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. 10 million child deaths
– Why?
HIV/AIDS
Measles Injuries
3%
4% 3%
For these 4 Malaria
causes, ~ 8% Neonatal
53% of deaths
deaths are 36%
malnourish
ed children Diarrhoea
17%
AIDS is much bigger
proportion in Southern Pneumonia Other
Africa. 19% 10%
Source: Bryce J et al for the Child Health Epidemiology Reference Group. The Lancet, March 2005. As used in WHR 2005

9. 4 million newborn deaths –
Why?
60 to 90% of
neonatal deaths
are in low birth
weight babies,
mostly preterm
Three causes
account for 86%
of all neonatal
deaths
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

10. Under five mortality rates: Trends from 1990-
2000
200
181 1990
180 175
Least 2000
reduction
160 3%
U5MR (deaths per 1000 births)
140
128
120
100
100
Greatest
80 reduction
80 32%
64
58
60 53
44 45
37 38
40
20
9 6
0
Sub-Saharan South Asia Middle East & East Asia and Latin America CEE/CIS and Industrialized
Africa North Africa Pacific & Caribbean Baltics countries
Source: UNICEF, 2001 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 5. Reduce MMR by three
poverty and hunger quarters
2. Achieve universal 6. Combat HIV/AIDS,
primary education malaria
and other diseases
3. Promote gender
7. Ensure environmental
equality sustainability
and empowerment of
women 8. Develop global
partnerships
4. Reduce child mortality for development
by two thirds

21. Integrated Management of
Chilldhood Illness (IMCI)
Assess and classify
Department of Child and Adolescent Health
and Development

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
25th 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
150
to MDG 4
N e o na t a l M o r t a lit y
R ate
U nd e r 5 M o r t a li t y R a t e
.
Mortality per 1,000 births
Inf a nt M o r t a l ity R a t e
10 0
M D G 4 Targ et
67
50 54
21
20
0
198 0 19 8 5 19 9 0 19 9 5 2000 2005 2 0 10 2 0 15
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
Others: 30%
PEM: 5%
Pneumonia: 6%
Low birth weight,
Neonatal 12%
Diarrhoea: 11% 18%
Asphyxia, 3%
Infections, 3%
HIV/AIDS: 40%
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)
90
80
70
60
50 East
40 West
30 North
20
10
0
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

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

45. 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

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

51. Causes of death of children in hospitals
(n = 1695)
35
30 33
25
20
% 20
15
15 16
10 12 13
12
5 10 7
3
0
2004 2005
ARI DD Sepsis AIDS TB PCP

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

66. South Africa:
Coverage along the
MNCH continuum of care
100%
The days
75% of highest risk
have the lowest
50% coverage of care
25%
no data 7%
94% 84% 93%
0%
Ant enat al care Skilled Post nat al care Excl. BF I m m unisat ion
( at least one at t endant ( DPT3)
visit ) during
childbirt h
Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006

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
100
90
Not BF
80
70
60
50 Solid mushy food
40
30
Other liquids
20
Plain water only
10
EBF at 6 months
0
0-4 4-6 7-9 10-12
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: Bringing it all together
Nutrition Appropriate
(Vitamin A) infant
feeding
IMCI PMTCT Maternal
EPI Plus
Health
Care of HIV
infected children
HOUSEHOLD AND COMMUNITY IMCI

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

84. Witbank NNMR 2000-2005
trend (=/> 1000 grams)
250
200
150 1000-1499g
NICU 1500-1999g
100 2000-2499g
>2500g
nCPAP
50
0
2000 2001 2002 2003 2005*

89. References
• SA IMCI chart booklet: UP Intranet (Block 10)
• www.who.int/child-adolescent-health/publications/CH
• 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