Presentation on theme: "Possible themes for South African- Norwegian Health research collaboration Halvor Sommerfelt, MD, PhD University of Bergen, Currently: University of the."— Presentation transcript:
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
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
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
Standardized mortality rates US 1900- 1973+gross national product->Medical care
Age-adjusted measles mortality per 1000 US 1900-1973 Vaccine Similar for other major infectious diseases, the interventions came “too late” Vaccines: diphteria, whooping cough Treatment: TB, pneumonia, diarrhea
Measles incidence US 1912 - 1982 if effective vaccine available from 1915 Vaccine
Age-adjusted measles mortality per 1000 US if vaccine available from 1915 Vaccine
Historically in industrialized countries: Close link between general std. of living and health, limited effect of specific health interventions 20 th /21 st 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.....)
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.
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
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
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
South Africa: The Lancet 2003: Child survival I TB
Justifications for devoting resources to health moral, ethical, humanitarian basic human right vital social goal Source: David Bloom and David Canning, Harvard University
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
About the links between health and wealth…. Source: David Bloom and David Canning, Harvard University
Income and Life expectancy in 2001 Source: David Bloom and David Canning, Harvard University
Impact of child health on economic growth developing countries Commission on Macroeconomics and Health
From income to health: one part of the story Income Health Source: David Bloom and David Canning, Harvard University
From income to health: one part of the story Income Better nutrition Better access to clean water Better sanitation Improved access to preventive & curative health services Better psycho-social resources Health Source: David Bloom and David Canning, Harvard University
From health to income – the rest of the story Income Health Source: David Bloom and David Canning, Harvard University
From health to income – the rest of the story Income Productivity Education Investment Demographics Health Source: David Bloom and David Canning, Harvard University
Health to income Income A 10 year gain in life expectancy translates into nearly 1 additional percentage point of annual growth of income per capita. Health 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
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
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
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
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
Global Immunization 1980-2002, DTP3 coverage global coverage at 75% in 2002 Source: WHO/UNICEF estimates, 2003
WHO/UNICEF: Review of Immunization Coverage in South Africa 1980-2003: DTP3 DEMOGRAPHIC AND HEALTH SURVEY (DHS) REPORT FOR EASTERN CAPE 1998
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
U5MR in Sub-Saharan Africa The State of the World’s Children 2003. UNICEF
Describe the problem. Disease burden studies Explore the contextual factors Select possible interventions Test interventions Identify risk factors Formulate public health interventions Assess efficacy of public health interventions Assess effectiveness of public health interventions Research steps in the development and evaluation of public health interventions De Zoysa et al, Bull WHO 1998, 76:127-133
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
Zinc syrup supplementation Nepal and India Funding: EU-INCO NUFU NORAD
Zinc for treatment of diarrhea, Nepal (n=1792) 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.
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) Zinc for treatment of Diarrhea, India (n=2050) Bahl, R., N. Bhandari, M. Saksena, T. A. Strand, G. T. Kumar, M. K. Bhan, and H. Sommerfelt. J. Pediatrics. 2002; 141: 677-682.
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% (95%CI 2-52%) –pneumonia 26% (95%CI 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.
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
With sufficient  or limited  evidence for reducing childhood mortality from the major causes of under 5 deaths Lancet 2003 child survival II
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
Burkina Faso Uganda Zambia South Africa Sweden Norway France
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
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: 200ME+200ME+200ME, of which 25% for capacity building, Cape Town selected as hosting institution of the African branch office of EDCTP Secretariat
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?: S&T/NRF and Research Council of Norway/Norwegian Centre for International Cooperation in Higher Education?
South Africa – Norway March 15 2005 Prof. R E Mhlanga, University of Kwazulu-Natal
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
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
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?