WHAT CIVIL SOCIETY CAN CONTRIBUTE : RESEARCH, TRAINING AND ADVOCACY TO

ADDRESS CHILD HUNGER AND UNDERNUTRITION

David SandersDirector: School of Public Health

University of the Western Cape

Member of Global Steering GroupPeoples Health Movement

A WHO Collaborating Centre for Research and Training in

Human Resources for Health

Outline of Presentation

Trends in child health and nutrition in the era of Primary Health Care - 1980 to 2004 – with special emphasis on Africa’s health situation

Impact of globalisation, health sector reform and HIV/AIDS on poverty, health “determinants”, health systems and human resources for health

The role of research, training and advocacy in addressing inequities and capacity weaknesses, with illustrative examples from Southern Africa

Despite successes, growing inequalities in global health

widening gap in infant mortality experience

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: babies dying before age 1 per thousand born live

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

Global health inequities

• A woman has a nine in ten chance of reaching the age of 65 years in a high-income OECD country,

• but a four in ten chance in Malawi.

• In Tanzania, every sixth child born alive will die before the age of five years,

• while in high income OECD countries, every 167th child dies before the age of five.

Growing inequalities in child health – within countries

Global Immunization 1980-2002, DTP3 coverage

global coverage at 75% in 2002

2023 25

3744

4852

5664

6975 72 71 72 74 75 75 75 74

7174 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, CIS

Industrialized countries East Asia and Pacific

Latin America and Caribbean Mid-East and N Africa

South Asia Sub-Saharan Africa

Slide Date: October 03

Source: WHO/UNICEF estimates, 2003

Declining Health Systems

Leading global risk factors and contributionsto global burden of disease : % DALYs, World

Rates of childhood stunting

The determinants of child mortalityConceptual framework of causality

Undernutrition

Inadequatedietary intake

Disease

Inadequate health services& unhealthy environments

Inadequate carefor children & women

Inadequate access to food

Resources & controlhuman, economic

& organisational resources

Potential resources

Political & ideological factors, economic structure

Outcome

Immediatecauses

Underlyingcauses

Basic causes

2002 FOOD CRISES IN SOUTHERN AFRICA

2002 FOOD CRISES IN SOUTHERN AFRICA

MALAWI: >70% of population facing food shortages; adult HIV prevalence 15%

MOCAMBIQUE: severe floods 2000, 2001 and 2007: drought 2002: adult HIV prevalence 13%

ZAMBIA: second year of crop failure: few food stocks: adult HIV

prevalence 21.5%

LESOTHO: second year of food shortages: maize prices high; adult HIV prevalence 31%

ZIMBABWE: food shortages: 31.4% of pregnant women in rural areas HIV+

Double Burden

Increased Oil Consumption

Rising Consumption of Poultry

Increasing poverty and inequality worsened by inequitable globalisation,

Selective PHC and Health sector

“reform”, and

HIV/AIDS

….. result in slow progress and reversals.

BUT what are the key ‘Basic Causes’ of Africa’s Health and Health Care Crisis?

The debt crisis, structural adjustment and globalisation:

• A crucial development in the current phase of globalisation…

External debt grows

External debt

• Between 1970 and 2002, African countries borrowed $540 billion from foreign sources, paid back $550 billion (in principal and interest), but still owe $295 billion (UNCTAD 2004)

• Africa spends more on debt servicing each year than on health and education -- “the building blocks of the AIDS response” (Piot 2004)

Debt Service Payments Dwarf Development Assistance Inflows

-150 -100 -50 0 50

East Asia & Pacific

Latin America, Caribbean

Middle East, North Africa

South Asia

Sub-Saharan Africa

US $ billion, 2002 (Source: Calculated from World Bank World Development Indicators database )

Developmentassistance

Debt service

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 and financial market liberalisation

Impact of SAPs on health

“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

Globalisation is primarily about trade…

Globalization, defined as the process of increasing economic, political, and social interdependence and global integration which takes place as capital, traded goods, persons, concepts, images, ideas, and values diffuse across state boundaries, is occurring at ever increasing rates

(Hurrell, 1995, p.447).

