(CoMMiC) - Abridged

47 Pages·2014·1.04 MB·English

2ND T R C
RIENNIAL EPORT OF THE OMMITTEE ON
M M C U 5
ORBIDITY AND ORTALITY IN HILDREN NDER
Y (C MM C): 2014
EARS O I

_____________________________________________________

ABRIDGED VERSION

November 2014

CONTENTS

Contents 1
Executive Summary 3
Overview of Child Mortality in South Africa, 2011 9
Recommendations 23
Child Mortality Data 35

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EXECUTIVE SUMMARY

‘Not everything that can be counted counts and not everything that counts can be measured’
Albert Einstein

The Committee on Morbidity and Mortality in Children under 5 years (CoMMiC) is one of
three national ministerial committees continuously reviewing maternal, perinatal and
childhood deaths in South Africa. CoMMiC’s primary objective is the monitoring of mortality
and morbidity data in children younger than five years in an effort to reduce deaths and
improve the health of young children. The committee is also tasked with improving clinical
governance and assisting in the development of appropriate standards of health care for
South African children. This is the committee’s second comprehensive report and covers the
triennium 2011 to 2013.

This report is being presented recognising that there is just over a year left for countries to
achieve the United Nations Millennium Development Goals (MDGs). Four of the MDGs are
directly relevant to children, with MDG 4 specifically calling for a two-thirds reduction in the
under-five mortality rate between 1990 and 2015. This report provides an opportunity to
reflect on the country’s past and recent child health related achievements and performance,
and to deliberate on, and recommend, an appropriate post-2015 agenda.

In the three years since the first triennial report, changes in the social environment and
health services in the country have positively affected the health status of children. Child and
infant mortality rates have both strikingly diminished. This is mainly because of fewer
HIV/AIDS deaths as a result of new regimens for the prevention of mother-to-child
transmission (PMTCT) of HIV as well as more children being eligible for, and initiated on,
antiretroviral treatment. The roll-out of rotavirus and pneumococcal conjugate vaccines have
also contributed to fewer diarrhoeal and pneumonia deaths, respectively.

The committee (and this report) depends on data from a number of sources, including:
 Health Data Advisory and Co-ordination Committee (HDACC) reports that use a rapid
mortality surveillance system (RMS) that depends on death notification data and offers
national trend data.
 Vital registration data collated and published by Statistics South Africa on an annual
basis provide provincial and district level data.
 The 2011 Census that collected data on household deaths during the preceding year.
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 The District Health Information System which only captures in-facility events in the public
sector.
 The Child Healthcare Problem Identification Programme (Child PIP) database which
collects data on deaths at approximately half of the nation’s public hospitals.

Discrepancy in the quality of data obtained from these different sources means that there
remains uncertainty about the exact child mortality rate in South Africa. Under five and infant
(under one year) mortality rates based on RMS data are shown below. Both rates have
consistently declined from 2009 to 2012 in all provinces as well as in the country as a whole.

2009 2010 2011 2012
Under 5 year mortality rate (per 1000 live births) 56 52 40 41
Infant mortality rate (per 1000 live births) 39 35 28 27

The number of under-five deaths has declined from approximately 60 000 in 2008 to 38 000
in 2012. Although this translates into about 60 fewer child deaths per day in 2012 than in
2008, it still means that more than 100 under-5 children died each day in 2012. Three-
quarters (74%) of them were aged less than one year. In 2011, the Free State under-five
mortality rate (71.2) was almost three times higher than that in the Western Cape (24.1).
Lower than expected mortality rates in a number of rural provinces suggest that under-
reporting remains pertinent, but its true extent is difficult to quantify.

The in-hospital mortality rate (IHMR) refers to the proportion of admitted children who died.
The IHMR for children under-one declined from 5.8% in 2010 to 3.9% in 2013, whilst the
IHMR for children under five years of age declined from 4.4% in 2010 to 2.8% in 2013. This
decrease probably reflects reduced illness severity as a result of fewer HIV/AIDS related
admissions rather than improvements in hospital health care delivery.

