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GLOBAL HEALTH RESEARCH: A PERSPECTIVE FROM THE SOUTH

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Title: GLOBAL HEALTH RESEARCH: A PERSPECTIVE FROM THE SOUTH


1
GLOBAL HEALTH RESEARCHA PERSPECTIVE FROM THE
SOUTH
  • David SandersDirector School of Public
    HealthUniversity 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 in Bergen, Norway, 21-22 September, 2004

2
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

3
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

4
Growing inequalities in global health
IMR
IMR decline (Percent) 1960-1981 1981-1999
World 38.5 26.9
SSA 19.2 15.1
SSA
World
UNICEF State of the Worlds Children
5
U5MR in Sub-Saharan Africa
The State of the Worlds Children 2003. UNICEF
6
1980s
  • Mixed progress in implementing
  • health policies

7
Progress in Implementing PHC Programme Elements
(Source WHO 1998)
8
Selective Primary Health CareChild Survival and
Development Revolution
  • Growth Monitoring
  • Oral Rehydration Therapy
  • Breast Feeding
  • Immunisation
  • Family Planning
  • Food Supplements
  • Female Education

9
1990s progress reversed
  • Inequitable globalisation,
  • Health sector reform, and
  • HIV/AIDS
  • result in slow progress and reversals.

10
The institutions promoting globalisation
  • World Bank
  • International Monetary Fund (IMF)
  • World Trade Organisation (WTO)

11
The debt crisis structural adjustment
  • A crucial development in the current phase of
    globalisation

12
External debt
13
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)

14
The global growth of poverty
15
Global distribution of income
16
The Health System, its financing and its human
resources
17
Health expenditure
Expenditure as of GDP 1990 Expenditure as of GDP 1996-1998
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)
18
Actual amounts of per capita public health
expenditure in Africa
Amount in USD Number of countries
gt USD 60 6
gt USD 34 USD 60 3
USD 12 USD 34 10
lt USD 12 27
No data 7
(Source Human Development Report, 2000)
19
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

20
Health personnel / population ratios
Health personnel vital, consume between 60 80
of recurrent public health expenditure (WB, 1994).
Doctor/ 100,000 Nurse/ 100,000
World 122 248
OECD 222 --
LDCs 70 91
SSA 32 135
  • Doctors
  • 31 of 53 African countries have lt 32 doctors /
    100,000 people,
  • 17 countries lt 10 doctors / 100,000 people
  • Nurses
  • 41 countries have lt 135 nurses/100,000 people,
  • 17 countries lt 50 nurses / 100,000 people.
  • Source UNDP, 2000

21
Health professional migration from Africa
  • Between 1985 and 1995, 60 of Ghanas medical
    graduates left
  • During the 1990s Zimbabwe lost 840 of 1,200
    medical graduates
  • In 1999, 78 of doctors in South Africas rural
    areas were non-South Africans
  • 2,114 South African nurses left for the UK during
    2001

22
International migrationwinners 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.

23
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
24
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

25
Global Immunization 1980-2002, DTP3
coverageglobal coverage at 75 in 2002
Source WHO/UNICEF estimates, 2003
26
Collapsing public health systems need to
implement more complex interventions and
programmes
27
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28
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

29
How well are researchers meeting the challenge?
30
Research steps in the development and evaluation
of public health interventions
De Zoysa et al, Bull WHO 1998, 76127-133
31
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

32
Classification of Articles in PUBMED 1994-2002,
SAJCN 1998 2002 (Keywords Nutrition, South
Africa)  
Effectiveness
Operational
Evaluation
 
33
EXAMPLES OF EFFECTIVENESS RESEARCH
34
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

35
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36
STUDY SETTINGPAEDIATRIC 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

37
Implementation Cycle
Advocacy
Policy
Evaluation
Capacity Development
Teambuilding
Implementation and Management
Situational Assessment
Planning
Analysis
38
CASE FATALITY IN RURAL HOSPITALS (Former Region E)
  • 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

39
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
40
Implementation Cycle
Advocacy
Policy
Evaluation
Capacity Development
Teambuilding
Implementation and Management
Situational Assessment
Planning
Analysis
41
Comparison of recommended and actual
practices in Mary Theresa and Sipetu hospitals
and perceived barriers to quality of care of
malnourished children
42
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

43
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

44
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

45
CHANGES IN CFRs IN RURAL HOSPITALS
46
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47
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?

48
  • 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

49
  • 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

50
  • STUDY POPULATION
  • POST DISCHARGE HOME VISITS(HV)
  • At 1 month (n) 30
  • At 6 month (n) 24

51
DEMOGRAPHIC SOCIO-ECONOMIC FACTORS
Average No. of people 8
Average No. of children lt 6 2.5
Female Headed HH 40
Residing in mud houses 82
Subsistence Crop Production 83
Livestock keeping 90
Average family income R550
52
CAREGIVER KNOWLEDGE OF NUTRITION
  • 76 of caregivers had lt9 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

53
  • 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
54
  • 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 eligible
  • CSG - currently R160

55
Implementation Cycle
Advocacy
Policy
Evaluation
Capacity Development
Teambuilding
Implementation and Management
Situational Assessment
Planning
Analysis
56
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

57
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

58
Sunday, September 22 2002 Starving 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
Robertson A 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.
EMPTY STOMACHS Year-old Samkelo is one of nine
children that his jobless grandmother, Nofuduka
Mbulawe, has to feed Picture Richard Shorey
59

Determinants research a global example
  • Available January 10, 2004 from
    University of Cape Town Press
  • Online ordering and
  • prepublication proofs
  • available at
  • http//web.idrc.ca/ev.php?ID45682_201ID2DO_TOPI
    C

60
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?

61
What we found
  • Promises kept 10
  • Promises broken 17
  • Figures changed since book went to press.

62
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)
63
Determinants research a local example The
Cape Town Equity Gauge
64
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

65
Equity Gauge5 Pillars
  • Measurement
  • Advocacy
  • Community Participation
  • Resource Allocation Framework
  • Implementation

66
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

67
Infant Mortality Rate (IMR)
68
HIV prevalence 2000 (estimates)
69
Households below poverty line
70
Inequity in Public Primary Care Expenditure
Zero line represents an average equitable
expenditure
71
District Health Information SystemsThe South
African Experience
  • Developing a Routine District Health Information
    System
  • and
  • Conducting Research on Information Systems

72
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

73
Enhancing Capacity for Public Health Research and
Action
74
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

75
Matrix of programmes and systems components
76
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
  • gt6,000 health workers graduated
  • Good evaluation from participants and WHO

77
School of Public Health University of the Western
Cape
Winter School 2001 2-20 July 2001
78
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

79
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80
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

81
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
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