Investing in health systems for universal health coverage in Africa.

BACKGROUND: This study focused on the 47 Member States of the World Health Organization (WHO) African Region. The specific objectives were to prepare a synthesis on the situation of health systems' components, to analyse the correlation between the interventions related to the health Millennium Development Goals (MDGs) and some health systems' components and to provide overview of four major thrusts for progress towards universal health coverage (UHC). METHODS: The WHO health systems framework and the health-related MDGs were the frame of reference. The data for selected indicators were obtained from the WHO World Health Statistics 2014 and the Global Health Observatory. RESULTS: African Region's average densities of physicians, nursing and midwifery personnel, dentistry personnel, pharmaceutical personnel, and psychiatrists of 2.6, 12, 0.5, 0.9 and 0.05 per 10 000 population were about five-fold, two-fold, five-fold, five-fold and six-fold lower than global averages. Fifty-six percent of the reporting countries had fewer than 11 health posts per 100 000 population, 88% had fewer than 11 health centres per 100 000 population, 82% had fewer than one district hospital per 100 000 population, 74% had fewer than 0.2 provincial hospitals per 100 000 population, and 79% had fewer than 0.2 tertiary hospitals per 100 000 population. Some 83% of the countries had less than one MRI per one million people and 95% had fewer than one radiotherapy unit per million population. Forty-six percent of the countries had not adopted the recommendation of the International Taskforce on Innovative Financing to spend at least US$ 44 per person per year on health. Some of these gaps in health system components were found to be correlated to coverage gaps in interventions for maternal health (MDG 5), child health (MDG 4) and HIV/AIDS, TB and malaria (MDG 6). CONCLUSIONS: Substantial gaps exist in health systems and access to MDG-related health interventions. It is imperative that countries adopt the 2014 Luanda Commitment on UHC in Africa as their long-term vision and back it with sound policies and plans with clearly engrained road maps for strengthening national health systems and addressing the social determinants of health.

Health financing in the African Region: 2000-2009 data analysis.

BACKGROUND: In order to raise African countries probability of achieving the United Nations Millennium Development Goals by 2015, there is need to increase and more efficiently use domestic and external funding to strengthen health systems infrastructure in order to ensure universal access to quality health care. The objective of this paper is to examine the changes that have occurred in African countries on health financing, taking into account the main sources of funding over the period 2000 to 2009. METHODS: Our analysis is based on the National Health Accounts (NHA) data for the 46 countries of the WHO African Region. The data were obtained from the WHO World Health Statistics Report 2012. Data for Zimbabwe was not available. The analysis was done using Excel software. RESULTS: Between 2000 and 2009, number of countries spending less than 5% of their GDP on health decreased from 24 to 17; government spending on health as a percentage of total health expenditure increased in 31 countries and decreased in 13 countries; number of countries allocating at least 15% of national budgets on health increased from 2 to 4; number of countries partially financing health through social security increased from 19 to 21; number of countries where private spending was 50% and above of total health expenditure decreased from 29 (64%) to 23 (51%); over 70% of private expenditure on health came from household out-of-pocket payments (OOPS) in 32 (71%) countries and in 27 (60%) countries; number of countries with private prepaid plans increased from 29 to 31; number of countries financing more than 20% of their total health expenditure from external sources increased from 14 to 19; number of countries achieving the Commission for Macroeconomics and Health recommendation of spending at least US$34 per person per year increased from 11 to 29; number of countries achieving the International Taskforce on Innovative Financing recommendation of spending at least US$44 per person per year increased from 11 to 24; average per capita total expenditure on health increased from US$35 to US$82; and average per capita government expenditure on health grew from US$ 15 to US$ 41. CONCLUSION: Whilst the African Region (AFR) average government expenditure on health as a per cent of THE increased by 5.4 per cent, the average private health expenditure decreased by the same percentage between 2000 and 2009. The regional average OOPS as a per cent of private expenditure on health increased by 4.9 per cent. The average external resources for health as a percentage of THE increased by 3.7 per cent. Even though on average the quantity of health funds have increased, we cannot judge from the current study the extent to which financial risk protection, equity and efficiency has progressed or regressed.In 2009 OOPS made up over 20% of total expenditure on health in 34 countries. Evidence shows that where OOPS as a percentage of total health expenditure is less than 20%, the risk of catastrophic expenditure is negligible. Therefore, there is urgent need for countries to develop health policies that address inequities and health financing models that optimize the use of health resources and strengthen health infrastructure. Increased coverage of prepaid health-financing mechanisms would reduce over-reliance on potentially catastrophic and impoverishing out-of-pocket payments.

