6 Child health Health... · 2018. 1. 30. · 2012/13. a Statistics South Africa. Mortality and causes of death in South Africa, 2015: Findings from death notification. Statistics

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Section A: Child health

6 Child healthNeil McKerrow

This chapter covers four indicators, namely child under 5 years diarrhoea case fatality rate, child under 5 years pneumonia case fatality rate, child under 5 years severe acute malnutrition case fatality rate and infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate.

6.1 Child under 5 years diarrhoea case fatality rate Despite the availability of cost-effective measures to prevent diarrhoeal diseases they remain the leading cause of child mortality outside the neonatal period in South Africa, and in 2015 accounted for 10.1% of all under-5 deaths.a Diarrhoeal diseases and pneumonia are sentinel conditions for the assessment of health services for children and the reduction of the facility case fatality rates for these two conditions is a key indicator in the National Department of Health’s (NDoH) 2012– 2016 Strategic Plan for Maternal, Newborn, Child and Women’s Health (MNCWH) and Nutrition.b

The child under 5 years diarrhoea case fatality rate (CFR) measures the proportion of all admissions under 5 years that died due to diarrhoea. The numerator is ‘child under 5 years with diarrhoea death’ and the denominator ‘child under 5 years with diarrhoea admitted’ expressed as a percentage. The target identified in the MNCWH plan is to reduce this to less than 3% by 2016.b The Annual Performance Plan (APP)c of the NDoH target for 2016/17 is 3.3%.

National overview

Table 1 shows that since 2012/13 there has been a sustained decline in the national diarrhoea CFR from 4.3% to 2.0% in 2016/17. The 2016/17 national APP target of 3.3% had already been achieved in 2014/15 although the rate of decline of the diarrhoea CFR has slowed over the past year.

Table 1: Trend in child under 5 years diarrhoea case fatality rate, 2012/13–2016/17 (%)

2012/13 2013/14 2014/15 2015/16 2016/17Eastern Cape 6.6 6.9 5.2 3.6 3.7Free State 3.6 4.5 4.1 2.8 2.8Gauteng 3.3 3.5 2.9 1.8 1.7KwaZulu-Natal 4.3 3.3 3.0 2.2 2.0Limpopo 7.8 5.2 4.7 3.0 2.1Mpumalanga 7.5 4.9 5.3 2.7 1.5Northern Cape 2.1 3.2 3.4 1.8 3.8North West 5.8 4.8 3.4 4.0 3.2Western Cape 0.1 0.2 0.2 0.1 0.3SA 4.3 3.9 3.3 2.2 2.0

Source: DHIS.

This ongoing decline in the child under 5 years diarrhoea CFR must be interpreted together with the absolute numbers which are presented in Table 2. The 5 years diarrhoea deaths have dropped to fewer than 1 000 for the first time since 2012/13.

a Statistics South Africa. Mortality and causes of death in South Africa, 2015: Findings from death notification. Statistics South Africa. Pretoria. 2017.

b National Department of Health. Strategic Plan for Maternal, Newborn, Child and Women’s Health (MNCWH) and Nutrition in South Africa: 2012–2016. National Department of Health. Pretoria. 2012.

c National Department of Health. Annual Performance Plan 2017/18–2019/20. National Department of Health. Pretoria. 2016.

Child under 5 years diarrhoea case fatality rate by province, 2016/17

Percentage [Source: DHIS]

NC

EC

NW

FS

LP

KZN

GP

MP

WC

2 4 6 8

3.7

0.3

2.8

2.0

1.5

2.1

3.2

1.7

3.8

SA: 2

Target: 3.25 ProvincesECFSGPKZNLPMPNCNWWC

85


Table 2: Trend in national diarrhoea admissions, deaths and case fatality rates in child under 5 years, 2012/13–2016/17

YearAdmissions

(No)Deaths

(No)

Child under 5 years diarrhoea

CFR (%)

2012/13 35 692 1 526 4.32013/14 45 880 1 775 3.92014/15 45 787 1 513 3.32015/16 47 758 1 049 2.22016/17 43 265 886 2.0

Source: DHIS.

In light of the ongoing high number of admissions, the reduction in deaths and the drop in child under 5 years diarrhoea CFR possibly reflects earlier entry into the health service, less advanced disease on presentation or better care within the health service.

Provincial overview

The national figure hides a wide inter-provincial variation, shown in Figure 1, from a low of 0.3% in the Western Cape (WC) to a high of 5.3% in Limpopo (LP). Seven provinces had rates below the APP 2016/17c target of 3.3%.

Figure 1: Child under 5 years diarrhoea case fatality rate by province, 2016/17

In the past year the child under 5 years diarrhoea CFR declined in five provinces and increased in three, and was static in the Free State (FS). However, over the past five years only three provinces, Gauteng (GP), KwaZulu-Natal (KZN) and Limpopo, have maintained a year-on-year reduction in the child under 5 years diarrhoea CFR.

