NEW
PARTNERSHIP FOR AFRICA’S DEVELOPMENT
HUMAN
DEVELOPMENT PROGRAMME
HEALTH
THINK
GLOBALLY: BUILD
LOCALLY
WORKING
DOCUMENT
SECTION
1: THE HEALTH PROBLEMS FACING AFRICA
Human development
has been one of the most serious casualties of the poverty,
social exclusion and marginalisation of and lack of
sustainable development in Africa. The health problems
facing Africa are rooted in this context, as are the
potential health benefits of a broad human development
strategy.
1.1
A HUGE BURDEN OF PREVENTABLE DISEASE AND DEATH
Africa’s 784
million people continue to suffer from a huge burden of
potentially preventable and treatable disease, which not
only causes volumes of unnecessary death and suffering, but
also stifles economic development and damages the
continent’s social fabric. Much of this burden is
consequent on HIV/AIDS, tuberculosis, malaria and other
communicable diseases.
The burden is there in spite of the availability of
many of the tools needed for prevention and treatment and
technological advances being within range, largely because
the diseases are rooted in poverty and in weak health
systems.
The HIV/AIDS
epidemic is turning back advances made in life expectancy
over the past half century, with life expectancy in the most
severely affected countries in sub-Saharan Africa reduced by
almost a third, from 60 years to 43. However, its impact is
not the same in all countries. HIV prevalence in adults
ranges from below 5% to above 20%. Approximately 2.4 million
people die from AIDS each year, 600 000 from tuberculosis
and 1 million from malaria. Communicable diseases of
childhood also carry a heavy toll. 800 000 children in the
African region die of diarrhoea before their fifth birthday,
1.2 million of pneumonia, 500 000 of measles and 600 000 of
malaria. AIDS deaths are growing. Malnutrition is linked to
more than 50% of all childhood deaths. 272 000 women a year
die in childbirth.
In the face of these
statistics, other important health problems can but should
not be overlooked. Poorly cared for mental ill health and
(much preventable) physical disability are widespread.
Sleeping sickness is resurging, now affecting between 300
000 and 500 000 and non-communicable disease burden is
growing. Although the levels in Africa for some non-communicable
disease deaths and morbidity are not yet at levels reached
elsewhere, the fact that 77% of deaths from non-communicable
disease worldwide occur in developing countries means that
action on existing problems (e.g. injuries, violence, mental
ill-health, disability and occupational disease) and
emerging diseases of lifestyle (for example due to unhealthy
diets, physical inactivity, tobacco and alcohol use) must
not be neglected.
1.2
TARGETS FOR REDUCTION OF BURDEN OF DISEASE
A number of targets
have been set for reduction of the disease burden in Africa,
notably the Okinawa Goals, the International Development
Targets, the Abuja Declarations and targets set in
Africa’s Health-for-All Policy. Yet,
if current trends continue it seems that the
major international initiatives against HIV/AIDS, TB,
malaria and childhood and maternal death, as was the case
with their predecessors, will
not achieve their targets. Quite simply, the scale of
programmes and of their financial / and human resources is
insufficient. However, success is possible, especially if a
comprehensive approach is used to deal with the reasons
behind the burden of disease and appropriate and innovative
strategies are used. There are many positive examples in
Africa from which lessons can be drawn. Even though they are
not spelt out in this report, they offer invaluable guidance
for the future. The situation differs from country to
country, so it is important to assess the feasibility and
trends of these goals for each country and to redefine and
refine resource requirements to achieve feasible country
targets.
The Okinawa Goals
A
25% reduction in HIV/AIDS prevalence in all young people
by 2010
(Also
a UN Special General Assembly goal)
A
50% reduction in TB deaths and prevalence by 2010
Reduce
malaria suffering and death by 50% by the year 2010
The International Development
Targets
Reduce
mortality rates for infants and children under-5 by 66% by
2015
Reduce
maternal mortality by 75% by 2015
Similar
targets have been set in the WHO Afro “Health-for-All
Policy in the African Region: Agenda 2020”, but with
2020 target dates.
1.3
THE REASONS BEHIND THE BURDEN OF DISEASE
The reasons why
Africa is not on track to achieve these targets is not
because they are impossible, but rather because:
- Continuing
poverty, marginalisation and displacement on the
continent undermine health
- Disease
control programmes fall short of the scale required to
be effective
- Health
services are too weak and under-funded to effectively
support significant disease reduction
- The
people of Africa are not sufficiently empowered to
improve their own health.
- The
benefits of development and health services tend to not
equitably reach those with the greatest burden of
disease
Poverty, marginalisation
and displacement
Improved health is
not simply a product of health service interventions, it is
a consequence of many complementary factors. Improved health
advances development, while development is a precondition,
although not a guarantee, for improved health. What makes
the most difference is how developments are linked to
factors that improve health and how well they reach the
poorest, most marginalized and displaced people. The links
between health and development are woven into every facet of
life on the continent
- While
peace is a pre-condition for development, it is also
essential for health. War and conflict on the continent
have had catastrophic effects on health, disease control
and disability. Maternal mortality, a sensitive
indicator of health system performance, increases
fourfold in conflict areas.
