Compendium of Public Health Strategies Volume 1

COMPENDIUM OF PUBLIC HEALTH STRATEGIES VOLUME 1

Adopted by WHO Regional Committees (1998 – 2011)

l l

REGIONAL OFFICE FOR Africa COMPENDIUM OF PUBLIC HEALTH STRATEGIES

VOLUME 1

COMPENDIUM OF PUBLIC HEALTH STRATEGIES

VOLUME 1 Adopted by WHO Regional Committees (1998 – 2011) Published by The World Health Organization Regional Ofﬁ ce for Africa Brazzaville Republic of Congo

Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Library, WHO Regional Offi ce for Africa, P.O. Box 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507; E-mail: [email protected]). Requests for permission to reproduce or translate this publication – whether for sale or for non- commercial distribution – should be sent to the same address. 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 specifi c companies or or 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 express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Offi ce for Africa be liable for damages arising from its use.

WHO/AFRO Library Cataloguing – in – Publication Data

Compendium of public health strategies. Volume 1: WHO Regional Committee for Af- rica 48th–61st Sessions (1998–2011) 1. Regional health planning 2. Health priorities – organization and administration 3. Health planning guidelines 4. Health status indicators 5. World Health Or- ganization I. World Health Organization. Regional Ofﬁ ce for Africa

ISBN 978 929 023 2001 (NLM Classiﬁ cation: WA 541 HA1)

Typeset by AMA DataSet Limited, Preston, Lancashire, UK Printed and bound by CPI Antony Rowe, Chippenham, SN14 6LH, UK Table of Contents

Foreword ...... vii

Acknowledgements ...... ix

Acronyms and Abbreviations ...... x

Strategies adopted by the Regional Committee for the African Region (48th to 61st sessions) classified by Strategic Direction (2010–2015) ...... xi

Strategic Direction 1: Continued focus on WHO’s leadership role in the provision of normative and policy guidance as well as strengthening partnerships and harmonization ...... 1 1.1 Strategic health research plan for the WHO African Region: 1999-2003 ...... 3

Strategic Direction 2: Supporting the strengthening of health systems based on the primary health care approach ...... 11 2.1 Regional strategy for the development of human resources for health ...... 13 2.2 Promoting the role of traditional medicine in health systems: A strategy for the WHO African Region ...... 21 2.3 Blood safety: A strategy for the WHO African Region ...... 27 2.4 Health financing: A strategy for the WHO African Region ...... 33 2.5 Knowledge management in the WHO African Region: Strategic directions ...... 43

Strategic Direction 3: Putting the health of mothers and children first ...... 49 3.1 Integrated management of childhood illness (IMCI): Strategic plan for 2000–2005 ...... 51 3.2 Adolescent health: A strategy for the WHO African Region ...... 58 3.3 Women’s health: A strategy for the WHO African Region ...... 64 3.4 Child survival: A strategy for the WHO African Region ...... 71

Strategic Direction 4: Accelerated actions on HIV/AIDS, malaria and tuberculosis ...... 79 4.1 HIV prevention in the WHO African Region: A strategy for renewal and acceleration ...... 81 4.2 Tuberculosis and HIV/AIDS: A strategy for the control of a dual epidemic in the WHO African Region ...... 88

Strategic Direction 5: Intensifying the prevention and control of communicable and noncommunicable diseases ...... 93 5.1 Integrated disease surveillance in the WHO Africa Region: A regional strategy for communicable diseases (1999–2003) ...... 95 5.2 Oral health in the WHO African Region: A regional strategy (1999–2008) ...... 104 5.3 Regional strategy for mental health (2000–2010) ...... 120 5.4 Non-communicable diseases: A strategy for the WHO African Region ...... 127

v Forword

5.5 Control of human African trypanosomiasis: A strategy for the WHO African Region ...... 133 5.6 Accelerating the elimination of avoidable blindness: A strategy for the WHO African Region...... 139 5.7 Diabetes prevention and control: A strategy for the WHO African Region ...... 144 5.8 Cancer prevention and control: A strategy for the WHO African Region ...... 150 5.9 Sickle-cell disease: A strategy for the WHO African Region ...... 156 5.10 Measles elimination by 2020: A strategy for the WHO African Region ...... 162

Strategic Direction 6: Accelerating response to the determinants of health ...... 169 6.1 Health promotion: A strategy for the WHO African Region ...... 171 6.2 Environmental health: A strategy for the WHO African Region ...... 178 6.3 Poverty and health: A strategy for the WHO African Region ...... 185 6.4 Food safety and health: A strategy for the WHO African Region ...... 191 6.5 A strategy for addressing the key determinants of health in the WHO African Region ...... 197 6.6 Reduction of the harmful use of alcohol: A strategy for the WHO African Region ...... 206

Annexes ...... 213

1. MALARIA 1.1 Roll back malaria in the WHO African Region: A framework for implementation ...... 215 1.2 Accelerated malaria control: Towards elimination in the WHO African Region ...... 221

2. HIV/AIDS 2.1 Scaling up interventions against HIV/AIDS, tuberculosis and malaria in the WHO African Region ...... 227 2.2 Acceleration of HIV prevention in the WHO African Region: Progress report ...... 233 Conclusion ...... 235

vi Foreword

The review of past and recent challenges in health the decision-making process by health managers development in the African Region showed that and policy leaders at various levels. The Strategic tangible achievements and significant progress Health Research Plan is an important tool to cannot be made without the development and enhance national capacity to carry out relevant implementation of sound policies and strategies. research for health to narrow the knowledge gap The strategies of the WHO in the African Region and accelerate the attainment of national and are drafted by the WHO Secretariat, peer- international health goals. reviewed by Representatives of countries during the Programme sub-committee meeting and Section SD2 relates to the health workforce, endorsed by the Ministers of Health during the health financing, medical products and medicines, annual session of the WHO Regional Committee including blood and technologies, and knowledge for Africa. management. These strategies contain the key ingredients required to bolster local and national These strategies provide guidance to countries and health systems and improve health outcomes. To serve as reference tools for governments, as well as this end, they provide sound policy and technical technical and financial partners in health in their guidance. effort to address major issues and challenges in order to improve health outcomes. Their structure Section SD3 contains orientations for scaling up has evolved over time and reflects the change of our proven and cost-effective interventions such as thinking on various issues. newborn care, infant and young child feeding, micronutrient supplementation, integrated Most of the public health strategies approved by the management of childhood illness, and immunization Regional Committee so far remain valid and could among others, which is key in reducing infant and enhance the way governments and partners design child mortality. In addition, promoting women’s specific national health programmes, interventions health and accelerating the attainment of relevant and services. We hope that having all the strategies milestones that are spelt out in several strategies, in an easily retrievable form can facilitate wider roadmaps and commitments will further contribute access and use. to the reduction of maternal mortality, which This was the justification for the preparation remains very high in the African region. of a compendium of strategies approved by the The strategies in section SD4 show that despite Regional Committee. This first volume of the some progress over the past decade, the burden of compendium contains strategies approved by the HIV/AIDS, Malaria and Tuberculosis, including Regional Committee between 1998 and 2011. the multidrug-resistant and extensively resistant We have also included in the annex, documents tuberculosis cases, is still gloomy and requires from the Regional Committee that address current special attention. Reversing the current trends will priority public health issues, which were not require the following: enhanced country ownership reflected in the strategies. and leadership for comprehensive scaling up of For ease of reference, the Strategic Directions (SD) cost effective interventions for the prevention and of WHO in the African Region (2010-2015), control of HIV/AIDS, malaria and tuberculosis. which were developed taking into account the Furthermore, the driving forces will be identified 11th General Programme of Work also known as by generating reliable data through research. “A New Global Health Agenda” and the Medium- Section SD 5 presents strategies that address the term Strategic Plan (2008-2013), are used as a scourge of communicable (63% of total deaths in matrix to relate each strategy to the current work the African Region) and noncommunicable diseases of WHO in the Region. (NCDs). In fact, NCDs constitute the biggest The section related to SD 1 contains the strategic challenge to the under-performing national health health research plan for the African Region. systems in the African Region. The morbidity and Research for health is instrumental in informing mortality burden attributable to noncommunicable

vii Forword diseases such as cardiovascular diseases, cancer and Despite the progress made to date, especially in diabetes is on increase; some of these diseases are controlling communicable diseases, there has associated with the following risk factors: tobacco been an alarming increase of noncommunicable use, abuse of alcohol, physical inactivity and diseases over the past few years and their burden unhealthy diets. The strategies contain innovative is projected to become the leading cause of death interventions for the prevention and control of in less than two decades. The success factors in communicable and noncommunicable diseases, addressing this emerging situation lie on social including mental health, violence and injuries, and economic development (not just growth!) which are central in the current efforts to curb the that results in betterment of environment, housing, plight of these diseases in the Region. food, provision of water, hygiene and sanitation. Section SD6 contains strategies related to It is our hope that this compendium will serve determinants of health. The determinants, most as a reference book for governments, public and of which are intertwined, constitute the root private health institutions, academia, professional causes of the double burden of communicable and associations, partners and health workers. noncommunicable diseases in the African Region. Dr L G Sambo Reginal Director

viii Acknowledgements

This compendium was prepared by a Review Panel from the WHO Regional Ofﬁ ce for Africa (AFRO), comprising Dr Alimata Nama-Diarra, Dr Rufaro Chatora, Dr Antoine Kabore, Dr Joses Kirigia and Dr Peter Ndumbe. We acknowledge the work of all Regional Directors, Directors of Programme Management, Directors of Divisions/Clusters and Regional Advisers (1998–2011) for their leadership and technical contributions in the development of these public health strategies. We are also grateful to Dr Matthieu Kamwa, Mrs Carine Sounga, Mrs Samba Bilombo Marie-Claudine, Messrs Pascal Mouhouelo, Christian Stéphane Tounta and Charthian Yarez Leroy Mambou for their contribution to the compilation of the Compendium. The assistance of Mrs Assamala Amoi-Seminet and her team in retrieving the strategies, and organizing the editors is gratefully acknowledged.

ix Acronyms and Abbreviations

AACHRD African Advisory Committee for Health IEC Information, Education and Communication Research and Development IDF International Diabetes Federation ACHR Advisory Committee on Health Research IDPCD Integrated Disease Prevention and Control ACT Artemisinin-based Combination Therapy Division ADB Asian Development Bank IM Intervention Measures AfDB African Development Bank IMAI Integrated Management of Adolescent and AFR WHO African Region Adult Illness AFR/RC Regional Committee for Africa IMCI Integrated Management of Childhood Illness AFRO WHO Regional Offi ce for Africa IPCS International Programme on Chemical Safety AIDS Acquired Immune Defi ciency Syndrome IPT Intermittent Preventive Treatment AIM African Initiative for Malaria IPTP Intermittent Preventive Treatment in AMFM Affordable Medicines Facility for Malaria Pregnancy ANUG Acute Necrotizing Ulcerative Gingivitis IRS Indoor Residual Spraying APOC African Programme for Onchocerciasis ITN Insecticide-Treated Nets Control LLIN Long-Lasting Insecticide-Treated Nets ARI Acute Respiratory Infections MAP Multisectoral AIDS Programme ART Anti-retroviral therapy MCV Measles-Containing Vaccine CBO Community Based Organization MDG Millennium Development Goals CCM Country Coordination Mechanism MDR TB Multidrug-Resistant Tuberculosis CHCM Comprehensive Health Care Management MOH Ministry of Health CMH Commission for Macroeconomics and Health MTEF Medium-Term Expenditure Framework COPD Chronic Obstructive Pulmonary Diseases NEPAD New Partnership for Africa’s Development CSDH Commission on Social Determinants of NGO Non-Governmental Organization Health NORAD Norwegian Agency for Development CVD Cardiovascular Diseases Cooperation DALY Disability Adjusted Life Years OAU Organization of African Unity DG Director General ODA Offi cial Development Assistance DGIS Dutch Ministry of Foreign Affairs PHC Primary Health Care DHMT District Health Management Teams PLWHA People Living with HIV/AIDS DHO District Health Offi ce PMTCT Prevention of Mother-to-Child Transmission DOTS Directly Observed Treatment, Short-course PRSP Poverty Reduction Strategy Papers EOC Emergency Obstetric Care RBM Roll Back Malaria EPI Expanded Programme on Immunization RDT Rapid Diagnostic Tests FAO Food and Agriculture Organization SCD Sickle-Cell Disease FGM Female Genital Mutilation SD Strategic Direction GDF Global Drug Facility SDH Social Determinants of Health GDP Gross Domestic Product STI Sexually Transmitted Infections GFATM Global Fund to Fight AIDS, Tuberculosis and SWAp Sector-Wide Approaches Malaria TAG Technical Advisory Group GMO Genetically-Modifi ed Organisms TB Tuberculosis GTZ Gesellschaft für Technische Zusammenarbeit TDR Special Programme for Research and Training HA CCP Hazard Analysis and Critical Control Points in Tropical Diseases HAT Human African Trypanosomiasis UN United Nations HbS Haemoglobin S UNAIDS Joint United Nations Programme on HIV/ HIPC Heavily Indebted Poor Countries AIDS HIV Human Immunodefi ciency Virus UNDP United Nations Development Programme HIV/AIDS/ Human Immunodefi ciency Virus/Acquired UNEP United Nations Environment Programme STI Immune Defi ciency Syndrome/Sexually UNGASS United Nations General Assembly Transmitted Infections UNICEF United Nations Children’s Fund HRD Human Resource Development UNIDO United Nations Industrial Development HPV Human papillomavirus Organization HRP Special Programme of Research, USAID United States Agency for International Development and Research Training in Development Human Reproduction VCT Voluntary Counselling and Testing HSR Health Sector Reform WHA World Health Assembly HSR Health Systems Research WHO World Health Organization HTC HIV Testing and Counselling XDR TB Extensively Drug-Resistant Tuberculosis HTP Harmful Traditional Practices IAPB International Agency for the Prevention of Blindness

x STRATEGIES ADOPTED BY THE REGIONAL COMMITTEE FOR THE AFRICAN REGION (48th to 61st SESSIONS1) CLASSIFIED BY STRATEGIC DIRECTION (2010–2015)

1RC48 (Harare, Zimbabwe, 31 August–4 September 1998); RC 49 (Windhoek, Namibia, 30 August–3 September); RC50 (Ouagadougou, Burkina Faso, 28 August–2 September 2000); RC51 (Brazzaville, Congo, 27 August– 1 September 2001); RC52 (Harare, Zimbabwe, 8–12 October 2002); RC53 (Johannesburg, South Africa, 1–5 September 2003); RC54 (Brazzaville, Congo, 30 August–3 September 2004); RC55 (Maputo, Mozambique, 22–26 August 2005); RC56 (Addis Ababa, Ethiopia, 28 August–1 September 2006); RC57 (Brazzaville, Congo, 27–31 August 2007); RC58 (Yaounde, Cameroon, 1–5 September 2008); RC59 ( Kigali, Rwanda, 31 August– 4 September 2009); RC60 (Malabo, Equatorial Guinea, 30 August–3 September 2010); RC61 (Yamoussoukro, Côte d’Ivoire, 29 August–2 September 2010).

Strategic Direction 1 Continued focus on WHO’s leadership role in the provision of normative and policy guidance as well as strengthening partnerships and harmonization

1.1 Strategic health research plan for the WHO African Region: 1999–2003 (AFR/RC48/11)

EXECUTIVE SUMMARY 1. Health managers and policy-makers need evidence-based information for decision-making in programme and policy matters. Such information should emanate from health research. Unfortu- nately, research has not been accorded the priority that it deserves in this Region. 2. Inadequate resources coupled with a feeling of rivalry and competition rather than cooperation between policy-makers and managers on the one hand and the researchers on the other explain in part the inadequate use of research to guide managers and policy-makers. 3. Countries, particularly developing countries in the African Region of WHO, no matter how poor they are, should use research to promote knowledge, guide policy, strengthen health action and maximize the use of limited resources in order to improve human health. 4. The WHO Regional Committee, at its forty-seventh session, requested the Regional Ofﬁ ce “to formulate and propagate a regional strategy that would help strengthen national capacity in health research”. 5. This strategic plan is intended to strengthen national capacity to carry out relevant health research; develop necessary mechanisms for ensuring adequate funding, effective coordination and efﬁ cient management of research; and promote the use of research results to address major health issues and problems.

INTRODUCTION search, behavioural research, health economics research and epidemiological research. 1. Health and health-related issues have recently moved very high on the political agenda worldwide 3. In many cases where information is available, and have thus gained greater international visibility. public health practitioners, especially high-level Governments are being increasingly requested by decision-makers, are still somewhat sceptical about their constituencies and other partners to develop a the value of research. At the same time, the research broad array of policies and programmes to deal with establishment tends to operate as a separate entity a wide spectrum of health problems and health with its own objectives and agenda. The scepticism management matters, the aim being to reduce the of public health practitioners about research is partly disease burden in order to enhance socioeconomic due to the belief that “we do not need more re- development. search; what is required is for us to apply what we already know”. Added to such a feeling has been the 2. In order to promote rational decision-making in controversy between policy-makers and managers programme and policy matters, health managers and regarding the role of research. This often culminates policy-makers need evidence-based information. in competition with health care for the limited re- Such information has to emanate, among others, sources available in the health sector. from health research. In this strategy document, the term health research includes clinical and bio medical 4. Yet research has led to tangible improvements in research, health systems research, operational re- two ways: by providing knowledge that people use

3 COMPENDIUM OF RC STRATEGIES daily in their homes to maintain their health and by Selected psychiatric conditions, heart disease, stroke producing direct technical interventions such as and road-traffi c accidents dominate the disease pro- vaccine development, new drugs and many other fi le projected for countries of the Region by the public health measures, which have had a major im- year 2020. Research and development is required to pact on diseases such as smallpox, onchocerciasis and ascertain ways of preventing and managing these leprosy. Research has also led to the introduction of conditions under budgetary constraints. insecticide-treated mosquito bed nets, to mention 10. All countries, particularly developing countries just a few. in the African Region, no matter how poor they 5. This regional strategic health research plan has are, should use research to promote knowledge, been developed following the request of the African guide policy, strengthen health action and maximize health ministers “to formulate and propagate a re- the use of limited resources in order to improve gional strategy that would help strengthen national human health. Each country should have a health capacity in health systems research”. research base which will enable it to address its health problems. National health agenda must be select ively targeted at the cross-sectional approaches JUSTIFICATION FOR HEALTH of biomedical, clinical, epidemiological, behavioural RESEARCH and health systems research. It must utilize all avail- Policy basis able expertise in the biomedical and social sciences and should serve as the starting point for inter- 6. There are several resolutions of the World country and regional research efforts. Health Assembly and the WHO Regional Commit- tee for Africa, which provide policy justifi cation for 11. Twenty-two African countries met in 1995 to health research. Resolutions WHA4.26 (1951) and discuss “Achieving evidence-based health sector re- WHA33.25 (1980) both focus on the need for forms in sub-Saharan Africa”. Focusing on the role health research; the latter specifi cally called for an of research in health sector reforms, the following effective WHO role in the coordination and pro- conclusion was drawn: Reforms especially require motion of research in order to achieve better health. specifi c data and objective information for rational The resolutions of the Regional Committee all decision-making, and every health sector reform point to the need for research for overall national programme should have a research component as its health development. integral part to provide reliable information.

Technical justifi cation SITUATION ANALYSIS 7. Despite the progress made, there remains an Research capacity overwhelming burden of infectious diseases that can be addressed with the cost-effective interventions 12. Health research plays a pivotal role in enhancing available. Addressing this unfi nished agenda is mostly the effectiveness and effi ciency of the provision and a matter of political will and commitment of ade- fi nancing of health services in any country. There- quate resources. But research and development can fore, adequate institutional capacity for research is a help through operational and behavioural research necessary condition for improving the health status (often by developing and evaluating linked packages of the people. Although some efforts have been of care, such as the proposed Mother-Baby Package) made to build or strengthen capacity in the coun- and by selective development of new tools and tries of the Region, institutional capacity for health technologies. research remains generally weak. 8. A more global class of challenges is emerging 13. The Special Programme for Research and Train- from the continually changing nature of microbial ing in Tropical Diseases (TDR) has played a pivotal agents. New pathogens – such as HIV – and the evo- role in the Region by strengthening research capa- lution of drug-resistant variants of familiar ones (e.g. bility. It has trained researchers at graduate level, those causing tuberculosis and malaria) are creating intro duced sandwich doctorate courses to motivate the need for new biomedical knowledge and for an and support qualifi ed researchers working in their understanding of the systemic determinants of the countries and provided programme-based research spread of resistance to new drugs and vaccines. grants and grants for institutional research capacity development. 9. Member States in the African Region are increas ingly facing major (and hitherto neglected) 14. The Joint WHO/AFRO Health Systems epidemics of injury and non-communicable diseases. Research (HSR) Project for Eastern and Southern

4 Continued focus on WHO’s leadership role

Africa has provided training to a considerable 22. The WHO Regional Offi ce supports some re- number of health personnel and has developed vari- search at country level. Most of the research funded ous training materials. Since January 1998, the by various regional programmes is geared towards WHO Regional Offi ce for Africa has absorbed the operational research and health systems research. project into its Health Systems Research pro- 23. Funding for research by national authorities and gramme, which has expanded to cover all Member institutions still remains relatively low as compared States. with external funding. This is, no doubt, a worri- 15. Also worthy of mention here is the Special Pro- some situation. gramme of Research, Development and Research 24. Funding for national health research from the Training in Human Reproduction (HRP). Among private sector is still at a low level. The high poten- other things, the Programme has provided technical tial of this source is still untapped. However, before and fi nancial support to strengthen the capacity of research funding from the private sector could be countries in the Region to undertake research in re- used, a code of conduct needs to be developed. productive health. 16. WHO collaborating centres are expected to Constraints serve as a valuable mechanism for securing scientifi c 25. Some of the constraints on health research in the and technical advice. They are, therefore, expected Region have already been alluded to above. Specifi c- to play a leading role as well as act as catalysts in ally, they include: weak to fragile institutional re- stimulating research and in organizing, planning and search capacity; lack of trained personnel capable of coordinating training activities in different areas of generating, implementing and managing research (a research. In recent times, there has been a lot of de- problem compounded by the brain drain); inade- bate on the extent to which collaborating centres quate political commitment to health research; lack have been able to play these roles successfully. of well-articulated national research policies and pri- 17. Most countries of the Region have at least a orities in Member States; and inadequate use of re- national research council, with a committee for search results due to lack of communication and health research. The role of these councils in pro- collaboration between researchers and potential viding direction and coordination in health research users of research results. in support of national health problems and needs has not been critically assessed. Challenges 18. There are many national medical research insti- 26. The problems enumerated above highlight some tutes in the Region. Their research capacity has also of the challenges of health research facing countries in been limited in recent times as a result of the brain the Region, namely, how to increase political aware- drain and the fi nancial squeeze. ness about the importance of health research and get countries to defi ne their national health research pri- 19. Academic training institutions, particularly uni- orities and policies within the context of their health versities, had potential research capacity, but this has needs and problems and to allocate adequate resourc- been weakened by the brain drain in many countries es; strengthen national health research capacity and set of the Region and by budgetary cuts. up appropriate coordination mechanisms to avoid duplication of health research efforts; arrest the current Research activities and funding trend of donor-driven health research priority-setting; 20. Within the limited research capacity that exists and ensure that health research results are used for in the Region, research activities have been and are health policy-making, improving the organization still being undertaken. Subjects addressed include and management of health services, and tackling the disease-specifi c problems, operational problems and various diseases that are taking a heavy death toll on health sector reform issues (including health care the people of the Region. fi nancing). 21. A large proportion of the health research under- THE REGIONAL STRATEGIC taken in the Region is externally funded from HEALTH RESEARCH PLAN sources which include TDR, HRD, the World Bank, the Rockefeller Foundation, Ford Founda- Goal tion, Carnegie Foundation, Kellogg Foundation as 27. The overall goal of the regional strategic health well as bilateral agencies such as USAID, ODA, research plan is to strengthen research capacity at both NORAD, GTZ and DGIS. institutional and individual health worker levels in

5 COMPENDIUM OF RC STRATEGIES

Member States in order to conduct priority research lizing adequate funds for implementing their that could be optimally used to improve the provi- priority research agendas. sion, fi nancing and management of health services. (c) At least 50% of the countries will have established mechanisms that will facilitate the utiliza- Principles tion of research results. (d) At least 50% of the research institutions will have 28. In order to achieve the above overall goal, the been adequately strengthened to undertake re- following basic principles must underpin the health search in defi ned priority areas. research to be promoted or for which health re- (e) At least 10% of health workers at different levels search capacity strengthening would be provided: of the health system will have been adequately (a) it must be as holistic, integrated and multidisci- trained to undertake research in defi ned priority plinary as possible; areas. (b) it must attempt to provide information that (f) The Regional Offi ce will have set up approp- would enhance the integration of health consid- riate mechanisms for facilitating inter country erations into decision- making at the individual, collaboration and networking in order to family, community, national and regional levels; strengthen the organization and management of (c) it must be relevant to the different health needs health research in the countries of the Region. and problems of each of the Member States; (d) it must contribute to the defi nition and implementation of policies that will support health Strategic thrusts development; (e) it must enhance both human resource develop- 31. In order to overcome the current problems of ment processes and actions that are necessary to and constraints on health research in Member States infl uence the values and behaviours of indivi- and achieve the objectives and targets defi ned above, duals and communities in a positive way; and the major strategic thrusts will be advocacy; national (f) it must contribute to the integration of health capacity-building; strengthening of mechanisms and determinants into the context of an overall strat- processes that support research; technical support; egy to achieve sustainable development. regional linkages and networking; strengthening of the capacity of the Regional Offi ce; and resource mobilization. Objectives 32. Advocacy: This is indispensable for obtaining and 29. The major objectives of the strategic health re- sustaining political will in support of health research. search plan are to: It helps to explain to the countries the relevance and (a) support Member States to develop a national necessity of evidence-based decision-making pro- health research strategy and the mechanisms cesses. Such commitment will enhance resource mo- needed to ensure adequate funding, effective co- bilization for research as long as the research to be ordination and effi cient management of re- carried out is focused on priority health problems. search; and 33. Capacity-building: Successful research will re- (b) support Member States to develop their national quire the availability of a critical mass of nationals capacity (at institutional and health worker trained in the various disciplines (the epidemio- levels) to carry out health research relevant to logical, biomedical, clinical and social sciences and major health needs and problems; health systems research) and working in an appro- (c) promote the use of research results to address priate institutional framework. Training should be major health issues and problems. in-country and directories and inventories of existing trained persons must be readily available to man- Targets agers, policy-makers and donors. Research career 30. Related to the above objectives, the following profi les need to be created in order to attract and targets must be met by the end of the strategic plan retain professionals. There is a need to organize spe- period (2003): cialized training in research management and leadership and in informatics and data management. (a) All countries of the Region will have clearly spelt out their health research policies and de- 34. Strengthening of mechanisms and processes that fi ned their health research priorities. support research: Such mechanisms as health research (b) At least 50% of the countries will have formu- advisory committees, institutional review panels, lated strategies and set up mechanisms for mobi- ethics committees and planned meetings for the

6 Continued focus on WHO’s leadership role

dissemination of research results are critical for sus- (b) determine existing national research capa city taining the research culture. and indicate the additional number of people to be trained. It should also create an appropriate 35. Technical support: Adequate technical support climate for retaining such staff; should be provided to enable countries to draw up (c) carry out, in conjunction with all interested par- their priority research agendas and to formulate re- ties, a participatory and trans parent exercise on search policies and strategies based on national health the prioritization of research issues at national plans and on-going reforms in the health sector. level. 36. Regional linkages and networking: Existing re- 42. The WHO country offi ce should play a leading gional initiatives on health research must be used to role in promoting and supporting health research complement Regional Offi ce efforts. Where neces- and in mobilizing resources for it. It should also sary, those initiatives should be actively pursued to identify a national offi cer among its national staff to enhance national research efforts and promote support the Ministry’s research staff and promote re- multi- centre studies on regionally identifi ed priority search coordination with other external partners. research issues. 37. Strengthening of the Regional Offi ce: It is impor- At Regional Offi ce level tant to advocate, promote, fund, coordinate, facili- 43. The Regional Offi ce should: tate and evaluate health research in the Region through individual task forces in the various pro- (a) provide research training and award training grammes, using a multidisciplinary and multisectoral grants; approach. Research coordination at the Regional (b) support research projects developed within Offi ce is facilitated by the Research Policy and national health research priorities and submitted Strategy programme (RPC). by researchers from Member States; (c) encourage various programmes at the regional 38. Resource mobilization: This should be carried level to commission research in priority areas out at the national level through support of WHO defi ned by it; country offi ces and at the regional and international (d) develop and update the regional health research levels. information system; (e) develop a new mechanism or approach for Implementation framework effectively supporting and utilizing WHO collaborating centres for various research activities; Priority Interventions (f) support Member States to establish or strengthen At country level any existing mechanisms for coordinating and managing health research activities; 39. Research activity should be promoted by Minis- (g) promote the exchange of individuals with skills try of Health through the prioritization of essential and experience between countries; national health research and identifi cation, recruit- (h) provide expertise and fi nancial and technologi- ment and remuneration of national professional staff cal resources for collaborative research partner- to coordinate all research at national level and to ships between countries; involve all stakeholders. Ministry of Health should (i) organize subregional conferences and workshops mobilize resources for research activities from both on health research issues or for sharing research national and external sources. results. 40. Ministry of Health research offi cers, in collaboration with the WHO research staff, should organize Partnerships for plan implementation national research workshops involving policy- 44. In order to effectively implement the strategic makers, managers, researchers and donors. Such health research plan, many ‘partners’ or ‘actors’ will workshops should be the forums for presentation of be involved. These can be broadly divided into research results and planning of how they will be three categories: actors at the country level, WHO used. Such meetings could focus on single topics or research supporting structures (particularly at the discuss multiple issues. Regional Offi ce), and other partners. 41. The Ministry of Health should: Country level (a) develop research policies and long-term research plans, with the participation of all interested 45. National research policies must be based on ex- partners; isting national health policies and ongoing health

7 COMPENDIUM OF RC STRATEGIES reforms. There is need for wide participation in the Global Advisory Committee on Health Research formulation of research policies. There should be 54. The Global Advisory Committee on Health constant reviews in order to capture and anticipate Research (ACHR) will provide global input to the changing health situations. African Advisory Committee on Health Research 46. It will also be necessary to involve universities, and Development (AACHRD) and the Regional policy-makers, managers, WHO collaborating cen- Offi ce Research Development Committee. tres, the private sector and health-related NGOs. Other agencies promoting health research 47. Institutional review panels will be needed to assess research projects and proposals before submis- 55. A strong political, technical and fi nancial com- sion for funding. mitment is required from international agencies to implement an integrated and long-term programme 48. A functional research coordination unit in Min- for strengthening health research in Africa. These istry of Health or a research institute with clear terms include multilateral and bilateral agencies, inter- of reference, a multidisciplinary core staff of epide- national scientifi c research institutions, professional miologists, health economists, social scientists and organizations and other public and private centres. support staff will be expected to play a pivotal role. In order to support Member States in health re- 49. WHO country offi ces should spearhead support search, WHO would provide guidance to, and col- and promote research at country level through laborate with these bodies in order to: advocacy with ministries of health, other UN agencies, external partners, NGOs, universities and (a) mobilize resources and equitably distribute them private institutions. with respect to geographical location and type of research to be conducted (operational vs. basic; clinical vs. community-based; disease vs. public Regional Offi ce research support structures health-oriented research, etc.); 50. The African Regional Advisory Committee on (b) train researchers wishing to apply their research Health Research and Development (AACHRD) is a skills but hampered by fi nancial diffi culties (local body that advises the Regional Director on research vs. foreign training; type and level of training); issues. The Research Policy and Strategy Pro- (c) determine relevant research topics and facili tate gramme, which is responsible for the overall coordi- the dissemination and use of fi ndings; and nation of health research, acts as the secretariat for (d) support national health research plans where they the AACHRD. It is located in the Programme exist or promote the preparation of such plans. Management and Development Unit under the charge of Director, Programme Management. 51. The Research and Development Committee is a MONITORING AND EVALUATION managerial organ that makes recommendations to 56. Monitoring and evaluation must provide feed- the Regional Director with respect to the Research back through planned information that is collected Policy and Strategy Programme. It identifi es mecha- periodically to guide decision-making. It serves as a nisms for strengthening relations with research pro- control mechanism and a basis for accountability; grammes at the three levels of WHO and is it also shows whether resources are being used responsible for the evaluation of nominations for re- effi ciently. search prizes and awards. 52. There are task forces for each priority programme Structures and mechanisms for monitoring in the Regional Offi ce. Each task force carries out and evaluation at country level research in its own area. What is needed is to maxi- 57. Health advisory committees should be asked to mize the use of such research for the bene fi t of all, carry out or commission regular monitoring and including the sharing of methodologies, co-funding evaluation of research in order to demonstrate its and provision of support for multi- centre studies. advantages and disadvantages in various programmes. WHO collaborating centres Structures and mechanisms for monitoring 53. Before designating new ones, existing collaborat- and evaluation at regional level ing centres should be strengthened and provided with adequate resources so that they can be maximally in- 58. Each programme should have an in-built mech- volved in conducting and promoting health research. anism for periodically monitoring and evaluating its

8 Continued focus on WHO’s leadership role research component, with special emphasis on community. The development of this strategic plan country research activities. bears testimony to the importance the Regional Offi ce attaches to health research as a means of con- Monitoring and evaluation tools tributing to the health and socioeconomic development of all the people of the Region. 59. In collaboration with Member States, the Re- gional Offi ce should spearhead the development of Resolution AFR/RC48/R/4 tools for the evaluation of research. Strategic health research plan for the WHO Role of WHO in support for Member States African Region 60. WHO’s regional structure is ideally suited to The forty-eight session of the Regional Committee provide specifi c technical or managerial support for for Africa, health research activities and training at the local, Having examined the Regional Director’s report country and sub-regional levels. Following the on health research in the Region; managerial and research cycles, this would focus on technical support to Member States in: Recalling World Health Assembly resolutions WHA4.26 and WHA33.25 relating to health research; (a) completing the situation analysis of countries, determining the existence and functioning of struc- Bearing in mind the importance accorded by the tures, institutions, coordinating mechanisms, Regional Committee to health research policies manpower and other resources for research; iden- during the different sessions of the Technical Dis- tifying research priorities and activities; utilizing cussions, particularly during the 42nd (ref. Doc; research results; and overcoming constraints; AFR/RC42/TD/1) and the 47th (AFR/RC47/ (b) developing and disseminating an inventory of re- TD/1) sessions; and search topics in health and related areas and pre- Considering that health research was one of the paring an inventory of priority research issues; means for obtaining reliable information to guide (c) designing protocols and guidelines for preparing decision-making and improve the management and and executing research projects; quality of the services of health systems; (d) training a critical mass of trainers for research, who will train other health workers to develop 1. APPROVES the strategic health research plan the analytical capacity to design and carry out for the African Region operational and epidemiological research; 2. REQUESTS the Member States; (e) facilitating the exchange of experience and dissemination and application of research fi ndings; (i) to determine, together with all parties con- and cerned, priority research areas at the national (f) mobilizing fi nancial and technical re sources and level; creating networks. (ii) to draw up medium-and long-term research policies and strategies consistent with national 61. WHO should facilitate the organization of re- health development policies; gional and country consultations, involving health (iii) to create an enabling environment for re- policy-makers, administrators, researchers, universi- searchers to function effectively; ties and related research institutions and potential (iv) to build national research capacities, particularly donors in order to review the situation of health re- through resource allocation, training of senior search in the Region and develop a strategy for offi cials, strengthening of research institutions strengthening not only health research capability but and establishment of coordination mechanisms; also coordination mechanisms and research manage- (v) to put in place a national health research plan, ment. Such consultations would also help identify in collaboration with health development priority health research issues and how results there partners; and from could be disseminated and applied. (vi) to establish a national committee to formulate and ensure compliance with ethics, especially regarding the conduct of clinical trials on hu- CONCLUSION mans; and 62. The implementation of the strategic research 3. URGES the Regional Director: plan for the African Region is an evolutionary process. Realization of the plan will require the com- (i) to draw up and disseminate an inventory of mitment of Member States and the international health research institutions in the Region;

9 COMPENDIUM OF RC STRATEGIES

(ii) to draw up and disseminate an inventory of (vii) to sensitize partners (NGOs, multilateral and research work on health and health- related bilateral cooperation agencies, etc.), and mobi- areas; lize fi nancial and technical resources to sup- (iii) to strengthen the health research programmes port the Member States in the implementation of the Regional Offi ce as well as the effective- of their priority research programmes; ness of the African Advisory Committee for (viii) to put in place mechanisms for monitoring and Health Research and Development; evaluating the progress made in the Region; (iv) to take stock of WHO collaborating centres and aiming at optimizing their role in the conduct (ix) to inform the Regional Committee every two and promotion of health research; years on the progress made in the implementa- (v) to promote the training of trainers in research tion of the strategic plan. methodology in the Member States; Tenth meeting, 2 September 1998 (vi) to encourage the exchange of experiences, the dissemination and application of research fi ndings;

10 Strategic Direction 2 Supporting the strengthening of health systems based on the primary health care approach

2.1 Regional strategy for the development of human resources for health (AFR/RC48/10)

EXECUTIVE SUMMARY 1. Health for all, through primary health care, proclaimed twenty years ago at the Alma-Ata Conference, will remain a major objective for the years and century to come. 2. Among the many resources to be mobilized to this end, human resources constitute the most precious. Unfortunately, they have not always received the attention they deserve, hence the persisting signiﬁ cant gaps between ongoing reforms in the health sector and the management of human resources for health. It is, therefore, crucial that the changes taking place in the organization, functioning and ﬁ nancing of health care systems be accompanied by appropriate measures for developing both human resources for health and supporting institutions. 3. The strategy proposed in this document aims to strengthen the capacity of Member States to optimize the utilization of their human resources for health with a view to achieving the health objectives of the Region. 4. This strategy is essentially based on the following: harmonization of global and national health policies with the development of human resources for health, including in the private sector; strengthening of institutional capacity; reorientation of medical training and practice; coverage of the whole country by competent and motivated health teams; research on the development of human resources for health; and regulation of professional practice.

INTRODUCTION development and development of the sector; poor 1. In all countries of the world, human resources numerical, spatial and qualitative distribution of constitute the most valuable asset because, in addi- personnel in the public and private sectors; the mis- tion to their economic impact, they enhance the match between training on the one hand, and needs value of all the other resources by converting them and job profi les on the other; non-identifi cation of into socially useful products. the health team appropriate to each health care delivery level; inability to retain and optimally utilize 2. Thus, in the health sector, efforts have been existing staff in a manner as to guarantee stability, made for many years to better integrate human which is required for achieving medium- and long- resources development into the health for all term objectives, such as health for all. objectives. 4. Investments in training at the national level and 3. Further, for the last fi ve years, at least, programmes within disease control programmes have rarely for enhancing and developing human resources have produced the expected results, probably due to been proposed and implemented in many African compartmentalized, isolated and uncoordinated countries, within the framework of bilateral and implementation approaches to all aspects of the multilateral cooperation activities, in order to cope development of human resources for health. with the chronic problems affecting the development of human resources for health. These problems 5. Indeed, developing human resources for health include lack of integration between human resources means attempting to provide: the health personnel

13 COMPENDIUM OF RC STRATEGIES we need, in suffi cient numbers, with the right health policy rarely led to the inclusion of competence, motivation and experience, in the human resources development for health on desired institutions, and at appropriate posts, at the the priority policy agenda of these countries right time, and at an affordable cost, so that users or to the allocation thereto of the resources may have quality health care adapted to the state of needed. health of the individual and the community. – The “medical model” as the dominant health model continued to infl uence to a 6. Human resources development is therefore large extent, the health and development directly associated with planning, training and man- policies related to human resources, despite agerial capacities of health personnel at all levels of the movement begun almost two decades the health system, especially at the policy and strate- ago in favour of community health and des- gic levels, on the one hand and on the other, with pite the adoption of primary health care as guaranteeing career prospects to health personnel. the strategy for achieving the social objective of health for all. JUSTIFICATION Situation analysis Factors related to the health sector 7. The development of human resources for health 9. The capacity to plan, produce and manage health depends on a number of factors, some of which personnel and guarantee them career prospects is a de- relate to the overall national situation, while others terminant factor in human resources development for relate to the health sector. The targeting of one or health. Yet, not much importance is always accorded the other of these factors instead of a systematic to this. The result, in the majority of the countries of approach is the source of the many problems com- the Region, has been ill-suited structural, technical promising the optimal utilization of health resources and regulatory arrangements. For example: and the implementation of health policies. (a) The department responsible for human resources for health is hardly ever structured or given Factors related to the overall national situation the tools with which to carry out the principal 8. Reforms are ongoing in all the sectors of national functions of modern day human resource man- life in the majority of African countries. These agement, namely, planning (qualitative and reforms are being encouraged and supported by the quantitative determination of staffi ng needs, international community. Despite this favourable identifi cation, projection and programming of environment, the rhythm of reforms remains slow those needs); production (training related to due to a number of social, economic and political needs and job profi les); management (routine, reasons. For example: forward-looking and performance evaluation). The activities of these departments are limited (i) The population, by its demographic character- essentially to routine personnel management. istics, behaviour in the face of disease and (b) Some laxity and politically-oriented measures death and the epidemiological profi le, exerts characterising health personnel planning exclude some infl uence on the demand for and utiliza- the private sector and neglect its planning and tion of health services, including the type of personnel training needs. personnel. (c) Initial and specialist training in the health (ii) The socioeconomic crises of the 80s and 90s, in sciences is still elitist and focused on hospitals, arresting economic growth and social progress, despite the recognized reform needs or the re- had serious repercussions on the health ser- orientation of medical training and practice. vices, particularly on personnel, whose training Continuing training, virtually inexistent in the and recruitment were sus pended in many private sector, is carried out almost exclusively African countries. within specifi c disease control programmes or (iii) The political situation certainly impacts on the for the purpose of promoting specifi c drugs. organization, functioning and management of These training efforts must necessarily be accom- the health sector. Nonetheless, the following panied by an organizational change of the health facts must be mentioned: system in order to have any chance of success. – Poor understanding by policy-makers and Conversely, isolated reforms without changes in health offi cials of the importance of human the knowledge base of the personnel will stand resources in the implementation of their little chance of success.

14 Supporting the strengthening of health systems based on the primary health care approach

(d) Training in human resource management, in the Programmatic justifi cation institutions where this is a training discipline, 14. The ongoing changes and reforms in the coun- seems to have rarely received privileged treat- tries and at the level of WHO offer both an oppor- ment; the expertise needed for such training, tunity and an obligation to tie in the issue of human especially for training permanent trainers adept resources development for health with the expected in human resource management, are often lack- changes in the organization, functioning, fi nancing ing; there is no inventory or needs assessment and management of the health system on the one and partnerships between the authorities con- hand, and on the other hand, with technical co- cerned; training institutions are also practically operation with countries of the Region. non-existent. (e) The tools to help act on the behaviour of staff or to infl uence their retention are generally few or THE REGIONAL STRATEGY non-existent, and not adapted to the sector or to 15. Reforming the health system means setting a ongoing reforms, be they in the area of legisla- number of objectives, namely, guaranteeing equity tion or existing regulations, including the legis- of access to health services and care to all citizens; lation applicable to professional practices, living improving the quality and effectiveness of health conditions, incentives or to the professional en- services; controlling health expenditure increases vironment. and ensuring effi cient management of available resources; increasing the degree of satisfaction of users Guiding principles and health personnel. Faced with such objectives, the insuffi ciency of staff, their poor distribution, the Policy basis absence of continuing training and of quality assur- 10. The Alma Ata Declaration attaches special ance mechanisms, and the low productivity and mo- import ance to the role of health personnel in the rale of the personnel are urgent problems requiring implementation of the primary health care strategy, solutions. and requires that the personnel adopt a more holistic approach, in conformity with WHO’s Constitution Aims and objectives and the defi nition of health. 16. This strategy aims to contribute to the achieve- 11. In 1995, the report of the working group on ment of the health objectives of the Region by WHO’s response to global changes called for a revi- strengthening the capacity of the countries to opti- sion of the health for all strategy, specially emphasiz- mize the use of their human resources for health. ing the development of health care systems based on the principles of human dignity, equity, solidarity Strategic objectives and professional ethics. 17. The strategy aims to ensure that each Member 12. The same year, in its resolution WHA48.8, the State: World Health Assembly urged Member States to un- (i) defi nes a human resources development policy, dertake coordinated health system reforms, in other supportive of the implementation of its health words, reforms in training and the practice of the policy. health professions. The importance of the role of the (ii) possesses the required capacities for diagnosing other categories, particularly nursing and midwifery, the problems of human resources development was reaffi rmed and addressed in a specifi c resolution for health, formulating relevant policies, mobi- in 1996 (WHA49.1) and in a special report in 1997. lizing actors and implementing, monitoring and evaluating the policies. Social justifi cation 13. Health costs to the society, especially those relat- Targets ing to health personnel (70% of the operational 18. The targets for the period 1999–2008 are as budget of the health sector in many countries), as- follows: sociated with the scarcity of resources, brain drain both within countries and the continent and outside (i) By the year 2004, the 46 countries of the Re- them, are additional arguments for improving the gion will have developed a policy for human effi ciency of health care services and, hence the resources development for health. competence and motivation of health personnel at (ii) By the year 2007, the 46 countries of the all levels of the health system. Region will have acquired the capacity to

15 COMPENDIUM OF RC STRATEGIES

implement their policy on human resources policies; coordination of the programmes con- development for health. cerned; and mobilization of resources.

Principal thrusts Planning the development of human resources for health 19. This strategy comprises six principal thrusts. They are: 23. Human resources planning consists of analysing the factors that infl uence the supply of and demand – a policy framework, in other words, the commit- for health personnel, with a view to improving per- ment of decision-makers and health offi cials to formance. The essential role of such planning will be consider the development of human resources to: for health as a necessary condition for achieving the objectives of the national health policy; (i) make operational the strategy or strategies by – planning of human resources development for clarifying them, identifying implications and health based on three elements: the environment the actions to be taken to achieve the set and its trends, the needs and aspirations of the objective; population, and employees’ expectations; (ii) facilitate coordination; – training-education of quality personnel, based on (iii) orient all actors to the desired direction; needs, the absorption capacity of the sector and (iv) stimulate the creativity of the offi cials in valid job profi les; data analysis and heighten awareness regarding – administration-management or creation of the acceptability and feasibility of envisaged working and living conditions that enhance the solutions. satisfaction of both the users and personnel; 24. Environmental uncertainty, the nature of the – research in key fi elds of human resources devel- resources to be planned and the necessity to take opment for health, with a view to clarifying the cognizance of the values and motivations of the per- choices of policy-makers and health offi cials; sonnel in realizing the selected plan make the task – regulation of the medical profession in order to both complex and diffi cult. protect the sick and the communities against risks and professional malpractice. 25. In the countries, the measures to be taken are as follows: Priority interventions (i) Preparation of a realistic plan for the develop- 20. The formulation and adoption of a policy for the ment of human resources for health. This plan development of human resources for health, in ac- must be compatible with the health objectives cordance with health objectives, is a fi rst step that is and in harmony with changes in the organiza- both diffi cult and delicate but indispensable, due to tion, functioning, fi nancing and management the nature of the resource concerned and its impact of the health system. It must take cognizance of on the preparation of strategies and sectoral plans. the values and motivations of the personnel and include the role and place of the private sector. 21. In the countries, advocacy before policy makers The plan must also: (a) defi ne qualitative and and health offi cials will be required to bring them to quantitative criteria for the production and dis- include human resources development for health on tribution of health personnel, such as to correct the list of national policy priorities, and to identify, inequity in access to health services; ensure mobilize and support institutional actors. This poli- effi cient utilization of personnel; assure the ef- tical will should be refl ected in restructuring and fectiveness of health care and services; as well as strengthening of the institutional capacity of minis- ensure users’ satisfaction; (b) adopt strategies to tries of health, in the establishment of coordination be implemented to achieve set objectives in the mechanisms, in the adoption of appropriate human following areas: production and distribution of resources development tools, and in the allocation personnel, education or training, performance of additional resources for the implementation, evaluation, working and living conditions; (c) monitoring and evaluation of the human resources identify the necessary resources; (d) indicate development policy. the schedule of implementation; (e) defi ne the 22. At the regional level, the measures to be taken mechanisms for monitoring, evaluating and will focus on the following: adoption of a resolution adjusting objectives and strategies. on the development of human resources for health; (ii) Acquisition of requisite capacities for diagnos- leadership to support the inclusion of human re- ing problems relating to human resources de- sources development for health among the priority velopment for health, formulation of a relevant

16 Supporting the strengthening of health systems based on the primary health care approach

policy and plan, mobilization of the institution- (i) make available to the countries guides on and al actors, and implementation, monitoring and methods for the evaluation and revision of evaluation of the plan. training programmes; (ii) organize evaluations and revisions of pro- 26. At the regional level, the envisaged arrange- grammes and disseminate their results; ments will aim at: (iii) select, every two years, two countries for (i) designing activities that will strengthen the assistance in their implementation of a co- capa city of countries to reach the levels ordinated reform of health practice and indicated above; training. (ii) making an inventory of lessons learnt and innovative experiences in the fi eld of human Administration and management resources development for health and dissemi- 30. To improve health personnel productivity and nating such information. performance, personnel managers must have relevant legal and regulatory texts: Education and training and skills – texts relating to health personnel functions; development – texts regulating the geographic distribution of 27. To ensure the success of current health sector health workers; reform, comprehensive efforts must be made to re- – texts relating to training and supervision of health orient training and update the knowledge base of personnel; the staff. It is necessary, therefore, to redefi ne the – texts relating to working conditions; roles of these staff and the missions of health institu- – texts relating to initial and continuing training tions in which they work. It is also necessary to and maintenance of skills; adapt basic training programmes, both for specialists – texts relating to the procedures, mechanisms and and continuing training, to the spirit of the Cape modes of fi nancing; Town Declaration and to global recommendations – texts relating to career plans; and and strategies aimed at this reform. – texts relating to professional ethics and deontology in health. 28. In the countries, it will be necessary to: 31. In responding, therefore, to multiple objectives, (i) undertake advocacy action vis-à-vis policy- the application of policies relating to the effi cient makers and training institutions; distribution and utilization of health personnel can (ii) defi ne the job profi le of each professional be facilitated through legislation. category to be trained; (iii) defi ne the missions and functions of health 32. In the countries, actions to be implemented will care facilities; aim at: (iv) evaluate the training given in faculties of (i) restructuring and strengthening functions for medicine and health schools in order to bring the development of human resources for health; about the necessary changes in training, re- (ii) training and recruiting competent managers; search, services offered to the community, and (iii) preparing appropriate legislative and regula- in cooperation with other institutions; tory instruments; (v) put in place structures to guide the reform (iv) setting up an information system and a system at the national level and within the training for managing human resources for health; institutions; (v) distributing, equitably, the available staff based (vi) train the personnel in the teaching of health on population distribution, health care levels, sciences and research; health services models or types of institution; (vii) train the personnel in the management of (vi) evaluating the performance of health workers human resources for health; in relation to job profi les and posts; (viii) combine training by example and the teaching (vii) adopting rules and regulations governing the of professional ethics and de ontology in health; profession and drawing up progressive career and plans; (ix) programme fellowships in accordance with the (viii) conducting studies and analysing the evalua- objectives of the plan relating to human re- tion of jobs, requisite qualifi cations, organiza- sources development for health. tional modalities, the professional environment 29. At the regional level, it will be necessary to: and staff remunerations;

17 COMPENDIUM OF RC STRATEGIES

(ix) creating merit-based systems of incentives and ( patients, communities) of quality care by qualifi ed rewards; health personnel who comply with professional (x) putting in place at all levels quality assurance rules. programmes; and 39. In the countries, and for each health profession, (xi) estimating costs (salaries and employer ex- a legal status, compulsory registration and a control penses) and fi nancial capacities. system governed by corresponding professional 33. At the regional level, it is necessary to study and boards or bodies should be established, a national evaluate country experiences, disseminate the results ethics committee created and made functional, and a thereof and provide support to national programmes. patient charter promulgated. 40. At the regional level, an awareness drive for Research good health care practices and the drafting of a Charter for the African Patient will be necessary. 34. Issues such as policy formulation, planning of the health professions and the training and utiliza- Mobilization of resources tion of health personnel deserve in-depth studies. (a) Actors in the countries 35. For the countries, this signifi es: 41. A number of actors are involved. These are so- – introducing research on human resources devel- called institutional actors, and are grouped as follows: opment for health as a component in national health systems research programmes; – the State and national institutions and agencies – conducting studies and research on prio rity themes; responsible for health issues – giving feedback to policy-makers and health of- – employers who pay salaries or national public or fi cials regarding research results and encouraging private health insurers them to use these results to improve the health – health sciences training and research institutions system and the health situation. – the health professions – bodies that regulate the health professions 36. For the regional level, this signifi es: – professional associations – promoting research on the development of – users of health care services human resources for health; – external partners and donors. – defi ning priority themes in the above-mentioned 42. The identifi cation, defi nition and recognition of areas; their respective roles, their mobilization and coordi- – encouraging institutions, groups and individual nation will be determinant factors in the implemen- researchers to draw up research protocols; tation and success of the national strategy for the – identifying sources of funding and encouraging development of human resources for health. policy-makers and health offi cials to utilize research results to develop human resources for health; (b) Actors at the regional level – promoting exchanges of information and data on experiences in the fi eld of human resources 43. The aim of WHO and the other partners development for health; ( bilateral and multilateral) will be to support the – creating a databank for collecting and disseminat- efforts of the country in the formulation, adoption ing information and knowledge on strategies and and implementation of the coordinated reform of methods in human resources development for training and practice in the health professions. health. 44. This support, considered an asset, should pro- 37. An inventory of the regional institutions for mote overall assistance to meet the needs of the training and research in public health and in manage- health sector. It should also stimulate the allocation ment, especially health management, could be made, of suffi cient funds to the health sector, and enhance from which some institutions could be selected and the equitable distribution and effi cient use of these supported with a view to making them real collabo- public funds, thereby, guaranteeing their sustain- rating centres for the development of human ability, while avoiding dependence on assistance. resources for health, to the benefi t of the Region. (c) The period covered Regulation of the health professions 45. The period concerned (2000–2012) sits astride 38. Respect for professional ethics and deontology that of the Tenth and Eleventh General Programmes in health will guarantee provision to the population of Work of WHO.

18 Supporting the strengthening of health systems based on the primary health care approach

(d) Financing 53. Partnerships and collaboration arrangements with other institutions involved in the development 46. Funding will be principally by the countries. of human resources for health will be sought. 47. WHO will work with other health development 54. A follow-up report will be submitted every year partners and other institutions to mobilize addi tional by the regional programme concerned. resources at the international level and to support the efforts of the countries of the Region. 55. Principal monitoring indicators are the number of support missions organized for the formulation of Managerial framework policies and plans, the number of fellowships granted for training in human resources management and 48. The viability and effectiveness of the proposed the number of managers trained. strategy will depend heavily on the importance given to political will and support of policy-makers Evaluation and health offi cials; ownership of the concept; orientation and implementation of country-specifi c 56. In the countries, evaluation will be conducted strategies at the different levels of the health pyramid; every two years by the orientation committee and effective partnerships among institutional actors; will analyse the reports relating to the different com- the quality of training and of health services and ponents. care; the judicious use of available resources and 57. At the regional level, evaluation will be done of research results; and formation of real health every two years with the collaboration of the multi- teams. disciplinary groups created; the indicators to be used will be: percentage of countries that have a realistic MONITORING AND EVALUATION policy and plan on human resources development congruent with their health objectives; percentage (a) In the countries of countries that have put in place coordinated reform of the health system and of training in health 49. A national advisory committee of all institution- sciences; percentage of countries that regulate the al actors will assist ministries of health to guide this health professions. coordinated reform of the system of health care and human resources development for health. Success and failure factors 50. Every year, it will examine the state of progress 58. The necessity for long-term political commit- of the following six components: ment, the duration of this programme on the na- – Policy: legislation and regulatory instruments, tional priority agenda, its orientation to assure resource allocation and coordination of actions; internalization of the process within the countries – Planning: formulation of a plan; level of imple- (health care system and institutional actors, minis- mentation annually; adjustments; tries and departments responsible for human re- – Education or training: analysis of annual results, sources, national institutions for training and research quality of training administered, number of in administration or management, especially of graduates, educationists, researchers and mana- health), scarcity or lack of resources, are all major gers trained, problem areas. – Administration or management: user and health 59. The commitment of Member States and other personnel satisfaction, partners to the health sector, and hence, to the – Research: publication, feedback and utilization development of human resources for health, demon- of results, strated by the proportion of national budgets alloca- – Regulation of the professions: creation of regula- ted to the social sectors such as education or training tory bodies, much discussed in the media. and health, will need to be encouraged and sustained. (b) At the regional level CONCLUSION 51. WHO will coordinate the implementation of this strategy. 60. Health personnel constitute the most important resource in health, on account of its cost and the 52. A regional multidisciplinary group of experts in value it gives to the other resources. health policy, health planning, and human resources development for health will be created with a view 61. Attaching value to and developing this resource to assisting the Regional Offi ce in this strategy. is a challenge that the countries of the Region,

19 COMPENDIUM OF RC STRATEGIES

WHO and other partners must face. The achieve- 1. ENDORSES the regional strategy for the devel- ment of health for all depends on it. opment of human resources for health contained in document AFR/RC48/10; 2. URGES Member States: Resolution AFR/RC48/R3 (i) to harmonize national health policy and the Regional strategy for the development of plan for the development of human resources human resources for health for health; The Regional Committee, (ii) to collaborate with all the institutional sectors of health development in the formulation and Having reviewed the Regional Director’s report implementation of policies and plans for the on the development of human resources for health; development of human resources for health in Recalling World Health Assembly resolutions order to better meet the needs and improve WHA42.27, WHA47.9, WHA48.8 and WHA49.1 the health status of the population; and Regional Committee resolutions AFR/RC37/ (iii) to promote and support health systems re- R13 and AFR/RC38/R15 on the role of health search with a view to determining the standard personnel in the implementation of national health health team for each of the various levels of the development policies and plans; health care system, the optimal numerical strength, the mix and deploy ment of health Seeking to apply the spirit of the 1993 World personnel and the technologies and working Conference and the 1995 Regional Conference on conditions most likely to improve their per- Medical Education; formance in the provision of quality health Mindful of the need to make optimal use of the care; and available human resources as part of the ongoing (iv) to support efforts to improve education, train- health sector reform in the countries of the African ing, utilization of health personnel and regula- Region; tion of health professions; and Recognizing the increasing burden of the prob- 3. REQUESTS the Regional Director: lem of brain drain on the Member States; (i) to encourage health authorities, professional Recognizing the increasing attrition of health associations and schools of health to study and personnel in Member States due to HIV/AIDS establish, in a coordinated manner, new mod- epidemic; els of care and new working conditions that will enable health personnel to play their spe- Aware that health sector reform and reorienta- cifi c roles in order to better meet the needs of tion of professional practice and training should be benefi ciaries of health care; coordinated, pertinent and acceptable; (ii) to support the development of guidelines and Recognizing the need for an integrated approach models that will enable the countries to to the development of health services and human strengthen their capacity to plan, train, utilize resources for health; and regulate health professions; (iii) to ensure continuity in the work of the re- Aware also that this approach to the development gional multidisciplinary advisory group on the of human resources should be adapted to the needs development of human resources for health; and means of the countries and be based on active (iv) to reorganize and strengthen the unit responsi- participation of the entire health personnel at all ble for human resources for health programme levels of the health system just as for benefi ciaries of in order to ensure easier co ordination of re- health care, policy-makers and offi cials of the private gional and national efforts for optimal use of and public sectors, representatives of professional as- health personnel; sociations and teaching institutions, and all persons (v) to sensitize partners to and mobilize resources in charge of economic and social development; and for the implementation of this strategy; and Considering WHO’s special role in health (vi) to keep the Regional Committee informed of matters, which can facilitate working relations be- the progress made in the implementation of tween health authorities, professional associations this resolution and to report to the Committee and schools of health in the African Region; every other year.

20 2.2 Promoting the role of traditional medicine in health systems: A strategy for the WHO African Region (AFR/RC50/9)

EXECUTIVE SUMMARY 1. In the Alma-Ata Declaration of 1978, recognition was given to the role of traditional medicine and its practitioners in achieving health for all. The WHO Regional Committee for Africa, by its resolution AFR/RC34/R8 of 1984, urged Member States to prepare speciﬁ c legislation to govern the practice of traditional medicine as part of national health legislation and ensure an adequate budget allocation that will make for effective development of traditional medicine. 2. The forty-ninth session of the Regional Committee invited WHO to develop a comprehensive regional strategy on traditional medicine and, by its resolution AFR/RC49/R5, requested the Regional Director to support countries in carrying out research on medicinal plants and promoting their use in health care delivery systems. In order to implement these orientations, the countries will need to articulate policies that would enhance the development and use of traditional medicine. Furthermore, research leading to improved access to essential traditional medicine and appropriate utilization of medicinal plants in health systems should be pursued. 3. The proposed strategy aims at assisting the countries to optimize the use of traditional medicine in order to contribute to the achievement of health for all. The principles on which the strategy is based are advocacy, recognition by governments of the importance of traditional medicine for the health of the people, institutionalization of traditional medicine and partnerships. The priority interventions are policy formulation, capacity building, promotion of research and development of local production. 4. The Regional Committee examined this strategy document and gave orientations for its implementation, consistent with national health policies.

INTRODUCTION and quality is available, and the generation of such evidence, when it is lacking. In this context, “inte- 1. The World Health Organization estimates that gration” means increase of health care coverage 80% of the population living in rural areas in devel- through collaboration, communication, harmoniza- oping countries depend on traditional medicine for tion and partnership building between conventional their health care needs1. WHO deﬁ nes traditional and traditional systems of medicine, while ensuring medicine as “the total combination of knowledge intellectual property rights and protection of in- and practices, whether explicable or not, used in digenous knowledge. diag nosing, preventing or eliminating physical, mental or social diseases and which may rely exclu- 2. The Alma-Ata Declaration of 1978, the relevant sively on past experience and observation handed recommendations of WHO governing bodies and down from generation to generation, verbally or in the orientations of the Regional Health-for-All writing”. This Strategy promotes the integration Policy for the 21st century underscore the import- into health systems of traditional medicine practices ance of traditional medicine and its practitioners in and medicines for which evidence on safety, efﬁ cacy primary health care. They also address the strategic

21 COMPENDIUM OF RC STRATEGIES options that are expected to help achieve health for rely on traditional medicine and traditional birth all. Other partner agencies of the United Nations and attendants. the Organization of African Unity have also been 7. The herbal medicine market has expanded tre- stressing the importance of traditional medicine. mendously in the last 15 years and the total annual 3. Despite these policy orientations, few countries sale of herbal medicines is still growing. In 1996, the have developed national policies, legal frameworks total annual sale of herbal medicines reached US$ 14 and codes of conduct for the practice of traditional billion worldwide. In China, traditional medicines medicine. Several countries have created associa- account for 30–50% of total medicinal consumption2. tions of traditional medicine practitioners and devel- 8. Some countries in the African Region are pro- oped programmes for the training and continuing ducing locally, on a pilot-scale, various plant-based education of traditional health (medicine) practi- preparations for chronic diarrhoea, liver disorders, tioners, including traditional birth attendants, and amoebic dysentery, constipation, cough, eczema, for their inclusion in undergraduate courses in the ulcers, hypertension, diabetes, malaria, mental health health sciences. and HIV/AIDS. Some of these medicines have been 4. The situation of traditional medicine remains registered and included in the national essential drug weak in some Member States. Major weaknesses in- lists. Some research institutions, including WHO clude inadequate policies and legal frameworks, in- collaborating centres, are carrying out research on suffi cient evidence on safety and effi cacy, lack of traditional medicine. knowledge of attitudes, practices and behaviours in 9. The African Region is facing diffi culties in en- traditional medicine, lack of coordination among suring equitable access to health care and only about institutions, inadequate documentation and lack of half of the population in the Region have access to protection of intellectual property rights and endan- formal health services. Traditional medicine, how- gered medicinal plant species, e.g. mass destruction, ever, maintains its popularity for historic and cul- inadequate protection of endangered medicinal tural reasons. In Benin and Sudan, for example, 70% plant species and bad harvesting practices. To ad- of the population rely on traditional medicine while, dress these weaknesses, there is need to strengthen in Uganda, users of traditional medicine make up and develop traditional medicine and integrate it 30% of the population. In Ghana, Mali, Nigeria and into the national health systems of Member States Zambia, 60% of children with fever were treated and to protect the genetic rights of the indigenous with herbal medicines at home in 1998. locale where the materials come from. 10. A survey, using a questionnaire, was carried out 5. This document responds to the recommenda- in 1998 on the situation of traditional medicine in tion of the 49th session of the Regional Committee countries of the African Region. The results of the for Africa requesting WHO to develop a compre- survey showed that many countries are yet to de- hensive strategy on traditional medicine. velop and implement national policies on traditional medicine as part of their overall national health policy, enact legislation, set up structures and develop codes of ethics and conduct for the practice of tradi- SITUATION ANALYSIS AND tional medicine. The organizational aspects of tradi- JUSTIFICATION tional medicine have to be strengthened. National 6. Trends in the use of traditional and complemen- bodies for the management of traditional medicine tary medicine are on the increase in many developed should be established, associations of traditional and developing countries. In Australia in 1998, medicine practitioners should be created, while about 60% of the population used complementary forging closer collaboration between practitioners of medicine, 17 000 herbal products had already been traditional medicine and those of conventional med- registered and a total of US$ 650 million was spent icine. Moreover, the survey indicated that needs in on complementary medicine. In 1992, 20 million traditional medicine had to be assessed and training patients in Germany used homeopathy, acupuncture programmes established and strengthened. There is as well as chiropractic and herbal medicine as the also need to improve the regulatory environment, most popular forms of complementary medicine. In the protection of intellectual property rights and the Malaysia, it is estimated that about US$ 500 million development of small-scale local production into are spent every year on traditional medicine, com- large-scale manufacturing; to document best prac- pared to only about US$ 300 million on modern tices; to curtail charlatans; and to take into account medicine. In Sri Lanka, 50–60% of the population cultural and religious dimensions.

22 Supporting the strengthening of health systems based on the primary health care approach

THE REGIONAL STRATEGY and the communities. Some of the organizational arrangements required are: Aim and objectives (a) The establishment of a multidisciplinary national Aim body responsible for the coordination of tradi- 11. The aim of this strategy is to contribute to the tional medicine; the formulation of a policy and achievement of health for all in the Region by opti- legal framework; the allocation of adequate re- mizing the use of traditional medicine. sources; the development of strategies and plans for improving the regulatory environment for Objectives the local production and rational use of traditional medicines; and greater protection of intel- 12. The objectives are: lectual property rights. (a) to develop a framework for integration of the (b) The setting up of professional traditional medi- positive aspects of traditional medicine into cine bodies to enhance the discipline in areas health systems and services; such as the drawing up of a code of conduct and (b) to establish mechanisms for the protection of ethics; the development of norms and standards; cultural and intellectual property rights; the establishment of mechanisms for the offi cial (c) to develop viable local industries to improve ac- recognition of traditional medicine, including cess to traditional medicines; the identifi cation, registration and accreditation (d) to strengthen national capacity to mobilize of qualifi ed practitioners. stakeholders and formulate and implement rele- (c) Mechanisms of collaboration between conven- vant policies; tional and traditional medicine practitioners in (e) to promote the cultivation and maintenance of areas such as referral of patients and information medicinal plants. exchange at local level.

Partnerships Principles 16. The ministry of health should collaborate and Advocacy promote contact with other ministries, professional 13. Countries should embark on advocacy for com- associations, consumer groups, nongovernmental or- munity orientation, dissemination of appropriate in- ganizations, associations of traditional medicine prac- formation, promotion of positive attitudes and titioners, regional and interregional working groups practices and discontinuation of bad practices. on traditional medicine and training institutions in both the public and private sectors to optimize the use of traditional medicine. The ministry of health Government recognition of traditional medicine should also facilitate effective collaboration between 14. The recognition by governments of the impor- traditional and conventional health practitioners. tance of traditional medicine for the health of the people in the Region and the creation of an en- Priority interventions abling environment are the basis for optimizing the Policy formulation use of traditional medicine. There is need to rally the sustainable political commitment and support of 17. The countries should formulate a national policy policy-makers, traditional medicine practitioners, on traditional medicine as part of their overall nongovernmental organizations, professional associ- national health policy. This should be followed by ations, the community, teaching and training insti- legislation, spelling out the rights and responsibilities tutions and other stakeholders, through advocacy of traditional medicine practitioners and addressing and utilization of social marketing and participatory legal issues related to the cultivation, conservation methods and development of a legal framework, and exploitation of medicinal plants and their ra- which will, inter alia, address the issue of charlatans. tional use. Existing legislation should be reviewed to conform to national policies. Institutionalization of traditional medicine 18. WHO will develop guidelines and organize re- 15. The setting up or strengthening of structures for gional and intercountry workshops to stimulate the traditional medicine is essential for optimizing the development of national policies on traditional use of traditional medicine and should be based on a medicine. WHO will also advise the countries on thorough analysis of the prevailing systems, with the relevant legislation for the practice of traditional involvement of traditional practitioners themselves medicine.

23 COMPENDIUM OF RC STRATEGIES

Capacity building Governments should play the key role of creating an enabling political, economic and regulatory envi- 19. The countries should assess their needs with ronment for local production. Access to traditional regard to traditional medicine practice, develop pharmaceutical products should be improved. A list regulations on traditional medicine practice and of traditional medicines could be agreed upon and draw up a code of ethics to guarantee the provision mechanisms worked out towards introducing medi- of safe and quality services. cines with evidence-based effi cacy and safety in the 20. Integration of traditional medicine into health essential drugs list. Large-scale cultivation and con- systems at country level requires a better understand- servation of medicinal plants should be carried out ing of the specifi c role of traditional medicine. There- with the involvement of traditional medicine practi- fore, health science institutions should incorporate tioners and the communities. aspects of traditional medicine into the training cur- 25. WHO will undertake advocacy and encourage ricula of health professionals and embark on continu- the countries to develop local production and in- ing education and skills development programmes. clude medicines with proven safety and effi cacy into The development of information, education and their national essential drug lists. communication approach on traditional medicine for traditional health practitioners, consumers and the general public should be encouraged. Implementation framework 21. WHO will promote the acquisition of knowl- The role of ministries of health edge and skills by facilitating the exchange of expe- 26. At the country level, governments should rec- riences and supporting the development of training ognize the importance of traditional medicine to programmes and training materials. their health systems. They must be instrumental in creating an enabling environment for promoting Research promotion traditional medicine. Their role should include allocating adequate resources to traditional medicine, 22. At the country level, research and training insti- and mobilizing additional resources to support the tutions, including WHO collaborating centres for institutionalization of traditional medicine and facili- traditional medicine, should be supported to carry tating the training of health personnel in traditional out research on traditional medicine. Resources medicine. should be mobilized to support participatory research particularly on knowledge, attitudes, practic- The role of other sectors es and behaviours and on safety, effi cacy and quality to enhance the role of traditional medicine in health 27. Sectors such as education, information and com- systems. Intercountry, regional and international munication should be involved in the development collaboration in medicinal plant research, cultivation and promotion of culture and traditional practices and use should be fostered. and in educating the population to empower them to make the right choices as regards the use of tradi- 23. WHO will identify and strengthen institutions tional medicine. The natural resources, agriculture carrying out research on traditional medicine. and industry sectors will have an important role to WHO collaborating centres will be strengthened to play in the conservation of medicinal plants and the carry out research and disseminate the results. Medi- local production of traditional medicines. cinal plant research that could promote self-reliance and reduce costs will be supported, as will the docu- The role of partners mentation of inventories of effective traditional medicine practices and development of national for- 28. Communities, nongovernmental organizations mularies on traditional medicines. and other partners will have major roles to play in optimizing the use of traditional medicine in Mem- Development of local production ber States. Several international partners are particularly well placed to facilitate specifi c aspects of the 24. At the country level, mechanisms for developing implementation of the regional strategy. They in- and improving the local production of traditional clude the ADB, UNEP and UNIDO in matters re- medicines should be put in place. Such mechanisms lated to the conservation of medicinal plants and the should include encouraging local industry to invest development of local production. in the cultivation of medicinal plants; exchanging information about ongoing research; and learning 29. WHO will advocate for political commitment, from experiences existing outside the Region. support from stakeholders and the creation of an

24 Supporting the strengthening of health systems based on the primary health care approach enabling environment for traditional medicine and 34. The Regional Committee examined this strat- will facilitate the mobilization of resources to assist egy document and gave orientations for its imple- the countries in the implementation, monitoring mentation, consistent with national health policies. and evaluation of this strategy. Guidelines and tools to assist the countries in developing policies and Resolution AFR/RC48/R3 regulations, strengthening national traditional medi- Promoting the role of traditional medicine in cine programmes and developing local production, health systems: A Strategy for the African among others will be prepared and made available to Region the countries. WHO will encourage the involvement of all interested partners in the Region in the The Regional Committee, implementation of the strategy. Recalling World Health Assembly resolutions WHA30.49, WHA31.33, WHA41.19, WHA42.43 MONITORING AND EVALUATION WHA44.33, WHA44.33, on the potential medical and economic value of medicinal plants, health 30. WHO will collaborate with the countries in human resources development and research on monitoring and evaluating the implementation of traditional medicine; the strategy. Recalling World Health Assembly resolutions Determinants of success AFR/RC36/59, AFR/R34/R8, AFR/RC40/R8, and AFR/RC49/R5 on the use of traditional 31. Critical determinants of success of the imple- medicines, legislations governing the practice of mentation of this strategy are political commitment, traditional medicine, promotion of traditional medi- ownership of the strategy, development of country- cine, development of the traditional medicine sys- specifi c strategies, mobilization and judicious use of tem and its role in health systems in Africa and available resources, utilization of research results for research on medicinal plants; decision making, effective partnerships and establishment of management bodies, availability of tradi- Aware of the fact that about 80% of the popula- tional medicinal products from traditional health tion living in the African Region depend on tradi- practitioners and sharing of information. The human tional medicine for their health care needs; and fi nancial resources of the Regional Programme Recognizing the importance and potential of on Traditional Medicine will be strengthened to traditional medicine for the achievement of health facilitate the implementation of the strategy. for all in the African Region and that development of local production of traditional medicines should CONCLUSION be accelerated in order to improve access; Noting that some countries in the Region have 32. The development of the present strategy refl ects established national bodies for the management of the importance Member States and WHO attach to activities in traditional medicine, formulated nation- the role that traditional medicine and its practi- al policies on traditional medicine, enacted legisla- tioners play in health development in Africa. Inte- tions and codes of ethics and conduct for the practice gration of traditional medicine in health systems will of traditional medicine, and created associations of result in increased coverage of, and access to, health traditional health practitioners; care. The promotion of positive traditional medicine practices and the use of traditional medicines of Further noting that research on traditional medi- proven effi cacy and safety will supplement other cine is being carried out in some countries in the efforts to achieve health for all. Region and that aspects of traditional medicine have been incorporated into the curricula of some train- 33 The implementation of this strategy requires ing institutions; concerted collaboration among all the partners and effective and rational mobilization of all resources 1. APPROVES the report of the Regional Direc- available at the country and regional levels. In that tor on promoting the Role of Traditional Medicine context, the promotion of the role of traditional in Health Systems: Strategy for the African Region; medicine in the African Region is critical to, if not 2. URGES Member States: decisive in, assisting Member States to integrate tradi tional medicine into their national health (i) to translate the regional strategy into realistic systems. national policies on traditional medicine,

25 COMPENDIUM OF RC STRATEGIES

followed by appropriate legislation and plans (iii) to develop guidelines for formulation and for specifi c interventions at national and evaluation of national policies on traditional local levels and to actively collaborate with medicine, advise countries on the relevant leg- all partners in their implementation and islation for the practice of traditional medicine evaluation; and the documentation of practices and medi- (ii) to consider the development of mechanisms cines of proven safety, effi cacy and quality and and establishment of institutions for enhancing facilitate the exchange and utilization of this the positive aspects of traditional medicine into information by countries; health systems in order to improve collabora- (iv) to advocate for the development of mecha- tion between conventional and traditional nisms for improving the economic and regula- health practitioners; tory environments for local production of (iii) to produce inventories of effective practices as traditional medicines and nurturing of medici- well as evidence on safety, effi cacy and quality nal plants, strengthening WHO collaborating of traditional medicines and undertake rele- centres and other research institutes develop- vant research; ing monographs of medicinal plants and dis- (iv) to actively promote, in collaboration with all seminating results on safety and effi cacy of other partners, the conservation of medicinal traditional medicines; plants, development of local production of tra- (v) to establish a regional mechanism to support ditional medicines and protection of intellec- Member States to effectively monitor and tual property rights and indigenous knowledge evaluate the progress made in the implementa- in the fi eld of traditional medicine; tion of the Regional Strategy on Promoting (v) to establish a multidisciplinary and multisecto- the Role of Traditional Medicine in Health ral mechanism to support the development Systems; and implementation of policies, strategies and (vi) to submit to the fi fty-second session of The plans; Regional Committee a report on progress (v) to foster strong regional and subregional col- made and challenges encountered in the im- laboration in information exchange. plementation of the Regional Strategy on Pro- moting the Role of Traditional Medicine in 3. REQUESTS the Regional Director: Health Systems. (i) to advocate for support from stakeholders for Seventh meeting, 31 August 2000 creation of an enabling environment for traditional medicine, and to facilitate the REFERENCES mobi lization of additional resources to assist countries in the implementation, monitoring 1. Bannerman RB, Buton J and Wen-Chieh C (1983). and evaluation of this strategy; Traditional medicine and health care coverage. World (ii) to purpose to Member States the institution Health Organization, 9–13. of an African Traditional Medicine Day for 2. WHO (1998) Background information for reviewing Advocacy; the Traditional Medicine Cabinet Paper, WHO/ EDM/HQ.

26 2.3 Blood safety: A strategy for the WHO African Region (AFR/RC51/9 rev.1)

EXECUTIVE SUMMARY 1. Blood safety is still a major concern of countries in the African Region in view of the high prevalence of HIV/AIDS and other transfusion-transmissible infections. 2. In 1994, the forty-fourth session of the WHO Regional Committee for Africa, by its resolution AFR/RC44/R12, invited Member States to take urgent measures to formulate and implement a policy on blood transfusion safety, mobilize resources for developing the infrastructure of the blood transfusion services of central and district hospitals and set the objectives for the transfusion, in hospital settings, of blood uninfected by HIV. 3. Today, very few countries have acquired the structures and resources needed to promote the develop ment of blood transfusion services. 4. The present strategy aims to propose concrete actions and a framework that will help the countries to have reliable and sustainable transfusion facilities. 5. The success of this strategy will depend primarily on the mobilization of adequate ﬁ nancial and material resources and the preparation and implementation of a realistic plan, based on an objective analysis of the situation prevailing in each country. 6. The priority interventions are the formulation and implementation of national blood transfusion policies, quality assurance, mobilization of funds and development of human resources. 7. The Regional Committee examined this strategy, enriched it, adopted it and gave guidance for its implementation.

