declining per capita health spending reducing
Health personnel numbers and morale Drug availability Transport for outreach & supervision
Promotion of the private sector through “health sector reform”
HIV/AIDS affecting and infecting health personnel
… reversing previous gains in PHC implementation
Global Immunization 1980-2002, DTP3 coverageglobal coverage at 75% in 2002
20 23 25
3744 48
52 5664
6975 72 71 72 74 75 75 75 74 71 74 74 75
01020
3040506070
8090
100
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, CISIndustrialized countries East Asia and PacificLatin America and Caribbean Mid-East and N AfricaSouth Asia Sub-Saharan Africa
Source: WHO/UNICEF estimates, 2003
Collapsing public health systems need to
implement more complex interventions and
programmes
For example, universal access to ART would need at least:
Information dissemination & encouragement to undergo VCT
VCT: Pretest counseling Testing & test interpretation Post-test counseling
Ensuring supplies of testing equipment & drugs
Administration of appropriate treatment: Monitoring of immune status Recognition & treatment of opportunistic infections
Nutritional & social support
¶ For 3 million people, most of whom are in poor countries¶ For 500,000 people in South Africa
Each step requires enough personnel with a range of skills
Key focus areas for health research
Research on health systems, particularly on operational aspects and on evaluation
Research on health determinants (local and global) with an equity lens
Case studies of comprehensive, community-based approaches
How well are researchers meeting the challenge?
Describe the problem
Explore the contextual factors
Select possible interventions
Test interventions
Identify risk factors
Formulate public health interventions
Assess efficacy public health interventions
Assess effectiveness public health interventions
Research steps in the development and evaluation of public health interventions
De Zoysa et al, Bull WHO 1998, 76:127-133
Nutrition Engineers
As well as researchers asking “what, why, where, and who?”
We should be asking “How?”
Berg A Sliding toward nutrition malpractice: time to reconsider and redeploy Am J Clin Nutr 1993
Classification of Articles in PUBMED 1994-2002, SAJCN 1998 – 2002 (Keywords: Nutrition, South Africa)
Food Science
Nutrition Science Efficacy Policy
Clinical Population (includes surveys)
Number of Articles
5 81 54 25 25 10 9
Percentage of Articles
2% 31.3% 20.8% 9.7% 29% 4% 4%
Total Articles
259
Effectiveness
Operational Evaluation
EXAMPLES OF EFFECTIVENESS RESEARCH
Research for Service Development and Health Promotion
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
INTEGRATED NUTRITION PROGRAMME
• PRIMARY PREVENTION –Address underlying socioeconomic and environmental causes
• SECONDARY PREVENTION – Regular Growth Monitoring with Nutrition Promotion & Supplementation
• TERTIARY PREVENTION – WHO 10-Steps Protocol for the Management of Severe Malnutrition
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
Capacity Development
Advocacy
Teambuilding
Analysis
Situational AssessmentPlanning
Implementationand Management
EvaluationPolicy
CASE FATALITY IN RURAL HOSPITALS (Former Region E)
PRE-INTERVENTION CFRs
Mary Terese 46% Sipetu 25%Holy Cross 45% St Margaret’s 24%St. Elizabeth’s 36% Taylor Bequest 21%Mt. Ayliff 34% Greenville 15%St. Patrick’s 30% Rietvlei 10%Bambisana 28%
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
Implementation Cycle
Capacity Development
Advocacy
Teambuilding
Analysis
Situational AssessmentPlanning
Implementationand Management
EvaluationPolicy
Comparison of recommended and actual practices inMary Theresa and Sipetu hospitals and perceived barriers
to quality of care of malnourished children
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 Feed every 2 hours during the day and night. Start straight away.
Children were left waiting in the queue in the outpatient department and during admission procedures. In the wards, they were not fed for at least 11 hours at night Hypoglycaemia not diagnosed
Lack of knowledge about risks of hypoglycaemia Lack of knowledge about how to prevent it Shortage of staff especially during the night No supplies for testing for hypoglycaemia
Training to explain why malnourished children are at increased risk 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.)
Malnourished childrenfed straightaway and 3 hourly during day and night. 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
10-STEPS EVALUATION RESULTS
Major improvements in the care of severely malnourished children:
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
10-STEPS EVALUATION RESULTS Problems still existed:
Intermittent supply problems for vitamins and micro-nutrients
Power cuts – no heat Poor discharge follow-up Staff shortage, of both doctors and nurses, and
resultant low morale
CHANGES IN CFRs IN RURAL HOSPITALS
CHANGES IN CFRs IN HOSPITALS
0102030405060
PER
CEN
TAG
ES
1998-1999
2000-2001
2002
2003
Follow-up research seeks to answer the following questions:
Why, with the same in-service training, do some hospitals achieve improved care in the management of severe childhood malnutrition, and others do not?