The effects are felt beyond the war zone, as the
toll of war on the people and the health system spreads
throughout countries.
- Economic
underdevelopment, including through reduced production
and raw goods prices, and protective trade and market
practices, have damaged health through a number of
paths, including unemployment and low incomes.
- Shortfalls
in agriculture and lack of land reform have had a direct
effect on food security and hence on malnutrition. Lack
of household food security is a consequence of more than
poverty and underdevelopment and its impact on disease
burden beyond malnutrition.
- Education,
and in particular women’s education, has many spin
offs for health. Literate
people are better able to take action to improve their
own health. Lack of education has made it difficult for
many to secure their basic needs, including nutrition,
or to include health-promoting actions in their lives.
- The
oppressed position of women has led to poorer health in
many ways, including a weak position in ensuring safer
sex practices.
- People
living in informal settlements with poor infrastructure
have been exposed to fire, health problems of social
instability and communicable disease, especially from
inadequate water supplies and sanitation and from air
pollution.
- 500
million Africans live without access to safe water or
sanitation, losing 24 billion work hours per annum
through illness. 40 billion work hours per annum are
spent collecting water.
- Lack
of general infrastructure, such as good roads, transport
and communications, have impeded health services,
especially the chances of care in an emergency.
- The
digital divide prevents Africa from fully exploiting the
many uses technological advances offer for improving
health.
- Governance
and institutional weaknesses, although not uniform,
influence health both indirectly and directly.
Governments are faced with an array of pressures and
health and health services are not necessarily afforded
the priority required to meet disease burden targets.
Quality of governance also impacts on economies
and public services, and through this, on health.
Disease control programmes
do not match scale of the problem
Although the
specific activities for prevention and control of the major
communicable diseases of Africa vary, their impact can be
massively reduced by effective programmes.
Influencing sexual behaviour to prevent HIV/AIDS,
treatment completion for tuberculosis, rapid treatment for
malaria, reaching children to immunise them against measles,
use of oral rehydration to prevent dehydration from
diarrhoea and early identification and treatment of
pneumonia are all within our grasp.
Yet, success to date has been limited, because the
overall effort to reduce disease burden has been
insufficient.
Although the
specific mode of transmission and incubation periods for
communicable diseases or the epidemiology of
non-communicable diseases vary, as do the complexity and
effectiveness of measures required for their prevention and
control, there are common requirements for success beyond
focussing on the disease. Countries also require a solid
health care system, capacity for strategic support,
effectively mobilizing personal action and addressing
underlying poverty and underdevelopment. In turn, disease
programmes, if developed effectively have the potential to
enable broader improvements in health systems. There is also
much potential for technological development to advance
disease control. The increased international focus on
disease burden, including new research initiatives are
certainly welcome.
Health services unable to
effectively support disease reduction
All the major
communicable disease programmes call for massive
improvements in health systems as a key to the success of
their efforts, as international experience has shown that
programmes focusing on single diseases can become like a
house without a foundation - they stay up for a while and
look good, but are prone to later collapse. At the same
time, systematic efforts to scale up disease control
programmes, if developed appropriately, have the potential
to strengthen health services, including into the periphery.
This can then be built on to address a wider range of health
problems.
Securing the health
system is critical to combating major diseases. If a person
is suffering from a genital discharge, a chronic cough, a
high fever, or shortness of breath, they need to be able to
access a health facility.
When they get there they should be able to consult
with a health worker capable of diagnosing and treating
their condition, and the essential drugs and supplies
required for their care should be available. The reality is
that many health systems are unable to provide this basic
care, have breakdowns in the supply chain and are unable to
effect referrals to hospital in emergencies, such as for a
women in obstructed labour. Adherence to therapy for chronic
diseases, such as tuberculosis, is particularly difficult in
a weak health system, rendering treatment ineffective and
leading to drug resistance. The same could apply to the
introduction of anti-retrovirals in a poor health system
environment. Disease prevention and health promotion
measures, such as immunization and contraception also
benefit from effective health systems.
Central
to any effective system is sufficient numbers of capable and
committed health workers, particularly so in more remote and
unstable areas. Negative attitudes displayed by health
workers towards their patients have all too often been a
complaint, while the inability to retain staff threatens the
system. Retaining health workers requires decent conditions
of service and a positive work environment. Yet, the reality
is often the opposite. Salary scales in a number of
countries are extremely poor, even though much of the health
budget goes into remuneration of staff. In addition, workers
also face adverse work environments and poor living
conditions for their families, which chip away at the morale
of even the most committed. This profoundly affects
auxiliary level workers, who are commonly the backbone of
more remote services. Under these conditions, the ongoing
brain drain into the private sector and out of the country
becomes understandable, if not desirable. Brain drain
affects the capacity for training, supervision and
management; and for staffing of first referral level
hospitals.
