Part 1 described the context of children growing up in SA. Part 2 outlines some of the indicators of child health and health services in the country:

So what about those health care services? Where are we? Actually, I’m going to postpone

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looking at health services as such as I am hoping that when we get there, we can look at them from the point of view of there being a solution rather than a problem. So let’s look at some indicators of child health in South Africa.

 

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Here’s the first indicator which is in fact not an indicator of child health at all: infant mortality rate or IMR is well established as a measure of a community development, and not directly of health – the poor little canaries (otherwise known as infants) being those who tell us by dying whether we live in a dangerous, poor human environment for not so dangerous human environment. The arrow on this table which comes from the MRC Rapid Mortality Survey published in 2012 shows that South Africa’s infant mortality rate is dropping and has done so rapidly in the last few years. The same is true of the under five mortality rate. This is shown more starkly on the next slide.
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Many of us were desperate during the first few years of the millennium as high rates of death among children stubbornly refused to budge, as the president and his health minister on the subject of AIDS. Things are now shifting nicely. (Except the neonates – the red line at the bottom, – please note)
However there is not much room for complacency here. The absolute level is significantly high still and as the next slide shows –
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This slide shows in the circled area, things things vary considerably by province [the big ? here is the Eastern Cape whose figures based on vital registration seemed to be way out of kilter – led by the former Transkei area – the OR Tambo district – which we saw is one of the areas with high levels of deprivation.] What is more, things vary considerably within provinces. Even in that Nirvana known as the Western Cape province, you will find areas the child mortality levels similar to areas such as Limpopo, and well above the national average. So there is a journey required of us all.
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So what are the children dying of? The top of the list is diarrhoea: one in five deaths under 14 years of age in this country is due to diarrhoea. Perhaps I should say that again. Amongst the youngest children the proportion is even higher. Next on the list are causes of death within the first month of life and the majority of these are within the first week of life and relate to 2 big causes: prematurity with associated complications and, rather sadly, birth asphyxia (euphemistically called “perinatal problems” on this slide). Pneumonia and respiratory infections get in at number three in South Africa. Note that these figures refer to the period before the introduction of rotavirus and pneumococcal vaccines. Evidence from 2009 is diarrhoea and pneumonia deaths are dropping, but neonatal deaths as a whole have not risen to the top of the pile yet. But neonatal deaths are stubbornly sticking at the same level, presenting a challenge to us all.
Had a high status of TB is not only an adult phenomenon. Where did children get there TB bugs from? Why can’t we stop it when we know that their immune systems cannot contain the infection once they have inhaled it? Why do we allow contact tracing to miss children?
I have circled ”immune disorders” because, although there last on the list, this is largely AIDS. But AIDS is a big contributor to all the other causes because, as with adults, HIV is not usually put on the death notification form, or its presence has not been ascertained). Or it is not given as a direct cause of death, but of course it isn’t.
So these 10 causes constitute two out of three deaths. I think you will agree with me that pretty much all of them are preventable to a large degree. Keep this in mind when we come to everyone to go and how to get there. Very obvious where to; but how to get there?
Now looking at hospitals where, beyond neonatal units and wards, just under half of young child deaths happen. (Note that most neonatal deaths occur within the health system, largely in nurseries, in all provinces. We will come back to them soon.) Doctors do most of the therapeutic decision-making in hospitals, so concentrate please.
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This slide is covers admissions to paediatric wards in South Africa and does not include neonatal nurseries. We see that here too has been a gratifying reduction in in-hospital mortality rates – that is, the number of children who died hospital wards per 1000 admissions. If you look at the right hand column on this table, this indicator fell from 50 deaths per thousand admissions in 2009 to 2011. And note (in the centre column) but even though the number of hospitals doing audits and rose as the number admissions monitored, the number of deaths dropped. These figures come from hospitals that audit child deaths (nearly half of all hospitals in the country and predominantly district hospitals). The process involved comes from the Child Healthcare Problem Identification Programme or Child PIP. Things may not be so rosy overall have these figures come from hospitals with clinical enthusiasts. And the next slide…
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… shows causes of death in hospital, and you’ll see that it is very similar to the causes of death overall – with three quarters of all deaths being due to infectious causes. Our old enemy who still laughs at us, diarrhoea, heads the list here too. It is important for us in the health fraternity to recognise that these are deaths of children who have made it to hospital wards and then die. Could more of them have been saved? And we ask again, need the children got sick enough to need hospitalisation? Well, look at the next slide:
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It may explain why children get so sick. Malnutrition is a significant co-factor in hospital deaths – look at the purple and green segment; in many of these the management of malnutrition was sub-optimal, especially if it was severe. Food for thought, if you will pardon the pun.

