The Health of the People
L: ^African
Regional Health Report
RKIONAL OFFICE FOR
World Health Organization
Africa
WHO Library Cataloguing-in-Publication Data
World Health Organization. Regional Office for Africa.
The health of the people : the African regional health report.
I. Public health 2. Development 3. Delivery of health care 4.Health status S.Africa I.Title.
ISBN929023 1033 (NLM classification: WA 541 HAI)
© World Health Organization. Regional Office for Africa, 2006
All rights reserved. Publications of the World Health Organization can be obtained from WHO Press. World Health Organization. 20 Avenue Appia. 121 1 Geneva 27. Switzerland (tel.: +41 22 791 3264: fax: +41 22 791 4857: e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications - whether for sale or for noncommercial distribution - should be addressed to WHO Press, at the above address (fax: +41 22 791 4806: e-mail: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no eve-nt shall the World Health Organization be liable for damages arising from its use.
This report has been prepared by a core team from the African Regional Office of the World Health Organization (WHO) under the general guidance of Dr. Luis G. Sambo and Dr. Paul-Samson Lusamba. The core team was coordinated by Drs. Derege Kebede. Amidou Baba-Moussa. and Doyin Oluwole: and included Drs. Rufaro Chatora. Alimata J. Diarra-Nama. Antoine Kabore, Chris Mwikisa, and James Mwanzia. The following have also contributed to the report: Drs. Djamila Cabral. Colette Dehlot. Abayneh Desta. Antonio Filipejr. Joses Muthuri Kirigia. Allel Louazani, Magda Robalo, Moeti Matshidiso. Patience Mensah. Fidelis Morfaw. Seipati Mothebesoane-Anoh, Tigest Ketsela. Benjamin Nganda, Dosithee Ngo Bebe. Louis H. Ouedraogo. Martins Ovberedjo. Thebe A. Pule. Edoh Soumbey-Alley. Thomas Sukwa, Prosper Tumusiime and Rui Gama Vaz. The assistance of the following staff from WHO'S African Regional Office is gratefully acknowledged: Therese Agossou. Sam Ajibola, Doris Durao. Wenceslas H. Kouvividila. Jennifer Nyoni, Jean X. Ramde. and. Khoko Soumahoro.
This report was edited and produced by the team from the Bulletin of the World Health Organization: Saba Amdeselassie, Diane d'Arcis. Fiona Fleck. Laragh Gollogly. Sophie Guetaneh Aguettant, Gael Kernen, Hooman Momen, Brenda Morris, Ian G. Neil. Kaylene Selleck. Ramesh Shademani.
The following journalists contributed material to this report: Mawusi Afele (Ghana). Arthur Asiimwe (Rwanda), Judith Basutuma (Burundi), Lauren Beukes (South Africa). Richard Brass (United Kingdom). Pam Chepki (United Republic of Tanzania). Phil Dickie (Switzerland). Anil Gundooa (Mauritius). Karen Hey (Angola). Pushpa Jamieson (Malawi). Douglas Kimani (Kenya). Pelekelo Liswaniso (Zambia), Peter Masebu (Senegal). Rodrick Mukumbira (Botswana). Helen Nyambura (United Republic of Tanzania). Paul Okunlola (Nigeria). Abiodun Raufu (Nigeria). Tsitsi Singizi (Zimbabwe). Sarah Venis (Ethiopia). Charles Wendo (Uganda). Jacqui Wise (South Africa).
The assistance of the following WHO staff is gratefully acknowledged: Samira Aboubaker. James Bartram, Robert Beaglehole Michel Beusenberg Zoe Brillantes. Jose Carlos Marlines. Carlos Corvalan. Timothy Evans. Michelle Funk. Maria Guraiib, Mie Inoue, Doris Ma Fat, Elizabeth Mason. Colin Mathers. Zoe Matthews, Jane McElligott. Chandika Indikadahena. Quazi Monirul Islam. Federico Montero. Tunga Namjilsuren. Ariel Pablos-Mendez. Gilles Poumerol. Thomson Prentice, Shekhar Saxena, Kenji Shibuya. Laura Sminkey. Nadia Soleman. Tessa Tan-Torres. Michel Thieren. Phyllida Travis. Colin Tutuitonga. Nathalie Van de Maele, Mark van Ommeren, Jelka Zupan.
The assistance of Don de Savigny and Kamran Abbasi is also gratefully acknowledged.
Printed in Switzerland
More information about this publication can be obtained from:
WHO - Regional Office for Africa Brazzaville / Republic of Congo
Contents
Message from the Regional Director ix
Foreword from the Chairperson of the African Union Commission xi
Executive Summary xiii
Introduction: The health of the people xxiii
The challenges confronting Africa xxiv
African Region of the World Health Organization xxv
Chapter 1 - Health and development in Africa 3
The cycle of poverty and ill-health 3
Putting health in the development context 6
Efforts to promote development in Africa 8
The Abuja Declaration 8
NEPAD 9
The United Kingdom's Commission for Africa 9
UN Millennium Development Goals 10
G8 Summit 2005 10
Conclusion: Making it happen 11
Bibliography 13
Chapter 2 - Maternal, newborn and child health 17
Africa's "silent epidemic" 17
Development goals for maternal and child health 18
Mothers: the causes and numbers of deaths 18
Newborns: the causes and numbers of deaths 19
Under-fives: the causes and numbers of deaths 20
Preventing millions of deaths 20
The obstacles 21
Conflict and emergencies 22
HIV/AIDS 23
Inadequate resource allocation 23
Weak health systems 23
Efforts to tackle the problem 24
Safe motherhood 24
Prevention of mother-to-child transmission of HIV 25
Repositioning family planning 26
Managing childhood illnesses 26
Increasing skilled attendance at birth 27
Immunizing more women and children 27
Conclusion: scaling up success 30
Bibliography 33
ill
Chapter 3 - Infectious diseases in Africa 37
Major obstacle to development 37
HIV/AIDS, tuberculosis and malaria 38
Challenges for disease control 38
Diseases for which control has been successful 41
Leprosy 41
River blindness 42
Poliomyelitis 43
Diseases of major public concern 44
HIV/ AIDS 44
Tuberculosis 48
Malaria 51
Diseases that are prone to cause epidemics 55
Neglected diseases 56
Conclusion: Learning from past success 57
Bibliography 59
Chapter 4 - Noncommunicable diseases in Africa 63
An emerging threat 63
Africa's double burden 63
Africa's lesser known toll of ill-health 65
Cardiovascular diseases 65
Obesity and undernutrition: an African paradox 65
Cancer 66
Injuries, violence and disabilities 67
Blindness 69
Mental health problems 70
Genetic diseases 71
Oral diseases 72
Efforts to tackle the problems 73
Legislation and marketing 73
Mental health legislation 74
Promoting healthy diets and lifestyles 74
Low-cost management programmes 75
Closer collaboration 75
Traditional health practitioners 75
The challenges 76
Scarcity of resources 76
Inadequate awareness and commitment 77
Limited data 77
Conclusion: Africa can learn from others' experience 79
Bibliography 80
Chapter 5 - Health and the environment in Africa 85
Environmental health risks in Africa 85
Challenges in the environment 86
Water and sanitation 86
Pollution and industrial waste 87
Urbanization 89
IV
Food safety 90
Emergency situations 92
Tackling poverty and environmental risks 94
Poverty reduction 94
Conflict prevention and management 95
Sustainable, low-cost solutions: water and sanitation 96
Making food safer: a shared responsibility 98
Conclusion: tracking progress 100
Bibliography 101
Chapter 6 - National health systems — Africa's big public health challenge 105
Building and reinforcing health systems 106
Public and private health-care provision 106
Scaling up health systems 107
Vertical programmes 107
Sector-wide approach 109
Health information systems 110
Vital registration 111
Getting the numbers right 112
Essential medicines 113
Improving access 113
Blood safety 115
Human resources: a continent in crisis 117
Approaches to filling the gap 120
Health financing 121
Donor funding 123
User fees 124
Evidence for resource allocation 124
Conclusion: Health systems - the key to better health 125
Bibliography 127
Statistical Annex - Statistical Annex
Health statistics in the African Region 129
Introduction 131
Demographic and socioeconomic statistics 132
Health status: mortality 134
Health status: morbidity 136
Inequities in health 138
Risk factors 140
Health service coverage 142
Health workers 144
Health expenditure ratios, 1999-2003 146
Per capita expenditure on health, 1999-2003 148
Explanatory notes 149
Glossary
Index 163
Boxes
Box 1.1: Achieving MDG 1: Poverty (Figure) 6
Box 1.2: MDG 8: A global partnership for development 10
Box 2.1: Achieving MDG 4: Child health (Figure) 18
Box 2.2: Achieving MDG 5: Maternal health (Figure) 19 Box 2.3: Psychosocial support for HIV-positive mothers and families
Box 2.4: Caring for sick children in the United Republic of Tanzania 28
Box 2.5: Giving birth in Mauritius 31
Box 2.6: Innovative financing to provide maternal care in Mali and Mauritania 32
Box 3.1: Guinea-worm disease and leprosy in Nigeria 40 Box 3.2: Activists give hope to people with HIV in Burundi
Box 3.3: How Cameroon secured lower prices for antiretrovirals 47
Box 3.4: HIV and tuberculosis in South Africa 50 Box 3.5: Treating malaria in Ethiopia
Box 3.6: Achieving MDG 6: HIV/AIDS, malaria, and other diseases (Figures) 58
Box 4.1: Rehabilitation for landmine victims in Angola 68
Box 4.2: Making roads safer in Rwanda 70
Box 4.3: Ghana is drafting a new mental health law 74 Box 4.4: Togolese people with epilepsy reintegrated into community
Box 5.1: Clearing the air with smoke hoods in Kenya 88
Box 5.2: Tackling mountains of waste in Lagos 89
Box 5.3: Making street foods safer in Ghana 91
Box 5.4: Healing post-conflict societies by healing peoples' minds 92
Box 5.5: Environmental control of schistosomiasis in Malawi 97
Box 5.6: Achieving MDG 7 on water and sanitation (Figure) 98
Box 6.1: What is a health system? 106
Box 6.2: Delivering health care to isolated communities 108
Box 6.3: Tanzanian farmers grow their own Artemisia annua 115
Box 6.4: Malawi's health sector "brain drain" 118
Box 6.5: Community home-based care in Botswana 121
Box 6.6: Uganda leads the way in simplified AIDS care 122
Figures
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)
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. 6.2: Coverage of death registration: mortality data (1995 onwards), by cause, available to WHO 111
Fig. 6.3: Member States with official national medicine policies, WHO African Region
Fig. 6.4: Total cost of malaria illness, Ghana, 2002
Fig. 6.5: Per capita government expenditure on health (US$), WHO African Region, 2003 124
Tables
Table 1.1: Burden of disease in the African Region 2002
Table 4.1: 20 leading causes of death in South Africa 66
Table 4.2: Leading causes of death in the African Region, 2002 69
Table 4.3: Mental health resources in selected countries in the African Region
Table 4.4: A stepwise approach for prevention and control of noncommunicable diseases
Table 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
REGIONAL OFFICE FOR
World Health Organization
Africa
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 man- made 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
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.
r;
H.E. Prof. Alpha Omar Konare,
Chairperson of the African Union Commission
XI
Executive summary
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.
Table a
Burden of disease in the African Region 2002
Malaria
Respiratory infections
Perinatal conditions
Diarrhoea
Top five subtotal (1 - 5)
Other communicable diseases
Communicable diseases (6 and 7)
Noncommunicable diseases
Injuries
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 1 5-59 years as described on pp. 1 56-7 of the 2004 World health report.
* See glossary for explanation.
Source: The world health report 2004. Geneva. World Health Organization; 2004.
Chapter 1 : Health and development in Africa
Economic development is impossible without major investments to apply tried- and-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 paradigm shift is needed: African countries and their partners need to address the underlying factors that determine ill-health. Investing in health, therefore, means investing in water, sanitation, environment, education, women's empowerment, governance and other related sectors.
WHO's African Region lags behind other regions of the world in terms of human development. This limited development is largely attributable to the Region's immense burden of infectious diseases, particularly that of HIV/AIDS, tuberculosis and malaria. This chapter describes the macroeconomic impact of the Region's heavy burden of infectious diseases as well as of unhealthy environments; maternal, newborn and child death and disease; and the growing burden of noncommunicable diseases. There are positive indications that things are changing as Member States of the Region and their partners continue to demonstrate the will to address poverty and development by bringing health issues to the forefront. This is demonstrated by regional initiatives, such as the New Partnership for Africa's Development (NEPAD) and efforts by the C8 and global financial institutions to cancel debt and encourage least-developed countries to channel
The African Regional Health Report
the resulting savings into health and related sectors. Chapter I 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 Coals (MDCs). 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 MDCs.
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 MDC 4 on child health and MDC 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
180
160
140
120
.183 Benchmark
171 Most recent
Progress made
Progress needed to achieve goal
61 Goal
1990 2002 2015
Based on data from: Tfte world health report, 2005. Geneva:World Health Organization; 2005.
Fig.b
Maternal mortality (deaths per
100000 live births) in the African Region
1000
900 800 700 600 500 400 300 200 100 0
Benchmark 870
910 Most recent
Progress needed to achieve goal
228 Goal
1990
2000
2015
Based on data from: The world health report. 2005. Geneva: World Health Organization; 2005.
The health of the people
Executive summary
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.
Fig.c
HIV prevalence among 15-24-year-olds in selected sub-Saharan African countries, 2001-03
20
8 is
10
> 5
z
Niger Mali Burundi Kenya Zambia South Africa Zimbabwe (2002) (2001) (2002) (2003) (2001-02) (2003) (2001-02)
Sources: Burundi (Enquete Nationale de Seroprevalence de I'infection par le VIH au Burundi. Bujumbura, Decembre 2002). Kenya (Kenya Demographic and Health Survey 2003). Mali (Enqueue DSmographique et de Same". Mali 2001 ). Niger (Enquete Nationale de Seroprevalence de I'infection par le VIH dans la population generate agee de 1 5 a 49 ans au Niger (2002)). South Africa (Pettifor AE, Rees HV, Steffenson A, Hlongwa-Madikizela L, MacPhal C, Vermaak K, Kleinschmidt I: HIV and sexual behaviour among young South Africans: a national survey of 1 5-24 year olds. Johannesburg: Reproductive Health Research Unit, University of Witwatersrand, 2004). Zambia (Zambia Demographic and Health Survey 2001 -2002). Zimbabwe (The Zimbabwe Young Adult Survey 2001-2002) .
Chapter 3 Infectious diseases in Africa
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, which kill more than three million people in the Region every year. HIV/AIDS prevalence is particularly high in southern African countries (see Fig.c). This high prevalence increases the occurrence of other infectious diseases, particularly tuberculosis. However, the shortage of health workers is hampering efforts to provide health care for this and other problems.
Chapter 3 describes the devastating effect of these three infectious diseases on society hardship, impoverishment, countless lives lost and reduced productivity - - and how governments are forced to divert scarce resources to tackle these diseases, spinning countries on an inescapable cycle of poverty and ill-health. But it also charts the progress made in the Region in rolling out antiretroviral treatment for HIV/AIDS in recent years.
It outlines some of the solutions that work in the Region. Tried-and-tested public health interventions — for example the provision
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 repre- sents 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
HIV/AIDS
Malaria
Lower respiratory infections
Diarrhoeal diseases
Perinatal conditions
Cerebrovascular disease
Tuberculosis
Ischaemic heart disease
Measles
Road traffic crashes
Violence
Whooping cough
Chronic obstructive pulmonary disease
Protein-energy malnutrition
Nephritis and nephrosis
Syphilis
War
Tetanus
Diabetes mellitus
Drowning
Source: Global Burden of Disease 2002.
The health of the people
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.
Fig.d
Improved water source (% of population without access) in sub-Saharan Africa
Benchmark 50
40 30 20 10
Most recent
Progress needed to achieve goal
1990
2002
2015
Source: WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation - Water for life: make it happen. 2005.
Chapter 5: Health and the environment in Africa
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.
The African Regional Health Report
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 peoples 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
i health of the peopli
Executive summary
Stronger health systems
can act as a bridge to
social stability, peace and
prosperity throughout the
Region.