District overview

The range of the child under 5 years diarrhoea CFR in the 52 districts in the country is reflected in Figure 2 and Map 1 which show a range from zero deaths in four districts (West Coast, Overberg and the Central Karoo in the Western Cape and Xhariep in the Free State), to a high of 7.7% (JT Gaetsewe in the Northern Cape (NC)). Only eight districts – two in the Eastern Cape (OR Tambo and Alfred Nzo); two in North West (NW) (Bojanala Platinum and RS Mompati); two in the Northern Cape (Pixley Ka Seme and JT Gaetsewe) and one each in Limpopo (Mopani) and the Free State (Thabo Mofutsanyana) – had a child under 5 years diarrhoea CFR above the 2016/17 target. The Western Cape and Mpumalanga (MP) were the only provinces where all districts have achieved a child under 5 years diarrhoea CFR below the national average and the 2016/17 target, and in KwaZulu-Natal and Gauteng all districts achieved a child under 5 years diarrhoea CFR below the 2016/17 target.

Child under 5 years diarrhoea case fatality rate by district, 2016/17


JT Gaetsewe: DC45A Nzo: DC44

OR Tambo: DC15T Mofutsanyana: DC19

RS Mompati: DC39Bojanala: DC37

Pixley ka Seme: DC7Mopani: DC33

West Rand: DC48Joe Gqabi: DC14

Zululand: DC26NM Molema: DC38

iLembe: DC29Mangaung: MANAmathole: DC12

Lejweleputswa: DC18Sekhukhune: DC47

C Hani: DC13Frances Baard: DC9

Ekurhuleni: EKUHarry Gwala: DC43

Capricorn: DC35uThukela: DC23

uMkhanyakude: DC27ZF Mgcawu: DC8Waterberg: DC36Ehlanzeni: DC32

Dr K Kaunda: DC40Tshwane: TSH

eThekwini: ETHUgu: DC21

uMzinyathi: DC24N Mandela Bay: NMA

uMgungundlovu: DC22Namakwa: DC6

Sedibeng: DC42King Cetshwayo: DC28

G Sibande: DC30Johannesburg: JHB

Vhembe: DC34Nkangala: DC31

S Baartman: DC10Fezile Dabi: DC20Buffalo City: BUF

Amajuba: DC25Cape Winelands: DC2

Cape Town: CPTEden: DC4

Central Karoo: DC5Overberg: DC3Xhariep: DC16

West Coast: DC1

2 4 6 8

0.6

0.3

0.0

0.6

2.7

2.6

3.2

6.4

0.0

2.7

5.2

0.4

0.6

1.8

1.6

2.4

1.6

0.6

3.2

2.3

1.3

2.9

0.0

1.1

0.8

2.1

3.3

1.0

2.4

2.1

3.6

3.1

4.0

0.1

2.0

1.3

2.5

6.47.7

2.7

3.2

0.0

1.5

3.3

2.3

2.52.5

1.8

1.0

2.8

1.6

1.9

SA: 2

Target: 3.25

ProvincesECFSGPKZNLPMPNCNWWC

86


Figure 2: Child under 5 years diarrhoea case fatality rate by district, 2016/17

87


Map 1: Child under 5 years diarrhoea case fatality rate by district, 2016/17

Although most districts show increases and decreases in the child under 5 years diarrhoea CFR from year to year the general trend over the past eight years across all districts is a falling child under 5 years diarrhoea CFR. The greatest decline has been in the districts in the Eastern Cape and the Free State and understandably the least decline has been in the districts of the Western Cape where the baseline child under 5 years diarrhoea CFR was already low. The greatest reduction in the child under 5 years diarrhoea CFR in the past year was 100% in the Central Karoo (WC), although this represented a drop from two deaths in 2015/16 to none in 2016/17, and the greatest increase was 929.6% in Pixley Ka Seme (NC) which represented an increase from just one death in 2015/16 to four in 2016/17.

The five districts with the highest child under 5 years diarrhoea CFR are listed in Table 3. Whilst these five districts accounted for 24.6% of deaths due to diarrhoeal diseases they did not necessarily have the greatest number of diarrhoeal deaths. However, OR Tambo (EC) had both the greatest number of deaths (110) and the third highest child under 5 years diarrhoea CFR (6.4%). The districts with the next greatest number of deaths but not the highest child under 5 years diarrhoea CFR were eThekwini in KwaZulu-Natal (41 deaths) and Tshwane in Gauteng (37 deaths).

Table 3: Districts with the highest child under 5 years diarrhoea case fatality rates, 2016/17

DistrictAdmissions

(No)Deaths

(No)

Child under 5 years diarrhoea CFR

(%)JT Gaetsewe (NC) 416 32 7.7Alfred Nzo (EC) 528 34 6.4OR Tambo (EC) 1 721 110 6.4Thabo Mofutsanyana (FS) 466 24 5.2RS Mompati (NW) 455 18 4.0Total 3 586 218 6.1

Source: DHIS.

Table 4 shows the child under 5 years diarrhoea CFR according to socio-economic circumstance and Figure 3 shows the trend in child under 5 years diarrhoea CFR across the five socio-economic quintiles (SEQ) since 2010. As one would expect the child under 5 years diarrhoea CFR declined as socio-economic circumstances improved, dropping from 3.6% in SEQ1 to 1.2% in SEQ5 in 2016/17.

Child <5 diar fat rate

FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017Financial year

Per

cent

age

2

4

6

8

10

7.1

11.0

8.0

9.4

1.92.4

3.63.1

1.51.2

Indicator value by SEQ (weighted average of data by district quintile)SEQ

SEQ 1 (most deprived)

SEQ 2 (deprived)

SEQ 3

SEQ 4 (well off)

SEQ 5 (least deprived)

88


Since 2010/11 all SEQs have experienced a sustained decline in the child under 5 years diarrhoea CFR with the greatest decline in SEQ1.