INTRODUCTION other transfusion-transmissible infections and a high frequency of malaria anaemia, deﬁ ciency anaemia 1. Transfusion therapy is a form of treatment based and severe haemorrhages which, sometimes, require on the use of blood and blood products of humans. massive transfusion. Although this therapy helps to save human lives in some circumstances, blood can nonetheless be a 3. The safety of blood transfusion depends on three dreadful vector of some infectious and parasitic dis- main factors: eases or can trigger serious and, sometimes, fatal re- (a) the availability of blood, which is contingent actions of rejection if the rules governing its upon the adequacy of storage facilities and the prescription and use are not properly followed. existence of a sound policy of recruitment and 2. The safety of blood and blood products is of retention of voluntary and benevolent donors; serious concern to the countries, all ofﬁ cials in (b) the safety of blood, taking into account all the charge of blood transfusion services and the clini- immuno-haematological and serological aspects; cians who prescribe blood. This concern is even (c) the appropriate use of blood transfusion as a greater in the African Region, where there is a mode of treatment, which requires smooth col- heavy burden of HIV/AIDS, a high prevalence of laboration between blood transfusion centres

27 COMPENDIUM OF RC STRATEGIES

and clinicians as well as adherence to the rules of in Africa are transmitted via blood. Furthermore, prescription. less than 50% of the units of blood are actually tested for hepatitis B in most of the countries, while barely 4. In May 1975, the Twenty-eighth World Health 19% of the countries test blood units for hepatitis C. Assembly, by its resolution WHA28.72, called on This situation exposes transfused patients to the risk Member States to promote national blood transfu- of infection by the viruses that cause hepatitis or sion services, based on voluntary and benevolent liver cancer.1 donations, and to promulgate laws to govern their operation. In spite of that recommendation, very 10. Inadequate supply of reagents still poses a major few African countries have a reliable and well- obstacle to the determination of the serological organized transfusion system, today. status of donated blood. Red tape in centralized systems, coupled with inadequate funding, often cre- 5. In 1994, the Regional Committee for Africa, in ates stockouts. Lack of national reagent procurement its resolution AFR/RC44/R12, noted with great strategies and of reference centres that can validate concern that only 10 out of the 46 Member States of the testing of blood for transfusion-transmissible in- the African Region could guarantee the safety of fections has led to the introduction, on national blood transfusion in health care settings and, conse- markets, of products whose quality is, sometimes, quently, urged Member States to take urgent steps to dubious. enact blood safety policies and mobilize resources for the development of the infrastructure of blood 11. The cold chain is an essential link in any blood services in central and district hospitals. transfusion system. In the African Region, the ir- regular supply of electricity, lack of equipment 6. Twenty-six years after the World Health Assem- suited to fi eld conditions or the absence of an effec- bly resolution and seven years after the Regional tive equipment maintenance programme adversely Committee resolution, there is still a lot to be done affect the storage of reagents and blood products. In to improve the safety of blood transfusion in coun- some Member States, this situation hampers the tries in the Region. The present strategy, therefore, establishment of functional blood transfusion serv- proposes interventions and a framework that will ices at all levels of the health pyramid and, more enable Member States to improve blood transfusion particularly, in district hospitals. safety. 12. The shortage of qualifi ed staff in the African Region puts a major limitation on health services in SITUATION ANALYSIS AND general and blood transfusion services in particular. JUSTIFICATION In addition, lack of career prospects for the staff of blood transfusion centres often leads to staff demoti- Situation analysis vation and consequent departure for other areas 7. Of the 46 Member States in the African Region, deemed to be more rewarding and more fulfi lling. only 30% have drawn up their national blood trans- This instability of the staff of transfusion services is fusion policy. Even so, the recommendations of the prejudicial to the development of the skills needed policy are not always implemented, with the result to establish sustainable and reliable blood transfusion that coordination has been lacking at fi eld level. services. This has led to non-standardization of practices, and, 13. In most cases, blood transfusion services are ad- indeed, to exposure of patients to complications that ministratively answerable to, and physically located are sometimes fatal, and exposure of health person- within, hospital laboratories. They, therefore, have nel to avoidable risks of contamination. no fi xed staff or specifi c budgets of their own, a 8. Less than 15% of countries in the Region have situa tion which adversely affects their smooth func- implemented effective strategies for the recruitment tioning. The fact that transfusion services are not of regular and benevolent blood donors. About 60% hierarchically structured is yet another impediment of the blood collected is from family replacement to their effective supervision and the quality of the donors even though it is fi rmly established that the services they provide. prevalence of transfusion-transmissible infections 14. Very few countries have built quality assurance among that category of donors is higher than among programmes into their blood transfusion services voluntary, regular and non-remunerated donors. or into the facilities serving such a purpose. 9. It is estimated that over 25% of the units of Consequently, the blood products made available to blood transfused in Africa, today, are not tested for prescribing physicians do not always meet the re- HIV, and that 5% to 10% of cases of HIV infection quired safety standards. Although in January 2000,

28 Supporting the strengthening of health systems based on the primary health care approach

WHO started a project on the provision of quality tives include the WHO quality management train- management training for blood transfusion centres, ing project. the lessons learnt from the project have yet to be 21. In the year 2000, WHO classifi ed all countries translated into deeds. of the world according to the level of safety of their 15. Few African countries have assigned a budget blood transfusion services. More than 85% of coun- line to activities related to blood transfusion safety. tries in the African Region were thus classifi ed Since blood transfusion is often not an independent among the countries in which blood transfusion is entity on its own, its funding in many countries is least safe. assured by bilateral or multilateral cooperation agen- 22. In the implementation of the present strategy by cies. Given the lack of national blood transfusion the countries, blood transfusion should be made a policies in most of the countries, the cooperation health priority and the related services must be re- agencies limit their funding to only the procurement organized so that blood transfusion safety in the of reagents. Unfortunately, the countries are unable Region can be improved. to purchase the reagents for themselves after the cooperation programme is ended. 16. Bilateral and multilateral cooperation has played, THE REGIONAL STRATEGY and continues to play, an important role in the de- Aim velopment of blood transfusion systems in Africa and, more particularly, in the prevention of HIV 23. The aim of the regional strategy is to improve transmission by blood. However, since there is no blood transfusion safety and bridge the gap between national coordination, each donor agency pursues its blood needs and blood availability in health services. own blood transfusion policy within the geographical area specifi cally assigned to it. The result is that, Objectives within a given country, the blood transfusion policy 24. The main objectives are: may vary from province to province or from region to region. (a) to assist the countries to set up an effective system of recruitment of low-risk, voluntary and 17. In 1999, the annual blood needs of countries in regular donors; the Region were estimated at 12 million units, but (b) to improve the safety of blood and blood prod- blood collection in that year totalled just 30% of that ucts by implementing quality assurance pro- quantity, thus leaving a substantial defi cit. grammes and mapping out effective strategies 18. Very few countries in Africa have laid down for the screening of blood for all transfusion- stringent rules to govern the use of blood and blood transmissible infections; products. In most cases, transfusion involves whole (c) to promote the appropriate use of blood and blood, and some of the accidents that occur in the blood products by clinicians. process are due to either inadequate staff training or non-adherence to the rules of sound professional Targets practice and ethics. Although the techniques of auto- 25. By the end of 2012: transfusion have undisputed advantages in regard to safety, they are not practised on a widespread scale. (a) all the Member States will have carried out a situation analysis of blood transfusion safety; (b) at least 75% of the countries will have drawn up, Justifi cation adopted or implemented their national blood 19. Despite the recommendation of the World transfusion policy; Health Assembly in 1975, and of the Regional Com- (c) one hundred per cent of the blood units trans- mittee in 1994, a situation analysis clearly shows that fused will be screened, beforehand, for HIV and the blood transfusion systems of countries in the Re- other transfusion-transmissible infections; gion are still fraught with weaknesses. (d) at least 80% of blood donors in all countries of the Region will be voluntary and regular do- 20. WHO has made blood transfusion safety one of nors. its priorities since the year 2000 when the main theme of World Health Day was blood safety. Guiding principles Further more, the year 2000 saw the birth of many initiatives aimed at mobilizing energies to promote 26. The principles that will guide the implementa- the safety of blood and blood products. These initiation of the strategy will be the following:

29 COMPENDIUM OF RC STRATEGIES

(a) formulation, adoption and implementation of ties, must be encouraged and supported by the national blood transfusion policies; countries. There is need for research into the opti- (b) establishment of universally applicable norms for mal use of blood products, including HIV-positive avoiding discrimination in the distribution and blood. use of blood products; 35. Particular attention must be given to the training (c) creation of an enabling environment for the de- of blood prescribers and care providers. Guidelines velopment of effective, reliable and sustainable for the prescription and use of blood and blood blood transfusion services at all levels, especially products, including for research on the technique of in the districts. auto-transfusion must be produced and made available to them. In each health facility, a committee Priority interventions must be set up to enforce the rules of good practice and, thereby, foster appropriate use of blood. 27. The fi rst intervention will consist in carrying out a situation analysis of blood transfusion safety in all countries in the Region in order that the prevailing Implementation framework problems and needs can be well identifi ed. The in- Role of Member States formation thus gathered will help improve the planning of future activities. 36. As proof of their commitment, Member States must include blood transfusion safety in the priori- 28. The second intervention will involve drawing ties of their health programmes, assign a budget up and/or implementing national blood transfusion specifi c ally to it and draw up programmes and plans policies and action plans whose main thrusts will be: of action for its development. That will lead to a the formulation of a strategy for the recruitment and more rational and more proactive approach to the retention of regular and benevolent donors; the def- resolution of blood transfusion problems. inition of norms to be followed in the screening and processing of blood donations; the development of 37. The ministry of health will, as a matter of duty, guidelines for the prescription of blood and blood prepare texts on the organization of blood trans- products; review of ethical and regulatory issues; fusion services, propose a plan of action, implement fi nancing and cost recovery. the national policy and coordinate this activity nationwide. Furthermore, it will play a normative 29. The third intervention will involve addressing role, ensure adherence to the set rules in the private the special challenge faced by countries with high and public sectors and undertake the development HIV prevalence, in terms of attracting and retaining of human resources. In addition, it will collaborate a pool of low-risk blood donors. with all national and international structures that are 30. The Member States must assess their staffi ng in a position to promote blood transfusion safety. needs, judiciously select persons to be trained and create an environment conducive to the advance- Role of partners ment of the staff of blood transfusion services and, 38. In the context of the national blood transfusion thereby, dissuade them from deserting, or resigning policy, and under the coordination of the ministry from, their posts. of health, the various bilateral and multilateral 31. In addition, each country must pursue a true international cooperation agencies as well as non- policy of education, sensitization and retention of governmental organizations will be called upon to low-risk donors. provide technical and fi nancial support for the imple mentation of strategies leading to effective and 32. Health authorities must ensure that safety reliable blood transfusion services. stan dards are met in the screening of blood for trans fusion-transmissible infections, in the context of Role of WHO clearly established national blood transfusion policies. 39. WHO will play a vital role in ensuring the suc- 33. Participation in the WHO project on the train- cess of this strategy by supporting the countries to ing of staff of blood transfusion centres in quality formulate and implement national blood transfusion management techniques and procedures will be the policies; establish a consultation framework for all bedrock of future actions and should foster concrete stakeholders in the area of blood transfusion safety; action at fi eld level. design and provide to Member States the tools 34. Blood transfusion research, which generates in- needed to assess the blood transfusion situation and; formation indispensable for the planning of activi- determine the blood transfusion profi le of each

30 Supporting the strengthening of health systems based on the primary health care approach country. In collaboration with the other partners, Recalling resolution AFR/RC44/R12 on HIV/ WHO, will produce procedures handbooks and AIDS control, which urges Member States to take guidelines and provide technical or fi nancial support urgent steps to enact blood safety policies, mobilize for staff training. Furthermore, WHO, in collabora- resources for blood service infrastructure develop- tion with Member States, will develop a database on ment at central and district hospitals and set goals blood safety and make it available to them. and targets for the attainment of HIV-free blood transfusion in health-care settings; MONITORING AND EVALUATION Noting with concern that only 30% of the countries in the Region have so far formulated a blood 40. It will be important to establish a mechanism for transfusion policy, and the need in all countries for the monitoring and evaluation of this strategy. The systematic screening of blood for the main transmis- monitoring should be undertaken, each year, in the sible infections, especially for blood transfusion; countries to enable the necessary adjustments to be made on time. At the regional level, a mid-term re- Recalling also that the transmission of HIV, view will be conducted after fi ve years of implemen- hepatitis B, hepatitis C, syphilis, malaria and other tation of the strategy and progress reports submitted parasitic infections through the blood can be effec- to the Regional Committee every two years. tively prevented by adopting a sound blood transfusion policy and carrying out systematic screening 41. WHO will develop evaluation indicators and for such infections in all units of donated blood; each country will, based on its specifi c situation, defi ne monitoring indicators that will be used to assess Concerned by the fact that, since the adoption of its own progress. resolution AFR/RC44/R12 in 1994, the changes that have taken place in most of the Member States in this area are hardly perceptible and that the current CONCLUSION economic situation has contributed to a worsening of the health situation in the countries of the Region; 42. Today, at the dawn of the 21st century, blood transfusion safety poses a real challenge to the Afri- Convinced that Member States in the African can continent. The present strategy, mapped out as a Region can achieve blood safety; consequence, examines the weaknesses of the blood 1. APPROVES the regional strategy for blood transfusion system in Africa and proposes a frame- transfusion safety as proposed in document AFR/ work and actions to expand the pool of low-risk RC51/9: blood donors, ensure adequate screening of blood for transfusion-transmissible infections and promote 2. COMMENDS the Regional Director for research as well as the judicious use of blood in order actions already taken to improve blood transfusion to foster progress. safety in the Region; 43. The Regional Committee examined this strate- 3. URGES Member States: gy, made the necessary amendments for its improve- (a) to formulate, adopt and implement a national ment, adopted it and gave guidance for its blood transfusion policy consistent with national implementation. needs and HO technical recommendations, especially for: Resolution AFR/RC48/R2 (i) the establishment of safety norms and standards and a quality assurance pro- Blood safety: A strategy for the WHO African gramme in order to provide all patients, Region who so require, with blood that is safe; The Regional Committee, (ii) the formulation of human resource policies which ensure the training, promotion Having considered the report of the Regional and retention of the staff of blood transfu- Director on the strategy for blood transfusion safety sion centres and the training of prescribers in the African Region; in the judicious use of blood; Considering World Health Assembly resolution (iii) the promotion of research in the area of WHA 28.72 recommending that Member States pro- blood transfusion safety, including the use mote the development of national blood trans fusion of blood and blood products; services based on voluntary non-remunerated blood (b) to allocate adequate funds for developing the in- donations and enact legislation governing them; frastructure of blood transfusion services and

31 COMPENDIUM OF RC STRATEGIES

creating an enabling environment for the estab- (e) to mobilize resources from international partners lishment of a reliable blood transfusion system, to fi nance blood transfusion safety in the Region; including the cold chain; (f) to strengthen technical cooperation and collabo- (c) to promote voluntary and non-remunerated ration between Member States and WHO so as blood donation on a regular and permanent ba- to improve the management of blood transfu- sis; sion centres and the quality of blood and blood (d) to mobilize bilateral and multilateral partners as products; well as nongovernmental organizations (NGOs) (g) to ensure the follow-up and implementation of to provide technical and fi nancial support for the this strategy and report to the fi fty-fourth session establishment of reliable and sustainable blood of the Regional Committee. transfusion services; Fifth meeting, 29 August 2001 4. REQUESTS the Regional Director: (a) to play a leadership role in instituting blood REFERENCES transfusion and AIDS control programmes in the 1. Report of the intercountry workshop of Directors of WHO African Region; national blood transfusion centres of the Francophone (b) to support Member States in drawing up and and Lusophone countries, Abidjan, 13–17 December implementing national blood transfusion poli- 1999. cies; – Report of the intercountry workshop of Directors (c) to promote and support training programmes for of national blood transfusion centres of the Anglo- the staff of blood transfusion services and pre- phone countries, Harare, 2–5 May 2000. scribing physicians; – WHO Global Database on Blood Safety, 1999. (d) to facilitate the use of reference centres in blood – Country reports presented at the above workshops, 1999 and 2000. transfusion in the Region for the training of ap- – Situation of blood safety in Africa, WHO/AFRO propriate staff from Member States; and UNAIDS/ICT, 1997.

32 2.4 Health ﬁ nancing: A strategy for the WHO African Region (AFR/RC56/10)

EXECUTIVE SUMMARY 1. The manner in which a health system is fi nanced affects its stewardship, input creation, service provision and achievement of goals such as good health, responsiveness to people’s non- medical expectations (short waiting times, respect for dignity, cleanliness of physical facilities, quality meals) and fair fi nancial contributions, so that individuals are not exposed to great fi nancial risk of impoverishment. 2. Countries of the Region are confronted with a number of key challenges, including low investment in health; low economic growth rates; dearth of comprehensive health fi nancing policies and strategic plans; extensive out-of-pocket payments; limited fi nancial access to health services; limi ted coverage by health insurance; lack of social safety nets to protect the poor; ineffi cient resource use; ineffective aid; and weak mechanisms for coordinating partner support in the health sector. 3. In order to reach the health-related Millennium Development Goals (MDGs) and achieve national health development objectives, national health systems in the African Region urgently need more money; greater equity in health services fi nancing and accessibility; effi cient use of health resources; and expanded coverage of health services, especially those targeting the poor. Countries are urged to institutionalize national health accounts to facilitate fi nancial planning, monitoring and evaluation. 4. The aim of this strategy is to foster development of equitable, effi cient and sustainable national health fi nancing to achieve the health-related MDGs and other national health goals. 5. The Regional Committee considered this strategy and the attached resolution and adopted the recommended actions.

INTRODUCTION 2. The performance of a health fi nancing system depends among others on its capacity for equitable 1. Health fi nancing is one of the four functions of and effi cient revenue generation; the extent to health systems. Health fi nancing refers to the collec- which fi nancial risk is spread between the healthy tion of funds from various sources (e.g. government, and the sick, and the rich and the poor; extent to households, businesses, donors), pooling them to which the poor are subsidized; effi cient purchasing share fi nancial risks across larger population groups, of health inputs and services; and the prevailing and using them to pay for services from public and macroeconomic situation, e.g. economic growth, private health-care providers.1 The objectives of unemployment, size of the informal sector com- health fi nancing are to make funding available, en- pared to the formal sector, governance, etc. sure choice and purchase of cost-effective interventions, give appropriate fi nancial incentives to 3. There is ample evidence that the manner in providers, and ensure that all individuals have access which a health system is fi nanced affects both the to effective health services.2 performance of its functions and the achievement of

33 COMPENDIUM OF RC STRATEGIES

3 its goals. The magnitude, effi ciency and equity in >100 health fi nancing determine the pace at which indi- 91-100 vidual countries are able to achieve national health 81-90 development objectives and the Millennium Devel- 71-80 opment Goals (MDGs). 61-70 51-60 US$ 4. Cognizant of the important role of fi nancing in 41-50 health development, African Heads of State, in 2001, 31-40 committed themselves to taking all necessary meas- 21-30 ures to ensure that resources are made available and 10-20 are effi ciently utilized. In addition, they agreed to <10 allocate at least 15% of their national annual budgets 010203040 to improving the health sector;4 this commitment Countries 5 was reaffi rmed in the Maputo Declaration. Recent Year 2002 Year 1998 resolutions6 of the WHO Regional Committee for Africa urge Member States to honour the pledge Figure 1: Per capita government expenditure on health made by Heads of State in Abuja. at average exchange rate (US$), WHO African. Source: 5. In May 2005, the Fifty-eighth World Health Compiled from data in WHO, The world health report Assembly adopted a resolution7 that urges Member 2005: Making every mother and child count, Geneva, World States to ensure that health fi nancing systems include Health Organization, 2005, Annex Table 5 a method for prepayment of fi nancial contributions for health care. This is aimed at sharing risk among and Health (CMH) recommendation9 of US$ 34 per the population and avoiding catastrophic health-care capita expenditure for health (see Figure 3) needed to expenditure and impoverishment of care-seeking buy an essential package of health services. Indeed, individuals. The resolution also encourages planned estimates based on 2002 data show that even if all transition to universal coverage and ensured, man- countries met the Abuja target, more than half of aged and organized external funds for specifi c health them would not have made much progress towards programmes or activities which contribute to the attaining the CMH and MDG targets.10 development of sustainable fi nancing mechanisms 8. In 24 countries, 50% of the total health expend- for the health system as a whole. iture came from government sources; in 17 coun- 6. This document briefl y reviews the state of health tries, 25% of total health expenditure came from fi nancing in the Region; proposes priority inter- external sources. Thus, the international community ventions that could be implemented to strengthen makes an important contribution to health fi nancing national health fi nancing systems; outlines roles and in the Region. However, the recurrent cost impli- responsibilities for countries WHO and partners; cations of donor-supported capital investments are and proposes a brief monitoring and evaluation often not taken into account, which impacts nega- framework. The proposed interventions should be tively on their sustainability. urgently implemented to ensure the achievement of 9. Private spending from households and businesses MDGs and other national health goals. This strategy constituted over 40% of the total health expenditure document is consistent with the spirit of the Health- in 31 countries. The bulk of private spending is from for-all Policy for the 21st Century in the African direct out-of-pocket household expenditures (see Region.8 Figure 4), i.e. including the Bamako Initiative cost recovery schemes.11,12 Prepaid health fi nancing SITUATION ANALYSIS mechanisms (including mutual health insurance schemes and community-based health insurance 7. As of 2002, out of 46 countries in the WHO schemes13) cover only a small proportion of popula- African Region, 15 countries spent less than 4.5% of tions in the Region. Prepaid fi nancing mechanisms their gross domestic product on health; in 29 coun- account for more than 72% of the private health ex- tries, government expenditure per person per year penditure in two countries. However, even in those was less than US$ 10 (see Figure 1); and 43 countries countries, the proportion of the population that is spent less than 15% of their national annual budget covered in prepaid health schemes is relatively small. on health (see Figure 2). Thus, most countries are far from reaching the 15% target set by African Heads 10. Health personnel employed by governments and of State in 2001. In addition, 31 countries failed to NGOs are often paid fi xed salaries unrelated to meet the WHO Commission for Macroeconomics workload. Financing of public services in most

34 Supporting the strengthening of health systems based on the primary health care approach

Zimbabwe Zambia Tanzania Uganda Togo Swaziland South Africa Sierra Leone Seychelles Senegal Sao Tome Rwanda Nigeria Niger Namibia Mozambique Mauritius Mauritania Mali Malawi Madagascar Liberia Lesotho Year 2002 Kenya Year 1998 Guinea Bissau Guinea Ghana Gambia Gabon Ethiopia Eritrea Equatorial Guinea DRC Côte d'Ivoire Congo Comoros Chad CAR Cape Verde Cameroon Burundi Burkina Faso Botswana Benin Angola Algeria 0 5 10 15 20 25

Figure 2: General government expenditure on health as % of total government expenditure, WHO African Region. Source: Compiled from data in WHO, The world health report 2005: Making every mother and child count, Geneva, World Health Organization, 2005, Annex Table 5.

countries is done through infl ation-adjusted histori- Challenges cal budgets and transfer of funds from one govern- 12. The challenges related to effi cient and equitable ment department to another with little strategy revenue collection include low investment in health; behind allocation decisions.14 heavy reliance on out-of-pocket expenditures; low 11. Some progress has been made during the past household capacity to pay due to widespread pov- few years in mobilizing more money for the health erty; high unemployment; low economic growth; sector and addressing a number of equity and effi - limited fi scal (budgetary) space; double burden of ciency issues, including revenue pooling and risk communicable and non-communicable diseases; management. There is also some understanding of high but declining population growth rates; erratic the key issues related to resource allocation and pur- disbursement of donor funds; weak mechanisms for chasing of health services. coordinating health partnerships.

35 COMPENDIUM OF RC STRATEGIES

>100 91-100 81-90 71-80 61-70 51-60 US$ 41-50 31-40 21-30 10-20 <10 02 4 6 8 10 12 1416 18 Countries

Year 2002 Year 1998 Figure 3: Per capita total expenditure on health at average exchange rate (US$), WHO African Region. Source: Compiled from data in WHO, The world health report 2005: Making every mother and child count, Geneva, World Health Organization, 2005, Annex Table 5.

Zimbabwe Zambia Uganda Togo Tanzania Swaziland South Africa Sierra Leone Seychelles Senegal Sao Tome Rwanda Nigeria Niger Namibia Mozambique Mauritius Mauritania Mali Malawi Madagascar Liberia Lesotho Kenya Guinea Bissau Guinea Ghana Gambia Gabon Ethiopia Eritrea Equatorial Guinea DRC Côte d'Ivoire Congo Comoros Chad CAR Cape Verde Cameroon Burundi Burkina Faso Botswana Benin Angola Algeria 0 20 40 60 80 100 %

Figure 4: Out-of-pocket expenditure as % of private expenditure on health, 2002, WHO African Region. Source: Compiled from data in WHO, The world health report 2005: Making every mother and child count, Geneva, World Health Organization, 2005, Annex Table 5.

36 Supporting the strengthening of health systems based on the primary health care approach

13. Challenges in revenue pooling and risk manage- of potential for increasing availability of resources ment persist. For example, direct out-of-pocket through effi ciency improvements; and increased household spending does not go through pooling knowledge-sharing in health fi nancing.18 mechanisms. Countries tend to rely only on one or two of the four risk management mechanisms (i.e. state-funded health care systems, social health insur- THE REGIONAL STRATEGY ance, community-based health insurance, and volun- Objectives tary health insurance), which may not be adequate to meet all the health fi nancing objectives. Limited re- 16. The general objective of this strategy is to foster insurance options make insurance schemes vulnerable development of equitable, effi cient and sustainable to bankruptcy.15 Risk management is also adversely national health fi nancing to achieve the health affected by weak management capacities in the public MDGs and other national health goals. sector, low quality of public health services, restrictive 17. The specifi c objectives of this strategy are: public benefi t packages, weak cross-subsidization, and underpaid public health-care workers. (a) to secure a level of funding needed to achieve desired health goals and objectives in a sustain- 14. There are a number of challenges related to re- able manner; source allocation and purchasing of health services. (b) to ensure equitable fi nancial access to quality Many governments still provide all their health serv- health services; ices through the public sector, despite the presence (c) to ensure that people are protected from fi nan- and popularity of NGO and private sector facilities. cial catastrophe and impoverishment as a result Donor funds are often earmarked for priority diseases of using health services; and thus cannot be used to strengthen health systems. (d) to ensure effi ciency in the allocation and use of Some subsidies to health-care providers are benefi ting health sector resources. the rich rather than the poor. Current salaries in the health-care sector in most countries in the Region do not create performance incentives, and payment Guiding principles mechanisms in public health institutions discourage 18. The choice and implementation of priority maximum output and cost containment. Health faci- health fi nancing interventions will be guided by the lities continue to make ineffi cient use of resources.16 following principles: (a) Country ownership must ensure that all health Opportunities fi nancing processes are led and owned by 15. Countries could take advantage of various countries. opportunities. These include the impetus provided (b) Provision of health-care services should aim at by the MDGs; commitment by African Heads of fostering equity in access among all population State to signifi cantly increase health spending; com- groups, with special attention to vulnerable mitment by the donor community (e.g. International groups (e.g. the poor, women and children). Financing Facility, G8, European Union, Organiza- Equity in fi nancing must ensure that contribution for Economic Co-operation and Development) tions to the funding of the health system are to signifi cantly expand aid instruments (e.g. Global made according to ability to pay and long before Fund to Fight AIDS, Tuberculosis and Malaria; Glo- health care is needed in order to protect families bal Alliance for Vaccines and Immunization; Highly from impoverishment. Indebted Poor Countries Initiative) and increase aid (c) Effi ciency must ensure that maximum health effectiveness;17 increased willingness of partners in benefi ts are derived from scarce available re- countries to participate in sector-wide approaches sources, with particular attention to both imme- (SWAps). Other opportunities are the increased de- diate operating expenditures and the long-term termination of the African Union, in the context of recurrent cost implications of major human re- the New Partnership for Africa’s Development, to sources and capital investments. promote governance, transparency and account- (d) Transparency in a high degree must be seen in ability in the Region; the increased evidence and all fi nancial procedures and mechanisms and in awareness of the pivotal role of health in develop- actual spending. ment; inclusion of a health component in national (e) Risk sharing mechanisms must be expanded to poverty reduction strategies (including Poverty Re- increase the proportion of the health budget that duction Strategy Papers [PRSPs]) and the Medium- is pooled and reduce the proportion that comes Term Expenditure Frameworks (MTEFs); existence as out-of-pocket payments.

37 COMPENDIUM OF RC STRATEGIES

(f) Evidence-based decision-making should be prac- 24. Removing or reducing out-of-pocket payments. Coun- tised on a day-to-day basis, align with health tries that choose to remove or reduce out-of-pocket fi nancing reforms, rely on best practices, and be payments must ensure that an alternative source of economically viable. fi nancing is available to continue providing high (g) Partnerships should involve all health-related quality services.19 sectors, various levels of government, the private 25. Improving effi ciency in revenue collection. Revenue sector, international development organizations, collection mechanisms should avoid wasting scarce communities and civil society. resources through high administrative costs and maximize resources from both the formal and infor- Priority interventions mal sectors. 19. The proposed priority interventions are centred around strengthening the three functions of health Revenue pooling fi nancing: revenue collection; revenue pooling and 26. Developing prepayment systems. Countries should risk management; and resource allocation and introduce or expand prepayment systems, where purchasing. funds are collected through taxes and/or insurance 20. This strengthening of functions may require contributions. Such systems allow people to access training and hiring new categories of staff with skills services when in need and protect the poor from in actuarial analysis; health economics; fi nancial and fi nancial catastrophe by reducing out-of-pocket asset management; information technology; insur- spending. When designing such systems, policy- ance management and prepayment programmes; makers will need to involve all other stakeholders.20 and planning, monitoring and evaluation. 27. Establishing new health fi nancing agencies. Because of the complex links between risk management and Revenue collection both revenue collection and purchasing of health services, many countries may choose to establish 21. Strengthening of fi nancing mechanisms. In the long new health fi nancing agencies to ensure proper co- term, the aim should be to develop prepaid mecha- ordination of the three health fi nancing functions. nisms such as social health insurance, tax-based The governance arrangements of the new health fi nanc ing (including earmarked taxes on alcohol and fi nanc ing agencies should include representation tobacco) of health care, or some mix of prepayment from all relevant stakeholders. Whatever institu- mechanisms (with maximum community participa- tional arrangements are made, issues relating to tion) to achieve the universal coverage goal. During quality of care, range of benefi ts, provider payment the transition to universal coverage, countries are mechanisms and staff remuneration should be ad- likely to use a combination of mechanisms to effec- dressed in a manner that supports revenue pooling tively manage fi nancial risk. These include subsidies and risk management. (taxes and donations), compulsory insurance (e.g. social health insurance coverage for specifi c groups), 28. Strengthening safety nets to protect the poor. The voluntary insurance (community-, cooperative- and effectiveness of exemption mechanisms could be enterprise-based), reinsurance, savings and limited enhanced through increased community awareness direct spending. of the exemption policy; issuance of exemption cards to poor people long before the need for health 22. Honouring of past regional commitments. Political care arises; decreased direct (including transport) and action is now needed to ensure that African Heads indirect costs to poor people; strengthened adminis- of State honour their commitment to allocate 15% trative capacity for monitoring, supervising, inter- of their national budgets to health. This requires preting and applying exemptions; compensation to ambitious but realistic increases in allocations to the health facilities for revenue lost through granting of health sector under each country’s Medium-Term exemptions; increased funding to health facilities Expenditure Framework. In addition, budgets ap- where the poor are concentrated; and strengthened proved through appropriate government processes political support for exemptions21. In addition, when should be fully executed. almost entire communities are living under the 23. Monitoring multi-donor budgetary support. There is poverty line, governments will need to provide sub- a need to closely monitor multi-donor budgetary sidized services; where community-based health in- support to ensure that the shift from sectoral to surance exists, government involvement will still be general budgetary support does not decrease donor needed in terms of subsidies and re-insurance contribution to the health sector. mechanisms.

38 Supporting the strengthening of health systems based on the primary health care approach

Resource allocation and purchasing tem. Equally benefi cial are improved referral systems, institutionalized equity and effi ciency monitoring, 29. Financing the strengthening of health systems. Exist- health sector coordination mechanisms (e.g. SWAps) ing and additional funding from both national and and an essential service package based on priority set- international sources for the health sector needs to ting and choice of interventions agreed by society. focus on both overall systems strengthening as well as specifi c disease programmes. Roles and responsibilities 30. Using priority disease resources to strengthen health 35. Securing increased fi nancial resources at the systems. In order to ensure that priority disease pro- country level in an equitable and effi cient manner grammes are implemented effectively, there is an will be critical to meeting the regional objectives of urgent need to strengthen the underlying health sys- accelerating progress towards reaching the MDGs tem, including management capacity and integrated and protecting populations from the impoverishing care (e.g. primary care and Integrated Management effects of illness. Because the health fi nancing strat- of Childhood Illness). egy will play a critical role in meeting these objec- 31. Contracting the private sector and nongovernmental tives, adequate human and fi nancial resources are organizations. Signifi cant resources exist through necessary for its successful implementation. NGOs and the private sector in the African Region. These resources can be harnessed to meet public Countries policy objectives through contracts with the public 36. National political will, commitment and support sector, but many countries need to create the neces- are crucial for successful implementation of this sary enabling environment with suitable policy and strategy. In addition, the technical leadership of the legislative frameworks. Governments should be en- ministry of health is essential for its implementation. couraged to contract services to nongovernmental Therefore, each country will: and private providers, especially in areas where they have a comparative advantage, and ensure mecha- (a) strengthen the leadership capacity of the minis- nisms are in place to provide access to high-quality try of health and its collaboration with the min- health services to the poor. istry of fi nance, ministry of labour and other relevant ministries and stakeholders; 32. Incorporating demand-side targeting mechanisms. (b) strengthen or develop a comprehensive health Some countries have tried demand-side targeting fi nancing policy and a strategic plan, which be- mechanisms such as conditional cash transfers, come essential parts of the national health policy vouchers and subsidized insurance premiums. Where and health development plan; in addition, the relevant and feasible, these mechanisms should be strategic health fi nancing plan should have a complementary to underlying broader fi nancing clear roadmap for achieving the MDG targets mechanisms. These demand-side mechanisms could and eventually universal coverage; be used more widely throughout the Region to low- (c) incorporate its health fi nancing strategic plan er the fi nancial barriers to health-care service access. into national development frameworks such as 33. Reforming provider payment mechanisms. Provider PRSP and MTEF; payment mechanisms can be used to create incen- (d) secure statutory protection for minimum health tives for greater productivity, effi ciency and equity.22 fi nancing allocations to the health sector; Countries need to ensure that remunerations, pro- (e) fulfi l the commitment made by African Heads of motions and contracts for health personnel are di- State to allocate at least 15% of the national bud- rectly linked to performance. Signifi cant payment get for health development; reforms often require parallel civil service reforms in (f) mobilize additional resources and utilize existing order to achieve the desired policy goal of maximiz- opportunities for funding to reach internation- ing health benefi ts from available resources.23 ally agreed targets (e.g. MDGs); (g) strengthen health sector stewardship, over sight, 34. Other interventions exist for reducing resource wastage. transparency, accountability and mechanisms for They include allocating resources on the basis of preventing wastage of health resources; assessed need for health services; improving input (h) strengthen fi nancial management skills, includ- procurement (e.g. through competitive tendering), ing competencies in accounting, audit ing, actu- distribution systems and prescribing practices; per- arial science, health econo mics, budgeting, fecting fi nancial management systems; and strength- planning, monitoring and evaluation; ening the costing, budgeting, planning, monitoring (i) strengthen the national health fi nancing system, and evaluation capacities at all levels of the health sys- including fi nancing structures, processes and

39 COMPENDIUM OF RC STRATEGIES

management systems as well as building or and should remain consistent with macro- strengthening prepayment systems (including economic and growth objectives; health insurance) with community participation; (c) the donation commitments made at various in- (j) institutionalize effi ciency and equity monitoring ternational forums24 are fulfi lled, including the and national and district health accounts within commitments made in the Paris Declaration on health information management systems; aid effectiveness.25 (k) reinforce capacities for health fi nancing (including cost) evidence generation, dissemination and MONITORING AND EVALUATION utilization in decision-making. 39. The overall objective of monitoring and evalua- WHO and partners tion for the fi nancing strategy is to assess progress towards achieving the objectives of the strategy and 37. WHO, in close partnership with the World to aid informed decision-making. Bank, International Monetary Fund, International Labour Organization, African Development Bank, 40. Member States, with support from WHO and regional economic communities, European Union, other development partners, should conduct regular bilateral donors, other relevant UN agencies (e.g. national health accounts exercises and develop a UNICEF), and other public and private donors, will monitoring and evaluation framework based on: provide technical and fi nancial support to countries (a) sources of fi nancing: level, distribution and of the Region to implement this strategy. There will execution rates be need to tailor technical and fi nancial support to (b) pooling: population coverage through pooling the special needs of countries. In addition, WHO mechanisms and partners will: (c) spending: expenditure tracking; benefi t inci- (a) prepare regional guidelines for developing com- dence of spending. prehensive health fi nancing policies and strategic 41. WHO will propose a set of global indicators for plans, and for monitoring and evaluating their intercountry comparability. In addition, countries implementation; will agree on a set of indicators to be used for mon- (b) provide technical support to Member States, as itoring the implementation of the strategy’s objec- appropriate, for developing tools and methods tives and priority interventions. With support from for evaluating different practices in health WHO and other partners, countries will collect infi nanc ing, including collection of revenue, pool- formation on the implementation of the strategy ing and purchasing (or provision) of services as continuously, and carry out intercountry evaluation they move towards universal coverage; of health fi nancing performance every three years. (c) create networking and mechanisms to facilitate the continuous sharing of health fi nancing experiences and lessons learnt; CONCLUSION (d) support health fi nancing research, disseminate 42. In order to achieve the health-related Millen- the research fi ndings and use them in decision- nium Development Goals, national health develop- making; ment objectives and expanded coverage of health (e) ensure that the key recommendations in this services, especially those targeting the poor, coun- regional strategy become a central part of the tries in the African Region urgently need increased health contents of all relevant action plans. funding; greater equity in fi nancing and access to 38. Furthermore, WHO and partners will work health services; and improved effi ciency in the use with Member States to ensure that: of health resources. (a) an increasing share of national budgets is allo- 43. The WHO Regional Committee for Africa cated to the health sector and other critical sec- considered this strategy and adopted the proposed tors in order to accelerate progress towards the attached resolution. health MDGs, in line with the commitments reaffi rmed by African Heads of State in Maputo in 2003; Resolution AFR/RC56/R10 (b) the funds allocated to the health and health- Health fi nancing: A strategy for the African related sectors from international donors and Region other development partners should be additional to, and not a substitute for, national resources The Regional Committee,

40 Supporting the strengthening of health systems based on the primary health care approach

Cognizant of the fi nding of the Commission on (e) to strengthen capacities for generating, dissemi- Macroeconomics and Health that poor health con- nating and using evidence from health fi nancing tributes signifi cantly to poverty and low economic in decision-making; growth; 3. REQUESTS the Regional Director, in collabo- Aware that investments in health yield substantial ration with the World Bank, other multilateral returns in terms of poverty reduction and economic and bilateral funding agencies, and public and development; private funding bodies: (a) to make available regional guidelines for devel- Recalling resolutions AFR/RC52/R4 on poverty oping comprehensive health fi nancing policies and health, AFR/RC53/R1 on macroeconomics and strategic plans, and for monitoring and eval- and health, and the World Health Assembly resolution uating their implementation; WHA58.30 on accelerating achievement of the (b) to provide technical support to Member States, internationally-agreed health-related development as appropriate, for developing tools for and goals; methods of evaluating different practices in Recalling the pledge made by Heads of State in health fi nancing; Abuja in 2001 to allocate at least 15% of their (c) to create networks and mechanisms to facilitate national budgets to health; the continuous sharing of health fi nancing experiences and lessons learnt; Recalling World Health Assembly resolution (d) to support health fi nancing research, the dissem- WHA58.33 urging Member States to ensure sus- ination of fi ndings there from and their use in tainable fi nancing mechanisms; decision-making; Recalling the resolution of ministers of health of (e) to report on implementation of the strategy eve- the African Union (Sp/Assembly/ATM (1) Rev.3) ry two years. on health fi nancing in Africa that renews their com- (f) to strengthen or develop comprehensive health mitment to accelerate progress towards achieving the fi nancing policies and strategic plans and incor- Abuja and Millennium Development Goal targets; porate them into national development frameworks such as Poverty Reduction Strategy Appreciating the support being provided under Papers and Medium-Term Expenditure international initiatives such as the Highly-Indebted Frameworks;(c) to fulfi l the commitment made Poor Countries; the Global Fund to Fight AIDS, by African Heads of State to allocate at least 15% Tuberculosis and Malaria; the Global Health Re- of their national budgets to health;(d) to search Fund; the Global Alliance for Vaccines and strengthen the national prepaid health fi nancing Immunization; Roll Back Malaria; Stop TB; and the systems, including fi nancing structures, processes Bill and Melinda Gates Foundation; and management systems; 1. ENDORSES the document entitled “Health fi - (g) to strengthen capacities for generating, dissemi- nancing: a strategy for the African Region”; nating and using evidence from health fi nancing in decision-making; 2. URGES Member States: (a) to strengthen leadership capacities of ministries 3. REQUESTS the Regional Director, in collabo- of health and re-enforce their collaboration with ration with the World Bank, other multilateral ministries of fi nance and labour as well as other and bilateral funding agencies, and public and rele vant ministries and stakeholders; private funding bodies: (b) to strengthen or develop comprehensive health (a) to make available regional guidelines for devel- fi nancing policies and strategic plans and incor- oping comprehensive health fi nancing policies porate them into national development frame- and strategic plans, and for monitoring and eval- works such as Poverty Reduction Strategy uating their implementation; Papers and Medium-Term Expenditure Frame- (b) to provide technical support to Member States, works; as appropriate, for developing tools for and (c) to fulfi ll the commitment made by African methods of evaluating different practices in Heads of State to allocate at least 15% of their health fi nancing; national budgets to health; (c) to create networks and mechanisms to facilitate (d) to strengthen the national prepaid health fi nanc- the continuous sharing of health fi nancing expe- ing systems, including fi nancing structures, riences and lessons learnt; processes and management systems;

41 COMPENDIUM OF RC STRATEGIES

(d) to support health fi nancing research, the dissem- 13. Ekman B. Community-based health insurance in ination of the fi ndings and their use in decision- low-income countries: a systematic review of the making; evidence, Health Policy and Planning, 19(5): 249–270, (e) to report on implementation of the strategy every 2004. two years. 14. Preker AS. Managing scarcity through strategic purchasing of health care. In: Preker AS, Langenbrunner Fifth meeting, 30 August 2006 JC (eds). Spending wisely: Buying health services for the poor, Washington, D.C., The World Bank, 2005, 23–60. REFERENCES 15. Dror DM, Preker AS (eds). Social reinsurance: A new 1. WHO, The world health report 2000: Health systems: approach to sustainable community health fi nancing, Wash- improving performance, Geneva, World Health Organi- ington, D.C., The World Bank and the International zation, 2000. Labour Organization, 2002. 2. Carrin G, James C. Social health insurance: Key 16. Kirigia JM, Emrouznejad A Sambo LG. Measurement factors affecting the transition towards universal cov- of technical effi ciency of public hospitals in Kenya: erage, International Social Security Review, 58(1): 45–64, Using data envelopment analysis, Journal of Medical 2005. Systems, 26 (1): 29–45, 2002; Asbu EZ, McIntyre D, 3. Preker AS, Carrin G (eds). Health fi nancing for poor peo- Addison T, Hospital effi ciency and productivity in ple: Resource mobilization and risk sharing, Washington, three provinces of South Africa, South African Journal D.C., The World Bank, 2004. of Economics, 69 (2): 336–358, 2001. 4. OAU, Abuja declaration on HIV/AIDS, tuberculosis and 17. WHO, Paris declaration on aid effectiveness: Ownership, other related infectious diseases, Addis Ababa, Organiza- harmonization, alignment, results and mutual accountabili- tion of African Unity, 2001. ty, Geneva, World Health Organization, High-Level 5. AU, Maputo declaration on HIV/AIDS, tuberculosis, ma- Forum, 2005. laria and other related infectious diseases, Addis Ababa, 18. Preker AS, Langenbrunner JC (eds). Spending wisely: African Union, 2003. Buying health services for the poor, Washington, D.C., 6. AFR/RC52/R4, Poverty and health: A strategy for The World Bank, 2005. More health fi nancing infor- the African Region. In: Fifty-second Session of the mation can be found at: http://www.who.int/health_ WHO Regional Committee for Africa, Harare, Zimbabwe, fi nancing; www.who.int/evidence/cea; http://www.who. 8–12 October 2002, Final Report, Brazzaville, World int/contracting; http://www.worldbank.org. Health Organization, Regional Offi ce for Africa, 19. Gilson L, McIntyre D. Removing user fees for 2002 (AFR/RC52/19), 11–13. AFR/RC53/R1, primary care in Africa: The need for careful action, Macroeconomics and health: The way forward in the British Medical Journal, 331: 762–765, 2005. African Region. In: Fifty-third Session of the WHO Re- 20. WHO, Designing health fi nancing systems to reduce gional Committee for Africa, Johannesburg, South Africa, catastrophic health expenditure, Technical Briefs for 1–5 September 2003, Final Report, Brazzaville, World Policy-Makers, Number 2, Geneva, World Health Health Organization, Regional Offi ce for Africa, Organization, 2005 (WHO/EIP/HSF/PB/05.02). 2003 (AFR/RC53/18), 11–12. 21. Masiye F. Analysis of health care exemption policy 7. Resolution WHA58.33, Sustainable health fi nancing, in Zambia: Key issues and lessons. In: Audibert M., universal coverage and social health insurance, Gene- Mathonnat J, de Roodenbeke E (eds). Le fi nancement va, World Health Organization, 2005 (WHA58/2005/ de la sante dans les pays d’Afrique et d’Asie a faible revenu, REC/1). Paris, Karthala, 139–159, 2003. 8. WHO, Health-for-all policy for the 21st Century in 22. Mills AJ and Ranson K. The design of health systems, the African Region: Agenda 2020, Harare, World In: Merson MH, Black RE, Mills AJ (eds), Inter- Health Organization, Regional Offi ce for Africa, national public health: Diseases, programs, systems, and 2002. policies, Sudbury, Mass., Jones and Bartlet Publishing, 9. WHO, Macroeconomics and health: Investing in health for 2005, 515–558. economic development, Geneva, World Health Organi- 23. WHO, Paris declaration on aid effectiveness: Ownership, zation, 2001. harmonization, alignment, results and mutual accountabili- 10. Atim C. Financial factors affecting slow progress in ty, Geneva, World Health Organization, High-Level reaching agreed targets on HIV/AIDS, TB and Forum, 2005. Malaria in Africa, London, DFID Health Resource 24. World Bank, IMF, Aid fi nancing and aid effective- Centre, 2006. ness, Washington, D.C., Development Committee of 11. WHO, Report on the review of the implementation the World Bank and International Monetary Fund, 16 of the Bamako Initiative in Africa, Harare, World September 2005 (DC2005–0020). Health Organization, Regional Offi ce for Africa, 25. WHO, Paris declaration on aid effectiveness: Ownership, 1999. harmonization, alignment, results and mutual accountabili- 12. Mcpake B Hanson K, Mills A. Community fi nancing ty, Geneva, World Health Organization, High-Level of health care in Africa: an evaluation of the Bamako Forum, 2005. Initiative, Social Science and Medicine. 36(11): 1383– 1395, 1993.

42 2.5 Knowledge management in the WHO African Region: Strategic directions (AFR/RC56/16)

EXECUTIVE SUMMARY 1. Effi cient Knowledge Management is now considered a key factor in organizational performance and competitiveness. New Knowledge Management approaches, including those using information and communication technology, can improve effi ciency through better time management, quality service, innova tion and cost reduction. 2. The WHO Knowledge Management Strategy, the WHO Regional Offi ce for Africa strategic orientations for 2005–2009, strategies of the African Union and the New Partnership for Africa’s Development, and the World Summit on the Information Society stress effi cient information and knowledge management as an important contribution to the achievement of the Millennium Devel- opment Goals and other internationally-agreed development goals, including those related to health. 3. The weak Knowledge Management culture and limited information and communication technology (ICT) skills and infrastructure represent serious impediments to knowledge access, sharing and application. The new Knowledge Management approaches and the current ICT revolution represent, for the WHO African Region, a historic opportunity to foster a culture of Knowledge Management and overcome the digital divide in order to strengthen health systems, improve health outcomes and provide equity in health. 4. Countries would benefi t from making Knowledge Management a priority component of their national health development policies and plans, and this emphasis requires allocation of adequate resources as well as the support of relevant partners. 5. The Regional Committee reviewed these strategic directions and adopted them along with the proposed resolution.

INTRODUCTION 2. The World Summit on the Information Society (WSIS), held in Geneva (2003) and Tunis (2005), 1. Effi cient Knowledge Management (KM) is now adopted a plan of action that emphasizes the impor- considered a key factor in organizational performance tance of Knowledge Management and the effi cient and competitiveness. New KM approaches, includ- use of information and communication technology ing those using information and communication (ICT) for the international development agenda, in- technology (ICT), can improve effi ciency through cluding health. The African Union and New Part- better time management, quality service, innovation nership for Africa’s Development have also addressed and cost reduction. The growing inequities in access the digital divide and e-Health2 as high priority to information and knowledge and in the transforma- issues in the continental development agenda. tion of knowledge into policy and action (the know- do gaps) as well as the digital divide1 (or electronic 3. WHO has defi ned Knowledge Management as: diversity) between and within countries present seri- “a set of principles, tools and practices that enable ous impediments to the achievement of the health- people to create knowledge, and to share, translate related Millennium Development Goals and other and apply what they know to create value and internationally-agreed health development goals. improve effectiveness.”3 The WHO Knowledge

43 COMPENDIUM OF RC STRATEGIES

Management strategy and Strategic orientations for WHO Internet services, and own 13 times more personal action in the African Region 2005–2009 implicitly computers than the 5.6 billion people living in low- suggest Knowledge Management for health as a income and lower middle-income countries. There key strategic priority.4 In addition, Resolution are currently 800 000 villages worldwide that lack WHA58.28 of the Fifty-eighth World Health access to even basic telephone services.6 As recog- Assembly5 urged Member States and requested the nized by the WSIS, sub-Saharan Africa is the world’s Director-General to actively promote and support most digitally-disadvantaged region. e-Health initiatives. 9. Policy-makers, health practitioners and commu- 4. This document proposes strategic directions for nities often lack relevant information and knowl- more effi cient knowledge generation, sharing and edge when and where they actually need it. application, and discusses the subsequent and respec- Conversely, there is an information overload which tive roles and responsibilities of countries, WHO results in time wastage, confusion and inappropriate and partners. decision-making and problem-solving. 10. E-Health and telemedicine are playing increas- SITUATION ANALYSIS ingly important roles in public health, clinical knowledge and medical practice. They provide a wide 5. The work of ministries of health, WHO and range of solutions for health situation assessment; other stakeholders already comprises Knowledge alert systems and responses to epidemics; manage- Management components such as the generation, ment of health institutions, services and programmes; sharing and application of scientifi c, technical, ex- health promotion; provision of health care; training; plicit and implicit knowledge. Concrete examples of and continuing education through e-learning. KM in health include health research; medical education and other elements of human resources de- 11. There is a proliferation of Communities of Prac- velopment; health situation analyses; programme tice, stakeholders interested in common specifi c monitoring and evaluation; and development of issues who exchange their information and knowl- strategies, norms, standards and guidelines. Publica- edge directly or through electronic tools. This tions, library services, documentation centres, meet- approach is a powerful instrument for knowledge ings, workshops and seminars are typical examples of sharing and application. KM tools and methods. 12. The most important strengths and opportunities 6. It is nevertheless widely acknowledged that for Knowledge Management in the African Region Knowledge Management for health is generally are the increasing awareness and commitment of weak and that there is a need for serious improve- policy-makers and professionals; the growing num- ment in this crucial area. Knowledge Management ber of partners willing to support KM programmes should deal not only with formal and explicit knowl- such as e-Health and telemedicine; the progress (al- edge deriving from health research and systematic- beit limited) in ICT infrastructure; and the condu- ally-documented health issues but also with tacit cive environment created by the World Summit on knowledge residing in people’s minds and linked to the Information Society. Several e-Health projects valuable individual and collective experiences. are being implemented, and others are being developed, such as the pan-African e-Network coordi- 7. New technological advances are rapidly chang- nated by the African Union. ing communications, widening possibilities and making new KM tools available. The most impor- 13. Weaknesses and threats in Knowledge Manage- tant are electronic mail, electronic databases, inter- ment area include lack of formal policies, norms, net web sites, intranets, search engines, video- and standards and strategies; managerial and leadership tele-conferencing, virtual libraries, electronic collab- styles that hinder learning, or knowledge sharing orative tools and expertise locators. and application; poor ICT infrastructure and the subsequent digital divide; and limited human and 8. The digital divide, which separates those who fi nancial resources. are part of the electronic revolution in digital communications and those who have no access to the 14. The main challenges for countries, WHO and benefi ts of the new technology, represents a major partners are the limited access to relevant knowledge obstacle to effective use of ICT solutions in KM. At (knowledge gap) and limited transformation of present, the 942 million people in developed coun- knowledge into action (know-do gap); weak learn- tries enjoy fi ve times better access to fi xed and mo- ing and knowledge-sharing behaviour; irrelevant bile phone services, have nine times better access to managerial processes and mechanisms for effi cient

44 Supporting the strengthening of health systems based on the primary health care approach

KM; and lack of coordination of the various 21. Capacity-building. Capacity concerns three main approaches and initiatives in KM. components of KM: people’s skills and behaviour, managerial processes and technologies. The key approaches to be implemented include training and REGIONAL AGENDA continuing education, staff incentives, institutional mechanisms and effective use of ICT infrastructure. Objectives 22. Fostering partnerships and mobilizing appropriate re- 15. The overall objective of this document is to sources. The global momentum in favour of Knowl- contribute to the improvement of health system edge Management and Information Technology performance and outcomes through effective development created by the WSIS and other inter- Knowledge Management in health. national and regional initiatives should be actively 16. The specifi c objectives are: used for building strong partnerships at country and regional levels, and for mobilizing adequate re- (a) to improve access to and sharing of health infor- sources for KM. mation and knowledge; (b) to maximize the impact of explicit and tacit 23. Effective knowledge generation, sharing and applica- knowledge, including health research and expe- tion. Countries and all stakeholders should foster riential knowledge, through effective knowl- Knowledge Management across health systems for edge sharing and application; health development and equitable health outcomes. (c) to foster e-Health as a powerful means of KM, including learning, sharing and application, strengthening health systems and improving should be an integral part of the managerial culture health service delivery, including quality of care. in health sectors and systems. Special attention should be given to health and health-related tacit, traditional and oral knowledge, particularly in rural Priority interventions areas. This includes extensive use of mechanisms 17. Advocacy. Knowledge Management for health such as communities of practice and ICT-assisted should be promoted by policy-makers at the highest tools. KM should be strongly associated with health level of government and by international and re- information systems, health research and human regional development partners. sources development. 18. Data and evidence generation. A situation analysis Roles and responsibilities of KM at regional and country levels through surveys and special studies should be performed and 24. Countries should develop Knowledge Man- regularly updated. Such analyses should generate agement programmes as part of their national health evidence; identify best practices; consider explicit, development policies and plans. Relevant strategies tacit, community-based and traditional knowledge; of the African Union and the New Partnership for and locate available expertise. Africa’s Development, the WSIS Plan of Action, the WHO Eleventh General Programme of Work, and 19. Development of policies and plans. Country-specifi c the strategic orientations of the WHO Regional policies and plans should be developed for further Offi ce for Africa should inform national policies, progress in KM and to ensure that KM is embedded strategies and plans for Knowledge Management. across the health system, including all programmes and Countries should also actively foster partnerships projects. They should agree with overall national de- and mobilize resources for the implementation, velopment policies and plans, ICT plans, and health monitoring and evaluation of KM and ICT pro- policies and plans. They should also consider the strat- grammes, in close collaboration with all stake- egies of the African Union, New Partnership for Af- holders, especially training and research institutions. rica’s Development, World Summit on the Information Society and World Health Organization. KM policies 25. WHO will provide support to countries for de- and plans should explicitly support national capacity veloping and implementing policies, plans and pro- building, human resource development and equity in grammes; setting norms and standards; monitoring health services provision and health outcomes. and evaluating programmes; and coordinating partnerships, advocacy and resource mobilization. 20. Setting of standards and norms. Appropriate norms, standards and regulations are the key for sustainable 26. All partners, including academic and corporate progress in KM, especially in e-Health and tele- institutions, are invited to strongly support countries medicine. They should be based on the best interna- in their efforts to foster information and knowledge tional practices and adapted to the national context. management for health. They should actively

45 COMPENDIUM OF RC STRATEGIES

contribute to effective coordination and consensus- (NEPAD) on the development of information and building and allocate appropriate ﬁ nancial resources communication technology; to support KM for health. Cognizant of the opportunities provided by the efﬁ cient use of information and communication MONITORING AND EVALUATION technology in all health development areas; 27. Countries should integrate appropriate Knowl- Noting the many national or regional initiatives edge Management indicators in their health devel- in the areas of knowledge management and e- opment plans; they should ensure that the monitoring Health; and evaluation of the health development plan in- Having examined the document presented by cludes a KM component. KM should be an integral the Regional Director on knowledge management; part of any important public health programme and evaluated as such. 1. APPROVES the strategic directions proposed by the Regional Director for health knowledge 28. Progress reports about Knowledge Management management; at country and regional levels will be presented to the Regional Committee every two years. 2. URGES Member States: (a) to prepare national strategic directions for knowledge management, including e-Health, CONCLUSION ensuring that they are integrated as a priority into their national health policies and plans; 29. In view of the paramount importance of Knowl- (b) to establish norms and standards, including ethi- edge Management for health development, Member cal ones, taking into account new technology States are encouraged to take full advantage of the and approaches to knowledge management; current revolutions in KM and ICT. These pheno- (c) to strengthen national capacity in knowledge mena present extraordinary opportunities to advance management; health development; achieve the health-related (d) to include the health sector in national informa- Millennium Development Goals and other internation and communication technology develop- tionally-agreed health goals; and avoid marginaliza- ment plans; tion at global, regional and country levels. KM for (e) to build sustainable partnerships, and allocate health, including appropriate use of ICT, deserves to and mobilize the resources needed to improve be put very high on the agendas in all Member knowledge management at all levels of the States and the Region as a whole. health sector; 30. The Regional Committee reviewed these strate- 3. REQUESTS the Regional Director: gic directions and adopted them along with the proposed resolution. (a) to continue advocacy for knowledge management as a key approach to strengthening health systems; Resolution AFR/RC48/R8 (b) to make available generic guidelines, norms and Knowledge management in the WHO African standards for knowledge management; Region: Strategic directions (c) to provide technical support to Member States for the development and implementation of na- The Regional Committee, tional policies and plans; Recalling resolution WHA58.28 on e-Health; (d) to strengthen partnerships at the regional level, in particular with the African Union, NEPAD Aware of the importance of knowledge manage- and regional economic communities; ment for improvement of national health system (e) to report every other year to the Regional Com- performance; mittee on progress in the implementation of this Recalling the WHO Eleventh General Programme resolution. of Work and the Strategic orientations for WHO action in Seventh meeting, 30 August 2006 the African Region 2005–2009; Considering the Plan of Action and Declaration REFERENCES of the World Summit on the Information Society, as 1. WSIS, Report of the Geneva phase of the World well as the orientations of the African Union and Summit on the Information Society, Geneva-Palexpo, the New Partnership for Africa’s Development 10–12 December 2003, Document WSIS-03/GE-

46 Supporting the strengthening of health systems based on the primary health care approach

NEVA A/9(Rev.1)-E 18 February 2004, Annex 2, the African Region 2005–2009, Brazzaville, World Geneva, World Summit on the Information Society, Health Organization, Regional Ofﬁ ce for Africa, 2005. 2003. 5. Resolution R58.28 eHealth. In: Fifty-eighth World 2. The term e-Health encompasses all of the information Health Assembly, Geneva, 16–25 May 2005. Volume 1: and communications technology necessary to make Resolutions and decisions, and list of participants. Geneva, the health system work; see http://www.itu.itn/ World Health Organization, 2005 (WHA59/2005/ itunews/issur/2003/06/standardization.html- REC/1), 108–110. 15/03/2006 (last accessed 23–03–2006). 6. See International Telecommunication Union web site 3. http://www.who.int/kms/resource/km_glossary.pdf (last accessed 15–03–2006): http://www.itu.int/part- 4. WHO Knowledge Management strategy, Geneva, World ners/qanda.html; http://www.itu.int/newsarchive/ Health Organization, 2005 (WHO/EIP/KMS/ press_releases/2005/07.html 2005.1). WHO, Strategic orientations for WHO action in

Strategic Direction 3 Putting the health of mothers and children ﬁ rst

3.1 Integrated management of childhood illness (IMCI): Strategic plan for 2000–2005 (AFR/RC49/10)

EXECUTIVE SUMMARY 1. In countries in sub-Saharan Africa, about 1.2 million children under fi ve years of age die every year of acute respiratory infections (ARI), especially pneumonia. An estimated 800 000 people die of diarrhoeal diseases, about 500 000 of measles and some 600 000 of malaria. Each of these diseases is also associated with malnutrition in more than 50% of the ensuing deaths. Projections based on an analysis of the global burden of disease, completed in 1996, indicate that these conditions will continue to be major contributors to morbidity and mortality up to the year 2020 unless signifi cantly more serious efforts are made to control them. 2. The need for a global response to this situation calls for the anchoring of health in a broad setting, which provides opportunities for the implementation of preventive, promotional, curative and developmental interventions. Achieving sustained improvement in child health requires integration of these efforts as well as long-term partnerships to support nationally-defi ned and evidence-based policies and strategies. 3. In response to the challenge of childhood illnesses, the WHO Regional Offi ce for Africa has, since 1995, intensifi ed its support to Member States by adopting the Integrated Management of Childhood Illness (IMCI) programme, which is a cost-effective strategy for the reduction of morbidity and mortality in this vulnerable group. As at December 1998, the strategy was being implemented in 22 of the 46 countries in the Region. 4. In spite of the potential gains of IMCI, a number of constraints exist at the regional, national and subnational levels, which require attention in order to accelerate implementation. These constraints are: limited human and fi nancial resources and weakness of health systems in many countries of the Region. 5. The purpose of this document is to provide a strategic plan for the acceleration of IMCI implementation during the next fi ve years in order to assist Member States in the reduction of childhood morbidity and mortality through the implementation of interventions at various levels of the health system, especially at the district and community levels. 6. The major thrusts of the proposed strategic plan are: strengthening of capacity at national, district and regional levels; strengthening of health systems; and promotion of sustainable IMCI implementation by introducing it into the curricula of medical and paramedical institutions. 7. The Regional Committee reviewed and adopted the IMCI strategic plan.

51 COMPENDIUM OF RC STRATEGIES

INTRODUCTION and two incorporating improvements in family and community practices. Other countries of the Region 1. About 11 million children under fi ve years of age are planning to begin implementation in 1999. die annually of common preventable diseases such as acute respiratory infections, diarrhoea, malaria, mea- 7. The purpose of this document is to provide a sles, and malnutrition. Many of these deaths occur in framework for the implementation of the IMCI countries in sub-Saharan Africa. Every year, some strategy during the next fi ve years. 1.2 million children under fi ve years of age die of acute respiratory infections (ARI), mainly pneumo- JUSTIFICATION nia; 800 000 of diarrhoeal diseases, 500 000 of measles, and about 600 000 die of malaria. Each of these Policy background conditions is also associated with malnutrition in 8. International events such as the Alma-Ata con- more than 50% of the ensuing deaths. ference of 1978, the adoption, in 1989, of the 2. Projections based on an analysis, completed in Convention on the Rights of the Child now ratifi ed 1996, of the global burden of disease indicate that by a record 191 countries, the World Summit for these conditions will continue to be major causes of Children in September 1990, during which govern- morbidity and mortality up to the year 2020 unless ment leaders committed themselves to Goals for signifi cantly more efforts are made to control them. Children by the Year 2000, the International Con- ference on Nutrition in 1992, the 1994 Internation- 3. The late 1980s and early 1990s witnessed grow- al Conference on Population and Development in ing global concern about child health and the pros- Cairo, and the Fourth World Conference on pect of controlling illnesses and health problems. Women in Beijing in 1995, have resulted in the im- Despite the fact that adequate tools are available for plementation by countries of interventions towards effective control, childhood diseases are claiming the improving child survival, development and protec- lives of millions of children worldwide. tion. The adoption of these goals was extremely 4. The need for a global response to this problem important in that it committed the countries to ob- calls for the anchoring of health in a broad setting taining concrete results with respect to reducing which provides opportunities for implementing mortality and morbidity and providing health care preventive, promotive, curative and developmental for children. interventions. The Integrated Management of 9. WHO and UNICEF, in collaboration with Childhood Illness (IMCI) strategy, prepared by other partners, have provided leadership in galvaniz- WHO and UNICEF in 1995, is intended to meet ing the international community towards coordi- this challenge. nated actions for children and have supported efforts 5. IMCI offers a set of interventions that promote to reduce child morbidity and mortality. To this rapid recognition and effective treatment of major end, the following specifi c steps have been taken: killers of children under fi ve years of age. It pro- (i) In 1990, there was a joint meeting of WHO motes the prevention of illness through improved and UNICEF to consider the possi bility of nutrition (including breast-feeding), vaccination, developing the Integrated Management of and the promotion of insecticide-treated materials. Childhood Illness (IMCI). It also promotes the use of micronutrients such as (ii) The WHO Ninth General Programme of vitamin A and iron therapy, and deworming of the Work (1996–2001) adopted the integrated most vulnerable. Lastly, IMCI reinforces family approach for the implementation of disease practices that are important for child health. These control programmes. can be achieved through the implementation of the (iii) In May 1995, the World Health Assembly three components of IMCI: adopted IMCI as a more cost-effective (i) improvement in the case management skills of approach for the survival and development of health staff the child. (ii) improvement in health systems (iv) In August 1995, the WHO/AFRO Policy (iii) improvement in family and community Framework for Technical Cooperation with practices. Member States confi rmed IMCI as an appropriate and effective approach for implementa- 6. The implementation of IMCI started in 1995 in tion in the Region. the African Region and, as at 1998, the strategy was being implemented in 22 of the 46 countries, with six 10. In the past decade, there has been a global re- countries already implementing it at the district level, awakening to equity and social justice. Children are

52 Putting the health of mothers and children fi rst the key in the pursuit of a future of equity and social trict levels to meet the needs of IMCI, espe- justice, hence, the need to include child health at the cially with respect to the availability of drugs top of the political agenda. and vaccines. (iv) Networks for the exchange of information, experiences and expertise are limited. Technical justifi cation (v) Different partners have different priorities at 11. Since the early 1980s, WHO and its partners country level. In addition, there are inconsist- have provided support to countries for the develop- encies in the approaches to child health. This ment of disease-specifi c control programmes. Effec- makes coordination diffi cult and may lead to a tive though these control programmes were, they duplication of effort. did not generally establish clear ties with other com- 14. A review of the three years of IMCI implementa- ponents of health care. Instead, they helped to focus tion in the African Region was conducted in 1998. the attention of health workers on specifi c signs and This revealed the following challenges, among others: symptoms of illnesses, which usually constituted the reasons why mothers sought care for their children. (i) providing adequate technical support in re- They did not establish a systematic assessment of sponse to increased country demands; other aspects of children’s health. Generally, there (ii) ensuring continuous collaboration with pro- was no clear link between preventive and promo- grammes such as malaria, essential drugs EPI, tional care within the overall approach to child child health, and nutrition, considering activi- health care. Consequently, there was a general case ties to be implemented in an integrated manner of missed opportunities for immunization and man- and those where only coordination is needed; agement of other conditions, duplication of efforts, (iii) bringing IMCI to families and communities and wastage of scarce resources. Based on the lessons with their active participation and ownership learnt from the implementation of disease-specifi c in order to prevent or reduce the high rate of control programmes, the need for an integrated deaths of children under fi ve years of age be- strategy to link individual strategies emerged, and fore they reach the health facilities; has constituted a major challenge for this decade. (iv) ensuring sustainable implementation of the strategy, considering the currently low level of 12. The IMCI strategy is unique in that it is con- allocations from countries and the internation- ceived in a generic form, which can be adapted to al community; the epidemiological and cultural realities of the (v) including and implementing IMCI in the de- countries as well as to the operational conditions for centralized health system and meeting the implementing activities that exist in each country. attendant needs; Thus, some components of the control programmes (vi) ensuring continuing collaboration with part- of the prevalent illnesses in some countries can be ners in order to have a common aim and added to the IMCI strategy. On the other hand, under standing of the IMCI strategy. other non-prevalent components (such as malaria) can be eliminated, depending on the characteristics of the area in question. THE REGIONAL STRATEGIC PLAN Situation analysis Aim 13. In spite of the potential gains of IMCI, a number 15. The strategic plan aims to contribute to the of constraints exist at the regional, national and sub- reduc tion of childhood mortality in the African national levels, which require attention so that IMCI Region by improving the case management skills of implementation can be accelerated: health staff and the support provided for health systems and family and community practices. (i) There is limited capacity at regional and national levels in terms of competent and available consultants and the number of staff to Guiding principles respond to the increasing demands of IMCI. 16. Eleven countries, which account for more than (ii) Available funds to provide technical assistance 80% of childhood mortality in the Region, will re- to countries and districts are limited. Many ceive intensive technical and fi nancial support in an countries are yet to allocate funds for IMCI effort to make a difference. implementation. (iii) The health systems in most countries in the 17. In implementing the IMCI strategy appropriate Region are too weak at both national and dis- effort should be made to ensure:

53 COMPENDIUM OF RC STRATEGIES

(i) country ownership and commitment at policy Expected outcomes and operational levels 20. The expected outcomes are: (ii) institutionalization of IMCI in national health services (i) Capacity for sustainable IMCI implementation (iii) district-based response to the expressed needs at the regional, national and sub regional levels of the population is increased. (iv) contribution to the prevention and early diag- (ii) IMCI implementation is achieved in a sustain- nosis and treatment of childhood illness. able way in each Member State. (iii) Partnerships for the effective implementation General objectives of IMCI at the regional, national and sub-national levels are built. 18. The overall objectives of the regional strategic (iv) Results of operational research activities are plan are to ensure that each Member State: used to strengthen IMCI implementation at all (i) improves the quality of care provided to chil- levels. dren under fi ve years of age at health facility and household levels; and (ii) strengthens the health system in order to sus- Priority interventions tain IMCI implementation. 21. Capacity-building will include training in IMCI at national, district, community and regional levels Specifi c objectives for improved quality of care. 19. To achieve the above, the Regional Offi ce will National level: National experts will be identifi ed to collaborate with Member States and partners: provide support to their countries as well as to other countries for planning, training, adaptation, evalua- (i) to strengthen capacity at the regional, national tion and monitoring. The use of IMCI focal points and district levels for sustainable implementa- will be encouraged. WHO and partners will provide tion of IMCI; this will be achieved through initial fi nancial support, but arrangements will be training in structured apprenticeships of na- made for devolution to countries for sustainable tional experts to ensure ownership of the strat- development purposes. egy and reduce costs; (ii) to promote sustainable IMCI implementation District level: District health management teams by introducing it into the curricula of medical (DHMTs) will be trained on IMCI in order to pro- and paramedical institutions; building partner- vide the needed support to the implementation of ships with technical programmes and partners IMCI at the health facility. The strategy will be part in the Region; ensuring the availability of es- of the district plan of action. sential drugs, an effective referral system, sup- Community level: Based on the documented experi- port supervision, programme monitoring and ences of ongoing activities in the countries, the a health information system, which are essen- capacity of the non-formal health care providers and tial to improve the quality of care; family members will be improved through appropri- (iii) to build partnerships with parties interested in ate training, monitoring and supervision of their health at the regional, national and community activities. Key family practices such as exclusive levels for more effective support to and coordi- breast-feeding, adequate complementary feeding, nation of country-level activities, including re- adequate micro nutrient intake or supplementation, source mobilization inside and outside the safe disposal of faeces, complete immunization, use countries, in order to increase the capacity to of insecticide-treated materials, appropriate care- respond to country demands and needs, sup- seeking, and correct treatment of infections will be port country-level implementation, promote strengthened. co-funding with partners, and conduct operational research; Regional level: The regional and subregional staffi ng (iv) to promote operational research to provide of WHO will be strengthened to help provide evidence-based answers to implementation is- prompt technical support to the countries. The sues which arise at the regional, national and inter country teams for western, southern and central subnational levels, including cost-benefi t anal- Africa and the Horn of Africa will be strengthened. yses, and in the process, build the capacity of A pool of consultants will be trained to supplement institutions in the Region for research. the efforts of staff.

54 Putting the health of mothers and children ﬁ rst

Promotion of sustainable activities Implementation framework 22. This intervention will target areas that are crucial The role of Member States for the sustainability of IMCI at country level, 25. At the country level, advocacy will be promoted including: to encourage inclusion of the IMCI strategy in the The strengthening of pre-service training: Current expe- national health policy and plan of action. Implemen- riences on pre-service training as a sustainable meth- tation will be carried out using a step-wise approach. od of improving health worker skills will be During the expansion phase, specifi c attention will extended to medical and paramedical institutions in be paid to the quality of implementation. countries of the Region. This will include training, evaluation through structured examination of stu- The role of WHO dents, and monitoring of the performance of trained 26. WHO will provide strategic direction for more health workers. effective action to tackle child health problems in The availability of drugs: The Bamako Initiative or Member States through the implementation of “Bamako-like” initiatives such as the promotion of IMCI. Innovative designs, broad ownership, full cost-sharing in order to ensure drug availability for private sector and community participation, fl exible mothers and children, with community ownership, implementation, and clear emphasis on outcomes will be used as an entry point for IMCI in selected will be promoted. WHO will play the leadership districts. Improvement of drug procurement, stor- role to promote adequate preparation and involve- age and distribution mechanisms and mobilization ment of a wide range of stakeholders in IMCI of resources to procure and supply seed stocks of implementation. drugs for implementation in countries will be carried out in collaboration with national pharmacists and Resource mobilization pharmaceutical boards. Involvement of the private sector and the non-formal drug distribution system 27. National and district plans of action will be used will be promoted. as tools for the mobilization of funds through country health budgets and additional resources from rele vant internal and external stakeholders. In order Building partnerships to maximize the contributions of multilateral and bilateral agencies as well as nongovernmental organ- 23 Implementation of IMCI will be carried out in izations (national and international), efforts will be close collaboration with partners at regional, nation- made to involve them at every stage of implementa- al and subregional levels. The comparative advan- tion. Co-funding will be explored for activities of tage of partners in specifi c areas such as research, common interest. Health sector reforms (HSR) will drug management, communication and community be used to foster resource mobilization. orientation will be used. Joint planning, implementation and evaluation will be encouraged. MONITORING AND EVALUATION Promotion of research 28. A continuous monitoring process will be ensured at country and regional levels through reports 24 The capacity of experts in countries will be of activities, documentation of the progress of im- strengthened through the priority operational re- plementation, and review and publication of research areas identifi ed during the fi rst meeting of the search results. At national level, periodic evaluation Regional IMCI Task Force in June 1998. These are: will be undertaken at two-year intervals to assess the drug supply management, pre-service training, re- impact of IMCI. WHO will collaborate with part- ferral systems, caretaker compliance, and organiza- ners in the development, design and implementation of work in health facilities. The Regional IMCI tion of impact assessment studies. research committee will develop appropriate protocols and conduct studies linking with the African 29. Networking for information sharing, using Advisory Committee on Research and the Research the IMCI Newsletter, global, regional and country- Development Committee in the Regional Offi ce. level meetings and conferences, electronic commu- Collaboration will be maintained with universities nication systems and other mechanisms, will be and research institutions. established.

55 COMPENDIUM OF RC STRATEGIES

30. The indicators to be used for monitoring are: hood Illness has the potential to achieve the above. Its implementation is taking place within structures (i) the percentage of countries in the Region existing at country and community levels, and it has implementing IMCI; been used as a major tool for fostering collaboration (ii) the percentage of countries where IMCI is among programmes and partners. implemented in all districts; (iii) the percentage of countries where IMCI is 36. This document will, serve as a guide to countries implemented in at least one medical school; for IMCI implementation. Individual country deci- (iv) the percentage of countries where IMCI is sions will help promote collective action to ensure implemented in at least one paramedical train- that the African child is not born just to die but to ing institution. live a long and healthy life. 31. At country level, the following indicators will be used to monitor the quality of IMCI implementation at the district level: Resolution AFR/RC49/R3 (i) percentage of children who need an oral anti- Integrated management of childhood illness biotic and who are prescribed the drug (IMCI): Strategic plan for 2000–2005 correctly; The Regional Committee, (ii) percentage of children who need an oral antimalarial and who are prescribed the drug Recalling World Health Assembly resolution correctly; WHA48.12 which adopted IMCI in May 1995 as a (iii) percentage of children who need an oral anti- cost-effective strategy for child survival and biotic and an antimalarial who are pres cribed development; the drugs correctly; Recalling the regional Policy Framework for Tech- (iv) percentage of children needing referral who nical Cooperation with Member States, in which IMCI are effectively referred; was confi rmed as an appropriate and effective strat- (v) number of operational research results used for egy that should be implemented in the Region; improving the implementation of IMCI. Considering that 70% of childhood deaths are Critical factors for success due to acute respiratory infections, diarrhoeal diseases, measles, malaria and malnutrition and that 32. The implementation of IMCI is a long-term IMCI is an appropriate strategy for controlling these process, considering the three components of the childhood killer diseases; strategy. It will be necessary that countries develop their ownership of the strategy by expressing their Bearing in mind the spirit of international events commitment, institutionalizing IMCI in the existing such as the 1978 Alma-Ata conference on primary structures, empowering districts and providing health care, the adoption of the Convention on the human and fi nancial resources. Rights of the Child in 1989, and the 1990 World Summit for Children during which government 33. The promotion of collaboration with all partners leaders committed themselves to giving the child a interested in the implementation of IMCI as a way better future; to maximize their additional contributions will need to be encouraged. Aware of the high infant and child mortality rates in the countries of the Region and the need to 34. Capacity-building at national, district and re- support health sector development in a broad setting gional levels is critical for sustained development of which provides opportunities for implementing the strategy. preventive, promotive, curative and rehabilitative interventions; CONCLUSION Acknowledging that the integrated strategy to childhood illness will help reduce under-fi ve mor- 35. Children have rights – the right to health and bidity and mortality and that the strategy is capable the right to health care. The Convention on the of enhancing cost effectiveness; Rights of the Child ‘Article 24’ calls on states to implement interventions to reduce infant and child- Considering the present status of implementation hood mortality, ensure medical assistance and health of IMCI in the African Region and the need to give care to ALL children, and combat disease and mal- more intensive support for the implementation of nutrition. The Integrated Management of Child- this strategic plan;

56 Putting the health of mothers and children ﬁ rst

Recognizing the invaluable support that multi- 3. REQUESTS the Regional Director: lateral and bilateral cooperation partners have given (i) to provide support to Member States to to the countries to date for IMCI implementation, strengthen and accelerate the implementation 1. APPROVES the regional strategic plan for the of the strategic plan; integrated management of childhood illness (IMCI) (ii) to develop human resources and mobilize reg- as presented in document AFR/RC49/10. ular budget and extrabudgetary resources to support the implementation of the strategic 2. CALLS UPON Member States: plan; (i) to include the IMCI strategy in national health (iii) to monitor the implementation of the strategic policies and plans of action; plan in the countries and facilitate the sharing (ii) to accelerate IMCI implementation, maintain- of experiences and lessons learned among the ing a step-wise approach and paying attention Member States; to quality, particularly during the expansion (iv) to report to the fi fty-fi rst session of the phase; Regional Committee on the progress made in (iii) to take the necessary steps to ensure greater the implementation of the strategic plan; availability of human and fi nancial resources, 4. REQUESTS international and other partners and to strengthen district health systems, for sus- concerned with the implementation of IMCI in the tainable implementation of the IMCI; African Region to intensify their support to the (iv) to revise their essential drug list in order to countries for the implementation of the IMCI stra- facilitate the implementation of the IMCI tegic plan. strategy; (v) to strengthen the nutritional rehabilitation of Fifth meeting, 1 September 1999 sick children ;

57 3.2 Adolescent health: A strategy for the WHO African Region (AFR/RC51/10 Rev.1)

EXECUTIVE SUMMARY 1. The health of adolescents is a component of public health, which is of major concern globally and in the African Region in particular. 2. Adolescence is characterized by physiologic, psychosocial, especially emotional, intellectual and spiritual development and maturation processes. Adolescent health is in part determined by the family environment that provides for basic needs for shelter, food, education, health care, and moral and spiritual values necessary for character building. Behaviour acquired in adolescence impacts health outcomes and lasts a lifetime. 3. The heterogeneous nature of adolescents, their difﬁ culty to access and fully utilize available health services and their vulnerability to morbidity and mortality are recognized. Their health and development problems include those related to reproductive health, risk-taking behaviour and accidents, mental illness and communicable diseases such as STI and HIV/AIDS. These are often interrelated and linked to behaviour. 4. Global concern for the health and well-being of young people has been expressed in various instruments, including the 1985 International Year of the Youth (UN General Assembly), the 1990 Convention on the Rights of the Child, the OAU African Charter on the Rights and Welfare of the Child and the Reproductive Health Strategy for the African Region. 5. The strategy aims at providing guidance to Member States and partners in the formulation of policies, programmes and interventions that address adolescent health and development. It draws attention to the health sector response, the role of parents, families, communities and other sectors and the active involvement of young people. 6. Effective and successful implementation of the strategy in Member countries will depend on its adaptation, with the full involvement and participation of health professionals, young people, families, communities and key partners in policy and programme development, and backed up by research, to make it culture and value sensitive.

INTRODUCTION development, especially emotional, intellectual and 1. The health of adolescents is a component of spiritual aspects occurs through a progressive matu- public health, which is of major concern globally ration process from childhood dependence to adult and in the African Region in particular. interdependence. 2. Adolescence, a period of transition from child- 3. The perception of adolescents as generally hood to adulthood, is characterized by rapid and healthy has changed due to a better understanding of objective physiologic changes, such as rapid growth, the adaptation processes that they undergo. It is evi- maturation of the reproductive system and changes dent that adolescents are vulnerable and at risk of in physical appearance. Signiﬁ cant psychosocial morbidity and mortality. Ill-health in adolescents is

58 Putting the health of mothers and children fi rst often caused by unhealthy environments, inadequate the wider community can promote health and well- support systems for promoting healthy lifestyles, being in the adolescents by providing an environ- lack of accurate information and inadequate or ment that is conducive to healthy development. inappropriate health services. Many behaviour pat- Conversely, they can create unsafe and hostile con- terns acquired and health conditions encountered ditions detrimental to health and development. during adolescence will last a lifetime. Ado lescents can either be victims or perpetrators of violence, for example, rape and assaults. 4. Young people’s health has a signifi cant impact on national development, and national development, in 9. Preventive health interventions and actions to turn, is central to addressing problems like poverty promote adolescent development can build the ado- that undermine young people’s health. Development lescents’ capacity to develop individual social and in the context of adolescents refers to total human life skills and competencies to offset negative social development. Youth are a valuable resource for so- infl uences. This is particularly true of interventions cio-economic and cultural development. Their en- that help them to feel appreciated, have belief in ergy and resourcefulness are not yet fully appreciated their own worth and a sense of belonging as well as and refl ected in national development policies. The hope in the future, including knowledge of their family has primary responsibility for the healthy de- rights and responsibilities.2 velopment of adolescents, supported by the commu- 10. There are also examples in Member countries of nity and the wider multisectoral environment. The how resourceful adolescents can be if their energy age-old values of respect for truth and human dig- and enthusiasm are directed towards the improve- nity as epitomized within the family or by societal ment of their own health and that of other young role models in general enable most adolescents to people in and out of school. Experience with the use emerge as well-adjusted members of society. of peer educators and health clubs (e.g. anti-AIDS, 5. Common adolescent health problems include anti-alcohol and drug abuse clubs in schools) man- sexually transmitted infections, parasitic and water- aged by young people with the support of teachers, borne diseases, malnutrition, injuries and disability parents and responsible adults has been positive. as a result of risk-taking activity, and mental illness such as depression and psychosis, which can lead to suicide and violence. Adolescents’ sexuality and re- SITUATION ANALYSIS AND productive health are generally not well addressed to JUSTIFICATION protect them from unwanted pregnancies, complications of unsafe abortion and HIV/AIDS. Situation analysis 6. Data on alcohol, tobacco and psychotropic drug 11. There are approximately 1700 million young people in the world, 86% of whom live in develop- usage among adolescents are fragmented. However, 3 use by young people in the Region is evident. Some ing countries. About 16% of those living in these cultural and traditional practices associated with ini- countries are in Africa. In many countries of the Region, young people constitute approximately tiation and early marriage have health consequences 4 and violate the rights of adolescents.1 33% of the population. Adolescents contribute to the high maternal mortality in the Region, account- 7. Whereas the general public is also susceptible to ing for up to 40% of all maternal mortality in some similar health threats, adolescents are particularly countries.5 Lack of access to reproductive health vulnerable due to several factors. They are not eco- services, including counselling, contributes to the nomically independent to access health services; high incidence of post-abortion complications. In they lack the level of maturity required to make some countries of the Region, 25% to 27% of fi rst respons ible decisions when they are sick; health births occur among adolescents.6 On average, boys services are not oriented to meet the health and de- and girls initiate sexual activity during adolescence. velopment needs of adolescents. These combined Of all new cases of HIV infection in 1999, 65% were factors contribute to under-utilization of available in young people living in Africa.7 services by adolescents. 12. The health problems of adolescents in Africa are 8. The health of adolescents is to a large extent de- associated with socio-economic conditions charac- termined by family environments that provide the teristic of the Region. Some parts of the Region are immediate basic needs for shelter, food, education, experiencing civil strife or armed confl icts resulting health care and moral and spiritual values necessary in mass displacements of people, disruption of family for character building as well as by schools and the life, dislocation of social support systems, and in- work environment. The infl uence of their peers and creased poverty. In others, intergenerational confl icts

59 COMPENDIUM OF RC STRATEGIES have weakened family structures and coherence, professionals, parents and communities, will in- leaving adolescents exposed to negative environmen- crease the rate of use of those services by the young tal infl uences such as drug abuse and prostitution. people. Disparities existing between rural, peri-urban and ur- 16. In general, Member States of the Region have ban living conditions, inadequate access to safe drink- recognized the long-term benefi ts of investing in ing water and sanitation, food, health services, formal healthy development, including recreation and cul- and informal education, employment, recreation and ture-promoting activities, of adolescents. Countries housing, associated with increased rural-urban migra- of the Region are at different stages of development tion of children and young people in developing and implementation of programmes for adolescent countries (70%), increase their vulner ability to poor health and development. Approximately 50% have health.8 established ministries of youth and 60% of these 13. Poverty, a cross-cutting factor, affects the major- have developed national policies on adolescent ity of the Member States of the Region. It increases health. About 97% of ministries of health have focal vulnerability of adolescents to poor health. It denies points responsible for adolescent health, while ap- them optimal conditions and opportunities for edu- proximately 60% of the countries have developed cation to acquire intellectual and vocational skills reproductive health and broad-based health policies that would enable them to improve their employ- for adolescents.9 ment options and potential. Poverty breeds environ- 17. Television, radio and other entertainment media ments where crime, drug abuse, violence, rape and reach a large proportion of adolescents in urban commercial sex thrive. Experience with projects areas and have the potential to reach those in rural that integrate young people in sustainable develop- areas. Adolescents can also be reached through social ment and poverty alleviation programmes to pro- structures such as families, peers, NGOs and the mote rural and urban development, coupled with civil society, as this has been proven to be effective life and vocational skills development, has shown in situations where the reach of the media is limited. the benefi t of equipping them to become respons- Non-formal means of communication in the form ible individuals, parents and citizens. This approach of entertainment such as drama and theatre have also has also increased young people’s opportunities for been effective channels of communicating informa- productive formal and informal employment. tion and presenting sensitive issues to young people 14. Adolescents are a heterogeneous group and are in general and to out-of-school youth in particular. exposed to different degrees of vulnerability based on different parameters such as their age, gender, Justifi cation nutritional, marital and employment status, school 18. Global concern for the health and well-being of enrolment and popular places where they hang out adolescents and young people has been expressed in and spend most of their leisure time. Male adoles- various fora. The United Nations General Assembly cents are more vulnerable to disability and mortality declared 1985 the International Year of the Youth. as a result of risk taking leading to unintentional and The 1990 Convention on the Rights of the Child intentional injuries from, for example, road traffi c recognizes the child as an individual in its own right accidents, violence and suicide. Female adolescents entitled to life, health, protection and education. The carry the brunt of consequences of unwanted preg- 1994 International Conference on Population and nancy. There are also adolescents living in diffi cult Development advocates for the promotion of healthy circumstances. These include those with disability, sexual maturation from pre-adolescence, responsible orphans, street children, those affected by HIV/ and safe sex throughout lifetime and gender equality. AIDS, and those living as refugees or displaced persons. 19. The 1990 Organization of African Unity Char- ter on the Rights and Welfare of the Child discour- 15. Adolescents are not adequately accessing and ages customs, traditions and cultural or religious adequately utilizing available health services due to practices inconsistent with the rights, duties and ob- lack of guidelines and orientations and they do not ligations contained in the Charter. It draws attention benefi t from the advances made in health and medi- to the right of every child to enjoy the best attain- cal technologies. They lack accurate information able state of physical, mental and spiritual health. about available services, and the necessary economic and social means to empower them to make in- 20. The Reproductive Health Strategy for the African formed decisions to protect their health. The setting Region 1998–2007 includes reproductive health up of services that address adolescent reproductive needs and problems of adolescents. Other regional health needs, and their endorsement by health strategies have specifi c components which address

60 Putting the health of mothers and children fi rst adolescent problems. The Regional Strategy for Mental (d) developing evidence-based policies and Health also addresses the prevention of substance programmes; abuse, especially among young people. (e) strengthening partnerships in support of adolescent health and development in countries and at THE REGIONAL STRATEGY regional and global levels. Aim and objectives Priority interventions 21. The aim of this strategy is to identify and re- 24. Member States will be encouraged to use strate- spond to the health needs of adolescents, as well as gic approaches to reach adolescents in different to promote their healthy development. circumstances and settings. The key areas for inter- 22. Its objectives are to support Member States to: ventions include but are not limited to: (a) review, develop, implement and evaluate (a) creation, implementation and strengthening of national policies and programmes on adolescent essential conditions to increase advocacy and health and development in order to meet their awareness about the needs and corresponding needs and rights; rights of adolescents, to orient national develop- (b) build the capacity of the health sector to provide ment policies and legislation and to place young basic services to meet the needs of adolescents people’s issues in the broader context of social through the active participation of young and economic development; the legal frame- people, families, communities, religious and key works provided by the Convention on the partners; Rights of the Child and the African Charter on (c) mobilize the private sector and other public the Rights and Welfare of the Child form the sector institutions to support programmes for basis for the review of existing national instru- the adolescent development, in particular, ments and formulation of new ones; educational, vocational, cultural and life skills (b) the conduct by countries of a participatory activities. situation analysis of adolescent health needs (d) utilize research fi ndings as a basis for policy and and use of fi ndings to formulate policies and programme development, problem solving, design programmes that include promotive, service design and promotion of best practices; preventive, curative and rehabilitative health (e) establish national mechanisms for ensuring services; collaboration among key partners, young people, (c) a review of health promotion interventions parents, community leaders, youth-serving or- and their adaptation for adolescents, families, ganizations and others involved in programmes and communities. The interventions will be cul- for adolescent health and development at differ- ture sensitive and based on local values that help ent levels. make the environment safe, supportive and protective (reducing risks), and that stimulate young Guiding principles people’s development; (d) a re-orientation of health services and their 23. The success and sustainability of the implemen- strengthening to be adolescent friendly so as to tation of the strategy will depend on the following improve their utilization; in particular, health principles: personnel will be oriented to enable them to rec- (a) adapting the generic strategy as a basis for devel- ognize and deal with young people’s holistic oping culturally sensitive national programmes health care needs, provide accurate information, that are modulated by policy orientations; maintain confi dentiality and attend to them (b) a good understanding of the problems affecting without judgement and with understanding and the health and development of adolescents by respect; special approaches will be developed to health professionals, young people, parents, provide health services for young people in diffi - families and communities, and of issues and fac- cult circumstances; tors affecting the health and development of (e) the building of the capacity of all categories adolescents; of personnel who deal with and care for young (c) establishing and strengthening effective manage- people, including strengthening of the capacities ment information systems to monitor trends and of families and communities and of the health evaluate the effectiveness of adolescent health system; training will be conducted to fi ll identi- programmes, based on carefully selected and fi ed gaps in competencies and skills of personnel; sensitive indicators; the capacity of communities to understand

61 COMPENDIUM OF RC STRATEGIES

adolescents’ need for basic health services and tion, community development, law enforce- to facilitate healthy development will be ment, economic planning and technical and strengthened. vocational skills development; (c) set norms and standards for basic package of 25. The development of the regional strategy has health services, conduct training, defi ne indica- been enriched through partnerships and collabo- tors, and monitor and evaluate the effectiveness ration with Member States, United Nations agen- of policies and programmes. cies, international and national non-governmental organizations, professional associations, researchers, Role of other sectors young people and youth-serving organizations. At country level, inter-agency collaboration and partner- 29. The strategy provides guidance for other sectors ships will be strengthened through the establishment to advocate for and reform legislation and policies of mechanisms that support country programmes at affecting education, child labour, human rights and all levels. rights relevant to the health and development of adolescents. Each sector will review its policies to 26. Countries will identify research priorities to support the national adolescent health strategy and support programme development and imple- policy. mentation. Linking adolescent health with socioeconomic activities will be achieved through the At regional and international levels promotion and use of participatory action research involving young people. Research is also needed to 30. WHO will provide technical support to Mem- differentiate between the information and health ber States in policy and programme development, needs of male and female adolescents. An important including advocacy and mobilization of resources. area for operational research is that which links ado- Collaboration with regional and international part- lescents’ health-seeking behaviour with psychosocial ners will be strengthened and coordinated to sup- and sociocultural beliefs of young people, parents, port national programmes and action plans. teachers, health service providers, community and religious leaders, and others. Other areas for research will be selected in response to problems arising from implementation. MONITORING AND EVALUATION 31. Monitoring and evaluation of country pro- Implementation framework grammes, using appropriate indicators, will be built At country level into national strategies. Evaluation results will be used to improve planning and implementation. 27. To achieve the objectives of the strategy within Mechanisms for regional monitoring and periodic the context of its guiding principles, countries will evaluation and reporting to the Regional Commit- implement interventions at different levels. Focus tee will be utilized. will be on the review of existing programmes and the assessment of needs; development of policies and legislation to protect and promote healthy development; and integration of adolescent health interven- CONCLUSION tions into programmes in other sectors. 32. The strategy clearly recalls the importance of the problems of adolescent health and their deter- Role of the health sector minants. It refl ects the multisectoral and multi- 28. The health sector will: disciplinary nature of the issues and the solutions relating to adolescent health and development. It (a) take the leading role in advocacy and adap tation underscores the roles and the collective will of of the regional strategy to national strategies and different levels in society (family, community and programmes and obtain wider government and adolescents themselves) in the effort to change the donor commitment; situation for the better, using all feasible means and (b) ensure that the approach to adolescent health re- approaches. Coherent and coordinated actions are fl ects the commitment and participation of other required now in order to achieve the aim of the sectors, including those responsible for educa- strategy.

