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THE STATE OF HEALTH in the WHO African Region An analysis of the status of health, health services and health systems in the context of the Sustainable Development Goals

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The peoples of Africa aspire to a future of good health and well-being. The health and health-related Sustainable Development Goals (SDGs) build on this hope, providing guidance to ensure that no one is left behind as the continent progresses towards sustainable and equitable health. To achieve this, a coherent and logical approach to the adaptation of the SDGs is needed, to ensure that the health dividend accrued in the coming years is enjoyed equitably and plays its role in accelerating the development of the continent. The WHO Regional O ce for Africa has set up a process to ensure that countries walk together as they march towards sustainable and equitable health. This report is a recognition of the complexity of actions needed. It aims to provide guidance on where countries need to focus as they plan their work towards attaining the SDGs. It will also serve as a benchmark for future comparison of progress. This report is not a country scorecard. Rather, its purpose is to act as a compass to guide progress towards health in the SDGs. The Regional O ce aims to regularly provide such information to countries, so that they can attain their health goals in the most e cient and eective manner.

ISBN 978-929023409-8 WHO Regional O ce for Africa Cité du Djoué, Brazzaville, Congo www.aho.afro.who.int THE STATE OF HEALTH IN THE WHO AFRICAN REGION An analysis of the status of health, health services and health systems in the context of the Sustainable Development Goals

Where we are Where we need to go

on no e b g e in h v i n

d d

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L L i n A AFRIC The state of health in the WHO African Region: an analysis of the status of health, health services and health systems in the context of the Sustainable Development Goals ISBN 978-929023409-8 © WHO Regional O ce for Africa 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any speci c organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. The state of health in the WHO African Region: an analysis of the status of health, health services and health systems in the context of the Sustainable Development Goals. Brazzaville: WHO Regional Oce for Africa; 2018. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, gures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. 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 WHO 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 and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of speci c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO 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 WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

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Printed and bound in the WHO Regional Oce for Africa, Brazzaville, Congo Contents

Foreword ...... vii Acknowledgments ...... viii Preface ...... ix Abbreviations and acronyms ...... x Executive summary ...... xi Introduction and context 1 The 2030 Agenda for Sustainable Development ...... 1 2 The un nished business of the Millennium Development Goals ...... 2 3 Health within the SDGs ...... 2 4 Expectations of the country health sectors in implementing the SDGs ...... 3 5 Role and focus of WHO in supporting the implementation of the SDGs ...... 4 6 Purpose, methodology and structure of this report ...... 7 Part I – Regional report 1 The status of health in the African Region ...... 13 Attributes of a good state of health in the context of the SDGs ...... 13 1.1 The state of healthy life in the WHO African Region ...... 14 1.2 Morbidity and mortality causes inuencing healthy life in the African Region ...... 16 1.3 Risk factors inuencing healthy life in the African Region ...... 18 2 The status of health and health-related population outcomes in the African Region ...... 19 Attributes of eective health and health-related outcomes in the context of the SDGs ...... 19 2.1 Availability of essential services across the life course ...... 23 2.2 Coverage of essential health interventions ...... 25 2.3 Levels of nancial risk protection ...... 29 2.4 Levels of appropriate health security ...... 31 2.5 Responsiveness of essential services to population needs ...... 34 2.6 Coverage of health-related SDG targets ...... 38 3 Health systems performance in the African Region...... 42 Attributes of a performing health system ...... 42 3.1 Access to essential services in the African Region ...... 46 3.2 Quality of care in the African Region ...... 47 3.3 Demand for essential services in the African Region ...... 49 3.4 Resilience of health systems for essential services provision in the African Region ...... 51 4 The state of health system investments ...... 55 Attributes of health system investments ...... 55 4.1 The status of the health workforce in the African Region ...... 56 4.2 The status of the health infrastructure in the African Region ...... 59 4.3 The status of medical products in the African Region ...... 61 4.4 The status of health service delivery systems in the African Region ...... 65 4.5 The status of health governance systems in the African Region ...... 68 4.6 The status of health nancing systems in the African Region ...... 71 4.7 The status of health information and research systems in the African Region ...... 73 5 Taking forward health agenda in the African Region ...... 78 5.1 Linking health expenditures with health and well-being ...... 78 5.2 Emerging implications for ‘leaving no one behind’ ...... 83 5.3 WHO Regional Oce for Africa priorities for supporting countries ...... 83 Part II – Countries’ report The state of health in the countries of the African Region ...... 87 Algeria ...... 89 Angola ...... 90 Benin ...... 91 Botswana ...... 92 Burkina Faso ...... 93

iii Burundi ...... 94 Cabo Verde ...... 95 Cameroon ...... 96 Central African Republic ...... 97 Chad ...... 98 Comoros ...... 99 Congo ...... 100 Côte d’Ivoire ...... 101 Democratic Republic of the Congo ...... 102 Equatorial Guinea ...... 103 Eritrea ...... 104 Eswatini ...... 105 Ethiopia ...... 106 Gabon ...... 107 The Gambia ...... 108 Ghana ...... 109 Guinea ...... 110 Guinea Bissau ...... 111 Kenya ...... 112 Lesotho ...... 113 Liberia...... 114 Madagascar...... 115 Malawi ...... 116 Mali ...... 117 Mauritania ...... 118 Mauritius ...... 119 Mozambique ...... 120 Namibia ...... 121 Niger ...... 122 Nigeria ...... 123 Rwanda ...... 124 Sao Tome and Principe ...... 125 Senegal ...... 126 Seychelles ...... 127 Sierra Leone ...... 128 South Africa ...... 129 South Sudan ...... 130 Togo...... 131 Uganda ...... 132 United Republic of Tanzania ...... 133 Zambia ...... 134 Zimbabwe ...... 135 Annexes Annex 1: Indicators ...... 139 Health outcomes – health and essential services ...... 139 Health outputs – Health system performance measurements ...... 144 Health inputs – Health system investment measurements ...... 146 Annex 2: Data by indicator used to generate indices ...... 147 Health nancing data ...... 147 Health investments data ...... 149 Health systems performance data ...... 152 Health and related service outcomes data ...... 157 Health impact data ...... 166

iv Figures

Figure 1. The Sustainable Development Goals ...... 1 Figure 31. Comparison of health security status by JEE Figure 2. Determinants of health and well-being across the domain areas in the African Region ...... 33 SDGs ...... 3 Figure 32. Comparison of health security by health Figure 3. WHO GPW13 triple billion goals and strategic expenditures and population in the African Region ..34 priorities for attainment of SDG 3 ...... 4 Figure 33. Scores for dierent attributes of service Figure 4. Framework for health systems development responsiveness for the African Region ...... 34 towards universal health coverage in the context Figure 34. Comparison of service responsiveness index of the SDGs in the African Region (the Framework across countries of the African Region ...... 36 of Actions) ...... 6 Figure 35. Comparison of responsiveness index by income Figure 5. Dimensions analysed and their interrelationships ...... 8 group for countries in the African Region ...... 37 Figure 6. Process for deriving indices for each dimension ...... 9 Figure 36. Comparison of service responsiveness index Figure 7. Attributes of good health and well-being in the by health expenditures and population in the context of the SDGs ...... 13 African Region ...... 37 Figure 8. Healthy life expectancy in the African Region, 2015 ..14 Figure 37. Variation of the coverage of non-SDG 3 targets Figure 9. Life expectancy and healthy life expectancy by index across countries in the African Region ...... 38 WHO region, 2015 ...... 15 Figure 38. Contribution of dierent domains to overall non- Figure 10. Dimensions of health and health-related services SDG 3 targets indices amongst African countries...... 38 in the African Region ...... 19 Figure 39. Comparison of non SDG 3 health targets Index Figure 11. Attributes of Universal Health Coverage in the by income groups in the African Region ...... 39 context of the SDGs ...... 19 Figure 40. Comparison of non-SDG 3 health targets index Figure 12. Comparison of health and health-related by health expenditures and country categories in population outcomes index by country of the the African Region ...... 39 African Region ...... 20 Figure 41. Attributes of health system performance ...... 43 Figure 13. Contribution of dimensions of health outcomes Figure 42. Variations in health system performance indices to the overall index ...... 21 amongst countries in the African Region ...... 44 Figure 14. Comparison of health and health-related services Figure 43. Contribution of performance indices to the index by income group in the African Region ...... 21 overall system performance index ...... 44 Figure 15. Comparison of health and health-related services Figure 44. Comparison of health system performance index index by health expenditures and population by country income level ...... 45 across countries of the African Region ...... 22 Figure 45. Comparison of health system performance index Figure 16. Comparison of consolidated UHC dimensions by health expenditures and population in the index across Member States of the African Region .....22 African Region ...... 45 Figure 17. Strategic shift needed in making essential Figure 46. Index of access to essential services amongst services available for populations ...... 23 countries in the African Region ...... 46 Figure 18. Proportion of respondents reporting none of Figure 47. Comparison of access index by income level tracer services available for the population ...... 24 between countries in the African Region ...... 47 Figure 19. Comparison of availability of essential services Figure 48. Comparison of access index by health index in countries of the African Region ...... 24 expenditures and population in the African Region ..47 Figure 20. Comparison of access to essential services score Figure 49. Attributes of the quality of care dimension ...... 48 by country income groups in the African Region ...... 25 Figure 50. Quality of care index ranges across countries in Figure 21. Comparison of access index by health the African Region ...... 48 expenditures and population across countries in Figure 51. Comparison of quality of care index by country the African Region ...... 25 income groups ...... 49 Figure 22. SDG 3 interventions index by public health function 26 Figure 52. Comparison of quality of care index by health Figure 23. Range of SDG 3 interventions utilization index expenditures and population in the African Region ..49 across countries in the African Region ...... 27 Figure 53. Country eective demand index for essential Figure 24. Comparison of SDG 3 utilization index by income services score ranges ...... 50 group across public health functions in the Figure 54. Comparison of eective demand index by level African Region ...... 28 of income between countries in the African Region ..50 Figure 25. Comparison of utilization by health expenditures Figure 55. Comparison of eective demand index by health and population for public health functions in the expenditures and population in the African Region ..51 African Region ...... 28 Figure 56. Comparison of resilience index across countries Figure 26. Country nancial risk protection index ...... 30 of the African Region ...... 51 Figure 27. Comparison of nancial risk protection score by Figure 57. Comparison of resilience index by country income group across nancing indicators in the income category ...... 52 African Region ...... 30 Figure 58. Comparison of resilience index by health Figure 28. Comparison of nancial risk protection by health expenditures and population in the African Region ..52 expenditures and population in the African Region ..31 Figure 59. Comparison of the performance of dierent Figure 29. Average and range for IHR core capacity index of elements of resilience in the African Region ...... 54 countries in the African Region ...... 32 Figure 60. Categorization of health system investment areas .....55 Figure 30. Health security score by domain areas ...... 33

v Figure 61. Allocation of government expenditures across Figure 75. Regulatory capacity for medical devices through investment area categories by year and country product lifecycle (No = 22) ...... 64 types ...... 56 Figure 76. Conceptual linkage of service delivery systems Figure 62. Comparison of health workforce index amongst attributes and areas of action ...... 65 countries of the African region ...... 57 Figure 77. Scope of engagement in a service delivery Figure 63. Availability of dierent health workers per 1000 system for UHC and SDGs ...... 65 population ...... 57 Figure 78. Key informant perceptions of presence of Figure 64. Comparison of health workforce index by income dierent service delivery system variables...... 66 classi cation ...... 58 Figure 79. Conceptual linkage of health governance attributes .68 Figure 65. Comparison of health workforce index by health Figure 80. Key informant perceptions of presence of expenditures and population in the African Region ..58 dierent service delivery system variables...... 69 Figure 66. Comparison of health infrastructure index Figure 81. Service users who said they had paid a bribe amongst countries of the African Region ...... 59 during services received in the past 12 months ...... 70 Figure 67. Comparison of health infrastructure index across Figure 82. Schema for health nancing systems in the dierent country categories ...... 60 African Region ...... 71 Figure 68. Comparison of health infrastructure score by Figure 83. Proportion of health funds from dierent sources health expenditures and population in the in countries of the African Region, 2015 ...... 72 African Region ...... 60 Figure 84. Proportions of health funds managed by Figure 69. Comparison of health products index across dierent institutional entities in the African countries in the African Region ...... 61 Region, 2015 ...... 73 Figure 70. Comparison of top performing country values Figure 85. Schema for health information and research across health product indicators, with regional systems in the African Region ...... 74 average ...... 62 Figure 86. Comparison of birth registration completeness Figure 71. Comparison of health products index by income amongst selected countries of the African Region .....76 classi cation ...... 62 Figure 87. Comparison of health research barometer score Figure 72. Comparison of availability of dierent types of amongst countries of the African Region, 2016 ...... 77 medical products by country income level ...... 63 Figure 88. Comparison of 2015 per capita THE int$ between Figure 73. Comparison of medical products index by health countries in the African Region ...... 78 expenditures and population in the African Region ..63 Figure 89. Association between total health expenditure, Figure 74. Regulation of medicines quality throughout and healthy life expectancy ...... 79 product lifecycle for select functions (No = 29) ...... 64 Figure 90. Comparison of association between health and well-being and consolidated scores ...... 80

Tables

Table 1. Country shifts needed for alignment with the Table 11. Critical essential interventions by public health Sustainable Development Agenda ...... 4 functions ...... 26 Table 2. Countries by income group classi cation, 2016 ...... 9 Table 12. Percentage of population with coverage Table 3. Top ten and bottom ten country rankings, Total of essential health interventions related to Health Expenditure (International dollars, 2014) ...... 10 reproductive, maternal, newborn and child health Table 4. Ten highest and lowest countries by population by wealth quintile in the African Region ...... 28 size in thousands in the African Region, 2015...... 10 Table 13. IHR areas for building core capacities for health Table 5. Trends in healthy life expectancy since 2010 ...... 15 security ...... 31 Table 6. Trends in the top 10 causes of morbidity and Table 14. Percentage of population with access to improved mortality, 2015 and 2000 ...... 16 sanitation by wealth quintile in the African Region. ...40 Table 7. Comparison of crude death rates and total deaths Table 15. Percentage of population with access to improved across WHO regions, 2000 to 2015 ...... 17 sanitation by wealth quintile in the African Region. ...41 Table 8. Comparison of top 10 causes of mortality in the Table 16. Attributes of health system performance ...... 42 African Region against dierent income groups ...... 17 Table 17. Results from mixed eects multiple linear Table 9. Comparison of risk factor prevalence in the African regression of domain scores of the Framework of Region ...... 18 Actions ...... 80 Table 10. Tracer essential services for each age-cohort ...... 23 Table 18. Comparison of country indices across the Framework of Actions ...... 82

vi Foreword

Since the year , the people of Africa have benetted from economic growth, with poverty largely in retreat. The health and well-being of people in Africa is improving, a result of investments targeting the most pressing health needs in a context of a changing social, economic, political and environmental landscape. The people of Africa currently share a vision for the future that is lled with optimism and hope. The United Nations Sustainable Development Goals (SDGs) reect the aspirations arising from this vision. By achieving the targets of the SDGs, the people of Africa will enjoy the health dividend they aspire to and contribute to the continents’ development in an equitable and sustainable manner. At the WHO Regional Oce for Africa, we recognize the need for Member States to engage with and learn from each other as important for movement towards sustainable and equitable health results. Health and wellbeing are clear aspirations whose attainment calls for the understanding and application of principles of work within complex sectors such as health. Member States have dierent lessons to learn from and share with each other. A process to analyse and identify areas where lessons can be shared across countries is important in guiding progress towards attainment of the SDGs in the Region. This report aims to respond to this need. My colleagues and I adopted a bold and ambitious Transformation Agenda in the African Region, to ensure that support to countries is built around achieving results based on shared values, smart technical focus countries’ priority needs, responsive strategic operations and eective communication and partnership. This report is evidence of this transformation. It reects two areas where change has occurred in the work of WHO in the African Region: . Transformation in data use. In the past, our information and reports focused on documenting past events. Our transformation in this instance is aimed at providing forward looking guidance to Member States on where they should place emphasis in their health systems as they move towards the attainment of their UHC and SDG targets. . Transformation in approach to the health sector. In the past, the health sector was fragmented and operated in independent silos. Our transformation here is informed by the guidance from the Health Systems Strengthening for UHC framework for action endorsed by the Sixty-seventh Regional Committee for Africa, which provides an integrated approach to addressing disease program outcomes, health systems and determinants of health. This report follows the same logic to provide guidance in a comprehensive manner – and not for select priority areas of the health sector. This report is not a country scorecard. Its purpose is to act as a compass to show countries where they were in relation to dierent elements of health at the beginning of the SDG era, and where they need to place emphasis and resources to drive progress towards health and wellbeing aspirations. As a region, we intend to march towards the SDG targets together, leaving no one behind.

Dr Matshidiso Moeti WHO Regional Director for Africa

vii Acknowledgments

This analytical report is the result of a call by countries and partners on the WHO Regional Oce for Africa for a more proactive approach to providing guidance towards attainment of the health and health-related Sustainable Development Goals, in contrast to the more reactive approach taken with the Millennium Development Goals. This is one of a series of products emerging from the eort to transform the WHO Regional Oce in the African Region to better respond to current and future health needs of its Member States. The compilation of this report is the result of eorts by several technical colleagues and teams. The Regional Oce acknowledges the contributions and guidance provided by the directors of planning in the ministries responsible for health in all countries of the WHO African Region, who convened for the Regional Forum on Strengthening Health Systems for the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC) in Windhoek, Namibia in December to deliberate on how to take forward UHC and other health related SDG targets in the Region. A Framework of Actions emerged from these deliberations, together with the overall focus and structure of this report. As a result of their input, the report addresses the full breadth of the health sector, not only health services and systems. The core editorial team was composed of Joseph Caboré, Director of Programme Management, Delanyo Dovlo, Director of Health Systems and Services and Humphrey Karamagi, SDG coordinator and Health Information and Knowledge Management team leader, working together with Aku Kwamie, a health policy and systems research expert and Health Systems Global board member. Core inputs and reviews were provided by technical experts at the Regional Oce, both individually and through their respective clusters. Of specic mention are Magda Robalo, Felicitas Zawaira, Ibrahima Soce Fall and Stephen Shongwe, directors of the communicable disease control, family and community health, health emergency, and noncommunicable disease control clusters, respectively. Their contribution to the design and review of the emerging report through the Management and Development Committee were critical in ensuring its alignment with current needs. In addition, specic contributions from individual members are acknowledged. These include Prosper Tumusiime, leader of the Services Delivery Systems team, Martin Ekeke Monono, leader of the Health Policies, Strategies and Governance team, and Jean Baptiste Nikiema, leader of the Health Technologies and Innovations team. In addition, Grace Kabaniha, Benson Droti, Ogochukwu Chukwujekwu, Kevin Ousman, Hillary Kipruto, Monde Mambimongo Wangou, Anaclet Geraud Nganga Koubemba, Harris Benito Koubemba Mona, Davy Audrey Liboko Gnekabassa and Berence Relisy Ouaya Bouesso all provided invaluable guidance to respective sections of the report. Yves Turgeon is acknowledged for leading the publication process of the report.

viii Preface

This report presents a comprehensive picture of the state of health and its determinants in the WHO African Region. It aims to act as a benchmark of progress, as Member States in the African Region adopt a range of actions to move their populations towards the health and well-being ideals of the Agenda for Sustainable Development. The report recognizes the inherent complexity of addressing the health needs of populations, which calls for actions across a multitude of actors, with results heavily driven by context. The Framework for health systems development towards universal health coverage in the context of the Sustainable Development Goals in the African Region (the Framework of Actions), adopted at the Sixty-seventh session of the Regional Committee for Africa (document AFR/RC/), provides the structure for this analysis. This report, an in-depth analysis of health statistics, explores the dierent dimensions of the Framework of Actions to better understand where countries lie, and why. As such, the results of this analysis are presented by areas of the logical framework: • state of health and well-being: the impact level; • state of health and health-related services: the outcome level; • performance of the health system: the output level; and • state of investments in the health system: the input/process level. A total of dimensions are analysed, covering the four areas of the Framework: three impact (health and well- being); six outcome (health and related services); four output (system performance) and seven input/process dimensions (investments). The report underscores the fact that all these dimensions are interconnected. The report is structured in three sections. The rst provides background and context information to better understand the other sections of the report. The second section presents the regional analysis across all areas and related dimensions of the Framework. A third and nal section presents a country by country analytical summary review, again following broadly the dimensions of the Framework. The indicators, data and statistics used to generate the analysis are presented in the annexes. It is our hope that this report will be interpreted as a single consolidated document, and not independently by section. Each chapter and area is connected to the others, for a comprehensive understanding of why health in Africa is the way it is, and what needs to be done to improve it. It is my hope that you will nd the information presented here useful for addressing UHC and the health and well-being aspects of the Agenda for Sustainable Development.

ix Abbreviations and acronyms

AIDS Acquired Immunodeciency Syndrome AMR Antimicrobial resistance CD Communicable disease CFA Compulsory Financing Arrangement CRD Chronic renal disease CVD Cardiovascular diseases EVD Ebola virus disease GFA Government Financing Arrangement HIC High Income Country HIV Human Immunodeciency Virus HRH Human Resources for Health HSS Health Systems Strengthening ICT Information Communication Technology IHP+ International Health Partnership Plus IHR International Health Regulations INFRA Infrastructure JEE Joint External Evaluation LIC Low-income country LMIC Lower-middle-income country MDGS Millennium Development Goals MIC Middle-income country NCD Noncommunicable disease NHA National health accounts OOPS Out-of-pocket spending PoE Points of entry PPP purchasing power parities SARA Service availability and readiness assessment SDGs Sustainable Development Goals SIDS Small island developing states SOPs Standard operating procedures TB Tuberculosis UHC Universal Health Coverage UMIC Upper middle-income country UNDAF United Nations Development Assistance Framework VHI Voluntary Financing Arrangement WB World Bank WHO World Health Organization

x Executive summary

Introduction and context

e Sustainable Development Goals (SDGs) of the United Nations Agenda for Sustainable Development provide a dierent approach to the preceding Millennium Development Goals (MDGs), in being more universal in scope, with a focus on local adaptation, an emphasis on sustainability, while seeking to magnify integration across actors and domains for results. e Agenda is built around SDGs containing a total of targets. While a single goal is explicitly for health, SDG , over of those SDG targets have an inuence on its attainment. A focus on only the targets in SDG will not lead to the health and well-being desired in that goal; a more comprehensive and logical approach is needed. is approach, developed for the African Region by its Member States, is embodied in the Framework of Actions for Strengthening Health Systems for UHC and the SDGs in Africa adopted at the Sixty-seventh session of the Regional Committee for Africa in . is Framework of Actions elaborates actions across dierent dimensions of logic that countries need to consider to lead to improvement in all the targets inuencing health and well-being. In contrast to the MDGs, Member States in the African Region have requested the Regional Oce to provide proactive guidance on where they need to place their eorts to enable movement towards Universal Health Coverage (UHC) and other health-related SDG targets in a manner that will enable attainment of SDG . is report is a part of the eort. is report provides a comprehensive analysis of health services and systems in the African Region from the context of achieving the Agenda and the SDGs. It focuses on developing a better understanding of the Region’s context: which categories of countries are achieving what, why, and how their results could be improved. e results of the analysis are organized and presented according to the levels of the logical framework: ◆ state of health and well-being – the impact level; ◆ state of health and health-related services – the outcome level; ◆ performance of the health system – the output level; and ◆ state of investments in the health system – the input/process level.

A total of dimensions covering these logical levels of the Framework of Actions are analysed in this report: impact (health and well-being), outcome (health and related services), output (system performance) and input/process (investments) dimensions. Within each dimension, a stepwise process is followed to derive the analysis. Data are identied and consolidated into an index for the dimension being analysed and then used to understand how they relates to other critical variables. Dimensions analysed and their interrelationships

OUTCOME INPUT/PROCESS IMPACT OUTPUT DIMENSIONS DIMENSIONS DIMENSIONS DIMENSIONS

Services available Access to essential Workforce Healthy lives– services level and distribution Interventions coverage Infrastructure for SDG 3 targets Quality of essential Medical products Burden of disease– Financial protection services by age and condition Delivery systems Interventions coverage E ective demand for for non-SDG 3 targets essential services Governance Burden of risk factors Health security Resilience of the Information systems system Service satisfaction Financing systems

e report is structured in two parts: a regional overview followed by a country by country section.

xi The state of health in the African Region

e state of health is analysed from three dierent dimensions: the state of healthy life (level and distribution); the burden of disease (by age and condition); and the burden of risk factors contributing to ill-health and death. ◆ e healthy life expectancy (a measure of life expectancy adjusted for years spent with disability) has been increasing in the Region, from 50.9 years to 53.8 years between 2012 and 2015, which represents the highest increase in any WHO region. Additionally, the gap in healthy life expectancy between the best and worst performing countries in the Region has reduced from 27.5 to 22 years. However, it still shows inequities, with healthy life highest in countries with better economies. e improvement is fastest in large population countries and in those with high population densities. Additionally, the levels of healthy life in the Region are still very low compared to other regions. ◆ e burden of disease is now driven by communicable conditions, noncommunicable conditions and violence/injuries. However, lower respiratory conditions, HIV/AIDS and diarrhoeal diseases still represent the top causes of both morbidity and mortality. Levels of morbidity and mortality are signicantly reduced. DALYs due to the top 10 causes of morbidity have more than halved between 2000 and 2015, driven by reductions in malaria, HIV/AIDS and diarrhoeal diseases. e crude death rate due to the top 10 causes of mortality has also fallen, from 87.7 to 51.3 per 100 000 population in the same period. No signicant reduction is seen for noncommunicable diseases (NCDs). ◆ However, the burden of risk factors to morbidity and mortality is not seeing commensurate reductions. A person in the Region aged between 30 and 70 years has a 20.7% chance of dying from one of the major NCDs. All the four major risk factors identied in the Global Action Plan for the prevention and control of NCDs (2013–2020) are high in the Region. ese include alcohol abuse, insucient physical activities, unhealthy diets and substance abuse.

While witnessing improvements in healthy life – seen in the relative improvements in healthy life and reductions in morbidity/mortality – the Region is coming from a very low base, with current levels still lower than the rest of the world. In addition, the high burden of risk factors prevents well-being from being assured, and the NCD burden will continue to rise to a level where the improvements in healthy life become eroded by losses in well-being.

The state of health services

e analysis of services needed for health and well-being is done across six dimensions of outcomes. Dimensions of health and health-related services in the African Region

Health and well-being for all at all ages

Availability of Coverage of Financial risk Service Health Coverage of essential services essential interventions protection satisfaction security non-SDG 3 for SDG 3 targets health targets by life cohort Promotive, From Responsive to Outbreak prevention, Social, economic, preventive, catastrophic population needs detection, response environmental, curative and health and recovery political palliative expenditures

Universal health coverage dimensions

xii e Region shows a mixed picture across the six health and health-related outcome domains of the Framework. An overall index for health services based on the average for the indices of each of the six dimensions gives a level of .® out of a possible . is implies that the population of the Region is only utilizing ®¯ of the possible health and health-related services needed for their health and well-being. Countries score in the Region range from . to .. Only ve countries have a score above ., with the best country in the Region (Algeria) only able to provide ¯ of the possible health and related services that its population needs – a worrying situation. All six dimensions of service outcomes underperform, with the best only able to provide ¯ of what is feasible. All Member States therefore need to be reviewing what they have available for their populations, with the aim of identifying and improving the services needed to improve each dimension. e worst performing dimensions relative to the others are service availability ( ¯ of what is feasible), and nancial risk protection ( ¯ of what is feasible). Improving population outcomes in the Region will accordingly require relatively more eort in further enhancing these two dimensions Contribution of the dimensions of health outcomes indices to the overall index

◆ Service availability is concerned with the range of services a country is making available to each age cohort of its population. e adolescent and the elderly age cohorts have the lowest range of services available in the Region. Countries need to plan for more comprehensive essential health packages to ensure the availability of services for all. ◆ Coverage of SDG 3 interventions analyses the levels of utilization achieved for ‘traditional’ health services: promotive, communicable and noncommunicable disease prevention, curative and rehabilitative. e coverages are lowest for noncommunicable disease and health promotion services, and highest for communicable disease control interventions. ◆ Financial risk protection focuses on the level of nancial barriers hindering the utilization of essential services, which is driven by low levels of social security and pooling of health resources in the Region. ◆ Health security focuses on the level of protection populations have from the health eects of outbreaks and disasters, which is based on the compliance score with the International Health Regulations (2005, IHR) across the attributes of prevention, detection and response. e challenge is primarily related to response and recovery capacities, as detection of outbreaks has signicantly improved in the Region. ◆ Service responsiveness focuses on how responsive the available services are to the needs of the population, using the seven attributes of dignity, autonomy, condentiality, promptness of attention, access to social support, quality of basic amenities and provider choice. e worst attributes of responsiveness are the quality of basic amenities and the levels of autonomy in decision making. Access to social support is the best performing attribute.

xiii ◆ Coverage of non-SDG 3 interventions reviews the levels of coverage of other SDG targets inuencing health and well-being across the social, economic, environmental and political determinants. e largest challenge in the Region lies with the economic determinants. ◆ e combined score for the UHC dimensions (essential services availability, essential services coverage and nancial risk protection) is 0.46.

The state of the health system performance

e analysis of health system performance is based on how well it is able to achieve across the four dimensions of access to essential services, quality of essential services, eective demand by communities for essential services, and the resilience of the system to shocks. e consolidated average system performance index in the region is ., implying that systems are only performing at ¯ of their possible levels of functionality. Countries’ performance scores range from . and .. All the indices for the performance dimensions are underperforming, with system resilience and access to essential services doing worst. Contribution of the performance indices to the overall system performance index

◆ Access to essential services is low, with only three countries (Mauritius, Sao Tome and Principe and Seychelles) having an access index above 0.50. Countries in the Region are unable to provide the infrastructure, sta and commodities needed for those services. ◆ e quality of essential services remains a challenge in the Region. Client perceptions, safety assurance and eectiveness of provided interventions need to be addressed to improve quality. ◆ e eective demand for services by communities reects the potential for households and communities to utilize essential services. Community-based interventions to improve ownership are critical. ese exist in various forms in the Region, but are unable to build the needed demand. ◆ System resilience ensures that the provision of essential services is uninterrupted by shocks to the system. System resilience levels in the Region are low.