For
many diseases, cheap generic drugs are still what is
required. Yet, systems to ensure that drugs are always on
the shelf are too often found wanting, with supply chains
compromised at multiple points. Adding to the difficulty is
the high cost of some drugs. In earlier days of
antimicrobrial therapy, penicillin for gonorrhoea and
chloroquine for malaria provided cheap and effective
treatments, but resistance is an increasing problem. The
cost of the alternatives to these drugs and of other newer
needed therapies, including drugs used for AIDS, is beyond
the means of even the better economies of Africa. The
pricing practices of the pharmaceutical industry play a
significant role in keeping costs high.
Governance
and management weaknesses, the impact of which should not be
underestimated, continue to undermine the system. A lack of
effective systems for community oversight adds to management
limitations. But, however judiciously available money is
spent, current funding levels are inadequate to allow for
viable health systems in Africa. If one has only 30 litres
of fuel to travel the 1000km from Lagos to Abuja, adding
another 2 or 3 will still leave you stranded, however well
you drive. Health system funding in Africa is in this
position. Per capita public expenditure on health services
is below US$50 in 38 of Africa’s 53 countries. Even if one
adds private payments, total expenditure remains below US$50
in 28 countries. In the least developed countries total
health expenditure is of the order of $15 per capita.
All health systems
must be underpinned by clear and coherent national health
and resource (e.g. drugs and human resource) policies and
plans and legislative frameworks. The extent to which such
policies and frameworks are in place varies across the
continent. There should be mechanisms for the rapid review
and registration of new technologies; a process that might
be best performed through a regional centre, managed
collectively by the countries.
Surveillance,
monitoring and evaluation are central to early intervention
in outbreaks and for improving health service delivery. It
is the basis of evidence based policies and strategies and
for assessing effectiveness of interventions. Systems for
surveillance, monitoring and evaluation in Africa, with
exceptions, are generally too weak to fulfil this role
effectively, and their development is often inhibited by the
more immediate pressures of dealing with patient loads and
fiscal constraints. Mortality data is often questionable.
Lack of support capacity
for health system development
Ministries of health
worldwide do not attempt to secure within their offices
every skill necessary to ensure effective health system
performance or disease control. They rely heavily on
appropriate use of experts, often based in universities,
research institutes or health NGO’s, to support their
programmes. In Africa, there is a dearth of such centres of
excellence, while those in place often lack the critical
mass of staff and resources required to be effective. This
institutional inadequacy leads to dependence on, rather than
partnership with commercial consultants, donor staff and
public health institutions of the developed world. Even the
support role of multilateral agencies is compromised by the
size of their country offices. Also, relationships between
Ministries of Health and Universities and other centres of
excellence are not always conducive to collaboration.
The 10:90 gap in
health research is used to describe the fact that 90% of the
worlds research goes into less than 10% percent of its
health problems i.e. into those of the developed world. We
still do not understand nearly enough about health behaviour
and about what health systems interventions are effective in
Africa. Disease surveillance, and monitoring and evaluation
of interventions, to identify trends early and to inform
management, are underdeveloped.
Although there are
important new initiatives, the lack of development of
vaccines and more effective drugs for the treatment of
malaria, tuberculosis, trypanosomiasis (sleeping sickness)
and other communicable diseases remains a blight on the
record of international organisations and the pharmaceutical
industry. Vaccines against the pneumococcus which causes
pneumonia, the rotaviruses and shigella which cause
diarrhoea and the meningococcus causing meningitis are all
within reach, but are not seeing rapid progress because the
commercial opportunity is not good enough. For the same
reason vaccines with any real efficacy against HIV TB and
malaria remain some years away.
If advances in
information and communication technology are a major driver
of the global revolution, then the lack of such technology
in the health systems of Africa is a major inhibitor. Few
hospitals, let alone clinics, are connected to the benefits
of the web and many suffer from a lack of telephone or radio
communication.
A number of UN
bodies (UNDP, UNAIDS, UNICEF and UNFPA) focus on health,
with the World Health Organisation (WHO) dedicated to it.
The bulk of Africa falls under the WHO regional office,
temporarily situated in Harare, (its permanent base is in
Brazzaville) while some of the northernmost countries fall
under the Eastern Mediterranean region. WHO spearheads many
international initiatives, but is not the only contributor.
There are numerous international partnerships, agencies,
philanthropic organisations and faith-based initiatives also
active in Africa, as is the World Bank. Individual countries
also play a key role. It is essential that the contributions
of all these players are complementary; that they consider
long term financing and that they work within an overall
country strategic plan. This has not always been the case.
People not sufficiently
empowered to improve their health
There is much that
individuals and families can do to improve their own health.
For example, a drop of chlorine in a litre of water
can prevent diarrhoea, while the early use of home made oral
rehydration solutions can prevent death from dehydration.
Use of insecticide-impregnated materials helps prevent
malaria and use of condoms, AIDS. Lifestyle changes could
impact on disease, while seeking health care early for
children with fast breathing, a cough and a hot body would
reduce deaths from pneumonia.