62 Putting the health of mothers and children ﬁ rst

Resolution AFR/RC51/R3 (c) to reorient and build the capacity of the health sector to provide basic services to meet the Adolescent health: A Strategy for the African special needs of adolescents, including those in Region difﬁ cult circumstances, through the active par- The Regional Committee, ticipation of young people, families, communities, religious leaders, local NGOs and other Recalling the Regional Committee resolution relevant partners; AFR/RC45/R7 on “The health of youth and ado- (d) to build multisectoral partnership and strengthen lescents: A situation report and trends analysis”, and collaboration to increase resources for adoles- the concern for the health and well-being of adolescent health and development; cents expressed through various instruments, both (e) to equip young people with the requisite skills to globally and regionally; enable them to participate meaningfully in the Cognizant of adolescence as an important phase in development and implementation of adolescent human development, characterized by signiﬁ cant health policies and programmes; changes that typify the transition from childhood to 4. REQUESTS the Regional Director: adulthood; (a) to continue to advocate for adolescent health Recognizing that common health problems of ado- programmes and to mobilize adequate resources lescents such as early and high-risk pregnancies, for their implementation; complications of abortion, sexually transmitted in- (b) to provide technical support to Member States fections, HIV/AIDS, alcohol and drug abuse, non- for the development and implementation of communicable diseases, depression and suicides are national policies and programmes on adolescent linked to behaviour and are inter-related; health; Aware of the critical roles that families, schools, (c) to mobilize governments, agencies of the United communities, religious institutions, governments, Nations, NGOs and other stakeholders to or- nongovernmental organizations (NGOs) and work, ganize youth seminars and conferences to discuss leisure and recreational places play in contributing the problems and challenges of adolescents in to the health and development of adolescents; order to improve their health and development; (d) to support institutions and national experts to Conscious of the multisectoral and multidiscipli- carry out research on the problems and needs of nary approach to address adolescent health and adolescent health; development; (e) to report to the Regional Committee in 2003 Appreciating the efforts of Member States and part- on progress made in implementing adolescent ners to improve the health and development of health programmes at national and regional adolescents; levels. 1. APPROVES the regional strategy on adolescent Fifth meeting, 29 August 2001 health as proposed in document AFR/RC51/10; 2. COMMENDS the Regional Director for pro- REFERENCES moting and supporting adolescent health and development in the Region; 1. World Youth Forum. African Youth and Health, April 2000 (AYF/UNS/1/2000/15 g). 3. URGES Member States: 2. UNICEF. Youth Health for A Change, 1997. (a) to accord adolescent health and development 3. Population Reference Bureau. The World’s Youth priority in their national social and economic 2000, August 2000. 4. Unpublished country reports. development agenda; 5. UNAIDS Report, 1999. (b) to review, develop, implement and evaluate na- 6. UNICEF. Youth Health for a Change, 1997. tional policies and programmes on adolescent 7. Survey by WHO/AFRO, 2000. health and development;

63 3.3 Women’s health: A strategy for the WHO African Region (AFR/RC53/11)

EXECUTIVE SUMMARY 1. Women’s health is a state of complete physical, mental and social well-being of women throughout their lifespan and not only their reproductive health. Women’s health is a result of the interaction of different factors: biological, psychological and sociocultural infl uences; environmental and occupational conditions; and economic development. The various stages in the life of a woman range from infancy, childhood, adolescence and adulthood to the post-reproductive years. Each stage has specifi c health problems that infl uence outcomes in subsequent years. 2. Women’s biological vulnerability, low social status, limited access to health services, low level of literacy and lack of decision-making powers are major determinants of ill-health. Diffi cult geographical and fi nancial access, poor quality of care, attitude of health care workers and long waiting hours in health facilities have limited women’s utilization of services. All these factors require detailed studies in order to inform policies and promote effective planning and interventions. 3. The creation of an enabling environment for women at all levels is critical to the attainment by them of the highest possible level of health as refl ected in the Health-for-All Policy for the 21st Century in the African Region: Agenda 2020. This consists of health system responsiveness to the needs of women, education of the girl-child, quality health care, elimination of gender discrimination and harmful traditional practices, and an appreciation of the role of women in sustaining human life. 4. The goal of the women’s health strategy is to contribute to the attainment of the highest possible level of health for women throughout their lifespan in line with the Millennium Develop- ment targets. It addresses the health conditions that are specifi c to or more prevalent in women, have severe consequences and imply certain risk factors. 5. The proposed interventions focus on improving the responsiveness of health systems based on well researched information on the specifi c needs of women; developing appropriate evidence-based policies, advocacy and communication strategies; and strengthening capacity of various cadres of health providers at all levels. 6. The Regional Committee adopted the proposed strategy for implementation by Member States.

INTRODUCTION conditions; economic development.2 The various 1. Women’s health is a state of complete physical, stages in the life of a woman3 range from infancy, mental and social well-being of women throughout childhood, adolescence and adulthood to the post- their lifespan and not only their reproductive health.1 reproductive years. Each stage has specifi c health Women’s health is a result of the interaction of problems and subsequent health outcomes are infl u- different factors: biological, psychological and socio- enced by the experience of previous stages. cultural infl uences; environmental and occupational

64 Putting the health of mothers and children ﬁ rst

2. Women’s biological vulnerability to some health tion, including FGM, all of which increase the risk conditions (such as HIV/AIDS), low social status, of morbidity and mortality. limited access to health services, low level of literacy 8. Early marriage, unwanted pregnancy and preg- and lack of decision-making powers are major deter- nancy complications coupled with sexual violence minants of ill-health. In the African Region, many and substance abuse characterize the period of ado- women are subjected to sociocultural discrimination lescence. In some countries, 25–27% of fi rst births as well as harmful traditional practices (HTPs) such as occur among adolescents, and this group accounts female genital mutilation4 (FGM), food taboos, early for up to 40% of total maternal deaths, a signifi cant and forced marriage and pregnancy. Various factors proportion of which results from unsafe abortions.8 such as diffi cult geographical and fi nancial access, poor quality of care, negative attitude of health care 9. WHO estimates that reproductive ill-health workers and long waiting hours in health facilities accounts for 33% of the total disease burden for have limited women’s utilization of services. These women, as compared to 12.3% for men of the same factors are more critical in rural population. age. Despite the availability of safe and affordable technologies, in developing countries, one woman 3. The collective effect of these factors determines in 14 dies of pregnancy and childbirth-related com- the way a woman’s health is perceived by her and plications compared with one in 4000 or even one others as well as the value placed on her well-being. in 10 000 in developed countries. This demonstrates The decision about when to seek health care is not a high level of inequity. Maternal mortality ratio in always vested in the woman but rather in those who the African Region remains at an extremely high have power over her. level of 1000 per 100 0009 live births, the world’s 4. Numerous conferences, meetings and symposia highest. Major causes include antepartum and post- have focused on aspects of women’s health, and var- partum haemorrhage, sepsis, malaria and complica- ious resolutions5 and guidelines for action have led to tions of abortion, and lack of antenatal care. While the disaggregation of data and the establishment of malaria occurs throughout the lifespan in both men programmes for improving women’s health world- and women, malaria in pregnancy presents an addi- wide. Despite global and regional calls for action, tional challenge to the woman and the baby. It re- there are still information gaps on what is required to sults in maternal anaemia, antepartum haemorrhage, improve women’s health and how to respond to the foetal anaemia and low birth weight or death. health risks and needs of poor women. 10. For every woman who dies as a result of mater- 5. A few countries in the Region have improved nal causes, approximately 20 others will suffer short- access to quality health services for all in terms of term or long-term disabilities such as obstetric both distribution and affordability. These countries fi stula, chronic depression, urinary incontinence, in- have reduced maternal mortality rates. On average, fertility, maternal exhaustion and chronic anaemia.10 there is a decline in total fertility rates in the major- Case studies on maternal disabilities in a number of ity of countries over the past ten years, as assessed in countries reveal an enormous but unaddressed prob- women’s health profi les in selected countries.6 lem shrouded in a “culture of silence and endurance” because of values that encourage women to 6. The women’s health strategy addresses the health give lower priority to their own health than that of of women holistically and proposes interventions other family members.11 that will assist Member States to identify priorities and plan their programmes accordingly. 11. Women account for the majority of the elderly population, and this trend is increasing. In Africa, the average life expectancy is 51 years for women SITUATION ANALYSIS and 48 years for men.12 This fact masks a very different profi le of morbidity and quality of life in women 7. Defi ciencies in early life affect women’s health due to reproductive disabilities. Major causes of ill- and reproductive performance and that of their health among elderly women include cervical and daughters, creating intergenerational health effects. breast cancers, osteoporosis, post-menopausal syn- Newborn survival is intricately linked to maternal drome and mental depression. Many of these prob- nutrition, health and care.7 The common childhood lems are usually silent and unrecognized in the early diseases — diarrhoea, acute respiratory infections, stages, hence the fatality associated with them in the measles and malnutrition — affect both female and post-menopausal period. male infants. The African girl-child suffers from a perpetual intergenerational cycle of under-nutrition, 12. HIV/AIDS occurs throughout the lifespan. child labour, abuse, neglect and social discrimina- Although it affects both women and men, women

65 COMPENDIUM OF RC STRATEGIES are more vulnerable due to biological and epidemio- These include access to reproductive health services, logical factors, sexual violence, low socioeconomic psychosocial support, care and rehabilitation ser- status and lack of negotiating powers with male vices. A minimum package of public health services partners. In sub-Saharan Africa, 55% of the in emergency situations has been developed by 28.1 million HIV-infected adults are women; among WHO to address some of these problems.22 the youth, there are four infected women for every 17. Over the years, fragmented approaches have HIV infected man.13 Increasing numbers of women been employed to address the health of women. The attending antenatal clinics are being diagnosed with present women’s health strategy focuses on the HIV infection. HIV transmission rates from mother- health conditions that are specifi c to women, have to-child range from 25% to 40% in some countries.14 severe consequences and imply different risk factors In sub-Saharan Africa, there are 11 million children for them. It also proposes interventions that will orphaned by HIV/AIDS. This large population of assist countries to contribute to the attainment of the orphaned children has increased the burden of care millennium development goals (MDGs) related to provided by the poor and elderly women. women’s health. 13. With the re-emergence of tuberculosis (TB), it has become the single leading infectious cause of death in women worldwide. It kills over one million women aged 15–44 years annually; 600 000 TB THE REGIONAL STRATEGY deaths occur in the African Region, mainly in Goal and objectives women.15 HIV, TB and malaria constitute a deadly triad in African women. 18. The goal of the strategy is to contribute to the attainment of the highest possible level of health for 14. Violence against women16 is recognized world- women throughout their lifespan in line with the wide as a violation of women’s human rights, al- Millennium Development targets. though regional data are sparse. Globally, 16–50% of women have been victims of physical violence at 19. The specifi c objectives are to support Member some time in their lives. In some African countries, States to: high levels of psychological abuse have been report- (a) advocate for women-sensitive health policies 17 ed. Adolescent girls have become the main victims and programmes that respond to their needs and of sexual assault and human traffi cking. The health are in line with agreed inter national instruments consequences of gender-based violence include and conventions; post-traumatic stress disorders, substance abuse, sex- (b) accelerate the implementation of interventions ually transmitted infections, HIV/AIDS, femicide, aimed at improving the health of women, focus- attempted suicide and suicide. ing on major causes of morbidity and mortality, 15. FGM and nutritional taboos are prevalent in in particular, maternal mortality; many societies. In many cultural settings, FGM is (c) improve access for all women to quality health viewed as a rite of passage from childhood to services that are responsive to their specifi c womanhood. The immediate and long-term conse- needs, and ensured safe motherhood; quences of FGM are numerous.18 In the African (d) accelerate the elimination of all forms of vio- Region, some form of FGM with its attendant im- lence and harmful traditional practices. mediate and long-term health consequences occurs in 27 of 46 Member States. The prevalence ranges Guiding principles from 5–98% in some countries.19 While there are some good reasons for recognizing and respecting 20. The success and sustainability of the implemen- the initiation of girls into womanhood, eliminating tation of the strategy will be guided by the following the associated mutilation has many advantages. principles: Some Member States that have adopted the 20-year (a) adopting a holistic approach to women’s health, Regional Plan of Action for the Acceleration of the including their physical, mental, social and eco- Elimination of FGM in Africa are showing a reduc- nomic well-being throughout their lives; tion in prevalence of FGM. (b) promoting equity in health through women’s 16. In armed confl icts, 80% of the refugees or inter- access to quality health services, in particular, nally displaced persons are women and children20 emergency obstetric care; who have special health needs. Women with dis- (c) empowering women to participate in, benefi t abilities and in specialized institutions21 live in diffi - from and play a leadership role in health, in par- cult situations that require specifi c interventions. ticular through the education of the girl-child;

66 Putting the health of mothers and children ﬁ rst

(d) advocating for the implementation of inter- 25. Member States will be supported to strengthen nationally agreed conventions and declarations mechanisms for the elimination of HTPs and all in countries; forms of violence by applying proven interventions (e) incorporating a gender perspective into health (such as community involvement, alternative rites of policies and programmes. passage, government commitment23) for prevention and timely case management. Priority interventions 26. Support will further develop and implement 21. Interventions addressing the promotive, preven- advocacy and communication strategies to promote tive, curative and rehabilitative aspects of women’s the human rights approach to women’s health at health will be implemented. individual, family and community levels, in the broader context of social and economic develop- 22. Member States will be supported to formulate ment. Results of the national women’s health profi le national women’s health policies and programmes and research fi ndings will inform the development derived from the national women’s health profi le. of appropriate advocacy and communication The profi le will enable countries to identify inter- strategies. ventions needed to improve the health and survival of women, and reduce the disease burden in the 27. Member States will be supported to identify and context of existing health care delivery systems. conduct priority research on issues related to wom- National women’s health policies should include en’s health and apply the results to improve policy, appropriate health care fi nancing mechanisms to en- programme planning and implementation. Areas for able the poorest of poor women to access the serv- operational research include understanding wom- ices. Countries may need to formulate or review en’s health care seeking behaviour, sociocultural be- laws to protect the health and rights of women. liefs, psychosocial support and service providers’ attitudes in women’s health. Specifi c participatory 23. Further support will re-orient health services to research will be conducted in response to problems provide accessible quality care which is convenient, arising in the course of implementation. timely, affordable and responsive to women’s specifi c health needs. These will include preventive Roles and responsibilities sexual and reproductive health services; appropriate and timely management of cervical and breast can- Role of countries cers, TB and HIV/AIDS, including prevention of 28. This strategy will be implemented in the context mother-to-child transmission of HIV; and early of national health policy or health sector reform, diag nosis and treatment of special conditions such as using the districts and communities as entry points, hypertension, diabetes and blindness that affect and putting emphasis on integration with relevant women’s health. Management and rehabilitation of health-related programmes. This integration will women with obstetric fi stula, where this is a prob- be done with the recognition that the health of lem, will be addressed. Special approaches will be women is the foundation for sustainable human developed to provide responsive health care services development. for women in diffi cult circumstances. 29. Member States will develop or strengthen 24. Support will be provided to strengthen the capa- national frameworks for implementing the strategy city of health personnel to provide basic and in an integrated manner in partnership with women, comprehensive emergency obstetric care (EOC), men, opinion leaders, community-based organiza- psychosocial support and counselling and to adopt tions, NGOs, relevant government ministries, and positive attitudes to women clients. Capacity of public and private institutions. Countries will imple- women and men, families and communities will also ment the Abuja Declaration so as to mobilize and be strengthened to advance the cause of women’s allocate adequate resources for women’s health. health, including the provision of information on appropriate care seeking for the reduction of mater- 30. The development or revision of country-specifi c nal mortality and the elimination of all forms of legal frameworks to prevent gender-based violence social violence and health risks. Building the capa- and HTPs will contribute greatly to women’s health. city of a multidisciplinary national collaborating 31. The ministry of health will play a stewardship group to conduct operations research on HTPs, role in ensuring the collection and collation of dis- gender-based violence and pre-service training of aggregated gender data as well as strengthening health personnel using WHO FGM training manuals health systems to meet the promotive, preventive, will be supported. curative and rehabilitative health needs of women.

67 COMPENDIUM OF RC STRATEGIES

The ministry of health will ensure the inclusion of 36. The creation of an enabling environment for gender perspectives in health sector reforms, poverty women at all levels is critical for the attainment of reduction strategy papers, quality of care and respon- the highest possible level of health as refl ected in the siveness of health systems. In addition, it will Health-for-All Policy for the 21st Century in the African strengthen mechanisms for a national multidiscipli- Region: Agenda 2020. This enabling environment nary and multisectoral coordination structure to must be in the context of health sector reforms in monitor trends in women’s health. countries. Major components are health system responsiveness to the needs of women, education of Role of WHO and partners the girl-child, quality health care, elimination of gender discrimination and HTPs, and an apprecia- 32. WHO will provide technical assistance to coun- tion of the role of women in sustaining human life. tries for the implementation of this strategy, taking into consideration major causes of morbidity and 37. The Regional Committee endorsed “Women’s mortality in countries, while ensuring equity and health: A strategy for the African Region” for im- rights of women to access quality health service. plementation in Member States. Generic tools and guidelines for implementation, monitoring and evaluation will be provided for Resolution AFR/RC53/R4 adap tation by countries. Women’s health: A strategy for the African 33. Partnerships for education, capacity building and Region leadership roles for women will be fostered to ensure their active participation in health develop- The Regional Committee, ment. This will involve interested and relevant UN Recalling previous World Health Assembly reso- and bilateral agencies as well as international and lutions WHA40.27, WHA42.42, WHA43.10 and national NGOs, private organizations, women’s WHA45.25 on women’s health and development; groups and communities. Bearing in mind the Regional Committee resolutions AFR/RC39/R9 on traditional practices MONITORING AND EVALUATION affecting the health of women and children, AFR/ RC43/R6 on women, health and development and 34. WHO will assist countries to select and apply AFR/RC47/R4 on promotion of the participation appropriate indicators for monitoring and evalua- of women in health and development; tion. These include disaggregated vital health statistics, percentage access to EOC, percentage access to Adhering to the Health-for-All Policy for the 21st cervical and breast cancer screening, contraceptive Century in the African Region: Agenda 2020 that calls prevalence rate, female literacy rate and percentage for the creation of conditions that will enable wom- of women in decision-making positions. Informa- en to participate in, benefi t from and play a leader- tion will be collected on strategy implementation, ship role in health development; and reports will be provided periodically to the Mindful of the human rights instruments stated Regional Committee. Evaluation results will be in international and regional conventions, declara- used for strengthening national programmes and tions and charters; action plans. Concerned about the extremely high level of morbidity and mortality in women, and the addi- CONCLUSION tional efforts that will be needed by Member States to achieve international goals for women’s health, 35. Women deserve special attention because of the including maternal health; high burden of disease they endure and because of the health conditions related to their reproductive Convinced of the need for sex-disaggregated data life. This calls for high-level commitment of families, and the incorporation of a gender perspective in communities, governments and international part- health programmes; ners. Efforts to scale-up interventions aimed at im- 1. APPROVES the document “Women’s health: proving women’s health must be coordinated and A Strategy for the African Region”, which focuses involve all stakeholders. Strategic budgeting and and emphasizes health conditions that are exclusive effective monitoring and evaluation mechanisms to or more prevalent in women as well as those that will ensure implementation of proven interventions have more severe consequences and imply specifi c and demonstrate change. risk factors;

68 Putting the health of mothers and children ﬁ rst

2. COMMENDS the Regional Director for advo- (f) to report to the fi fty-sixth session of regional cating for, promoting and supporting women’s Committee and every three years thereafter on health in the Region; the progress made in the implementation of the women’s health strategy. 3. URGES Member States: (a) to accord greater priority to women’s health in REFERENCES their national socioeconomic development agenda through strengthening and expanding 1. Resolution WHA45.25, Women, health and devel- efforts to meet international targets for improved opment, 1992. women’s health, particularity the education of 2. Women’s health: Across age and frontier, WHO, the girl-child; Geneva, 1992. (b) to make additional efforts to improve advo cacy 3. In this document, the term women includes female infants, children, adolescents, adults, women in post- at the highest level for women sensitive health reproductive years and women in diffi cult situations, policies and programmes, resources, partnerships as well as rural and urban women. creation and sustained political commitment to 4. FGM constitutes all procedures which involve the par- the Abuja Declaration; tial or total removal of the external female genitalia or (c) to promote access by all women to a full range of other injury to the female genital mutilation organs for information and quality health services, focusing cultural or other non-therapeutic reasons. WHO, Re- on the major causes of morbidity and mortality; gional plan of Action to accelerate the elimination of (d) to accelerate the implementation of interven- female genital mutilation in Africa, Brazzaville, 1997. tions aimed at eliminating all forms of violence 5. Resolutions AFR/RC39/R8, AFR/RC39/R9, and harmful traditional practices, based on exist- AFR/RC40/R2, AFR/RC43/R6 and AFR/ RC44/R11; Resolutions WHA40.27, WHA42.42, ing international and regional strategies; WHA43.10 and WHA45.25; 1993 International (e) to equip health personnel, communities families Conference on Human Rights; 1994 World Social and individuals, women and men, with the req- and Economic Summit; 1994 International Confer- uisite skills to enable them develop, implement, ence on Population and Development, 1995 World monitor and evaluate women’s health policies Conference on Women. and programmes at all levels; 6. Reports of national women’s health profi les in 18 countries in the African Region: Algeria, Burkina 4. REQUESTS the Regional Director: Faso, Cape Verde, Côte d’Ivoire, Ethiopia, Ghana, Lesotho, Mali, Mauritania, Mozambique, Namibia, (a) to provide technical support to Member States Niger, Nigeria, Democratic Republic of Congo, for the development of policies, and the imple- Seychelles, South Africa, Tanzania, Zimbabwe. mentation of agreed conventions and declara- 7. Africa’s newborns: the forgotten children, WHO tions towards the attainment of international Regional Offi ce for Africa, 2002. goals on women’s health; 8. UNDP, Human development report 2001, New (b) to continue to advocate for a strategic approach York, 2002. to the reduction of morbidity and mortality in 9. WHO, The road to safe motherhood, Harare, 2001. women, including the effective interventions in 10. Khattab HAS The silent endurance, Cairo, UNICEF and Population Council, 1992; Fortney JA and Smith the Safe Motherhood Initiative, regional plans JB, The base of the iceberg: Prevalence and percep- for the elimination of female genital mutilation tions of maternal morbidity in four developing coun- and other harmful traditional practices, preven- tries, Research Triangle Park, NC, FHI, 1996. tion of violence, and education of the girl-child; 11. UN, Women’s indicators and statistics database (c) to mobilize governments, UN agencies, NGOs (WISTAT), New York, UN Population Division, and other stakeholders to organize symposia, 2000. conferences and workshops to refocus women’s 12. UNAIDS/WHO, Report on the global HIV/AIDS health in the national development goals; epidemic, Geneva, 2002. (d) to support public and private institutions and na- 13. UNAIDS/WHO, Report on the global HIV/AIDS tional experts to carry out research on identifi ed epidemic, Geneva, 2000. 14. WHO/AFRO, TB surveillance report, Brazzaville, priorities and document fi nd ings and best prac- 2001. tices for use by Member States in full implemen- 15. Violence against women is any act of gender-based tation of cost-effective approaches for improved violence that results in, or is likely to result in physi- women’s health; cal, sexual or psychological harm or suffering to (e) to maintain WHO commitment to incorporation women, including threats of such acts, coercion or of gender perspective in policies and programmes arbitrary deprivation of liberty, in private and public

69 COMPENDIUM OF RC STRATEGIES

life (1993 UN Declaration on the elimination of all 18. WHO, Female genital mutilation: a handbook for forms of violence against women). It includes rape, frontline workers, Geneva, 2000. battering, homicide, incest, psychological abuse, 19. UNHCR, Report on refugees and internally dis- forced prostitution, female traffi cking, forced mar- placed persons, Geneva, 2000. riage, female abduction and sexual slavery. 20. Women in prison, elderly women in nursing homes, 16. World Bank, Engendering development, Washing- psychiatric hospital, etc. ton, D.C., 2001. 21. WHO, Reproductive health during confl ict and dis- 17. Immediate health complications: pain, shock, acute uri- placement, Geneva, 2000. nary retention, injury to adjacent tissues, risk of trans- 22. Report of the intercountry meeting to review effec- mission of blood-borne infections leading to death. tive interventions for the elimination of FGM in the Long-term complications are dysmenorrhoea, dyspare- African Region, Bamako (Mali), 2002. Unpublished unia, sexual dysfunction, chronic pelvic infection, vesi- document. co-vaginal fi stulae, prolonged and obstructed labour, psychological and social consequences. WHO, 2000.

70 3.4 Child survival: A strategy for the WHO African Region (AFR/RC56/13)

EXECUTIVE SUMMARY 1. The past 20 years have witnessed improvements in child survival due to effective public health interventions and better economic and social performance worldwide. Nevertheless, about 10.6 million children die yearly, 4.6 million of these in the African Region. About one quarter of these deaths occur in the fi rst month of life, over two thirds in the fi rst seven days. The majority of under-fi ve deaths are due to a small number of common, preventable and treatable conditions such as infections, malnutrition and neonatal conditions occurring singly or in combination. 2. The average decline in under-fi ve mortality experienced globally over the years is mainly attri buted to decline in rates in countries with rapid economic development. The African Region needs to increase its average annual mortality reduction rate to 8.2% per annum if Millennium Development Goal 4 is to be achieved by 2015. A number of affordable recommended interventions have been identifi ed which could prevent 63% of current mortality. 3. The key to making progress towards attaining the goal by 2015 is reaching every newborn and child in every district with a limited set of priority interventions. New and serious commitments are necessary to prioritize and accelerate child survival efforts and allocate resources within countries. 4. Priority child survival interventions that will be implemented and scaled up include newborn care with a life-course approach and continuum of care; infant and young child feeding, including micronutrient supplementation and deworming; provision and promotion of maternal and childhood immunization and new vaccines; prevention of mother-to-child transmission of HIV; and using Integrated Management of Childhood Illness to manage common childhood illnesses and care for children exposed to or infected with HIV. 5. This document presents a strategy for optimal survival, growth and development of children 0–5 years of age and for reduction of neonatal and child mortality in the African Region in line with the Millennium Development Goals. 6. Governments will take the lead in ensuring an integrated and focused approach to programme planning and service delivery to scale up newborn and child health interventions. WHO and partners will support countries in this effort. 7. The Regional Committee reviewed the proposed WHO, UNICEF and World Bank strategy and adopted it along with the attached resolution for use by countries in the African Region.

71 COMPENDIUM OF RC STRATEGIES

INTRODUCTION Child (1990), the adoption of the Integrated Man- agement of Childhood Illness strategy by the WHO 1. Child survival, which refers to survival of chil- Regional Committee for Africa (1999) and the dren aged 0–5 years, is a major public health con- African Union Declaration on Child Survival (2005) cern in most countries in Africa. The past 20 years recognize the duty to accelerate action for child have witnessed improvements in child survival due survival. to effective public health interventions and better economic and social performance worldwide. Nev- 8. The African Union requested all Member States ertheless, about 10.6 million children die yearly, 4.6 to mainstream child survival into their national million of these in the African Region. About one health policies. Health and child survival have been quarter of these deaths occur in the fi rst month of prioritized by the New Partnership for Africa’s De- life, over two-thirds in the fi rst seven days. The ma- velopment. The Delhi Declaration (2005) on mater- jority of under-fi ve deaths are due to a small number nal, newborn and child health and the subsequent of common, preventable and treatable conditions. Fifty-eighth World Health Assembly resolution3 call for the highest political commitment. 2. In 2000, the nations of the world met and agreed to the Millennium Development Goals (MDGs). 9. This document provides strategic direction for One of the targets is to reduce by two-thirds be- Member States of the African Region to address tween 1990 and 2015, the under-fi ve mortality rate child survival and development, decrease the un- (MDG 4). A few countries have made progress, but acceptably high child mortality rates and attain overall, countries in sub-Saharan Africa are not on Millennium Development Goal 4. track to achieve MDG 4. The African Region needs to increase its average annual mortality reduction rate to 8.2% if MDG 4 is to be achieved by 2015.1 SITUATION ANALYSIS AND 3. International treaties and conventions such as JUSTIFICATION the Convention on the Rights of the Child (1990), 10. The average decline in under-fi ve mortality ex- the UN Special Session on Children (2002) and the perienced globally over the years can be mainly WHO/UNICEF Global Consultation on Child and attributed to the decline in rates in countries with Adolescent Health and Development (2002) em- rapid economic development.4 phasize the inherent right to life and the urgency of reducing child mortality for future prosperity. 11. The situation of most African children remains critical and is exasperated by the serious poverty on 4. The Millennium Declaration and the MDGs the continent. A number of factors contribute to the provide a framework for addressing the high mortal- slow reduction in the average annual mortality rate ity rates in the Region. The pertinent goals call for and the large disparities in child survival between reduction in hunger (MDG 1), reduction in under- and within developing countries. These include fi ve mortality rates (MDG 4) and improvement in socioeconomic, cultural, traditional and develop- maternal health (MDG 5) and combating HIV/ mental circumstances as well as natural disasters, AIDS, malaria and other diseases (MDG 6). armed confl ict, exploitation and hunger. Poverty is 5. A number of affordable recommended interven- the single most important factor accounting for low tions have been identifi ed, which could prevent coverage of effective interventions. 63% of current mortality if implemented at very 12. In the African Region, infections are the main high levels of coverage.2 New and increased com- direct cause of child mortality. Although the relative mitments are necessary to prioritize and accelerate importance of infections varies from country to child survival efforts and allocate resources within country, on average, more than 70% of child deaths countries. are attributed to just a few mainly preventable causes, 6. Partnerships, resources and more effective pro- namely, acute respiratory infections, diarrhoea, ma- grammes at all levels are increasingly needed to laria, measles, malnutrition and neonatal conditions reach the MDGs. Only a focused, coordinated effort (asphyxia, prematurity, low birth weight and infec- and appropriate action by the international commu- tions), singly or in combination. HIV/AIDS may nity and Member States can bring newborns and account for up to 57% of under-fi ve deaths in coun- children the health care they need in a more effi - tries with the highest HIV prevalence. cient way. 13. The HIV pandemic has contributed to increased 7. In Africa, the Organization of African Unity poverty, the erosion of the family and community African Charter on the Rights and Welfare of the support needed for child survival, and the human

72 Putting the health of mothers and children fi rst resource crisis in the health and other sectors. vival interventions and has contributed to a 13% Although it is known that HIV treatment for chil- mortality reduction over a two-year period in dis- dren can reduce mortality and improve quality of tricts in Tanzania where it has been implemented.11 life, very few countries have comprehensive 19. For greater impact, however, it is imperative to approaches to paediatric HIV care and support. implement the IMCI strategy by applying the life- 14. Indirect determinants of health may vary be- course approach and to coordinate its implementa- tween countries; however, malnutrition is a critical tion with strategies for other relevant intervention risk factor in most countries, and food and nutrition areas. Growth and development during pregnancy is security remain fundamental challenges to child sur- essential to ensure a healthy neonatal period. Re- vival.5 Lack of water and sanitation, poor living con- ducing newborn morbidity, on the other hand, is ditions, and inadequate child spacing are associated essential to healthy growth and development during with high mortality. In Africa, water, sanitation and childhood, adolescence and adulthood. This re- hygiene are seldom linked to national child survival quires a holistic approach, which combines a com- strategies. prehensive child survival strategy with strategies for eradicating extreme poverty and hunger, improving 15. There are a few cost-effective interventions that maternal health, and combating HIV/AIDS, malaria could signifi cantly reduce mortality, and these inter- and other diseases. ventions vary greatly between and within countries. In some countries, progress achieved in the early 1980s and 1990s has not been sustained, and coverage rates have actually regressed. For example, use of THE REGIONAL STRATEGY insecticide-treated nets can reduce child deaths from Objective malaria by about 17%,6 but coverage remains low at about 15%7 in Africa. Interventions such as oral rehy- 20. The objective of the strategy is to accelerate the dration therapy and treatment of acute respiratory reduction of neonatal and child mortality in infections seem to have lost their momentum. Newer line with the Millennium Development Goals by interventions such as those for improving newborn achieving high coverage of a defi ned set of effective health have received little attention because of mis- interventions. conceptions about their complexity and cost.8 16. There are multiple constraints in health systems Guiding principles that hamper effective scaling up of interventions. In- 21. The strategy is founded on the following suffi cient human, fi nancial and material resources principles: coupled with limited managerial capability, out-of- pocket payments and inadequate mechanisms for (a) Life-course approach: This strategy promotes opti- families to access health care are just some of the fac- mal growth and development of the foetus and tors that lead to poor service delivery and low cov- across the 0 to 5 age group to prepare each indi- erage of interventions. Insuffi cient availability of vidual for a healthy, well-adjusted, productive essential drugs and supplies, and inadequate supervi- adult life, through coordinated implementation sion of health-care providers are among the persist- with other strategies aimed at achieving the ent problems of the health systems in many countries. MDGs and promoting health. (b) Equity: Emphasis will be on ensuring equal 17. Financial resources for child survival pro- access to child survival interventions for all grammes are far from adequate for reaching every children. community in every district with low-cost interven- (c) Child rights: Rights-based planning will be in- tions. Globally, US$ 52.4 billion are needed to reach corporated in child health interventions to en- universal coverage in addition to current expendi- sure protection of the most vulnerable. tures. This corresponds to US$ 0.47 per individual (d) Integration: All efforts will be made to implement initially, increasing to US$ 1.48 in year 10 when the proposed priority interventions at various 95% of the child population would be covered.9 levels of the health system in a coherent and 18. In 1999, the WHO Regional Committee for effective manner that is responsive to the needs Africa adopted Integrated Management of Child- of the child. hood Illness (IMCI) as the major strategy for child (e) Multisectoral collaboration: Considering that health survival and the reduction of the high child mortal- issues are development issues, achieving health ity rate in the Region.10 IMCI has been found to be outcomes requires contributions from other an effective delivery strategy for various child sur- sectors.

73 COMPENDIUM OF RC STRATEGIES

(f) Partnerships: Emphasis will be put on developing Pregnancy and Childbirth offers opportunities for new partnerships and strengthening existing addressing early newborn health. Integrated Man- ones to ensure that child survival interventions agement of Childhood Illness will also be expanded are fully integrated in national and district health to include newborns in the fi rst seven days of life. systems in a sustainable way. 25. Infant and Young Child Feeding, including micronutrient supplementation and deworm- Strategic approaches ing. Key interventions to be emphasized are exclu- 22. The strategic approaches are: sive breastfeeding for the fi rst six months of life, including colostrum, timely and appropriate com- (a) Advocating for harmonization of child survival goals plementary feeding, and adequate micronutrient and agendas in order to promote, implement, intake (particularly vitamin A, iron and iodine). scale up and allocate resources to achieve the Regular deworming throughout childhood and internationally-agreed goals and targets; during pregnancy will be promoted for its function- (b) Strengthening health systems by building capacity al and developmental benefi t. Special emphasis will at all levels of the health sector and ensuring be given to prevention and treatment of malnutri- quality service delivery to achieve high population. Integration of Infant and Young Child Feeding tion coverage of child survival interventions in in other child health services, such as Baby Friendly an integrated manner; Hospital Initiative, IMCI, PMTCT, and Growth (c) Empowering families and communities, especially Monitoring Promotion and Referral, provides criti- the poor and marginalized, to improve key cal entry for scaling up these interventions. child-care practices and to make the treatment of malaria, pneumonia, diarrhoea and HIV/ 26. Prevention of malaria using insecticide- AIDS available within the community; treated nets and intermittent preventive treat- (d) Forming operational partnerships to implement ment of malaria. Use of insecticide-treated nets promising interventions with government in the (ITNs) for both under-fi ves and pregnant mothers lead, and donors, NGOs, the private sector and and incorporating intermittent preventive treatment other stakeholders engaged in joint programming of malaria (IPT) during pregnancy in malaria- and co-funding of activities and technical reviews; endemic areas are priority interventions for reducing (e) Mobilizing resources at international, regional and low birth weight, child morbidity and child mortal- government levels for child survival to scale up ity. One mechanism to ensure universal access to proven interventions. ITNs is to provide free or subsidized ITNs on a regular basis or through campaigns. ITNs and IPT Essential package of services should be integrated with the Expanded Programme on Immunization (EPI), antenatal care and IMCI 23. Integrated Management of Childhood Ill- activities to increase coverage rapidly. ness will remain an important delivery mechanism for most of the priority interventions listed below. In 27. Immunization of mothers and children. Pro- addition, strong linkages with Road Map for accel- vision of tetanus toxoid to pregnant women in ante- erating the attainment of MDG 5 and Making Preg- natal clinics and childhood immunizations, including nancy Safer (MPS) services will be promoted, new vaccines, at community and facility levels especially for newborn care and Prevention of through outreach and fi xed services will be promot- Mother-to-Child Transmission of HIV (PMTCT). ed. Proven ways of improving access to and coverage of services include outreach campaigns to provide 24. Newborn care. Taking into consideration the services to the remote and integration of EPI with life-course approach and continuum of care, neo- other child survival interventions such as vitamin A, natal interventions that need to be scaled up will deworming and ITN distribution. The implementa- include access to skilled care during pregnancy, tion of this child survival strategy will be closely co- childbirth and the immediate postnatal period at ordinated with the implementation of the WHO/ community and facility level. Capacity building of UNICEF Global Immunization Vision and Strategy. professional and non-professional staff will include optimal newborn care practices of newborn resusci- 28. Prevention of Mother-to-Child Transmis- tation, early and exclusive breastfeeding, warmth, sion of HIV. The key to ensuring an HIV-free start hygienic cord and skin care as well as timely and in life is the prevention of HIV transmission to appropriate care-seeking for infections and care of children by preventing HIV infection in mothers. low-birth-weight infants. The Making Pregnancy Other interventions are family planning, antiretro- Safer initiative through Integrated Management of viral therapy, counselling in infant feeding and

74 Putting the health of mothers and children ﬁ rst

support for HIV-infected women and their infants immediately. The minimum package may in- in countries with high HIV prevalence. Integration clude ITNs for pregnant women and infants; an- of PMTCT interventions in antenatal care, nutrition tenatal care ; promotion of early, exclusive and programmes, IMCI and other HIV/AIDS services prolonged breastfeeding; neonatal care; routine enhances opportunities for reducing paediatric HIV immunization of mothers and children; vitamin and the associated deaths. A supplementation; deworming; complementary infant feeding; oral rehydration therapy and zinc 29. Management of common childhood ill- supplementation for diarrhoea; malaria treatment, nesses and care of children exposed to or in- including artemisinin-based combined therapy; fected with HIV. Interventions include oral management of pneumonia in newborns and rehydration therapy and zinc supplementation for children; antiretroviral drugs for the management the management of diarrhoea; effective and appro- of paediatric AIDS; and birth spacing; priate antibiotic treatment for pneumonia, dysentery (b) An expanded package equivalent to the mini- and neonatal infections; and prompt and effective mum package plus additional evidence-based treatment of malaria at health facility and commu- interventions such as expanded neonatal care, nity levels. Care of HIV-exposed and HIV-infected Haemophilus infl uenzae type B vaccine, and children is the key to improved quality of life. Inte- emergency obstetric care; grated Management of Childhood Illness provides (c) A maximum package equivalent to the expanded an approach for addressing these common illnesses package plus new planned interventions such as in an integrated manner. rotavirus and pneumococcal vaccine, and intermittent preventive treatment of malaria in young Implementation Framework children. 30. To achieve universal coverage with these inter- 32. The total resources required to implement the ventions, this strategy proposes that countries base strategy for each of the proposed packages through their health system and long-term plans on a suitable the various delivery modes is indicated in a separate mix of delivery channels based on the following document to be fi nalized. service delivery modes: (a) Family-oriented, community-based services that Roles and responsibilities can be delivered on a daily basis by trained community health or nutrition promoters with peri- Countries odic supervision from more skilled health staff; 33. Governments will take the lead in ensuring an (b) Population-oriented scheduled services that re- integrated and focused approach to programme quire health staff with basic skills (e.g. auxiliary planning and service delivery to scale up newborn nurses, midwives and other para-medical staff) and child health interventions. They will ensure cer- and can be delivered either by outreach or in tain priority interventions for universal access and health facilities in a scheduled way; high coverage among under-fi ve children, including (c) Individually-oriented clinical services that re- newborns. Specifi c roles of countries will be: quire health workers with advanced skills (such as registered nurses, midwives or physicians) (a) Policy development: To put in place the necessary available on a permanent basis. policies that allow effective scaling up of interventions; 31. Not all countries can currently ensure full cover- (b) Capacity building: To strengthen national capacity age of the whole range of interventions. Obstacles to to effectively plan, implement and monitor ac- comprehensive implementation of the continuum- tivities, including implementation of policies of-care concept across service delivery modes will that address child survival and related health sys- need to be addressed in the medium and long term. tem constraints; To facilitate long-term planning, the strategy identi- (c) Communication and social mobilization: To ensure fi es a phased approach that allows each country to relevance and consistency of messages for priority defi ne and implement an essential package of service child survival interventions, countries will de- interventions that, over time and with increasing velop a national communication strategy to sup- coverage, can then be expanded to arrive at an opti- port integrated health promotion activities with a mal (or maximum) package of interventions. The focus on empowering families, households and essential packages include: communities, ensuring clear links with effective (a) A minimum package of high-impact, low-cost in- delivery of essential services by different sectors, terventions that need to be implemented at scale institutions and players;

75 COMPENDIUM OF RC STRATEGIES

(d) Advocacy and partnership development: To advocate 36. The monitoring process will conform to child and develop partnerships within the framework of rights principles. Information and results will be the Maternal, Newborn and Child Health Part- stratifi ed by various groups so that comparisons can nership by ensuring consensus building, harmoni- be made about the impact of different policy and zation of interventions and resource mobilization programme measures. Evaluation will be conducted from within and outside the country; this includes every two years. child survival interventions in the various global and national development initiatives such as Poverty Reduction Strategy Papers, sector-wide CONCLUSION approaches and the Global Fund to Fight AIDS, 37. Children represent the future of Africa. Hence, Tuberculosis and Malaria as well as close collabo- investing in children’s health is imperative in ensur- ration with partners in the health sector and linking healthier and more productive future genera- ages with other programmes such as malaria tions who will guide the socioeconomic development control, HIV/AIDS, Maternal and Neonatal of the continent. Health, EPI, Integrated Disease Surveillance and Response, and Health System Development; 38. This strategy refl ects a life-course and compre- (e) Operational research: To conduct operational re- hensive approach to child health issues and health- search in priority areas in order to improve pol- care service delivery. It underscores the need for icy, planning, implementation and scaling-up of implementing cost-effective maternal newborn and cost-effective child survival interventions; child health interventions for reducing newborn (f) Documentation: To assess, document and share deaths by three fourths and child deaths by two their experiences and programme efforts to thirds in the largest population possible. achieve set goals and apply the lessons during the 39. The key to making progress towards attaining expansion phase and for advocacy purposes; Millennium Development Goal 4 by 2015 is reach- (g) Development of a framework for monitoring and eval- ing every newborn and child in every district with a uation: To develop a framework for monitoring few priority interventions. The interventions des- and evaluation that includes gathering baseline cribed above are not new; however, this strategy data, tracking progress, documenting and shar- calls for a strong commitment to prioritize intervening experiences with countries and regions. tions, allocate resources and accelerate a few known cost-effective child survival interventions for imple- WHO, UNICEF, World Bank and other mentation at high levels of population coverage. partners 40. The Regional Committee reviewed the Re- 34. WHO, UNICEF, World Bank and other part- gional Child Survival Strategy proposed by WHO, ners will: UNICEF and the World Bank, and adopted it along (a) advocate for the priority interventions and mo- with the attached resolution for use by countries. bilization of resources; (b) provide technical support to countries to scale Resolution AFR/RC56/R2 up child survival interventions by strengthening country and intercountry capacity, monitoring Child survival: A strategy for the African and evaluation mechanisms, and health manage- Region ment information; The Regional Committee, (c) support countries to identify, document and disseminate best practices in implementing these Alarmed that of the 10.6 million children who interventions; die every year globally, 4.6 million are from the Af- (d) support countries to develop capacity for opera- rican Region, and that the majority of these under- tional research; fi ve deaths are due to a small number of common, (e) facilitate coordination and collaboration. preventable and treatable conditions; Taking due account of the fact that Millennium Development Goal number 4 aims to reduce under- MONITORING AND EVALUATION fi ve mortality by two-thirds by 2015 compared to 1990 levels; 35. A minimum set of process and impact indicators to track progress will be agreed upon with partners Recognizing that international treaties and con- and stakeholders. ventions, including the 1990 Convention on the

76 Putting the health of mothers and children ﬁ rst

Rights of the Child, the United Nations Special Ses- apply the lessons learnt during the expansion sion on Children (2002) and the WHO/UNICEF phase and for advocacy purposes; Global Consultation on Child and Adolescent Health (g) to develop a monitoring and evaluation frame- and Development (2002), emphasize the inherent work, including gathering baseline data and right to quality life and the urgency to reduce child tracking progress, documenting the data and mortality; sharing them among countries and regions; Considering that children represent the future of 3. REQUESTS the Regional Director: Africa and that investing in their health is imperative (a) to stimulate partnerships and work with to ensure a healthier and more productive genera- UNICEF, the World Bank and other relevant tion for the socioeconomic development and pros- partners to support the implementation of this perity of the Region; strategy; Mindful of the fact that the OAU African Char- (b) to advocate for the scaling up of priority inter- ter on the Rights and Welfare of the Child (1990), ventions and mobilization of resources; the strategy for Integrated Management of Child- (c) to provide technical support to countries to scale hood Illness (IMCI) adopted by the WHO Region- up child survival interventions by strengthening al Committee for Africa in 1999, and the Tripoli country and intercountry capacities, monitoring Declaration on Child Survival adopted by the Afri- and evaluation mechanisms, and health manage- can Union Assembly in 2005, recognize the urgent ment information; need to accelerate action for child survival; (d) to support countries to identify, document and widely disseminate best practices in implement- Having carefully examined the document enti- ing these interventions; tled “Child survival: a strategy for the African Re- (d) to support countries to develop capacity for gion”, jointly developed by WHO, UNICEF and operational research; the World Bank, proposing a strategy on child sur- (f) to facilitate coordination and collaboration with vival for the African Region; the African Union and regional economic com- 1. APPROVES the proposed strategy for child sur- munities; vival in the African Region; (g) to report every other year on progress in the implementation of the child survival strategy for 2. URGES Member States: the African Region. (a) to put in place the policies needed for effective Fourth meeting, 29 August 2006 implementation of the child survival strategy; (b) to strengthen national capacity to effectively REFERENCES plan, implement and monitor activities, including implementing policies that address the issue 1. WHO, The world health report, 2005: Make every moth- of child survival in the context of health-care er and child count, Geneva, World Health Organiza- delivery systems; tion, 2005. (c) to ensure the relevance and consistency of mes- 2. Jones G. et al. How many child deaths can we prevent sages for priority child survival preventive inter- this year? Lancet 362: 65–71, 2003. 3. Resolution WHA58.31, Working towards universal ventions and develop national communication coverage of maternal, newborn and child health inter- strategies to support integrated health promotion ventions. In: Fifty-eighth World Health Assembly, activities with a focus on empowering indivi- Geneva, 16–25 May 2005. Volume 1: Resolutions and duals, families and communities; decisions, and list of participants. Geneva, World Health (d) to ensure consensus-building, harmonization of Organization, 2005 (WHA59/2005/REC/1), 118– interventions and resource mobilization from 121. within and outside the country, within the 4. Ahmad OB, Lopez AD, Inoue M. The decline in framework of maternal, newborn and child child mortality: a re-appraisal, Bulletin of the World health partnerships; Health Organization 78(10):1175–1191, 2000. (e) to conduct operational research in priority areas 5. Resolution WHA58.32, Infant and young child nutrition. In: Fifty-eighth World Health Assembly, Geneva, in order to improve policy, planning, imple- 16–25 May 2005. Volume 1: Resolutions and decisions, mentation and scaling up of cost-effective child and list of participants. Geneva, World Health Organi- survival interventions; zation, 2005 (WHA59/2005/REC/1), 121–124. (f) to assess, document and share experiences and 6. Schellenberg JRA et al. Effect of large-scale social programmatic efforts to achieve set goals so as to marketing of insecticide-treated nets on child survival in rural Tanzania, Lancet 357: 1241–1247, 2001.

77 COMPENDIUM OF RC STRATEGIES

7. WHO/UNICEF, World malaria report 2005, Geneva, 2000–2005. In: Forty-ninth Session of the WHO Re- World Health Organization, 2005. gional Committee for Africa, Windhoek, Namibia 30 8. Schellenberg JRA et al. Effect of large-scale social August–3 September 1999, Final Report. Harare, World marketing of insecticide-treated nets on child survival Health Organization, Regional Ofﬁ ce for Africa, in rural Tanzania, Lancet 357: 1241–1247, 2001. 1999 (AFR/RC49/18), 9–10. 9. WHO, The world health report 2005: Make every mother 11. Armstrong Schellenberg J et al. The effect of Inte- and child count, Geneva, World Health Organization, grated Management of Childhood Illness on observed 2005. quality of care of under-ﬁ ves in rural Tanzania, Health 10. Resolution AFR/RC49/R4, Integrated Manage- Policy and Planning 19(1): 1–10, 2004. ment of Childhood Illness (IMCI): Strategic plan for

78 Strategic Direction 4 Accelerated actions on HIV/AIDS, malaria and tuberculosis

4.1 HIV prevention in the WHO African Region: A strategy for renewal and acceleration (AFR/RC56/8)

EXECUTIVE SUMMARY 1. Nearly two-thirds of the world’s HIV-positive population live in sub-Saharan Africa. In 2005 alone, out of the 4.9 million new infections, 3.2 million occurred in the African Region, the majority of those affected aged between 15 and 49 years. 2. Countries in the African Region have made encouraging progress in implementing various elements of prevention and treatment interventions to control the HIV/AIDS epidemic. The main challenges include limited effective coverage of services in order to have the required impact, weak linkage between prevention and treatment interventions, weak health systems, lack of favourable policy environment for HIV prevention and inadequate resources at all levels. 3. Recognizing the alarming trend in HIV incidence in the Region and the need to increase measures to control further progress of the epidemic, the WHO Regional Committee for Africa, at its ﬁ fty-ﬁ fth session in August 2005, adopted Resolution AFR/RC55/R6, “Acceleration of HIV prevention efforts in the African Region”. By that resolution, the Regional Committee declared 2006 the “Year for Acceleration of HIV Prevention in the African Region” and urged Member States to re-emphasize and re-invigorate HIV prevention efforts. 4. The main objective of this strategy is to contribute to the acceleration of HIV prevention and to the reduction of the impact of HIV/AIDS in the context of universal access to prevention, treatment, care and support. The strategic approaches proposed focus on scaling up access to prevention interventions and integrating prevention with treatment, care and support. 5. The Regional Committee reviewed and adopted this proposed strategy along with its resolution.

INTRODUCTION Region are unlikely to achieve Millennium Devel- 1. The regional HIV strategy adopted in 1996 dur- opment Goal No 6.2 It is, therefore, imperative to ing the forty-sixth session of the WHO Regional reshape strategies of prevention, identify measures Committee for Africa reaffi rmed the major role of to quickly scale up successful interventions and the health sector in national response to the HIV/ highlight what should be done differently. AIDS epidemic with a clear prevention compo- 3. Recognizing the alarming trend in HIV inci- nent.1 In spite of the resources and efforts invested, dence in the Region and the need to increase meas- the epidemic has continued unabated, with high ures to control further spread of HIV, the WHO morbidity and mortality, undermining health gains Regional Committee for Africa at its fi fty-fi fth and the improvement of health status in the Region. session, held in Maputo in August 2005, adopted 2. HIV prevention efforts have been outpaced Resolution AFR/RC55/R6, “Acceleration of HIV by the HIV/AIDS epidemic, with a rising trend of prevention efforts in the African Region”. By that HIV incidence in most countries. Should the cur- resolution, the Regional Committee declared 2006 rent trends continue, most countries in the African the “Year for Acceleration of HIV Prevention in

81 COMPENDIUM OF RC STRATEGIES the African Region” and urged Member States to 9. Prevention, like treatment, remains concentrat- urgently re-emphasize and re-invigorate HIV ed in urban areas. Vulnerable groups are inadequate- prevention efforts, establish stronger partnerships ly targeted, fuelling the epidemic. Prevention would and coordination mechanisms, and ensure effective be more effective if closely coordinated with treat- leadership and coordination. ment, care and support interventions. It has been shown that HIV prevention is cost-effective and 4. Current global initiatives and commitments pro- that implementation of a comprehensive HIV vide an enabling environment to scale up preven- prevention package (linked to treatment) could tion efforts in the Region, while ensuring linkages avert 29 million (63%) of the 45 million new to treatment, care and support interventions. In June infections expected to occur in the Region by 2005, UNAIDS approved a policy position paper, 2010.8 “Intensifying HIV prevention”.3 Similarly, the Gleneagles G8 Summit of July 2005 made a com- 10. In 2003, the proportion of adults receiving vol- mitment to provide support to countries for achiev- untary counselling and testing was 7%, while the ing universal access to prevention, care and treatment proportion of pregnant women covered by preven- for all those who need it by 2010.4 tion of mother-to-child transmission (PMTCT) services was 5% in sub-Saharan Africa.9 Coverage of 5. Recognizing that there were insuffi cient re- voluntary counselling and testing (VCT) and pre- sources to protect and save children, UNICEF, with vention of mother-to-child transmission services in its partners, launched a global campaign under the the Region remains among the lowest in the world, theme: “Unite for children, unite against AIDS”. estimated at 7% and 5%, respectively.10 In 2004, The campaign seeks to place children infected and condom use with non-cohabiting partners was affected by HIV/AIDS at the centre of the global reported as 19% in sub-Saharan Africa.11 Of the response through focused efforts to scale up preven- estimated 4.7 million adults and children in need tion and care interventions.5 of antiretroviral drugs in the Region, only 17% 6. In March 2006, representatives of 53 African received treatment by the end of 2005.12 countries adopted the “Brazzaville Commitment” 11. Efforts to accelerate HIV prevention inter- calling on countries to take urgent and bold actions ventions and move towards the goal of Universal to address the bottlenecks that impede progress in Access will face a number of challenges: the implementation of prevention, treatment, care and support services. (a) Lack of favourable policy environment. Prevention and care that improve utilization of services and 7. This document proposes key interventions and address underlying factors of HIV transmission actions for accelerating HIV prevention interven- require an enabling policy environment. tions in the health sector and highlights the linkages (b) Low coverage of HIV prevention interventions. In to treatment, care and support interventions within order to ensure comprehensive coverage at all the context of universal access. However, effective levels of the health system, HIV prevention implementation of this strategy requires multi- intervention will need to be expanded and inte- sectoral involvement and coordination. grated. (c) Weak linkages. HIV prevention, treatment, care SITUATION ANALYSIS and support interventions should be linked in the context of an “essential package”. 8. At the end of 2005, of the estimated 40 million (d) Limited access for target populations. Participation of people living with HIV/AIDS, 25.8 million were in the private sector, civil society groups, PLWHA sub-Saharan Africa.6 According to the WHO- and all target groups would be ensured by a UNAIDS report of December 2005, of the 4.9 mil- national public health response to HIV/AIDS. lion new infections, worldwide, 3.2 million (65%) (e) Weak health systems. In order to meet the occurred in sub-Saharan Africa, with an overall increased demand for HIV/AIDS prevention, prevalence of 7.2% (6.6%–8.0%). During the same treatment, care and support services, health year, an estimated 2.4 million adults and children systems need to be strengthened. died, and more than 12 million children were or- (f) Inadequate fi nancial resources. There is a need to phaned due to AIDS. Now the leading cause of mobilize and ensure additional and sustainable death for both children and adults, AIDS has refi nancial resources that reach operational levels, duced average life expectancy from 62 years to 47 while ensuring effective coordination and years7 in the African Region. accountability of resources.

82 Accelerated actions on HIV/AIDS, malaria and tuberculosis

12. However, several opportunities exist to scale up scaling up of culturally- and socially-acceptable comprehensive HIV services with a focus on HIV preventions. prevention. They include: (c) Linkages. HIV prevention and HIV care, treatment and support interventions should be (a) increased commitment at global, regional and implemented simultaneously. Every situation in country levels for scaling up response to HIV; which an individual seeks health care should be (b) existence of the “Three Ones” principle13 with an opportunity for HIV prevention. improved management, coordination, partner- (d) Community participation. Communities and ships, monitoring and evaluation; civil societies should be promoted and supported (c) lessons learned from The “3 by 5” Initiative and as key components in scaling up intervention sharing of experiences and best practices; at all levels. Participation should be from all (d) progress in operational and clinical research to communities, including PLWHA. inform programmes and generate new preven- (e) “Three Ones” principle. Governments should tive and therapeutic alternatives. take the lead and, with participation of all stakeholders, update or develop an overall strategic Objectives framework for national response, national HIV/ 13. The main objective is to contribute to the AIDS coordination, and national monitoring acceleration of HIV prevention and to the reduction and evaluation. of the impact of HIV/AIDS in the context of (f) Sustainability and accountability. There is a universal access to prevention, treatment, care and need to advocate for additional resources, ensure support. proper disbursement and utilization of resources, and develop a system to monitor appropriate use Targets of funds. 14. By the end of 2010: Strategic approaches (a) all districts will provide counselling and testing services; 16. Accelerating the implementation of HIV pre- (b) 100% safe blood and blood products will be vention services will require decentralized imple- ensured; mentation of the strategic approaches set forth (c) at least 80% of pregnant women attending below. antenatal care will access PMTCT services; (d) at least 80% of patients with sexually transmitted Creating an enabling policy environment infections will access comprehensive STI man- 17. Specifi c policies and legislation that promote a agement; human rights-based approach should be developed. (e) at least 80% of people living with HIV and AIDS Where these exist, they should be revised to ensure will have access to comprehensive prevention, that approaches for the prevention of discrimination treatment and care services; and for increasing access to services are incorporat- (f) condom use will reach at least 60% in high-risk ed. Specifi c issues that need to be addressed include sexual encounters. stigmatization of people living with HIV; discrimination against them in employment, marriage, Guiding principles founding a family, access to health care and 15. The following guiding principles will underpin medicines; youth testing and counselling; sexual the acceleration of HIV prevention in the African violence and deliberate transmission of HIV. Poli- Region: cies should take into account age and gender issues (including rape) and exposure of under-age persons (a) Human rights approach. Equitable access to to alcohol and drug consumption and other risky quality services based on a human rights approach behaviours. will ensure adequate attention to vulnerable populations, including women, children, par- 18. All channels of communication should be drawn ticularly those affected by confl icts, the poor, upon to ensure that the general public and specifi c and populations in underserved areas. Issues of target groups are adequately informed about existing sexual violence and deliberate transmission of policies and legislation related to HIV/AIDS. HIV need to be given due attention. Emphasis should be put on channels that facilitate (b) Adaptation of proven interventions. Priority interactive discussions with communities, families should be given to identifi cation, adaptation and and individuals.

83 COMPENDIUM OF RC STRATEGIES

Expanding and intensifying effective HIV care providers), health care waste management, prevention interventions timely availability of safety equipment and supplies, and treatment. 19. Prevention efforts and interventions that work best in the Region should be identifi ed and tailored 26. Use of condoms, including female condoms, by to specifi c cultural and social circumstances prevail- both men and women should be promoted through- ing locally. out the society. There should be a special focus on STI clients, TB patients, commercial sex workers 20. Behaviour change communication interventions and their clients, PLWHA and their partners. should be strengthened using all opportunities of contact with various groups. These services should be youth-friendly and should also target commercial Linking HIV/AIDS prevention, treatment, sex workers. Operational research should also be care and support in an “essential package” strengthened to guide behaviour change communi- 27. A Technical Working Group should be set up to cation programmes, particularly among the most defi ne the “essential package” and develop opera- vulnerable populations. tional mechanisms for all levels. The Technical 21. It is necessary to strengthen management of sex- Working Group should include as many stakehold- ually transmitted infections (STIs) by building the ers as possible and adopt a participatory approach capacity of health-care workers to provide quality to achieving national consensus on the essential syndromic management, ensure availability of drugs, package. improve tracing and treatment of partners, promote 28. In order to effectively contribute to the imple- correct and consistent use of condoms, and strength- mentation of interventions, the essential package for en STI surveillance systems. HIV/AIDS prevention, treatment, care and support 22. Routine testing at tuberculosis (TB) clinics, STI should be defi ned as encompassing public health, units, and other inpatient and outpatient depart- education, legal and social service issues. The ap- ments can help to scale up HIV testing and counsel- proach should be decentralized and integrated with ling services. VCT services can be expanded to emphasis on delegation of authority, collaborative reach peripheral and remote health centres where activities between programmes, task shifts and ca- there is also the possibility of using mobile and satel- pacity building at the district and community levels. lite units. The use of simple techniques such as rapid 29. Existing technical policies and guidelines for the testing and working with lay providers for counsel- delivery of prevention, treatment, care and support ling and testing services has also proved successful. policies will have to be revised to embrace the 23. Implementing innovative strategies and using all essential package. The revised technical policies points of contact with pregnant women can expand and guidelines should refl ect new approaches for coverage and uptake of PMTCT interventions. increasing access to services, including task shifts. These include universal testing and counselling for pregnant mothers with an “opt out” option, rapid Increasing access by scaling up HIV testing during labour, routine offer of family implementation and adopting a national planning services to women who have been through simplifi ed public health approach antenatal care and postnatal services and who want 30. It will be necessary to develop or update nation- to avoid future pregnancies, and routine rapid HIV al plans for HIV/AIDS prevention, treatment and testing for newborns of untested high-risk mothers. care with a view to universal access. The develop- Infant feeding policies and support mechanisms ment of the plan should be based on consensus should be put in place to assist mothers in reducing among all key stakeholders. The plan should quan- the risk of HIV transmission through breastfeeding. tify resource gaps; build on existing programmes, 24. Development and implementation of appropri- resources and capacities; and defi ne the role of ate national blood transfusion policies and expansion various stakeholders. of services to the peripheral levels can strengthen 31. Simplifi ed and evidence-based methods should blood and blood products safety programmes. be adopted for the implementation of interventions. 25. Infection prevention and control measures can This ensures that fi rst-line health workers are able to be strengthened by ensuring development and use these approaches with Integrated Management implementation of policy guidelines and workplans of Childhood Illness (IMCI), Integrated Manage- on injection safety, post-exposure prophylaxis (to ment of Adolescent and Adult Illness (IMAI), TB, include services for the sexually-abused and health- malaria and PMTCT activities. For their part,

84 Accelerated actions on HIV/AIDS, malaria and tuberculosis

heath-care workers should integrate such inter- systems, including estimation and projection of re- ventions with the interim WHO clinical staging of quirements, use of information on best prices and HIV/AIDS and HIV/AIDS case defi nition for sur- suppliers. Quality control systems for generic and veillance,14 HIV testing and counselling guidelines, proprietary diagnostics and medicines should be simple and standardized antiretroviral therapy regi- strengthened. mens and enrolment guidelines, monitoring of 37. The laboratory plays a critical role in HIV/AIDS patients who are on treatment, prevention in HIV- prevention and control. Countries should ensure positive and discordant couples, and syndromic that the needs for strengthening and decentralizing management of STIs. laboratory services are adequately addressed in the 32. There is need to strengthen community partici- comprehensive implementation plan. pation as part of scaling up HIV interventions. Eve- 38. Strategic information collection and manage- ry effort must be made to encourage communities ment are important to guide the implementation of to talk about HIV/AIDS, its effect on their lives, scaling up HIV prevention, treatment, care and sup- and actions to be taken to deal with the epidemic. port programmes. Countries must develop systems They should also be engaged in activities aimed at for tracking progress of the epidemic, implementa- positive behaviour change, improving knowledge tion and outcomes of interventions, and HIV drug about treatment, and creating awareness regarding resistance. testing and counselling. Associations of PLWHA must be supported to play a leading role in facilitat- Increasing and sustaining fi nancial resources ing community participation in prevention, treatment adherence and reduction of HIV-related 39. Countries should continue to strive to achieve stigma. the Abuja Declaration target of allocating 15% of their budgets to the health sector. Additional re- Strengthening health systems to meet sources need to be mobilized from donors and de- increasing demand velopment partners for overall health system strengthening, including human resources for health 33. The leadership role of the Ministry of Health and improvement of infrastructure. Innovative (MOH) should be strengthened to include coordi- methods of mobilizing funds from the private, cor- nation, regulation, implementation, monitoring and porate sector and communities should be pursued. evaluation of activities. In accordance with the HIV/AIDS interventions should be integrated with “Three Ones” principle, appropriate mechanisms the national agendas for development and poverty for coordination of the activities of relevant MOH alleviation. Resource mobilization should consider departments and other stakeholders need to be appropriate utilization and reallocation of existing defi ned, including the specifi c and complementary resources, while strengthening the country’s capac- roles of the MOH, national AIDS councils or ity to absorb additional resources. commissions, other sectors of government, and the private and corporate sectors. 40. Member States should increase their efforts to put in place sustainable pro-poor fi nancing mecha- 34. Revitalization of district structures and capacities nisms for the provision of services.15 Countries is necessary because HIV prevention and care pro- should strengthen mechanisms for reporting and grammes are mainly implemented at district level. tracking funds in order to ensure accountability and District health teams need to be strengthened in transparency. Particular attention should be given to terms of staffi ng and skills to effectively plan, imple- mechanisms for rapid disbursement of funding to ment and monitor interventions. Linkages with peripheral levels to improve access to services. community-based organizations and civil society groups should be established at district level. 41. Existing partnerships should be strengthened and nurtured through the involvement of key stake- 35. It is imperative that knowledge and skills for key holders, including PLWHA, in programming as well interventions are integrated into pre-service and as regular sharing of information on progress. The in-service training curricula. Innovative ways for United Nations Theme Group, the International expanding training as well as retaining and motivat- Donor Groups, Country Coordinating Mecha- ing staff, especially at peripheral levels, need to be nisms, the Technical Working Group on HIV/ explored. AIDS as well as other partnership forums should be 36. To ensure availability of quality diagnostics, utilized. The momentum generated by the “3 by 5” medicines and commodities, countries will need to Initiative should be used to scale up HIV prevention improve their procurement and supply management interventions.

85 COMPENDIUM OF RC STRATEGIES

Roles and responsibilities vention efforts have not been adequate. It is imperative to renew and accelerate HIV prevention, Countries linking it with treatment, care and support, and 42. Governments should ensure stewardship and adopting clear and comprehensive strategies and leadership as well as forge partnerships with civil so- actions as set out in this document. ciety and PLWHA for developing plans and mobi- 48. The Regional Committee reviewed and adopt- lizing both internal and external resources for ed this proposed strategy along with the attached accelerating HIV/AIDS prevention, treatment, care resolution. and support interventions. Governments should also ensure effective coordination of interventions; the health sector should provide technical guidance for Resolution AFR/RC56/R3 the implementation of this health sector HIV pre- HIV prevention in the African Region: A vention strategy, within the framework of intersec- strategy for renewal and acceleration toral collaboration. The Regional Committee, 43. Countries should be responsible for implementing planned activities, monitoring and evaluating Considering that HIV/AIDS is a leading cause of programmes, and coordinating all partners. mortality in the African Region, with a disproportionate burden on young people and women; World Health Organization and other partners Alarmed that despite early signs of decline in 44. WHO will provide technical leadership and HIV prevalence in some countries, more than 3 normative guidance for developing plans of action, million new infections continue to occur annually implementing programmes, monitoring and evalua- in the African Region; tion. Bearing in mind the increasing political commit- 45. WHO and other partners will provide support ment and engagement by governments and the to countries in resource mobilization, planning (in- international community in the ﬁ ght against HIV/ cluding estimation of costs) and strengthening gov- AIDS in the African Region; ernment capacity to coordinate the activities within Encouraged by the progress made in scaling up the framework of the “Three Ones” principle. antiretroviral treatment and convinced that treatment and care offer a good opportunity for acceler- MONITORING AND EVALUATION ating HIV prevention; Cognizant of the March 2006 Brazzaville Com- 46. Global consensus has been reached on a moni- mitment on Universal Access to HIV Prevention, toring and evaluation framework for HIV/AIDS.16 Treatment, Care and Support, and the May 2006 The indicators and approaches in the framework and Abuja Call for Action by the Heads of State Special other agreed interagency indicators will guide mon- Summit on HIV/AIDS, Tuberculosis and Malaria; itoring and evaluation of this regional strategy. In- tensiﬁ ed efforts will be made to monitor the Mindful of the progress made in implementing incidence of HIV infection in order to more effec- resolution AFR/RC55/R6: Acceleration of HIV tively assess the impact of prevention interventions. prevention efforts in the African Region, adopted in Monitoring of progress in the implementation of the Maputo in August 2005; the declaration of 2006 as strategy will be carried out every two years and re- the Year for Acceleration of HIV Prevention in the ported to the Regional Committee. African Region under the leadership of the African Union; the mobilization of the UN family to support the acceleration of HIV prevention in the CONCLUSION African Region; and the steps being taken by countries to accelerate HIV prevention; 47. The impact of the HIV/AIDS epidemic has seriously undermined progress made in human devel- 1. APPROVES the document entitled “HIV pre- opment in the past decades. It has contributed to vention in the African Region: a strategy for renew- high morbidity and mortality, resulting in reduction al and acceleration”; of life expectancy, with grave social and economic 2. URGES Member States: consequences. Despite the efforts undertaken at national, regional and international levels, HIV inci- (a) to develop, adapt or revise national strategies for dence remains very high, indicating that HIV pre- accelerating HIV prevention in the context of

86 Accelerated actions on HIV/AIDS, malaria and tuberculosis

universal access to HIV prevention, treatment, 4. The Gleneagle Communiqué http://www.fco.gov. care and support; uk/Files/kfi le//PostG8_Gleneagles_Communique,0. (b) to develop operational plans for implementation pdf (last accessed 12-04-2006). of the strategy in the context of multisectoral 5. Calling attention to the impact of HIV/AIDS on the collaboration, with targets for scaling up HIV African family. Fourteenth ICASA Conference http://www.unicef.org/uniteforchildren/youth/ prevention and based on those defi ned in the youth_30394.htm (last accessed 12-04-2006). regional strategy; 6. WHO, AIDS Epidemic Update, Geneva, WHO/ (c) to ensure political leadership and coordination UNAIDS, December 2005. for implementation of the strategies and plans; 7. Impact of HIV/AIDS on Africa http://www.avert. (d) to ensure operational research on behaviour org/aafrica.htm (last accessed 12-04-2006). change in order to guide behaviour change 8. Stover J, Walker N, Garnett GP et al. Can we reverse communication programmes; the HIV/AIDS pandemic with an expanded response? (e) to commit long-term resources, with interna- Lancet, 360 (9326): 73–77, 2002. tional support, to ensure scaling up of sustainable 9. UNAIDS, Report on the global AIDS epidemic, national HIV prevention efforts; New York, Joint United Nations Programme on HIV/AIDS, 2004. 3. REQUESTS the Regional Director: 10. Anon, Coverage of selected services for HIV/AIDS prevention, care and support in low and middle in- (a) to provide technical support to Member States come countries in 2003, Washington D.C., USAID, in the development and implementation of UNAIDS, WHO, UNICEF and the POLICY health-sector-based HIV prevention strategies; Project, June 2004. (b) to advocate for more resources and help mobi- 11. UNAIDS, Report on the global AIDS epidemic, lize long-term international support for scaling New York, Joint United Nations Programme on up HIV prevention efforts; HIV/AIDS, 2004. (c) to monitor progress in the implementation of 12. WHO, Scaling up HIV/AIDS prevention, treatment the strategy and report to the Regional Com- and care: a report on WHO’s support to countries in implementing the “3 by 5” Initiative, April 2006. mittee every other year. 13. The “Three Ones” principle refers to one agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners; one national REFERENCES AIDS coordinating authority with a broad-based multisectoral mandate; and one agreed country-level 1. Resolution AFR/RC46/R2, Strategy on HIV/ monitoring and evaluation system. AIDS/STD prevention and control in the African 14. Interim WHO clinical staging of HIV/AIDS case Region. In: Forty-sixth Session of the WHO Re- defi nition for surveillance http://www.who.int/hiv/ gional Committee for Africa, Brazzaville, Congo pub/epidemiology/en/me toolkit en.pdf (last ac- 4–11 September 1996, Final Report. Brazzaville, cessed 12-04-2006). World Health Organization, Regional Offi ce for 15. WHO, The practice of charging user fees at the point Africa, 1996 (AFR/RC46/18), p.5. of service delivery for HIV/AIDS treatment and care, 2. The Millennium Development Goals Report 2005. Geneva, World Health Organization, discussion http://unstats.un.org/unsd/mi/pdf/MDG%20Book. paper, December 2005. pdf (last accessed 12-04-2006). 16. Monitoring and evaluation toolkit HIV/AIDS, TB 3. Scaling up towards universal access. UNAIDS http:// and malaria http://www.who.int/hiv/pub/epidemi- www.unaids.org/en/in+focus/topic+areas/ ology/en/me toolkit en.pdf (last accessed 12-04- universal+access.asp (last accessed 12-04-2006). 2006).

87 4.2 Tuberculosis and HIV/AIDS: A strategy for the control of a dual epidemic in the WHO African Region (AFR/RC57/10)

EXECUTIVE SUMMARY 1. The tuberculosis epidemic in the WHO African Region has reached emergency proportions. Based on recent surveillance data, the Region accounts for 25% of the global notifi ed tuberculosis cases but only 10% of the world population. During the past ten years, tuberculosis notifi cation rates have more than doubled in most countries. While the increase is widespread, it is most notice- able where HIV prevalence is high. On average, 35% of tuberculosis patients in the Region are co-infected with HIV, and tuberculosis accounts for approximately 40% of deaths in people living with HIV/AIDS. 2. Several randomized trials have demonstrated the effectiveness of joint tuberculosis and HIV/ AIDS interventions in reducing morbidity and mortality among the dually infected. Notwith- standing the recognized importance of co-infection in driving the TB epidemic as well as evidence of effective delivery of joint interventions, TB and HIV/AIDS control, programmes continue to implement control activities independent of each other. The result has been low coverage, limited access and ineffi cient use of scarce resources. 3. This strategy proposes interventions for strengthening mechanisms for collaboration; improving prevention, case-fi nding and treatment of TB among people living with HIV/AIDS; improving access to HIV testing and counselling among TB patients; infection control to reduce transmission; advocacy, communication and social mobilization; partnerships; resource mobilization; and research. 4. The Regional Committee reviewed and adopted the proposed strategy.

INTRODUCTION upon Member States to implement urgent and ex- 1. Tuberculosis cases have more than trebled in traordinary actions to bring the TB epidemic under many countries over the past 10 years,1 especially control, including scaling up TB and HIV/AIDS where HIV prevalence is high. With approximately interventions. Resolution AFR/RC55/R6 called 35% of TB patients also infected with HIV, TB and for accelerating HIV prevention interventions in HIV co-infection has become the most important countries. Earlier, African ministers of health had factor driving the TB epidemic in the African committed to the goals of the “3 by 5” Initiative and Region. universal access to antiretroviral therapy for people living with HIV/AIDS (PLWHA). 2. Recognizing the public health importance of the two epidemics, the WHO Regional Committee 3. This strategy proposes priority interventions to for Africa passed two resolutions at its ﬁ fty-ﬁ fth ses- promote and accelerate the implementation of joint sion in 2005. Resolution AFR/RC55/R5 declared activities against the two diseases, to reduce morbid- TB an emergency in the Region; it further called ity and mortality associated with TB and HIV

88 Accelerated actions on HIV/AIDS, malaria and tuberculosis

co-infection, and to improve the quality of life of provision of joint TB and HIV/AIDS interventions, people living with TB and HIV/AIDS. However, programmes for the control of the two conditions effective implementation of this strategy requires have largely been implemented independent of each multisectoral involvement, coordination, and addi- other. TB control programmes focus on implement- tional and sustainable resources. ing DOTS; HIV/AIDS control programmes tend to view TB only as one of the opportunistic infections, giving little attention to the special care needs of SITUATION ANALYSIS AND PLWHA co-infected with TB. JUSTIFICATION 9. There is increased political commitment at both Situation analysis the regional and international levels for universal access to TB and HIV/AIDS control services, includ- 4. Over one million new TB cases were reported ing joint TB and HIV/AIDS interventions. There is in 2005. With only 10% of the world population, also increased funding from the Global Fund to the African Region accounts for at least 25% of noti- 2 Fight AIDS, Tuberculosis and Malaria (GFATM) fi ed TB cases every year. Since the beginning of and other partners to scale up such interventions. 2006, evidence of increasing incidence of TB cases resistant to fi rst-line and second-line antituberculosis Justifi cation drugs have emerged in some countries in the Re- gion. By the end of 2006, all Member States were 10. To date, several randomized trials have shown implementing the recommended directly-observed the effectiveness of joint interventions to reduce TB treatment short-course for controlling TB.3 incidence and death among PLWHA. The use of cotrimoxazole and isoniazid preventive therapy and 5. Sub-Saharan Africa carries the highest burden of management of other opportunistic infections have HIV infections and HIV/AIDS-related mortality in reduced morbidity and mortality among PLWHA. the world, accounting for more than 60% of In addition, antiretroviral therapy has reduced the PLWHA. Approximately three quarters of women incidence of tuberculosis by more than 80% in and nearly 90% of children living with HIV/AIDS PLWHA.6 are in this Region. 11. While the negative effect of dual TB-HIV infec- 6. In HIV-infected persons, the virus promotes tion is known, and the positive impact of joint inter- progression of active TB if there is latent or recent- ventions has been shown, TB and HIV/AIDS ly-acquired Mycobacterium tuberculosis infections. At a control programmes have largely been implemented pathological level, TB accelerates the development independently. This has limited access to available of AIDS among people living with HIV and is a effective interventions for the dually-infected and defi ning condition for AIDS. In some countries, resulted in ineffi cient utilization of scarce resources. especially in southern Africa, HIV prevalence among TB patients is as much as 70%, and TB is responsible 12. Effective TB and HIV/AIDS control must nec- for at least 40% of deaths of PLWHA in the Region.4 essarily include delivery of interventions to address the dual epidemic. TB patients must have ready 7. Coverage with key TB and HIV/AIDS inter- access to HIV/AIDS prevention, care and support ventions is still unacceptably low in the Region. In interventions; likewise, PLWHA must have access 2005, between 2% and 50% of TB cases were being to TB prevention, care and support interventions. tested for HIV, and less than 10% of eligible dually- infected TB patients were accessing antiretroviral 13. This strategy emphasizes the importance of the treatment. Just over 50% of dually-infected HIV dual TB and HIV/AIDS epidemic and will facilitate patients were accessing cotrimoxazole prophylactic the scaling up of available effective interventions to therapy while less than 10% of PLWHA were improve the quality of life of the dually-infected. screened for active TB. Overall, antiretroviral therapy coverage in sub-Saharan Africa is approximately THE REGIONAL STRATEGY 28% (24%–33%). By the end 2005, among the general population, the median percentages of men and General objective women who had been tested for HIV and had re- 5 14. The aim of this strategy is to contribute to the ceived the results were 12% and 10%, respectively. reduction of morbidity and mortality associated 8. Despite the known negative synergistic inter- with TB and HIV co-infection in the Region by action between the two infections and evidence of ensuring universal access to TB and HIV/AIDS reduced morbidity and mortality through the interventions as guided by the Stop TB strategy.

