GLOBAL CHILD HEALTH - Heidelberg University

GLOBAL CHILD HEALTHAn Introduction

HEIDELBERG – OCTOBER 13TH, 2017

Dr. med. Carsten Krüger M D, M I H , F R C P C H ( U K )

Consultant Paediatr ic ian , Neonatologist , Paediatr ic Gastroenterologist

Zu meiner Person

Kinder- und Jugendarzt, Neonatologe, Kinder-Gastroenterologe, Master of International Health

Chefarzt der Klinik für Kinder und Jugendliche, St. Franziskus Hospital Ahlen

Ehemaliger Leiter der Pädiatrie & Neonatologie am Haydom Lutheran Hospital, Tansania (1997-2000)

Gastdozent an der Universität Münster (Lehrauftrag) und der Universität Witten-Herdecke

Gastdozent an der Catholic University of Health and Allied Sciences, Mwanza/Tansania (2007/ 2008/2013/2016) und der University of Dodoma, Dodoma/Tansania (2017)

Consultant Paediatrician für das Tanzania Telemedicine Network

Vorsitzender der Gesellschaft für Tropenpädiatrie und Internationale Kindergesundheit e.V. (GTP)

Sprecher der Kommission für Globale Kindergesundheit der Deutschen Akademie für Kinder- und Jugendmedizin (DAKJ)

www.tropenpaediatrie.de | www.sfh-ahlen.de | www.haydom.com | www.carstenkrueger.net

CARSTEN KRÜGER, GLOBAL CHILD HEALTH, 13.10.2017

Global Child Health – Terms andDefinitions

MDG: Millennium Development Goals

SDG: Sustainable Development Goals

U5MR: Under-5 Mortality Rate

IMR: Infant Mortality Rate

NMR: Neonatal Mortality Rate

PMR: Perinatal Mortality Rate

IMCI: Integrated Management of Childhood Illness

EPI: Expanded Program on Immunization

PEM/SAM: Protein-Energy-Malnutrition/Severe Acute Malnutrition

IPTi/IPTp: Intermittent Preventive Treatment of Infants/in Pregnancy (Malaria)

PMTCT/PLUS: Prevention of Mother-to-Child-Transmission (HIV)

DOTS: Directly-observed Therapy Short-course (Tuberkulose)


Kleinkindersterblichkeit (Under-Five Mortality Rate - U5MR) - Sterblichkeit der Kinder unter 5 Jahren pro 1000 Lebendgeborene

Säuglingssterblichkeit (Infant Mortality Rate - IMR) - Sterblichkeit der Kinder unter 1 Jahr pro 1000 Lebendgeborene

Perinatale Mortalität (PMR) - setzt sich zusammen aus Totgeburt eines verstorbenen Fetus nach mindestens 22 (28) Schwangerschaftswochen bzw. mit > 500 (1000) g Geburtsgewicht bzw. mit > 25 (35) cm Geburtslänge und Tod eines lebend geborenen Neugeborenen in den ersten 7 Lebenstagen

Neonatale Mortalität (NMR) - Tod eines lebend geborenen Neugeborenen in den ersten 28 Lebenstagen (frühe Phase = early NMR: Tag 1-7; späte Phase = late NMR: Tag 8-28)

Postneonatale Mortalität (PNMR) = IMR - NMR

Global Child Health – Terms andDefinitions


Contents

Definitions

Concepts

Data

Determinants

Coverage

Health systems

Health workers

Outlook

Conflict of Interest: None


Planetary Health: Our Limits of Viability

Despite ongoing and far-reaching changes to the Earth’s natural systems global health has widely improved.

WHY?

Mankind has “been mortgaging the health of future generations to realise economic and development gains in the present. By unsustainably exploiting nature’s resources, human civilisation has flourished but now risks substantial health effects from the degradation of nature’s life support systems in the future.”

