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DoH: Directorate: Child and Youth Health Children’s Bill Children’s Bill Department of Health presentation to the portfolio committee on Social Development 25 August 2004

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DoH: Directorate: Child and Youth Health

Children’s BillChildren’s BillDepartment of Health

presentation to the portfolio committee on Social Development

25 August 2004

DoH: Directorate: Child and Youth Health

Current status of child health in SA

DoH: Directorate: Child and Youth Health

Infant and under 5 mortalityInfant and under 5 mortality Figure 1. Childhood Mortality, South Africa: 1978-1996

45.4

14.7

59.459

23

89

39.2

50.7

16.220.4

54.8

70.1

46

56

19

20

67

80

0

10

20

30

40

50

60

70

80

90

100

1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998

Per

1 0

00 li

ve b

irths

IMR(98) 1-4MR(98) U5MR(98)

IMR(90) 1-4MR(90) U5MR(90)

DoH: Directorate: Child and Youth Health

Leading Underlying Causes of Death among Children Aged 0 - 14 years: StatsSA 1997 - 2001

0 5 10 15 20

Intestinal infectious diseasesInfluenza and pneumonia

Unspecified unnatural causes HIV disease

Ill-defined causes of mortality

Intestinal infectious diseasesInfluenza and pneumonia

HIV diseaseIll-defined causes of mortality

Unspecified unnatural causes

Male

sF

em

ale

s

%

1997 1998 1999 2000 2001

DoH: Directorate: Child and Youth Health

Causes of Deaths in Under 5's, 2000

HIV AIDS41%

LBW11%

Diarrhoeal10%

LRTI6%

PEM4%

Other28%

HIV AIDS

LBW

Diarrhoeal

LRTI

PEM

Other

Source: Bradshaw D, Bourne D, Nannan N. What are the leading causes of death among South African children? MRC Policy Brief No. 3, December 2003. Bradshaw D, Groenewald P, Laubscher R et al. Initial Burden of Disease Estimates for South Africa, 2000. Cape Town: SAMRC, 2003.

DoH: Directorate: Child and Youth Health

Mortality: CommentMortality: Comment Large inter and intra- provincial variation in

U5MR and IMR Average IMR higher than countries with

comparable economies e.g. Cuba Main causes of deaths are preventable:

– Infants: diarrhoea, chest infections, malnutrition– under-5: trauma, diarrhoea, chest infections,

malnutrition and HIV– 5-14 years: violent intentional trauma and

accidental trauma

HIV Diarrhoea, pneumonia, malnutrition

DoH: Directorate: Child and Youth Health

Morbidity: CommentMorbidity: Comment Mostly preventable causes e.g. diarrhoea,

malnutrition and chest infections

Disabilities often the result of: – delayed recognition / management or – inappropriate management e.g. birth asphyxia

DoH: Directorate: Child and Youth Health

MULTIFACTORIAL FACTORS associated with freq. & severity (incl. death) of child health conditions

e.g. diarrhoea, chest infections, malnutrition, HIV, abuse, accidents

Immediate Causes

Underlying Causes

Basic Causes

Bacterial / Viral load; Availability of and access to health services incl.

PHC package, hospital / institutional care, home care / protection

Feeding pattern / household food security (poverty), Unhygienic conditions;

Smoking; Pollution; Access to safe water, sanitation, environments; Education (esp

maternal)

Allocation and distribution of resources; Intersectoral planning; Gender issues; Budgeting and prioritisation of children

To improveTo improveChild health:Child health:

ALL national , provincial

district & localorgans of govt. and all sectors

must be guided byThe best interest of

the child

when making policy

legislativebudgetary and administrative

decisions

DoH: Directorate: Child and Youth Health

INTERNATIONAL AND INTERNATIONAL AND NATIONAL CONTEXTNATIONAL CONTEXT

DoH: Directorate: Child and Youth Health

International Context

CRC: “Putting children first” African charter on the health and welfare of childrenMDGUNGASSA World Fit for childrenGlobal Strategy on Infant and Young Child FeedingNEPADWHA Resolution (54.19), May 2001, on

