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Possible themes for South African-Norwegian Health research collaboration

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Title: Possible themes for South African-Norwegian Health research collaboration


1
Possible themes for South African-Norwegian
Health research collaboration
  • Halvor Sommerfelt, MD, PhD
  • University of Bergen,
  • Currently University of the Western Cape
    Medical Research Council, Cape Town

Prof. Mhlanga A nation without (healthy) women
and children is a nation doomed
2
Main messages
  • Cost-effective (mother child) health promotion
    programs Powerful instruments ? economic growth
    and poverty reduction, if
  • ?main disease burden contributors (diseases
    risk factors)
  • ? research to generate evidence-base for
    program-relevant interventions
  • ? extensive coverage and equitable delivery
    (Research?functional health system).
  • Experiences from other collaborations, e.g.
    Indo-Norwegian RSA as node for health research
    and post-graduate education in SSA?
  • Suggested areas for collaborative research
    post-graduate education in health
  • Suggested strategies for collaborative health
    research

3
Sources
  • Presentations by Prof. David E. Bloom and David
    Canning, School of Public Health, Harvard
    University and Prof. David Sanders, School of
    Public Health, University of Western Cape at the
    GAVI-funded seminar Development and Deployment
    of Vaccines Against Poverty-Related Diseases,
    Bergen, Norway, September 21, 2004
    (http//www.cih.uib.no/GAVI/seminar2004/index.htm)
    .
  • David E. Bloom and David Canning. The health and
    wealth of nations, Science. 2000 287 pp.
    1207-1209 David E. Bloom et al. Health, Wealth,
    and Welfare. Finance Development. 2004 pp.
    10-15.
  • WHO/UNICEF
  • Demographic Health Surveys (DHS)
  • PF Basch. Textbook of International Health. ISBN
    0-19-504897-0. Oxford University press, 1990
    pp. 164-183.
  • Kramer, S. Mausner Bahn. Epidemiology. An
    introductory text. ISBN 0-7216-6181-5. W. B.
    Saunders, Philadelphia, 1985, pp. 239-256.
  • World Development Report 1993. ISBN
    0-19-520890-0, Oxford University Press, 1993.
  • Commission on Macroeconomics and Health
  • Lancet series on child survival 1993

4
Standardized mortality rates US 1900-1973gross
national product-gtMedical care
5
Age-adjusted measles mortality per 1000 US
1900-1973
Similar for other major infectious diseases, the
interventions came too late Vaccines
diphteria, whooping cough Treatment TB,
pneumonia, diarrhea
6
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7
Measles incidence US 1912-1982
8
Measles incidence US 1912 - 1982 if effective
vaccine available from 1915
9
Age-adjusted measles mortality per 1000 US if
vaccine available from 1915
10
Historically in industrialized countries Close
link between general std. of living and health,
limited effect of specific health interventions
  • 20th/21st century transitions (i.e. in developing
    countries) are often propagated or even initiated
    by health interventions
  • Declines in mortality and then fertility are
    often sharper than seen in present day
    industrialized countries (immunizations, health
    education, early treatment.....)

11
Historical data on health and disease
  • Countries where large differences in S-E status
    (e.g. India and South Africa) Different strata
    of the population are actually simultaneously at
    two different stages of the demographic and
    epidemiological transitions!

Fight at two fronts Cheap - to - prevent/treat
communicable diseases (of children) vs.
expensive - to - treat degenerative diseases of
adults/elderly.
12
The good
  • UN/UNICEF data show that the global child
    mortality rate has declined from 196 (deaths per
    1000 live births) in 1960 to 93 in 1990 to 82 in
    2002
  • Between 1960 and 2002, the child mortality rate
    has fallen in every country in the world.
  • Immunization coverage increased from 5-10 in
    1974 to about 75 by 1990.

Source David Bloom and David Canning, Harvard
University
13
The bad
  • 10.5 million children under the age of 5 (U5)
    died in 2002, accounting for nearly 20 of all
    global deaths (U5 only 10 of world population).
  • 6-7 million of those deaths could have been
    easily averted through immunization and early
    treatment (as they are due to malnutrition, acute
    respiratory infections, diarrhea, malaria, and
    measles).
  • One fourth of children worldwide have not been
    immunized with DTP.

