Main The health of the people: The African regional health report
The health of the people: The African regional health reportWorld Health Organization. Regional Office for Africa
The Health of the People: the African Regional Health Report is the first report to focus on the health of the 738 million people living in the African Region of the World Health Organization. This fully-illustrated 196-page report provides expert analysis of all the key areas of public health in Africa. It also contains the most comprehensive annex of health statistics on the region to date.
Contents Message from the Regional Director Foreword from the Chairperson of the African Union Commission Executive Summary Introduction: The health of the people The challenges confronting Africa African Region of the World Health Organization Chapter 1 - Health and development in Africa The cycle of poverty and ill-health Putting health in the development context Efforts to promote development in Africa The Abuja Declaration NEPAD The United Kingdom’s Commission for Africa UN Millennium Development Goals G8 Summit 2005 Conclusion: Making it happen Bibliography Chapter 2 - Maternal, newborn and child health ix xi xiii xxiii xxiv xxv 3 3 6 8 8 9 9 10 10 11 13 17 Africa’s “silent epidemic” 17 Preventing millions of deaths 20 Efforts to tackle the problem 24 Development goals for maternal and child health Mothers: the causes and numbers of deaths Newborns: the causes and numbers of deaths Under-fives: the causes and numbers of deaths The obstacles Conflict and emergencies HIV/AIDS Inadequate resource allocation Weak health systems Safe motherhood Prevention of mother-to-child transmission of HIV Repositioning family planning Managing childhood illnesses Increasing skilled attendance at birth Immunizing more women and children Conclusion: scaling up success Bibliography 18 18 19 20 21 22 23 23 23 24 25 26 26 27 27 30 33 iii Chapter 3 - Infectious diseases in Africa Major obstacle to development 37 Diseases for which control has been successful 41 Diseases of major public concern 44 Diseases that are prone to cause epidemics Neglected diseases Conclusion: Learning from past success 55 56 57 HIV/AIDS, tuberculosis and malaria Challenges for disease control Leprosy River blindness Poliomyelitis HIV/AIDS Tuberculosis Malaria Bibliography Chapter 4 - Noncommunicable diseases in Africa 38 38 41 42 43 44 48 51 59 63 An emerging threat 63 Africa’s lesser known toll of ill-health 65 Efforts to tackle the problems Legislation and marketing Mental health legislation 73 73 74 The challenges 76 Africa’s double burden Cardiovascular diseases Obesity and undernutrition: an African paradox Cancer Injuries, violence and disabilities Blindness Mental health problems Genetic diseases Oral diseases Promoting healthy diets and lifestyles Low-cost management programmes Closer collaboration Traditional health practitioners Scarcity of resources Inadequate awareness and commitment Limited data Conclusion: Africa can learn from others’ experience Bibliography Chapter 5 - Health and the environment in Africa Environmental health risks in Africa Challenges in the environment Water and sanitation Pollution and industrial waste Urbanization iv 37 63 65 65 66 67 69 70 71 72 74 75 75 75 76 77 77 79 80 85 85 86 86 87 89 Food safety Emergency situations Tackling poverty and environmental risks Poverty reduction Conflict prevention and management Sustainable, low-cost solutions: water and sanitation Making food safer: a shared responsibility Conclusion: tracking progress Bibliography Chapter 6 - National health systems — Africa’s big public health challenge 90 92 94 94 95 96 98 100 101 105 Building and reinforcing health systems 106 Health information systems 110 Essential medicines 113 Human resources: a continent in crisis 117 Health financing 121 Conclusion: Health systems — the key to better health 125 Public and private health-care provision Scaling up health systems Vertical programmes Sector-wide approach Vital registration Getting the numbers right Improving access Blood safety Approaches to filling the gap Donor funding User fees Evidence for resource allocation Bibliography Statistical Annex - Statistical Annex Health statistics in the African Region Introduction Demographic and socioeconomic statistics Health status: mortality Health status: morbidity Inequities in health Risk factors Health service coverage Health workers Health expenditure ratios, 1999–2003 Per capita expenditure on health, 1999–2003 Explanatory notes Glossary Index 106 107 107 109 111 112 113 115 120 123 124 124 127 129 131 132 134 136 138 140 142 144 146 148 149 158 163 Boxes Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box Box 1.1: Achieving MDG 1: Poverty (Figure) 1.2: MDG 8: A global partnership for development 2.1: Achieving MDG 4: Child health (Figure) 2.2: Achieving MDG 5: Maternal health (Figure) 2.3: Psychosocial support for HIV-positive mothers and families 2.4: Caring for sick children in the United Republic of Tanzania 2.5: Giving birth in Mauritius 2.6: Innovative financing to provide maternal care in Mali and Mauritania 3.1: Guinea-worm disease and leprosy in Nigeria 3.2: Activists give hope to people with HIV in Burundi 3.3: How Cameroon secured lower prices for antiretrovirals 3.4: HIV and tuberculosis in South Africa 3.5: Treating malaria in Ethiopia 3.6: Achieving MDG 6: HIV/AIDS, malaria, and other diseases (Figures) 4.1: Rehabilitation for landmine victims in Angola 4.2: Making roads safer in Rwanda 4.3: Ghana is drafting a new mental health law 4.4: Togolese people with epilepsy reintegrated into community 5.1: Clearing the air with smoke hoods in Kenya 5.2: Tackling mountains of waste in Lagos 5.3: Making street foods safer in Ghana 5.4: Healing post-conflict societies by healing peoples’ minds 5.5: Environmental control of schistosomiasis in Malawi 5.6: Achieving MDG 7 on water and sanitation (Figure) 6.1: What is a health system? 6.2: Delivering health care to isolated communities 6.3: Tanzanian farmers grow their own Artemisia annua 6.4: Malawi’s health sector “brain drain” 6.5: Community home-based care in Botswana 6.6: Uganda leads the way in simplified AIDS care Figures 6 10 18 19 25 28 31 32 40 46 47 50 53 58 68 70 74 75 88 89 91 92 97 98 106 108 115 118 121 122 Fig. 1.1: Life expectancy at birth, for males and females, in countries by WHO region, 2003 4 Fig. 1.2: Proportion of population living on less than US$ 1.08 per day at 1993 purchasing power parity (PPP) 5 Fig. 1.3: Investments in health contribute to economic development 7 Fig. 2.1: Causes of maternal mortality in the African Region 18 Fig. 2.2: Global distribution, by region, of maternal deaths, world population and live births, 2000 19 Fig. 2.3: Causes of neonatal mortality in the African Region 20 Fig. 2.4: Neonatal mortality rate in the WHO regions (per 1000 live births) 20 Fig. 2.5: Causes of under-5 mortality in the African Region 21 Fig. 2.6: Patterns of reduction of under-5 mortality rates, 1990-2003 21 Fig. 2.7: Immunizaton coverage with EPI (Expanded Programme on Immunization) vaccines, African Region, 1982–2003 29 Fig. 3.1: Regional progress towards 70% case detection of tuberculosis 38 Fig. 3.2: Mass drug administration for elimination of lymphatic filariasis 39 Fig. 3.3: Prevalence of leprosy in the African Region, by countries, 1985 and 2003 41 Fig. 3.4: HIV prevalence among 15–24-year-olds in selected sub-Saharan African countries, 2001–03 45 Fig. 3.5: Trends in incidence of malaria cases and distribution of insecticide-treated nets (ITNs), Eritrea (1997–2004) 52 Fig. 3.6: Status of malaria drug policy change and implementation in the African Region as of July 2005 54 Fig. 4.1: Burden of noncommunicable diseases and injuries in DALYs by cause in the WHO African Region, estimates for 2001 64 Fig. 5.1: Sanitation coverage in the African Region 86 Fig. 6.1: Types of household surveys that have been conducted in the African Region 110 vi Fig. Fig. Fig. Fig. 6.2: Coverage of death registration: mortality data (1995 onwards), by cause, available to WHO 6.3: Member States with official national medicine policies, WHO African Region 6.4: Total cost of malaria illness, Ghana, 2002 6.5: Per capita government expenditure on health (US$), WHO African Region, 2003 111 113 123 124 Tables Table Table Table Table Table Table 1.1: Burden of disease in the African Region 2002 8 4.1: 20 leading causes of death in South Africa 66 4.2: Leading causes of death in the African Region, 2002 69 4.3: Mental health resources in selected countries in the African Region 72 4.4: A stepwise approach for prevention and control of noncommunicable diseases 78 5.1: Deaths and DALYs attributable to indoor air pollution from solid fuel in the African Region, 2000 87 Table 6.1: Outflow of health workers from 16 African countries, 1993–2002 119 vii Dr Luis Gomes Sambo Regional Director WHO – Regional Office for Africa Much can be done to prevent disease and disability through the promotion of healthy lifestyles and health education. ... We know which treatment, diagnostic and preventive methods are needed and what works in Africa. We also have the institutions. This report shows clearly that health systems are the key to providing a range of essential health care. African governments and their partners need to invest more funds to strengthen the continent’s fragile health systems. Message from the Regional Director Every year millions of Africans are dying needlessly of diseases that are preventable and treatable. The Health of the People: the African Regional Health Report provides vital reading for those who want to understand why and what can be done about it. The vast majority of people living in Africa have yet to benefit from advances in medical research and public health. The result is an immense burden of death and disease that is devastating for African societies. This report looks at: HIV/AIDS, tuberculosis and malaria, and the pregnancy-related conditions that kill mothers and babies. It also highlights the lesser known problems of chronic diseases, such as diabetes and hypertension, and other noncommunicable conditions, such as mental illness and injuries. The challenges are many, including: weak and fragmented health systems; inadequate resources for scaling up proven interventions; limited access to the health services and technologies that are available; poor management of human resources for health; recurrent natural and manmade disasters and emergencies; and extreme poverty. And yet these pages do not merely recount tales of misery, indeed, they describe in detail some of Africa’s public health success stories that may serve as a models for others in the continent. Much can be done to prevent disease and disability through the promotion of healthy lifestyles and health education. ... And when people become sick with malaria or suffer with other health problems, the solutions are within our grasp. ... We know which treatment, diagnostic and preventive methods are needed and what works in Africa. We also have the institutions. WHO is working tirelessly with WHO’s 46 Member States in the African Region to help build and reinforce health systems that are central to improving the health of the people across the Region. This report shows clearly that health systems are the key to providing a range of essential health care. African governments and their partners need to invest more funds to strengthen the continent’s fragile health systems. The challenge for African governments and their partners is to coordinate the provision of health care more effectively than ever before, and to ensure that all funds are used in an accountable manner to the benefit of the African people. On behalf of the African Regional Office of WHO, I would like to express our gratitude to the 46 Member States and our partners in the Region for their commitment to improving the health of their people. Dr Luis Gomes Sambo Regional Director WHO – Regional Office for Africa ix H.E. Prof. Alpha Omar Konaré, Chairperson of the African Union Commission This report is an excellent review of the public health situation across the WHO African Region, that includes 46 African countries that are all Member States of the African Union. ... The African Union Commission