Schistosomiasis and STH infections

DoH: Directorate: Child and Youth Health

International Context: CRCright to survival and development (6)protection from all forms of violence / abuse (19, 25,34)special consideration for all mentally or physically disabled children (23)right to health and facilities for the treatment of illness and rehabilitation of health (24)rehabilitation (39) As a country we need

to further define these rights and provide a supportive milieu to

realise them

As a country we need to further define these rights and provide a supportive milieu to

realise them

In all actions the best interests of the child shall be a primary consideration (3)State parties shall undertake all appropriate legislative, administrative and other measures for the implementation…(4)

DoH: Directorate: Child and Youth Health

International Context

Millennium Development Goals: 3/7 goals are directly related to health

By 2015:Reduce by 2/3 the U5MR Reduce maternal mortality by 3/4Combat HIV/AIDS, malaria and other dx

How far are

we?

How far are

we?

DoH: Directorate: Child and Youth Health

International Context

NEPAD Health StrategyNEPAD Health Strategy

Focus on poorest and most marginalised incl. women and childrenReduce IMR and U5MR by 2/3 by 2015Targets:

oEffective implementation of IMCI and EPI; oPolio eradication

Consolidation of:oIMCIoProgr. on HIV and AIDS, TB and malariaoImmunisation

oEBF and appropriate nutrition

DoH: Directorate: Child and Youth Health

International Context

National Context

Legislation

Policy

Strategies

Programmes

DoH: Directorate: Child and Youth Health

National Health Act As it relates to children will be presented by

my colleague at the end of this presentation

DoH: Directorate: Child and Youth Health

Legislation

Other health-related legislation that impact on children exist, including, inter alia: – food fortification– tobacco Control

These will not be presented

DoH: Directorate: Child and Youth Health

Health sector strategic plans / frameworks

DoH: Directorate: Child and Youth Health

The Health Sector Strategic Framework, 1999-2004 (10 point plan)

aims to– improve access to health care for all (and build on

achievements since 1994);

– reduce inequities in health care, and

– improve the quality of care at all levels of the health care system

DoH: Directorate: Child and Youth Health

The Health Sector Strategic Framework, 1999-2004 (10 point plan)

Prioritises: – improving the quality of care, – speeding up delivery of an essential package of

PHC through the district health system, – decreasing morbidity and mortality through

strategic interventions, – improving resource mobilisation and the

management of resources bearing in mind “equity” issues

DoH: Directorate: Child and Youth Health

The Strategic Plan for HIV / AIDS 2000-2005

4 priority areas: • prevention; • treatment, care and support; • research and • human and legal rights.

translates into: • preventing primary HIV infection, • preventing unwanted / unintended pregnancies in

HIV+, • PMTCT; • preventing common illnesses, and ensuring

ongoing care and support for mothers and children infected or affected by HIV and AIDS within a human rights paradigm.

DoH: Directorate: Child and Youth Health

Policies / Programmes / Strategies currently offered by the DoH

DoH: Directorate: Child and Youth Health

Child Health Policies and GuidelinesChild Health Policies and GuidelinesPoliciesDraft: Child Health Policy and Implementation GuidelinesDraft: Infant and Young Child Feeding Policy Draft: Policy Framework for non-communicable chronic conditions in children Policy Guidelines for the Management and Prevention of Genetic Disorders, Birth Defects, and DisabilitiesDraft: National Policy Framework for Child Abuse National Health Policy Guidelines for Improved Mental health in South AfricaPolicy Guidelines for Child and Adolescent Mental HealthNational Rehabilitation Policy