The state of the health system investments

Countries need to invest across seven areas – through programmes or cross cutting system investments – to perform at the level needed to move towards UHC: health workforce, health infrastructure, medical products, service delivery, health governance, health nancing and health information. Countries are spending an average of ¯ of their health expenditures on tangible investments (health workforce, health infrastructure, and medical products) as compared to intangible ones. Within the tangible investments, highest spending of government funds is on medical products ( ¯ of government spending), followed by the health workforce (¯). Only ¯ of government expenditure is on infrastructure, which includes equipment, transport and ICT.

xiv A country with a good performing health system puts more emphasis on the health workforce (¯ versus ¯) and infrastructure ( ¯ versus ¯) compared to countries with less performing systems. Finding a similar pattern in other countries with good performing systems would suggest that the investment focus should shift to health workforce and infrastructure investments. Implications for the achievement of the Agenda

A complex picture of the African Region emerges from the ndings of this analysis. Looking at the level of funding available for countries to produce the results observed (using the per capita THE in USµ PPP), one sees a mixed situation: only nine countries in the Region are spending above USµ per capita (all, with the exception of Eswatini, are upper middle or high-income countries), and half the countries () have a total health expenditure of less than USµ per capita. Analysing the linkage between health expenditure and healthy life expenditure shows a weak association between the two areas. Further analysis of associations shows that healthy life expenditure is more strongly associated with health system performance, as opposed to all other areas of the Framework of Actions. Countries need to place monitoring of performance of their systems at the centre of their eorts to move towards SDG . Countries in the Region are diverse, due to cultural, economic, governance and political dierences, which makes a ‘one size ts all’ approach in addressing health in the Agenda not possible. To move forward, countries need to: ◆ Find means to extend their health services to currently unreached populations, including urban informal settlements; ◆ Increase their focus on improving the process of care, not only its availability; ◆ Proactively identify and increase services to all age cohorts, including the adolescents and the elderly; ◆ Anticipate and mitigate health and governance security challenges, as they have the potential to undo any progress made; and ◆ Develop country-specic mechanisms to engage all health-related stakeholders to ensure that social, economic, environmental and political SDG targets are on track.

xv xvi © WHO/Julie Pudlowski Introduction and context

1 The 2030 Agenda for Sustainable Development

e Agenda for Sustainable Development, including As the Agenda is meant to be implemented in the its Sustainable development goals (SDGs) and context of countries’ existing commitments, a translation targets, was adopted on September by Heads process is required to adapt the SDGs into their of State and Government at a special United Nations national development plans. ere is recognition that summit. e Agenda represents an unprecedented countries will require strengthening to build new types focus of the global community to eradicate poverty and of capacities and meet new priorities to address old and achieve sustainable development worldwide by . e new challenges alike. Agenda is global in nature with a strong focus on equity. Figure 1. The Sustainable Development Goals

NO ZERO GOOD HEALTH QUALITY GENDER CLEAN WATER 1 POVERTY 2 HUNGER 3 AND WELL-BEING 4 EDUCATION 5 EQUALITY 6 AND SANITATION

AFFORDABLE AND DECENT WORK AND INDUSTRY, INNOVATION REDUCED SUSTAINABLE CITIES RESPONSIBLE CLEAN ENERGY ECONOMIC GROWTH 9 AND INFRASTRUCTURE 10 INEQUALITIES 11 AND COMMUNITIES 12 CONSUMPTION 7 8 AND PRODUCTION

CLIMATE LIFE LIFE PEACE, JUSTICE PARTNERSHIPS 13 ACTION 14 BELOW WATER 15 ON LAND 16 AND STRONG 17 FOR THE GOALS INSTITUTIONS

Source: United Nations

1 2 The un nished business of the Millennium Development Goals

e SDGs have not evolved in a vacuum, but rather in also been mixed: most countries in the Region were not the context of years of global e£orts to implement the able to achieve their targets for these goals, apart from Millennium Development Goals (MDGs). While the the reduction of HIV incidence between and , SDGs can be considered a continuation of global e£orts achieved by of the countries in the Region. towards poverty alleviation and prosperity improvement, Across the African Region, under-ve mortality decreased they fundamentally di£er from their predecessors in by . against the target of reducing it by two-thirds their universal scope, their focus on local adaptation and between and . e Region still maintains the their implementation approach which seeks to magnify highest proportion of under-ve mortality globally, with integration across actors and domains. only countries in the Region having achieved the e results achieved by the MDGs in the African Region MDG target. Globally, the African Region also has the have been largely positive, considering the challenging highest maternal mortality ratio. For MDG A, only baseline conditions that existed in many countries. countries (Cabo Verde and Rwanda) achieved the target However, compared to other WHO regions, the African to reduce the maternal mortality ratio by three-quarters Region experienced a rate of poverty decline of only . between and . between and , far below the MDG target of Regarding health-related MDGs, countries met .. the target of halving the proportion of people without Progress on Health MDG Goal (reduce child sustainable access to safe drinking water by , while mortality), Goal (improve maternal health) and Goal only one country met the target of halving the proportion (combat HIV/AIDS, malaria and other diseases) have of people without basic sanitation by . 3 Health within the SDGs

In a departure from the MDGs, health is re¦ected across ▶ Environmental determinants for SDG 3: ese most of the SDGs. While the single health goal SDG are targets in¦uencing health, found within the relates to direct actions that in¦uence health, achieving environmentally oriented SDGs (6, 11, 12, 13, 14 health and well-being is also closely intertwined with and 15) other SDGs, including poverty reduction, the central ▶ Political determinants for SDG 3: ese are targets theme of the Agenda as a whole. Including the targets in¦uencing health, found within the politically of SDG , nearly of the targets of the SDGs oriented SDGs (14, 15, 16 and 17). have a direct e£ect on health and well-being. For the ese SDG determinants are shown in gure . purpose of organization, we have classied the SDG targets in¦uencing health into ve broad areas depending on how they are re¦ected in the SDGs: SDG represents the goal around which all health ▶ Health service determinants for SDG 3. ese are targets in the SDGs coalesce. Conversely, all SDGs the targets 3.1 to 3.9, all within SDG 3 and their are interdependent, with SDG also in¦uencing most means of verication. other SDGs. Moving towards improvements in all ▶ Social determinants for SDG 3: ese are targets health and health-related targets calls for a whole of in¦uencing health, found within the socially government approach and not a sectorial delegation of oriented SDGs (1, 2, 3, 4 and 5) responsibilities. For example, e£ects of climate change ▶ Economic determinants for SDG 3: ese are (target .) in¦uence almost all sectors, not just the targets in¦uencing health, found within the health of the people. Likewise, a reduction in substance economically oriented SDGs (7, 8, 9 and 10) abuse (target .) in¦uences education, economy and many other sectors beyond health.

United Nations Development Programme. From the MDGs to sustainable development for all: lessons from years of practice. New York: United Nations Environment Programme, (http://www.undp.org/content/dam/undp/library/SDGs/English/FromtheMDGsto SDAll.pdf?download, accessed March ). United Nations Economic Commission for Africa, African Union, African Development Bank, United Nations Development Programme. MDG report : lessons learned in implementing the MDGs. Assessing progress in Africa toward the Millennium Development Goals. Addis Ababa: Economic Commission for Africa; (https://www.afdb.org/leadmin/uploads/afdb/Documents/Publications/MDG_Report_.pdf, accessed March ). Atlas of African Health Statistics : Health situation analysis of the African Region. Brazzaville: WHO Regional O¡ce for Africa; (http:// www.aho.afro.who.int/en/publication//atlas-african-health-statistics--health-situation-analysis-african-region, accessed March ). 2 UHC (target .) underpins all SDG targets. Realizing not expose the user to nancial hardship” . Progressing UHC presents an opportunity for countries to align their towards UHC is dependent on integration, readiness actions towards achieving health and well-being. UHC is and adaptability at the operational levels (districts and dened as “ensuring that all people can use the promotive, facilities) as well as the broader national, regional and preventive, curative, rehabilitative and palliative health global policy contexts, inclusive of economic, social, services they need, of su¡cient quality to be e£ective, cultural and environmental factors. while also ensuring that the use of these services does Figure 2. Determinants of health and well-being across the SDGs

SUSTAINABLE DEVELOPMENT GOAL 3 Ensure healthy lives and promote well-being for all at all ages

Social targets Economic targets SDG 3 targets Environmental targets Political targets

1.3 Social 7.1 Energy services 3.8 Universal health 6.1 Drinking water 16.1 Violence protection 8.1 Economic growth coverage 6.2 Sanitation 16.2 Violence against and torture 2.2 Malnutrition 8.5 Employment 3.1 Maternal mortality and hygiene of children 4.1 Primary and and decent 3.2 Child mortality 6.3 Water quality secondary work 16.5 Corruption 3.3 End epidemics of 11.1 Housing and bribery education 8.8 Migrant workers AIDS, TB, NTDs, etc. 11.2 Transport 16.6 Institutions 4.2 Early childhood 9.1 Infrastructure 3.7 Sexual and systems 16.7 Decision making development reproductive health 9.c ICT 11.3 Human 16.9 Birth registration 5.2 Violence 3.4 NCDs and mental settlement against all 10.2 Inclusion 17.1 Domestic resources health mobilization women and 10.4 Equality 11.5 Disasters girls 3.5 Substance abuse 17.6 Knowledge sharing 10.7 Migration 11.6 Cities 5.3 Female genital 3.6 Injuries & RTA 17.9 National plans 10.b Development 13.1 Climate- mutilation 3.9 Contamination related hazards 17.5 Policy space assistance and leadership 3.a FCTC 13.2 Climate change 17.16 Global 3.b Medicines partnership 3.c Financing, staﬀ 17.17 Strategies of partnerships 3.d Risk management

4 Expectations of the country health sectors in implementing the SDGs

For the health sector, this breadth of targets implies the Identication of country-level actions to achieve the need for ministries responsible for health to have a much SDG targets should be done using a multisectoral broader approach to attaining health and well-being. A approach. It is critical that governments coordinate the focus only on the health services determinants (SDG dialogue on SDGs and involve key stakeholders. Some targets) may not lead to the sustainable achievement of of the changes expected in the health sector focus, arising SDG goal that the countries aspire to. from the need to adopt a sustainable development agenda, are shown in the table below.

3 Table 1. Country shifts needed for alignment with the Sustainable Development Agenda

Previous emphasis Shift in emphasis Mobilize and allocate resources for the provision of a basic package that is Plan and mobilize resources to facilitate a progressive improvement in the a ordable ability to provide the essential package of services needed to improve all targets inuencing health and well-being Design and focus on a single service delivery model based on the majority Design and apply multiple service delivery models, depending on the target population’s needs population, to ensure that no one is left behind. A focus on the services needed by all age cohorts – ensuring that each person - A focus on services to mothers and children from children to elderly – receives the services needed A focus on interventions to address all the major causes of disease burden and A focus on interventions addressing acute, infectious diseases risk factors across all public health functions A focus on building capacity for the provision of services for known and expressed A focus on building capacity for the provision of services for potential (such as needs potential health emergencies) and implicit (for example, mental health) needs Building government capacity for stewardship of the provision of services, with Building government capacity for the provision of essential services delivery by most suited public or private stakeholders Focus on increasing domestic funding, with prioritization of cross-government, Focus on increasing donor funding, with prioritization of MoH-external partners civil society and external partner coordination tools (overall funding coordination tools (aid e ectiveness) e ectiveness) Interventions planned and programmed by diseases (disease-centric) Interventions planned and programmed around the person (person-centric) Health goals can be attained by focusing on those interventions and services that Health goals can be attained by focusing on those interventions and services that are cheap and/or cost e ective provide value for money

5 Role and focus of WHO in supporting the implementation of the SDGs

e World Health Organization has instituted the lives and well-being for all at all ages is attained by changes in its focus and guidance on health in the all countries. ese strategic priorities are: achieving context of the SDGs. Its th General Programme of universal health coverage, addressing health emergencies Work (GPW, -), which provides the overall and promoting healthier populations. A triple billion focus of the organization, has provided a vision, rooted goal around these strategic priorities has been agreed by in the WHO constitution, of ‘a world in which all people WHO, Member States and other partners. attain the highest possible standard of health and well- is clear and ambitious set of strategic priorities have being’ and a mission around a triple focus to: promote set a target for the countries to focus on, as they optimize health; keep the world safe; and serve the vulnerable. the actions needed to attain the SDG targets in¦uencing In line with this mission, WHO has dened three SDG . interconnected strategic priorities to ensure that healthy Figure 3. WHO GPW13 triple billion goals and strategic priorities for attainment of SDG 3

Resolution A/ of the st World Health Assembly on the th General Programme of Work. Accessed on may from http://apps.who.int/ gb/ebwha/pdf_les/WHA/A_-en.pdf

4 e WHO Regional O¡ce for Africa has dened the In line with this strategic focus in the Region, the WHO Africa Health Transformation Programme – : Regional Committee for Africa adopted a strategy for a vision for universal health coverage as the strategic health systems development towards UHC in the context framework guiding WHO’s contribution to the of the SDGs in August . is ‘Framework of Actions’ Agenda in the African Region. e programme’s goal provides linkages between health system investments is to guarantee access to a package of essential health and health service outcomes to ensure synergies of action and health-related services in all Member States and across system and service interventions that are also thus achieve UHC with minimal geographical, nancial needed to reach SDG . It provides guidance to countries and social obstacles. e work of WHO in the Region is on the realignment of system investments needed to built around ve strategic priorities, re¦ecting the unique attain a comprehensive set of health and health-related issues in¦uencing health and well-being for all in the outcomes critical to achieving SDG . region: e framework follows a logical approach to elaborate i) Improving health security by tackling epidemic- the investments (inputs/processes) needed to assure the prone diseases, emergencies and new health performance of health systems (outputs) in a manner threats; that provides the health and related services needed by all persons (outcomes) to attain the level and distribution ii) Driving progress towards equity and universal of health and well-being for all, at all ages (impact). health coverage through health systems Specic dimensions are dened at each level of the strengthening; logical framework, from which a menu of options of iii) Pursuing the post- development agenda actions are elaborated for countries to review and decide while ensuring that the MDGs are completed; whether they add value in their e£orts towards attaining iv) Tackling the social and economic determinants their health aspirations. of health; and v) Building a responsive and results-driven WHO secretariat

WHO Regional O¡ce for Africa (). Africa Health Transformation Programme –: a vision for Universal Health Coverage. Brazzaville: WHO Regional O¡ce for Africa; (http://www.afro.who.int/sites/default/les/-/fullrepoty.pdf accessed on March ) Sixty-seventh session of the Regional Committee for Africa, Victoria Falls, Republic of Zimbabwe, August– September . Framework for health systems development towards universal health coverage in the context of the Sustainable Development Goals in the African Region. AFR/ RC/. Brazzaville: WHO Regional O¡ce for Africa; . (http://www.afro.who.int/sites/default/les/-/UHCframework_eng_- -_small.pdf accessed on March ). 5 Figure 4. Framework for health systems development towards universal health coverage in the context of the SDGs in the African Region (the Framework of Actions)

IMPACT SDG 3 goal HEALTHY LIVES AND WELL BEING FOR ALL AT ALL AGES

OUTCOMES - Essential services OTHER SDGS HEALTH Essential services availability INTERVENTIONS utilization - Essential services 1. Poverty 8. Econ growth coverage 2. Nutrition 10. Inequalities 4. Education 13. Climate - Financial risk UNIVERSAL 5. Equality 16. Inclusiveness protection 6. Clean water 17. Partnerships HEALTH SECURITY HEALTH HEALTH COVERAGE HEALTH SERVICE SATISFACTION

OUTPUTS Health system RESILIENCE IN performance ACCESS TO QUALITY OF DEMAND FOR ESSENTIAL ESSENTIAL ESSENTIAL ESSENTIAL SERVICES SERVICES SERVICES SERVICES PROVISION : e ciency, equity and eectiveness Guiding: e ciency, principles

NATIONAL AND SUB NATIONAL INPUTS / SERVICE DELIVERY SYSTEMS PROCESSES Health system HEALTH MEDICINES, PRODUCTS building block INFRASTRUCTURE & SUPPLIES investments HEALTH WORKFORCE HEALTH FINANCING HEALTH

HEALTH GOVERNANCE INFORMATION HEALTH

6 6 Purpose, methodology and structure of this report

is report is a result of calls on WHO by governments and their partners this overall, cross cutting picture of and partner stakeholders to provide more in-depth where they lie in their e£orts to attain their SDG targets, analysis of health and investments to enable targeted and why they are where they are. guidance to progress towards the SDGs. Currently, most e report is a core part of the WHO Regional O¡ce analyses within health are based on programmes or specic for Africa’s approach to reform the use of data in guiding indicators, which creates di¡culties in understanding how SDG progress. is reform is structured around three these contribute to the overall picture of health and well- areas: statistics, information and knowledge. being. is report is aimed at providing Member States

Health Health Health Statistics Information Knowledge

▶ Reform in health statistics aims to rationalize from the statistics and information are developed in the indicators and their data needed across all the response to critical decision-making questions within dimensions of the Framework of Actions (the each dimension of the Framework. In addition, good/ Framework) illustrated in gure 4 above. For each best practices are identied within each dimension of dimension, a set of indicators is dened, whose data the Framework for sharing across countries is useful in understanding progress being made in Health statistics reform is re¦ected in the Atlas of African Member States in the Region e reform focuses Health Statistics, where the trends and distribution on ensuring that countries are identifying and of di£erent health indicators are highlighted. Health building their capacity for generating data for the information reform is re¦ected in this report, to be indicators they deem useful for each dimension published biennially, which analyses available statistics to of the Framework. us, a specic indicator is interpret the state of health, services and investments in important only if it can provide guidance towards countries. Finally, the health knowledge reform is re¦ected a given dimension – and not important on its own. in policy briefs and good/best practice publications. e menu of indicators across the dimensions includes all the SDG monitoring indicators relating is report – an in-depth analysis of health statistics – to health7 and the WHO 100 core indicators8. As analyses the di£erent dimensions of the Framework of such, the country indicator set is aligned to the Actions to better understand where countries lie and SDG and other health sector monitoring processes why. As such, the results of the analysis are presented by and can provide data for these. areas of the logical framework: ▶ Reform in health information aims to provide ▶ state of health and well-being – the impact level; comprehensive and scientic analyses of the ▶ state of health and health-related services – the available data for each dimension in the Framework. outcome level; e indicators contained in each dimension are ▶ performance of the health system – the output level; used to better understand how well that dimension and is contributing to the overall health and well- ▶ state of investments in the health system – the being, and why. e data is brought together and input/process level. compared against other variables that may o£er an A total of dimensions are analysed, covering the four understanding of the performance (such as GDP, or areas of the Framework : three impact (health and well- other indicators). being); six outcome (health and related services); four ▶ Reform in health knowledge aims to structure the output (system performance) and seven input/process statistics and information from analyses to generate (investments). e report emphasizes the fact that these health intelligence for decision makers. Coming dimensions are all interconnected. from a decision-making lens, policy briefs generated SDG comprehensive monitoring indicator list accessible here: https://unstats.un.org/sdgs/indicators/GlobalIndicatorFramework afterrenement_Eng.pdf Global Reference List of Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; . Licence: CC BY-NC-SA . IGO. Accessible here: http://apps.who.int/iris/bitstream/handle///WHO-HIS-IER-GPM-.-eng. pdf;jsessionid=BBEECEBBAE?sequence= 7 Figure 5. Dimensions analysed and their interrelationships

OUTCOME INPUT/PROCESS IMPACT OUTPUT DIMENSIONS DIMENSIONS DIMENSIONS DIMENSIONS

Within each dimension, a stepwise process is followed perspectives on these attributes based on a to derive the analysis, for consistency and transparency. – Likert scale. eir responses were added 1. Indicators for each dimension are identied. e to provide a summary of the score for each aim is to have as many indicators as possible, to responding country. increase the strength of the analysis – the more the c. Where no data were found in the above indicators, the stronger the inferences. Appendix 1 databases, or there were no key informant highlights the indicators used for each dimension. responses for a country, then the indicator has been left blank and has not been used further 2. As it was important to have comparable data for in the analysis. each indicator, a standard source of data has been preferred for each. No country was contacted for 3. Given the fact that there are di£erent types of data – only publicly available data and values were indicators in each dimension, a process to make used. Use of standard sources means that the data them comparable has been rst carried out. is used have been veried independently and ensures has been achieved by normalizing the data at that they are comparable. For example, the use of each point to a range of 0 and 1, in line with their global estimates for measles coverage is preferred value relative to the other country’s values. Zero over those of country reported statistics, as the represents no achievement and one represents data has been corrected to make it comparable. the highest possible achievement by a country in e standard data source used was the WHO the African Region. Where the desired trend is Global Health Observatory9. negative (such as Maternal Mortality ratio), the reverse of the normalized value [1 - the normalized a. Where data were missing in the WHO Global value] is applied. Health Observatory, the UN database was consulted and, if still unable to nd the data, 4. e analysis generated an index for each then the World Development Indicators dimension of the Framework, which is the average database of the World Bank was used. normalized value of the indicators used for the Appendix summarizes the data values used dimension. e average is used as all indicators for each indicator against the dimensions of are perceived to be important for the dimension. the Framework. Normalization allows direct comparison of the di£erent indicators, as they are all now unitless – b. For indicators for which a score is required with values ranging from 0 to 1. Where data were (service responsiveness, service availability and missing, the given indicator was not included in system resilience), attributes for each indicator the calculation of the index. However, no index were derived from the literature – each of was generated with only one indicator, as this which is referenced within the report. Nine would be too biased. key informants were identied in each country, representing state, non-state and external stakeholders (three of each), to give di£erent

WHO Global Health Observatory (http://www.who.int/gho/en/ . Last accessed for data on March ). UN SDG database link (https://unstats.un.org/sdgs/indicators/database/) https://data.worldbank.org/products/wdi 8 Figure 6. Process for deriving indices for each dimension

INDICATORS NORMALIZED DIMENSION AND VALUES INDICATORS VALUES INDEX

Indicator 1 Indicator 1 normalized Average value of Indicator 2 Indicator 2 normalized normalized Indicator 3 Indicator 3 normalized indicators Indicator 4 Indicator 4 normalized ranging from Indicator n Indicator n normalized 0 to 1

e derived indices represent the achievement in the e analysis provides a regional picture for each Region for the given dimension. e more the indicators dimension and area of the Framework. It also provides are available and used, the more accurate the derived the index values for each country that contribute to the index is. As the analysis is dependent on publicly available overall regional picture. Further comparison was also and veried data, the index represents a calculation of the done to see how the index changes for certain country status of the dimensions based on available data. Moving groupings. ese include countries with similar income, forward, WHO in the Africa Region is encouraging health expenditure, population and the Small Island countries to make data more available for more of the Developing States (SIDS), e specic countries in indicators that are critical for assessing health and well- each of these groupings are shown in Tables –. being, to make the ndings more accurate. Table 2. Countries by income group classi cation, 201613 High-income countries (1) Upper middle-income Lower middle-income Low-income countries (26) countries (7) countries (13) HICs UMICs LMICs LICs Seychelles Algeria Angola Benin Botswana Cabo Verde Burkina Faso Equatorial Guinea Cameroon Burundi Gabon Congo Central African Republic Mauritius Côte d’Ivoire Chad Namibia Eswatini Comoros South Africa Ghana Democratic Republic of the Congo Kenya Eritrea Lesotho Ethiopia Mauritania Gambia Nigeria Guinea Sao Tome and Principe Guinea-Bissau Zambia Liberia Madagascar Malawi Mali Mozambique Niger Rwanda Senegal Sierra Leone South Sudan Togo Uganda United Republic of Tanzania Zimbabwe

In the WHO African Region, SIDS are Cabo Verde, Comoros, Guinea Bissau, Mauritius, Sao Tome and Principe and Seychelles. http://databank.worldbank.org/data/download/site-content/OGHIST.xls 9 Table 3. Top ten and bottom ten country rankings, Total Health Expenditure (International dollars, 2014)

Bottom ten countries, THE intl per capita, Top ten countries, THE intl per capita,

No Country Int No Country Int

Central African Republic . Equatorial Guinea . Democratic Republic of the Congo . South Africa . Madagascar . Algeria . Eritrea . Mauritius . Niger . Botswana . Burundi . Seychelles . Guinea . Gabon . South Sudan . Eswatini . Ethiopia . Namibia . Togo . Congo .

Table 4. Ten highest and lowest countries by population size in thousands in the African Region, 2015

Lowest population countries ( population) Highest population countries ( population)

No Country Population No Country Population

Seychelles Nigeria Sao Tome and Principe Ethiopia Cabo Verde Democratic Republic of the Congo Comoros South Africa Equatorial Guinea United Republic of Tanzania Mauritius Kenya Eswatini Algeria Gabon Uganda Guinea-Bissau Mozambique Gambia Ghana

e results of the analysis are presented in the order of the area and its constituent dimensions. Each area starts the areas of the Framework: impact (status of health); with a description of its role in supporting health and outcomes (status of health and related services); outputs well-being, followed by an overall analysis of its status (status of the health system); and inputs/processes and concludes with an analysis of each of its constituent (status of health investments). Each area constitutes a attributes. stand-alone section, to allow comprehensive analysis of

10 WHO African Region

Algeria

Mauritania

Cabo Verde Mali Niger Eritrea

Chad Senegal Gambia

Guinea Bissau Nigeria Ethiopia South Guinea Central African Sudan Sierra Leone Republic Liberia Benin Ghana Togo Burkina Faso Uganda Kenya Democratic Côte d’Ivoire Sao Tome and Principe Gabon Republic Rwanda Cameroon of the Congo Burundi United Equatorial Guinea Republic of Congo Tanzania This report refers to the 47 Member States Seychelles of the WHO African Region, as illustrated Comoros Angola in this map. The WHO African Region does Zambia not include all the countries on the African continent and is not limited to sub-Saharan Africa. Zimbabwe Malawi The “Region” is used when referring to the African Region Namibia Madagascar Mauritius Botswana as dened by WHO, while “Africa” is used when discussing Mozambique the continent as a whole, including its islands. It should be noted that the World Bank divides the African continent into two regions: North Africa and sub-Saharan Eswatini Africa, while UNICEF divides it into three regions: Eastern South Africa and South Africa, West and Central Africa, and North Africa. Lesotho The three-letter ISO country codes below (ISO 3166-1 alpha-3) have been used in some of the gures and tables of the report for conciseness.