The question is why
the potential for reducing disease from such personal
actions is not realised in Africa. The roles of poverty and
illiteracy are well recognized, but it goes deeper than
this. People do not intentionally risk their health and
lives. More needs to be done to empower individuals and
communities to take action to improve their own health - and
done in a manner that enhances dignity and consciousness.
Approaches that, however subtly so, are patronising,
condescending or humiliating, tend to alienate people from
health enhancing actions. Exploitative advertising is a
counter force, which not only needs to be controlled, but
whose power to use the media needs to be emulated in pursuit
of health.
Health services can
only go so far; they need to be supplemented by efforts of
communities and their structures. These efforts are diverse
in nature, ranging from campaigns to care. They can be more
general, but often tend to focus on a specific health
problem e.g. AIDS or disability.
They have the ability to achieve results and mobilise energy
and voluntarism in a manner that is difficult for formal
health services to match. Results of many efforts in Africa
are nothing less than extraordinary and there are many
examples to learn from. The efforts can be rooted in
NGOs, CBOs, faith-based organisations, or as part of a more
general development structure. These organisations play an
invaluable role in the health systems of Africa and their
efforts have been growing in many countries; but there are
massive gaps to be filled and a lack of emergence or
sustainability of indigenous organisations.
Ø
The
benefits of development and health services tend to not
equitably reach those with the greatest burden of disease
The burden of
disease is not evenly spread between and within countries of
Africa. This is not chance - it is a product of inequity,
inequity that results in benefits of development not being
evenly shared, nor are health services evenly spread. The
poorest and most remote people and those displaced by war
and other emergencies are especially vulnerable and
contribute disproportionately to the burden of disease. In
consequence, if the aim is to massively reduce disease
burden, then development, public services and health care
should be skewed towards the poorest and most marginalised
people. Yet, the inverse is generally true. The poor and
marginalised not only face fewer clinics and health workers,
but also the least fair financing. Co-payments are a greater
proportion of (meagre) incomes and serious illness can
impoverish families for many years, as they not only lose
income and production, but also have to pay back moneys
lent.
Displaced
communities and those affected by war are even more
vulnerable, yet receive even less health care. Even when
peace prevails, capacity and resource limitations have not
allowed health services to be rapidly scaled up.
SECTION
2: THE NEPAD HEALTH STRATEGY
2.1
THE NEPAD HEALTH VISION
An
Africa rid of the burden of unnecessary death and ill
health.
2.2
THE STRATEGY
Given that efforts
at disease control will not match the targets if they
continue on their current path, there are two
choices and they are quite stark. They are to abandon
the targets and accept that Africa will continue to be
weighed down by disease, or to put in place a plan
that is of sufficient scale and breadth to be genuinely
capable of reducing the burden in line with the
international goals. The worst thing would be to retain the
goals, but only support programmes obviously well short of
what is required - and then suggest that Africa has not been
able to deliver. The NEPAD health programme has chosen the
latter option – to offer a strategy that can truly impact
on the impossible burden of disease that Africa’s people
carry; a burden that is choking its social and economic
development.
The
NEPAD health strategy derives from an understanding of the
health problems facing Africa and the reasons for them. The
strategies and actions draw on international and African
best practice, continental experience, a multiplicity of
analytic and strategic reports and the many African
programmes that offer innovative ideas. A number of the
strategies have been endorsed by African heads of state or
government, or by their health ministers. The strategy is
based on a view that piecemeal and under-resourced efforts
do not offer the potential to match the challenging goals.
The strategy is therefore to build a
comprehensive attack on the forces that drive the burden of disease
- a composite and integrated, rather than a
fragmented approach. It therefore foresees a massive
scaling up of commitment, effort and funding to give it a
realistic chance of success.
As the disease
profile of Africa is first and foremost one of poverty, such
as from a lack of food, leading to malnutrition and
diminished immune capacity to fight off disease, the NEPAD
health strategy recognizes that reduction in poverty
is a health intervention. The overall NEPAD programme is
therefore supportive of health – its strategy is not
duplicated here. However, as any development is not
automatically positive for health, the health potential and
impact of planned developments should be considered and
health-promoting ones preferentially selected.
There is no doubt that equitable development that
provides sustainable incomes and access to services for the
poorest will have the greatest impact on health.
Although reduction
in poverty is necessary for achieving Africa’s health
goals, this needs to be paired with health interventions,
many of which have a more immediate impact.
Health services are
not simply mitigators of the effect of illness; they are
basis for interventions for disease prevention and control.
This is why all the major disease burden programmes
emphasise the importance of an effective health system to
their success. The NEPAD health strategy thus twins a strong
focus on the heavy burden of communicable disease in Africa
with a commitment to achieving a secure and sustainable
health system – a joint massive effort. The NEPAD
health strategy recognises that there are common features
that go into making a health system secure. However, it does
not prescribe a single recipe for Africa, because of the
uniqueness of each country situation. Rather, it starts with
each country undertaking a review of what it needs to do to
secure its health system – to scale it up in a sustainable
way to the point at which it can truly support programmes
for the reduction of burden of disease. Each strategy will
recognise the multiplicity of players in the health sector
and the role of communities, to which services need to
become more responsive and accountable.