…..unfair trade

Northern agricultural subsidies:Japan, the EU and the

US Source: UNDP

HDR 2005

Northern agricultural subsidies go

to large farms, not

smallSource: UNDP HDR

2005

Unfair Trade (1)• “..drawing the poorest countries into the global economy

is the surest way to address their fundamental aspirations”

(G8 Communiqué, Genoa, July 22, 2001)

• BUT… many developing countries have destroyed domestic economic sectors, such as textiles and clothing in Zambia (Jeter 2002) and poultry in Ghana (Atarah 2005), by lowering trade barriers and accepting the resulting social dislocations as the price of global integration

.

Unfair Trade (2)

• In addition industrialized countries apply much higher tariffs (tariff peaks), sometimes amounting to more than 100 percent, to the labour-intensive exports that are of special importance to developing countries. For example, the EU tariff on raw cocoa exported from Ghana is just 0.5 percent, but the tariff rises to 30.6 percent on chocolate imported from the same country (Elliott 2004b). Thus, although 90 percent of cocoa beans are grown in developing countries, they account for just four percent of the value of global chocolate production (IMF, 2002).

Trends in income inequality, selected Latin American & Caribbean countries

0

10

20

30

40

50

60

70

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

UruguayVenezuelaArgentinaCosta RicaChileEl SalvadorJamaicaMexicoBrazil

Share of nationalincome, ratio oftop to bottom decile

Source: de Ferranti et al, 2004 (Table A.2)

The result… unequal growth of wealth within countries

The result… unequal growth of wealth between countries

..and unequal distribution of global income

UNDP 1997

..and growth of poverty

•According to the World Bank’s most recent figures, in sub-Saharan Africa 313 million people, or almost half the population, live below a

standardized poverty line of $1/day or less (Chen and Ravallion 2004).

•Sub-Saharan Africa is the only region of the world in which the number of people living in extreme poverty has increased – indeed, almost

doubling between 1981 and 2001.

Governance - Bribery & Corruption

• SAPs, by lowering public expenditures and workers’ salaries, abetted low level corruption as a means of survival

(Hanlon, How Northern Donors Promote Corruption, The Corner House, 2004)

• Superpowers in Africa “backed venal despots who were less interested in developing their national economies than in looting the assets of their countries…”

• Amongst worst MNC bribery offenders are those located in G8 countries

(Transparency International)

0 500 1000 1500 2000 2500 3000

US dollars

J apan annual dairy subsidy, per cow

EU annual dairy subsidy, per cow

Per capita annual income, sub-Saharan Africa

Per capita cost of package of essential health interventions

Per capita annual health expenditure, 63 low income countries

Why should a Japanese cow enjoy a higher income Why should a Japanese cow enjoy a higher income than an African citizen?than an African citizen?

The Health System, its financing and Health Sector

‘Reform’

Sub-Saharan African Country per capita expenditures on health (1997-2000)

Recommended expenditure: >$60/capita (Brundtland); >$34/capita (CMH)

Number of countries Amount of spending

4 > $60

2 $34 - $60

11 $12 - $34

18 < $12

13 Data not available or population <1.5 million

World Bank, World Bank, World Development ReportWorld Development Report 2004 2004

• For instance, Ethiopia spends 22% of its national budget on health and education, but this amounts to only US$1.50 per capita on health. Even if Ethiopia were to spend its entire budget on healthcare, it would still not meet the WHO target of US$30–40 per capita (Save the Children 2003).

• ““Countries just don’t have enough money.” Countries just don’t have enough money.”

Rt. Hon. Hilary Benn, April 2004, Rt. Hon. Hilary Benn, April 2004, WFPHA/UKPHA, BrightonWFPHA/UKPHA, Brighton

A focus on cost-effective technologies and a neglect of social and environmental determinants of health has proposed essential “packages” of interventions – reminiscent of selective PHC..

