Post on 10-Jun-2015
transcript
UN
IV E R S I T Y O F K I S U MU
GREAT LAKES
98GREAT LAKES UNIVERSITY OF KISUMU (GLUK)
COMMUNITY HEALTH ASPECTS
OF HIV/AIDS
Dan Kaseje, MBChB, MPH, PhDDan Kaseje, MBChB, MPH, PhD
Professor of Public Health,Professor of Public Health,
December, 2009December, 2009
UN
IV E R S I T Y O F K I S U MU
GREAT LAKES
98GREAT LAKES UNIVERSITY OF KISUMU (GLUK)
CONTEXT� 9yrs ago, world leaders set goals to free humanity from the
shackles of extreme poverty, hunger, illiteracy &disease by 2015
� They established quantitative benchmarks for poverty,
hunger, education, gender equity, child/maternal mortality,
malaria and HIV, environmental sustainability and global
partnership for development.
� But progress has been slow, casting doubts as to the
possibility of achieving the goals in Sub-Sahara Africa.
� Less than 6 yrs away, progress is threatened by
unprecedented economic crisis that has led to diminished
resources, fewer opportunities for lower income countries,
worsening already unacceptable DISPARITY (between and within
countries).
Proportion of people living on less than $1.25 a day, 1990, 1999 and 2005 (Percentage)
The global economic crisis derails fight against poverty
� Worldwide, the number of people living in extreme poverty in 2009 is 90 million higher than anticipated before the Global economic crisis
� Minimal poverty reduction in SS Africa, farthest from target
� Steady global reduction
International food price index and consumer food price index in selected countries, 2008 (Year 2000=100)
A decrease in international food prices fails to translate into more
affordable food at local markets� A decrease in international
food prices in the second
half of 2008 was expected to
lower prices in local mkts
� This has not materialized,
and consumer access to
food in many developing
countries, such as Brazil,
India and Nigeria did not
improve as expected
� FOOD PRICE INDEX
HIGHEST IN SS AFRICA.
UN
IV E R S I T Y O F K I S U MU
GREAT LAKES
98GREAT LAKES UNIVERSITY OF KISUMU (GLUK)
SUPPLY SIDE�There is poor preparedness for emerging scenario, inadequate
skills mix (particularly leadership and management) to face
the context
�Competing systems of care contribute to delays in care seeking
(since available, accessible, acceptable) yet ignored and
unregulated (effectiveness unknown). Delayed care seeking leads
to COSTLY CONSEQUENCES�Solutions which tend to be developed outside the context of the problem (by professionals), too simplistic against complex situations surrounding the households, entrapped in the a vicious cycle of poverty and ill-health, as well as layers of disabling socio-economic realities (culture, stigma, discrimination)
UN
IV E R S I T Y O F K I S U MU
GREAT LAKES
98GREAT LAKES UNIVERSITY OF KISUMU (GLUK)
SUPPLY SIDE�CONDOM (less than 50% coverage)
�MALE CIRCUMSCISION (20%)
�VCT, PMTCT (only 10% know their status)
�TREATMENT OF STI (less than 20% access treatment)
�Home based testing
�ART, HAART
�OVC interventions
�Home based care
(all effective yet not reaching hh, individuals enough to change
situation)
THERE IS COMLEX INTERFACE: HH TO CARE
Tertiary Hospital
Secondary Hospital
Primary Hospital
Health Centre, Maternity and Nursing Home
Dispensary/Clinics
Community: Village/Household/Family/Individuals
Interface: Distance, transport, costs, culture etc
Demand side: 70%HH IN POVERTY TRAP
ILL HEALTHILL HEALTHTRAPPED TRAPPED HOUSEHOLDSHOUSEHOLDSPOVERTYPOVERTY
THE VICIOUS CYCLETHE VICIOUS CYCLE
Demand: affected by
�Distance
�Costs (direct and indirect)
�Gender and other discriminations
�Decision making processes
�Stigma
�Extreme poverty and hunger
�Illiteracy�Problems are greatest where resources are least (inverse law)
Girls’ secondary school enrolment in relation to boys’,1998/1999 and 2006/2007 (Girls per 100 boys)
The gender gap increases in
secondary school enrolment,
girls fall behind due to poverty,
hunger and RH issues
� The gap is wider where overall
enrolment is lower, increases
in secondary school enrolment tend to be accompanied by
reductions in gender disparities.
� Target to eliminate
disparities by 2005 target
was missed
Secondary school net attendance ratio of boys andgirls, by place of residence and household wealth,1998/2007 (Percentage)
POVERTY IS MAJOR CAUSE OF DISPARITY
� Gender parity has been
reached in urban areas
and among the richest 40
per cent of households.
� In contrast, girls are
more likely to be
excluded from primary
education in rural and
when they reside in the
poorest households.
