Global Hälsa och Utveckling. Stefan Swartling Peterson

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1 Global Hälsa och Utveckling Stefan Swartling Peterson

2 Il faut cultiver son jardin

3 Global hälsa är ett tvärvetenskapligt utbildnings-, forsknings- och verksamhetsområde som inriktar sig på hälsofrågor av global betydelse och som prioriterar uppnåendet av världsomfattande jämlikhet med avseende på hälsan.

4 FN:s deklaration om de mänskliga rättigheterna 1948 Artikel 1 Alla människor är födda fria och lika i värde och rättigheter. De har utrustats med förnuft och samvete och bör handla gentemot varandra i en anda av gemenskap Artikel 3 Var och en har rätt till liv, frihet och personlig säkerhet Artikel 25 Var och en har rätt till en levnadsstandard tillräcklig för den egna och familjens hälsa och välbefinnande, inklusive mat, kläder, bostad

5 Rätten till liv

6 Women and children with goitres, a marker condition for Iodine Deficiency Disorders (IDD) Sweden, ca 1930 Höjer, 1931

7 Iodine is a necessary requirement for proper body functioning. It is too scarce in the food and needs to be added Sweden has suffered from iodine deficiency. Picture shows congenital mental retardation, Cretinism, Sweden, 1930 Höjer, 1931

8 Iodine deficiency is so easy to prevent that it is a crime to let a single child be born mentally handicapped for that reason. Labouisse, UNICEF We were striving for the best, but it turned out as usual. Victor Chernomyrdin, Former Prime Minister of Russia

9 Rätten till hälsa Controlling Iodine Deficiency Disorders Studies for Program Management in Sub-Saharan Africa by Stefan Peterson

10 Uganda Ministry of Health Four Main Causes of Under Five Mortality -under 5 mortality rate 99/1000 live births (150,000 /year) Integrated Management of Childhood Illness (IMCI) Black et al, Lancet 2003

11 Child ill with Fever Mother Recognizes symptom Labels disease Resorts to care 50% Mother gives home care In the HOME Providers OUTSIDE the HOME Govt Clinic 8% 50% NGO Clinic 1% Drug shop 15% Private Clinic 21% Tradition al 1% Shop 4% Fever Care at Home: 14% herbal 79% western drug Pariyo et al, 2000

12 Home Management of Fever Strategy presumptive Rx all febrile children with Antimalarials, <24 hours of onset, in the village, from a CHW Prepacks increased correct dose and duration (OR 37) Used by 40% of febrile children after 18 months Raised correct treatment practices from 7% to 14% Nsungwa TransRoyalSocTMH, 2007 Photo: Karin Källander

13 But fever could also be pneumonia Demographic Surveillance Site: 164 under-five deaths, 27% pneumonia 44 pneumonia deaths: Sick a median of 7 days, half died in hospital, 1/3 at home 55% first treated with Antimalarial; 29% with an Antibiotic Källander et al, Bull WHO, 2008 Previous treatment with antimalarial is a risk factor for severe pneumonia Hildenwall, Nantanda 2009

14 (30%) Fever Rapid Breathing Effect on careseeking, quality of care and drug use? Cough Källander, Nsungwa, Peterson 2004 Community Health Workers may handle antibiotics. (WHO/FCH/CAH/04.06) Policy in 18/68 priority MDG countries Countdown WG Lancet, 2008

15 Further studies on Community Health Worker capacity to handle RDTs, Timer, and 3 treatments Mukanga et al motivation and supervision Kallander et al - GATES Community drug use patterns Nakayaga-Kalyango et al Antibiotic Resistance Lindstrand, Bwanga et al Mortality reduction Chinbuah et al

16 Changing WHO and UNICEF policies Tackling three major killers in one Integrated Community Case Management of Malaria, Pneumonia, Diarrhoea (iccm) Fever 70% Cough + Fast breathing 28% 12% Diarrhoea + Fever 36% Källander Nsungwa Peterson 2002

17 Population Based Research Site

18 But how about the private sector? Iganga/Mayuge DSS, Uganda - Health Centers: 12 - Private clinics and drugs shops: 122 Sources of care for Recent Febrile Illness in under-fives: - Govt/NGO Health Centres:35% - Drug Shops/Private clinics 62% Reasons: - Qualification 28% - Nearby 63 % Rutebemberwa Malaria Journal, 2009

19 Percentage Baseline 8 Months Private sector and acute febrile illness Integrated Care for Malaria Pneumonia Diarrhea works fine in Drug Shops(RDT, Timer, AM/AB/ORSzinc Awor, Wamani, Peterson et al Treatment of Cough with difficult breathing (Amoxicillin, correct dose for 5-7 days)

20 Four Main Causes of Under Five Mortality - Newborn Black et al, Lancet 2003

21 Neonatal and Under-Five Mortality Rates,

22 Global Newborn deaths Globally, 136 million newborn babies are born every year Of these, 3.8 million die each year But another 3.2 million are stillbirths Uganda neonatal deaths - 50% home deliveries

23 Care for Pregnant and Newborn home visits by CHWs

24 Care for preterm KMC in Iganga Hosp

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27 Percent of Burden of Disease Disease Transition 100% 80% 60% 40% Inj%of total NC %of total Comm%of total 20% 0% Uganda India Brazil Iran,Islamic Republic of China Sweden Kazakhstan

28 DALY rates/1000 population Disease Transition III. Injuries DALYs/1000 pop II. Noncomm DALYs/1000 pop I. Communic DALYs/1000 pop Uganda India Iran Brazil China Kazakhstan Sweden

29 Men varför rädda fler liv?

30 Health Systems have a lot of Hardware.

31 which often does not work as expexted 2/3 of under five deaths avoidable with known technologies if delivered at scale Jones, Lancet 2003

32 And we respond by improving hardware Research funding: NIH Gates New technologies: 97% 73% Delivery & utilization: 3% 27% Leroy et al, Am J of Public Health, 2007

33 Hardware and/or Software improvement? 6.9 million under-five deaths Newborn, Pneumonia, Malaria, Diarrhoea Proportion of total under-five deaths averted: New vaccine for ROTA virus: 2% Scale up ORS and Zinc: 20% Gill, Lancet 2013

34 From efficacy to effectiveness Efficacy 70% 90% X Access x 50% X Quality x 60% X Adherence x 75% 20% = Effectiveness = 16%

35 Health Systems Building Blocks Current Architecture AHPSR and WHO, 2010

36 Governance for Public Service Provision.governance challenges are not fundamentally about one set of people getting another set of people to behave better. They are about both sets of people finding ways of being able to act collectively in their own best interests. They are about collective problem-solving in fragmented societies hampered by low levels of trust. Africa Power and Politics Programme. Policy Brief

37 Towards a New Architecture EMPOWERED PEOPLE MEDICINES & TECH MEDICINES AND TECHN GOVERNANCE HUMAN RESOURCES INFORMATIOIN FÍNANCING INFOMATIOIN SERVICE DELIVERY

38 Global Hälsa, Uppsala och framtiden UTBILDNING!!!!! partneruniversitet i Syd Antibiotika resistens o Rationell Läkemedelsanvändning Dubbel sjukdomsbörda i låginkomstländer Hälsosystem utmaning Vetenskaplig möjlighet andra gener o livsmönster Science for Life ben i Afrika!

39 Andra gör det!

40 En värld, en mänsklighet, en vetenskap. Världens Chans!