89 COMPENDIUM OF RC STRATEGIES

Specifi c objectives as developing joint TB and HIV plans of action. In order to establish the basis for collaboration, it is 15. The specifi c objectives are: necessary to develop a comprehensive package of (a) to provide a framework for planning, organiz- interventions as well as technical guidelines and ing, implementing, monitoring and evaluating tools to deal with co-infection. All stakeholders and delivery of joint TB and HIV/AIDS interven- care providers in the public and private sectors need tions; to be sensitized and trained to support delivery of all (b) to promote the provision of TB and HIV/AIDS collaborative interventions. prevention, care and support services as an integral part of a comprehensive package of care for Improving prevention, case-fi nding and dually-infected persons; treatment of TB among PLWHA (c) to provide a platform for advocacy to control the TB and HIV dual epidemic; 19. Reducing the burden of tuberculosis among (d) to enhance intersectoral collaboration and part- PLWHA is one of the critical pillars of this strategy. nerships for dual TB and HIV/AIDS control; This could be achieved through intensifi ed tubercu- (e) to promote universal access to TB and HIV losis case-fi nding among PLWHA to identify and services. treat those with active TB, while providing isoniazid preventive therapy and other methods for Guiding principles PLWHA without active TB. 16. Implementation of the strategy will be guided by the following principles: Improving access to HIV testing and counselling among TB patients (a) Equitable access to TB and HIV/AIDS interventions includes deliberate targeting and inclu- 20. This strategy is for improving HIV testing and sion of all vulnerable groups. counselling among TB patients. This can be achieved (b) National ownership and leadership of the strat- by offering routine HIV testing and counselling as egy and implementation process should be an entry point, with an opt-out option, for all TB country-owned and managed to ensure harmo- patients and for continuum of HIV/AIDS care and nization and sustainability. support for dually-infected TB patients. Other serv- (c) Partnership and collaboration involve all sectors, ices include interventions to prevent new HIV in- including the civil society and communities at all fections, reduce HIV transmission, offer prophylactic stages of programme development and imple- therapy for other opportunistic bacterial infections mentation to increase acceptability of interven- and provide antiretroviral drugs for eligible dually- tions, expand access to services, and broker infected TB patients to reduce viral load. additional human and fi nancial resources for programme implementation. Infection control to reduce transmission Priority interventions 21. Infection control measures must be implemented as an integral part of joint TB/HIV interventions. 17. The key interventions are aimed at strengthen- Special attention should be given to preventing cross ing collaboration between the two control pro- transmission of multidrug resistant and extensively grammes; improving prevention, case-fi nding and drug resistant TB to vulnerable PLWHA and other treatment of TB among PLWHA and vulnerable high-risk groups such as prisoners and refugees. This populations such as prisoners; and improving access could be facilitated where possible by patient triage, to HIV testing and counselling among TB patients. physical separation (isolation and barrier nursing), The proposed actions are recommended for all areas environmental engineering of facilities, and improv- where HIV prevalence among TB patients exceeds ing patient compliance to TB treatment to prevent 5%, and are to be carried out within the context of acquired drug resistance. existing TB and HIV/AIDS control programmes.

Strengthening mechanisms for collaboration Contributing to health systems strengthening 18. It is necessary to develop improved mechanisms 22. Health systems strengthening is a component for collaboration between TB and AIDS control of the Stop TB strategy. Strengthening of human programmes. This could be facilitated by setting up resources for health, laboratory infrastructure and joint coordinating bodies at operational level as well medicines supply and management are major

90 Accelerated actions on HIV/AIDS, malaria and tuberculosis

contributions of TB control programmes to health Roles and responsibilities systems strengthening. The innovations in TB serv- Countries ice delivery within general health services need to be documented and shared. The ongoing work by 27. Countries should allocate funding for priority WHO on development of documents and tools to interventions to promote universal access to TB and support active engagement of national tuberculosis HIV/AIDS services. Specifi c roles and responsibili- programmes in health systems strengthening should ties for countries are: development and implementa- be accelerated and guidance should be provided to tion of advocacy and social mobilization activities, Member States. and short- and medium-term action plans for controlling the dual TB and HIV epidemic; development and adaptation of tools and technical guidelines; Advocacy, communication and social mobilizing both internal and external resources for mobilization implementation of activities; monitoring and evalu- 23. In order to promote popular support for imple- ation of programme implementation and impacts; mentation of the activities, there is need to create coordination of collaborating partners; and develop- community and health care worker awareness and ment of national partnerships for the delivery of TB, sensitization to the importance of TB and HIV co- HIV/AIDS and joint TB-HIV/AIDS activities. infection. This could be facilitated through implementation of targeted advocacy, communication WHO and other partners and social mobilization strategies for TB and HIV 28. The strategy envisages the following roles and control. responsibilities for WHO and other partners: support of national programmes to promote effective Partnerships and resource mobilization control of TB, HIV/AIDS and dual TB-HIV infections; provision of technical support to countries to 24. Mobilization of additional fi nancial and other develop or adapt tools and national guidelines, pro- resources is critical for meaningful scaling up of the gramme implementation, monitoring and evalua- proposed interventions. While donor funding is an tion; and support to countries in resource option to increase the resource envelope, allocation mobilization and strengthening health delivery sys- of suffi cient national resources and inclusion of TB/ tems. WHO should identify and support centres of HIV interventions within national development excellence, particularly for MDR and XDR TB, plans are crucial to ensure sustainable resources. and develop a strategy for resistant TB strains. Support can be elicited by submitting grant applica- tions to funding agencies such as the Global Fund to Resource implications Fight AIDS, Tuberculosis and Malaria; the Bill and Melinda Gates Foundation; and other bilateral and 29. According to WHO and the International Un- multilateral donor partners. ion against Tuberculosis and Lung Disease, it costs about US$ 5–10 to screen one case for TB, US$ 17 25. It is equally important to enhance the capacity of to treat one uncomplicated TB case, and about US$ collaborating partners to deliver joint interventions 2000 to treat one case of multidrug resistant TB. through decentralization of decision-making proc- UNAIDS estimates that one HIV test costs approxi- esses and delivery of services. This could be achieved mately US$ 2, and antiretroviral therapy for one through increased community and civil society par- year costs US$ 130–300 per patient. Thus a mean- ticipation as well as public-private partnerships in ingful scaling up of interventions to control the TB- the delivery of identifi ed services. HIV/AIDS dual epidemic will require an increased level of fi nancial resources on a sustainable basis. Research 30. Additional resources are required to cater for the 26. Ongoing clinical and other research for better increased numbers of people who will require test- understanding and evaluation of the impact of inter- ing and counselling for HIV, screening for TB and ventions is an important element of programme correct management of dual infections. implementation. This could be done through promoting close collaboration with national research MONITORING AND EVALUATION institutions and researchers to carry out operational research useful for TB and HIV/AIDS prevention 31. In order to monitor and evaluate implementa- and control. tion of the proposed joint TB and HIV/AIDS

91 COMPENDIUM OF RC STRATEGIES

interventions, the following indicators will be mon- 33. The strategy calls for joint delivery of services in itored according to locality, age group and sex: order to accelerate the scaling up of interventions for TB and HIV/AIDS towards universal access and (a) proportion of target population with defi ned to maximize on scarce resources and health impacts. geographical access to joint TB and HIV/AIDS services; 34. The Regional Committee reviewed and adopt- (b) proportion of eligible HIV-positive TB patients ed the proposed strategy. accessing core HIV/AIDS services, including antiretroviral therapy; REFERENCES (c) HIV/AIDS-related mortality among TB pa- 1. WHO, Tuberculosis surveillance report, Brazzaville, tients, and TB-related mortality among AIDS World Health Organization, Regional Offi ce for patients; Africa, 2005. (d) proportion of PLWHA screened for active TB 2. WHO, Tuberculosis surveillance report, Brazzaville, and proportion of PLWHA with active TB World Health Organization, Regional Offi ce for accessing effective TB treatment; Africa, 2006. (e) tracking of MDR and XDR TB. 3. WHO, Interim policy on collaborative TB/HIV activities, Geneva, World Health Organization, 2004. 4. WHO, Interim policy on collaborative TB/HIV acti- CONCLUSION vities, Geneva, World Health Organization, 2004. 5. WHO, UNAIDS, UNICEF, Towards universal access: 32. HIV co-infection is the most important risk Scaling up priority HIV/AIDS interventions in the health factor for increased TB incidence in the African sector, Progress Report, Geneva, World Health Organi- Region. At the same time, TB is the commonest zation, 2007. cause of death among PLWHA. Interventions to 6. Badri M, Wilson D, Wood R. Effect of highly active reduce the impact of the dual epidemic exist but are antiretroviral therapy on incidence of tuberculosis in currently delivered independently by separate con- South Africa: a cohort study, The Lancet, 359: 2059– trol programmes. The result is limited access to serv- 2064, 2002. ices; missed opportunities for diagnosis, treatment and care; reduced effectiveness; and ineffi cient use of resources.

92 Strategic Direction 5 Intensifying the prevention and control of communicable and non-communicable diseases

5.1 Integrated disease surveillance in the WHO African Region: A regional strategy for communicable diseases (1999–2003) (AFR/RC48/8)

EXECUTIVE SUMMARY 1. In September 1993, through resolution AFR/RC43/R7, the Regional Committee approved the proposed steps for strengthening epidemiological surveillance at various levels of the health system, including organization of training activities at district level. Furthermore, the Com- mittee declared the next ﬁ ve years as a period for preventing and combatting epidemics of communicable diseases in Member States, through improved epidemiological surveillance at district level. 2. Despite the increasingly important role of disease surveillance in planning, resource allocation and mobilization, and for early detection of, and response to epidemic outbreaks as well as for quantifying the impact of disease prevention and control programmes, the existing system in many Member States is not producing the required relevant information. 3. Currently, the dysfunction in disease surveillance systems in most Member States is causing failure to detect epidemic outbreaks, resulting in diseases spreading, human suffering and loss of lives. Among other things, weaknesses in data collection, analysis, and use of information for action at all levels, lack of resources and lack of awareness on the usefulness of the system are some of the reasons for the weak surveillance system. 4. Consequently, the Regional Director proposes that each Member State should strengthen its disease surveillance system, following an integrated approach, the details of which are presented in this document. 5. The Regional Committee reviewed and adopted this strategy.

INTRODUCTION epidemics and monitoring and evaluation of disease 1. Communicable diseases remain the major health prevention and control programmes. The current problem in Africa. The commonest causes of death disease surveillance systems are neither working ef- and illness in the Region are acute respiratory infec- fectively to measure the health impact of dominant tions, diarrhoeal diseases, malaria, tuberculosis, diseases nor adequately evaluating current disease HIV/AIDS/STIs, and vaccine preventable infec- control programmes, not to mention detecting tions. Epidemic-prone diseases such as meningococ- outbreaks for early intervention. cal meningitis, cholera, yellow fever and viral 3. Because of the above, the Regional Ofﬁ ce pro- haemorrhagic diseases, especially Lassa fever and poses to strengthen national disease surveillance sys- Ebola virus fever, are also dominant health threats in tems using an integrated approach. This approach the continent. aims to coordinate and streamline all surveillance 2. A functional disease surveillance system is useful activities and ensure timely provision of surveillance for priority setting, planning, resource mobilization data to all disease prevention and control pro- and allocation, prediction and early detection of grammes. As part of the strengthening process, the

95 COMPENDIUM OF RC STRATEGIES

Regional Offi ce plans to develop guidelines for a veillance, prevention and control of diseases in comprehensive, integrated surveillance system for general and of epidemics in particular and to the community level, health facility level, the dis- support Member States in the formulation of trict and national levels, and at the Regional Offi ce simple and effective measures for the surveil- itself. lance and control of communicable diseases. (vi) Resolution AFR/RC38/R13, of September 4. This strategy describes the need for strengthen- 1988, calling on all affected Member countries ing the disease surveillance system and suggests to intensify national surveillance of dracuncu- the approach that Member States may adopt in the liasis and report regularly to WHO, and urging strengthening process for the next fi ve years (1999– the Regional Director to intensify regional 2003). surveillance of trends. (vii) Resolution AFR/RC43/R7, of September JUSTIFICATIONAND POLICY BASIS 1993, approving the proposed steps for strengthening epidemiological surveillance at 5. The policy basis for strengthening the surveil- various levels of the national health systems, lance system of communicable diseases emanated including the organization of training activities from the following resolutions of the World Health at district level and declaring the next fi ve Assembly and Regional Committee meetings: years as a period for preventing and combatting epidemics of communicable diseases in (i) Resolution WHA22.47, July 1969, requesting Member States, through improved district- the Director-General to assist Member States level epidemiological surveillance. in utilizing their existing services to perform epidemiological surveillance as effectively as possible. Major problems (ii) Resolution WHA41.28, May 1988, declaring 6. A review of national surveillance systems in the commitment of WHO to the global eradi- selected Member States helped to identify the cation of poliomyelitis by the year 2000 and following problems: urging all Member States to intensify surveillance to ensure identifi cation, investigation (i) Vertical surveillance systems established as a and accurate and timely case reporting at component of different disease control pro- national and international levels. grammes have resulted in duplication of efforts (iii) Resolution WHA48.13, 12 May 1995, urging and resources, with different programmes Member States to strengthen national and local approaching the same agency for funding for programmes of active surveillance for infec- surveillance activity. tious diseases, ensuring that efforts are directed (ii) Health workers fail to report on time the fi rst to early detection of outbreaks and prompt cases of epidemic-prone diseases that fi t stand- identifi cation of new, emerging, and re- ard case defi nitions. This delay in reporting the emerging infectious diseases. It also requested earliest suspected cases signifi cantly retards the the Director-General to draw up plans for im- identifi cation of outbreaks and impedes the proved national, regional and international effectiveness of response. surveillance of infectious diseases and their (iii) Collection, analysis and dissemination of sur- causative agents as well as plans for accurate veillance data at the district level have been laboratory diagnosis and prompt dissemination inadequate. For the most part, surveillance of case defi nition and surveillance information, data are passed without adequate analysis from and to coordinate the implementation of these the district level to the national level. Feed- plans by Member States, agencies and other back has also generally been inadequate at groups. every level. (iv) Resolution AFR/RC38/R9, of September (iv) Little attention has been given to seeking 1988, urging Member States to strengthen the opportunities to integrate surveillance activi- epidemiological surveillance of HIV/AIDS ties and increase effi ciency. As a result, each and to report regularly to the Organization on programme organizes programme-specifi c the situation. training courses (including courses on surveil- (v) Resolution AFR/RC38/R34, of September lance) for the same health personnel, especially 1988, requesting the Regional Director to col- at the district and health facility levels. laborate with Member States in evaluating the (v) The system does not include pneumonia and potential capabilities of Member States for sur- diarrhoeal diseases, which are the number one

96 Intensifying the prevention and control of communicable and noncommunicable diseases

and two causes of childhood death in Africa. demics as well as the monitoring and evaluation Surveillance of malaria is also defi cient. Infor- of intervention programmes; mation collected is inadequate for diseases (iii) introduction of two sets of case defi nitions to with highly effective intervention or large out- facilitate case detection by health facilities and break potential and whose case load is relative- the community respectively. ly low. (vi) Inadequate attention has been given to evalu- Development of integrated disease ating programmes, using surveillance data. surveillance systems Large quantities of resources are being put into inadequately evaluated interventions. 11. The need to strengthen the surveillance system, (vii) Laboratory involvement in the surveillance using the integrated approach, stems from the fol- system is inadequate. Neither national nor lowing common actions, which should be under- inter-country laboratory networks have been taken in a coordinated manner: established to carry out important public health (i) building awareness among clinicians (physi- functions, including the confi rmation of cases cians and nurses attending patients) regarding and outbreaks when clinical diagnoses cannot the use of case defi nitions and actions, speci- be specifi c. men collection and timeliness of reporting; (viii) Supervisory support, completeness and timeli- (ii) initiating case-based surveillance for selected ness of reporting are generally inadequate. diseases, including neonatal tetanus, haemorrhagic fever, yellow fever, and for diseases with highly effective intervention or large outbreak Strengthening disease surveillance systems: potential whose case load is relatively low; An integrated approach (iii) strengthening health personnel skills and prac- 7. Currently, different intervention programmes tices regarding all components of surveillance have their own disease surveillance systems and are (particularly analysis and dissemination of sur- making efforts to strengthen them in order to get veillance data) at the district, intermediate and regular and timely surveillance data. national levels through integrated in-service training and supervisory support; 8. The WHO Regional Offi ce for Africa proposes (iv) establishing or strengthening feedback loops at to all Member States to adopt the integrated ap- all levels; proach for strengthening surveillance systems. This (v) building the capacity of the laboratories and approach envisages integration of all surveillance strengthening their involvement in supporting activities (collection, analysis, interpretation and dis- the disease surveillance system; semination of surveillance data) at district level. All (vi) monitoring of surveillance activities including the support for implementing the integrated disease timeliness and completeness of reporting. surveillance system, including training, supervision, resources (fi nancial and material) from all programmes and donors, will be assigned to the dis- THE REGIONAL STRATEGY FOR tricts. INTEGRATED DISEASE 9. At the central level, all support for the imple- SURVEILLANCE mentation of integrated disease surveillance systems Long-term vision will be coordinated by the surveillance unit. Data management for routine surveillance will also be 12. Within ten years, all Member States will have performed by the same unit, while specialized analy- established a functional integrated disease surveil- sis could be left to the concerned intervention pro- lance system that ensures continuous and timely grammes. provision of information to all national programmes for disease prevention and control as well as to 10. As part of the implementation of the strategy, health services at all levels. With adequate surveil- the Regional Offi ce is suggesting the following to lance data, there will be improved prediction and Member States for consideration: control of epidemics, enhanced quality of planning, (i) a list of priority diseases for the integrated rational allocation of resources and improvement in disease surveillance system; monitoring and evaluating the feedback loop. This (ii) minimum data (total case and death counts) for will result in a reduction in disability, morbidity and reporting to enable the monitoring of epide- mortality attributable to major communicable dis- miological trends and early detection of epi- eases.

97 COMPENDIUM OF RC STRATEGIES

Guiding principles (ii) Completeness of reporting means that all reporting requirements have been met, includ- 13. The basis for the integrated disease surveillance ing reporting on diseases selected for system is “data collection for action”, implying that surveillance from all reporting units, while only data necessary for taking action is collected and timeliness refers to the receipt of data on or processed. This will be achieved and sustained by before the due date. Indeed, failure to make complying with the overall guiding principles of information available on time retards public usefulness, simplicity and fl exibility of the health action. system; action-specifi c orientation and inte- (iii) Specifi city refers to the ability of the system to gration. be specifi c in detecting those cases without ob- (i) Usefulness refers to the applicability of the data vious symptoms. It refers to the proportion of to programme management (monitoring dis- persons without visible disease conditions who ease trends, detecting or predicting epidemics, are correctly identifi ed through a case defi ni- quantifying the impact of intervention pro- tion as having the disease. grammes, etc.). The current system ensures (iv) Sensitivity refers to the ability of the system to that only data that aid public health decision- detect a disease or an outbreak, be it epidemic making and action will be collected. or other changes in disease occurrence. It re- (ii) Simplicity is the ease of putting the system into fers to the proportion of persons with disease operation. The watch words of integrated correctly identifi ed through case defi nition as disease surveillance are “keep the system as having the disease. simple as possible” (case defi nition, types of data to be reported, reporting tools and Strategic framework procedures, etc.). The simpler the system the more likely the compiling of the reporting Strategic objectives forms by clinicians and health workers and 15. The strategic objectives of the integrated disease their timely transmission to the next higher surveillance system are: level. (iii) Flexibility of the system refers to adaptability (i) to design an integrated disease surveillance sys- to changes in information needs and opera- tem that includes: (a) an index of the principal tions (revision of lists of priority diseases, case causes of disability, morbidity and mortality in defi nitions, and reporting) with little addition- Africa, (b) case-based reporting on selected al personnel, time and fi nancial resources. The diseases; and (c) the enhanced use of standard current approach is designed to be as fl exible as case defi nitions for notifi cation. possible. (ii) to integrate all surveillance activities, including (iv) Action-specifi c orientation in the context of transportation of specimens, training of health integrated disease surveillance refers to making personnel on surveillance and provision of su- information available to specifi c intervention pervisory support to the districts and health programmes for action. facilities. (v) Integration refers to the coordination of all (iii) to strengthen surveillance data management surveillance activities common to all control (collection, analysis, interpretation and dis- programmes (data collection, processing and semination) and the use of surveillance data dissemination, training, supervision, monitor- and outcomes for decision-making and the ing and evaluation of the surveillance system, monitoring and evaluation of intervention etc.). Specifi c follow-up action is left to the programmes. different intervention programmes. (iv) to strengthen the capacity and involvement of laboratories in surveillance activities. 14. Other attributes of the surveillance system include acceptability and reliability of data, timeli- Targets ness and completeness of reporting, sensitivity and 16. The country targets for the integrated disease specifi city. surveillance system are: (i) Acceptability refl ects the willingness of indi- (i) By the end of 1999: viduals and organizations to participate in a (a) 80% of the Member States will have as- surveillance system. Reliability of data refers to sessed their national surveillance system as the accuracy and quality of data made available part of the implementation of the regional through the system. strategy;

98 Intensifying the prevention and control of communicable and noncommunicable diseases

(b) 80% of the Member States will have country at all levels, the supply of recommended ba- formed a central body to coordinate all sic laboratory equipment for specifi c levels and surveillance activities; spheres of activities and the fostering of in-service (a) a surveillance unit will have devel- training of laboratory personnel in relevant labora- oped at the WHO Regional Offi ce tory techniques. In addition, strengthening existing level to coordinate all disease surveil- laboratory facilities, concentrating on simple, cost- lance activities. effective techniques for rapid diagnosis and estab- (ii) By the end of 2003: lishing a referral laboratory network by defi ning the (a) all Member States will have assessed their appropriate laboratory activity for different levels, national surveillance systems as part of the are the key steps in strengthening the process. It is implementation of the regional strategy; envisaged that viable referral channels for samples (b) all Member States will have formed central and results and the safe handling of specimens during bodies to coordinate all surveillance storage and transportation will be assured. activities; (c) all Member States will have had functional Antimicrobial resistance and integrated disease surveillance systems. 20. An increase in antimicrobial resistance in the last Major thrusts few years has affected the treatment and control of important diseases, leading to prolonged illnesses Priority diseases or syndromes for integrated and epidemics and increased case fatality. Therefore, disease surveillance data will be collected from sentinel laboratories in 17. The Regional Offi ce has suggested 18 (eight- order to document resistance patterns relating to een) communicable diseases or syndromes for malaria, tuberculosis, S. dysentriae, chancroid, gon- integrated disease surveillance. Member States are orrhea, pneumonia (S. pneumoniae, H. infl uenzae). expected to adapt the list to suit their local epidemiological profi les, taking into consideration Data Management national, regional and international perspectives. 21. Surveillance data management includes the col- 18. The suggested list of diseases or syndromes and lection, collation, analysis and interpretation of sur- their grouping includes: veillance data and the dissemination of information (i) Epidemic-prone diseases to those who take action or prepare the report. Cholera, Bacillary dysentery, Plague, Measles, Yellow fever, Meningococcal meningitis, Viral Data collection haemorrhagic fever (ii) Diseases targeted for eradication 22. Only basic information on selected priority dis- Dracunculiasis, Poliomyelitis eases is collected for routine programme monitoring (iii) Diseases targeted for elimination and evaluation at all levels. However, health facilities Neonatal tetanus, Leprosy are expected to record all necessary information re- (iv) Other diseases of public health import- garding individual cases, for future use. For routine ance surveillance, monthly recording of the total number Diarrhoea (in children under 5), Pneumonia of cases and deaths, (including “zero reporting”) for (in children under fi ve), HIV/AIDS, all the selected diseases is recommended, using an STIs, Malaria, Trypanosomiasis, Tuberculosis appropriately designed reporting format. However, each Member State will determine the minimum Involvement of laboratories in surveillance surveillance data required for national level use. Table 1 shows sources of surveillance data by disease 19. In resolution AFR/RC43/R7, Member States and periodicity of reporting. were urged to develop well-staffed and equipped laboratory services as a step toward the strengthen- 23. For epidemic-prone diseases, there is need to ing of their disease surveillance systems. The major maintain immediate notifi cation upon suspicion or role of a laboratory in the integrated surveillance diagnosis followed by weekly reporting during the system is to provide on time and reliably the confi r- epidemic period. In addition, the normal functions mation of suspected cases. The laboratory will also of the other supplemental surveillance systems such essentially monitor drug resistance and changes in as laboratory-based surveillance for antimicrobial re- the strains of disease agents. This calls for a thorough sistance, case-based or sentinel-based surveillance assessment of the current diagnostic capacity of each for other selected diseases will continue unchanged.

99 COMPENDIUM OF RC STRATEGIES

Table 1: Sources of surveillance data by disease and Decisions for action periodicity of reporting 27. A decision to take action follows data analysis Sources of and interpretation. The specifi c action will depend surveillance data Disease Periodicity on the causes of the problem, types of diseases and level of structures. Health facility and district Routine reports All diseases Monthly health team personnel are expected to take immedi- Epidemic reports cholera, cerebrospinal Immediately, ate action without necessarily waiting for approval meningitis, yellow then weekly from the higher level. The approach is to identify fever, plague, malaria, possible solutions for each problem identifi ed viral haemorrhagic during data analysis and interpretation and to take fever, measles necessary action as promptly as possible, at each Case-based reports neonatal tetanus, as it occurs, level. poliomyelitis, immediately dracunculiasis Communication Network Sentinel site malaria (drug monthly/ 28. Communication of surveillance data from the reports resistance), HIV quarterly/ health facility level right to the national and inter- sero-prevalence annually national levels and back to the community level (in the form of feedback loops) is important. In this connection, the means of communication used to transmit the information plays a vital role. In order to ensure timely receipt of surveillance data, the fast- est means of communication should be used as appropriate, including e-mail, telephone, fax and 24. The district health offi ce compiles all reports radio communication. The recommendation is that from health facilities and sends them to the national transmission of surveillance data: (a) from the health level. The national level compiles all reports and facility to the district health offi ce (DHO) could be sends them to the WHO country Offi ce, which will by telephone or radio; (b) from the DHO to the eventually send them to the Regional Offi ce. national level could be by telephone, radio, fax or e-mail; (c) from the national level to the WHO Data analysis and interpretation country Offi ce could be by e-mail or diskettes; and (d) from the WHO country Offi ce to WHO Epide- 25. Data analysis and interpretation are critical at all miological Block and the Regional Offi ce could be levels, especially at the health facility and district lev- by e-mail. Consequently, it is planned that every els. At the district level, a continuous and systematic WHO country Offi ce will have e-mail. collation and analysis of all data derived from the lower level should help to keep track of the disease situation in the area. Data interpretation is equally Strategic orientations emphasized in the integrated approach and should Capacity building be practised at all levels, particularly at the health facility and district levels. 29. Strengthening disease surveillance systems, using the integrated approach, involves: Dissemination of information (i) orientating and re-orientating intensifi ed in- 26. Distribution of information to those who are re- service training at all levels, using appropriate sponsible for taking action (programme managers) training materials, and targeting in particular or using the information for managing intervention the district health team and attending physi- programmes (programme staff) is an important, but cians and nurses; often neglected, component. Community leaders (at (ii) establishing a focal point or organ for coordi- community level), administrators, police, staff of nating the integrated disease surveillance ac- other sectoral and nongovernmental agencies (at dis- tivities at all levels, particularly at the national trict and national levels) are important players. Feed- level; back to those who generate the information (health (iii) placing systems for computerized data man- care providers) and those who transmit the reports agement at central and intermediate levels to the next higher level (intermediate health agen- and simple data presentation tools (tables and cies) will be strengthened. graphs) at district level;

100 Intensifying the prevention and control of communicable and noncommunicable diseases

(iv) establishing inter-country collaboration and At health facility level networking to exchange information on dis- 34. The fi rst opportunity for disease surveillance eases of interest at international level; occurs at this level when the clinician at the health (v) establishing effi cient communication networks facility sees the patient. At this level, clinicians will within the country for prompt reporting; and identify priority diseases, using case defi nition. Tasks (vi) building the capacity of laboratories, including at health facility level comprise: that of networks at national and regional levels. (i) diagnosing and managing cases; Promotion of integrated surveillance systems (ii) responding promptly to any epidemic alert by community leaders; 30. Integrated surveillance systems will be promoted (iii) submitting monthly summary reports and at all levels (community, health care providers, weekly reports during outbreaks; health authorities, including decision and policy- (iv) collecting specimens (if needed) and sending makers) in order to create well informed groups them to the district health offi ce (DHO); with an enhanced sense of responsibility, urgency (v) preparing tables and graphs and displaying and ownership regarding the activity and to ensure derived data for monitoring the trends of dis- maximum cooperation. This could be done through eases; and sensitization meetings, training workshops on inte- (vi) using available data to initiate action at the grated disease surveillance, advocacy campaigns, local level. using different media channels, and surveillance activity or programmatic interventions. District level Promotion of operational research 35. At this level, continuous analysis of surveillance data from the health facility is carried out in order to 31. Surveillance promotes research by identifying recognize outbreaks or changes in disease trends. research issues and generating hypotheses, which are This analysis is linked to responses from the investi- picked up by researchers as research issues. The gations; the required interventions could also be fi ndings of these research efforts could be used to assessed using the same data sources. Tasks at district modify and fi ne-tune control programmes. level comprise: Implementation framework (i) analysing surveillance data from the peripheral level in order to identify epidemiological links At country level and trends, and to achieve control targets; 32. The community, health care providers, and (ii) providing support for specimen transportation health care agencies (at district, provincial and na- to the laboratory network for diagnosis or tional levels) are key players in integrated disease confi rmation of suspected cases; surveillance. Activities and tasks for each level are (iii) initiating investigation of suspected outbreaks; outlined below. Those Member States with provin- (iv) providing feedback to the health facility level; cial or regional structures could adapt the activities and to those levels since the functions are essentially the (v) sending to the central level monthly summary same. reports on selected diseases and outbreaks. 33. At the community level, community leaders or Central level health workers with instructions on how to recognize certain disease conditions could be used as con- 36. By supporting the district level, the central level tact persons in the community for the purpose of plays a key role in ensuring the proper functioning detecting and reporting suspected cases to the health of the system. Analysis of overall disease trends is facility. Tasks at community level comprise: carried out continuously. The central level liaises with countries and international agencies to ex- (i) notifying the nearest health facility of the oc- change information and mobilize resources. Tasks at currence of the cases selected for community- central level comprise: based surveillance; (ii) supporting health workers during case or out- (i) providing overall support and coordinating break investigation; national surveillance activities, including prep- (iii) using feedback from health workers to take ac- aration of the national plan of action; tion, including action for health education, (ii) coordinating timely transportation of speci- and to coordinate community participation. mens to the national reference laboratory, if

101 COMPENDIUM OF RC STRATEGIES

such service is only available at national level, Prevention and Control Division, in collaboration and to regional or international reference labo- with intercountry epidemiologists. The Task Force ratories and notifying the results; for Emerging and Re-emerging Communicable (iii) analysing data from the district level in order Diseases can play an advisory role; a subcommittee to identify epidemiological links, trends and to for surveillance could also be set up. The Regional achieve control targets; Offi ce will support the WHO teams in the epide- (iv) providing feedback to district level, possibly miological blocks to coordinate the intercountry the health facility and, through them, the meetings. community; (v) reporting to the WHO country Offi ce; and Partnerships (vi) preparing national reports on the epidemiological situation. Actors and areas of collaboration 40. Collaboration and partnerships of all potential At the WHO country Offi ce partners at all levels will be further strengthened in 37. At country level, the WHO country Offi ce will all Member States in order to ensure better imple- be working closely with the Ministry of Health and mentation of the integrated disease surveillance liaising with WHO Epidemiological Block Teams strategy. The main actors and areas of collaboration and the Regional Offi ce. Tasks at the WHO coun- are summarised in Table 2. try Offi ce will also comprise: Managerial framework (i) providing technical support to the Member State to make initial assessment of the national Resource mobilization disease surveillance system, train personnel in- Financial and material resources volved in surveillance, and prepare the national plan of action; 41. Resources will be required to support training, (ii) providing resource materials such as training strengthen communication and laboratory networks modules, guidelines and manuals; and put in place data processing equipment. Gov- (iii) mobilizing resources to enhance the strength- ernments are expected to mobilize local resources to ening process; and keep the system going. Governments will also have (iv) providing feedback and disseminating data, to look for additional funds from partners to cover whenever necessary, in accordance with initial costs. The Regional Offi ce will play a major WHO’s mandate to monitor the cross-border role in mobilizing resources both from within and movement of infectious diseases. outside the Region to ensure the implementation of the integrated disease surveillance system. Intercountry and regional levels Human resources Intercountry level 42. The staff required to implement the strategy will 38. At the intercountry level, it is necessary to estab- be mobilized by the governments. WHO will pro- lish mechanisms for the exchange of experiences and vide technical support to the ministries of health to information on diseases among neighbouring coun- build national expertise for ensuring sustainable sys- tries, especially on cross-border movements of in- tem development. fectious diseases. Therefore, countries in each WHO epidemiological block are encouraged to organize regular meetings for the exchange of information Coordination and for discussions on issues concerning the inte- 43. Coordination mechanisms will be set up under grated approach. Meetings of district health teams the leadership of the ministries of health to support along common borders should also be organized. the implementation of the integrated disease surveil- WHO teams in the epidemiological blocks should lance strategy. Coordination of activities instead of take the lead to arrange such meetings. This should structures will be the focus of the strategy. be in close collaboration with sub-regional agencies, the WHO country offi ces and ministries of health. At district level

Regional level 44. District health management committees could be entrusted with the responsibility of coordinating 39. At the regional level, the implementation of the the integrated disease surveillance system. District strategy is coordinated by the Integrated Disease health managers are expected to assume leadership as

102 Intensifying the prevention and control of communicable and noncommunicable diseases

Table 2: Actors and areas of collaboration by level

Level Actor Area of collaboration Community Community leaders Notifi cation of suspected epidemic-prone diseases, based on case defi nition. District Other governmental sectors Use of their communication facilities; Notifying rumours and assisting investigation. NGOs and private practitioners Reporting diseases under surveillance; Logistics support /transport facilities. Central Other government agencies Participating in the central coordinating body. NGOs and UN agencies Participating in the central coordinating body; Mobilizing and allocating resources. Intercountry WHO teams in the Epid. Block: Exchange of information, intercountry coordination – epidemiologists; and provision of technical support. – laboratory experts; Subregional agencies Regional Regional Offi ce, Same as above. – *IDPCD. and other technical units; – Other divisions and appropriate units; Regional bodies (OAU) WHO collaborating centres

*IDPCD = Integrated Disease Prevention and Control Division secretariats of the committees, and to coordinate the oped to ensure the quality of the surveillance sys- partners at the district level (including community tem. This will be done through supportive representatives). Technical advisory committees, supervision and regular review meetings. Relevant chaired by district health managers, could be estab- indicators will be developed as part of the Integrated lished to provide support on technical matters. Surveillance Guidelines.

At country level CONCLUSION 45. All potential partners (other sectoral structures 47. A strong disease surveillance system is the foun- such as ministries of agriculture, universities, agen- dation of effective disease prevention and control cies of the United Nations system, bilateral and non- programmes. Strengthening of the surveillance sys- governmental agencies) need to be approached to tem through an integrated approach is, therefore, form a central level committee to support the min- the preferred strategy for Africa. istries of health in the coordination and streamlining of inputs for the surveillance system. Those Member 48. The success of this strategy will depend on the States with task forces for the control of emerging willingness of health care providers to report all cases and other communicable diseases could be given the and deaths at their facilities. It will also depend on additional task of coordinating the integrated disease the diligence of health offi cials and personnel at all surveillance system. Furthermore, a technical advi- levels to analyse and distribute information to all sory committee could be set up to advise the coor- those responsible for taking action and to provide dinating committee on technical matters and to feedback to the peripheral level. Without doubt, ensure linkage to public health action. commitment both by policy makers in terms of resource allocation and by all partners in terms of technical and fi nancial support will contribute MONITORING AND EVALUATION signifi cantly to the success of the strategy. 46. Monitoring the process and the outcome of the 49. The Regional Committee reviewed and adopt- integrated disease surveillance strategy will be devel- ed this strategy.

103 5.2 Oral health in the WHO African Region: A regional strategy 1999–2008 (AFR/RC48/9)

EXECUTIVE SUMMARY 1. The important contribution of oral health to general community health and well-being has been highlighted in resolutions adopted at the World Health Assembly (WHA) and Regional Com- mittees. However, these resolutions have had limited impact. 2. Previous approaches to oral health in Africa have failed to recognize the epidemiological priorities of the Region or to identify reliable and appropriate strategies to address them. Efforts have consisted in the provision of unplanned, ad hoc and spasmodic curative oral health services, which in most cases are poorly distributed and only reach afﬂ uent or urban communities. 3. There was, therefore, a compelling need to review existing strategies and develop a comprehensive strategic framework to support countries in the Region. 4. This document focuses on the most severe oral problems that people have to live with, like noma, oral cancer and oral consequences of HIV/AIDS infection. It proposes a strategy for assisting Member States and partners to identify priorities and interventions at various levels of the health system, particularly at the district level. 5. The strategy aims at strengthening the capacity of countries to improve community oral health by effectively using proven interventions to address speciﬁ c oral health needs. It represents a new approach that has the potential to fundamentally improve community oral health in the African Region. 6. The Regional Committee reviewed and adopted the oral health strategy for the African Region for the period 1999–2008.

INTRODUCTION oral diseases are not always life-threatening, they too 1. Oral health describes the well-being of the oral are important public health problems because of c avity, including the dentition and its supporting their high prevalence, public demand and their structures and tissues. It is the absence of disease and impact on individuals and society in terms of pain, the optimal functioning of the mouth and its tissues discomfort, social and functional limitations and in a manner that preserves the highest level of handicap, and the effect on the quality of life. In ad- self-esteem. dition, the fi nancial impact on the individual and community is very high. 2. Oral diseases affect all human beings irrespective of location, country, nationality, race or colour. In 3. Because oral health is so fundamentally infl u- the African Region, there is a disproportionate enced by many of the environmental factors that amount of oral disease, which has grave and often infl uence general health, an effective oral health fatal consequences. Some of these diseases seem to policy or programme must address both generic and be growing in prevalence as a result of the massive specifi c infl uences on oral health. Such policy or social disruption on the continent. Although many programme may include:

104 Intensifying the prevention and control of communicable and noncommunicable diseases

• support for generic programmes that are private care systems in the Region, as they effective in reducing poverty and promoting have been from the educational programmes equity in the Region; for oral health personnel. These are diseases • support for generic programmes that are that increasingly have the greatest morbidity effective in providing clean water, proper and mortality of all oral conditions in the sanitation and durable housing for all; Region. • participation in health promotion and edu- 6. The important contribution of oral health to cation programmes to control tobacco and general community health and well-being has been alcohol use and promote correct nutritional highlighted in resolutions adopted at the World practices, including prudent use of sugar. Health Assembly (WHA) and Regional Committee 4. The strategy is a tool for assisting Member States (RC) meetings, namely: and their partners to more systematically identify • resolution WHA36.14(1983), which called priorities and plan viable programmes, particularly at on Member States to follow available health the district level. It aims to strengthen the capacity strategies when developing their national of countries to improve community oral health by oral health strategies; effectively matching proven interventions to specif- • resolution AFR/RC24/R9 (1974), which ic oral health needs. This in turn will require coun- requested the WHO Regional Director for tries to refocus the education and training of the Africa to provide for the establishment of personnel required to address these new demands on dental advisory services within the Regional the oral health system. Offi ce; • resolution AFR/RC30/R4 (1980), which JUSTIFICATION AND POLICY BASIS called on Member States of the African Region to integrate oral health into primary 5. There is a compelling need to review existing health care programmes; strategies and develop a comprehensive strategic • resolution AFR/RC44/R13 (1994), which framework to support countries, considering that: called on Member States to formulate a comprehensive national oral health policy • previous approaches to oral health in Africa and plan, based on primary health care have failed to recognize the epidemiological (PHC) and to develop appropriate training priorities of the Region or to identify reliable programmes for oral health care workers at and appropriate strategies to address them; all levels, particularly at the district level. • only 14 out of the 46 countries (30%) of the Region have a national oral health plan. Of 7. Furthermore, the Conference of Heads of Den- these, very few countries have made any tal Health Services in the African Region (1969) and progress towards implementation and none the Regional Experts Committee on Oral Health have evaluated what has been done, which (1978) recommended the establishment of oral strongly suggests that such plans are funda- health services based on the public health approach. mentally fl awed or too ambitious; Various international conferences on oral health and • efforts have consisted in providing un- other related initiatives have also endorsed the need planned, ad hoc and spasmodic curative oral for a comprehensive approach to oral health. health services. An emphasis on the production of the kind of personnel demanded by Oral health priorities this approach has compelled a number of African countries to create institutions, 8. Dental caries and periodontal disease have his- where students in the oral health sciences torically been considered the most important oral receive training in sophisticated and inap- health problems around the world. However, in propriate forms of oral health care, while in African countries, these appear to be neither as com- others little or no training at all is available; mon nor of the same order of severity as in the • the oral health care available in the Region is developed world. The oral health profi le of Africa almost entirely curative and largely directed today is very different from that perceived previ- towards combating one main problem, ously. This profi le of oral disease is not homogene- namely dental caries. Severe oral diseases ous across Africa. Thus, oral diseases known to exist such as noma, oral cancer, the oral manifes- in each community need to be individually assessed tations of HIV infection and trauma have in terms of the basic epidemiological criteria of been largely omitted in both public and prevalence and severity. This is a prerequisite for the

105 COMPENDIUM OF RC STRATEGIES meaningful ranking of community needs and the 12. The African Region also faces an acute lack of development of intervention programmes with recent, reliable and comparable data and the relative which to address them. absence of processes for converting data into information for planning. 9. There is no doubt that the African Region has to urgently address a number of very serious oral conditions, because of either their high prevalence or the Determinants of oral health problems in severe damage or death that can arise from them. Africa Severe problems 13. Poverty is an important determinant of health and ill-health. The prevalence of oral diseases close- 10. Cancrum oris (NOMA) and acute necrotizing ly mimics prevailing levels of social deprivation. In a ulcerative gingivitis (ANUG), with which it is continent where the majority of the population are known to be associated, is still common among chil- desperately poor, preventable oral diseases such as dren in Africa. The most recently available annual NOMA and oral cancer are rife. High levels of incidence fi gure for NOMA is 20 cases per 100 000. bottle feeding in the urban parts of the Region have About 90% of these children die without receiving been associated with high rates of baby bottle tooth any care. With increasing poverty and given the fact decay. Increasing urbanization has also been shown that many children are malnourished or undernour- to lead to observable increases in the prevalence of ished and have compromised immune systems, the oral disease. Greater access to alcohol is associated prevalence of conditions such as NOMA is likely to with higher levels of interpersonal trauma and oral increase. The prevalence of oral cancer is also on the cancer. increase in Africa. Annual incidence fi gures for oral and pharyngeal cancer are estimated at 25 cases per 14. The presence of widespread poverty and under- 100 000 in developing countries. Rapid urbaniza- development in Africa means that communities are tion and increasing use of tobacco and alcohol are increasingly exposed to all the major environmental considered to greatly increase the incidence of oral determinants of oral disease. pre-cancer and cancer. The highest prevalence of 15. By adopting a predominantly Western model of infections by Human Immunodefi ciency Virus oral health care, African health systems have failed to (HIV) and Acquired Immunodefi ciency Syndrome address these important determinants of oral health. (AIDS) is found in Africa. Studies have shown that Oral health systems in Africa are characterized by oral manifestations of HIV/AIDS are very wide- the predominance of dentists, most of whom are in spread and most commonly include fungal infec- private practice in urban settings. Where public or tions such as those caused by candida, necrotizing private oral health services do function, they are gingivitis or oral hairy leukoplakia. National surveys treatment-oriented, mainly providing for the relief and smaller studies in Africa have shown the preva- of pain and sepsis and, occasionally, other curative lence of dental caries to be quite low, but with sub- forms of care. stantial regional variations. Most of these cases (90%) remain untreated. Development needs Other problems 16. It is clear from the above analysis of oral health 11. Maxillo-facial trauma has increased in many in the African context that a successful approach to countries as a result of inter-personal violence, mo- oral health in the Region needs to take account of tor vehicle accidents and war. Chronic destructive these circumstances to effectively focus on the real periodontal disease is known to occur in a small pro- determinants of oral disease. portion of most populations, regardless of location 17. The needs to be addressed, using this strategy, or socioeconomic status. Harmful practices such as include equitable and universal access to affordable the removal of tooth germs of deciduous canines, and appropriate quality oral health services through: extraction of upper and lower anterior teeth and the trimming or sharpening of upper anterior teeth still • community involvement in identifying oral prevail. Fluorosis is very common in certain parts of health problems, needs and interventions; Africa such as the Rift Valley area of East Africa. • proper planning, administration and evalua- The presence of malnutrition is known to increase tion of services; the likelihood of fl uorosis in children. Edentulism, • prevention-oriented services and multi- congenital malformations and benign tumours occur sectoral action, especially in relation to par- but little prevalence data is available. ticipatory health education and promotion;

106 Intensifying the prevention and control of communicable and noncommunicable diseases

• proper balance between personnel types and • begun to carry out essential research on oral population needs. health priority problems and needs.

Regional objective: THE REGIONAL STRATEGY 21. To assist countries develop and implement oral Long-term vision health strategies and plans that will ensure equitable and universal access to quality oral health services 18. Within the next 25 years, all people of the Re- through the district health system. gion should enjoy improved levels of oral health and function through a signifi cant reduction of all oral Priority programmatic areas diseases and conditions that are prevalent in the Region, equitable access to cost-effective quality 22. Based on the oral health priorities indicated oral health care and adoption of healthy lifestyles. earlier, the following programmatic areas and objectives have been identifi ed. Guiding principles (a) Development of national oral health strategies 19. The effective implementation of this strategy and implementation plans and its sustainability will be guided by the following Objective 1: To formulate national oral health principles: strategies and plans. • high priority to promotion of oral health and (b) Integration of oral health into other programmes prevention of oral diseases; Objective 2: To integrate oral health into pro- • focus of oral health interventions on the grammes for vulnerable groups and district and its communities, with particular in the training programmes of emphasis on children, pregnant women and primary and pre-school teachers. other vulnerable groups; Objective 3: To deliver optimal levels of fl uoride • use of only interventions that have proven through water supplies or other effi cacy; methods, where indicated and fea- • integration of oral health programmes across sible, and introduce defl uoridation all appropriate sectors; water systems in areas where fl uor- • participation of communities in oral health osis is endemic. activities that affect them. (c) Delivery of effective and safe oral health services Objective 4: To ensure equitable population Strategic framework access to quality oral health care Strategic objectives through the district system. Objective 5: To ensure that district oral health 20. Country targets: It is expected that by 2008, all service is adjusted to focus on com- countries of the African Region would have: munity oral health needs and that • developed national oral health strategies appropriate forms of technology and implementation plans, focusing on the are selected. district and community levels; Objective 6: To establish effective control meas- • integrated oral health activities in other ures for cross infection. health and related programmes and (d) Regional approach to education and training for institutions (e.g. maternal and child oral health health, nutrition, schools, water related Objective 7: To share common approaches to programmes); oral health education for the level • strengthened their health facilities with ap- and type of care needed in the propriate oral health technologies, methods, African Region. equipment and human resources; • integrated training in essential oral health (e) Development of effective oral health management skills in the curricula of health personnel and information systems others who have the responsibility for oral Objective 8: To gather and coordinate the health promotion; collection of information needed • set up effective oral health management for planning, monitoring and eval- information systems; uating oral health activities.

107 COMPENDIUM OF RC STRATEGIES

Strategic orientations At intercountry and regional levels (a) Advocacy and social mobilization 24. Mechanisms to secure the exchange of experi- Implementation of the strategic orientations ences in implementing the oral health strategy need must be sustained through continued advocacy to be established between countries in the Region, for oral health. This will involve using social in the spirit of Technical Cooperation among marketing and participatory methods to mobi- Developing Countries. Maximum use will be made lize support from policy-makers, political and of the expertise and resources of WHO collaborat- community leaders, training institutions, NGOs, ing centres for oral health, particularly in the areas professional associations, business and social of capacity building and research promotion. In groups and industry. collaboration with international partners, WHO (b) Capacity-building will provide technical support to Member countries This will involve the development of human in the following areas: resources through appropriate training and re- • development of comparable national data training programmes related to the priority oral systems on oral health and disease trends for health problems. Training needs and processes use in planning, including the identifi cation should be coordinated and standardized as far as of suitable indicators with which to evaluate possible, and draw upon the combined expertise progress; and resources of the Region. • development of effective interventions for (c) Information and education the promotion of oral health; Appropriate information should be provided to • development of national oral health strate- individuals, families and communities for the gies and implementation plans; promotion of healthy oral health behaviour and • estimation of personnel needs and develop- lifestyles. People should be involved in all stages ment of suitable training programmes for the of developing oral health education, promotion effective delivery of oral health programmes. and information materials. (d) Equitable access to quality oral health services Partnerships This requires the achievement of greater equity in oral health and access to quality oral health 25. Partners who can assist the process should be services particularly for rural, peri-urban and un- identifi ed as early as possible. A wide network of derserved communities. Recent advances in oral interested parties must be established at country health and available technical excellence must be level to facilitate implementation of the strategy and adapted in the forms that are economically, mobilization of resources. technologically and culturally appropriate for 26. The district health management team has the the African Region. primary responsibility for implementing the pro- (e) Promotion of operational research grammes, strategies and interventions. It is here that In order to strengthen research capacity and pro- interaction and partnership between community mote relevant research that responds to the oral interest groups, health and development workers health needs of communities, a research culture occur in order to successfully operationalize district should be developed within national oral health oral health plans. Districts will also benefi t from programmes and the fi ndings widely dissemi- sharing information, experiences and problems with nated and used for planning purposes. one another and from collaborating in programmes of mutual interest. Implementation framework 27. Partners that may be engaged at the national At country level level include professional associations, commerce, 23. The district remains the location with the industry, dental, medical and allied professions, greatest potential for successful integration of oral NGOs, aid agencies, WHO and other UN agencies. health programme planning and implementation The national level must ensure that good com- into other health and development programmes. An munication occurs between all levels of the health implementation matrix, which illustrates a frame- system and various partners. It should, therefore, be work for planning priority interventions, will be well equipped to facilitate partnerships and collabo- developed. ration.

108 Intensifying the prevention and control of communicable and noncommunicable diseases

Managerial framework tures, which should extend well beyond the mere sharing of information. Where a regional or provin- Resource mobilization cial level exists in a country, it has the responsibility Financial resources for providing support to district health activities and for coordinating programmes that extend across dis- 28. Mobilization of internal and external resources is trict boundaries. It has to provide the link between essential for the execution of national oral health district and national levels of activity. It can help programmes. The programmes should be adjusted districts with coordination of tender processes, in- to the funds that are actually available. The oral formation collection and analysis activities, planning health sector should also set aside a share of the gen- processes and resource allocation. The national level eral health care budget allocated to fund integrated is primarily responsible for coordination, as opposed health programmes and activities of which oral to programme or service delivery and must be prop- health is a component. Ministries of health and erly equipped for this role. Existing subregional NGOs will be encouraged to mobilize extrabudget- development organizations should also be involved ary funds for oral health. Other cost-sharing initia- in coordination efforts. At the regional level, imple- tives must also be explored to support oral health mentation will be coordinated by the Division of interventions. Health Protection and Promotion in collaboration with existing WHO structures and governing Human and institutional resources bodies. 29. At country level, government needs to support the training of adequate numbers of appropriate per- MONITORING AND EVALUATION sonnel to support implementation of the oral health strategies it has selected. Negotiations with training Monitoring institutions, government and other stakeholders to 32. It will be important to monitor the process of establish appropriate post structures, career paths and negotiating acceptance, adoption and dissemination job descriptions, etc. for staffi ng public oral health of the strategy by WHO structures, country chief services will be necessary. At regional level, WHO dental offi cers and their respective ministers of will facilitate the training of experts who can pro- health. After this, the strategy must reach the provide technical support to the oral health strategy vincial and district structures responsible for its process and assist in the monitoring and evaluation implementation. This process must be monitored of programmes. These experts will also support the against the proposed time frame. After this, it will be development of country research capacities in col- important to monitor outcome indicators that refl ect laboration with the International Association for the extent to which the strategy and priority pro- Dental Research (African Division), World Dental grammatic areas have been responded to and imple- Federation, Commonwealth Dental Association, mented. The indicators to be assessed include the Aide Odontologique Internationale and others. country targets selected. Material resources Evaluation 30. Every effort should be made internally and 33. WHO has a particularly important role in facili- externally to generate funding for oral health pro- tating the implementation process as well as moni- grammes. Development and acquisition of toring and evaluating the progress of the strategy as appropriate and robust equipment that suits the Af- a whole. Periodic reviews and evaluations will be rican environment should be promoted. Whilst bulk undertaken and regular reports will be made availa- purchases of equipment and supplies should be un- ble in accordance with WHO resolutions. dertaken where appropriate, more effi cient ways of making available low cost toothpastes, toothbrushes, chewing sticks and other items should also be ex- CONCLUSION plored. 34. This document has set out a process that WHO plans to follow to assist countries improve and sus- Coordination tain the oral health of their communities. It provides 31. The setting up of coordination mechanisms technical and managerial orientations that countries among partners is crucial for the implementation of can use to streamline oral health services to effi cient- the oral health strategy. Emphasis should be placed ly and effectively deliver interventions that are af- on the coordination of activities instead of struc- fordable and that match the oral health needs of the

109 COMPENDIUM OF RC STRATEGIES community. This strategy represents a new approach (ii) systematically and meaningfully interpret oral that has the potential to fundamentally improve health epidemiological information by de- community oral health in the African Region. scribing oral disease prevalence, severity and age-wise distribution in the population; 35. The Regional Committee reviewed and adopt- (iii) pay particular attention to the most severe oral ed the oral health strategy for the African Region for problems that people have to live with (e.g. the period 1999–2008 NOMA, oral cancer and oral manifestations of HIV infection/AIDS); (iv) develop appropriate and affordable pro- a) Resolution AFR/RC48/R5 grammes that match the oral health needs of Oral health in the African Region: A regional the community; strategy (v) integrate oral health activities into all primary health care programmes; The Regional Committee, (vi) integrate training into essential oral health Bearing in mind that health and well-being skills in the curricula of health personnel and directly infl uence oral health; others who have the responsibility for oral health promotion; Concerned about the deterioration of oral health (vii) strengthen health facilities with appropriate in the African Region; oral health technologies, methods, equipment Recognizing that previous approaches to oral and human resources; health in the Region have neither taken account of (viii) undertake operational research on oral health the epidemiological priorities of the Region nor priority problems and needs; and identifi ed reliable and appropriate strategies to (ix) integrate oral health into national health man- address them; agement information systems; and Noting that previous efforts have consisted of an 3. REQUESTS the Regional Director to: unplanned and ad hoc evolution of curative oral (i) provide technical support to the Member health services which, in most cases, are poorly dis- States for the development of national tributed and only reach affl uent or urban communi- (ii) oral health strategies and implementation ties; plans; Mindful of World Health Assembly resolution (iii) provide support to all countries to enable them WHA36.14 and Regional Committee resolutions to strengthen or develop and AFR/RC30/R4 and AFR/RC44/R13 adopted in (iv) implement cost-effective oral health care serv- the past; and ices, particularly at the district level; (v) provide guidelines and technical support that Having carefully examined the report of the will facilitate the proper identifi cation of oral Regional Director contained in document AFR/ health priority problems and appropriate cost- RC48/9 outlining a WHO regional strategy for oral effective interventions; health; (vi) promote and support the development of suit- 1. APPROVES the proposed strategy aimed at able training programmes for effective delivery strengthening the capacity of the Member States to of oral health services; improve community oral health; (vii) promote and support relevant research activities aimed at providing solutions to oral health 2. CALLS on the Member States to: problems; and (i) develop national oral health strategies and im- (viii) report to the 50th session of the Regional plementation plans with emphasis on preven- Committee on the progress made in the im- tion, early detection and management of oral plementation of the strategy. diseases; Tenth meeting, 2 September 1998

110 Intensifying the prevention and control of communicable and noncommunicable diseases b) Epidemiological basis for ranking oral disease burden in low-economic status community

Oral disease Prevalence Morbidity Mortality 1 Cancrum oris ( Noma) High High High 2 Oral manifestations of HIV/AIDS High High High 3 Oral cancer Medium High High

4 Facial trauma Very High Medium Medium 5 Congenital abnormalities High Medium Medium 6 Harmful practices High Medium Low 7 Dental caries Medium Medium 8 Chronic periodontal disease Medium Low Low 9 Fluorosis Medium Low Low 10 Benign tumours Low Medium Low 11 Edentulism Low Medium Low

c) Conclusions of the consultative meeting on In his opening address, the WHO Regional Direc- implementation of the regional oral health strategy tor for Africa, Dr E.M. Samba noted that previous in African countries approaches to oral health in Africa had failed to recognize the epidemiological priorities of the Region Brief Summary or to identify reliable and appropriate strategies to In September 1998, the African Ministers of Health address them. Efforts had consisted of an unplanned, attending the forty-eighth session of the WHO Re- ad hoc and spasmodic evolution of curative oral gional Committee Meeting in Harare, Zimbabwe, health services. Dr Samba stressed that the new strat- adopted the oral health strategy for the African Re- egy focussed on the most severe oral problems that gion for a ten-year period (1999–2008). A corre- people have to live with, like noma, oral cancer and sponding resolution was also adopted. the oral consequences of HIV/AIDS infection. The strategy was a tool for assisting Member States and As a follow-up to the adopted regional oral health partners to identify priorities and interventions at strategy, a Consultative Meeting, jointly organized various levels of the health system, particularly at the by WHO/AFRO and WHO/HQ, took place in district level. He further indicated that the strategy Harare, Zimbabwe from 30 March to 01 April 1999. aimed at strengthening the capacity of countries to The purpose of the meeting was to identify concrete improve community oral health by effectively using actions to assist Member States in implementing the proven interventions to address speciﬁ c oral health strategy. needs. The Regional Director charged participants There were thirty-nine participants from four main to identify practical cost-effective ways of imple- groups, namely: experts on oral health in Africa, menting the regional oral health strategy. chief dental ofﬁ cers (CDOs) from selected countries The following are the main outcomes of the Con- in the Region, some oral health partners and heads sultative Meeting. of some WHO collaborating centres for oral health. There were also representatives from WHO/HQ and WHO/AFRO.

111 COMPENDIUM OF RC STRATEGIES ed Identity areas where existing data need to be strengthened and devise appropriate research protocols. Initiate operational research at all levels. Develop a simpliﬁ revised oral health survey methodology based on the perception of need, resource availability and potential outcome of interventions at the local level. Promote research in appropriate technology. ed Ensure priorities identiﬁ are directed at the most vulnerable. Allocate resources on the basis of need. Establish district- focused services. Promote use of appropriate technology. Equitable access to quality oral health services Promotion of operational research Strategic Orientations Implementation Framework Disseminate and explain the strategy and plan at all levels. Ensure that strategy and plan involve opinions and needs at the lowest levels of the system. Design and disseminate participatory oral health education and promotion materials for use in schools and communities. Information, education and communication Ensure there is institutional capacity for training appropriate oral health personnel. Assist and encourage the development of appropriate protocols where indicated. Include non- oral health personnel workers in training programmes. Promote collaboration for regional education and training. Raise awareness at policy and political levels on the need for national strategy and plan on oral health. Advocate for the implementation and evaluation of the prepared strategy and plan. Advocate for multidisciplinary approach. Mobilize the private sector and city/town health management to promote oral health. Advocacy and social mobilization Capacity building Priority Programmatic Area Development of national oral health strategies and implementation plans Objective: formulate 1. To national oral health strategies and plans.

112 Intensifying the prevention and control of communicable and noncommunicable diseases Continued t, outcome measures, Support operational research into the provision of oral health services that are integrated into general health services and school programmes (e.g. Cost- benefi early diagnosis, etc.) Promote research into the effectiveness of education and training for integrated services. Expand oral health services within district health services. Provide adequate infrastructure for the provision of oral health care. Introduce oral health in safe motherhood programmes. Disseminate information on the determinants of oral health and disease. Integrate oral health messages into: – MCH clinics and programmes. – curriculum of primary schools. – national nutrition programmes. – programmes for the elderly. – campaigns against violence. – campaigns against tobacco use – campaigns against alcohol consumption. Train all district health Train personnel and school teachers on oral health education and promotion as well recognition of oral diseases, their management and referral. uoridation uoridation, where and defl indicated and feasible. Raise awareness that oral health arises from the same conditions as general health. Advocate for integration of oral health into other programmes. Advocate for issues such as food and agricultural tobacco use and policy, alcohol consumption, drink and driving road safety. Advocate for fl

Integration of oral health into other programmes Objectives: integrate oral 2. To health into all PHC programmes and into the training programme of primary and teachers pre-school deliver 3.To optimal levels of uoride through fl water supplies or other methods indicated and where feasible, and to introduce uoridation defl water systems in where areas uorosis is endemic fl

113 COMPENDIUM OF RC STRATEGIES Promote recording and analysis of data relevant to the processes and intervention. Establish or expand oral health services to all districts as part of existing health services. Ensure allocation of appropriate resources and infrastructure based on need and vulnerability. Ensure availability of appropriate equipment and adequate stock of materials. instruments and spare parts. Ensure regular maintenance of equipment. Equitable access to quality oral health services Promotion of operational research Strategic Orientations Implementation Framework Disseminate information on infection control. Promote the use of evidence-based interventions. Promote campaigns against the use of tobacco and alcohol consumption. Promote competition among oral health programmes. Information, education and communication Train all district health Train personnel on infection control measures. Ensure there are trained personnel or maintenance of equipment. oral health personnel Train in research. uoride Advocate for the creation of infrastructure necessary to ensure safe and effective delivery of oral health care at district level.Mobilize non-health sectors such as local authorities and NGOs to promote oral health. Advocate for oral health materials and drugs to be part of the essential drug list (including ﬂ toothpaste). Advocacy and social mobilization Capacity building tion access to quality oral health through the care district system. ensure 5. To district oral health service is adjusted to focus on community oral health needs and that appropriate forms of technology selected. are establish 6. To effective control for measures cross-infection. Delivery of effective and safe oral health service Objectives: ensure 4. To equitable popula Continued Priority Programmatic Area

114 Intensifying the prevention and control of communicable and noncommunicable diseases Determine the minimum data set. Assess appropriateness of the data collected Develop measures to assess effectiveness and appropriateness of existing educational programmes. Continually assess geographical distribution of personnel found in each institution into the Region. Ensure coordination of information at all levels. Ensure relevant information is collected and properly utilised Assess number, type and Assess number, distribution of training institutions required. Ensure optimal use of existing institutions and their availability to all countries in the Region. ne information for Continually assess and defi planning process. Communicate need to collect and use this data to all health workers Inform relevant role-players of advantages a regional approach. ed. Develop capacity to collect, collate, analyse and interpret data at all levels especially at the district level. Develop computer skills where necessary. Ensure education and training are related to needs and strategies identifi uorosis Advocate for the collection of data for planning, monitoring and evaluation at each level. Advocate for mapping of geographical areas with endemic fl Advocate and mobilize countries of the Region to develop a common approach to education and training of personnel for oral health. Advocate for system of based on common entry, needs of both country of origin and the Region as a whole. Advocate for the education and training of more auxiliaries Effective integration of oral health in national health management information systems Objective: gather and 8. To coordinate the collection of information needed for planning, monitoring and evaluating oral health activities Regional to approach education and training for oral health Objective: share 7. To common approaches to oral health education for the level and type of care needed in the African Region

115 COMPENDIUM OF RC STRATEGIES cation of high-risk Formulate targets for Formulate targets training at all levels for heath personnel and other types of resource persons (parents, teachers, opinion leaders ) in: Identiﬁ groups detection of intra-oral-oral lesions, and management at all levels of the disease. This means that each country needs to rtant to them. The framework provided resources they have and an assessment of which d to be set and these will vary from the earliest ty. For example, with noma, different countries/ ty. Promote basic and operational research. (i) Primary care: Arranging for health services to treat patients. Making sure necessary drugs and nutritional supplements are available. (ii) Specialized oral care-surgery and rehabilitation: referring patients who have sequelae for surgical treatment, setting up specialized centres for treatment. (iii) Complex case management of social and psychological effects, including social integration treatment. after surgical (i) Improve environmental and personal hygiene dietary practices. (ii) Early detection and referral (of precursor conditions), using existing social and health structures. (iii) Participation in national programmes and campaigns on improved nutrition and immunization. able Surveillance(i) Establish a surveillance system based on identiﬁ records from all available sources of data. (ii) Include demographic, and Promotion Prevention sociological intervention and other outcome variables. Disease Management Research Capacity Building/Training Cancrum Oris/ Noma option is likely to work best for them. It not a prescriptive list that countries should feel obliged adopt in its entire districts will require different may nee levels and forms of training that is relevant to their needs. For each level a target detection level in the village to specialist care level. begin the process of oral health strategy development by identifying and prioritizing those problems that are particularly impo below should assist in sifting through the available options for intervention that each country wishes to select, based on the FRAMEWORK TO ADDRESS PRIORITY AREAS OF PREVENTION AND OTHER INTEVENTIONS AT COUNTRY LEVEL COUNTRY FRAMEWORK TO ADDRESS PRIORITY AREAS OF PREVENTION AND OTHER INTEVENTIONS AT PREAMBLE: The situation of each country and the nature of oral health problem each country has to deal with are different.

116 Intensifying the prevention and control of communicable and noncommunicable diseases Continued c country cation and manage- rst aid and health personnel (i) the community in Train fi management in emergency of facial injuries. suspicious lesions. (i) Devise a specifi plan for training. (ii) Get a focal person to co-ordinate training. (iii) Collaborate with AIDS units and other groups. (iv) all oral health and Train general health personnel in identifi ment of these conditions. (i) health personnel at Train district level in the early diagnosis of oral cancer and referral for appropriate management. (ii) recognition of Teach

(i) Research on behaviour and lifestyles, vehicles etc. road safety, (i) Research on the most predictive value of oral manifestations of HIV/ AIDS, laboratory saliva tests infection control, etc. (i) Research on behaviour and lifestyles. (ii) Kola nut investigations. (iii) Link between viral infections and cancer. interventions. (iv) Evaluate (ii) Set up collaborative research with other countries. referral to appropriate hospitals. (iii) Establish network of centres to share expertise for all types of reconstructive surgery. (i) Emphasis on careful and continuous oral hygiene / mouth care at home and treatment centres to maintain a healthy oral environment. (ii) Utilize oral antiseptics and traditional medications. treatment (iii) Write protocols. (i) Draft protocol for treatment at primary care level. (ii) Early diagnosis and (i) Appropriate referral. (ii) Management of cases in national and regional treatment centres. for (iii) Campaign indigenous training of maxillo-facial oral surgery staff. Participation of oral health personnel in national programmes and campaigns on prevention and control of HIV/AIDS. transmission (ii) Highlight risk in health care services among health personnel. (iii) Prepare manuals for patients and health workers on self care and prevention of HIV. (i) Participation of oral health personnel in campaigns against all forms of violence and its consequences. (i) Engage with national campaigns against tobacco and alcohol etc. (ii) Dietary advice on antioxidants and use of areca nut. systematic (iii) Promote examination of the whole mouth (i) Establish surveillance (i) Establish systems to monitor prevalence, severity and intervention outcomes for oral mucosal lesions associated with HIV/AIDS. (ii) Set up selected additional surveys, where necessary (i) Develop a record-based surveillance system to monitor the prevalence of facial trauma and its causes. (i) Establish similar (i) Establish record-based surveillance systems as for HIV to monitor the prevalence of oral pre-cancer and cancer. (ii) Establish a cancer register. HIV/AIDS Oral Manifestations Facial Trauma Oral Cancer

117 COMPENDIUM OF RC STRATEGIES uorosis and referral cation of dental and (i) authority members Train of the community such as teachers, MCH aids, nurses, PHC workers in oral health matters as part of general health education. (ii) appropriate health Train workers in screening and extraction during their pre-professional courses. (iii) district oral health Train technique. workers in ART (i) Same as for other conditions above. (i) the community Train and health personnel on identifi skeletal fl for appropriate management of cases. uoride. uoride. uoridation ed revised oral (i) Cultural and professional determinants of tooth loss. cost-effective (ii) Rapid procedures production. health survey method. of (ii) Effectiveness community oral health education. evaluation. (iii) Process (iv) Quality of care assessment. effectiveness (v) Research of traditional methods oral health promotion and protection. (i) Into defl technology. exposure. (ii) Fluoride mapping; (iii) Fluoride (iv) Sources of fl (v) Utilization of fl (i) Simplifi llings, llings, etc). uoridation of (i) Denture provision (i) Denture where infrastructure and resources permit. (i) De-fl available drinking water in small communities. restoration (ii) Appropriate of affected anterior teeth. treatment (i) Emergency for pain relief (extraction, temporary fi fi (ii) Preventive technique. using ART uorosis uoride uoride toothpaste. (i) Promote healthy smile and other caries periodontal disease prevention strategies (i) Develop appropriate (i) Develop education programmes (ii)In areas where fl is endemic, identify alternative water supply (and other fl sources). (i) Integrate effective oral health promotion materials. mouth (ii) Promote cleaning, using indigenous and other oral hygiene aids, including chewing sticks. dietary (iii) Integrate measures into existing nutrition programme efforts to ensure avoidance of frequent excess sugar intake. affordable (iv) Promote fl viability (v) Consider nder type guring uorosis. uorosis that requires (i) Records based surveillance as for oral cancer. Surveillanceepidemiologi- (i) Selective cal studies on the extent of cosmetically disfi fl professional intervention and on skeletal fl and Promotion Prevention Disease Management Research Capacity Building/Training (i) Selected pathfi (i) Selected epidemiological studies on prevalence where existing data are inadequate. Continued Edentulismuca- tion Fluorosis Dental Caries

118 Intensifying the prevention and control of communicable and noncommunicable diseases ce for ts has yet to be (i) PHC workers and Train school teachers on oral health education and promotion activities (see caries list above). tion of their beneﬁ (i) Effectiveness of (i) Effectiveness community oral health education. (ii) Aetiological and risk factor research. between (iii) Interaction systemic and other conditions related to periodontal diseases. (iv) Factors that cause progression of gingivitis to ANUG to noma. (v) methods of Traditional prevention and self care.

(i) Referral to the next level of care. treatment (ii) Emergency for pain relief. (iii) Selected use of scaling and other forms of treatment aimed at preventing plaque retention. treatment (iv) Complex such as periodontal surgery. (i) Develop effective oral health education and promotion materials with strong messages on mouth cleaning. (ii) Promote use of effective traditional methods of oral care (See caries above). (iii) Integrate oral hygiene practices into environmental hygiene promotion efforts by local health workers. Deal with as for trauma above. Deal with as for oral cancer above, depending on nature of the tumour. Deal with as for destructive facial conditions such noma and other requiring reconstructive surgery. c evidence that exist in support of their use. This work will be initiated by the WHO Regional Offi ects the need for research into the utilization of these practices known to work. Further research is needed and a data base (i) Utilize existing data and record systems to monitor these conditions. Periodontal Diseases Africa (AFRO). developed for recording the practices and scientifi Harmful Practices completed. The table above refl Benign Tumours Congenital Malformations (indigenous) interventions Traditional (indigenous) interventions are well-understood and accepted by many people in the Region, but systematic evalua Traditional

119 5.3 Regional strategy for mental health 2000–2010 (AFR/RC49/9)

EXECUTIVE SUMMARY 1. Mental health and the prevention and control of substance abuse are not treated as priority areas in a majority of the countries of the WHO African Region. These countries do not have national mental health policies; there is a shortage of specialized personnel, which is compounded by the constant brain drain. Widespread civil strife and the resulting violence and its consequences are a common occurrence on the African continent. All these factors call for the formulation of a regional strategy for mental health and the prevention and control of substance abuse. 2. In line with the WHO deﬁ nition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or inﬁ rmity”, and taking into consideration the various resolutions of the World Health Assembly, the Regional Committee for Africa and the United Nations General Assembly inviting Member States to consider mental health and psychosocial issues as important aspects of health, this document proposes a strategy for mental health, including the prevention and control of substance abuse in the African Region, for the period 2000–2010. The strategy is expected to contribute to the development of national programmes in Member States with the involvement of governments and partners. 3. The Regional Committee reviewed and adopted this strategy and gave the necessary orientations for its implementation.

INTRODUCTION provement of the quality of life of the general public, through the prevention and control of mental, neuro- 1. Mental health is an essential and integral part of logical and psychosocial disorders and the promotion health as stated in the Constitution of the World of healthy behaviours and lifestyles and mental well- Health Organization. Just as health is not merely the being are the goals of national programmes for mental absence of disease, mental health is also not simply health and the prevention of substance abuse. the absence of mental disorder or illness but represents a positive state of mental well-being. 4. The regional strategy for mental health and the prevention and control of substance abuse for the 2. Mental health can be defi ned as total balance of the period 2000–2010, as set forth below, is a tool for individual personality, considered from the biological assisting Member States and their partners to iden- and psychosocial points of view. Mental disorders are tify priorities and develop and implement pro- illnesses characterized by abnormalities in emotional, grammes at various levels of the health system, with cognitive or behavioural spheres. It is unfortunate that particular emphasis on what can be done at district in its current usage the term ‘mental health’ is identi- and community levels. fi ed with mental disorders only. Prevention, treatment and rehabilitation of mental disorders are, however, part of the broader fi eld of mental health. JUSTIFICATION AND POLICY BASIS 3. Alcohol and tobacco abuse and drug-related 5. Considering that previous approaches to mental problems are becoming major public health con- health in the African Region have failed to identify cerns for most countries in the African Region. Im- priority areas and appropriate strategies to address

120 Intensifying the prevention and control of communicable and noncommunicable diseases them, decision-makers are unaware of the mental reports from some African countries, the rate could health needs of their countries and there is a need for be much higher. Inadequate care at childbirth, mal- advocacy to address those needs. The status of mental nutrition, malaria and parasitic diseases may be the health as an essential component of individual and cause of the high rate of epilepsy in Africa. Further- community health has been stressed in various reso- more, the disease is still highly stigmatized, particu- lutions adopted by the World Health Assembly, the larly because it is often considered infectious, leading WHO Regional Committee for Africa, the United to the social isolation of the sufferer. Simple and in- Nations General Assembly and the United Nations expensive anti-convulsion treatment can be very Drug Control Programme1. There is, therefore, an effective in preventing seizures. urgent need to review existing strategies and develop Children’s mental health problems: Half of the popula- a comprehensive strategic framework for mental tion of the Region is made up of children below the health and the prevention and control of substance age of 15 years. It is estimated that, of those aged 0–9 abuse in the countries of the African Region. years, about 3% suffer from a mental disorder. Many children suffer from poor psychosocial development Situation analysis because of neglect by their mothers and other care- takers. This neglect may be due to the lack of social Magnitude of the problem support for the mother or to post-natal depression, 6. Populations in the African Region are beset by which can lead to poor emotional and cognitive de- numerous mental and neurological disorders that are velopment of the child in later life. Brain damage is a major cause of disability. There is a lack of reliable one of the main causes of serious mental retardation. information systems in most countries. However, Organic mental disorders: Dementia is a chronic dis- some of the basic global fi gures are available and are order that occurs more frequently among elderly given below. people. In Africa, the population of elderly people is 7. It has been estimated that over 12.5% of the glo- still low, with only 3–4% of the total population bal burden of disease is caused by mental and neuro- aged above 65 years. Other brain syndromes, which logical disorders, which might be also true for the usually follow an infection or trauma of the central African Region. In addition to the disability caused nervous system, are, however, common in the by these disorders, the problem is made worse by African Region. the social handicap brought about by the stigma at- Post-traumatic stress disorders: Many countries in the tached to them. Some of the common mental con- African Region are engulfed in confl icts and civil ditions are discussed below. strife with their attendant adverse impact on the men- Common mental disorders: These occur at a rate of tal health and well-being of the affected populations. 20–30% among the population, and up to 40% Psychoactive substance use and abuse: Alcohol, tobacco among those who attend general outpatient clinics. and drug-related problems are becoming an increas- Unfortunately, these are not appropriately diagnosed ing concern in the Region. Many of the countries in by health workers and scarce resources are often Africa are used as transit points for illicit drug trade, wasted on laboratory investigation and inappropriate and these drugs are fi nding their way into local pop- medication. ulations, adding to the indigenous problems associ- Depression: Major depression occurs in about 3% of ated with cannabis consumption. the population, with attendant risks of suicide. It is Tobacco: As the demand for tobacco faces gloomy often not properly diagnosed by primary health care prospects in many countries in the North, there is workers and is, therefore, not treated appropriately growing pressure to increase tobacco sales in the de- in most cases. Factors contributing to depression in- veloping world, where tobacco use is indeed grow- clude genetics, socioeconomic problems and insecu- ing rapidly and children are starting to smoke at a rity, which are so common in the African Region. very early age. Member States will have to adopt the Schizophrenia: It is estimated that 1% of the total Tobacco-free Initiative as a means of achieving a population suffer from schizophrenia. This condi- tobacco-free status. tion leads to serious disability and puts a considerable Alcohol: There is an increased demand for home- burden on the families and communities of the brewed beer or locally distilled liquor. In most affec ted persons. countries, there are no national policies on alcohol Epilepsy: The global prevalence of epilepsy is esti- or tobacco. Consequently, their advertising, distri- mated to be between 0.5 and 1.0%, but according to bution and sale are largely uncontrolled.

121 COMPENDIUM OF RC STRATEGIES

8. Increasing poverty, natural disasters, wars and In addition to these, there are a number of innova- other forms of violence and social unrest are major tive mental health activities taking place in the causes of growing psychosocial problems, which in- Region, which are unfortunately not documented. clude alcohol and drug abuse, prostitution, street children, child abuse, domestic violence. THE REGIONAL STRATEGY 9. HIV infection has added considerably to the psy- Aim chosocial problems already being experienced in many countries of the Region, creating a need for 14. The aim of the strategy for mental health and extra support and counselling for those affected and the prevention and control of substance abuse is to care for their surviving family members, especially help prevent and control mental, neurological and children. psychosocial disorders, thus contributing to the improvement of the quality of life of the populations. 10. Many risk behaviours and social problems are This can be achieved through the formulation and the result of people’s lack of mental maturity, self- strengthening of national mental health policies and esteem and self-confi dence. Strong cultural beliefs the development and implementation of pro- about the causes and management of mental disor- grammes in all Member States in the African Region. ders in the Region also explain the non-utilization of conventional health services as a fi rst choice. 15. While adopting and implementing the regional strategy, all Member States should integrate mental Mental, neurological and psychosocial health health and the prevention of substance abuse into services their national health services. This will lead to: 11. In most countries of the African Region, men- (i) a reduction in the incidence and prevalence of tal health programmes are limited to curative health specifi c mental and neurological disorders care of poor quality, usually provided in decrepit (epilepsy, depression, mental retardation and hospitals located far away from residential areas. psychosocial disorders due to man-made disas- These conditions create a serious problem of access ters) and other prevalent conditions; to and acceptability of the treatment. Hence, drop- (ii) equitable access to cost-effective mental, out rates are very high, and follow-up treatment as neurological and psychosocial care; an outpatient is seriously hampered. In those coun- (iii) progress in the adoption of healthy lifestyles; tries where some services are provided, these are and mainly for adults with major psychiatric disorders, (iv) improvement in the quality of life. the needs of children not being catered for. Objectives Weaknesses and strengths 16. The objectives of the strategy are: 12. Major constraints to the development of mental (i) to promote mental health and prevent mental, health programmes at country level are: lack of neurological and psychosocial disorders and awareness of the magnitude of the problem; lack of drug abuse-related problems; reliable information systems; insuffi cient human and (ii) to reduce disability associated with neurologi- fi nancial resources, among others2. cal, mental and psychosocial disorders through 13. A number of countries have, however, made community-based rehabilitation; progress in reducing their reliance on big psychiatric (iii) to reduce the use of psychoactive substances institutions. These countries have begun decentral- (alcohol, tobacco and other drugs); izing mental health and integrating it into primary (iv) to change people’s negative perceptions of health care at the community level, based on the mental and neurological disorders; and district health system approach, in accordance with (v) to formulate or review existing legislation in Regional Committee resolution AFR/RC40/R9. support of mental health and the prevention Strong community and family ties in African socie- and control of substance abuse. ties have helped immensely in supporting patients by strengthening community-based care. There is a Guiding principles growing number of mental health training institu- 17. The guiding principles for the implementation tions in the Region that take into account the Afri- of the strategy are: can realities. These institutions are being used for the training of both nationals and persons from oth- (i) integration of issues related to mental health er African countries, often under WHO fellowships. and the prevention and control of substance

122 Intensifying the prevention and control of communicable and noncommunicable diseases

abuse in the national health sector reforms according to country priorities. Training of staff agenda, particularly with regard to organiza- should be considered a priority and encouragement tion, legislation and fi nancing; must be given to the integration of modules on (ii) promotion of mental health and provision of mental health and the prevention of substance abuse health care, targeting especially the vulnerable into the training courses of general health workers and high-risk groups; and (e.g. doctors, nurses, social workers, and medical (iii) prevention of substance abuse (tobacco, alco- assistants). The involvement of communities is reco- hol and other psychoactive substances), espe- mmended. They can be sensitized through short- cially among young people. duration workshops, using locally-adapted teaching aids and participatory methods. Training needs and Expected outcomes possibilities should be assessed and the use of national training institutions and WHO collaborating centres 18. By the end of 2010: should be encouraged. (i) All Member States will have formulated 22. Advocacy and social mobilization. Social marketing national mental health policies and strategies; of the importance of mental health and the preven- (ii) All countries in the Region will have estab- tion and control of substance abuse is an important lished national programmes and action plans element in the implementation of the strategy. for the implementation of activities on mental health and the prevention and control of sub- 23. Information and education. Programmes for the stance abuse, according to their priorities; promotion of mental health and the prevention of (iii) Community-based psychosocial rehabilitation mental, neurological and psychosocial disorders can programmes will have been established, imple- benefi t from the appropriate use of information pro- mented and evaluated in countries in post-war vided to individuals, families and communities. The situations; information materials should be developed with the (iv) All Member States will have formulated or re- involvement of the target populations, taking into viewed existing legislation in support of men- account their cultural background. tal health and the prevention and control of 24. Research. A research culture should be devel- substance abuse. oped within national programmes for mental health and the prevention and control of substance Priority interventions abuse. Priority areas of research should be identifi ed 19. The priority interventions listed below are in Member States and research fi ndings should based on various elements which the countries may be widely disseminated and used for appropriate re- select from and focus on according to the availability programming. of resources and their different settings. 25. Partnerships and collaboration. Collaboration 20. Policy formulation and programme development. among ministries of health and other government Policies on mental health and the prevention and departments as well as professional associations3, fam- control of substance abuse should be formulated in ily groups, consumer groups, NGOs, community all Member States. Specifi c programmes and action and religious leaders, traditional healers’ associations, plans should be drawn up for implementation, tak- women and youth organizations, training institutions ing into account country priorities. Integration of and other UN agencies should be encouraged. mental health into general health services through a 26. Technical cooperation among countries of the reliable health information system, decentralization, Region and with WHO collaborating centres and multisectoral collaboration and community partici- other programmes of the Regional Offi ce must be pation should all be encouraged. Equitable access strengthened. Good communication and coordina- can be provided through the integration of mental tion would be needed to ensure better results from health into primary health care. To achieve this, these partnerships. members of the primary health care team need to maintain close links with the specialist services so Implementation framework that they can receive regular support for their work. Services provided should be adapted to the econom- Country level ic, technological and cultural contexts of countries 27. Member States of the African Region should ad- in the African Region. dress the problems related to mental health and the 21. Capacity-building. Appropriate policies for prevention and control of substance abuse as a prior- human resources development should be drawn up ity within their national health policies and health

123 COMPENDIUM OF RC STRATEGIES development plans. National programmes should re- must also be explored. Mobilization of external refl ect the need for the promotion of mental health as sources is also important and WHO has an impor- well as the prevention and control of substance abuse tant role to play in the formulation of guidelines (i.e. the abuse of tobacco, alcohol and other psycho- which can be adapted by Member States to their active substances). They should form an integral part specifi c circumstances. of essential health care. A community-based approach must be encouraged, as set out in Regional Commit- Drugs and equipment tee document AFR/RC40/10 Rev.1 (1990). A focal 31. The availability of essential psychotropic drugs point should be designated in the Ministry of Health needs to be ensured according to the prescribing ca- to manage the mental health programme. pacity of health professionals at different levels of the health care system. Each level of the mental health Role of WHO care system should have the equipment necessary for and appropriate to that level for the treatment of 28. WHO can play a key role in supporting and neuropsychiatric disorders. sustaining effective action to address the issue of mental health and the prevention and control of Infrastructure and services substance abuse in Member States. Funds should be allocated from WHO country budgets for the im- 32. Mental health care should be delivered as part of plementation of the programme. At the regional general health care services such as health centres. level, WHO will provide technical support to The custodial type of care in old and big psychiatric Member States in the following areas: hospitals must be discouraged. Hospitalization of persons with mental, neurological or psychosocial (i) development of national programmes for problems should be resorted to only when other al- mental health and the prevention and control ternatives of family and community care are not suf- of substance abuse; fi cient. The length of stay in hospitals must be (ii) intercountry technical cooperation; reduced to the minimum and to what is absolutely (iii) integration of mental health and the preven- necessary, and after-care services (day centres and tion and control of substance abuse into the sheltered accommodation) should be created, when general health care system, using the commu- possible. nity-based approach; (iv) strengthening of cooperation with WHO collaborating centres in the Region in research MONITORING AND EVALUATION and training; 33. After the adoption and launch of the regional (v) resource mobilization for the strengthening of strategy, the development of activities at country national capacities; level will be monitored and evaluated within the (vi) integration of different aspects of mental health stipulated time frame of 2000–2010. Member States and substance abuse issues into the health in- will be invited to establish specifi c programmes ac- formation system; and cording to their priorities and available resources. (vii) needs assessment and programme evaluation. WHO’s contribution to the implementation of the strategy will be incorporated in the WHO regular Human resources programme budget. 29. Training of adequate numbers of staff to pro- 34. Monitoring and evaluation indicators will be vide services in the areas of mental health and sub- formulated to assess the implementation of the strat- stance abuse should be made an integral part of egy. Periodic reviews and evaluations will be under- human resource development policies in Member taken and regular country reports will be produced States. WHO, at the regional level, will facilitate the and analysed to update the regional mental health identifi cation and training of experts who can assist programme profi le. countries with programming, monitoring and evaluation. CONCLUSION Financial resources 35. The promotion of mental health, the preven- 30. Ministries of health and social affairs should be tion and treatment of mental, neurological and psy- encouraged to allocate funds from national sources chosocial disorders and the prevention and control as well as from WHO country budgets for the men- of substance abuse are challenges for all the countries tal health programme. Other cost-sharing initiatives of the African Region.