What are the key factors that constrain and facilitate
successful implementation of the WHO treatment guidelines?
What are the most effective actions necessary to replicate successful performance in poorly performing hospitals or new settings?
How can training and/or support be improved to overcome potential constraints and allow facilitating factors to flourish?
EVALUATION OF FEASIBILITY OF IMPLEMENTING 10 STEPS
STEP 10 OF THE IMCI MALNUTRITION PROTOCOL
Giving Nutrition Education to caregivers by health staff
Planning Follow- up of the child at regular intervals post discharge
OBJECTIVES
To determine Household Food Security(HHFS), caregiver knowledge & factors associated with malnutrition
To look at the rate of recovery & health status at 1 month & 6 month post discharge
STUDY POPULATION
POST DISCHARGE HOME VISITS(HV) At 1 month (n) = 30 At 6 month (n) = 24
Average No. of people 8Average No. of children < 6 2.5
Female Headed HH 40 %
Residing in mud houses 82 %
Subsistence Crop Production 83 %
Livestock keeping 90 %
Average family income R550
DEMOGRAPHIC & SOCIO-ECONOMIC FACTORS
76% of caregivers had <9 years education 78% of caregivers were literate
76% remembered key messages about food fortification
71% of caregivers unable to implement acquired knowledge of feeding practices
CAREGIVER KNOWLEDGE OF NUTRITION
STAPLE FOOD INVENTORY LIST Samp / Maize Beans Maize Meal Flour Rice Sugar Soup Tea / Coffee Milk Oil Peanut Butter Eggs
No. of food items in HH Cupboard
% of HH
0 7
1 – 4 40
5 - 8 30
9 - 11 23
HOUSEHOLD SOURCE OF INCOME PENSION GRANT 40 % MIGRANT LABOURERS 25 % NO INCOME FAMILIES 20 % DOMESTIC WORKERS 15 % CHILD SUPPORT GRANT (CSG) 0 % ANTI POVERTY PROGRAMME 0 %
CSG – Children aged 0-9 years in families earning less than
R800 per month eligibleCSG - currently R160
Implementation Cycle
Capacity Development
Advocacy
Teambuilding
Analysis
Situational AssessmentPlanning
Implementationand Management
EvaluationPolicy
Advocacy Component
Presentation of data to Government Commission on Social Welfare
Newspaper articles on malnutrition and child welfare Partnership with ACESS resulted in TV documentary – ‘Special
Assignment’ – elicited unexpected response from both public and government
Minister of Social Development visited Mt Frere and ordered mobile team in to process CSGs
Questions in Parliament re child welfare Recent ‘Sunday Times’ articles on child malnutrition in Eastern
Cape Massive Child Support Grant Campaign in E. Cape, October 2002
No of Poor Children (0-6) and No. of Children Receiving CSG in Oct 2002
0200400600800
10001200
KZN EC L NW MP GT FS WC NC
Nos
of C
hn ('
000s
)
No. chn (0-6) in poverty No. of CSG benefs.
Sources of Data for these graphs:
Grant Voucher Uptake: SOCPEN daily record Oct 2002
Poverty Levels: Streak (2002). IDASA. Using a poverty line of R400 per capita per month (in ‘99 terms)
Population: Census 1996. Stats SA., in T. Guthrie, UCT & ACESS, Feb. 2003
EMPTY STOMACHS: Year-old Samkelo is one of nine children that his jobless grandmother, Nofuduka Mbulawe, has to feed
Picture: Richard Shorey
Sunday, September 22 2002Starving to death on arable land Poverty is killing children in the Eastern Cape. But breaking out of its grip is no easy task, write Thabo Mkhize and Heather RobertsonA nutrition study by the University of Western Cape showed that Samkelo is one of the more fortunate - 166 babies at 11 hospitals in the northeastern district have died of malnutrition
ONE-year-old Samkelo Mbulawe has only a tattered blanket to cover his distended stomach and flaking skin. He has just returned home after two months in the Mount Ayliff Hospital where he was treated for kwashiorkor, a form of malnutrition.
Available January 10, 2004 from University of Cape Town Press
Online ordering andprepublication proofs
available at:http://web.idrc.ca/ev.php?ID=45682_201&ID2=DO_TOPIC
“Determinants” research: a global example
Assessed G8 health/development commitments 1999-2001 summits with respect to three criteria:
1. Have the G8 lived up to the commitment?2. Was the commitment adequate, when
measured against the need addressed?3. Was the commitment appropriate, or was it,
e.g., rooted in a paradigmatic economic orthodoxy that may actually undermine determinants of health?