fully supports the central message of this report: that African governments and their partners need to do more to build and reinforce health systems to deliver essential health-care interventions to people living on this continent. Foreword Chairperson of the African Union Commission Public health in Africa has come under the international spotlight in recent years. The sheer enormity of the disease burden in African countries and the often inadequate response has prompted many regional and international initiatives. More funds than ever before have been pledged for health in Africa, yet many problems prevail. This report is an excellent review of the public health situation across the WHO African Region, that includes 46 African countries that are all Member States of the African Union. The health of the people: the African regional health report provides vital insight into why Africa has such a heavy burden of premature death and disease, but also a valuable overview of the interventions that work and need to be extended to everyone who needs them. The African Union Commission has been working closely with WHO’s African Regional Office in several public health areas. In May 2006, the African Union Commission, in collaboration with United Nations agencies and other development partners held a Special Summit on HIV/AIDS, tuberculosis and malaria in Abuja, Nigeria, to look at progress so far and the way forward to achieve universal access to treatment for these diseases by 2010. In collaboration with WHO and other United Nations’ agencies, the African Union launched a campaign this year to prevent HIV/AIDS in Africa. We want to promote widespread awareness of HIV and how it is caused through media campaigns and public health education. We want more Africans to embrace HIV counselling and testing and we want governments to ensure that HIV prevention services are available — along with antiretroviral therapy — for everyone who needs them. Violence is a major public health problem in Africa. The African Union’s 53 Member States declared 2005 the African Year of Prevention of Violence, and the African Union and WHO are working closely on violence prevention in Africa. The African Union supports key health partnerships and initiatives, including the STOP–TB partnership and the Road Map on the Reduction of Maternal and Newborn Morbidity and Mortality in Africa. Much progress has been made in the fight against polio by the Global Polio Eradication Initiative, but more efforts by African governments and their partners are needed to ensure that new outbreaks are quickly brought under control and that high immunity levels are maintained in all populations through vaccination. The African Union has been working closely with WHO and other partners on a preparedness and response plan to reduce the risk of bird flu and human pandemic influenza. The African Union Commission fully supports the central message of this report: that African governments and their partners need to do more to build and reinforce health systems to deliver essential health-care interventions to people living on this continent. H.E. Prof. Alpha Omar Konaré, Chairperson of the African Union Commission xi Executive summary The health of the people This report comes at a crucial time, when much attention is being devoted to Africa and when African countries are finding their own voice and their own solutions to their problems. The health of the people: the African regional health report provides an overview of the public health situation across the 46 Member States of the African Region of the World Health Organization. This report charts progress made to date in fighting disease and promoting health in the African Region. It reviews the success stories and looks at areas where more efforts are needed to improve people’s health. The central message of the report is clear: African countries will not develop economically and socially without substantial improvements in the health of their people. The health-care interventions — treatments, diagnostic and preventive methods — that are needed in this Region are known. The challenge for African countries and their partners is to deliver these to the people who need them, and the best way to do this is to establish well-functioning health systems. xiii Chapter 1: Health and development in Africa Economic development is impossible without major investments to apply triedand-tested health-care interventions that work. This chapter shows how much the severe burden of disease hampers social progress and economic development in many African countries. Ill-health pushes people into the poverty trap. Poverty is a major factor determining ill-health, as well as being both a cause and an outcome of ill-health. Several studies have sought to quantify the macroeconomic impact of the disease burden (see Table a). Governments in the African Region and their development partners need to invest more in health care. Recent rapid economic growth in some African countries provides an opportunity to do this. Their partners need to increase donor funds to scale up tried-and-tested public health interventions. A Table a paradigm shift is needed: African countries and Burden of disease in the African Region 2002 their partners need to address the underlying Burden of disease in DALYs* by cause and mortality stratum in the African Region factors that determine ill-health. Investing in health, therefore, means investing in water, Mortality stratum sanitation, environment, education, women’s High child, high High child, very empowerment, governance and other related adult high adult sectors. (000) (000) WHO’s African Region lags behind 1 AIDS 14 620 49 343 other regions of the world in terms of human development. This limited development is 2 Malaria 20 070 20 785 largely attributable to the Region’s immense 3 Respiratory infections 18 976 16 619 burden of infectious diseases, particularly that of HIV/AIDS, tuberculosis and malaria. This 4 Perinatal conditions 10 869 10 485 chapter describes the macroeconomic impact of 5 Diarrhoea 11 548 11 689 the Region’s heavy burden of infectious diseases as well as of unhealthy environments; maternal, 6 Top five subtotal (1 – 5) 76 083 108 921 newborn and child death and disease; and the 7 Other communicable diseases 39 234 41 484 growing burden of noncommunicable diseases. There are positive indications that things 8 Communicable diseases (6 and 7) 115 317 150 405 are changing as Member States of the Region 9 Noncommunicable diseases 30 124 34 727 and their partners continue to demonstrate the will to address poverty and development 10 Injuries 14 974 15 829 by bringing health issues to the forefront. This Total Total (8 – 10) 160 415 200 961 is demonstrated by regional initiatives, such as the New Partnership for Africa’s Development The Member States of the Region have been divided into mortality strata on the basis of their levels of mortality in (NEPAD) and efforts by the G8 and global children under five years of age and in males aged 15–59 years as described on pp. 156–7 of the 2004 World health report. financial institutions to cancel debt and * See glossary for explanation. encourage least-developed countries to channel Source: The world health report 2004. Geneva. World Health Organization; 2004. xiv The African Regional Health Report the resulting savings into health and related sectors. Chapter 1 reviews these and other current initiatives to combat high mortality and morbidity in Africa, including regional efforts, such as the Abuja Declaration and international efforts, including the United Kingdom’s Commission for Africa and the UN Millennium Development Goals (MDGs). More needs to be done to encourage African nations to honour the pledge they made in Abuja to allocate 15% of their national budgets to health. Similarly, developed countries should honour the pledge they made to committing 0.7% of their gross domestic product (GDP) to development assistance. The challenges for public health in the African Region are enormous. But with true commitment and resolve by governments in the Region and their development partners, these challenges can be overcome, helping countries in the Region to move closer to achieving the MDGs. Chapter 2: Maternal, newborn and child health This chapter describes Africa’s “silent epidemic”, the tragedy that millions of mothers, newborn babies and children die every year from preventable, treatable causes. It summarizes the trends of death and disease among mothers during pregnancy and childbirth, and of their children in the African Region. Progress in this area of health was made in the 1970s and 1980s, as African states established health-care systems providing antenatal and emergency obstetric care. Improved child survival became a global phenomenon during those years, largely due to immunization and the success of oral rehydration therapy for diarrhoeal diseases. But since the early 1990s, little or no progress has been made in maternal, newborn and child health in many parts of the Region largely due to the HIV/AIDS epidemic and armed conflicts. In some parts of the Region, progress in maternal, newborn and child health has been reversed. Major global efforts to address the situation have so far produced limited results. Few countries in the Region are likely to achieve MDG 4 on child health and MDG 5 on maternal health (see Fig. a and Fig. b). The obstacles and challenges are many: conflict and emergencies, HIV/AIDS, inadequate resource allocation and weak health systems. Renewed efforts are now under way to make motherhood safer; prevent mother-to-child transmission of HIV; provide family planning services; and manage childhood illness. This chapter looks at some success stories, for example, in the countries and districts that have improved maternal, newborn and child health in the Region. It reviews the tried-and-tested interventions, such as skilled birth attendance, immunization and family planning, that need to be scaled up and replicated throughout the Region. Furthermore, women need to receive better education to improve their economic and social status and, in turn, their own health and that of Fig. a Under-5 mortality (deaths per 1000 live births) in the African Region 200 183 Benchmark 180 171 Most recent 160 Progress made 140 120 100 80 Progress needed 60 to achieve goal 61 Goal 40 20 0 1990 2002 2015 Based on data from: The world health report, 2005. Geneva:World Health Organization; 2005. Fig. b Maternal mortality (deaths per 100 000 live births) in the African Region 1000 Benchmark 910 Most recent 900 870 800 700 600 500 400 Progress needed 300 to achieve goal 200 228 Goal 100 0 1990 2000 2015 Based on data from: The world health report, 2005. Geneva: World Health Organization; 2005. The health of the people Executive summary xv their families. Governments in the Region have committed themselves to improving the health of mothers, newborn babies and children. Now they need to act by allocating more funds to this vital, but neglected area of public health. Chapter 3: Infectious diseases in Africa % HIV prevalence Infectious diseases are a major obstacle to human development in the African Region. This chapter recalls that people in Africa suffer from a vast range of preventable and treatable infectious diseases. It reviews the challenges for infectious disease control in the Region and shows how factors, such as climate, geography and parasites, make this task especially difficult. Chapter 3 charts the Region’s successes in controlling certain infectious diseases, such as river blindness and leprosy, as well as vaccine-preventable diseases, such as polio. It looks at the diseases in the Region that are prone to epidemics, such as cholera, meningitis, Lassa fever and yellow fever, and the neglected diseases, such as Buruli ulcer and sleeping sickness. The chapter also takes a detailed look at three diseases of major public health concern: HIV/AIDS, tuberculosis and malaria, Fig. c which kill more than three million people in the Region every year. HIV/AIDS prevalence is HIV prevalence among 15–24-year-olds in selected sub-Saharan African countries, 2001–03 particularly high in southern African countries (see Fig. c). This high prevalence increases the 20 occurrence of other infectious diseases, particularly Men Women tuberculosis. However, the shortage of health 15 workers is hampering efforts to provide health care for this and other problems. 