UN
IV E R S I T Y O F K I S UMU
GREAT LAKES
98GREAT LAKES UNIVERSITY OF KISUMU (GLUK)
Asia43%
Africa51%
6%
Africa
Asia
Rest of theworld
Maternal Death: 2005
Source: UNICEF global database 2009
(276,000)
(232,000)
(28,000)
Maternal deaths per 100,000 live births, 1990 and 2005 7
Giving birth safely is still
largely a privilege of the Rich
Maternal Health
“Maternal death rate is the largest health disparity in the world”
Who is dying?
Ronsmans C, Graham WJ. Maternal mortality: who, when, where and why. Lancet 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69380-X.
Why are they dying?• Direct Causes:
– Hemorrhage– Htn of
Pregnancy– Infections– Obstructed
Labor– Unsafe Abortion
• Indirect Causes:– HIV/AIDS– Malaria– Violence
Ronsmans C, Graham WJ. Maternal mortality: who, when, where and why. Lancet 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69380-X.
Proportion of women (15-49 years old) attended four or more times during pregnancy by skilled health personnel, 2003/2008 (Percentage)
Less than half of pregnant women in developing
countries have the benefit of adequate prenatal careOnly 40% of women
receive four or more
antenatal visits in
sub-Saharan Africa
to benefit from
PMTCT, less still
deliver in health
facility
Number of people living with HIV, number of people newly infected with HIV and number of AIDS deaths in the world (Millions), 1990-2007
New HIV infections and
AIDS deaths have
peaked 1996, 2005 but 33
million people are still
living with HIV, two
thirds in s-s Africa,
majority are women
Urgent innovations
needed to address the
interface complexities
to accelerate progress
�Many studies show benefits of collaborative action research
(providers, users, researchers and decision-makers), (Ross,
2003; Kogan et al, 2006; Lomas, 2000) in improving policy
and practice.
�Is this an opportunity for SAHARA to engage, facilitate
knowledge generation linked to actions to address problems
of uptake of effective technologies?�Partners engage in an iterative process of joint assessment, dialogue, planning and action (ADPA) for improvement
�Findings fed into dialogue enabling all parties to contribute toquestions and solutions based on own expertise.
Collaborative in Action Research, focusing
on the interface
UN
IV E R S I T Y O F K I S UMU
GREAT LAKES
98GREAT LAKES UNIVERSITY OF KISUMU (GLUK)
Collaborative research process�Dialogue promotes radical thinking, ability to search for new models, innovations, more likely to succeed.
�Dialogue synergizes efforts and motivation through ADPA cycle for continuous improvement.
�Actions taken to address barriers around households, that have to do with the social fabric, context in which they live
�The approach links action to available evidence,
demonstrates progress towards the goals, which justifies
continued action, in areas of influence/responsibility.
UN
IV E R S I T Y O F K I S UMU
GREAT LAKES
98GREAT LAKES UNIVERSITY OF KISUMU (GLUK)
Community Dialogue for cont. ImprovementCommunity Dialogue for cont. Improvement
�What is the situation from evidence? Why?
�What improvement can we accomplish in 1 year?
�What can we do to improve the situation?
�How will we measure the improvement?
Act Assess
Plan Dialogue
UN
IV E R S I T Y O F K I S UMU
GREAT LAKES
98GREAT LAKES UNIVERSITY OF KISUMU (GLUK)
Leverage Intellectual Resources and Knowledge To Develop New Approaches across the interface
Problem Characterization
Idea Generation
SolutionDevelopment
Drive Strategy
Problem
Knowledge Management
Consolidate Learnings | Cross-fertilize Ideas | Educate/Train | Guide Investments | Create a Knowledge Community
Innovation
Invest in Research | Challenge Thinkers | “Connect the Dots”
Leadership
Develop Vision | Mentor Talent | Transition to Execution
Support Execution: Clear the Way for Entrepreneurs to Succeed
Planning Implementation Scale Up
Support Execution
Partnership Platform
Planning | Organizing | Implementing | Assessing | Reporting Advocating | Social mobilization for change
Network
PHASA Skills | Provide Leadership | Enhanced Human Capacity
Capital/resourcing
Commercial | Non-Profit | Government
IMPACT
UN
IV E R S I T Y O F K I S U MU
GREAT LAKES
98GREAT LAKES UNIVERSITY OF KISUMU (GLUK)
Key messages
1. Scale up community-based strategies, partnerships,
to address both demand and supply, supported by
evidence
2. Promote collaborative action research, to drive
policy reforms aimed at accelerated continuous
improvement (successful local models embedded
into policy and practice)
3. Move beyond Afro-Pessimism to concrete action to
continuously improve starting at your own area of
responsibility and influence, increasing in ever
expanding concentric circles.
JICA Nyanza Health Management Project
THANK YOUTHANK YOU
Moving beyond Moving beyond AfroAfro--pessimism,pessimism,for the future of for the future of
AfricaAfrica