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. •
The African Regional Health Report
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
The 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 (MDCs) 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 intercon- nected, 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 im- prove 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 pro- fessionals 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 devel- oped over the last 10-15 years and tracks progress — or lack of it — towards achiev- ing 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.
The solutions described in this report draw on the advances in diagnosis, treat- ment 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 deter- mination 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 wide- ranging 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 repre- sents 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$ I a day. About 330 million people in this Region — one-third of the world's I . I 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 productiv- ity. 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.
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 1 980s but fell during the 1 990s 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. In- ternational 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
Cape Verde
A
Senegal / Gambia
Guinea-Bissau
Guinea
Sierra Leone
Liberia Burkina Faso Cote d'lvoire
Sao Tome and Principe
Cameroon
Equatorial Guinea
Gabon
WHO African Region B Outside WHO African Region
Zambia
Namibia
Botswana
Uganda
Rwanda Burundi
United Republic of Tanzania Seychelles — Comoros
Mozambique
- Mauritius
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
I
•',
-.
Key messages
a 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
^^ eople living in the African Region face a heavy and wide-ranging burden of • J disease, which takes its toll on social and economic development and short- ens 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. I.I). 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$ I a day from 1 64 million to 3 1 4 million. While Africans represented only 1 6% 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
80
70
60
30
Countries in other regions Countries in African Region
30 40 50 60 70
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 coun- tries 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 (JS$ 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 40 30 20 10
Sub-Saharan Africa
South Asia
Middle-East and North Africa
Latin America and the Caribbean
Eastern Europe and Central Asia
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 noncommu- nicable diseases. In Africa, by contrast, according to 2002 estimates. 72% of deaths are caused by communicable diseases such as HIV/AIDS, tuberculosis, malaria, re- spiratory 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 I of cutting poverty in half by 20 1 5 (see Box. I.I). 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
Achieving MDG 1: Poverty
MDG 1 aims to halve by 201 5 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 mak- ing progress in achieving the poverty target.
Proportion of the population living on less than US$1 a day (sub-Saharan Africa)
k48 Benchmark
46 Most recent
24 Goal
Progress needed to achieve goal
1990 2002
Source: World Bank.
2015
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 per- formance 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 econo- mies 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.
Fig. 1.3
Investments in health contribute to economic development
Enhanced labour productivity
Improved educational attainment
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 (PHRplusI E-version: http://www.phrplus.org/Pubs/sp12.pdf
Several studies have sought to quantify the macroeconomic impact of the disease burden (see Table I.I ). The prevalence of HIV/AIDS for adults aged 1 5-49 years in the African Region is estimated at about 7.2%. In every other WHO region the average was less than l%. There is general agreement that the economic and social impact of HIV/AIDS in the African Region has been devastating. The epidemic has drastically re- duced the workforce in many countries, while the cost of caring for the growing genera- tion of AIDS orphans could slowdown long-term GDP growth by as much as I -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 econom- ic growth per annum compared with similar non-endemic countries, and that in Africa the annual cost of lost productivity and providing treatment is US$ 1 2 billion.
lealth and development in Africa • •
Table 1.1
Burden of disease in the African Region 2002
Burden of disease in DALYs* by cause and mortality stratum in the African Region
Mortality stratum
High child, high High child, very adult high adult
(000) (000)
AIDS
Malaria
Respiratory infections
Perinatal conditions
Diarrhoea
Top five subtotal (1 - 5)
Other communicable diseases
Communicable diseases (6 and 7)
Noncommunicable diseases
Injuries
Total (8 - 10)
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 200 1 . A year lat- er, the United Nations called on developed countries to increase their overseas devel- opment 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 industrialized countries in 2005 to 23 countries in Africa presents an opportunity for the lat- ter countries to invest more in health, as well as in water, sanitation and education. Fol- lowing pledges by governments in Africa to invest more in health and health-related sec- tors, mechanisms need to be set up to moni- tor spending. Below are some of the major re- gional and international initiatives to promote development in Africa.
14620
20070
18976
10869
11548
76083
39234
115317
30124
14974
160 415
49343 20785 16619 10485 11689
108 921
41484
150 405
34727
15829
200 961
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 1 5-59 years as described on pp. 1 56-7 of the 2004 World health report.
* See glossary for explanation.
Source: The world health report 2004. Geneva. World Health Organization; 2004.
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 in- fectious diseases" should constitute their "top priority for the first quarter of the 21st cen- tury". Their declaration said that tackling these epidemics was an integral part of poverty reduc- tion 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 African Regional Health Report
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 sus- tainable 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 1 5% of their annual national budgets.
NEPAD argues that peace and security are vital for development and acknowl- edges the devastating impact of war on human health and development.
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 poor- est 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.
NEPAD recognizes the central role of building and reinforcing health systems to assist in improving health in Africa.
Health and development in Africa
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 politi- cal 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.
MDG 8: A global partnership for development
MDG 8 calls for international trade and finance that are more equitable and give a fair chance to poor countries. It calls for sustainable development and youth employment as well as better access to essential drugs and communication technology in developing countries. Progress in these areas depends not only on developing countries them- selves, but also hinges on policy changes made by wealthy countries, such as debt forgiveness, commitments to increased aid, freeing of market restrictions and relaxing patent protection for life- saving technology. Some progress has been made in these areas. For example, partial debt relief has been offered to Burkina Faso, Mali, Mauritania, Mozambique, the United Republic of Tanzania and
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 sup- port African strategies to improve health, education and food security. The G8 also
pledged to support investment in improved health systems, includ- ing the training and retraining of health workers to tackle the major Uganda. Thirty-four of a total of 42 countries in the diseases affecting Africa, such as
heavily-indebted poor countries initiative are in the African Region. Donor countries have also agreed to harmonize aid and respect development priori- ties in recipient countries. However, official devel- opment assistance declined in sub-Saharan Africa from US$ 34 per capita in 1990 to US$21 in 2001. The goal reminds rich nations of their commitment to give 0.7% of their annual income in aid. By early 2006, only Denmark, Luxembourg, the Netherlands, Norway, and Sweden had actually honoured that commitment. However, increased aid can only lead to progress on the rest of the goals if recipient countries improve governance and commit them- selves to a policy of poverty reduction.
HIV/AIDS, malaria, tuberculosis, polio and other neglected diseases. The G8 pledged to give support for investments in water and sani- tation and to comprehensive food security and famine prevention programmes. It also pledged to support African countries in build- ing peace and security, promoting good governance, investing in people, and promoting growth and development.
The African Regional Health Report
Conclusion: Making it happen
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 trans- mission 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 commit- ment 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 dis- eases 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 tack- le 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 antiretrovi- rals 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 suffi- cient 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
Health and development in Africa
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.
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 dis- ease, 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 magni- tude 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 partner- ships and political will. •
The African Regional Health Report
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. Available from: http://www.cmhealth.org/docs/wg1_paper8.pdf
• Bryce J. Boschi-Pinto C, Shibuya K, Black RE, WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. Lancet 2005:365:1147-52.
• Our common interest report of the Commission for Africa London; Commission for Africa: 2005.
• Global indicators. In: World development indicators 2005. Washington, DC: World Bank, 2005. Available from: http://www. worldbank.org/data/wdi2005/wditext/Section6J.htrn
• Global Partnership to Roll Back Malaria. World malaria report 2005. Geneva: World Health Organization and UNICEF; 2005.
• Health Economics: getting value for money. African Health Monitor Jan-June 2005. Brazzaville: World Health Organization, Regional Office for Africa; 2005.
• Human development report 2004: cultural liberty in today's diverse world New York: United Nations Development Programme; 2004.
• Macroeconomics and health: investing in health for economic development Report of the Commission on Macroeconomics and Health. Geneva: World Health Organization; 2001.
• Our common interest report of the Commission for Africa. London; Commission for Africa: 2005.
• Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, et al. World report on road traffic injury prevention. Geneva: World Health Organization; 2004.
• Ranis G, Stewart F, Ramirez A. Economic growth and human development. World Development 2000;28:197-219.
• Regional economic outlook sub-Saharan Africa Washington, DC: International Monetary Fund; 2005. Available from: http:// www.imf.org/external/pubs/ft/AFR/REO/2005/eng/01/SSAREO.htm
• Regional HIV and AIDS estimates 2005. Geneva: UNAIDS; 2005. Available at: http://www.unaids.org/epi2005/doc/report.html
• Report on the International Conference on Financing for Development Monterrey. Mexico. 18-22 March 2002. New York: United Nations; 2002. UN document A/CONF.198/11. Available from: http://www.un.org/esa/ffd/aconf198-11.pdf
• Sachs J, Malaney P. The economic and social burden of malaria. Nature2QQ2; 415:618-85.
• Saunders MK, Gadhia R, Connor C. Investments in health contribute to economic development Bethesda (MD): Partners for Health Reformp/us (PHRp/us). Available from : http://www.phrplus.org/Pubs/sp12.pdf
• Subbarao K, Coury, D. Reaching out to Africa's orphans: a framework for public action. Washington, DC: World Bank; 2004. Available from: http://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1103037153392/ ReachingOuttoAfricasOrphans.pdf
• The world health report 2004: changing history. Geneva: World Health Organization, 2004.
• /Tie world health report 2005: make every mother and child count. Geneva: World Health Organization, 2005.
• 7776 state of the world's children 2005. New York: UNICEF. Geneva: World Health Organization, 2005.
• UNAIDS epidemic update 2004. Geneva: UNAIDS; 2004. Available from: http://www.unaids.org/wad2004/EPI_1204_pdf_ en/EpiUpdate04_en.pdf
• United Nations Development Programme. Human development report 2002: deepening democracy in a fragmented world New York: Oxford University; 2002. Available from: http://hdr.undp.org/reports/global/2002/en/
• World health statistics 2005. Geneva: World Health Organization; 2005.
• World report on knowledge for better health: strengthening health systems. Geneva: World Health Organization; 2004.
tealth and development in Africa
, newborn and child health
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
Solution*
• 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"
4 * illions of women, newborns and children in Africa are dying from preventable ^^i causes every year. Millions more suffer ill-health or disability related to preg- I j nancy 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 Mother- hood Initiative, there have been pockets of improvement in maternal, newborn and child health in the African Region but no overall reduction in pregnancy- and child- birth-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 I960, countries in the African Region accounted for 14% of deaths of children aged under five years globally. In 1 980, the proportion was 23% and by 2003 this had increased to 43%.
Maternal, newborn and child health
Achieving MDG 4: Child health
MDG 4 on child health set the target of reduc- ing by two-thirds the 1990 level of mortality of children aged under five by 201 5. The child health goal is measured by three indicators; the under-five mortality rate, the infant mor- tality rate and the proportion of one-year-old children immunized against measles. Mortal- ity of children aged under five years has im- proved slightly in sub-Saharan countries, ac- cording to the World Bank. The world health report 2005 found that child mortality in the fol- lowing 1 0 countries in the Region had increased: Botswana, Cameroon, Cote d'lvoire, 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
200 180 160 140 120
183 Benchmark
• 171 Most recent Progress made
"Z....
Progress needed to achieve goal
61 Goal
60
40 20
0 1990 2002 2015
Based on data from: The world health report, 2005. Geneva:World Health Organization; 2005.
Fig. 2.1
Causes of maternal mortality in the African Region
Severe bleeding
Infection
Source: African health monitor 2004; vol. 5(1).
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.
Development goals for maternal and child health
In recognition of the importance of maternal and child health, an MDC 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 MDC 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 1 990 levels before they could contemplate moving beyond them. Some coun- tries 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
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, 1 9 are in Africa and one — Afghanistan — is in Asia. The African Region accounts for about one-tenth of the world's popula- tion 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 second- leading cause of death and disability for women aged 15-49 years in this Region in 2002 with an estimated 23 1 000 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 devel- opment of countries.
African Regional Health Report
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 1 5 years. Many women in this Region face an even greater risk of dying as a result of pregnancy or childbirth than they did 1 5 years ago. A woman in sub-Saharan Africa faces a I -in- 1 6 risk of dying due to pregnancy or childbirth during her lifetime compared with I 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, infer- tility and obstetric fistula.
Harmful traditional practices such as female genital mutilation and nutritional taboos also contribute to poor maternal health. Female geni- tal 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
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 dur- ing 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 1 970s and 1 980s. the health of neonates — babies in their first 28 days of life — remained a neglect- ed 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.
Achieving MDG 5: Maternal health
MDG 5 on maternal health set the goal of re- ducing the 1990 level of maternal mortality by three-quarters. It is measured by two indica- tors: the maternal mortality ratio (MMR). which is the number of maternal deaths per 100 000 live births, and by the average proportion of de- liveries by skilled birth attendants. The differ- 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 1 990. Estimates for 1 990 and 2000 suggest that there has been little change in the levels of maternal mortality ratios in the African Region.
Maternal mortality (deaths per 100000 live births) in the African Region 1000
900 800 700 600 500 400 300 200 100 0
UONMmtf
P-o£-sis -eece: to achieve goal
1990
2000
2015
Based on data from: The world health report, 2005. Geneva: World Heal* Organization; 2005.
Fig- 2.2
Global distribution, by region, of maternal deaths, world population and live births, 2000
100
Maternal deaths
• Africa
Source: World Heal* Organization.
World's Live
population births
n Other world regions
Maternal, newborn and child health
Fig. 2.3
Causes of neonatal mortality in the African Region
Birth asphyxia
24% ,
Congenital
anomalies
6%
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
40
8 30
i
a 20
10
ion
of the Americas
South-East Asia Region
European Eastern Western Region Mediteranean Pacific Region Region
Source: World health statistics, 2005. Geneva: World Health Organization; 2005.
The first global estimates for neonatal deaths were made as late as 1983, while more rigorous estimates were made in 1 995 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.
Under-fives: the causes and numbers of deaths
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 1 2 000 children die in sub-Saharan Africa from easily prevent- able 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 1 990 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 fur- ther 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.
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 1 990s, the level of
African Regional Health Report
i\
antenatal care rose by 4% to a currently estimated 70% of women in sub- Saharan 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 child- hood illnesses.
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,
Fig. 2.5
Causes of under-5 mortality in the African Region
~:.'.r "r:: ":'.'• ifectiOR
21%
The percentages do not add up to 100% due to rounding.
Source: WortdheaHh repcrtXm Geneva: World Heal* Organization:
2005.
Fig 2.6
Patterns of reduction of under-5 mortality rates, 1990-2003
^_^ On track
U Slow progress ^H Reversal H Stagnation • No data
* More than 2 years of humanitarian crisis between 1992 and 2004
Source: World health report 2005 Geneva: World Health Organization; 2005.
Maternal, newborn and child health
• • •
Women displaced by conflict, in a camp in Freetown, Sierra Leone.
skilled attendants assist in only 43% of the deliveries in the African Region. The remaining births are assisted by traditional birth attendants, relatives and neigh- bours, 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.
Conflict and emergencies
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 hu- manitarian 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 re- percussions and which require specialized clini- cal 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 1 00 000 live births in 2002. It also had a stillborn rate of 50 per 1 000 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.
African Regional Health Report
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, new- born 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 in- sufficient 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 differ- ence. For instance, Chad and Zimbabwe are among the 12 countries with the world's highest maternal mortality rates. Each has a rate of 1 100 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.
aternal, newborn and child heal
Efforts to tackle the problem
Breastfeeding is one of the
best ways to ensure the
baby's survival.
More than a decade of research has shown that modest, low-cost measures can sig- nificantly 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
The Safe Motherhood Initiative, launched in Nairobi, Kenya, in 1 987 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 1 994 urged all countries to address the human rights issues relating to maternal and child health. It called on them to provide public infor- mation on sexual and reproductive health, to protect pregnant women and to crimi- nalize 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 as- sist 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 im- proved 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 New- born Health also created in 2004) were merged in 2005 to form the Partnership for Maternal, Newborn and Child Health.
African Regional Health Report
Prevention of mother-to-child transmission of HIV
Countries in the African Region started introducing the Prevention of Mother-to- Child 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).
Psychosocial support for HIV-positive mothers and families
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 dis- 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 trans- 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 shat- tered, ashamed and afraid," said Gladys. Like other mothers in Zimbabwe and other African countries, Gladys discovered she was HIV positive when she sought ante- natal care. She was four months pregnant with her third child.
"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 con- 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 bom free of HIV. Two years later after regular counselling sessions and receiving psychoso- 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".
ping strategies are important for women who are at risk of becoming infected with HIV.