10 Chapter 3 describes the devastating effect 5 of these three infectious diseases on society — hardship, impoverishment, countless 0 lives lost and reduced productivity — and Niger Mali Burundi Kenya Zambia South Africa Zimbabwe how governments are forced to divert scarce (2002) (2001) (2002) (2003) (2001–02) (2003) (2001–02) resources to tackle these diseases, spinning countries on an inescapable cycle of poverty Sources: Burundi (Enquête Nationale de Séroprévalence de l’infection par le VIH au Burundi. Bujumbura, Décembre 2002). Kenya (Kenya Demographic and Health Survey 2003). Mali (Enquête Démographique et de Santé. Mali and ill-health. But it also charts the progress 2001). Niger (Enquête Nationale de Séroprévalence de l’infection par le VIH dans la population générale agée de made in the Region in rolling out antiretroviral 15 à 49 ans au Niger (2002)). South Africa (Pettifor AE, Rees HV, Steffenson A, Hlongwa-Madikizela L, MacPhal C, treatment for HIV/AIDS in recent years. Vermaak K, Kleinschmidt I: HIV and sexual behaviour among young South Africans: a national survey of 15-24 year olds. Johannesburg: Reproductive Health Research Unit, University of Witwatersrand, 2004). Zambia (Zambia It outlines some of the solutions that work Demographic and Health Survey 2001-2002). Zimbabwe (The Zimbabwe Young Adult Survey 2001-2002) . in the Region. Tried-and-tested public health interventions — for example the provision xvi The African Regional Health Report of universal HIV testing and counselling and simplified treatment for HIV/AIDS — need to be applied more widely. These simplified, low-cost approaches to treatment need to be scaled up so that they are available to all the people in the Region who need them. Research and development is needed to find more effective medicines for diseases such as tuberculosis and other neglected diseases and vaccines for malaria and HIV/AIDS. Meanwhile, countries in the Region need to promote safe sex and more countries need to provide HIV testing and counselling to prevent further HIV infections and reverse the AIDS pandemic. Political will backed by financial support is crucial to scaling up tried-and-tested control methods that are specific to each disease. Chapter 4: Noncommunicable diseases in Africa Noncommunicable diseases and injuries constitute a growing public health problem in the African Region, but at the same time represent one of the most neglected areas of public health. Although the noncommunicable diseases and injuries burden repressents 27% of the Region’s total disease burden (see Table b), African countries and their partners do not devote resources that are adequate to address the problem. The risk factors for noncommunicable and chronic diseases — such as unhealthy diet and lack of physical exercise, are on the rise in many African countries. The result is that stroke, diabetes, cancer and heart disease — diseases that are seen as affecting mainly wealthy industrialized countries — are becoming increasingly prevalent in Africa and represent an emerging threat. Chapter 4 looks closely at Africa’s growing “double burden” of infectious and noncommunicable disease. It charts Africa’s lesser known toll of ill-health, including a growing burden of cardiovascular diseases, malnutrition and obesity, cancer, injuries, blindness, mental illnesses, genetic and oral diseases. Some of these conditions are a consequence of infectious diseases, such as cervical cancer, while others, such as noma, are specific to this Region. There is a huge unmet need in terms of addressing noncommunicable diseases, mental health and injuries in the African Region. This state of affairs must be rectified. The challenges are many and include a scarcity of resources; inadequate awareness and commitment to this area; and limited data. Donor agencies and research institutions, too, are neglecting the growing burden of noncommunicable diseases and injuries in the Region. The chapter gives an overview of tried-and-tested solutions for tackling the problems. These include: legislation and marketing which can be particularly effective to control tobacco; mental health legislation; promotion of healthy diets and lifestyles is also an effective, low-cost solution; and low-cost disease management programmes. Table b Leading causes of death in the African Region, 2002 Rank All ages 1 HIV/AIDS 2 Malaria 3 Lower respiratory infections 4 Diarrhoeal diseases 5 Perinatal conditions 6 Cerebrovascular disease 7 Tuberculosis 8 Ischaemic heart disease 9 Measles 10 Road traffic crashes 11 Violence 12 Whooping cough 13 Chronic obstructive pulmonary disease 14 Protein–energy malnutrition 15 Nephritis and nephrosis 16 Syphilis 17 War 18 Tetanus 19 Diabetes mellitus 20 Drowning Source: Global Burden of Disease 2002. The health of the people Executive summary xvii Priority should be given to primary prevention of noncommunicable diseases by tackling risk factors, such as diet, physical activity, alcohol consumption and tobacco use. Secondary prevention should focus on controlling risk factors among those affected, with special emphasis on obesity, high blood pressure, high blood sugar and high blood lipid levels. The third approach is tertiary prevention through proper clinical management of cardiovascular disease, chronic obstructive respiratory disease, diabetes, and cancer. Similar approaches are needed for mental health disorders and oral health. Government departments, such as health, transport and education, need to work together to introduce measures to reduce the risk of injuries and noncommunicable diseases, such as seat-belt laws and promotion of healthy diets. There also needs to be more collaboration between government, nongovernmental organizations and the media. Many developed countries are only now realizing the value of health promotion strategies, such as tobacco control. African countries have the opportunity to learn from the mistakes made in developed countries and to act early before the growing epidemic of noncommunicable disease gets out of control. Chapter 5: Health and the environment in Africa Fig. d Improved water source (% of population without access) in sub-Saharan Africa Benchmark 50 40 30 20 10 0 1990 Most recent Goal Progress needed to achieve goal 2002 2015 Source: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation – Water for life: make it happen. 2005. xviii The African Regional Health Report People living in the African Region face a number of environmental health risks. High levels of air pollution, both within and outside the home, unsafe water supplies, inadequate sanitation and unhygienically prepared food are widespread in many parts of the Region. There are also emerging environmental risks to health in the African Region, such as ecosystem degradation and climate change. Rapid urbanization has forced millions of people to live in shanty towns without basic services, meanwhile day-to-day environmental threats to people’s health are made worse by armed conflict and natural disasters. There is a growing problem of industrial pollution, the management of solid and liquid waste, and of medical waste. This chapter summarizes trends in the environmental risk factors for health in the Region, it outlines the efforts to tackle them and underscores areas where more needs to be done to tackle these factors. Wider coverage of clean water and sanitation, and wider provision of sewage and waste disposal would be major steps towards a healthier environment (see Fig. d). The challenges for governments are immense. Widespread poverty limits people’s ability to address environmental problems. Success in tackling environmental heath problems depends very much on collaboration between ministries and agencies. Chapter 5 describes some success stories, where communities have used locally developed technologies and innovations that are effective, affordable and sustainable. Low-cost, sustainable solutions for water and sanitation need to be scaled up. Countries in the Region and international organizations need to work more closely together to prevent and resolve conflicts. Governments in the Region also need to scale up food safety and hygiene education. Closer cooperation between government ministries and sectors in those countries is also key to making the environment more healthy. WHO has several strategies to address these issues. For example, WHO’s strategy on health and the environment urges governments to develop environmental health policies and to make communities more aware of the relationship between the environment and public health. Community-management programmes run by WHO and other agencies using the Participatory Hygiene and Sanitation Transformation, Demand-Responsive Approach and Ecological Sanitation, along with the Africa 2000 Water and Sanitation programme, have all shown results. Through the Healthy Settings approach, several countries in the Region are for the first time, addressing complex urban health problems in a holistic way. WHO programmes aim at empowering people and improving conditions at community and workplace level to prevent and reduce factors that prevent communities and individuals from achieving better economic and positive health outcomes. In this way, WHO helps countries to improve their capacity to plan, implement and evaluate their programmes to inform policies and implementation plans. The challenges for governments are immense. Widespread poverty limits people’s ability to address environmental problems. Success in tackling environmental heath problems depends very much on collaboration between ministries and agencies. Chapter 6: National health systems — Africa’s big public health challenge One of Africa’s major public health challenges is building and reinforcing health systems capable of delivering essential health care to the population. Countries in the African Region have weak and dysfunctional health systems. Several key elements are required for health systems to function properly: adequate numbers of skilled health workers, basic infrastructure and equipment; essential medicines and supplies; and health financing systems. It is also important to establish effective health information systems, including vital registration, to measure the scale of a given health problem in order to gauge the appropriate response. Health care in these countries is provided by a mix of public and private providers, often resulting in “vertical” or single-disease/issue programmes. Funds for health care come from a variety of public and private sources, including donor funds. Some governments have started to take a “sector-wide approach” to improve The health of the people Executive summary xix Stronger health systems can act as a bridge to social stability, peace and prosperity throughout the Region. xx The African Regional Health Report the coordination of those funds so that they can be used more effectively and to avoid duplication. The chapter closes with one of the report’s key messages: that establishing well-functioning health systems is essential to addressing the many health problems described throughout this report. Furthermore, health systems need to be tailored to their specific setting, whether urban or rural. To strengthen health systems, governments of Member States need to forge strong collaboration with other partners at national and local level, including the private sector, civil society and communities. Universal access to health care can only be achieved by scaling up essential health system interventions. This will be difficult to achieve without adequate investment and without taking the delivery of essential health services as close to the communities as possible through strong and effective district health systems. Stronger health systems can act as a bridge to social stability, peace and prosperity throughout the Region. ■ Introduction Introduction Improving the health of the 738 million people in the 46 Member States of the African Region of the World Health Organization (WHO) is absolutely essential, along with education, good