The Rockefeller Foundation–Lancet Commission on planetary health.Lancet 2015; 386: 1973-2028


Towards a “Definition” of Global (Child) Health“Global health is an area for study, research, and practice that places apriority on improving health and achieving equity in health for all peopleworldwide. Global health emphasizes transnational health issues,determinants, and solutions; involves many disciplines within and beyondthe health sciences and promotes inter-disciplinary collaboration; and is asynthesis of population-based prevention with individual-level clinicalcare.“ (Koplan JP et al. Lancet 2009; 373: 1993-5)

Global health encompasses A broader perspective on the determinants of health (including the political, social andeconomic sectors as well as biomedical factors) A concern with all countries, including high-income countries as well as LMICs* An integration of population-based health approach and individual care; A primary emphasis on collective global rather than national goods

*: Low- and Middle-Income Countries


Millennium Development Goals (1990-2015)

MDG 1 Reduce extreme poverty and hunger by halfMDG 2 Achieve universal primary educationMDG 3 Promote gender equality and empowerment of womenMDG 4 Reduce under five mortality by two-thirdsMDG 5 Reduce maternal mortality by three-quarters MDG 6 Prevent the spread of HIV, malaria and other diseasesMDG 7 Ensure environmental sustainabilityMDG 8 Develop a global partnership for development


MDG 5 Müttersterblichkeit

Erfolge

Müttersterblichkeit ↓ um 45% seit 1990

Zunahme der Frauen mit 4 Schwangerschaftsvorsorgeuntersuchungen von 35 auf 52%

Herausforderungen

40 Millionen Frauen entbinden immer noch ohne professionelle Hilfe, 2 Millionen völlig alleine

Frauen in armen Haushalten und auf dem Land haben 3 x seltener professionelle Geburtshelfer

Mangel an qualifizierten Mitarbeitern im Gesundheitssystem, besonders in Afrika, um die Kinder- und Müttersterblichkeit weiter zu senken


Save the Children 2015Countdown to 2015 ReportProgress for children No. 11, 2015

Some Milestones on the Every WomanEvery Child (EWEC) Journey

MDGs

GAVI

2000

2002

GFATM

GAIN

PMNCH

Count-down to

2015

2005

2006

UNITAID

IHP+

2007

2008

PEPFAR

EWEC

Muskoka

IGME

2010

2011

iERG

Com-mittingto Child Survival

FP2020

2012

2013

Global Action Plan

Pneumo-nia and

Diarrhoea

GIP

ENAP

EndingPrev.

Matern. Morta-

lity

2014

2015

Launch of

SDGs

Imple-menta-tion ofSDGs

2016

2010Global Strategyfor Women‘s &

Children‘s Health

2015Global Strategyfor Women‘s, Children‘s & Adolescents’

Health


0

500

1000

1500

2000

2500

3000

3500

4000

J F M A M J J A S O N D

OPD children

OPD Adults

Data Sibanor 1996, courtesy Dr. Gisela Schneider


Outpatient Attendance by Month in a Mission Hospital in The Gambia

0

100

200

300

400

500

600

700

J F M A M J J A S O N D

all

children

adults


Data Sibanor 1996, courtesy Dr. Gisela Schneider

Hospital Admissions by Month in a Mission Hospital in The Gambia

Characteristics of Global Child Health in LMICs More than 85% of all children and adolescents <18 yrs. live in LMICs

About 40% of the world population, more in these countries, arechildren and adolescents < 18 yrs

About 30% live below the absolute poverty line (< 1.90 USD/day).

Severe childhood disease is often recognized too late by theparents/caretakers

Financial/cultural barriers delay the contact with a health institution

Accessibility of health institutions may be difficult (distance, transport etc.)