Source David Bloom and David Canning, Harvard
University
14
The ugly.
  • 98 of child deaths occur in developing countries
  • The ratio of child mortality in developing
    countries to child mortality in industrial
    countries was
  • 5.5 in 1960
  • 10.3 in 1990
  • 13.0 in 2002
  • The child mortality rate increased in 15
    countries from 1990-2002, many of which in SSA

Source David Bloom and David Canning, Harvard
University
15
The Lancet 2003 Child survival I
16
Justifications for devoting resources to health
  • moral, ethical, humanitarian
  • basic human right
  • vital social goal

Source David Bloom and David Canning, Harvard
University
17
Justifications for devoting resources to health
  • moral, ethical, humanitarian
  • basic human right
  • vital social goal
  • health is a crucial element in the development of
    strong economies

Source David Bloom and David Canning, Harvard
University
18
About the links between health and wealth.
Source David Bloom and David Canning, Harvard
University
19
Income and Life expectancy in 2001
Source David Bloom and David Canning, Harvard
University
20
Impact of child health on economic growth
developing countries
Commission on Macroeconomics and Health
21
From income to health one part of the story
  • Income

Health
Source David Bloom and David Canning, Harvard
University
22
From income to health one part of the story
  • Income

Health
  • Better nutrition
  • Better access to clean water
  • Better sanitation
  • Improved access to preventive curative health
    services
  • Better psycho-social resources

Source David Bloom and David Canning, Harvard
University
23
From health to income the rest of the story
  • Income

Health
Source David Bloom and David Canning, Harvard
University
24
From health to income the rest of the story
  • Income

Health
  • Productivity
  • Education
  • Investment
  • Demographics

Source David Bloom and David Canning, Harvard
University
25
Health to income
  • Income

Health
A 10 year gain in life expectancy translates into
nearly 1 additional percentage point of annual
growth of income per capita.
In addition to this health effect, demographic
transition accounted for roughly one-third of the
East Asian miracle 2 percentage pts/year.
Comparison E-economy 2-3 percentage points/year.
Source David Bloom and David Canning, Harvard
University
26
The bottom line.
The rate of return to investment in the GAVI
immunization program is conservatively estimated
at 12 in 2005, rising to 18 in 2020.
Source David Bloom and David Canning, Harvard
University
27
By comparison.
These figures are comparable to average rates of
return to investments in schooling (based on a
survey of 98 country studies during
1960-97) primary 19 secondary 13 higher 11
Source G. Psacharopoulos and H. Patrinos,
Returns to Investment in Education A Further
Update, World Bank Policy Research Working Paper
2881, September 2002 (social rates of return from
Table 1).
Source David Bloom and David Canning, Harvard
University
28
Thus

Vaccination and other cost-effective child health
promotion programs have a strong claim to be
powerful instruments of economic growth, poverty
reduction, and human betterment. But A
prerequisite is extensive coverage and equitable
delivery and therefore a functional health system
that can deliver.
Source David Bloom and David Canning, Harvard
University
29
Main Take-Home Message
Immunization and other cost-effective child
health promotion programs can be highly
cost-beneficial tools for promoting both the
health and wealth of nations
Source David Bloom and David Canning, Harvard
University
30
Global Immunization 1980-2002, DTP3
coverageglobal coverage at 75 in 2002
Source WHO/UNICEF estimates, 2003
31
WHO/UNICEF Review of Immunization Coverage in
South Africa 1980-2003 DTP3
32
1990s progress reversed
  • Inequitable globalisation,
  • Health sector reform, and
  • HIV/AIDS result in slow progress and reversals.

Source David Sanders, University of the Western
Cape
33
U5MR in Sub-Saharan Africa
The State of the Worlds Children 2003. UNICEF
34
Research steps in the development and evaluation
of public health interventions
De Zoysa et al, Bull WHO 1998, 76127-133
35
The Lancet 2003 Child survival IV
36
The Lancet 2003 Child survival V
37
Indo-Nepali-Norwegian research consortium on
childhood illnesses and nutrition
  • Generate evidence-base for improving child
    health and nutrition in developing countries.
    Contribute to
  • Improve case management of children with diarrhea
    and pneumonia
  • Reduce the incidence of severe diarrhea and
    pneumonia
  • Promote adequate childhood nutrition
  • Institutional strengthening linked to
    post-graduate education. India?Nepal

38
Zinc syrup supplementation Nepal and India
  • Funding
  • EU-INCO
  • NUFU
  • NORAD

39
Zinc for treatment of diarrhea, Nepal (n1792)
  • Zinc reduced the risk of persistent diarrhea by
    ?40
  • Zinc was equally effective when given by mother
  • Children receiving zinc experienced some more
    regurgitation and vomiting

