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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


      

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

The contribution of specific elements of the broad reasons for the burden of disease vary from country to country, but a broad assessment can be made:

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.

In consequence, national, African and international strategies and efforts to reduce the burden of disease have been strengthening over the past few years. These include the International Partnership Against Aids in Africa, Stop TB, Roll Back Malaria, the Integrated Management of Childhood Illnesses and the Making Pregnancy Safer Programme. The Framework Convention on Tobacco Control, Vision 2020 - The Right to Sight and the Global Campaign against Epilepsy are examples of programmes aimed at non-communicable disease burden. There is wide consensus on and regular updating of the strategies they employ - the key challenge is to scale up to the point of real impact. The specific situation on the individual major communicable diseases and other important health problems is presented in Boxes 1-6 (see end).

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.

Ř      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.

The strategy is committed to a massive assault on the major burdens of disease.  It is committed to build on existing initiatives, including the International Partnership Against Aids in Africa (IPAA), Stop TB, Roll Back Malaria, the Integrated Management of Childhood Illnesses (IMCI) and Making Pregnancy Safer. It is also allied to the declarations of heads of state or government or health ministers, and the plans to achieve these. In view of their massive burden, there would be a strong initial focus on AIDS, TB and malaria, but the express intention is to rapidly widen the scope.  It is also the intention to develop the disease programmes in a manner that enables broader improvements in health systems. NEPAD explicitly supports programmes to reduce the burden of non-communicable disease, such as The Framework Convention on Tobacco Control, Vision 2020 - The Right to Sight and the Global Campaign against Epilepsy.

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.

Tuberculosis control is to be based on early presentation of chronic coughers, a high index of suspicion in HIV+ve people, case detection using microscopy and multiple drug treatment using the “directly observed treatment short course” or DOTS strategy.

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.

The prevention and control of childhood infectious diseases is through consolidation of the “Integrated Management of Childhood Illnesses” (IMCI). In addition to HIV/AIDS, TB and malaria, early identification and treatment of pneumonia and prevention and rehydration for diarrhoea are critical. Immunisation coverage must be ensured. Exclusive breastfeeding for six months, adding oil to staple diets, vitamin A capsules, iodised salt and iron rich foods all supplement the core requirement of food security. Indeed, good nutrition and household food security have a critical role to play in reducing the burden of disease, both directly and indirectly.

Women and their newborns must have ready access to skilled assistance in childbirth and easy referral for further care, such as Caesarean sections.

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

TABLE 1: THE NEPAD STRATEGY FOR HEALTH: GOALS, TARGETS AND ACTIONS

 

 

Focus areas

 

 

Goals

 

Targets

 

African action

 

International action

1

Strengthen disease control programmes

To strengthen communicable disease programmes to reduce the burden of disease

Comprehensive programmes that meet international and continental plans by 2005

Leadership by heads of state, ensuring visibility for problems, support for strategies

Committed and unwavering support to reduce the magnitude of suffering and death

1.1

AIDS and other STDs

 

To halt and begin to reverse the spread of HIV/AIDS

To reduce HIV prevalence in young people by 25% in the most affected countries by 2005 and globally by 2010

 

Increased access to HIV prevention interventions

Reduce the proportion of infants infected with HIV by 20% by 2005 and by 50% by 2010 

Appropriate support and care to those infected and affected, with special assistance to children orphaned by HIV/AIDS

Expanded, resourced and decentralised responses, as per targets by 2005

 

Match commitments made in the Abuja declaration and at the UN Special General Assembly and in the Millennium Declaration

To have national strategies in place to address the socio-economic factors that make individuals particularly vulnerable to HIV infection and for multi-sectoral action against HIV by 2005

As per the IPAA programme and Abuja declaration

1.2

TB

 

To reduce TB deaths and prevalence by 50% by 2010

 

Targeted detection of infectious cases by 2010