Cause of death data was obtained through the Vital Registration system (death certificates).
In 2011, one-quarter of deaths were reported to be due to neonatal causes, whilst gastro-
enteritis (15%) and acute respiratory infections (mostly pneumonia) (13%) were the next
most important. Non-natural causes (6%), malnutrition (4%), congenital abnormalities (4%)
and tuberculosis (2%) were other major contributors. Most non-natural deaths were ascribed
to preventable causes such as drowning, burns and electrocution. Of concern is that the
cause of death was classified as being ill-defined in 16% of instances, indicating that the
quality of death certificate completion by health professionals remains a problem.
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HIV/AIDS and malnutrition contributed as both primary and underlying causes of child
mortality. Based on Child PIP data, about thirty percent of children who died between 2010
and 2013 were classified as being severely malnourished. The proportion of children who
were HIV-infected or HIV-exposed (with unknown HIV-infection status) declined from almost
half in 2010 to approximately one third in 2013. PMTCT interventions in South Africa have
greatly reduced the need for antiretroviral treatment (ART). A United Nations report infers
the number of South African children needing treatment dropping from nearly 60,000 to
about 10,000 per annum over the past decade. DHIS data indicated a catch up in the
provision of ART to children, although only 50-60% of eligible children were recipients.

A high proportion of child deaths are preventable. Audit of child deaths through the Child PIP
system continues to reveal many modifiable and avoidable factors at home and at all levels
of the health system. Approximately 30% of modifiable factors occurred at home, and
included the failure by the caregiver to recognise a child’s severity of illness, delays in
seeking care for the child and inadequate nutrition. Among the remaining 70% of health
system factors, most (80%) related to health personnel. A disproportionate number of
modifiable factors continue to take place in the Accident and Emergency setting, considering
the relatively short period that children spend there.

Access to health care for sick children remains a problem. More than half of all registered
child deaths (55%) occurred outside the health service, despite many of these children
having prior contact with the health service shortly before dying. Only 36% of deaths in the
post-neonatal period (1 month to 5 years) occurred in health facilities. The distribution of
paediatricians, which is as a proxy indicator for access to more specialised services, shows
extreme geographic inequities. Notwithstanding inequities in access to health services,
utilisation of primary healthcare services is reasonably good, with some of the poorest
provinces having better attendance rates.

In compiling recommendations for this report, the Committee focussed on the word
‘ACCESS’. Firstly, the word has powerful intrinsic worth in indicating why the country has not
adequately dealt with preventable childhood killers and what might be done. Secondly, it
serves as a useful acronym to point to actions required to improve life outcomes for children
in South Africa. The recommendations section highlights seven key words that can ‘open the
door’ to improved outcomes for children: A-ccountability, C-onnected, C-apacitated, E-
ssential, S-upport and S-tandard. The required actions or activities associated with these key
words is related to how they involve households, health workers and the health system. This
is summarised below:
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Households Health workers Health systems
Accountability By government to To care–seekers through To the community
ensuring a safe living empowerment of health
environment workers
Connected With the health system To the system where they To all sectors who ensure
work healthy children
Capacitated To provide a safe, caring To deliver appropriate To meet the needs of
and stimulating health care children with emergency,
environment acute and chronic
conditions
Essential Package of care that is Package of care Package of care available
available understood and delivered and accessible
Support For ECD activities For training, health care To meet the demands of
delivery and personal the community served
health
Standard Package of care Human resource (staffing) Data sets for children
norms

Priority interventions identified within the above framework to improve child health and
reduce morbidity and mortality include:

A-ccountability for an adequate standard of living and a safe environment for all children:
 Ongoing health and nutrition education through Mom-Connect and other media
channels.
 WBOT support to households for health education, promotion and prevention
activities.
C-onnected easily between households and the health system:
 Ensure lodger mother facilities in all hospitals and birthing units.
C-apacitated front line health care workers:
 Pre- and post-basic training and continuing education on all flagship programmes,
ECD and EPOC.
 Non-rotation of staff at all levels.
E-ssential Package of Care (EPOC):

 Finalise the development of the essential package of care including equitable

access to all levels of care.

 Train health workers around the essential package of care.

 Progressive roll out of the essential package of care.

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S-upport:
 Early child development and the first 1,000 days.
 Frontline health workers through outreach programmes.
S-tandard data sets and tools:
 Introduce standard data sets for children for monitoring, evaluation and feedback.

 Adopt the Road to Health Booklet as the standard record of a child’s health care.

The global child health agenda is moving beyond survival to sustainable development with a
particular focus on actions that in the first 1 000 days of life can alter the life course
trajectory. While it is anticipated that reducing child mortality will continue to pre-occupy
much of CoMMiC’s attention in the next triennium, one would expect that securing for
children the potential gains of introducing the National Health Insurance will be a key
mandate for the new committee. This will demand new activity and actions that can open the
“ACCESS” door.

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