PHA-Exch> Meeting Child Survival targets in South Africa

[Claudio Schuftan]

   Millennium Development Goals: Progress & prospects for meeting Child
Survival targets in South Africa

David Sanders, Louis Reynolds, Tony Westwood, Brian Eley, Max Kroon, Heather
Zar,

Mary-Ann  Davies, Phumza Nongena, Tharina van Heerden, George Swingler
 T*he Millennium Development Goals are eight goals that 189 United Nations
Member states including South Africa are committed to achieve by 2015. This
paper takes a critical look at South Africa's prospects for meeting the MDG
targets for child survival. *

MDG 4 commits South Africa to reduce the under-5 mortality rate (U5MR) from
1990 levels by two thirds in 2015.
The U5MR in South Africa in 1990 was 60, South Africa needs to achieve an
U5MR of 20 by 2015 to meet the MGD 4 targets.
In contrast to most countries, the U5MR in South Africa is rising rather
than declining. Based on current trends, unless urgent measures are taken to
address the main causes of under 5 child death, South Africa has little hope
of reaching the MDG. To develop an effective intervention strategy, a
critical examination of the determinants of under-5 mortality is necessary.

*Causes and trends in child mortality *

The determinants of childhood mortality and morbidity remain unchanged.
HIV/AIDS, diarrhoea, acute respiratory infections. low birth weight and
malnutrition are the biggest killers of small children.

Most of these conditions are preventable or, when prevention fails, easily
treatable. Overwhelmingly they affect children living in conditions of
poverty and socio-economic exclusion.
*Underlying determinants of child death*

The proximal underlying risk factors for both maternal and child
under-nutrition are dietary inadequacy and frequent disease (especially
diarrhoea and HIV/AIDS) and, in the case of mothers, excessive physical
labour.

In turn, household food insecurity, inadequate child-caring practices and
poor health and environmental services underlie inadequate diets and
frequent illness among children.

Underlying most common childhood infections and infestations are
environmental risk factors that include inadequate sanitation and water
supply, poor hygiene practices, and poorly ventilated, crowded, smoky living
spaces.

The more distal risk factors are clustered within households affected by
poverty. These include "poverty", which is in effect a lack of access to a
range of resources, whether financial, physical, educational or
organisational. The most basic, or upstream, risk factors are structural.
They operate at local, national and global levels. They include but are not
limited to policies and programmes in the areas of: Social welfare and
employment, Housing, Environmental health, Land and agriculture, and Micro-
and macro-economics, including trade.
 At the global level, trade policies and patterns (including trade in
services and intellectual property rights) play an increasingly important
role in shaping diets, as well as affecting food security, the nature of
work, and access to basic services. Dominant and neo-conservative
macro-economic policies, which emphasise fiscal stringency above all other
considerations, place a limit on the State's investment in those services
important for child health.
*Towards Meeting the Millennium Goals*

The past few decades have seen impressive advances in our understanding and
technical ability to prevent, treat and mitigate the effects of many
childhood illnesses. Key examples are immunisation, treatment of diarrhoeal
dehydration and prevention of mother-to-child transmission of HIV. The
challenge, increasingly, is to implement successfully these efficacious
interventions, especially among the poorest, and to adopt social policies
that improve equity in child health.

Despite a widening gap between rich and poor, in terms of health outcomes
and access to services, there are examples of successful large scale child
health and nutrition programmes. Most of these examples demonstrate the
successful implementation of a comprehensive primary health care approach
where interventions have simultaneously addressed the immediate (proximal)
and the underlying (distal) factors impacting on child survival and health.
In a few low-income countries broad-based approaches have resulted in
significant and sustained improvements in child and maternal health. In all
of these examples – and in the past experience of industrialised rich
countries – such improvements have been secured through a combination of
social policies and efficacious public health interventions.

In all cases a favourable political context facilitated this comprehensive
and equity-oriented approach. Such contextual factors are crucial in
ensuring both investment in social services and the provision of
infrastructure and community mobilization.  This allowed effective
technologies and interventions to be successfully promoted.

Successful programmes were characterized by participatory programme design
and implementation. They also addressed key factors like coverage,
targeting, intensity and resource mobilisation.

There are few examples of large-scale successful comprehensive child health
programmes. This may be attributed to the dominance of conservative
macroeconomic policies in the past two decades. A narrowing of the primary
health care approach may also have contributed to this. Some technical
interventions have been preserved and promoted while interventions to
address broader social determinants (as well as participatory processes)
have been denigrated or abandoned. Such 'selective', technicist approaches
have been vigorously promoted as 'packages of care'.
*Global economics erodes public health*

Public health systems in poor countries, including South Africa, have been
considerably weakened by a combination of conservative macro-economic
policies and health policies that constitute 'health sector reform'. Chronic
underfunding of health (and social) services has led to a serious weakening
of the 'delivery' infrastructure, and especially of the human resource
component. Health personnel capacity has been severely undermined as a
result of a fiscal crisis and the impact of HIV/AIDS. In addition, active
recruitment of personnel by rich countries experiencing a health workforce
shortage has further depleted staffing levels and seriously aggravated the
dysfunctionality of health systems.

The current HIV/AIDS pandemic and the new initiatives launched to address it
may already have aggravated the crisis in child health and healthcare by
diverting attention and resources away from other endemic, health problems
and their social determinants. There is also a strong possibility that new
'vertical' programmes and structures will be created, further delaying the
long-term imperative of creating strong and sustainable 'horizontal' health
systems.
*A return to comprehensive PHC?*

The time is long overdue for energetically translating the rhetorically rich
promises of the Primary Health Care Approach to reality, turning dormant
policies into action.

The main actions should centre around the development of comprehensive,
well-managed programmes involving the health sector, other sectors and
communities. The process needs to be structured into functioning district
systems. In most countries these need to be considerably strengthened,
particularly at the household, community and primary levels. Comprehensive
health centres and their personnel should be the focus of these efforts and
investment. The reinstatement of community health workers and other
community workers (e.g. treatment and breastfeeding counsellors) should be
seriously considered.

The successful development of decentralised health systems requires targeted
investment in infrastructure, personnel, management and information systems.
A key primary step is capacity development of district personnel through
training and guided health systems research. Such human resource development
must be practice-based and draw upon re-orientated educational institutions
and professional bodies.

Clearly, the implementation and sustenance of comprehensive primary health
care requires inputs and skills that demand resources, expertise and
experience not sufficiently present in the health sectors of the Western
Cape. Partnerships with non-governmental organisations with expertise in
community development is crucial.

The engagement of communities in health development needs to be pursued with
much more commitment and focus. The identification of functioning organs of
civil society, whether or not they are presently active in the health
sector, needs to be pursued.

Poor child health and nutrition impose significant and long-term economic
and human development costs, especially on the poorest communities and
further entrenching their status. Improving child health and nutrition is
not only a moral imperative, but a rational long-term investment.
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