Algeria DZA Eswatini SWZ Namibia NAM Angola AGO Ethiopia ETH Niger NER Benin BEN Gabon GAB Nigeria NGA Botswana BWA Gambia GMB Rwanda RWA Burkina Faso BFA Ghana GHA Sao Tome and Principe STP Burundi BDI Guinea GIN Senegal SEN Cabo Verde CPV Guinea-Bissau GNB Seychelles SYC Cameroon CMR Kenya KEN Sierra Leone SLE Central African Republic CAF Lesotho LSO South Africa ZAF Chad TCD Liberia LBR South Sudan SSD Comoros COM Madagascar MDG Togo TGO Congo COG Malawi MWI Uganda UGA Democratic Republic of the Congo COD Mali MLI United Republic of Tanzania TZA Côte d’Ivoire CIV Mauritania MRT Zambia ZMB Equatorial Guinea GNQ Mauritius MUS Zimbabwe ZWE Eritrea ERI Mozambique MOZ

11 © WHO/Julie Pudlowski Part I – Regional report

1 The status of health in the African Region

Attributes of a good state of health in the context of the SDGs

Good health, seen from the perspective of the SDGs, is perceived in a broader context, away from the earlier emphasis on identifying and managing specic diseases. To monitor health in the context of the SDGs, the Regional Oce focuses on healthy and productive periods of life, with health and well-being seen as a function of three attributes: 1. e level and distribution of healthy life that individuals and communities have 2. e level and distribution of conditions that aect health and well-being 3. e level and distribution of risk factors whose presence would aect health and well-being Figure 7. Attributes of good health and well-being in the context of the SDGs

Maximized healthy life

GOOD HEALTH AND WELL-BEING 3 Minimized Minimized exposure to avoidable risk factors to ill health health and and/or well-being death

13 1.1 The state of healthy life in the WHO African Region

Healthy life expectancy is dened as the years one healthy life expectancy, which has increased can expect to live in full health. In the context of the from 50.1 to 53.6 years between 2012 and 2015. SDGs, the analysis of healthy life expectancy is more is suggests an improving trend in overall useful than life expectancy because it distinguishes health and well-being of the persons living in between simply living and living free of disease or ill- the Region. Four countries – Algeria, Cabo health. Verde, Mauritius and the Seychelles – have a 1. e overall average healthy life expectancy is on signicantly better life expectancy compared to an increasing trend in the African Region, from the other countries, and nine other countries 50.9 years to 53.8 years for the period 2012– have a healthy life expectancy under 50 years, 2015. is trend is also seen with the median representing a large loss in healthy life. Figure 8. Healthy life expectancy in the African Region, 2015

44–49

50–54

55–59

60–64

65–70

No data

Cabo Verde Comoros Mauritius Sao Tome and Principe Seychelles World Health Statistics 2017: Monitoring World Source: Source: the SDGs health for

2. ere has been a reduction in the range of base that large population countries have healthy life expectancy across countries in the – 51.1 years as opposed to 55 years. A focus Region in the past 5 years, which went from on these large population countries may yield 27.5 to 22 years. is suggests a reduction of higher improvements in healthy life expectancy dierences between countries of the region, regionally. although the dierences are still signicant. 5. Healthy life expectancy is improving 3. e improvement in healthy life is highest marginally faster amongst countries with low amongst upper middle-income countries, population density, as opposed to those with followed by lower middle income, and lastly higher population densities. Again, this may be by low income countries. High income because they are coming from a lower healthy countries paradoxically are not experiencing life base (51.4 years) as opposed to countries this improving trend – though this should be with higher population densities (54.2 years). A cautiously interpreted given that there is only focus on countries with low population density one high income country in the African Region. would present relatively higher improvements Current evidence suggests this dividend is in healthy life and well-being regionally. maximized when the country attains upper 6. e healthy life expectancy in SIDS is only middle-income status. marginally improving. ese states have unique 4. Healthy life is improving faster amongst large demographic and health make-up and call for population countries. is could be attributed special approaches to accelerate improvements to the overall lower healthy life expectancy in their health and well-being. Many SIDS

14 already have high levels of healthy life, lowering 8. ere does not appear to be a signicant the potential for higher increases compared to variation in the improvement of healthy life other countries. based on a country’s level of spending on health. While the overall healthy life is higher 7. Countries classied as in/recent post-conict in countries spending most, the rate of change in 2010 showed signicant improvements is the same in countries spending least (2.9 in healthy life of their populations. ere is a years versus 3.1 years respectively). signicant healthy life dividend to be attained by focusing on these countries in the Region. Table 5. Trends in healthy life expectancy since 2010

Measure of healthy life expectancy (at birth) Average healthy life expectancy . . . Median value, healthy life expectancy . . . Regional range of healthy life expectancy . . . Healthy life expectancy by country income level Low income countries . . . Lower-middle iIncome countries . . . Upper-middle income countries . . . High income countries . . . Healthy life expectancy for special country categories Large population countries (top ) . . . Small population countries (bottom ) . . . High population dense countries (top ) . . . Low population dense countries (bottom ) . . . Small Island States . . . In-/post- conict states, - . . . Healthy life expectancy by health investment levels High total health expenditure (top ) . . . Low total health expenditure (bottom ) . . . Source: World Health Statistics 2017: Monitoring health for the SDGs

e levels of healthy life in the African Region remain e African Region has a ¥.¦-year gap in healthy much lower than the rest of the world. e Region is life as compared to the Western Pacic Region, the the only WHO region with a healthy life expectancy best performing region globally, representing a major under (¡¢.£ years as compared to the next lowest, disparity for its population. the Eastern Mediterranean Region, at .¥ years). Figure 9. Life expectancy and healthy life expectancy by WHO region, 2015

Source: World Health Statistics 2017: Monitoring health for the SDGs

15 1.2 Morbidity and mortality causes inuencing healthy life in the African Region

Direct causes of ill health and death in the Region and congenital abnormalities (¬.¢« reduction). are varied, with eight conditions in the top ¥ causes. Similarly, the levels of mortality are also getting lower, Lower respiratory infections, HIV/AIDS and with an average crude death rate due to the top ¥ diarrhoeal diseases still represent the top three causes causes of mortality falling from ¯¬.¬ to ¡¥.£ per ¥ of both morbidity and mortality. population. As with morbidity, the reductions in crude It should however be noted that the levels of morbidity death rate were most signicant in the same three are on a signicantly reducing trend. e DALYs per communicable conditions: Malaria (« reduction); ¥ population associated with the top ¥ conditions HIV/AIDS (¡¬« reduction) and diarrhoeal diseases have dropped by half since the year ¢. e largest (¡¢« reduction). Again, the reductions in mortality are drops are associated with communicable conditions, least with noncommunicable conditions, led by road with malaria (« reduction), HIV/AIDS (¡¬.®« injuries (¥« reduction), ischaemic heart disease (¢« reduction) and diarrhoeal diseases (¡.¡« reduction) reduction) and stroke (£« reduction). is reinforces having the highest morbidity reductions. On the other the need for countries to scale up interventions to hand, the conditions associated with the least reductions reduce mortality associated with noncommunicable are all noncommunicable: road injuries (.®« reduction) conditions Table 6. Trends in the top 10 causes of morbidity and mortality, 2015 and 2000

Morbidity cause Mortality cause DALYs lost per population Crude death rate per population Condition Condition Rank change Rank change Lower respiratory -. Lower respiratory . . - infections infections HIV/AIDS - . HIV/AIDS . . - Diarrhoeal diseases - . Diarrhoeal diseases . . - Malaria -. Stroke . . - Preterm birth -. Ischaemic heart disease . . - complications Birth asphyxia and -. Tuberculosis . . - trauma Congenital anomalies -. Malaria . . - Tuberculosis -. Preterm birth . . - complications Road injury -. Birth asphyxia and . . - trauma Neonatal sepsis/ - . Road injury . . infections Total , Average . . .

Source: World Health Statistics 2017: Monitoring health for the SDGs

e overall reduction in disease burden in the African registering a reduction in the total deaths (all causes); Region is more marked than in other WHO regions. all other regions, apart from the European Region, All-cause mortality in the Region has reduced by are registering increases in total deaths. is suggests £¬« since ¢, as compared to ¥« globally. e that eorts to reduce excess/avoidable mortality are African Region is also one of the only two regions bearing fruit in the African Region.

16 Table 7. Comparison of crude death rates and total deaths across WHO regions, 2000 to 2015

WHO region Crude death rate Total deaths (all causes)/ population (all causes) s African . . Americas . . South-East Asia . . European . . Eastern Mediterranean . . Western Pacic . . Global . .

Source: World Health Statistics 2017: Monitoring health for the SDGs

Table 8. Comparison of top 10 causes of mortality in the African Region against dierent income groups

Condition Crude death rate per – top causes African Low-income Lower middle- Upper middle- High-income Region countries income income countries (LICs) countries (MICs) countries (HICs) (UMICs) Lower respiratory infections . . . . . HIV/AIDS . . Diarrhoeal diseases . . Stroke . . . . . Ischaemic heart disease . . . . . Tuberculosis . . Malaria . . Preterm birth complications . . . Birth asphyxia and birth trauma . . Road injury . . . . Chronic Obstructive Pulmonary disease . . . Diabetes Mellitus . . . Liver cirrhosis . Cancers – respiratory . . Alzheimer’s & other dementias . . Cancer – liver . Cancer - stomach . Cancer - colorectal . Kidney disease . Cancer - breast .

Average . . . . .

Source: WHO Global Health Observatory, 2017

17 1.3 Risk factors inuencing healthy life in the African Region

Risk factors inuencing healthy life remain a key area 1. alcohol consumption (6.3 L of pure alcohol of concern in the African Region, as they are associated consumption per capita per year); with fuelling the disease burden patterns observed. e 2. insucient physical activity (82.3% and 87.9% Global action plan for the prevention and control of inactivity amongst male and female adolescents NCDs (¢¥£–¢¢)¥¡ recommends that countries focus respectively); on addressing four conditions (chronic respiratory disease, cardiovascular disease, cancer and diabetes) 3. unhealthy diets (7.7% and 15.1% children and through four risk factors (alcohol abuse, insucient adolescents’ obesity respectively); and physical activity, unhealthy diets and tobacco use). 4. tobacco use (24.2% and 2.4% tobacco use At present, a person in the African Region aged between amongst 15 years old male and females £ and ¬ years has a ¢.¬« chance of dying from one respectively). of these major NCDs, a probability consistent with the Insucient physical activity and unhealthy diet are global pattern or ¥®.¦«. e lowest probability of dying signicantly higher amongst females, while use of from these NCDs is seen in the Region of the Americas tobacco products is higher amongst males. Furthermore, (¥¡.¦«) and the European Region (¥¯.¦«), which may be there is evidence from the WHO STEPwise approach a function of the highly specialized services available to to surveillance (STEPs) surveys in countries of the populations in some countries of these regions. Eorts Region that some of the risk factors – particularly to make available highly specialized services responding tobacco use – are increasing disproportionately more to these NCDs can therefore bear fruit. amongst females than males, especially in adolescents. ere is a signicant risk associated with each of the ese ndings suggest a need for strategies focused on four risk factors contributing to this level of mortality: dierent sexes and age groups.

Table 9. Comparison of risk factor prevalence in the African Region

WHO Region African Americas South- European Eastern Western Global East Asia Mediterranean Pacic

Probability of dying . . . . . . . from any of CVD, cancer, diabetes, CRD between age and exact age , ()

Total alcohol per capita . . . . . . . (> years of age) consumption, in litres of . . . . . . pure alcohol, – . . . . . . .

Percent of –-year Male . . . . . . olds insuciently active, by sex Female . . . . . .

Prevalence of overweight Male . . . . . . . among children and adolescents, by Female . . . . . . . sex ()

Prevalence of smoking Male . . . . . . any tobacco product among persons aged ≥ Female . . . . . . . years by sex

Source: World Health Statistics 2017: Monitoring health for the SDGs

¥¡ http://www.who.int/nmh/publications/ncd-action-plan/en/

18 2 The status of health and health-related population outcomes in the African Region

Attributes of eective health and health-related outcomes in the context of the SDGs

e state of health and well-being is a function of to cover all the populations, irrespective of their the levels of attainment of the dimensions related needs and locations. e six dimensions of health to outcomes – the health and health-related outcomes provide this breadth, irrespective of where a services desired by the population. For sustainable population is within the Region. development, these services must be broad enough Figure 10. Dimensions of health and health-related services in the African Region

Health and well-being for all at all ages

Universal health coverage dimensions

ere is recognition that UHC is an umbrella target ▶ Universality ensures that all persons are targeted within SDG £. UHC is based on universality and without any discrimination – leaving no one sustainability and is underpinned by principles of behind. It denotes a shift of focus from priority eciency, eectiveness and equity spanning health services to vulnerable populations to essential system inputs and processes (interactions across the services for all, at all ages. various building blocks) and health system performance ▶ Sustainability, on the other hand, ensures that outputs as measured by access, quality, demand and gains can be maintained at least over a strategic resilience of essential services. It is achieved in concert planning cycle (3–7 years). It denotes a shift from with health security, service satisfaction and other short term project-driven results, to longer term (non-health) SDG interventions: developmental gains. Figure 11. Attributes of Universal Health Coverage in the context of the SDGs

UNIVERSALITY LITY SUSTAINABI Universal Health Coverage

Source: WHO Regional Oﬃce for Africa

19 To understand the current state of health and health- being able to provide only ¦¯« of health and health- related services in the African Region, the scores of related services that could potentially be provided to each of the dimensions making up the health and its population. related services are consolidated. e value of the is ¦¯« of of provided services masks major consolidated score for the entire Region was .¦¯. disparities between countries in the Region. e Given that a score of ¥ represents the best possible gure below shows the variation across countries of attainment, this score is interpreted as the Region the Region. Figure 12. Comparison of health and health-related population outcomes index by country of the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

Source: World Health Statistics 2017: Monitoring health for the SDGs

e country scores in the Region range from a low All the dimensions underperform in the Region, with of .£¥ to a high of .¬. Only ve countries in the the best only able to provide ¡¬« of what is feasible. Region have a score above .: Namibia (.¢), Kenya All Member States therefore need to review what (.¦), South Africa (.), Seychelles (.¯) and they have available for their populations, with the Algeria (.¬). Algeria, the country with the best aim of identifying and improving the services needed score in the Region, is only able to provide ¬« of the to improve each dimension. e worst performing possible health and health-related services needed by dimensions relative to the others are service availability its population – a worrying situation. (£« of what is feasible), and nancial risk protection (£¦« of what is feasible). Improving population outcomes in the Region will require relatively more eort in improving these two dimensions.

20 Figure 13. Contribution of dimensions of health outcomes indices to the overall index

Source: World Health Statistics 2017: Monitoring health for the SDGs

Further analysis of the health and health-related single high income country level, to .¦¡ in the low population outcomes index is accomplished by income countries, a variation of over ¡«. is again looking at the average of the countries index by illustrates the levels of inequity in the Region, where income level, as dened by the World Bank. e index populations of countries that are better o utilizing for countries increases as country GDP increases, more of the health and health-related services they showing a relationship between country income and need for health and well-being. Innovative methods health and health-related population outcomes. e are needed to improve health and health-related index average ranges from .¯ in Seychelles, the outcomes in lower income countries. Figure 14. Comparison of health and health-related services index by income group in the African Region

Source: World Health Statistics 2017: Monitoring health for the SDGs

A further analysis of the variation of the outcomes as compared to those with the lowest total health index in the Region can be done by looking at country expenditure. ere is also a marginal dierence in the groups based on levels of health expenditure, population utilization score in large versus small countries (a ¦« size and specic focus on Small Island Developing dierence). SIDS countries show a higher index (.¡¡) States (SIDS) countries. ose with higher total as compared to the regional average (.¦¯), suggesting health expenditure show a signicantly higher level that populations in these countries benet from better of utilization of health and health-related services, health and health-related service outcomes.

21 Figure 15. Comparison of health and health-related services index by health expenditures and population across countries of the African Region

Source: World Health Statistics 2017: Monitoring health for the SDGs

Finally, the dimensions related to service availability, to go to attain UHC. It is most often the availability SDG £ services coverage and nancial risk protection of services that scores poorly, as countries have been show a mixed picture. Only four countries had a focusing on improving coverage and/or nancial risk combined score above .: Algeria (.¬), Seychelles protection, without signicant eorts towards making (.¯), South Africa (.) and Kenya (.¦). Since sure a wider range of services are available for their this is just an average across the £ dimensions, it is populations. clear that all countries in the Region have a long way Figure 16. Comparison of consolidated UHC dimensions index across Member States of the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

Source: World Health Statistics 2017: Monitoring health for the SDGs

22 2.1 Availability of essential services across the life course

e availability of essential services is a measure of cross-cutting. As such, deployment of medical ocers which services exist for the population. ose services assumes that the services a medical ocer can provide need to be aligned with health and well-being are available. While this holds true in some instances needs. Availability of essential services represents – and assuming all other inputs a medical ocer needs the ‘forgotten’ arm of UHC; a system that can make are available – there are some cohort-specic services available services that people need at any age group is which the health sector need to proactively plan to on its way to achieving UHC. ensure their provision. ese services are recognized as critical to a given life cohort for their health and In many countries, availability of essential services well-being. e Framework of Actions proposes a set is assumed though the provision of inputs that are of services for each cohort. Table 10. Tracer essential services for each age-cohort Pregnancy and Childhood Adolescence Adulthood Elderly newborn • Antenatal care services • Childhood immunization • Adolescent sexual and • Screening for common • Annual screening and • Perinatal care services • Child nutrition (under and over) reproductive health services communicable conditions medical exams • Care for the new-born • Integrated childhood services • Adolescent/youth friendly • Screening for common non- • Elderly persons social • Postnatal care services • Primary school health services health services communicable conditions support services • Promotion of childhood healthy • Secondary school health and risk factors • Clinical and rehabilitative lifestyles services • Reproductive health services services for the elderly • Harm reduction services including family planning for prevention of drug and • Promotion of adulthood alcohol use healthy lifestyles • Promotion of adolescent • Adult nutrition services healthy lifestyles • Clinical and rehabilitative health services Source: Leave no one behind: strengthening health systems for UHC and the SDGs in Africa. Brazzaville: WHO Regional Oﬃce for Africa; 2017

e assessment of the availability of these tracer of the essential services needed by their populations services across African countries is based on a review to attain health and well-being. is is a very low by a group of key informants in each country (see score, with a signicant amount of eort needed by Appendix ¢ for attributes and emerging scores). countries to increase services within their essential e respondents were asked to identify which tracer packages. Many countries have been dening their services were available to the population. eir essential services as a basic package that is aordable. responses were converted into an overall service However, this package is usually not aligned with the availability index, composed from the normalized needs of the population. A strategic shift is needed values of each age cohort. e overall availability score for countries to move from a budgeting process to a for the Region of .£ shows that on average, the planning process. countries of the Region are only making available £«

Figure 17. Strategic shift needed in making essential services available for populations

Budgeting process Planning process to determine to determine essential services essential services

Determining Determining how what to provide to expand services with available to what their budget populations need

23 e age cohorts for which the services are least the populations health and well-being, and the elderly, available are the adolescents and the elderly. ese who possess a relatively higher disease burden. A two cohorts represent critical age groups for UHC: large proportion (¢¬«) of respondents highlighted the the adolescents, for whom a·iction with disease or absence of ANY services for the elderly population in risk factors has a disproportionately high impact on their countries. Figure 18. Proportion of respondents reporting none of tracer services available for the population

Looking across the ¢® countries that provided making available the services that their populations information on the availability of these essential need for their health and well-being because health services, there is a wide variation across the Region, services have traditionally focused on a small select ranging from a low of . (Tchad) to a high of ¥. set of ‘priority services’. is situation needs to be (Kenya). is overall low score, and the wide variation, quickly addressed to move towards UHC. are a cause for real concern. Health systems are not Figure 19. Comparison of availability of essential services index in countries of the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

24 Even at this low level of availability of essential middle-income countries have a higher average services, there are still variations by income. e indices as compared to other countries. Figure 20. Comparison of access to essential services score by country income groups in the African Region

is variation in availability of essential services is the increased probability of having more services as marginal when looking at the availability of services the health sector grows in size. SIDS countries have by health expenditure. Level of expenditure therefore low essential services available, again a reection of does not drive availability of services. However, the diculty in assuring a wide range of services for a countries with large populations have a higher index small population: value as compared to other countries. is may reect Figure 21. Comparison of access index by health expenditures and population across countries in the African Region

2.2 Coverage of essential health interventions

e availability of essential services only looks at results in terms of improved health and well-being, what is available for dierent age cohorts. However, and vice versa. the presence of services does not mean that they will Essential health interventions need to be provided be utilized as intended by the potential beneciaries. across all public health functions – health promotion, e coverage of essential health interventions looks disease prevention, curative and rehabilitation/ at how well the potential beneciaries are using the palliative. Some of the critical essential interventions services. High levels of utilization imply improved are shown in the Table ¥¥ below.

25 Table 11. Critical essential interventions by public health functions

Domain area Essential interventions

Health promotion Individual / family based healthy behaviours and actions (HPR) Health workplace and safety Behaviour change communication for healthy lifestyles in targeted environments Community initiated and owned health promoting actions Communicable Immunization / vaccinations disease prevention Surveillance for health threats and control Integrated Vector Management (CDC) Environmental hygiene management Prevention & control of common communicable conditions: HIV, Hepatitis, STIs, TB and Malaria Control and prevention neglected tropical diseases Noncommunicable Mental health services disease prevention Violence and injury prevention and control Prevention of cardiovascular disease, cancer, diabetes and obstructive pulmonary disease (NCD) Food quality and safety Prevention of tobacco use, unhealthy nutrition, physical inactivity and harmful use of alcohol Control and prevention of drug and substance abuse Medical and Outpatient care rehabilitative Emergency and trauma care services (CUR) Maternity services Investigative / diagnostic services Inpatient care Operative care Specialized therapies Palliative and end of life care Rehabilitation

Countries should aim to maximize the coverage of have the highest rate of utilization in the Region, these interventions to facilitate movement towards as compared to the other public health functions. UHC. e SDG £ utilization index value of .¡¬ However, as much as one quarter of the population suggests populations in the Region are utilizing is still not utilizing these communicable disease only ¡¬« of interventions needed to attain the interventions. e NCD score is the lowest (.¦¦), SDG £ targets, which is a low level of utilization. showing the very low utilization of interventions e public health function with the highest score is aimed at preventing noncommunicable diseases, communicable disease control (.¬), which implies which is at odd with the high NCDs burden of that interventions targeting communicable diseases disease of the African Region. Figure 22. SDG 3 interventions index by public health function

26 e regional score also shows variations across and Mauritius, Sao Tome and Principe and the Seychelles) within countries. In the Region, this utilization score have a score above .¬, a reection of high utilization ranges from .£ to .¬®, a reection of the range of of SDG £ interventions. utilization that exists. Only four countries (Algeria, Figure 23. Range of SDG 3 interventions utilization index across countries in the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

ere are signicant inequities in the utilization of 3. Countries with lower populations have higher services in the Region. utilization of interventions, compared to 1. ere is a clear dividend in terms of utilization those with higher populations. is may be of services by level of income, with the associated with the relative ease of attaining utilization score increasing with the country coverage interventions in lower population economic ranking. e 11% higher utilization countries, where identifying and accessing non- in high income countries is signicant: this covered populations may be better achieved. trend is only reversed for health promotion e variation is most pronounced with SIDS interventions, whose score is decreasing as the countries, which have a more than 10% higher income level of the country grows. is may utilization score. reect the increasing medicalization of services 4. Inequities in utilization of interventions are in higher income countries. not only between countries; they can also be 2. Countries with the highest health expenditure seen within countries. A review of population have higher utilization of services – with the coverage with essential health interventions highest variation being with curative and relating to reproductive, maternal, newborn and rehabilitative services. Low country spending child health by wealth quintile across African on health shows higher utilization of health countries shows an average of 22% reduction promotion services, an indication of a lower in coverage between the highest and lowest focus on health promotion as countries spend quintile in countries of the Region. more on health.

27 Figure 24. Comparison of SDG 3 utilization index by income group across public health functions in the African Region

Figure 25. Comparison of utilization by health expenditures and population for public health functions in the African Region

Comparison by health expenditure Comparison by country size and SIDS

Table 12. Percentage of population with coverage of essential health interventions related to reproductive, maternal, newborn and child health by wealth quintile in the African Region Country Quintile Quintile Quintile Quintile Quintile (Poorest) Second Middle Fourth (Richest) Central African Republic () . . . . . Chad () . . . . . Democratic Republic of the Congo () . . . . . Sierra Leone () . . . . . Eswatini () . . . . . Togo () . . . . . Ghana () . . . . . Mauritania () . . . . . Nigeria () . . . . . Malawi () . . . . . Zimbabwe () . . . . . Burkina Faso () . . . . . Burundi () . . . . . Malawi () . . . . . Rwanda () . . . . . Source: WHO Global Health Observatory

28 Table 12. Percentage of population with coverage of essential health interventions related to reproductive, maternal, newborn and child health by wealth quintile in the African Region Country Quintile Quintile Quintile Quintile Quintile (Poorest) Second Middle Fourth (Richest) Senegal () . . . . . United Republic of Tanzania () . . . . . Zimbabwe () . . . . . Benin () . . . . . Cameroon () . . . . . Congo () . . . . . Côte d’Ivoire () . . . . . Ethiopia () . . . . . Mozambique () . . . . . Uganda () . . . . . Comoros () . . . . . Gabon () . . . . . Guinea () . . . . . Mali () . . . . . Niger () . . . . . Senegal () . . . . . Democratic Republic of the Congo () . . . . . Gambia () . . . . . Liberia () . . . . . Namibia () . . . . . Nigeria () . . . . . Sierra Leone () . . . . . Togo () . . . . . Zambia () . . . . . Ghana () . . . . . Senegal () . . . . . Source: WHO Global Health Observatory

2.3 Levels of nancial risk protection

Financial risk protection (FRP) aims at reducing ▶ General Government Health Expenditure the nancial barriers communities face in accessing (GGHE) as % of THE: Higher government essential services by ensuring that the nancial spending as a proportion of total health costs of using essential services are minimized for expenditure implies a higher proportion of health households and individuals. Out of pocket payments expenditures are indirect (not paid at the point are recognized as one of the major barriers to of use); accessing essential services, as utilization is inuenced ▶ Out of Pocket Expenditure (OOPS) as % of by a person having the funds required to use needed Private Health Expenditure (PvtHE): Higher out services. of pocket spending within private expenditures imply higher inequities as these expenditures are Financial protection is measured by monitoring the driven by ability to pay, not need; and proportion of the population with large household ▶ Social Security Funds as % of General expenditures on health as a share of total household Government Health Expenditure (GGHE): expenditure (for example, ¥« and/or ¢¡«). is Higher spending on health social security implies information is not available in all countries, as it that more government spending is pooled for requires a nationally representative survey that health use. contains both information on household expenditure on health and household total expenditure. As a e FRP index of .£¦ suggests protection is only at proxy, the analysis is based on a score derived from £ £¦« of what is feasible in the Region. is index varies commonly available indicators: markedly between countries, ranging from a low of .¥ to a high of .¬ out of a possible ¥.

29 Figure 26. Country nancial risk protection index

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

is level of the FRP Index is primarily driven by low lead towards UHC, it is important for countries to investment in social security funding by governments critically look at how they can increase the focus of (score of .¥ versus .£¡ and .¡¢ for OOPS and their funding towards social security. government spending, respectively). Many countries e FRP Index is also dependent on the level of have not introduced social insurance mechanisms for income of the country – the higher the income health due to the perceived high costs governments classication, the higher the Index. e nancial risk would have to incur, subsidizing those with low protection in low income countries is less than half ability to pay and covering at least the start-up that in high income countries, a trend seen with all management costs. However, for eective movement the three indicators used to derive the score.. towards nancial risk protection in a manner that will Figure 27. Comparison of nancial risk protection score by income group across nancing indicators in the African Region

Inequities are also seen based on the overall health higher the nancial risk protection – though this expenditures. e countries with the highest health pattern is reversed for social security funding, with expenditures also have the highest nancial risk higher population countries having higher spending protection Index – more than double that for the on social security. is may be a result of a preference countries with the lowest health expenditures. is for government funded and managed services in suggests health expenditures are increasingly spent smaller countries, where social security mechanisms in areas that provide better nancial risk protection. may not provide the economies of scale needed to run Additionally, the smaller the country population, the them.

30 Figure 28. Comparison of nancial risk protection by health expenditures and population in the African Region

Comparison by health expenditure Comparison by country size and SIDS

2.4 Levels of appropriate health security

Health security is a key measure of UHC in the vulnerable to events and to respond to their needs. African Region, given the devastating eect of disease Health security is assured if a country can build core epidemics and health emergencies on health and well- capacities to prevent, detect and respond eectively being, as shown by the devastating ¢¥¦–¢¥¡ EVD to outbreak and disaster events that inuence health. epidemic in West Africa. Such country capacities are monitored using the e region is particularly vulnerable to outbreak events, International Health Regulations (IHR) framework. with an average of over ¦ events being monitored at Countries need to build core capacities across ¥® areas any given time. is high vulnerability calls for a need in the three health security domain areas listed below to focus on identifying and monitoring populations to ensure an adequate level of health security.

Table 13. IHR areas for building core capacities for health security Health security domain Core capacity area Prevention National Legislation, Policy and Financing IHR Coordination, Communication and Advocacy AMR Zoonotic Disease Food Safety Biosafety and Biosecurity Immunization Points of Entry (PoE) * Detection National Laboratory Systems Real-Time Surveillance Reporting Workforce Development Response Preparedness Emergency Operations Centres Linking Public Health with Law and Multisectoral Rapid Response Medical Countermeasures and Personnel Deployment Risk Communication Other Chemical Events Radiation Emergencies

31 Based on countries’ feedback regarding these e score in the African Region masks a wide range of respective capacities, WHO has developed for each capacities, which range from .¥¯ to ¥.. is wide range country an IHR score for ¥£ core capacities for which of core capacities is being reected in the large number cross-country comparative data exist. of new and/protracted health security events, due for example to dengue, regular Viral Haemorrhagic e latest value shows that only ¡¬« of the required Fevers (VHFs), plague or yellow fever), normalized capacities exist in countries in the Region. is is the outbreaks, such as cholera, and humanitarian crises. lowest score across all WHO regions, with the next Cameroon, Côte d’Ivoire, Seychelles, South Africa lowest, the Eastern Mediterranean Region, having a and Zambia have the highest health security scores, score of ¬¦«. e highest scores are ¯« in the South- above .¯. On the other hand, ¥ countries have IHR East Asia and European regions. is reects the high scores under .£, representing critical focus countries global discrepancy in health security, and the need for for improvement of health security. major focus and investment in the African Region.

Figure 29. Average and range for IHR core capacity index of countries in the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

To better understand the root causes of the IHR in the past two years. e average JEE score for these scores for countries in the Region, information from ¢¢ countries is .¬£, with the highest values attributed the Joint External Evaluation of the core capacities to the detection capacity followed by prevention. e for implementation of the International Health response capacity score is the lowest of the three JEE Regulations (IHR ¢¡) of the WHO Health areas, reecting the low capacity to respond to health Emergencies Programme was analysed. Only ¢¢ of the threats, even if the countries can detect them. ¦¬ countries of the Region have completed their JEEs

32 Figure 30. Health security score by domain areas

ere is also evidence of inequities in the countries and detection capacities. e variation in detection health security status. ere is a clear correlation capacity by income level does not appear signicant, between the IHR score and the level of income, with but the response capacity is the opposite, with higher the high-income countries having the highest and the response capacity in the lower income countries. low-income ones the lowest scores. e level of health is may reect the focus on response in low income security is ¦« lower in the low-income countries as countries, as compared to a focus on prevention in the compared to the high-income ones. Based on the higher income countries. JEE scores, this trend is mainly driven by prevention Figure 31. Comparison of health security status by JEE domain areas in the African Region

A similar trend is observed when countries are Finally, health security is more robust across all the compared by their levels of health expenditure. ose health security areas in large countries as compared to with higher health expenditures have marginally small or SIDS countries. better health security than those that spend the least on health.

33 Figure 32. Comparison of health security by health expenditures and population in the African Region

Comparison by health expenditure Comparison by country size and SIDS

2.5 Responsiveness of essential services to population needs

Service responsiveness recognizes that the interaction In this analysis, the attributes used to look at process during care inuences outcomes and use of responsiveness were dignity, autonomy, condentiality, the available services. is is important for UHC prompt attention, access to social support, quality of in ensuring that essential services are provided in a basic amenities and choice of care providers. Key manner that responds to the legitimate needs of the Informants knowledgeable about health services recipients, thus improving utilization and desired in countries have shared their perception of their health outcomes. A country where services are health system’s responsiveness. From these responses, responsive to the needs of the population will have responsiveness scores – representing the proportion of better health outcomes, and so accelerate its progress responses that were positive in terms of the respective towards UHC. attributes – were generated for each attribute. e responsiveness index was the average of these scores. WHO has been carrying out normative work on e index value (.¦¬) is primarily driven by access to responsiveness since the publication of the ¢ World ¥ social support (.¬£), while quality of basic amenities Health Report , which recognized responsiveness as (.¢¬) and autonomy (.£¬) represent the lowest one of the goals of any health system. Many attributes performing areas of responsiveness. for responsiveness have since then been crystallized.

Figure 33. Scores for dierent attributes of service responsiveness for the African Region

¥ World Health Organization. (¢). e World Health Report: ¢ : Health systems: improving performance. Geneva: World Health Organization. http://www.who.int/iris/handle/¥¡/¦¢¢¯¥ accessed on ¥¡ March ¢¥¯).

