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Children’s health in 2020: Top 10 issues to watch

Children’s health in 2020: Top 10 issues to watch
Provincial annual reports have noted positive trends in vaccination rates for children younger than one, and data from the 2017/2018 District Health Barometer estimated immunisation coverage at 77%. (Photo: Leila Dougan / Daily Maverick)

With little progress being made in certain areas of child, adolescent and maternal health, Spotlight spoke to the experts to outline the top 10 issues to watch for in the new year and the new decade.

1. Can more provinces reduce under-five mortality?

In South Africa, one in 31 children die before their fifth birthday, and though the country has made great strides in reducing under-five mortality rates, one age group remains particularly vulnerable.

According to the 2019 Child Gauge published in December by the Children’s Institute at the University of Cape Town, neonatal mortality rates have fluctuated since 1997. 

Spotlight analysed the 2018/2019 neonatal mortality rates in all the provinces and found that the majority did not show decreased death rates. According to provincial health department annual reports, reasons for this included overcrowded and understaffed hospitals, poor infrastructure in neonatal units, and high infection rates as a result.

Recently, the Gauteng Department of Health confirmed that 10 neonates had died at Tembisa Hospital as a result of a bacterial outbreak between November and December of last year. The hospital’s neonatal unit has only 44 beds but reportedly admits almost 90 patients at a time. Gauteng was nevertheless one of only a few provinces to reduce its neonatal mortality rate in 2018/2019. 

2. Are pregnant women accessing care in the first 20 weeks?

The Gauge reports that in 2018 just over a quarter of pregnant women did not access antenatal care within the first 20 weeks. Antenatal care can help healthcare practitioners detect early risks such as HIV and diabetes. Antenatal care is part of a child’s first 1,000 days of life, which are critical for a child’s further development.

Most provinces reported successfully increasing their percentage of antenatal visits before the first 20 weeks in the 2018/2019 year. Provinces that failed to reach their targets cited late bookings as well as the late presentation of teenage pregnancy due to the fear of stigmatisation and cultural shaming.

3. Can we further reduce stunting and hunger?

South Africa has made great strides in reducing child hunger to 11% (child hunger is defined as children living in households who reportedly go hungry “often”, “sometimes” or “always” due to a lack of food), but although children may not be hungry, they may not be getting the nutrition they need.

As a result, children are often stunted, malnourished or overweight. Stunting is when a child’s height-for-age is below the average of others in the same population. Stunting rates in SA have remained high at over 27%, and have seen minimal change in the last 20 years.

In terms of child hunger, the Gauge reported that for 2018, KwaZulu-Natal had the highest number of children living in households with child hunger: 753,000. This was two to four times more than other provinces, and accounted for over a third of the cases in the country as a whole.

For under-five mortality, malnutrition-related deaths accounted for half of hospital deaths. This is split between cases of severe acute malnutrition (SAM) and moderate acute malnutrition.

4. Can we increase immunisation rates in rural areas?

Provincial annual reports have noted positive trends in vaccination rates for children younger than one, and data from the 2017/2018 District Health Barometer estimated immunisation coverage at 77%. However, this national average is not reflective of the disparities in immunisation coverage between urban and rural districts.

For a facility in an urban area, access to vaccines and the equipment to store them properly is easier than a rural clinic. In the Eastern Cape for example, the province reported that during the 2018/19 financial year, only 72% of children were vaccinated, compared to the province’s target of 87%.

The Eastern Cape has had long-term issues with its Mthatha depot, resulting in the eastern side of the province bearing the brunt of stock-outs and shortages. In its annual report, the province noted the issues with the Mthatha depot as well as with rural facilities that did not have electricity or vaccine fridges.

Similarly, Limpopo reported immunisation rates well below its desired targets, citing low stock and budgetary constraints.

Immunisation rates are an issue to watch, given South Africa’s struggle with stock-outs and shortages, but also the differences in healthcare access in urban and rural communities. While the national average may be 77%, many rural districts remain well below this average.

5. Can we help more adolescents stay healthy and alive?

Adolescent health as a category is very broad, but there are issues within the category that need urgent attention.

Gauge contributors on adolescent health, Elona Toska and Millicent Atujuna, told Spotlight that addressing issues in adolescent health required an equally complex and intersectional approach.

“Our research has shown that it is the intersectionality of multiple issues that makes adolescents’ health experiences a major issue. For example, the combination of structural drivers such as extreme poverty and inequality with poor access to education and mental health has been linked to higher rates of early unintended pregnancy and increased risk of HIV infection,” they said.

