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Western Cape Province Burden of Disease Reduction Project:

The approach taken

Prof Jonny Myers Symposium 25 – 26 June 2007

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History of Project

• Approach from Prof Househam 9/2005• Nature of the Mandate/conceptual model• Project Reference Group established 9/2005• 6 Proposals identified• Formation of a Project Management Team• 2 Workteams and 5 Expert Groups

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The Project Mandate: looking upstream for risk and intervention

StructuralSocietalBehavioural

Biological

SexAge STIsViral load

Method of sexNo of partnersSubstance abuse

GenderOlder partnersViolent crimeSocial systems

Indicators of povertyMigration / UrbanisationEducationInstitutionsInfrastructures

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It must be said

• Very atypical request• Amounting to a PH Professionals dream in

its far-sightedness• Not the usual Health Sx or systems Mx

request or even clinical request• But directed at the primary end of the

prevention hierarchy, and • Intrinsically inter-sectoral in approach

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History of Project

• Approach from Prof Househam 9/2005• Nature of the Mandate/conceptual model• Project Reference Group estab 9/2005• 6 Proposals identified• Formation of a Project Management Team• 2 Workteams and 5 Expert Groups

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History of Project

• Approach from Prof Househam 9/2005• Nature of the Mandate• Project Reference Group established 9/2005• 6 Proposals identified• Formation of a Project Management Team• 2 Workteams and 5 Expert Groups

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The six original proposalsPROPOSAL 1:To produce estimates of the Provincial burden of disease for the Western

Cape , utilizing both morbidity and mortality data, both at a provincial level and at the level of the 6 districts, for the year 2005.

PROPOSAL 2: To optimally design a rapid mortality surveillance system for districts with expert public health support from the MRC and UCT Public Health, and assist with its institutionalization and rollout.

PROPOSAL 3: To ascertain the available information on the incidence and prevalence of mental health morbidity both nationally and in the Western Cape, in order to derive estimates of the BoD in DALYs due to mental illness in the Province and explore the scope for conducting morbidity surveillance.

PROPOSAL 4: To ascertain the availability of current facility-based morbidity data within Western Cape health information systems, and its potential utility for input to provincial Burden of Disease estimation.

PROPOSAL 5: To produce an inventory of public (and private/NGO) sector interventive responses aimed at reducing BoD risk factors

PROPOSAL 6: To compare the inventory of interventive responses with a master list of interventions, to identify gaps and to evaluate existing interventions within the context of a surveillance system.

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History of Project

• Approach from Prof Househam 9/2005• Nature of the Mandate• Project Reference Group established 9/2005• 6 Proposals identified• Formation of a Project Management

Team• 2 Workteams and 5 Expert Groups

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Project Structure

PMT

WT 1Surveillance (P1-4)

WT 2Prevention (P5 -6)

PRG

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PMT

• Project Leader• DOH Representative• WT 1 Champion• WT2 Champions (5)Function: Project Management to deliver

high quality product within budget and timelines

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The 2 Work Teams

• Work Team 1: Proposal 1 -4 Surveillance

• Work Team 2: Proposal 5 -6– Preventive interventions– Evidenced based upstream recommendations

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Ranked BoD components provided

focus for Work Team 2

Rank Cause of Death % YLL1 HIV/AIDS 14.12 Homicide/Violence 12.93 TB 7.94 Road Traffic Accidents 6.95 Ischaemic Heart Disease 5.96 Stroke 4.6

Total 52.3%

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Principal components of the BOD

Cause of Death % YLL

MID: HIV/AIDS/ TB 22.0INJURY: Violence & Road Traffic related

19.8

CVD: Ischaemic Heart Disease/Stroke

10.5

Childhood Diseases 6.0 minimum

Total 58.3%

hidden burden of Mental Health Disorders not captured by mortality

PLUS

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5 Expert GroupsOutcome (disease group) Major risk factor(s) for this outcome

1. Major Infectious diseases Unsafe sex

2. Injury Alcohol abuse

3. Mental disorders Early Childhood Development

3. Cardiovascular disease Obesity and Exercise

4. Childhood diseases Environmental factors

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5 Expert Groups

• Structure and function– each group with specific champion– Authors identified– Multi stakeholder expert group assembled–including

many members of PRG– examined evidence for intervention effectiveness

(where this existed or was possible) or promise (where more complex causally).