governance and sound economic policy. Improvements in health can spur social progress and economic growth, but cannot be achieved without increasing current levels of investment in health in this Region. The health of the people T he first African Regional Health Report comes at a crucial time for Africa, a time when the continent has come into sharp focus. Major international efforts have recently got under way to reduce poverty and achieve other Millennium Development Goals (MDGs) in Africa. In July 2005, the Group of Eight (G8) industrialized nations provided debt relief and increased aid to African countries. In December 2005, the 148 Members of the World Trade Organization (WTO) agreed on a package of trade and aid measures intended to help the world’s poorest countries. The package is a small first step towards the “trade-for-aid” goal of the Doha Development Round: to abolish tariffs on African products and subsidies paid to farmers in wealthy countries, tariffs and subsidies that make it difficult if not impossible for African farmers to compete internationally. This report shows that improving the health of the 738 million people (in 2005) in the 46 Member States of the African Region of the World Health Organization (WHO) is absolutely essential, along with education, good governance and sound economic policy. Improvements in health can spur social progress and economic growth, but cannot be achieved without increasing current levels of investment in health in this Region. The need to invest more in health is not only a moral imperative to alleviate suffering and to address a basic human right to health, but — in today’s interconnnected, globalized world — it also makes economic sense, and can help pave the way to a more prosperous and secure future for all. At the same time, efforts to impprove health need to be closely coordinated and monitored as never before to ensure that funds are used to optimal effect and in an accountable way. This report provides an overview for governments, civil society and health proffessionals in Africa, as well as for donors and other members of the international community. It reviews how the health of the people in the African Region has develooped over the last 10–15 years and tracks progress — or lack of it — towards achieviing the health-related MDGs by 2015. Outlined are the main public health challenges this Region faces as well as the initiatives and programmes intended to tackle these, and their successes to date. xxiii The solutions described in this report draw on the advances in diagnosis, treatmment and prevention of major diseases that have led to greater life expectancy in the rest of the world, but from which most people in Africa have yet to benefit. The path to success in providing people in Africa with these basic services is in implementing the solutions and strategies outlined in these pages: strategies that are known to work in this Region, strategies that invest in the welfare of the African people. The starting point for improving public health is firm political resolve on the part of Member States of the African Region (see map and definition on p. xxv) andtheir partners. In order to make progress, some Member States could increase spending on health, while donor countries could seek ways to provide a more reliable and sustainable flow of aid. In this way, health can be a bridge to economic prosperity for every African nation. The challenges confronting Africa Success in improving public health in Africa depends on renewed efforts and determmination to overcome a number of challenges in the African Region. A child born in Africa faces more health risks than a child born in other parts of the world. Such a child has more than a 50% chance of being malnourished, a high risk of being HIV-positive at birth, while malaria, diarrhoeal diseases and acute respiratory diseases account for 51% of deaths. A child born in the African Region is more likely to lose his or her mother due to complications in childbirth or to HIV/ AIDS, while that child has a life expectancy of just 47 years, and is very likely — at least once in his or her short life — to be affected by drought, famine, flood or civil war, or to become a refugee. People living in the African Region are more exposed to a heavy and wideranging burden of disease partly because of this Region’s unique geography and climate. These factors make malaria, for instance, more intractable in Africa than it is elsewhere. At the same time, noncommunicable diseases and injuries are emerging as significant contributors to the disease burden. Nowhere has HIV/AIDS killed such large proportions of the population as it has in Africa. Nowhere has the old scourge of tuberculosis re-emerged to fuel the HIV/AIDS epidemic as it has in the African Region. No other region has witnessed so many armed conflicts and other humanitarian emergencies. Nowhere is poverty so prevalent. The population of the African Region repressents about 10% of the world’s population, but an estimated 45% or more of its people live below the poverty line, on less than US$ 1 a day. About 330 million people in this Region — one-third of the world’s 1.1 billion poor — are caught in this poverty trap, in which low household incomes lead to low household consumption and, in turn, the countries in which they live have low capacity and low productiviity. Agricultural productivity is lower than in other regions due to unreliable water supply, inadequate irrigation and poor soil quality. High transportation costs for the continent’s interior, due to the lack of navigable rivers and the slow diffusion of technology, also hamper development. xxiv The African Regional Health Report Nowhere has life expectancy reversed so sharply as in the African Region. Life expectancy at birth in this Region was 45 years in 1970. This rose to 49.2 years in the late 1980s but fell during the 1990s and early 2000s to just 47 years. Overall life expectancy for people born in the African Region in 2002 would be 54 years, if it were not for about six years of life lost due to the sole impact of HIV/AIDS. The African Region faces some of the same constraints as other regions. Intternational trade agreements that benefit the world’s wealthier countries make it difficult for poorer countries to compete in international markets. Only about 10% of research and development funds for medicines and vaccines go into diseases that account for 90% of the global disease burden. The challenge confronting public health in the African Region today is that most diseases and conditions described in this report are preventable, treatable or both. Most deaths in this Region could be avoided if basic health care — vaccines, drugs, diagnostic methods and the health systems to deliver them — were widely available. This report is about how to make this happen. ■ African Region of the World Health Organization ������� ���� ����� ���������� ������� ������ ������������� ������ ������������ ���� ���� ������� ����� ������������ ������������� ��������������������� �������� ����������������� ����� ����� ������� ���� ������� ��������������� �������� ����� �������� ������ ����� ������ ������� ���������� ����������� ��������� ����� ��������������������������� ������ ������ ������ ���������� ���������� ������� ��������� ������� ���������� WHO African Region Outside WHO African Region �������� �������� ����� ������ ��������� ������� This report is about the 46 Member States of the African Region of the World Health Organization (WHO), as illustrated in this map. The African Regional Office of WHO is based in Brazzaville, the Republic of the Congo. When this report refers to “Africa”, it is referring to the continent and islands as a whole. When the report refers to “the African Region” or “the Region”, it is as defined by WHO. It is important to note that the WHO African Region does not include all the countries on the African continent and the Region itself is not limited to all of sub-Saharan Africa. Please note: the World Bank divides the continent into two regions: North Africa and sub-Saharan Africa, while UNICEF divides it into three regions: Eastern and South Africa, West and Central Africa, and the Middle-East and North Africa. The health of the people Introduction xxv Chapter 1 Chapter 1 Key messages Health can drive social progress and economic growth Ill-health pushes people into the poverty trap Severe burden of disease in Africa hampers development Current investment in health is inadequate Solutions African governments need to invest more in health Africa needs more development support from outside Scale up tried and tested public health solutions Paradigm shift is needed: need to address underlying determinants of ill-health, such as poverty Health and development in Africa The cycle of poverty and ill-health P eople living in the African Region face a heavy and wide-ranging burden of disease, which takes its toll on social and economic development and shorteens their life expectancy. The HIV/AIDS epidemic as well as the resurgence of malaria and tuberculosis have swept away improvements in life expectancy in some sub-Saharan countries (see Fig. 1.1). Other infectious diseases and — increasingly — noncommunicable conditions are also a severe burden, while the complications of pregnancy and childbirth take millions of lives every year. The health services that have evolved in countries in Africa are often not able to address adequately this severe burden of disease. These health systems are weak, reflecting the overall state of the economies in the African Region. In many countries out-of-pocket payments are high in proportion to household incomes and are a major factor driving poverty. The cost of treatment for an adult with HIV/AIDS, in addition to lost income due to time off work, can drag a whole household below the poverty line. Therefore, just as health can drive economic growth, ill-health can push people into poverty and make it very difficult for them to escape the poverty trap. This vicious cycle of poverty and ill-health can be seen in many countries in Africa. Some 76% of the population of sub-Saharan Africa live on less than US$ 2 a day, and 46.5% on less than US$ 1.08 a day (see Fig. 1.2). While poverty has declined in other parts of the world, such as East and South Asia, over the past 20 years, in sub-Saharan Africa the trend has been strongly in the other direction. Between 1981 and 2001 the gross domestic product (GDP) of sub-Saharan countries decreased by 13%, resulting in a doubling in the number of people in the Region living on less than US$ 1 a day from 164 million to 314 million. While Africans represented only 16% of the world’s poor in 1985, by 1998 this proportion had risen to 31%. The trend is likely to continue, with poverty expected to decline over the next 20 years in every part of the world except sub-Saharan Africa, where a dramatic increase is expected. Health and development in Africa Fig. 1.1 Life expectancy at birth, for males and females, in countries by WHO region, 2003 Female life expectancy (years) 80 70 60 50 Countries in other regions Countries in African Region 40 30 30 40 50 60 70 80 Male life expectancy (years) Figure shows low life expectancy in countries in the African Region. Source: World Health Statitstics 2005. Geneva: World Health Organization; 2005. Progress in human development made by some African countries in the 1970s and 1980s has been sharply reversed by HIV/AIDS and by armed conflict. On top of that, countries in the Region continue to suffer from other emergencies, large-scale migration, famine and economic decline. Chronic diseases are becoming increasingly prevalent in middle-income counttries of the African Region, such as South Africa and Kenya. Furthermore, road traffic collisions place a heavy burden on households and, in turn, regional and national economies. For instance, road traffic collisions cost the Ugandan economy around US$ 101 million per year, which is 2.3% of the country’s gross national product (GNP). In addition mental health is one of the most under-resourced areas of public health in the African Region, even though mental health problems are on the rise and mental health services are desperately needed in post-conflict