Maternal, newborn and child health
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 idea of IMCI is to
improve the prevention or
early detection
and treatment of the
main childhood
killers in developing
countries.
Repositioning family planning
The African Region has some of the highest fertility rates in the world — 4.9 chil- dren per woman on average — and a low prevalence of contraceptive use of 17%. In contrast, global fertility has dropped from 4.5 to 2.8 children per woman since the 1970s. The low use of contraception is not the only reason for this. High fertil- ity rates drop in societies where people are convinced that their children have good chances of survival. The high fertility in this Region increases the life-time risk a woman faces of dying from pregnancy and childbirth-related complications
In the African Region, where women are at greater risk of dying in pregnancy or childbirth than anywhere else in the world and where they have some of the high- est fertility rates in the world, family planning is essential. However, over the last 10 years it has become a neglected area of public health because of conflicting priorities, insufficient high-level political commitment and lack of donor interest. One of the challenges here is overcoming religious barriers and cultural beliefs that encourage high fertility and create misconceptions that prevent men and women from using effective family planning methods or prevent providers from suggesting certain family planning methods as options.
Countries need to address reproductive health to come closer to achieving the Millennium Development Goals on maternal and child health. In 2004, the 46 minis- tries of health in the African Region adopted a 10-year framework called Repositioning Family Planning. This aims to provide guidance on how to revitalize the family plan- ning component of national reproductive health programmes. WHO'S Regional Office for Africa is working with countries to help strengthen their family planning services.
Managing childhood illnesses
Improved child survival became a global phenomenon largely due to the success of oral rehydration therapy for diarrhoeal diseases and immunization. Another key strategy for improving child health is the Integrated Management of Childhood Illnesses (IMCI). Developed in the 1990s by WHO and UNICEF, this 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 idea of IMCI is to improve the prevention or early detection and treatment of the main childhood killers in developing countries. Six conditions account for about 70% of all deaths. These are: acute respiratory infections — mostly pneumonia — as well as diarrhoea, malaria, measles, HIV/AIDS and neonatal conditions.
IMCI training guidelines are designed to be adapted to the situation in each country. In addition, some countries are training health workers to address the prob- lem of HIV/AIDS in children. Health workers have also been trained to support and counsel HIV-positive mothers on appropriate infant nutrition in over 20 countries in this Region. It is estimated that 6% of deaths of children aged under five years in Africa are due to HIV/AIDS.
African Regional Health Report
There have been reductions in child mortality in some countries that have imple- mented IMCI. Malawi and Mozambique have managed to lower their child mortality rates over the last 10 years. The United Republic of Tanzania reduced the mortality of children aged under five years by 1 3% over the two-year period from mid-2000 to mid-2002 in two districts, where IMCI was part of a comprehensive strategy to improve access to health care (see Box 2.4).
The Global Strategy on Infant and Young Child Feeding (GSIYCF) adopted by the World Health Assembly in 2002 is also a step towards addressing malnutri- tion in children under five years of age. WHO is supporting 17 countries in this Region in developing and implementing a GSIXCF plan to address the problem of malnutrition.
Increasing skilled attendance at birth
Traditional birth attendants, who have no formal training, are often the only people available to assist with a birth in the African Region. These women can play an important role in educating mothers about nutrition, breastfeeding and childcare, but studies show that in countries where births are increasingly attended by skilled health workers, maternal and newborn deaths decline.
WHO has developed a set of technical and managerial guidelines and tools for the Integrated Management of Pregnancy and Childbirth (IMPAC). Coun- tries can adapt these guidelines to provide better access to quality maternal and newborn care services. The tools can be used to improve the health workers' skills, fine tune the organization of maternal, newborn and child health-care service delivery and promote health education and community involvement in pregnancy and childbirth.
Maternal mortality in Botswana has declined since independence in 1962 with the training of skilled birth attendants and implementing other recommended guide- lines. In 2000, 94% of births in this southern African country were attended by skilled health workers compared with an estimated level of 43% across the African Region. The prevalence of contraceptive use in Botswana was 39% compared with an average of 1 7% in this Region. The maternal mortality ratio in Botswana was 100 deaths per 100 000 live births — one of the lowest in this Region — and neonatal mortality was 40 per 1000 live births.
Immunizing more women and children
Immunization can do much to improve child, newborn and maternal health, but its potential has still not been exploited to the full in the African Region, where vaccine- preventable diseases remain a major cause of death and disease. In 2001, WHO and other partners from the Global Alliance for Vaccines and Immunization (GAVI) launched a new initiative. Reaching Every District, to make routine immunization more widely available. So far the approach has been implemented in 26 countries in this Region.
Immunization can do much to improve child, newborn and maternal health, but its potential has still not been exploited to the full in the African Region.
Maternal, newborn and child heal
Caring for sick children in the United Republic of Tanzania
The Tanzanian district of Morogoro introduced free child health care and the Integrated Management of Childhood Illness strategy as part of the Tanzania Essential Health Interventions Project (TEHIP) 10 years ago. Since then, fewer children are dying of preventable and treatable causes, but challenges remain.
Zena Juma first took her sick child, Abduli Yahya, to a private clinic believing she would get better service there than in a public clinic. The boy showed no improvement, so she brought him to Morogoro Regional Hospital. On arrival at the clinic where health workers use the IMCI guidelines to manage sick children, Zubeda Dihenga, paediatric nursing officer, immediately diagnosed the little boy with severe dehydration after pinching his tummy. His skin remained bunched where she had pinched it. The child had a listless unblinking stare, and the sides of his mouth were cracked.
The child was then given an oral rehydration solution, and put on a drip while some tests were done to give a diagnosis of what was ailing him. "I just hope he will be better. I hope this hospital does something for my child," Juma said.
Meshack Massi, head doctor at Morogoro Regional Hospital, said that there were many benefits to using the Integrated Management of Childhood Illness (IMCI) approach. "IMCI is a strategy where children are treated immediately according to symptoms that they exhibit," Dr Massi said. "In the rural areas where they don't have access to laboratories, the doctors or medical personnel know that the biggest child killers are diseases with symptoms and signs of fever, diarrhoea or a cough. I am happy to say that we have since seen a reduction in child morbidity and mortality."
Habiba Ramadhani did not know about the free medical care for children under five years. Her son, Juneydi Maulidi, fell sick with malaria at the beginning of the month. She took him to the village dispensary, which is about 40 km away from Morogoro town. Medical personnel at the dispensary pre- scribed antibiotics and paracetamol for the four-year-old boy although tests showed he had malaria.
"They didn't have medicine and asked us to buy some from the pharmacy," 22-year-old Ramadhani
said. "He got worse over the month and we decided to bring him to the bigger hospital."
When they got to the clinic at Morogoro, where IMCI is imple- mented, Ramadhani's child was immediately seen by a clinical offi- cer, and was diagnosed as having anaemia and admitted to hospital. As she waited for a relative to donate some blood so that her son could get a transfusion, Ramadhani said she was not aware of any free medical services for children aged under five years.
Ramadhani had to get a relative to donate some blood to re- place the blood that her son would use up. There is a perennial short- age of blood in most Tanzanian hospitals and family or friends have to give blood if their sick relative is to receive any.
A woman in the same ward as Ramadhani had not been so lucky. Nineteen-year-old Geroda Robert's baby had just died a few minutes earlier. She and her family live in a remote village in Morogoro. Her one-year-old child fell sick but they could not get her to a doctor quickly because a neighbouring river had flooded and was impassable. They were marooned in their village until the river subsided. They came as quickly as they could to the dispensary where they were referred to Morogoro Regional Hospital, but the baby died soon after arrival.
Sifa Juma is a 27-year-old mother of four children whose ages range between nine years to four months. She stays at home to care for them while her husband buys tomatoes from village farmers and sells them in Morogoro town. Her two youngest children have ben- efited from the recent introduction of free medical care in the district.
"With the first two children, you had to pay for everything: medicine, tests, to see the doctor and if your child needed to sleep a few nights in hospi- tal, then that would mean a lot of money. But now, as long as the child is below five, you get all that for free," Juma said, adding: "Another good thing is that there is now a clinic set aside for sick children. Before, we had to sit in the queue to see the doctor even with children who were there for routine check-ups."
Zena Juma watches her sleeping son Abduli Yahya.
African Regional Health Report
As a result, routine vaccination coverage, as measured by coverage of DPT3 (diphtheria toxoid, tetanus toxoid and pertussis vaccine) improved from 2002 to 2005. This can be seen in overall national immunization coverage as well as in the numbers of districts that have achieved DPT3 coverage of 80% and higher. WHO/ UNICEF data for 2005 show that coverage continued to improve and that the average regional DPT3 coverage was 69% at the end 2003 (see Fig 2.7)
By the end of 2004, hepatitis B vaccine was introduced in the routine immuniza- tion programme in 24 countries in the African Region, Haemophilus influenza type B (Hib) vaccine in 1 1 countries and yellow fever vaccine in 2 1 countries. Thirty-four countries in this Region have been granted immunization system support (ISS) by CAVI. The ISS fund has provided them with resources to strengthen their immuniza- tion systems, so that they can introduce new vaccines. The countries also received ISS to improve injection safety by providing autodisable syringes for three years as well as safety boxes for the collection of the syringes once they have been used.
Routine immunization plays a role in the prevention of vitamin A deficiency. Thirty-two countries in the African Region have a policy on using vitamin A in rou- tine immunization, while 36 countries have used vitamin A supplementation during polio and/or measles supplemental immunization activities.
The African Region's accelerated measles control initiative has seen significant success over the last five years. The average rou- tine measles vaccination coverage for the Region stood at 69% in 2003, up from 54% in 1999. Thirty-seven countries in this Region reported routine measles coverage of 60% or more. Since 2001. at least 26 countries have conducted mass immunization campaigns and instituted case- based measles surveillance.
Since 1999, countries that have conducted these accelerated measles control activities have documented a more than 95% decline in measles cases. The overall reduction in measles deaths for the African Region is estimated to be more than 50% compared with 1999 estimates. If the project continues in current areas and expands into new ones, it will help to achieve the 2005 World Health Assembly (WHA) goal of a 90% reduction in global measles deaths by 2010.
A total of 139 million children in 31 coun- tries were vaccinated between January 2001 and December 2004. An additional 75 million children were targeted for vaccination in 2005. These campaigns will help the African Region achieve its goal of vaccinating 200 million chil- dren by the end of 2005. From the beginning
Fig 2.7
Immunizaton coverage with EPI (Expanded Programme on Immunization) vaccines,
African Region, 1982-2003
100
0,60
ttfl CD
03
o 40 o
20
1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2003
Figure shows coverage for BCG (tuberculosis), DPT3 (diphtheria, pertussis or whooping cough, and tetanus), TT2 (tetanus toxoid) and measles.
Source: Communicable diseases in the WHO African Region 2003. Division of Prevention and Control of Communicable Diseases. WHO Regional Office for Africa; 2004
Maternal, newborn and child health
Chapter
of 2006, all countries in this Region — except Liberia and Nigeria — were due to conduct nationwide catch-up measles campaigns targeting children aged 9 months to 1 5 years. Most countries have integrated their supplemental measles immunization ac- tivities into their measles immunization strategy, such as the provision of vitamin A supplementation, de-worming medicines, insecticide-treated nets for malaria control and oral polio vaccine. The savings that resulted have allowed health au- thorities to spend more on expanding the reach of these important public health interventions. The efficiency and success of integrating supplemental activities in immunization programmes has increased donor interest, and it has helped to boost multisectoral collaboration and partnerships on an unprecedented scale.
Conclusion: scaling up success
In much of the African Region, there has been little or no improvement in maternal, newborn and child health since the end of the 1980s. In some parts, some of the gains of the post-independence years have been reversed. However, there are inter- ventions that work in the African setting and the key to success is scaling these up effectively.
Cape Verde, Mauritius (see Box 2.5) and Seychelles have improved ma- ternal and newborn health through public health education including education for girls, family planning and strong political commitment to HIV/AIDS prevention and care. Similar best practices implemented in Uganda's Soroti district in 2001 with the adoption of the Making Pregnancy Safer initiative have also reaped positive results. There, community involvement, improved communications and transport, training to produce more skilled birth attendants and upgrading of health facilities led to a reduction in maternal and neonatal deaths over a period of 18 months.
Some countries in the African Region have found successful ways to address the challenges they face in financing health care for maternal, newborn and child health. For example, Mali and Mauritania have both developed community financing schemes to subsidize maternal health-care services (see Box 2.6).
Another success story is improved access to antenatal care. Many countries reached the relatively high level of 70% of women in sub-Saharan Africa receiving at least one antenatal consultation in the 1990s. Some African countries are already building on this by using antenatal consultations not only to prepare the mother for the birth but as a platform to provide other essential screening and care, such as for HIV/AIDS, tuberculosis and malaria.
A further key to success in the African context is boosting commu- nity involvement. Many people in African countries do not go to a health facility when they need care. Increasing the quality of care at health facilities alone would not reduce the maternal, neonatal and child mortality rates significantly. Essential health
African Regional Health Report
Giving birth in Mauritius
Gone are the days when deliveries were performed at home by traditional midwives in the Indian Ocean island of Mauritius. Now, 99% of births are carried out by skilled attendants, many in hospitals or clinics. Mothers like Geeta Ramdin, a 25-year-old mother from the island, re- ceive a high standard of antenatal and postnatal care, and if complications arise, emergency obstetric care is available.
Geeta went to her local clinic in the fourth month of pregnancy to begin monthly checks of her weight and blood pressure, and for blood and urine tests. Testing for HIV is recommended, but only done with the patient's con- sent, which Geeta readily gave. She was advised to have a balanced diet and take regular exercise. In the seventh month she was referred to a hospital for more comprehen- sive tests, including an ultrasound scan of her baby.
All was going fine. When her contractions started three days before the birth was due. doctors at the hos- pital said she was not dilated enough and eventually de- cided to do an emergency Caesarian. Obstructed labour can result in the death of the baby, the mother or both. and accounts for 12% of maternal deaths in the African Region. Geeta was fortunate enough to have access to a well-equipped hospital, able to provide her with a straightforward Caesarian delivery.
Nurses helped her to express breast milk to feed Shaksh immediately after the birth. Once Geeta recovered, she started breastfeeding Shaksh herself: "I was over- joyed to be able to hold my baby in my arms," she said. Six weeks later, Geeta took Shaksh to the health centre for a check-up. Shaksh, who is now a healthy one-year-old tod- dler, has had a full course of routine vaccinations.
Over the last four decades the infant mortality rate
— that of babies aged less than one year — has dropped sharply in Mauritius from 60 per 1000 live births in 1962 to 12.4 in 2003. The maternal mortality ratio in 2003 was 21 per 1 00 000 live births, on a par with the level in developed countries.
A WHO report found that Mauritius owed this success to strong political commitment to building health systems, providing primary health care and having an efficient drug supply system. The report also found that free education
— resulting in today's 95% literacy rate — and free health care were also key. Public health experts believe that health districts in other African countries that are the same size as Mauritius can emulate some of these successes.
Geeta Ramdin and one-year-old Shaksh
care needs to be brought closer to the community. One way to do this is to deliver more services through community providers, for example by supporting community- based family planning services to improve utilization of contraception.
Scaling up health systems is vital but will not be effective if many people — particularly girls and women — remain uneducated about their health. Lack of edu- cation and illiteracy are major challenges in this Region and can be overcome by taking a multisectoral approach that calls for investment in girls' education as well as an improved public health infrastructure.
Governments and international agencies need to deliver essential and sustain- able maternal, newborn and child health care to the people who need them. Unless current efforts are stepped up, most countries in the African Region will have little or
temal, newborn and child healt
Chapter
Innovative financing to provide maternal care in Mali and Mauritania
Families in the African Region cannot always afford antenatal, delivery and postnatal care, and their lack of financial access to these sometimes life-saving services contributes to the high rates of maternal and newborn deaths. Mali and Mauritania have developed community cost-sharing schemes to relieve poor fami- lies of this financial burden and to subsidize care in a bid to reduce high rates of maternal and neonatal mortality. Mali introduced a community-funded scheme in 2002 to provide 35 of 57 community health centres with staff trained to deliver babies and perform emer- gency obstetric surgery as well as to supply the centres with emergency kits, containing anaesthetic and other medicines for mothers who need a Caesarian. The cost is shared between community health associations, development partners and the government, while pa- tients also make a small contribution.