Establishment of the African Public Health Emergency Fund

The Regional Committee; by resolution AFR/RC61/R3 requested the Regional Director to set up the African Public Health Emergency Fund (APHEF) including taking appropriate actions to ensure that the fund is fully operational. The resolution also requested the Regional Director to report regularly to the Regional Committee on the operations of the APHEF. The first progress report was submitted to; and discussed by; the Sixty-second session of the Regional Committee in Luanda; Angola; in 2012. The members of the Monitoring Committee of the Fund (MCF): the Ministers of Health of Gabon; Namibia and Nigeria; the Ministers of Finance of Algeria; Cameroon and South Africa; and the Chairman of the Programme Subcommittee; were appointed at the Sixty-second session of the Regional Committee. In the actions proposed in the first progress report submitted to the Regional Committee; the Regional Director was requested to convene the first meeting of the MCF to deliberate on the modalities for the commencement of operations of the APHEF. Furthermore; the Sixty-second session of the Regional Committee reiterated the mandate to the Regional Director to continue African Development Bank to take up the proposed role of Trustee of the APHEF. In the interim; WHO was designated to mobilize; manage and disburse contributions to the APHEF using its financial management and accounting systems

Perceptions and viewpoints on proceedings of the Fifteenth Assembly of Heads of State and Government of the African Union Debate on Maternal, Newborn and Child Health and Development, 25-27 July 2010, Kampala, Uganda.

BACKGROUND: Out of 358000 maternal deaths that occurred globally in 2008, 57.8% occurred in continental Africa. Africa had a maternal mortality ratio of 590 compared to 14 in developed regions, 68 in Latin America and Caribbean, and 190 in Asia. This article reflects on the discussions held during the Fifteenth Assembly of the Heads of State and Government of the African Union on the reasons why the maternal mortality ratio is so high in Africa and what can be done to reduce it. METHODS: Methods employed included panel and open public discussions among the Heads of State and Government of the African Union. The article uses the WHO health systems strengthening framework, which consists of six pillars (information systems, leadership and governance, health workforce, financing, and medical products, vaccines and technologies, and health services) to describe the proceedings of the discussions. DISCUSSION: The high maternal mortality ratios in countries were attributed to weak national health information systems; leadership and governance challenges related to poverty, health illiteracy, poor transport networks and communications infrastructure, risky cultural practices, armed conflicts and domestic violence, dearth of women empowerment; inadequate levels of skilled birth attendants; inadequate domestic and external funding; stock-outs of consumable inputs; and limited coverage of maternal and child health interventions.In order to accelerate progress towards MDGs 4 and 5, the Heads of State and Government recommended that countries should make maternal deaths notifiable and institutionalize maternal death audits; develop, fund and implement policies and strategies geared at improving maternal, newborn and child health; accelerate inter-sectoral action to address the broad health determinants; increase the number of skilled birth attendants; fulfil commitment to allocate at least 15% of the national budget to the health sector and allocate adequate resources to prevent stock-outs of essential medicines and reproductive health commodities; leverage health promotion approaches to raise national awareness; and ensure that there is a health centre within a radius of four kilometres equipped to provide good quality integrated maternal, newborn and child health services. CONCLUSIONS: There was consensus among the discussants that there was urgent need to speed up actions for strengthening health systems to improve coverage of maternal, newborn and child health services; and to address broad determinants of women, newborn and children's health for sustained improvements in health and other development goals.

Health financing in Africa: overview of a dialogue among high level policy makers.

BACKGROUND: Even though Africa has the highest disease burden compared with other regions, it has the lowest per capita spending on health. In 2007, 27 (51%) out the 53 countries spent less than US$50 per person on health. Almost 30% of the total health expenditure came from governments, 50% from private sources (of which 71% was from out-of-pocket payments by households) and 20% from donors. The purpose of this article is to reflect on the proceedings of the African Union Side Event on Health Financing in the African continent. METHODS: Methods employed in the session included presentations, panel discussion and open public discussion with ministers of health and finance from the African continent. DISCUSSION: The current unsatisfactory state of health financing was attributed to lack of clear vision and plan for health financing; lack of national health accounts and other evidence to guide development and implementation of national health financing policies and strategies; low investments in sectors that address social determinants of health; predominance of out-of-pocket spending; underdeveloped prepaid health financing mechanisms; large informal sectors vis-à-vis small formal sectors; and unpredictability and non-alignment of majority of donor funds with national health priorities.Countries need to develop and adopt a comprehensive national health policy and a costed strategic plan; a comprehensive evidence-based health financing strategy; allocate at least 15% of the national budget to health development; use GFATM and PEPFAR funds for health systems strengthening; strengthen intersectoral collaboration to address health determinants; advocate among donors to implement the Paris Declaration on Aid Effectiveness and its Accra Agenda for Action; ensure universal access to health services for pregnant women, lactating mothers and children aged under five years; strengthen financial management capacities; and develop prepaid health financing systems, especially health insurance to complement tax funding.In addition, countries need to institutionalize national health accounts; undertake feasibility studies of various health financing mechanisms; and document and share best practices in health financing. CONCLUSION: There was consensus that every country ought to have an evidence-based comprehensive health financing strategy with a road map for attaining universal health service coverage vision; and increase physical and financial access by pregnant women, lactating mothers and by children under five years to quality health services.