The
NEPAD health strategy also offers a mechanism to build the support
capability
required by the strategy - public health capacity, relevant
research including efforts to develop new drugs and
vaccines, information and communication technology and calls
for a more co-ordinated effort by international partners.
Improvement in
health will not come without the full participation of
families and communities. The NEPAD strategy recognises that
people must become empowered to take action to
improve their own health. This is built on increasing
the levels of health literacy and community involvement in
health issues. Community involvement will be diverse in the
health problems tackled, in the activities undertaken and in
the organisations involved. They will reach out to all
sectors of society and have sustained social mobilisation at
their core. The details of how best to achieve community
involvement will vary from country to country. The principle
is therefore part of the strategy, but the mechanism is not
prescribed. Involvement of those with and affected by the
health problem that is being addressed is critical, not the
least because they are the ones who tend to be most
passionate and committed in their efforts.
The strategy
recognises that biggest return on investment will come from
a focus on the poorest and most marginalized. People
in deep rural areas, in urban fringes and those displaced by
conflict carry the greatest burden of preventable and
treatable disease. Yet, for many reasons, health systems
often reach them last.
It is recognised that the pressures of limited
budgets, of staffing rural services and of visible pressure
for services in urban areas have skewed health services. The
NEPAD health strategy makes a specific commitment to equity
in health care.
There
is much that Africa can and will do for itself. But,
success will require a partnership between African
leaders and their counterparts in the developed world and
the support of international agencies. The strategy
recognises this and calls for unprecedented levels of
commitment from donor countries.
Much as taking US$10
into a supermarket in the developed world will not meet the
nutritional needs of a family for a month, however
judiciously the money is spent and low cost nutritional
foods bought, so does much the same logic apply to health
system funding in Africa. A decision has to be made if the
aim is to offer a sheet of plastic to put on top of a shack
to prevent it leaking, or to achieve funding for a modest
house with basic amenities. Too often, costs are thought of
in individual disease terms – x cents to do y, without
recognising that it is not just the cost of the drug that
resolves a health problem, but also the cost of the basic
health system which is needed to deliver it.
The NEPAD health
strategy seeks not only to secure recognition of what is
required, but also to mobilise the funds to achieve the
massive scaling up. If funding needs to be sufficient to
build effective disease interventions and secure health
services – to make a real difference - then an increase in
the order of US$8 billion, or US$10 per capita per annum is
the starting figure that should be rapidly reached. Much
less will, when distributed, be spread too thin to make the
impact required. The slow response to and deficit on the
targets of the Global Fund are of great concern, recognising
that the amount will need to grow over time to the order of
US$20 billion or US$25 per capita. (There is still some
debate on the amount needed to make a real impact, but it is
magnitudes more than rolling out existing levels of
support.)
As evidence of their
own commitment to this programme, Heads of State will lay
the ground for sustainable interventions and increase the
allocation of their own funds to fight the scourge of
disease in Africa. For each country, the amount committed
will be different, but will be such that no observer would
question the country’s resolve to tackling its burden of
disease. As economies grow with implementation of the
overall NEPAD programme, so will dependence on donors reduce
for sustaining the health systems of Africa.
The
partnership will also require patience – turning around
AIDS, TB and malaria is not going to happen overnight. They
are not single action interventions. Like a bicycle, a
number of parts need to work in unison, and be well oiled,
to move forward. Take away the wheels or the chain and you
are stuck, without handlebars you lose direction and without
a rider you will crash.
Given
that building a health system is a decades long programme,
the strategy calls for donor support to be ready to stay the
long road and not become fatigued early on Therefore, one
can’t put funds in, expect concrete deliverables on medium
term projects in 1 year and be disappointed when they are
not there. At the same time, realistic interim targets will
be set and need to be delivered on.
It
is critical to recognise that it is not the intention of
NEPAD to see money thrown at problems. NEPAD countries are
committed to showing that this investment will reap its
rewards. To this end, leadership will come from Heads of
State themselves. The nature of the proposed Millennium
Partnership is premised on African countries achieving what
they can from their own abilities and resources and creating
an environment for sustainability and only then looking with
confidence to donor countries to support the NEPAD health
strategy. Confidence and trust returned, and an agreement on
the challenges to be faced and the strategies to address
them are at the core of a successful effort. Indeed, it is
this combination of an African strategy and the support of
African heads of state that are important added values of
the NEPAD health strategy. It gives an African voice to the
debates on the steps needed to improve health on the
continent.
NEPAD also envisages
that donor partners will respect the right of African
countries to take responsibility for the plans and
programmes of the strategy, rather than for them to be donor
determined or driven, as this is what will engender the
African ownership and commitment that is so crucial to
sustaining efforts for reducing the burden of disease.