– Peer review (incl. international review) where possible given time constraints

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The Report: March 2007 and as edited June 2007

Volume 1 - You have been given hardcopy of the June 2007 versionForeword by Prof C Househam, Head of Health Overview chapter by Jonny Myers and Tracey Naledi and executive

summaries from Volumes 2 to 7 from other authors

There is a CD Rom in your pack containing electronic copy of everything from Volume 1 through Volume 7 June 2007 version

Volume 2: Mortality surveillanceExecutive summary with appendices• Paper 1: Cape Town Mortality by authors• Paper 2: Boland/Overberg Mortality by authors• Paper 3: Western Cape overall Mortality by authors

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The Report (2)Volumes 3,4,5,6 • Order of appearance follows the degree of contribution to the overall

burden of disease• Each has an executive summary. • Authored by Champions plus authors’ groups• Incorporating where appropriate Reviewers’ comment

Volume 3: Major Infectious Diseases (HIV/AIDS and TB)Volume 4: Mental Health Volume 5: Injury – intentional/violence and unintentional/RTIVolume 6: Cardivascular Diseases - IHD and stroke

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The Report (3)

Volume 7

Overview of Childhood Diseases with 5 appendices:

HIV/AIDS in childrenDiarrhoeaLow birth weight Acute Respiratory InfectionsMalnutrition

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The 7 Volumes

Constitute a rich source of outputs with useful information about interventions against the major risk factors for the top 5 BoD components for which there is either– Evidence– Or which are agreed to be promising

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Fidelity to mandate

• Maintained faithfulness of mandate to look upstream in terms of – The conceptual model focussing on societal and

structural risk factors and levels of intervention – and beyond the health department to other sectors

and relevant government departments• While retaining focus on “downstream” health

sector based interventions with recursive preventive effects at the primary level eg ARVs, Mental Health Services

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The Project Mandate: looking upstream for risk and intervention

StructuralSocietalBehavioural

Biological

SexAge STIsViral load

Method of sexNo of partnersSubstance abuse

GenderOlder partnersViolent crimeSocial systems

Indicators of povertyMigration / UrbanisationEducationInstitutionsInfrastructures

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Main Points: 1. Surveillance is crucial

• Whatever we do with interventions into the future we need to know where we are at any one time, and what the impact measurable at the population level could be.

• So we need improved and institutionalised mortality surveillance systems sensitive to rapid change at the most disaggregated level

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2. Upstream risks and upstream interventions for all risks

are critical for reduction of BoD

• Have highlighted the role of behavioural factors (alcohol, road use, sexual and health-seeking) in contributing to the BoD

• And how these link to even more upstream infrastructural risks of material and social deprivation

• And how upstream interventions have multiple direct and indirect impacts on all risks

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Used global and local evidence

• To provide highlights of upstream

interventions that have been:– shown to be effective– or are considered by consensus to be promising

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Value of the output

• Study has not broken entirely new ground• Overlap with WCPPoA 07/08 – provincial

strategic objectives• Our recommended interventions can provide

detail and more concrete proposals for the achievement of these strategic policy objectives

• Provides a menu of interventions for policy makers – and a guide to feasibility and practicability

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Value of the output (2)

• Our recommendations can help assessment of current, consideration of new, and dropping of existing interventions that have been shown not to work.

• The devil is in the detail – some interventions are nominally present but

not implementable any time soon and – others are inadequately targeted to high risk

groups who could benefit most

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Tasks ahead for 2007/8

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Principal tasks as seen by the project team

1. Institutionalisation of mortality surveillance should continue

2. Intersectoral engagement with other non-health government departments on upstream interventions to mitigate risk, involving:

a. Identification of optimal intersectoral structures and vehicles for reducing the BoD

b. Making specific Public Health contributions to this work including assistance with design of intervention implementation and monitoring systems and data analysis and interpretation for evaluating these interventions over time

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Structure of Symposium

• Presentations in some detail• Lots of time for input from the floor