Strategies and Guidelines (excluding training packages)Comprehensive Primary Health Care Package + Norms and StandardsDistrict Hospital Service Package for South AfricaDraft Maternal and Neonatal Strategy SA Breastfeeding Guidelines for Health WorkersGuidelines for Nutrition Interventions at Health Facilities to Manage and Prevent Child MalnutritionPMTCT Protocol for Pilot SitesExpanded Programme on Immunisation (South Africa) – Immunisation Schedule and Fact SheetsIntegrated Management of Childhood Illness Strategy: Case Management Guidelines National Guidelines on Palliative Care for ChildrenDraft: Guidelines for health care providers managing suspected child abuse, neglect and exploitationHIV and / or AIDS: Strategic Plan of the National Department of Health: 2000-2005Comprehensive Treatment Plan for HIV and AIDSManagement of Diabetes Type I in children (<18 years) at hospital levelManagement of Asthma in Children National Guidelines on Primary Prevention and Prophylaxis of Rheumatic Fever and Rheumatic Heart Disease for Health Professionals at primary level

DoH: Directorate: Child and Youth Health

Child survival and improved quality of

life in children

MCWHMCWH

ANC, ATT

Genetics services

KMC

Oral health

EPI +ATT

INP: BFHI; Code,, growth monitoring, PSNP

IMCI

PMTCT

ART

SHS

Services for abused incl. ARV PEP

School health services

Health Health PromotionPromotion

HPSI

Healthy environment for children

Anti tobacco

Mental HealthMental Health

Victim empowerment

FAS

Counselling

Rehabilitation

TBTB

Prevention

Treatment

DOTS

HIV and AIDSHIV and AIDS

VCT

PMTCT

ART

HBC

STIs

Malaria (RBM) / Malaria (RBM) / cholera / other cholera / other VBDVBD

Prevention

Case management

Outbreak response

Progra

mmes

or

Strategies

offere

d

IMCI

DoH: Directorate: Child and Youth Health

IMCI Components and IMCI Components and Intervention areasIntervention areas

Improving case

management

Strengthening the health

system

Improving household, community and family behaviours

Targets:

80% of district must have 60% of health workers trained in IMCI by 2005

HHCC must be implemented in ALL districts by end 2005

DoH: Directorate: Child and Youth Health

Programme Programme ImplementationImplementation

DoH: Directorate: Child and Youth Health

IMCI Expansion in SAIMCI Expansion in SAProvince % facilities with at

least 1 hw trainedNo. hw trained in IMCI in province

HHCC started Pre-service training started

Hospital level

EC 39% 273/700 530 Ukahlamba

P -

NW 47% 170/365 256 P -

G 38% 123/327 550 -

KZN 64% 388/712 1322 Ugu, Uthukela

P -

MP 65% 229 /352 634 -

L 79% 331/474 1506 3 districts

FS 88% 254/350 823 Motheo -

NC **/256 255 P -

WC **/334 653 6 sites -

TOTAL >1768/3870 (>46%) 6529 (50%)

** no data; P planning; --not started and no plans yet

Shortage of funding for training

Shortage of facilitators, course directors

NC: no training this year

No transport for supervision

DoH: Directorate: Child and Youth Health

Fully Immunised (annualised) by Fully Immunised (annualised) by District - 2003District - 2003

Key :Yellow : 60-79%Green : ≥80%

Target: 80%

DoH: Directorate: Child and Youth Health

Fully Immunised (annualised) in Fully Immunised (annualised) in Gauteng Province - 2003Gauteng Province - 2003

Ekurhuleni Metro

Mestw

eding DMCity of Tswane

Wes

t Ran

d D

M

City of Johannesburg

Sedibeng DM

Key:Red : 0-59%Yellow : 60-79%Green : ≥ 80%

DoH: Directorate: Child and Youth Health

INPINP >25% health facilities are baby friendly

PMTCTPMTCT At >1260 facilities 99% of HIV exposed infants receive nevirapine >2800 health care providers trained in PMTCT

and IF

IMCI

DoH: Directorate: Child and Youth Health

Infrastructure for these servicesInfrastructure for these services

• District Health System• Local authorities

DoH: Directorate: Child and Youth Health

Human / Material Resources Human / Material Resources availableavailable

(National ) Chief Directorate: MCWHNChild and Youth Health:

EPI

Child

Youth and Adolescent

Provincial

District

No dedicated structures or

budget for child health at district levels

or in LSAs

DoH: Directorate: Child and Youth Health

Challenges and Gaps:Challenges and Gaps:

• Children still die of preventable conditions

• Socio-economic issues impact negatively on health e.g. poverty

• Inequitable distribution of resources

• Competing priorities at local levels

• Services for children not prioritised

DoH: Directorate: Child and Youth Health

Challenges and Gaps:Challenges and Gaps:• Sub-optimal implementation of

programmes e.g. Immunisation / SHS

• Poor inter-sectoral collaboration resulting in poor / non-existing implementation e.g. SHS

• Data on progress needed (addressed through NHA)

• Ineffective child protection

DoH: Directorate: Child and Youth Health

The Children’s BillThe Children’s Bill

DoH: Directorate: Child and Youth Health

Addressing challenges Addressing challenges through the Billthrough the Bill

Healthy children

Education

Water

Refuse removal

Safe environments

Protection by Justice system

and SAPS

Social Welfare System

Sanitation

DoH: Directorate: Child and Youth Health

Children’s BillChildren’s Bill• Provides unique opportunity to legislate in

favour of one of the most vulnerable groups of society:

CHILDREN

• If properly developed Children’s Bill, can accelerate and improve implementation of health services for children

DoH: Directorate: Child and Youth Health

Children’s BillChildren’s Bill• Currently adopts a piece-meal approach:-

• Needs to go one step further and state that:

“The Minister, after consultation with the Ministers of Justice, Education, Health, Correctional services and Safety and Securty, develop a national policy framework to ensure a uniformed and coordinated approach by all Government departments in dealing with matters pertaining to children to guide the implementation and enforcement and administration of this Act”

• This will facilitate implementation of Health Programmes that optimise the growth and development of our children

DoH: Directorate: Child and Youth Health

Current intersectoral responseCurrent intersectoral response

• Falling short• Not bound / guided / obligated by law • Participation often inadequate /

delegated to junior officials• Faces numerous internal challenges

which has hindered its function and achievements

• Needs to be re-energised

DoH: Directorate: Child and Youth Health

Bill needs to elaborate on rightsBill needs to elaborate on rights• It currently is a re-statement of section 28 of the

Constitution• Needs to include the ffg:

• Basic health care and information about health – (part of PHC package and IMCI)*

• Basic nutrition and appropriate information about nutrition (part of PEM scheme and IMCI)*

• Water and sanitation – stated in chapter 6 (83) – minimum norms and standards for partial care – needs to be mainstreamed to prevent disease in general

• Safe environments • Leisure and recreation• Education• Social security * would not necessitate policy shifts but would assist with implementation of policy

DoH: Directorate: Child and Youth Health

Cont…/ elaboration of rightsCont…/ elaboration of rights• Protection from abuse, neglect, maltreatment,

degredation and other harmful practices• Protection from economic exploitation• Unfair discrimination – with specific reference to

disability; ethnicity, pregnancy• Family / safe alternate care• Property and possessions• Shelter• Social services

DoH: Directorate: Child and Youth Health

Cont…/ elaboration of rightsCont…/ elaboration of rights• Children with special needs deserve recognition

and special mention in relation to their rights:• Long-term health conditions: diabetes, epilepsy,

asthma• Disabilities• Born to parents who are HIV+ / debilitated• Orphans• Child-headed households• Living on street • Care centres• Refugee / unaccompanied minors

DoH: Directorate: Child and Youth Health

Cost ImplicationsCost Implications

DoH: Directorate: Child and Youth Health

CostCost• Would require integrated planning, budgeting and

prioritisation for children at district level

• Cost of ARVs covered by Conditional grants• Cost of school health services: R71 646 505 for full

coverage over 5 years (policy already accepted by Health MINMEC and PHRC)

• Cost of IMCI implementation to ensure 100% coverage still has to be done but plans underway for full implementation