Public Health package: Immunizations School-based health services Family planning and nutrition education Programs to reduce tobacco

and alcohol consumption Actions to improve the household environment

Clinical package: Pregnancy-related services Family planning and STD

services Tuberculosis control,

mainly through drug therapy

Care for the common serious illnesses of young children - IMCI

Health sector ‘reform’Quest for efficiency

“[C]ost-effectiveness analyses have shown improved water supply and sanitation to be costly ways of improving people’s health. …. encouraging people to wash their hands and making soap available have reduced the incidence of diarrhoeal disease by 32% to 43%... (Commission on Macroeconomics and Health,2001/02)

For example, water provision can:

Improve hygiene practice and thus reduce incidence of diarrhoeal diseaseSave women’s time for caring and economic activity, thus improving household income and food securityContribute to increased agricultural production, thus improving household income and food security

CEA cannot evaluate the effectiveness of ‘broader’ interventions that may result

in health improvement through numerous direct and indirect

mechanisms

..subverting the Mission of Public Health

“Ensuring the conditions in which people can be healthy”

(Institute of Medicine)

A return to vertical programmes; Erosion of intersectoral work and

community health infrastructures Fragmentation of health services and

reversal of health gains

Health sector ‘reform’ Quest for efficiency cont.- The move from equity and comprehensiveness to efficiency and selectiveness leads to:

AIDS and Aid may both disrupt health systems…

Labonte, 2005, presentation to Nuffield Trust

In 2000, Tanzania was preparing 2,400 quarterly reports on separate aid-funded projects and hosted 1,000 donor visit meetings a year.

At last count there were over 90 GHIs (the best known being GAVI, GFATM, Pepfar), each funding different diseases and programmes.

Health systems & personnel in Africa

Health personnel vital, consume between 60 – 80% of recurrent public health expenditure (WB, 1994).

Burden of diseaseBurden of disease

Share of populationShare of population

Share of health workersShare of health workers

Our Common Interest 2005:184 Our Common Interest 2005:184

NURSE REGISTRATION IN UK :Increase during a period when a “ban” on active international recruitment had just come into effect

Buchan et al 2003

The brain drain

In relation to health care professionals, especially nurses … there are aggressive and targeted international recruitment initiatives.

The UK government, for example, has stated that international recruitment is part of the solution to meeting its staffing needs.

This type of active recruitment can have a marked effect on a sending country, especially because it … is aimed at getting significant numbers of workers from the country …

International migration—winners & losers How much do importing countries gain from

international migration?

UN Conference on Trade and Development (UNCTAD):for each professional aged between 25 and 35 years, US$ $184,000 is saved in training costs by rich countries

(UNECA, 2000)

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

Enhancing Capacity for Public Nutrition Action

Decentralised health services have dramatically increased need for public health skills – for policy, advocacy, planning, programme design, implementation, monitoring and evaluation

Implementation Cycle

Capacity Development

Advocacy

Teambuilding

Analysis

Situational Assessment

Planning

Implementationand Management

EvaluationPolicy

Components of Capacity to Perform Tasks

Have the knowledge and skills to perform the tasks

Accept responsibility to carry out the tasks

Have the authority to carry out the tasks

Have access to and control of resources necessary to perform the tasksAfter Gillespie and Jonsson

Potter and Brough (2004).

Household and Community Capacities

The Challenge in Research and Training

Need to train personnel from different backgrounds to facilitate process of change

Short to medium term priority is to upskill those already in the field

Needs to be as least disruptive, both to the participants and the health services, as possible

Key focus areas for public health research

Research and advocacy on health determinants (local and global) with an equity lens

Participatory research on health systems, particularly on effectiveness - operational aspects and evaluation, and on human resources

Case studies of comprehensive, community-based approaches

Sanders et al, Bull WHO 2004,

82(10)

1. Examples of Priority Research and Advocacy

Research on health determinants and equity – at a global level

Available from University of Cape Town Press, 2004.

Online ordering andprepublication proofs

available at:http://web.idrc.ca/ev.php?ID=45682_201&ID2=DO_TOPIC

“Determinants” research: a global example

What We Did

Identified health-related commitments made at 1999, 2000, 2001 summits

Updated to 2002, 2003 and 2004 summits

Commitments either relate directly to health, or

Have implications for policy areas that affect the determinants of population health (e.g. macroeconomic policy, trade and market access, environment)

Assessed Commitments with Respect to Three Criteria:

Have the G8 lived up to the commitment?