Quality of health care at the health institutions is often poor


Characteristics of Global Child Health in LMICs

Neonates and children represent the most vulnerable segment of a society suffer disproportionately in terms of mortality risk (95 -

98% of all childhood deaths in LMICs)

Improvements in child health good measure of societal progress

Childhood illnessesmainly due to infectious diseases, neonatal disorders

and malnutritionmay cause life-long disability contribute substantially to the global burden of disease

Majority of childhood deaths (> 2/3) preventable or treatable with currently available

interventions

0 20 40 60 80

0-9

10-19

20-29

30-39

40-49

50-59

60-69

70+

Ag

e a

t D

eath

(Y

ears

)

Percentage

Less-developed Countries More-developed Countries


Organisation of health care services

Preventive and curativein- and outpatient carein health institutions

Preventive and curativemeasuresin the community

Preventive and curativemeasuresin the core family

Financial systemEducation

Social system

Infrastructure

Women‘s position

Place of living

Security

Political system

Environment

Economy

Determinants ofChild HealthSafe living conditions (safe water, sanitation, air, housing, wealth)

Social and emotional well-being

Nutrition

Education

Stable environment

Culture (traditions, arts, music, religion)

Health care


ChildMortality

+ 10%Annual Income per Capita

+ 10%School Education for Women

+ 10%Access to Clean Water

+ 10%Density of Tarmac Roads

+ 10%Health Sector Spending

- 4%

- 3%

- 3%

- 1.5%

- 1.5% World Bank 2003(modified after A. Sobanjo, GTZ)

Contribution of Different Sectors towardsReducing Child Mortality


Conceptual Framework of Global Child Health: the Continuum of Care Approach(Integrated service delivery packages for maternal, newborn and child health)

Lawn et al. Health Policy Plan 2012; 27: iii6-iii28; Lancet Every Newborn Series 2014

Photo credits: HaydomLutheran Hospital, TZ


Global Under-Five & Neonatal Deaths(millions)

12,7

10,99,7

8,2

6,95,9

1985 1990 1995 2000 2005 2010 2015 2020

4,74 3,7 3,3 2,9 2,7

1985 1990 1995 2000 2005 2010 2015 2020

Under-five deaths

Neonatal deaths

UN-IGME Report 2015


GBD 2015

5.8

2.6

Lancet 2016;388: 1725–74


49%

A Promise RenewedReport 2014

Under-Five Mortality Rates (1990 vs 2015)

Cau

casu

s&

12

6

UN-IGME Report 2015


Causes of Deaths in 5.9 Million Childrenunder Five Years (2015)

44%

Up to 50% of deaths areassociated with

malnutrition


PneumoniaThe commonestcause of death in children underfive

16 month-old toddler, hx of 5 days of cough-ing and fever, since last day dyspnea and refusal to eat or drink


Courtesy Dr. A. Biebl

Diarrhoea & Dehydration


Distribution of 2.7 Million NeonatalDeaths (2014) [GBD 2015: 2.6 million]

Lawn JE et al. Lancet 2014


Distribution of 2.6 Million Stillbirths (2015)(1.2 million occur during delivery) [GBD 2015: 2.1 million]

Lawn JE et al. Lancet 2016


Child Health (6-9 Years)

0.935 million deaths in 2010

40-50% infectious diseases

15-20% injuries (unintentional, intentional, transport, disaster, war)

10-15% long-term complica-tions of perinatal disorders


0

50

100

150

200

250

300

350

400

450

500

Esti

mat

edN

um

ber

of

An

nu

al D

eath

s(x

10

00

)

Boys Girls

Lozano R et al. Lancet 2012; 380: 2095–128Hill K et al. Lancet Glob Health 2015; 3: e609–16

Adolescent Health (10-19 Years)

1.3 million adolescents died in 2012 Road injuries, HIV, suicides, lower

respiratory tract infections, violence

Girls aged 15-19: suicide, pregnancy-related complications

2.5 million < 16 give birth

15 million < 18 married

30 million at risk of FGM

1 in 10 girls (120 million) victim of sexual violence


Mo

rtal

ity

Rat

es/1

00

00

0 (

20

04

)

Patton et al. Lancet 2009; 374: 881-92; EWEC 2015

15-19 years

10-14 years

Adolescents and Young People(10-24 yrs)

Total 1.8 billion

The world’s largest untapped resource

The most neglected group in global health


Patton GC et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet 2016

Percentage of the total population aged 10-24 years in 2013

Demographic Changes

Current demographic trendskept equal

5 billion children born between2015 and 2030

Among them 1.6 billion born in sub-Saharan Africa

In 2050 37% of all children under 5 years will live in sub-Saharan Africa (1950: 9%)