Table 4: Diarrhoea admissions, deaths and case fatality rates in children under 5 years by socio-economic quintile, 2016/17

SEQ1Most

deprivedSEQ2

DeprivedSEQ3

Average

SEQ4Less

deprived

SEQ5Least

deprived TotalAdmissions No) 8 961 8 078 6 395 4 399 15 432 43 265Deaths (No) 324 194 124 64 180 886CFR (%) 3.4 2.9 1.9 1.4 1.2 2.0

Figure 3: Trends in average district values by socio-economic quintile for child under 5 years diarrhoea case fatality rate, 2009/10–2016/17

Key findings ✦ The total child under 5 years diarrhoea deaths has dropped with an all-time low of less than 1 000 deaths.

✦ The 2016/17 national target for the child under 5 years diarrhoea CFR was met already in 2014/15 and if the current trend is sustained it is likely that all provinces will match the achievement of the Western Cape and may meet the World Health Organization (WHO)/ United Nations Children’s Emergency Fund (UNICEF) 2025 target of a mortality rate for diarrhoeal diseases of less than one per thousand live births.d

Recommendations ✦ For provinces to meet the WHO/UNICEF mortality rate for diarrhoeal diseases target of less than one per thousand

live births, the following is recommended:

• Effective treatment at home for children with diarrhoea,

• Early entry into the health service, and

• Improved care within the health service.

6.2 Child under 5 years pneumonia case fatality rate Pneumonia is a major contributor to under 5 mortality and accounts for 9.9% of under 5 deaths in South Africa.a The child under 5 years pneumonia case fatality rate is a key indicator in the National Department of Health’s 2012–2016 Strategic Plan for MNCWH and Nutritionb and was included as an indicator in the National Department of Health’s 2013 programme on mortality targeting for all public sector health facilities and districts.

The child under 5 years pneumonia case fatality rate measures the proportion of all admissions under 5 years that died

d WHO/Unicef. End Preventable Child Deaths from Pneumonia and Diarrhoea by 2025. The Integrated Global Action Plan for Pneumonia and Diarrhoea. France. 2013.

Child under 5 years pneumonia case fatality rate by province, 2016/17


MP

FS

EC

LP

NW

KZN

NC

GP

WC

2 4 6

3.0

0.4

3.2

1.8

3.4

2.9

2.5

1.5

1.6

SA: 2

Target: 2.6 ProvincesECFSGPKZNLPMPNCNWWC

89


due to pneumonia. The numerator is ‘child under 5 years with pneumonia death’ and the denominator ‘child under 5 years with pneumonia admitted’ expressed as a percentage. The target identified in the MNCWH strategic plan was to reduce this to less than 3% by 2016.b

National overview

In 2016/17 the national average child under 5 years pneumonia CFR was 2.0% (Table 5). There has been a sustained downward trend in the national pneumonia CFR since 2012/13 when the rate was 3.8%.

Table 5: Trend in national pneumonia admissions, deaths and case fatality rates in child under 5 years, 2012/13–2016/17

YearAdmissions

(No)Deaths

(No)

Child under 5 years pneumonia CFR

(%)2012/13 36 444 1 395 3.82013/14 43 445 1 532 3.52014/15 48 383 1 411 2.92015/16 53 343 1 240 2.32016/17 49 861 1 003 2.0

Source: DHIS.

Provincial overview

Figure 4 shows a wide variation in the child under 5 years pneumonia CFR between the provinces from 0.4% in the Western Cape to a high of 3.4% in Mpumalanga. Five provinces had a rate below the 2016/17 target of 2.6%.

In the past year the child under 5 years pneumonia CFR increased in three provinces, namely the Western Cape, Northern Cape and the Free State and declined in all other provinces.

Figure 4: Child under 5 years pneumonia case fatality rate by province, 2016/17

90


As shown in Table 6, the highest number of pneumonia deaths occurred in KwaZulu-Natal, the Eastern Cape and Limpopo, however, the highest child under 5 years pneumonia CFRs were in Mpumalanga and the Free State. Although the Western Cape had the lowest child under 5 years pneumonia CFR, the Northern Cape had the fewest number of deaths from pneumonia.

Table 6: Pneumonia admissions, deaths and case fatality rate in child under 5 years by province, 2016/17

ProvinceAdmissions

(No)Deaths

(No)


(%)Eastern Cape 6 232 188 3.0Free State 1 980 63 3.2Gauteng 8 790 129 1.5KwaZulu-Natal 11 081 200 1.8Limpopo 5 981 175 2.9Mpumalanga 3 667 123 3.4Northern Cape 1 610 26 1.6North West 2 577 64 2.5Western Cape 7 943 35 0.4SA 49 861 1 003 2.0

Source: DHIS.

District overview

The range of child under 5 years pneumonia CFR in the 52 districts in the country is reflected in Figure 5 and Map 2. Three districts in the Western Cape (Overberg, Eden and the Central Karoo) had no deaths from pneumonia; and 37 had rates below the national target. The highest child under 5 years pneumonia CFR was 7.3% in Fezile Dabi in the Free State.