34 Dignity – ¡¦« of the respondents agreed that clients are Con dentiality – ¡¦« of respondents agreed that treated with respect during the care process compared consultations between clients and providers is to ¢« who disagreed. e rights of clients with carried out in a manner that protects condentiality. potentially stigmatizing conditions were perceived ¦®« of respondents believed that condentiality of to be eectively safeguarded by ¦£« of respondents. information provided by clients is preserved, except if Only ££« of respondents believed that clients were needed by other providers to further the care process. encouraged to discuss their concerns and needs freely A lesser proportion of respondents (£«) agreed that during the consultation process, compared to ££« medical records are preserved in a manner that ensures who disagreed. Only £¯« of respondents agreed that that there is limited or no chance of their leaking respect is shown for a client’s desire for privacy during to unauthorized users, as compared to ¢« who the consultation process as compared to ¢£« who disagreed. Respondents pointed to challenges in ling disagreed. Respondents indicated that while service systems, especially in public facilities, which reduces providers had been sensitized to issues of client rights the ability to achieve maximum condentiality. Such and dignity such as privacy and stigma, there existed issues include poor medical record management and some contradictions in the eective implementation insucient numbers of medical record assistants. Space of policies to support approaches to dignied care. to keep records is a challenge, and there are cases where ese included heavy client ows and inadequate sta clients can take their les home. In general, the opinion numbers, preventing sta from taking their time to of the respondents was that while condentiality was address client concerns, and infrastructural challenges largely upheld, it was not totally guaranteed. which hindered privacy – particularly acute in public Prompt attention – Just ¥¢« of respondents felt facilities as compared to private facilities. Respondents that clients can get to a facility oering services they also noted the existence of stigma in some cases, and need in under £ minutes, as compared with ¯« a need to increase awareness of patient charters where who disagreed. Furthermore, only ¬« of respondents they exist. As one respondent noted: thought that clients usually spend under £ minutes “Client dignity remains an ideal in the health at a, facility before they received services, in contrast sector, despite its universal appeal.” with ¯¥« who disagreed. ¥£« of respondents agreed that clients will usually receive all the services they Autonomy – ¦« of respondents agreed that client need within ¢ hours of arriving at a health facility consent is explicitly sought before testing or starting as compared to ¢« who disagreed. at clients to manage their conditions. In comparison, only will usually spend an unnecessarily long time £¡« of respondent felt that clients are provided with waiting for elective procedures was agreed by ¬¥« information on alternative management options, of respondents. Respondents referred to inadequate as compared to ¢¡« who disagreed. Only £¥« of numbers and cadres of human resources, long queues respondents agreed that clients are consulted, and due to overcrowding and congestion, especially in that their views were considered in relation to their public facilities (and perhaps as well in secondary management preferences of their conditions, as and tertiary facilities), lack of health facilities near compared to ¢¯« who disagreed. Again, respondents households, particularly in rural settings, and service drew attention to the variation in care between private delivery organization within facilities (such as triage and public facilities. Respondents also articulated the capacities) as reasons for delayed attention. information asymmetry between clients and providers as a challenge to client autonomy in all cases: Access to social support – Respondents were largely in agreement that during the care process, clients “e health workers’ – especially clinicians’ – word should be allowed to receive guests, that families and is taken by and large as truth. Most clients are not friends should be allowed to cater for their personal enlightened enough to provide their views. Health needs (both £«), and that clients should also be workers on the other hand take advantage of client allowed to be involved in religious activities (¢«). ignorance. Due to workload, health workers seem Respondents pointed to the inadequate levels of to be in a hurry to nish their work and hence most stang, which necessitated additional social support of the time do not encourage a discussion with the and care from family and friends. Faith-based clients. In rare occasions, and especially with well- activities were allowed where they did not interfere educated clients who more than not have access to with patient care. information, then they do provide their views and health workers do then comply.”

35 Quality of basic amenities – ¦®« of respondents Choice of care providers – is was assessed by agreed that health facilities are usually clean. However, respondents as being low for clients’ choice on only £¥« of respondents agreed that linen and other providers in each facility (¡« of respondents personal items provided to clients were usually clean disagreed that this was the case, and ¢¥« of and appropriate. ¢¥« of respondents believed that respondents strongly disagreed). In contrast, £¯« of water and sanitation services for clients were usually respondents believed that clients usually did have a adequate in health facilities and ¢« of respondents choice of facilities providing their required services, agreed that food for clients was usually adequate whereas £®« disagreed; ££« of respondents believed for their nutritional needs. Respondents further that clients could freely seek a second opinion without commented on the dierences between private and fear of penalization, compared to ¢« who disagreed; public health facilities and that, in particular, the and £¦« of respondents viewed clients as having the provision of food and linens was seen as one of the opportunity to see specialists if they wished compared social supports provided by the clients’ families. Often, ¢¥« who disagreed. Respondents noted poor stang the lack of adequate nutrition was linked not only to in health facilities which limits choice within its non-inclusion in a facility’s budgets, but also the facilities, as well as the nancial aspects and payment lack of any dietary plan, or absence of nutritionists. mechanisms which limit choice options for the poor. One respondent made the following comment: e overall service responsiveness varies across “To the extent possible, cleanliness of buildings countries of the Region, from a high of .¯¡ to a low and surroundings is ensured, but patients are of .¥¦. e Seychelles registered a very high level of not provided with food, and water is not always responsiveness, which is signicantly dierent from suciently available.” the other countries. Eswatini also showed high levels of responsiveness. Figure 34. Comparison of service responsiveness index across countries of the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

36 e levels of responsiveness appear to be inuenced of higher income levels having provided information by the country’s income level: the higher the income on responsiveness. For lower middle and low-income level, the higher the level of service responsiveness. countries, for which there were many countries is perspective however needs to be interpreted with information, the responsiveness score is not with caution, due to a limited number of countries signicantly dierent, varying by only .£ points. Figure 35. Comparison of responsiveness index by income group for countries in the African Region

e variation amongst countries is more distinct Additionally, services are more responsive in smaller when comparing countries with highest versus lowest countries than larger countries, with SIDS having the total health expenditures. Services are perceived to be highest levels of service responsiveness. more responsive where health expenditures are higher. Figure 36. Comparison of service responsiveness index by health expenditures and population in the African Region

37 2.6 Coverage of health-related SDG targets

e health-related targets across the other SDGs are ¡¬« of what it can achieve with regard to targets classied into social, economic, environmental and across the health-related SDGs. ere is clearly work political determinants. e index score of .¡¬ is an to be done to improve this score. Again, the scores average from the values of indicators constituting vary widely between countries, ranging from .¦¡ to these targets. e African Region is only achieving .¯. Figure 37. Variation of the coverage of non-SDG 3 targets index across countries in the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

Of these determinants, the environmental of the economies in the Region is driving the non- determinants contribute highest to the overall index performance of health-related SDG targets, with low (.¡) while the economic determinants drag down infrastructure being the primary driver. the index the most (.¦). e overall low performance Figure 38. Contribution of dierent domains to overall non-SDG 3 targets indices amongst African countries

ere are also inequities in coverage of health-related SDG services, apart from governance where SDG targets across countries, shown across four areas. there is no signicant dierence between 1. Countries with higher income levels have countries of dierent income levels. e high- higher levels of utilization of health-related income country group has also reached the SDG interventions. is pattern exists environmental targets score needed for eective across all the domain areas of health-related contribution to health and well-being.

38 Figure 39. Comparison of non SDG 3 health targets Index by income groups in the African Region

2. Countries with the highest health expenditure ii) e higher the health expenditure, the have higher coverages for health-related SDG better the quality of stewardship leading targets, apart from those in the governance to better inuence on health-related SDG domain. is is unexpected, as it is usually targets in other sectors. assumed country health expenditures are spent 3. Countries with lower populations have higher on SDG 3 health targets. is nding could be coverage of health-related SDG 3 targets, as suggestive of several issues: compared to those with higher populations. is may be associated with the relative ease i) e higher the health expenditure, the higher of attaining coverage interventions in lower the chance that funds are spent on some population countries, where identifying and of the health-related SDG interventions accessing uncovered populations may be better inuencing health, or achieved. e variation is most pronounced with SIDS countries. Figure 40. Comparison of non-SDG 3 health targets index by health expenditures and country categories in the African Region Comparison by health expenditure Comparison by country size and SIDS

4. We see evidence of these inequities even poorest population had less than 30% access17. within countries. Across 19 countries in 2016, e absence and inequitable distribution of over 40% of children under-5 years of age water has huge implications on sanitation in the lowest income quintile had chronic and hygiene, often resulting in high burden of malnutrition, compared to less than 20% in the diseases such as cholera, typhoid fever, malaria, richest quintile. e richest quintile population yellow fever which can rise to epidemic group in most countries had over 50% access proportions18. to improved sanitation facilities, while the

¥¬ WHO (¢¥). Atlas of African Health Statistics ¢¥. Health situation analysis of the African Region. African Health Observatory, World Health Organization Regional Oce for Africa ¥¯ WHO (¢¥¬). Financing universal water, sanitation and hygiene under the sustainable development goals. UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS) ¢¥¬ report. Geneva: World Health Organization; ¢¥¬ 39 Table 14. Percentage of population with access to improved sanitation by wealth quintile in the African Region.

First quintile Second Third Fourth Fifth quintile (poorest) quintile quintile quintile (richest) Algeria () . . . . . Benin () . . . . . Burkina Faso () . . . . . Burundi () . . . . . Cameroon () . . . . . Central African Republic () . . . . . Chad () . . . . . Comoros () . . . . . Congo () . . . . . Côte d’Ivoire () . . . . . DR Congo () . . . . . Equatorial Guinea () . . . . . Eritrea () . . . . . Eswatini () . . . . . Ethiopia () . . . . . Gabon () . . . . . Gambia () . . . . . Ghana () . . . . . Guinea () . . . . . Guinea-Bissau () . . . . . Kenya () . . . . . Lesotho () . . . . . Liberia () . . . . . Madagascar () . . . . . Malawi () . . . . . Mali () . . . . . Mauritania () . . . . . Mozambique () . . . . . Namibia () . . . . . Niger () . . . . . Nigeria () . . . . . Rwanda () . . . . . Sao Tome and Principe () . . . . . Senegal () . . . . . Sierra Leone () . . . . . South Sudan () . . . . . Togo () . . . . . Uganda () . . . . . United Republic of Tanzania () . . . . . Zambia () . . . . . Zimbabwe () . . . . . Data source: Data from latest population survey (MICS, DHS). The databases of population-based surveys such as DHS or MICS have disaggregated data and 41 countries had fully disaggregated by wealth quintiles. Wealth quintiles are developed using social and economic indicators. Countries without disaggregated data wealth/socioeconomic indicators data were excluded from the analysis

40 Table 15. Percentage of population with access to improved sanitation by wealth quintile in the African Region. First quintile Second Third Fourth Fifth quintile (poorest) quintile quintile quintile (richest) Algeria () . . . . .

Benin () . . . . .

Burkina Faso ( ) . . . . .

Burundi () . . . .

Cameroon () . . . . .

Central African Republic () . . . . .

Chad () . . . . .

Congo () . . . . .

Côte d’Ivoire () . . . . .

DR Congo () . . . .

Eswatini () . .

Ethiopia () . . . .

Gabon () . . . .

Gambia () . . . .

Ghana () . . . .. ..

Guinea () . . . . .

Guinea Bissau () . . . .

Kenya () . . . . .

Liberia () . . .

Madagascar () . . . .

Malawi () . . . .

Mali () . . . . .

Mauritania () . . . . .

Mozambique () . .

Niger () . . . .

Nigeria () . . . . .

Sao Tome and Principe () . . ..

Sierra Leone () . . . .

South Sudan () . . . . .

Togo () . . .

Uganda () . . . .

Zambia () . . . . .

Zimbabwe () . . . . .

Data Source: Population survey data (MICS, DHS). Countries without data disaggregated by social parameters were excluded from analysis

41 3 Health systems performance in the African Region

Attributes of a performing health system

A performing health system is one that can ensure all elements of the system needed to provide the the delivery of essential health and health-related respective service services to the population where and when they are ▶ Systems-focus on investing in specic building needed. Health systems – investments primarily blocks to make them functional, without made to facilitate the organization of the people, investing in related building block interventions institutions and resources needed to deliver health needed to deliver required services and health-related services – have traditionally been e assessment of health system performance therefore dened using the WHO’s concept of six building needs to move from assessment of individual building blocks¥®. However, this approach has led in practice to blocks to measures that look holistically at the results the verticalization of the eorts at improving health arising from investments across dierent building systems, with a focus on intervention within specic blocks. e WHO African Region, in its Framework blocks, as opposed to the interactions across building of actions, proposed a focus on the eect of health blocks. Examples of this verticalization abound: ¢ system investments on four areas, as highlighted in ▶ Disease programmes have primarily invested in the table below. selected elements of the building blocks (mainly health products/vaccines supply or training) ese represent the desired results arising from to attain health and health-related service investments in the health system. By improving in outcomes, without comprehensively investing in these four areas, the delivery of essential health and health-related services is assured.

Table 16. Attributes of health system performance Attribute Description Measures of achievement Access to health and Removal of physical barriers faced by the population Health and health-related services are health related essential that hinder their use of services. This is primarily through close to households and communities, services making available hardware needed to deliver services allowing their utilization as and when – health workforce, infrastructure and equipment, plus needed medicines and products – as close to the population as is feasible.

Quality of care during How well the services being provided are aligned to Health and health related services provision of essential the legitimate needs of the clients. This includes the provision is designed in a manner to health and health-related experiences during use of essential services, safety maximize possible benets for the services elements and eectiveness of provided interventions. household and community

Eective demand for Knowledge, attitudes and practices of households and Households and communities are health and health-related communities that lead to their use of available essential utilizing available health and health- essential services health and health-related services. related services in a manner that maximises their health and well-being

Resilience in provision The inbuilt capacity of the system to sustain provision of Households and communities of essential health and essential health and health-related services even when continue to access health and health- health-related services challenged by outbreaks, disasters, or other shocks related services even when the system is responding to shocks

¥® http://www.who.int/healthsystems/strategy/en/ ¢ e areas of eciency and equity are not considered health system performance measures. ese rather are measures of health sector performance – how well the existing system can deliver sought after health outcome results.

42 Figure 41. Attributes of health system performance

ACCESS to essential services

RESILIENCE QUALITY to of provided shocks services DEMAND for essential services

As there is no cross-country data in the African ◆ Person-centredness indicators from key Region to monitor and analyse the performance of informants’ perspectives relating to dignity, health systems using these attributes, proxy variables condentiality and prompt attention are used instead. ▶ A demand index is derived from the analysis ▶ An access index is derived, based on availability of of drop-out rates for services requiring repeat key inputs needed to provide services. Indicators interventions. Demand is eective if clients used to derive the score are for availability of the come back for the repeat services. e services tangible health system investments: with most consistent data and which are used as ◆ Health workforce, focusing on physicians, a measure of demand are: nursing and midwifery, dentistry, ◆ DPT 1–3 drop-out rates pharmaceutical, laboratory, environmental, ◆ BCG–measles drop-out rates community, support and other health ◆ ANC 1 to ANC 4 drop-out rates workers per 1000 population ◆ TB initiation to completion rate (TB ◆ Health infrastructure, focusing on hospital completion rate) beds, hospitals, health posts, health centres, ▶ A resilience index is derived from the analysis of district hospitals, provincial hospitals and responses from key informants in relation to the specialized hospitals per 100 000 population dierent resilience attributes in their systems. ◆ Health products, focusing on mean ese include: availability and median consumer price ◆ Awareness ratios for selected generic medicines in ◆ public and non-public sectors Diversity ◆ ▶ A quality of care index is derived, based on Versatility and self-regulation selected outcomes reective of quality of care ◆ Mobilization, adaption and integration received, plus specic readiness and person- Based on these indices, the consolidated health system centredness indicators: performance score for the African Region is .¦®, which ◆ Tuberculosis (TB) treatment success, means that health systems are only functioning at a suicide rates and diabetes mellitus deaths are possible ¦®« of their achievable level of performance. indicators used as a measure of outcomes. ere is wide variation in system performance across ese should improve if the quality of care the Region, with the consolidated score ranging from provided is improved .¢ to .¬. is implies that the best performing ◆ Service readiness score is based on the system in the African Region is only performing at Service Availability and Readiness ¬« of what is feasible. However, most of the countries Assessment (SARA) surveys data (¦¥ out of ¦¬) performance ranges from .¦ to ., a rather narrow performance range.

43 Figure 42. Variations in health system performance amongst countries in the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

e performance of a few countries needs further better than expected. is is most probably elaboration and analysis: related to the diculty in having reliable data ▶ e performance of Angola is rather low (0.26). from these countries, due to information system e country was in conict for a long time, breakdown. e indicator data used to construct hampering comprehensive system building indices for these countries are either missing, or eorts. Following the war, system building has not reective of their current situations. focused strongly on some elements, such as All the indices that constitute this overall performance specialized workforce. level are underperforming. System resilience and ▶ e performance of countries with recent political access to essential services are performing at the challenges that are known to have negatively lowest levels of the attributes. Marked improvements aected their health systems functionality (such in systems performance are required for eective as Burundi, South Sudan and Zimbabwe) seems movement towards health and well-being. Figure 43. Contribution of performance indices to the overall system performance index

44 A further analysis of system performance shows that income systems even though they have economically the higher the level of income of the country, the graduated. A signicant variation is noted when better performance is. is ‘income dividend’ is most countries become upper middle-income. is nding likely a result of more investment available in the has implications for how countries are graded and system as a country’s level of income rises. However, supported by the international community. Lower system performance is not markedly dierent between middle-income countries remain disadvantaged low-income and lower middle-income countries. because they lose access to international development is similarity in performance is likely a result nancing, while their systems and infrastructure of the middle-income countries still having low- continue to resemble those of low-income countries. Figure 44. Comparison of health system performance index by country income level

is variation in health system performance by the lowest total health expenditure. e nal variation income level is further illustrated when we look at the appears to be seen across country populations and performance by total health expenditure. Countries sizes: larger countries’ performance is lower than with the highest total health expenditure clearly have smaller countries’ – with the SIDS having the best systems performing at a higher level than those with health systems performance. Figure 45. Comparison of health system performance index by health expenditures and population in the African Region

45 3.1 Access to essential services in the African Region

e level of access that populations have to health is eorts towards attaining UHC and other health re- a major determinant of whether essential health and lated targets needed for health and well-being of their health-related services can be provided to support the populations. attainment of their health and well-being. Health in- e access index varies signicantly between coun- vestments in the workforce, infrastructure/equipment ¢¥ tries, ranging from a low of .¥¢ (Central African and supplies remain low in the Region, as shown by ¢¢ Republic) to a high of .¬ (Mauritius) . Only three the low access index of .£¢. On average, the systems countries – Mauritius, Seychelles and Sao Tome and in the region are only able to assure £¢« of the po- Principe (All SIDS) have an access index above .¡, tentially possible access to essential services. is will highlighting the very low levels of access in the Re- continue to be a major hindrance to Member States gion. Figure 46. Index of access to essential services amongst countries in the African Region

No data

Cabo Verde Comoros Mauritius Sao Tome and Principe Seychelles

e proxy indicators used to measure access are largely income countries have up to three times the level resource-dependent. As a result, we would expect to of access to services as the low-income countries in see countries investing more in health having higher the Region. is has signicant implications on the values of access. In comparing countries by income ability to attain UHC and the health and well-being level, there is a consistent improvement in access to goals, which are largely dependent on the population services, the higher the GNI of the country. High being able to access the essential services they need.

¢¥ ese are proxies used for access, based on cross country data availability issues. ¢¢ Statistics with data for South Sudan and Rwanda were too limited to be included in the analysis

46 Figure 47. Comparison of access index by income level between countries in the African Region

is variation in access is further seen in levels of associated with improvements in access to services. health expenditure and country sizes. ere is a Additionally, a country’s size and population matter, two-times variation in access to essential services with access improving the smaller the country size in countries with the highest THE, as compared to and population are. those with the lowest. Increasing THE is therefore Figure 48. Comparison of access index by health expenditures and population in the African Region Comparison by health expenditure Comparison by country size and SIDS

3.2 Quality of care in the African Region

e quality of care remains a key determinant of that reduce quality of care to maximise the benet utilization and UHC in the Region. A signicant of investments made. However, quality of care is amount of eort has gone into improving availability a dicult dimension of performance to measure. of services, with less focus on the quality of those e Who Framework of actions characterises three services. For sustainable and eective utilization important attributes of quality, all related to the care of services, populations need to be sure the services process: client perceptions of the care process based they receive are going to help them. Poor service on their experiences, level of safety (no harm done) quality erodes that belief. As such, it is important during the care process; and the eventual eectiveness for a system to proactively plan and address issues of care provided.

47 Figure 49. Attributes of the quality of care dimension

QUALITY CARE

Client perception Safety Eﬀectiveness of the care process assurance during of the care the care process process

e indicators for which there were comparable data estimate) and suicide rates (age-standardized per across countries were TB treatment success, Service ¥ population)¢£. e quality of care index of readiness score (from SARA surveys), Person-centred .£ shows that quality of care in the Region is only care score (dignity, condentiality, prompt attention £« of what is feasible. is varied markedly between scores arising from key informants responses), dia- countries in the region, from a low of .¢¡ to a high betes mellitus, deaths per ¥ (age-standardized of .®¦. Figure 50. Quality of care index ranges across countries in the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

Only ve out of the ¦¬ countries of the Region the average score for high, middle and low-income have a quality index above .¬¡: Seychelles, Algeria, countries doesn’t show any signicant pattern. Apart Madagascar, Malawi and Zambia in order of from the high score for the high-income country, performance. countries with lower levels of income indicate the e quality of care score does not seem to be inuenced same level of quality of care. by the level of income of the country. Comparing

¢£ Data were from the Global Health Observatory, apart from the person-centred care scores from the key informants.

48 Figure 51. Comparison of quality of care index by country income groups

A similar lack of trends is noted when the average variations are present but are too small to be able to quality of care scores by total health expenditures and condently discern a pattern. by country sizes and populations are compared. e Figure 52. Comparison of quality of care index by health expenditures and population in the African Region

ese ndings suggest that progress in improving of nancing in a country. Eorts to improve quality quality of care can be made, irrespective of the level of care should be universally applied in the Region. 3.3 Demand for essential services in the African Region

e eective demand for essential services reects the systems are providing the services that people want potential for households and communities to utilize for their health and well-being. ere is still scope for the essential preventive and curative services they improvement though, as the score of ¬« in eective need. By analysing demand based on repeat services, demand is still low to reach eective performance. we can identify how well the services provided are More targeted eorts at ensuring services provided aligned to the needs of the people. If demand is poor, are what people want and educating populations on it suggests services being provided are not valued by the value of available services are needed to improve the population. the eective demand for services. e demand score for countries in the African e eective demand varies signicantly across Region is relatively high as compared to other countries, with the lowest country having an eective performance measures. is implies that health demand that is half that of the highest countries.

49 Figure 53. Country eective demand index for essential services score ranges

0,44 - 0,53 0,54 - 0,64 0,65 - 0,75 0,76 - 0,86 0,87 - 0,98 No data

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

e variations in eective demand across countries demand for other income groups does not appear to be does not appear to be driven by the level of income, as signicant. is may reect the dierent approaches seen with some of the other health system performance taken to build up eective demand, which can be variables. Apart from the single country in the high- applicable in high or low-income settings. income category, the variation in the average eective Figure 54. Comparison of eective demand index by level of income between countries in the African Region

A similar lack of variation is also seen when comparing demand does not appear to be driven by any of these countries with high and low total health expenditure, variables. Only SIDS have a clearly higher level of and countries by population. e variation in eective eective demand compared to other countries.

50 Figure 55. Comparison of eective demand index by health expenditures and population in the African Region

3.4 Resilience of health systems for essential services provision in the African Region

e low score for resilience in the African Region is a Resilience levels vary signicantly across the Region. direct cause of the frequent and devastating eects on Data were available for £¦ out of the ¦¬ countries in service delivery arising from outbreaks and disasters. the Region. eir relative resilience ranged from ¡« to Countries facing these shocks will usually witness ¯®«. It is interesting to note that the countries most signicant reductions in health services outcomes because aected by EVD – Guinea, Liberia and Sierra Leone of poor resilience. Resilience levels in the Region are only – all have resilience scores above the regional average, at £®« of what would be needed to sustain delivery of which suggests that lessons were learnt and the right essential services during outbreaks and disasters. investments made. Figure 56. Comparison of resilience index across countries of the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

51 Health systems resilience appears to be inuenced by therefore could be looked at as a function associated the country income category. e higher the income with income levels, though this association is not very level, the higher the level of resilience¢¦. Resilience strong.

Figure 57. Comparison of resilience index by country income category

In addition, countries with higher levels of total smaller countries appear more resilient, with SIDS health expenditure show a higher level of resilience. showing a markedly higher level of resilience. is suggests a resilience dividend can be gained through better investment in health. Additionally, Figure 58. Comparison of resilience index by health expenditures and population in the African Region

¢¦ e upper-middle-income countries appear to move against this trend, though this may be a result of only having data for one of the countries in this group.

52 Key respondents largely agreed that there are pre-ex- modelling of major health risks (¢« disagreed, isting capacities to mobilize regional technical sup- £¦«strongly disagreed and £¦« were undecided); (¦) port (¦¢«) and global nancial and technical support simulation exercises to mimic logistics response to (¡¬«) in the event of shocks and stresses. In general, stress events of the highest occurrence (¥¢« disagreed, respondents noted there were several international ¢¯« strongly disagreed and £« were undecided). frameworks and coordination mechanisms in place, On the variable of health system diversity, there was such as IHP+ or UNDAF, and country assistance was high agreement that primary healthcare facilities were continuously sought. However, the degree to which providing at least ¯« of the essential services they are such mechanisms were country-owned and driven expected to provide (¦£«), and that there was a clear was uncertain. Respondents perceived legal frame- strategy to scale up the provision of essential services not works (¦£«) and policy environments (¢«) to be ad- currently being provided (¦¡«). Respondents were in equate and comprehensive enough to guide response lesser agreement that barriers hindering access to essential recovery eorts in the wake of stress events. Respond- services (for example, physical, nancial and/or social) ents commented in some cases on the outdated nature were minimized (¢¯«), that health facilities had basic of some health legislation. Several noted the changing capacities needed to provide a broad range of essential contexts of decentralization and the need to strength- services (such as amenities, equipment, medicines, en legal enactment, coordination and oversight at standard precautions for infection prevention) (¢¯«), sub-national levels. ¦¦« of respondents believed that and that sta were appropriately skilled and supervised the IHR core capacities of the health sector were ap- to identify uncommon events when they occur (¢®«). propriate to facilitate prevention, detection and response to a stress event, while ¢« disagreed and ¢« In terms of mobilization, adaptation and integration, were undecided. Emphasis was placed on strengthen- ¡« of respondents agreed that functional mechanisms ing the IHR sub-national focus. ere was indication exist for communication and engagement with non- in some countries that though coordination structures public health partners working within the areas existed, they were not operating optimally. of responsibility of primary care facilities. ¡¬« of respondents agreed that functional mechanisms exist Respondents largely disagreed that health workforce for communication and engagement of primary care numbers were appropriate for the delivery of the facilities with communities they are working with. country’s dened essential service (¦« disagreed, ¦¯« of respondents agreed that there are regular ¢¯« strongly disagreed and ¥¡« were undecided). £« mechanisms (annual, for example) to monitor health of respondents disagreed that there exists adequate system performance and ensure its constant adaptation levels of health worker social capital and empathy – a to changing health needs. Only ££« of respondents level of togetherness, trust and responsibility shared felt that functional communication mechanisms with the community; ¢£« strongly disagreed and ¥¯« existed with other sectors. ¢£« of respondents agreed were undecided. that there were pre-agreed mechanisms to share On the variable of health system awareness (of events personnel, funds and capacities amongst stakeholders and potential shocks) there was widespread agreement working within their areas of responsibility of primary that functional epidemiological surveillance networks care facilities. existed and were reporting regularly (weekly) for Respondents’ perceptions reected the poor potential disease events (¡« of respondents agreed performance on the versatility and self-regulating and ¥¡« strongly agreed). In contrast, there was lower nature of the health system: ££« agreed that primary respondent agreement that (¥) up-to-date (under ¥ care facilities had the capacity needed to identify year) data mapping existed on health system assets and isolate a health threat, whereas £¢« disagreed, (human resources, infrastructure, commodities) which ¯« disagreed strongly and ¢« were undecided. ¢£« could be mobilized in the event of a stress or potential agreed that management-level mechanisms existed shock (£¦« disagreed, ¢£« strongly disagreed and to support health facilities to target local resources ££« were undecided); (¢) up-to-date (under ¥ year) without need for bureaucratic authorizations mapping of potential health risks at local levels (compared to £¥« who disagreed, ¥« who disagreed (¢« disagreed, ££« strongly disagreed and £¥« were strongly and £¦« who were undecided). Only £« of undecided); (£) regular (at least annual) predictive respondents agreed that sources of and procedures

53 for needed additional human resource capacities were into place contingency mechanisms that allowed known and agreed, and ££« of respondents agreed continued essential service provision when responding that protocols exist to guide absorption of mobilized to a threat. A key issue identied by respondents resources and skills into the routine system. is was the continued centralization of health sector contrasts with ¦¦« of respondents who believed management. that health facilities were aware of, and able to put

Figure 59. Comparison of the performance of dierent elements of resilience in the African Region

54 4 The state of health system investments

Attributes of health system investments

ese represent the actual areas where the health i) Tangible inputs that provide the essential sector needs to invest to perform at the level needed services needed, such as the health workforce, to move towards UHC. ere are seven health system the health infrastructure and the medical investment areas dened in the framework, broadly products and technologies; classied into two categories: ii) Intangible processes needed to support the use of the tangible inputs – which include the way systems are designed for service delivery, health governance, health information and health nancing. Figure 60. Categorization of health system investment areas