WHO and Malian officials have praised people's willingness to contribute financially to improve their own maternal, newborn and child health and say the scheme needs to be extended to general hospitals and
villages, where the majority of maternal and newborn deaths occur. Such deaths often result from delays in transportation and seeking help from traditional heal- ers before taking mothers to a clinic.
Mauritania has introduced a health insurance scheme called the Obstetric Package in the capital, Nouakchott, and several other districts, to cover the costs of antenatal, delivery and postnatal care. Each pregnant woman and her family contribute US$ 0.26 to cover the costs of antenatal, delivery and postnatal care. The remaining costs are covered by French devel- opment aid, WHO and the Nouakchott health district. The scheme has helped to finance the training of nurs- es in emergency obstetrics and the hiring of doctors to perform Caesarians. Community members are trained to manage funds to cover the cost of ambulances.
Mauritania was one of the five countries in WHO'S African Region to join the Making Pregnancy Safer pro- gramme in 2002 in a drive to halve its high maternal death rate by 2010. This year the authorities plan to extend the cost-sharing system to four other regions of the country.
no chance of substantially reduc- ing the toll of avoidable maternal, newborn and child death and dis- ease in the foreseeable future. Rapid progress is needed to come even close to achieving the target reduc- tions envisaged by the MDGs on maternal and child health. The Road Map and the IMCI strategy are there to accelerate progress towards these goals. This ambitious MDG project can only succeed in the African Region if governments and donors pledge substantially more funds and if their joint efforts to improve ma- ternal, newborn and child health are tightly coordinated in a way that can be sustained in the long-term. •
The future prospects for children depend on decisions made today.
'African Regional Health Report
Bibliography
• Black RE, Morris SS. Bryce J. Where and why are 10 million children dying every year? Lancet 2003:361:2226-34.
• Communicable Diseases in the WHO African Region 2003. WHO Regional Office for Africa. Brazzaville: 2004.
• Family and reproductive health: 2002 in brief. Making the difference throughout the lifespan Brazzaville: WHO Regional Office for Africa; 2004. WHO Regional Office for Africa document AFR/RHR/04/01.
• Hyder AA, Wali SA, McGuckin J. The burden of disease from neonatal mortality: a review of South Asia and sub-Saharan Africa. &70G1 10:894-901.
• Lawn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. Bulletin of the World Health Organization 2005:83:409-17.
• Maruping A. Policy interventions for reducing maternal and newborn mortality in adolescents. African health monitor January-June 2004:11-4.
• Maternal mortality in 2000: estimates developed by WHO. UNICEFand UNFPA Geneva: Department of Reproductive Health and Research. World Health Organization; 2004.
• Murray C and Lopez A. Health dimensions of sex and reproduction, the global burden of sexually transmitted diseases. HIV. maternal conditions, perinatal disorders, and congenital anomalies, Harvard School of Public Health. Cambridge (MA), 1998.
• Phumaphi J. Fighting the "silent epidemic". Bulletin of the World Health Organization 2005;83:247-8.
• Prual A. Bouvier-Colle MH. de Bernis L, Breart G. Severe maternal morbidity from direct obstetric causes in West Africa: incidence and case fatality rates. Bulletin of the World Health Organization. 2000:78:593-602.
• Road map for accelerating the attainment of the Millennium Development Goals relating to maternal and newborn hearth in Africa Brazzaville: WHO Regional Office for Africa. Document AFR/RC54/R9.
• Schellenberg JRA, Adam T, Mshinda H. Masanja H, Kabadi G, Mukasa 0, et al. Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMC!) in Tanzania. Lancet 364;2004:1 583-94.
• The world health report 2002. reducing risks, promoting healthy life. Geneva: World Health Organization; 2002.
• The world health report 2005: make every mother and child count Geneva: World Health Organization; 2005.
• World health statistics 2005. Geneva: World Health Organization; Geneva: 2005.
Maternal, newborn and child health
• • •
Key messages
Infectious diseases are a major obstacle to development
Geography and climate are conducive to infectious diseases
HIV/AIDS increases occurrence of other infectious diseases, particularly
tuberculosis
Health worker shortage is hampering health-care efforts
Solution*
Wider application of tried and tested public health interventions Scale up simplified, low-cost approaches to treatment Research and Development to find more effective medicines and vaccines Promotion of safe sex, and HIV testing and counselling to prevent further HIV infections and reverse AIDS pandemic
Infectious diseases in Africa
Major obstacle to development
I A anV people in Africa have yet to benefit from the improvements in diagno- nr* sis, prevention, treatment of common diseases and of living standards that I * have contributed to greater life expectancy in most of the rest of the world over the past half century. Unlike other regions of the world, the African Region still largely attributes its slow progress in terms of human development to the ravages of infectious diseases.
People in Africa suffer from a vast range of preventable and curable infectious diseases. HIV/AIDS, tuberculosis and malaria alone are estimated to kill about three million people every year in the Region. Africa's children bear the brunt of ill-health caused by measles, waterborne infections and parasitic diseases. The result is hard- ship, impoverishment, countless lives lost and reduced productivity. The diversion of scarce resources into tackling these diseases spins countries on an inescapable cycle of poverty and ill-health.
One reason for limited progress in the control of infectious diseases in Africa is cost. Many African countries cannot always afford to diagnose and treat common infections adequately. Expenditure on health is rarely as much as 5% of a country's gross domestic product, and often is as little as 2%. Average public spending on health is about US$ 10 per person per year, while patients and their families must cover the remaining costs, and these can be substantial. A realistic estimate of the cost of providing minimum health care to people in Africa is about US$ 34 per person per year. In contrast, high-income countries spend US$ 2000 per person, or more.
ifectious diseases in Africa
Chapters
Fig 3.1
Regional progress towards 70% case detection of tuberculosis: Europe low, SEAsia acceleration, Americas high
70
-!£- 0
4— '
CD
60
50
40
& 30
o>
T3
0) </)
co o
20
10 0
HIV/AIDS, tuberculosis and malaria
The devastating impact of HIV/AIDS, tuberculosis and malaria — known as the "big three" — on people in developing countries has earned them their own Millennium Development Goal: MDC 6. Meeting this goal in the African Region is proving dif- ficult and may be impossible without adequate funding.
Of the major contributors to short lifespans in the Region, more than six are infectious diseases: HIV/AIDS, tuberculosis, malaria, diarrhoeal diseases, acute re- spiratory infections and vaccine-preventable diseases. Concerted efforts to control infectious diseases in Africa have resulted in some spectacular gains against leprosy, river blindness (onchocerciasis), poliomyelitis and guinea-worm disease (dracuncu- liasis), while other efforts — such as those targeting the "big three" • - have had little impact, despite recent improvements in prevention and treatment techniques. HIV/AIDS is the leading cause of death and disease for adults in the Region, while malaria is the leading cause of death and disease for children aged under five years. The HIV/AIDS epidemic affects southern African countries most.
Malaria has been a constant scourge in countries south of the Sahara for centu- ries and, despite decades of control efforts, Africa has more than 90% of the global disease burden. Young children and pregnant women in rural areas suffer most from the complications of malaria and are most likely to die from the disease. Despite intense efforts and increased funding, the populations that are most at risk still lack adequate access to effective prevention and treatment.
With the advent of curative drugs over 50 years ago, tuberculosis came to be per- ceived in wealthy industrialized countries as a disease of the past. Yet, tuberculosis is on the rise in the Region with over one million new cases notified in 2003. To achieve MDG 6, case detection (Fig. 3.1) and treatment for tu- berculosis need to reach many more people, particularly those who are also infected with HIV. MDG 6 will not be reached until HIV/ AIDS transmission is almost interrupted in the 24 high-burden countries of the African Region. Under the "3 by 5" initiative, there are 34 high-burden countries globally.
Americas
Africa
Europe
1994
1996
1998
2000
2002
2004
2006
Source: Communicable diseases in the WHO African Region 2003. Division of Prevention and Control of Communicable Diseases. WHO Regional Off ce for Africa; 2004.
Challenges for disease control
Infectious diseases continue to exact a heavy toll on African countries for a number of rea- sons. Vectors, such as mosquitoes and flies,
The African Regional Health Report
have developed resistance to insecticides and this has reduced the impact of control measures for vector-borne diseases. For many diseases — notably HIV/AIDS and ma- laria — there are no vaccines. Another reason why control strategies may not succeed is that some pathogens quickly become drug resistant. Also, the type and severity of infectious diseases in Africa are altering due to changes in human behaviour. Outbreaks of lethal viral fevers are examples of the unpredictable consequences of changing pat- terns of land use. People are thrown into close contact with infectious agents by urban- ization, conflict, migration, tourism and trade.
Africa's climate and geography are conducive to the spread of infectious dis- eases. Mosquitoes that transmit malaria breed all year round in the hot, humid cli- mate that dominates large swathes of the continent. In areas of scrubland, sandflies transmit leishmaniasis. Blackflies that transmit river blindness (onchocerciasis) breed on the rocks of fast-running river water. Tsetse flies transmit sleeping sickness (try- panosomiasis) and ordinary flies transmit trachoma, which causes blindness. Dogs, cats and bats transmit rabies, which can be fatal for humans. Freshwater snails carry schistosomes, the parasites that cause schistosomiasis (bilharziasis).
People living south of the Sahel region and in parts of the Great Lakes region and southern Africa are at risk of epidemic meningitis. Forests harbour rare but head- line-grabbing haemorrhagic fever viruses, such as Marburg and Ebola. By cutting down the trees surrounding a village, people can expose themselves to an outbreak of one of these highly fatal diseases. Mosquitoes that transmit malaria are capable of breeding in a footprint filled with water. Other mosquitoes transmit yellow fever, lymphatic filariasis (see Fig. 3.2) and some of the haemorrhagic fever viruses. Hepatitis, typhoid and diarrhoeal diseases — including cholera and bacillary dysentery — are also frequent in cities.
Schistosomes are transmitted via fresh- water snails, while worms such as round- worm, hookworm and tapeworm are soil- transmitted. Schistosomiasis has a major impact on the healthy development of chil- dren and the quality of life of adults. Some 1 60 million people in Africa are infected with schistosomes. Schistosomiasis also contrib- utes to anaemia among pregnant women. Worms of all species are particularly prob- lematic for children aged 5- 1 4 years. Studies show that heavy infestations may impair the cognitive function of these children.
Fig 3.2
Mass drug administration for elimination of lymphatic filariasis: Population targeted versus number treated
|
50 |
|
|
45 |
|
|
c |
40 |
|
0 |
|
|
1 |
35 |
|
c |
30 |
|
0 |
|
|
5> |
25 |
|
Q. o |
20 |
|
Q. |
|
|
15 |
|
|
10 |
|
|
5 |
|
|
0 |
Target
Treated
2000
2001
2002
2003
2004
2005
Year
Source: Roungou JB. Mubila L. Dabire A. Kinvi EB. Kabore A. Progress in lymphatic filariasis elimination in the African Region. Communicable Diseases Bulletin for the African Region 2005 Mar; 3:10-1.
Infectious diseases in Africa
Chapters
The good news is that highly effective and affordable de-worming drugs exist that are safe for all groups at risk, including pregnant women. Large-scale control is technically feasible, but sustaining this control is a challenge. Worms have proved hard to combat where water supplies are poor and sanitation inade- quate. Intestinal worms tend to persist as long as people live in extreme poverty.
Guinea-worm disease and leprosy in Nigeria
Guinea worm eradication: a major public health success
Control of dracunculiasis, also known as guinea-worm disease, in the African Region has been hailed as a major public health success, but sus- taining this success remains a challenge. People become infected with guinea worm by drinking water containing water fleas that are infected with guinea-worm larvae. These larvae are reintroduced into water sources by people who are infected with the disease and who dip their feet in water. Guinea-worm disease can be prevented by filtering water with simple material, such as cloth. Global control efforts have been successful, with an estimated 97% reduction in cases from 1986 to date. Most remaining cases are in 13 Afri- can countries, where the final phase of eradication is proving difficult.
Despite years of control efforts and a measure of progress, residents in the village of Ikija in south-western Nigeria are still becoming infected, though not as much as in the past. "There was a time when we had people removing hundreds of worms from their legs. Now, the situation has really improved," said village head Isaiah Sobowale.
"Our river is basically stagnant water. We fetch water there around 5 am. After that, there is nothing left until the next morning. Officials treat the water regularly, but we need a better water supply," said farmer Lekan Fabowale, add- ing that shallow wells become infected quickly and what the village needed was a deep borehole.
; drinking-water supply is necessary for the control of guinea worm.
Curing and reintegrating people with leprosy
There are 90% fewer cases of leprosy today than 20 years ago globally, but it is proving hard to reach the last remaining cases. In the African Region seven countries have not yet reached the global elimination target of less than one case per 10 000 people. Nigeria reached that target in 2003, but is still struggling to overcome discrimination against people with obvi- ous signs of the disease and to address the disability it causes.
"Attempts to treat leprosy in Nigeria are hampered by stigma, socioeconom- ic problems and physical disability, which makes it difficult for many patients to seek help despite the fact that treatment is free," said Dr MO Lawal, the Leprosy Programme Manager in the Ministry of Health in Oyo State.
The Nigerian Government established a National Tuberculosis and Leprosy Control Programme in 1988. Lawal said that there is a long-term government plan to close down leprosy colonies and to provide a community-based treatment pro- gramme. Many people with leprosy have already left the colonies. Some live in roadside huts and beg passing motorists for alms. "My father said I could not leave education. I said, 1 must go and beg because I am a leper'. Later, I tried to get an education, but they would not accept me because I had leprosy," said Alhaji Shedu
Abdullah!, the chairman of Integration, Dignity, Economic and Advancement, a non- People with leprosy can
governmental organization which supports people with leprosy in Nigeria. lonq-lastinq disability
suffer
and improvements in nutrition and sanitation could be more effective than drug treatment in the long run.
Lessons from the successful efforts to control infectious diseases elsewhere in the world can be applied in Africa, although the continent faces different obstacles. Africa's geography, climate and political turmoil complicate the task. However, there are parts of the African Region where some infectious diseases are being tackled successfully.
Diseases for which control has been successful
Infection control has been successful in African countries where diseases have char- acteristics that make them easier to control and where these characteristics have been countered with timely and effective interventions. Diseases that are transmitted by an insect vector can be controlled as long as an effective insecticide exists and/or humans can protect themselves from contact with the vector. One simple method is sleeping under a mosquito net to avoid the night-biting mosquitoes that transmit malaria. A cheap, effective and easily administered vaccine is an invaluable tool that can render a viral pandemic, such as polio, within reach of complete eradication as is the case today.
It has proved possible to limit the spread of diseases that follow a long course but that are not easily transmissible, such as leprosy, and to limit the spread of diseases that can be controlled by simple measures, such as filtering drinking-water to prevent guinea-worm disease. These simple solutions need to be tirelessly applied to make disease control sustain- able and to lead to long-lasting improvements in public health (see Box 3. 1). 1985 2003
Leprosy
Leprosy is close to being eliminated — reduced to a prevalence of below one case per 10 000 people — in Africa despite traditional perceptions that it is both incurable and highly infectious. Since the disease is so disfiguring, people with leprosy have traditionally suffered social stigma and exclusion. Effective treat- ment exists, but case-finding can be difficult and. even today, the remaining patients scattered over large areas of the African Region have poor access to diagnosis and treatment. The Regional Strategy for Leprosy Control is a simple and effective approach, relying on early detection of cases and cure with multidrug therapy.
The prevalence of leprosy has dropped sharply because of successful application of this strategy (Fig. 3.3). Patient numbers reported to WHO'S African
Reported cases per 10 000 inhabitants
D Countries outside the African Region D 1-2 cases D Unknown • >2 cases
• < 1 case
Source: tte database of the World Health Organization. Regional Office for Africa. Brazzaville.
ifectious diseases in Africa
Chapters
Regional Office declined by over 60% from 127 500 in 1991 to 51 200 in 2003. Treatment coverage soared from 28% to 98% during this period. Over this 12-year period, a total of more than 800 000 cases were cured using multidrug therapy and no resistance has been reported. The Central African Republic, Comoros, the Democratic Republic of the Congo and the United Republic of Tanzania are approaching the elimination target. Angola, Madagascar and Mozambique still have areas that are highly endemic. Twenty-four-month multidrug therapy is effective and in routine programmes the relapse rate is only 0.1% per five-year period.