Across the country, 35 districts reduced the child under 5 years pneumonia CFR between 2015/16 and 2016/17. The only province in which this was achieved in every district was the North West whilst in the Free State and Mpumalanga this was only achieved in a single district. A reduction of 100% occurred in two districts in the Western Cape, in Eden, where the number of deaths declined from six to zero, and in Overberg, where the number fell from one to zero. The greatest increase in the child under 5 years pneumonia CFR was 572.7% which was seen in Pixley Ka Seme (NC) and this represented an increase from one death in 2015/16 to six deaths in 2016/17.

The greatest increase in the actual number of deaths occurred in Capricorn (LP), with 35 more deaths in 2016/17 compared to 2015/16, and Lejweleputswa (FS) and West Rand (GP) with 10 more deaths each. The greatest reduction in the number of deaths between 2015/16 and 2016/17 was seen in King Cetshwayo (KZN) and OR Tambo (EC) with 32 fewer deaths each, and eThekwini (KZN) with 27 fewer deaths.

Child under 5 years pneumonia case fatality rate by district, 2016/17


Fezile Dabi: DC20Capricorn: DC35

OR Tambo: DC15Ehlanzeni: DC32

Lejweleputswa: DC18Pixley ka Seme: DC7

Zululand: DC26N Mandela Bay: NMA

Sekhukhune: DC47Bojanala: DC37

A Nzo: DC44JT Gaetsewe: DC45

Mopani: DC33RS Mompati: DC39

Nkangala: DC31NM Molema: DC38West Rand: DC48

Harry Gwala: DC43eThekwini: ETH

uMkhanyakude: DC27Waterberg: DC36Ekurhuleni: EKU

Xhariep: DC16C Hani: DC13iLembe: DC29

Vhembe: DC34G Sibande: DC30Amathole: DC12

Frances Baard: DC9Namakwa: DC6

uMzinyathi: DC24uMgungundlovu: DC22

Mangaung: MANJoe Gqabi: DC14

Ugu: DC21Tshwane: TSH

King Cetshwayo: DC28uThukela: DC23Sedibeng: DC42

Dr K Kaunda: DC40Buffalo City: BUF

Johannesburg: JHBT Mofutsanyana: DC19

Amajuba: DC25West Coast: DC1Cape Town: CPT

S Baartman: DC10Cape Winelands: DC2

ZF Mgcawu: DC8Central Karoo: DC5

Eden: DC4Overberg: DC3

2 4 6

1.1

0.50.6

0.5

1.7

1.8

1.6

4.9

1.8

4.6

1.0

0.4

7.3

1.5

1.6

1.3

1.6

1.0

3.2

1.9

1.3

1.8

0.0

1.7

2.7

4.8

2.9

1.8

5.8

1.9

3.2

2.6

2.8

0.0

1.21.3

2.1

3.13.0

3.2

2.3

0.0

1.7

3.6

0.2

1.7

1.9

2.0

1.1

1.6

3.2

1.5

SA: 2

Target: 2.6


91


Figure 5: Child under 5 years pneumonia case fatality rate by district, 2016/17

92


Map 2: Child under 5 years pneumonia case fatality rate by district, 2016/17

The five districts with the highest pneumonia CFR are listed in Table 7. These five districts accounted for 29.4% of all deaths due to pneumonia and OR Tambo (EC) also had the greatest number of diarrhoea deaths. The districts with the next greatest number of deaths were eThekwini (KZN) (59 deaths) and Tshwane (GP) (36 deaths).

Table 7: Districts with the highest child under 5 years pneumonia case fatality rates, 2016/17

DistrictAdmissions

(No)Deaths

(No)


(%)Fezile Dabi (FS) 262 19 7.3Capricorn (LP) 1 059 61 5.8OR Tambo (EC) 2 213 109 4.9Ehlanzeni (MP) 1 614 78 4.8Lejweleputswa (FS) 612 28 4.6Total 5 760 295 5.1

Source: DHIS.

The child under 5 years pneumonia CFR according to socio-economic circumstance is shown in Table 8 and the trend across the five SEQs since 2010/11 is shown in Figure 6. Although the pneumonia CFR is highest in the most deprived communities, SEQ1 (3.0%), and lowest in the least deprived communities, SEQ5 (1.2%), there is very little difference in the rate between the three intermediate SEQs varying between 2.2% and 2.4%. Since 2010/11 all SEQs have experienced a sustained decline in the child under 5 years pneumonia CFR with the greatest decline occurring in SEQ1.

Table 8: Pneumonia admissions, deaths and case fatality rates in children under 5 years by socio-economic quintile, 2016/17

SEQ1Most

deprivedSEQ2

DeprivedSEQ3

Average

SEQ4Less

deprived

SEQ5Least

deprived TotalAdmissions No) 8 635 8 710 7 433 5 379 19 704 49 861Deaths (No) 262 211 169 120 241 1 003CFR (%) 3.0 2.4 2.3 2.2 1.2 2.0

Source: DHIS.