2.3
OBJECTIVES
The objectives of
the NEPAD Health Strategy are:
- To
strengthen programmes to reduce the burden of disease
-
To reduce HIV prevalence in
young people by 25% by 2010
-
To reduce TB deaths and
prevalence by 50% by 2010
-
To reduce malaria suffering
and death by 50% by 2010
-
To reduce mortality rates
for infants and children under-5 by 2/3
by 2015
-
To reduce maternal
mortality by 75% by 2015
-
To enable effective
prevention and care for other major burdens of disease
- To
have a secure health system that broadly meets needs and
effectively supports disease control in place by 2015
- To
ensure the necessary support for sustainable development
of an effective health system by 2010
- To
achieve health literacy in Africa by 2010
- To
impact successfully on the disease burden of the poorest
people of Africa by 2015
- To
mobilise sufficient sustainable funding to build
effective disease interventions and secure health
services by 2004
SECTION
3: THE NEPAD HEALTH PROGRAMME
The NEPAD health
programme follows a comprehensive, integrated approach to
addressing the disease burden of Africa outlined in
the strategy. It recognises the overall role of NEPAD in
addressing the poverty, marginalisation and displacement on
the continent that is undermining health. The health
programme specifically seeks to:
- Strengthen
disease control programmes so that they do not fall
short of the scale required to be effective
- Secure
health systems so that they are not too weak and
under-funded to effectively support significant disease
reduction
- Build
the support capacity necessary for development of a
sustainable health system
- Empower
the people of Africa to take action to improve their own
health through achieving health literacy and wider
community involvement.
- Share
the benefits of development and health services
equitably, so as to reach those with the greatest burden
of disease
- Mobilise
sufficient funding to build effective disease
interventions and secure health services
The programmes are
outlined in more detail below
and the priority goals
and targets are spelt out in Table 1. Table 1 also
identifies actions that African heads of state or government
should take in support of the health strategy and the
contribution of international partners to facilitate viable
efforts to reach these goals.
While elements of the programmes have the potential
to make rapid gains, the full programme will take time to
unfold and become secure. Some elements are best seen as a
ten or more year investment.
While the NEPAD
health programme offers a medium-term approach, there are
concrete projects that will make a difference now. A set of
immediate projects is outlined in Appendix 2, and is listed,
with objectives and estimated costs, as a Table in Appendix 2.
These projects should not be seen in isolation, nor
as a replacement for the massive scaling-up and medium term
strategy that is required.
Rather, they have been selected as they are first
steps on the longer road, or because, if not dealt with
early on, they are likely to become rate limiting steps to
achieving other elements of the strategy.
3.1
Strengthen programmes to reduce the burden of disease
Although
there is a need to address the full range of health problems
affecting Africa, there is little doubt that the immediate
priority must be to reduce the burden of disease caused by
AIDS, TB, malaria, infections of childhood and deaths
related to childbirth. Many of the NEPAD disease control
proposals are aligned to existing international or
continental initiatives. NEPAD is also committed to the
action plans of the Abuja Declarations on Malaria and on
HIV/AIDS, TB and Other Related Infections and to securing
the funding needed for their implementation.
NEPAD envisages a
massively scaled up AIDS prevention effort incorporating
education, access to condoms, voluntary counselling and
testing, treatment for sexually transmitted infections and
prevention of mother to child transmission. Targeting of
those at high risk, such as sex and migrant workers must be
stepped up and youth programmes prioritised and
appropriately pitched. Care includes home based care and
care of orphans, improvements in quality of life, treatment
and prophylaxis of opportunistic infections and use of anti-retrovirals.
As with other diseases, effective care will require
affordable drugs and strengthened health systems, including
effective drug distribution, strengthened laboratory
services and caring health staff. It also requires community
action and empowered individuals and families.
Malaria efforts
foresee increased use of insecticide treated materials and,
where appropriate other vector control measures, rapid
diagnosis and treatment of malaria, including home initiated
care, chemoprophylaxis for pregnant women, and early
detection and response to outbreaks.
Strategies to
address other important burdens of disease are recognised in
the NEPAD programme. These include tackling other
communicable diseases of importance in Africa, such as
sleeping sickness and river blindness and the reduction of deaths
and disability from non-communicable diseases, (NCDs)
including those related to tobacco, mental ill-health,
substance abuse, violence and injuries and work-related
injury and disease as well as the emerging chronic diseases
of lifestyle.
3.2
Build a secure health system
The process of building a health system that effectively meets needs and supports
disease control has to take time, and will require sustained
commitment over 10 years and more. Many parts will need to
work in synchrony. There can be no single health system
recipe, given the diversity of both country and health
service situations in Africa. Also, each country will have
different priority areas for attention early on – in one
country it may be drugs, in another human resources and in
another communication. Thus, each NEPAD partner will need to
prepare a country specific plan for securing its health
system.