People with leprosy are no longer as stigmatized as they used to be, while medical treatment is now available to them. After these people have been cured, it is easier for them to integrate back into the community. However, in countries that are ap- proaching elimination, it is difficult to reach the last few patients living in isolated communities. Active surveillance is needed to ensure that these people are diag- nosed and treated.
River blindness
Abandoned villages along valuable stretches of river bear silent testimony to the di- lemma people face between having enough to eat and being able to see. River blind- ness, or onchocerciasis, is a parasitic disease caused by worms that are transmitted by a blackfly that breeds in turbulent river water. Seventeen million people living in West and Central Africa are estimated to be infected. Chronic infection gradually causes skin changes and blindness. People who become blind with onchocerciasis have a life expectancy only one-third of that of sighted people in the same area. The Onchocerciasis Control Programme began in 1974 by using chemical and biological larvicides to kill blackfly larvae on virtually every infested river in I I West African countries. It has become one of the Region's biggest and most successful public health campaigns. A total of 1.2 million square kilome- tres in West Africa are now completely free of onchocerciasis. Fertile land has been resettled and about 40 000 new cases of blindness per year have been prevented. As the adult worms responsible for the dis- ease live for 10-15 years, control measures have to continue for at least this time. Large-scale vector control — using aircraft to spray larvicides on rivers — has been replaced by mass treatment of people living in endemic areas with ivermectin, once or twice a year to prevent blindness and reduce residual transmission. The African Programme for Onchocerciasis Control — which was launched in 1995 — has treated 34 million people in 16 countries to date. These programmes are exemplary cases of scale matching needs in terms of infectious disease control.
The African Regional Health Report
with three decades of sustained efforts tackling this persistent parasitic disease and achieving measurable gains. By helping to eliminate river blindness as a public health problem, WHO and other partners have made a major contribution to re- ducing poverty in the African Region. Sustaining this historical success, however, remains a challenge.
Poliomyelitis (polio)
When the Global Polio Eradication Initiative was launched in 1988, wild poliovirus was endemic in 125 countries and paralysed more than 1000 children a day. By vaccinating two billion children against the disease, this enormous public health campaign has reduced the number of cases to less than 1 000 per year globally, most of which are in Africa.
In 2004. there were 935 cases of polio across over 12 countries in the African Region. 84% of which occurred in Nigeria. This was a 100% increase in the number of cases recorded in 2003. This setback, however, has to be seen in the context of tremendous progress overall. Despite outbreaks in Angola, Cape Verde and the Democratic Republic of the Congo in 2000, 31 countries have maintained a polio-free status for more than three years. Polio vaccination resumed in 2004 in Nigeria after 1 1 months' suspen- sion, and cases are subsequently decreasing. In addi- tion to mop-up campaigns following sporadic cases, routine immunization is needed to prevent the wild poliovirus from re-establishing itself.
Each country must continue surveillance for cases of acute flaccid paralysis, which can be caused by other viruses, and test stool specimens to rule out polio as a cause. This surveillance also helps to assess the cov- erage of other immunizations, and measure progress towards eradication of polio. Countries must show they are continuing surveillance and stool testing to confirm that there have been no cases of polio for three consecutive years, the point at which eradica- tion can be declared and the countries certified polio free. In 2005, 35 of the 46 countries in the African Re- gion achieved certification surveillance standards. The
eventual eradication of polio in the Region depends very much on the quality of work performed by the 16 laboratories in the Regional Polio Laboratory Network in the African Region. All members of the network kept their WHO accreditation status in 2005 — a necessary step towards a polio-free Region.
It has been an uphill struggle to eradicate polio.
Infectious diseases in Africa
Chapters
Diseases of major public concern
In contrast to the diseases which have been controlled with relative success, some diseases have persisted despite control measures and are of major public concern. HIV/AIDS, tuberculosis and malaria have become more prevalent in Africa during the last 20 years. In the case of HIV/AIDS, the failure to control the epidemic is largely due to the lack of a vaccine and the inability to change human behaviour. Tuberculosis is re-emerging where it is spurred by the HIV epidemic. The persistence of malaria is due to inadequate vector control and drug resistance.
HIV/AIDS
Africa is the region of the world most affected by the HIV/AIDS pandemic. It has about 1 1 % of the world's population but is home to more than 60% of all people in the world living with HIV infection. In 2005, an estimated 25.8 million people were living with HIV/AIDS, 3.2 million people became infected with the virus and 2.4 million people died of AIDS in the Region. In 16 countries in Africa, at least 10% of the population is infected.
Heterosexual transmission of HIV is the predominant mode in Africa. Some 5.7% of infected adults are women. Of young people who are infected, 75% are women and girls (see Fig. 3.4). Many factors contribute to the spread of the virus, namely commercial sex, sexual violence, population mobility, poverty, social in- stability, lack of education, high levels of sexually transmitted infections, stigma and discrimination.
The HIV epidemic has had disastrous ef- fects on African society through its destruction of individuals, families, health systems and the public sector. Nevertheless, countries in the Region have made efforts to prevent the spread of HIV. Most countries are mounting an inter- sectoral response to the epidemic, in which different ministries and agencies are working together. These responses are led by national AIDS councils many of which are chaired by heads of states, such as in Angola and Burundi. Mass media and information campaigns for the general public are also being implemented in many countries, including programmes target- ing young people and other vulnerable groups, The past decade has seen real advances in Girl weeping after their mother died of HIV/AIDS the treatment of HIV/AIDS and its complications.
Antiretroviral (ARV) drugs lower the level of HIV in the blood and postpone the development of opportunistic infections, allowing people to regain a good quality of life. ARV medicines are also extremely effective in preventing mother-to-child transmission of HIV during pregnancy and birth, and — as the price of these drugs has decreased — their widespread availability is a realistic target even for poor countries.
WHO and UNAIDS declared the lack of access to ARV medicines to treat HIV/ AIDS in developing countries a public health emergency in 2003. Since then, the two agencies and their partners have campaigned to scale up ARV treatment as part of the "3 by 5" initiative to put three million people with HIV/AIDS on antiretroviral therapy (ART) by the end of 2005. By December 2005, the number of people living in sub-Saharan Africa receiving ART had increased more than eight-fold to 810 000 from 100 000 over the two-year period. Of the three million people targeted by "3 by 5", 2.3 million live in sub-Saharan Africa. WHO and its partners have
Fig. 3.4
HIV prevalence among 15-24-year-olds in selected sub-Saharan African countries, 2001-03 20
15
f,
1
Men
Women
Niger (2002)
Mali (2001)
Burundi (2002)
Kenya (2003)
Zambia (2001-02)
South Africa (2003)
Zimbabwe (2001-02)
Sources: Burundi (Enquete Nationale de Seroprevalence de I'infection par le VIH au Burundi. Bujumbura, Decembre 2002). Kenya (Kenya Demographic and Health Survey 2003). Mali (Enqu&e Dgmographique et de Santa Malt 2001). Niger (Enqueue Nationale de Seroprevalence de I'infection par le VIH dans la population generale agee de 1 5 a 49 ans au Niger (2002)). South Africa (Pettifor AE, Rees HV, Steffenson A. Hlongwa-Madikizela L, MacPhal C. 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 Demographic and Health Survey 2001-2002). Zimbabwe (The Zimbabwe Young Adult Survey 2001-2002) .
fectious diseases in Africa
Chapters
Activists give hope to people with HIV in Burundi
Testing positive for HIV in the 1980s or 1990s in Burundi was like a death sentence. In the absence of treatment and with the common belief that it was a punishment sent by God, many people succumbed to despair, abandoned by their families, who were unaware of the reality that HIV/AIDS is a treatable and preventable disease.
Three associations have been set up in Burundi to educate people more about the disease, to fight discrimination against people with HIV/AIDS and to provide support for them: the Burundian Society for Women Against AIDS in Africa (SWAA) formed in 1 992, the Asso- ciation for the Support of HIV Positive People (ANSS) and the Reseau Burundais des Personnes vivant avec le VIH/SIDA (RBP+ Network of HIV-positive people). These associations encourage Burundians to be tested for HIV, give hope and strength to HIV-positive people to stand up for their rights and, among their many other public health activi- ties, raise awareness about the dangers of HIV.
Years of lobbying has produced results. Activists have started dis- cussing on television what it means to be HIV positive — which had been a major taboo. The Burundian Government responded by propos- ing a new law against discrimination of HIV-positive people. This was adopted by the national assembly in March 2005. Adrienne Munene, who is in charge of counselling with RBP+, said that the law would help people such as an HIV-positive nurse, who was hired in 2000 by a private health centre in Bujumbura but never given a contract. "They kept telling her that she was not like others," Munene said.
Activists have also lobbied hard for treatment for people with HIV and persuaded the government to waive taxes on antiretroviral drugs. The government has also agreed to subsidize these drugs with help from the Global Fund to Fight AIDS, Tuberculosis and Malaria, and it has also negotiated with pharmaceutical firms to reduce the cost of therapy from US$ 96 to US$ 30 per person per month.
Today more than 4000 Burundians receive free antiretrovirals. HIV-positive people in that country expect to live longer thanks to
support they receive from their associations and to subsidized treat- ment. But despite their achievements, these associations are over- stretched. Dr Marie Jose Mbuzenakamwe, ANSS Coordinator, said they cannot cope with increasing demand for testing and support. She believes that all health facilities should provide HIV services so that these patients have access to treatment without travelling long distances.
The National AIDS Council has already identified hospitals and associations to help with distribution of antiretrovirals and related services but not all have adequate facilities and human resources. There is a shortage of diagnostic kits and associations fear that if donor funding dries up patients will be cut off from a drug supply.
This kiosk is run by the Burundian Society of Women Against AIDS in Africa (SWAA). People come here to buy condoms and booklets on HIV. They can also watch videos on HIV/AIDS here at certain times of the day.
helped 24 high-burden countries in the Region to train more staff to deliver ART. ART coverage is expected to increase further due to solid commitment from those involved, in particular, people living with HIV/AIDS and their governments (See Box 3.2). Rapid expansion of treatment to many more people with HIV/AIDS is expected to contribute further to the lowering of ARV prices (See Box 3.3).
At least 90% of people living with HIV/AIDS across the African Region do not know that they are HIV-positive, and HIV tests are often expensive and not always available. But now that ARVs are becoming more widely available, more people will be encouraged to come forward to be tested for HIV. To encourage people to do this and to make testing services more widely available, WHO and UNAIDS have developed regional guidelines on voluntary counselling and testing (VCT)
How Cameroon secured lower prices for antiretrovirals
and have issued a policy statement on the provision of HIV testing and counsel- ling services.
Twenty-eight countries — including 21 high-burden countries — have developed plans to scale up ART with the support of WHO and its partners, and 20 countries have developed plans to monitor and evaluate ART as they roll out the treat- ment. Botswana. Cote d'lvoire and Lesotho are expanding people's access to treatment by taking the logical first step of providing universal HIV testing and counselling. VCT guidelines have been developed in at least 29 countries, including all 24 high-burden countries. These are the countries where HIV prevalence of women attending ante- natal clinics is above I % and where preva- lence of HIV/AIDS among high-risk groups is 5% or more.
The Region is also making progress in rolling out a simplified public health ap- proach to ART delivery based on the Inte- grated Management of Adult and Adoles- cent Illness (IMAI) approach. Thirty-three countries have developed and adapted their own simplified guidelines, based on the IMAI model, for delivering and rolling out ART to more people in need. These tools are con- tinuously being updated based on the best available international evidence. Moreover, Regional Knowledge Hubs for HIV/AIDS Treatment and Technical Resource Networks ^^^—^^^^.^^^^^^^B of experts in ART have been established for East/Southern and West/Central Africa.
WHO and partners are helping at least 1 6 countries in the Region to improve laboratories to provide HIV testing and CD-cell count services. With an increase in demand for ARV medicines. WHO and its partners are training staff in 3 1 countries in the Region to develop procurement and supply management plans and helping countries across the Region to monitor HIV drug resistance, as part of efforts to provide appropriate treatment and care for everyone in need.
While progress has been made in the fight against HIV/AIDS in the African Region, significant challenges remain. The scarcity of diagnostic services and surveillance mecha- nisms makes it difficult to measure the incidence and prevalence of opportunistic infections. The most widespread opportunistic infection is Pneumocystis jiroved
Negotiating more affordable prices for anti- retrovirals has helped many poor countries deliver more of these life-saving drugs to more people who need them. Meanwhile, generic pharmaceutical companies who manufacture copies of the original pat- ented drugs have helped to push prices further down.
UNAIDS. WHO and other UN agen- cies established the Accelerating Access Initiative in 2000 with seven pharmaceu- tical companies: Abbott Laboratories, Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Gilead Sciences, Merck & Co., Inc. and Roche.
The combination of the UN initiative and pressure from generic manufacturers of antiretrovirals has helped Cameroon obtain these drugs at prices that have de- creased from USS 10 000 per patient per year to about USS 300 in the space of a few years.
Cameroon has also removed import duties and taxes on essential medicines. a further obstacle to providing the life-
saving medicines. The Cameroon experi- ence shows the simple steps that can be taken to provide antiretrovirals to people in need even with limited resources.
First. Cameroon negotiated with drug manufacturers to lower the price of anti- retrovirals to USS 50 per patient per month in earty 2001 . then the country won a further re- duction to USS 40 in mid-2002. By early 2003 — with generic competition growing — the price dropped further to about USS 30 per month for the first-line regimen. If a patient does not respond to the first-line regimen, they are given second-line treatment
Some countries — including Botswana, Burkina Faso, Burundi, Ethiopia, Mali, Mauritania, Senegal and Zambia — pro- vide first-line treatment free to patients, while others such as Cameroon charge USS 8-9 a month and the government covers the remaining costs. Since October 2004, Cameroon has been able to offer its citizens first-line regimen at USS 6-9 per month and second-line at USS 14-20 per month.
Infectious diseases in Africa
Chapters
pneumonia, which is responsible for the vast majority of AIDS-related deaths in children. Following studies in Cote d'lvoire, UNAIDS has recommended trimethroprim- sulfamethoxazole prophylaxis for HIV-infected adults and children.
Some people have called for universal prophylaxis for HIV-positive children to prevent deaths from opportunistic pneumonia. Plans are also under way to imple- ment preventive programmes for children in Senegal and Uganda. A vaccine for HIV and an effective microbicide gel to protect women have yet to be developed. The most powerful rallying point for HIV activists has been their campaign for access to ARVs, as these drugs are the only way to reduce complications of HIV/AIDS, prolong life and prevent mother-to-child transmission.
WHO's African Regional Office declared 2006 "the year of HIV prevention in the African Region". The aim of the campaign is to make media, governments and people in the Region as well as development partners, other stakeholders, and the global HIV prevention and control community more aware of the HIV/AIDS epidemic.
The need for further rapid scale-up of HIV/AIDS treatment and prevention in the Region raises many issues: how do countries sustain rapid expansion of treat- ment in the long-run without neglecting overall health system development? How can prevention be better funded and scaled up to make testing and counselling services more widely available? How can countries galvanize support from all government sectors for these public health efforts S to prevent and treat HIV/AIDS, a disease that affects all public and private sectors.
A Tuberculosis
Tuberculosis is one of the world's oldest infectious diseases. Although there has been an effective, affordable and acces- sible cure for the disease since the 1950s, the disease still *V kills over 1.6 million people every year globally. In the , African Region alone, there are an estimated 2.4 mil- lion new tuberculosis cases and half a million tuber- culosis-related deaths every year. In 2003, the Region
— which is home to I 1% of the world's population
— accounted for 24% of notified cases. Nine of the 22 high-burden countries that are responsible for
80% of all new tuberculosis cases are in this Region: the Democratic Republic of the Congo (DRC), Ethiopia, Kenya, Nigeria, Mozambique, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe. Eleven of the 15 countries with the highest incidence are also in the Region: Botswana, Kenya, Lesotho, Malawi, Namibia, Sierra Leone, South Africa, Swaziland, Uganda, Zambia and Zimbabwe.