Was the commitment adequate, when measured against the need addressed?

Was the commitment appropriate, or was it, e.g., rooted in an economic model that may actually undermine determinants of health?

What We Found (1999 – 2001):

Promises kept: 8 or 9*

Promises broken: 17 or 18*

* * Depends on whether one regards the 2003 TRIPSDepends on whether one regards the 2003 TRIPS Council ruling on parallel imports as a kept or brokenCouncil ruling on parallel imports as a kept or broken promisepromise

Development assistance as % of Gross National Income

00.10.20.30.40.50.60.70.80.9

1

FY 2003

NorwayDenmarkLuxembourgNetherlandsSwedenBelgiumFranceIrelandUKAustraliaCanadaNew ZealandUS

Source: Source: OECD/DAC Annual Report 2004OECD/DAC Annual Report 2004

Anglo-American

Annual cost of meeting the 0.7 percent of GNI ODA target, in Big Macs/capita

0

10

20

30

40

50

60

70

80

90

Canada

France

Germany

Italy

Japan

U.K.

U.S.

Based on 2002 ODA figures from OECD, Big Mac prices Based on 2002 ODA figures from OECD, Big Mac prices from from The EconomistThe Economist, April 25, 2002, April 25, 2002

“Too much of the history of the industrialised world’s involvement in Africa is a miserable history of broken promises.”

Report of the Commission for Africa, 2005, p.18Report of the Commission for Africa, 2005, p.18

2. Examples of Priority Research

Research on health determinants and equity – at a local level

The Cape Town Equity Gauge

Part of a global movement: Global Equity Gauge Alliance (GEGA)

14 initiatives:

11 country initiatives

3 city initiatives Funded by Rockefeller Foundation

Equity requires a balance between resources and needs

Health DistrictGeographic Area

ResourcesNEEDS

Example: Resource allocation in Primary Care

To assess health need To assess primary care resources and

compare to need To develop a resource allocation tool to

rectify the inequities

0

10

20

30

40

50

Ath

lone

Bla

auw

berg

Cen

tral

Hel

derb

erg

Kha

yelit

sha

Mitc

hells

Pla

in

Nya

nga

Oos

tenb

erg

SP

M

Tyg.

Eas

t

Tyg.

Wes

t

Reg

ion

Infant Mortality Rate

0%

2%

4%

6%

8%

10%

12%

Ath

lon

e

Bla

au

wb

erg

Cen

tral

Held

erb

erg

Kh

aye

lits

ha

Mit

ch

ell

sP

lain

Nyan

ga

Oo

ste

nb

erg

So

uth

Pen

ins

ula

r

Tyg

erb

erg

Eas

t

Tyg

erb

erg

We

st

HIV prevalence 2000(estimate)

0%

20%

40%

60%

Athl

one

Blaa

uwbe

rg

Cent

ral

Held

erbe

rg

Khay

elits

ha

Mitc

hells

Plain

Nyan

ga

Oost

enbe

rg SP

M

Tyge

rber

gEa

st

Tyge

rber

gW

est

TOTA

L

% households below the poverty line

0%10%20%30%40%50%60%

Athlo

ne

Blaa

uwbe

rg

Cen

tral

Held

erbe

rg

Khay

elits

ha

Mitc

hells

Plai

n

Nyan

ga

Oos

tenb

erg

SPM

Tyge

rber

gEa

st

Tyge

rber

gW

est

TOTA

L

% unemployed

Health Need across Cape Town Districts

Distance to Equity in Resource Allocation for Primary Care (Health Centres and Clinics)

-20,000,000

-15,000,000

-10,000,000

-5,000,000

0

5,000,000

10,000,000

15,000,000

20,000,000At

hlon

e

Bla

auw

berg

Cen

tral

Hel

derb

erg

Kha

yelit

sha

Mitc

hells

Pla

in

Nya

nga

Oos

tenb

erg

Sou

thP

enin

sula

Tyge

rber

gE

ast

Tyge

rber

gW

est

ME

TRO

PO

LE

3. Examples of Priority Research

Participatory research on health systems, particularly on effectiveness - operational aspects and evaluation, and on human resources

More focus on Health Systems Research to improve coverage and quality of care

As well as researchers asking “what, why, where, and who?”