The Gauge reported that mortality and morbidity among adolescents stem from communicable diseases like HIV/AIDS and TB, as well as injuries and violence. HIV incidence is extremely high among adolescents, who account for over a third of new infections. Young women are also three times more likely to become infected than men.

“Supporting adolescents who are not HIV infected to remain HIV-free, while providing care for adolescents who are living with HIV to not only survive but also thrive, is a key issue for this generation,” said Atujuna and Toska.

Together, Atujuna and Toska have done research to document the impact of physical and emotional violence on adolescents. 

“Integrating violence prevention within our HIV response and improving access to family planning and comprehensive sexuality education are key to our efforts,” they added. 

6. What steps will be taken to reduce rising obesity rates?

Along with stunting and hunger, obesity is the third part of the triple burden of poor nutrition in children and adolescents. The “triple burden”, as the Gauge writes, is undernutrition, overnutrition and micronutrient deficiencies. In other words, malnutrition, stunting and obesity.

The Gauge reports that 18.4% of children between the ages of five and 17 and 13.3% of children under the age of five, are overweight or obese. Among adolescents, obesity is highest among females, at 8% compared to males at 1%.

Lake told Spotlight that obesity was rapidly increasing, particularly between childhood and adolescence. This has serious implications for the development of non-communicable diseases (NCDs) in adults. 

Combating obesity requires a thorough look at the current food system and a push to make healthier foods more affordable and widely available as opposed to processed, high-sugar foods.

7. Will more finally be done to combat childhood TB?

TB prevalence in children is not only an issue to watch, but a topic that requires significantly increased research and awareness.

Currently, provincial annual reports do not distinguish between TB prevalence in children and adults, and there is limited data on child TB.

“We don’t know what the [current] prevalence rate is,” said Lake. “That’s partly because it’s not seen as a priority because it’s slightly harder to diagnose in children. The concern is, are we following through and doing active case finding and making sure we’ve identified an adult with TB [and] that we are putting protections in place for children.”

There is also a call for more child-friendly TB drugs.

In 2017 the National Department of Health reported that TB accounted for only 1% of under-five deaths, but this estimate may not be particularly accurate due to the difficulty of diagnosing TB in children.

8. How will we manage the impact of climate change on children?

The consequences of climate change affect everyone, but children are more at risk of health and developmental challenges. As South Africa continues to experience prolonged periods of drought and extreme weather, children may face greater risk than adults.

While the country has made progress in improving access to safe water and sanitation, drought-stricken areas mean diminished water supply and greater risk of infection. Drought also affects food supply which can contribute to malnutrition.

Child health experts are calling for greater advocacy of children’s rights in policy relating to climate change and industry; such as the Carbon Tax Act, the draft National Climate Change Adaptation Strategy and the Department of Health’s draft National Climate Change and Health Adaptation Plan. 

9. Will NHI be changed to make more provision for children’s health?

Previously Spotlight reported that children’s health was missing from the National Health Insurance (NHI) Bill. Though the bill recognises a child’s right to healthcare, there is little information on an essential package of care for children.

These would include norms and standards, as well as information about paediatric essential medicines and child health support teams such as district clinical specialist teams (DCSTs).

Provinces have already worked to establish DCSTs, but should the NHI not include these teams, children’s health could lose significant traction and leadership.

In the White Paper on NHI, DCSTs are mentioned, as are ward-based outreach teams and integrated school health programmes (ISHPs). In the bill, mention of “district specialist support teams” is in one of the amendments.

The Gauge has further called for the NHI to include representatives from the child health sector in the decision-making process.

10. Will we see greater leadership in 2020?

One of the all-encompassing issues to watch for this year is the push for leadership in children’s health. Though provinces have established DCSTs and other outreach teams, shortages of paediatric specialists and staff leave many of these teams incomplete, particularly in rural districts.

There may be a need to have a closer look at the composition of those teams, because they play such a central role in really evaluating the state of child health at district level and identifying areas that need quality improvement,” said Lake.

The Gauge continuously calls for leadership at a district, provincial and national level. Aside from the DCSTs, only three provinces have provincial paediatricians, which has been an ongoing recommendation by a child health advisory committee to the health minister.

“Without that leadership, child health is likely to get lost,” said Lake. MC

This article was produced by Spotlight – health journalism in the public interest.

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