The incidence of tuberculosis in the Region has increased in tandem with the HIV/AIDS epidemic. People with HIV easily contract tuberculosis
infections because of their weakened immune systems and go on to develop active tuberculosis. People with healthy immune systems recover easily from primary tuberculosis infection and have only a 10% chance of re-developing tuberculosis in their lifetime. In contrast, it is estimated that one-third of people who died of tuber- culosis in 2003 in the African Region, were HIV positive.
On average, about one-third of tuberculosis patients notified in countries in the African Region are co-infected with HIV, and in most countries in southern Africa — such as Lesotho. Malawi, South Africa. Swaziland, Zambia and Zimbabwe — over two- thirds of children and adults with tuberculosis are co-infected with HIV. Tuberculosis is increasingly occurring in younger, economically productive members of society in this Region, especially girls and women, closely resembling the trend of HIV prevalence.
The recommended method for diagnosing tuberculosis is through sputum smear microscopy. The need for specialized equipment and skilled personnel to per- form this test places limitations on the availability of diagnostic services. This has been complicated further by the fact that sputum microscopy in tuberculosis/HIV co-infected people is not as effective in picking up tuberculosis as in people who are not infected with HIV. With an increasing number of tuberculosis cases that are due to co-infection with HIV, more and more cases of tuberculosis are not being picked up. As a result of co-infection, tuberculosis is occurring increasingly in people aged 1 5-49 years. Children under five years of age are the most susceptible members of a population to tuberculosis due to HIV infection, while those aged 3-15 years are relatively resistant. The risk of an HIV-positive mother transmitting HIV to her child is 25-48% in the absence of treatment to prevent mother-to-child transmission and these HIV-positive children have a high risk of contracting tuberculosis.
Unfortunately, tuberculosis is difficult to diagnose in children, as its signs and symptoms are not specific. Also, because the tuberculin test in HIV-positive children is often negative, many children with tuberculosis are not diagnosed and do not receive treatment. Furthermore, children do not produce much sputum on demand, and mi- croscopy tends to yield negative results due to relatively small numbers of active bacilli. It is estimated that only half of existing infectious tuberculosis cases in Africa are being detected and put on treatment. Among those put on treatment, about a fifth of them are lost to follow up before completing treatment.
The DOTS strategy, the most effective approach for combating tuberculosis, has been successfully implemented in the African Region. The strategy depends on government commitment, high-quality microscopy for diagnosis, reliable supply of high quality short-course anti-tuberculosis drugs administered under appropriate conditions, including direct observation of drug taking at least for the initial intensive phase of treatment as well as a system to monitor and evaluate case-finding and treatment outcomes.
Close supervision means better cure rates, fewer relapses and prevents drug resistance. However, the growing shortage of trained health workers in the African Region is making this very difficult to achieve. A course of treatment lasts six to eight months. This lengthy time frame is a burden on both patients and the health-care provider system. New shorter-course drugs are urgently needed.
With an increasing number of tuberculosis cases that are due to co-infection with HIV, more and more cases of tuberculosis are not being picked up.
ifectious diseases in Africa
Chapters
BCG (bacille Caimette-Guerin) vaccination is routinely given to newborns in the African Region. However, even though the BCG vaccine protects people against severe forms of tuberculosis, it has only a minimal effect in preventing pulmonary tuberculosis and therefore does little to reduce the global burden of tuberculosis. A new more effective vaccine is clearly needed.
Multidrug-resistant strains are not yet a significant problem in the African Re- gion, but occur nevertheless in some places. Thus multidrug-resistant tuberculosis needs to be contained and treated, and the interaction with the HIV epidemic needs to be studied further. Interventions for people infected with both tuberculosis and
HIV and tuberculosis in South Africa
HIV/AIDS and tuberculosis are compounding one another to devastat- ing effect in parts of the African Region. The realization that it will be impossible to curb the spread of HIV and reduce mortality from AIDS without tackling tuberculosis has led to an upsurge in initiatives to treat the two diseases in tandem and to support people infected with both.
It was estimated that in 2003 more than 100 000 people were co-infected with HIV and tuberculosis in South Africa, the highest number in any country in the world. The country has the thirteenth- highest prevalence of tuberculosis cases globally and an estimated 61% of these people in South Africa with tuberculosis are also in- fected with HIV.
The Massive Effort Campaign, a non-profit organization, tries to combine efforts to combat tuberculosis, HIV and malaria. "Tuberculosis is now the most important killer of people with HIV/AIDS in South Africa. Yet, it is an easily treated and curable disease: the drugs and diagnosis are free and accessible everywhere in the country," said the campaign's regional coordinator, Patrick Bertrand.
The ProTEST Initiative, sponsored by WHO-UNAIDS, has provided the anti-tuberculosis drug isoniazid to HIV-positive people to prevent them from developing active tuberculosis. ProTEST has run pilot programmes in the Eastern Cape, KwaZulu-Natal and the Central and Western Cape. Another initiative, the Raphael Centre in Grahamstown, Eastern Cape, was set up and is run by volunteers. The centre provides residents of the local townships with counselling, support and practical assistance to help them comply with treatment and come to terms with the diagnosis of both dis- eases. The Raphael Centre also provides on-the-spot HIV testing, one of the first steps recommended by ProTEST to combat the dual epidemic.
Xoliswa Mjuleni, who visits the centre regularly, found out she was HIV positive in 1999. Initially she was terrified but after she started going to the centre she gained confidence, new friends and "a reason to live". "We support each other. It doesn't always help having someone
who has not experienced it telling you HIV is not the end of the world. It is so much better to have someone who knows exactly what it is like to live with HIV, someone who has the same problems, the same pain."
The challenges in treating the dual infection are many. The stan- dard tuberculosis smear test is often negative in HIV patients which can delay starting treatment under tuberculosis protocols. Delays in test re- sults can prove fatal and many tuberculosis patients are reluctant to be tested for HIV because of the stigma associated with the disease. WHO and national guidelines recommend first treating patients with the six- month course of directly observed tuberculosis treatment before moving on to antiretroviral (ARV) drugs for HIV/AIDS. For tuberculosis patients with advanced clinical symptoms of AIDS, the alternative is to give two months of tuberculosis treatment then start on ARV drugs. But for some patients the only option is to begin tuberculosis and ARV treatment simultaneously, which can mean taking 10 to 12 pills three times a day.
Skilled microscopists are an essential part of tuberculosis control efforts.
HIV, such as chemoprophylaxis with isoniazid for 6-12 months, have proved to be effective in reducing the incidence of tuberculosis in HIV-positive people. This inter- vention is being provided in some countries, but has not yet been implemented on a wide enough scale for significant impact (see Box 3.4). The battle against tubercu- losis has not yet been won in the African Region and was declared a public health emergency by the Regional Committee in 2005.
Malaria
Malaria causes untold human misery as well as economic and social devastation in the African Region, where it is endemic in 42 of the 46 Member States. Estimates show that countries in Africa with endemic malaria have 1.3 percentage points less economic growth per annum compared with similar non-endemic countries, and that the annual cost of lost productivity and providing treatment for malaria in the Region is about US$12 billion.
Africa accounts for over 90% of an estimated 300-500 million clinical cases of malaria that occur in the world every year. Children in Africa account for some 90% of nearly one million malaria-related deaths estimated to occur annually in children worldwide. Malaria contributes significantly to anaemia in pregnant women, and malaria-related anaemia is estimated to cause 10 000 maternal deaths each year. In addition, malaria contributes to low birth weight in newboms.
At a meeting in Abuja. Nigeria, in 2000, African heads of state and govern- ment acknowledged the heavy disease burden due to malaria and agreed to reduce its impact through universal implementation of tried and tested interventions. They pledged to provide access to treatment to at least 60% of people with symptoms of the disease within eight hours of onset by 2005 and to halve the number of malaria deaths in the Region by 2010. Also by 2005, they pledged to provide at least 60% of pregnant women in endemic areas with preventive doses of antimalarial drugs and to ensure access to insecticide-treated nets for at least 60% of vulnerable population groups, particularly children aged less than five years and pregnant women. This concerted effort, however, faced major challenges and these goals were not met. Among those chal- lenges, climate change has helped to expand mosquito habitats, insecti- cide resistance has made it more difficult to control the vectors, and the emergence and spread of drug-resistant parasites has rendered affordable treatments that were once effective, completely useless.
Other factors also make it difficult to overcome malaria. Concur- rent infections with HIV have also increased the overall malaria disease burden. Malaria has re-emerged in areas where conflict and civil unrest have destroyed health systems and/or driven refugees from non-endemic areas into areas that are highly malarious, sparking epidemics.
Treating mosquito nets with insecticide increases their efficiency.
factious diseases in Africa
Chapters
Environmental control, such as the removal of standing water, and the use of bednets are two effective means of controlling malaria, but the scale of the need for simple interventions such as these is daunting. Insecticide-treated nets have been shown to reduce transmission of malaria by 50% and the need to re-apply the insec- ticide has been circumvented by development of nets with insecticide incorporated into the fibres and which do not require re-treatment. Eight and a half million insecti- cide-treated nets were distributed in 2003, bringing the total number in Africa to 20 million. But with 650 million people at risk of infection, and the fact that most insec- ticide-treated nets only last up to about three years, many people are still not be- ing protected from the malaria-bearing mosquitoes that bite at night.
It seems unlikely that all the Abuja targets will be met as fewer than 5% of the population at risk and only 3% of children under five years old were sleeping under ITNs, according to the \Vor/d malaria report 2005.
Studies done in Kenya showed insec- ticide-treated nets significantly improve the health of pregnant women and chil- dren, and that the benefits were extended through decreased transmission to house- holds that did not have nets. The best argument for persisting with this simple but effective means of malaria control is il- lustrated in countries such as Eritrea, where nets are distributed free of charge (Fig 3.5). Since the Second World War, at- tempts to control mosquitoes have been less successful in Africa than in the Ameri- cas. Indoor residual spraying with DDT and other insecticides can be an effective method for mosquito control, especially during epidemics and emergencies. WHO recommends that countries select insecticides according to local needs. At least 10 African countries include indoor residual spraying as part of their malaria control efforts.
From the 1 970s to the 1 980s, malaria was reasonably well controlled in much of East Africa, as cheap and affordable drugs such as chloroquine and sulfadoxine- pyrimethamine were readily available. Today cheap and effective treatment for malaria with one drug — known as monotherapy — is no longer an option for most countries in Africa because of drug resistance. Chloroquine, amodiaquine and sulfadoxine-
|
Fig. 3. Trends nets (1 700 •y 600 1 500 § 5 400 | 300 3 Z 200 100 0 Source: |
in incidence of malaria cases and distribution of insecticide-treated FNs), Eritrea (1997-2004) |
|
- ITNs distributed |
|
|
Malaria cases |
|
|
/ |
|
|
/ |
|
|
/ |
|
|
7_ y^—^ |
|
|
.^ -^^ |
|
|
1997 1998 1999 2000 2001 2002 2003 2004 Year the database of the World Health Organization, Regional Office for Africa, Brazzaville. |
The African Regional Health Report
pyrimethamine are still effective medicines for malaria in other parts of the world but now fail widely in Africa. That leaves many countries with little choice but to purchase drugs that are more effective but also more expensive (see Box 3.5).
No resistance to artemisinin combination medicines has been reported to date, but many African countries simply cannot afford the US$ 2 per adult it costs for a
Treating malaria in Ethiopia
Like many countries in the African Region, Ethiopia faces a malaria treatment crisis due to increasing resistance of the malaria parasites to common drugs. Recent experience shows the benefits of switching from old drugs to new effective com- bination therapies, which are currently more expensive.
When Ethiopia adopted the antimalarial artemether- lumefantrine for first-line treatment, the impact on the remote district of Kafta Humera Wereda was dramatic. "The people were fed up taking the old drugs and them not working, again and again," said Seyoum Dejene, an Ethiopian doctor working there. "The people like it: they call Coartem a 'miracle drug'." he said, referring to one brand name of artemether-lumefantrine.
More than 100 000 migrant workers pour into Kafta Humera Wereda every year from August to November to help with the harvest, adding to a resident population of 65 000. These months coincide with the peak of the malaria season, which starts as the rains end in September. Many migrants from the highlands — where malaria is not endemic — do not have natural immunity to the disease. They sleep outside with no protection from the mosquitoes and have poor access to health services, and so many get sick. The presence of so many migrant work- ers can trigger a malaria epidemic, as these people are more susceptible than the resident population.
In 2003. about 45 000 people died in a malaria epidemic in Ethiopia largely because of parasite resistance to old antimalarial drugs. Jo Mesure, former medical coordinator of Mede- cins Sans Frontieres (MSF) in northern
Ethiopia, recalled how until 2004, when the government ap- proved artemether-lumefantrine for first-line treatment, staff had to give people two drugs, sulfadoxine-pyrimethamine and chloroquine, to treat suspected falciparum malaria, knowing that these drugs were ineffective. Artemether-lumefantrine is one of a group of drugs, known as ACTs or artemisinin-based combina- tion therapies, which are the only antimalarials that currently face no resistance. But at US$ 0.60 to treat a child and US$ 2 to treat an adult, these cost 10 times more than the older drugs.
According to Mesure, the effect of the change in drug policy was immediate and dramatic. Manica Balasegaram, who led an MSF study to inform the Ethiopian national drug policy, agreed: "Before we started the project we had reports from the health staff of people being treated seven to eight times with SP (sulfadoxine-pyrimethamine) — it just was not working."
Patient in Kafta Humera Woreda receiving artemether-lumefantrine for treatment of malaria.
ifectious diseases in Africa
Chapters
Fig 3.6
Status of malaria drug policy change and implementation in the African Region as of July 2005
Adopted and implementing ACT* policy
Adopted but not implementing ACT policy
Implementing other policies
Countries outside the WHO African Region
* Artemisinin-based combination therapy drugs (ACTs).
18 countries in the African Region have switched their malaria drugs policy to ACTs
Source: the database of the World Health Organization, Regional Office for Africa, Brazzaville.
course of artemether-lumefantrine, the only fixed-dose artemisinin-based combi- nation currently on the WHO Essential Medicines List. A recent trial in Mbarara, Uganda, showed that unsupervised administration of artemether-lumefantrine was as efficacious as directly supervised treatment, offering some hope for the feasibil- ity of widespread use in a Region where public health efforts are often hampered by a shortage of trained health workers. Drug resistance and the change in drug policy (Fig. 3.6) in about 1 8 countries all at once in 2004 has led to a surge in global demand for artemisinin and some efforts are under way to increase supply. For example, farmers, in the United Republic of Tanzania have started to grow the shrub from which artemisinin is obtained. The active ingredient is being extracted, made into pills abroad and being shipped back to the United Republic of Tanzania and other African countries. The plan is eventually to produce tablets locally to meet domestic demand.
Another area of concern for malaria control is drug quality and regulations. Countries in Africa are improving drug regulations to adapt to the use of the new antimalarial drugs and meet inter- national standards. Countries are also working on their pricing policies as ex- pensive drugs could be re-sold on the street or counterfeited. When the street value is high, deaths increase either way. This is because the malaria parasites de- velop resistance when some patients fail to complete their course of treatment and because hoarding or reselling drugs encourages incorrect use. People unsus- pectingly buy counterfeit drugs because they may be cheaper.
In areas where malaria is endemic, fever is often attributed to malaria and people often take antimalarial drugs without being diagnosed properly. It is essential to balance the provision of timely access to drugs with specific diagnosis, but this balance is difficult to achieve when coun- tries lack sufficient numbers of adequately trained health workers in communities where the burden of disease is greatest.
The African Regional Health Report
Intermittent preventive treatment — in the form of two or three doses of sulfadoxine-pyrimethamine during pregnancy — reduces maternal anaemia and the risk of low birth weight in newborn babies. Intermittent preventive treatment of preg- nant women has been implemented in Kenya. Malawi, Uganda, the United Republic of Tanzania. Zambia and Zimbabwe.
Insecticide-treated nets, intermittent preventive treatment during pregnancy and artemisinin combinations for diagnosed infections cost US$ 2-8 per person per year, depending on how many of these three simple antimalarial measures are applied, according to WHO's Regional Office for Africa. In many African countries, some people cannot afford to pay this much for only one of the many health problems they encounter, and that is why subsidized treatment is needed to make progress. Fewer than 5% of the population at risk and only 3% of children under five years old were sleeping under ITNs, according to the World malaria report 2005.
