1. Child Health: Overview Dr E Malek, Principal Specialist Department of Paediatrics, University of Pretoria, Witbank Hospital emalek@postino.up.ac.za

2. Acknowledgements Dr Joy Lawn (Save the Children Fund) DR Lesley Bamford (National DOH) Dr Debbie Bradshaw (MRC NBD unit) Prof T Duke (CICH, University of Melbourne) Dr M Weber (WHO-CAH, Geneva) Dr N McKerrow (PMB Hospital) DR Macharia (UNICEF, Pretoria) Dr N Rollins (UKZN) DR C Sutton (MEDUNSA, Polokwane)

3. Outline Global child health Child Health in South Africa

4. Global Context (1) Child Health Inequity Causes of global child mortality Child disability and development Neonatal Health Adolescent Health Children in complex emergencies Effect of poor child health on communities

5. Global Context (2) Child Health in context of Maternal Health International Conventions and child health Evidence for effective intervention in reducing child mortality Pathways to & principles of global child health

8. Source: Bryce J et al for the Child Health Epidemiology Reference Group. The Lancet, March 2005. As used in WHR 2005 10 million child deaths – Why? For these 4 causes, ~ 53% of deaths are malnourish ed children AIDS is much bigger proportion in Southern Africa.

9. 4 million newborn deaths – Why? Source: Lawn JE, Cousens SN, Zupan J Lancet 2005. for 192 countries based on cause specific mortality data and multi cause modelled estimates. As used in World Health Report 2005 60 to 90% of neonatal deaths are in low birth weight babies, mostly preterm Three causes account for 86% of all neonatal deaths

10. Source: UNICEF, 2001 Under five mortality rates: Trends from 1990- 2000 Slide: Ngashi Ngongo

16. International Conventions Declaration of Alma Ata: “Health for All by the year 2000” UN Convention of the Rights of the Child (1990) UN Millenium Development Goals (MDGs)

17. Millennium Development Goals (MDGs) 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empowerment of women 4. Reduce child mortality by two thirds 5. Reduce MMR by three quarters 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop global partnerships for development

21. Integrated Management of Chilldhood Illness (IMCI)

22. IMCI facility based usage in Bangladesh (Lancet, 2004)

23. WHO Initiatives to improve quality of care for children at hospital level: state of the art and prospects Martin Weber, Harry Campbell, Susanne Carai, Trevor Duke, Mike English, Giorgio Tamburlini 25 th International Congress of Paediatrics, Athens, 25-30 August 2007

25. Standards of Hospital Care for Children: Hospital IMCI Evidence-Based Guidelines

27. Child Health in South Africa Child Health Inequity Causes of Child Mortality Neonatal Health National interventions for improving child health Children’s Act (Amendment Bill: 2007) Challenges

28. UNICEF remarks at opening of SA Child Health Priorities conference (Dec 2007, Durban)

29. Distribution of Resources

32. Slide: Ngashi Ngongo

34. South Africa progress to MDG 4 Under 5 mortality is increasing, related to HIV (73 000 a year) Neonatal mortality is probably static and accounts for ~30% of under five deaths (23,000 newborn deaths a year) Source: Lawn JE, Kerber K Opportunities for Africa ’ s Newborns. PMNCH, 2006

36. Causes of U5M Source: MRC 2003

38. Every Death Counts

40. Challenges: Health Service in South Africa

42. Child Mortality (1) The National Burden of Disease study estimated just over half a million deaths of which 106 000 were of children under the age of 5 years A further 7800 were children aged 5-14 years. An estimated 4564 deaths are from protein- energy malnutrition (Kwashiorkor) In general, young babies are much more vulnerable than older The cause of death patterns in the different age groups are very different.

43. Top twenty specific causes of death in children under 5 years, South Africa 2000 (NBD)

44. Leading causes of death among infants under 1 year of age, South Africa 2000

46. Child Mortality (2) The NBD study estimates that by the year 2000, –the Infant Mortality Rate had risen to 60 per 1000 live births and –the Under-5 mortality rate had risen to 95 per 1000. This deterioration in child health occurred despite the introduction of free health care and nutrition programmes and was attributable to paediatric AIDS, commensurate with the high prevalence of HIV observed among pregnant women.