Health Medical products & Health workforce technologies infrastructure

123.45

1 2 3 + 4 5 6 - 7 8 9 x 0 . = /

Service delivery Health Health Health systems ﬁnancing information governance

Countries make investments across seven investment infrastructure – which includes equipment, transport areas – whether through programmes or through and ICT. ere is need for further analysis to better cross cutting system investments – to reach the system understand whether this apportioning of investments performance needed to deliver essential services and is ecient. is is especially so, as we see a dierent move towards UHC. A country’s health system pattern of government expenditures in one of the performance is a function of level, distribution/ countries that has a good performing health system, fairness and eciency of investments made across where expenditures on medicines, infrastructure, these seven areas. health workforce and intangibles are ¥£«, ££«, ¦« and ¥¦« respectively. More emphasis is placed on the A review of levels of government nancing in health workforce (¦«, versus ¥¦«) and infrastructure ¥¯ countries of the African Region across these (££«, versus ¬«) in this country with a relatively better investment areas shows an average of « spending performing health system, as compared to the other on the tangible input areas, and ¦« spending on countries with less performing systems. Should this the intangible process areas. is trend is broadly pattern be consistent across the other countries with sustained across a number of years. Within the good performing health systems, then there would be tangible areas, highest spending of government a need to focus increasing government expenditures funds is on medical products (£®« of government primarily on funding for health workforce and spending), followed by the health workforce (¥¦«). infrastructure investments. Only ¬« of the government expenditure is spent on

55 Figure 61. Allocation of government expenditures across investment area categories by year and country types

COUNTRY WITH A GOOD PERFORMING SYSTEM

e issues associated with each of the seven areas better understand the status and focus needed across of the health system investment are analysed to countries of the Region. 4.1 The status of the health workforce in the African Region

e health workforce remains a critical input area for ▶ Physicians density (per 1000 population) health systems. Inappropriate numbers, quality and/ ▶ Nursing and midwifery personnel density (per or management constitute a major challenge to reach 1000 population) the level of performance required to attain UHC and ▶ Dentistry personnel density (per 1000 the SDGs. population) ▶ Pharmaceutical personnel density (per 1000 Several actions require investments, ranging from population) production, recruitment, deployment, management ▶ Laboratory health workers density (per 1000 and motivation of the sta needed to contribute population) to service provision. e output from all these ▶ Environmental and public health workers investments is aimed at ensuring an adequate, qualied density (per 1000 population) and t for purpose workforce in each country, able ▶ Community and traditional health workers to provide the essential health and health-related density (per 1000 population) services needed to attaining health and well-being. ▶ Health management and support workers e status of the workforce in the Region is measured density (per 1000 population) by a health workforce score which, ideally, would incorporate elements of adequacy, skills base and When scores across the dierent countries of the productivity. However, the only information available African Region are compared, there is a signicantly across countries relates to the numbers of sta. As wide range from a high of .¬¦ to a low of .¢ of the such, the score is derived from the availability of a health workforce score, highlighting the major gaps wide range of health workforce sta expected to be across the Region. present in all countries. ese are:

56 Figure 62. Comparison of health workforce index amongst countries of the African region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

Looking across the dierent categories of health these categories is very high between countries. For workers, the nursing sta are the most frequently instance, the nursing sta range from .¥¦ to ¡.¥ per available sta, followed by community and health ¥ persons. management sta. e variations in the number of Figure 63. Availability of dierent health workers per 1000 population

and

57 ere is also a signicant variation in the health health workforce is closer to that of the low-income workforce score in countries of dierent income countries than the upper middle-income countries. levels. e higher the income classication, the better e low-income countries have on average one eighth the investment in the health workforce. is gap is of the workforce in the high-income countries of the widest between the upper-middle and lower middle- Region. income countries. e lower middle-income countries Figure 64. Comparison of health workforce index by income classication

is variation is also seen when we compare countries however a smaller variation in countries based on by health expenditure. ose having the highest total population, though SIDS have a signicantly better health expenditure show a six-point dierence from workforce. those with the lowest health expenditure. ere is Figure 65. Comparison of health workforce index by health expenditures and population in the African Region

58 4.2 The status of the health infrastructure in the African Region

ere has been limited focus on coordinating investment ▶ Total density per 100 000 population: Total in health infrastructure across the Region. As a result, many hospitals countries have a variety of types, quality and functionality ▶ Total density per 100 000 population: Health of infrastructure making the assurance of eciency and posts equity dicult. Infrastructure, which encompasses the ▶ Total density per 100 000 population: Health physical infrastructure, equipment, transport, and ICT centres requirements, needs coordinated planning, maintenance ▶ Total density per 100 000 population: District/ and use for it to input into health system performance in rural hospitals a manner required to attain universal health coverage and ▶ Hospital beds (per 10 000 population) SDGs. We assess the status of the health infrastructure e emerging health infrastructure score is based in the region based on a health infrastructure score. on averaging country normalized values for these is ideally would incorporate elements of availability, variables – normalized from to the highest value, to functionality and readiness for the dierent forms of a range of to ¥. Countries are only included if they infrastructure. However, the available information across have information on more than one of these variables. countries relates to: When we compare the score across the dierent General readiness of facilities to provide essential countries of the African Region, we see there is a services (presence of electricity, water, and other signicantly wide range from a high of .¬ to . facilities needed to facilitate eective service provision) of the health infrastructure score. e highest score is ▶ Availability of basic amenities needed for service seen in Guinea Bissau and is driven by high hospital provision density in the country. ▶ Availability of basic equipment for general service provision Figure 66. Comparison of health infrastructure index amongst countries of the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

59 It should be noted that this overall score is too low to compared to the other country groups. is presents facilitate reaching the needed system’s performance. risks and opportunities: is variation in infrastructure, however, cannot ▶ Risks: countries may be spending a be explained fully by the countries income levels. disproportionately higher cost for service Apart from the single high-income country, the provision due to the high cost nature of hospital- infrastructure score does not dier signicantly based services, and between the other country income groups. e low- ▶ Opportunities: these low-income countries income countries appear to have higher levels per can design public health services around their capita for hospitals – including rural hospitals – as existing infrastructure Figure 67. Comparison of health infrastructure index across dierent country categories

Country income categorizations Low and lower middle-income country by infrastructure variables

Further disaggregation by health expenditure and marked. However, countries with smaller populations population shows a mixed picture. Countries with have higher infrastructure, though this pattern is not higher health expenditures appear to have better sustained amongst SIDS. infrastructure, though the variation is not very Figure 68. Comparison of health infrastructure score by health expenditures and population in the African Region

60 4.3 The status of medical products in the African Region

Health products represent a wide range of interven- ▶ Percentage of essential medicines prescribed in tions provided to clients during the process of care or outpatient public health facilities to facilitate that process. ese range from medicines, ▶ Percentage of medicines prescribed in outpatient including vaccines and other biologicals, medical de- facilities by international non-propriety names vices, diagnostic and laboratory supplies, blood and ▶ Percentage of patients in outpatient public other medical products of human origin, and tradi- health facilities receiving antibiotics tional medicines. As an integral part of the healthcare ▶ Percentage of adequately labelled medicines in process, it is critical for countries to invest in ensuring outpatient public health facilities their availability and quality. To assess access to medi- ▶ Blood donation rate per 1000 persons cal products in the Region, we use a medical products’ e medicines score is the average normalized score that is composed from many indicators, namely: value for these dierent indicators in each country, ▶ Diagnostics readiness normalized from to the highest value, to a range ▶ Essential medicines readiness of to ¥. Countries are only included if they have ▶ Pharmaceutical expenditure as percentage of information on more than one of these variables. THE When health products scores are compared across ▶ Density of qualied pharmacy personnel per the dierent countries of the African Region, there is 10 000 population a signicantly wide range from a high of .¯¬ to .¥. ▶ Average number of medicines prescribed per Most countries in the Region have a score of between patient contact in public health facilities .¦ and .¡¡, reecting a largely similar state of health products across many countries. Figure 69. Comparison of health products index across countries in the African Region

Cabo Verde Comoros Mauritius Sao Tome and Principe Seychelles

61 ree countries – Mauritius, Namibia and Seychelles exceptions, such as a high antibiotic use, medicines – are performing signicantly better than the other prescribed, and readiness for diagnostics and countries of the Region. is unique performance medicines in Mauritius, and low pharmaceutical appears consistent across most of the indicators expenditure in the Seychelles. that make up the health products score, with a few Figure 70. Comparison of top performing country values across health product indicators, with regional average

Comparing countries further, we see that there is a investments in health products are closer to the variation in health products investments based on a low-income bracket and much lower than the upper country’s income status. e high and upper middle- middle-income country groups. is suggests that income countries demonstrate up to three times investments needed in lower middle-income countries more investments as compared to the lower middle are similar to those in low-income countries, possibly and low-income countries. It is especially important because they have not yet established the institutional to note that the lower middle-income country’s make up of upper middle-income countries. Figure 71. Comparison of health products index by income classication

e single high-income country performs better middle-income countries, a nding which is worrying on most of indicators – apart from proportion of given the high demand for blood products. Innovative total health expenditure spent on medicines – when approaches for low and lower middle-income compared to the other country groupings. Blood countries that can boost collection of blood in these donation rates are very low in the low and lower settings need to be explored.

62 Figure 72. Comparison of availability of dierent types of medical products by country income level

ere are also clear variations in health products lowest total health expenditure. Additionally, the investments, based on the health expenditure by smaller the country, the better the investments in countries, with those having the highest total health health products, with the SIDS having more than expenditure demonstrating some ve times better double the health products investments of the other health products score as compared to those with the countries in the African Region. Figure 73. Comparison of medical products index by health expenditures and population in the African Region

63 SDG target £.¯ highlights the quality of medical for preventing and counteracting proliferation of products as an integral element of improved access. substandard and falsied medicines. Regulatory mechanisms are deployed at the national, e regulatory infrastructure in the African Region sub-regional, regional and continental levels to assure consists of ¦¡ national medicines regulatory authorities product quality and ascertain supply chain integrity. with varying levels of maturity and functionality. ey contribute to global and regional collaboration Figure 74. Regulation of medicines quality throughout product lifecycle for select functions (No = 29)

100%100

80%80

60%60

40%40

20%20 31% 79% 93% 97% 93% 41% 100% 86% 97% 86%

0% 0

Preclinical Clinical trials Registration Variations Pharmacovigilance Haemovigilance Import licensing Export licensing QC lab testing Post-marketing

Haemo- Import Export licensing/ licensing/ Variations, Pharmaco- vigilance Preclinical Registration control control developmentClinical trials amendments, vigilance QC lab testing re ... Post-marketing surveillance

Furthermore, ¢ national regulatory authorities have devices, including in-vitro diagnostics. mandate and frameworks for regulating medical Figure 75. Regulatory capacity for medical devices through product lifecycle (No = 22)

100%100

80%80

60%60

40%40

20%20 68% 95% 100% 18% 23% 82%

0% 0

Trial/testing Registration Import Techno Cyber Post-marketing

Import Techno- Cyber- licensing/ vigilance vigilance control Trials/testing Registration Post-marketing surveillance

64 4.4 The status of health service delivery systems in the African Region

Service delivery consists of all the actions needed actions dened in the Framework for actions range to facilitate the ecient management of inputs for across a number of key areas, as shown below. delivery of services to users/clients. e scope of Figure 76. Conceptual linkage of service delivery systems attributes and areas of action

National Management Teams Tertiary Care Providers guidance, norms Facility Management Teams • National hospitals (public) National level • National ministries of health • Special hospitals (public/private) • (Semi) autonomous entities administrative • Guidance translation • Non-state entities supervision essential quality & clinical client-centred packages governance care

administrative clinical guidance referral supervision supervision

Secondary Care Providers Sub-National Health Facility Management Teams guidance, norms Management Teams • Primary referral hospitals (public/private) Sub-national • Secondary referral hospitals (public/private) level • District/county/province administrative • Guidance translation essential quality & clinical client-centred supervision packages governance care administrative clinical guidance referral supervision supervision

Primary Care Providers Sub-District Health Facility • Health centres/dispensaries Primary Management Teams guidance, norms Management Teams • Clinics/maternity centres care level • Community units • Sub-district/county/province administrative • Guidance translation essential quality & clinical client-centred supervision packages governance care engagement engagement services

Clients – households

Figure 77. Scope of engagement in a service delivery e design and level of performance of service system for UHC and SDGs delivery systems has a critical impact on the levels of access, coverage and utilization of essential health and health-related services. To facilitate the achievement of the health SDG, this service delivery system Public sector actors for the should be designed, not only as a coordination and provision of management mechanism for the provision of public essential health services services, but also a system with strong features that: ▶ Ensure engagement of non-state providers of services, particularly the private sector, at all Households Non-state service levels of services provision and management and communities providers for ▶ Ensure the identication and engagement of for healthy service provision behaviour and coordination health-related social, economic, environmental actions and political sectors actors at all levels of services provision and management ▶ Social, economic, Appropriately link with, and engage the environmental and communities and households in the care process in political providers to in uence the provision a manner that assures their needs and expectations of health-related are incorporated into the process of care essential services

65 In the African Region, there is inadequate focus system that are guiding quality improvement on designing, nancing and monitoring the service initiatives delivery systems needed for the eective provision ▶ ere is a comprehensive and functionally of health and health-related services. As a result, supportive supervision and mentoring process the eective use of available resources is minimized. that is eectively providing guidance to health Service delivery systems performance in the Region service delivery is explored through the perceptions of key informants ▶ ere is a process to improve and sustain person- of specic elements of these service delivery systems centredness during the provision of services in their respective countries. Key informants were e percentage that agreed/disagreed with the specically asked to rate, on a scale of ¥ to ¡ (¥ – statements on each element of service delivery is shown strongly disagree and ¡ – strongly agree), their level of in the gure below. All key informants agreed that agreement with the following statements, as related not all elements of service delivery were present. is to dierent service delivery system elements: is particularly worrying for service delivery systems. ▶ ere exist patient service charters in all facilities, Most key informants agreed to the presence of service which dene the services patients should expect, delivery standards, while the presence of person plus their rights and obligations during the care centredness in service provision was acknowledged by process the smallest number of informants. Most informants ▶ Hospitals in the country have the required disagreed with the presence of service charters in the capacity to provide eective referral services facilities – a key communication tool between services ▶ ere exist clear and well disseminated standards and clients. for the delivery of services at all levels of the Figure 78. Key informant perceptions of presence of dierent service delivery system variables

e status of the dierent attributes was further ▶ In most countries, guidance provided is largely explored from the perspective of each functional programme-specic, with limited cross-cutting area of service delivery – health management teams, guidance. Cross-cutting guidance includes facility management teams and care provision. denition of sector-wide service standards and norms to ensure common service delivery, Health management teams are expected to provide plus systems for monitoring adherence to this guidance, supervise administrative support and, at guidance. Lack of up-to-date health service the primary care level, support the engagement of standards and norms and ongoing monitoring households and communities in health actions. of adherence characterize many country systems in the Region

66 ▶ Administrative supervision is critical to ensure ▶ Facility managers are usually clinically oriented, that inputs are available and eectively utilized and part of the service delivery team calling for (quality of service delivery). In many countries extensive in-service management trainings that of the Region, these systems are dened but take up a great deal of the time of the managers. not functional due to lack of prioritization or e service delivery teams are responsible for direct ineective follow up of recommendations. engagement with clients during the provision of ▶ At the primary care level, the health management preventive, promotive, curative or rehabilitative teams are expected to plan, coordinate and health or health-related services. ese persons are manage community engagement processes. is the face of the health system, and their actions drive ensures that all communities are being engaged the perception of the care process. It is important with the correct messaging and services needed. for the system to guide them in three key areas: Many of the sub district management teams essential services to be provided; quality and clinical are carrying out this engagement together with governance; and the person-centredness of the care their local authorities, but with limited guidance process. and involvement of the sub national levels. As ▶ Many providers are not given comprehensive a result, many of the good examples of practice guidance on the scope of essential services they are not ltering to other levels of the system, are expected to provide. is is usually driven by with the benets limited to local systems. programmes, leading to the providers focusing Additionally, engagement of communities and on specic services at the expense of others. management of local service delivery is in some Clients are therefore unable to receive the scope countries done in a haphazard manner, limiting of essential services the systems are expected to eectiveness of actions at this level. give. is is not only a funding issue, as some e health facility management teams are expected services – such as screening for some NCDs – to translate the guidance provided into coordination are not universally carried out even when their of service delivery. As the front-line managers costs are close to zero. responsible for guiding the service delivery workforce, ▶ Clinical governance is focused on ensuring that their role is critical in any service delivery systems. a standard quality of preventive, promotive, ey need to translate the normative functions into clinical or rehabilitative care is provided to each service delivery tasks, primarily around essential person, irrespective of where they access services. service packages, clinical governance and client is requires clearly dened and comprehensive centredness of care. However, within the Region, the clinical standards and management guidelines, state of the functioning of the facility management plus facility-driven mechanisms for monitoring teams is still challenging. adherence. ese clinical standards and ▶ Most countries have dened and put in place management guidelines are dened in some teams to manage the facilities. However, in countries, but very few countries of the Region many countries, these teams do not have up- have in place mechanisms to monitor and enforce to-date comprehensive Standard Operating them. As a result, varying levels of quality of care Procedures (SOPs) to guide them in carrying are seen within a given system, disenfranchising out their work of translating normative guidance the population, and leading to clustering of into operations. clients seeking services around specic providers ▶ Most facility managers focus on administrative perceived to be eective. management, with limited guidance and focus ▶ Person-centredness is focused instead on the care on clinical management. Few countries have process and aims to ensure the person is placed at service charters in all service points to ensure the centre of decisions regarding care. However, clients are aware of services they are entitled to most care in the Region is disease-centric as receive. In addition, therapeutic committees to opposed to person-centric and, as a result, there monitor adherence to care standards are only is a high perception of poor experiences with partially functioning – and non-existent at the the care process that is aecting demand for primary care level. services. Many private providers in the Region are perceived to provide good services as they focus on this element of the care process.

67 4.5 The status of health governance systems in the African Region

e state of governance systems is a key determinant elements of the system, governance is constructed for how well available tangibles are translated into from many inter-dependent attributes. e Regional adequate performance needed to deliver health and Oce structures them as shown in the conceptual health-related services. As with other intangible framework below. Figure 79. Conceptual linkage of health governance attributes

Authority and mandate

Policies, Organization strategies structure & & plans culture Steward capacity

Legal & Leadership regulatory skills systems

Corruption Intelligence control, generation & integrity & accountability public Stakeholder conﬁdence engagement & partnership

Source: WHO Regional Oﬃce for Africa health governance briefcase (in press)

Governance results are based on the capacity of the the following statements, as they relate to dierent health steward (MoH or other public sector decision health governance elements: maker in health) to carry out a series of actions across ▶ e top-level leadership (Minister, Principal/ the dierent attributes, where capacity is a function Permanent Secretary, Director) are not of the authority and mandate that the steward holds. frequently changed, being able to implement the is authority and mandate is devolved from the policies they initiate elected ocials in a country and represents the level ▶ ere exist formal mechanisms for engaging with of decision space a given steward has to guide the communities that maximise their involvement health agenda. Where this authority and mandate and participation in planning and monitoring are low, the steward’s capacity to inuence the service provision attributes is likewise reduced. Decentralized systems ▶ e health sector regularly generates evidence, are, by design, expected to increase this authority such as through annual performance reports, and mandate for local health stewards. e level of which is used to guide decision-making stability of the health stewards is a good measure of ▶ ere exist functional processes that allow for the authority and mandate they hold. ere is a good coordination of service delivery between public level of authority and mandate in a system where the and private actors, and development partner steward is allowed the space to make decisions and engagement see through their implementation. ▶ e MoH has adequate leadership and management capacity to steward the health For a perspective on the quality of governance, key sector, including the engagement of non-health informants in countries of the Region were asked for sectors their perception of the status of selected governance issues in their countries. ey were specically asked e percentage that agreed/disagreed with each to rate, on a scale of ¥ ro ¡, their level of agreement with of these selected elements of health governance is

68 shown in the gure below. A higher proportion of on the capacity for health governance in the Region informants (¡¥«) were of the view that the national – if their authority and mandate is limited, their level health stewards were not stable enough to actions inuencing the governance attributes will be guide implementation of policies. is places limits diminished. Figure 80. Key informant perceptions of presence of dierent service delivery system variables

A look at the state of the governance attributes shows ▶ Corruption control, integrity and public condence: several hindrances in countries; this governance attribute has at times been ▶ Organizational structure and culture: While all perceived as a window into the quality of ministries (and sub-national structures) have governance in the sector. All countries in the some written or implied structure, in practice Region have normative and legal instruments many function dierently. to control corruption. ese have not built the ▶ Legal and regulatory systems: All countries required level of public condence in the integrity have a legal framework guiding health that is of the health services. However, relative to other usually dened at three levels: constitutional government services, the health sector usually is provisions impacting health; comprehensive perceived as one of the less corrupt. In Transparency health acts, and disease/area specic acts (for International’s Global Corruption barometer: People example, HRH act, Diabetes act, etc); and/ and Corruption, Africa Survey 201525, public health or decentralized health laws. ese are rarely services were reported to have the least levels of interlinked, leading to some areas with multiple reported corruption amongst government services legal provisions and others without. In addition, assessed. e challenge is that even low levels of these instruments are rarely updated to reect corruption, integrity and low public condence current legal needs. Additionally, regulations to are devastating in health, given the ‘life or death’ enforce these provisions are rarely enacted or nature of the service. In addition, there are few enforced. As a result, critical instruments that assessments that have focused on corruption in could facilitate movement towards appropriate the non-public sector, which is quite signicant in health and health-related services are not many countries. Anecdotal evidence suggests this eectively utilized. is also a major problem, particularly in relation to how priorities are selected and funded.

¢¡ https://www.transparency.org/whatwedo/publication/people_and_corruption_africa_survey_¢¥¡

69 Figure 81. Service users who said they had paid a bribe during services received in the past 12 months

Adapted from: Global Corruption Barometer: People and corruption, Africa survey 2015

▶ Stakeholder engagement and partnerships: Only skills that stewards need to possess. ese range 25 of the 47 countries of the African Region from ‘hard’ technical knowledge over the areas have some form of instrument – a compact or being stewarded, through to ‘soft’ skills such memorandum of understanding – implying lack as communication, brokering, negotiation and of management of partnerships. In addition, others. ere are constant ‘training’ sessions only 49% of key informants reported the carried out for ministries of health to address presence of a formal mechanism for engagement these skills. However, only 51% of the key of private sector or external actors, and only informants felt the stewards had the needed skills 51% for engagement with communities. is set for managing the health agenda. Trainings implies a high potential for ineciencies in the is often not well coordinated, with a lack of a allocation and/or use of health resources, as lack standard curriculum of core skills, which makes of eective coordination and engagement with it dicult to build the required capacity in an partners makes a comprehensive sector approach equitable manner. dicult to achieve. ▶ Policies, strategies and plans: ese aim to provide ▶ Intelligence generation and accountability: Up to a succinct ‘roadmap’ for the direction the country 60% of the interviewed informants were of the is taking in the long, medium and short term. view that their countries had some form of regular ey are useful not just as roadmaps, but also evidence generation mechanism to facilitate in the value the process of their development informed decision making. is accountability adds to a common understanding of the health process is however not well institutionalized. needs and priorities amongst stakeholders. All Only 16 out of the 47 countries of the African countries have some form of policy, strategy and/ Region have some form of monitoring and or plan. However, these are not always produced evaluation (M&E) M&E plan to guide and with the active involvement of the stakeholders. make transparent the accountability process. In addition, they are often incomplete, not ▶ Leadership skills: e management of the health covering the full scope of priorities that need to agenda calls for a specic set of soft and hard be addressed.

70 4.6 The status of health nancing systems in the African Region

Health nancing systems are complex, encompassing the inter-relations of the dierent elements and dierent mechanisms for mobilizing, managing components a country needs to consider for health and using resources. e WHO schema showing nancing systems is shown below. Figure 82. Schema for health nancing systems in the African Region

External sources Government sources Private sources

Donor Budget support projects

Government Mandatory Voluntary Direct Project/programme

Sources tax revenue pre-payment pre-payment out-of-pocket

Subsidies Mandatory Fee for

type and institutions contribution service

Public programmes/ Mandatory Voluntary No scheme projects insurance schemes insurance schemes

Management Ministry of Health Social Health Insurance Facility/community Private insurance Directly funded services funded services insurance funded services funded services funded services type and institutions

Input based purchasing Output based purchasing Outcome based purchasing Purchasing

type and institutions Provision of health and health-related services

No single path can ensure that the objectives of health for better health nancing systems. nancing are achieved; rather, each country needs to e status of the dierent sources, management and dene its processes, taking cognizance of its context, purchasing mechanisms in the Region is explored in to ensure the goals of resource adequacy, equity the following section. and eciency are attained in its nancing system. Countries need to strategically think through the Sources of health funds elements of health nancing to determine the best Health funds come from government, private or system that would apply. A national health nancing external sources. ey are characterized as project/ strategy is aimed at facilitating this process. However, programme funds, tax revenues, pre-payment funds ¢® out of the ¦¬ countries in the Region have yet to start (mandatory/voluntary) or out-of-pocket funds. work on elaborating their health nancing strategy. ere is a wide variation in the Region in the use Financing is therefore left as a passive process, whose of dierent sources of health nancing. ese structure, form and outputs are not well coordinated. sources have dierent characteristics – government Country ministries need to more proactively focus on sources are most equitable, external sources most health nancing, ensuring they are driving the agenda

71 easily targeted and private sources most sustainable. ¬.¦« to a high of ®¬« of current health evvxpenditure However, government sources are dicult to (¢¥¡). External funding, on the other hand, ranges augment, external sources are not sustainable and from .¡« to ¬¥« of current health expenditure. And private sources inequitable, especially where incomes nally, the private (individual) expenditure ranges are low. Government funding ranges from a low of from ¢.¡« to ¬¬« of current health expenditure. Figure 83. Proportion of health funds from dierent sources in countries of the African Region, 2015

Note: GGHE – General Government Health Expenditure; PVTHE – Private Health Expenditure; CHE – Current health Expenditure; EXT – External health expenditure

Management of health funds health insurance mechanisms are still managing a low proportion of their health funds through ese funds are managed in dierent ways – either compulsory mechanisms – these include as public (MoH/district) programmes; insurance Rwanda (9% of funds), Ghana (9%), United schemes (mandatory/voluntary), or directly by Republic of Tanzania (7%) and Kenya (4%). It individuals. Each source of funds tends to focus on is expected these should increase, as the benet specic mechanisms for their management. packages and insurance service utilization in ▶ Funds managed by governments range from 13% these countries move towards UHC. (Sierra Leone) to 97% (Seychelles). Eswatini, ▶ Voluntary insurance mechanisms account for Lesotho and Seychelles have all more than 60% 0% to 47% (South Africa). Other countries of health funds managed by the government, with relatively high voluntary insurance whereas the percentage in Comoros, Nigeria mechanisms include Botswana (32% of health and Sierra Leone is under 16%. While more funds), Namibia (19%) and Zimbabwe (16%) – equitable and aligned with country ownership, all located in Southern Africa. is presents a there are allocative and technical eciency worrying trend, particularly for equity in these challenges that need to be specically addressed countries. in the countries that have a high proportion of ▶ Finally, direct out-of-pocket spending ranges health funds channelled through government from 2% (Seychelles) to 75% (Comoros). arrangements. Other countries with high direct out-of-pocket ▶ Funds managed through compulsory insurance management of funds include Nigeria (74% mechanisms range from 0% to 28% (Algeria). of health funds), Equatorial Guinea (72%) Cabo Verde and Gabon have the relative highest and Cameroon (70% ). ese are very high proportion of health funds managed through proportions of funds to be managed by out of compulsory insurance. Countries that have pocket mechanisms and suggest high levels of recently been shown to have made progress with inequities.

72 Figure 84. Proportions of health funds managed by dierent institutional entities in the African Region, 2015 SLE COM NGA CMR CIV ZWE CAF MLI GNQ UGA TCD ETH TGO LBR NER GAB SSD KEN GIN BEN MRT SEN TZA RWA DZA ZAF GHA COD STP ERI MWI ZMB AGO MUS BFA MDG MOZ COG CPV BWA BDI GMB GND NAM LSO SWZ SYC

Note: GFA – Government Financing Arrangement; C – Compulsory Financing Arrangement; V – Voluntary Financing Arrangement; OOPS – Out-of-pocket Spending; OTHER – other

Purchasing of services achieved, such as institutional deliveries and children immunized. While linking outputs with ere are three distinct purchasing modalities used in nancing improves eciency of resource use, it the Region: input, output and outcome/results-based has proved dicult to scale up, due to inherent purchasing. Each of these have specic benets and institutional hindrances that limit nancing challenges. using this approach. ▶ Input-based purchasing is used by most ▶ Outcome/results-based purchasing has been government funds, with resources used to buy used in some countries of the Region, particularly inputs, for example recruiting health workers, in insurance or out-of-pocket payment building infrastructure and buying products. is arrangements. Funding is by specic results/ is the most bureaucratically feasible approach outputs that are usually dened by diagnoses. to purchasing services, but it is inecient as it It allows a focus of payment based on the unlinks funds from results. All countries in the actual result attained from the care process. e Region use this modality to purchase services. experience in the Region is mixed – while easier ▶ Output-based purchasing is increasing as a to administer, it requires signicant investments mode of funding for health services, with good in audit capacity to manage diagnosis creep, results seen in Rwanda, Kenya and other pilot which results from providers favouring diagnoses countries. It is based on funding specic results with higher nancial returns. 4.7 The status of health information and research systems in the African Region

Health information and research systems encompass systems (HMIS), vital statistics, research, surveys, all the mechanisms for data generation and validation, surveillance and census data sources. A country analysis, dissemination and knowledge translation in health information system needs to focus on all these relation to routine health management information elements to ensure functionality.