Coverage for intermittent preventive treatment for pregnant women in the Region is low, and the number of people receiving effective antimalarial medicines within 24 hours of onset of symptoms also remains low and is made worse by in- creasing drug resistance. A total of 33 of the 42 malaria-endemic countries in the Region have adopted artemisinin combinations as first-line treatment, but only nine of these are currently implementing such treatment policies.
Diseases that are prone to cause epidemics
The last two decades have seen the re-emergence in Africa of diseases that are prone to cause epidemics as well as new diseases, all of which require rapid and appropri- ate response. Countries of the African Region started implementing integrated disease surveillance and response (IDSR) systems as an important step to tackling outbreaks of diseases — such as cholera, meningitis. Lassa fever, yellow fever, hepatitis E, dysentery, plague, malaria and leptospirosis — that can trigger epidemics. These surveillance systems have led to improved epidemiological reporting and outbreak detection, as well as better laboratory confirmation, data analysis and use of information.
Thirty-nine of the 46 Member States have developed integrated disease sur- veillance and response guidelines. A review of 15 countries in the Region in 2004 showed that a median of 82% of districts were submitting epidemiological reports on time and that 50% of districts notified suspected disease outbreaks within two days. These initial findings show significant progress.
WHO'S Office for the African Region is helping countries build and reinforce these systems. A comprehensive regional database for communicable diseases has been set up and by the end of 2004. 26 countries were submitting monthly disease surveillance reports on time. WHO has established a rapid response network of 54 experts to provide technical support to countries in the event of an outbreak or epi- demic. Emergency stocks of drugs, vaccines, equipment and reagent have also been made available to countries in need.
JJje last two decades have seen the re-emergence in Africa of diseases that are prone to cause epidemics as well as new diseases, all of which require rapid and appropriate response.
Infectious diseases in Africa
Y
Raising the profile
of neglected diseases
is the first step towards
curing them.
WHO has in recent years helped to establish a network of national public health laboratories in Member States to improve each country's outbreak investigation and report those to the Region's central epidemiological database. In 2004. all major outbreaks in the Region were confirmed through this regional public health labora- tory network. WHO has also helped train staff from Member States to run integrated disease surveillance and response systems. The main challenge in future will be to scale up these systems to every district in every Member State and to ensure the delivery of timely analysis of data and use of surveillance information as the basis for effective health interventions. Another challenge is to sustain the commitment of national authorities and partners to providing adequate resources and funding for these systems.
Neglected diseases
Neglected diseases — such as sleeping sickness, visceral leishmaniasis and Buruli ulcer — continue to take their toll in the African Region, but they no longer figure on the disease-control agenda of the developed world. Progress has stalled on drug research and development to treat these diseases, but they still have a considerable impact on human development in the Region and have become worse while efforts have focused on other diseases.
Raising the profile of neglected diseases is the first step towards curing them. Renewed awareness of these diseases and their devastating impact is as badly need- ed in the Region as the final stages towards attaining the much-publicized goal of eradicating polio. The Drugs for Neglected Diseases Initiative was launched in 2003 to promote the development of drugs for diseases such as sleeping sickness, which affects 500 000 people in 36 African countries, but for which the only effective drug is highly toxic and must be given intravenously. Buruli ulcer is another disease that does not attract adequate funds to fight it but happens to be the most common mycobacterial infection after tuberculosis and leprosy. Buruli ulcer cases have been found in 30 countries worldwide, 1 7 of which are in the African Region, according to the Global Buruli Ulcer Initiative. Surgery can be used to treat Buruli ulcer, but it has recently been shown that the drugs used for treating other mycobacterial diseases, such as leprosy and tuberculosis, have some effect on the ulcers. Of 1450 new drugs that have gone on the global market since the 1 970s, only 13 target the diseases that mainly affect poor people in the tropics of which Africa has by far the greatest share, according to the Drugs for Neglected Diseases Initiative.
Conclusion: Learning from past success
The examples of successful disease control: smallpox, leprosy, polio, guinea-worm disease and river blindness show that the huge burden of infectious diseases in Africa can be reduced by better use and wider application of current knowledge and techniques. Political will backed by financial support are the crucial prerequisites to scaling up the tried and tested control methods that are specific to each disease. Effective disease control is eminently feasible given a judicious mix of environmental control, mass chemotherapy, vaccination, case detection, treatment and prevention strategies. For HIV/AIDS, there has been significant progress in improving access to ARV medicines. In the first half of 2005. most African countries reported that demand for ARV treatment was outstripping their capacity to supply it, and stressed their urgent need for increased resources and technical support to maintain their momentum in scaling up this treatment.
Interventions need to be implemented on a large scale and be above critical levels of coverage; they also need to be sustained in order to have an impact. More research and development leading to good vaccines for malaria and HIV and to a more effective vaccine for tuberculosis would prevent the greater part of infectious- disease-related deaths in the African Region and go a long way to meeting MDG 6 (see Box 3.6). More aid is needed for this research and development, as well as for capacity building in public health. The World Bank estimates that it will take a ten- fold increase in current aid levels to bridge the financing gap of US$ 25-40 per person per year it estimates are needed for basic public health in the low-income countries of Africa. Meanwhile, more use of available solutions is also an imperative: better distribution of insecticide-treated nets; very high coverage of routine immunization with recommended vaccines; effective drugs for malaria where and when they are needed; universal testing for HIV; prevention of mother-to-child transmission; and targeted HIV prevention for high-risk and vulnerable groups, such as sex workers.
Finally, more collaboration is needed to provide adequate food and clean water, and to promote safe sex. This combined effort would bring the African Region closer to achieving the Millennium Development Goals than any disease- specific intervention. •
MDG 6: HIV/AIDS, malaria, and other diseases
The MDG 6 target for HIV/AIDS — the leading cause of morbidity and mortality in the African Region — is to halt and reverse the spread of the virus by 2015. Progress is measured by HIV prevalence among pregnant women aged 15-24 years, condom use and the number of children orphaned by the epidemic. The MDG 6 target for malaria, tuberculosis and other major infectious diseases is also to halt and reverse their spread by 201 5. Progress is measured by prevalence and deaths associated with malaria and the proportion of the population in endemic areas using effective malaria prevention and treatment measures. For tuberculosis, progress towards the target is measured by prevalence and deaths due to tuberculosis and the proportion of cases detected and cured under the DOTS strategy.
The HIV/AIDS epidemic is most severe in southern Africa, with more than 15% prevalence among pregnant women aged 15-24 years
Incidence of tuberculosis* (rate) by WHO Region
Western Pacific South-East Asia
Europe Eastern Mediterranean
Americas Africa
L 12004 D 1990
100
200
300
400
* Estimates for incidence of smear positive tuberculosis cases include patients with HIV. Estimates for all years are re-calculated as new information becomes available and techniques are refined, so they may differ from those published previously. See Explanatory notes on page 149 for further details. Data can be downloaded from www.who.int/tb
Source: WHO report 2006 Global tuberculosis control - surveillance, planning, financing
in eight countries in 2003-2004. According to the World Bank, the epidemic in sub-Saharan Africa has risen steadily from a prevalence of just under 3% in 1990, taken as the baseline for measuring progress on the MDGs, to just over 7% in 2000. In 2005, HIV prevalence of adults aged 15-49 was estimated at 5.8%. This lower estimate for the African Region is partly due to an expansion of surveillance in rural areas where prevalence is lower. There are no clear signs that HIV prevalence is declining in southern Africa, where exceptionally high infection levels continue in some countries.
A major obstacle to tracking progress towards achieving the target of reducing the burden of malaria is the limited availability of data. Most people with malaria in Africa are treated at home. Therefore, reported cases from countries are not a reliable way to measure prevalence. Better data collection is needed to measure progress in fighting malaria.
Estimates and ranges for adult HIV prevalence (ages 15-49) in 2005 by WHO Region
Western Pacific j 0.1% 2%]
South-EastAsia [J 0.7% [0.5'
Europe Qj 0.5% 1 0.3% -0.7%]
Eastern Mediterranean I 0.2% [0.1% - 0.3%]
Americas H 0.6% [0.5% - 1.1%]
Africa I
5.8% 15,1% -6.5%]
01 234567
Figures in brackets are the range. Source: UNAIDS/WHO, May 2006.
Bibliography
• 2004 report on the global AIDS epidemic 4th global report Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS)
2004. UNAIDS document UNAIDS/04.16E. Available from: http://www.unaids.org/bangkok2004/GAR2004Jitrnl/ GAR2004_00_en.htm
• 2006 report on the global AIDS epidemic a UNAIDS 10th Anniversary Special. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS) 2004. Available from: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp
• Africa malaria report 2003. World Health Organization/UNICEF 2003. http://www.rbm.who.int/amd2003/amr2003/amr_toc.htm
• AIDS in Africa: three scenarios to 2025. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2005. UNAIDS document UNAIDS/04.52E. Available from: http://www.unaids.org/en/AIDS+in+Africa_Three+scenarios+to+2025.asp
• 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.
• Ait-Khaled N. e Enarson D. Tuberculose Manuel pour les etudiants en Medecine. World Health Organization et L'Union Internationale Contre la Tuberculose et les Maladies Respiratoires. Available from: http://www.tbrieder.org/publications/ students_fr.pdf
• Anti-tuberculosis drug resistance in the world report no. 3. Available from: http://www.who.int/tb/publications/who_htm_ tb_2004_343/en/
• Bide L, Regional Advisor, Leprosy Elimination Programme, DDC Division, AFRO. Annual leprosy situation reports.
m Chitsulo L, Engels D, Savioli L, Montresor A. The global status of schistosomiasis and its control. Acta Tropica 2000;77:41-51
• Cohen D. Human capital and the HIV/AIDS epidemic in sub-Saharan Africa. Geneva: International Labour Organization; 2002.
• Communicable diseases in the WHO African Region 2003. Division of Prevention and Control of Communicable Diseases. WHO Regional Office for Africa; 2004.
• Global tuberculosis control: surveillance, planning, financing. Geneva: World Health Organization; 2005. WHO document WHO/HTM/TB/2005.349.
• Global Partnership to Roll Back Malaria. World malaria report 2005. Geneva: World Health Organization and UNICEF. 2005
• HIV/AIDS Epidemiological Surveillance Report for the WHO African Region. 2005 Update. Harare, Zimbabwe; December
2005. World Health Organization, Regional Office for Africa.
• HIV/AIDS and work global estimates impact and response 2004. Geneva: International Labour Organization; 2004.
• Human development report 2003. Millennium Development Goals: a compact among nations to end human poverty. UNDP. New York: Oxford University Press; 2003. Available from: http://hdr.undp.org/reports/global/2003/
• Interim Policy on Collaborative JB/HIV activities. WHO/HTM/TB/2004.330; WHO/HTM/HIV/2004.1 . Geneva: World Health Organization; 2004. Available from: http://whqlibdoc.who.int/hq/2004/who_htm_tb_2004.330.pdf
• Macroeconomics and health: investing in health for economic development Report of the Commission on Macroeconomics and Health. Geneva: World Health Organization; 2001.
• Piola P, Fogg C, Bajunirwe F, Biraro S, Grandesso F, Ruzagira E, et al. Supervised versus unsupervised intake of six-dose artemether-lumefantrine for treatment of acute, uncomplicated Plasmodium falciparum malaria in Mbarara, Uganda: a randomised trial. Lancet 2005,365:1467-73.
• Progress on global access to HIV antiretroviral therapy: an update on "3x5" Geneva: UNAIDS and World Health Organization; 2005
• Progress on global access to HIV antiretroviral therapy: A Report on ~3x 5" and Beyond Geneva: UNAIDS and World Health Organization; 2006
• Roungou JB, Mubila L, Dabire A, Kinvi EB, Kabore A. Progress in lymphatic filariasis elimination in the African Region. Communicable Diseases Bulletin for the African Region. 2005 Mar; 3: 10-1.
• Roungou J. Regional Advisor Annual Reports, Other Tropical Diseases (OTD) DDC Division, WHO Regional Office for Africa. Annual reports, other tropical diseases.
Infectious diseases in Africa
Chapters
Sachs J, Malaney P. The economic and social burden of malaria. Nature 2002:415:618-85.
Steketee RW, Nahlen BL, Parise ME, Menendez C. The burden of malaria in pregnancy in malaria-endemic areas. American Journal of Tropical Medicine and Hygiene 2001 ;64:28-35.
Stephenson LS, Latham MC, Ottesen EA. Global malnutrition. Paras/fo/og/2000;121 Suppl:S5-22
Strategic Framework to reduce the burden of TB/HIV. Geneva: World Health Organization: 2002. Available from http://www.
who.int/docstore/gtb/publications/tb_hiv/2002_296/pdf/tb_hiv_2002_296_en.pdf
TB/HIV 'Clinical Manual. Second Edition. Geneva: World Health Organization: 2004. Available from http://whqlibdoc.who. int/publications/2004/9241546344.pdf
Treatment of Tuberculosis. Guidelines for National Programmes. Geneva: World Health Organization: 2003. Available from http://www.who.int/tb/publications/cds_tb_2003_313/en/
UNAIDS/WHO AIDS epidemic update: December 2005. http://www.unaids.org/epi/2005/doc/EPIupdate2005_html_en/ epi05_05_en.htm
UNECA Compact For African Recovery: Operational/zing the Millennium Partnership for the African Recovery Programme. Addis Ababa: United Nations Economic Commission for Africa. Available from: http://www.uneca.org/cfm/compact_for_african_ recovery.htm
Ntincommunicabl'
diseases in Africa
Key messages
Noncommunicable diseases and injuries constitute a growing public
health problem in the African Region
African countries do not devote adequate resources to address
noncommunicable diseases
Donor agencies and research institutions are neglecting the growing
burden of noncommunicable diseases and injuries
Risk factors for noncommunicable and chronic diseases are on the
rise in many African countries
Solution/
African governments should act fast to avoid the mistakes of wealthy
industrialized countries
Scale up key, low-cost health solutions, particularly prevention and
health promotion to whole population
Legislation can improve mental health care and control of
noncommunicable diseases
All government departments and nongovernmental organizations
should work together to ensure a comprehensive approach to the
problem
Noncommunicable diseases in Africa
An emerging threat
f | oncommunicable diseases such as stroke, diabetes, cancer and heart disease ^k I - usually thought of as "Western diseases" -- are becoming increasingly / TJ common throughout the African Region. Injuries have also become a sig- nificant public health problem. But these chronic diseases and injuries tend to be overshadowed by other headline-grabbing illnesses such as HIV/AIDS and are given low priority and few resources (Fig. 4-1).
In fact, twice as many deaths from cardiovascular disease now occur in de- veloping countries as in developed countries. In South Africa noncommunicable diseases were the number one cause of death in 2000, accounting for 37% of deaths and 21% of years of life lost due to premature death (see Table 4.1).
Furthermore, complications — especially stroke, cardiac and renal failure — and certain forms of cancer, such as cervical cancer, occur at younger ages and in larger numbers in the Region than in developed countries. The average age at death from cardiovascular disease is at least 10 years younger in low-income settings than in developed countries and as a result adults are hit in their most productive years.
Africa's double burden
Health systems in the African Region are straining under a double burden: a high mortality and morbidity due to communicable diseases coupled with increasing rates of noncommunicable diseases including mental illness and injury. Health systems developed to provide acute, episodic care in some countries are inadequately de- signed and resourced to care for people with chronic conditions.
Noncommunicable disease in Africa
The most common noncommunicable diseases are linked to a few common and modifiable risk factors: high blood pressure, high cholesterol levels, tobacco use, excessive alcohol use, inadequate intake of fruit and vegetables and being over- weight, obese or physically inactive. Indeed, 75-85% of new cases of coronary heart disease can be explained by these risk factors. In the African Region these risk factors are increasing and they are linked to urbanization and globalization. As people move out of villages into towns and cities, a traditional diet rich in fruit and vegetables is gradually being replaced by one rich in calories from animal fats and low in complex carbohydrates.
This dietary change is combined with a decrease in physical activity as people move away from traditional farming into sedentary jobs. Global marketing of tobacco, alcohol, and fatty, sugary and salty foods has reached into all but the most remote parts of the Region.