124 Intensifying the prevention and control of communicable and noncommunicable diseases

36. This document sets out a strategy for the pro- 1. APPROVES the proposed strategy aimed at motion of mental health and healthy lifestyles, the strengthening the capacity of Member States to im- prevention of mental, neurological and psychosocial prove the quality of life of their people by promot- disorders and the treatment and rehabilitation of ing health lifestyles, and preventing and controlling people suffering from those problems, in order to mental, neurological and psychosocial disorders; contribute to the improvement of the quality of life of the people. It is an important approach, which 2. REQUESTS Member States: involves governments and their partners in the ﬁ eld (i) to take into account mental health concerns in of mental health and the prevention and control of their national health policies and strategies; rec- substance abuse. ognize the need for the multisectoral approach 37. The Regional Committee reviewed and adopt- and integrate mental health into their general ed this strategy and gave orientations for its imple- health services, particularly at the district level, mentation. with adequate community participation; (ii) to establish or update national programmes Resolution AFR/RC49/R3 and plans of action for the implementation of activities on mental health and the prevention Regional strategy for mental health 2000–2010 and control of substance abuse, according to The Regional Committee, their priorities; (iii) to promote mental health and healthy behav- Aware of the magnitude and the public health iour, using the commemoration of the World importance of mental, neurological and psychosocial Mental Health Day (10 October); problems, which have been aggravated by the stig- (iv) to formulate or review legislation in support of ma attached to them; mental health and the prevention and control Concerned about the growing poverty, the in- of substance abuse; creasing frequency of natural disasters, and the esca- (v) to designate a focal point in the ministry of lation of war and other forms of violence and social health to manage the mental health pro- disruption, which are causing growing psychosocial gramme thus established; problems such as alcohol and drug abuse, prostitu- (vi) to provide ﬁ nancial resources for the imple- tion, the phenomenon of street children, child abuse mentation of the related activities and consider and domestic violence; introducing cost-sharing schemes, where appropriate; Recalling World Health Assembly resolutions (vii) to intensify capacity-building, taking into WHA28.81 (1975) on the assessment of problems account the mental health dimension, when relating to alcohol abuse, WHA30.45 (1977) on the drawing up national human resources devel- creation of the African Mental Health Action opment plans and to use regional health train- Group, Regional Committee resolution AFR/ ing institutions; RC40/R9 (1990), which called on Member States (viii) to ensure that a research culture is built into to implement community mental health care based their national programmes; on the district health system approach, and AFR/ (ix) to undertake community-based psychosocial RC44/R14 (1994) on accelerating the development rehabilitation interventions, targeting vulner- of mental health in the African Region; able and high-risk groups, especially displaced Appreciating the efforts already made by Mem- persons, refugees, victims of landmines, health ber States and their partners to improve the mental workers, and people with chronic mental and health of their people and prevent and control sub- neurological conditions as well as people living stance abuse; with HIV/AIDS; Recognizing the need to review existing ap- 3. REQUESTS the Regional Director: proaches in this area and develop a comprehensive (i) to provide technical support to Member States strategic framework for mental health and the pre- for the development of national policies and vention and control of substance abuse in the coun- programmes on mental health and the preven- tries of the African Region; tion and control of substance abuse as well as Having carefully examined the report of the Re- development or revision of mental health gional Director as contained in document AFR/ legislation; RC49/9, which sets forth WHO’s regional strategy (ii) to take appropriate measures to enhance WHO’s for mental health; capacity to provide timely and effective technical

125 COMPENDIUM OF RC STRATEGIES

support, at regional and country levels, to WHA 30.45(1977) – creation of AMHAG, the Afri- national programmes on mental health and the can Mental Health Action Group. prevention and control of substance abuse; AFR/RC38/R1(1988) – Prevention and Treatment (iii) to increase support for the training of health of mental and neurological disorders. professionals in mental health at different levels AFR/RC40/R9(1990) – on community mental health care based on the district health system ap- of the health system and promote the use of proach in Africa. traditional medicine within the context of AFR/RC44/R14(1994) – on accelerating the devel- African realities; opment of mental health in the African Region. (iv) to facilitate the mobilization of additional re- UN General Assembly Resolution 46/119(1991) on sources for the implementation of the mental protection of persons with mental illness and the need health strategy in Member States; for improvement of mental health care. (v) to develop operational plans for the imple- United Nations Declaration and Guiding Principles mentation of the regional strategy for the of Drug Demand Reduction (March 1998). period 2000–2001; 2. About 70–80% of the population in the Region lives (vi) to report to the 51st session of the Regional in rural areas, where access to health care is difﬁ cult or is not available. There is lack of essential drugs for the Committee on the progress made in the im- treatment of the most common neurological and plementation of the regional strategy for men- mental disorders. Many countries in the Region have tal health. no mental health legislation. Where it exists, it is outdated. REFERENCES 3. The World Federation for Mental Health, the World Psychiatric Association, the World Association for 1. WHA 28.81(1975) – on assessment of problems relat- Psychosocial Rehabilitation, the International League ing to Alcohol Abuse. Against Epilepsy and others.

126 5.4 Non-communicable diseases: A strategy for the WHO African Region (AFR/RC50/10)

EXECUTIVE SUMMARY 1. The attainment of health for all, proclaimed at the World Health Assembly in 1977, will remain a major objective for the foreseeable future. 2. For many years, the Region has been experiencing an accelerated increase in non-communicable diseases (NCDs), adding to the already heavy burden of communicable diseases. If no steps are taken now, NCDs might become the leading cause of morbidity and mortality by 2020. As pointed out in the Global Burden of Disease study, under all disease scenarios, NCDs are assum- ing increasing importance in Africa. 3. Many NCDs that pose public health problems share common risk factors like tobacco consumption, obesity, high alcohol consumption, physical inactivity and environmental pollution, and are amenable to health promotion and preventive action. 4. The strategy proposed here aims at strengthening the capacity of Member States to draw up policies and implement programmes for the prevention and control of NCDs, using comprehensive multisectoral approaches. 5. The major thrusts of this strategy focus on strengthening health care for people with NCDs, supporting integrated disease surveillance, promoting research for community-based interventions, improving the capacity of health personnel, and ﬁ nding ways to reduce premature mortality and disability due to NCDs. 6. Countries must address NCDs within the general framework of health sector reform and ﬁ nd solutions to problems like equity, access to health care, allocation of resources and service management. 7. The Regional Committee examined and adopted this strategy and gave orientations for its implementation.

INTRODUCTION and communicable diseases persist, almost 50% of 1. The morbidity and mortality burden attributable morbidity and mortality will be caused by NCDs. to non-communicable diseases (NCDs) such as 3. The magnitude of NCDs in the Region varies cardio vascular diseases, cancer and diabetes, is on the from country to country. However, there is currently increase. In 1990, morbidity was 41% of the overall a rapid epidemiological transition, with NCDs add- disease burden worldwide, and will rise to 60% in ing to the burden of communicable diseases. This 2020. will become more signiﬁ cantly apparent in the com- 2. In 1990, NCDs and injuries caused 28% of mor- ing decades if nothing is done about the situation. bidity and 35% of mortality in sub-Saharan Africa1. Furthermore, complications of NCDs such as kid- If communicable diseases control programmes attain ney failure, stroke, heart failure, blindness, etc., are their goals, these ﬁ gures will rise to 60% and 65% extremely costly. Action should start now, before respectively by 2020. If those goals are not achieved countries are overwhelmed by NCDs.

127 COMPENDIUM OF RC STRATEGIES

4. The present regional strategy on NCDs is in obesity, high alcohol consumption, physical inactiv- response to requests by countries to the Regional ity, diabetes mellitus and lipid disorders. Director during the forty-eighth session of the 8. Hypertension is the most frequent and most im- Regional Committee. Other problems related to portant risk factor for cardiovascular diseases. Its NCDs have already been addressed through region- prevalence is estimated to be about 20 million in the al strategies or global initiatives. They include oral Region. Some 250 000 deaths could be prevented health, mental health, nutrition and health, tobacco each year through effective case management. control, disability prevention, rehabilitation and in- Complications of untreated hypertension include jury prevention. This document will, therefore, heart failure, chronic renal failure, stroke and coro- focus on other NCDs which are also of public health nary heart disease. The hypertension-related stroke importance in the Region. rate in the Region is high and victims are generally relatively young. 9. Rheumatic heart disease is still frequent despite SITUATION ANALYSIS AND the availability of several potential cost-effective JUSTIFICATION measures for preventing rheumatic fever. Its preva- Situation analysis lence could be as high as 15 per 1000 among school children3. The disease continues into the second and 5. Reliable information on NCDs in the Region is third decades of life, leading to social and family limited. However, studies carried out in certain problems and increased demand for health care. countries have helped to determine the magnitude of NCDs and some risk factors. Some countries 10. The prevalence of diabetes in the Region is esti- have even developed speciﬁ c programmes. Lack of mated to vary between 1% and 5% and is as high as data is often mistaken for non-existence of the prob- 20% in some urban and ethnic groups. The public lem and often little attention is given to NCDs. health consequences of poorly managed diabetes These diseases are caused by a combination of fac- such as kidney failure, coronary heart disease, blind- tors that include poverty2 and urbanization, which ness, diabetic foot and coma are high. lead to changes in lifestyles. As African populations 11. The numbers of new cases and of deaths by can- age, thanks to longer life expectancies, the impor- cer are higher in developing countries than in devel- tance of NCDs increases in relation to other causes oped countries. Out of nine million new cases of ill health. Indeed, by 2025, about half of Africa’s recorded in 1985, 55% were in developing coun- population will be living in urban areas, while the tries. In 2015, out of 15 million cases, 66% will number of Africans aged over 60 years will increase occur in developing countries. In Africa, it is esti- from the present 39 million to 80 million. mated that infectious agents cause 40% and 29% of 6. Therefore, conditions will exist for an increase cancers affecting men and women respectively, in cases of NCDs, which will constitute some of the which emphasizes the fact that some of the cases are most threatening diseases in the Region. Genetic avoidable. Effective preventive measures against disorders like sickle cell disease are very frequent in liver and cervical cancers, for example, are available certain countries of the Region. Health systems in through immunization and general prevention of most Member States are inadequate to deal with sexually transmitted diseases. Among African popu- NCDs. Countries currently manage these diseases lations with high maize consumption, aﬂ atoxin is a through the provision of expensive clinical services major cause of liver cancer. Exposure to radioactive that have limited coverage and impact on the health and industrial waste that has been inappropriately status of the population. Moreover, NCDs generate stored or disposed of may account for an increase in considerable needs in essential drugs and psychoso- the number of certain cancers. cial support and require organizational adjustments 12. So far, there are only a few cancer registries in in health services and systems. These conditions are the Region but the information they provide is rarely met. As a result, NCDs are less effectively highly useful. Cervical, breast and liver cancers are managed in primary health care facilities by staff common among women, while liver, prostate and who are not adequately prepared. This creates lim- stomach cancers are common among men. Cancer ited accessibility and greater inequity and leads to of the lungs and oesophagus are also frequent, espe- inappropriate management of patients with NCDs. cially in southern Africa where they are linked to 7. Many NCDs share some behavioural, environ- high tobacco consumption. In countries with a high mental or genetic risk factors. Major risk factors that prevalence of HIV infection, the incidence of can- are amenable to preventive measures are smoking, cer, especially skin cancer, is also high.

128 Intensifying the prevention and control of communicable and noncommunicable diseases

13. Asthma often starts in infancy and, if not ade- 19. NCDs, often occurring at ages of increased re- quately treated, may have serious consequences sponsibility, deprive families of precious income and throughout life. Its prevalence is increasing as a re- communities of productivity reserves. Given the sult of urbanization, smoking and air pollution. limited resources for health in the face of numerous Sudden and unexpected deaths caused by asthma priorities, the management of NCDs based on the have been reported in some Member States. hospital-curative model alone cannot work. It is diffi cult to guarantee accessibility and equity when 14. The most important risk factor for chronic ob- costs are virtually unbearable for both health systems structive pulmonary diseases (COPD) is smoking, and households. It is, therefore, necessary to develop although air pollution from burning domestic waste a comprehensive and coherent community-based and exhaust fumes also contribute. Biomass and fos- approach, using comprehensive health promotion sil fuels4 are major sources of energy in the Region. strategies to encourage healthy lifestyles, particularly It is necessary to assess the effect on health of the among the youth; prevent NCDs; detect cases early inhalation of smoke from these sources. enough; and choose effi cient clinical interventions. 15. There are several important genetic diseases, As it takes years to change risky behaviours, we many of which are aggravated by consanguinity. should start now if we are to reverse the trend and Among these are sickle cell disease, thalassemia, reduce the burden of morbidity and mortality at- Glucose6 Phosphate Dehydrogenase (G6PD) defi - tributable to NCDs. ciency and various birth defects. Further research is required to assess the magnitude of the problem in the Region. Prevalence of the causative gene of THE REGIONAL STRATEGY sickle cell disease is estimated to vary between 10 Aim and objectives per l000 and 30 per 1000 in some populations in the Region6. 20. The aim of this strategy is to alleviate the burden of NCDs through, inter alia, the promotion of 16. Trends in mortality and morbidity caused by in- healthy lifestyles among the peoples of the African juries are likely to double in 2020, compared to Region. 1990. 21. The objectives of the strategy are: Justifi cation (a) to support integrated disease surveillance aimed 17. The objective of WHO, as stipulated in its Con- at quantifying the burden and trends of NCDs, stitution, is the “attainment by all peoples of the their risk factors and major determinants; highest possible level of health”6. For more than (b) to strengthen health care for people with NCDs thirty years, the World Health Assembly (WHA) has by supporting health sector reforms and cost adopted resolutions7 calling for the rapid develop- effective interventions based on primary health ment of long-term programmes to control cardio- care; vascular diseases (CVDs), with special emphasis on (c) to support prevention approaches aimed at re- research on the prevention, etiology, early detec- ducing premature mortality and disability due to tion, treatment and rehabilitation of patients. Vari- NCDs; ous WHA resolutions have requested the Director (d) to improve the capacity of health care personnel General to intensify measures aimed at encouraging to manage and control NCDs; the prevention of cardiovascular diseases, as a model (e) to support research on effective community- for all other NCDs; assist developing countries based interventions, including traditional herbal and others to control diabetes; and encourage the medicines. development of NCD prevention and control programmes8. Resolution EB 105.R12 calls for Guiding principles community-based prevention and control of noncommunicable diseases. 22. Success in the prevention and control of NCDs in the Region will depend on the following 18. As indicated earlier, the forty-eighth and forty- principles: ninth sessions of the Regional Committee clearly expressed the concerns of Member States with re- (a) tackling the challenges of NCDs, guided by a gard to the increase in chronic diseases. This con- clear vision and careful long-term planning cern was reiterated during the fourth meeting of the within the health sector; Organization of African Unity (OAU) health minis- (b) integrating NCD prevention and control within ters held in Cairo in November 1999. the health sector reform process;

129 COMPENDIUM OF RC STRATEGIES

(c) focusing on cost-effective interventions within human and material resources are developed. Imple- effective national programmes; mentation plans should be developed in collabora- (d) promoting equity by providing poor and mar- tion with teams work ing at all levels of the health ginalized groups with minimum acceptable care system. This encourages ownership and moti- standards of health care; vation for action. The health sector should develop (e) developing advocacy programmes, using staff in an effi cient health information system; initiate cost- the fi eld who are not only familiar with the cul- effective measures for the prevention and control of ture and local conditions but also have the right NCDs; establish a standard essential package for the information; treatment and surveillance of NCDs, including the (f) building partnerships to share responsibilities use of traditional pharmaco poeia; and adopt positive and resources for maximum impact. practices with proven effi cacy. 28. Enhancement of the pre-service and in-service capacity of health care workers to meet the chal- Priority interventions lenges of NCDs in order to reduce premature morta lity and disability should include training pro- 23. Member States and WHO will need to address grammes in the management, control and preven- the following priorities in order to prevent and con- tion of NCDs. Changes in lifestyles in communities trol NCDs: should be studied and the results thereof dissemi- (a) assessment of the burden of diseases attributable nated in order to facilitate the formulation of poli- to NCDs, their risks and major determinants; cies and implementation of programmes. (b) preparation of strategies for the prevention and 29. In order to generate suffi cient data on NCDs, control of non-communicable diseases within trigger community-based responses to these diseases health development plans; and encourage the use of traditional medicine, (c) integration of NCD surveillance existing sur- countries should develop focused research plans. veillance systems; (d) enhancement of the capacity of health care 30. The most effi cient approaches for the preven- workers; tion and control of NCDs are those based on com- (e) development of operational research; prehensive, multisectoral and multidisciplinary (f) enhancement of partnership with all stakeholders; interventions implemented through partnerships (g) development of sustained advocacy. with all stakeholders. These may involve setting up a common standard for water supply and waste 24. It is important to have a local data on the disease treatment, promoting legislation and regulations on burden attributable to NCDs, their risk factors and smoking, the quality of food and air pollution, and major determinants. This knowledge will facilitate instituting an interactive information and education priority setting and adoption of appropriate actions. strategy on healthy lifestyles through schools, public Wherever data are limited, specifi c baseline studies media and the work place. should be conducted. Evidence strengthens advocacy and facilitates decision-making. 31. WHO will support the implementation of these approaches by immediately starting sustained advo- 25. A strategy for the prevention and control of non- cacy with institutional partners in all programmes communicable diseases should be prepared and in- outside its mandate that are crucial in the prevention corporated into national health development plans. and control of NCDs. Human resource develop- Countries must also consider NCDs in the general ment for the effective prevention and control of framework of their health sector reform agenda. non-communicable diseases will be promoted. 26. Poor and marginalized populations are more affected by NCDs and should benefi t from health fi nancing and social security schemes. The imple- Implementation framework mentation of such schemes by countries constitutes 32. Implementation plans should be developed at an important contribution to the successful imple- the lowest possible level with the participation of mentation of strategies for the prevention and con- communities. On the basis of clear national plans trol of non-communicable diseases. and programmes with realistic implementation time 27. Surveillance of NCDs should be adapted to frames, ministries of health should mobilize funds to mechanisms already existing such as integrated dis- support NCDs programmes. It is advisable that ease surveillance programmes. It may start in a dis- countries engage partners early in their programme trict and expand to other districts as and when development process.

130 Intensifying the prevention and control of communicable and noncommunicable diseases

33. In developing programmes for the prevention strengthen the role of WHO collaborating centres and control of non-communicable diseases, priority in support of country activities. should be given to comprehensive and integrated approaches. The designation of a national structure with responsibility for NCDs at the ministry of CONCLUSION health would facilitate contacts, exchanges and col- 40. At the dawn of the 21st century, the African laboration. Countries with established structures Region is confronted with a two-fold burden caused should strengthen their management capacities and by the persistence of communicable diseases and the focus on surveillance, operational research and eval- rapid emergence of NCDs. The problem is further uation, particularly in terms of the comparative costs complicated by the deterioration of the economic of different interventions. situation of many countries in the Region. This sit- 34. Countries should facilitate the organization of uation calls for an innovative response from Mem- national consensus workshops in order to dis- ber States. seminate the strategy and develop frameworks to 41. The present strategy aims at assisting African implement their programmes within the primary countries within the next ten years to implement a health care system. They should strive to expand comprehensive strategy for the prevention and con- ownership of programmes by all stakeholders. trol of non-communicable diseases. It also under- 35. Emphasis will be placed on surveillance, im- scores the importance WHO Member States attach provement of the performance of the health system to the prevention and control of NCDs as a means and the development of multisectoral strategies for of contributing to the health and development of reducing risk factors, particularly those related to the peoples of the Region. tobacco use, unhealthy diets and physical inactivity. 42. The Regional Committee examined and adopt- 36. WHO will step up advocacy for the implemen- ed this strategy and gave orientations for its imple- tation of the recommendations of this strategy with- mentation. in countries, particularly for the inclusion of NCDs in national priorities. Technical support will be pro- Resolution AFR/RC50/R4 vided to improve national capacities in the development, implementation, monitoring and evaluation Non-communicable diseases: A strategy for of programmes. The exchange among Member the African Region (AFR/RC50/R4) States of information on good practices will be The Regional Committee, encouraged. Aware of the magnitude and the public health 37. WHO will support the efforts of countries and importance of non-communicable diseases (NCDs), specialized bodies to carry out research on the pre- many of which have common risk factors; vention and control of non-communicable diseases. It will promote inter-country cooperation, particu- Concerned about the accelerated increase in the larly through support of multi-centre research prevalence of NCDs, adding onto the already heavy activi ties and the establishment of a network of burden of communicable diseases; relevant regional databases. Recalling resolutions WHA19.38, WHA25.44, WHA29.49, WHA36.32,, WHA38.30, WHA42.35, MONITORING AND EVALUATION WHA42.36, WHA51.18, WHA53.17 and EB105. R12 that called for intensiﬁ ed measures to prevent 38. Countries will adapt and use generic monitoring and control NCDs, and the recommendation by and evaluation indicators that will be developed by Member States adopted at the 48th and 49th sessions WHO and will conduct a mid-term review of the of the Regional Committee; implementation of their national strategies. Coun- tries should carry out the monitoring and evaluation Appreciating all the efforts that Member States of their programmes with the support of WHO. and their partners have made in the past to manage some NCDs and, thereby, improve the health of 39. WHO will take the lead in strengthening re- their population; gional partnerships for the surveillance, prevention and control of NCDs and develop mechanisms and Recognizing the need to review the existing ap- processes to help monitor activities that affect health proaches and develop a comprehensive strategic across the various sectors of government. The framework for the prevention and control of NCDs Organization will also sensitize other partners and in countries of the African Region;

131 COMPENDIUM OF RC STRATEGIES

Having carefully examined the Regional Direc- 3. REQUESTS the Regional Director: tor’s report contained in document AFR/RC50/10 (i) to provide technical support to Member States and outlining the WHO regional strategy for non- for the development of national policies and communicable diseases; programmes to prevent and control NCDs; 1. APPROVES the proposed strategy aimed at (ii) to increase support for the training of health strengthening the capacity of Member States to im- professionals in NCD prevention and control, prove the quality of life of their populations through including monitoring and evaluation of pro- the alleviation of the burden of NCDs by, inter alia, grammes at different levels, and promote the promoting healthy lifestyles and taking other use of training institutions in the Region tak- appropriate interventions. ing into account the realities in the African Region; 2. URGES Member States: (iii) to facilitate the mobilization of additional resources for the implementation of the regional (i) to develop or strengthen national policies and strategy in Member States; programmes targeting the prevalent NCDs (iv) to draw up operational plans for the decade affecting their populations; 2001–2010; (ii) to support integrated disease surveillance aimed (v) to report to the 53rd session of the Regional at quantifying the burden and trends of NCDs, Committee, in the year 2003, on progress in their risk factors, the quality of the manage- the implementation of this regional strategy. ment of cases and their major determinants; Seventh meeting, 31 August, 2000 (iii) to strengthen health care for people with NCDs by supporting health sector reforms and REFERENCES cost-effective interventions, based on primary health care; 1. C. Murray and Allan Lopez. The Global Burden of Dis- (iv) to support prevention strategies based on ease. WHO, Harvard School of Public Health, World Bank. 1996. knowledge of the risk factors, aimed at reduc- 2. Gwatkin et al. The burden of disease among the global ing the occurrence of cases and, consequently, poor. The Lancet 354: 586–589, 1999. premature mortality and disability due to 3. Longo-M Benza B. et al. “Survey of rheumatic heart NCDs, using multisectoral approaches that in- disease in school children of Kinshasa town”. Int. J. clude measures such as regulations and taxa- Cardiol. 63(3): 287–94, February 1998. tion, where applicable; 4. Wood, cow dung, charcoal, kerosene, etc. (v) to improve the capacity of health care person- 5. Akinyanju O. Proposed goals and strategies to develop ge- nel in the management and control of NCDs; netic services in Africa. Joint WHO/AOPBD Meeting (vi) to support research on the identiﬁ cation of ef- on the prevention and care of genetic diseases and fective community-based intervention strate- birth defects in developing countries. The Hague, 5–7 January 1999. gies, including traditional herbal medicines; 6. Article 1. WHO Constitution (vii) to consider the experience and progress made 7. WHA 19.38 (1996), WHA25-44 (1972), WHA29-49 in the prevention of prevalent genetic dis orders (1976) and WHA36-32 (1983). when developing programmes for the commu- 8. Resolutions WHA38-30, WHA42-35, WHA 42-36 nity-based management of these diseases. and WHA 51-18.

132 5.5 Control of human African trypanosomiasis: A strategy for the WHO African Region (AFR/RC55/11)

EXECUTIVE SUMMARY 1. Human African trypanosomiasis (HAT) is caused by trypanosomes that are transmitted by the tsetse fl y. HAT is the only vector-borne parasitic disease with a geographical distribution limited to the African continent. Populations in the age group 15–45 years living in remote rural areas are the most affected, leading to economic loss and social misery. 2. In the early 1960s, the prevalence of HAT had been reduced to very low levels (prevalence rate less than one case per 10 000 inhabitants). Unfortunately, due to lack of regular surveillance activities and reduced resource allocation to HAT as well as changing health priorities and non- availability of drugs, the disease has been neglected. 3. During the 1980s and 1990s, considerable progress was made in the development or improvement of epidemiological tools suitable for HAT control; however, these were not suffi ciently used in the fi eld. All this led to the resurgence of the disease in areas where it was previously controlled, reaching epidemic levels in some instances. WHO estimates are that infected individuals number between 300 000 and 500 000. 4. The proposed regional strategy for the control of HAT is aimed at eliminating the disease as a public health problem by 2015. To attain the set targets, the strategy proposes an integrated approach, consisting of continuous surveillance of the population at risk, passive and active case detection and treatment, reduction of animal reservoirs through selective or mass treatment of livestock, and intense tsetse control in highly endemic and epidemic areas. 5. Implementation of this strategy should reduce morbidity and mortality due to human African trypanosomiasis and improve the economic and social status of the affected populations. 6. The Regional Committee examined and adopted the strategy.

INTRODUCTION months. The early stage is usually characterized by 1. Human African trypanosomiasis (HAT), com- malaria-like symptoms, including fatigue, headache, monly known as “sleeping sickness”, is caused by recurrent fever and swollen lymph nodes. In advanced trypanosomes that are transmitted by the tsetse ﬂ y. stages, the disease affects the central nervous system, The disease was recognized centuries ago. HAT is the causing severe neurological and mental disorders and only vector-borne parasitic disease with a geographi- making the individual dependent on others. Infected cal distribution limited to the African continent. individuals are weakened, often for many years, caus- There have been three severe epidemics: one at the ing economic loss, poverty and social misery. HAT is end of the nineteenth century, the second during the completely fatal if untreated. 1920s, and the third from the 1970s to the present. 3. HAT constitutes a major public health problem 2. The disease progresses through two stages, fol- in the African Region. Given the resurgence of both lowing an asymptomatic period of several weeks or human and animal trypanosomiasis, the epidemic

133 COMPENDIUM OF RC STRATEGIES potential, high fatality rate and signifi cant impact on cases to WHO. More than 80% of these cases were socioeconomic development, many countries re- reported from Angola (3000 cases) and the Demo- quested more active WHO support to control the cratic Republic of Congo (11 000 cases). disease. The aims of this proposed strategy are to 6. Sleeping sickness is mainly a disease of poor, control the intensity of transmission in endemic and marginalized and rural populations who depend on epidemic countries in the medium term and to their land and labour for a livelihood. HAT repre- eliminate the disease in the long term. sents a major threat to economic development because it mainly affects the most productive age SITUATION ANALYSIS group (15–45 years) and sustains the disease-poverty- disease cycle. 4. During the nineteenth century, HAT was an enormous public health problem. Currently, there 7. A signifi cant proportion of children are affected are more than 250 active foci within the “tsetse by HAT, and many will have considerable delay in belt” in sub-Saharan Africa, mainly involving coun- mental development even after successful treatment. tries of the WHO African Region and the Sudan. This will impact negatively on their school perform- Within this area, sleeping sickness threatens over 60 ance and eventual lifetime achievements. million people. Less than 10% of the at-risk popula- 8. According to recent estimates,3 the disability ad- tion are currently under surveillance. In recent justed life years (DALYs) lost due to sleeping sick- years, an annual average of about 45 000 cases has ness was 2.05 million. The same source reported been reported; however, WHO estimates that be- 66 000 deaths in 1999 due to HAT. tween 300 000 and 500 000 individuals are infected.1 9. Given the negative socioeconomic impact of 5. The true number of endemic countries is un- HAT, the Regional Committee, in 1982, adopted known. It is reported that HAT is endemic in 35 Resolution AFR/RC32/R1 recommending to countries in the African Region, but there are dif- Member States to implement trypanosomiasis control ferent levels of endemicity2 (see Figure 1). Countries activities. This was later endorsed by World Health are classifi ed as: (a) non-endemic with no case re- Assembly resolutions WHA36.31, WHA50.36 and ported in fi ve or more years; (b) unknown endemic- WHA57.2. ity (0–25 new cases per year); (c) low endemicity (26–100 new cases per year); (d) moderate endemi- 10. The disease was brought under control in the city (101–500 new cases per year); (e) highly en- early 1960s when the prevalence was dramatically demic or epidemic (more than 500 new cases per reduced to very low levels (less than one case per year). In 2003, countries reported about 17 000 new 10 000). Active case detection by examination of lymph-node aspirates, treatment with toxic drugs, vector control and mobile teams were utilized. 11. Unfortunately, these successful results could not be sustained. Regular and systematic surveillance, which is the cornerstone of HAT control, was aban- doned because of the progressive shortage of qualifi ed personnel. Population movements following political upheavals and economic crises as well as changing priorities in national policies led to the allocation of fewer resources to the health sector. A substantial proportion of the inhabitants of endemic foci were no longer participating in screening activities. Hence, active case detection was greatly reduced, and drugs for treatment were often not available. All these factors contributed to the resurgence of the disease to epidemic levels. Non-AFRO countries Epidemic country 12. In some countries, control efforts resumed, but Highly endemic country Low level of endemicity the situation continued to worsen. Current HAT Endemicity level not clear Non endemic AFR country control in the Region faces a lot of constraints and challenges: insuffi cient fi nancial allocations, severe Figure 1: Human African trypanosomiasis endemicity in shortage of skilled personnel, inadequate health the WHO African Region infrastructure, diagnostic and treatment procedures

134 Intensifying the prevention and control of communicable and noncommunicable diseases that are diffi cult to implement at peripheral level, (b) By 2008, at least 60% of the endemic countries severe drug side-effects, increased drug resistance, in the African Region will have deployed a poor community awareness and participation in suffi cient number of skilled personnel for the control activities, remote disease foci, and lack of implementation of national control programmes; multisectoral coordinated action to implement dis- (c) By 2010, at least 35% of endemic countries in ease control programmes. the African Region will have a prevalence rate of one case or less per 10 000; 13. Strong enabling factors for human African (d) By 2012, targeted vector control interventions trypanosomiasis control do exist. In affected coun- will have been implemented in epidemic and tries, there is strong willingness and commitment to highly endemic areas (prevalence rates equal to HAT control. The private sector, including pharma- or greater than 1%); ceutical companies and the international community, (e) By 2015, all known endemic countries will have is expressing willingness to offer support to neglected a prevalence rate of less than one case per 10,000 diseases, including HAT. New tools have been devel- persons at risk. oped for diagnosis and vector control, which further facilitate the implementation of control activities. 18. Taking into account the diversity of conditions in the different foci, this strategy should be adapted to local conditions. Rapid reduction of the parasite THE STRATEGY reservoir in humans is the backbone of the control of human African trypanosomiasis, while reduction of 14. The success of HAT control in the African the animal reservoir plays an important complemen- Region will depend on the following guiding tary role in the control of animal trypanosomiasis. principles: To achieve the set objectives, various interventions (a) Formulation, adoption and implementation of a should be implemented. These are capacity building, national policy for HAT control in each affected case detection and treatment, vector control, control country; of animal reservoir, surveillance, health promotion, (b) Ownership of the control programme by advocacy and operational research. govern ments and communities of the endemic 19. Capacity building for HAT control should be countries; undertaken as a matter of urgency, and training of (c) Coordination of stakeholders by national con- nationals should be a priority. Detection and treat- trol programmes; ment centres should be appropriately equipped, and (d) Sustainability of control programme activities. supervision should be instituted and enforced for 15 The goal of the human African trypanosomiasis strengthening capacity. strategy is to reduce the morbidity and mortality 20. Case detection and treatment should be carried attributed to sleeping sickness in the African Region. out at least once a year in each focus, especially in The main objective is to support governments to highly endemic and epidemic areas, to ensure rapid develop HAT control plans and programmes. reduction of the parasite reservoir in humans. Activi- 16. The specifi c objectives are: ties will include setting up and equipping diagnostic and treatment centres; setting up, equipping and (a) to strengthen capacities to plan, implement, staffi ng mobile teams at district level; ensuring avail- monitor and evaluate national HAT control ability of drugs at district level; following-up sero- programmes; logical suspects and tracking post-treatment patients. (b) to conduct baseline studies on HAT prevalence, incidence and mortality; 21. The technology to be used for tsetse control (c) to promote and coordinate the involvement of should be determined by individual countries. They public and private sectors in HAT control; may opt for targeted tsetse control after an epide- (d) to promote operational research as a tool to miological assessment of the disease and vector, per- identify and address issues arising from the haps choosing cost-effective tsetse traps. imple mentation of national HAT control 22. Communities should contribute to sustainability programmes. and minimizing costs. Local manufacture of tsetse 17. The targets of the regional strategy are as follows: traps, for example, will promote community ownership of the programme. (a) By 2007, at least 80% of endemic countries in the African Region will have established nation- 23. Strengthening control of the animal reservoir al policies and control programmes for HAT; requires intersectoral linkages. All sectors should,

135 COMPENDIUM OF RC STRATEGIES therefore, collaborate from planning to implementa- review fi ndings and strengthen collaboration be- tion phase for control of the animal reservoir in both tween research and control activities. animal and human trypanosomiasis. Treatment of livestock in areas reporting T.b. rhodesiense will re- Priority interventions duce the reservoir population. The treatment could 28. Priority interventions will include mapping dis- be either selective (after diagnosis) or comprehen- ease distribution, case detection and treatment, set- sive (treating all livestock). Farmers should be sensi- ting up a surveillance system, and control of animal tized and mobilized to present their animals for reservoirs and vectors. The starting point in HAT examination and treatment. The role of animals in control is assessment of the disease situation. This T.b. gambiense is not clear; therefore, treatment of will result in the mapping and delimitation of the livestock in endemic areas needs to be evaluated. foci where the disease prevails and allow better plan- 24. Efforts should be made to collect HAT data ning of control interventions. through the integrated disease surveillance approach. 29. Case detection should be passive and active; pas- Sentinel sites should be set up, and the collected data sive detection being when patients seek intervention could be used for mapping disease distribution, moni- on their own initiative; active detection is based on toring disease trends and resistance to drugs, establish- clinical surveys in the fi eld. Interventions should ing HAT data banks at decision-making and planning emphasize active case detection, especially in highly levels, epidemic preparedness and response, and case endemic and epidemic areas; appropriate treatment reporting. Other activities will be the development of based on specifi c drugs available at treatment centres data collection and management tools (such as TRY- close to patients’ residences; adequately trained DATA) and promotion of cross-border surveillance health workers; patient follow-up for a period of 18 through information sharing and meetings. months. 25. Health promotion should be implemented with- 30. HAT control has been and will continue to be in the context of the regional health promotion strat- based on passive and active surveillance of popula- egy. Individual and community knowledge of HAT tions at risk and the treatment of cases detected, can be increased through health education and infor- coupled with vector control interventions in hyper- mation-education-communication. Health educa- endemic and epidemic areas. Failure to maintain tion should be included in the curricula at primary surveillance will result in resurgence and epidemics school level. HAT can be a component of national that will substantially increase morbidity and mortal- health education packages and other disease control ity and require expensive control measures. programmes. Social mobilization can strengthen community action. National programmes should be 31. It is important to carry out selective or mass encouraged to form partnerships with the media to treatment in order to minimize animal reservoir disseminate information about HAT and its control. hosts (especially in T.b. rhodesiense). This mainly calls for the treatment of livestock in the endemic areas. 26. Advocacy should be aimed at mobilizing resources at national and international levels for the 32. In highly endemic foci, case detection must be implementation of national programmes. Govern- coupled with tsetse control to achieve more rapid ments should be encouraged to allocate funds for and effective control. Ministries of livestock and HAT control interventions to ensure sustainability. agriculture should be involved in vector control Advocacy is also crucial for building public-private activities. Trapping of tsetse fl ies is effective, simple, partnerships. environmentally-friendly and preferable to insecticide spraying. Insecticide application in cattle dips 27. The Regional Offi ce should support operational can also be used. These methods should involve research and research on health systems in collabora- community participation. tion with the WHO Special Programme for Re- search and Training in Tropical Diseases, the United 33. The sterile insect technique still poses a series of Nations Development Programme and the World technical, fi nancial and logistic problems. Therefore, Bank. Research issues should arise as a result of the it is not yet recommended in epidemic situations. implementation of national HAT control programmes and include treatment failures; relapses; Roles and responsibilities clinical trials of drug combinations; rapid methods Countries for mapping; socioeconomic burden of the disease; knowledge, attitudes and practices of the communi- 34. Ministries of health at national level should ties. Meetings should be held to prioritize topics, develop human African trypanosomiasis policies,

136 Intensifying the prevention and control of communicable and noncommunicable diseases plans and implementation frameworks. These docu- 42. WHO will also collaborate with other inter- ments will be the basis for all stakeholder support national organizations and projects such as the and will ensure uniform control activities and strong African Union, the Food and Agriculture Organiza- partnerships. tion, the United Nations Development Programme, the International Atomic Energy Agency, and the 35. Districts will be responsible for planning; imple- Pan African Tsetse and Trypanosomiasis Eradication menting, supervising, monitoring and evaluating Campaign to promote treatment of animal reservoirs HAT control activities in countries. Communities and tsetse control. The Organization will monitor should participate and thus own HAT control pro- and evaluate the regional strategy and national grammes; they should be involved from the concep- programmes. tual phase. 36. A national HAT programme manager should be MONITORING AND EVALUATION appointed in each country. Multidisciplinary task forces and committees for HAT control should be 43. Monitoring and evaluation of the national control established at all levels to ensure intersectoral co- programmes include continuous internal monitoring ordination. and periodic external review and evaluation. The progress and impact of the programme will be assessed 37. Diagnosis and management will be decentralized and redirected, if necessary. Core indicators for moni- in such a way that each affected district will partici- toring and evaluation will be developed by the WHO pate in control of the disease. Vector control will be Regional Ofﬁ ce. Countries will be encouraged to integrated with other control activities, where adapt indicators to their speciﬁ c contexts. appropriate. 38. Coordination will ensure standards and uni- formity of activities, while collaboration will aim at CONCLUSION establishing strong partnerships at all levels. Inter- 44. Human African trypanosomiasis is endemic only ministerial collaboration will ensure promotion of in Africa, where the disease is of great public health tsetse control and treatment of animal reservoirs. importance. The continent is currently facing a third 39. Ministries of health are responsible for mobiliz- epidemic. The social and economic consequences of ing resources for the programme and for providing the disease impact negatively on the development of overall coordination, supervision, monitoring and the affected countries. evaluation. They will offer technical support to dis- 45. HAT control necessitates close collaboration be- tricts and promote public-private sector partner- tween public and private sectors and strong involve- ships. ment of communities and NGOs. 40. The public sector will collaborate with the pri- 46. Implementation of this strategy in the affected vate sector and international bodies to ensure avail- countries should reduce morbidity and mortality ability of HAT control products and technologies. due to human African trypanosomiasis in the Region According to their comparative advantages, non- and, hence, eliminate the disease as a public health governmental organizations will support national problem by 2015. programmes and work closely with them. Partners will contribute in advocacy, resource mobilization 47. The Regional Committee examined and adop- and capacity building. ted the strategy.

Resolution AFR/RC55/R3 WHO responsibilities Control of human African trypanosomiasis: 41. WHO will support the development and imple- Strategy for the African Region mentation of national control programmes through technical support and capacity building (including The Regional Committee, support to research institutions working on sleeping Having carefully examined the regional strategy sickness). Intercountry teams based on epidemio- for the control of human African trypanosomiasis logical blocs will be strengthened. WHO will also (HAT) during the next decade; promote linkages between this strategy and other relevant WHO regional strategies on integrated vec- Deeply concerned about the resurgence of tor management, health promotion and integrated African trypanosomiasis and its devastating effect on disease surveillance. human and livestock populations, both of which

137 COMPENDIUM OF RC STRATEGIES contribute to poverty accentuation on the African mass treatment of livestock, where appropriate, continent; are implemented for HAT control; (d) to advocate for an increased awareness of the Aware of the public health importance of human risks and consequences of HAT, with emphasis African trypanosomiasis, the epidemic potential, the on community participation at all stages of the high fatality rate and the socioeconomic impact of fi ght against this disease; the disease; (e) to mobilize and coordinate national and interna- Noting that a signifi cant proportion of children tional stakeholders involved in the fi ght against are affected by the disease and many of them suffer sleeping sickness, including local communities, considerable delay in their mental development, public and private sectors, NGOs, and bilateral which impacts negatively on their school perform- and multilateral organizations; ance and professional advancement; (f) to promote operational research as a tool for improved planning, implementation, monitoring, Recalling Resolution AFR/RC32/R1 (1979) evaluation and integration of national HAT con- recommending to Member States to implement trol programmes into the national health system; human African trypanosomiasis (HAT) control acti- (g) to develop standardized guidelines for the im- vities, which was later endorsed by the World plementation, monitoring and evaluation of the Health Assembly resolutions WHA36.31 (1986), regional strategy; WHA50.36 (1997), WHA56.7 (2003) and WHA57.2 (2004); 3. REQUESTS the Regional Director: Appreciating the commitment and efforts made (a) to provide technical support to Member States so far by Member States and their partners to bring for the development of national policies and the resurgence of the disease under control; strategic plans for HAT control; (b) to advocate for additional resources at national Convinced that controlling human African try- and international levels for the implementation panosomiasis will ultimately contribute to poverty of HAT and tsetse control activities in endemic alleviation in the affected rural communities; Member States; 1. APPROVES the proposed strategy, which aims (c) to report to the fi fty-seventh session of the at strengthening the capacity of Member States to Regional Committee in 2007, and every three eliminate the disease as a public health problem by years thereafter, on the progress made in the im- 2015; plementation of the Regional Strategy for HAT control. 2. URGES Member States of affected countries: Eighth meeting, 25 August 2005 (a) to develop national policies, strategies and plans for the implementation of national control pro- REFERENCES grammes for human African trypanosomiasis and tsetse control in line with the regional strategy; 1. WHO, Control and surveillance of African trypano- (b) to provide suffi cient fi nancial and human somiasis. Report of WHO expert committee. WHO resources for the implementation of national technical report series, Geneva, World Health Organization, 1998. human African trypanosomiasis control pro- 2. Pépin J, Meda AH. The epidemiology and control of grammes, including capacity strengthening human African trypanosomiasis, Advances in Parasito- through training of health workers; logy, 49, 71–132, 2001. (c) to ensure that active and passive case detection 3. WHO, The world health report 2000: Health systems: and treatment combined with targeted vector Improving performance, Geneva, World Health Organi- control in high prevalence areas and selective or zation, 2000.

138 5.6 Accelerating the elimination of avoidable blindness: A strategy for the WHO African Region (AFR/RC57/6)

EXECUTIVE SUMMARY 1. The number of blind people in the African Region is estimated at 6.8 million. Blindness is a real public health problem. 2. Several countries in the Region have blindness control programmes. However, the programmes have limited impact due to lack of appropriate structures and resources. The Global Initiative for the Elimination of Avoidable Blindness, also known as “Vision 2020: The Right to Sight”, launched in partnership with the International Agency for the Prevention of Blindness, is an oppor tunity and appropriate response to the challenges posed by blindness. 3. The present strategy is intended to help implement the Vision 2020 Initiative in the African Region. 4. Interventions proposed under the strategy are: (i) advocacy and development of policies and plans; (ii) integrating eye care activities in existing health systems; (iii) adopting speciﬁ c approaches to controlling priority diseases; (iv) developing human resources and infrastructures; (v) strengthening partnership and mobilizing resources; (vi) developing research. 5. The Regional Committee reviewed and adopted the strategy to eliminate avoidable blindness.

INTRODUCTION themselves to supporting this global initiative by de- 1. Visual impairment refers to low vision and veloping national Vision 2020 plans in partnership blindness, which correspond to partial or total loss of with nongovernmental organizations, the private sight as measured by a standard scale.1. Blindness is sector and civil society, and by starting to implement preventable or treatable in 75% of cases. these plans by 2007 at the latest. 2. Blindness is a real public health and socio- 5. Resolution WHA59.253, for its part, urges economic problem. In developing countries, it Member States to develop and strengthen eye care worsens the problem of poverty. The burden of services, integrate them into existing health systems, blindness remains high despite all efforts. train key categories of personnel, re-train health workers in visual health care and mobilize domestic 3. “Vision 2020: The Right to Sight” is a global ﬁ nancial resources. initiative that aims to eliminate avoidable blindness by the year 2020. The Initiative is a partnership 6. The present strategy proposes speciﬁ c interven- between WHO and the International Agency for tions as part of the Vision 2020 Initiative for pre- the Prevention of Blindness (IAPB), which is a venting and eliminating avoidable blindness in the broad coalition of nongovernmental organizations. African Region. 4. The World Health Assembly, by its Resolution WHA56.26,2 urges Member States to commit

139 COMPENDIUM OF RC STRATEGIES

SITUATION ANALYSIS AND 13. Onchocerciasis is endemic in 30 countries of the JUSTIFICATION Region. It has been controlled successfully in 10 out of 11 affected West African countries, thanks to the Situation analysis Onchocerciasis Control Programme (OCP) that 7. Lack of reliable epidemiological data is a basic ended in 2002. In the remaining 19 affected coun- problem in Africa. About 161 million people have tries in the Region, the African Programme for visual impairment worldwide; of these, 37 million Onchocerciasis Control (APOC) aims to eliminate are blind. It is estimated that the number of people the disease. with visual impairment in sub-Saharan Africa is 27 14. Childhood blindness is preventable or avoidable 4 million, of whom 6.8 million are blind. in the majority of cases, and its incidence has been 8. The main causes of avoidable blindness in devel- reduced through integrated actions for combined oping countries worldwide are: cataract (50%); glau- elimination of vitamin A defi ciency and measles (Glo- coma (12%); corneal opacity (5%); diabetes (5%); bal Child Survival Initiative). Preventive measures in- trachoma (4%), affecting especially women and chil- clude immunization and prevention of both vitamin dren; childhood blindness due to vitamin A defi - A defi ciency and sexually-transmitted infections. De- ciency, measles and neonatal conjunctivitis (4%); tection and management of congenital cataract and onchocerciasis (0.8%); other causes (14%)5, includ- congenital glaucoma remain diffi cult in the Region. ing low vision and refractive errors. Only four pilot countries (Ethiopia, Ghana, Kenya and Mali) have the appropriate surgical facilities. 9. Cataract is the main cause of blindness in the Region. It is either congenital or acquired (due to 15. Refractive errors and low vision affect a signifi - ageing, diabetes, injury) and corresponds to opacity cant proportion of the population. With the excep- of the lens, gradually leading to diminished vision. It tion of Ethiopia, countries of the Region do not is estimated that 3–4 million cataract cases are not have reliable data on these two conditions. Some operated upon, and only a small proportion of countries have initiated and started implementing patients actually undergo surgery. Specifi cally, only specifi c programmes. 200 cases per million inhabitants undergo operation 16. Eye care facilities are often inadequate, with ob- annually in the African Region, as opposed to 3000 solete and dysfunctional equipment. Lack of staff 6 to 5000 in the developed countries. Diffi culties of and shortage of medicines and other essential eye access to care and the high cost of surgery make this care products are frequent. The resulting rise in the situation even worse. incidence of diseases that cause blindness increases 10. Glaucoma, a condition linked to insidious rise in the threat to health in the Region. Adequate man- intraocular pressure, raises the problem of adherence agement of eye conditions in the Region would re- due to long-term treatment. The main risk factors quire a reorganization of care systems and services. are high ocular pressure, age (over 40 years), family history and ethnicity (the black race at greater risk). Justifi cation Its treatment, whether by lifelong intake of medi- 17. Blindness is one of the main public health prob- cines or by surgical intervention, requires expensive lems in Africa, even though 75% of the underlying clinical services, yet the outcomes are modest. causes are preventable. The World Health Assembly 11. Diabetic retinopathy is an ocular complication has already adopted two resolutions on blindness of diabetes. Globally, 2% of cases develop into blind- prevention. Vision 2020 is an appropriate response ness. Its rate of development into blindness in the to the problem of blindness and provides an oppor- African Region is unknown. This disease, which is tunity for governments, nongovernmental organiza- a complication of uncontrolled diabetes, raises prob- tions, eye care professionals and the private sector to lems of case detection and management. work together to eliminate avoidable blindness. This strategy for the African Region will facilitate the im- 12. Lack of hygiene, poverty and diffi culty of access plementation of Vision 2020. to water are enabling factors for trachoma, an infectious eye disease whose complications and sequels can lead to blindness. A four-component strategy THE REGIONAL STRATEGY called SAFE (meaning Surgery, Antibiotics, Facial cleanliness and Environmental change), implement- Aim and objectives ed in the 19 endemic countries of the Region,7 can 18. The aim of this strategy is to help reduce the help reduce the burden of blinding trachoma. burden of avoidable blindness.

140 Intensifying the prevention and control of communicable and noncommunicable diseases

19. The objectives of the strategy are: primary health care principles, including the referral function. At the community level, promotional ac- (a) to help create a favourable political environment tivities and health education should be integrated for the implementation of Vision 2020; into common familiar activities and the activities of (b) to integrate eye care services into primary health already-established associations. Basic eye care and care; the management of simple cases of refractive errors (c) to strengthen the development of human re- should be developed at the primary level under sources and appropriate technologies and infra- formative supervision. structure; (d) to strengthen partnership and resource mobiliza- 26. Cases beyond the competency of the primary tion; level, especially cataract cases recommended for (e) to support studies on effective community inter- operation and trichiasis cases in blinding trachoma ventions. recommended for surgery should be referred to the secondary level. Complicated and diffi cult cases be- Guiding principles yond the competency of the secondary level should be referred to the tertiary level. Rehabilitation, train- 20. The proposed strategy is based on the following ing and research should be carried out at all levels. guiding principles: (a) adopting preventive, curative and rehabilitative Adopting specifi c approaches to controlling priority interventions that are cost-effective; diseases (b) promoting equity by ensuring that disadvantaged groups have access to quality care; 27. Vision 2020 provides specifi c orientations on in- (c) multisectoral and multidisciplinary partnerships, terventions deemed appropriate for cataract, tracho- with the health sector playing a predominant ma, onchocerciasis, childhood blindness and refractive role; errors. The need for countries to have access to these (d) community involvement in obtaining adequate interventions will be stressed. Screening and surgery data on blindness, and fostering community re- are the recommended interventions for cataract. sponsiveness to eye diseases. 28. The SAFE strategy should be intensifi ed and better implemented in countries where blinding Priority interventions trachoma is endemic. For countries where blinding trachoma and other parasitic diseases are co- 21. Priority interventions for improving blindness endemic, the antibiotics component of the SAFE prevention and control are: strategy should be integrated into programmes on neglected tropical diseases. Facial cleanliness and Advocacy and development of policies and plans environmental hygiene should also be integrated 22. Creating and strengthening favourable condi- within other water and sanitation programmes. tions for increasing advocacy and awareness are 29. Implementation of the Yaounde Declaration of crucial to decision making and resource mobiliza- 2006 will help accelerate onchocerciasis elimination for the implementation of interventions. tion in the Region. To that end, activities, including 23. Data on avoidable blindness should be gathered surveillance, should be strengthened in countries in to create an evidence base for use partly in the policy post-confl ict situations and countries where there development process in order to convince stake- are pockets of onchocerciasis co-endemicity with holders during discussions to support and guide loiasis, another parasitic disease. In addition, the ac- interventions. tivities must be extended to the ex-OCP countries. 24. There is a need to strengthen the development 30. Partnership with the Global Child Survival Ini- and implementation of national plans. In addition, tiative should be strengthened. Education and all blindness control stakeholders must be brought training of community health workers and tradi- together for consultations leading to appropriate tional health practitioners should be developed. national programmes. There is need to enhance the capacity of maternity and postnatal care providers and mothers to detect Integrating eye care activities into existing health congenital eye conditions, particularly those linked systems to vitamin A defi ciency and congenital cataract. 25. Integration of eye care will involve all existing 31. Refractive error cases involving children aged levels of health care systems. It should be inspired by from 6 to 15 years and adults over 45 years should be

141 COMPENDIUM OF RC STRATEGIES given priority. This will require developing and national, interregional and international levels in strengthening case detection within schools, col- order to ensure and facilitate the implementation of leges, associations and public places. This activity interventions and optimize the use of resources. should be supplemented with a programme for sup- Existing partnerships should be strengthened. plying low-cost spectacles. Developing research 32. For glaucoma, there will be need to develop and strengthen health education, screening tar- 39. Countries will identify research priorities to sup- geted at high-risk subjects and early management. port the implementation of avoidable blindness pre- Access to affordable, essential antiglaucoma medi- vention and control programmes. They will be cines will be provided. encouraged to support and fi nance research work, especially operational research. It will be helpful to 33. Primary and secondary prevention of diabetes encourage training of researchers and equip re- should be strengthened to minimize the onset of search institutions, schools of medicine and training diabetic retinopathy, which, once developed, is irre- centres. versible. Appropriate equipment and technology should be made available to stop the progression of Roles and responsibilities blindness. 40. Countries should: Developing human resources and infrastructures (a) develop and implement blindness control poli- 34. Strengthening the capacities of all categories of cies and plans and integrate eye care into existing eye care personnel is essential. Training should be health systems, based on fi eld surveys; provided for eye care personnel in order to fi ll the (b) strengthen health systems and blindness control noted shortfalls in skills and abilities. The capacity of capacities by fostering community involvement, communities to conduct preventive and promotion- collaboration with partners and operational al activities and identify cases of visual impairment research; will be strengthened. (c) mobilize resources from domestic and external sources, establish national committees, coordi- 35. At the primary level, competencies in cataract nate the activities of all stakeholders and monitor and active trachoma detection in endemic countries blindness control programmes; and provision of basic eye care should be strength- (d) coordinate all partners; ened. The programme for initial training of para- (e) undertake synchronized and integrated cross- medical staff should be improved by including basic border cataract campaigns. notions of priority eye diseases. 41. WHO and partners should support countries to: 36. At the secondary and tertiary levels, it will be necessary to train a larger number of ophthalmolo- (a) provide technical assistance for the development gists; cataracts surgeons from among general practi- of policies and plans, and for data collection tioners, and eye care assistants, based on the specifi c through surveys and data analysis and dissemina- context of each country; other categories of essential tion; medical and non-medical staff such as nurses special- (b) support countries to establish and implement ized in ophthalmology, refractionists, low vision control mechanisms and standards; technicians, maintenance technicians and programme (c) carry out advocacy among policy-makers, inter- managers. The skills of ophthalmologists must be re- national partners and other key stakeholders for inforced with additional sub-specialities. increased resources; (d) support training programmes; 37. Infrastructure should be rehabilitated, equip- (e) support harmonization of country programmes. ment renovated, and eye care consumables and medicines made available all year round. At the same time, new eye care services that meet the set stand- Resource implications ards in microsurgery and basic eye tests should be 42. Additional domestic and external resources are established. needed to support the strategy in the context of a broader partnership (bilateral and multilateral fund- Strengthening partnerships and mobilizing resources ing partners, NGOs and donors). Blindness control 38. It is essential to strengthen the mobilization of programmes in countries are currently supported resources and the development of effective and mainly by partners with very limited contribution coordinated partnerships among all actors at the from governments. The proposed interventions will

142 Intensifying the prevention and control of communicable and noncommunicable diseases require reorganization and concentration of re- be put on the need for advocacy to sensitize deci- sources to facilitate their implementation. sion-makers, partners, health professionals and the populations to support the implementation of these 43. Available human resources adequately trained in interventions. eye care delivery at all levels; essential eye care equipment, medicines and consumables; and a community 46. The Regional Committee reviewed and adop- monitoring mechanism should be guaranteed. ted the strategy to eliminate avoidable blindness.

MONITORING AND EVALUATION REFERENCES 44. Establishment of a monitoring and evaluation 1. International Statistical Classifi cation of Diseases (ICD- system will help improve the implementation of in- 10), volume 1, H54, 456–457. 2. Resolution WHA56.26, Elimination of avoidable terventions in accordance with the main objectives blindness, Geneva, World Health Organization, 28 of this strategy. Countries will be provided with in- May 2003. dicators for monitoring cataract surgery rates, the 3. Resolution WHA59.25, Prevention of avoidable prevalence of trichiasis and active trachoma, imple- blindness and visual impairment, Geneva, World mentation of the SAFE strategy in endemic coun- Health Organization, 27 May 2006. tries, national onchocerciasis control programmes, 4. Resnikoff S et al. Global data on visual impairment in measles immunization coverage, incidence of vita- the year 2002, Bulletin of the World Health Organiza- min A defi ciency, and prevalence of blindness and tion, 82: 844–851, 2004. ocular disability due to uncorrected refractive errors. 5. Resnikoff S et al. Prévention de la cécité: nouvelles données et nouveaux défi s, Revue de santé oculaire communautaire 2(1): 1, 2005. CONCLUSION 6. Thylefors B. Une initiative mondiale pour l`élimination de la cécité évitable, Revue de santé oculaire communautaire, 45. Blindness is a real and serious public health 1(1) : 1–3, 2004. problem in the African Region. Existing interven- 7. Algeria, Burkina Faso, Chad, Ethiopia, Gambia, Gha- tions are highly cost-effective and will help achieve na, Guinea, Guinea-Bissau, Kenya, Mali, Malawi, the objective of reducing avoidable blindness, which Mauritania, Mozambique, Niger, Nigeria, Senegal, accounts for 75% of blindness cases. Emphasis must Tanzania, Togo and Zambia.

143 5.7 Diabetes prevention and control: A strategy for the WHO African Region (AFR/RC57/7)

EXECUTIVE SUMMARY 1. Diabetes is a chronic disease characterized by chronic hyperglycaemia, which requires lifelong treatment. Its prevalence in Africa varies between 1% and 20%. Type 2 diabetes, which is the most common form, can be life threatening due to its complications, particularly, cardiovascular diseases. It constitutes a serious public health problem. 2. Diabetes, like other non-communicable diseases in the Region, receives lower attention than it deserves, despite its social, human and economic costs. Few countries have national programmes and basic facilities that are appropriate for the control of diabetes. 3. The present strategy urges Member States to evaluate the magnitude of diabetes and identify and improve areas of intervention in terms of primary, secondary and tertiary prevention activities. 4. Countries are encouraged to create the conditions required for prevention, early detection diagnosis, treatment, guarantee of equitable access to care, and availability of drugs at health facilities. 5. The Regional Committee examined and adopted the strategy for diabetes prevention and control.

INTRODUCTION 4. During the Forty-second World Health Assem- 1. Diabetes mellitus is a chronic disease whose bly (1989), WHO adopted Resolution WHA42.36 global spread has given it the characteristics of a pan- on the prevention and control of diabetes, inviting demic. The most frequent form is Type 2 diabetes Member States to evaluate the prevalence of dia- which represents more than 85% of the cases. Other betes at national level, take measures that focus on forms are Type 1 (10%), specifi c diabetes and gesta- the population and are adapted to the local situation, tional diabetes (5%).1 and create a model for an integrated approach in the fi ght against diabetes at community level.3 2. The disease presents with metabolic anomalies characterized by chronic hyperglycaemia, resulting 5. In the African Region, efforts made to create an from defective secretion or action of insulin (insulin environment that enhances the fi ght against diabetes resistance) or both. It is confi rmed with a random include adoption of resolutions AFR/RC50/R4 on venous plasma glucose higher than 2g/l (11.1 mmol), non-communicable diseases: strategy for the African or fasting glycaemia that is higher than 1.26g/l Region, in 2000, and AFR/RC55/R4: cardiovas- (7.0 mmol/l) at two tests, or a fasting glycaemia cular diseases in the African Region, in 2005. The higher than 2g/l (11.1 mmol) 2 hours after a glucose World Health Organization and the International intake.2 Diabetes Federation (IDF) jointly carried out other actions to contribute to it. 3. Diabetes is serious due to its complications, namely: cardiovascular ailments, cerebral vascular 6. This document examines the situation of dia- acci dents, renal insuffi ciency, blindness, sexual impot- betes (Type 2) in the African Region and proposes a ence and gangrene of the feet leading to amputation. strategy for its prevention and control.

144 Intensifying the prevention and control of communicable and noncommunicable diseases

SITUATION ANALYSIS AND 11. The dearth of specialists and health workers JUSTIFICATION trained in diabetes makes its treatment diffi cult. General practitioners or traditional healers some- 7. Diabetes mellitus is no longer rare in Africa (Fig- times assure its management.11 Very few countries ure 1). Meta-analytic estimates and recent investiga- have care facilities that are appropriate for diabetes 4,5 tions based on the STEPwise approach for management, and testing for glycaemia is not always monitoring the risk factors of non-communicable dis- carried out in health facilities. eases indicate prevalence of between 1% and 20%. In some countries like Mauritius, it reaches 20%.6 The 12. In the Region, people affected by chronic diseas- global prevalence was estimated at 2.8% in 2000, with es, including diabetes, seek care from facilities at the projections of 4.8% in 2030. The total number of per- peripheral levels. Though these facilities are oriented sons affected would rise from 171 million in 2000 to toward acute problems, they are generally not adapted 366 million in 2030 if no action is taken.7 to provide care to those affected by chronic diseases. 8. The factors that affect the onset of diabetes are 13. Treatment compliance for diabetes, in the long well-known. They comprise non-modifi able factors term, remains problematic because of prohibitive like old age (over 45 years of age), heredity (direct cost and unavailability, or lack of, state subsidies. collateral) and the causes of diabetes in pregnancy. The annual direct cost of treatment by insulin is esti- The modifi able factors are obesity, physical inactiv- mated at US$ 229, with more than 70% of it used ity and excessive alcohol consumption. for the insulin.12 The monthly cost using glibenclamide is equivalent to the salary for 6.1 working days 9. Africa, which faces the dual burden of commu- in Nigeria and 16.6 working days in Uganda of an nicable and non-communicable diseases, is witness- employee on minimum wage.13 In Cameroon, the ing changes in traditional lifestyles that have direct cost per patient in 2001 was US$ 489, which disrupted feeding patterns. This in turn leads to includes 56.5% for hospitalization, 33.5% for drugs, physical inactivity that promotes obesity. The emerg- 5.5% for tests and 4.5% for consultation. ing Type 2 diabetes observed in the child and adolescent is linked to obesity. Justifi cation 10. The disease burden is very high. Unknown dia- 14. The present regional strategy on diabetes is based betes in Africa is in the order of 60% to 80% in cases on the resolution14 on non-communicable diseases 8 diagnosed in Cameroon, Ghana and Tanzania. The in the Region. It responds, in a specifi c way, to the rate of limb amputations varies from 1.4% to 6.7% of need to increase the impact, alas, still limited, of pro- diabetic foot cases. Annual mortality linked to diabe- grammes based on an integrated approach in the 9 tes worldwide is estimated at more than one million. fi ght against the common risk factors of non- In some countries of the Region, the mortality rate communicable diseases. is higher than 40 per 10 000 inhabitants.10 15. In the Region, vulnerability to diabetes among the 45–65 age group exposes them to complications and premature deaths. It causes a decline in productivity, with an economic cost, which added to the cost of treating other types of diabetes (Type 1 and diabetes in pregnancy), constitutes an additional burden for the already weakened health systems. 16. Type 2 diabetes can be prevented by simple measures in 80% of cases. The efforts to fi ght diabetes in Africa fall far below the expected results. Also, it is advisable to revisit the in-patient care 1–3% model for diabetes by integrating it into the primary 4–6% health care system. 7–10%

>10%

Non-AFRO countries THE REGIONAL STRATEGY Figure 1: Diabetes prevalence rate in WHO African Aims and objectives Region. Sources: 1. Infobase.who.int; 2. Sobngwi E et al. Diabetes in Africans: Part 1: epidemiology and clinical 17. The goal of this regional strategy is to contribute speciﬁ cities, Diabetes and Metabolism 27(6): 628–634, 2001. to the reduction of the burden of diabetes-related

145 COMPENDIUM OF RC STRATEGIES morbidity and mortality and its associated risk (g) support for operational research. factors. Creating conditions that enhance advocacy and 18. The strategy aims: action (a) to increase sensitization and advocacy in the 21. Advocacy would centre on the importance of fi ght against diabetes, using reliable epidemio- diabetes, placing it alongside the main NCDs, logical data for policy-makers and the general namely cardiovascular diseases and cancer. It must public; be based on real partnerships for increased sensitiza- (b) to promote primary, secondary and tertiary pre- tion. It must focus on the community level, using vention interventions in favour of diabetes; prevention and information messages that target the (c) to strengthen the quality of health care by inte- populations at risk of diabetes. grating diabetes into primary health care in order to provide just and equitable access; 22. Collection of reliable data is required to guide (d) to improve the capacities of health personnel to and plan actions in favour of the control of diabetes better deal with diabetes and associated diseases; and its associated risk factors. For that, STEPwise (e) to support research in community interventions, investigations should be planned and carried out including traditional medicine. throughout Africa, particularly Step 3 required for glycaemia testing. Guiding principles 23. Diabetes should be on the list of medical priorities, be legislatively recognized as a medico-social 19. For prevention and control of diabetes, the disease and be given adequate resources. National follow ing principles must guide the implementation initiatives and plans for the fi ght against diabetes can of the strategy: serve as entry points for non-communicable disease (a) comprehensive management of diabetes through programmes. cost-effective prevention, curative, rehabilitation and participatory actions; Preventing diabetes and its risk factors (b) integration of diabetes into a national programme for the prevention and control of non- 24. Most risk factors for diabetes that are common communicable diseases; to NCDs are modifi able and preventable. The im- (c) equity and accessibility to quality care for people plementation of the global strategy on food, physical affected by diabetes; exercise and health15 is the primary key for diabetes (d) multisectoral approach and partnerships, with prevention. This strategy, together with the fi ght the health sector playing a leading role, with against tobacco use and alcohol abuse, will be civil society being involved and with enhanced strengthened. These interventions should begin cooperation from associations involved in the from childhood and reach educational establish- fi ght against diabetes; ments and adolescents. (e) community participation, gender sensitivity and consideration of local beliefs as necessary to Detecting diabetes and its complications better generate awareness on diabetes. 25. The targeted screening of people at risk of dia- Priority interventions betes will have to be encouraged in health facilities. Testing for fasting glycaemia makes it possible to 20. In order to better prevent and control diabetes, diagnose unknown diabetes, which, though evolv- the following priority interventions are envisaged: ing silently, is very often revealed by complications. (a) creation of conditions that enhance advocacy 26. The status of impaired fasting glycaemia must be and action for diabetes; focussed on, particularly, those at risk of diabetes. (b) prevention of diabetes and its associated risk Early diagnosis is interesting in identifying those at factors; increased risk of developing the condition, thus (c) targeted screening of diabetes and its complica- leading to prevention and management. tions; (d) early diagnosis and adapted treatment of diabetes Early diagnosis, fast and better treatment and its complications; (e) strengthening of the capacities of health systems; 27. Diabetes should be promptly managed. In- (f) reorganization of health care to focus on the deed, there is a direct correlation between the patient, family and community; level of glycaemia progression, onset of diabetes and

146 Intensifying the prevention and control of communicable and noncommunicable diseases its complications, and outcome of treatment. make the patient an active actor. Health workers Routine glycaemia testing would prevent or delay must guide the patient towards being independent. complications. In proactive management of diabetes, the role of the family and the community enhances treatment. 28. Testing for glycaemia should be carried out in all health facilities, using gluco meters whose reliability has been proven. Once the diagnosis has been made, Supporting research counselling and guidance should be given, based on 35. To better target priority research areas and better the protocol drawn up in the countries. prevent and control diabetes, countries will be en- 29. Secondary prevention activities should be based couraged to support and ﬁ nance research activities, on treating cases that are declared in order to pre- and also integrate traditional medicine. It will be vent or delay complications. The management of necessary to encourage the training of researchers diabetes should be comprehensive, integrating ef- and equip universities, research institutions, schools fective treatment of diabetes, arterial hypertension, of medicine and training centres. lipidic disorders, and activities for alcohol consumption cessation. Type 1 diabetes and gestational dia- Roles and responsibilities betes would be given specialized treatment. Countries 30. Access to oral antidiabetic medications, insulin and basic supplies must be assured. A good drug 36. The countries should: policy should ensure accessibility and reduced prices (a) prepare and implement diabetes control policies of these drugs. Health centres and hospitals must be and plans, integrated into the national pro- provided with affordable essential and generic drugs. gramme for the prevention and control of non- Concerning oral antidiabetic medications, met- communicable diseases; set up, at national level, formine and glibenclamide are recommended by integrated surveillance systems; consensus.16 (b) strengthen their health systems and capacities for 31. Tertiary prevention remains crucial because of diabetes control by promoting: (i) the participa- the many complications related to late diagnosis. tion of individuals and communities in the care Particular stress will be put on the prevention of and support of persons affected by diabetes; (ii) blindness, renal insufﬁ ciency and especially on le- collaboration with partners; (iii) fundamental sions of the foot, the cause of amputations. The care and operational research on diabetes; of diabetic feet will have priority in health centres. (c) mobilize internal and external resources and allo cate them regularly, assure coordination of Strengthening the capacities of health systems the interventions of the different actors, and the monitoring of the programmes for the control of 32. It is essential to integrate the management of dia- diabetes and non-communicable diseases; betes into primary health care facilities through the (d) conduct and publish their STEPwise surveys; delivery of a minimum package of activities. This en- (e) strengthen partnerships with other stakeholders. tails identifying the people (groups) at high-risk and referring them to the health facilities for screening, follow-up and monitoring of care. Health personnel WHO and partners will be trained in diabetes management, prevention 37. WHO and partners should: and control as part of primary health care. This will ensure that the care usually administered only by the (a) provide technical assistance to countries for the doctor can be undertaken by a multidisciplinary team analysis and development of policies; data collec- trained and integrated within the health centres. tion and analysis, as well as their dissemination; (b) develop and make available standards and guide- 33. First referral levels and high quality of care will lines for the diagnosis and treatment of diabetes, be of help to primary health care facilities in screen- its complications and its associated risk factors; ing, diagnosis and initial treatment of patients. They (c) encourage the principal partners, namely the should also manage complications which could be Inter national Diabetes Federation and others, to treated in integrated specialized clinics. allocate additional resources to interventions in favour of diabetes; Patient-focused care (d) encourage and support research on diabetes in 34. Routine care for diabetes requires a lifestyle order to better prevent and improve the quality change. The role and responsibility for treatment of life of the affected persons.

147 COMPENDIUM OF RC STRATEGIES

Implications in terms of resources Aware of the rapid increase in the prevalence of diabetes and other non-communicable diseases and 38. Most countries already spend a considerable the high burden of communicable diseases, which amount of resources, mainly in support of clinical constitute a double burden for health systems and a management of diabetes. The interventions pro- factor aggravating poverty among the people; posed in this document imply reorganizing and channelling resources to facilitate implementation. Recalling resolutions WHA42.36117, More specifi c is the need to ensure the availability of WHA53.17118, WHA57.16119, WHA57.17120, EB suitably trained human resources at different levels 120/22121, AFR/RC50/R4122 and AFR/RC55/ of the health care system, medicines and supplies R423, urging the intensifi cation of measures to con- needed for screening and treating those affected, and trol diabetes and cardiovascular diseases and efforts support for a mechanism of community follow-up. by Member States and their partners in this area; 39. In many countries, additional resources must be Recalling United Nations General Assembly mobilized, fi rstly from national resources and then Resolution 61/225 of December 2006 instituting from partners. In this regard, countries using the in- World Diabetes Day; formation available on the costs of medicines and Recalling further the relevance of primary other necessary commodities should estimate their prevention and the integrated approach to non- total needs to facilitate their resource mobilization communicable disease surveillance and management, programme. including the control of their common risk factors; MONITORING AND EVALUATION Acknowledging the need for sustainable community action to ensure better prevention and control 40. The surveillance of diabetes and its risk factors of diabetes at all levels of the health system, espe- remains one of the major components of monitoring cially the primary level; and evaluation. The STEPwise investigation is one Acknowledging further the importance of the of the indispensable tools, as isthe diabetes register. continuing availability, accessibility, affordability and safety of medicines, particularly insulin, to dia- CONCLUSION betes patients; 41. Diabetes represents a real and growing health 1. APPROVES the document entitled “Diabetes problem in the Region. Sustained commitment prevention and control: A strategy for the WHO from the authorities would increase the ability to African Region”; cope with the dual challenge of prevention and 2. URGES Member States: treatment on the one hand, and on the other, the lethal burden of complications, particularly cardio- (a) to develop or strengthen national policies, plans, vascular diseases. or programmes targeted at diabetes and noncommunicable diseases; 42. Multidisciplinary and multisectoral approaches (b) to develop and implement integrated surveill- are indispensable for the prevention and control of ance and primary prevention activities for non- diabetes. In Africa more than elsewhere, they con- communicable diseases, including diabetes, and stitute the cornerstone of interventions, which based on the common risk factors approach; should focus on the patient and the community, (c) to strengthen the mobilization and allocation of within the framework of primary health care. resources for diabetes prevention and control, 43. The Regional Committee examined and adop- and to ensure the availability, affordability and ted the strategy for diabetes prevention and control. safety of medicines; (d) to conduct STEPwise surveys at least every three years; Resolution AFR/RC57/R4 (e) to develop and implement strategies for the reten tion of their skilled human resources for Diabetes prevention and control: A strategy health; for the WHO African Region (f) to develop partnerships with the pharmaceutical The Regional Committee, industry, scientifi c foundations and philanthro- pic organizations to accelerate the implementa- Noting the report of the Regional Director en- tion of national strategies; titled “Diabetes prevention and control: A strategy for the African Region”; 3. REQUESTS the Regional Director:

148 Intensifying the prevention and control of communicable and noncommunicable diseases

(a) to provide technical support to Member States 8. IDF, Diabetes Atlas, 2nd Edition, Brussels, Inter- for surveillance and the development and national Diabetes Federation, 2003. strengthening of national policies and pro- 9. WHO, Preventing chronic diseases: A vital investment, grammes for the control of diabetes and other Geneva, World Health Organization, 2005. non-communicable diseases; 10. WHO, The burdern of mortality attributable to diabetes, Geneva, World Health Organization, 2004. (b) to increase support for the training of health 11. Motala A. Diabetes trends in Africa, Diabetes/Metabo- professionals in control of diabetes and other lism Research and Reviews 18(S3): S14–S20, 2002. non-communicable diseases by evaluating the 12. Chale SS et al. Must diabetes be a fatal disease in programmes implemented in the Region; Africa? Study of costs of treatment, British Medical (c) to maintain and strengthen WHO’s collabora- Journal 304: 1215–1218, 1992. tion with all the partners involved in diabetes 13. WHO, Study on cost of drugs and interventions proposed control; for improving access to drugs in six sub-Saharan African (d) to promote the mobilization of additional fi nan- countries, Geneva, World Health Organization, 2006. cial resources for the implementation of the 14. Resolution AFR/RC50/R4, Non-communicable present strategy and bargain with partners and diseases: A strategy for the African Region. In: Fiftieth session of the WHO Regional Committee for Africa, pharmaceutical companies on the availability Ouagadougou, Burkina Faso, 28 August-2 September and affordability of medicines; 2000, Final Report, 13–14, Harare, World Health (e) to advocate for reduction in the cost of diag- Organization, Regional Offi ce for Africa, 2000. nostics and medicines for diabetes and non- 15. Resolution WHA57.17, Global strategy on diet, communicable diseases. physical activity and health. In: Fifty-seventh World Health Assembly, 14–22 May 2004, Volume 1: Resolu- Seventh meeting, 30 August 2007 tions and decisions, 39–41, Geneva, World Health Organization, 2004. REFERENCES 16. IDF, Guide on the management of type 2 diabetes in 1. WHO, WHO/IDF report of consultation: Defi nition, sub-Saharan Africa, Dar es Salaam, International diag nosis and classifi cation of diabetes mellitus and its com- Diabetes Federation, 2006. plications, Geneva, World Health Organization, 1999. 17. WHA42.36 (1989) Prevention and control of 2. WHO, WHO/IDF report of consultation: Defi nition and diabetes. diagnosis of diabetes mellitus and intermediate hyperglycae- 18. WHA53.17 (2000) Prevention and control of non- mia, Geneva, World Health Organization, 2006. communicable diseases. 3. WHO, Forty-second World Health Assembly; item 18.2 19. WHA57.16 (2004) Health promotion and healthy of the Agenda. lifestyles. 4. WHO, Survey of the STEPwise approach for the sur- 20. WHA57.17 (2004) Global strategy on diet, physical veillance of the risk factors of NCDs, Brazzaville, activity and health. World Health Organization, Regional Offi ce for 21. EB 120/22 (2007) Prevention and control of non- Africa, 2006. communicable diseases: Implementation of the global 5. Sobngwi E et al. Diabetes in Africans: Part 1: strategy. epidemio logy and clinical specifi cities, Diabetes and 22. AFR/RC50/R4 (2000) Non-communicable diseas- Metabolism 27(6): 628–634, 2001. es: A strategy for the African Region. 6. http://www.who.int/ncd_surveillance/infobase/ 23. AFR/RC55/R4 (2005) Cardiovascular diseases in the web/InfoBasePolicyMaker/Reports/reportList- African Region: Current situation and perspectives. Countries.aspx (accessed 15 March 2007). 7. Gojka R et al. Global prevalence of diabetes, Diabetes care 27(5): 1047–1053, 2004.

149 5.8 Cancer prevention and control: A strategy for the WHO African Region (AFR/RC58/4)

EXECUTIVE SUMMARY 1. Cancer is a problem in the African Region, where 582 000 cases were recorded in 2002, a ﬁ gure expected to double by 2020. While data on the burden and pattern of cancer in the Region are insufﬁ cient, the available studies and estimates show an increased incidence due to infectious agents and to growing tobacco and alcohol use, unhealthy diet, physical inactivity and pollution. 2. The most common cancers in the African Region are cancers of the cervix, breast, liver and prostate as well as Kaposi’s sarcoma and non-Hodgkin’s lymphoma. Enough knowledge and evidence exist for preventing one third of all cancers, providing effective treatment for a further one third and providing pain relief and palliative care for all cases. This strategy proposes interventions which, if promptly implemented, will contribute to reducing the burden of cancers. 3. Cancer control programmes should be established in a comprehensive and systematic framework and be integrated within national health plans. They should have adequate documentation, monitoring and evaluation systems. Country ownership, equity, partnership, accountability and integrated approach should guide the implementation of interventions. 4. Priority interventions should include development of policies, legislation and regulations; mobilization and allocation of adequate resources; partnerships and coordination; training of health personnel; acquisition of adequate infrastructure and equipment for primary, secondary and tertiary prevention; and strategic information, surveillance and research. These interventions, with primary and secondary prevention as top priorities, and availability, affordability and accessibility of drugs for cancer treatment, should be implemented and scaled up in countries. 5. The Regional Committee reviewed and adopted this strategy.

