Dorothy Mbori-Ngacha UNICEF

Transcription

1 THE DOUBLE DIVIDEND Action to improve survival of HIV exposed infected and uninfected children in the era of emtct and renewed child survival campaigns Dorothy Mbori-Ngacha UNICEF

2 Outline The Double Dividend concept Background Child Survival HIV The rationale for the Double Dividend concept How to apply it and what are the returns? Conclusion

3 Definition Dividend: A benefit from an action or policy synonyms: Additional benefit, advantage, gain, bonus, more Action to improve survival of HIV exposed, infected and uninfected children in the era of emtct and renewed child survival campaigns

4 Major causes of death in neonates and children under-five in the African Region *Globally undernutrition contributes to 45% of all child deaths Sources: (1) WHO. Global Health Observatory ( (2) *For undernutrition: Black et al. Lancet, 2013

5 Trends in the U5MR have improved over the past two decades The global burden of under-five deaths has fallen steadily since 1990 which is a substantial achievement but, Global under-five, infant and neonatal mortality rates, Global under-five deaths, millions acceleration is needed to reach the MDG 4 target of 30 deaths per 1,000 live births by 2015

6 Together, South Asia and sub-saharan Africa account for 4 out of 5 U5 deaths globally, with SSA lagging most SSA s U5MR 98 deaths per 1000 births By 2050, SSA: 37% U5MR, 40% of live births, globally

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8 Wide gap between adults and children on ARTs 100% 90% 80% 70% 60% 50% 40% 30% 20% > > Adults (aged 15+) Children (aged 0 14) Children (34%) half as likely as adults (64%) to get treatment 39% of infants receive HIV testing 10% 0% Botswana Namibia Swaziland Zambia Zimbabwe South Africa Kenya Malawi Uganda Untd. Rep. of Tanzania Ethiopia Burundi Ghana Lesotho Côte d'ivoire Cameroon Mozambique Angola Chad Dem. Rep. of the Congo Nigeria 21 priority countries

9 Significant progress towards the Global Plan targets

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11 A growing number of HIV-exposed but uninfected Children 0-4 in Low and Middle Income Countries, most of them in Eastern and Southern Africa Asia Caribbean EECA LA MENA Oceania EA SA WCA HIV-exposed but uninfected children have poorer health They have slower early growth and higher risk of morbidity and mortality from childhood diseases (e.g. diarrhoea & pneumonia) compared to HIV unexposed children

12 The rationale for the Double Dividend concept Causes of U5 Mortality Diarrhea Pneumonia Neonatal HIV/AIDS Malaria TB Other Under nutrition

13 The Double Dividend: action to improve survival of HIVexposed infected and uninfected children in the era of emtct and renewed child survival campaigns THE GOALS Improved child health outcomes both morbidity and mortality Improved health outcomes for children exposed to HIV both infected and uninfected THE STRATEGY: Focus on integrating paediatric HIV within the wider child health/survival agendas

14 Leaky cascade of Pediatric HIV care needs innovative solutions Outcome of HIV positive infants in Uganda Chatterjee A et al. BMC Public Health Jul 13;11

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16 The existing opportunities and points of entry to leverage- SERVICE DELIVERY PLATFORMS MCH ANC Postnatal L + D IMNCI (iccm) Nutrition (CMAM, IYCF, SAM) EPI Inpatients Community outreach HIV Adult ART PMTCT/B+ EID Community-based HIV programmes

17 The Double Dividend - 4 step framework 1. Understand 2. Design 3. Deliver 4. Sustain Know your epidemiology: causes of U5MR, comorbidities. Including PMTCT and Pediatric HIV Identify gaps in U5 mortality and successes Know your geography and population spread where is the epidemiology located and where are your services? Review existing plans and performance; will you meet your target? Define the unmet need and set your targets Define approaches for improving identification of children in and at most risk Define areas of unmet needs where joint investment could reduce those gaps; an optimal package of services for children; Define system for referral and follow up including community level Define capacity, mgmt. structure and forecast supply Deliver capacity development and monitoring plan including laboratory and district oversight systems Deliver management structure and additional needs including HR and community support Deliver system for referral system and tracking patients Support other health system bottlenecks to enhance performance Review existing resources and leverage joint management approaches with existing child survival programmes Conduct regular programme reviews to assess performance and improve efficiency

18 1. Understand the gaps in both MNCH and HIV in order to identify the unmet need - MNCH HIV Zimbabwe Late first booking for ANC (20% before 12 wks.) Low institutional delivery (66%) 40% of neonatal morality 2 nd to preventable causes Low PNC f/u (34%) Drop off on immunization schedule; 10% missed at measles #1 Stunting 36% 26% of maternal mortality related to HIV causes Average age of first test is 10 weeks with long turnaround time Low PITC at 9 months Late initiation of ART in children (7 years median) Limited number of paediatric ART facilities

19 1. Understand the gaps in both MNCH and HIV in order to identify the unmet need - Swaziland MNCH High maternal mortality despite high rate of facility birth Poor maternal nutrition contributing to MM (factor in 50% of cases) and NB outcomes Neonatal mortality 31% of U5M (104/1000)(2010) Postnatal care 22% within first week Underweight and stunting Stock outs of ORS, zinc, amoxicillin HIV Some women are still on Option A; limited information on infant retention through breastfeeding Identification of HIV as a cause of U5MR Low rates of male partner HIV testing Weak PITC (identification) of sick and malnourished children

20 2. Design leveraging plans for scaling up PITC IMNCI INPATIENT SICK CHILDREN HIV TESTING PITC Improved nutrition, reduced stunting and reduced child mortality and improve HIV case finding Nutrition and growth monitoring

21 2. Design programs to expand HIV Testing WELL CHILDREN Infant testing Decentralized infant testing and increase opportunities for identification outside PMTCT programmes EPI

22 2. Design the programme to do what makes sense 0 months 6-8 weeks 9-12 months 18 months Screening at birth with BCG Prevention of mother-to-child transmission and maternal and child health postnatal visits Immunization Measles HIVexposed infants Immunization DPT 1, 2, 3 Provider-initiated testing of sick children Paediatric wards, under-5 clinics, nutrition clinics, Community Integrated Management of Childhood Illness Community outreach support and tracking of LTFU Child Health weeks, voluntary counselling and testing campaigns Source: WHO 2014 adapted from Chewe Luo, UNICEF, presented at ICASA 2013

23 Conclusion Globally countries have made substantial progress in reducing under five mortality but not enough to achieve MDG4 targets. Double Dividend is a framework for ACTION to improve survival of HIV- exposed, infected and uninfected children in the era of emtct and renewed child survival campaigns The DD approach is evidence informed and context specific and has the potential to accelerate the reduction in child mortality in the region Improve collaboration and integration among programmes and services where possible to scale up priority HIV and MNCH interventions across the continuum.

24 Acknowledgements Sostena Romano Chewe Luo Dick Chamla Morkor Newman Martina Penazzato Mary Mahy John Stover Raul Gonzalez Meg Doherty

25 Thank you Countdown to 2015 Progress report Hard and soft copies available at: The Double Dividend Synthesis Document Soft copies available at The Double Dividend Action Framework Hard and soft copies available at