societies to help them achieve stability. In many countries of the Region this area of public health requires more attention than it is currently receiving. The African Regional Health Report Fig. 1.2 Proportion of population living on less than US$ 1.08 per day at 1993 purchasing power parity (PPP) 60 % 50 Sub-Saharan Africa 40 South Asia 30 Middle-East and North Africa Latin America and the Caribbean 20 Eastern Europe and Central Asia 10 0 East Asia 1981 1984 1987 1990 1993 1996 1999 2001 Source: Chen S, Ravallion M. How have the world’s poorest fared since the early 1980s? World Bank Policy Research Working Paper 3341. Washington, DC: World Bank; June 2004. Outside the African Region, about two-thirds of deaths are due to noncommunnicable diseases. In Africa, by contrast, according to 2002 estimates, 72% of deaths are caused by communicable diseases such as HIV/AIDS, tuberculosis, malaria, resspiratory infections, other infectious diseases, and complications of pregnancy and childbirth. These are largely preventable deaths, which account for about 23% of mortality in other regions. The WHO Commission on Macroeconomics and Health made a powerful case in favour of investment in health — by scaling up known, cost-effective interventions — as an important driver of economic growth. No other region of the world has so much potential to benefit from such investment in health as the African Region. African economies are growing fast, but not fast enough to achieve the UN Millennium Development Goals (MDGs). The economies of sub-Saharan countries need to grow at an average annual rate of 7% over the next decade to achieve the UN Millennium Development Goal 1 of cutting poverty in half by 2015 (see Box. 1.1), according to the International Monetary Fund. At current rates some countries may succeed, but many will fail. Economic growth and more investment in health will not help countries attain the improvements envisaged by the MDGs alone. More efforts are needed to achieve greater peace and security, good governance, gender equality and sustainable management of the environment. Health and development in Africa Chapter 1 Box 1.1 MDG 1 aims to halve by 2015 the number of people who were living on less than US$ 1 a day in 1990. The poverty rate and number of poor increased in the 1990s, making sub-Saharan Africa the region with the largest proportion of people living on less than US$ 1 a day. World Bank economists say that projected economic growth over the 2006–15 period marks a reversal of the region’s long-term decline but is far short of the growth needed to reduce poverty to half the 1990 level. Bank economists say, however, that a few countries, such as Uganda and Ghana, have sustained remarkable growth and achieved some progress in poverty reduction and other MDGs. They say there are indications that Cameroon is makiing progress in achieving the poverty target. Proportion of the population living on less than US$ 1 a day (sub-Saharan Africa) % Achieving MDG 1: Poverty 50 48 Benchmark 46 Most recent 40 24 Goal 30 20 Progress needed to achieve goal 10 0 1990 2002 2015 Source: World Bank. Some countries in the African Region are not far off achieving the MDG targets and may need increased overseas development support to help bridge the gap in economic growth rates. Sub-Saharan countries reported their best economic perfformance for years in 2004, with an average 5% growth in real GDP, while average inflation fell to below 10% for the first time in 25 years. Oil producers, such as Nigeria and Equatorial Guinea, and post-conflict countries, such as Burundi and Sierra Leone, have seen some rapid though often sporadic growth in recent years. Economic growth has not always led automatically to improvements in public health in the African Region. Current growth rates are an opportunity for African governments to invest more in health, an investment that would lead to more social and economic stability. Increased investment in public health can reduce the burden of preventable and treatable diseases that — on macroeconomic level — can be a drag on national econommies and — on microeconomic level — a drain on household and individual incomes. Health must, therefore, constitute a central pillar of any coherent vision of African development, while increased investments in health should include those in health-related sectors, such as water and sanitation, education and environmental protection (see Fig. 1.3) Putting health in the development context Development experts have long recognized health as an important moral and social goal. Health is also a key component of a sound development strategy, along with education, economic growth and good governance. As a form of human capital, health is essential to a productive society. Furthermore, the MDG project of the United Nations fully endorses the central role of health in development. The African Regional Health Report Fig. 1.3 Investments in health contribute to economic development Enhanced labour productivity Improved educational attainment Investment in health Improved health status Improved economic growth Increased savings & investment Demographic dividend: lower dependency ratio Source: adapted from: Saunders MK, Gadhia R, Connor C. Investments in health contribute to economic development. Publisher: Partners for Health Reformplus (PHRplus) E-version: http://www.phrplus.org/Pubs/sp12.pdf Several studies have sought to quantify the macroeconomic impact of the disease burden (see Table 1.1). The prevalence of HIV/AIDS for adults aged 15-49 years in the African Region is estimated at about 7.2%. In every other WHO region the average was less than 1%. There is general agreement that the economic and social impact of HIV/AIDS in the African Region has been devastating. The epidemic has drastically redduced the workforce in many countries, while the cost of caring for the growing generattion of AIDS orphans could slow down long-term GDP growth by as much as 1–1.5% in countries with high prevalence of HIV/AIDS, such as Kenya and South Africa. Exacerbated by HIV/AIDS, the older scourge of tuberculosis has made a comeback in many parts of the world. Southern Africa has become the epicentre of the dual epidemic and both diseases are causing untold human suffering and reducing household income, in turn slowing economic growth in southern African countries. Malaria has been dubbed “an African disease” because 90% of cases occur in this continent. Estimates show that countries with endemic malaria have 1.3% less economiic growth per annum compared with similar non-endemic countries, and that in Africa the annual cost of lost productivity and providing treatment is US$ 12 billion. Health and development in Africa Chapter 1 Efforts to promote development in Africa There have been many regional and international initiatives to promote development in Africa. Some have focused on health as well as education, governance and sound economic policy, while others have focused entirely on health. In recent years both governments in Africa and donors have pledged to provide more money for health and development. African governments pledged to raise their spending on health to 15% of their annual national budgets at a meeting in the Nigerian city of Abuja in 2001. A year lateer, the United Nations called on developed countries to increase their overseas develoopment assistance to 0.7% of their GDP by 2015. European countries have pledged to do this, but only a few have done so. By early 2006, Denmark, Luxembourg, the Netherlands, Norway and Sweden had actually honoured that commitment. The debt forgiveness granted by the G8 Table 1.1 industrialized countries in 2005 to 23 countries Burden of disease in the African Region 2002 in Africa presents an opportunity for the lattBurden of disease in DALYs* by cause and mortality stratum in the African Region ter countries to invest more in health, as well as in water, sanitation and education. FollMortality stratum lowing pledges by governments in Africa to High child, high High child, very invest more in health and health-related sectadult high adult (000) (000) tors, mechanisms need to be set up to monittor spending. Below are some of the major reg1 AIDS 14 620 49 343 gional and international initiatives to promote 2 Malaria 20 070 20 785 development in Africa. 3 Respiratory infections 18 976 16 619 4 Perinatal conditions 10 869 10 485 5 Diarrhoea 11 548 11 689 6 Top five subtotal (1 – 5) 76 083 108 921 7 Other communicable diseases 39 234 41 484 8 Communicable diseases (6 and 7) 115 317 150 405 9 Noncommunicable diseases 30 124 34 727 10 Injuries 14 974 15 829 160 415 200 961 Total Total (8 – 10) The Member States of the Region have been divided into mortality strata on the basis of their levels of mortality in children under five years of age and in males aged 15–59 years as described on pp. 156–7 of the 2004 World health report. * See glossary for explanation. Source: The world health report 2004. Geneva. World Health Organization; 2004. The African Regional Health Report The Abuja Declaration Leaders of African countries gathered in the Nigerian city of Abuja in April 2001 to declare their continent to be in a “State of Emergency” over the HIV/AIDS pandemic. Governments declared that “containing and reversing the HIV/AIDS epidemic, tuberculosis and other inffectious diseases” should constitute their “top priority for the first quarter of the 21st centtury”. Their declaration said that tackling these epidemics was an integral part of poverty reducttion and sustainable development as well as peace and security, and that the fight against HIV/AIDS was “the highest priority issue in our respective national development plans”. In the Declaration, the governments in Africa called for the lifting of all tariff and economic barriers to funding AIDS-related treatment and medicines. For their part, the governments pledged to increase spending on health to at least 15% of their annual budgets. NEPAD The New Partnership for Africa’s Development (NEPAD) was launched in 2001 by the Organization of African Unity (OAU) to eradicate African poverty, promote susttainable growth and development, help countries in Africa take a more active part in the global economy and improve the status of women in African society. In NEPAD’s 2002 Health Strategy, African governments identified the “huge burden of potentially preventable and treatable disease” as causing “unnecessary deaths and untold suffering”. According to NEPAD, the burden of disease in Africa “continues to block economic development and damages the continent’s social fabric”. NEPAD recognizes the central role of building and reinforcing health systems to assist in improving health in Africa, but also that health-care services are “too poorly funded”. The NEPAD health strategy calls on African governments to honour their pledge to raise health spending to a level of 15% of their annual national budgets. NEPAD argues that peace and security are vital for development and acknowleedges the devastating impact of war on human health and development. NEPAD recognizes the central role of building and reinforcing health systems to assist in improving health in Africa. The United Kingdom’s Commission for Africa According to a report released by the UK’s Commission for Africa in March 2005, Africa and its partners have a unique opportunity to act now to promote social and economic development in the continent. The report argues that Africa should drive its own development and that it is already doing so through the African Union and NEPAD. The report states that it is in the interests of the rich countries to support Africa’s development agenda to create a more prosperous and secure world. The one-year Commission brought together by the United Kingdom — mainly made up of African political leaders, public servants and private entrepreneurs — sought wide consultation. The Commission calls for more investment in education and the rebuilding of health systems. To achieve this end, it recognizes that the top priority in health care is scaling up services to respond to the human tragedy of HIV/AIDS. The Commission for Africa report argues that a stronger investment climate is required to boost the economies of Africa and reduce poverty, and