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WHAT CIVIL SOCIETY CAN CONTRIBUTE : RESEARCH, TRAINING AND ADVOCACY TO ADDRESS CHILD HUNGER AND UNDERNUTRITION. David Sanders Director: School of Public Health University of the Western Cape Member of Global Steering Group Peoples Health Movement.

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David SandersDirector: School of Public HealthUniversity 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
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
Despite successes, growing inequalities in global healthwidening gap in infant mortality experience

IMR: babies dying before age 1 per thousand born live



UNICEF: State of the World’s Children

u5mr in sub saharan africa
U5MR in Sub-Saharan Africa

The State of the World’s Children 2003. UNICEF

global health inequities
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.
Slide Date: October 03

Declining Health Systems

Global Immunization 1980-2002, DTP3 coverage

global coverage at 75% in 2002

Source: WHO/UNICEF estimates, 2003

the determinants of child mortality conceptual framework of causality

Inadequatedietary intake


Inadequate carefor children & women

Inadequate health services& unhealthy environments

Inadequate access to food

Resources & controlhuman, economic & organisational resources

Political & ideological factors, economic structure

Potential resources

The determinants of child mortalityConceptual framework of causality




Basic causes

2002 food crises in southern africa

ZIMBABWE: food shortages:

31.4% of pregnant women in rural areas HIV+

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

ZAMBIA: second year of crop failure: few food stocks: adult HIV prevalence 21.5%

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

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

but what are the key basic causes of africa s health and health care crisis
BUT what are the key ‘Basic Causes’ of Africa’s Health and Health Care Crisis?
  • Increasing poverty and inequality worsened by inequitable globalisation,
  • Selective PHC and Health sector “reform”, and
  • ….. result in slow progress and reversals.
the debt crisis structural adjustment and globalisation
The debt crisis, structural adjustment and globalisation:
  • A crucial development in the current phase of globalisation…
external debt
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)
structural adjustment programmes the main components
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
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
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 1
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
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
The result… unequal growth of wealth within countriesTrends in income inequality, selected Latin American & Caribbean countries

Share of national

income, ratio of

top to bottom decile

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

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.

..and growth of poverty

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)

Governance - Bribery & Corruption
Sub-Saharan African Country per capita expenditures on health (1997-2000)Recommended expenditure: >$60/capita (Brundtland); >$34/capita (CMH)

World Bank, World Development Report 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 Ethiopiawere 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.”

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

Public Health package:


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

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

CEA cannot evaluate the effectiveness of ‘broader’ interventions that may result in health improvement through numerous direct and indirect mechanisms

“[C]ost-effectiveness analyses have shown improved water supply andsanitation 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 disease

Save women’s time for caring and economic activity, thus improving household income and food security

Contribute to increased agricultural production, thus improving household income and food security

subverting the mission of public health
..subverting the Mission of Public Health
  • “Ensuring the conditions in which people can be healthy”

(Institute of Medicine)

Health sector ‘reform’ Quest for efficiencycont.- The move from equity and comprehensiveness to efficiency and selectiveness leads to:
  • A return to vertical programmes;
  • Erosion of intersectoral work and community health infrastructures
  • Fragmentation of health services and reversal of health gains
AIDS and Aid may both disrupt health systems…

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.

Labonte, 2005, presentation to Nuffield Trust

health systems personnel in africa
Health systems & personnel in Africa
  • Health personnel vital, consume between 60 – 80% of recurrent public health expenditure (WB, 1994).
Burden of disease

Share of population

Share of health workers

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
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
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
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
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
Implementation Cycle




Capacity Development



and Management





components of capacity to perform tasks
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 tasks

After Gillespie and Jonsson

Household and Community Capacities

Potter and Brough (2004).

the challenge in research and training
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
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
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 and

prepublication proofs

available at:

“Determinants” research: a global example

what we did
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
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
What We Found (1999 – 2001):

Promises kept: 8 or 9*

Promises broken: 17 or 18*

* Depends on whether one regards the 2003 TRIPS

Council ruling on parallel imports as a kept or broken


development assistance as of gross national income
Development assistance as % of Gross National Income


Source: OECD/DAC Annual Report 2004

annual cost of meeting the 0 7 percent of gni oda target in big macs capita
Annual cost of meeting the 0.7 percent of GNI ODA target, in Big Macs/capita

Based on 2002 ODA figures from OECD, Big Mac prices from The Economist, 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.18

2 examples of priority research
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
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
Equity requires a balance between resources and needs



Health District

Geographic Area

example resource allocation in primary care
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
Health Need across Cape Town Districts

HIV prevalence 2000(estimate)

Infant Mortality Rate

% unemployed

% households below the poverty line

3 examples of priority research
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
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 cycle1
Implementation Cycle




Capacity Development



and Management





case fatality in rural hospitals


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 cycle2
Implementation Cycle




Capacity Development



and Management







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 children

fed straightaway and 3 hourly during day and night.

The number of night staff was increased

Dextrostix and 10% glucose obtained

Comparison of recommended and actual practices

who 10 steps training mt frere district eastern cape
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
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 morale

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

educational strategies
Based on assessed training needs


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

Educational Strategies
cear brazil
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)).


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.

unfair trade 11
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).

Household and Community Capacities

Potter and Brough (2004).

Household and Community Capacities

Potter and Brough (2004).