Fig 4.1
Burden of noncommunicable diseases and injuries in DALYs* by cause in the WHO African Region, estimates for 2001
Noncommunicable diseases and injuries represented 27% of the total burden of disease in the WHO African Region in 2001
Unintentional injuries
Intentional injuries
Oral diseases
Skin diseases
Diabetes mellitus -*
Nutritional/endocrine disorders
Musculoskeletal diseases
Diseases of the genitourinary system
Congenital abnormalities
Sense organ disorders
Injuries
Noncommunicable conditions
Neuropsychiatric disorder;
Digestive diseases
Cardiovascular diseases
Neoplasms Respiratory diseases
Source: The world health report 2002: reducing risks, promoting healthy life. Geneva: World Health Organization: 2002. * Disability-adjusted life years
The African Regional Health Report
A survey carried out in Algeria in 2003 illustrates the extent of the problem. Of the 4000 people surveyed from both urban and rural areas: 12.8% were current daily smokers, 5.1% were current alcohol consumers. 55.8% consumed less than five servings of fruit and vegetables per day, 25.6% were mostly inactive, 1 6.4% were obese, 29.1% had high blood pressure, 2.9% had high blood sugar and 36.5% had high cholesterol.
Other surveys done in Cameroon, the Republic of the Congo, Eritrea and Mozambique have produced similar results, though alcohol consumption is much higher in these countries.
Africa's lesser known toll of ill-health
Cardiovascular diseases
The world health report 2001 showed that cardiovascular diseases alone accounted for 9.2% of the total deaths in Africa in 2000 compared with 8.15% in 1990. More than 20 million people have hypertension in the African Region — with a prevalence ranging from 25% to 35% in adults aged 25-64 years and a clear upward trend over time.
In general, people living in urban areas are more likely to be at risk of cardiovas- cular diseases than those in rural areas. A study of more than 1000 men and women in Ghana found that the prevalence of hypertension was 33% in semi-urban villages compared with 24% in rural areas. Detection, treatment and control of high blood pressure was found to be poor overall, but was particularly bad in rural areas.
If hypertension is left untreated it increases the risk of stroke and cardiovascular disease. Globally 15 million people suffer a stroke every year. Of these, five million die and another five million are left permanently disabled. The African Region is one of the most heavily affected areas in this respect. For example, mortality rates from stroke were up to 10 times higher in the United Republic of Tanzania than in the United Kingdom. This high incidence of stroke is believed to be due to untreated hypertension. The ageing of populations in the Region may lead to a large increase in incidence of stroke in the coming years.
Obesity and undernutrition: an African paradox
Africa is a vast continent containing extremes of poverty and wealth. Undernutrition is still the most important underlying factor causing high infant and child mortality in the Region. According to the Demographic and Health Surveys published in the 10-year period 1988-99. the prevalence of low birth weight in sub-Saharan Africa ranges from 1 1 % to 52%. Between 30% and 40% of children suffered from stunting due to chronic undernutrition, and 10% suffered from emaciation or wasting due to acute undernutrition. Half of the children aged under five years were iron deficient and a quarter were deficient in vitamin A. Between 4% and 40% of women of child- bearing age were underweight. The highest prevalence of undernutrition in adults was found among displaced people, including refugees.
Young smokers are at risk throughout the Region.
Noncommunicable disease in Africa
Table 4.1
20 leading causes of death in South Africa
HIV/AIDS
Ischaemic heart disease'
Homicide/violence
Stroke
Tuberculosis
Lower respiratory infections
Road traffic accidents
Diarrhoeal diseases
Hypertensive heart disease
Diabetes melitus
COPD"
Low birth weight
Nephritis /nephrosis
Trachea/bronchi/lung cancer
Asthma
Suicide
Septicaemia
Oesophageal cancer
Cirrhosis of liver
Protein-energy malnutrition
Source: South African Health Survey 2000.
a Text in italic indicates noncommunicable disease.
b Chronic obstructive pulmonary disease.
Surveys carried out in Nigeria show that the situation there is not really improv- ing. In 1 990, 43% of children under five years old were found to be stunted or short for their age. A repeat study in 2003 found that 38% of children were stunted, 19% were severely stunted, almost one in every 10 children was wasted and almost one in three children was underweight with 9% being severely underweight.
Early childhood undernutrition may be a risk factor for noncommunicable dis- eases in adulthood, particularly when coupled with lifestyle changes such as high consumption of sugars, fats and reduced physical activity. The African Region has seen an alarming increase in obesity since the early 1990s. The trend towards an unhealthy diet rich in saturated fat, sugar and salt and poor in fruit and vegetables means that in some countries, such as South Africa and Kenya, children are over- weight but malnourished because they are receiving more than enough calories but not enough necessary nutrients to grow into healthy adults.
In South Africa, according to a survey undertaken in 1998, 29% of men and 56% of women were overweight. Almost one in 10 men and three in 10 women were obese with the general tendency towards being overweight increasing with age. Urban men and women were more likely to be obese than rural men and women. The proportion with a body mass index (BMI) greater than 30 reached 46% in women aged 45-64.
Obesity is a major risk factor for type-2 diabetes, which is increasing rapidly in the Region. In wealthier African countries such as Mauritius and Seychelles almost a quarter of middle-aged people are affected.
Cancer
Cancer is the second leading cause of morbidity and mortality due to noncommu- nicable diseases. Tobacco use is the single largest causative factor, accounting for about 30% of all cancers in developed countries and an increasing number in the developing world. Smoking causes 90% of lung cancer and is a major risk factor for at least I I other types of cancer as well as causing heart disease, stroke and chronic lung diseases such as bronchitis and emphysema. In Africa, there were 200 000 tobacco-related deaths in 2000. The prevalence of tobacco use was 29% in males and 7% in females in 2000. The Global Youth Tobacco Survey showed that smoking in 13-15-year-olds ranged from 13% in Kenya to 33% in Uganda.
Dietary factors account for around 20% of the burden of cancer in developing countries. Being overweight or obese is a serious risk factor for cancer, particularly for cancers of the stomach, colon, breast, uterus and kidney. Diets high in fruit and vegetables may reduce various types of cancer, while high consumption of preserved and/or red meat increases cancer risk. Eating a regular diet of highly salted foods doubles the risk of stomach cancer.
Some cancers are linked to infectious diseases. If these diseases were prevented or identified early enough then the associated cancers would not develop. For example, primary liver cancer is one of the top three causes of cancer death in much
The African Regional Health Report
of Africa, Asia and the Pacific Basin but is relatively rare in the West. The major risk factor is infection with hepatitis virus B or C. Another risk factor is exposure to afla- toxin: a toxic substance present in mouldy peanuts, wheat, soybeans, groundnuts, corn and rice. People who eat these contaminated foods over a long period of time are at increased risk of developing liver cancer. This problem is more common in Africa and Asia than in other parts of the world.
Human papillomavirus (HPV) causes cervical cancer and is the fifth-leading cause of cancer death among females worldwide with some 239 000 deaths a year. About 68 000 cases of cervical cancer are reported each year in Africa. Cervical cancer offers a unique public health opportunity. Unlike most other cancers it is cost-effective to screen for precursor lesions and then treat them before they develop into cancer. The highest-risk lesions are most common among women in their thirties and forties, with the cancer that develops when the lesions are left untreated being most common among women in their forties and fifties. Countries that have a well managed cervical cancer screening service can achieve dramatic results in terms of treatment and prevention. For example, the age-standardized incidence for cervical cancer is 68.6 cases per 100 000 women in the United Republic of Tanzania compared with 7.7 cases per 100 000 women in North America.
Injuries, violence and disabilities
Injury is a leading cause of death and disability in the African Region, particularly in those aged 5-29 years. Three of the top five causes of death for this age group are injury related. Armed conflict is a frequent occurrence in many African countries and is a major cause of ill-health and mortality. Five of the world's 10 most serious conflicts during the 1990s took place in the African Region. In addition to the deaths and injuries occurring on the battlefield, there are health consequences resulting from the displacement of populations, the breakdown of health and social services and the heightened risk of disease transmission. Even in countries that have not experienced armed conflicts there is a heavy toll from firearm injuries and other types of interpersonal violence which can lead to physical disability. This presents a special challenge for rehabilitation and contributes to poverty in the affected communities (see Box 4.1). Drowning is a leading cause of death in children. Burns are another common injury, especially for people with epilepsy who may fall into cooking fires when they have a fit. Because of inadequate care for the injured, all these conditions lead to more deaths and more severe disabili- ties than would be the case if trauma care systems and rehabilitation services were more developed (see Table 4.2).
Road traffic deaths in the African Region are 40% higher than in all other low- and middle-income countries and 50% higher than the world average. The epidemic of road traffic injuries in developing countries is still in its early stages but it threatens to grow exponentially with the rapid increase in the number of vehicles. Some countries, including Algeria, Benin, Kenya and Rwanda, are taking
Armed conflict is a frequent occurrence in many African countries and is a major cause of ill- health and mortality.
Even in countries that have not experienced armed conflicts there is a heavy toll from firearm injuries and other types of interpersonal violence which can lead to physical disability.
Noncommunicable disease in Africa
Rehabilitation for landmine victims in Angola
"I thought my life was over. I wanted to die," said Jose Antonio, as he recalls the day he stepped on an anti-personnel mine while fighting on the front line during Angola's civil war. The blast ripped off much of his left leg.
After recovering from his above-knee amputation Jose moved to Luanda, Angola's capital, for better medical care. There, he heard about the Centra Neves Bendinha, a rehabilitation centre for amputees, run by the provincial health authority and supported by the International Committee of the Red Cross (ICRC).
"I've been very lucky," said the father of seven, as he waded through a sand pit and climbed nimbly up and down steps, testing his new artificial limb. "For years after the accident I was nervous. I would jump at loud noises and was scared to leave the house. But my wife persuaded me I needed a job. Our family was growing and we were all relying too heavily on her. I could walk, so there was no reason not to work. I just needed courage."
Now spray-painting cars for a living, Jose believes that work stopped him from feeling sorry for himself. "Of course, I can't do all the things I used to do, but I'm alive, I have a job so I feel useful, and I have a good woman who made me see that there was more to life than me and my leg," he laughed.
An estimated six million landmines — a legacy of the country's brutal 27-year conflict — are littered around Angola's countryside. They have left a trail of physical destruction and one in every 415 Angolans disabled, according to UNICEF.
When available, rehabilitation services tend to be located in cities and provincial centres and are often inaccessible for
people from rural areas. Beneficiaries of the few services available, like Jose, can lead productive lives. But the lack of post-trauma support services and life-skills training is hampering the integration of landmine victims into society. Many amputees think they are only fit to beg on the street.
"Physical rehabilitation is just one piece of the puzzle. Assistance to landmine survivors is much more complex," said Tracy Brown, country representative of the Viet Nam Veterans of America Foundation (WAF), a nongovernmental organization that runs rehabilitation programmes for landmine survivors in eastern Angola.
Brown argues that post-trauma support and life-skills training are critical to social reinte- gration through training opportunities and employment. But they are expen- sive. Materials and assem- bly of an average limb already cost between US$ 300 and US$ 800, but that leaps to some US$ 2000 when post- trauma rehabilitation services are included.
Jose Antonio tests his new leg at the Centra Neves Bendinha.
steps to reduce crashes involving pedestrians, cyclists, and passengers on public transportation (see Box 4.2).
Uganda has an annual road traffic fatality level of 1 60 deaths per 10 000 vehicles, one of the highest in the Region. Road traffic collisions cost the Ugandan economy around US$ IOI million per year, which is 2.3% of the country's gross na- tional product. Road crashes not only place a heavy burden on national and regional economies but also on households. A study in Kenya showed that more than 75% of road traffic casualties were economically active young adults, and that those most at risk of death were pedestrians and users of motorized two-wheelers, who accounted for 80% of the deaths.
The death toll is only the tip of the iceberg with 20-50 million people injured or disabled each year in road traffic crashes worldwide. Pedestrians and users of motorized two-wheelers, who tend to be from lower-income groups, are most at risk of injury and death on the roads.
The African Regional Health Report
Table 4.2
Leading causes of death in the African Region, 2002
Rank 0-4 years
5- 14 years
15-29 years
|
Malaria |
Lower respiratory infections |
HIV/AIDS |
HIV/AIDS |
|
Lower respiratory infections |
HIV/AIDS |
Tuberculosis |
Malaria |
|
Diarrhoeal diseases |
Road traffic crashes |
Violence |
Lower respiratory infections |
|
Perinatal conditions |
Measles |
Lower respiratory infections |
Diarrhoeal diseases |
|
HIV/AIDS |
Trypanosomiasis |
Road traffic crashes |
Perinatal conditions |
|
Measles |
Fires |
War |
Cerebrovascular disease |
|
Whooping cough |
Drowning |
Maternal haemorrhage |
Tuberculosis |
|
Protein-energy malnutrition |
Tuberculosis |
Abortion |
Ischaemic heart disease |
|
Tetanus |
Malaria |
Malaria |
Measles |
|
Congenital anomalies |
Violence |
Maternal sepsis |
Road traffic crashes |
|
Syphilis |
Meningitis |
Hypertensive disorders |
Violence |
|
Tuberculosis |
Poisoning |
Drowning |
Whooping cough |
|
Fires |
Falls |
Obstructed labour |
Chronic obstructive pulmonary disease |
|
Road traffic accidents |
Upper respiratory infections |
Syphilis |
Protein-energy malnutrition |
|
Vitamin A deficiency |
Hepatitis B |
Self-inflicted injuries |
Nephritis and nephrosis |
|
Anaemia |
Epilepsy |
Trypanosomiasis |
Syphilis |
|
Drowning |
Protein-energy malnutrition |
Epilepsy |
War |
|
Poisoning |
Lymphomas, multiple myeloma |
Poisoning |
Tetanus |
|
Endocrine disorders |
Anaemia |
Cerebrovascular disease |
Diabetes mellitus |
|
Meningitis |
Leishmaniasis |
Rheumatic heart disease |
Drowning |
Source: Global Burden of Disease 2002.
Alcohol is an important factor in causing crashes. A study in South Africa found that around 29% of non-fatally injured drivers and over 47% of fatally injured drivers had been drinking. A later study found excess alcohol levels in over 52% of trauma patients involved in road crashes.
Blindness
The major causes of blindness in the Region are cataract, trachoma, glaucoma, on- chocerciasis and childhood blindness. The number of blind people in sub-Saharan Africa is expected to increase from about 9 million to 15 million by 2020 unless measures are taken to counter the problem. Some 80% of the causes of blindness are avoidable.
The most important cause of blindness in sub-Saharan Africa is cataract, which accounts for about 50% of blindness in this part of Africa. Trachoma is the most
Noncommunicable disease in Africa
Making roads safer in Rwanda
Liliane Uwamahoro can still walk, but only with the help of crutches. She was one of six passengers in a public taxi who survived when it crashed in Rwanda's capital, Kigali, in 2002. Liliane lost her right leg, and has an artificial one. Eight fellow passengers lost their lives. She complains of pain in her left leg and still can't come to terms with the loss of her right leg. Liliane broke off her studies for three years and spent the first in hospital. Her family scraped their money together to pay for her treatment. This year she plans to return to college, but it won't be easy. "I have to do everything slowly now," she said.
Road traffic deaths in the African Region are 40% higher than all other low- and middle-income countries and 50% higher than the world average. Rwanda — a country of eight million people — is one of a growing number of African countries taking steps to combat this high mortality. Police spokesman Tony Kuramba said the number of traffic collisions reached unprecedented levels in 2002 and 2003. "We were doing a lot, but we realized that we had to double our efforts to bring discipline to the roads".
In 2003, Rwandan police launched a public awareness campaign. They told trans- port unions to make sure their staff were driving safely and used the media to reinforce the message that motorists and pedestrians must obey traffic regulations. As part of the campaign, primary and secondary schools started teaching road safety.
The number of people killed in road traffic collisions in the following year, 2004, fell by nearly a quarter compared with the previous year to 324 deaths, and the number of people injured on the roads fell by 10% to 331 0, Kuramba said. "But we realize that losing over 3000 people in collisions ... is still a big number," he said.
Under legislation passed since then, passengers who do not wear a seat belt and people on motorbikes or mopeds who do not wear a helmet face US$ 1 0 fine, one-fifth of a Rwandan civil servant's monthly salary. The number of traffic police in the capital has doubled to check for drunken or reckless driving, speeding and violations such as driving a vehicle with mechanical defects. Police posts have been created in rural provinces to monitor the highways leading to Kigali, where most crashes take place.
Road traffic injurie