Strand, T. A., R. K. Chandyo, R. Bahl, P. R.
Sharma, R. K. Adhikari, N. Bhandari, R. Ulvik, K.
Mølbak, M. K. Bhan, and H. Sommerfelt.
Pediatrics. 2002 109 898-903.
40
Zinc for treatment of Diarrhea, India (n2050)
  • Zinc syrup reduced duration and severity
  • Zinc-ORS reduced the duration and severity and
    but was not as efficacious as zinc syrup
  • No adverse effects in the zinc-ORS group, only in
    the zinc syrup group (as in Nepal)

Bahl, R., N. Bhandari, M. Saksena, T. A. Strand,
G. T. Kumar, M. K. Bhan, and H. Sommerfelt. J.
Pediatrics. 2002 141 677-682.
41
Routine zinc supplementation for prevention of
diarrhea and pneumonia, India
  • 2 RDA of zinc (10 or 20 mg) every day for four
    months (1250 children vs. 1250 controls)
  • Reduced incidence of
  • Persistent diarrhea 31 (95CI 2-52)
  • pneumonia 26 (95CI 1-44)

Bhandari, N., R. Bahl, S. Taneja, T. A. Strand,
K. Mølbak, R. J. Ulvik, H. Sommerfelt, and M. K.
Bhan. 2002. Pediatrics. 109 (6) e86.
42
South Africa Among few countries which fortifies
flour with zinc
  • Community- and hospital-based intervention trials
    to measure the efficacy of zinc as adjuvant
    therapy for pneumonia
  • India-Nepal-Norway
  • NUFU ? ?0.6 mill EURO
  • EU-INCO-DC ?0.9 mill EURO

43
Lancet 2003 child survival II
With sufficient 1 or limited 2 evidence
for reducing childhood mortality from the major
causes of under 5 deaths
44
PROMISE-EBF
  • Promoting infant health and nutrition in
    Sub-Saharan Africa Safety and efficacy of
    exclusive breastfeeding promotion in the era of
    HIV
  • EU-INCO ?1.3 mill. EURO

45
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46
Key health research areas to consider
  • Cause-specific burden of disease studies? guide
    intervention-oriented research. Mother and child
    health, HIV/AIDS, TB
  • Studies of disease determinants (SA and SSA) with
    an equity lens
  • Clinical/field trials
  • Efficacy trials
  • Program-relevant effectiveness trials
  • Studies (including trials) of comprehensive,
    community-based approaches
  • Health systems research, particularly on
    operational aspects and on evaluation

47
  • EDCTP aims to
  • accelerate the development of new clinical
    interventions to fight HIV/AIDS, tuberculosis and
    malaria
  • build relevant capacities in developing countries
    for clinical trials-based evaluation of such
    interventions
  • Budget 200ME200ME200ME, of which 25 for
    capacity building
  • , Cape Town selected as hosting institution
    of the African branch office of EDCTP Secretariat

48
Possible strategies for RSA-Norwegian health
research
  • Regional collaboration SADC
  • Other South-South collaboration, e.g. w. India
  • Funding EU/EDCTP SA as a regional nodal point
  • Research linked to postgraduate training and
    institutional strengthening in both (all)
    countries

Management after 2009? ST/NRF and Research
Council of Norway/Norwegian Centre for
International Cooperation in Higher Education?
49
ENKOSI!NGIYA BONGA!DANKIE! THANK YOU! TAKK!
50
  • South Africa Norway
  • March 15 2005
  • Prof. R E Mhlanga,
  • University of Kwazulu-Natal

51
Health collaboration
  • Priorities for the Country
  • Free Health Care for pregnant and lactating women
    and for children under 6 years of age
  • Notification of and Confidential Enquiry into
    Maternal Deaths
  • Micronutrient fortification of basic foods
  • Safe(r) Motherhood
  • Millennium Development Goals
  • PERINATAL HEALTH

52
Health collaboration
  • 130 million babies are born every year
  • 4 million die within 4 weeks of having been born
  • 4 million are born dead
  • Majority are in Sub-Sahara
  • How can perinatal health be improved National
    question
  • How are the initiatives contributing to the
    national solution - SUSTAINABILITY

53
Health collaboration
  • PROPOSALS NATIONAL
  • Management of HIV and other infections
  • Present projects skills for midwives and
    advanced midwives
  • Management and administrative skills for midwives
  • Exchange programmes under- and postgraduate
    students for health
  • Intersectoral collaboration what do partners
    bring to the table to ensure a healthy nation?
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