In developing the
country specific plans, the role of the various players must
be recognised. In a generic strategy such as this one,
because of country variations, one cannot make definitive
statements about the specific roles of the public service,
private sector, NGOs, CBOs and other players who make up the
diverse group of health care providers. What one can say is
that all need to work in a co-ordinated fashion towards
achieving the country’s health and health service goals.
Also, each one has particular strengths, such as the
national base of the public sector, the responsiveness of
private providers and the unique ability of NGOs to reach
high risk and often marginalised groups.
It is also not
possible to define precisely which interventions will work
best to improve health systems, in part because of
insufficient health systems research and of course country
variability. However, there are developments that appear to
offer good returns and are likely to feature in all plans.
These include:
·
Strengthening peripheral
health systems and in particular the circumstances of lower
level health workers – low salaries and low morale
included - as they are the vital ones in delivering care.
·
Strengthening management at
district level and decentralisation of decision making.
Decentralisation will not be undertaken in a manner that
constitutes dumping of responsibility on local health
workers and communities without the resources to deliver
care.
·
More trained managers, who
can effectively mobilise, motivate and innovate, as well as
plan, organise and budget, and manage information.
·
Greater local involvement
in health facilities, including community oversight of
health workers and greater accountability through service or
performance agreements
·
Regular supervision of
health workers. This should be done in a manner that
encourages and enables performance, rather than as a
policing exercise. Health workers should look forward to
supervisory visits as they would a visit from a friend from
whom they except support and ideas on how to deal with
challenges.
Although there may
be no generic prescription, it is possible to identify
common requirements of an effective health system. All
countries will need to:
- Strengthen
peripheral health services
- Provide
accessible services by increasing the number of local
clinics and ensuring the necessary infrastructure –
energy, communication and safe water
- Staff
services with sufficient numbers of capable health
workers through more effective training, better
conditions of service and reduced brain drain
- Ensure
essential drugs and supplies through strengthened
distribution systems and affordable prices
- Revitalize
hospitals to function effectively as sources of referral
- Achieve
management capability commensurate with running services
efficiently at national, regional and local levels
- Fully
harness the potential of the private (for profit and
not-for-profit) sector, as appropriate to the country,
in support of reduced burdens of disease.
- Have
clear national health and resource (human, drugs)
policies and legislative frameworks
- Provide
sufficient surveillance, monitoring and evaluation to
inform interventions
- Strengthen
planning, managing and monitoring capacity within
ministries of health.
Health is a labour intensive and dependent sector. Therefore
central to any strategy for an effective health system is it
human resources. All country strategies will therefore need
to adopt a comprehensive approach to the range of factors
influencing human resource availability and performance and
prioritise their implementation
3.3
Support for sustainable development of the health
sector
Capacity
to support development of the health system is not a “nice
to have”, it is essential to disease control and to
building a secure health system. The support needed is
diverse.
Institutional public
health capacity and expert centres on the continent, within
a sub-regional framework, must be developed, as must
south-south co-operation and more effective and relevant
links with the north, which will continue to play an
important role. They might be reference laboratories,
Schools of Public Health or research institutes. Africa’s
experts should collaborate and network more with each other,
be it on disease control or health service issues, and
systems and organisations put in place to enable sharing of
information. Existing structures, such as that for Polio
Surveillance could be readily expanded to serve a broader
disease surveillance role.
Health systems,
disease programme and operational research must become
recognized as a necessity for improving health system
performance and not a luxury. It must be budgeted for and
structured into the system. Ways for its product to be able
to influence health policy and practice should be
established. Research capability is in need of a strong
injection, as are some surveillance systems and the
collection of routine mortality statistics.
Every support is
offered to the major drive to put relevant vaccine and drug
development onto a fast track, including through GAVI. The
potential that these international public goods hold must
not be allowed to slip through because of issues of
ownership and markets.
The digital divide
in hospitals and clinics is another capacity weakness
undermining system development in Africa. NEPAD strategies
in ICT hold real potential and clinics should be prioritised,
costs kept affordable and mobile telephone and satellite
technology exploited.
More and more
international players are recognising that policies and
strategies need to come from and be driven by Africa and not
imposed on it, and that the role is a supportive one. They
should continue to provide not only moral and material
support, but also the unique expertise that they can
mobilise. At the same time, they need to be realistic, and
targets should not be set without recognising the necessary
resource requirements, lest Africa be labelled as failing to
achieve something that was not possible in the first place.
Successful
implementation of the NEPAD health programme will require a
range of partnerships. These will be between African
countries, regional and continental networks and United
Nations bodies (including UNDP, UNAIDS, UNICEF and WHO)
multilateral agencies, regional structures e.g. the EU,
philanthropic organisations, non-governmental organisations,
universities and the private sector. The World Health
Organisation Regional Office for Africa, in collaboration
with its Mediterranean counterpart, must certainly play a
central role. Regional structures, such as ECOWAS and SADC
also have a critical role to play in expanding regional
initiatives and networks and in facilitating harmonisation
of policies, bulk procurement and consistency in care. The
capacity of the WHO Regional Office for Africa and the
regional bodies (ECOWAS, SADC etc.) should be strengthened,
commensurate with their expanded responsibility.
