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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.
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
IMR: babies dying before age 1 per thousand born live
UNICEF: State of the World’s Children
The State of the World’s Children 2003. UNICEF
Declining Health Systems
Global Immunization 1980-2002, DTP3 coverage
global coverage at 75% in 2002
Source: WHO/UNICEF estimates, 2003
Inadequate carefor children & women
Inadequate health services& unhealthy environments
Inadequate access to food
Resources & controlhuman, economic & organisational resources
Political & ideological factors, economic structure
Potential resourcesThe determinants of child mortalityConceptual framework of causality
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%
Breman and Shelton, WHO CMH WG6, 2001
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).
(G8 Communiqué, Genoa, July 22, 2001)
Share of national
income, ratio of
top to bottom decile
Source: de Ferranti et al, 2004 (Table A.2)
..and growth of poverty
(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
than an African citizen?
World Bank, World Development Report 2004
Rt. Hon. Hilary Benn, April 2004, WFPHA/UKPHA, Brighton
School-based health services
Family planning and nutrition education
Programs to reduce tobacco and alcohol consumption
Actions to improve the household environment
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..
“[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
(Institute of Medicine)
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
Share of population
Share of health workers
Our Common Interest 2005:184
Buchan et al 2003
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
The AIDS debate, BBC News
Decentralised health services have dramatically increased need for public health skills – for policy, advocacy, planning, programme design, implementation, monitoring and evaluation
After Gillespie and Jonsson
Sanders et al, Bull WHO 2004, 82(10)
Cape Town Press, 2004.
Online ordering and
“Determinants” research: a global example
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
Source: OECD/DAC Annual Report 2004
Based on 2002 ODA figures from OECD, Big Mac prices from The Economist, April 25, 2002
Report of the Commission for Africa, 2005, p.18
11 country initiatives
3 city initiatives
Funded by Rockefeller Foundation
HIV prevalence 2000(estimate)
Infant Mortality Rate
% households below the poverty line
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
2 nurses on night duty
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%
Practice prior to intervention
Perceived barriers to quality care
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.)
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
Ashworth et al, Lancet 2004; 363:1110-1115
1986 statewide survey of child health and nutrition resulted in new health policies, including GOBI plus vitamin-A supplementation.
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
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.
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:
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.
(G8 Communiqué, Genoa, July 22, 2001)
Potter and Brough (2004).