Child <5 pneumo death


Per

cent

age

2

4

6

8

109.3

10.3

6.4

2.32.2

7.4

3.0

1.2

3.12.4



SEQ 2 (deprived)

SEQ 3

SEQ 4 (well off)


93


Figure 6: Trends in average district values by socio-economic quintile for child under 5 years pneumonia case fatality rate, 2009/10–2016/17

Key findings ✦ In 2016/17 the national average child under 5 years pneumonia CFR was 2.0%. Whilst the number of deaths due

to pneumonia has decreased each year, apart from 2013/14, the number of admissions has fluctuated markedly. Despite this there has been a sustained downward trend in the national pneumonia CFR since 2012/13 when the rate was 3.8%.

✦ Given the current rates and the general trend for declining pneumonia CFR at both provincial and district levels, there is a realistic chance that the country can meet the WHO/UNICEF 2025 target of a pneumonia case fatality rate of less than three per thousand live births.d

Recommendations ✦ As with diarrhoeal diseases this will require effective prevention programmes, early entry into the health services

and improved care once in the health service.

✦ Pixley Ka Seme (NC) and OR Tambo (EC) had high child under 5 years diarrhoea and pneumonia case fatality rates and should be investigated.

6.3 Child under 5 years severe acute malnutrition case fatality rate The most recent death notification processes record that malnutrition accounts for 4.6% of under 5 deaths in South Africa.a Severe acute malnutrition (SAM) has been included together with diarrhoeal disease and pneumonia in the mortality targeting programme recently introduced by the National Department of Health to improve the performance of health facilities.

The child under 5 years SAM case fatality rate measures the proportion of all admissions under 5 years who died due to severe malnutrition. The numerator is ‘child under 5 years with SAM death’ and the denominator ‘child under 5 years with SAM admitted’ expressed as a percentage.

National overview

In 2016/17 the average child under 5 years SAM CFR in children under 5 years in South Africa was 8.0% which is below the national target of 9.0%. Table 9 shows the recent figures for severe acute malnutrition which show a fluctuating number of admissions but a steady decline in deaths and in the child under 5 years SAM CFR, except in 2014/15 when there was an increase in admissions, deaths and the child under 5 years SAM CFR.

Child under 5 years severe acute malnutrition case fatality rate by province, 2016/17


NW

EC

FS

MP

LP

KZN

GP

NC

WC

5 10 15

10.2

0.6

9.6

7.4

8.4

8.3

10.6

6.5

5.1SA: 8

Target: 9 ProvincesECFSGPKZNLPMPNCNWWC

94


Table 9: Trend in national severe acute malnutrition admissions, deaths and case fatality rates in child under 5 years, 2012/13–2016/17

YearAdmissions

(No)Deaths

(No)

Child under 5 years SAM CFR

(%)2012/13 12 911 1 642 12.72013/14 14 847 1 672 11.32014/15 15 910 1 852 11.62015/16 15 537 1 380 8.92016/17 14 931 1 188 8.0

Source: DHIS.

Provincial overview

The provincial child under 5 years SAM CFRs are presented in Figure 7 and Table 10 which show a wide inter-provincial variation from a low of 0.6% in the Western Cape to a high of 10.6% in the North West. The child under 5 years SAM CFR rose in two provinces, the Eastern Cape and Free State, but fell in the remaining seven. Six provinces had rates below the 2016/17 target of 9%.

The greatest decreases were in the Northern Cape (39.2%), Mpumalanga (32.6%) and the Western Cape (32.2%) and the greatest increase was in the Free State (18.3%). Despite year-on-year fluctuations the child under 5 years SAM CFR has decline substantially across all provinces since 2012/13.

Figure 7: Child under 5 years severe acute malnutrition case fatality rate by province, 2016/17

Table 10: Severe acute malnutrition admissions, deaths and case fatality rates in child under 5 years by province, 2016/17

ProvinceAdmissions

(No)Deaths

(No)


(%)Eastern Cape 2 221 226 10.2Free State 1 070 103 9.6Gauteng 1 848 120 6.5KwaZulu-Natal 3 122 230 7.4Limpopo 2 141 178 8.3Mpumalanga 986 83 8.4Northern Cape 771 39 5.1North West 1 931 204 10.6Western Cape 841 5 0.6SA 14 931 1 188 8.0

Source: DHIS.

95


District overview

The child under 5 years SAM CFR in the 52 districts in the country is reflected in Figure 8 and Map 3. Five districts had no deaths due to SAM (Cape Town, West Coast, Overberg and Central Karoo in the Western Cape and Namakwa in the Northern Cape). Thirty-three districts had rates below the national target of 9.0%. The highest child under 5 years SAM CFR was 15.8% in Lejweleputswa (FS). More than half the districts in the Eastern Cape, Free State and Limpopo did not reach the national target.

Between 2015/16 and 2016/17 the child under 5 years SAM CFR declined in 32 districts including all districts in the Northern Cape and Mpumalanga and the majority of districts in KwaZulu-Natal, Limpopo and the North West. Only in the Eastern Cape, the Free State and Gauteng the child under 5 years SAM CFR increased in more districts than it declined. The greatest increase occurred in Joe Gqabi (EC) (220.7%) with an increase from 8 deaths in 2015/16 to 18 deaths in 2016/17. The greatest decline was in Cape Town (WC) where the number of deaths fell from six to zero in the same period and in the West Coast (WC) and Namakwa (NC) the number fell from one to zero deaths.