 

 

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Nearly one in five, folks, for severe acute malnutrition. 20% overall mortality. True, sometimes it is the underlying disease that contributes malnutrition, that calls for early identification of illness, and earlier intervention to prevent and treat concomitant nutritional diseases. Anyone not want to promote breastfeeding after seeing this slide?
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HIV wields its sickle in our wards as well (red and green segments this time). I have recently reviewed the audit data from hospitals and unhappy report – as in the next slide…

 

 

 

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… that this particular Grim Reaper is having a harder time of it. HIV-associated diarrhoea deaths have dropped by 30% over three years – the third column of figures; HIV-associated TB deaths have dropped by the same margin. Bacterial meningitis deaths dropped by even more. PMTCT, ARV, PCV. More letters child health scrabble game

 

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But we need to be sober. When our intrepid auditors reviewed their own practice and that of the primary health care system that referred sick children, they found that much more could have been done a lot better. Nearly half the deaths might have been avoided if things had been handled better – please remember that we are talking about things like diarrhoea and pneumonia here. The top of this table indicates the sites where things might have been done better. Hospitals and homes of the main places where care must be improved if fewer South African children are not to die. Delaying getting to care is the main problem in homes raising questions both the recognition of danger signs but also ease of access to primary and urgent health care for our communities. In the lower half of the table, note that every death between one and two modifiable factors were ascribed to clinical personnel who should have done things better. For diarrhoea, this mainly relates to recognition of shock and dehydration and use of fluids – fundamental skills, surely!?
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And for neonates there is a lot that could have been done better too as this slide shows. Why are women presenting late in labour? Why are many pregnancies and booked? Why don’t we know how to look after sick newborns in our nurseries but we don’t equipment properly?

 

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Most of the deaths I have covered so far are in children under the age of five years. What about the older children? This graph shows that as you get older, your chances of dying of a non-natural cause rise to nearly half of all causes in the ages 15 to 19. Other main causes include AIDS and cerebral palsy. Remember that much cerebral palsy in this country is due to secondary causes such as birth asphyxia and meningitis, so deaths in older children must be considered potentially preventable in this day and age. Taming gangs, alcohol and fast cars is a bigger challenge.
So that is a lot about child health at the extremes – death. But we talk to morbidity in children,
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… We’re talking about the same things that matter less severe scale. So what keeps the primary health care system in hospitals busy the same things that cause children to die. The same things that need to a lot of child disability.
It is important to recognise that children have long-term problems in significant numbers. Herein are the children with neuromuscular diseases and disabilities, congenital conditions such as cardiac disease and haematological disorders, acquired diseases such as type I diabetes, rheumatic disorders and the large number of learning disabled and attention deficit hyperactivity disorder children and young people. I have separated out mental health disorders because these go a long way beyond the severe things like autism to include a huge level of (often undiagnosed) problems of anxiety/depression and substance abuse. There is a lot here that represents the antecedents of adult somatiform disorders that keep the health system very busy. Almost untouched in this country.
One major concern is that the success of programmatic IMCI-based case management in providing primary health care to children, to the lack of access to more sophisticated care within the primary health care system. My corralling children into narrow IMCI-trained nurse-led to services, we have lost decade of clinical nurse practitioner who was able to recognise and treat a lot of common childhood disorders and make a much better referral to a doctor. In improving access to and quality of care for a narrow spectrum disorders, we have inadvertently reduced access to care for children with other disorders and children in the age of five years. I will talk to how this might be remedied later.
You’ll recognise that subliminally I have been sharing new issues around health services even though I said I was leaving for a while. So much of what kills aims children is because of sub-is optimal handling by our health systems, private and public. So let us talk about them overtly:
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The good first: mostly programmatic and acronymic as shown in the slide. The learning purposes it is worth looking up in the acronyms you do not recognise.
When it comes to the not so good, there is much that we know about that affects children as well as adults – in equitable distribution of services and resources, poor service management, staff attitudes, too few staff, waste. The big concern is how some flagship policies such as IMCI, EPI-SA, and PMTCT are inadequately implemented. But on a positive note, much is now being done to remedy this, such as a focused drive to improve efficacy of a complex sequence of activities known as PMTCT with the aim of eliminating new vertical infections by 2015. I have to mention breastfeeding. Do in the health services really believe and its benefits, you wouldn’t think so from the way we don’t provide spaces and energy for it, even some of our maternity services. And have you recognise that with a RVs, breastfeeding is the safer, even life-saving option of HIV-exposed babies in that very large deprived community I spoke earlier? With your support, it can be done with massive benefits for the country and the children.
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It is certainly our intention in the Western Cape – and not only because we looked like a breast with lacteals converging on Cape Town!