Similar projections apply to the to-tal population in sub-Saharan Africa UNICEF. Committing to Child Survival. Progress Report 2013


(Mal-) Nutrition


UN MDG Report 2015

1 in 7 children under 5 (90 million)(1990: 1 in 4; in SSA only 33% reduction)

The Lancet series on maternaland child undernutrition 2013

Prevalence of stunting in children under 5

1 in 4 children under 5 (161 million)(in SSA 33% increase between 1990 and 2013)

Stunting twice as high in rural as in urban settings

(Mal-) Nutrition & U5MR


0

2

4

6

8

10

12

14

-3.5 -2.5 -1.5

Average weight-for-age z-score

Diarrhea

Pneumonia

Malaria

Measles

Overall

Caulfield et al.Am J Clin Nutr 2004

The Lancet series on maternaland child undernutrition 2013


Stabilisation Rehabilitation

Tag 1-2 Tag 2-7 Woche 2-6

1. Hypoglykämie

2. Hypothermie

3. Dehydratation

4. Elektrolyte

5. Infektionen

6. Mikronährstoff- ohne Eisen mit Eisen

mangel

7. Vors. Ernährung

8. Catch-up

9. Anregung

10. Vorbereitung

des Follow-up

Management der SAM


Household Air Pollution (HAP) 3 billion people rely on solid fuels(biomass) / coal and use open stoves

3.5-4 million deaths/year

Women and children most severelyexposed

Neonatal infections, pneumonia anddeaths may be related to HAP (OR 1.14 to 18.54)

455,000 children die each year fromHAP-related pneumonia

Half of pneumonia cases are related toHAP Photo credits: University of Liverpool,

Martin WJ II et al. PLoS Med 2013; 10(6): e1001455


Gordon SB et al. Lancet Respir Med 2014; 2: 823-60

U5MR, Poverty&Wealth


UN-IGME Report 2011

836 million (14%) of the world population live in extreme poverty (< 1.25 USD/day) 30-40% < 18 years

U5MR 2x higher in poorest than in richest quintile

Out-of-pocket payments for child illness form a substantial part of healthcare

expenditure

contribute to low levels of healthcare seeking

can lead to catastrophic health expenditure

can push families into poverty

Share of Global Wealth of the Top 1% and Bottom 99%

The dashed lines project the 2010–2014 trend.

By 2016, the top 1% will have more than 50% of total global wealth!

Oxfam 2015


U5MR & Education

U5MR 2.8x higher in childrenwhen mother has no education vsmother with secondary education

No primary school education Rural 20% vs urban 9%

Poor families 32% vs rich families 7%

Poor schooling conditions 40%

Diminishing difference betweengirls and boys


UN-IGME Report 2011UN-MDG Report 2015

U5MR & Place of Residence

U5MR in rural areas 1.7x higher thanin urban settings

Long distance to health facilities

Poverty prevails

Poorer educational level


UN-IGME Report 2011

Rural & Urban Population

The Rockefeller Foundation–LancetCommission on planetary health.Lancet 2015; 386: 1973-2028


Photo credits: M. Niemi (Finland), C. Schmidt (Germany)

Shifts from Rural to Urban Health

Majority lives nowadays in urban environment

900 million people live in slums

Disrupted communities

Poverty, poor nutrition & poorhealth in slums

Difficult provision of healthservices

New strategies needed


Photo credit: Oxfam 2015Lancet 2016, October 16online

0

20

40

60

80

100

120

140

Childhood

malnutrition (%)

U5MR MMR

25% poorest 25% second poorest

25% second richest 25% richest

Who dies? It is the Poor who die!

Wagstaff/ClaesonWorld Bank 2004

“If health is central to poverty reduction, then issues of equity must be central to health.” - UN MDG Task Force on Child Health and Maternal Health -

Especially the poor and disadvantaged must benefit from interventions (pro-poor policy).


