Africa: Africa Health Report

Africa Health Report

• Challenges
• Opportunities

The weakness of national health systems in the Region has been a matter of concern for decades. Despite ongoing efforts to improve health systems performance, some issues related to governance, health financing, human resources for health, health technologies, data systems and service delivery are from now on to be addressed. There is, therefore, a need for continued work to update policies and strategies, and to translate them into sound strategic plans featuring well financed country operational plans and services that are accessible to the poor and most vulnerable, especially women and children.

The national health systems in the Region have inadequate human and financial resources, and limited infrastructure especially in regard to laboratories, data and communication systems and this leads to a weak capacity to provide universal coverage and respond to outbreaks and disasters. The establishment of the Health Workforce Observatory at regional and country levels, which provides data on the health workforce situation part others, is an significant step towards improving the evidence base for advocacy, policy-making, strategic planning and capacity building. There are some successes that have resulted in expansion of community-based health financing schemes. These will be further documented and disseminated.

Maternal mortality is of Africa’s most tragic health problems, hence the commitment to reduce it by three quarters between 1990 and 2015. Recent estimates of maternal mortality have shown that the Region has made no evolution towards achieving the MDG target and, to date, 31 nations have very high maternal mortality ratios (MMRs) ranging from 550 to 1000 per 100 000 live births. Nevertheless, successful implementation and monitoring of the decentralization of health policy and the basic health package in under-served areas have resulted in declines in MMR. There was as well an increase in deliveries assisted by skilled birth attendants between 1992 and 2008 in some nations.

In 2008, it was estimated that about 4.2 million children under the age of died of preventable and treatable conditions including pneumonia, diarrhoea and malaria. Premature introduction of complementary foods and nutritional deficiencies are part the major risk factors. Recent data show that only out of 46 nations in the Region are on track to achieve MDG 4.

Since 2007 the African Region has experienced a three-fold surge in the number of polio-infected nations. Resurgence and continued circulation of wild poliovirus are associated with low people immunity as a result of the failure to sustain high coverage of routine immunization. However, significant evolution was made during 2009 and has led to the reduction by at least 25% in the number of cases of poliomyelitis as a result of the implementation of the Reaching Each District (RED)border and the high quality supplementary immunization campaigns.

Implementation of measles control strategies in the African Region led to a 92% reduction in estimated measles deaths by 2008, but constraints in sustaining immunization service performance still exist in some nations. There is a requirement for sustained action that produces the desired results including increasing routine immunization coverage, providing second opportunity for measles immunization, establishing case-based surveillance and improving case management. The RED approach is an significant tool for addressing immunization performance gaps and strengthening the management of immunization and other health services at the district level.

The number of malaria cases reported globally is estimated at 247 million with the Region accounting for 86% of these. In 2006 the estimated number of deaths was 881 000 of which the African Region accounted for 90%. Malaria causes an estimated 17% of the under mortality in the Region. In highly endemic nations malaria reduces economic increase by about 1.3% mainly due to absenteeism from work. The poorest people are most exposed because of inadequate housing, poor living conditions especially in urban settings, and limited access to health care. The number of cases and deaths in health facilities, however, has reduced dramatically in certain nations as a result of integrated malaria control interventions.

HIV prevention programmes have not from now on adequately reached the majority at-risk populations including the youth, sex workers, injecting drug users and prisoners, resulting in a high incidence of HIV infection; however, there are some best practices in nations. Preventing mother-to-child transmission (PMTCT) and scaling up the testing of infants reduced mother-to-child transmission and facilitated early detection of infection. Factors pivotal to success include access to antenatal care and delivery services; sustained political and financial commitment; effective collaboration; partner support and coordination; innovative solutions to shortages of skilled human resources; and approaches to HIV testing and counselling. Voluntary counselling and testing was used as an entry point in scaling up HIV prevention, treatment, care and support services. In addition, initiatives targeting sex workers and other high-risk groups resulted in increased awareness, knowledge and uptake of testing and counselling, and as well reduced sexual transmission and stabilized the prevalence of HIV.

Experiences from some nations demonstrated that delivery of antiretroviral therapy (ART) is possible despite limitations of infrastructure and human resources. Indeed the estimated number of people receiving ART in the Region increased from 100 000 in 2003 to 2 925 000 in 2008; however, the need to intensify HIV prevention efforts in order to reduce the number of new infections remains.

Over million cases of tuberculosis were reported in 2005. Recent surveillance data have shown that although the Region accounts for 10% of the world people, it has 25% of the world notified cases of tuberculosis. In some nations the incidence of TB cases resistant to first-line and second-line TB medicines has been increasing since the beginning of 2006. On average, 35% of tuberculosis cases in the Region are co-infected with HIV, and tuberculosis accounts for approximately 40% of deaths in people living with HIV/AIDS. Trends in tuberculosis cases detected and cured under Directly Observed Treatment, Short course (DOTS) indicate that the WHO African Region is unlikely to achieve the 2015 MDG targets for TB control; however nations have already achieved the target and other nations are likely to do so. Nations should therefore be supported in scaling up this approach.