The greatest increase in the actual number of deaths occurred in Zululand (KZN) with 25 more deaths in 2016/17 than in 2015/16, RS Mompati (NW) with 19 more deaths and Tshwane and West Rand (both GP) each with 12 more deaths. The greatest reduction in the number of deaths between 2015/16 and 2016/17 was seen in Vhembe (LP) (40 fewer deaths), Gert Sibande (MP) (38 fewer deaths) and OR Tambo (EC) (29 fewer deaths).

Map 3: Child under 5 years severe acute malnutrition case fatality rate by district, 2016/17

Child under 5 years severe acute malnutrition case fatality rate by district, 2016/17


Lejweleputswa: DC18Zululand: DC26uThukela: DC23

Joe Gqabi: DC14A Nzo: DC44

Mopani: DC33Bojanala: DC37

NM Molema: DC38OR Tambo: DC15

Sekhukhune: DC47T Mofutsanyana: DC19

Ekurhuleni: EKUWest Rand: DC48

Amathole: DC12Fezile Dabi: DC20

Dr K Kaunda: DC40G Sibande: DC30Capricorn: DC35

RS Mompati: DC39Ehlanzeni: DC32

N Mandela Bay: NMABuffalo City: BUF

Tshwane: TSHPixley ka Seme: DC7

Harry Gwala: DC43Vhembe: DC34

King Cetshwayo: DC28Ugu: DC21

Nkangala: DC31eThekwini: ETHAmajuba: DC25

C Hani: DC13Mangaung: MAN

Frances Baard: DC9uMkhanyakude: DC27

S Baartman: DC10ZF Mgcawu: DC8uMzinyathi: DC24

JT Gaetsewe: DC45uMgungundlovu: DC22

Waterberg: DC36iLembe: DC29

Johannesburg: JHBCape Winelands: DC2

Xhariep: DC16Sedibeng: DC42

Eden: DC4Namakwa: DC6

Central Karoo: DC5Overberg: DC3

West Coast: DC1Cape Town: CPT

5 10 15

7.7

0.0 0.0

5.1

10.5

5.8

14.2

11.8

2.4

15.8

11.0

2.9

10.2

7.2

4.2

14.2

4.5

6.1

15.7

5.6

7.2

3.4

0.0

9.3

6.5

8.9

13.0

7.4

9.2

4.1

12.912.1

9.1

0.6

9.4

2.1

7.5

14.0

4.4

11.3

10.6

0.0 0.0

7.6

4.5

5.6

10.7

6.2

3.4

5.7

8.6

7.7

SA: 8

Target: 9


96


Figure 8: Child under 5 years severe acute malnutrition case fatality rate by district, 2016/17

Child <5 sev mal fata


Per

cent

age

5

10

15

2018.4

15.2

19.7

7.4

18.4

10.0

22.4

9.08.0

5.2



SEQ 2 (deprived)

SEQ 3

SEQ 4 (well off)


97


The five districts with the highest child under 5 years SAM CFR are listed in Table 11. These five districts accounted for 13.6% of deaths due to SAM although only Zululand (KZN) was amongst the five districts with the highest number of deaths. The districts with the greatest number of deaths from severe acute malnutrition in 2016/17 was OR Tambo (EC) (99 deaths), NM Molema (70 deaths) and RS Mompati (69 deaths) in the North West and Ehlanzeni (MP) (49 deaths).

Table 11: Districts with the highest child under 5 years severe acute malnutrition case fatality rates, 2016/17

DistrictAdmissions

(No)Deaths

(No)


(%)Lejweleputswa (FS) 196 31 15.8Zululand (KZN) 299 47 15.7uThukela (KZN) 211 30 14.2Joe Gqabi (EC) 127 18 14.2Alfred Nzo (EC) 250 35 14.0Total 1 083 161 14.8

Source: DHIS.

The child under 5 years SAM CFR according to socio-economic circumstance is shown in Table 13 and the trend since 2009/10 across the five SEQs is shown in Figure 9. Although the child under 5 years SAM CFR is highest in the most deprived communities, SEQ1 (10.0%), and lowest in the least deprived communities, SEQ5 (5.2%), there is very little difference in the rate between the three intermediate SEQs varying between 7.4% and 9.0%.

Despite a slight increase in the child under 5 years SAM CFR across all SEQ in 2015/16, they have all experienced a sustained decline in the SAM CFR since 2010/11.

Table 12: Severe acute malnutrition admissions, deaths and case fatality rates in children under 5 years by socio-economic quintile, 2016/17

SEQ1Most deprived

SEQ2Deprived

SEQ3Average

SEQ4Less deprived

SEQ5Least deprived Total

Admissions (No) 3 867 3 123 2 574 1 834 3 533 14 931Deaths (No) 387 282 191 146 182 1 188CFR (%) 10.0 9.0 7.4 8.0 5.2 8.0

Source: DHIS.

Figure 9: Trends in average district values by socio-economic quintile for child under 5 years severe acute malnutrition case fatality rate, 2009/10–2016/17

98


Key findings ✦ Severe acute malnutrition is an underlying factor in almost a third of childhood deaths in the public sector of South

Africa.

✦ The average children under 5 years SAM CFR in South Africa more than halved from 16.4% in 2010/11 to 8.0% in 2016/17 which is below the national target of 9.0%. There was wide inter-provincial variation in 2016/17 from a low of 0.6% in the Western Cape to a high of 10.6% in the North West.