suggests that such a boost might be achieved through stronger public–private partnerships. In addition, it suggests that donors should double their spending on infrastructure — including both rural development and slum upgrading — so that Africa’s pooreest people will also be able to participate in economic growth. Corruption, customs procedures, bureaucracy and trade tariffs must be minimized to boost trade between African nations, it says. Health and development in Africa Chapter 1 UN Millennium Development Goals The United Nations Member States agreed in 2000 to work towards eight Millennium Development Goals (MDGs). These goals set a number of targets to be achieved by 2015. The targets include halving extreme poverty and providing universal primary education. The health goals are to reduce the number of deaths of under-five-year olds by three-quarters, to reduce maternal deaths by two-thirds and to reverse epidemics of HIV/AIDS, malaria, tuberculosis and other infectious diseases. The MDG project has galvanized a global effort to meet the needs of the poorest people in the world. In 2005, a UN report identified four main reasons why some regions are not making enough progress towards the MDGs. The first was poor governance. The second was national poverty traps, a particular problem in the African Region. The third was the presence of pockets of poverty within countries. The fourth was politiccal neglect. The UN report recommends that every government should adopt and implement a national strategy — with the help of bilateral and multilateral donors and organizations — to help each country achieve the MDGs. G8 Summit 2005 The Group of Eight industrialized countries (G8) agreed to cancel the debt of 18 of Africa’s poorest countries and to increase aid to developing countries by US$ 50 billion at a summit in Gleneagles, Scotland, in July 2005. Of those, 23 are in Africa. The G8 lamented declining life expectancy in Africa and pledged to continue to suppport African strategies to improve health, education and food security. The G8 also pledged to support investment in improved health systems, includiBox 1.2 ing the training and retraining of MDG 8: A global partnership for development health workers to tackle the major diseases affecting Africa, such as MDG 8 calls for international trade and finance Uganda. Thirty-four of a total of 42 countries in the HIV/AIDS, malaria, tuberculosis, that are more equitable and give a fair chance to heavily-indebted poor countries initiative are in the poor countries. It calls for sustainable development African Region. Donor countries have also agreed polio and other neglected diseases. and youth employment as well as better access to harmonize aid and respect development prioritThe G8 pledged to give support to essential drugs and communication technology ties in recipient countries. However, official develofor investments in water and sanitin developing countries. Progress in these areas opment assistance declined in sub-Saharan Africa depends not only on developing countries thems- from US$ 34 per capita in 1990 to US$ 21 in 2001. tation and to comprehensive food selves, but also hinges on policy changes made The goal reminds rich nations of their commitment security and famine prevention by wealthy countries, such as debt forgiveness, to give 0.7% of their annual income in aid. By early programmes. It also pledged to commitments to increased aid, freeing of market 2006, only Denmark, Luxembourg, the Netherlands, support African countries in buildirestrictions and relaxing patent protection for life- Norway, and Sweden had actually honoured that saving technology. Some progress has been made commitment. However, increased aid can only lead ing peace and security, promoting in these areas. For example, partial debt relief has to progress on the rest of the goals if recipient good governance, investing in been offered to Burkina Faso, Mali, Mauritania, countries improve governance and commit themspeople, and promoting growth Mozambique, the United Republic of Tanzania and selves to a policy of poverty reduction. and development. 10 The African Regional Health Report What should be done to ensure that health development in the African Region plays its rightful role in national development efforts? The answer is that there are tried and tested health-care interventions that work, interventions that enable safe childbirth, treat acute respiratory and diarrhoeal illnesses, and prevent HIV transmission and early death from AIDS. There are established methods of preventing malaria transmmission and treating tuberculosis. The results of a public heath experiment called the Tanzania Essential Health Interventions Project (TEHIP) suggest that it is possible to achieve dramatic gains in maternal, newborn and child health at little additional cost. Mauritius achieved some of the best reproductive health indicators in WHO’s African Region through providing family planning services, strong political commitmment to tackling HIV/AIDS, health promotion, public health education and accurate recording of statistics to gauge changes in health indicators. African governments can avoid some of the burden of noncommunicable diseeases that wealthy, developed countries now face. While the greatest focus is on the diseases that kill the most people, more efforts are needed to improve on outdated methods of control and cure for neglected diseases, such as sleeping sickness, which also hamper development in African countries. Some countries are already linking public health and economic interests to tacklle shortages of essential medicines, while others may follow suit. For example, some African countries are already using new ways to purchase drugs at reduced prices, such as negotiating low prices for patented antiretrovirals for HIV/AIDS. Other countries are hoping to purchase cheaper generic antiretrovirrals from other developing countries, making use of a waiver in international trade law for poor countries that was made permanent at the WTO meeting in December 2005. Farmers in the United Republic of Tanzania are growing the Artemisia annua plant to improve domestic supply of antimalarial medicines. Empowering women is crucial to lifting countries out of poverty and improving the health of the people in the Region. Health systems cannot function without the talents of sufficcient health workers. Successful development reform, such as disbursing and spending aid in a more accountable manner, is more likely to happen if it is driven by local priorities. A concerted effort by African governments and their partners is gathering momentum for change and to help the Region come closer to achieving the MDGs (see Box 1.2). Five key elements are vital for success. First, stronger political will and commitment is essential to ensure solutions are implemented. Second, African nations need to allocate a WHO/H. Anenden Conclusion: Making it happen Health and development in Africa Chapter 1 11 If the African Region is to achieve peace, prosperity and health for all, African nations and their partners need to act now to implement the many known solutions. 12 The African Regional Health Report higher percentage of their national expenditure to health and their partners need to increase aid to Africa to address the lack of financial resources. Third, to draw full benefit from that additional donor aid, African nations need good governance to use it wisely. Fourth, adequate numbers of health-care staff are required across the African Region to provide health care, and governments and their partners need to implement adequate programmes to train, retain and utilize these resources better. Fifth, governments and their partners — domestic and international — need to translate good policies into action. If the African Region is to achieve peace, prosperity and health for all, African nations and their partners need to act now to implement the many known solutions. A paradigm shift is needed. While delivering interventions to prevent and treat diseease, governments also need to shift their focus to addressing the underlying factors that determine health, such as poverty and education. The development challenge that Africa faces is evident from the sheer magnittude of human death and disease that is outlined later in this report. These are not simply catalogues of despair or tales of woe. Within the African Region, solutions to the continent’s challenges exist. Africa can overcome its problems through partnersships and political will. ■ Bibliography Ainsworth M, Fransen L, Over M, editors. Confronting AIDS: evidence from the developing world: Selected background papers for the World Bank Policy Research Report. Brussels: European Commission; 1998. Abuja Declaration on HIV/AIDS, tuberculosis and other related infectious diseases. 27 April 2001. Available from: http://www. uneca.org/adf2000/Abuja%20Declaration.htm Barro RJ. Health and economic development. Washington, DC: World Bank; 1996. Available from: http://www.paho.org/ English/DPM/SHD/HP/barro.pdf Bloom DE, Canning D, Sevilla J. Health, human capital, and economic development. Commission on Macroeconomics and Health Working Paper Series, Paper No. WG1: 8. 2001. 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Health and development in Africa Chapter 1 13 Chapter 2 Chapter 2 Key messages Millions of women, newborns and children die every year in Africa needlessly Most deaths are from treatable, preventable causes Little or no improvement in maternal, newborn and child health over the last 20 years Major global effort to address the situation is needed Solutions African governments must take more action to save these lives Allocation of resources to this area of public health is needed Scale up tried and tested public health solutions Educate women and improve their economic and social status Maternal, newborn and child health Africa’s “silent epidemic” M illions of women, newborns and children in Africa are dying from preventable causes every year. Millions more suffer ill-health or disability related to pregnnancy and childbirth. African women risk death to give life and their offspring have the smallest survival chances in the world. It is the sheer magnitude of this death, disease and disability that constitutes Africa’s “silent epidemic”. High-level political commitment is vital, but not enough, to make a difference in the lives of these women, newborns and children. More needs to be done to save these lives. A concerted effort is under way to remedy this situation. The World health report 2005: make every mother and child count and World Health Day 2005 were devoted to maternal and child health. Both of these focused on the tragedy that so many mothers, newborns and children die of preventable, treatable causes. In 2004, all 46 Member States of the African Region agreed to improve maternal and newborn health through the adoption and implementation of the Road Map for accelerating the attainment of the Millennium Development Goals (MDGs) relating to maternal and newborn health in Africa. The Region is also making progress in implementing the Integrated Management of Childhood Illness (IMCI) to improve child health. Nearly 20 years after the launch of a major global campaign, the Safe Motherhhood Initiative, there have been pockets of improvement in maternal, newborn and child health in the African Region but no overall reduction in pregnancy- and childbbirth-related death and disease. During the 1990s, the countries with the highest tolls of maternal, newborn and childhood disease and death made the least progress in reducing them, while advances in some countries, such as Botswana, South Africa and Zambia, have been reversed by the spread of HIV/AIDS. In 1960, countries in the African Region accounted for 14% of deaths of children aged under five years globally. In 1980, the proportion was 23% and by 2003 this had increased to 43%. Maternal, newborn and child health 17 Box 2.1 Achieving MDG 4: Child health MDG 4 on child health set the target of reducii ing by two-thirds the 1990 level of mortality of children aged under five by 2015. The child health goal is measured by three indicators; the under-five mortality rate, the infant morti tality rate and the proportion of one-year-old children immunized against measles. Mortalii ity of children aged under five years has impi proved slightly in sub-Saharan countries, acci cording to the World Bank. The world health report 2005 found that child mortality in the folli lowing 10 countries in the Region had increased: Botswana, Cameroon, Côte d’Ivoire, Kenya, Rwanda, South Africa, Swaziland, the United Republic of Tanzania, Zambia and Zimbabwe. These countries are unlikely to achieve the child health goal. Under-5 mortality (deaths per 1000 live births) in the African Region 200 183 Benchmark 180 171 Most recent 160 Progress made 140 120 100 80 Progress needed 60 to achieve goal 61 Goal 40 20 0 1990 2002 2015 Fig. 2.1 Causes of maternal mortality in the African Region Severe bleeding 24% Other direct causes 8% Infection 15% Obstructed labour 8% Eclampsia 12% Unsafe abortion 13% Source: African health monitor 2004; vol.5(1). 