0,82

0,84

0,86

0,88

0,9

0,92

0,94

0,96

0,98

1

1,02

0 3 6 9 12 15 18 21 24 27 30 33

36 39 42 45 48 51 54 57 60

Cu

mu

lati

ve s

urv

ival

Poor BRAC member

Poor non-member

Non-poor non-member

Age in months

Bhuiya et al., 2001

The BRAC-poverty reduction program, focused on women, reduces differences in child mortality (Matlab, Bangladesh 1993-1996)


Coverage of Essential Interventions acrossthe Continuum of Care


Countdown Report 2015

Expanded Program on Immunization (EPI)In 2015 86% coverage for DTP3 worldwide , BUT 19.4 million infants did not receive DTP3

BCG

DTP

OPV/IPV

HiB

HepB

PCV

Rotavirus

Measles

Rubella, HPV

Yellow Fever

Japanese Encephalitis


WHO 2016

State of the Health Systems

Poorly organized, weak health systems

Poor acceptance and utilization

Lack of qualified health workers

Too weak for introduction of new interventions/programs

Too often institution-based activities, marginalized groups difficult to reach


41

15

8

Tanzania

Uganda

Bangladesh

% of sick children who were primarily brought to a health institution

Arifeen S, Paryio G, Schellenberg J et al; MCE-IMCI

Utilization of child health services is very often too low


Essential items rarely or never available in 11 or morehospitals: 12-71% Oxygen saturation monitor, paediatric fluid giving sets

Chest drain tubes, intraosseous needles

Cloxacillin, third-generation cephalosporin, griseofulvin

Iron syrup, multivitamins, vitamin K, oral potassium

Spironolactone

Special milk/mineral mix for malnutrition

Newborn formula milk

English M et al; Lancet 2004; 364: 1622-9

> 35,000 admissions

4 paediatricians, 6 general practitioners

2-8 nurses/day shift, 1-2/night shift

Inpatient fatality rate 4-15%

Delivery of Paediatric Care at the First-Referral Level in 14 Hospitals in Kenya - Key Findings


Health Workers: Critical Shortage

Welt-Sichten 10-2015


Access to Physicians, Nurses and Midwives

UN High-Level Commission on Health Employment and Economic Growth (2016)

2013: shortage of 17.4 million qualified health workers (2.6 million physicians, 9 million nurses/ midwives, others)

2030: projected shortage of 14.5 million qualified health workers (2.3 millionphysicians, 7.6 million nurses/ midwives, others)

Especially sub-Saharan Africa and Asia affected


Anand & BärnighausenLancet 2004; 364: 1603-09; WHO 2006

Health Workers Save Lives


MDG 4+5: NMR, MMR & Health Worker Availability


Neonatal Mortality Maternal Mortality

Physicians Midwives

Lawn et al. 2010Sem Perinatol 34: 371-386;www.worldmapper.org

Quantity

Quality

Availability

Enabling environment

Work output

Relationship with patients

Perception by patientsTibandebage P, Mackintosh M. The market shaping of charges, trust and abuse: health care transactions in Tanzania. Soc Sci Med 2005; 61: 1385-95

Not only quantity counts ….


http://www.conflictmap.org/

Direct consequences Injuries, deaths, child soldiers

Violence against (young) women

Psychiatric disorders

Indirect consequences >3.5 mill. children displaced /

refugees just from Syria

Collapse of health systems

Preventable deaths from infections and malnutrition

Highest U5MR (Afghanistan, Chad, DR Congo, Iraq, Somalia, Sudan, Pakistan, Yemen)

Child Health in War-Torn Countries

CARSTEN KRÜGER, GLOBAL CHILD HEALTH, 13.10.2017Bhutta ZA et al. Curr Probl Pediatr AdolescHealth Care 2010;40:20-35

1 billion< 18 yrs

From MDGs to SDGs (2016-2030)

In September 2015 all UN memberstates agreed to theSDGs

17 Goals with 169 Targets

Goal 3: Health

Goal 2: End hunger

Goal 1: End poverty


Goal 3 Targets3.1By 2030, reduce the global MMR to less than 70/100,000 live births3.2By 2030, end preven-table deaths of new-borns and children under 5 yrs of age, with all countries aiming to reduce NMR to at least as low as 12/1,000 live births and U5MR to at least as low as 25/ 1,000 live births