INTRODUCTION to screening, early diagnosis, treatment or palliative care. Furthermore, the health systems of countries are 1. Cancer refers to a group of diseases characterized not suffi ciently equipped to provide cancer services. by abnormal cell proliferation with a tendency to invade adjacent tissues and produce metastases. It 3. Cancers impact negatively on the overall health poses a real global problem, accounting for 12.5% of status of the population in Member States and lead all deaths worldwide in 2005; by 2020, new cases of to loss of income and huge health expenditures. cancer are projected to reach about 15 million every They mostly occur in the economically productive year, 70% of which will be in developing countries, age group. Faced with a growing burden of non- including over one million in the African Region.1 communicable diseases (NCDs) and a high burden of communicable diseases, countries in the Region 2. The main factors contributing to the increasing are having diffi culties in providing adequate cancer incidence of cancer in the African Region are grow- prevention and treatment services. ing tobacco and alcohol use, unhealthy diet, physical inactivity, environmental pollution and action of in- 4. There is now suffi cient understanding of the risk fectious agents. Most cancer patients have no access factors such that at least one third of all cancers

150 Intensifying the prevention and control of communicable and noncommunicable diseases worldwide are now preventable. Evidence is also pylori, Epstein-Barr virus and human immuno- available for early detection and effective treatment defi ciency virus (HIV). Vaccines exist for some of and cure of a further one third of cancer cases. In these infectious agents, including hepatitis B and addition, treatment exists to help relieve pain and HPV. However, the vaccine for HPV is expensive provide palliative care. and not yet widely available in the Region. 5. The declaration by Heads of State and Govern- 10. Kaposi’s sarcoma has increased dramatically in ment of the African Union in Durban, in 2002, parts of central, southern and east Africa where HIV making a commitment to address cancer adequately prevalence is high. Liver cancer, caused by high in the development policies of countries; the WHO levels of exposure to afl atoxins and chronic hepatitis regional strategy for prevention and control of B virus infection, remains very common across sub- NCDs; the WHO regional strategy for health pro- Saharan Africa.5 motion; the Framework Convention on Tobacco 11. Tobacco use is the most avoidable cause of Control; and the Global Strategy on Diet, Physical cancer. It causes cancer of the lungs, larynx, pan- Activity and Health, are all part of the effort of the creas, kidney, bladder, oral cavity and oesophagus. international community to address the problem of The prevalence of tobacco use in Africa is rising, cancer.2 with attendant increase in passive exposure to to- 6. This document provides an overview of the bacco smoke. It is estimated that, in 2006, more cancer situation in the African Region and proposes than 50% of children in Algeria and Namibia6 were a strategy for appropriate action by Member States exposed to passive smoke. and partners. The strategy builds on an existing 12. Access to prevention, diagnosis and treatment World Health Assembly resolution (WHA58.22 on services and psychosocial care for patients and fami- cancer prevention and control) and past achieve- lies in the Region are severely hampered by in- ments in the area of NCDs and proposes a set of suffi cient funding and general weakness of health public health interventions aimed at reducing the systems. Infrastructure and equipment are in- burden of cancer. adequate, outdated and poorly maintained. Quali- fi ed personnel for cancer control are inadequately SITUATION ANALYSIS AND trained, and most health-care workers, especially at peripheral levels, have too little knowledge and skills JUSTIFICATION with regard to cancer. 7. Information on the burden and pattern of cancer 13. In almost all Member States, national cancer in the Region is scarce because of lack of accurate prevention and control programmes are either lack- population-based data and the weakness of health ing or very weak; policies, legislation and regula- information systems. In 2002, Globocan, a world- tions are found wanting; and actions of partners are wide database deriving estimates from available can- fragmented and poorly coordinated. The few exist- cer registries, recorded 582 000 cases of cancer in ing cancer diagnosis and treatment facilities are Africa, a fi gure expected to double in the next two centralized in urban areas. decades, if interventions are not intensifi ed.3 14. Most patients report to health services when 8. Data from localized studies and derived estimates the disease is already at an advanced stage, with the indicate that there is a high burden of cancer in the result that patients with fi ve-year survival rates in Region. The most common cancer recorded in the the Region are among the lowest ever reported.7 Region is cervical cancer, which accounts for 12% Chemotherapy and other treatment tools remain of all new cases each year. Other major cancers re- beyond affordability. Pain relief and palliative care corded in the Region are cancers of the breast services are limited because of insuffi cient awareness (10%), liver (8%) and prostate, as well as Kaposi’s 4 among health-care providers, patients and the sarcoma (5%) and non-Hodgkin’s lymphoma (5%). general public, as well as excessive regulation of the Cervical cancer and breast cancer are among the use of opioids. major public health problems in the Region, although tools for their screening and early diagnosis are available. Justifi cation 9. Infectious agents are at the origin of almost 25% 15. The burden and risk of cancer in the Region are of cancer deaths in the developing countries. They increasing. Most resources are used for treating include hepatitis B and hepatitis C viruses, human cancers already at an advanced stage and for costly papillomavirus (HPV), schistosomiasis, Helicobacter referral of patients abroad. In contrast, too little is

151 COMPENDIUM OF RC STRATEGIES invested in cancer prevention, while health systems (d) Innovation, creativity and accountability, are not well prepared to combat the threat of cancers. with the involvement of individuals, cancer patients, civil society and communities, and at all 16. Implementing this strategy will contribute to re- stages of decision-making, planning, implemen- ducing cancer risks and lead to a decrease in cancer tation and evaluation; incidence and mortality, thus resulting in improved (e) Systematic and integrated approach to step- health and quality of life. by-step implementation of priority interventions as part of a national cancer action plan. THE REGIONAL STRATEGY Priority interventions Aim, objectives and targets 21. Cancer prevention and control policies, 17. The aim of this strategy is to help reduce cancer legislation and regulations. Cancer policies, morbidity and mortality in the African Region. legislation and regulations are necessary to ensure 18. The specifi c objectives are: that all individuals in countries have access to cancer services. They must aim to prevent infectious agents (a) to provide Member States with an orientation from causing cancers and to reduce exposure to for the development and implementation of tobacco smoke, chemicals such as pesticides, toxins national strategies and programmes for cancer such as afl atoxins, pollution and radiation. A cancer prevention and control; prevention and control policy document should be (b) to scale up cancer prevention, cure and care adopted and implemented within an integrated na- services; tional health policy and plan. (c) to provide a platform for advocacy for increased resource allocation, increased action, multisecto- 22. Establishment of comprehensive national ral collaboration and cancer control partnerships; cancer control programmes. Cancer control (d) to promote cancer research and cancer data col- programmes8 should comprise primary, secondary lection and use. and tertiary prevention and include screening, early diagnosis, curative therapy and palliative care, as an 19. Targets: integral part of NCD programmes. The interven- (a) By 2013, 20% of Member States will have tions should be adapted to local settings and imple- achieved 10% reduction of passive exposure to mented in a cost-effective manner. The experience tobacco smoke among youths aged from 13 to and lessons learnt should be documented for sharing. 15 years; National, regional and subregional centres of excel- (b) By 2013, 40% of countries in the Region will lence for cancer control should be designated and have developed and be implementing cancer supported as part of a programme to build capacity control programmes, including primary, second- and maintain quality care across the health system. ary and tertiary prevention; 23. Advocacy, resource mobilization and ap- (c) By 2013, at least 35% of Member States will be propriate allocation. Advocacy and resources are equipped with cancer registries and adequately crucial to the implementation of cancer prevention trained staff. and control programmes, and to their legislation and regulation within national health policies. These re- Guiding principles sources, to be mobilized from governments, indi- 20. The guiding principles of this strategy are: viduals, the private sector and international partners, should be sustainable and equitably distributed (a) Country ownership, leadership and fairness among different levels of the health system. Member in the implementation of this regional strategy; States should establish mechanisms for results-ori- (b) Equity and accessibility of services, especially ented resource allocation. There is a need for coun- for the poor and rural communities; tries to advocate for the reduction of the cost of (c) Partnership, team building and coordina- cancer medicines and the production of generic tion, with the involvement of all partners at drugs for cancer treatment. various levels (government, private sector, civil society) in the development, planning and im- 24. Mobilization of partners and coordination plementation of interventions; such coordina- of interventions. It is necessary to clearly defi ne tion should be based on a clear defi nition partners’ areas of contribution, as well as the rele- and understanding of roles, responsibilities and vance of their support in line with national priori- mandates; ties. Partners should work collaboratively within

152 Intensifying the prevention and control of communicable and noncommunicable diseases international and national alliances and networks 30. Additional primary prevention interventions in- in order to support countries in building effective clude using existing immunization programmes to national programmes and strengthening health make available suitable vaccine and to immunize systems. populations at risk against the biological agents at the origin of carcinogenesis (hepatitis B viruses, HPV); 25. Capacity development. It is also necessary to reinforcing tobacco control; and involving tradi- improve the skills of decision-makers, health per- tional health practitioners in ensuring early referral sonnel and care providers at primary, secondary and of patients to health-care facilities. tertiary levels of health systems. More specifi cally, cancer information for policy-makers and decision- 31. Secondary prevention. Screening, early de- makers should be reinforced for better understand- tection and diagnosis at the stages where cancers are ing of technical and institutional aspects as well as curable should be given high priority in community international agreements and regulatory frameworks interventions. Interventions in reproductive health for cancer prevention and control. This information and childhood cancers should be promoted and im- will prepare them to initiate, promote and better plemented at different levels of the health system. communicate national policies, legislation and regu- Techniques of visual examination for cervical cancer lations. At the same time, there is need to strengthen screening followed by immediate treatment by and develop community capacity for cancer preven- cryo therapy will reduce cervical cancer morbidity tion and control. and mortality. A step-wise approach is recommended when starting or reorienting implementation so 26. Given that many cancer risk factors, such as that each step will have a measurable outcome and pollu tion and exposure to chemicals, are beyond the progress can be monitored. control of the health sector, it is necessary to implement interventions to strengthen cross-sector colla- 32. Tertiary prevention. Diagnosis and treatment boration. Such collaboration should involve relevant strategies through tertiary prevention will ensure government sectors and stakeholders such as profes- that the majority of patients have access to effi cient sional associations, civil society, community repre- diagnostic and suffi cient treatment facilities. Cancer sentatives, nongovernmental organizations, and the diagnosis and treatment should be carried out at the private sector. secondary and, eventually, primary level of health systems. Countries should ensure sustained availabil- 27. Development of human capacity at all levels of ity of a minimum set of affordable and cost-effective the health system should be strengthened for cancer medications for cancer management. The use of dif- prevention and control. This should include labora- ferent mechanisms, including subregional economic tory skills for diagnosis as well as telemedicine, a communities, will ensure sustainable availability of useful tool for medical education and diagnosis. At these medicines. An enabling environment should the same time, health systems should be strength- be created, with palliative care integrated into the ened to address the problem of cancer at various existing health delivery system. In addition, psycho- levels. This should include the provision of adequate social support mechanisms based on collaboration infrastructure as well as equipment and their mainte- between health services and communities should be nance for screening, diagnosis and treatment at all developed at local level. levels. 33. Strategic information, surveillance and re- 28. Primary prevention. Primary interventions search. Surveillance, research and knowledge man- are cost-effective approaches to reduce exposure to agement play pivotal roles in cancer control. the major risk factors at individual and community Countries should establish cancer registries to moni- levels. They reach out to school children, adults, the tor the trends of cancer incidence, prevalence and elderly and people at risk. mortality as well as the risk factors. There is a need 29. Primary prevention ensures that preventable for increased investment in research; operational re- cancers are targeted by health promotion strategies search should be promoted as an integral part of can- through improved communication for behaviour cer prevention and control in order to identify change. Implementation should be done in a cross- knowledge gaps and evaluate strategies. Research on cutting manner, linking communicable and non- traditional medicines must produce evidence of communicable diseases, and starting at the their safety, effi cacy, quality and appropriateness for community level. Specifi c interventions should be use in cancer chemotherapy and palliative care. strengthened to reduce the incidence of AIDS- Findings of research on new cancer therapies, in- related cancers and HIV transmission and to im- cluding gene therapy, should be recommended for prove the diet and physical activity of HIV patients. wider use in the Region.

153 COMPENDIUM OF RC STRATEGIES

Roles and responsibilities MONITORING AND EVALUATION 34. Countries should: 37. Progress monitoring indicators include the avail- (a) adopt regulations and legislation aimed at reduc- ability and effective implementation of cancer con- ing avoidable exposure to cancer risk factors and trol policy, legislation, regulations and programmes. strengthen clinical practices; Outcome and impact indicators include the reduc- (b) develop and strengthen comprehensive cancer tion of cancer incidence and mortality, trends of control programmes tailored to the socio- morbidity and reduction of risk factors. economic context and integrated into national 38. Continuous monitoring and evaluation are cru- health systems; cial to the success of cancer control programmes and (c) mobilize and allocate resources for cancer con- should be based on progress, outcome and impact trol programmes; measurements. The progress indicators should be (d) create public awareness of cancer prevention well managed to meet the requirements of national methods; health management systems and of reporting mech- (e) establish surveillance systems, particularly cancer anisms relevant to international bodies, including registries, as part of the existing health informa- the African Union. tion systems; (f) establish a system for procurement and maintenance of cancer diagnosis and treatment equip- CONCLUSION ment in relevant services; (g) increase the knowledge and skills of health 39 The cancer prevention and control challenges workers and non-health care providers in cancer facing the African Region include inadequate poli- prevention and control. cies, legislation and regulations and limited access to prevention, diagnosis and treatment services. Com- 35. WHO and partners should support countries by: prehensive cancer control programmes require a (a) mobilizing communities in the fi ght against can- multisectoral approach. cer and by facilitating effective linkages, co- 40. Strong advocacy and commitment at the highest operation, collaboration and coordination political level are needed for cancer prevention and among partners and stakeholders; control in order that interventions can be success- (b) carrying out advocacy for increased resource fully implemented. The interventions, with high allo cation especially for cancer prevention, in- priority to primary and secondary prevention, frastructure, equipment, medicines and research; should be implemented promptly in Member States (c) providing technical and material support for es- to reduce cancer morbidity and mortality. tablishing or strengthening national cancer control programmes; 41. The Regional Committee reviewed and adopt- (d) providing technical and material support for ed this strategy. monitoring and evaluating cancer prevention and control programmes; (e) establishing and generating evidence-based in- REFERENCES formation and analysis to be used by govern- 1. WHO, Preventing chronic diseases: a vital investment, ments to develop cancer prevention and control Geneva, World Health Organization, 2005. legislation. 2. WHO, Non-communicable diseases: a strategy for the African Region, Harare, World Health Organiza- Resource implications tion, Regional Offi ce for Africa, 2000 (AFR/ RC50/10); WHO, Health promotion: a strategy for 36. The existing level of fi nancial allocation to cancer the African Region, Brazzaville, World Health Or- control is generally insuffi cient. The situation is ganization, Regional Offi ce for Africa, 2003 (WHO worsened by referral abroad of many cancer patients. AFR/RC51/12 Rev.1); Resolution WHA56.1, Additional resources are required to support the im- WHO Framework Convention on Tobacco Control, plementation of this strategy, particularly primary pre- Geneva, World Health Organization, 2003 (WHA56/ vention, early detection, care and management 2003/REC/1); WHO, Global Strategy on Diet, Physical Activity and Health, Geneva, World Health components. This will reduce costs in the long term. Organization, 2004 (WHA57.17/2004). Furthermore, there is a need to ensure the availability 3. http://www.afro.who.int/dnc/databases/cancer/ not only of trained human resources at different levels incidence/index.html. of the health-care system but also of the equipment 4. Ferlay J et al. Cancer incidence, mortality and prevalence and medicines needed for screening and treatment. worldwide, Lyon, IARC Press, 2004.

154 Intensifying the prevention and control of communicable and noncommunicable diseases

5. Parkin DM et al. Cancer in Africa: Epidemiology and pre- A et al. Cancer survival in a southern African urban vention, IARC Scientiﬁ c Publication No. 153, Lyon, population, International Journal of Cancer, 112(5): 2003. 860–864, 2004. 6. http://www.who.int/tobacco/surveillance/gyts/en/. 8. WHO, National Cancer Control Programmes: Policies and 7. Gondos A. et al. Cancer survival in Kampala, Uganda, managerial guidelines, 2nd edition, Geneva, World British Journal of Cancer, 92: 1808–1812, 2005; Gondos Health Organization, 2002.

155 5.9 Sickle-cell disease: A strategy for the WHO African Region (AFR/RC60/8)

EXECUTIVE SUMMARY 1. Sickle-cell disease (SCD) is an inherited disorder of haemoglobin. It is the most prevalent genetic disease in the WHO African Region. In many countries, 10%–40% of the population carries the sickle-cell gene resulting in estimated SCD prevalence of at least 2%. 2. The situation in the Region indicates that current national policies and plans are inadequate; appropriate facilities and trained personnel are scarce; and adequate diagnostic tools and treatment are insuffi cient. 3. Deaths from SCD complications occur mostly in children under fi ve years, adolescents and pregnant women. Strategies and interventions to reduce SCD-related morbidity and mortality should focus on adequate management of these vulnerable groups. 4. This strategy provides a set of public health interventions to reduce the burden of SCD in the African Region through improved awareness, disease prevention and early detection. The interventions include improvements in health-care provision; effective clinical, laboratory, diagnostic and imaging facilities adapted to different levels of the health system; screening of newborns; training of health workers and development of protocols; genetic counselling and testing; accessibility to health care; establishment of patient support groups; advocacy; and research. 5. Success in implementing identifi ed interventions will depend on the commitment of Member States to integrate SCD prevention and control into national health plans, and provide an environment conducive for various stakeholders to contribute to the reduction of SCD prevalence, morbidity and mortality. 6. The Regional Committee examined and adopted the sickle-cell disease control strategy.

INTRODUCTION with other abnormal haemoglobin genes. Structural studies of the βS gene suggest that the sickle-cell 1. Sickle-cell disease (SCD) is a genetic condition mutation arose in at least four different places in in which the red blood cells contain haemoglobin S Africa and a ﬁ fth mutation occurred in the Arabian (HbS), an abnormal form of the oxygen-carrying peninsula.2 protein. Individuals who inherit sickle-cell genes from both parents are homozygotes and develop 3. The SCT is widespread in the WHO African SCD, while those who inherit the gene from only Region;3 the βS gene prevalence in at least 40 coun- one parent have the sickle-cell trait (SCT). Those tries varies between 2% and 30%, resulting in high with the trait are carriers, have no symptoms, but SCD-related morbidity and mortality. Deaths from can pass the gene on to their offspring. SCD complications occur mostly in children under ﬁ ve years, adolescents and pregnant women.4 2. SCD is the most prevalent genetic disease in the African Region.1 There are different subtypes of 4. Because there is little genetic counselling avail- SCD in which the abnormal S gene (βS) coexists able for prospective parents, unions between SCT

156 Intensifying the prevention and control of communicable and noncommunicable diseases carriers result in the birth of SCD children. Most affected persons, families, communities and the countries have inadequate national health policies nation. Recurrent sickle-cell crises interfere with the and plans, and scarce facilities, diagnostic tools, patient’s life, especially regarding education, work treatment services and trained personnel. There is and psychosocial development. In the Democratic therefore, a need for urgent interventions to address Republic of Congo, 12% of children hospitalized in this public health problem. paediatric wards have SCD; the estimated annual cost for care is more than US$ 1000 per patient.9 5. This document provides an overview of SCD in the Region and proposes a strategy for action by 10. Despite logistic and economic constraints, neo- Member States and partners. It outlines a set of pub- natal SCD screening along with CHCM have been lic health interventions to reduce the burden of the successfully practised in some parts of Africa. For ex- disease through national development or strength- ample, in Benin, where neonatal screening and ening of policy; early identifi cation; management; CHCM were practised, the under-fi ve mortality and community awareness. rate of SCD was 15.5 per 10 000, which is ten times lower than the overall under-fi ve mortality rate.10 SITUATION ANALYSIS AND These fi ndings are consistent with those from developed countries, demonstrating the benefi t of new- JUSTIFICATION born screening and close follow-up of children using Situation analysis CHCM.11 6. Sickle-cell disease prevalence depends on sickle- 11. Research has been done in several countries in cell trait. Where the prevalence of SCT exceeds the Region to achieve better understanding of 20%, SCD is estimated to be at least 2%.5 The βS SCD,12 but more remains to be done. The research gene concerns the population of at least 40 countries includes issues related to effi cacy of conventional in the Region, and in about 23 countries of west and traditional medicines. The safety, effi cacy and and central Africa the prevalence of SCT varies be- quality of some traditional medicines have been tween 20% and 30%; it is as high as 45% in some evaluated and appeared to be safe and effective in secluded areas in western Uganda.6 reducing crises associated with severe pain.13 How- ever, there is no substantive documented evidence 7. Although more than 40 countries are affected, to support the effi cacy of traditional practice or much of the data are still hospital-based and not herbal medications in curing SCD. population-based. Most SCD manifestations are readily amenable to treatment, using available interventions; however, the interventions are not ac- Justifi cation cessed by the majority of patients, specifi cally the 12. The burden of sickle-cell disease in the African vulnerable groups: children under fi ve years, adoles- Region is increasing with the increase in popula- cents and pregnant women. In addition, laboratory tion. This has major public health and socio- facilities for accurate diagnosis are limited. economic implications. Despite recent high-level 8. Adequately trained health professionals are few, interest in SCD, including commitment from some specialized health care facilities are insuffi cient and African First Ladies and the adoption of a UN reso- effective medicines, vaccines and safe blood trans- lution recognizing SCD as a public health problem,14 fusion are very limited. Presently, even in developed investment in SCD prevention and management, countries, where stem cell transplantation can be using effective primary prevention measures and contemplated, there is no widely acceptable public CHCM, remains inadequate. 7 health intervention for the clinical cure of SCD. 13. This strategy evolves around existing documents15 Consequently, the median survival of SCD patients and past achievements in non-communicable diseases in Africa is less than fi ve years; about 50%–80% of control. The WHO resolution WHA59.20 empha- the estimated 400 000 infants born yearly with SCD 8 sized the urgency for Member States to design, im- in Africa die before the age of fi ve years. The survi- plement and reinforce in a systematic, equitable and vors suffer end-organ damage, which shortens their effective manner, comprehensive national, integrat- lifespan. Thus, to improve management of SCD ed programme for the prevention and management there is a crucial need for early case identifi cation of SCD. The African Union Assembly resolution and implementation of comprehensive health care 1(V) and the United Nations General Assembly management (CHCM). resolution 63/237 both recognized SCD as a public 9. Persons with SCD are often stigmatized, and health problem and urged Member States to raise SCD has major socioeconomic implications for awareness about SCD. The United Nations

157 COMPENDIUM OF RC STRATEGIES

Assembly also suggested making June 19 of each based approach for step-by-step implementation year the SCD Day. of priority interventions as part of the national health plan; 14. The SCD strategy for the WHO African Re- (d) partnership, team building and coordina- gion seeks to increase individual and community tion involving all players at various levels; co- awareness about SCD and strengthen primary pre- ordination should foster clear defi nition and vention, reduce disease incidence, morbidity and understanding of roles, responsibilities and man- mortality, and improve quality of life. The Strategy dates; also contributes toward the achievement of Millen- (e) cultural sensitivity, creativity and account- nium Development Goals 4 and 5. ability involving individuals, patients, civil society and communities in decision-making, THE REGIONAL STRATEGY planning, implementation and evaluation. Aim, objectives and targets Priority interventions 15. The aim of the strategy is to contribute to the 19. SCD control interventions for Member States of reduction in incidence, morbidity and mortality due the African Region evolve around Primary Health to sickle-cell disease in the African Region. Care and health promotion approaches to ensure policy development and implementation, legislation 16. The specifi c objectives are: and regulation, expansion of primary and secondary (a) to identify priority interventions for Member prevention. These interventions include: States to develop and implement programmes (a) improvements in health care provision: clinical and policies for SCD prevention and control at and laboratory management at all levels of the all levels; health system, screening of newborns, training (b) to provide a platform for advocacy to increase of health professionals, and development of resource allocation for prevention and control of protocols; SCD through multisectoral collaboration and (b) genetic counselling and testing; action; (c) geographical and fi nancial accessibility to health- (c) to establish mechanisms for monitoring, evalua- care services; tion and research on SCD and apply the fi ndings (d) public awareness in schools, communities, health in policies and programmes. institutions, media and associations; 17. Targets for 2020 are that: (e) establishment of patient support groups; advocacy; and policies on employment for SCD (a) 50% of the 23 Member States with high SCD patients. prevalence should have developed and be implementing a clearly designed national sickle-cell The following interventions should be adapted to disease control programme within the context of local settings. a national health strategic plan; 20. Advocacy for resource mobilization and (b) 25% of the countries in the African Region increased awareness. Member States should de- should have adopted the concept of comprehen- velop and implement effective advocacy interven- sive health care management of SCD; tions to create awareness of SCD and enhance efforts (c) at least 50% of all sickle-cell trait countries will for local and international resource mobilization in have established a SCD surveillance system with order to ensure availability of appropriate infrastruc- adequately trained staff. ture, equipment, supplies and medicines. WHO and countries should collaborate in developing regional Guiding principles networks and global alliances to help reduce the 18. The guiding principles of this strategy are: burden of SCD. High-level advocacy should be explored and encouraged. (a) country ownership, leadership, fairness and community participation in the implementa- 21. Partnerships and social impact. Partnerships tion of this regional strategy; should be fostered between health professionals, par- (b) effectiveness, cost-effectiveness and acces- ents, patients, relevant community interest groups, sibility of proven interventions and services, nongovernmental organizations (NGOs) and the especially for the poor and for rural dwellers; media. Partnerships will facilitate public educa tion, (c) integrated and evidence-based interven- which will increase awareness and encourage screen- tions and prevention-focused population- ing among members of the community. Partners

158 Intensifying the prevention and control of communicable and noncommunicable diseases should support the prioritization of SCD interven- 26. Early identifi cation and screening. Ideally, tions such as widespread provision of screening, lab- the disease should be identifi ed at birth as part of oratory equipment, and specifi c vaccines that are not routine newborn screening or at any subsequent part of routine national immunization programmes; contact the child has with a health facility. Depend- the development of appropriate interventions to ing on national policy, early identifi cation can be strengthen existing health delivery systems; and a done by universal screening of all newborns, target- multi-disease approach. ed screening of babies born to carrier mothers, and screening of pregnant women. Screening of babies 22. Creation or strengthening of national SCD should be done by collecting blood from a heel programmes within the framework of non- prick; testing can be done using iso-electric-focus- communicable disease prevention and control ing or high-performance liquid chromatography. and in harmony with national maternal and Such services should be available alongside counsel- child health programmes. The development of ling and health education since diagnosis raises these interventions is the basis for improving the serious medical, ethical and cultural issues, which health care of those affected by SCD. Essential areas may differ from one country to another. of work include advocacy; prevention and counselling; early identifi cation and management; data col- 27. Comprehensive health care management lection, surveillance and research; community for SCD patients of all ages. CHCM consists of education; and partnership. An integrated multisec- the following: parent and patient education; toral and multidisciplinary team involving health adequate nutrition; adequate hydration; use of and social workers, teachers, parents and concerned prophylactic antibiotics and antimalarials; folic acid NGOs could be established to work on the practical supplementation; use of specifi c vaccines; continu- aspects of care delivery as well as programme imple- ous medical follow-up; and early detection and mentation and monitoring. management of complications. These measures will reduce morbidity, prevent complications and im- 23. Capacity-building. Health professionals should prove quality of life. In line with the Ouagadougou be given pre-service and in-service training in SCD Declaration, CHCM should also be integrated into control, including prevention, diagnosis and manage- health systems using the PHC approach to meet the ment of cases, and complications. The basic require- needs of both rural and urban dwellers, including ments to meet these service needs at various levels of prevention of complications and patient referral to the health system should be provided. All members of higher care centres when necessary. Family and the health-care team are important for successful pro- community-based care should be integrated into the gramme establishment and implementation. national programme. Implementation of CHCM 24. Supportive activities for special groups, requires trained personnel, adequate facilities and in- namely children under fi ve years, adolescents terventions adaptable to local needs of communities. and pregnant women. Member States should re- 28. Provision of affordable medicines for SCD inforce national SCD supportive activities for vulner- management and pain relief. The use of quality able groups such as children under fi ve years, generic medicines as part of the national essential adolescents and pregnant women who should benefi t medicines list should be promoted. Subregional eco- from fi nancial packages for case management. Other nomic entities can help in the manufacture and pur- supportive measures include early diagnosis and treat- chase of these medications. Since many SCD patients ment of complications; special transfusion regimens; tend to revert to traditional medicine practices, tradi- surgery; immunization; prophylactic antibiotics, folic tional pharmacopoeias should be fostered after prop- acid and antimalarials; and special programmes for er testing, validation and standardization. Traditional prenatal care, psychosocial and professional support health practitioners should be involved in SCD man- to patients, and adaptive educational interventions. agement and referral whenever possible. 25. Primary prevention, including genetic 29. Strengthening laboratory and diagnostic counselling and testing. Prevention entails setting capacity and supplies with nationwide cover- up genetic counselling and testing interventions in age. Tools for the diagnosis of SCD should be made high prevalence countries to reduce partnering be- available according to their complexity at all levels tween carriers. Genetic counselling and health proof the health system starting at primary care level. A motion activities can lead to substantial reduction in system for maintenance and uninterrupted provision the number of children born with the disease. Wide- of supplies should be developed. Diagnostic and im- spread community involvement and support are aging facilities should be made available for early essential. detection of complications.

159 COMPENDIUM OF RC STRATEGIES

30. Initiate and enhance sickle-cell disease sur- cies and programmes, including monitoring and veillance. Community-based activities, including evaluation; surveillance and supervision, monitoring at all levels (d) promoting and supporting partnerships to im- of operation, and periodic evaluation at national prove training and expertise of health personnel level should be undertaken to reduce the burden of and to undertake research. SCD. The information generated should be disseminated and used as evidence in policy-making as well Resource implications as in day-to-day decision-making in the management of the programme. 34. The existing level of funding allocated to SCD prevention and control is generally insuffi cient. 31. Research promotion. It is important to des- Additional internal and external resources will be cribe the history of SCD, its clinical evolution and required to support implementation of this strategy. association with malaria and other diseases. In line Specifi cally, there is need to ensure the availability of with the Algiers Declaration, there is a need to pro- trained human resources at different levels of the mote innovative research in SCD directed towards health system along with the provision of medicines basic knowledge and its transformation into new and equipment. tools such as medicines, vaccines and diagnostic tools; it is also important to identify knowledge gaps and evaluate strategies. It is necessary to promote MONITORING AND EVALUATION research in both conventional and traditional medicine to produce evidence of safety, effi cacy and 35. Continuous monitoring and evaluation are cru- quality. cial to the success of SCD control programmes and should be based on process, outcome and impact measures. These indicators should meet the require- Roles and responsibilities ments of national health management systems and be reportable to relevant international forums over 32. Countries should: the next 5–10 years. (a) develop, implement and reinforce comprehen- 36. Indicators for monitoring progress will include sive national integrated SCD programmes ori- availability and enforcement of SCD control poli- ented towards the socioeconomic environment cies, legislation, regulations, programmes and guide- within which the health system operates; lines. Outcome and impact indicators will include (b) mobilize and allocate resources for SCD pro- reduction of SCD incidence, mortality, morbidity grammes; and risk factors; educational achievements; and job (c) promote community awareness and involve- security of SCD patients. ment in SCD prevention, patient care and support; (d) integrate SCD surveillance within the national CONCLUSION health information system; (e) improve the knowledge and skills of health and 37. Despite being the most prevalent genetic disease non-health care providers in SCD control; in Africa, sickle-cell disease, along with its serious (f) collaborate with partners to undertake basic and health and socioeconomic impacts, is largely neglec- applied research; ted. SCD ultimately results in multiple organ failure (g) support and coordinate national associations and premature death, occurring mostly in children working in SCD prevention and control. under fi ve years, adolescents and pregnant women. 33. WHO and partners should support countries by: 38. A comprehensive health care management agenda needs national promoters, committed leader- (a) mobilizing the international community for pre- ship and effective action at all levels. Strong partner- vention and effective management of SCD; and ships must be forged between Member States, facilitating effective linkage, collaboration and WHO and other development partners, communi- coordination among partners and stakeholders; ties and individuals. (b) advocating for increased resource allocation especially for prevention; provision of adequate 39. Implementation of the interventions suggested infrastructure, equipment and medicines; and in this strategy would ensure prevention, care and research; support at all levels and result in improved quality of (c) providing technical and material support for life and life expectancy of affected individuals. This establishing or strengthening national SCD poli- will contribute towards the achievement of MDGs 4

160 Intensifying the prevention and control of communicable and noncommunicable diseases and 5 and enable affected people to live more pro- 10. Rahimy MC et al. Newborn screening for sickle cell ductive lives. disease in the Republic of Benin. Journal of Clinical Pathology, 2009, 62(1): 46–8. 40. The Regional Committee examined and adopt- 11. Rahimy MC et al. Effect of active prenatal manage- ed the sickle-cell disease control strategy. ment on pregnancy outcome in sickle cell disease in an African setting. Blood, 2000, 96: 1685–89. 12. WHO, Management of Haemoglobin Disorders: re- REFERENCES port of joint WHO-TIF meeting, Nicosia, Cyprus, 2007; Akinyanju OO. A proﬁ le of sickle cell disease 1. Cook GC, Zumla AI (eds). Manson’s tropical diseases, in Nigeria. Annals of the New York Academy of Sci- 21st edition. London, WL Saunders, 2003. ences, 1989, 565:126–36; Diagne N et al. Prise en 2. Lapouméroulie C et al. A novel sickle gene of yet charge de la drépanocytose chez l’enfant en Afrique: expéri- another origin in Africa: the Cameroon type. Ameri- ence de la cohorte de l’Hôpital d’Enfants Albert Royer de can Journal of Human Genetics, 1992, 89: 333–37; Dakar. Med Trop, 2003, 63:513–20; Ogunfowora Cook GC, Zumla AI (eds). Manson’s tropical diseases, OB et al. A comparative study of academic achieve- 21st edition. London, WL Saunders, 2003. ments of children with sickle cell anaemia and their 3. Weatherall DJ et al. Inherited disorders of hemo- healthy siblings. Journal of the National Medical globin. In: Disease Control Priorities in Developing Association, 2005, 97:405–8; Oshikoya KA et al. Countries. Jamison D. et al. New York, Oxford Uni- Family self medication for children in an urban area of versity Press and the World Bank, 2006, 663–680. Nigeria. Archives of Disease in Childhood: Paediatric 4. Dennis-Antwi JA et al. Healthcare provision for sickle and Perinatal Drug Therapy, 2007, 8:124–30; Tchilolo cell disease: challenges for the African context. Diver- L. La drépanocytose en République Démocratique du Con- sity in Health and Social Care 2008, 5:241–54. go: apercu sur la situation actuelle et perspectives d’avenir. 5. Cook GC, Zumla AI (eds). Manson’s tropical diseases, Congo Médical, 2003, 3(12):1044–52. 21st edition. London, WL Saunders, 2003. 13. Wambebe C et al. Double-blind, placebo-controlled, 6. Weatherall DJ et al. Inherited disorders of hemo- randomized cross over clinical trial of NIPRISAN in globin. In: Disease Control Priorities in Developing patients with sickle-cell disease. Phytomedicine, Countries. Jamison D. et al. New York, Oxford Uni- 2001, 8(4): 252-61; Sibinga EMS et al. Paediatric versity Press and the World Bank, 2006, 663-80; patients with sickle cell disease: use of complementary Dennis-Antwi JA et al. Healthcare provision for sickle and alternative therapies. Journal of Alternative cell disease: challenges for the African context. Diver- and Complementary Medicine, 2006, 12: 291–98; sity in Health and Social Care 2008, 5:241–54. Oshikoya KA et al. The use of prescribed and non- 7. Rahimy MC et al. Effect of a comprehensive clinical prescribed drugs in infants in Lagos, Nigeria. Journal care program on disease course in severely ill children of Medical Science, 2008, 8:111–17. with sickle cell anemia in a sub-Saharan Africa setting. 14. UN General Assembly. Recognition of sickle-cell Blood, 2003, 102(3): 834–38. anaemia as a public health problem, 2008 (A/RES/ 8. Weatherall DJ et al. Inherited disorders of hemo- 63/237). globin. In: Disease Control Priorities in Developing 15. African Union. Documents Assembly/AU/Dec. 73– Countries. Jamison D et al. New York, Oxford Uni- 90 (V), Assembly/AU/Decl. 1–3 (V) and Assembly/ versity Press and the World Bank, 2006, 663-80. AU/Resolution 1 (V), 2005; WHO. Sickle-cell anae- 9. Tshilolo L et al. Neonatal screening for sickle cell mia, Geneva, World Health Organization, 2006 anaemia in the Democratic Republic of Congo: ex- (Resolution EB117.R3/2006); WHO, Sickle-cell perience from a pioneer project on 31204 newborns. anaemia. Geneva, World Health Organization, 2006 Journal of Clinical Pathology, 2009, 62: 35–38. (Resolution WHA/59R20.9).

161 5.10 Measles elimination by 2020: A strategy for the WHO African Region (AFR/RC61/8)

EXECUTIVE SUMMARY 1. The African Region adopted measles mortality reduction goals starting in 2001 and has been implementing the WHO-UNICEF recommended strategies. Successful implementation of these strategies resulted in a 92% reduction in the estimated number of measles deaths in the Region between 2000 and 2008. 2. Despite the signiﬁ cant reduction in measles mortality, the reality is that measles vaccination coverage, the quality of measles supplementary immunization activities and the quality of disease surveillance in the African Region have not yet reached the levels required to avert resurgence of measles. In 2010, 28 countries in the African Region experienced measles outbreaks. 3. Measles elimination is biologically and programmatically feasible, building upon the experiences of measles mortality reduction in the past decade. The elimination efforts should be entirely led by countries, and implemented to strengthen immunization systems and promote equity of service delivery. 4. The priority interventions should include improving immunization coverage through systematically implementing a combination of approaches; providing a second opportunity for measles vaccination,; conducting sensitive disease surveillance; building the capacity of health workers;, improving the quality of immunization monitoring data; conducting sustained advocacy and mobilizing local and international partners; and scaling up operational research. 5. This document proposes a strategy for the elimination of measles by 2020 in the African Region. The Regional Committee examined and adopted this strategy.

INTRODUCTION the WHO-UNICEF recommended strategies since 2001.2,3 These strategies include increasing the 1. Measles elimination is defi ned as the absence of cover age of measles-containing vaccines (MCV) in endemic measles cases for a period of twelve months routine immunization; providing a second opportu- or more, in the presence of adequate surveillance. nity for measles immunization through Supplemen- Global measles eradication is the sum effect of tary Immunization Activities (SIAs); establishing measles elimination in all WHO regions. case-based surveillance, including laboratory confi r- 2. The Millennium Development Goal 4 (MDG mation; and improving case management. 4)1 aims to reduce under-fi ve mortality by two- 4. The strategies for measles mortality reduction thirds by 2015 compared with the 1990 level. have been implemented through collaboration be- Vaccination against measles will reduce measles tween national governments and partners, and in a mortality and contribute to the attainment of manner that promotes integrated delivery of child MDG4. survival interventions. The successful implementa- 3. The African Region has adopted measles mor- tion of the measles mortality reduction strategies re- tality reduction goals and has been implementing sulted in 92% reduction in the estimated number of

162 Intensifying the prevention and control of communicable and noncommunicable diseases measles deaths in the African Region between 2000 7. This document proposes a strategy for the elimi- and 2008.4 nation of measles in the African Region by 2020. 5. The African Regional Measles Technical Advi- sory Group (TAG) proposed a pre-elimination goal SITUATION ANALYSIS AND of reducing measles mortality by 98% by 2012 compared with 2000 estimates, reducing measles in- JUSTIFICATION cidence to less than fi ve cases per one million inhabi- Situation analysis tants annually in all countries, and attaining the targets for the main surveillance performance indi- 8. Between 1980 and 1989, an average of one mil- cators. The two main measles surveillance perform- lion suspected measles cases were reported in the ance indicators are: (i) non-measles febrile rash African Region annually. This ten-year annual aver- illness rate (target of at least 2 per 100 000 people); age dropped to 450 000 in the 1990s and to 250 000 and (ii) the proportion of districts that have investi- between 2000 and 2009. Between 2006 and 2009, the average annual reported measles cases was below gated at least one suspected case of measles with 6 blood specimen per year (target of 80% or more per 100 000 for the whole Region. annum). 9. The WHO/UNICEF estimated coverage with 6. In 2010, the Sixtieth session of the WHO the fi rst dose of measles-containing vaccine (MCV1) in the African Region increased from 56% in 2001 Regional Committee for Africa adopted Resolution 7 AFR/RC60/R4: Current status of routine immu- to 69% in 2009. Similarly, the number of countries nization and polio eradication in the African Region: with MCV1 coverage above 90% increased from challenges and recommendations. The resolution four to thirteen, while the number of countries with expressed concern about the fragility of the gains in coverage below 50% reduced from eight to two measles mortality reduction and requested Member (Figure 1). States to increase immunization fi nancing, strength- 10. Four hundred and forty-fi ve million children in en immunization research and improve the quality 43 Member States8 were vaccinated through SIAs of implementation of strategies for the control of between 2001 and 2010. Measles SIAs have pro- vaccine-preventable diseases.5 vided a platform for cost-effective delivery of

20 number of countries number 15

0 2001 2002 2003 2004 2005 2006 2007 2008 2009

less than 50% 50–59% 60–69% 70–79% 80–89% 90% and above

Figure 1: Number of countries in the African Region by category of MCV1 coverage, 2001–2009 (WHO/UNICEF estimates).

163 COMPENDIUM OF RC STRATEGIES

high-impact child survival interventions, including nically feasible and is cost-effective and benefi cial to the supply of vitamin A, insecticide-treated bednets health systems strengthening.14 (ITNs) and anti-helminths. 19. Regional measles elimination can build on the 11. As of December 2010, 40 Member States9 have successes in the implementation of measles mortality established case-based measles surveillance supported reduction strategies and the lessons from the Polio by a network of 44 national laboratories, using stan- Eradication Initiative.15 Measles elimination will fos- dard procedures and tools to confi rm measles cases, ter the integration of child survival interventions and undertaking regular quality control exercises. and contribute towards the strengthening of immunization systems by enhancing the skills of health 12. In 2010, the non-measles febrile rash illness rate workers, strengthening vaccine management sys- was 4.1 per 100 000 in the Region, with 25 coun- tems, mobilizing communities, and reaching out to tries10 (63%) meeting the target. In addition, 29 populations that do not normally benefi t from rou- countries11 (73%) met the target of 80% or more of tine service delivery. districts investigating measles cases. 20. Four of the six WHO regions16 have already 13. In 2010, 28 countries12 in the Region experi- adopted measles elimination goals. The Region of enced measles outbreaks with a cumulative total of the Americas has already achieved and maintained 223 016 reported cases and 1193 ensuing deaths. measles elimination since 2002 through high and These outbreaks were due to the shift of epidemio- sustained routine immunization coverage, high- logical susceptibility to include older age groups, sub- quality measles SIAs, and sensitive surveillance. optimal routine immunization coverage and gaps in SIAs coverage. In some countries in Southern Africa, resistance to immunization from certain religious communities contributed to large-scale outbreaks. THE REGIONAL STRATEGY 14. The problems identifi ed in regard to the quality Aim, objectives and targets of immunization monitoring and surveillance data include inaccuracies in denominators, and gaps in 21. The aim of this Regional strategy is to achieve the documentation and verifi ability of immuniza- the elimination of measles in all Member States in tion coverage data. Furthermore, surveillance and the African Region by 2020. outbreak data are incomplete. 22. The specifi c objectives are: 15. Detailed data are lacking as regards the reasons (a) to reduce measles incidence in all countries; for the failure of immunization services to adequate- (b) to increase access to immunization services in all ly reach target populations, underscoring the need districts; for further operational research to identify the un- (c) to improve coverage during all scheduled derlying reasons and the best approaches to address measles SIAs and outbreak response immuniza- these weaknesses. tion activities; 16. In 2009 and 2010, in 21 of the 30 follow-up (d) to improve the quality of measles surveillance, as measles SIAs, countries raised less than 50% of the well as the epidemiological and virological in- operational costs from local sources. Such resource vestigation of measles outbreaks in all countries. gaps have led to postponements of SIAs and under- 23. Targets: By 2020, all countries in the African mined the quality of SIAs. Region will achieve and maintain:

Justiﬁ cation (a) measles incidence of less than 1 case per million population at national level; 17. In 2008, it was estimated that measles killed (b) at least 95% measles immunization coverage at around 28 000 children annually in the African national level and in all districts; Region,13 representing a signiﬁ cant decrease in mea- (c) at least 95% coverage in all scheduled measles sles mortality in the Region. However, these gains SIAs, and in outbreak response immunization would be lost and measles deaths would increase activities; again if Member States do not maintain high immu- (d) at least 80% of districts investigating one or more nization coverage. suspected measles cases within a year, and a non 18. Feasibility studies done at the global level indi- measles febrile rash illness rate of at least 2 per cate that measles eradication is biologically and tech- 100 000 population at national level.

164 Intensifying the prevention and control of communicable and noncommunicable diseases

Guiding principles lead to high performance of SIAs and high coverage will be promoted and widely implemented. 24. The guiding principles of this strategy are: 27. Improve immunization monitoring data (a) Country ownership and leadership in the quality. Immunization programme managers implementation of this regional strategy. should assess the quality of immunization coverage (b) Allocation of adequate resources and their data and conduct regular data quality checks using efﬁ cient use to attain the targets on time and standard methods such as Data Quality Assessment maintain the gains of the regional elimination. and multistage cluster coverage surveys, as appropri- (c) Strengthening of partnerships at local and ate, and use such information to ensure better man- global levels, and fostering sustainable intersec- agement of the elimination programme. toral collaboration, given the need to institutionalize coordinated intersectoral action in 28. Improve the quality of disease surveillance. order to improve health determinants. Sensitive surveillance will be required in order to (d) Community ownership by ensuring that monitor the epidemiological situation and guide communities and civil society are actively in- the immunization strategy. The implementation of volved and play a pivotal role in the implemen- measles surveillance should build on the existing tation of the elimination strategies. vaccine-preventable diseases surveillance network. (e) Integration of measles interventions into health The geographical scale and the programmatic scope services and using the opportunities created of the detection, investigation and reporting of sus- through the implementation of the measles pected measles cases will have to be strengthened. elimination strategies to deliver additional high 29. Enhance information sharing among impact child survival interventions. Member States. High quality surveillance will re- (f) Equitable access to essential health services quire that countries regularly exchange epidemio- especially to people living in border areas, logical information between the public and private migrant and nomadic communities and other sectors and particularly in border areas where meas- underserved segments of the population. ures need to be taken collaboratively to rapidly respond to measles outbreaks. The expanded role of the national measles laboratories in an elimination Priority interventions context should be supported especially in viral strain 25. Improve routine immunization coverage identiﬁ cation and characterization. through systematic implementation of a combina- 30. Promote operational research. In the process tion of approaches to reach everyone targeted for of implementing these priority interventions, in- immunization. These approaches, including the creased investment in operational research will be Reaching Every District approach, the periodic needed. Standard epidemiological research will be Child Health Days and others, basically involve required for better understanding of the characteris- increasing community demand for immunization; tics of the un-immunized populations, the reasons improving service delivery through the use of infor- for immunization default, overall quality of immu- mation for programme management; expanding nization services and the development of innovative access to immunization, including outreach services; approaches to addressing immunity gaps in under- and improving and strengthening vaccine manage- served populations. ment systems. 31. Ensure capacity building. Appropriate quan- 26. Provide a second opportunity for measles titative and qualitative studies should be carried out immunization through high quality measles SIAs to assess the training needs of health workers in ad- and/or the introduction of a second dose of measles dition to capacity building activities to address gaps immunization in the routine immunization schedule in the capacity of health workers to plan, implement in eligible countries as a major strategic approach to and monitor routine immunization services, imple- maintain high population immunity. However, the ment high quality supplementary immunization ac- target age group for SIAs and the interval between tivities, and carry out sensitive disease surveillance. SIAs will have to be determined according to the local epidemiological patterns, the need to reduce 32. Carry out sustained advocacy and resource the incidence of the disease in all age groups and mobilization. There is need to undertake strong build immunity levels so as to interrupt local trans- advocacy for, and champion measles elimination, mission, and transmission driven by importations. develop advocacy materials, and engage partners and Strategic approaches and best practices proven to donors through regular meetings to ensure adequate

165 COMPENDIUM OF RC STRATEGIES

ﬁ nancing for the implementation of the measles (a) provide technical assistance to countries for the elimination strategies. The experiences should be development of strategic and operational plans documented and best practices and lessons learnt and for the implementation of the measles elim- disseminated. ination strategies; (b) support Member States to conduct operational 33. Mobilize partners and coordinate interven- research to better guide the implementation of tions. It is important to continue to use the platform measles elimination strategies; of the Interagency Coordination Committees (ICC) (c) develop and make available updated standards, and other national and subnational forums to including immunization schedules, and guide- strengthen local partnerships and forge new ones lines for the implementation of interventions; when necessary. Member States should coordinate (d) support Member States to mobilize the neces- and lead the partnerships in a manner that will opti- sary resources to achieve measles elimination by mally utilize the inputs to achieve the measles elimi- 2020; nation goal and contribute towards the strengthening (e) scale up support to countries for cross-border of immunization systems. surveillance and management of measles out- 34. Ensure availability of quality and afforda- breaks; ble vaccines and medicines. There is need to (f) undertake advocacy among global partners and strengthen the procurement, supply and manage- donors for increased resources. ment of vaccines and medicines, while ensuring accessibility and affordability to the population, in Resource implications order to achieve universal coverage and better case 37. Measles elimination will require high levels of management. national commitment and the ﬁ nancial support necessary for full implementation of comprehensive Roles and responsibilities national immunization plans, which include measles elimination. Measles elimination efforts should be Member States integrated into the overall health system strengthen- 35. Member States should: ing, especially improving access to immunization services, ensuring safe immunization practices, and (a) adopt a measles elimination goal to be attained improving the capacity of health workers, laboratory by 2020; networks, epidemiological surveillance and cold- (b) develop strategic plans towards measles elimina- chain systems. tion by 2020; (c) mobilize and allocate adequate resources to im- 38. It is estimated that a total of US$ 2.6 billion will plement strategic plans; be required to attain measles elimination in the (d) adopt, adapt or develop and use standards to African Region by the year 2020. Forty-six percent facilitate the implementation of strategies; of these costs are related to the existing programmat- (e) develop sustainable mechanisms for regular co- ic costs of conducting routine immunization services. ordination of stakeholders and partners in the 39. It will be important to continue to promote glo- implementation of the strategies, including bal and local partnerships, building on the Measles across borders; Initiative model. Member States should create viable (f) conduct operational research on the various as- mechanisms for coordination of partners in order to pects of strategy implementation in order to en- pool resources from local partners and make optimal sure the attainment of the targets; use of the opportunities created by the private sec- (g) document lessons from the measles mortality re- tor, civil society organizations, faith-based organiza- duction efforts and identify best practices for tions and other sectors. emulation and scale up; (h) mobilize, involve and empower communities to effectively use immunization services. MONITORING AND EVALUATION 40. Monitoring of progress towards the elimination of measles in the Region will be done through ongoing WHO and Partners monitoring of the coverage of routine measles immu- 36. Taking into account the proposed priority inter- nization and monitoring of SIA coverage at national ventions, WHO, in collaboration with UNICEF and district levels. In addition, the DPT1 – MCV1 and other partners, including the Measles Initia- dropout rate will be monitored and periodic coverage tive,17 should: surveys will be carried out to validate administrative

166 Intensifying the prevention and control of communicable and noncommunicable diseases coverage of routine immunization and SIA doses. tensive implementation of priority interventions and Data analysis will be done in a dis aggregated manner adequate fi nancing from both Member States and in order to monitor the equity of service delivery local and international partners. across geographical areas and populations. 47. The Regional committee examined and adop- 41. High quality measles case-based surveillance, ted this strategy. supported with laboratory confi rmation of cases and outbreaks, will provide the crucial information need- Resolution AFR/RC61/R1 ed to monitor the epidemiological situation and the incidence of measles. In addition, to cater for the gaps Measles elimination by 2020: A strategy for in case detection and notifi cation, epidemiological the African Region modelling will provide estimates of measles deaths. The Regional Committee, The standard measles surveillance performance monitoring indicators will be monitored regularly to Having carefully examined the document ensure that surveillance remains sensitive. The distri- “Measles elimination by 2020: a strategy for the bution and circulation of measles viral strains will also African Region”; be monitored through laboratory characterization of Recalling Resolutions AFR/RC52/R2 on the viral strains in every measles outbreak. Regional strategy for immunization during the 42. Operational research will be conducted to de- period 2003–2005; AFR/RC56/R1 on the Re- termine the causes of non-immunization and will be gional strategic plan for the Expanded Programme used to develop new approaches to improve the de- on Immunization 2006–2009; and AFR/RC60/R4 livery of immunization services through the routine on Routine immunization and polio eradication in programme and SIAs and to introduce new and up- the African Region; coming technologies for measles case confi rmation Appreciating the achievements made so far by and measles vaccine delivery. Member States and partners in reducing measles 43. Progress towards the regional measles elimina- mortality by 92% by 2008 as compared with 2000 tion goal will be independently assessed in 2015 and estimates; the results will be used to re-align and refi ne the im- Noting the challenges concerning the accuracy plementation of the strategy. A comprehensive end- of population estimates for the monitoring of im- term evaluation of the strategy and its impact on munization coverage; immunization systems will be conducted in 2020. Deeply concerned about the recent resurgence of CONCLUSION measles in the African Region, and the fragility of the gains in measles mortality reduction; 44. The WHO/UNICEF measles mortality reduc- Noting the changing epidemiological pattern of tion strategies have proven to be effi cient in reduc- measles, with an increasing proportion of cases in ing measles deaths in the African Region. Measles young infants, older children and adults; elimination efforts will build on these experiences from the past decade in a manner that strengthens Recognizing the programmatic feasibility as immunization systems, especially through building well as the system-wide challenges of measles the competences of health workers to plan, imple- elimination; ment and monitor immunization services, and Convinced that eliminating measles will contri- through strengthening the cold chain system and bute signifi cantly to the attainment of MDG 4 and vaccine management practices. Operational research towards health systems strengthening; will be required for enhanced understanding and better implementation of strategies to improve and 1. ENDORSES the document aimed at the adop- maintain high level immunization coverage. tion of a measles elimination goal for the African Region; 45. The implementation of the regional measles elimination strategy will be supported by a commit- 2. URGES Member States: ted global and regional partnership as well as broad- (a) to develop and implement national plans for the based local partnerships in order to ensure the elimination of measles by 2020, in line with the availability and effi cient use of resources. Regional Strategic Plan; 46. The elimination of measles is biologically and (b) to provide adequate fi nancial and human re- programmatically feasible. However, it requires in- sources for the implementation of national plans

167 COMPENDIUM OF RC STRATEGIES

to sustain the gains in measles mortality reduc- 6. Measles cases reported by countries to the WHO tion, in order to reach the measles pre-elimina- (1980–2009). Immunization monitoring global sum- tion targets by 2012, and ultimately attain mary. http://apps.who.int/immunization_monitor- measles elimination by 2020; ing/en/globalsummary/timeseries/tsincidencemea. (c) to mobilize national and international stake- htm last accessed on 1 Nov, 2010. 7. Vaccination coverage fi gures according to WHO/ holders from the public and private sectors, UNICEF coverage estimates for MCV1. http://apps. NGOs, bilateral and multilateral organizations, who.int/immunization_monitoring/en/globalsum- including local communities, and coordinate all mary/timeseries/tsincidencemea.htm accessed on 1 activities in the measles elimination efforts; Nov, 2010. (d) to generate reliable and updated population data 8. All countries in the African Region except Algeria, to be used for monitoring measles immunization Mauritius and Seychelles. coverage. 9. All countries in the African Region except Algeria, Comoros, Guinea-Bissau, Mauritius, Sao Tome and 3. REQUESTS the Regional Director: Principe and Seychelles. (a) to develop a Regional Strategic Plan for measles 10. Botswana, Burkina Faso, Burundi, Cameroon, Cen- tral African Republic, Congo, Ethiopia, Gabon, elimination; Gambia, Ghana, Kenya, Lesotho, Malawi, Mali, (b) to provide evidence-based technical guidance Mozambique, Namibia, Nigeria, Rwanda, Senegal, on programmatic issues, including the age for South Africa, Swaziland, Togo, Uganda, Zimbabwe. measles vaccination; 11. Botswana, Burkina Faso, Burundi, Cameroon, Cen- (c) to provide technical support to Member States tral African Republic, Congo, Côte d’Ivoire, Demo- for the development and implementation of cratic Republic of the Congo, Eritrea, Ethiopia, national plans for the elimination of measles; Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, (d) to advocate for additional resources at national Namibia, Niger, Nigeria, Rwanda, Senegal, Sierra and international levels for the elimination of Leone, South Africa, Swaziland, Tanzania, Togo, measles in Member States; Uganda, Zambia and Zimbabwe. 12. Angola, Benin, Botswana, Burkina Faso, Burundi, (e) to report to the Regional Committee beginning Cameroon, Central African Republic, Chad, Côte in 2012 and, thereafter, every two years on the d’Ivoire, Democratic Republic of the Congo, progress made towards the elimination of measles. Ethiopia, Guinea, Lesotho, Liberia, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, REFERENCES Senegal, Sierra Leone, South Africa, Swaziland, Togo, Zambia and Zimbabwe. 1. http://www.who.int/topics/millennium_develop- 13. Global reductions in measles mortality 2000–2008 ment_goals/child_mortality/en/ last accessed on 1 and the risk of measles resurgence WER. No. 49, 4 March 2011. December 2009, 509–516. 2. WHO, Resolution AFR/RC52/R2: Regional strate- 14. Global technical consultation to assess the feasibility of gy for immunization during the period 2003–2005. In: measles eradication. Washington DC. 28–30 July Fifty-second session of the WHO Regional Committee for 2010. Africa, Harare, Zimbabwe, 8–12 October 2002, Final Re- 15. Measles pre-elimination and the programmatic feasi- port, Brazzaville, World Health Organization, Regional bility of measles elimination in the African Region. Offi ce for Africa, 2002 (AFR/RC52/19), pp. 8–9. Paper presented at the Global technical consultation 3. WHO, Resolution AFR/RC56/R1: The regional to assess the feasibility of measles eradication. strategic plan for the Expanded Programme on Im- Washington DC. 28–30 July 2010. munization 2006–2009. In: Fifty-sixth session of the 16. WHO Regions of Eastern Mediterranean, the WHO Regional Committee for Africa, Addis Ababa, Americas, Western Pacifi c and Europe. Ethiopia, 28 August–1 September 2006, Final Report, 17. The Measles Initiative is a partnership led by the Brazzaville, World Health Organization, Regional American Red Cross, the United Nations Founda- Offi ce for Africa, 2006 (AFR/RC56/24), pp. 7–10. tion, the U.S. Centers for Disease Control and 4. Global reductions in measles mortality 2000–2008 Prevention, UNICEF and the WHO. Other mem- and the risk of measles resurgence WER. No. 49, 4 ber-partners include Becton, Dickinson and Compa- December 2009, 509 – 516. ny, Bill & Melinda Gates Foundation, Canadian 5. WHO, Resolution AFR/RC60/R4: Current status International Development Agency, Church of Jesus of routine immunization and polio eradication in the Christ of Latter-day Saints, GAVI Alliance, Inter- African Region: Challenges and recommendations. national Federation of Red Cross and Red Crescent In: Sixtieth session of the WHO Regional Committee for Societies, the Izumi Foundation, the Kessler Family Africa, Malabo, Equatorial Guinea, 30 August–3 Septem- Foundation, Merck Co., the Vodafone Foundation, ber 2010, Final Report, Brazzaville, World Health Or- and governments of countries affected by measles. ganization, Regional Offi ce for Africa, 2010 (AFR/ RC60/21), 15–17.

168 Strategic Direction 6 Accelerating response to the determinants of health

6.1 Health promotion: A strategy for the WHO African Region (AFR/RC51/12 Rev.1)

EXECUTIVE SUMMARY 1. Broad determinants of health, most of which are intertwined, underlie the double burden of communicable and non-communicable diseases in the Region. To reduce the impact of these determinants on health, it is necessary to apply integrative comprehensive approaches. 2. Health promotion facilitates increased social and community participation in health. While health education is central to health promotion, legal, fi scal, economic, environmental and organizational interventions are also essential. Health promotion contributes to programme impact through the prevention of disease, the reduction of risk factors associated with specifi c diseases, the fostering of lifestyles and conditions conducive to health, and increasing use of available health services. 3. Health promotion is a cost-effective approach, which has great potential for accelerating the realization of health for all in the Region. It is effected through the empowerment of individuals and communities, the changing of socio-economic conditions, mediation between different interests in society (through healthy public policies), reorientation of health services and advocacy for health. 4. The strategy proposed aims at supporting Member States to foster actions that enhance physical, social and emotional well-being and contribute to the prevention of leading causes of disease, disability and death. 5. The objectives of the strategy involve strengthening national capacities for health promotion, supporting priority programmes to achieve set objectives, implementing specifi c initiatives in order to achieve priority health objectives, increasing the recognition of health promotion as an integral component of socio-economic development and promoting the involvement of non-health public and private sectors in health development. 6. The priority interventions proposed are: advocacy, capacity building, development of country plans, incorporation of health promotion components in non-health sectors and strengthening of priority programmes, using health promotion interventions.

INTRODUCTION 2. Health promotion practice has been in existence for a long time though the use of the term to refer 1. Health promotion is a means of increasing indi- to a specifi c fi eld started only in the 1980s. The vidual and collective participation in health action development of health promotion was greatly infl u- and strengthening programmes through the inte- enced by the evolution of other broad approaches to grative use of various methods. These methods are human development such as: combined through comprehensive approaches, which ensure action at all levels of society, leading to (a) the increased demand for social justice and for enhanced health impact. the rights of women, children and minorities (b) the health for all concept

171 COMPENDIUM OF RC STRATEGIES

(c) movements to protect and improve the physical was motivated by the recognition of the impact of environment and social, behavioural, economic and organizational (d) the increased attention being paid to poverty as factors on health status. Since most health problems a major underlying cause of illness. have multiple causes, an integrated response to these problems became necessary. 3. The development of health promotion is part of the global search for effective means of preventing 8. Health promotion is any combination of health disease and improving general living conditions. education with appropriate legal, fi scal, economic, There has progressively been increased recognition environmental and organizational interventions in of the need to address behavioural, lifestyle (harmful programmes to achieve health and prevent disease.2 cultural practices) and other underlying socio- Other health promotion methods include informa- economic, physical and biological factors, referred tion, education and communication, social mobili- to here as the broad determinants of health, so as to zation, mediation, lobbying and advocacy. These improve health. methods are especially relevant in mobilizing non- 4. By the mid-20th century, the Public Health health sectors to contribute to health development. model was well established and technologies for 9. Health promotion action can signifi cantly con- manipulating the physical environment were tribute towards the achievement of the Region’s regarded as the ultimate answer to critical health priority programme objectives, which include: issues. During this period, emphasis was placed on controlling specifi c diseases through biomedical (a) prevention of priority communicable diseases interventions. Non-professionals played a minimal such as HIV/AIDS, tuberculosis and malaria; role in these developments.1 (b) prevention of priority non-communicable diseases such as mental illness, cardiovascular 5. During the 1960s, the role of behavioural factors diseases, diabetes and cancer; in ensuring improved health became widely recog- (c) reduction of risk factors, such as conditions and nized. It was then understood that besides bio- behaviours that expose people to HIV/STI, to- medical care and improvements in the physical bacco use and other substance abuse, diabetes, environment, individual lifestyles also infl uence and other priority communicable and non- morbidity and mortality. Health education became communicable diseases; the main method of informing people on how to (d) fostering lifestyles and conditions that are positively change their behaviour so as to prevent conducive to physical, social and emotional specifi c diseases and improve their health. At that well-being, such as healthy dietary practices, time, health education was applied through a top- active living and use of life skills; and down approach to learning, often using general, (e) increasing effective use of existing health serv- untargeted messages, within a strictly biomedical ices and stimulating demand for others. understanding of health. The participation of com- 10. Health promotion action contributes towards munities and the lay public in health was still limited. the achievement of priority health programme 6. In the 1970s, the health for all concept and the objectives3 by: primary health care strategy were developed. This (a) increasing individual knowledge and skills using development gave health education and related health education and information- education- information, education and communication communication (IEC); approaches a prominent role in health. Health edu- (b) strengthening community action through social cation was then viewed as an activity for supporting mobilization; the other primary health care components. Applica- (c) creating environments that are protective and tion of health education and related approaches in supportive of health using mediation and nego- the Region resulted in increased participation of the tiation; public in health action, though many people, in- (d) developing healthy public policies, legislation cluding policy-makers, still regard health develop- and economic and fi scal controls, which en- ment as the domain of health professionals. hance health and development through lobby- 7. The development of health promotion with a ing and advocacy; view to increasing social and community control (e) reorienting health services by emphasizing pre- and participation in health started in the 1980s. It vention and consumer needs.

172 Accelerating response to the determinants of health

SITUATION ANALYSIS AND 16. Reports from various countries indicate innova- JUSTIFICATION tive use of entertainment and communication media in the Region. However, the main media used con- Situation analysis tinue to be print. Radio, focus groups, folk media, 11. Countries in the Region are experiencing a interactive theatre, puppetry and television are also double burden of disease: communicable diseases, used to some extent.8 which are highly prevalent and non-communicable 17. The major challenges relating to the implemen- diseases, which are increasing rapidly. The HIV/ tation of health promotion in the Region include: AIDS pandemic, malaria and the re-emergence of tuberculosis, etc. have further compounded this (a) poor defi nition of expected health outcomes, situation. Low levels of literacy (especially among specifi c factors and conditions to be infl uenced women), poor sanitation, inadequate food, civil through health promotion; strife and risky behaviours (e.g., smoking, increasing (b) lack of health promotion policies and guidelines sedentary living and unhealthy diets), which consti- for coordination of different methods and tute broad determinants of health, underlie many approaches; health problems in the Region. “Poverty fuels the (c) inadequate capacity (especially in human re- impact of these factors on health as it keeps people sources) to develop, implement and evaluate in poor health and poor health keeps people in health promotion programmes and activities; poverty”.4 (d) insuffi cient intra- and intersectoral collaboration at national and regional levels; 12. WHO recognizes the need to involve all people (e) low investment in preventive and promotive in addressing these broad determinants to improve services within the health sector; health. The WHO Constitution states that informed (f) limited operational research and dissemination opinion and active cooperation on the part of the of information on good practices in health public are of the utmost importance in the improve- promotion; 5 ment of the health of the people. The Organiza- (g) lack of appropriate linkages between health tion, therefore, encourages and supports countries promotion and the delivery of health services; to use health promotion to address the broad deter- (h) lack of full understanding of the effectiveness minants. of health promotion by the public and policy 13. Countries recognize the value of health educa- makers; tion and also that to achieve its full potential, it (i) political and social instability and poor govern- has to be combined with other health promotion ance, which impede the process of democratiza- methods as proposed in this strategy. tion and participation of civil society in health action. 14. A recent WHO survey in the Region reveals the existence of various health promotion approaches and methods institutionalized in diverse structures. Justifi cation Of a total of 37 countries, 15 have health education; 18. There is evidence that the application of health 11 information, education and communication; fi ve promotion leads to positive outcomes such as em- health promotion; two information, education and powerment for health action, healthy public policies communication and health education; one informa- and increased community involvement. tion, education and communication and social mobilization; one other health education and social 19. Health promotion makes a unique contribution mobilization; and two have no specifi c approach.6 to health development by integrating various ap- Health promotion is being increasingly incorporated proaches and methods to address broad determinants into non-health sectors, especially education and of health. It is a necessary component in all health agriculture. Seventeen countries are already imple- and related programmes. Health promotion plays a menting the Health Promoting Schools Initiative.7 central role in the creation and management of enabling environments for health. 15. A report of an expert consultation shows that the implementation of health promotion and related 20. Health promotion has a rapidly increasing dis- approaches in the Region has traditionally been tinct body of knowledge, principles and methodol- spearheaded by the health sector although the ogy. It is important, therefore, that countries of the participation of individuals, communities and non- Region have a strategy to ensure its development health actors is gradually increasing. and use.

173 COMPENDIUM OF RC STRATEGIES

21. Since 1986, fi ve global health promotion con- HIV/AIDS, Malaria, Tuberculosis, Immunization, ferences have been convened by WHO and key Mental Health, the Tobacco Free Initiative and partners. The conferences have infl uenced the de- Reproductive Health. Though currently these pro- velopment and implementation of health promotion grammes have elements of health promotion, the in countries. During the latest of these conferences proposed strategy should facilitate strengthening (Mexico, June 2000), African participants called on and systematization of the application of health the WHO Regional Offi ce for Africa to develop a promotion to improve programme effectiveness and regional health promotion strategy. The strategy sustainability. would help countries in the Region to adapt the Mexico framework for the development of health THE REGIONAL STRATEGY promotion within the African context. Aim and objectives 22. Reports of fi ve global health promotion conferences indicate, among other things, that there is a 27. The aim of the strategy is to foster actions that need to ensure the mobilization of new players in enhance physical, social and emotional well-being health by involving all sectors and cutting across sec- and contribute to the prevention of leading causes of toral, departmental and institutional boundaries. disease, disability and death. The challenge in the coming years is to unleash the 28. The objectives of the strategy are: potential for health promotion inherent in many sectors of society, communities and families.9 (a) to strengthen the capacity of countries to design, implement and evaluate health promotion 23. Various WHO resolutions prior to 1989 did not (b) to support priority health programmes to achieve specifi cally deal with health promotion but empha- set objectives sized the role of public information and education in (c) to implement specifi c health promotion initia- health. The resolutions specifi cally urged Member tives to achieve priority health objectives States to develop infrastructure for health education (d) to increase recognition of health as a necessary and information, education and communication.10 component of socio-economic development 24. WHO resolutions after 1989 deal specifi cally (e) to promote the involvement of non-health with health promotion.11 The resolutions call upon public and private sectors in health develop- Member States to develop health promotion as an ment. essential element of primary health care and take steps to train health and related professionals in Guiding principles health promotion. Intercountry cooperation and 29. The success of health promotion interventions exchanges of experience in health promotion are will depend on the following principles: encouraged. The United Nations system, international and non-governmental organizations and (a) Existence in countries of knowledge and skills foundations, donors and the international commu- for implementation of evidence-based health nity are called upon to mobilize and cooperate with promotion; Member States to develop and implement health (b) Integration of health promotion into all health promotion strategies. Countries are urged to secure programmes, with clearly defi ned goals and infrastructure for health promotion. The WHO Di- objectives; rector-General thus gives top priority to health pro- (c) Systematization of the use of the interventions motion, the development of which is supported to complement priority health programmes; within the Organization.12 (d) Recognition of health as a resource for development and achievement of equity in communities 25. A WHO Regional Committee for Africa’s and within countries; of expenditure on health resolution calls on Member States to develop or as an investment in human resources and devel- strengthen information, education and communica- opment; of policies and practices that avoid tion strategies as essential elements of health promo- harming individual health, protect the environ- tion.13 The resolution emphasizes the role of ment, restrict trade in or production of harmful communication strategies in health promotion but goods and substances, and safeguard health in does not address health promotion specifi cally. the workplace;15 26. The Regional Offi ce recognizes health promo- (e) Tapping the potential for health promotion in all tion as a necessary component in its priority pro- sectors, creating partnerships and identifying grammes as part of the effort to achieve health for non-health sector actors in support of peace, all in the 21st century.14 The programmes include: shelter, education, food, adequate income, a

174 Accelerating response to the determinants of health

stable ecosystem, social justice, respect for Implementation framework human rights and equity that are conditions for At country level health and that can reduce poverty, which is the greatest threat to health. 36. The technical leadership of the health sector is crucial to the implementation of this strategy. Coun- tries will: Priority interventions (a) undertake advocacy to increase awareness and 30. Member States and WHO need to address the support for the use of health promotion, target- following priorities in order to develop and imple- ing both the health and non-health sectors and ment effective health promotion programmes and mobilizing new players for health; activities: (b) develop and adjust policy, establish institutional (a) Advocacy on use of health promotion to frameworks and mechanisms, and mobilize and improve health and prevent disease; allocate resources for health promotion compo- (b) Capacity building for strengthening health pro- nents in programmes; motion policies, mechanisms and interventions; (c) establish mechanisms for linking health promo- (c) Country plans of action for strengthening the tion interventions in non-health sectors with the use and institutionalization of health promotion national health system; in health systems; (d) formulate action plans to facilitate the develop- (d) Incorporation of health promotion components ment of health promotion capacity and support into non-health sector interventions and pro- at various levels; the plans should be based on grammes; and a framework that includes situation analysis, (e) Strengthening of priority health programmes problem defi nition, objectives, mechanisms for through the use of health promotion methods coordination, partnership building, monitoring and approaches. and evaluation; (e) strengthen the health promotion component in 31. Since health promotion is still being developed priority programmes by adapting available in many countries of the Region, there is a need for guidelines for the Health Promoting Schools advocacy of its use in health development. The sup- Initiative, the Tobacco Free Initiative, Immuni- port of community and political leaders, academic zation,16 etc. institutions, NGOs, donors, professional associations and private enterprises should be solicited in order 37. To plan, implement and evaluate health promo- to accelerate the development and application of tion efforts, each country will: health promotion. (a) identify goals in terms of health outcomes to 32. National health promotion policy should facili- which the health promotion effort will contrib- tate the coordination of activities, the mobilization ute; of resources and capacity building. Health promo- (b) delineate the behaviours or conditions associated tion practitioners should be orientated or trained as with each targeted health outcome that are to be necessary, and training curricula should refl ect health infl uenced by the health promotion effort; and promotion components. (c) defi ne the specifi c changes that are intended to be achieved by the health promotion effort in 33. Health promotion should be integrated through- order to infl uence targeted behaviours or condi- out the health system and plans of action should be tions, focusing on: developed for this purpose. • increasing individual knowledge; 34. Collaborative mechanisms to support the imple- • strengthening community action; mentation of health promotion in non-health sec- • creating environments supportive of health; tors should be put in place. These should involve all • developing, implementing and enforcing potential players, including, but not limited to, the health-related policies; and private sector, academia, NGOs and community- • reorienting health services. based organizations. At regional level 35. The health promotion component in priority health programmes should be strengthened. Availa- 38. WHO will continue to advocate for renewed ble guidelines and examples of good health promo- political commitment and for the creation of envi- tion practice should be used. ronments that are supportive of health in accordance

175 COMPENDIUM OF RC STRATEGIES with the health-for-all policy in the African Region several levels results in increased health knowledge, for the 21st century.17 More speciﬁ cally, WHO will: skills and community participation, healthy public policies and environments, which are supportive of (a) Support, technically and materially, countries of health. Priority actions recommended include advo- the Region to implement the recommendations cacy, capacity building, plans of action, involvement of this strategy; of all sectors and strengthening of health pro- (b) provide leadership and guidance to regional grammes. counterparts, international NGOs and agencies to enable them understand, support and use Resolution AFR/RC51/R4 health promotion to address health and development; Health promotion: A strategy for the African (c) mobilize and support countries to participate in Region (AFR/RC51/R4) intercountry consultations and to form health The Regional Committee, promotion partnerships; (d) advocate with governments and agencies to sup- Aware that the physical, economic, social and port the implementation of health promotion cultural factors, known to be the broad determinants and sharing of experiences; of health, underlie the double burden of communi- (e) facilitate the training of designated national cable and non-communicable diseases and are re- health promotion focal persons; sponsible for the general health conditions in the (f) coordinate the development of guidelines and a Region; regional implementation framework, including Convinced about the necessity to apply, in an clearly deﬁ ned targets, for strengthening health integrated manner, various health promotion promotion in countries; approaches and techniques to address these factors (g) use health promotion actions to carry out re- and reduce their impact on health; gional initiatives and to support country efforts. Recalling resolutions WHA27.27, WHA31.42, 39. Partners in health development will support the WHA42.44, WHA51.12 and AFR/RC47/R2, and use of health promotion in countries through the Executive Board decision EB1.1.12, which called provision of resources and strengthening of the for the development and implementation of health health promotion component in their programmes. promotion approaches, and the recommendation by Member States adopted at the 50th session of the MONITORING AND EVALUATION Regional Committee, and the WHO Secretariat’s report on health promotion to the Fifty-fourth 40. Countries will agree on indicators to be used for World health Assembly (A54/A/SR/7); monitoring the implementation of the strategy’s objectives and country actions to increase capacity and Appreciating the efforts made so far by Member support, and to plan, implement and evaluate health States and their partners in developing and imple- promotion. menting various approaches which constitute health promotion; 41. Countries will monitor implementation of the strategy using agreed indicators. Recognizing the need to integrate and consolidate existing approaches and develop a comprehen- 42. WHO will collect information on the imple- sive framework for strengthening the application mentation of the strategy two years after its adoption of health promotion in countries of the African and every three years thereafter. Region; 43. Countries and WHO will carry out periodic in- Having carefully examined the Regional Direc- tercountry evaluation of the effectiveness of health tor’s report contained in document AFR/RC51/12, promotion. which outlines the regional strategy for health promotion; CONCLUSION 1. APPROVES the proposed strategy, which aims 44. The major thrust of the strategy is the emphasis at supporting Member States to foster actions that on health promotion as a means of integrating vari- enhance the physical, social and emotional well- ous methods and approaches to improve the health being of the African people and contribute of of the people. Integration of methods and actions at disease, disability and death;

176 Accelerating response to the determinants of health

2. URGES Member States: REFERENCES (a) to advocate for increased awareness of and sup- 1. Egger, G et al (1990). Health Promotion Strategies and port for the use of health promotion in the Methods. McGraw-Hill Book Company, Sydney, p. 5. health and health-related sectors; 2. Adapted from a statement in Tones, K. et al (1990). (b) to develop national strategies incorporating Health Education: Effectiveness and effi ciency. Chapman policy, frameworks and action plans for strength- and Hall, London, p. 4. 3. Adapted from WHO (1998). Health Promotion Glos- ening the institutional capacity for health pro- sary (WHO/HPR/HEP/98.1), p. 2. Action at all or motion, and provide support at various levels of most of these levels is motivated by the understanding the health system, as appropriate; that many causes of illness and death can be addressed (c) to strengthen the health promotion component through simple measures directed at the individual, of health and related development programmes, the community and the environment. using available guidelines such as the ones for the 4. WHO Regional Offi ce for Africa, Report of the Tobacco-free Initiative and the Community- Regional Consultation on Poverty and Health. July Based Interventions for Malaria Control; 2000, Harare, p. 8. (d) to plan, implement and evaluate health promo- 5. Constitution of the World Health Organization, tion actions which are comprehensive in nature, Section One, p. 1. 6. A questionnaire was sent to countries and these are and focus on the following areas of intervention; the responses which had been received by September, (i) increasing individual knowledge and skills 2000. Only two countries have full health promotion (ii) strengthening community action structures. Three others combine health promotion (iii) creating environments supportive of health with health education or information, education and (iv) developing, implementing and infl uencing communication. health-related policies 7. Health Promoting Schools Initiative is a school health (v) reorienting health services; focused programme introduced by AFRO in the Re- (e) to mobilize new resources and players for health gion with donor support. The programme encourages action from the public and private sectors, non- use of the school as a setting for health promotion. governmental organizations, communities and Health Promoting Schools Initiative interventions include school health policy development, service international and bilateral bodies; delivery, health education and environmental health 3. REQUESTS the Regional Director: activities. 8. African Medical and Research Foundation. Together (a) to develop a generic framework and guidelines in Hope: A report of an intercountry consultation on for the implementation of the regional strategy Health Promotion. Nairobi, March 2000, pp. 1–14. and to provide technical leadership to Member 9. The key reports are: The Ottawa Charter, The Ad- States to enhance the development and applica- elaide Recommendations on Healthy Public Policy, tion of health promotion, including strengthen- The Sundsvall Statement on Supportive Environ- ing of the technical capacity of national focal ments for Health, The Jakarta Declaration on Leading points; Health Promotion into the 21st century, and the Mexico Statement for the Promotion of Health. (b) to facilitate operational research on health pro- 10. The relevant resolutions are: WHA27.27, WHA31.42 motion and dissemination to Member States of and WHA42.44. the results on best practices through consulta- 11. The resolutions are: WHA51.12 and EB101/SR/12. tions, networks and workshops; 12. The Jakarta Declaration states that to address emerg- (c) to mobilize additional resources and encourage ing threats to health, new forms of action are needed. partnerships among key actors for supporting the The challenges require the mobilization of new play- implementation of the Health Promoting ers in health drawn from non-health public and Schools Initiative and related regional inter- private sectors. It also stresses partnerships for health. ventions; 13. Resolution AFR/RC47/R2. (d) to draw up operational plans for the period 14. WHO Reginal Offi ce for Africa. Health-for-All Policy for the 21st Century in the African Region: 2002–2012; Agenda 2020. (e) to report on progress made in the implementa- 15. WHO (1997). Jakarta Declaration, p. 5. tion of the regional strategy to the fi fty-fourth 16. The guidelines will be based on the use of settings, session of the Regional Committee in 2004, and public health issues and specifi c population groups as thereafter, every two years. the entry points for health promotion interventions. 17. Doc AFR/RC50/8Rev.1. Fifth meeting, 29 August 2001

177 6.2 Environmental health: A strategy for the WHO African Region (AFR/RC52/10)

EXECUTIVE SUMMARY 1. In spite of the commendable efforts of many governments and external support agencies for many decades, in the year 2000, some 276 million people in Africa still lacked access to safe water supply, while 284 million were without adequate sanitation (AFR/WSH/00.3). The pollution of scarce water sources, the contamination of soils by industrial, municipal and agricultural wastes containing toxic and hazardous chemicals and the rampant spread of disease vectors have rendered water treatment and vector control very costly. 2. It is also becoming increasingly evident that the future of health in the entire world, and in Africa in particular, will be determined by the environment. While other regions are faced with problems of one era, Africa is confronted by the combined problems of pre-industrial, industrial and post-industrial eras. Countries need to prepare themselves to face these challenges or else they will be overwhelmed by a future that they can plan for, using the resources at their disposal. 3. The strategy on environment and health, therefore, aims to stimulate the development of environmental health policies in the health sector. These policies should enable the health sector within countries to inform the policies of the other social sectors in order to make them health sensitive. The strategy should also enable the health sector to improve the knowledge and awareness of communities about the relationship between the environment and health. It is important for communities to make informed choices so as to improve their health status and quality of life and contribute to sustainable development. 4. The Regional Committee examined and adopted this strategy.

INTRODUCTION and planners. This is reﬂ ected in the low level of 1. In spite of the commendable efforts of many resources allocated for the maintenance of an governments and external support agencies over enabling environment to support life and health. many decades, in the year 2000, some 276 million The diseases that burden communities, in particular people in Africa still lacked access to safe water deprived communities and rural and urban fringe supply, while 284 million were without adequate communities in Africa are mainly due to environ- sanitation (AFR/WSH/00.3). The pollution of mental conditions that can be avoided. The situation scarce water sources, the contamination of soils of deprived communities is worsened by poor envi- by industrial, municipal and agricultural wastes ronmental conditions that could easily be managed containing toxic and hazardous chemicals and the by environmental health services. rampant spread of disease vectors have rendered 3. It is, therefore, crucial to differentiate between water treatment and vector control very costly. environment and health and environmental health. 2. It is widely noted that the contribution and ben- Environmental health comprises those factors of human eﬁ ts of the environment to other determinants of health, including quality of life, that are determined by health are not well understood by policy-makers physical, chemical, biological, social and psychosocial factors

178 Accelerating response to the determinants of health in the environment (WHO/EH/98.9). It also refers to Source Activities the theory and practice of assessing, correcting and preventing those factors in the environment that can adversely affect the health of present and future Traditional Hazards generations. Thus, environmental health services Modern Hazards can be deﬁ ned as those services implementing envi- Human Activities Development Activities ronmental health policies through monitoring and control activities.