18 The African Regional Health Report Development goals for maternal and child health In recognition of the importance of maternal and child health, an MDG has been devoted to each of these. Many countries in the African Region have a long way to go to achieve MDG 4 on child health (see Box 2.1 and Figure) and MDG 5 on maternal health (Box 2.2 and Figure). In 2000, when UN Member States unanimously adopted the Millennium Declaration agreeing on eight MDGs, some countries in the African Region faced the daunting task of having to catch up with 1990 levels before they could contemplate moving beyond them. Some counttries in this Region are still struggling to catch up with those levels of maternal and child health mainly due to HIV/AIDS, which has reversed advances made in the 1970s and 1980s. Mothers: the causes and numbers of deaths Based on data from: The world health report, 2005. Geneva:World Health Organization; 2005. Indirect causes 20% A few countries in the African Region, such as Cape Verde, Mauritius and Seychelles, have very low maternal, neonatal and child mortality rates that are comparable with those in industrialized countries. If progress is going to be made in improving maternal, newborn and child health in this Region, these successes need to be replicated where possible and primary health-care systems in these countries need to be revived as conduits to deliver essential care and treatment. The main causes of maternal death are severe bleeding (haemorrhage), infection (sepsis), eclampsia, obstructed labour and unsafe abortion, but increasing numbers of mothers in this Region die from indirect causes, such as HIV/AIDS, tuberculosis, malaria and anaemia (see Fig. 2.1). Of the 20 countries with the highest maternal mortality ratios in the world, 19 are in Africa and one — Afghanistan — is in Asia. The African Region accounts for about one-tenth of the world’s populattion and 20% of global births, yet nearly half of the mothers who die globally as a result of pregnancy and childbirth are in this Region (see Fig. 2.2). Pregnancy- and childbirth-related complications were the secondleading cause of death and disability for women aged 15–49 years in this Region in 2002 with an estimated 231 000 deaths, according to WHO data. The leading cause was HIV/AIDS with 866 000 deaths. Apart from the personal tragedy for the children and families concerned, the deaths of so many mothers in pregnancy and childbirth is a disaster for communities and a major setback for the economic and social develoopment of countries. Box 2.2 Achieving MDG 5: Maternal health During the 1970s and 1980s, maternal mortality fell across the Region as countries started establishing primary health care, including antenatal services and emergency obstetric care. Millions more lives could be saved if health systems were capable of ensuring that good quality services are available to everyone who needs them. It is clear, however, that maternal mortality in this Region has hardly improved over the last 15 years. Many women in this Region face an even greater risk of dying as a result of pregnancy or childbirth than they did 15 years ago. A woman in sub-Saharan Africa faces a 1-in-16 risk of dying due to pregnancy or childbirth during her lifetime compared with 1 in 2800 in developed countries. African women are more likely to suffer debilitating complications linked to pregnancy and childbirth. A study in West Africa showed that for each maternal death, a further 30 women may suffer long-lasting disabilities due to a range of conditions, such as chronic anaemia, inferttility and obstetric fistula. Harmful traditional practices such as female genital mutilation and nutritional taboos also contribute to poor maternal health. Female genittal mutilation, which is the partial or total removal of external genitalia is practised in 27 Member States of the 46 in this Region, Newborns: the causes and numbers of deaths MDG 5 on maternal health set the goal of redi ducing the 1990 level of maternal mortality by three-quarters. It is measured by two indicati tors: the maternal mortality ratio (MMR), which is the number of maternal deaths per 100 000 live births, and by the average proportion of deli liveries by skilled birth attendants. The differei ent values of MMR for 1990 and 2000 are due to differences in methodology and not because there has been an increase in MMR since 1990. Estimates for 1990 and 2000 suggest that there has been little change in the levels of maternal mortality ratios in the African Region. Maternal mortality (deaths per 100 000 live births) in the African Region 1000 Benchmark 910 Most recent 900 870 800 700 600 500 400 Progress needed 300 to achieve goal 200 228 Goal 100 0 1990 2000 2015 Based on data from: The world health report, 2005. Geneva: World Health Organization; 2005. Fig. 2.2 Global distribution, by region, of maternal deaths, world population and live births, 2000 100 80 55 60 % The main causes of neonatal death in this Region are: severe infections, birth asphyxia (the inability to breathe normally after birth), preterm birth, neonatal tetanus, congenital anomalies and other conditions (see Fig. 2.3). In developing countries, the children of mothers who die duriing the first six weeks of their babies’ lives are up to 10 times more likely to die within two years than children with two living parents. The reason is that the babies do not get breastfed, the family food supply is threatened and there is no direct care for those children. The dead woman’s children are also less likely to get adequate health care and education as they grow up. While progress was made in improving the health of children aged one month to five years in the 1970s and 1980s, the health of neonates — babies in their first 28 days of life — remained a neglecteed area of public health. Recent data show that neonates represent about 40% of children who die before their fifth birthday and that 29% of global neonatal deaths occur in Africa. The African Region’s neonatal mortality rate is the highest in the world (see Fig. 2.4). For every newborn baby that dies, another 20 face illness or disability from conditions such as birth injury, infection and the complications of premature birth. 89 80 40 20 0 45 Maternal deaths Africa 20 11 World’s Live population births Other world regions Source: World Health Organization. Maternal, newborn and child health Chapter 2 19 The first global estimates for neonatal deaths were made as late as 1983, while more rigorous estimates were made in 1995 and 2000. There are scant vital data on newborn babies but even less is known about stillborn babies. WHO estimates that the African Region has the highest proportion of stillbirths in the world: 30% of an estimated 3.3 million stillborn babies globally in 2000. Fig. 2.3 Causes of neonatal mortality in the African Region Severe infections 27% Birth asphyxia 24% Neonatal tetanus 9% Other neonatal causes 7% Under-fives: the causes and numbers of deaths Diarrhoeal diseases 3% Congenital anomalies 6% Preterm birth 23% The percentages do not add up to 100% due to rounding. Source: World health report 2005. Geneva: World Health Organization; 2005. Fig. 2.4 Neonatal mortality rate in the WHO regions (per 1000 live births) 50 Rate (per 1000) 40 30 20 43 10 0 38 12 African Region Region of the Americas The vast majority of deaths of children aged under five years in this Region are due to preventable causes. Fig. 2.5 shows that the chief causes are neonatal conditions, acute respiratory infections, malaria, diarrhoeal diseases, HIV/AIDS and measles, all complicated by malnutrition. The importance of malnutrition as an underlying cause of death for children aged under five years has been recognized for many years and has recently been reconfirmed: 53% of all of these child deaths could be attributed to underweight and 35% of deaths are due to the effect of undernutrition on diarrhoea, pneumonia, malaria and measles. Deaths of children under five years of age are increasingly concentrated in the African Region, at 43% of the global total in 2003, up from 31% in 1990. Of an estimated 10.6 million children under five years of age who died each year during 2000–03, some 4.4 million died in the African Region, according to WHO estimates. Every day an estimated 12 000 children die in sub-Saharan Africa from easily preventaable or treatable illnesses and conditions, such as pneumonia, diarrhoea, measles, malaria and malnutrition. Fig. 2.6 shows that mortality of children aged under five stagnated between 1990 and 2003 in 29 countries globally, and that 23 of these countries were in Africa. This lack of change occurred in Africa partly because modest reductions in death rates due to improved health care were offset by population growth and the increasing number of births. Lesotho, Malawi, Mozambique and Namibia made slow progress in reducing child mortality, while under-five child mortality fell in a furtther 10 countries in this Region. However, the number of under-five deaths has since increased, and during the 13-year period there has been no overall reduction in child mortality in this Region. 40 11 South-East Asia Region Eastern European Region Mediteranean Region 19 Western Pacific Region Source: World health statistics, 2005. Geneva: World Health Organization; 2005. 20 The African Regional Health Report Preventing millions of deaths The tragedy of maternal, neonatal and child mortality today is that the vast majority of these deaths can be prevented by making sure pregnant women and children have access to good quality health care. Considerable progress has been made across much of the African Region in terms of providing antenatal care. In the 1990s, the level of antenatal care rose by 4% to a currently estimated 70% of women in subSaharan Africa receiving at least one antenatal consultation. Millions more lives could be saved if health systems were developed to ensure that services are of high quality and extended to everyone who needs them. This means providing every woman with skilled care during childbirth and emergency obstetric and neonatal care if complications arise. It also means ensuring children’s access to quality services for prevention and treatment of childhhood illnesses. Fig. 2.5 Causes of under-5 mortality in the African Region Malaria 18% Acute respiratory infections 21% Measles 5% Neonatal conditions 26% Diarrhoeal diseases 16% The obstacles Inadequate education, illiteracy and the women’s lack of economic power compounded by their low social status contribute to women’s low utilization of available health services. Other major factors that have led to inadequate coverage of maternal health services are poverty, weak health systems and the shortage of skilled health workers. According to the latest estimates, HIV/AIDS 6% Others 5% Injuries 2% The percentages do not add up to 100% due to rounding. Source: World health report 2005. Geneva: World Health Organization; 2005. Fig 2.6 Patterns of reduction of under-5 mortality rates, 1990-2003 0OUSBDL 4MPXQSPHSFTT 3FWFSTBM 4UBHOBUJPO /PEBUB .PSFUIBOZFBSTPGIVNBOJUBSJBO DSJTJTCFUXFFOBOE Source: World health report 2005. Geneva: World Health Organization; 2005. Maternal, newborn and child health Chapter 2 21 skilled attendants assist in only 43% of the deliveries in the African Region. The remaining births are