GLOBAL HEALTH RESEARCH: A PERSPECTIVE FROM THE SOUTH

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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

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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

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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

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Growing inequalities in global health
IMR
SSA
World
UNICEF State of the Worlds Children
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U5MR in Sub-Saharan Africa
The State of the Worlds Children 2003. UNICEF
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1980s

• Mixed progress in implementing
• health policies

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Progress in Implementing PHC Programme Elements
(Source WHO 1998)
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Selective Primary Health CareChild Survival and
Development Revolution

• Growth Monitoring
• Oral Rehydration Therapy
• Breast Feeding
• Immunisation
• Family Planning
• Food Supplements
• Female Education

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1990s progress reversed

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

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The institutions promoting globalisation

• World Bank
• International Monetary Fund (IMF)
• World Trade Organisation (WTO)

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The debt crisis structural adjustment

• A crucial development in the current phase of
  globalisation

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External debt
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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)

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The global growth of poverty
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Global distribution of income
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The Health System, its financing and its human
resources
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Health expenditure
(Source UNDP Human Development Report, 2000)
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Actual amounts of per capita public health
expenditure in Africa
(Source Human Development Report, 2000)
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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

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Health personnel / population ratios
Health personnel vital, consume between 60 80
of recurrent public health expenditure (WB, 1994).

• 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

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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

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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.

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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
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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

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

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

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

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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

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

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WHO 10-STEPS PROTOCOL Nutrition component of
hospital level IMCI
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Implementation Cycle
Advocacy
Policy
Evaluation
Capacity Development
Teambuilding
Implementation and Management
Situational Assessment
Planning
Analysis
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Comparison of recommended and actual
practices in Mary Theresa and Sipetu hospitals
and perceived barriers to quality of care of
malnourished children
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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

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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

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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

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CHANGES IN CFRs IN RURAL HOSPITALS
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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?

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• 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

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• 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

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

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DEMOGRAPHIC SOCIO-ECONOMIC FACTORS
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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

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• STAPLE FOOD INVENTORY LIST
• Samp / Maize
• Beans
• Maize Meal
• Flour
• Rice
• Sugar
• Soup
• Tea / Coffee
• Milk
• Oil
• Peanut Butter
• Eggs

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• 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

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

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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

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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
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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

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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?

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What we found

• Promises kept 10
• Promises broken 17
• Figures changed since book went to press.

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Promises kept
Promises broken
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Determinants research a local example The
Cape Town Equity Gauge
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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

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Equity Gauge5 Pillars

• Measurement
• Advocacy
• Community Participation
• Resource Allocation Framework
• Implementation

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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

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Infant Mortality Rate (IMR)
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HIV prevalence 2000 (estimates)
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Households below poverty line
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Inequity in Public Primary Care Expenditure
Zero line represents an average equitable
expenditure
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District Health Information SystemsThe South
African Experience

• Developing a Routine District Health Information
  System
• and
• Conducting Research on Information Systems

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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

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Enhancing Capacity for Public Health Research and
Action
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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

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Matrix of programmes and systems components
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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

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

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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

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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