We should be asking “How?” ie increase research on health systems, particularly

on effectiveness - operational aspects and evaluation

Berg A Sliding toward nutrition malpractice: time to reconsider and redeploy Am J Clin Nutr 1993

AN EXAMPLE OF EFFECTIVENESS RESEARCH: 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

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 Assessment

Planning

Implementationand Management

EvaluationPolicy

CASE FATALITY IN RURAL HOSPITALS

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%

Implementation Cycle

Capacity Development

Advocacy

Teambuilding

Analysis

Situational Assessment

Planning

Implementationand Management

EvaluationPolicy

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

Comparison of recommended and actual practices

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

Evaluation of Implementation

Major improvements: 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

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 moraleAshworth et al, Lancet 2004; 363:1110-1115

CHANGES IN CFRs IN RURAL HOSPITALS

0

5

10

15

20

25

30

35

40

45

50

Holy-cross St. Patricks Mt. Ayliff St. Elizabeth

1998-1999

2000-2001

2002

2003

Educational Strategies

Based on assessed training needs

Problem-oriented Adult education

techniques Linked to systems

development

Distance learning materials

Training guides Location should be

as close to workplace as possible

Training of teams Follow-up support

4. Case studies of comprehensive, community-based approaches

Ceará, Brazil Early1980s IMR over100 per 1,000 and malnutrition very common 1986 statewide survey of child health and nutrition resulted in new health

policies, including GOBI plus vitamin-A supplementation.

Coverage improvement through large new programmes of community health workers and traditional birth attendants.

health services decentralised to rural municipalities with worst health indicators

social mobilisation campaign for child health implemented using media and small radio stations to broadcast educational messages

surveys repeated in 1990 and 1994, and results incorporated into health policy. This process was sustained by four consecutive state governors

Improved outputs By 1994 ORS use increased to more than 50 per cent nearly all children had a growth chart and half had been weighed

within the previous three months immunisation coverage was 90 per cent or higher; and median

breastfeeding duration increased from 4.0 to 6.9 months.

Improved outcome indicators low W/A fell from 12.7% to 9.2%; low H/A from 27.4% to 17.7% reduced diarrhoea from 26.1% to 13.6% IMR fell from 63 per 1,000 live births in 1987 to 39 per 1,000 in 1994 diarrhoea deaths fell from 48% to 29% perinatal deaths increased as a proportion from 7 per cent to 21 per cent and

respiratory infections from 10 per cent to 25 per cent. (Victora et al, 2000)).

Conclusions

Main actions required from Public Nutrition Community: Challenge unfair globalisation and ill-considered health sector reforms

through research and advocacy

Advocate for increased investment in enhancing capacity of and reorientating Southern institutions (incl. equitable collaboration/partnerships with Northern institutions)

Develop capacity through health systems research, practice-based and problem-oriented training.

Improve quality of interventions and develop well-managed comprehensive programmes

Involve other sectors and communities

Support with better management systems

Focus on health centres

Rapidly (re)train CHWs

Provide resources to and develop partnerships with progressive civil society

PEOPLE´S HEALTH MOVEMENT

The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHO’s strategy of Primary Health Care.  

www.phmovement.org

www.ghwatch.org

Unfair Trade (1)• “..drawing the poorest countries into the global economy is the surest way to

address their fundamental aspirations”

(G8 Communiqué, Genoa, July 22, 2001)

• BUT… many developing countries have destroyed domestic economic sectors, such as textiles and clothing in Zambia (Jeter 2002) and poultry in Ghana (Atarah 2005), by lowering trade barriers and accepting the resulting social dislocations as the price of global integration

• Import liberalization was a key element of structural adjustment programs; a recent study found that PRSPs may include “trade-related conditions that are more stringent, in terms of requiring more, or faster, or deeper liberalization, than WTO provisions to which the respective country has agreed”(Brock and McGee 2004) .

The Notion of “Capacity”

Potter and Brough (2004).

Potter and Brough (2004).

Household and Community Capacities

Potter and Brough (2004).

Household and Community Capacities