4. Environment and health refers to the interface Emissions between the environment on one side and health on the other. To explain this further, the ability to link health and environmental data, and, thereby, understand relationships between levels of exposure and health out- Environmental Concentration comes, is vital in attempts to control exposures and protect health. This capability is particularly important in coun- Air Water Food Soil tries in which issues of environmental pollution have traditionally taken second place to demands of economic development (WHO/EHG/95.26). Environment and health mainly deals with risk assessment and man- Exposure agement of this interface (see conceptual framework at the individual level, Figure 1). External Exposure

5. It is becoming increasingly evident that the future of health, particularly in Africa, will be determined by the environment. While other regions are faced with problems of one era, Africa is confronted Absorbed Dose by the combined problems of the pre-industrial era, of industrialization and of the twenty-fi rst century. Countries need to prepare themselves to address these challenges or else they will be overwhelmed by a future that they can plan for, using the resourc- Health Effects es at their disposal. Subclinical Effects 6. The Environment and Health strategy aims to stimulate the development of environmental health policies in the health sector. These policies should Morbidity enable the health sector within countries to inform the policies of the other social sectors in order to make them health sensitive. The strategy should also enable the health sector to improve the knowledge Figure 1 The environmental health hazards and awareness of communities about the relation- pathways: conceptual framework at the individual ship between the environment and health. It is im- level. Source: WHO/EHG/95.26, page 8. portant for communities to make informed choices so as to improve their health status and quality of life and contribute to sustainable development. SITUATION ANALYSIS 7. In order to address the above-mentioned 8. In Africa, water-related diseases such as malaria, problems, it is necessary to adopt an institutional schistosomiasis and river blindness are some of the arrangement to support the political commitment causes of high morbidity, which impact negatively made by countries in the New Partnership for on the economy and the health sector. Infectious Africa’s Development (NEPAD) and by ministers of diseases linked to poor environmental conditions health, through various regional efforts, to ensure kill one out of every fi ve children in Africa. Diar- healthy and safe environments for their people. The rhoea and acute respiratory infections are two of the regional strategy aims to strengthen preventive and major killers of children and under-fi ves. Cholera is health promotion measures in all countries of the endemic in at least a dozen of the countries in the Region. Region. In 1999, a total of 187 775 cases of cholera

179 COMPENDIUM OF RC STRATEGIES with 7831 deaths were reported, representing a case under the age of fi ve from high indoor air polluted fatality rate of 4% (WHO/EH 98.7). localities are likely to suffer more from upper respiratory problems than those from less polluted locali- 9. Occupational injuries and diseases play an ties. They are also more likely to underachieve in important role in developing countries, where 70% school compared to those from improved areas. This of the working population of the world lives. By limits their ability and chances in life. affecting the health of the working population, occupational injuries and diseases have profound 14. The effects of activities such as the burning of effects on work productivity and on the economic fossil fuel and use of chemical substances have con- and social well-being of workers, their families and tributed to the depletion of the ozone layer, thereby dependants, thus triggering a cycle of low capacity, low creating conditions favourable to the resurgence of revenue, low productivity and low consumption that tend diseases such as malaria, dengue fever and cholera. to trap societies into poverty. 15. The spread of unplanned, poorly constructed 10. Globally, chemical substances have brought urban settlements in African cities and towns, often about improvements in the lives and health of na- in unsuitable locations, not only impacts negatively tions. Every year, more than a hundred new chemi- on health but also undermines good values. These cal substances enter the market even though the settlements put pressure on the environment and the toxicology of a number of these chemical substances existing infrastructure and hence overload the sys- is not fully known. In the African Region, these tem and threaten the health of the people, particu- chemical substances are used mainly in agriculture larly that of children. More often, governments will and in some cottage industries, with little or no un- respond by providing water without improving derstanding of their immediate and long-term ef- waste control and sanitation though both are insepa- fects. Chemical substances have cumulative effects rable. It is a known fact that the quality of potable in the body. They can cause both acute and chronic water provided in areas where sanitation is lacking conditions resulting in very serious complications or low will be affected. and death. 16. The management of both solid and liquid waste 11. It is common occurrence for women workers to is far from satisfactory in the African Region. The carry their babies with them, while working in the result is visible heaps of rubbish in uncontrolled fi elds, thus exposing themselves and the babies to dumping sites, which attract salvaging, vermin and these chemical substances. WHO has developed a disease vectors. This is due to lack of planning and strategy, The Health Sector and Chemical Safety in the implementation of waste disposal measures. Com- 21st Century (Cape Town, July 2001), for addressing munities settle on unsuitable land that might have chemical substances within the health sector that been used as dumping sites of general waste and are will act as a guide to countries. thus exposed to potent gases and explosion from 12. Apart from exposure to chemical substances, built-up gases. Waste, when not properly managed, there are periodic oil spillages and leakages in some will directly or indirectly negatively affect the envi- countries in Africa, which further pollute the soil ronment and health. Waste from health care activi- and water. These oil spillages and leakages some- ties in particular poses a special risk to the people of times cause fi res and thus contribute to air pollution. the Region and thus calls for undivided urgent Of particular interest are additives in petrol, particu- attention. Yet, properly managed waste can create larly lead, which easily gains entry into the body employment and alleviate poverty. If waste is care- through various ways. Lead limits the ability of chil- fully recycled, re-used and reclaimed, very little of dren to learn, thereby triggering a cycle of illiteracy, it will be disposed of, which will save on space so which subsequently leads to poverty. desperately needed for other activities. 13. Pollution of indoor air results in various respira- 17. The safety and quality of food in its various tory and other non-communicable diseases in the forms is, therefore, affected by many of the unsafe world. In Africa, the situation is further aggravated conditions created. Its ability to support life is then by overcrowding, poorly ventilated houses, use of greatly compromised. In fact, food then becomes biomass and kerosene for space heating and lighting, dangerous to health and life. The way food is pro- lack of information on the use of chemical substanc- duced, stored, transported and handled as a comes, old and derelict motor vehicles and motor cycles. mercial product is, therefore, very important as it This has resulted in an increased disease burden determines the benefi ts that it may bring to people. within the populations. It also affects productivity, Particular attention must therefore be paid to the thus perpetuating the cycle of poverty. Children handling of food and foodstuffs to ensure their safety

180 Accelerating response to the determinants of health and quality. WHO treats food safety and hygiene as disseminated throughout other developing a separate very important aspect that needs a strategy regions of the world. Emerging threats such of its own. as air pollution will have been largely controlled due to the adoption of new, appro- 18. To ensure that determinants of success accom- priate technologies and political stability, as pany such a strategy, there are three possible sce- evidenced by the absence of political strife narios of environmental health development in and confl ict, will be the norm in most of the the Region for 2020. The purpose of the scenario continent. approach is to guide decision-making and to build a certain capability for anticipating events. THE REGIONAL STRATEGY • Status quo – This scenario assumes little or no change in the Region. Besides the occa- Long-term goal sional success stories, environmental health 19. By 2020, an enabling environment that pro- considerations will continue to receive the motes health and contributes to sustainable develop- scant attention and resources they now get. ment will have been created and maintained in the The explosive growth of peri-urban slums Region. will continue unabated. In line with standard demographic projections, environmental health issues will become a serious problem Objectives in the urban areas of the Region, where 20. The overall goal of this strategy, is to infl uence most of the population will reside by 2020. these environmental conditions to impact on the Air pollution, unsafe water and food, poor determinants of health in order to promote positive housing and occupational health problems outcomes for the people and communities, in will continue to take a heavy toll on African particular for rural and urban fringe communities. populations. Specifi c objectives are to support countries: • Catastrophe – The combination of rapid population growth, increasing poverty, nat- (a) to develop their own policies on environmental ural resource depletion and extensive envi- health by 2010; ronmental pollution will simply overwhelm (b) to establish appropriate structures for environ- decision-makers. Consequently, they will mental health services by 2010; operate in a state of denial of the issues being (c) to improve human resource capacities in envi- faced. Their interventions will focus on the ronmental health in ministries of health by 2015; privileged few at the expense of the majori- and ty. The sheer magnitude of the problem (d) to foster sector collaboration and partnership. confronted will put them in a state of inaction and poor environmental health Guiding principles conditions will be considered as normal. It is 21. Four guiding principles are necessary for the only when these poor environmental health implementation of the environment and health conditions have a direct impact on the lives strategy: of the privileged few that action will be taken to address the problem. (a) The participation of the people in decision- • The new age – Under this scenario, in- making implies involving all stakeholders in creased public participation in environmen- decision-making at the local level, particularly tal health efforts, coupled with strengthened in natural resource management. Dialogue, the capacity, heightened awareness and strong participation of the people and confl ict resolu- political commitment will combine to dras- tion among stakeholders strengthen the accept- tically improve the environmental health ability of and readiness to adopt concepts, situation of the continent. Thanks to sus- projects and programmes, thus rendering inter- tained efforts, environmentally induced dis- ventions more cost effective and more culturally eases (dysentery, cholera, malaria, etc.) will appropriate. become a thing of the past. Potable water (b) The provision of environmental health services will be made available to all, and low-cost to all people means some for all rather than all participatory sanitation practices will be infor some. Equity, that is the absence of system- stitutionalized throughout the continent. In atic potentially remediable differences in one or fact, the African success story will be widely more aspects of health across the population or

181 COMPENDIUM OF RC STRATEGIES

population groups defi ned either socially, eco- nants of health. They are, therefore, expected to nomically or demographically, is critical. In the create conditions that ensure success, namely ade- context of least developed countries, equity in quate resource allocation to environmental health access to public health services has become a services to enable them to undertake risk manage- more important objective from the poverty ment, provide inputs for the development of poli- alleviation perspective. cies for the other sectors and foster collaboration and (c) A pro-poor focus ensures that the main objective community participation. of planning is to benefi t poor people. Other- 25. Communities and other social sectors within wise, the poor will remain peripheral to the countries are expected to be involved in the health planning and development process. sector. It is also important for communities to par- (d) Intersectoral collaboration between various ticipate in policy development and implementation social-sector departments, particularly housing, and in the monitoring and evaluation of projects and local government, land, agriculture, transport programmes. (roads), environment and water, should ensure integrated planning and implementation. 26. The expertise of the private sector is crucial for policy development and implementation and service Priority interventions delivery. This creates a conducive environment for communities to participate in the private sector, 22. In an effort to address the numerous and com- thereby, helping to defuse tension between the plex environmental determinants of health, the private sector and communities, which may arise health sector will have to implement the following from misconceptions. priority interventions: 27. The participation of institutions of higher learn- (a) improve the capacity of institutional structures ing and research helps these institutions to under- to respond to challenges; stand the direction developments are taking. In this (b) coordinate the use of resources to benefi t the way, they are able to develop relevant human Region, particularly the poor and deprived resources and to initiate and undertake relevant population groups; research for priority activities. This also empowers (c) bring countries together to share experiences ministries of health and facilitates continuous profes- and expertise; sional development. (d) seek indigenous knowledge and encourage its application, where appropriate; 28. Other partners such as the ministries in charge of (e) undertake risk management as one of the basic housing; land; environment; trade and industry; approaches in environmental health service local government; agriculture; transport; mining, delivery; water and education have to work closely with the (f) use proven approaches such as healthy settings, ministry of health in developing policies. It will also cities, neighbourhoods, markets, etc. – and par- benefi t the people if the social sectors support initia- ticipatory hygiene and sanitation transformation tives for sector collaboration and include in their (PHAST); WHO has developed guidelines on development of human resources the culture of these approaches; integrated planning and implementation. For the (g) introduce environment and health as a life-long education sector in particular, the inclusion of envi- lesson in educational curricula; and ronment and health as part of life-long learning will (h) support research on the implementation of cost- help to shift the paradigm. effective measures that benefi t communities.

Roles and responsibilities WHO and partners 23. To address the issues stated above pertaining to 29. The World Health Organization, in collabora- environment, development and health and to ensure tion with its partners (UNEP, UNDP, IPCS, World that the strategy succeeds, the following roles and Bank) should assist in the adoption of Environmental responsibilities are assigned to the main stakeholders: Health: A Strategy for the African Region by ministers of health of the Region. In addition, WHO will develop guidelines for environmental health policy Countries and norms and standards for use by countries to de- 24. Ministries of health in countries should take the velop their own policies. WHO will also assist in lead in the development of policies that enable them identifying enhancers and disablers in the develop- to address and implement environmental determi- ment of policies and in improving capacities and

182 Accelerating response to the determinants of health

capabilities for environmental health service deliv- (d) The availability of trained personnel in the Afri- ery. It will also foster cooperation between countries can Region to utilize tools such as Environmental in the sharing of resources, expertise and experi- Health Hazard Mapping and Environmental Impact ences and encourage the mobilization of communi- Assessment to better deliver environmental health ties to participate in health development programmes. services is critical. WHO will help to mobilize the private sector to take part in and provide support for environmental CONCLUSION health service delivery. In-built monitoring and evaluation mechanisms will be encouraged to enable 32. This strategy is an attempt to address the cycle countries to measure progress in the implementation of environment, development and human health of their projects and programmes. issues. It particularly targets the poor and deprived populations. The strategy deliberately uses the primary health care approach, with emphasis on health MONITORING AND EVALUATION prevention and promotion, as a primary tool. This approach has been adopted by all countries of the 30. The following will be used to monitor progress world, including those of the African Region, to in the achievement of the environment and health ensure maximum health benefi ts for their countries goal and objectives: and people. (a) development of an environmental health policy 33. Suffi cient knowledge has been gained and by countries and ministries of health; appropriate tools developed to enable the health sec- (b) development by countries of relevant institu- tor to contribute to health outcomes and sustainable tional arrangements to plan and implement development. Africa has, since the Rio Earth Sum- policies for addressing environmental and health mit in 1992, developed consensus through various concerns; efforts on environment and health for sustainable (c) improvement by countries of human resource development. It is time to consolidate those efforts. capacities in environmental health within their ministries of health; 34. Environmental factors that contribute to poor (d) development by countries, through the minis- health and, therefore, to poverty have been identi- tries of health, of mechanisms for collaboration fi ed, as have critical factors that help to improve with other social sectors and cooperation with them in order to ensure health gains and enhance partners; the quality of life of the people. Countries them- (e) mobilization of communities to take part in selves, in collaboration with other partners, have to environment and development issues affecting cooperate in dealing with these factors. Communi- health; and ties as partners and benefi ciaries will be mobilized to (f) development of research capacities and agendas ensure that they take charge of their own health and for environmental determinants of health. well-being. 35. Ministries of health in particular are expected to Determinants of success take the lead in the promotion of environmental health because it is the health sector that has to carry 31. Determinants of success range from the steward- the burden resulting from unsafe policies. By ensur- ship role of the government to the use of strategic ing that social policies are sensitive to the health tools: needs of the people and are easily understood and (a) Governments in the Region should commit implemented, countries stand a better chance of themselves politically, fi nancially and socially to making improvements not only in health but also in implementing policies on environmental deter- the economy, life expectancy and quality of life minants of health. years. (b) Greater awareness and appreciation by profes- 36. The Regional Committee examined and adopt- sionals of the linkages between environment, ed this strategy. health and sustainable development is fundamental to the adoption and implementation of the strategy for the Region. Resolution AFR/RC52/R3 (c) There is a need for a shift from the status quo Health and environment: A strategy for the mindset to a multiple alternatives approach to African Region addressing both current and emerging issues and concerns. The Regional Committee,

183 COMPENDIUM OF RC STRATEGIES

Aware of the intricate link between health, envi- (b) to develop or review their national programmes ronment and development; and plans of action, with emphasis on advocacy, awareness-raising and education in health and Concerned about the increasing poor quality of environment; life and the negative health outcomes resulting from (c) to collaborate with institutions of higher learn- neglect and deterioration of the environment in the ing to develop and improve capacity for human WHO African Region; resources to better manage health and environ- Recognizing the efforts of countries to improve ment programmes; the health of their populations through various re- (d) to identify, mobilize and allocate resources for gional and country instruments, notably the Pretoria health and environment programmes to better Declaration on Health and Environment (1997) and respond to challenges; Promoting environmental health in countries of the (e) to collaborate with other sectors outside health, WHO African Region: The role of ministries of with partners and civil society in pursuance of health (AFR/RC48/TD/1); improved health by targeting environmental determinants of health; Appreciating the contribution of sectors outside (f) to conduct research in the use of indigenous health and of communities and partners in pursuit of technologies and innovations that are effective, improved health and environment; affordable and sustainable in pursuit of improved Determined to consolidate efforts towards attain- health of communities; ment of the highest quality of life affordable within 3. REQUESTS the Regional Director: the Region, especially in advocating for the improvement of environmental determinants of health; (a) to improve the capacity of WHO to effectively provide technical support to Member States for Having carefully examined the report of the the development and implementation of policies Regional Director as contained in document AFR/ on health and environment; RC52/10 (Health and environment: A strategy for (b) to support the improvement of the capacity the African Region), which is aimed at improving of countries to implement and monitor the health of the people through the development programmes and action plans; and implementation of policies for the management (c) to update the Regional Committee in 2005 on of environmental determinants of health; the progress made in the implementation of the 1. APPROVES the proposed strategy; strategy; 2. REQUESTS Member States: 4. APPEALS to other relevant specialized agencies and partners for technical and ﬁ nancial support. (a) to take account in their national policies and strategies of health problems resulting from the environment;

184 6.3 Poverty and health: A strategy for the WHO African Region (AFR/RC52/11)

EXECUTIVE SUMMARY 1. The paradox of the African Region is the extreme and increasing poverty of its people who face various forms of deprivation (ill-health, illiteracy, unemployment, inadequate housing, poor governance, etc.) in a land so richly endowed with natural resources. This paradox is increasingly visible in the light of the changes in the world poverty profi le: while poor people in Africa repre- sented only 16% of the world’s poor in 1985, this proportion had risen to 31% by 1998. In the next 20 years, poverty is likely to decline in every other part of the world except in Africa, where a dramatic increase is projected. 2. Many policies and strategies have been adopted in the health sector in the recent past in order to improve the health status of people in developing countries in general and in the African Region in particular. The most recent of these was the Health-for-all Policy for the 21st Century, adopted by the 49th session of the Regional Committee for Africa. The health-for-all policy aims to signifi cantly improve the health status of African people by promoting healthier lifestyles, preventing the occurrence of disease, increasing life expectancy at birth and reducing mortality. It also aims to arrest the increasing morbidity due to malaria, TB and HIV/AIDS. 3. Health constitutes a strong entry point for poverty reduction and economic growth. In this context, this strategy provides a framework of analysis and interventions at three levels: (a) increasing advocacy and mobilization of all stakeholders inside and outside the health sector; (b) implementing health systems reform to redirect interventions towards the poor; and (c) targeting the priority needs of the poorest, with specifi c interventions that ensure universal access to basic health services. 4. The success of this strategy is based on its implementation in Member countries as consistent with national health policies.

INTRODUCTION areas, where the majority of the African populations 1. Poverty is a multidimensional and cross-sectoral live. Unfortunately, the incidence of poverty is phenomenon. To facilitate a comparative analysis of on the rise in Africa, causing deterioration in social the different poverty profi les across the world, a and health indicators, particularly life expectancy, standard defi nition of poverty, based on daily con- child and infant mortality, maternal mortality and sumption, has been adopted. This defi nition consid- morbidity due to malaria, TB and HIV/AIDS. ers as “poor” anyone who cannot afford a daily 3. Yet, health impacts upon and is affected by issues consumption of US$1. of the environment, transportation, water, energy, 2. Using this US$1 as the universal poverty-line urbanization and employment. Consequently, health defi nition, more than two billion people worldwide presents an optimal entry point in order to adopt can be counted as poor1. In the WHO African Re- a comprehensive development approach, which is gion, more than 45% of the population fall under consistent with the internationally-agreed objectives this category. Poverty is more prevalent in rural of poverty reduction and development.

185 COMPENDIUM OF RC STRATEGIES

4. In the African context, the heavy burden of the Region have access to safe water and less than disease causes signifi cant loss of output which, in 40% have access to sanitation. The Region has a low turn, accentuates the gap between the actual and the primary-school enrolment rate and a high adult potential economic growth. Reducing the burden illiteracy rate (especially of women), which have of disease in Africa, a noble objective in itself, will direct repercussions on infant and maternal mortali- directly release countries’ potential to increase pro- ty rates, which remain the highest in the world. duction and achieve the high growth rates that are 10. The link between poverty and health is very vital for poverty reduction. clear. The poor in the African Region are caught in 5. In many African communities, the linkages a complex poverty trap in which low incomes lead to between ill-health and poverty are well perceived. low consumption, which in turn results in low capacity and For example, reports from the ‘Voices of the Poor’ low productivity. This concept was brilliantly illustrat- survey, conducted in Ghana, Malawi, Mauritania ed by the landmark report of the WHO Com- and Zimbabwe in 2000, showed how individuals, mission of Macroeconomics and Health, which families and communities linked their capacity to demonstrated that the disease burden attributable to earn adequately to their health status. Some three diseases (malaria, tuberculosis and HIV/AIDS) respondents equated health with wealth, which annually reduces GDP growth by as much as 1.3%. underscores the importance of good health as a 11. Addressing the health needs of the poor has been critical factor for living a decent life. a long-standing preoccupation of the health sector. 6. On the basis of the clear linkages between pov- The Alma-Ata Conference, which endorsed the erty and ill-health, this strategy explores the poten- principle of primary health care and led to the tial contribution of health to poverty reduction, Health-for-all policy by the year 2000, was very economic growth and human development. It much infl uenced by the need to ensure that health builds on the current profi les of poverty, health and care was accessible to the majority of the population. socioeconomic indicators. In the African Region, the adoption of the three- phase Health Development Scenario (1985) 7. The regional strategy proposes a paradigm shift reaffi rmed the validity of the primary health care from an overly biomedical approach to a more pre- approach at district level, and the Bamako Initiative ventive and promotional pattern of health interven- (1987) highlighted the need for community partici- tions. Such a reorientation is necessary in the light of pation in health development and also underscored the inability of current health interventions to meet the need to address the vulnerability of women and the health needs of the poor in the African Region. children. SITUATION ANALYSIS 12. Nevertheless, the health sector, despite formulating different strategies (e.g. Alma-Ata, Bamako 8. Overall, about 45% of the African population Initiative) has not implemented explicit interven- are living below the poverty line. The incidence of tions targeting poverty. The time is ripe to develop poverty in Africa is higher in rural areas, although such a strategy. The central role of health in the urban poverty is an explosive problem. The Region development process is increasingly recognized, and is facing many health challenges, especially HIV/ national and international goodwill for improving AIDS. Although 92% of the causes of death in poor health, especially of the poor, has never been so countries are related to communicable diseases, 60% evident. of deaths are attributable to a few diseases, namely, 13. Therefore, alleviating the disease burden of poor tuberculosis, malaria, HIV/AIDS and some child- countries will contribute to the improvement of hood illnesses. There has also been a very signifi cant their social status. Combating the diseases that affl ict rise in non-communicable conditions (cancers, car- the poor will reduce their vulnerability to poverty- diovascular diseases, accidents and mental illness) inducing health shocks and increase their productiv- due to changes in lifestyles. Malnutrition is a persist- ity. This will help to increase economic growth so as ent problem, particularly in children and women. It to reduce poverty. accounts for 45% of child deaths. 9. Furthermore, environmental degradation, pri- THE REGIONAL STRATEGY marily poor water and waste management, has contributed to the outbreak of diseases. Rapid and 14. Considering the multidimensional nature of uncontrolled urbanization has also had serious health health, the contribution of the health sector to consequences. Only 45% of the total population of poverty reduction will include interventions both

186 Accelerating response to the determinants of health outside and within the health sector. This endorses (d) Intersectorality and partnership. Health the leadership role of the health sector as a valid issues are development issues. Achieving health entry point to poverty reduction and the need for outcomes, therefore, calls for the contribution of intersectoral approaches. other sectors, especially as concerns maternal and child health. Hence, partnerships based on a Objectives clear defi nition of the roles and responsibilities are critical to meeting the concerns of the poor. 15. The overall objective of the strategy is to have (e) Strong monitoring and evaluation mecha- the health sector, because of its comparative advan- nism. To ensure that the set objectives of the tage, contribute to poverty reduction by improving complex interventions are met, it is necessary to health. Specifi cally, the strategy will: measure improvement, effi cacy and effi ciency as (a) Outside the health sector: develop and main- well as qualitative aspects such as equity, fairness, tain a strong advocacy platform targeting stake- gender sensitivity and community involvement. holders and partners operating outside the health sector in order to sensitize them on the contri- Priority interventions bution of health to poverty reduction, and to 17. In the light of the increasingly recognized and provide orientations on how other sectors (edu- appreciated role of health in the development proc- cation, agriculture, transport, energy, water and ess and in view of the substantial increase in resourc- environment, fi nance and planning, housing, es available to the health sector, derived particularly sanitation) should incorporate health considera- from the HIPC/PRSP mechanism, the Global Fund tions into policies and practices to improve to fi ght HIV/AIDS, tuberculosis and malaria, and health outcomes; other fi nancial instruments, per capita expenditures (b) At health system policy level: address the on health are progressively being scaled up to meet reforms with a view to shifting the focus of the expenditure levels required to ensure a mini- health systems away from an overly curative mum package of health services for all. approach to a more preventive and promotional pattern of health interventions, with a view to 18. At the community level, empowerment by accelerating the improvement of the health increasing accessibility to health services, providing status of the poor; and health information, etc., should be the strategic (c) At the implementation level: target the most option. At the national level, health-promoting vulnerable population groups (the handicapped, services (hygiene, education, nutrition, immuniza- women and children) and direct specifi c inter- tion, food safety, water and sanitation) should be ventions towards their concerns by strengthen- strengthened. ing and promoting their capacities, instead of 19. Specifi cally, the priority interventions include: focusing on limiting their vulnerability. (a) generating evidence on the linkages between Guiding principles health and other socioeconomic sectors (education, transport, agriculture, energy, chemicals, 16. To attain these objectives, the following princi- tourism) for advocacy outside the health sector; ples will guide the implementation of the strategy: (b) setting up a transparent resource allocation and (a) Equity and fairness of services. If equity and utilization mechanism with a view to recording equality of opportunities are not ensured, any the responsiveness of interventions to poverty additional investments will only increase existing reduction objectives; inequalities. (c) extending health coverage (infrastructure, mo- (b) Quality, accessibility and sustainability. bile units and health services, including antenatal Because poor people usually have access only care and birth attendance) to underserved areas to public health services, it is important that for the benefi t of vulnerable populations as well fi nancial and geographical accessibility as well as as improving the local production of drugs and quality are ensured on a sustainable basis. traditional medicines; (c) Community participation and gender (d) reinforcing immunization programmes against sensitivity. Many health interventions fail to childhood illnesses through regular monitoring achieve their objectives in Africa because of and mobilization of adequate funding; inherent gender bias and lack of community (e) strengthening environmental health services, involvement. These two aspects are critical in including safe water, nutrition, safe food and interventions focused on the poor. hygiene education;

187 COMPENDIUM OF RC STRATEGIES

(f) strengthening health promotion initiatives to Roles and responsibilities of WHO improve health and prevent diseases, particularly 23. In addition to identifying and disseminating best those afﬂ icting the poor; practices among the countries of the Region, WHO (g) scaling up interventions against malaria, tuber- should: culosis, HIV/AIDS, other priority diseases and childhood illnesses. (a) provide sustained technical support for policy analysis, formulation and implementation; 20. Such health interventions will create new (b) mobilize partners to allocate additional resources opportunities for poor people to enter the labour to health-related poverty reduction interven- market with increased capacities and thus result tions; in higher productivity. This, in turn, will help to (c) assist countries in formulating and implementing reduce poverty insofar as it affects the individual, the the health component of their national poverty community and the nation. reduction programme.

Roles and responsibilities of the different Roles and responsibilities of partners stakeholders 24. New cooperation mechanisms that promote 21. The contribution of all stakeholders in the health development and which are more benefi cial to poor and non-health sectors is required for achieving countries (e.g. the Global Fund to fi ght HIV/AIDS, overall poverty-reduction objectives. For example, tuberculosis and malaria) should be encouraged. child nutrition and health are critical for the achieve- Global partnerships of all development partners, in- ment of universal primary education. The specifi c cluding bilateral and multilateral agencies, involved roles and responsibilities of each stakeholder, there- in the PRSP process should also be consolidated. fore, need to be clearly defi ned. MONITORING AND EVALUATION Roles and responsibilities of countries INDICATORS 22. Governments, particularly ministries of health, 25. The monitoring and evaluation indicators are should: based on the sectoral targets of the Health-for-all (a) undertake regular assessments of poverty and policy for the 21st century. They refl ect the health epidemiological profi les, focusing on health- sector’s contributions to poverty reduction in the related poverty determinants; Region. The framework of objectives, strategic (b) implement the institutional changes required for interventions and the role and responsibility of reorienting health-care delivery by moving stakeholders constitute the measures of attainment. away from an approach which is too biomedical Therefore, by 2020: to a more promotive and preventive approach (a) one-hundred per cent of countries of the Re- (e.g. extending health coverage, both personnel gion will have developed health components of and infrastructure, to underserved areas); ex- Poverty Reduction Strategy Papers; panding health promotion activities to cover all (b) seventy-fi ve per cent of the population in the levels of the health system; and developing Region will have access to safe water and budget frameworks that are responsive to inter- adequate sanitation; ventions targeting the poor; (c) seventy per cent of the population in countries (c) encourage more micro-interventions (e.g. will have safe mechanisms for dealing with through the Healthy Settings approach), espe- chemical and industrial waste that are public cially at community level, with increased health risks; involvement of the benefi ciaries. (d) the health sector will help to reduce the inci- (d) strengthen the technical competencies of dence of poverty in the Region by half ; community practitioners, e.g. traditional birth (e) health systems will provide quality health serv- attendants, community care-givers; ices for 80% of the population; (e) document indigenous best practices; (f) infant mortality will be reduced by 50%; (f) devise performance-based indicators to capture (g) the current burden of malaria will be reduced by community contribution. 75%.

188 Accelerating response to the determinants of health

CONCLUSION Having carefully examined the Regional Direc- tor’s report contained in document AFR/RC52/11 26. The strategy highlights the comparative advan- outlining the regional strategy for poverty and tage of the health sector in poverty reduction and health, and aiming at supporting the health sector provides guidance on health-related poverty reduc- for a signifi cant contribution in achieving national tion policy content. Specifi cally, it argues that to poverty reduction objectives; achieve health-related poverty reduction objectives, it is critical and necessary to shift the paradigm reo- 1. APPROVES the proposed strategy; rienting the pattern of public health expenditures 2. URGES Member States: from curative care to preventive and promotional health care. (a) to undertake appropriate reforms in the health sector in the context of broader public reforms 27. The countries of the Region will have to rely on that effectively improve, in the short term, the their own capacities to improve the quality of life of health status of the poor; their people. The recent creation of the African Un- (b) to update national health policies based on a ion (2002) and the adoption of the New Partnership long-term strategic planning approach; for Africa’s Development (NEPAD, 2001) already (c) to increase the budget allocated to the health refl ect the strong political commitment to poverty sector in accordance with the Abuja Declara- reduction and development in the Region. tion, which commits countries to allocate 15% of their total budget to the health sector; Resolution AFR/RC52/R4 (d) to support efforts made by civil society and oth- Poverty and health: A strategy for the African er stakeholders to improve the health of the Region (AFR/RC52/R4) poor at the grass roots level in order to increase the absorptive capacity of the health sector and The Regional Committee, improve the responsiveness of public sector Aware of the intricate and complex linkages be- management to poverty reduction goals; tween poverty and health, especially in African (e) to advocate at the national and international lev- countries; els for more resources to be allocated to the health sector, and to develop a transparent Concerned about the deterioration of the health mechanism for managing, monitoring and eval- status of the majority of African people during the uating such resources; last decade, in addition to the heavy burden of disease on adults and children; REQUESTS the Regional Director: Recalling resolution AFR/RC50/R1 related to (a) to provide technical support to Member States the regional strategy entitled ‘Health-for-All Policy for the development of national health policies for the 21st Century in the African Region: Agen- and programmes for poverty reduction; da’, and the recommendations of the Commission (b) to increase support, through training institu- on Macroeconomics and Health to scale up invest- tions, to national professionals in the fi eld of ments in the health sector in order to reduce pov- health and development in order to strengthen erty and foster economic growth in African their capacity for policy analysis, monitoring and countries; evaluation; (c) to assist in mobilizing additional resources for Appreciating the efforts Member countries and the implementation of this strategy; the international community have made in recent (d) to report to the fi fty-fi fth session of the Region- years through the Highly-Indebted Poor Countries al Committee in 2005 on the progress made in (HIPC)/Poverty Reduction Strategy Paper (PRSP) the implementation of this strategy. framework in order to improve policy implementation towards poverty reduction objectives; Sixth meeting, 10 October 2002 Recognizing the necessity for WHO to fully play its critical role in reducing poverty and catalysing REFERENCES economic growth and social welfare, consistent with 1. Poverty reduction is a complex exercise, which the internationally-adopted Millennium Develop- broadly follows this sequence: ment Goals; (i) Analysis of prevailing poverty profi le;

189 COMPENDIUM OF RC STRATEGIES

(ii) Measurement of the different magnitudes of inci- (vi) Formulation of relevant strategies, i.e.: (a) setting dence, income gap, severity, etc; goals; (b) formulating a framework of analysis and (iii) Identiﬁ cation of the poor, according to the ﬁ nd- implementation, including indicators for moni- ings of (ii); toring/evaluation and the institutional changes (iv) Diagnosis of their livelihood; required. (v) Assessment of current interventions for reducing poverty;

190 6.4 Food safety and health: A strategy for the WHO African Region (AFR/RC57/4)

EXECUTIVE SUMMARY 1. The burden of foodborne diseases in the African Region is diffi cult to surmise, but available data for diarrhoea due to contaminated food and water estimate mortality to be around 700 000 persons per year in all ages. African children suffer an estimated fi ve episodes of diarrhoea per child per year, mostly due to contaminated infant food. Microbial and chemical contaminants are of concern. Unless these issues are addressed, countries will have diffi culty in achieving the health- related Millennium Development Goals. 2. Despite efforts by governments and both multilateral and bilateral agencies, weaknesses remain in national food control systems. Absence of enforceable policies, regulatory mechanisms, resources and coordination in addressing challenges may be the cause. Assuring food safety is a shared responsibility that requires the common vision of all stakeholders. 3. This strategy will assist countries to defi ne their food safety challenges and design national action plans with specifi c interventions for effective outcomes. The guiding principles of the strategy include country ownership and leadership; holistic and risk-based actions; intersectoral cooperation and collaboration; community participation; strengthened health systems; individual responsibility; and participation of women and communities. Priority interventions include formulation and implementation of policies and regulations; capacity building in foodborne disease surveillance and inspection; and health education. Particular attention must be given to ensure food safety in school feeding programmes. 4. The Regional Committee reviewed and adopted the proposed strategy.

INTRODUCTION 2. Bacteria, parasites and viruses are the major causative agents of foodborne diseases in the African 1. Food security is defi ned as physical and econom- Region. Outbreaks of cholera, which occurs due to ic access to suffi cient, safe and nutritious food to contaminated water, are common in the Region meet dietary needs.1 Food safety is an integral part and available data show an upward trend.2,3 Food- of food security and is defi ned as protecting the borne zoonotic diseases and chemical contamination food supply from microbial, chemical and physical of food from pesticides and veterinary drug residues hazards that may occur during all stages of food pro- are also of concern. There are multiple sources of duction, including growing, harvesting, processing, contamination from the environment, and contami- transporting, retailing, distributing, preparing, stor- nants could enter food during production, harvest, ing and consumption, in order to prevent foodborne storage, retailing and preparation for consumption. illnesses. Because of insuffi cient food to meet demand on the African continent, the majority of 3. It is imperative that food safety remain a concern people are only concerned with satisfying hun- in all situations in order to derive maximum benefi t ger and do not give due attention to the safety of from even the little available food. Strong political food. will and relevant food safety systems are essential

191 COMPENDIUM OF RC STRATEGIES from production to consumption. Resolution AFR/ as well as lack of sanitation, running water, washing RC53/R5 of the WHO Regional Committee for facilities, refrigeration and disinfection. Washing of Africa, urging countries to strengthen food safety hands is rare, and food is often exposed to fl ies and programmes, was endorsed in 2003; since then, other insects.14 The preparation of food well in many countries have initiated activities to improve advance of consumption and manual food prepara- food safety. tion were additional risks factors. Certain cold foods, such as salads, meats and sauces, when sold at 4. This strategy on food safety consolidates past ambient temperature, have the greatest potential for gains and provides a framework for protecting public disease transmission. health and economic development through reduction of the burden of foodborne diseases. 10. Few countries have foodborne disease surveillance systems. Only Cameroon, Ethiopia, Madagas- SITUATION ANALYSIS AND car, Nigeria, Senegal and South Africa report data to Global Salm Surv, a global network of laboratories JUSTIFICATION and individuals involved in surveillance, isolation, Situation analysis identifi cation and antimicrobial resistance testing of Salmonella and other foodborne pathogens. Capacity 5. The incidence of foodborne and waterborne building in surveillance, microbiological and chemi- diarrhoea is estimated at fi ve episodes of diarrhoea 4 cal testing of foods is currently ongoing in 12 coun- per child per year. Due to microbial contamination, tries. introduction of complementary foods is associated with increased diarrhoea.5 The estimated annual 11. Data from all Member States in the WHO mortality rate for diarrhoea in all ages is around 700 African Region indicated that 45 countries have 000. Massive displacement of people and unhygien- proposed food control legislation, but only 13 coun- ic environmental factors compound the situation tries have enacted any laws.15 In a recent survey, data during emergencies. from 36 respondent countries showed that 29 had national standards authorities that establish food 6. In 2004, an outbreak of acute afl atoxicosis from standards based on Codex Alimentarius guides.16 A consumption of contaminated maize in Kenya 6 few countries had legislation on pesticide residues, resulted in 317 cases and 125 deaths. Lead and other food additives and contaminants, biotoxins, and chemical contaminants have been detected in some 7,8 genetically-modifi ed foods. Of the 26 countries that foods in several countries. provided data, 21 had import-export inspection and 7. Unsafe food not only results in ill-health but also certifi cation systems, but most of these control has economic consequences due to absenteeism, export products. hospital fees and international trade losses. In Ni- 12. Genetically-modifi ed foods, defi ned as food geria, the Food and Drug Administration destroyed products containing some quantity of genetically- afl atoxin-contaminated food worth more than US$ 9 modifi ed organisms (GMOs) as an ingredient, were 200 000. Available data show that a cholera out- discussed extensively in the African Region during break in Tanzania in 1998 resulted in a loss of US$ the southern African famine in 2002.17 GMOs have 36 million in fi sh exports to the European Union certain potential benefi ts, including increased agri- (EU);10 likewise, in 1997, a ban on Ugandan fi sh 11 cultural yield due to resistance to plant diseases and exports to EU markets resulted in a similar loss. increased nutritional content as in vitamin A rice. 8. The estimated disability adjusted life years lost There are a number of concerns about safety, envi- to foodborne and waterborne diarrhoeal diseases ronmental effects, displacement of traditional stocks is 4.1% globally, as compared to 5.7% to 7.1% in and permanent loss of traditional genetic material. Africa.12 However, food safety along with its health Genetically-modifi ed varieties of maize, sorghum, and economic benefi ts, has received little attention soya beans, cotton, fruits and vegetables may be in diarrhoeal disease control programmes in Africa. available in some countries. The lack of laboratory facilities for testing foods on the market makes it 9. Preparation, protection, sale and consumption diffi cult to ascertain the level of GMOs being con- of street foods in inappropriate places are on the in- sumed in Africa, as well as to monitor food imports crease. Street foods are sources of nourishment and to avoid dumping of food that is not fi t for human income for the urban poor. Some street foods are consumption. microbiologically safe and provide alternative sources of safe food.13 However, the hygiene of most 13. The Codex Alimentarius Principles cover food street foods is substandard due to incorrect handling safety and risk assessment, while the Cartegena

192 Accelerating response to the determinants of health

Protocol on Biosafety covers environmental safety.18 THE REGIONAL STRATEGY Only a few countries have established regulatory frameworks on food derived from modern biotech- Aim nology, including genetically-modifi ed foods. The 18. The aim of the strategy is to contribute to the issue of labelling had been before the Codex Com- reduction of morbidity and mortality due to con- mittee for Food Labelling for more than ten years. taminated food. Some Member States, such as Ethiopia and South Africa, have regulations for labelling GMOs, while others do not accept genetically-modifi ed food as Objectives aid. 19. The specifi c objectives are: 14. In the African Region, some countries have (a) to provide a platform for advocacy for food several ministries or departments involved in food safety; safety regulation. The result is overlap as mandates (b) to provide Member States with a framework for are often not clear. Lack of collaboration and co- the development and implementation of national ordination results in confl ict; duplication of efforts; policies for food safety; and ineffi cient use of human, material and fi nancial (c) to strengthen food control systems, including resources. foodborne disease surveillance and food moni- 15. The food safety challenges facing the African toring for prevention, detection and control of Region include unsafe water and poor environmen- emergencies; tal hygiene; weak foodborne disease surveillance; (d) to facilitate the development of intersectoral inability of small- and medium-scale producers to collaboration and partnerships for food safety. provide safe food; outdated food regulations and weak law enforcement; inadequate capacity for food Guiding principles safety; and inadequate cooperation among stakeholders. 20. The implementation of the strategy will be guided by country ownership and leadership, equity Justifi cation and fairness. 16. Food is central to the prosperity, health and 21. Holistic, comprehensive and risk-based actions social well-being of individuals and societies. apply the farm-to-fork paradigm and risk-based Strengthening food safety within the Region will approaches such as the Hazard Analysis and Critical help to decrease the burden of foodborne diseases, Control Points (HACCP) along the entire food reduce poverty and achieve Millennium Develop- chain. Countries should proactively ensure responsi- ment Goals 1, 4 and 8. bility by producers, processors, retailers and consumers in order to facilitate voluntary compliance to 17. Member States have expressed their commit- food safety regulation rather than detection of faults ment to improving food safety at various forums. In for prosecution. May 2000, the Fifty-third World Health Assembly unanimously adopted Resolution WHA53.15 on 22. Intersectoral coordination, cooperation and col- food safety, which confi rmed food safety as a public laboration involve all partners at various levels of health concern. The WHO Global Strategy for government, in the private sector and in inter- Food Safety was endorsed by the WHO Executive national partnerships for development, planning and Board in January 2002. Further impetus was pro- implementation of interventions. Such coordination vided by the FAO/WHO Regional Conference on should be based on clear defi nitions of roles, respon- Food Safety for Africa, which recommended a fi ve- sibilities and mandates. year strategic plan for adoption by the United Na- 23. Individual responsibility, participation of women tions and the African Union in 2006. Additionally, and community participation involve communities, the Regional Offi ce Strategic orientations for WHO consumers, civil society and particularly women in action in the African Region (2005) emphasized the decision-making. Initiatives such as the Healthy importance of food safety in disease prevention. The Cities Initiative and the Healthy Food Market following strategy consolidates existing guidelines to Projects assure ownership and sustainability of provide countries with a single document. interventions.

193 COMPENDIUM OF RC STRATEGIES

Priority interventions must be given to ensure food safety in school feeding programmes. 24. The proposed priority interventions are based on the farm-to-fork paradigm and also apply in 30. National, regional and international coopera- emergencies. Important linkages require inter- tion, collaboration and coordination are essential. ventions based on a coordinated and collaborative Governments, the food industry, the private and approach. public sectors, consumers and other stakeholders will develop systems to enable them to work in a 25. Food safety policies, programmes, legislation and concerted manner. Countries will be guided to im- regulation will be developed to assure the safety of prove their participation in international standard food from production to consumption. National setting to ensure that the process serves all parties action plans will be developed that offer mechanisms rather than only those attending Codex meetings. for intersectoral involvement in food safety inter- The intrinsic link between food security, quality and ventions. This includes interaction with other safety requires close collaboration between WHO, sectors, in particular water and sanitation, and case the Food and Agriculture Organization of the management programmes in the planning of United Nations and the World Food Programme; evidence-based policies and strategies that have a di- this will ensure articulation of health concerns in the rect bearing on implementation of food safety plans. implementation of interventions. 26. Food legislation will be developed to provide the foundation for national food safety programmes Roles and responsibilities and play its pivotal role in directing the food control Countries efforts of inspectors. Government commitment is essential for comprehensive review of food laws, 31. National governments are urged: regulation, standards and harmonization of national (a) to include food safety in overall national devel- and international standards. opment plans and health policies as well as 27. Capacity building will be developed and im- provide the legal basis for national food safety proved to provide analytical skills for monitoring assurance; foods on the market. Monitoring of microbiological (b) to strengthen national analytical capacity for and chemical contaminants will be strengthened to foodborne disease surveillance and research reassure communities of safe food supply, identify through appropriate training; capacity-building; potential risks and provide data to regulatory au- establishment of quality assurance protocol and thorities. Capacity will also be built for foodborne procedures; as well as services for inspection and disease surveillance and research to provide data for export and import certiﬁ cation; rapid detection and response to outbreaks, estima- (c) to establish diverse approaches to enhance con- tion of burden of diseases, programme evaluation, sumer awareness and participation in food safety advocacy, decision-making and allocation of activities, including promotion of food safety resources. As an essential public health objective, education; capacity will be built for public health laboratories to (d) to develop effective links and coordination conduct both laboratory-based and epidemiological among food safety agencies for reviewing re- surveillance as part of national and regional integrat- sponsibilities and capabilities as well as clarifying ed surveillance systems. overlaps in regulatory roles. 28. Food inspectorates will be strengthened as inte- World Health Organization and partners gral parts of food control systems. They will ensure that strong food safety legislation and policies are 32. WHO and partners will support countries by: effectively enforced. In order to ensure effective (a) carrying out advocacy among policy-makers, participation, including harmonization of national international partners and other key stakeholders standards, further capacity will be developed in the for increased resources; work and procedures of the Codex Alimentarius (b) providing norms, standards and guidelines for Commission. adaptation and use; 29. Transparent health promotion systems and pro- (c) providing evidence-based options for food cedures will be established to ensure that producers, safety; processors, retailers, consumers and other stakehold- (d) providing technical and material support for ers are properly informed on safe food handling as planning implementation as well as monitoring well as food safety emergencies. Particular attention and evaluation of priority interventions;

194 Accelerating response to the determinants of health

(e) facilitating effective participation in relevant Acknowledging the World Health Assembly committees of the Codex Alimentarius Com- Resolution WHA53.15 of May 2000 recognizing mission; food safety as an essential public health function; (f) strengthening joint efforts in capacity-building; Mindful of the Regional Offi ce Strategic orienta- international standard setting; information shar- tions for WHO action in the African Region 2005–2009, ing; food contamination monitoring, including emphasizing the importance of food safety in disease establishment of regional reference laboratories; prevention; (g) facilitating effective linkage, cooperation, collaboration and coordination among food safety Recalling Regional Committee Resolution agencies. AFR/RC53/R5 of September 2003 entitled “Food safety and health: A situation analysis and perspec- Resource implications tives”; 33. Financial, material and human resources will Recognizing that most contaminants in food be required for the implementation of this strategy. originate from unhygienic environments, low Although countries have been allocating resources awareness and inadequate knowledge of the role of for food safety, these are generally insuffi cient. toxins, pesticides and pathogens in disease causation; Member States may need to reallocate existing Concerned that contaminated food and water resources or mobilize additional funds to facilitate continue to cause up to fi ve episodes of diarrhoea the implementation process. per child per year, resulting in 5.7% to 7.1% of lost disability-adjusted life years in the African Region; MONITORING AND EVALUATION Cognizant of the fact that lack of surveillance and 34. The core indicators for monitoring and evalua- research hinders the early detection of food safety tion will include trends in morbidity from food- incidents and evidence-based interventions; borne diseases; reduction in mortality associated Approving the document entitled “Food safety with foodborne diseases; availability and enforce- and health: A strategy for the WHO African ment of food safety policy and legislation; and avail- Region”; ability of food safety education programmes. 1. URGES Member States: CONCLUSION (a) to include food safety in overall national development policies and the fi ght against poverty as 35. The food safety challenges facing countries in well as provide the legal framework for national the African Region include inadequate commit- food safety assurance; ment; unsafe water and poor environmental hy- (b) to include food safety in education curricula at giene; weak foodborne disease surveillance; inability all levels; of small- and medium-scale producers to produce (c) to strengthen national and regional analytical safe food; outdated food regulations and weak law capacity through appropriate training, capacity- enforcement; inadequate capacity for food safety; building and establishment of quality assurance and inadequate cooperation among stakeholders. A protocols and procedures; number of priority interventions have been pro- (d) to strengthen national laboratory capacity to posed to improve food safety and thus contribute to monitor foods, especially food imports contain- improved public health, increased food trade, con- ing GMOs; tinued economic development and achievement of (e) to strengthen foodborne disease surveillance as the health-related Millennium Development Goals. part of national and regional integrated disease 36. The Regional Committee reviewed and adopt- surveillance and response systems; ed the proposed strategy. (f) to strengthen multisectoral food safety inspection from production to consumption and proactively ensure compliance; Resolution AFR/RC57/R2 (g) to establish a diversity of approaches to enhance Food safety and health: A strategy for the consumer awareness and participation in food African Region safety activities and promotion of food safety education, including the integration of food The Regional Committee, safety into maternal and child survival pro- Guided by the WHO Constitution, which in- grammes as well as healthy settings, poverty cludes mandates on food safety for the Organization; alleviation, and health promotion initiatives;

195 COMPENDIUM OF RC STRATEGIES

(h) to ensure individual responsibility as well as 6. CDC, Outbreak of afl atoxin poisoning—Eastern and participation of women, communities and con- Central Provinces, Kenya, January–July 2004, Mor- sumer associations in decision-making; bidity and Mortality Weekly Report 53(34): 790–793, (i) to develop effective links and coordination 2004. among food safety agencies, including reviewing 7. Tomlins KI et al. Enhancing product quality: Street food in Ghana: A source of income, but not without of responsibilities and capabilities as well as its hazards. PhAction News 5–2002, http://www.iita. clarifying overlaps in regulatory roles; org/info/phnews5/mr8.htm, accessed 5 February 2. REQUESTS the Regional Director: 2007. 8. Ngengerio-Ndossi JP, Cram G. Pesticide residues in (a) to continue carrying out advocacy among table-ready foods in Tanzania, International Journal of policy-makers, international partners and other Environmental Health Research and Public Health key stakeholders on food safety and food secu- 15(2): 143–149, 2005. rity; 9. Anyanwu RC, Jukes DJ. Food safety control systems (b) to strengthen joint efforts in capacity-building, for developing countries, Food Control 1: 1726– international standard setting, effective partici- 1736, 1990. 10. http://www.who.int/director-general/speech- pation in the relevant committees of the Codex es/1999/english/19990323_wmo.html, accessed 5 Alimentarius Commission, food safety monitor- February 2007. ing, information sharing, etc; 11. http://www.iso.org/iso/en/commcentre/presenta- (c) to facilitate effective linkage, cooperation, col- tions/wkshps-seminars/casco/casdev2003/casdev laboration and coordination among agencies 2003SamuelBalagadde-slides.pdf, accessed 5 February involved in food safety; 2007. (d) to provide technical and material support for 12. WHO, The world health report 2003: Shaping the planning, implementation as well as monitoring future, Annex Table 3, 160, Geneva, World Health and evaluation of interventions; Organization, 2003. (e) to report to the Regional Committee for Africa 13. Mosupye FM, von Holy A, Microbiological quality and safety of ready-to-eat street-vended foods in every two years. Johannesburg, South Africa, Journal of Food Protec- tion 62(11): 1278–1284, 1999. REFERENCES 14. Mensah P et al. Street foods from Accra, Ghana: How 1. FAO, Report of the World Food Summit, Rome, safe are they?, Bulletin of the World Health Organiza- 13–17 November 1996, Food and Agriculture tion 80(7): 549–554, 2002. Organization, 1996, http://www.fao.org/dorep/003/ 15. FAO, National food control systems in Africa—A w3548e/w3548e000.htm, accessed 17 November situation analysis, a paper presented at the FAO/ 2006. WHO Regional Conference on Food Safety for 2. Brankett RE. Incidence, contributing factors and Africa, Harare, Zimbabwe, 3–6 October 2005, Accra, control of bacterial pathogens in produce, Postharvest Food and Agriculture Organization, Regional Offi ce Biology and Technology 15: 305–311, 1999. for Africa. 3. WHO, Annual summary report on major outbreaks/ 16. WHO, Status of Food Safety Programmes in the epidemics in the African Region, Brazzaville, World WHO African Region, Brazzaville, World Health Health Organization, Regional Offi ce for Africa, Organization, Regional Offi ce for Africa, 2006, Division of Communicable Diseases Prevention and unpublished. Control, 2005, unpublished. 17. WHO, Modern food biotechnology, human health and 4. Koesk M et al. The global burden of diarrheal disease, development: An evidence-based study, Geneva, World as estimated from studies published between 1992 and Health Organization, 2005. 2000, Bulletin of the World Health Organization 81: 18. http://www.biodiv.org/biosafety/signinglist.asp (25 197–204, 2003. May 2005). 5. Mensah P et al. Microbial quality of infant foods from peri-urban Ghana, African Journal of Health Sciences 2: 282–286, 1995.

196 6.5 A strategy for addressing the key determinants of health in the WHO African Region (AFR/RC60/3)

EXECUTIVE SUMMARY 1. The past few decades have witnessed increased interest in commitment to greater equity in health through addressing the social determinants of health and their consequences. Health gaps exist in countries of the African Region and are widening in some cases. This document proposes a strategy for closing this health equity gap through action on the key determinants of health. 2. The strategy proposes priority interventions in line with the three overarching recommendations of the WHO Commission on the Social Determinants of Health, namely: (i) improving the daily conditions of living; (ii) tackling the inequitable distribution of power, money and resources; and, (iii) measuring and understanding the problem and assessing the impact of action. The interventions are divided into those that are within the immediate remit of the ministry of health, and those that come under other sectors or are cross-sectoral. 3. The proposed intervention takes cognizance of the widening health equity gap within and among Member States. The strategy places emphasis on addressing the structural causes of ill- health and premature death associated with access, affordability and availability, and addresses issues even beyond the risk factors. 4. Member States are called upon to reduce the health equity gap through action on the social determinants of health. The prerequisite for success is political commitment to provide an enabling environment for all to contribute to reducing health inequities through action on the social determinants of health, including measures to improve living conditions, tackling uneven distribution of power, money and resources, and routine monitoring of the health equity gap. 5. The Regional Committee reviewed and adopted this strategy.

INTRODUCTION 2. These conditions include income, wealth and 1. According to the Constitution of the World their distribution, early childhood care, education, Health Organization, the enjoyment of the highest working conditions, job security, food security, attainable standard of health is one of the fundamen- gender, housing, including access to safe water and tal rights of every human being.1 Health2 is not just sanitation, and social safety nets. Governance, and social and economic forces, in turn, shape these the outcome of genetic or biological processes. It is 3 inﬂ uenced by the social and economic conditions, conditions. For different social groups, unequal in which people are born, grow, live, work and age, access to these social and economic conditions gives and the systems put in place to deal with illness. rise to unequal health outcomes. These conditions, commonly referred to as the 3. Although health inequalities exist worldwide, ‘social determinants of health’ (SDH), can help between and within countries, the majority of them create or destroy peoples’ health. are avoidable. For many common indicators of

197 COMPENDIUM OF RC STRATEGIES

socioeconomic status, people living in poverty face a target of halving, between 1990 and 2015, the pro- higher risk of adverse health outcomes than those portion of people who suffer from hunger.15 Twenty who are better off.4 countries in the Region have developed MDG- consistent (second-generation) poverty reduction 4. The Final Report of the WHO Commission on strategies or national plans. Social Determinants of Health (CSDH) calls for a new global agenda for health improvement and 10. The Region made very little progress towards health equity. It advocates for an approach to health reducing under-fi ve mortality. The vast majority of and human development in which equity is a funda- countries in the Region made only negligible im- mental objective of reform.3 provements in reducing under-fi ve mortality by about 2% between 1990 and 2005. Only six coun- 5. The Sixty-second World Health Assembly tries16 are on track to achieve this target.17 There was passed a resolution calling for a reduction of health only a marginal improvement in infant mortality inequities through action on the social determinants rates (from 110 to 99 per 1000 live births) between of health, as recommended by the CSDH report 1990 and 2005. However, Malawi and Mauritius (see Resolution WHA62.14 annexed herewith). recorded improvements exceeding 5%. The Region Similar calls have been made in the World Health made virtually no progress towards achieving the Report 2008,5 the Algiers Declaration,6 the Libre- MDG target of reducing maternal mortality, ville Declaration,7 the Ouagadougou Declaration,8 although there was a 30% increase in access to and the Nairobi Call to Action.9 contraceptives among currently married women. In 6. This document proposes a strategy for reducing general, the prevalence of HIV/AIDS has stabilized health inequities through action on the social deter- but the challenge of providing support and treat- minants of health. ment for cases remains. 11. Most countries are likely to achieve gender SITUATION ANALYSIS AND parity by 2015. Ten countries achieved gender parity JUSTIFICATION in primary education in 2005.18 Seventeen countries had a gender parity of over 0.90,19 while six others Situation analysis achieved net rates of enrolment in primary educa- 7. In the 1980s and 1990s, most parts of sub- tion in excess of 80%.20 Between 2004 and 2005 Saharan Africa witnessed increasing economic dep- Ethiopia, Kenya, Mozambique and Zambia record- rivation and poverty, diminishing food security, ed increased enrolments in primary education in devastation by the HIV/AIDS pandemic, environ- excess of 4%. Ethiopia, Ghana and Tanzania main- mental destruction, increasing unemployment, and tained the momentum of high enrolment achieved general reversal of human development indicators.10 in previous years, posting growth rates in enrolment Extreme poverty increased from 47% in 1990 to of 6.5%, 4.2% and 17.3% respectively between 2005 50% in 2009.11 Women, the elderly and displaced and 2006. populations were the worst affected groups. 12. Despite the progress noted in some of the MDG 8. The African Region lags behind most other indicators as set out above, most MDG targets are WHO regions in its overall health attainments. Life not likely to be met. Even in those countries that are expectancy at birth was estimated at only 52 years in making some progress, although improvements in 2007. This contrasts with 64 and 65 years in the national averages for the health and other MDG WHO regions of the Eastern Mediterranean and indicators are likely, the situation of the poor and South East Asia, respectively and with the global av- vulnerable groups is not likely to change. Conse- erage of 68 years.12 Improvements in child survival quently, there is need to address the social determi- in many countries in the Region have not refl ected nants of health in countries in order to ensure that as in higher life expectancy because these have been countries strive to achieve the MDGs targets, the eroded by higher levels of adult mortality due to poor are not left behind. HIV/AIDS and confl ict. 13. Widespread health inequalities exist in various 9. Progress towards achieving the Millennium De- health outcome measures such as infant and velopment Goals in the Region has been slow but child mortality, maternal mortality and stunting, and perceptible.13 Although reliable data on income in access to health service indicators.21 The health poverty is lacking, available information suggests system, itself a determinant of health, has not been that progress towards reducing poverty is slow.14 adequately prepared to address the “ causes of the Only eight countries are on track to achieve the causes” as regards the major communicable diseases,

198 Accelerating response to the determinants of health maternal and child health problems and the increas- determinants of health, the upstream factors and the ing prevalence of chronic diseases. fundamental ‘causes of causes’.24 14. There are wide inequities, within and between 18. The responsibility for tackling many of the key countries, in health services coverage, safe water determinants of health rests with ministries other supply and sanitation, and health outcomes.21 In the than the ministry of health. The challenge, there- majority of countries, some common patterns are fore, is how the ministry of health can infl uence observed as regards urban/rural location, education actions by these other ministries. Although WHO and gender. The patterns are: urban dwellers gener- and Member States are already addressing these ally live longer than rural inhabitants; higher educa- challenges through various initiatives,25 there is an tion results in higher life expectancy; and females urgent need for a more coherent approach. This live longer than males. In some countries, there are strategy should be seen also as an opportunity to major disparities in health status between the rich streamline and implement World Health Assembly and the poor, while for others the difference is Resolution WHA62.12, which strongly reaffi rms insignifi cant. Disparities across households are also the values and principles of primary health care, increasing.21 including equity, solidarity, social justice, universal access to services, multisectoral action, decentraliza- 15. Globalization, trade, urbanization, climate tion and community participation as the basis for change, information technology, and civil confl icts health systems strengthening. are among the major external drivers that have an impact on social, cultural and behavioural practices and ultimately on health outcomes across population THE REGIONAL STRATEGY groups. These factors, which are structural and Aim and Objective intermediate, are beyond the remit of the health sector apart from environmental issues related to 19. The aim of this strategy is to assist Member water supply and sanitation traditionally linked with States to promote actions to reduce health inequities public health. However, they have a huge cumula- through intersectoral policies and plans in order to tive impact on health due to their infl uence on effectively address the key determinants of health. lifestyle-related factors such as food consumption, The objective is to provide Member States with a use of tobacco, alcohol, drugs and other psycho- structured approach to implementing the CSDH active substances, physical activity, violence, sanita- recommendations in line with World Health tion and hygiene, unsafe sex, health information Assembly Resolution 62.1426 and to promote their seeking and high-risk behaviours, among others. uptake in countries. The overall goal is to ensure that all countries in the Region address the social 16. Climate change is threatening to erode the gains determinants of health, using a “whole-of- made in economic growth and poverty reduction. government” approach. Sub-Saharan Africa suffers from natural fragility, with two-thirds of its surface area being a desert land Guiding principles or arid land. In addition, it is exposed to spells of drought and fl ooding predicted to intensify due to 20. In this regard, there is a need to adhere to the climate change.22 Malaria, one of the major killer following general guiding principles:27 diseases in the Region, is spreading to previously (a) levelling up i.e., health equity policies should non-endemic areas usually of high altitude.22 In strive to raise the health status of individuals and addition, the global economic crisis threatens to groups at the bottom of the ladder; worsen the current health situation if the limited (b) equity for all i.e., the health system should be resources available are diverted from health to other built on principles of fairness; areas accorded greater priority. (c) universal participation i.e., all voices, including those of marginal groups, should be heard; Justifi cation (d) partnerships i.e., implementation should be 17. The health inequities that exist within and based on partnership between the country and between countries of the African Region are all development partners; hampering progress in attaining the Millennium (e) multisectorality i.e., implementation should be Development Goals (MDGs).23 In order to improve the responsibility of all sectors; health outcomes and attain the MDGs, countries (f) ownership i.e., there should be a sense of should promote sectoral policies that address the key ownership by country and relevant stakeholders.

199 COMPENDIUM OF RC STRATEGIES

Priority interventions strengthen or mobilize public fi nance for action on SDH by building capacity for progressive taxation. 21. The priority interventions presented below They should consider establishing mechanisms to emanate from the overarching recommendations of fi nance cross-government actions on SDH and the CSDH: allocate funds fairly between geographical regions (a) improve day-to-day living conditions by im- and social groups. proving the circumstances in which people are born, grow, live and age; (B) Interventions in sectors other than health, (b) address the inequitable distribution of power, including cross-sectoral actions money and resources; and 28. Ensure social protection throughout the (c) measure and understand the problem and assess life-course. Countries should establish and the impact of action. strengthen comprehensive universal social protec- 22. The proposed interventions are grouped into tion policies that support a level of income suffi cient two broad categories, namely: interventions specifi c for healthy living for all. to the health sector; and interventions in sectors 29. Develop or promote policies for healthy other than health, including cross-sectoral actions. places and healthy people. Health equity between rural and urban areas should be promoted. (A) Interventions specifi c to the health sector There is need for investment in rural development and for addressing the exclusionary policies and 23. Strengthen the stewardship and leadership processes that lead to rural poverty, landlessness, and role of the ministry of health to coordinate and displacement of people from their habitats. For advocate for multisectoral and multidisciplinary urban areas, there is need to place health and health interventions to reduce the health equity gap equity at the heart of urban governance and plan- through addressing SDH. The responsibility for ning. There is need also to ensure economic and action on health and health equity should itself be social policy responses to climate change and envi- assigned to the highest level of government. ronmental degradation, taking into account health 24. Build capacity for policy development, equity. Countries will need to take measures for leadership and advocacy to address SDH. increased resilience and for protection against There is need to build the capacity of the staff of the adverse changes in the climate. ministry of health to provide leadership in develop- 30. Ensure health equity in all policies. Coun- ing policies and programmes for improving health tries should place the responsibility for action on literacy, knowledge transfer and research on social health and health equity at the highest level of determinants of health, using multisectoral and government and ensure its coherent consideration multidisciplinary approaches. across all policies. Health and health equity should 25. Advocate for legislations and regulations to be the corporate business of the entire government, ensure a high level of protection of the general supported by the head of state and should be a population from harm and from the impact of marker of government performance. some social and economic determinants of health e. 31. Assess and mitigate the adverse effects of g., globalization, commercialization, urbanization. international trade and globalization. Countries 26. Create health systems based on universal should institutionalize health impact assessments of and quality health care. Health systems in the major global, regional and bilateral trade agreements Region should be built on the basis of the principles and ensure and strengthen the representation of of equity, disease prevention, and health promotion. public health in domestic and international eco- Quality health care services should be aimed at uni- nomic policy negotiations. versal coverage of primary health care. Leadership 32. Enhance good governance for health and of the public sector in equitable health care should health equity. Countries and development part- be strengthened. The health workforce should be ners, including civil society, should make health developed or strengthened and their capabilities to equity a shared developmental goal as part of act on SDH should be strengthened. ensuring social corporate responsibility e.g., in the 27. Enhance fairness in health fi nancing and areas of trade, urbanization and climate change, resource allocation. The role of the ministry of among others. There is need for a framework with health should be to advocate for fair allocation of appropriate indicators for monitoring progress, fi nancial and technical resources. Countries should taking into consideration country contexts.

200 Accelerating response to the determinants of health

33. Invest in early childhood development to bilities and other vulnerable groups and communi- ensure equity from the start. Countries should ties. If appropriate, information about health and commit themselves to implementing a comprehen- welfare entitlements and public services should be sive approach to early life, building on existing child made available in a broad range of formats and survival programmes and expanding interventions in languages. Data collection strategies should ensure early life to include social, emotional, language and that adequate information about the social and cognitive development. Depending on the availabil- geographical patterns of health of the population is ity of resources, quality compulsory primary and routinely available. secondary education should be provided for all 38. Enhance political empowerment. All groups children. in society should be empowered through fair repre- 34. Promote fair employment and decent sentation in decision-making about how society work. Full and fair employment and decent work operates, particularly in relation to its effect on should be a central goal of national social and eco- health equity and the creation and maintenance of nomic policy making. Decent work should be a a socially-inclusive framework for policy making. shared objective of national institutions and a central Civil society should be empowered to organize and part of national policy agendas and development act in a manner that promotes and realizes the strategies with strengthened representation of political and social rights in regard to health equity. workers in the creation of policy, legislation and 39. Protect/improve SDH in confl icts. Coun- programmes relating to employment and work, tries need to improve SDH and promote human including occupational health. rights through building health care systems that pro- 35. Mainstream health promotion. Priority mote health equity and community participation in should be given to mainstreaming health promotion confl ict situations. in all policies and programmes to reduce the equity 40. Ensure routine monitoring, research and gap through community empowerment. Priority training. There is urgent need: actions should be implemented within the primary health care (PHC) approach to advocate for health; (a) to ensure that routine monitoring systems for invest in sustainable policies and infrastructure; build health equity and SDH are in place and to capacity for policy development and leadership; strengthen vital statistics and health equity ensure high level protection from harm through surveillance systems to collect routine data on adequate regulation and legislation; and build part- SDH and health equity; nerships with various players to create sustainable (b) to conduct social, cultural and behavioural intersectoral action. studies applying social science research methodologies to determine social factors likely to 36. Mainstream and promote gender equity. hinder or promote the bridging of the equity Countries should address gender biases in the struc- gap through action on social determinants of ture of society: gender-based cultural and social health that have an impact on priority public biases; biases in national and local government laws health issues such as control of communicable and their enforcement; biases in the way organiza- and non-communicable diseases. This will com- tions are run, how interventions are designed, how plement the action of countries in implementing economic performance is measured. Policies and and monitoring the Algiers Declaration, the programmes aimed at bridging the gaps in education Libreville Declaration and the Ouagadougou and skills and supporting female economic participa- Declaration. tion need to be developed and adequately fi nanced. (c) to provide training on the social determinants of There is need to expand investments in sexual and health for policy actors, stakeholders and practi- reproductive health services and programmes geared tioners, and invest in raising public awareness. towards universal coverage and respect for human rights. Roles and Responsibilities of Member States, 37. Address social exclusion and discrimina- WHO and Partners tion. Addressing social exclusion, promoting social Member States inclusion and respecting diversity should be key public policy priorities. Public service delivery 41. In addition to the actions requested of Member should be equitable, culturally sensitive, appropriate States in World Health Assembly Resolution to diverse needs and accessible to people with disa- WHA62.14, countries should:

201 COMPENDIUM OF RC STRATEGIES

(a) In the short term: (b) establish a mechanism for annual monitoring (i) strengthen the stewardship role of the ministry of the progress that countries are making in of health to coordinate and advocate for inter- addressing SDH and reducing health inequities; sectoral action to reduce health inequities (c) ensure greater coordination within WHO in through action on social determinants of order to provide the necessary technical support health; and guidance to countries in reducing the health (ii) institutionalize mechanisms for advocacy, evi- equity gap through action on SDH. dence gathering and dissemination in order to act on socially-determined health inequities Resource Implications both within and outside the health sector; (iii) cooperate with training and research institu- 43. Implementing this strategy will require new and tions in order to document the situation with additional resources. Countries, WHO and partners respect to the distribution of the key determi- are called upon to mobilize resources for implemen- nants of health. This analysis would further tation of this strategy. consolidate the evidence-base on the impact of SDH in order to inform policy making and MONITORING AND EVALUATION establish a baseline for evaluation of the outcomes of these policies; 44. The following three elements of monitoring and (iv) build national capacity to advocate for reduc- evaluation are crucial to the implementation of this ing the health equity gap through addressing strategy: (a) monitoring the overall implementation SDH in all priority public health concerns of the strategy over the next 3–5 years; (b) monitor- such as HIV/AIDS, NCD, mental illness and ing country progress in implementing the recom- TB; mendations; (c) tracking and documenting health (v) adapt a “whole-of government” approach to equity trends for intercountry comparisons. health promotion through multisectoral and multidisciplinary collaboration by establishing CONCLUSION a “Social Determinants of Health Task Force” to, among others, identify and build support 45. This regional strategy proposes interventions for for health in all policies, at all levels of govern- addressing SDH. The priority interventions outlined ment and across all sectors; fall into three key areas of action contained in the (b) In the long term: CSDH Report. They are: (a) improving the condi- (i) ensure that health policies, plans and pro- tions of peoples’ daily life; (b) tackling the inequita- grammes are oriented to addressing the key ble distribution of power, money and resources – the SDH;28 structural drivers of the conditions of daily life; and (ii) review health and other training curricula to (c) measuring and understanding the problem. ensure that linkages between health and SDH 46. The strategic interventions are grouped into two are included in all training activities and in areas, namely (a) those that are specifi c to, or driven research funding criteria; by, the health sector; and (b) those that are driven by (iii) provide the fi nancial resources required to sectors other than health, including cross-sectoral support activities for implementing these actions. actions; (iv) advocate for good governance and corporate 47. Reducing health inequities through action on social responsibility at local and global levels SDH requires committed leadership and bold action since the widening health equity gap results at all levels. It requires strong partnerships between from structural forces such as globalization, Member States, WHO and other development trade and urbanization. partners, communities, and individuals. 48. Member States are encouraged to implement WHO and Partners the proposed interventions, integrate SDH across 42. In addition to the actions requested of WHO in sectors and settings, and provide an enabling envi- Resolution WHA62.14, WHO and partners should: ronment for all stakeholders to contribute to the reduction of health inequities. (a) hold consultations and discussions on priorities and add them to already identifi ed areas of 49. The Regional Committee reviewed and adopt- collaboration; ed this strategy.

202 Accelerating response to the determinants of health

Resolution AFR/RC60/R1 population groups and result in increased premature deaths, disability and illness from preventable causes; A strategy for addressing the key determinants of health in the African Region Acknowledging the efforts by individual Mem- (Document AFR/RC60/3) ber States of the African Region to reduce the health equity gap and the progress made by some of the The Regional Committee, Member States; Having examined the document entitled “A Recognizing the growing evidence suggesting strategy for addressing the key determinants of that action on the equity gap and its determinants is health in the African Region”; possible; Recalling the report and recommendations of Noting the need for Member States to integrate the WHO Commission on Social Determinants of health equity into all policies and programmes, Health (CSDH); advocate for reduction of the equity gap through Noting global and regional calls and commit- action on determinants of health, and document the ments to reduce the health equity gap by addressing evidence; the risk factors and their determinants, namely, the 1. ENDORSES the Regional Strategy for address- Bangkok Charter for Health Promotion in a ing the key determinants of health in the African Globalized World (2005); and the Nairobi Call to Region as contained in Document AFR/RC60/3 Action for closing the implementation gap (2009); and expresses its appreciation for the work done by the Ouagadougou Declaration and the Libreville the WHO Secretariat and the Commission on Social Declaration; Determinants of Health; Noting the global consensus through United 2. URGES Member States: Nations to achieve the Millennium Development Goals by 2015 and the concern about inadequate (a) to deliberate on the recommendations of the progress in many countries of the African Region to CSDH Report and identify recommendations achieve these goals to date; that are relevant to the contexts of countries; (b) to establish sustainable national leadership, poli- Welcoming, in this regard, Resolution cies and structures to coordinate intersectoral WHA61.18 ,which requires annual monitoring by action to address the determinants of health the Health Assembly of the achievement of health- across population groups and priority public related Millennium Development Goals; health conditions; Taking note of Resolution WHA62.14 on (c) to monitor the health equity trends and docu- “ Reducing health inequities through action on the ment and disseminate the fi ndings to strengthen social determinants of health” adopted by the 62nd policy and programme implementation across Session of the World Health Assembly 2009; priority public health conditions; (d) to promote both quantitative and qualitative re- Acknowledging that health inequities and search in order to understand factors infl uencing inequalities exist within and between countries of the health equity trends, including the role of the African Region and that the structural drivers cultural beliefs and values; include education, trade, globalization, employment (e) to establish or strengthen national institutional and working conditions, food security, water and mechanisms for monitoring the implementation sanitation, healthcare services, housing, income and of the regional strategy and document the its distribution, unplanned urbanization and social fi ndings; exclusion; 3. REQUESTS the Regional Director: Noting that most of these key determinants of health are rooted in political, economic, social and (a) to strengthen the leadership role of WHO and environmental contexts and are, therefore, linked to the ministries of health to advocate and coordi- good governance and social justice for all particu- nate intrasectoral and intersectoral actions by larly the poor, women, children and the elderly; providing guidelines, policies and strategies to address the social determinants of health across Concerned that growing poverty, the global sectors and priority public health conditions; fi nancial crisis, climate change, pandemic infl uenza, (b) to support countries to establish routine moni- globalization and urbanization could further widen toring systems that include the collection of the health equity gap by differentially impacting on disaggregated data and health equity analysis;

203 COMPENDIUM OF RC STRATEGIES

(c) to support national and regional research on www.afro.who.int/en/regional-declarations.html social, cultural and behavioural risk factors and (last accessed 3 April 2010). the determinants likely to infl uence health 9. WHO (2009), “The Nairobi Call to Action,” The 7th outcomes; Global Conference on Health Promotion on Closing (d) to strengthen the capacity of Member States to the implementation gap,” Nairobi, Kenya 27–30 October, 2009. http://www.who.int/healthpromo- empower individuals, families and communities tion/conferences/7gchp/documents/en/index.html through increased literacy in determinants of (last accessed 3 April 2010). health within the context of revitalizing primary 10. Economic Commission for Africa, (2005). The health care; Millennium Development Goals in Africa: Progress (e) to report to the Sixty-second session of the and Challenges. Addis Ababa: United Nations Eco- Regional Committee (2012) on the progress nomic Commission for Africa. http://www.uneca. made in the implementation of this resolution. org/mdgs/MDGs_in_Africa.pdf (last accessed 3 April 2010). REFERENCES 11. People living on less than US$1.25/day are said to be in extreme poverty. See World Bank MDGs website: 1. World Health Organization, 1946 Constitution. http://web.worldbank.org/WBSITE/EXTERNAL/ Geneva. http://www.who.int/governance/eb/who_ EXTABOUTUS/0,,contentMDK:20104132~menu constitution_en.pdf (last accessed 02/03/2010 11:38). PK:250991~pagePK:43912~piPK:44037~theSite 2. The Constitution of the World Health Organization PK:29708,00.html, (last accessed 12/29/2009). defi nes health as “a state of complete physical, mental 12. WHO (2009), World Health Statistics, 2009. Geneva: and social well-being and not merely the absence of Department of Health Statistics and Informatics of the disease or infi rmity”. World Health Organization, Information, Evidence and Research Cluster. http:// 1946 Constitution. Geneva. www.who.int/whosis/whostat/2009/en/index.html 3. WHO Commission on the Social Determinants of (last accessed 6 April 2010). Health (CSDH) (2008) Closing the Gap in a Genera- 13. WHO, Towards reaching the health-related Millennium tion: Health equity through action on the social de- Development Goals: Progress report and the way forward, terminants of health. Final Report of the Commission. Brazzaville, World Health Organization, Regional Geneva: World Health Organization. http://www. Offi ce for Africa, 2009 (AFR/RC59/3). who.int/social_determinants/thecommission/fi nalre- 14. ECA, (2007). Assessing Progress towards the Millennium port/en/index.html (last accessed 3 April 2010). Development Goals. Report to the Conference of 4. Mackenbach JP. (2006), Health Inequalities: Europe Ministers of Finance, Planning and Economic Devel- in Profi le, COI, London. http://www.dh.gov.uk/ opment. Addis Ababa. prod_consum_dh/groups/dh_digitalassets/@dh/@ 15. WHO, Towards reaching the health-related Millennium en/documents/digitalasset/dh_4121584.pdf – (last Development Goals: Progress report and the way forward, accessed 4 April 2010). Brazzaville, World Health Organization, Regional 5. WHO, Primary Health Care: Now more than ever. Offi ce for Africa, 2009 (AFR/RC59/3). The World Health Report, 2008. Geneva, 2008, 16. They include Algeria, Cape Verde, Eritrea, Malawi, World Health Organization. http://www.who.int/ Mauritius and Seychelles. whr/2008/en/index.html (last accessed 3 April 2010). 17. WHO, Towards reaching the health-related Millennium 6. WHO, (2008), The Algiers Declaration. Ministerial Development Goals: Progress report and the way forward, Conference on Research for Health in the African Brazzaville, World Health Organization, Regional Region, a declaration by Member States of the WHO Offi ce for Africa, 2009 (AFR/RC59/3). African Region, Algiers, 23–25 June 2008. http:// 18. These include Gambia, Gabon, Lesotho, Malawi, www.afro.who.int/en/regional-declarations.html. Mauritius, Mauritania, Namibia, Rwanda, Seychelles 7. WHO, Libreville Declaration on Health and Envi- and Uganda. ronment in Africa. First Inter-ministerial Conference 19. They were Algeria, Botswana, Cape Verde, Congo, on Health and Environment in Africa: Health security Equatorial Guinea, Ghana, Kenya, Madagascar, Sao through healthy environments, a declaration by Tome and Principe, Senegal, South Africa, Tanzania, Member States of the WHO African Region, Libre- Zambia and Zimbabwe. ville, Gabon, 26–29 August 2008. http://www.afro. 20. Algeria, Benin, Botswana, Cape Verde, Mauritius and who.int/en/regional-declarations.html (last accessed Tanzania. 3 April 2010). 21. WHO, Health Inequities in the WHO African 8. WHO, (2008), Ouagadougou Declaration on Primary Region: magnitudes, trends and sources. World Health Health Care and Health Systems in Africa: Achieving Organization, Regional Offi ce for Africa, Brazzaville Better Health for Africa in the New Millennium. 2010. A declaration by the Member States of the WHO 22. World Bank, Regional Vulnerability to Climate African Region. International Conference on Prima- Change. World Development Report 2010: Devel- ry Health Care and Health Systems in Africa, 28–30 opment and Climate Change – http://econ.world- April 2008, Ouagadougou, Burkina Faso. http:// bank.org/WBSITE/EXTERNAL/EXTDEC/

204 Accelerating response to the determinants of health

EXTRESEARCH/EXTWDRS/EXTWDR2010/0 Libreville Declaration on Health and Environment, ,,contentMDK:22303545~pagePK:64167689~piPK: and the Algiers Declaration on Health Research for 64167673~theSitePK:5287741,00.html#AFR last Health in the African Region, the Regional Strategy accessed 10/29/2009. on Poverty and Health, and “Agenda 2020” on 23. WHO, Towards reaching the health-related Health for All in the African Region by the Year Millennium Development Goals: Progress report and 2020. the way forward, Brazzaville, World Health Organi- 26. WHO, World Health Assembly Resolution WHA zation, Regional Offi ce for Africa, 2009 (AFR/ 62.14 on “Reducing health inequities through action RC59/3). http://www.afro.who.int/en/fi fty-ninth- on the social determinants of health”, World Health session.html – last accessed 4 April 2010. Organization, Geneva, May 2009. http://apps.who. 24. WHO, Achieving Health Equity: from root causes int/gb/ebwha/pdf_fi les/A62/A62_R14-en.pdf – last to fair outcomes, Interim Statement, Commission on accessed 4 April 2010. Social Determinants of Health. World Health Organ- 27. Whitehead, M. and Dahlgren, G. (2006) Levelling ization, Geneva, 2007. http://whqlibdoc.who.int/ Up (part 1) Concepts and Principles for Tackling publications/2007/interim_statement_eng.pdf – last Social Inequities in Health. Discussion Paper. WHO accessed 4 April 2010. Europe. http://test.cp.euro.who.int/document/ 25. For example, through work emanating from the e89383.pdf – accessed 4 April 2010. Ouagadougou Declaration on Primary Health Care 28. Evidence from the fi nal report of the WHO-CSDH and Health Systems in Africa: Achieving Better Knowledge Network on priority public health Health for Africa in the New Millennium, the conditions can help inform this process.

205 6.6 Reduction of the harmful use of alcohol: A Strategy for the WHO African Region (AFR/RC60/4)

EXECUTIVE SUMMARY 1. Public health problems related to alcohol consumption are substantial and have a signiﬁ cant adverse impact on both the alcohol user and the society. In the African Region, the alcohol- attributable burden of disease is increasing with an estimated total of deaths attributable to harmful use of alcohol of 2.1% in 2000, 2.2% in 2002 and 2.4% in 2004. However, with new evidence suggesting a relationship between heavy drinking and infectious diseases, alcohol-attributable deaths in the African Region could be even higher. 2. No other product so widely available for consumer use accounts for so much premature death and disability as alcohol. Alcohol-related problems and their adverse impact result not only from the quantities of alcohol consumed but also from the detrimental patterns of use. Effective and adequate policy measures and interventions, surveillance mechanisms and public awareness need to be developed or enforced in the Region. 3. The Strategy aims to contribute to the prevention and reduction of harmful use of alcohol and related problems in the Region. It reviews the regional situation and provides a framework for action in Member States and for the Region, taking into consideration the global developments. The Strategy is intended to provide balanced guidance on priority interventions to be implemented, taking into account the Region’s economic, social and cultural diversity. 4. The Regional Committee reviewed and adopted this strategy.