73 Figure 85. Schema for health information and research systems in the African Region

Health Health Health statistics information knowledge

Data generation Data analysis Intelligence Focus: targeted Focus: capacity for generation improvements in attribution and Focus: informing capacity for prediction of trends decision-making generating data and distribution processes

Comprehensive, real-time statistics Country/Region progress and Evidence-based on SDG targets performance analysis decision making

Targeted interventions focusing on SDG Routine analysis of statistics for each • Real-time policy briefs for decision- monitoring processes area of the Framework of actions makers, using analytical products • Routine HMIS: alignment to burden • Country and regional indices (on-the-go evidence) • Vital events: community/facility • Attribution (why?) • Repository for policy briefs, accessed by academia, decision-makers, • Surveillance: specific data • Prediction (UHC/SDG implications partners, etc. • Surveys: rationalization – NHA; DHS; • Contribution (e.g. to ‘triple billion’ • Intelligence for health planning • Research: identification; analysis Demand-driven analysis of statistics • Research agenda identification for Aggregation of statistics (DHIS  use) • Performance monitoring evidence generation

e African Region is specically focused on inte- favoured system. However, digitization of pri- grating eHealth solutions across these dierent ele- mary data is still low. In addition, there are no ments of health information and research to improve regional standards to guide countries in deciding the availability and use of information for decision which digital systems work best in their environ- making. e regional status for the dierent systems ment. Being a dierent way of working, there are is discussed below. also technical, administrative and technological challenges in rolling them out. Routine HMIS Routine HMIS data analysis HMIS are systems capturing events occurring in In many cases, countries capacity to analyse newly health facilities. collected data is low, as most of the investments have Routine HMIS data generation focused on data collection systems, with less focus All countries have some form of HMIS that captures on strengthening capacities of the health workforce these events. ey are either digital, paper-based or a to collect, understand and use the data in routine combination of the two. use. is is true both at the operational facility level ▶ Paper-based systems are still predominant in (although there is some analysis done at the data the Region, capturing almost all primary patient collection points, with trend graphs produced, this data. While it is the least costly approach, it is not uniformly practiced or supported), and at the requires complex logistics to ensure that the strategic level, where data and evidence are required required data capture tools are always available. for policy formulation. ey are prone to errors and delays, and are time Information from HMIS is typically used to produce consuming for the health workforce. annual/quarterly health statistics in countries. ere ▶ Digital systems use is growing, particularly for are such documents in many countries in the Region, data aggregation and transmission. Many coun- but they do not usually give a comprehensive picture tries use some form of electronic mechanism to due to low timeliness and lack of accurate reporting transmit data, with DHIS2 currently being the from the facilities.

74 Routine HMIS knowledge generation and translation allow key information to be made available to the public for brief periods of time. is has been ere is very limited knowledge translation of HMIS successful in reaching a wide audience. information taking place in countries of the Region. As a result, decision makers are generally making Survey knowledge translation decisions without using HMIS information, even e dissemination method usually involves policy when it exists in reports. makers. In addition, policy briefs are sometimes produced to get the information into the body politic Health surveys and census and guide policy. is has been successful, particularly Survey data generation for the demographic and health surveys, in bringing Many countries carry out routine health surveys, issues onto the policy table for discussion and action. particularly the Demographic and Health Surveys Vital statistics systems (DHS). In addition, countries are expected to conduct some census every ¥ years and carry out other Vital statistics relate to birth, death and cause of surveys, such as household utilization surveys, service death information. is is critical for understanding availability and readiness assessments (SARA) and population events and trends and targeting national health accounts (NHAs). ese surveys are interventions where they are most needed. usually partner driven, with the execution and funding Vital statistics data generation managed externally. ere are few countries in the region that proactively plan for surveys, limiting the e process of collecting vital statistics data is only utility of this health information source. In addition, close to being complete in SIDS countries, with the the content of the surveys is usually determined by completion rate being very low for the rest of the the funding source, as opposed to the needs on the Region. e vital statistics are usually collected at ground. facilities, and by civil registration units ▶ For vital statistics collected at facilities, the Survey data analysis quality of vital statistics is very poor, due to Countries’ capacity to analyse survey information is inappropriate standardizations of disease also quite low, most being done by external partners. classication (using the ICD for example), poor Survey data usually consists of large volumes of coding and certication capacities. variables, requiring complex analytical tools that are ▶ For vital statistics collected during civil often out of reach of the governments. Simpler, open registration, the process is usually bureaucratic, source analytical tools need to be made available, as with signicant gaps in coverage. e process a rst step towards building analytical capacity for is typically manual, with data only aggregated surveys. after a few years. ere is low uptake and use of automation, and limited use of verbal autopsies Most survey dissemination is through reports to help standardize cause of death information. launched at high level stakeholder meetings. ese

75 Figure 86. Comparison of birth registration completeness amongst selected countries of the African Region

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

Vital statistics data analysis Vital statistics knowledge generation and translation e analysis of vital statistics data is largely carried Information on vital statistics does not feed into out by the civil registration teams in countries, with the health sector decision-making processes. Many limited interlinkages with the health sector teams. ministries make decisions without knowledge from As a result, the analysis is usually limited to reporting vital statistics, as this is not made available. percentages and rates but with limited trend of Health research condence analysis. Health research capacity and focus varies signicantly A small number of countries have been able to produce within the Region. An analysis based on a health regular (annual) reports on vital statistics. ese are research barometer tool showed an average capacity usually produced for immigration and registration of only ¦¢.£« in the region, ranging from « to ¯¥« purposes, with little input from the health sector. For amongst the countries. Capacities vary in areas of these reasons, there are few instances in the Region action, with gaps seen in management capabilities, of regular and consistent production of life tables and research governance or technical research skills. burden of disease estimates.

76 Figure 87. Comparison of health research barometer score amongst countries of the African Region, 2016

Cabo Verde Comoros Mauritius Sao Tome Seychelles and Principe

Research data generation Almost all research is disseminated in research publications, which range from peer reviewed journals Research data is generated in all countries of the through to research reports, conferences and study Region. In most instances, it is commissioned by theses. researchers, as opposed to policy makers. As a result, the data generated does not always align with the Research knowledge translation needs of decision makers. In addition, the capacity for e translation of research to policy remains a critical research audit through national research committees is challenge in the Region. In some countries, formal limited, with many countries not having the required research dissemination meetings are held with policy capacities to guide research processes. makers to share ndings. In addition, some countries Research data analysis researchers work with policy makers to dene upfront the research agendas that will guide the conduct of is is usually left to the persons conducting the research. All these eorts are bearing location-specic research, with limited input from the health sector. results, due to the complex nature of decision making.

77 5 Taking forward health agenda in the African Region

5.1 Linking health expenditures with health and well-being

A complex picture of the African Region emerges Gabon, in this zone. When looking at the scores of from the ndings of this analysis. Looking at the these ¢ countries, there are wide swings in their rating level of funding available for countries to produce of systems performance, service outcomes and health the results observed (using the ¢¥¡ per capita THE impact. Eswatini, a lower middle-income country, in US¿ PPP), one sees a mixed situation: only nine moves from position ¥¢ in system performance to ¥¡ countries in the Region are spending above US¿ ¡ in service outcome and drops to £¯ out of ¦¬ countries per capita (all, with the exception of Eswatini, are in impact performance. Gabon on the other hand, upper middle or high-income countries) and half the moves in the opposite direction, from position £® countries (¢¦) have a total health expenditure of less in system performance to ¥¯ in service outcome and than US¿ ¥¦ per capita. eight out of ¦¬ at the impact level. ese represent countries migrating towards increasing THE (and are ere is a large gap between a THE of ¦–¯ also in transition between upper and lower middle- US¿ per capita, with only ¢ countries, Eswatini and income status). Figure 88. Comparison of 2015 per capita THE int$ between countries in the African Region CAF COD ERI GIN MOZ BDI ETH SSD NER MDG BEN TGO TZA SEN BFA GNB TCD MWI GMB MLI COM LBR RWA UGA KEN CMR ZWE MRT ZMB AGO CIV NGA COG GHA SLE LSO AVER STP CPV GAB SWZ SYC NAM BWA DZA MUS ZAF GNQ

Source: WHO Global Health Observatory, 2017

We would expect a linear association between levels a. Category ¥ (bottom left quadrant): Total of funding and healthy life and well-being. However, health expenditure and healthy life when we compare these two variables, we see an expectancies below the regional average interesting set of issues emerging: b. Category ¢ (top left quadrant): Total i) e association is not strong – only ¢« of health expenditure below, but healthy life the values are attributable to this relationship. expectancy above the regional averages c. Category £ (bottom right quadrant): Total ii) Many countries in the Region are clustered health expenditure above, but healthy life within a zone of Healthy Life Expectancy expectancy below the regional averages between ¦¡ and years, plus a total health expenditure between and £ Int US¿. d. Category ¦ (top right quadrant): Total health expenditure and healthy life expectancy iii) Countries can be grouped in four categories: above the regional averages

78 Figure 89. Association between total health expenditure, and healthy life expectancy

Source: WHO Global Health Observatory, 2017

Category represents the most ecient countries To further understand the association between in terms of production of health and well-being. e health and the attainment of the SDGs, we looked countries in this quadrant are shown below, with their at associations of the dierent domain areas of the respective healthy life expectancy and total health Framework. Specically, we looked for the levels of expenditure values. ese countries show how to association between health and well-being – SDG attain high levels of healtÀy life and well-being, even £ goal (using healthy life expectancy as a proxy), with low resources. compared to the dierent domain areas of the Framework – the system performance and health Category countries are only two – Equatorial and health-related service outcomes. is is aimed at Guinea and Eswatini. ese have a level of health and identifying where most policy emphasis needs to be well-being below that expected for their level of total placed for the most eective progress. health expenditure. When healthy life expectancy is plotted against either Category countries have the highest healthy life of health system performance and health and health- expectancy but are achieving this with signicantly related outcome scores, we nd the association of more resources. ey represent the high income/upper health and well-being is strongest with the health middle-income countries with the highest THE per system performance score (R squared value of .¦¡¬ capita (apart from Equatorial Guinea and Eswatini). for health system performance score compared with ese countries show how to improve healthy life and .£¬¬ for health and health-related service outcome well-being, in the presence of an increased resource score). is suggests health system performance is a base. better predictor of health and well-being, as compared to the levels of achievement of health and health- related service outcomes in the Region.

79 Figure 90. Comparison of association between health and well-being and consolidated scores Health and well-being against system performance score Source: WHO Global Health Observatory,Health Global WHO 2017 Source:

We further tested this nding by subjecting the eects multiple linear regression. is showed country scores of health expenditures, health system that only health system performance scores were performance scores, health and health-related service signicant in association with healthy life expectancy. outcome scores and health and well-being to mixed

Table 17. Results from mixed eects multiple linear regression of domain scores of the Framework of Actions

Healthy life expectancy Coecient Standard z P>|z| [ condence interval] error THE per capita US PPP Á.ÁÁÂÃÄÅ Á.ÁÁÆÇÃÄÈ Æ.ÅÆ Á.ÆÈÇ -Á.ÁÁÆÁÆÇÈ Á.ÁÁÃÂÇÃÅ Health system performance ÄÆ.ÉÄÂÂÆ É.ÇÅÇÅÄÇ Ä.ÂÅ Á.ÁÁÆ ÆÂ.ÃÂÉÃÄ ÈÆ.ÂÄÅÊÉ Health services outcomes È.ÉÆÈÄÅÃ É.ÆÁÂÊÃÈ Á.ÃÈ Á.ÈÆÃ -ÆÆ.ÉÂÈÊÈ ÂÄ.ÊÈÃÅÅ _cons ÄÄ.ÉÂÆÇÈ Ä.ÅÊÇÁÈÊ É.ÊÈ Á.ÁÁÁ ÂÊ.ÆÁÅÉÉ ÅÁ.ÊÄÇÊÂ

is is further corroborated with a Procrustes of countries on specic health outcome programmes analysis¢. e maps showed the relationship between which, while improving the programme outcomes healthy life expectancy and health and health-related in question, had a lower eect on overall health and service outcomes was a poor t compared to the well-being. As countries look at how best to invest to health system performance. attain the SDGs, it will be critical to re-align their focus towards health system performance, as opposed is nding is contrary to what one would expect, to specic programme performance. as the assumption is that investment focused on health and health-related services leads to the desired Finally, looking at how countries ranked in the outcomes. However, it could be a result of the focus dierent domains of the Framework of Actions, and

¢ Procrustes analysis is a statistical shape analysis which seeks to analysis the distribution of a set of shapes by superimposing them together. In this case, the orthogonal transformation subject (health system performance and health/health-related outcome scores) were superimposed to healthy life expectancy to measure their ‘t’.

80 Health and well-being against service outcomes score Source: WHO Global Health Observatory,Health Global WHO 2017 Source: how these ranks changed as one progressed across the lower healthy life value. More eort is needed Framework, shows what kinds of lessons countries to translate its investments into healthy life and can learn from each other. Table ¥¯ overleaf shows the well-being. country summary indices consolidated for each area We further explored the dierent areas of the of the action framework. e top ¥ countries in the logical framework to better understand at what level Region are highlighted in green and the lowest ¥ in ineciencies are greatest. is was done by exploring red. ¢ the R value between any two areas of the Framework, ere are only ¦ countries out of the ¦¬ in the region with the assumption that the lower the value, the that remain in the top ¥ for all areas of the Framework. higher the potential ineciencies. ¢ is a measure of how ese are Algeria, Mauritius, Namibia and Seychelles. close the data are to a tted regression line, assuming Only one country is in the bottom ¥ for all the areas the relationship between the dierent areas of the of the Framework, the Central African Republic. is logical framework is a linear one. e highest R¢ value suggests high levels of ineciencies in the production was found in the relationship between health systems of health and well-being in the countries of the performance and health and health-related outcomes Region. Angola and South Africa deserve special (.¡¥) while the lowest was in the relationship between mention: health and health-related outcomes and health impact ▶ Angola is allocating a signicant amount to (.£). is suggests that countries are not adequately health, but is amongst the bottom 10 countries translating health and health-related outcome for investments, system performance, health and achievements into healthy life – possibly due to over- related outcomes and healthy life. e available emphasis on some outcomes and under-emphasis on resources are not used to produce health and others. Additionally, a focus on system performance by well-being. countries represents the best area of focus for moving ▶ South Africa is amongst the top 10 in funding, towards healthy life and well-being, corroborating the system investments, performance and health ndings from the association done previously. and health-related outcomes but has a relatively

81 Table 18. Comparison of country indices across the Framework of Actions

Total health expendi- Investments Index Performance Index Outcomes Index Impact (Healthy Life ture per capita, Expectancy) int   Algeria . . . . Angola . . . . Benin . . . . Botswana . . . . Burkina Faso . . . . Burundi . . . . Cabo Verde . . . . Cameroon . . . . Central African Republic . . . . Chad . . . . Comoros . . . . Congo . . . . Côte d’Ivoire . . . . Democratic Republic of the Congo . . . . Equatorial Guinea . . . . Eritrea . . . . Eswatini . . . . Ethiopia . . . . Gabon . . . . The Gambia . . . . Ghana . . . . Guinea . . . . Guinea-Bissau . . . . Kenya . . . . Lesotho . . . . Liberia . . . . Madagascar . . . . Malawi . . . . Mali . . . . Mauritania . . . . Mauritius . . . . Mozambique . . . . Namibia . . . . Niger . . . . Nigeria . . . . Rwanda . . . . Sao Tome and Principe . . . . Senegal . . . . Seychelles . . . . Sierra Leone . . . . South Africa . . . . South Sudan . . . Togo . . . . Uganda . . . . United Republic of Tanzania . . . . Zambia . . . . Zimbabwe . . . . Average . . . . Green – Country amongst the top in the Region for the area of the logical framework. RED – Country amongst the bottom in the Region for the area of the logical framework

82 5.2 Emerging implications for ‘leaving no one behind’

is report has highlighted the status of health at countries of the Region as the adopted the dierent levels of the ¢£ Agenda and the SDGs, ¢£ Agenda. A common approach will not identifying where progress is good and drawing be feasible, as the countries are all at dierent attention to areas that need to be accelerated. Many positions along the trajectory towards UHC issues that emerge from the analysis are of importance and the SDGs. to progress towardsUHC and the SDGs, particularly c. Regarding UHC actions, all £ dimensions from the equity perspective. dened for the Region are lagging behind 1. e Region still has a long way to go before (.£; .¡¬ and .£¦ for service availability, people in Africa have a similar state of health coverage and nancial risk protection and well-being as the rest of the world. respectively). ere is urgent need to Improvements are needed in all countries: the accelerate eorts addressing all the UHC best performing country in the Region is only dimensions if the Region is going to attain able to guarantee 66.8 years of healthy life to its the desired health and well-being. people, compared with the global average of 62 6. e economic determinants for health are years (range of 49–70 years). having the lowest index value (0.40) followed by 2. e amount of healthy life lost due to disability/ political (0.56), social (0.59) and environmental disease is decreasing and is currently comparable (0.65). Economic and political events are having to that of other regions. the greatest eect on overall health and well- 3. e disease burden is getting lower, with DALYs being in the Region. Without concerted eorts associated with the top 10 conditions halved to improve these, countries will nd it hard to since year 2000, and the crude death rate due to attain the health and well-being they desire. the top 10 mortality causes reduced from 87.7 to 7. Health systems in the region are 51.3 persons per 100 000 population. underperforming, only able to perform at 49% 4. e evidence shows signicant variations across of what they can. is low performance is largely countries and is suggestive of similar variations due to low levels of access to essential services within countries. ese inequities in health and low system resilience (each having an index are a result of inequities in investments in and of 0.32). Health system performance can only outcomes from these investments. be raised by improving these dimensions across 5. e health and health-related services are all the region below the values needed for UHC, with an a. Countries with higher total health Index value of only 48% of utilization of what is expenditure do show higher nancial risk feasible in the Region. Regarding UHC: protection and signicantly higher health a. e UHC index (.¦) is marginally lower service utilization, primarily focused on than that for the overall services index, curative and rehabilitative services. showing the higher eort countries need to b. Several countries do not perform as might be put in addressing UHC vis-à-vis the other expected from their total health expenditure. SDG targets inuencing health to attain is may be due to ineciencies or wastage, the desired improvements in healthy life and or even poor models of service delivery. well-being. 8. Countries all have dierent levels of achievement b. ere is a wide variation in the UHC index, and challenges as compared to the overall indicating the dierent ‘starting points’ of the regional picture. 5.3 WHO Regional Oce for Africa priorities for supporting countries

Supporting health in the ¢£ Agenda and the SDGs health system and service interventions investments. represents for WHO a fundamental shift in focus UHC, health security, service satisfaction and other and expectations in the Region. e Framework of health related outcomes are underpinned by health A ctions, which provides country guidance system performance as measured by access, demand, on realigning health system investments to health quality and resilience of essential services, which in and other related outcomes is a step in synergizing turn are derived from health system building blocks

83 working holistically together. While many countries ◆ Developing monitoring and evaluation systems are still struggling with basic health challenges, this for the SDGs analysis has shown that there is a need for re-focusing 2. Provide up-to-date technical tools, guidelines and the engagement with, and support to countries. For SOPs guiding service delivery, focusing on: example, there is need to: ◆ Planning, implementation and monitoring ▶ Find means of taking services to previously guidelines and tools – including disease unreached populations; not only those physically programmes un-reachable but even those un-reached when in ◆ Policy dialogue for the SDGs plain sight – like the urban informal settlements. ◆ Capacity building for national and district level ▶ Increase focus on improving the process of care, planning for health in the SDGs not only on the presence of care. 3. Provide targeted technical support to countries in ▶ Have a proactive approach to identify and increase SDG adoption/implementation activities, primarily the services needed for health and well-being. All in: age cohorts, but mostly the adolescents and the ◆ Involving the health sector in wider SDG elderly, lack access to needed services. discussions in country ▶ Health and governance security challenges, if not ◆ Training of MOH/WHO on planning, and eectively anticipated and mitigated against, have monitoring of SDG actions the potential to undo any progress made. 4. Provide proactive support to assure availability of ▶ Country specic mechanisms of engaging with information on SDGs in countries, with focus on: health-related stakeholders need to be planned to ◆ Development and management of a regional ensure that social, economic, environmental and health SDGs database political SDG targets are on track. ◆ Analysis and production of regular analytical Countries in the African Region are very dierent, reports on SDG status and issues across due to cultural, economic, governance and political countries peculiarities. A ‘one size ts all’ approach in addressing Furthermore, WHO will work closely – through an health in the SDGs era is not possible. ere is a need implementation research approach with a group of to understand the context of each country in relation ‘agship countries’ – to plan, apply and monitor results to its peers for a comprehensive and sustainable arising from actions driving health in the ¢£ Agenda. movement towards health and well-being for all at Implementation research is an approach that embeds all ages. Consequently, WHO in the African Region research as an integrated, systematic part of existing is taking a proactive approach to supporting countries policies and programmes. It allows for meaningful in moving towards attaining their health-related engagement between researchers and decision-makers goals in the SDGs. WHO engagement is focused on to ensure locally-driven research that is socially and the following: contextually relevant and transformed into evidence 1. Develop a common conceptualization of health in used to strengthen the health system. ese agship the SDGs in the Region, prioritising: countries are being selected to represent the dierent ◆ Mobilization of intersectoral action by multiple aspects of health in sustainable development in the stakeholders to achieve the SDG targets Region. Clear lessons on key actions to prioritise and inuencing health their resultant eects on health that emerge from this ◆ Health systems strengthening for UHC in the work will be shared for action with peer countries in context of the SDGs the Region. ◆ Respect for equity and human rights in the design It is also the intention of the Regional Oce to update and operationalization of health actions this baseline report to reect the overall progress of ◆ Strengthening domestic resource mobilization the countries in the WHO African Region towards ◆ Leveraging scientic research and innovation to successfully achieving the health and health-related improve SDG actions, and SDG targets of the ¢£ Agenda for Sustainable Development.

84 85 © WHO/Julie Pudlowski Part II – Countries’ report

The state of health in the countries of the African Region

In this second part, a summary of the information is A standard approach is used for the recommendations: presented for each country of the African Region. As ▶ Where a country is performing below expectation with the regional overview, this summary covers the for a given dimension, there are signi cant gaps, state of health, the state of health services, the state of and existing strategies being employed may not the health system performance and the state of health move the country towards its health aspirations. investments. e recommendations here focus on encouraging ▶ e state of health summarizes data on healthy life the country to identify innovations to address the expectancy and on morbidity and mortality levels. dimension. A commentary on the overall country GDP, size ▶ Where a country has an average performance for and any other contextual information important for a given dimension, it appears that the uptake of the SDGs is also provided. needed interventions has been good, but gaps still ▶ e state of health services highlights the country exist, most likely for hard to reach populations. index against the regional average for the six e country should focus on scaling up existing dimensions of outcomes. A commentary is provided interventions, concentrating eorts on identifying on the country status vis-à-vis the regional picture, and targeting hard to reach populations as existing followed by its implications for the attainment interventions have most probably reached those of the SDGs (where the country needs to place ‘easy to reach’. emphasis for improving health service outcomes). ▶ Finally, where a country is performing better than Dimensions with missing data are reected as ‘zero’ expected for a given dimension, and it appears that and do not contribute to the average index for the the uptake even amongst hard to reach populations state of health services, system performance or has been good. Focus for moving forward is investments. threefold: (i) identifying remaining pockets of hard ▶ e state of the health system performance and to reach populations, (ii) sharing best practices, the state of investments highlight the country and (iii) exploring alternative institutional service index against the four dimensions of performance delivery models that improve sustainability, as and the three input system investment areas. A existing approaches are close to exhausting their commentary is provided on the country status vis-à- capacity for change. vis the regional results, followed by its implications Countries are encouraged to improve the availability of for the SDGs (where the country needs to place data to ensure that more comprehensive information emphasis for improving investments and system can be provided going forward. performance).

87 88 Algeria State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 66.3 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 5.7 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 271.0 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 62.6 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 178.5 177.6 234.9 190.6 180.3 170.6 Due to injuries 29.8 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ An upper-middle-income country with the third largest total GDP in the WHO African Region ▶ Health status is commensurate with that needed to achieve the SDGs (representing 9% of the total GDP) and the eighth highest GDP per capita (US$4160 in current ▶ Country to share lessons on improving length and quality of life and prices) based on 2015 estimates reducing communicable diseases and injuries burdens ▶ It has the eighth largest population in the Region (4.01% of total population), the largest land ▶ Focus on identifying remaining pockets of hard to reach populations, area (10.74% of the Region) and the 38th highest population density (16.74 persons/km ) sharing best practices and exploring alternative institutional service ▶ Health status is commensurate with that of a high-income country delivery models that improve sustainability for noncommunicable ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional diseases average ▶ Mortality due to noncommunicable conditions is marginally higher than that of the Region

* The capacity to attain the SDGs is related to how far the country’s Healthy Life Expectancy is from that of the best performing income group (high income countries – 65.5 years) Data is from the World Bank Health Population and Nutrition database for the year closest to 2015 for which data is available. Source: http://databank.worldbank.org/data/source/health-nutrition-and-population-statistics, last accessed on 30 April 2018. State of health services and the health system Services dimensions System performance dimensions Investment dimensions

1.00 0.90 0.84 0.80 0.79 0.75 0.73 0.70 0.70 0.71 0.70 0.68 0.60 0.58 0.50 0.48 0.43 0.40 0.37 0.30 0.27 0.20 0.10 - ND - ND - ND - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments ▶ Highest performer in the Region for overall service ▶ Relative system performance close to that of a high-income country Comments outcomes, UHC indices and for SDG 3 services coverage ▶ Relative system performance is highest for quality of care and lowest for access (together with Mauritius) dimension of outcomes ▶ Tangible system investments are good compared to the regional average, particular- ▶ Overall utilization of health and health-related services to ly for the health workforce achieve the SDGs is 70% of what is feasible in the Region and ▶ Information is suggestive of eective system processes (service delivery, nancing, higher than the regional average (48%) governance, information), with a high ratio of overall performance score to consoli- ▶ Country utilization is higher than the regional average across dated tangible investments scores all outcome domains assessed (no data for service availability and responsiveness) ▶ Compared with other upper-middle-income countries, the country utilization is higher for all outcome areas assessed

Implications ▶ Share lessons with other countries in improving SDG 3 services ▶ Explore areas to share lessons in establishing eective system processes (governance, for the SDGs coverage and nancial risk protection information, delivery systems, nancing systems) ▶ Accelerate ongoing interventions to address health security ▶ Accelerate ongoing initiatives to improve access, quality and demand for services and health-related SDG services coverage focusing on the hard specically targeting hard to reach populations, prioritizing innovative approaches to to reach populations improve infrastructure investments ▶ Improve information availability, particularly for service ▶ Improve data availability, particularly for health products and to monitor system availability and service responsiveness resilience

89 Angola State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 45.9 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 13.9 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 1 054.8 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 703.1 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 240.0 177.6 234.9 190.6 180.3 170.6 Due to injuries 110.7 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income country with the fourth largest total GDP in the WHO African Region ▶ Health status is below that needed to reach the SDGs (representing 6.15% of the total GDP) and the ninth highest GDP per capita (US$ 3696 in current ▶ Introduce innovative approaches to address low healthy life and high prices) based on 2015 estimates disease burden for the whole population ▶ It has the 10th largest population in the Region (2.8% of total population), the fth largest land ▶ High resource base suggests eort should be more on introducing area (5.28% of the Region) and the 35th highest population density (22.35 persons/km ) more ecient mechanisms to attain health goals ▶ Health status is commensurate with that of a low-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average ▶ Mortality due to noncommunicable conditions is lower than that of the Region.