assisted by traditional birth attendants, relatives and neighbbours, while some mothers give birth alone. In some parts of the African Region, about one-third of pregnant women are adolescents. Adolescent mothers face a greater risk of death in pregnancy and childbirth than women aged 20 or over. Their babies are particularly vulnerable to premature birth, low birth weight and risk dying in the first month of life. In some countries in this Region, adolescents represent 40–60% of mothers who die in pregnancy and childbirth. If these adolescents had access to family planning services many deaths and much ill-health could be avoided. IOM/JP Chauzy Conflict and emergencies Women displaced by conflict, in a camp in Freetown, Sierra Leone 22 The African Regional Health Report Over the last two decades, the African Region has seen more armed conflict and humanitarian emergencies than any other. Between 1992 and 2004, 22 of 33 hummanitarian crises globally that lasted two or more years occurred in Africa alone, according to the Consolidated Appeals Process for humanitarian disasters. These crises have taken a major toll on human life and disrupted routine health services. Conflict situations fuel sexual violence and rape, which have reproductive and mental health reppercussions and which require specialized cliniccal and psychological care. Pregnant women and their infants are often the most vulnerable members of displaced and refugee populations. Emergencies, such as floods and other natural disasters, and armed conflict also result in the destruction of hospitals and loss of medical staff. In humanitarian emergencies, pregnant women still need routine antenatal care and skilled assistance when they give birth, and if there are complications they need back-up services, including emergency obstetric and neonatal care. After giving birth, women need access to child care and family planning services. In the vast majority of cases these services are not available. A bitter testament to the impact of conflict on maternal and child health is the example of Sierra Leone. After a devastating 1991–2001 civil war, the West African country was estimated to have the highest maternal mortality ratio in the world with 2000 deaths per 100 000 live births in 2002. It also had a stillborn rate of 50 per 1000 births and a neonatal mortality rate of between 42 and 56 per 1000 live births. Since 2000, Sierra Leone has been at the top of the list of the 20 countries worldwide with the highest maternal mortality ratio. HIV/AIDS HIV/AIDS has had a dire impact on maternal and child health over the last two decades. In some African countries an estimated 20–30% of pregnant women are infected with HIV, while transmission rates from mother to child range from 25% to 40%. In Botswana, South Africa, Zambia and Zimbabwe, the spread of HIV/AIDS has in part reversed progress made in maternal, newborn and child health. HIV/AIDS has, in turn, spurred the re-emergence of tuberculosis and complicated forms of malaria, and all three diseases have become the biggest indirect causes of maternal and neonatal death in this Region. Inadequate resource allocation Despite numerous maternal and child health campaigns, political commitment in the African Region has not been sufficient to make a difference to the lives of mothers and their children. Many governments in this Region are aware of the magnitude of the problem but are prevented from allocating adequate resources to maternal, newbborn and child health care by poverty, indebtedness, armed conflict or humanitarian emergencies. Also donors are not always prepared to provide substantially more aid for this area of public health. As a result, efforts to reduce the toll of maternal and child death and disease in this Region have had limited success. Weak health systems Public health experts broadly agree that widespread exclusion from good quality health care and the absence of well functioning public and private health systems — whether through the absence, destruction or neglect of those health systems — are at the root of the problem: that millions of mothers, newborns and children aged under five die every year of preventable causes. It is vital to scale up health-care services, but if the resulting services are of inssufficient quality people will not benefit from improved coverage. In some parts of this Region antenatal care has been scaled up and extended to a large proportion of pregnant women, but the quality of this care is so poor that it barely makes a differeence. For instance, Chad and Zimbabwe are among the 12 countries with the world’s highest maternal mortality rates. Each has a rate of 1100 maternal deaths per 100 000 live births, yet Zimbabwe’s antenatal services have a 82% coverage rate compared with only 51% in Chad. The indicators of the quality of antenatal care reflect how well this care screens for major complications of pregnancy and childbirth, and prevents them. Health systems also serve to gather reliable data. One of the main challenges for improving the health of women, newborns and children is gathering data to measure progress. Many countries with the highest burden of maternal, newborn and child death and disease lack reliable data which they need to gauge an adequate response. WHO helps such countries develop information systems to collect reliable data. Many countries with the highest burden of maternal, newborn and child death and disease lack reliable data which they need to gauge an adequate response. Maternal, newborn and child health Chapter 2 23 Efforts to tackle the problem More than a decade of research has shown that modest, low-cost measures can signnificantly reduce the health risks that women face when they become pregnant; for instance, educating the woman to look after herself and recognize danger signs that indicate when she should seek help at a health facility. These measures also include providing basic and regular antenatal care to check blood pressure, weight gain and renal function, diagnose anaemia and treat infections. Breastfeeding is one of the best ways to ensure the baby’s survival. Safe motherhood Breastfeeding is one of the best ways to ensure the baby’s survival. 24 The African Regional Health Report The Safe Motherhood Initiative, launched in Nairobi, Kenya, in 1987 by international agencies, placed maternal health — previously regarded as a private or family matter — firmly on the global public health agenda. The initiative has succeeded in drawing more attention to maternal health over the last two decades. Critics, however, argue that it failed to bring about a broad-based improvement in this area of public health because countries were not given the technical assistance they needed to translate its recommendations into practice. Moreover, donors and humanitarian agencies failed to coordinate efforts well enough to fill the gaps in public health services in the African Region, leading to a patchwork approach. Another major initiative, the UN International Conference on Population and Development in Cairo, Egypt, in 1994 urged all countries to address the human rights issues relating to maternal and child health. It called on them to provide public informmation on sexual and reproductive health, to protect pregnant women and to criminnalize violence against women, and it condemned the harmful traditional practice of female genital mutilation. The most important outcome of this conference was the commitment by governments to provide universal access to reproductive health care including family planning information and services by 2015. WHO launched the Making Pregnancy Safer (MPS) initiative in 1999 to asssist countries to strengthen their health systems to improve access to skilled care, including access to emergency obstetric and newborn care. The aim is to ensure that mothers and their newborns have timely access to the care they need through strengthening the health system and appropriate community involvement. WHO started working with Ethiopia, Mauritania, Mozambique, Nigeria and Uganda in 2002 to implement the MPS initiative and later that year 34 more Member States in the African Region requested similar assistance. To advocate more effectively for the continuum of care that is needed for impproved Maternal and newborn and child health, the three initiatives that address newborn and child health (the Healthy Newborn Partnership established in 2000, the Child Survival Partnership created in 2004; and the Safe Motherhood and Newbborn Health also created in 2004) were merged in 2005 to form the Partnership for Maternal, Newborn and Child Health. Prevention of mother-to-child transmission of HIV Countries in the African Region started introducing the Prevention of Mother-toChild Transmission of HIV (PMTCT) programme in 2002. This programme aims to prevent HIV-positive mothers from infecting their babies during pregnancy, delivery and afterwards. Its goal is also to prevent men and women from becoming infected with HIV and to prevent unwanted pregnancies in HIV-positive women. A successful pilot project conducted in a clinic in Zimbabwe in 2001 showed that PMTCT programmes are more effective if clinical treatment given to HIV-positive mothers is combined with psychosocial support for those mothers and their families (see Box 2.3). Box 2.3 Psychosocial support for HIV-positive mothers and families “I had a lot of questions. ‘How will I disclose my status to my husband? Who will look after my children and my unborn baby? How long will I live?’ I isolated myself and felt hopeless. Every day I conti templated suicide.” An HIV-positive diagnosis is devastating for pregnant women, leaving them feeling even more vulnerable, but Gladys was lucky enough to attend the clinic in 2002, when it started offering counselling and psychosocial support. The clinical treatment was a success and Gladys’s daughter was born free of HIV. Two years later after regular counselling sessions and receiving psychosoci cial support at the clinic, Gladys said: “The pain and sadness will never go away completely, but now I know how to cope with them when they resurface. The counselling and social support from the caregivers and counsellors gave me hope”. IOM/JP Chauzy The modest two-room Zengeza clinic in the Zimbabwean city of Chitungwiza is playing a pioneering role in helping expectant mothers and their families cope with the disci covery that they are HIV positive. This is one of a growing number of antenatal clinics in the African Region that have started to provide counselling and psychosocial support to HIV-positive mothers in addition to clinical treatment as part of their programmes to prevent transmi mission of HIV from mother to child. A recent study found that mothers who received counselling and psychosocial support at Zengeza were better equipped to cope with being HIV positive than those who did not. Staff and activists are now calling for all antenatal clinics in Zimbabwe to adopt this approach. They say it has led to an increase in voluntary HIV/AIDS counselling and testing, and higher awareness levels in the community at large — a major step to curbing the spread of HIV/AIDS. The only problem, they say, is that not enough men participate in the counselling sessions. Gladys Nyamunokora, 35, said the programme had helped her to build up the courage to disclose her HIV-positive status to her husband and to discuss this openly with him. The study showed that mothers like Gladys are better informed about HIV/AIDS than those who do not receive counselling. “When I found out I was HIV positive I was shatti tered, ashamed and afraid,” said Gladys. Like other mothers in Zimbabwe and other African countries, Gladys discovered she was HIV positive when she sought anteni natal care. She was four months pregnant with her third child. Coping strategies are important for women who are at risk of becoming infected with HIV. Maternal, newborn and child health Chapter 2 25 Repositioning family planning Developed in the 1990s by WHO and UNICEF, the Integrated Management of Childhood Illnesses (IMCI) strategy is being implemented in 44 of the 46 countries of the African Region to reduce the growing number of child deaths attributable to a few preventable, treatable illnesses. The id