47. Leading causes of death among children aged 1-4 years, South Africa 2000

49. Child Mortality (3) As children get older, external causes of death (eg. road traffic injuries and drowning) rise in importance. This is particularly noticeable among boys who die in greater numbers than girls. This pattern becomes particularly marked among the 10 -14 year age group, where road traffic accidents is the leading cause of death. Homicide and suicide feature in the top causes among the 10-14 year age group, homicide is the second leading cause of death.

50. * Source: WHO World health Statistics 2006 www.who.intwww.who.int Child PIP (%) (1532 deaths) 1 month to 5 years WHO* (%) Zero to 5 years HIV/AIDS - 57 Pneumonia 22 1 Septicaemia/meningitis 21 - Diarrhoea 20 1 TB 5 - PCP 11 - Other 19 1 Malaria - 0 Measles - 0 Injuries Included under “other” 5 Neonatal (16% of all admissions but causes tabulated for 1 month to 5 years) 35 Child deaths in RSA - Why? HIV test ~ 54% tested 26% +ve 20% exposed Only 8% tested -ve HIV clinical stage ~ 58% staged of which half were Stages III & IV 88% HIV if exclude neonatal Most deaths 1 month to 5 yrs Child PIP in Mpumalanga: ChPIP Data: Witbank Hospital had 2244 child admissions & 101 child deaths in 2006; overall case fatality rate 4.5; 31% of all deaths within 1 st 24 hours of admission ChPIP Sites: 2004: Witbank 2006: Witbank & Barberton 2007: above plus 8 new sites

51. Causes of death of children in hospitals (n = 1695)

52. Child Mortality: HIV/AIDS 1998 SADHS U5MR 61/1000 (1994-8) 2003 SAHDS U5MR 58/1000 (1999-2003)? Without PMTCT one third of babies born to HIV+ mothers will be infected: of these, 60% expected to die before 5 years of age 40% U5 hospital deaths due to AIDS Child mortality in SA too high for middle-income country, and increasing, despite children’s rights

53. Child mortality: HIV/AIDS Vertical transmission rate 20.8% (KZN) <50% pregnant women being tested 2/3 all HIV+ infants needing ART by 10 months of age – without access to ARV 1/3 of HIV+ children die in 1 st year of life One in 6 qualifying children get ARV

54. Policy Brief: Child Mortality The Medical Research Council published the Initial Burden of Disease Estimates for South Africa, 2000 in March 2003. A major finding of the study was the quadruple burden of disease experienced in South Africa resulting from the combination of the pre- transitional causes related to underdevelopment, the emerging chronic diseases, the injury burden and HIV/AIDS.

55. Policy Implications (1) The mortality data indicates that many of the child deaths occurring in South Africa are preventable. We have identified three broad areas that will require differing approaches for intervention:

56. Policy Implications (2) 1. The prevention of mother-to-child transmission of HIV, even at its current efficacy, is the single most effective intervention to reduce mortality among under-5-year olds, eclipsing all other interventions for other causes of death combined.

58. Policy Implications (3) 2. Although dominated by the rise of HIV/AIDS, the classic infectious diseases such as diarrhoea, respiratory infections and malnutrition are still important causes of mortality. Environment and development initiatives such as access to sufficient quantities of safe water, sanitation, reductions in exposure to indoor smoke, improved personal and domestic hygiene as well as comprehensive primary health care will go a long way to preventing these diseases. Poverty reduction initiatives are also important in this regard.

59. Policy Implications (4) 3. Road traffic accidents and violence, which includes homicide and suicide is another group of high mortality conditions that will require dedicated interventions.