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of required essential health and health-re- ▶ A lower-middle-income country with a history of major civil conict impeding lated services is only 31% of what is feasible in the Region and investments in development lower than the regional average (48%). ▶ An oil-dependent economy facing shrinking global revenues, thus limiting other sectors ▶ Country utilization is lower than the regional average across all ▶ System performance is lower than that of low-income countries outcome domains assessed (no data for service availability) ▶ Across system monitoring domains, relative performance is highest for eective ▶ Compared with other lower-middle-income countries, the demand and lowest for access country utilization is lower for all outcome areas assessed ▶ Tangible system investments are very low compared to the regional average, particularly for health products and infrastructure ▶ Tangible system investments are too low for eective system processes (service delivery, nancing, governance and information)

Implications ▶ Interventions to address nancial risk protection and non-SDG ▶ Introduce innovative strategies to improve access, quality, resilience and demand for for the SDGs 3 services coverage focusing on the hard to reach populations services for the whole population, focusing on investments across the health system ▶ Introduce innovative approaches to improve SDG 3 services through a dedicated health system recovery programme coverage, health security and service responsiveness for all populations ▶ Improve information availability, particularly for service availability

90 Benin State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 52.5 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 9.6 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 633.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 378.7 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 190.8 177.6 234.9 190.6 180.3 170.6 Due to injuries 63.4 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 29th largest total GDP in the WHO African Region (representing ▶ Health status is low, below that needed to reach the SDGs 0.49% of the total GDP) and the 25th highest GDP per capita (US$ 783.9 in current prices) based ▶ Introduce innovative approaches to tackle the burden of communica- on 2015 estimates ble diseases, noncommunicable diseases and injuries ▶ It has the 26th largest population in the Region (1.06% of total population), the 30th largest land area (0.48% of the region) but the 16th highest population density (93.97 persons/km2) ▶ Health status is commensurate with that of a low-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average ▶ Crude mortality rate and mortality due to injuries are at the regional average

1.00 0.90 0.80 0.70 0.73 0.60 0.59 0.55 0.50 0.51 0.50 0.44 0.45 0.40 0.40 0.39 0.38 0.36 0.30 0.32 0.32 0.26 0.26 0.23 0.20 0.18 0.10 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services is ▶ A low-income country with system performance lower than that of other low-in- 38% of what is feasible in the Region, lower than the regional come countries average (48%). ▶ The government has recently introduced mandatory health insurance for all ▶ Country utilization is higher than the regional average for ▶ Across system performance monitoring domains, relative performance is highest for health and health-related services coverage, but lower for all quality of care, lowest for access other outcome areas ▶ Tangible system investments are above the regional average, but are particularly ▶ Compared with other low-income countries, the country low for the health workforce utilization is higher for health and health-related services ▶ Information is suggestive of some eective system processes (service delivery, coverage only nancing, governance and information) – high ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Accelerate ongoing interventions to address health and ▶ Explore areas to share lessons in establishing eective system processes for the SDGs health-related services coverage, focusing on the hard to reach ▶ Accelerate strategies improving quality of care and system resilience specically populations targeting hard to reach ▶ Introduce innovative approaches to improve service availability, ▶ Introduce innovative strategies to improve eective demand and access for the nancial risk protection, health security and service responsive- whole population, focusing on scaling up investments in HRH and infrastructure ness for all populations

91 Botswana State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 56.9 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 7.2 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 428.5 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 232.9 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 156.2 177.6 234.9 190.6 180.3 170.6 Due to injuries 38.7 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ An upper-middle-income country with the 16th largest total GDP in the WHO African Region ▶ Health status is low, below that needed to reach the SDGs (representing 0.86% of the total GDP) but the fth highest GDP per capita (US$ 6532 in current ▶ Explore lessons to be shared with keeping low the burden of disease prices) based on 2015 estimates due to injuries and violence ▶ It has the 36th largest population in the Region (0.22% of total population), the 19th largest ▶ Accelerate ongoing eorts to reduce communicable and noncommu- land area (2.4% of the Region) but the second lowest population density (3.9 persons/km2) nicable diseases burdens, targeting hard to reach populations ▶ Health status is commensurate with that of a low-income country ▶ The health status is on the low side for its classication, being a lower and upper-middle-income country ▶ Overall healthy life expectancy; morbidity and mortality rates are better than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness

Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to ▶ An upper-middle-income country with system performance similar to other achieve the SDGs is 57% of what is feasible in the Region, upper-middle-income countries higher than the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average for all eective demand and quality of care, while lowest for access outcome domains assessed (no data for service availability and ▶ Tangible system investments are good compared to the regional average, but are responsiveness) particularly low for health infrastructure ▶ Compared with other upper-middle-income countries, the ▶ Information is suggestive of some eective system processes (service delivery, country utilization is marginally higher for nancial risk protec- nancing, governance and information), with a high ratio of overall performance tion, and lower for all other outcome areas assessed score to consolidated tangible investments scores

Implications ▶ Accelerate ongoing interventions to address all outcome areas ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs assessed, focusing on the hard to reach populations ▶ Accelerate strategies improving access, quality of care and service demand focused ▶ Improve information availability, particularly for service on hard to reach availability and responsiveness ▶ Introduce innovative approaches to improve investment in infrastructure and equipment ▶ Improve on data availability, particularly on system resilience

92 Burkina Faso State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 52.6 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 9.5 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 625.5 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 386.5 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 168.5 177.6 234.9 190.6 180.3 170.6 Due to injuries 69.6 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 24th largest total GDP in the WHO African Region (representing ▶ Health status too low compared to that needed to achieve the SDGs 0.62% of the total GDP), but only the 36th highest GDP per capita (US$ 575 in current prices) ▶ Accelerate ongoing eorts to reduce noncommunicable disease based on 2015 estimates burden, targeting hard to reach populations ▶ It has the 16th largest population in the Region (1.82% of total population), the 24th largest ▶ Explore innovative approaches to reduce the burden due to communi- land area (1.16% of the region) and the 22nd highest population density (66.19 persons/km2) cable diseases and injuries ▶ Health status is commensurate with that of its classication ▶ Increasing security threats are limiting economic growth ▶ Overall healthy life expectancy, morbidity and mortality rates are at the regional average ▶ Mortality due to noncommunicable conditions is marginally lower than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to ▶ A low-income country with system performance lower than average for low-income reach SDGs is 45% of what is feasible in the Region, below the countries regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is at par with the regional average for quality of care, and lowest for access coverage of non-SDG 3 health targets only (no data for service ▶ Tangible system investments are average to low compared with the Region and availability and responsiveness) particularly low for the health workforce ▶ Compared with other low-income countries, the country ▶ Information is suggestive of some eective system processes (systems for service utilization is only marginally higher for health-related services delivery, nancing, governance and information), high ratio of overall performance coverage outcome area score to consolidated tangible investments scores

Implications ▶ Accelerate ongoing interventions to address health security ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs and SDG 3 and non-SDG 3 interventions coverage, focusing on ▶ Accelerate strategies improving quality of care focused on hard to reach populations, the hard to reach populations prioritizing investments in the health workforce ▶ Introduce innovative approaches to improve nancial risk ▶ Introduce innovative approaches to improve access, and eective demand for the protection for all populations whole population ▶ Improve information availability, particularly service availabili- ▶ Improve data availability, particularly system resilience ty and responsiveness

93 Burundi State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 52.2 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 11.1 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 659.2 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 407.5 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 173.4 177.6 234.9 190.6 180.3 170.6 Due to injuries 77.5 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 10th smallest total GDP in the WHO African Region (representing ▶ Health status too low compared to that needed to reach the SDGs 0.18 % of the total GDP) and the lowest GDP per capita (US$ 300.7 in current prices) based on ▶ A low-income and fragile country, whose health system has with- 2015 estimates stood socio-political and economic shocks to sustain an average level ▶ It has the 27th largest population in the Region (1.03% of total population), but the 9th smallest of performance largest land area (0.11% of the Region) resulting in the 4th highest population density (397.2 ▶ Explore innovative approaches to reduce burden of communicable persons/km2) diseases and injuries ▶ Health status is commensurate with that of its classication ▶ Accelerate ongoing eorts to reduce noncommunicable diseases ▶ The country has suered protracted civil conict hampering sustainable development burden, targeting hard to reach populations ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average ▶ Mortality due to noncommunicable conditions marginally lower than that of the Region

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to ▶ A post conict low-income country with low grade persisting insurgency in some achieve SDGs is 50% of what is feasible in the Region, higher areas, making real-time system assessment dicult than the regional average (48%). ▶ System performance similar to the average for lower-middle-income countries ▶ Country utilization is higher than the regional average only for ▶ Across system performance monitoring domains, relative performance is highest for nancial risk protection (no data for service availability and quality of care, lowest for access responsiveness) ▶ Tangible system investments are average to low compared with the regional average ▶ Compared with other low-income countries, the country and are particularly low for the health workforce utilization is higher only for nancial risk protection and health ▶ Information is suggestive of some eective system processes (service delivery, security nancing, governance and information), high ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Accelerate ongoing interventions to address nancial risk pro- ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs tection focusing on the whole population – the score is too low ▶ Accelerate strategies improving quality of care specically targeting hard to reach ▶ Introduce innovative approaches to improve coverage of SDG populations, prioritizing investments in the health workforce 3 and non-SDG 3 health services, plus health security for all ▶ Introduce innovative strategies to improve access and eective demand for the populations whole population ▶ Improve information availability, particularly service availability and responsiveness

94 Cabo Verde State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 64.2 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 5.2 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 253.2 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 73.2 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 151.0 177.6 234.9 190.6 180.3 170.6 Due to injuries 28.2 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income small island state with the sixth smallest total GDP in the WHO African ▶ Health status on track towards that needed to attain the SDGs Region (representing 0.09% of the total GDP), but the 11th highest GDP per capita (US$ 2954 in ▶ Focus on identifying remaining pockets of hard to reach populations, current prices) based on 2015 estimates sharing best practices, and exploring alternative institutional service ▶ It has the third smallest population in the Region (0.05% of total population), the fth smallest delivery models that improve sustainability for health and well-being land area (0.02% of the region), but the 12th highest population density (132.24 persons/km2) ▶ Its health status is commensurate with that of a high-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

1.00 0.98 0.90 0.80 0.73 0.70 0.69 0.64 0.60 0.62 0.58 0.56 0.59 0.52 0.55 0.50 0.47 0.40 0.30 0.30 0.30 0.20 0.22 0.16 0.19 0.10 0.10 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services ▶ Highest performer in the Region for e ective demand for essential servic- to reach the SDGs is 56% of what is feasible in the es and system resilience (together with Eswatini) dimensions of system Region, higher than the regional average (48%) performance ▶ Country utilization is higher than the regional average ▶ A lower-middle-income country, small island state with system performance similar across all outcome domains assessed to an upper-middle-income country ▶ Compared with other lower middle-income countries, ▶ Across system performance monitoring domains, relative performance is highest for the country utilization is higher for all outcome areas eective demand and system resilience, while it is lowest for access assessed ▶ Tangible system investments are very low compared with the regional average, particularly for health products and workforce ▶ Information is suggestive of some eective system processes (service delivery, nancing, governance, information), high ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Share lessons with other countries in improving cover- ▶ Explore areas for sharing lessons in establishing eective system processes and for the SDGs age of SDG 3 services building service demand and system resilience ▶ Accelerate ongoing interventions to address utilization ▶ Accelerate strategies improving system resilience specically targeting hard to reach across all the outcome areas focusing on the hard to populations reach populations ▶ Introduce innovative strategies to improve access and quality of care for the whole population, focusing on scaling up investments in the health workforce, products and infrastructure

95 Cameroon State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 50.3 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 10.8 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 700.5 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 421.1 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 204.0 177.6 234.9 190.6 180.3 170.6 Due to injuries 74.5 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income country with the 11th largest total GDP in the WHO African Region (rep- ▶ Health status too low compared to that needed to achieve the SDGs resenting 1.85% of the total GDP) and the 17th highest GDP per capita (US$ 1353.9 in current ▶ Need to explore innovative approaches to improve health and prices) based on 2015 estimates well-being ▶ It has the 14th largest population in the Region (2.3% of total population), the 20th largest land area (2.00% of the region) and the 27th highest population density (48.31 persons/km ) ▶ Its health status is commensurate with that of a low-income country ▶ Ongoing low level societal tensions across dierent portions of the country will hinder uniform movement towards the SDGs ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to ▶ A lower-middle-income country with system performance similar to its classication reach the SDGs is 52% of what is feasible in the Region, which ▶ Across system performance monitoring domains, relative performance is highest for is marginally above the regional average (48%). eective demand and lowest for access ▶ Country utilization is higher than the regional average only for ▶ Tangible system investments are low compared with the regional average, particu- coverage of SDG 3 services and health security outcome areas larly for the health workforce and health infrastructure ▶ Compared with other lower-middle-income countries, the ▶ Information is suggestive of eective system processes (service delivery, nancing, country utilization is higher for only health security outcome governance and information), high ratio of overall performance score to consolidat- area ed tangible investments scores

Implications ▶ Share lessons with other countries in improving health security ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs ▶ Accelerate ongoing interventions to address coverage of SDG 3 ▶ Accelerate strategies improving quality of care, eective demand and system and non-SDG services, plus service responsiveness focusing on resilience specically targeting hard to reach populations the hard to reach populations ▶ Introduce innovative strategies to improve access for the whole population, focusing on ▶ Introduce innovative approaches to improve service availability scaling up investments in the health workforce and infrastructure and nancial risk protection for all populations

96 Central African Republic State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 45.9 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 14 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 926.0 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 612.0 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 215.3 177.6 234.9 190.6 180.3 170.6 Due to injuries 98.3 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the seventh smallest total GDP in the WHO African Region (repre- ▶ Health status very low compared to that needed to reach the SDGs senting 0.09 % of the total GDP) and the second lowest GDP per capita (US$ 384.4 in current ▶ Need to explore innovative approaches to improve health and prices) based on 2015 estimates well-being in the context of sustained conict ▶ It has the 32nd largest population in the Region (0.46% of total population), the 15th largest land area (2.64% of the region) and the fourth lowest population density (7.30 persons/km2) ▶ Health status is commensurate with that of its income classication ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with a long period of low grade conict hampering invest- the SDGs is 31% of what is feasible in the Region, lower than ments in development and health the regional average (48%). ▶ System performance is lower than that of other low-income countries ▶ Country utilization is higher than the regional average only for ▶ Across system performance monitoring domains, relative performance is highest for service responsiveness outcome area out of all assessed (there system resilience and lowest for access is no data for service availability) ▶ Tangible system investments are very low across all areas compared with the ▶ Compared with other low-income countries, the country uti- regional average lization is higher only for the service responsiveness outcome ▶ Tangible system investments are too low for eectiveness of system processes area (service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address service responsive- ▶ Accelerate strategies improving system resilience, specically targeting hard to reach for the SDGs ness, focusing on hard to reach populations populations ▶ Introduce innovative approaches to improve coverage of SDG ▶ Introduce innovative strategies to improve access, quality and demand for services 3 and non-SDG 3 services, health security and nancial risk for the whole population, focusing on investments across the health system through protection for all populations a dedicated health system recovery programme ▶ Improve information availability, particularly service availability

97 Chad State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 46.1 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 13.6 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 982.5 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 689.0 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 199.2 177.6 234.9 190.6 180.3 170.6 Due to injuries 93.6 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 23rd largest total GDP in the WHO African Region (representing ▶ Health status very low compared to that needed for the attainment of 0.65% of the total GDP) and the 26t highest GDP per capita (US$ 777 in current prices) based on the SDGs 2015 estimates ▶ Need to explore innovative approaches to improve health and ▶ It has the 22nd largest population in the Region (2.8% of total population), but with the fourth well-being largest land area (5.33% of the Region), leaving it with the sixth lowest population density (11.13 persons/km2) ▶ Health status is commensurate with that of its classication ▶ Aected negatively by a dicult Sahel environment, low grade insecurity and uctuating global oil prices ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with recent history of conict (Boko Haram) and outbreaks the SDGs is 33% of what is feasible in the Region, lower than (EVD) in selected areas of the country, disrupting system strengthening initiatives the regional average (48%) ▶ System performance is lower than that of other low-income countries ▶ Country utilization is higher than the regional average for none ▶ Across system performance monitoring domains, relative performance is highest for of the outcome areas assessed eective demand, and lowest for access ▶ Compared with other low-income countries, the country ▶ Tangible system investments are low compared with the regional average, particu- utilization is higher for none of the outcome areas assessed larly for the health workforce ▶ Tangible system investments are too low for eectiveness of system processes ( service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address non-SDG 3 services ▶ Accelerate strategies improving access, and service demand specically targeting for the SDGs coverage focusing on the hard to reach populations hard to reach populations ▶ Introduce innovative approaches to improve services availabil- ▶ Introduce innovative strategies to improve quality of care and system resilience for ity and responsiveness, SDG 3 services coverage, nancial risk the whole population, focusing on scaling up investments across all health system protection and health security for all

98 Comoros State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 55.9 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 8.2 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 497.1 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 275.6 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 167.9 177.6 234.9 190.6 180.3 170.6 Due to injuries 52.8 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income small island state with the second smallest total GDP in the WHO African Region ▶ Health status low compared to that needed to reach the SDGs (representing 0.03% of the total GDP), and the 29th highest GDP per capita (US$ 727.6 in ▶ Accelerate ongoing eorts to reduce communicable diseases, current prices) based on 2015 estimates noncommunicable diseases and injuries burdens, targeting hard to ▶ It has the fourth lowest population in the Region (0.08% of total population), the third smallest reach populations land area (0.01% of the Region), but the third highest population density (417.75 persons/km2) ▶ Health status is commensurate with that of an upper-middle-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional averages

1.00 0.90 0.80 0.73 0.70 0.68 0.60 0.60 0.56 0.50 0.50 0.40 0.40 0.37 0.30 0.29 0.27 0.29 0.20 0.22 0.21 0.10 0.13 - ND - ND - ND - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance of an upper-middle-income the SDGs is 40% of what is feasible in the Region, lower than country the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average only for quality of care, lowest for access the SDG 3 service coverage outcome area (no data for service ▶ Investments highest in products and lowest for HRH availability and responsiveness) ▶ Tangible system investments are very low compared with the regional average ▶ Compared with other low-income countries, the country utili- ▶ Tangible system investments are too low for eectiveness of system processes zation is higher only for SDG 3 services coverage outcome areas (service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address SDG 3 and ▶ Accelerate strategies improving quality of care and system demand specically for the SDGs non-SDG 3 services coverage, focusing on the hard to reach targeting hard to reach populations populations ▶ Introduce innovative strategies to improve access to services for the whole popu- ▶ Introduce innovative approaches to improve nancial risk lation, focusing on scaling up investments across the health system – workforce, protection and health security for all populations products and infrastructure ▶ Improve information availability, particularly service availability and responsiveness

99 Congo State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 56.6 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 10.1 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 494.1 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 288.9 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 153.5 177.6 234.9 190.6 180.3 170.6 Due to injuries 51.2 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ An lower-middle-income country with the 28th largest total GDP in the WHO African Region ▶ Health status low compared to that needed to reach the SDGs (representing 0.51% of the total GDP) and the 13th highest GDP per capita (US$ 1712 in current ▶ Accelerate ongoing eorts to reduce communicable diseases, prices) based on 2015 estimates noncommunicable diseases and injuries burdens targeting hard to ▶ It has the 31st largest population in the Region (0.50% of total population), with the 22nd larg- reach populations est land area (1.45% of the Region) but the 8th lowest population density (14.63 persons/km2) ▶ Health status is within the expected range for its income level ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average ▶ Death rate is lower than regional average, at the level of a low-income country

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to ▶ A lower-middle-income country with system performance lower than that of other reach SDG is 43% of what is feasible in the Region, close to the lower-middle-income countries regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average only for quality of care, lowest for access responsiveness outcome area ▶ Tangible system investments are very low compared with the regional average ▶ Compared with other lower-middle-income countries, the ▶ Tangible system investments are too low for eectiveness of system processes country utilization is higher only for service responsiveness (systems for service delivery, nancing, governance and information) outcome area

Implications ▶ Accelerate ongoing interventions to address service responsive- ▶ Accelerate strategies improving demand for services and system resilience specical- for the SDGs ness focusing on the hard to reach populations ly targeting hard to reach populations ▶ Introduce innovative approaches to improve coverage of SDG ▶ Introduce innovative strategies to improve access and quality of care for the whole 3 and non-SDG 3 services, nancial risk protection and health population, focusing on investments across all health system areas security for all populations

100 Côte d’Ivoire State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 47 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 12.6 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 840.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 501.2 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 246.4 177.6 234.9 190.6 180.3 170.6 Due to injuries 92.6 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 10th largest total GDP in the WHO African Region (representing ▶ Health status very low compared to that needed to reach the SDGs 1.98% of the total GDP) and the 15th highest GDP per capita (US$ 1434.3 in current prices) ▶ Need to explore innovative approaches to improve health and based on 2015 estimates well-being ▶ It has the 13th largest population in the Region (2.33% of total population), the 23rd largest land area (1.35% of the region) and the 20th highest population density (72.67 persons/km2) ▶ Health status is commensurate with that of its income classication ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average ▶ Civil conict in the recent past had an inuence on sustainable development

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance lower than that of other low-in- the SDGs is 52% of what is feasible in the Region, higher than come countries the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average for quality of care, lowest for access health security, service availability and non-SDG 3 services ▶ Tangible system investments are low compared with the regional average, being coverage outcome areas highest for health products ▶ Compared with other low-income countries, the country ▶ Tangible system investments are too low for eectiveness of system processes utilization is higher for only health security, service availability (service delivery, nancing, governance and information) and non-SDG 3 services coverage outcome areas

Implications ▶ Share lessons with other countries in improving health security ▶ Accelerate strategies improving quality of care, and system resilience specically for the SDGs ▶ Accelerate ongoing interventions to address services availabil- targeting hard to reach populations ity and non-SDG 3 services coverage focusing on the hard to ▶ Introduce innovative strategies to improve eective demand and access for the reach populations whole population, focusing on scaling up investments across all health system areas ▶ Introduce innovative approaches to improve SDG 3 services coverage, nancial risk protection and service responsiveness for all populations

101 Democratic Republic of the Congo State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 51.8 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 13.7 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 722.7 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 475.0 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 170.9 177.6 234.9 190.6 180.3 170.6 Due to injuries 76.2 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the eighth largest total GDP in the WHO African Region (represent- ▶ Health status very low compared to that needed to reach the SDGs ing 2.26% of the total GDP) but the 8th lowest GDP per capita (US$ 497.6 in current prices) ▶ Need to explore innovative approaches to improve health and based on 2015 estimates well-being ▶ It has the third largest population in the Region (7.67% of total population) and the second ▶ Accelerate ongoing interventions addressing noncommunicable largest land area (9.60% of the region) but with only the 34th highest population density (33.61 diseases targeting hard to reach populations persons/km2) ▶ Health status is commensurate with that of its income classication ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average ▶ However, mortality due to noncommunicable conditions is marginally higher than that of the Region

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services for the ▶ A low-income country with system performance similar to its classication attainment of the SDGs is 43% of what is feasible in the Region, ▶ Across system performance monitoring domains, relative performance is highest for lower than the regional average (48%). quality of care, and lowest for access to services ▶ Country utilization is higher than the regional average only ▶ Tangible system investments are all low compared with the regional average, being for health security, due to signicant investments in detection lowest for the health workforce capacity, but low for all other dimensions ▶ Tangible system investments are too low for eectiveness of system processes ▶ Compared with other low-income countries, the country (service delivery, nancing, governance and information) utilization is average for service availability, health security and non-SDG 3 services coverage outcome areas

Implications ▶ Accelerate ongoing interventions to address health security ▶ Accelerate strategies improving quality of care, eective demand and system for the SDGs outcomes focusing on the hard to reach populations resilience specically targeting hard to reach populations ▶ Introduce innovative approaches to improve service availability, ▶ Introduce innovative strategies to improve access to services for the whole popula- SDG 3 services coverage, service responsiveness, non SDG 3 tion, focusing on scaling up investments across all health system areas health services coverage and nancial risk protection for all populations

102 Equatorial Guinea State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 51.3 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 11.5 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 685.7 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 388.5 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 222.6 177.6 234.9 190.6 180.3 170.6 Due to injuries 74.2 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ An upper-middle-income country with the 20th largest total GDP in the WHO African Region ▶ Health status very low compared to that needed to reach the SDGs (representing 0.75% of the total GDP), but the second highest GDP per capita (US$ 10 717.5 in ▶ Need to explore innovative approaches to improve health and current prices) based on 2015 estimates well-being ▶ It has the fth smallest population in the Region (0.12% of total population), 10th smallest land area (0.12% of the region) and the 30th highest population density (41.90 persons/km2) ▶ Health status is commensurate with that of a low-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are at the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ An upper-middle-income country with system performance lower than that of a the SDGs is 39% of what is feasible in the Region, lower than low-income country the regional average (48%). ▶ Across system performance monitoring domains, relative performance is lower than ▶ Country utilization is higher than the regional average in none the regional averages, being lowest for access to essential services of the outcome domains assessed (no data for service availabil- ▶ Investments have mainly been channeled through the “Salud para todos-Health ity and service responsiveness) for all” program that has signicantly expanded the supply of both health services ▶ Compared with other upper-middle-income countries, the for better access to preventive and curative care, plus sports facilities for promoting country utilization is not higher in any of the outcome areas healthy lifestyles assessed ▶ Tangible system investments are all low compared with the regional average ▶ Tangible system investments are too low for eectiveness of system processes (service delivery, nancing, governance, information)

Implications ▶ Accelerate ongoing interventions to address non-SDG 3 services ▶ Accelerate ongoing strategies improving access to services, specically targeting for the SDGs coverage focusing on the hard to reach populations hard to reach populations ▶ Introduce innovative approaches to improve SDG 3 services ▶ Introduce innovative strategies to improve quality of care and eective demand for coverage, nancial risk protection and health security for all the whole population, focusing on scaling up investments across all health system populations areas

103 Eritrea State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 55.7 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 6.3 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 414.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 214.2 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 147.1 177.6 234.9 190.6 180.3 170.6 Due to injuries 52.9 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 11th smallest total GDP in the WHO African Region (representing ▶ Health status still low for the attainment of the SDGs 0.23% of the total GDP) and the ninth lowest GDP per capita (estimated at US$ 514 in current ▶ Explore lessons to share in reducing death rates (better than high prices) based on 2015 estimates income countries in the Region) ▶ It has the 30th largest population in the Region (0.53% of total population), the 31st largest ▶ Accelerate ongoing eorts to reduce communicable diseases, land area (0.43% of the region) and the 25th highest population density (51.76 persons/km2) noncommunicable diseases and injuries burdens targeting hard to ▶ Health status is commensurate with that of an upper-middle-income country reach populations ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

1.00 0.90 0.80 0.75 0.70 0.73 0.71 0.65 0.60 0.54 0.55 0.50 0.49 0.45 0.44 0.40 0.43 0.44 0.30 0.20 0.22 0.21 0.21 0.15 0.10 0.08 0.06 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance between that of an upper-mid- the SDGs is 44% of what is feasible in the Region, marginally dle-income and a lower-middle-income country lower than the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average across eective demand for services outcome areas of SDG 3 services coverage, and health security ▶ Tangible investments in the health system are highest for health products and ▶ Compared with other low-income countries, the country lowest for health infrastructure utilization is higher than that for SDG 3 services coverage and ▶ Tangible system investments are too low for eectiveness of system processes health security (service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address health security ▶ Accelerate strategies improving quality of care, eective demand and system for the SDGs and SDG 3 services coverage focusing on the hard to reach resilience specically targeting hard to reach populations populations ▶ Introduce innovative strategies to improve access to services for the whole popula- ▶ Introduce innovative approaches to improve service availability, tion, focusing on scaling up investments in health workforce and infrastructure nancial risk protection and service responsiveness for all populations ▶ Improve information availability, particularly for service availability and responsiveness

104 Eswatini State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 50.9 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 11.8 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 589.1 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 340.7 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 185.2 177.6 234.9 190.6 180.3 170.6 Due to injuries 62.2 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income country with the 36th largest total GDP in the WHO African Region (rep- ▶ Health status too low compared with that needed for the attainment resenting 0.24% of the total GDP) but the 10th highest GDP per capita (US$ 3047.9 in current of the SDGs prices) based on 2015 estimates ▶ Accelerate ongoing eorts to reduce burden of communicable diseas- ▶ It has the seventh smallest population in the Region (0.13% of total population), the seventh es, focusing on hard to reach persons smallest land area (0.07% of the Region) but the 19th highest population density (76.69 ▶ Explore innovative approaches to reduce the burden of noncommuni- persons/km ) cable diseases and injuries ▶ Health status is commensurate with that of a low-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average ▶ Additionally, mortality due to communicable diseases is marginally lower than the regional average

1.00 1.00 0.90 0.80 0.74 0.70 0.68 0.60 0.63 0.56 0.55 0.50 0.53 0.50 0.50 0.44 0.40 0.38 0.30 0.30 0.25 0.20 0.19 0.16 0.10 0.11 - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ Highest performer in the Region for system resilience (together with Cabo the SDGs is 50% of what is feasible in the Region, marginally Verde) dimension of system performance higher than the regional average (48%). ▶ A lower-middle-income country with system performance closer to that of an ▶ Country utilization is higher than the regional average for upper-middle-income country SDG 3 services coverage, nancial risk protection and service ▶ Across system performance monitoring domains, relative performance is highest for responsiveness outcome areas system resilience ▶ Compared with other lower middle-income countries, country ▶ Tangible system investments are lower than regional averages utilization is higher for SDG 3 services coverage, nancial risk ▶ Tangible system investment levels are too low to provide information on eective- protection and service responsiveness outcomes ness of system processes (service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address SDG 3 services ▶ Accelerate strategies improving quality of care, and system resilience specically for the SDGs coverage, nancial risk protection, and service responsiveness targeting hard to reach populations focusing on the hard to reach populations ▶ Introduce innovative strategies to improve access to services and quality of care for ▶ Introduce innovative approaches to improve service availability, the whole population, focusing on scaling up investments across all health system and non-SDG 3 services coverage for all populations areas

105 Ethiopia State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 56.1 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 7.2 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 483.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 269.5 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 158.8 177.6 234.9 190.6 180.3 170.6 Due to injuries 55.1 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the fth largest total GDP in the WHO African Region (representing ▶ Health status lower than that needed for the attainment of the SDGs 3.85% of the total GDP), but only the 33rd highest GDP per capita (US$ 645 in current prices) ▶ Accelerate ongoing eorts to reduce communicable diseases, based on 2015 estimates noncommunicable diseases and injuries burdens targeting hard to ▶ It has the second largest population in the Region (10.05% of total population), the ninth reach populations largest land area (4.23% of the region) and the 15th highest population density (99.87 persons/ km2) ▶ Health status is commensurate with that of a middle-income country ▶ Country has several areas of localized civil unrest, together with frequent disease outbreaks and disaster events ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance at the level of an upper-middle-in- the SDGs is 54% of what is feasible in the Region, higher than come country the regional average (48%). ▶ A large country with high population ▶ Country utilization is higher than the regional average for all ▶ Across system performance monitoring domains, relative performance is highest for outcome areas apart from nancial risk protection eective demand ▶ Compared with other low-income countries, the country ▶ Tangible system investments are low compared with the regional average particu- utilization is higher for all outcome areas assessed apart from larly for health workforce nancial risk protection ▶ Information is suggestive of some eective system processes (service delivery, nancing, governance and information), with above average investments and high ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Accelerate ongoing interventions to address service availability, ▶ Explore areas for sharing lessons in establishing eective system processes and for the SDGs SDG 3 and non-SDG 3 services coverage, health security, system resilience and service responsiveness focusing on the hard to reach ▶ Accelerate strategies improving access to services and eective demand for care populations specically targeting hard to reach populations ▶ Introduce innovative approaches to improve nancial risk ▶ Introduce innovative strategies to improve quality of care for the whole population, protection for all populations focusing on scaling up investments in health workforce

106 Gabon State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 57.2 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 9 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 471.8 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 254.2 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 170.6 177.6 234.9 190.6 180.3 170.6 Due to injuries 46.7 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ An upper-middle-income country with the 17th largest total GDP in the WHO African Region ▶ Health status low compared with that needed for the attainment of (representing 0.85% of the total GDP), but the fourth highest GDP per capita (US$ 7389 in the SDGs current prices) based on 2015 estimates ▶ Accelerate ongoing eorts to reduce communicable diseases, ▶ It has the ninth smallest population in the Region (0.19% of total population), the 25th largest noncommunicable diseases and injuries burdens targeting hard to land area (1.09% of the region) and the fth lowest population density (7.49 persons/km2) reach populations ▶ Health status is commensurate with that of its classication ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ An upper-middle-income country with system performance lower than that of the SDGs is 53% of what is feasible in the Region, higher than low-income countries the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average for eective demand for services service availability, nancial risk protection, and service ▶ Investments highest in products, and lowest for HRH responsiveness outcome areas ▶ Tangible system investments are fair compared with the regional average, being ▶ Compared with other upper-middle-income countries, the lowest for health products country utilization is higher for outcome areas of nancial risk ▶ Information is suggestive of low eective system processes (service delivery, nancing, protection governance, information), high system investments scores, but low ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Share lessons with other countries in improving nancial risk ▶ Accelerate strategies improving access to services specically targeting hard to reach for the SDGs protection populations ▶ Accelerate ongoing interventions to address service availability, ▶ Introduce innovative strategies to improve quality of care, eective service demand SDG 3 and non-SDG 3 services coverage, and responsiveness and system resilience, focusing on eectiveness of system processes and health focusing on the hard to reach populations products areas of the system ▶ Introduce innovative approaches to improve health security for all populations