Recommendations ✦ A reduction in the rate of malnutrition requires effective growth monitoring and appropriate early intervention at

the primary health care level as well as improved inpatient management of those children who are admitted with severe acute malnutrition.

6.4 Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rateBreastfeeding is recognised as a key intervention for the prevention of malnutrition, diarrhoeal diseases and pneumonia.

Since the Tshwane Declaration,e the National Department of Health has recognised the importance of breastfeeding and has increased efforts to promote it. Modelling projections, using the Lives Saved Tool (LiST),f suggest that if 15 key interventions achieved 95% coverage in South Africa breastfeeding would be the most cost-effective intervention for reducing under 5 mortality.

The infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate is the number of infants exclusively breastfed at 14 weeks as a proportion of those receiving the DTaP-IPV-Hib-HBV 3rd dose vaccination. The numerator is ‘infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose’ and the denominator ‘DTaP-IPV-Hib-HBV B 3rd dose’ expressed as a percentage. This indicator was introduced in 2014/15 to monitor infant feeding practices at 14 weeks in order to identify those districts where community interventions need to be strengthened.

Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose is defined as an infant receiving breast milk only (the child may have received medicines/vaccines prescribed by a health professional). An infant who has received any solids, milk (other than breast milk) or other liquids (including water) should not be counted.

National overview

Since 2014/15 the number of infants being exclusively breastfed has fluctuated markedly and although Table 13 indicates that this number has increased over the past year it remains well below the number achieved in 2014/15. The 2016/17 national Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate was only 41.6% which is below the national target of 55%. It should be noted that the global shortage of DTaP-IPV-Hib-HBV that lasted approximately 9 months and was resolved at a national level in October 2016 could have resulted in the data for the numerator ‘infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose’ not being properly recorded.

Table 13: Trend in infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate, 2014/15‒2016/17

YearBreastfeeding

(No)

Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate

(%)2014/15 466 014 45.02015/16 339 047 33.72016/17 365 419 41.6

Source: DHIS.

Provincial overview

Figure 10 shows the wide difference in the infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate between the provinces, ranging from 55.0% in Northern Cape to 28.9% in Limpopo. Only the Northern Cape has achieved the national target although KwaZulu-Natal was close.

e The South African Journal of Clinical Nutrition. The Tshwane declaration of support for breastfeeding in South Africa. S Afr J Clin Nutr 2011;24(4). http://www.sajcn.co.za/index.php/SAJCN/article/view/586. [Accessed 29 July 2017].

f Chola L, Pillay Y, Barron P, Tugendhaft A, Kerber K, Hofman K. (2015). Cost and impact of scaling up interventions to save lives of mothers and children: taking South Africa closer to MDGs 4 and 5. Glob Health Action, 8: 27265. http://dx.doi.org/10.3402/gha.v8.27265.

Infant exclusively breastfed at DTaP−IPV−Hib−HBV 3rd dose rate by province, 2016/17


LP

WC

EC

MP

GP

NW

FS

KZN

NC

20 40 60 80

32.8

31.8

46.2

53.9

35.3

28.9

45.5

44.0

55.0

SA: 41.6

Target: 55


99


Figure 10: Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate by province, 2016/17

Table 14 shows the 2016/17 provincial infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rates as well as the wide variation in the trend in the number of infants being exclusively breastfed at 14 weeks across the provinces since 2014/15. Only Gauteng has experienced a sustained increase in the number of infants being exclusively breastfed each year since 2014/15. Four provinces, the Eastern Cape, Limpopo, Mpumalanga and the Northern Cape, have seen a sustained decline over this period and the numbers have moved up or down in the remaining provinces.

Table 14: Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate by province, 2016/17, and the number of infants being breastfed by province, 2014/15 ‒2016/17

Province

Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate

2016/17 (%)

Breastfeeding(No)

2014/15

Breastfeeding(No)

2015/16

Breastfeeding(No)

2016/17Eastern Cape 32.8 51 234 37 239 34 273Free State 46.2 41 238 18 577 18 896Gauteng 44.0 59 056 66 834 90 123KwaZulu-Natal 53.9 110 038 91 590 104 402Limpopo 28.9 77 105 34 394 30 684Mpumalanga 35.3 49 424 28 512 24 899Northern Cape 55.0 13 898 10 602 10 434North West 45.5 39 307 24 384 25 736Western Cape 31.8 24 714 26 915 25 972SA 41.6 466 014 339 047 365 419

Source: DHIS.

District overview

The infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate in the 52 districts in the country is reflected in Figure 11 and Map 4. These results show a range from just 18.8% in Buffalo City (EC) to 75.0% in uMzinyathi (KZN). Thirteen districts achieved an exclusive breastfeeding rate above the national target, including six districts in KwaZulu-Natal and four in the Northern Cape.

Between 2014/15 and 2015/16 the rate declined in 43 districts across the country. Four of the nine districts where the rate increased were in Gauteng and three were in the Western Cape. From 2015/16 to 2016/17 this pattern was reversed with the rate improving in 41 districts. This included all districts in five provinces –Free State, Gauteng, KwaZulu-Natal, North West and Western Cape. In this second period the rate decline in most districts in Limpopo (three out of five) and Mpumalanga (two out of three) and in an equal number in the Eastern Cape. The greatest improvement in the rate occurred in Alfred Nzo (65.8%) in the Eastern Cape and Ekurhuleni (65.2%) and Tshwane (60.0%) in Gauteng.