Malaria control in the African Region: perceptions and viewspoints on proceedings of the Africa Leaders Malaria Alliance (ALMA).

BACKGROUND: In 2009 a total of 153,408 malaria deaths were reported in Africa. Eleven countries showed a reduction of more than 50% in either confirmed malaria cases or malaria admissions and deaths in recent years. However, many African countries are not on track to achieve the malaria component of the Millennium Development Goal (MDG) 6. The African Leaders Malaria Alliance (ALMA) working session at the 15th African Union Summit discussed the bottlenecks to achieving MDG 6 (specifically halting and beginning to reverse the incidence of malaria by 2015), success factors, and what countries needed to do to accelerate achievement of the MDG. The purpose of this article is to reflect on the proceedings of the ALMA working session. METHODS: Working methods of the session included speeches and statements by invited speakers and high-level panel discussions. DISCUSSION: The main bottlenecks identified related to the capacity of the health systems to deliver quality care and accessibility issues; need for strong, decentralized malaria-control programmes with linkages with other health and development sectors, the civil society and private sector entities; benefits of co-implementation of malaria control programmes with child survival or other public health interventions; systematic application of integrated promotive, preventive, diagnostic and case management interventions with full community participation; adapting approaches to local political, socio-cultural and administrative environments.The following prerequisites for success were identified: a clear vision and effective leadership of national malaria control programmes; high level political commitment to ensure adequate capacity in expertise, skill mix and number of managers, technicians and service providers; national ownership, intersectoral collaboration and accountability, as well as strong civil society and private sector involvement; functional epidemiological surveillance systems; and levering of African Union and regional economic communities to address the cross-border dimension of malaria control.It was agreed that countries needed to secure adequate domestic and external funding for sustained commitment to malaria elimination; strengthen national malaria control programmes in the context of broader health system strengthening; ensure free access to long-lasting insecticide treated nets and malaria diagnosis and treatment for vulnerable groups; strengthen human resource capacity at central, district and community levels; and establish strong logistics, information and surveillance systems. CONCLUSION: It is critically important for countries to have a clear vision and strategy for malaria elimination; effective leadership of national malaria control programmes; draw lessons from other African countries that have succeeded to dramatically reduce the burden of malaria; and sustain funding and ongoing interventions.

Strengthening the monitoring of progress on the health-related MDGs in the African Region

There is an emerging view that progress on achieving the Millennium Development Goals (MDGs) in the African Region may be better than what is currently being reflected by official statistics. This is believed to be a result of the lack of recently updated data on the MDGs in the Region. In order to strengthen the monitoring of the MDGs; it is important to look for viable options for the timely collection; processing; analysis of relevant and quality data; and the dissemination of information products based on this data. It is essential to improve the institutional capacities in countries in order to overcome the weak data sources and data management. The monitoring of progress on the MDGs could be strengthened by: improving the content; frequency; quality and efficiency of national health surveys; strengthening birth and death registration and cause of death scertainment; improving the availability of demographic data by completing the 2010 census round; improving surveillance and service statistics; enhancing the monitoring of health systems strengthening; and; strengthening country analytical and evaluation capacity; and data use for decision-making. The latter requires the establishment and strengthening of national health observatories charged with health statistics analysis; synthesis; dissemination; sharing; and use of information and evidence

Progress on the Health-related MDGs in the African Region

Progress towards the achievement of the health-related MDGs in the African Region is slow. Currently six African countries are on track to achieve the MDG target of reducing child mortality. There is no progress on the MDG target on reducing maternal mortality. Eleven countries have started to observe declines or stabilization in HIV prevalence trends among the 13 countries that have complete trend data. A third of the population with advanced HIV infection had access to antiretroviral drugs in 2007. There were increases in the proportions of children under fi ve sleeping under insecticide treated bednets between 1999 and 2006 in all 18 countries with trend data; although coverage rates were lower than 50. Few countries have shown suffi cient progress on targets related to reducing hunger; use of improved water and sanitation facilities. Countries and their partners should increase resources significantly to strengthen health systems; maternal and child health services; combat HIV/AIDS; malaria; and TB; tackle the broader determinants of health. Measures to monitor country progress towards the MDGs should also be improved by a major effort at strengthening data sources and capacity for data management