INTRODUCTION However, with new evidence suggesting a relationship between heavy drinking and infectious diseases, 1. Public health problems related to alcohol alcohol-attributable deaths in the African Region consumption are substantial and have a signiﬁ cant could be even higher. adverse effect on people other than the alcohol user. Intoxication and the chronic effects of alcohol 3. In 2007, at the Fifty-seventh session of the consumption can lead to permanent health damage WHO Regional Committee for Africa, Member (e.g. foetal alcohol syndrome, delirium tremens), States expressed concern about the impact of harm- neuropsychiatric and other disorders with short- ful use of alcohol2 on public health and emphasized and long-term consequences, social problems (e.g. the need to strengthen response in the Region. At unemployment and violence) and trauma or even the Fifty-eighth session of the Regional Committee, death (e.g. road trafﬁ c accidents). There is also a set of evidence-based actions that would serve as a increasing evidence linking alcohol consumption basis for developing national policies was adopted3 with high-risk sexual behaviour and infectious dis- and countries called for a Regional Strategy. eases such as tuberculosis and HIV. 4. At the global level, Member States requested the 2. The alcohol-attributable burden of disease is submission to the Sixty-third World Health Assem- increasing in the African Region, with an estimated bly, in 2010, of a global strategy to reduce harmful total of deaths attributable to harmful use of alcohol use of alcohol.4 In the process of collaboration to of 2.1% in 2000, 2.2% in 2002 and 2.4% in 2004.1 develop the draft global strategy, the WHO African

206 Accelerating response to the determinants of health

Region has gathered information from Member 9. Adequate policies are few and coordination with States about existing evidence-based strategies and relevant sectors and within government is lacking. their applicability globally and in the Region, taking Multisectoral approaches involving the private into account local needs and various national, reli- sector, professional associations, civil society, the gious and cultural contexts including national public informal sector, traditional healers, political and health problems, needs and priorities, and differ- community leaders are not developed. At the com- ences in Member States’ resources, capacities and munity level, there is a low level of awareness and capabilities.5 nongovernmental organizations are not engaged in addressing the problem. 5. This document analyses the situation in the Af- rican Region and proposes a strategy for appropriate 10. Within the health system, alcohol problems are action. The strategy builds on existing World Health often not recognized, tend to be minimized or are Assembly resolutions and on discussions at regional not properly addressed due to lack of appropriate and global levels, proposing a set of public health skills, knowledge, adequate resources or lack of interventions aimed at reducing the harmful use of coordination and integration among different health alcohol. programmes. 11. Although alcohol and illicit drugs share com- SITUATION ANALYSIS AND mon neurobiological, psychological and behavioural characteristics, their related health hazards are often JUSTIFICATION seen and treated separately, thus increasing the 6. Although alcohol constitutes an important resources needed to address substance abuse in source of income and its use is part of social and general. In the Region, there is a lack of integrated cultural practices and norms in many countries of approaches to dealing with substance use disorders. the Region, alcohol-related health and social costs 12. The absence or misplacement (in psychiatric cannot be ignored. No other product so widely hospitals) of effective and adequate interventions, available for consumer use accounts for so much ranging from brief interventions in primary care to premature death and disability as alcohol. Alcohol- more intensive treatment in specialized settings, is a related problems and their adverse impact result not 6 reality in the African Region. Access to prevention, only from the quantities of alcohol consumed but screening and treatment services and psychosocial also from the detrimental patterns of use. Public care for patients and families are severely hampered awareness, especially of specifi c types of harm, is low by low or nonexistent budgetary allocations, general in many of the countries. weakness of health systems and lack of public health 7. Recent studies and surveillance data provide an infrastructure. 7 insight into harmful use of alcohol in the Region. 13. Interventions such as enactment of drinking and The two main characteristics that describe alcohol driving laws, taxation, restrictions on advertising and consumption patterns in the Region are the high community information are already being used in level of abstention in some countries and the high the Region. Even so, they are used in an ad hoc, volume of consumption by drinkers, with severe informal and fragmented manner, and frequently health and social consequences. Overall, the adult lack adequate control and enforcement systems. per capita consumption of alcohol in the WHO Afri- can Region in 2004 was estimated at 6.2 L of pure 14. It is estimated that unrecorded consumption alcohol. accounts for about 50% of the overall consumption of alcohol in African countries.8 Despite concerns 8. In 2008/2009, countries collaborated in the about the potential health hazards arising from WHO Global Survey on Alcohol and Health. unregulated or illicit production, there is little This process showed that out of the 46 countries information on the problem and the issue is often in the Region, only 10 countries had recent overlooked or not given the necessary consideration alcohol policies and 16 countries had advertising in policy development. regulation. In many countries, regular and systematic surveillance and monitoring systems with Justifi cation appropriate fi nancial and human resources are still non-existent; basic indicators are not defi ned; and 15. The reduction of public health problems caused even when data are available they are often scattered by harmful use of alcohol and the required interven- among different departments and, therefore, diffi - tions by governments to control alcohol-related cult to collect. harm are an essential step to improving the health of

207 COMPENDIUM OF RC STRATEGIES the populations in the Region. Important and effec- harm from other people’s act of drinking, and tive alcohol control measures are available. from pressures to drink. (c) Strong political commitment, leadership 16. Therefore, the development and implementa- and appropriate funding will ensure that tion of a regional strategy in the African Region is effective approaches to alcohol problems are a timely and needed response. At the Fifty-eighth formulated, taking into account public health session of the WHO Regional Committee, in 2008, principles. Member States requested WHO to support the (d) Actions should be undertaken in a coordinat- development, implementation and evaluation of ed, strategic and integrated manner jointly national policies and plans to combat the harmful with key agencies and with appropriate involve- use of alcohol and, to this end, submit a Regional ment of all partners and stakeholders at all stages Strategy to the Committee. of decision-making, planning, implementation 17. The magnitude and nature of alcohol-related and evaluation. harm clearly underscore the need for concerted (e) Equitable and non-stigmatized access to action not only at national level, but also at regional effective prevention and care services should be and global levels. Strengthening national and given to all individuals and families; human region-wide capacities will enhance the capacity rights should be respected. to respond effectively to the magnitude of the problem. Priority interventions 21. Develop and implement alcohol control THE REGIONAL STRATEGY policies. Alcohol control policies, legislation and regulations should be based on clear public health Aim and objectives goals and best available evidence and should refl ect 18. The aim of this Strategy is to contribute to the national consensus regarding their implementation prevention or at least reduction of harmful use of at country level. The policies require strong leader- alcohol and related problems in the African Region. ship and political commitment and are necessary to ensure transparency, continuity and sustainability of 19. The specifi c objectives are: the measures adopted by all the relevant partners. (a) to provide a platform for advocacy for increased Policy options can be grouped into the following resource allocation, strengthening of action and areas: intersectoral and international collaboration in 22. Leadership, coordination and partners’ responding to the problem; mobilization. Coherent, consistent and strong (b) to provide guidance to Member States for the action with relevant actors such as producers, retail- development and implementation of effective ers, health workers and communities, is fundamental alcohol control policies, based on public health for effective implementation and reinforcement of interests; national policies and action plans. It is necessary to (c) to address low awareness on alcohol related clearly defi ne partners’ areas of contribution, their harm in the community; roles in implementation, their responsibilities and (d) to promote the provision of adequate health- mandates and the relevance of their support, in line care interventions for preventing harmful use of with national priorities. An appropriate coordina- alcohol and managing the attendant ill-health tion mechanism is, therefore, important to bring and conditions; together all intervening agencies, organizations and (e) to encourage the creation of systems of system- stakeholders.9 The capacities of local authorities and atic surveillance and monitoring of alcohol pro- the role of NGOs in this drive should be strength- duction, consumption and harm in countries. ened. Guiding principles 23. Awareness and community action. Provi- sion of information for decision-makers and com- 20. This strategy is based on fi ve key principles, munities should be strengthened in order to increase which should guide policy development at all levels commitment to public health protection, recogni- in countries: tion of alcohol-related harm in the community and (a) Policies should be based on best available active participation in policy measures and in evidence and be sensitive to national contexts. implementation. A dedicated day or week should (b) Citizens, especially those at risk, should be pro- be established to increase community and political tected from alcohol-related harm, particularly awareness.

208 Accelerating response to the determinants of health

24. Information-based public education. Pro- accompanied by regular public awareness and viding alcohol education and information to the information campaigns have a sustained effect on public, and religious and community leaders is fun- drink-driving. damental to support alcohol control policy measures and to increase community participation in their 28. Regulating alcohol marketing. There is a implementation. Efforts are needed to improve its need to regulate the content and scale of alcohol quality and keep it under the responsibility of public marketing and the promotion of alcoholic beverag- bodies. The harmful use of alcohol should be es, in particular sponsorship, product placement, as integrated into the school curriculum. Community well as internet and promotional merchandising action programmes should be usefully combined strategies. Public agencies or independent bodies with interventions in schools and other settings such should closely monitor the marketing of alcohol as workplaces to mobilize public opinion to address products. Effective systems of deterrence should be local determinants of the increasing alcohol con- put in place and enforced. sumption and related problems. Local community 29. Addressing accessibility, availability and action should be based on rapid assessment and in- affordability of alcohol. Commercial licensing volve the community and young people in problem systems that regulate the production, importation identifi cation, planning and policy implementation. and sale (wholesale and retail) of alcoholic beverages 25. Improvement of health sector response. should be put in place. Stricter regulation of the for- Efforts are needed to improve health sector response mal and informal sector and licensing of traditional through adequate training, infrastructures and fund- outlets is crucial to ensure that beverages meet safety ing and by strengthening integrated approaches to requirements and that they are controlled in order to alcohol problems at different levels of the health sys- protect most vulnerable groups such as adolescents tem in both urban and rural areas. Early detection and the low income population. There is a need to and management of alcohol-related harms at pri- enact and enforce legislation on the minimum age at mary care level and effective treatment of people which alcohol drinking and purchasing is authorized with drinking-related disorders are vital. Health and to restrict the times and places of sale. At the professionals have an essential role to play in educat- point of sale in supermarkets, alcoholic beverages ing the community and mobilizing and involving should not be displayed together with water and players within and outside the health sector. other non-alcoholic drinks. Taxation should be in- creased11, with regular review of prices, based on the 26. Strategic information, surveillance and infl ation rate, income levels and alcohol contents. research. Surveillance and monitoring, research To that end, adequate enforcement mechanisms and knowledge management play pivotal roles in should be established. alcohol control. Countries should establish information systems to monitor alcohol production, 30. Addressing illegal and informal production consumption and related health, social and econom- of alcohol. The illegal and informal production of ic indicators as well as the application of existing alcoholic beverages12 is seen as a major impediment laws and regulations and their effect on the general to the adoption of effective policies. Nevertheless, population. Alcohol indicators with direct relevance this situation impacts on health and on tax revenues to national policy priorities need to be identifi ed and and reduces the ability to control production. This opportunities to integrate alcohol indicators into needs to be addressed and included in the national other surveillance systems should be adequately policy response. Some measure of quality control is utilized. New partnerships with research entities needed including licensing and training of producers should be explored and operational research should and introduction of appropriate enforcement meas- be promoted as an integral part of alcohol control ures. In addition, it is important to raise awareness in order to map unrecorded drinking patterns and among the general population and consumers about document effective alcohol policy interventions. the dangers inherent in the consumption of certain forms of alcoholic beverages and to fi nd funding to 27. Enforcing drink-driving legislation and assist local informal producers to establish alternative countermeasures. Drink-driving countermeas- income-generating business. ures, including setting and enforcing a maximum limit of 0.5 g/l for blood alcohol concentration,10 31. Resource mobilization, appropriate alloca- frequent random-breath testing by the police and tion and integrated approach. Resources are sobriety check-points, should be a high-priority in- crucial to the implementation of the measures tervention. The visibility of such measures, rigorous needed to reduce alcohol-related problems. These and sustained enforcement of existing legislation resources, to be mobilized by governments, from

209 COMPENDIUM OF RC STRATEGIES individuals, the private sector and international part- (d) facilitating the creation and capacity building of ners, should be available on sustainable basis and dis- Intercountry networking for exchange of expe- tributed among the different levels of the health riences; system according to relative needs. There is a need (e) facilitating effective linkages, cooperation and to include harmful use of alcohol as a priority in the collaboration among international agencies, health development plans of countries. The devel- partners and stakeholders. opment of an integrated approach to prevention and treatment can facilitate the use of existing resources Resource implications in other areas or programmes for implementing the 34. Resources are required to support the imple- necessary interventions. mentation of this strategy, particularly the implementation surveillance and recording systems, policy Roles and responsibilities monitoring, including enforcement measures, research and early detection and treatment compo- 32. Countries should: nents. This will reduce costs in the long term. (a) develop and implement comprehensive alcohol Furthermore, there is a need to ensure the availabil- policies that are evidence-based and focus on ity not only of trained human resources at different public health interest; to facilitate this task, a levels of the health care system but also of treatment coordination body such as a national alcohol structures. In most countries in the Region, part of council should be established; the revenues gathered from alcohol taxes should (b) mobilize and allocate resources for alcohol be allocated to support the implementation of this policies; strategy. (c) create public awareness on alcohol-related harm and mobilize communities to support the imple- MONITORING AND EVALUATION mentation of evidence-based policy; (d) adopt and enforce regulations and legislation 35. Continuous monitoring and evaluation will be aimed at reducing alcohol consumption and based on progress, outcome and impact measure- related harm and strengthen clinical practices; ments, formulated under a regional plan of action, (e) promote and strengthen independent research in and reported every two years to the Regional Com- order to assess the situation and monitor nation- mittee. Progress monitoring indicators include: al trends and the impact of adopted policy (a) the availability and effective implementation of measures; policies to reduce alcohol consumption and (f) reinforce training and support for all those related harm; engaged in alcohol control policy activities in (b) the implementation of sustainable national mon- an attempt to increase knowledge and skills and itoring systems capable of collecting, analysing facilitate policy implementation; and disseminating data for evidence-based policy (g) establish systems for monitoring and surveillance decisions; in order to capture the magnitude of alcohol (c) the development and implementation of appro- consumption and related health, social and eco- priate health care interventions at all levels of the nomic harms, provide information on existing health system, ranging from early interventions laws and regulations and contribute to the to adequate treatment. exchange of alcohol surveillance information between regions and countries. 36. Outcome and impact indicators will require the availability of data on trends and alcohol-related 33. WHO and partners should support countries by: harm. (a) developing and providing evidence-based tools and guidelines for policies, interventions and CONCLUSION services; (b) maintaining a regional information system and 37. The African Region is faced with the growing providing technical support to Member States burden of harmful alcohol consumption and lacks in surveillance, monitoring and evaluation of appropriate mechanisms to respond to this situation. alcohol consumption and related problems; The main challenge is how to develop such mecha- (c) providing them technical support in the devel- nisms for effective implementation of national opment and review of effective and comprehen- actions that will contribute to reducing harmful use sive alcohol policies and strategies; of alcohol and strengthen global initiatives.

210 Accelerating response to the determinants of health

38. This strategy outlines actions needed to reduce Noting the lack of public awareness and the low alcohol-related harm and facilitate policy develop- recognition of alcohol-related harm; ment and implementation at the country level. In Conscious of the need to ensure government order to reduce alcohol-related morbidity and mor- leadership in order to protect at-risk populations, tality in countries, Member States are invited to take youths, and people affected by harmful drinking of guidance from this document according to their others; specifi c needs and situation. This strategy will pave the way for action region-wide, including stronger Noting the existing opportunities to mobilize cooperation among Member States, stakeholders the community, the health sector and partners to and partners. Strong advocacy and commitment at improve surveillance and develop evidence-based the highest political level are fundamental elements interventions; for its success. Mindful of the need to consider multisectoral 39. The Regional Committee reviewed and adopted approaches and coordinate with key intervening this strategy. agencies, organizations and stakeholders; 1. endorses the Regional Strategy to reduce harmful use of alcohol in the WHO African Region, as Resolution AFR/RC60/R2 proposed in Document AFR/RC60/PSC/4; Reduction of the harmful use of alcohol: 2. URGES Member States: A strategy for the African Region (a) to acknowledge harmful use of alcohol as a The Regional Committee, major public health issue and accord it priority in their national health, social and development Having examined the document entitled agendas; “ Reduction of the harmful use of alcohol: A strategy (b) to develop, strengthen and implement evidence- for the WHO African Region”; based national policies and interventions and Recalling World Health Assembly resolutions adopt and enforce necessary regulations and WHA58.26 on public-health problems caused by legislation in this area; the harmful use of alcohol; WHA61.4 on strategies (c) to mobilize and ensure appropriate fi nancial and to reduce the harmful use of alcohol; and the human resources to implement national alcohol endorsement at the Sixty-third World Health policies and consider using revenues resulting Assembly, in May 2010, of the global strategy to from alcohol taxes to support the implementa- reduce harmful use of alcohol; tion of this Strategy; (d) to set up the necessary research, surveillance and Having considered the report of the Regional monitoring mechanisms to assess performance Director on “Harmful use of alcohol in the WHO in alcohol policy implementation and ensure African Region: situation analysis and perspectives” regular reporting to the WHO Secretariat; and on “Actions to reduce the harmful use of (e) to ensure intersectoral coordination through the alcohol”, respectively presented at the Fifty-seventh creation of an intersectoral committee bringing and Fifty-eighth sessions of the WHO Regional together all relevant governmental sectors, agen- Committee for Africa; cies and governmental and nongovernmental Recognizing that the alcohol-attributable burden organizations; of disease is increasing in the African Region and (f) to create public awareness on alcohol-related that public health problems related to alcohol con- harm and encourage the mobilization and active sumption are substantial and can adversely affect engagement of all the social and economic people other than the alcohol user; groups concerned in reducing harmful use of alcohol; Acknowledging that a signifi cant proportion of alcohol consumed in the Region is produced 3. REQUESTS the Regional Director: informally and that it may entail additional health (a) to continue to support and give priority to pre- hazards; vention and reduction of harmful use of alcohol Concerned about the increasing evidence linking and to increase efforts to mobilize necessary alcohol with illicit drugs consumption and with resources to implement this Strategy; high-risk sexual behaviour and infectious diseases (b) to provide technical support to Member States such as tuberculosis and HIV/AIDS; in building and strengthening institutional

211 COMPENDIUM OF RC STRATEGIES

capacity to develop and implement national 4. Resolution WHA61.4: Strategies to reduce the harm- policies and evidence-based interventions to ful use of alcohol. In Sixty-fi rst World Health Assem- prevent harm from alcohol use; bly, Geneva, May 2008, World Health Organization. (c) to provide technical support to Member States 5. Report on the WHO Regional Technical Consulta- for integrating prevention and treatment inter- tion on a Global Strategy to Reduce Harmful Use of Alcohol. WHO Regional Offi ce for Africa, 2009. ventions for harmful use of alcohol into the 6. Estimated mean of 20.24 litres of pure alcohol per primary health care approach, and to strengthen resident alcohol user aged 15 or over, higher than the country capacity for adequate treatment, care global consumption rate estimated to be 15.8 litres. In and support for those with alcohol use disorders Rehm, J et al. Alcohol, social development and infec- and their families; tious disease. Ministry of Health and Social Affairs, (d) to support further collection and analysis of data Sweden, 2009. on alcohol consumption and its health and social 7. Global Information System on Alcohol and Health – consequences and reinforce the WHO regional GISAH, http://apps.who.int/globalatlas/default.asp; information system on alcohol and health; South African Community Epidemiology Network (e) to facilitate research on and dissemination of best on Drug Use (SACENDU), http://www.sahealthin- fo.org/admodule/sacendu.htm; Roerecke, M. Vol- practices among African countries through con- ume of alcohol consumption, patterns of drinking and ferences and facilitate the implementation of this burden of disease in sub-Saharan Africa, 2002. African Strategy by organizing a regional network of Journal of Drug and Alcohol Studies, 7(1), 2008. national counterparts; Obot I. Alcohol use and related problems in sub- (f) to draw up a regional action plan for implement- Saharan Africa, African Journal of Drug and Alcohol ing this Strategy; Studies 5(1): 17–26, 2006. (g) to organize regional open consultations with 8. WHO, Global Status Report on Alcohol, Geneva 2004: representatives of the alcohol industry, trade, World Health Organization, Department of Mental agriculture and other relevant sectors on how Health and Substance Abuse. they can contribute to reducing harmful use of 9. Policies to reduce the harmful use of alcohol must reach beyond the health sector and engage such alcohol; sectors as development, transport, justice, social (h) to report on progress made in the implementa- welfare, fi scal policy, trade, agriculture, consumer tion of the regional strategy to the Regional policy, education and employment. Committee every two years and at regional or 10. Over the years, the stipulated maximum level has international forums as appropriate. been lowered. It is as low as zero or 0.2g/l in a number of countries, and 0.5g/l or lower in most REFERENCES countries in Europe. 11. Several studies have found mean price elasticity of 1. Rehm et al. Global burden of disease and injury and –0·46 for beer, –0·69 for wine, and –0·80 for liquor, economic cost attributable to alcohol use and alcohol- meaning that if the price of beer is raised by 10%, beer use disorders. Lancet 2009; 373: 2223–33. consumption would fall by 4.6%; if the price of wine 2. Harmful drinking encompasses drinking that is detri- was increased by 10%, wine consumption would fall mental to health and has social consequences for the by 6.9%; if the price of spirits was increased by 10%, alcohol user, the people around the alcohol user and consumption of liquor would fall by 8.0%. Anderson, society at large, as well as patterns of drinking that are P et al. Effectiveness and cost-effectiveness of policies associated with increased risk of adverse health out- and programmes to reduce the harm caused by comes. alcohol. Lancet 2009; 373: 2234–46. 3. WHO, Harmful use of alcohol in the WHO African 12. Illegally-produced alcohol refers to alcoholic bever- Region: situation analysis and perspectives (AFR/ age not produced according to law or not authorized RC57/14), Brazzaville, World Health Organization, by law; Informally-produced alcohol means alcoholic Regional Offi ce for Africa, 2007; WHO, Actions to beverages produced at home or locally by fermenta- reduce the harmful use of alcohol (AFR/RC58/3): tion and distillation of fruits, grains, vegetables and the Brazzaville, World Health Organization, Regional like, and often within the context of local cultural Offi ce for Africa, 2008. practices and traditions.

212 Annexes

1. MALARIA 1.1 Roll back malaria in the WHO African Region: A framework for implementation (AFR/RC50/12)

EXECUTIVE SUMMARY 1. Malaria remains a disease of major public health concern in the WHO African Region. There are 270–480 million cases annually in the continent, representing ninety per cent of global malaria deaths per year. In 1997, the total annual cost of the disease was more than US$ 2000 million and is projected to reach US$ 3600 million by the year 2000. In recognition of this, OAU Heads of State adopted a Declaration in 1997 calling on Member States to intensify the ﬁ ght against malaria. In response, the Director General (DG) of WHO established the Roll Back Malaria (RBM) initiative in July 1998. 2. RBM in the African Region builds on the accelerated implementation of malaria control, the Regional Strategy for Malaria Control and the African Initiative for Malaria (AIM) Control in the 21st Century. 3. RBM approach emphasizes the technical aspects of malaria control as well as building of partnerships at all levels: regional, country and district. The implementation of RBM would be multisectoral, involving governments, NGOs, the private sector, research institutions and, more importantly, the communities. 4. RBM in the African Region will contribute to strengthening the health systems. Capacity building at all levels with emphasis on managerial aspects constitutes one of the ways in which RBM would contribute to strengthening health systems. In addition, RBM would lead to improved delivery of quality health care and address equity by focusing on the poor and marginalized people. 5. It is expected that RBM implementation in the African Region will bring stronger social mobilization and additional support so that by the year 2030, malaria will not be a signiﬁ cant public health problem. 6. This document proposes a framework for the implementation of RBM in our Region. It provides orientation on the implementation process and the roles of Member States, WHO and other partners. 7. The Regional Committee considered the proposed framework and provided orientation for the adoption and implementation of RBM in the Region for the purpose of achieving the set objectives.

215 COMPENDIUM OF RC STRATEGIES

INTRODUCTION (e) increase in capacity building at the regional, national and district levels 1. Malaria is a major public health problem in the (f) introduction of Insecticide Treated Nets (ITNs) WHO African Region. In 1991 and 1992 respec- into 30 countries tively, regional and global strategies for malaria con- (g) increased advocacy, including increased visibility trol were developed. In 1995, the World Bank and of national malaria control programmes WHO/AFRO decided to develop long-term col- (h) improved collaboration among partners. laboration on malaria control. 8. The challenges encountered were: 2. The political support given to malaria control during the 1997 Organization of African Unity (a) addressing epidemiological surveillance of ma- (OAU) Summit led to the establishment, in April laria and other priority diseases as part of efforts 1998, of the African Initiative for Malaria Control in to take technical interventions to scale within the 21st century (AIM). In July 1998, the DG of the health sector reforms; WHO established the RBM initiative. Since the (b) improving accessibility and quality of care at goals and the concept of the two programmes were facility level; similar, it was agreed that AIM would be called (c) sustaining and boosting the interest of key play- RBM in the African Region. ers in malaria control; (d) developing information, education, and com- 3. With its focus on health sector reforms and an munication (IEC) programmes based on local enhanced role for communities in the implementa- knowledge, attitudes, perceptions and beliefs in tion process, RBM is in line with the Regional order to inﬂ uence the behaviour and practices of Health for All policy. The purpose of the current individuals and communities; document is to provide Member States with an (e) mobilizing resource at all levels; adaptable framework for RBM implementation. (f) ensuring patient compliance with prescribed dosages; SITUATION ANALYSIS (g) increasing the coverage of insecticide treated nets; 4. Estimated 270–480 million cases of the disease (h) assuring malaria control in emergency situations; occur in the continent annually. This amounts to (i) integrating priority actions at operational level of about one million deaths, representing 90% of global primary health care; malaria deaths. Eighty per cent of these deaths occur (j) developing and implementing effective anti- among children under the age of ﬁ ve years. Malaria malaria policy; is a major contributing cause of poverty and absen- (k) assuring mandatory intersectoral collaboration teeism in endemic areas. It may account for loss of for effective result. up to 5% of the GDP. 5. Weak health systems and inadequate coverage of RBM IN THE AFRICAN REGION control interventions complicate the scenario. Pre- vious efforts to control the disease have suffered Goal from fragmentation, lack of coordination, and 9. The goal of Roll Back Malaria (RBM) in the inadequate consideration of socio-cultural factors. WHO African Region is to reduce malaria burden 6. The accelerated implementation of malaria to a level where it is no longer one of the major control in the African Region took off in 1995, contributors to mortality and morbidity in the enhanced by funds of US$ 18 million from WHO in African Region. 1997 and 1998 and support from partners. Objectives: 7. Some of the achievements of the accelerated implementation of malarial control are: 10. The objectives of RBM in the African Region are: (a) plans of Action for Malaria Control developed in 38 African countries (a) to reduce mortality due to malaria (b) development of monitoring indicators and es- (b) to reduce morbidity due to malaria tablishment of monitoring and evaluation activi- (c) to maintain malaria free areas ties (d) to expand areas where malaria is controlled (c) improvement in malaria case management (e) to reduce the adverse socio-economic conse- (d) development of antimalarial drug policies quences of malaria.

216 Annex 1: Malaria

Targets: countries that are malaria free in 2000 will remain malaria free. 11. The targets of RBM are: By 2001: 50% of 42 malaria endemic countries in the Re- IMPLEMENTATION STRATEGIES gion will have introduced RBM and developed 12. The seven pillars of RBM implementation are: plans of action; 75% of 42 malaria endemic countries will have (a) ownership; introduced IMCI; (b) contributing to health sector reform; 80% of 42 malaria endemic countries will have (c) integration of malaria control activities into increased the coverage of Insecticide-treated PHC, and socio-economic development activi- nets (ITNs) to 25%; ties; countries that are malaria free in 2000 will (d) increasing the coverage of cost-effective techni- remain malaria free. cal interventions; (e) building and strengthening partnerships; By 2005: (f) strengthening community participation; 50% of households in targeted districts will have (g) strengthening health information system and at least one ITN research. 25% of childhood fevers will be correctly managed using IMCI Ownership countries that are malaria free in 2000 will remain malaria free. 13. RBM will have to be country-driven to ensure that malaria control efforts are planned and imple- By 2010: mented according to country priorities and commu- all countries in the Region would be fully nity needs as well as to assure sustainability. This implementing RBM requires the ownership of the RBM by countries, reduction of malaria morbidity by 50% of the including active total involvement of communities. 2000 levels1 reduction of malaria mortality by 50% of the Contributing to health sector reforms 2000 levels1 countries that are malaria free in 2000 will 14. RBM in the African Region will contribute to remain malaria free. the overall national health system performance through: By 2015: further reduction in malaria mortality by 50% of (a) capacity building for malaria programme man- the 2010 fi gures agement further reduction in malaria morbidity by 75% (b) improved planning and management as part of of the 2010 fi gures ongoing health sector reforms areas where malaria is controlled in the countries (c) increased decision capacity for malaria pro- will increase by 50% of 2000* fi gures gramme managers countries that are malaria free in 2000 will (d) coordination and implementation of RBM remain malaria free. activities within a decentralized health system. By 2025: 15. Integration of malaria control within health further reduction of malaria mortality by 50% of sector reform will assist to ensure: the 2015 fi gures (a) improved access to and availability of services, further reduction in malaria morbidity by 80% through appropriate design of services for effec- of the 2015 fi gures tive coverage, including for groups at greatest areas where malaria is controlled in the countries risk; will increase by 20% of 2015 fi gures (b) improved quality of care and utilization of countries that are malaria free in 2000 will services; remain malaria free. (c) linkage to human development and poverty By 2030: reduction and the promotion of mechanisms to malaria mortality reduction maintained at the enhance utilization of services by targeted 2025 levels groups; malaria morbidity reduction maintained at the (d) improved overall health structure, including 2025 levels better organization and management systems for

217 COMPENDIUM OF RC STRATEGIES

drugs, personnel, equipment, referrals, transport, (d) linkage of malaria activities with gender-based communications, and maintenance, thus im- development activities; pacting positively on other programmes such as (e) broadening of the resource base at community safe motherhood, HIV/AIDS, EPI, IMCI, etc. level by facilitating community-based ﬁ nancing initiatives to ensure sustainability of malaria Integration of malaria control activities into activities; primary health care approach (f) mobilization of all segments of the society for relevant activities; 16. To achieve the targets in the African Region, (g) integration of RBM activities into other com- RBM will be implemented within evolving nation- munity-based activities such as Bamako Initia- al health systems. Its activities will be integrated tive, IMCI, EPI, etc.; within PHC, to ensure wide accessibility to the (h) linking of community activities with national communities and address equity issues. efforts to control malaria. Increasing the coverage of cost-effective technical interventions Strengthening of Health Information System and Research 17. In order to achieve the RBM targets, an appropriate mix of proven cost-effective technical inter- 20. RBM, in collaboration with Integrated Disease ventions must be taken to scale. These interventions Surveillance, will contribute to the strengthening of must target the following priorities: health information systems through: (a) early diagnosis and prompt effective treatment at (a) capacity building in data collection, analysis, in- home, the community and health facility; terpretation, information sharing and decision- (b) preventive measures, including selective cost- making and practice at district and national effective anti-vector control activities e.g. ITNs; levels; (c) promotion of health information and education (b) capacity building in research, particularly opera- activities; tional research, at all levels; (d) epidemiological surveillance; (c) strengthening epidemiological surveillance ca- (e) forecast, early detection, prevention and control pacity and capability, particularly at the opera- of epidemics; tional level. (f) research on traditional medicines; (g) drug development from traditional medicines; Roles and responsibilities (h) regular assessment of country malaria situation in order to improve control activities. Countries 21. Countries will develop ﬁ ve- or six-year Building and strengthening partnerships evidence-based RBM plans of action that confer 18. A broad-based, multisectoral RBM partnership priority on capacity building in order to ensure sus- forum will be established under country leadership. tainability. They will also play the following roles: It will promote and ensure: (a) advocacy (a) coordination of national efforts (b) consensus building (b) comprehensive RBM policies (c) resource mobilization and coordination (c) point planning, monitoring and evaluation (d) human resource development (d) improvement in mobilization and allocation of (e) planning and implementation of RBM plans resources (f) monitoring and Evaluation. (e) enhanced public and private sector collaboration. World Health Organization 22. WHO will: Strengthening community participation (a) facilitate building of sustainable partnerships at 19. At the community level, RBM will promote: the regional and country levels (a) ownership of malaria control activities by the (b) by strengthening and expanding collaboration communities; with multilateral and bilateral agencies, NGOs (b) improved quality in home care; and the private sector; (c) capacity building of communities for implemen- (c) by strengthening collaboration with IMCI, tation and sustainability of activities; Integrated Disease Surveillance and other

218 Annex 1: Malaria

programmes and sectors that have malaria related country-driven and sustained, country partnerships activities; will be signifi cant for mobilizing in-country re- (d) contribute to advocacy and resource mobiliza- sources, including untapped private and community tion for country and inter-country activities; resources. (e) provide technical support, including orientation, 32. A clear system to ensure easy fl ow of resources as to countries in the implementation of RBM. well as accountability, transparency and information 23. National capacity and capability building is high sharing would be set up at country, regional and priority. global levels. Emphasis will be on allocation of resources to country and local levels. 24. Technical support will include: (a) provision of technical guidelines Phases of implementation (b) development of strategy documents 33. The districts will constitute the fi rst level for the (c) strengthening country-level expertise implementation and evaluation of RBM as follows: (d) support to implementation of planned activities (e) monitoring and evaluation. Phase 1: Introduction and Implementation – 2000 to 2015 25. Country Offi ce will provide active support to Stage 1: Preparatory and planning (up to countries in terms of RBM activities coordination. end of 2000): In this phase, the priority processes will be: Other Partners (i) inception meetings 26. Other partners’ support to the development and (ii) strengthening of priority actions implementation of country RBM plans of action (iii) development and assessment of will be provided through their efforts in: the strategy and plan of action. Stage 2: Implementation from 2001 to 2005 (a) areas of comparative advantage and expansion from 2005 to 2015. (b) national capacity development Activities will focus on strengthen- (c) resource mobilization ing implementation, assuring avail- (d) agreed plan of work. ability of services and monitoring. 27. Eleven countries will serve as “spotlight” for Expansion will follow by 2005, developing the RBM experience. drawing on lessons learned. Phase 2: Consolidation – 2016 to 2025 28. A regional-level partnership for RBM will be Countries, with the support of RBM built and developed through the annual meeting of partnerships, will have instituted sustain- the Task Force for malaria control in Africa. able mechanisms for disease control and strengthened the health systems. The Resources results from country level would have 29. The quantum of resources required to support started to have impact on mortality and country plans of action is expected to grow signifi - morbidity. cantly to cover major investments for scaling up Phase 3: Maintenance – 2026 to 2030 RBM activities. Countries will be expected to During this stage, efforts would be made increase the levels of resources allocated to RBM to keep the burden of disease low and activities. RBM partnership at global, regional and maintain gains made. This will include country levels will also be expected to mobilize efforts at continued capacity building refi nancial, human, and material resources for the orientation and re-training of personnel. implementation of the planned activities. 30. Investment in malaria control currently stands at MONITORING AND EVALUATION about US$ 12 million. To meet the commitments of RBM, the resources needed at country level be- 34. For the evaluation process, the following indica- tween the year 2000 and 2005 has been put at more tors will be used at country level: than 10–15 times the current investments. By the (a) malaria-related mortality among the under-fi ve year 2015 when it will be at full implementation, it (b) percentage of the under- fi ve sleeping under might go up to 40 times the current budget. ITNs 31. Resources will, therefore, need to be mobilized (c) number of malaria epidemics detected within at all levels. Given the need for RBM to remain two weeks of onset and control measures initiated

219 COMPENDIUM OF RC STRATEGIES

(d) percentage of severe malaria cases properly equity, accessibility, effi ciency and delivery of qual- managed in clinics ity services. (e) percentage of malaria-free areas. 38. The development of multisectoral partnerships, 35. Monitoring is, of course, a continuing process. including opportunities like IMCI, will feature high However, programme monitoring will be conduct- in the implementation strategy of RBM in Africa. ed annually and programme evaluation every fi ve 39. The implementation of RBM in the African years. Programme review will take place at intervals Region will contribute to the control of the disease determined by the countries and the Regional and to assuring the socio-economic well-being of Offi ce. the society. CONCLUSION 40. The Regional Committee approved the present framework as a tool to ease and facilitate the imple- 36. RBM with its additional resources will bring to mentation of RBM in the Region. scale technical interventions for malaria control, with emphasis on community-based activities. 37. RBM will be country-specifi c and country- REFERENCE driven. It is expected to contribute to the strength- 1. The level will be determined through surveys under- ening of health systems for the purpose of ensuring taken in year 2000.

220 1.2 Accelerated malaria control: Towards elimination in the WHO African Region (AFR/RC59/9)

BACKGROUND 5. The key malaria interventions are vector control, using insecticide-treated nets (ITNs), indoor 1. Africa is the continent most affected by malaria, residual spraying (IRS), intermittent preventive accounting for 86% of the estimated 247 million treatment of malaria in pregnancy (IPTp) and effec- malaria episodes and 91% of malaria deaths world- tive treatment. Artemisinin-based combination wide in 2006. Malaria also accounts for 25%–45% of therapy (ACT) is now the treatment of choice in 41 all outpatient clinic attendances and between 20% of the 43 malaria-endemic countries; 20 countries and 45% of all hospital admissions. Furthermore, it is are implementing ACT country-wide. By the end estimated that malaria represents 17% of under-ﬁ ve 1 of 2007, IPTp had been adopted in all the 35 mortality in the WHO African Region. endemic countries where it was recommended, and 2. In high endemic countries in the Region, it is 20 countries are implementing IPTp country-wide.5 estimated that malaria reduces economic growth by 6. Between 2000 and 2006, ITN distribution an annual average rate of 1.3%, mainly from absenc- 2 increased three- to ten-fold in most countries. Sub- es from work or school. The poorest people are sidized or free ITNs have increased bednet cover- most exposed to malaria and its complications be- age. ITN distribution is often linked to antenatal cause of inadequate housing, poor living conditions care, routine immunization services and campaigns. and limited access to health care. By the end of 2007, 17 of the 43 malaria-endemic 3. Since 1991, several initiatives, resolutions and countries in the African Region were using indoor meetings have put malaria back at the top of the residual spraying as one of the key malaria control public health agenda.3 In 1998, the Roll Back interventions, while six countries were pilot-testing Malaria initiative was launched to advocate for and IRS in a few selected districts. coordinate malaria control efforts aimed at halving 7. A rapid decline in malaria burden is possible the malaria burden by 2010. Roll Back Malaria pro- when a comprehensive package of malaria preven- gressively led to increased commitment to malaria tion and control interventions is implemented in the prevention and control, culminating in the 2006 same geographic area at the same time, as has been Abuja African Union Heads of State call for univer- shown in Botswana, Eritrea, Ethiopia, Kenya, sal access to HIV/AIDS, tuberculosis and malaria Rwanda, Sao Tome and Principe, South Africa and services by 2010 and the call for malaria elimination. Swaziland.6 This was followed by the UN Secretary-General’s call for 100% coverage of malaria control interven- 8. The purpose of this document is to give guid- tions by 2010. ance to countries on how to accelerate implementation of malaria prevention and control interventions 4. Malaria control results from deliberate efforts to towards eventual elimination. reduce the disease burden to a level where it is no longer a public health problem. Malaria elimination, for its part, is an interruption of local mosquito- borne malaria transmission in a deﬁ ned geographic ISSUES AND CHALLENGES area.4 Moving from malaria control to elimination 9. Some countries do not have comprehensive pol- should be seen as a continuum with the ultimate icies and strategies to guide the scaling up of malaria goal of interrupting malaria transmission. control. The private sector is not usually engaged or

221 COMPENDIUM OF RC STRATEGIES involved during adoption of national policies for ac- issue. By the end of 2008, none of the malaria- cess to malaria prevention and treatment services. endemic countries had fulfi lled the Abuja commit- The long wait between policy adoption and implement to allocate 15% of government expenditure to mentation has delayed efforts to control the disease the health sector. Resources from African govern- in many countries, as shown, for example, by the ments represent only 18% of the US$ 622 million wide gap between the adoption of artemisinin-based disbursed in 2007.10 Furthermore, many countries combination therapy policy and its actual country- have diffi culties accessing international funds, or wide implementation. managing them appropriately, where they are available. 10. While access to any antimalarial medicine ranges from 10% to 63% for children under fi ve years of 15. The prevailing socioeconomic environment in age with fever, access to ACT for the same group sub-Saharan Africa further compounds the malaria has remained at only 3% in the 13 countries with situation. Poor households in malaria-endemic data for 2006.7 The continued use of artemisinin countries spend signifi cant proportions of their monotherapy, particularly in the private sector, income on malaria treatment, which pushes them remains a major setback, potentially contributing to further into poverty. The ongoing climate change the emergence of resistance and the shortening of related to global warming could further expand ma- the useful therapeutic life of ACT. laria transmission areas and put more people at risk.11 11. Although progress has been made by countries 16. Global and regional political commitment has in scaling up ITNs and IRS, many countries have led to increased interest in malaria elimination in the not yet reached the internationally agreed targets. African Region. Figure 1 shows malaria programme This is due to lack of capacity for large-scale IRS phases and transitions from control to elimination. campaigns. As a result, in 2006, only fi ve African Countries in stable transmission areas should com- countries reported IRS coverage suffi cient to pro- plete the consolidation phase before engaging in tect at least 70% of people at risk of malaria. By the stepwise reorientation of the programme to pre- end of 2007, 34% of households in 18 countries of elimination and then elimination and prevention of the African Region owned at least one ITN. How- reintroduction, as per the milestones shown. ever, there is a gap between ownership and effective 17. All malaria-endemic countries in the African use of ITNs, which needs to be addressed through Region are in the control phase but lack reliable operational research. While uptake of the fi rst dose data to enable them proceed to programme reorien- of intermittent preventive treatment of malaria for tation. Weak health systems in most moderate and pregnant women ranges from 23% to 93%, coverage low transmission settings in the Region need to be for the second dose is still low and ranges from 5% strengthened in order to cope with the demands of to 68%.8 The challenge is to ensure that all pregnant an elimination programme. A major challenge is women take their recommended doses of IPTp and posed by the large asymptomatic reservoir coupled also that all households with ITNs use them. with high vector capacities in many sub-Saharan 12. Malaria treatment is characterized by gross over- countries. Currently, malaria control relies on a diagnosis and over-treatment. Studies have shown limited number of insecticides and medicines for that 32% to 96% of febrile patients receive antima- prevention and treatment.12 Resistance to some larial treatment without parasitological diagnosis. In insecticides and medicines has already occurred. some cases, it has been shown that only 30% of Therefore, global elimination of malaria is likely to febrile patients receiving ACT are proven to have require research and development of new biomedi- malaria.9 Such improper diagnostic practices under- cal tools, operational research, behaviour change mine the correct management of malaria and non- and adjustment of existing interventions to meet malarial fevers. country-specifi c requirements. 13. Although many endemic countries have estab- 18. In many countries there is an increasing number lished national malaria control programmes, there is of partners investing in malaria control; however, inadequate human resource capacity at all levels to coordination is still a major challenge. In many in- ensure effi cient utilization of resources available for stances, fragmented implementation of malaria con- scaling up the various interventions. Weak health trol is a consequence of project-based approaches. information systems also make it diffi cult to report 19. Signifi cant progress has been made thanks to the on programme performance and impact. opportunities offered by high-level political com- 14. Despite the increased infl ow of external resourc- mitment and the increased resources from various es, inadequate funding for malaria control is still an partners such as the Global Fund to Fight AIDS,

222 Annex 1: Malaria

WHO certification SPR <5% in <1 case/1000 0 locally fever cases acquired population at risk/year cases 3 years

Control & Prevention of Pre-elimination Elimination Consolidation reintroduction

1st programme reorientation 2nd programme reorientation

SPR – slide or rapid diagnostic test positivity rate. These milestones are only indicative: in practice, the transition will depend on the malaria burden that the programme can realistically handle, including case notification, case investigation etc.

Figure 1 Malaria programme phases and milestones on the path from control to elimination in a country or area with low to moderate endemicity. Source: adapted from WHO, Malaria elimination: a ﬁ eld manual for low and moderate endemic countries, Geneva, World Health Organization, 2007.

Tuberculosis and Malaria, the World Bank Booster management, planning, partnerships, resource mo- Programme, the US President’s Malaria Initiative, bilization, case management, integrated vector the Affordable Medicines Facility for malaria management, surveillance, monitoring and evalua- (AMFm), and the Bill and Melinda Gates tion, procurement and supply management, and Foundation. However, important issues and chal- community-based interventions are carried out. lenges remain at national and international levels. Countries should decentralize their programmes to Various actions to address these issues and challenges ensure appropriate fl ow of resources and work are needed for countries to accelerate the scaling up towards appropriate integration at the operational of malaria elimination in the African Region. level. 22. Procure and supply quality antimalarial ACTIONS PROPOSED commodities. Countries should ensure uninterrupted availability of quality, affordable malaria 20. Update malaria policies and strategic plans. medicines and commodities, while avoiding stock- Where required, the national health policy should outs by implementing adequate procurement and be updated and correctly implemented. It is impor- supply-chain management systems. This can be tant to undertake comprehensive country pro- done by strengthening quantifi cation, forecasting, gramme reviews in order to identify the gaps acquisition, stock and logistics management, distri- between the targets and the current situation; it bution, quality assurance, appropriate use, informa- is also necessary to assess the interventions and tion system management, and pharmacovigilance, resource gaps in order to minimize the time lag be- involving both the public and private sectors in the tween planning and implementation. Health system context of existing national systems for essential bottlenecks should be identifi ed and addressed in medicines and health technologies procurement and order to accelerate and scale up programme imple- management. mentation. 23. Accelerate the delivery of key interventions 21. Strengthen national malaria control pro- for universal coverage and impact. Countries grammes. The structures of national malaria con- should ensure that a comprehensive package of trol programmes should be based on the national interventions is progressively implemented nation- health strategic plan, human resource strategic plan wide for impact. Interventions for prevention and the local epidemiological setting. It is important include long-lasting insecticide-treated nets (LLINs), to ensure that enough fi nancial resources are pro- indoor residual spraying (IRS), using an inte- vided so that key functions related to programme grated vector management approach and

223 COMPENDIUM OF RC STRATEGIES

intermittent preventive treatment of malaria in country, regional and global levels to avoid duplica- pregnancy (IPTp). Interventions for case manage- tion of efforts and to improve effi ciency. Strong ment are parasitological diagnosis and effective advocacy for increased and sustained funding as well treatment. Quality control and assurance systems for as effective and effi cient use of existing resources to microscopy and rapid diagnostic tests (RDTs) must fi ll existing gaps needs to be maintained at all levels also be ensured. The interventions should be deliv- for sustainable impact on malaria. To maximize ered free-of-charge or at an affordable cost through resources and to address the socioeconomic deter- health facilities and community structures and inte- minants of health, the fi ght against malaria should be grated with other programmes. Community in- linked to poverty alleviation programmes. volvement is critical for accelerating implementation 28. Strengthen malaria research. For countries in of proven interventions. Where effectively imple- the control phase, operational research, including mented, community-based interventions, including behavioural aspects should focus on the best ap- appropriate use of case management guidelines and proaches and tools to quickly deliver and sustain the algorithms, contribute signifi cantly to the scaling up main interventions at community and health facility of interventions. level. For countries which have achieved sustained 24. Consolidate malaria control achievements impact, operational research should focus on the in high endemic countries. Areas which were technical and fi nancial feasibility of moving to pre- formerly of high stable transmission and which elimination and elimination. Countries and partners achieve a marked reduction in the burden of malaria should advocate for operational research to expand should have a consolidation period before embark- the knowledge base as well as research and developing on pre-elimination if their slide positivity rates ment for new tools. are less than 5%. Cross-border collaboration should 29. The Regional Committee examined and en- be promoted and supported by regional economic dorsed the actions proposed in this document and communities and partners to maximize impact. adopted the resolution attached. 25. Move from control to pre-elimination and elimination when appropriate. In some countries, natural conditions or control efforts have re- Resolution AFR/RC59/R3 duced the risk of malaria transmission to low levels Accelerated malaria control: towards and have localized unstable transmission in well- elimination in the African Region defi ned areas. Such countries should conduct comprehensive malaria programme reviews followed The Regional Committee, by programme reorientation to pre-elimination. In Having examined the document entitled “Accel- the pre- elimination phase, the surveillance system eration of malaria control: towards elimination in should be adapted to detect and respond to all the African Region’’; malaria outbreaks by active case detection, parasitological diagnosis, effective treatment and focal vector Recalling Regional Committee Resolution control. AFR/RC50/R6 on Roll Back Malaria in the Afri- can Region: a framework for implementation; the 26. Strengthen surveillance, monitoring and 2000 and 2006 Abuja OAU and AU Summits’ com- evaluation. There is need to strengthen malaria mitments on HIV and AIDS, tuberculosis and surveillance in the routine work of health informa- malaria; Resolution AFR/RC53/R6 on scaling up tion systems and integrated disease surveillance and interventions against HIV/AIDS, tuberculosis and response, including reporting confi rmed malaria malaria; Resolutions WHA58.2 and WHA60.18 on cases. The surveillance, monitoring and evaluation malaria control and establishment of Malaria Day systems should use the health information system as and the UN Secretary-General’s 2008 Malaria Ini- the main source of data, complemented by surveys. tiative, which called for universal access to essential Drug effi cacy and insecticide susceptibility tests malaria prevention and control interventions; should be performed annually to enable timely identifi cation of resistance as well as the necessary actions Aware of the persisting heavy burden of malaria and policy decisions. in the African Region and its devastating consequences on health and socioeconomic development; 27. Scale up partnership coordination and alignment as well as resource mobilization. Recognizing that lack of evidence-based policies, Partner coordination and alignment, using the comprehensive strategies, delays in implementation, established mechanisms, should be strengthened at weak health systems and inadequate human resource

224 Annex 1: Malaria capacity negatively infl uence programme perform- (d) to strengthen the institutional capacity of ance; national malaria programmes at central and decentralized levels for better coordination of Mindful of the fact that coordination and harmo- all stakeholders and partners in order to ensure nization of partner activity for resource mobilization programme performance, transparency and and effi cient utilization are critical for national and accountability in accordance with the ‘Three regional performance in malaria control; Ones’ principles; Aware that scaling up cost-effective interventions (e) to lead joint programme reviews, develop [Long Lasting Insecticidal Nets (LLINs), Indoor comprehensive need-based and fully-budgeted Residual Spraying (IRS), Intermittent Preventive strategic and operational plans with strong Treatment of malaria in pregnancy (IPTp), Artem- surveillance, monitoring and evaluation compo- isinin-based combination therapies (ACTs)] for uni- nents; versal coverage results in a critical reduction of the (f) to strengthen health information systems, inte- malaria burden and that malaria control currently grated disease surveillance and response and un- relies on a limited number of tools; dertake appropriate surveys in order to generate reliable evidence, facilitate translation of knowl- Confi rming the usefulness and effectiveness of edge into successful implementation and inform IRS, using DDT as a major intervention for malaria programmatic transitions; control within the provisions of the Stockholm (g) to invest in health promotion, community edu- Convention; cation and participation, sanitation, and increase Acknowledging the invaluable support received human resource capacity with emphasis on from multilateral and bilateral cooperation partners, mid-level and community health workers for foundations, malaria advocates and community- universal coverage of essential interventions based organizations; using integrated approaches; (h) to ensure rigorous quantifi cation, forecasting, Analysing the new opportunities provided at the procurement, supply and rational use of afford- international level to control and eliminate malaria able, safe, quality-assured medicines and com- [the UN, AU, World Economic Forum, GFATM, modities for timely and reliable malaria diagnosis Affordable Medicines Facility for malaria (AMFm), and treatment at health facility and community the World Bank Booster Programme, the US Presi- levels; dent’s Malaria Initiative (US/PMI), the Bill and (i) to develop cross-border malaria control acceler- Melinda Gates Foundation]; ation initiatives based on proven cost-effective 1. ENDORSES the document entitled ‘Acceler- interventions and taking into account existing ated malaria control: towards elimination in the subregional mechanisms; African Region’; 3. REQUESTS partners involved in supporting 2. URGES Member States: malaria control efforts in the Region to increase (a) to integrate malaria control in all poverty reduc- funding for malaria control in order to reach the tion strategies and national health and develop- UN targets of universal coverage, reduce malaria ment plans in line with the commitments of deaths to minimal levels, and achieve health-related UN, AU and regional economic communities Millennium Development Goals to which malaria and mobilize local resources for sustainable control contributes; implementation and assessment of the impact of 4. REQUESTS the Regional Director: accelerated malaria control; (b) to support health systems strengthening, includ- (a) to facilitate high-level advocacy, coordination of ing building of human resource capacity through partner action in collaboration with the UN, pre- and in-service training for scaling up essen- RBM, other partner institutions, the AU and tial malaria prevention and control interven- regional economic communities for adequate tions; resource mobilization and effi cient technical (c) to support ongoing research and development cooperation; initiatives for new medicines, insecticides, diag- (b) to support the development of new tools, medi- nostic tools and other technologies for malaria cines, applied technologies and commodities control and elimination and invest in operation- and help revitalize drug and insecticide effi cacy al research for informed policy and decision- monitoring networks; making in order to scale up and improve (c) to report to the sixty-fi rst session of the Region- programme effi ciency for impact; al Committee, and thereafter every other year,

225 COMPENDIUM OF RC STRATEGIES

on the progress made in the implementation 5. WHO, The work of WHO in the African Region of accelerated malaria control in the African 2006–2007, Brazzaville, World Health Organization, Region. Regional Offi ce for Africa, 2008. 6. WHO, World malaria report 2008, Geneva, World Ninth meeting, 2 September 2009 Health Organization, 2008. 7. WHO, World malaria report 2008, Geneva, World REFERENCES Health Organization, 2008. 8. WHO, Roll Back Malaria–Global malaria action plan, 1. WHO, World malaria report 2008, Geneva, World Geneva, World Health Organization, 2008. Health Organization, 2008; WHO, Africa malaria 9. Hamer DH et al. Improved diagnostic testing and report 2006, Brazzaville, World Health Organization, malaria treatment practices in Zambia, Journal of the Regional Offi ce for Africa, 2006; RBM/WHO/ American Medical Association 297: 2227–2231, 2007; UNICEF, World malaria report 2005, Geneva, World Amexo M et al. Malaria misdiagnosis: effects on the Health Organization 2005; WHO, World health statis- poor and vulnerable, Lancet 364: 1896–1898, 2004; tics, Geneva, World Health Organization,2008. Reyburn H et al. Overdiagnosis of malaria in patients 2. Gallup JL, Sachs J, The economic burden of malaria, with severe febrile illness in Tanzania, British Medical American Journal of Tropical Medicine and Hygiene 64- Journal 329: 1212, 2004; Zurovac D et al. Microscopy (1–2 Suppl): 85–96, 2001. and outpatient case management among older chil- 3. WHO, Resolution AFR/RC50/R6, Roll Back dren and adults in Kenya, Tropical Medicine & Inter- Malaria in the African Region: a framework for im- national Health 11: 1185–1194, 2006; WHO, World plementation. In: Fiftieth session of the WHO Regional malaria report 2008, Geneva, World Health Organiza- Committee for Africa, Ouagadougou, Burkina Faso, 28 tion 2008. August–2 September 2000, Final report. Brazzaville, 10. WHO, World malaria report 2008, Geneva, World World Health Organization, Regional Offi ce for Health Organization, 2008. Africa, 2000, (AFR/RC50/17), 19–22; WHO, Res- 11. Thomson MC et al. Malaria early warnings based on olution AFR/RC53/R6, Scaling up interventions seasonal climate forecasts from multi-model ensem- against HIV/AIDS, tuberculosis and malaria in the bles, Nature 439: 576–579, 2006; Teklehaimanot HD African Region, In: Fifty-third session of the WHO et al. Weather-based prediction of Plasmodium falci- Regional Committee for Africa, Johannesburg, South Africa, parum malaria in malaria epidemic prone regions of 1–5 September 2003, Final report. Brazzaville, World Ethiopia, I. Patterns of lagged weather effects refl ect Health Organization, Regional Offi ce for Africa, biological mechanism, Malaria Journal 3: 41, 2004. 2003 (AFR/RC53/18), 20–22; Resolution 12. WHO, Global malaria control and elimination: report of a WHA58.2, Malaria control, Geneva, World Health technical review, Geneva, World Health Organization, Organization, 2003 (WHA58/2005). 2008. 4. WHO, Malaria elimination: a fi eld manual for low and moderate endemic countries, Geneva, World Health Organization, 2007.

226 2. HIV/AIDS 2.1 Scaling up interventions against HIV/AIDS, tuberculosis and malaria in the WHO African Region (AFR/RC53/13rev.1)

EXECUTIVE SUMMARY 1. HIV/AIDS, tuberculosis and malaria contribute to high morbidity and mortality in the WHO African Region, accounting for more than 90% of the global cases and deaths associated with these diseases. They exert an enormous economic burden on governments, communities and families, trapping millions in a vicious cycle of poverty and ill-health. 2. A number of innovative and cost-effective interventions have been developed over the years to reduce the burden of the three diseases. The Region has adopted strategies, frameworks and resolutions, and countries have developed and are implementing plans of action in line with these decisions. 3. The following achievements have so far been made: increased political commitment, development of national strategic plans and partnership building for accelerating implementation of interventions; ongoing capacity building for the prevention and control of the three diseases; increased knowledge about HIV/AIDS and safe blood for transfusion; increased tuberculosis (TB) case detection rates and implementation of the DOTS strategy; and more capacity to plan, implement, monitor and evaluate malaria prevention and control programmes in almost all countries. 4. Despite these achievements, coverage and access to interventions remain low. Only 6% of the adult population has access to voluntary counselling and testing, 40% of countries have nationwide use of directly-observed treatment short-course services and coverage of insecticide-treated nets is 5%. Trends in these diseases are not declining. This has largely been due to limited human and ﬁ nancial resources, unaffordable drugs for prevention and treatment, and poor infrastructure. These constraints are compounded by inadequate approaches to the implementation of existing strategies for the programmes. 5. Implementation of the approaches outlined in this document will signiﬁ cantly contribute to scaling up interventions for the three diseases. The Global Fund to Fight AIDS, TB and Malaria, the Global Drug Facility and the Roll Back Malaria initiative offer enormous opportunities to scale up implementation of activities. The Regional Committee is therefore requested to consider and adopt this framework.

227 COMPENDIUM OF RC STRATEGIES

INTRODUCTION million children under 15 years are living with HIV/ AIDS. Despite reports of observed reductions in 1. AIDS, tuberculosis and malaria are the most new infections in a few countries, the incidence has important communicable diseases in the African continued to increase in most countries. Region. During the past decade, the Region has experienced a resurgence of tuberculosis as a direct 6. Several countries in the Region have experi- result of the HIV/AIDS epidemic. In 2000, the enced huge increases in the number of notifi ed TB Region harboured 24% of the global TB cases and cases. Between 1995 and 2000, the Region experi- 21% of new smear positive cases. Effective malaria enced a 95.1% increase in total reported cases and a case management is being threatened by rapidly 131.7% increase in reported new smear positive cas- increasing levels of Plasmodium falciparum resistance es. Some countries of the Region have some of the to commonly used antimalarial drugs, and 13 coun- highest TB prevalence rates in the world, ranging tries have changed their antimalarial drug policy in from 100 to over 700 per 100,000 in the general the last decade. The three diseases exert an enor- population.4 mous economic burden on governments, commu- 7. Malaria currently causes more than 270 million nities and families, trapping millions in a cycle of acute episodes and over 900,000 deaths per year in poverty and ill-health. Africa.5 It accounts for about 30% to 50% of all out- 2. In response, the Regional Committee has passed patient clinic visits and hospital admissions. The a number of resolutions1 on the prevention and problem has further been compounded by the evo- control of the three diseases in order to stimulate lution of parasites that are resistant to the commonly country action. Countries have developed and are used antimalarial drugs, particularly chloroquine. implementing plans in line with these resolutions. Economic loss due to malaria in the Region is estimated at US$ 12 billion annually.6 3. Despite these efforts, coverage and access to interventions against these diseases remain low and Achievements their impact limited. This has been due to limited human and fi nancial resources, unaffordable drugs 8. A number of innovative and cost-effective inter- for prevention and treatment, and poor infrastruc- ventions exist for the prevention and care of the ture. These constraints are compounded by inade- three diseases. Most prevention activities rely on quate approaches to the implementation of existing health promotion; information, education and com- programmes and strategies. munication (IEC); voluntary counselling and testing (VCT); early diagnosis and treatment as well as 4. There is an urgent need to scale up the available preparedness. cost-effective interventions for the prevention and control of these diseases in order to reduce the as- 9. Countries in the Region have made several sociated morbidity and mortality. Recent initiatives2 achievements. HIV prevalence has declined in a few such as the Global Fund to Fight AIDS, Tuberculo- countries; 94% of blood for transfusion is screened sis and Malaria (GFATM), the United Nations for HIV, and over 70% of countries have established General Assembly Special Session on HIV/AIDS surveillance systems to monitor trends in HIV prev- (UNGASS), the World Bank Multisectoral AIDS alence.3 For TB, 85% of the countries are imple- Programme (MAP), the Global TB Drug Facility menting the DOTS strategy for TB control, 40% of (GDF), the Roll Back Malaria (RBM) initiative and these attained 100% population coverage by 2000, the Abuja Declarations provide opportunities for in- and case detection rates increased from 35% to 41% creasing coverage and access to the interventions for between 1995 and 2000.1 The capacity to plan, these diseases. This document provides a framework implement, monitor and evaluate malaria preven- for scaling up these interventions. tion and control interventions and monitoring of antimalarial drug effi cacy has been strengthened or developed in over 80% of countries. Initiativesto SITUATION ANALYSIS provide ITNs to target groups is ongoing in 43 Magnitude of the problem countries.8

5. The WHO African Region accounts for about Constraints 29.4 million people living with HIV/AIDS. Ap- proximately 3.5 million new infections occurred in 10. Despite these achievements, coverage and access the Region in 2002, while the epidemic claimed the to interventions remain low and disease trends are lives of an estimated 2.4 million people;3 ten million not declining. Various constraints have been identi- young people aged 15–24 years and almost three ﬁ ed.

228 Annex 2: HIV/AIDS

11. Confusion about multisectoral action: The applica- access to funding which would enable them to take tion of multisectoral action has posed numerous their own initiatives, create demands and force challenges but often slowed down activities in HIV/ health systems to respond. AIDS; at the same time, it has not been adequately 16. Weak partnerships with the private sector (both for- exploited for TB and malaria. In many countries, profi t and not-for-profi t): Workplaces provide ample the lack of a clear defi nition and separation of the opportunities for service delivery, but they are insuf- respective roles of national AIDS councils and min- fi ciently exploited. The regulatory role of govern- istries of health have led to confusion and confl ict, ments in ensuring compliance of private health care thus slowing down implementation of programmes. providers with national standards and guidelines for 12. Inadequate linkage between health systems develop- case management of HIV/AIDS, TB and malaria is ment and interventions: Many countries are engaged in often weak. Some of the technical capacities available health sector reforms with a view to enhancing the in countries outside ministries of health are often responsiveness and effectiveness of health systems. insuffi ciently utilized. However, there are often weak linkages between 17. Increasing poverty, civil unrest and confl ict: Worsen- these reforms and key interventions for these dis- ing poverty has limited the ability of countries to eases. The essential packages of care, which have allocate appropriate resources to health systems in been developed as part of mainstream health reform, general and HIV/AIDS, TB and malaria pro- often fail to adequately refl ect the needs of programmes in particular. Access to essential health grammes to address the three diseases. The three services is compromised, as households are less able programmes have established vertical planning, to pay out of pocket or through health insurance. resource mobilization, logistics and management This is aggravated by the prolonged and increased systems. The roles of other departments and units of situations of civil unrest and confl ict in the Region, health ministries such as clinical services, essential which result in population displacement and drugs, laboratory services and training are not clear- facilitates transmission of the three diseases. ly defi ned. These often have little access to the resources available to the three programmes and, Challenges and opportunities thereby, are unable to contribute adequately to implementation of activities. 18. Key challenges include ensuring effective decentralization of services, strengthening human 13. Centralization of programme planning and manage- capacity (in both numbers and skills), increasing ment: The strategies for HIV/AIDS, TB and malaria fi nancial resources, improving the infrastructure, are well-defi ned. However, dominant centralized ensuring uninterrupted provision of affordable drugs planning and management, and inappropriate com- and supplies, and increasing the involvement of position of coordinating bodies often hamper their communities, NGOs, CBOs and the private sector. operationalization. In many cases, national strategic plans are developed at the central level, with little 19. There are now enormous opportunities to scale participation from district and sub-district levels. up implementation of activities in countries. Politi- This leads to insuffi cient action plans and inter- cal commitment at both national and international ventions for benefi ciary groups. levels has increased during the past few years. The Abuja declarations2 of 2000 and 2001 clearly set out 14. Failure of fi nancial resources to reach operational levels: the aspirations of African Heads of State for the Implementation of district plans is often hampered actions to be taken in intensifying the response to by failure of disbursement of allocated and approved malaria, HIV/AIDS, tuberculosis and other related budgets. In many countries, district health plans do infectious diseases. The 2001 United Nations not adequately refl ect the strategies that are included General Assembly Special Session on HIV/AIDS in the strategic plans at central level. Declaration, the World Bank Multisectoral AIDS 15. Weak interaction between health services and commu- Programme, Roll Back Malaria, Global TB Drug nities: Community participation often forms part of Facility, Global Fund to Fight AIDS, TB and Ma- most health development policies and strategies. laria, the New Partnership for Africa’s Development However, implementation is often weakened by and other initiatives for poverty reduction further lack of orientation and skills for health workers to re-affi rm the global commitment and provide addi- effectively facilitate the interface with communities. tional resources for accelerating actions against these Community-based organizations usually have no diseases.

229 COMPENDIUM OF RC STRATEGIES

OBJECTIVES 24. Advocacy: There is need to advocate for a health sector that is responsive to the needs of peo- 20. The general objective is to contribute to the ple and that focuses on increasing coverage, equity, acceleration of the reduction of morbidity and mor- quality and effi ciency in the provision of services at tality associated with HIV/AIDS, TB and malaria. all levels. Appropriate policies and legislation should 21. The specifi c objectives, in accordance with the be put in place to create a supportive environment. Abuja and UNGASS declarations, are to: Partnerships should be established with the media, both public and private, including local and rural (a) increase the coverage of HIV/AIDS, TB and radio stations for regular information and education malaria prevention and treatment interventions; activities to create demand for services and for be- (b) increase access to effective medicines and sup- haviour change. Interpersonal communication plies for treatment and prevention of HIV/ should also be used. AIDS, TB and malaria; (c) ensure availability of the human and fi nancial 25. Enhancing multisectoral action: The poten- resources required to reach the targets. tial benefi ts of the multisectoral approach must be exploited fully and at all levels of service delivery. Roles and responsibilities must be defi ned clearly GUIDING PRINCIPLES and agreed upon for each of the sectors involved. 22. In scaling up implementation of control activi- Ministries of health must play a leadership role in the ties against the three diseases, the following guiding health sector response and a catalytic role in enhanc- principles need to be considered: ing responses from other sectors according to their comparative advantages. (a) Country ownership: The scaling up process should be country-driven to ensure that 26. Harnessing capacity for service delivery at interventions are planned and implemented country level: There is a need to increase the according to country priorities and community quantity and quality of staff involved in the delivery needs. of services. These requirements must be estimated at (b) Equity: Access to services, particularly for the the planning stage. Countries must exploit the op- poor and the diffi cult-to-reach, should be taken portunities that exist within and outside ministries of into consideration during the planning and im- health, and at all levels, in order to harness the un- plementation of interventions in countries. derutilized human capacity for the delivery of the (c) Sustainability: In order to ensure sustainability intervention packages. The following approaches and participation of the community in the may be used: implementation of activities, strategies should (a) identifying and engaging new partners such as take into account cultural acceptability and academic institutions, NGOs and CBOs, using human resource capacity, especially at district innovative methods such as contracting for hu- and peripheral levels. man resources development; (d) Partnerships: Strong and effective partnerships (b) providing orientation to private health care pro- should be developed at the global, regional, viders, the corporate sector, NGOs, CBOs and national, district and community levels in order professional associations on the interventions for to enhance coordination of programme activi- the three diseases to enable them to participate ties, avoid duplication of efforts and maximize in service delivery; the use of resources. (c) intensifying training for all three diseases through in-service short courses, simplifi ed modules for IMPLEMENTATION APPROACHES lower cadres and pre-service training; (d) expanding service delivery efforts to workplaces 23. The scaling up of interventions against HIV/ in collaboration with the private sector. AIDS, TB and malaria requires increased geographical and programmatic coverage in a way that will 27. Strengthening programme management make them available, accessible and affordable to the and resource allocation: The increased commit- majority of the people in need. Hence, various ap- ment expressed nationally, regionally and globally to proaches are proposed to reinforce effective imple- control the three diseases has brought about the es- mentation of already existing strategies for the three tablishment of Country Coordination Mechanisms diseases. Particular attention and local adaptation (CCMs) made up of core partners, public, private need to be ensured in countries affected by emer- and civil society in many countries in the Region. gencies. These committees have been central to the

230 Annex 2: HIV/AIDS

development of proposals for the Global Fund to ment and management of interventions and services fi ght AIDS, Tuberculosis and Malaria. They should at local level. Health workers should be provided be appropriately constituted and strengthened to with adequate orientation and skills through the use facilitate partnership and joint planning processes at of participatory approaches in situation analysis and country level, with emphasis on micro-planning needs assessment as well as planning, monitoring and involving all partners at district level and ensuring evaluation to enable them to effectively facilitate the clearly defi ned roles for the implementing partners. interface with communities. Efforts should be made to build on community-based initiatives such as the 28. To effi ciently deliver services at district and Bamako Initiative in order to enhance better service community levels, decentralization of services is im- delivery for HIV/AIDS, TB and malaria. Partner- portant and this will include: ship with the traditional health sector should be (a) delegating and supporting planning, implemen- expanded, including more focus on research into tation, monitoring and evaluation to local and traditional medicines for the prevention and treat- district levels, based on national strategic frame- ment of the 3 diseases. works; 32. Ensuring availability of drugs and com- (b) building district and local level capacity for man- modities at all levels: Drug supplies, diagnostic agement and service delivery through partner- facilities and other related commodities are crucial ship with locally-based NGOs; for effective implementation of the intervention (c) developing mechanisms for resource allocation packages for the three diseases. Innovative ways to and disbursement, management and monitoring make these accessible and affordable to the of resources, especially at district and local levels; benefi ciary groups must be vigorously pursued. For (d) ensuring that district activities are captured in example, drugs, diagnostic equipment and other instruments for resource mobilization such as commodities that are locally manufactured could be Poverty Reduction Strategy Papers and High- procured and distributed in pre-packed form to lyIndebted Poor Countries initiatives; operational levels through partnership with local (e) including packages of intervention for the three manufacturing companies. For imported drugs, bulk diseases in the essential health package for dis- purchasing mechanisms could be established for trict level; groups of countries in order to lower costs. Mecha- (f) strengthening referral systems between appro- nisms should be put in place to prevent leakages of priate levels and ensuring effective monitoring drugs purchased at reduced prices to developed and supportive supervision at all levels. country markets. 29. Enhancing integrated service delivery at 33. Promoting operational research for im- district level: It is essential that key interventions proved management and service delivery: are integrated at the point of service delivery. All More attention should be paid to operational service providers (including community develop- research, particularly at the implementation level. ment offi cers and community resource persons) and Operational research should be incorporated and service delivery points (mother and child health funded as part of district health plans. This would clinics, Expanded Programme on Immunization ensure that solutions to implementation constraints service delivery points, pharmacies) should be given and the most effective approaches to scaling up pro- orientation to provide services for the three diseases grammes are identifi ed. New cost-effective inter- to the communities and mobilize them for behav- ventions to address the three diseases should iour change. continue to be explored. 30. Integrating a service into another that is al- 34. Ensuring fi nancial resource mobilization ready being offered: Large-scale integration can and disbursement at operational level: Even at be used as a means to hasten scaling up. For exam- the current low levels of coverage, considerable ple, voluntary counselling and testing services can be amounts of resources are being spent on the re- integrated into outpatient services for sexually trans- sponse to HIV/AIDS, TB and malaria. Resource mitted infections and tuberculosis. Where feasible, mobilization from national and external sources for TB clinic staff could be trained and equipped to do the three diseases should be integrated into the HIV counselling and testing among TB patients. national development planning process; programme 31. Strengthening partnerships with commu- needs should be considered in the plans and budgets nities for service delivery: Communities should of government ministries. Governments must estab- be consulted and involved in the planning, develop- lish effi cient and accountable mechanisms to ensure

231 COMPENDIUM OF RC STRATEGIES that funds allocated to districts are disbursed for im- Other partners plementation. Innovative methods for mobilizing 39. Other partners will participate at all levels in the resources from the private sector and communities development of national strategic frameworks and should be pursued. In addition, ministries of health implementation plans, monitoring and evaluation as should ensure that the needs of the three diseases are well as provide ﬁ nancial and technical inputs at all incorporated into Poverty Reduction Strategy levels, based on their comparative advantages. In Papers. Special funds such as the GFATM and GDF addition, they will support national capacity build- should be accessed and national resources reallocated ing relevant to implementation of interventions at to meet the increasing needs for prevention and all levels. care.

MONITORING AND EVALUATION CONCLUSION 40. Despite the achievements made in the response 35. Monitoring and evaluation of interventions and to HIV/AIDS, TB and malaria, coverage and access activities at country level are important to ensure to these interventions still remain low, and trends in that programme targets are being reached and should these diseases are not declining. Inadequate health be used to accelerate implementation. The OAU services, insuffi cient human and fi nancial resources, summit targets for malaria, HIV/AIDS, TB and unaffordable drugs and supplies for prevention and other related infectious diseases provide frameworks treatment, and limited involvement of communities, for monitoring and evaluation. In addition, existing NGOs and private sector are the major challenges. indicators, tools and guidelines for monitoring and The adoption and implementation of the approach- evaluating implementation of the regional strategies es outlined above will enable countries to scale up should be used. HIV/AIDS, TB and malaria prevention and control 36. The Regional Offi ce will monitor progress in activities. scaling up the implementation of interventions 41. There are now enormous opportunities to scale against the three diseases through periodic reviews up implementation of interventions against HIV/ and reports to the Regional Committee. Core indi- AIDS, TB and malaria. The Regional Committee cators for assessing progress in implementation will considered and adopted this framework. be developed based on the Abuja and UNGASS declarations as well as Millennium Development REFERENCES Goals. 1. HIV/AIDS Strategy in the African Region AFR/ RC46/R2 (1996); HIV/AIDS Strategy in the African ROLES AND RESPONSIBILITIES Region: A Framework for Implementation AFR/ Countries RC50/R5 (2000); Roll Back Malaria in the African Region: A Framework for Implementation AFR/ 37. Ministries of health have a key leadership role in RC50/12 (2000); Review of Tuberculosis Pro- developing plans and mobilizing both internal and gramme AFR/RC40/R7 (1990); Regional Pro- external resources for scaling up implementation of gramme for Tuberculosis AFR/RC44/R6 (1994). activities. In addition, it is the responsibility of 2. African Summit on Roll Back Malaria (2000); African countries to implement planned activities, monitor Summit on HIV/AIDS, Tuberculosis and other Related Infectious Diseases (2001). and evaluate programmes, and ensure coordination 3. UNAIDS/WHO, AIDS Epidemic Update, Dec of partners. 2002. 4. WHO, Global TB report, WHO, Geneva, 2002; WHO WHO, TB surveillance report, Harare, 2001. 5. WHO, Biennial report of the Regional Director, the 38. WHO will provide technical support for the work of WHO in the African Region 2000–2001, development of strategic plans and plans of action AFR/RC52/2, 2002. for scaling up interventions as well as support for 6. Gallup JL and Sachs JD. The economic burden of programme implementation, monitoring and evalu- malaria, American Journal of Tropical Medicine and ation. WHO will also advocate for more resources Hygiene 64 (1, 2) S:85–96, 2001. 7. WHO, Tuberculosis surveillance report in the African internationally and assist countries in coordinating Region, 2001. partner support for scaling up interventions at 8. WHO Malaria Unit, Semi-annual monitoring and national level. mid-term review report, 2002.

232 2.2 Acceleration of HIV prevention in the WHO African Region: Progress report (AFR/RC59/INF.DOC/1)

BACKGROUND 5. In 2007, 40 countries reported that 100% of the blood used for transfusion was screened for HIV; 1. In 2005, ministers of health adopted resolution this compared to 98% in 2004.4 Eleven countries5 AFR/RC55/R6 on acceleration of HIV prevention are implementing specifi c programmes6 to strength- in the African Region, calling upon Member States en infection prevention and control; however, to accelerate HIV prevention and declaring 2006 the reports indicate that 50% of medical injections ad- Year of Acceleration of HIV Prevention in the ministered in developing countries were given with African Region. The resolution also requested the re-used, non-sterilized equipment.7 Regional Director to develop a strategy for acceleration of HIV prevention, provide the necessary tech- 6. Uptake of PMTCT increased from 10% in 2005 nical support to countries, help mobilize additional to 34% in 2007, ranging from 11% in western and resources and monitor implementation. central Africa to 43% in eastern and southern Afri- ca.8 Botswana has reached the 80% target and fi ve 2. The strategy document, “HIV prevention in the other countries9 are moving towards the target. In African Region: strategy for acceleration and re- addition, available data from 19 countries10 in the newal,” was developed and subsequently adopted at Region indicate that by mid-2008, 13 174 antenatal the fi fty-sixth session of the Regional Committee. 1 care facilities were providing PMTCT, as compared The strategy includes targets to be met by 2010, to 10 600 in 2007. This represents an increase from particularly in areas of HIV testing and counselling 31% to 40% in only six months. (HTC); blood safety; prevention of mother-to-child transmission (PMTCT) of HIV; prevention and 7. STIs remain a burden in the Region, and Herpes control of sexually transmitted infections (STIs); simplex virus type-2 has become the leading cause of condom use; and access to comprehensive preven- genital ulcer disease. Updates of treatment protocols tion, treatment and care. were reported from 31 countries,11 and integration of comprehensive STI case management into train- 3. This report complements the previous one sub- ing and reproductive health programmes is under mitted at the fi fty-eighth session of the Regional way. Committee. It provides updated information on key health sector HIV prevention indicators defi ned in 8. By June 2008, over 2.6 million patients were on the strategy, and it highlights issues that should be antiretroviral therapy, representing a 24% increase in taken into consideration for moving the HIV pre- just six months. Approximately 22% of tuberculosis vention agenda forward in the health sector. patients were screened for HIV and 89% of tuberculosis patients with HIV were on cotrimoxazole preventive therapy, while 37% of them were on PROGRESS MADE antiretroviral therapy.12 4. Between 2007 and mid-2008, all districts re- 9. Demographic and Health Surveys carried out ported at least one HTC facility, and the proportion between 2005 and 2008 indicate that condom use of health facilities providing HTC services increased for last high-risk sexual encounter among people from 17% to 22%.2 Innovative approaches to scale aged 15–49 years ranged from 26% to 71% for males up HTC include mobile and home-based HTC and and 14% to 47% for females, with a median of 45% HIV testing weeks. However, in sub-Saharan Afri- for males and 26% for females. Condom use among ca, on average, only 16.5% of people living with 15–24-year-olds engaging in high-risk sex increased HIV are aware of their HIV status.3 in 10 out of 14 countries with trend data.13

233 COMPENDIUM OF RC STRATEGIES

10. Other notable developments include initiatives 80% of people living with HIV/AIDS will have access to scale up male circumcision for HIV prevention in to comprehensive prevention, treatment and care 12 countries,14 analysis of modes of epidemic trans- services; condom use will reach at least 60% in high- missions and responses for strengthening HIV pre- risk sexual encounters. vention in 14 countries,15 and implementation of 2. WHO, World Health Organization, Regional Offi ce for Africa database, 2008. school-based HIV prevention through training of 3. WHO, Towards universal access: scaling up priority HIV/ 16 teachers in 25 countries. AIDS interventions in the health sector. Progress report 11. HIV prevention is fi rmly on the agenda of 2008, Geneva, World Health Organization, 2008. Member States and development partners. Despite 4. Tapko JB, Sam O, Diarra-Nama AJ. Status of blood safety in the WHO African Region: report of the 2004 progress made, prevention programmes have not yet survey, Brazzaville, World Health Organization, Re- adequately reached the most-at-risk populations, gional Offi ce for Africa, 2008. including young females, sex workers, injecting 5. Botswana, Côte d’Ivoire, Ethiopia, Kenya, Mozam- drug users, prisoners and men who have sex with bique, Nigeria, Rwanda, South Africa, Tanzania, men. Challenges include weak health systems to Uganda and Zambia. support scaling up of effective HIV prevention 6. PEPFAR projects being implemented in countries interventions, addressing multiple and concurrent with support from John Snow Incorporated in close sexual partnerships, translating research fi ndings on collaboration with the WHO Regional Offi ce for Af- male circumcision into programme implementation, rica. and limited use of available data. 7. WHO, Injection Safety Programme, www.who.int/in- jection_safety/en/, accessed 29 September, 2008. 8. WHO, Towards universal access: scaling up priority HIV/ NEXT STEPS AIDS interventions in the health sector. Progress report 2008, Geneva, World Health Organization, 2008. 12. Scaling up of HIV testing and counselling should 9. Kenya, Namibia, Rwanda, South Africa and Swazi- be accelerated, using all possible entry points, and land. coverage of antenatal care should be increased for 10. Benin, Botswana, Burkina Faso, Cameroon, Central greater PMTCT uptake. Effective scaling up of HIV African Republic, Democratic Republic of Congo, prevention interventions also requires strengthened Ethiopia, Gambia, Guinea-Bissau, Liberia, Malawi, health systems, effective community participation Mali, Namibia, Rwanda, Sierra Leone, Tanzania, and strategic partnerships. Togo, Uganda and Zimbabwe. 11. Algeria, Botswana, Burkina Faso, Cameroon, Cape 13. Multisectoral collaboration is needed to address Verde, Central African Republic, Côte d’Ivoire, sexual transmission of HIV. Greater attention should Democratic Republic of Congo, Equatorial Guinea, be given to targeting those who are most-at-risk, Eritrea, Ethiopia, Ghana, Guinea, Guinea-Bissau, Le- controlling STIs, strengthening the control of HIV- sotho, Liberia, Madagascar, Malawi, Mali, Mozam- TB dual infection, and intensifying prevention pro- bique, Namibia, Nigeria, Rwanda, Senegal, Sierra Leone, South Africa, Swaziland, Tanzania, Togo, grammes that target people living with HIV/AIDS. Zambia and Zimbabwe. 17 Recent evidence calls for addressing multiple con- 12. WHO, Status report on tuberculosis in Africa, Brazzaville current sexual partnerships and scaling up male cir- World Health Organization, Regional Offi ce for Af- cumcision services, particularly in high prevalence rica, 2008; WHO, Global tuberculosis control: surveil- countries. lance, planning, fi nancing, Geneva, World Health Organization, 2008. 14. There is need to strengthen strategic informa- 13. Benin, Burkina Faso, Cameroon, Ethiopia, Guinea, tion to better assess the driving factors of the epi- Kenya, Malawi, Mali, Tanzania and Zambia. demics and the impact of interventions, ensure 14. Botswana, Kenya, Ghana, Lesotho, Mozambique, effective monitoring and better understand the Namibia, Nigeria, Rwanda, Swaziland, Tanzania, impeding factors. Uganda and Zimbabwe. 15. Benin, Burkina Faso, Ghana, Guinea, Kenya, Lesot- ho, Liberia, Mali, Mozambique, Niger, Nigeria, Sen- REFERENCES egal, Togo and Uganda. 1. HTC: All districts to provide HIC testing and coun- 16. Benin, Botswana, Burkina Faso, Burundi, Cote selling services; 100% safe blood and blood products d’Ivoire, Ethiopia, Gabon, Ghana, Guinea, Kenya, ensured; at least 80% of pregnant women attending Lesotho, Liberia, Malawi, Mali, Namibia, Niger, antenatal care will access PMTCT services; at least Rwanda, Senegal, Sierra Leone, South Africa, Swazi- 80% of patients with sexually-transmitted infections land, Tanzania, Uganda, Zambia and Zimbabwe. will access comprehensive STI management; at least 17. www.the lancet.com, Volume 372, August 9, 2008.

234 CONCLUSION

It is disheartening that the African Region lost Plan, the Road Map for the Attainment of the almost 10.9 million human lives in 20081 from vari- MDGs Related to Maternal and Newborn Health, ous diseases and health conditions. According to the and regional strategies on adolescent health, wom- WHO Commission on Macroeconomics and en’s health, child survival and measles elimination Health2 most deaths and disability can be prevented could save most of those deaths. because effective health interventions already exist to either prevent or cure the priority diseases. These The HIV/AIDS, malaria and tuberculosis caused interventions do not reach a signifi cant proportion 160, 94 and 30 deaths per 100 000 population in the of those in need. The Commission argues that African Region; which was 24.6-fold, 37.6-fold and scaling up essential interventions and making them 1.9-fold higher than those of the Eastern Mediter- 3 available region-wide would alleviate countless ranean Region. Once again, cost-effective inter- suffering, dramatically reduce illness and deaths, ventions for combatting the three diseases are concretely reduce poverty and ensure economic known, and thus, full implementation of the region- growth and security. al strategies for HIV prevention, and tuberculosis and HIV/AIDS could prevent majority of premature Unfortunately, health care coverage in the African deaths and improve quality of life. region is low due to weak and under-resourced health systems. Some of the weaknesses can be In 2008 cancer, cardiovascular diseases and diabetes, attributed to challenges related to leadership and and chronic respiratory conditions caused 147, 382 governance; health workforce; medicines, vaccines and 92 deaths per 100 000 population aged between and other health technologies; information; fi nanc- 30 and 70 years in the African Region. These deaths ing; and services delivery. Full contextualized imple- rates are higher than those reported in the Eastern mentation of regional strategies for the development Mediterranean Region – 127 per 100 000 popula- of human resources for health; promoting the role of tion from cancer, 344 per 100 000 population from traditional medicine in health systems; blood safety; cardiovascular diseases and diabetes, and 46 per 100 health fi nancing; and knowledge management 000 population from chronic respiratory conditions.3 would enable countries to address some of the above Complete implementation of the regional strategies mentioned challenges. The guidance provided in on non-communicable diseases (NCDs), diabetes, the strategic health research plan is still very perti- cancer, sickle cell diseases, mental health and elimi- nent for strengthening national health research sys- nation of avoidable blindness could avert many tems; which are vital for generating, archiving and deaths and enormous suffering caused by NCDs. disseminating information and evidence need for It is worth mentioning that health sector response decision-making and for policy development and alone will not be enough in preventing and control- planning. ling disease. There is need to address the inequities The African Region infant mortality rate of 75 per in health. As eloquently pointed out by the WHO 1000 live birth, under-fi ve mortality rate of 119 per Commission on Social Determinants of Health, 1000 live births and maternal mortality ratio of 480 these inequities in health, avoidable health inequali- per 100000 live births in 2010 were 6.8-fold, 8.5- ties, arise because of the circumstances in which fold and 24-fold higher than those of the European people grow, live, work, and age4. This calls for Region3. The relatively high infant, child and concerted inter-sectoral action to tackle the maternal mortality rates are largely attributed to low broad determinants of health such as economic coverage rates of existing effective public health development, peace, security, governance, shelter, interventions. Complete implementation of the In- education, gender, food security, nutrition and envi- tegrated Management of Childhood Illness Strategic ronment. The appropriate guidance for accelerating

235 COMPENDIUM OF RC STRATEGIES response to the determinants of health is outlined REFERENCES in the regional strategies for addressing the key 1. WHO: The global burden of disease: updated projec- determinants of health, health promotion, environ- tions. Geneva; 2008. http://www.who.int/evidence/ mental health, poverty and health, food safety and bod. health, and reducing harmful use of alcohol. 2. WHO: Investing in Health. Final report of the Com- We strongly encourage governments and partners to mission on Macroeconomics and Health. Geneva; 2001. allocate adequate resources for full implementation 3. WHO. World Health Statistics 2012. Geneva; 2012. of public health strategies adopted by the WHO 4. WHO: Commission on Social Determinants of Regional Committee for Africa in order to avert Health – Closing the gap in a generation. Geneva; premature deaths and suffering. 2008.

236 l l

REGIONAL OFFICE FOR Africa