Global Agenda for 2016 – 2030:Sustainable Development Goals

Major MDG achievements

Mobilised broad support from governments and the donor community for a global development agenda

Served as the basis for the SDG development

Despite falling short of several MDG goals, considerable progress was achieved on many of the MDG targets and goals

Major MDG criticism

Developed by a small group of “experts”, not UN member state-driven

Too much aid-focussed/donor-driven

Did not address the issue of equity

Major SDG innovations/advantages

Universally applicable to and developed by all countries (HICs, LMICs), including civil society

Address main economic, social & environmental aspects of sustainable development better success?

The 17 Goals with 169 Targets cover a broad range of sustainable development issues

Ending poverty and hunger

Improving health and education

Making cities more sustainable

Combating climate change

Protecting oceans and forests


Possible Problems Health only 1 out

of 17 Goals MNCAH may

become invisible

Africa lags behind due to poverty, rapid population growth, political instability

and lack of qualified health workers

SDGs have to focus on inequity between poor & rich people, rural & urban popula-tion, women & men, and different educational levels

Objectives

1. SURVIVEEnd preventable deaths

2. THRIVEEnsure health and well-being

3. TRANSFORMExpand enabling environments


Weblinks & Literature

http://www.who.int/child-adolescent-health/

http://www.who.int/pmnch/en/

http://www.unicef.org

http://www.thelancet.com/collections/global-health

http://www.thelancet.com/journals/langlo/issue/current

http://www.savethechildren.org/programs/ health/

http://www.countdown2015mnch.org/

http://www.ipa-world.org/

http://www.ichg.org.uk

http://www.tropenpaediatrie.de


WHO 2005 + 2013WHO 2000

WHO Treatment Guidelines


WHO 2012

WHO – IMCI / ETAT


Every Newborn Action Plan (ENAP)

WHO, UNICEF & UN in 2014

www.everynewborn.org

www.healthynewbornnetwork.org

www.lancet.com/series/everynewborn

www.pmnch.org


WHO – Malaria


WHO – HIV/AIDS


WHO – Tuberkulose


Child Survival 2003

Child Development in Developing Countries 2007 / 2011

Adolescent Health 2007 / 2012

Maternal and Child Undernutrition 2008 / 2013

Equity in Child Survival, Health, and Nutrition 2012

Childhood Pneumonia and Diarrhoea 2013


The Lancet Child Health Series

Neonatal Survival 2005

Preterm Birth 2008

Stillbirths 2011

Every Newborn 2014

Ending Preventable Stillbirths 2016


The Lancet Neonatal Health Series

Maternal Survival 2006

Maternal and Child Undernutrition 2008 / 2013

Family Planning 2012

Perinatal Mental Health 2014

Midwifery 2014

Breastfeeding 2016

Maternal Health 2016


The Lancet Maternal Health Series

Health Systems 2004

Millennium Development Goals 2005

Who Counts 2007

Alma Ata: Rebirth and Revision 2008

Counting Births and Deaths 2015


The Lancet Public Health Series

Health systems

Financing

Human Resources

Sexual/reproductive health and rights

Child mortality

Maternal mortality

Global mechanisms

Information systems

Targets and indicators


Millennium Project Task Force 2005

The situation in 2005

Programme strategies

System and policy implications


The World Health Report 2005

Health and globalization

Health care services and systems

Health of vulnerable groups

The wider health context (climate, water, food, education, war)

Beyond the health sector

Holding to account: global institutions, transnational corporations and rich countries


Global Health Watch 2005-2006 / 2008 / 2011 / 2014


Joint Learning Initiative 2004: Human Resources for Health


The Countdown to 2015 Reports


UNICEF - State of the World‘s Children


UNICEF - Other Reports



Photo credit:Haydom Lutheran Hospital, TZ

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GLOBAL CHILD HEALTH - Heidelberg University