Neglected tropical diseases (NTDs) including Buruli ulcer, leprosy, human African trypanosomiasis, schistosomiasis, onchocerciasis, soil-transmitted helminthiases, lymphatic filariasis and dracunculiasis affect an estimated billion people worldwide with Africa bearing the highest burden. Various NTDs control programmes have been initiated by some nations and partners resulting in a reduction in the burden of onchocerciasis, trypanosomiasis, drancunculiasis and leprosy. The Community-Directed Treatment with Ivermectin (CDTI), an intervention adopted by the African Programme for Onchocerciasis Control (APOC), has been shown to be the majority effective. The use of the CDTI approach could be promoted for the delivery of other public health interventions.

Millions of people living in the African Region are suffering from or threatened by epidemic-prone diseases such as cholera, cerebrospinal meningitis, viral haemorrhagic fevers and, additional recently, the Pandemic Influenza A (H1N1) 2009. A significant number of emerging new diseases originate from animals, making the animal–human interface a critical source of disease that could have public health implications at world level.

The situation regarding cholera and other foodborne and waterborne diseases in the African Region has been worsening since the early 1990s. The number of reported cholera cases ranges from 150 000 to 200 000 per year in 30 nations. Lack of potable water and inadequate sanitation inclunding unhygienic handling of food are leading risk factors in the Region. The capacity building activities of the World Foodborne Infections Network have strengthened foodborne disease surveillance in nations, resulting in early detection of outbreaks.

The Region has been experiencing an accelerated increase in noncommunicable diseases (NCDs), including violence and injuries, adding to the already heavy burden of communicable diseases. If no steps are taken, NCDs will represent at least 50% of mortality in the African Region by 2020. Major common risk factors for chronic NCDs are related to individual lifestyles and non-changeable risk factors including genetic and ethnic considerations together with an increase in life expectancy, prenatal factors and gender. The Commission on Social Determinants of Health in 2008 called for action in three principal areas: improving the daily living conditions of people; tackling the inequitable distribution of power, money and resources; and measuring and understanding the problem and assessing impact for action. Despite these recommendations, governance and the social and economic forces which shape the key determinants of health, including safe water, sanitation and healthy environments, are not being addressed in a systematic manner in the Region.

Challenges

In the African Region, evolution towards achievement of the health MDGs has been slow. Assessment of world and regional commitments, achievements and opportunities shows that a number of challenges still need to be addressed entirely.

These include inadequate funding and earmarking of resources which constrain WHO in fully exercising its mandate to deliver its core functions in certain strategic and priority areas such as health data systems, knowledge management and sharing, disease surveillance, maternal health, noncommunicable diseases, food and nutrition, and the strengthening of health systems.

Emerging challenges include the double burden of new and emerging diseases combined with resistance to antituberculosis medicines, antiretrovirals, antimalarials and other medicines. Other challenges include inadequate collaboration with health-related sectors such as education, environment, agriculture, animal health, trade and finance, in order to ensure that their policies and actions contribute to health development. It is as well significant to adopt health policies that address human rights, ethics and equity in health care.

Opportunities

Despite these challenges there are a lot of opportunities for health action in the African Region. Health is now recognized as a key aspect of human development. Currently, there is increased focus on improving the health of the people in Africa, resulting in a convergence of commitments part partners and additional especially at country level. The African Union has a continental Health Strategy whose implementation could benefit from subregional integration and development. WHO is committed to supporting the implementation of this health strategy. Peace-building efforts resulting in stability are additional opportunities. The social sectors are receiving better attention and ongoing reforms undertaken by African governments will have a positive impact on the health of populations.

The Paris Declaration and the Accra Schedule for Action made commitments to improve aid effectiveness. The High Level Task Force on Innovative International Financing for Health Systems has identified a menu of innovative financing mechanisms to complement traditional aid and bridge the financing gaps which compromise the attainment of the health-related MDGs. The World Fund, The World Alliance for Vaccines and Immunization (GAVI), The World Bank, WHO and other partners are exploring the possibilities of establishing a common funding and technical platform for health systems strengthening. The World Health Initiative spearheaded by the Government of the United States of America promotes a new business model for sustainable delivery of essential health care and public health programmes. The International Health Partnership Plus (IHP+) and the Harmonization for Health in Africa mechanisms are as well promoting harmonization and alignment.

World health partnerships and initiatives that support nations in their efforts to improve health outcomes have increased over the past few years. In addition, significant support is being provided by the Advanced Market Commitment (AMC) for pneumococcal vaccines and The International Drug Purchase Facility for AIDS, Tuberculosis and Malaria (UNITAID). New partnerships with emerging economies are as well expanding.

The focus on the renewal of primary health care and the strengthening of health systems offers great opportunities for scaling up of essential health interventions and universal coverage. The International Health Regulations (2005) create an opportunity for strengthening surveillance systems and health security. New technologies including eHealth offer innovative solutions to health challenges such as the scarcity of healthprofessionals and access to difficult terrains. Building on the achievements and lessons learnt from the implementation of the 2005–2009 Strategic Orientations for WHO Action in the African Region, a better focus on aid effectiveness and accountability bygovernments, health development stakeholders and partners would be a key many formoving forward.