Infant exclusively breastfed at DTaP−IPV−Hib−HBV 3rd dose rate by district, 2016/17


Buffalo City: BUFMopani: DC33

Sekhukhune: DC47G Sibande: DC30OR Tambo: DC15Joe Gqabi: DC14

Eden: DC4Vhembe: DC34

West Coast: DC1Cape Town: CPT

C Hani: DC13Waterberg: DC36Amathole: DC12Nkangala: DC31Sedibeng: DC42Ekurhuleni: EKU

A Nzo: DC44T Mofutsanyana: DC19

Ehlanzeni: DC32Bojanala: DC37

JT Gaetsewe: DC45Capricorn: DC35

Cape Winelands: DC2Johannesburg: JHB

Overberg: DC3Dr K Kaunda: DC40

eThekwini: ETHN Mandela Bay: NMA

NM Molema: DC38Ugu: DC21

Fezile Dabi: DC20Xhariep: DC16

Mangaung: MANS Baartman: DC10Harry Gwala: DC43Central Karoo: DC5

uMgungundlovu: DC22Lejweleputswa: DC18

Zululand: DC26RS Mompati: DC39

King Cetshwayo: DC28West Rand: DC48

Pixley ka Seme: DC7Amajuba: DC25Tshwane: TSH

Namakwa: DC6uMkhanyakude: DC27

iLembe: DC29Frances Baard: DC9

ZF Mgcawu: DC8uThukela: DC23

uMzinyathi: DC24

20 40 60 80

18.8

30.127.8

48.4

34.4

31.3

25.725.3

48.1

51.1

38.6

42.2

47.847.3

50.7

67.775.0

57.6

52.6

59.2

55.7

60.1

45.3

24.9

34.9

39.0

21.3

27.7

42.2

31.5

40.8

47.2

55.3

27.3

45.3

35.8

48.8

38.5

42.0

22.5

55.7

50.1

58.2

56.6

61.960.4

36.3

45.9

42.3

48.2

46.5

58.0

SA: 41.6

Target: 55


100


Figure 11: Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate by district, 2016/17

101


Map 4: Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate by sub-district, 2016/17

The five districts with the lowest infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate are listed in Table 15. These districts not only had the lowest exclusive breastfeeding at 14 weeks rate but, apart from OR Tambo (EC), were also amongst those districts with the greatest decline in exclusive breastfeeding rates from 2015/16 to 2016/17. The greatest decline occurred in Gert Sibande (34.1%) in Mpumalanga, followed by Buffalo City (17.5%) and Amathole (10.8%) in the Eastern Cape and Mopani (10.1%) in Limpopo.

Table 15: Districts with the lowest infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate, 2016/17

District

Infant exclusively breastfed at DTaP-

IPV-Hib-HBV 3rd dose rate

(%)Breastfeeding

(No)

% change in Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate between 2015/16 and 2016/17

Buffalo City (EC) 18.8 2 010 -17.5Mopani (LP) 21.3 4 408 -10.1Sekhukhune (LP) 22.5 5 124 -6.7Gert Sibande (MP) 24.9 3 079 -34.1OR Tambo (EC) 25.3 6 921 +2.3Amathole (EC) 34.4 4 380 -10.8

Source: DHIS.

Figure 12 shows the trend in the infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate since 2014/15 across the SEQs. The wide gap between SEQ5 and the other quintiles in 2014/15 narrowed substantially in the following years. Of concern is the persisting trend for the most deprived communities in SEQ1 to have the lowest rate of infants who are exclusively breastfed.

Inf excl b_fed Hex 3 rate

FY 2015 FY 2016 FY 2017Financial year

Per

cent

age

30

35

40

45

50

55

60

43.341.8

40.6

30.8

58.158.8

53.3

46.3



SEQ 2 (deprived)

SEQ 3

SEQ 4 (well off)


102


Figure 12: Trends in average district values by socio-economic quintile for infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate, 2014/15‒2016/17

Key findings ✦ Although the exclusive breastfeeding rate at 14 weeks has improved in 41 districts between 2015/16 and 2016/17, it

remains low and only one province and 13 districts have met the national target of 55%.

Recommendations ✦ A higher exclusive breastfeeding rate is required in order to improve child survival in the country.

✦ For successful breastfeeding protection, promotion and support a multi-layered, intersectoral approach involving different government sectors and levels of society are required to create an enabling environment for breastfeeding in South Africa.g

✦ Three elements of an enabling environment that have been detailed are: knowledge and evidence, politics and governance, and capacity and resources. These are three linked elements that create an enabling environment in South Africa to improve breastfeeding rates.i

g du Plessis L, Peer N, Honikman S, et al. (2016).Breastfeeding in South Africa: Are we making progress? In Padarath A, King J, Mackie E, Casciola J, editors South African Health Review. Health Systems Trust. Durban. 2016.

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6 Child health Health... · 2018. 1. 30. · 2012/13. a Statistics South Africa. Mortality and causes of death in South Africa, 2015: Findings from death notification. Statistics