3.4
Enable personal action to improve health
Attaining the basic
knowledge and skills to enhance ones health in a manner that
favourably influences attitudes and behaviour can be termed
health literacy. In much the same way as literacy enables
people to read and experience all the benefits associated
with it, so achieving
health literacy would allow people to experience the
benefits of better health. The approach should be
comprehensive and developmental. Too often, single disease
programmes provide a burst of information in a manner that
tells people what to do, rather than contextualising their
learning.
A package of health
learning should be identified and linked to its target
audience. The resources of the state, including public
broadcasters, should be optimally used to spread health
messages. Packaging learning in interesting formats, such as
radio dramas and linking it to real life make the greatest
impact. Community structures and community-based
organisations are potentially very valuable routes for
health promotion, while use of national figures, such as
musicians, and peer education, are also influential means of
learning. If there is leadership from Heads of State and a
high profile, concerted effort, there is no reason why
health literacy cannot be rapidly improved.
The NEPAD health
programme seeks to achieve a real scaling up of community
involvement in a range of health issues, starting with the
major burdens of disease. At the core is a commitment to mobilise
energy and voluntarism in a manner that is difficult for
formal health services to match, and to achieve results in
groups that formal services struggle to reach.
On
the one hand, it is important that people do not simply wait
for government to do things for them, yet on the other,
organisations do not arise spontaneously in sufficient
numbers. Health Ministries will therefore need to intervene
to create an enabling environment for community involvement,
facilitate the emergence of local NGOs and organisations and
provide seed funding to get efforts off the ground in
hitherto unserved areas. As
situations vary from country to country, there is no single
way of going about this. Each country should consider its
own situation and incorporate a deliverable approach to
community involvement in its country plan. The
details may be different, but the aim is common to all
countries - to reach all
sectors of society, including the poorest and most
marginalized, in a sustained programme of social
mobilisation in support of health.
3.5
A focus on the poorest and most marginalized
Successfully
impacting on the disease burden of the poorest people
of Africa requires economic recovery, pursued in a manner
where real benefits reach those in greatest need. A central
feature of NEPAD is a war on poverty and marginalisation,
whose every success will contribute to health. A strong
focus on the needs of the poor, including basic food
security will provide significant health returns.
Strengthening public services, impacts most on the
poor as this is where they access social and other services.
Displaced
communities and those affected by war need to receive
services, however challenging the situation. This should
include services for women and children, including
immunisation. Special arrangements may need to be made to
provide care. Health will need to adopt a neutral position,
possibly delivering care through NGOs. Then, as soon as
peace prevails, health services need to be rapidly scaled
up. This is not only because of the burden of treatable
disease that is likely to have built up, but because it is
an effective way of starting the reconstruction of
communities and societies and building their confidence in
post-conflict government.
What must also reach
the poor for their health to improve, are health services.
In many countries the cost of health care to poor families
is catastrophic and NEPAD envisages changes in health
financing systems to achieve greater fairness. Each country
will need to apply this principle to its own financing
system. Equity in health systems is not only of moral value,
it also offers the best return on investment.
3.6
Mobilise sufficient funding
It is quite clear
that the massive effort envisaged against the major burdens
of disease and unnecessary death in Africa will require
substantially increased funding. This will not only need to
go into disease specific programmes but also into securing
the vehicle that provides much of the specific prevention
and care that has to be implemented - the health system.
The additional funds
will come from 3 main sources, NEPAD countries committing
more of their own resources to health in line with
commitments made in the Abuja declarations, directing funds
mobilised from debt cancellation preferentially to health
and from the Global Health Fund being pioneered by the UN
secretary general. NEPAD supports the global health fund
because it holds the possibility of an increase in funding
to the level required to make a difference. However, it is
critical that the Global Fund and any response to the report
of the Commission on Macroeconomics and Health brings in new
money and is not just a shuffling of the pack or a drawing
out of funds from other sectors needing support, otherwise
there is a serious risk that other essential health efforts
and institutions get undermined. It is also crucial that the
Global Fund is targeted towards all the elements required to
reduce disease burden i.e. securing health systems, ensuring
support capacity and enabling health literacy and not only
to programmes against the 3 major communicable diseases. At
the same time, the disease programmes must receive enough
funds to match the scaling up that is required of them.
Also, more effective co-ordination of donor funding and
assistance is needed, to ensure that essential links in the
chain of reduction of disease burden and building of health
systems do not occur.
Each country will
show its commitment to this programme by setting explicit
goals for domestic spending in the health sector. NEPAD is
further committed to strengthening mechanisms in its member
countries for accessing, allocating, distributing and
managing additional sources of funding. NEPAD countries
recognise well that funding flows are in no small part going
to be linked to their ability to effectively use and account
for funds. Ministries of Finance will pay particular
attention to this and to capacity building