What we found:
Promises kept: 10 *Promises broken: 17 *
* Figures changed since book went to press.
Promises kept
+ Global Fund to Fight AIDS, Tuberculosis and Malaria was established (‘primed’ with US $1.3 billion initial contributions)
+ Agreement reached (August 2003) on flexibility in TRIPS to ensure access to essential medicines (although considerable uncertainty still surrounds implementation)
Promises broken Reductions in AIDS, tuberculosis and malaria mortality highly unlikely to
meet targets set in 2000
“Strong” national health systems not being supported (G7 ODA for health actually declined)
“Determinants” research: a local example – The Cape Town Equity Gauge
AIM OF PROJECT
To Decrease Inequities in the distribution of Public Health Services and other Basic Services in Cape Town
Match Service Resources according to Need for services in Cape Town
Equity Gauge5 Pillars
Measurement Advocacy Community Participation Resource Allocation Framework Implementation
Measurement
Assess Health Needs Population
Population Dependent on Public Services Other Measures of Need (Diseases, Socio-economic)
Weighted Dependent Population Assess Resources
Staff, Equipment, Drugs, Supplies, Utilities Finances (Operating Budget)
Compare Resources to Need Establish Equity Amount Assess level of Inequity
Infant Mortality Rate (IMR)
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Inequity in Public Primary Care Expenditure Zero line represents an average
equitable expenditure
District Health Information SystemsThe South African Experience
Developing a Routine District Health Information System
andConducting Research on Information
Systems
Information Systems Research Action Research on Developing a Basic District
Health Information System Development of an Information Audit tool Development of Policies and Procedures to ensure
Accuracy of Routinely Collected Data Development of a Hospital Information System
Morbidity, mortality, service coverage, efficiency Development of a Community Based Information
System Child Health Monitoring community health workers programme
Enhancing Capacity for Public Health Research and Action
Responses from SoPH Education
Continuing education Post-graduate education Programme-based training
Research Health systems research, focusing on
implementation and its evaluation Service development
Focused on key programmes and systems components
Matrix of programmes and systems components
Systems/Strategies
Programmes
HRD Health information
Health Management
Health promotion
HIV/TB x x
Nutrition x x x
MCH
School Health x
Water & Sanitation
x x
Continuing Education - Short Courses 24 Winter & Summer Schools About 40 courses offered: i)Reorientation
ii)Systems and management related iii)Specific Programmes iv)Research
1-3 weeks duration >6,000 health workers graduated Good evaluation from participants and WHO
School of Public Health
University of the Western Cape
Winter School 2001: 2-20 July 2001
Formal Postgraduate Education Masters in Public Health Adapted to working students and small
teaching staff Part time teaching blocks of classroom
learning and practice-based assignments at workplace
Multiple entry and exit points Adapted for Distance Learning
Diagram Illustrating the School of Public Health’s Configuration of its Postgraduate Certificate, Postgraduate Diploma and Masters In Public Health (University of the Western Cape) for 2003
Modules
ENTER
Possible streams for Post Graduate Diploma: General (consisting of Health Management & Health Promotion), Human Resource Development, Health Information Systems, Health Promotion, Health Management, Health Systems Research, Nutrition
Masters in Public Health 2 Selectives (20 credits each) Mini-Thesis (40 credits) * all credits at NQF level 8
Postgraduate Certificate Modules Understanding Public Health Health Development and
Primary Health Care I Health Systems Research I Measuring Health & Disease I Health Management I Health Promotion I (20 credits for each module at NQF Level NQF level 6)
Entry Point
Postgraduate Diploma Modules Understanding Public Health Health Development and Primary Health Care II Measuring Health & Disease II
Stream Module I Stream Module II Elective Module Composite exam (20 credits for each module at NQF level 7)
Enter Graduate
Postgraduate Diploma in Public Health (120 credits)
Masters in Public Health ( 200 credits)
Graduation
Post-graduate Certificate in Public Health (120 credits)
Student profile cont.:Students come from twelve countries:
South Africa (101) Namibia (18) Zambia (9) Zimbabwe (1) Uganda (2) Tanzania (3) DRC (1)
Botswana (1) Niger (1) Peru (1) Greece (1) China (1) Northern Ireland (1) Canada (1)
Virtually all health professions; many nurses, district managers & facility managers
In conclusion Health systems in SSA are in crisis. HIV/AIDS
accentuates this. Research can improve effectiveness and equity by
prioritising: HSR especially implementation issues Equity issues at local and global levels Advocacy based upon evidence
Key responses must include: Increased investment in HSR and equity orientated
research Increased investment in enhancing capacity of Southern
institutions (incl. equitable collaboration/partnerships with Northern institutions)
Support for innovative teaching and research efforts