60. PMTCT (1) Most important intervention to reduce HIV infection in children Almost all ANC services provide PMTCT, but many barriers to testing and effective treatment. Cotrimoxazole prophylaxis from 6 weeks of age reduces HIV related child mortality by as much as 43%

61. PMTCT (2) Recommendation: Mandatory testing all children at 6 week immunisation visit & double testing of pregnant women Currently 300 000 HIV infected children – 50-60% expected to currently need ARV’s SA is one of only 9 countries world-wide where child mortality is increasing

62. PMTCT (3) Routine provider-initiated testing for all 6 week old infants is currently excluded from the NSP on HIV/AIDS Memorandum of concern: Maternal & Child survival (2007) TAC Media Statement: Call for finalisation of Revised PMTCT Guidelines (Jan 2008)

63. Key Child Survival Strategies 1.Infant and Young Child Feeding (including EBF) 2.Immunisation 3.Treatment of common childhood illnesses 4.Care of children with HIV-infection 5.Provision of Vitamin A 6.PMTCT

64. National Health Targets

65. Key MCH interventions MATERNAL CARE 1.Focused ANC 2.PMTCT-Plus 3.Skilled attendant deliveries 4.EMOC 5.Family planning NEONATAL CARE Basic neonatal care 1.Resuscitation 2.LBW care 3.Early EBF 4.KMC 5.PMTCT-Plus 6.Infection management CHILD CARE 1.Infant and Young Child Feeding 2.HIV care 3.IMCI (clinic) 4.Hospital care 5.EPI 6.Vitamin A 7.HIV testing, cotrim, ARV

66. South Africa: Coverage along the MNCH continuum of care Source: Lawn JE, Kerber K Opportunities for Africa ’ s Newborns. PMNCH, 2006 The days of highest risk have the lowest coverage of care

69. Infant and Young Child Feeding Exclusive breastfeeding (BFHI) Provision of good quality complementary feeds Appropriate care of children with malnutrition

70. Only 12% of infants EBF by 6 months Source: Demographic Health Survey 2003 Slide: Ngashi Ngongo

71. Immunisation Good coverage Major reduction in number of children with measles South Africa declared polio free Need to ensure high coverage is maintained, and to use every opportunity to immunise children Community outreach programmes RED STRATEGY Management issues e.g. cold chain, monitoring coverage Not linked to HIV screening (6 week visit!)

72. Existing norms and standards Primary Health Care package District Hospital package Regional hospital package Service Transformation Plan Modernization of Tertiary Services

73. Existing norms and standards IMCI Clinic supervisors manual EDL WHO pocketbook

74. Staffing norms No official staffing norms for the country Various systems have been used

75. Service transformation plan PHC clinics: 1 for 10 000 people CHC: 1 for 60 000 people District hospital: 1 for 300 000 people Regional (Level II) hospital:1 for 1.2 million Tertiary (Level III) hospital:1 for 3- 3.5million people

76. Standard Treatment Guidelines & Essential Drug List

78. Care of children with HIV-infection Prevention is key Early diagnosis and preventive care Staging and referral for ART when appropriate Psychosocial support

79. IMCI IMCI: Bringing it all together Maternal Health HOUSEHOLD AND COMMUNITY IMCI EPI Nutrition (Vitamin A) Care of HIV infected children PMTCT Plus Appropriate infant feeding

83. TEMBA BARBERTON PIET RETIEF ERMELO CAROLINA STANDERTON WITBANK MIDDELBURG TINTSWALO EVANDER ROB FERREIRA Active Site Future Site

84. Witbank NNMR 2000-2005 trend (=/> 1000 grams) N ICU nCPAP

89. References SA IMCI chart booklet: UP Intranet (Block 10) www.who.int/child-adolescent- health/publications/CHILD_HEALTH/PB.htmwww.who.int/child-adolescent- health/publications/CHILD_HEALTH/PB.htm www.who.int/child-adolescent-health/over.htm www.ichrc.org www.unhchr.ch/html/menu3/b/k2crc.htm www.unicef.org/sowc02 www.developmentgoals.org/Child_Mortality.htm www.doh.gov.za www.thelancet.com

90. “There can be no keener revelation of a society’s soul than the way it treats its children” Nelson Mandela, 1988