107 The Gambia State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 53.8 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 8.2 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 576.1 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 350.0 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 162.4 177.6 234.9 190.6 180.3 170.6 Due to injuries 62.8 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the second smallest total GDP in the WHO African Region (represent- ▶ Health status very low compared with that needed for the attainment of ing 0.05% of the total GDP) and the seventh lowest GDP per capita (US$ 459 in current prices) the SDGs based on 2015 estimates ▶ Accelerate ongoing eorts to reduce burdens of communicable ▶ It has the 10th smallest population in the Region (0.20% of total population), the sixth smallest diseases, noncommunicable diseases and injuries targeting hard to land area (0.04% of the region), but the ninth highest population density (195.41 persons/km2) reach populations ▶ Health status is commensurate with that of a middle-income country ▶ The country has undergone recent political changes with the potential for major governance reforms ▶ Overall healthy life expectancy, morbidity and mortality rates are at/better than the regional average; however, mortality due to injuries conditions is marginally higher than that of the Region

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance lower than that of other low-in- the SDGs is 43% of what is feasible in the Region, lower than come countries the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average for SDG eective demand for essential services 3 services coverage, and nancial risk protection outcome areas ▶ Tangible system investments are low compared with the regional average, being ▶ Compared with other low-income countries, the country lowest for health workforce utilization is higher for SDG 3 services coverage and nancial ▶ Tangible system investments are too low for eectiveness of system processes risk protection outcome areas (service delivery, nancing, governance, information)

Implications ▶ Accelerate ongoing interventions to address SDG 3 services ▶ Accelerate strategies improving access to services, quality of care and eective for the SDGs coverage, and nancial risk protection outcome areas focusing demand for services specically targeting hard to reach populations on the hard to reach populations ▶ Introduce innovative strategies to improve system resilience for the whole popula- ▶ Introduce innovative approaches to improve services availa- tion, focusing on investments across all system areas bility, health security, service responsiveness and non-SDG 3 services coverage for all populations

108 Ghana State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 55.3 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 8.1 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 520.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 275.9 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 190.0 177.6 234.9 190.6 180.3 170.6 Due to injuries 54.5 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income country with the ninth largest total GDP in the WHO African Region ▶ Health status still low compared to that needed for reaching the SDGs (representing 2.24% of the total GDP) and the 16th highest GDP per capita (US$ 1361.1 in current ▶ Accelerate ongoing initiatives to reduce the burden due to communi- prices) based on 2015 estimates cable diseases and injuries targeting hard to reach populations ▶ It has the 11th largest population in the Region (2.78% of total population), but with only the ▶ Introduce innovative approaches to address the burden due to 27th largest land area (0.96% of the region) and the 13th highest population density (121.22 noncommunicable diseases persons/km2) ▶ Health status is on the upper side of its income classication, between a lower and an upper-middle-income countries ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average ▶ Mortality due to noncommunicable conditions is lower than that of the Region

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A lower-middle-income country with system performance similar to that of an the SDGs is 57% of what is feasible in the Region, higher than upper-middle-income country the regional average (48%). ▶ Across system performance monitoring domains, relative performance is lowest for ▶ Country utilization is higher than the regional average in SDG 3 access to services and highest for eective demand for services and non-SDG 3 services coverage, nancial risk protection and ▶ Tangible system investments are too low for eectiveness of system processes health security outcome areas (systems for service delivery, nancing, governance and information) ▶ Compared with other lower-middle-income countries, the ▶ Information is suggestive of some eective system processes (service delivery, country utilization is higher for SDG 3 and non-SDG 3 services nancing, governance, information), low system investments, but with very high coverage, nancial risk protection and health security ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Share lessons with other countries in improving nancial risk ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs protection ▶ Accelerate strategies improving quality of care, eective demand for services and ▶ Accelerate ongoing interventions addressing SDG 3 and non- system resilience specically targeting hard to reach populations SDG 3 services coverage, nancial risk protection and health ▶ Introduce innovative strategies to improve access to essential services for the whole security focused on hard to reach populations population, focusing on scaling up investments across all the system areas ▶ Introduce innovative approaches to improve services availability for all populations

109 Guinea State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 51.7 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 10.1 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 697.9 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 451.7 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 182.0 177.6 234.9 190.6 180.3 170.6 Due to injuries 64.1 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 27th largest total GDP in the WHO African Region (representing ▶ Health status low compared to that needed for the attainment of the 0.52% of the total GDP) and the 30th highest GDP per capita (US$ 725.1 in current prices) based SDGs on 2015 estimates ▶ Introduce innovative approaches to address the burden due to com- ▶ It has the 23rd largest population in the Region (1.22% of total population), the 26th largest municable diseases, noncommunicable diseases and injuries land area (1.04% of the Region) and the 26th highest population density (49.21 persons/km2) ▶ Health status is commensurate with that of its income classication ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country recently recovered from a major disruption of the system due the SDGs is 47% of what is feasible in the Region, close to the to EVD outbreak regional average (48%). ▶ System performance is lower than that of other low-income countries ▶ Country utilization is higher than the regional average for ▶ Across system performance monitoring domains, relative performance is highest for service responsiveness outcome area quality of care ▶ Compared with other low-income countries, the country ▶ Tangible system investments are lower than the regional averages, particularly for utilization is higher for health security, service responsiveness the health workforce. However, a major recruitment of 4,000 health workers has and non-SDG 3 service coverage outcome areas since greatly improved the health workforce density ▶ Tangible system investment levels are too low for eectiveness of system processes (service delivery, nancing, governance, information)

Implications ▶ Accelerate ongoing interventions to address service responsive- ▶ Explore areas for sharing lessons in building system resilience, learning from the EVD for the SDGs ness area, focusing on the hard to reach populations outbreak ▶ Introduce innovative approaches to improve service availability, ▶ Accelerate strategies improving quality of care specically targeting hard to reach health security, SDG 3 and non SDG 3 services coverage and populations nancial risk protection for all populations ▶ Introduce innovative strategies to improve access to services and eective demand for the whole population, focusing on scaling up investments across all health system

110 Guinea Bissau State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 51.5 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 12.3 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 688.0 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 451.0 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 173.5 177.6 234.9 190.6 180.3 170.6 Due to injuries 63.0 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the fourth lowest total GDP in the WHO African Region (representing ▶ Health status is low compared to that needed for the attainment of 0.06% of the total GDP) and the 35th highest GDP per capita (US$ 585.2 in current prices) based the SDGs on 2015 estimates ▶ Introduce innovative approaches to address the burden due to ▶ It has the eighth smallest population in the Region (0.18% of total population), the 37th largest communicable diseases and injuries land area (0.12% of the region) and the 23rd highest population density (62.96 persons/km2) ▶ Health status is commensurate with that of its income classication ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average ▶ Burden of noncommunicable diseases is marginally lower than that of the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance lower than that of other low-in- the SDGs is 42% of what is feasible in the Region, lower than come countries the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average for none quality of care, lowest for system resilience of the outcome areas ▶ Tangible system investments are higher than the regional average for health infra- ▶ Compared with other low-income countries, the country structure, but lower for health workforce and health products utilization is higher for none of the outcome areas ▶ Information is suggestive of low eectiveness of system processes (service delivery, nancing, governance and information), relatively high investment scores in some areas, but a low ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Introduce innovative approaches to improve service availa- ▶ Explore areas for sharing lessons in improving health infrastructure for the SDGs bility, SDG 3 and non-SDG 3 services coverages, nancial risk ▶ Accelerate strategies improving access to services, and quality of care specically protection, health security and service responsiveness for all targeting hard to reach populations populations ▶ Introduce innovative strategies to improve eective demand and system resilience for the whole population, focusing on scaling up investments in health workforce and health products

111 Kenya State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 55.6 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 8.3 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 474.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 281.0 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 142.0 177.6 234.9 190.6 180.3 170.6 Due to injuries 51.3 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income country with the sixth largest total GDP in the WHO African Region ▶ Health status is low compared with that needed for the attainment (representing 3.81% of the total GDP) and the 18th highest GDP per capita (US$ 1350 in current of the SDGs prices) based on 2015 estimates ▶ Accelerate ongoing eorts to address the communicable diseases, ▶ It has the sixth largest population in the Region (4.75% of total population), the 18th largest noncommunicable diseases and injuries targeting hard to reach land area (2.41% of the Region) and the 17th highest population density (83 persons/km2) populations ▶ Health status is commensurate with that of that of its classication ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Highest performer in the Region for service availability ▶ A lower-middle-income country with system performance at the level for its dimension of outcomes classication ▶ Overall utilization of health and health-related services to reach ▶ Across system performance monitoring domains, relative performance is highest for the SDGs is 64% of what is feasible in the Region, higher than quality of care the regional average (48%). ▶ Tangible system investments are average, being higher than the regional average for ▶ Country utilization is higher than the regional average across health infrastructure all outcome areas ▶ Information is suggestive of some areas of eectiveness of system processes ▶ Compared with other lower middle-income countries, the (service delivery, nancing, governance and information), with an average level country utilization is higher for health security, and non-SDG 3 of investment scores, and an above average ratio of overall performance score to service coverage outcome areas consolidated tangible investments scores

Implications ▶ Accelerate ongoing interventions to address service availability, ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs SDG 3 and non-SDG 3 service coverages, nancial risk protec- ▶ Accelerate strategies improving access to services, quality of care, eective demand tion, health security and service responsiveness focusing on the for services and systems resilience specically targeting hard to reach populations hard to reach populations and focusing on scaling up investments in the health workforce, health products and improving eectiveness of system processes

112 Lesotho State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 46.6 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 14.1 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 771.7 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 528.3 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 179.1 177.6 234.9 190.6 180.3 170.6 Due to injuries 63.3 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income country with the ninth smallest total GDP in the WHO African Region ▶ Health status too low compared with that needed for the attainment (representing 0.15% of the total GDP), but the 21st highest GDP per capita (US$ 1152.3 in of the SDGs current prices) based on 2015 estimates ▶ Explore introduction of innovative approaches to reduce the burden of ▶ It has the 11th smallest population in the Region (0.22% of total population), the 12th smallest communicable diseases, noncommunicable diseases and injuries land area (0.13% of the region) and the 21st highest population density (71.63 persons/km2) ▶ Health status is commensurate with that of a low-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average

1.00 0.90 0.80 0.70 0.69 0.60 0.63 0.57 0.56 0.50 0.50 0.52 0.50 0.44 0.40 0.36 0.38 0.30 0.20 0.24 0.21 0.22 0.10 0.08 - ND - ND - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A lower-middle-income country with system performance at the level of its the SDGs is 50% of what is feasible in the Region, higher than classication the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average health eective demand for services security outcome areas (no data for service availability and ▶ Tangible system investments are below the regional averages for all areas, particu- responsiveness) larly low for health workforce ▶ Compared with other lower middle-income countries, the ▶ Tangible system investment levels are too low for eectiveness of system processes country utilization is higher for SDG 3 service coverage, nan- (service delivery, nancing, governance and information) cial risk protection and health security

Implications ▶ Accelerate ongoing interventions to address health security ▶ Accelerate strategies improving quality of care and eective demand for care, for the SDGs focusing on the hard to reach populations specically targeting hard to reach populations ▶ Introduce innovative approaches to improve SDG 3 services ▶ Introduce innovative strategies to improve access to services for the whole popula- coverage, non-SDG 3 services coverage and nancial risk tion, focusing on scaling up investments across all health system areas protection for all populations ▶ Improve information availability, particularly for service availability and service responsiveness

113 Liberia State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 52.7 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 8 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 583.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 374.2 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 149.9 177.6 234.9 190.6 180.3 170.6 Due to injuries 59.1 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the eighth smallest total GDP in the WHO African Region (repre- ▶ Health status lower than that needed for the attainment of the SDGs senting 0.12% of the total GDP) and the sixth lowest GDP per capita (US$ 452 in current prices) ▶ Accelerate ongoing eorts to reduce burden of noncommunicable based on 2015 estimates diseases and injuries targeting hard to reach populations ▶ It has the 33rd largest population in the Region (0.45% of total population), the 32nd largest ▶ Explore innovative approaches to reduce communicable diseases land area (0.41% of the region) and the 28th highest population density (46.72 persons/km2) burden ▶ Health status is commensurate with that of a lower-middle-income country ▶ Overall healthy life expectancy and communicable disease burden is lower than the regional average ▶ However, crude death and noncommunicable disease /injuries burden are better than that of the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income-country recently recovered from a major disruption of the system due the SDGs is 39% of what is feasible in the Region, lower than to EVD outbreak the regional average (48%). ▶ System performance similar to that of other low-income countries ▶ Country utilization is higher than the regional average for none ▶ Across system performance monitoring domains, relative performance is best for of the outcome areas quality of care ▶ Compared with other low-income countries, the country ▶ Tangible system investments are below regional averages across all areas utilization is higher for non-SDG 3 service coverage ▶ Tangible system investment levels are too low for eectiveness of system processes (service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address non-SDG 3 service ▶ Accelerate strategies improving quality of care, and system resilience specically tar- for the SDGs coverage focusing on the hard to reach populations geting hard to reach populations, building on lessons learnt from the EVD outbreak ▶ Introduce innovative approaches to improve service availability, ▶ Introduce innovative strategies to access to services and eective demand for SDG 3 services coverage, nancial risk protection, health services for the whole population, focusing on scaling up investments across all security and responsiveness for all populations system areas

114 Madagascar State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 56.9 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 7 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 439.8 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 236.5 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 156.5 177.6 234.9 190.6 180.3 170.6 Due to injuries 46.6 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 25th largest total GDP in the WHO African Region (representing ▶ Health status lower than that needed for the attainment of the SDGs 0.58% of the total GDP) and the fth lowest GDP per capita (US$ 402.1 in current prices) based ▶ Accelerate ongoing eorts to reduce burden of communicable on 2015 estimates diseases, noncommunicable diseases and injuries targeting hard to ▶ It has the 12th largest population in the Region (2.44% of total population), the 17th largest reach populations land area (2.46% of the region) and the 31st highest population density (41.65 persons/km2) ▶ Health status is commensurate with that of a middle-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance lower than that of other low-in- the SDGs is 34% of what is feasible in the Region, lower than come countries the regional average (48%). ▶ Across system performance monitoring domains, relative performance is best for ▶ Country utilization is higher than the regional average only quality of care for SDG 3 services coverage outcome area (no data for service ▶ Tangible system investments are lower than the regional average in all areas availability) ▶ Tangible system investment levels are too low for eectiveness of system processes ▶ Compared with other low-income countries, the country (service delivery, nancing, governance and information) utilization is higher for SDG 3 service coverage

Implications ▶ Accelerate ongoing interventions to address SDG 3 services ▶ Accelerate strategies improving quality of care and eective service demand speci- for the SDGs coverages focusing on the hard to reach populations cally targeting hard to reach populations ▶ Introduce innovative approaches to improve nancial risk pro- ▶ Introduce innovative strategies to improve access to services and system resilience tection, health security, service responsiveness and non-SDG 3 for the whole population, focusing on scaling up investments in all the health services coverage for all populations system areas ▶ Improve information availability, particularly for service availability

115 Malawi State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 51.2 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 9 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 568.3 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 370.7 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 150.3 177.6 234.9 190.6 180.3 170.6 Due to injuries 46.7 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 32nd largest total GDP in the WHO African Region (representing ▶ Health status too low for the attainment of the SDGs 0.38% of the total GDP) and the third smallest GDP per capita (US$ 362.7 in current prices) ▶ Accelerate ongoing eorts to reduce burden of noncommunicable based on 2015 estimates diseases and injuries targeting hard to reach populations ▶ It has the 17th largest population in the Region (1.77% of total population), the 33rd largest ▶ Introduce innovative approaches to address communicable diseases land area (0.40% of the region) and the 10th highest population density (186 persons/km2) burden ▶ Health status is commensurate with that of its income classication ▶ Overall healthy life expectancy and communicable disease burden are lower than the regional average

1.00 0.90 0.80 0.75 0.70 0.60 0.63 0.60 0.50 0.53 0.47 0.45 0.45 0.45 0.40 0.43 0.40 0.43 0.30 0.24 0.25 0.20 0.20 0.19 0.10 0.07 0.06 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance marginally lower than that of other the SDGs is 45% of what is feasible in the Region, lower than low-income countries the regional average (48%). ▶ Across system performance monitoring domains, relative performance is lowest for ▶ Country utilization is higher than the regional average for only access to services and system resilience SDG 3 service coverage ▶ Tangible system investments are lower than regional averages, particularly for ▶ Compared with other low-income countries, the country utili- health workforce and infrastructure zation is higher for service availability, SDG 3 service coverage, ▶ Tangible system investment levels are too low for eectiveness of system processes nancial risk protection and responsiveness (service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address SDG 3 service ▶ Accelerate strategies improving quality of care and access to services, specically for the SDGs coverage, focusing on the hard to reach targeting hard to reach populations ▶ Introduce innovative approaches to improve service availability, ▶ Introduce innovative strategies to improve eective demand and system resilience health security, nancial risk protection, service responsiveness for the whole population, focusing on scaling up investments across all the health and non-SDG 3 service coverage for all populations system areas

116 Mali State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 51.1 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 11.2 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 767.0 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 518.5 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 176.5 177.6 234.9 190.6 180.3 170.6 Due to injuries 71.6 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 19th largest total GDP in the WHO African Region (representing ▶ Health status low compared with that needed for the attainment of 0.78% of the total GDP) and the 28th highest GDP per capita (US$ 750 in current prices) based the SDGs on 2015 estimates ▶ Accelerate ongoing eorts to reduce burden of noncommunicable ▶ It has the 18th largest population in the Region (1.76% of total population), but with the sixth diseases targeting hard to reach populations largest land area (5.17% of the region) and the seventh lowest population density (14.32 ▶ Introduce innovative approaches to address communicable diseases persons/km2) and injuries burden ▶ Health status is commensurate with that of its income classication ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average ▶ Mortality due to noncommunicable conditions is marginally higher than that of the Region

1.00 0.90 0.80 0.70 0.60 0.58 0.55 0.55 0.55 0.50 0.50 0.52 0.45 0.40 0.43 0.42 0.41 0.35 0.30 0.33 0.26 0.20 0.20 0.19 0.10 0.07 0.07 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance lower than that of other low-in- the SDGs is 45% of what is feasible in the Region, lower than come countries the regional average (48%). ▶ Across system performance monitoring domains, relative performance is lowest for ▶ Country utilization is higher than the regional average for none access to services of the outcome areas ▶ Tangible system investments are lower than regional averages, particularly for ▶ Compared with other low-income countries, the country health workforce and infrastructure utilization is higher for health security, service responsiveness ▶ Tangible system investment levels are too low for eectiveness of system processes and non-SDG 3 service coverage (service delivery, nancing, governance, information)

Implications ▶ Accelerate ongoing interventions to address health security, ▶ Accelerate strategies improving eective demand for services specically targeting for the SDGs service responsiveness and non-SDG 3 service coverage, hard to reach populations focusing on the hard to reach populations ▶ Introduce innovative strategies to improve access, quality of care and system ▶ Introduce innovative approaches to improve service availability, resilience for the whole population, focusing on scaling up investments across all the SDG 3 service coverage and nancial risk protection for all health system areas populations

117 Mauritania State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 55.1 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 7.8 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 528.2 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 313.1 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 159.6 177.6 234.9 190.6 180.3 170.6 Due to injuries 54.6 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income country with the 33rd largest total GDP in the WHO African Region (rep- ▶ Health status low compared with that needed for the attainment of resenting 0.29% of the total GDP) and the 20th highest GDP per capita (US$ 1158.3 in current the SDGs prices) based on 2015 estimates ▶ The country needs to accelerate ongoing eorts to reduce the burden ▶ It has the 34th largest population in the Region (0.42% of total population), but the eighth of communicable diseases, noncommunicable diseases and injuries largest land area (4.36% of the region) leaving it with the third smallest population density targeting hard to reach populations (4.06 persons/km ) ▶ The country is part of the dicult Sahel region, with the associated health risks ▶ Health status is commensurate with that of its economic classication ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

1.00 0.90 0.80 0.76 0.70 0.67 0.70 0.60 0.54 0.50 0.51 0.50 0.48 0.42 0.40 0.38 0.39 0.30 0.29 0.25 0.20 0.20 0.20 0.16 0.10 0.12 0.11 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A lower-middle-income country with system performance lower than that of the SDGs is 51% of what is feasible in the Region, higher than lower-income countries the regional average (48%). ▶ Across system performance monitoring domains, relative performance is lowest for ▶ Country utilization is higher than the regional average for access to services and system resilience service availability, SDG 3 service coverage, and nancial risk ▶ Tangible system investments are lower than regional averages, particularly for protection outcome areas health workforce and infrastructure ▶ Compared with other lower middle-income countries, the ▶ Tangible system investment levels are too low for eectiveness of system processes country utilization is higher for SDG 3 service coverage and (service delivery, nancing, governance and information) nancial risk protection outcome areas

Implications ▶ Accelerate ongoing interventions to address service availability, ▶ Accelerate strategies improving quality of care specically targeting hard to reach for the SDGs SDG 3 service coverage, and nancial risk protection outcome populations areas focusing on the hard to reach populations ▶ Introduce innovative strategies to improve access to services, eective demand for ▶ Introduce innovative approaches to improve health security, services and system resilience, focusing on scaling up investments in all the health service responsiveness and non-SDG 3 service coverage for all system areas populations

118 Mauritius State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 66.8 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 7.4 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 308.7 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 27.7 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 258.8 177.6 234.9 190.6 180.3 170.6 Due to injuries 22.2 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ An upper-middle-income small island state with the 21st largest total GDP in the WHO African ▶ Health status commensurate with that needed to attain the SDGs Region (representing 0.7% of the total GDP) but the third highest GDP per capita (US$ 9260 in ▶ Introduce innovative approaches to address the burden of noncom- current prices) based on 2015 estimates municable diseases ▶ It has the sixth smallest population in the Region (0.13% of total population), and the fourth ▶ Focus on identifying remaining pockets of hard to reach populations, smallest land area (0.01% of the region) leading to the highest population density (621.97 sharing best practices, and exploring alternative institutional service persons/km ) delivery models that improve sustainability for communicable ▶ Health status is commensurate with that of a high-income country diseases and injuries ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average ▶ However, mortality due to noncommunicable diseases is higher than that of the Region and high-income countries

1.00 0.90 0.88 0.80 0.79 0.72 0.75 0.70 0.68 0.70 0.69 0.60 0.59 0.62 0.55 0.58 0.50 0.49 0.40 0.39 0.30 0.20 0.19 0.10 - ND - ND - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Highest performer in the Region for SDG 3 services ▶ Highest performer in the Region for access to essential services coverage (with Algeria) dimension of outcomes ▶ An upper-middle-income country with system performance close to that of a ▶ Overall utilization of health and health-related services to high-income country reach the SDGs is 59% of what is feasible in the Region, ▶ Across system performance monitoring domains, relative performance is highest higher than the regional average (48%). for eective demand and access to services, and lowest for quality of care ▶ Country utilization is higher than the regional average for SDG 3 ▶ Tangible system investments are higher than regional averages, particularly for and non-SDG 3 service coverage and health security (there is no health workforce and products data for service availability and responsiveness) ▶ Information is suggestive of some eective system processes (service delivery, ▶ Compared with other upper middle-income countries, the nancing, governance, information), high system investment scores with an country utilization is higher for all outcome areas assessed, average ratio of overall performance score to consolidated tangible investments apart from nancial risk protection scores

Implications ▶ Share lessons with other countries in improving SDG 3 ▶ Explore areas for sharing lessons improving access and demand, and setting up for the SDGs services coverage system processes ▶ Accelerate ongoing interventions to address health security ▶ Introduce innovative strategies to improve quality of care for the whole popula- and non-SDG 3 services coverage focusing on the hard to tion, focusing on scaling up investments in health infrastructure reach populations ▶ Introduce innovative approaches to improve nancial risk protection for all populations ▶ Improve information availability, particularly for service availability and responsiveness 119 Mozambique State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 49.6 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 11.8 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 701.4 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 450.2 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 186.2 177.6 234.9 190.6 180.3 170.6 Due to injuries 64.3 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 15th largest total GDP in the WHO African Region (representing ▶ Health status too low compared with that needed for the attainment 0.88% of the total GDP) but the 10th lowest GDP per capita (US$ 528.3 in current prices) based of the SDGs on 2015 estimates ▶ Introduce innovative approaches to address the burden of communi- ▶ It has the ninth largest population in the Region (2.92% of total population), the 13th largest cable diseases and injuries land area (3.33% of the region) but with only the 33rd highest population density (35.62 ▶ The country needs to accelerate ongoing eorts to reduce the burden persons/km2) of noncommunicable diseases targeting hard to reach populations ▶ Health status is commensurate with that of its economic classication ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance lower than that of other low-in- the SDGs is 47% of what is feasible in the Region, just below come countries the regional average (48%). ▶ Facing economic challenges, including suspended international aid (IMF loans) and ▶ Country utilization is higher than the regional average for banking reforms nancial risk protection and health security. ▶ Across system performance monitoring domains, relative performance is lowest for ▶ Compared with other low-income countries, the country utili- system resilience zation is higher for nancial risk protection and health security ▶ Tangible system investments are only higher than regional averages for health products; they are very low for other areas ▶ Tangible system investment levels are too low for eectiveness of system processes (service delivery, nancing, governance and information)

Implications ▶ Share lessons with other countries in improving nancial risk ▶ Accelerate strategies improving quality of care, and eective demand for services for the SDGs protection specically targeting hard to reach populations ▶ Accelerate ongoing interventions to address health security ▶ Introduce innovative strategies to improve access to services, and system resilience and non-SDG 3 service coverage focusing on the hard to reach for the whole population, focusing on scaling up investments in health workforce populations and health infrastructure ▶ Introduce innovative approaches to improve service availability, SDG 3 service coverage and service responsiveness for all populations

120 Namibia State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 57.5 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 5.7 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 417.4 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 230.1 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 143.1 177.6 234.9 190.6 180.3 170.6 Due to injuries 43.3 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ An upper-middle-income country with the 22nd largest total GDP in the WHO African Region ▶ Health status low compared with that needed for the attainment of (representing 0.69% of the total GDP) but the seventh highest GDP per capita (US$ 4770.5 in the SDGs current prices) based on 2015 estimates ▶ The country needs to accelerate ongoing eorts to reduce burden of ▶ It has the 35th largest population in the Region (0.24% of total population), but with the 12th communicable diseases, noncommunicable diseases and injuries, largest land area (3.49% of the region) leaving it with the lowest population density (2.95 targeting hard to reach persons persons/km2) ▶ Health status is commensurate with that of its economic classication ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

1.00 0.90 0.80 0.70 0.70 0.71 0.65 0.66 0.67 0.65 0.60 0.62 0.58 0.61 0.50 0.45 0.40 0.40 0.37 0.30 0.31 0.20 0.19 0.10 - ND - ND - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Highest performer in the Region for nancial risk ▶ An upper-middle-income country, with system performance appropriate for its protection dimension of outcomes classication ▶ Overall utilization of health and health-related services to reach ▶ Across system performance monitoring domains, relative performance is highest for the SDGs is 61% of what is feasible in the Region, higher than quality of care, lowest for access to services the regional average (48%). ▶ Tangible system investments are higher than regional averages, apart from health ▶ Country utilization is higher than the regional average for all infrastructure where it is below expectations outcome areas apart from non-SDG 3 service coverage (heath ▶ Information is suggestive of eective system processes (service delivery, nancing, determinants) governance, information) – with high system investment scores and a high ratio of ▶ Compared with other upper middle-income countries, the overall performance score to consolidated tangible investments scores country utilization is higher for SDG 3 service coverage, nancial risk protection and health security

Implications ▶ Share lessons with other countries in improving nancial risk ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs protection ▶ Accelerate strategies improving quality of care and eective demand for services ▶ Accelerate ongoing interventions to address SDG 3 service specically targeting hard to reach populations coverage and health security focusing on the hard to reach ▶ Introduce innovative strategies to scale up investments in health infrastructure populations ▶ Introduce innovative approaches to improve non-SDG 3 service coverage (health determinants) for all populations ▶ Improve information availability, particularly for service availability and service responsiveness

121 Niger State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 54.2 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 10.2 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 676.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 463.2 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 144.8 177.6 234.9 190.6 180.3 170.6 Due to injuries 68.1 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 31st largest total GDP in the WHO African Region (representing ▶ Health status is low compared with that needed for the attainment 0.43% of the total GDP), but the fourth lowest GDP per capita (US$ 362.5 in current prices) of the SDGs based on 2015 estimates ▶ Accelerate ongoing eorts to reduce noncommunicable diseases, ▶ It has the 15th largest population in the Region (2.00% of total population), but the third targeting hard to reach populations largest land area (5.36% of the region) leaving it with the ninth lowest population density ▶ Explore innovative approaches to reduce burden of communicable (15.71 persons/km ) diseases and injuries ▶ Health status is commensurate with that of a low-income country ▶ Healthy life expectancy is better than, but the morbidity/mortality levels worse than the regional average ▶ However, mortality due to noncommunicable diseases is better than that of the Region.

1.00 0.90 0.80 0.79 0.70 0.68 0.60 0.57 0.55 0.51 0.53 0.50 0.47 0.47 0.48 0.49 0.42 0.40 0.37 0.38 0.32 0.30 0.27 0.20 0.18 0.10 - 0.02

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance similar to that of low-income the SDGs is 47% of what is feasible in the Region, marginally countries lower than the regional average (48%). ▶ Across system performance monitoring domains, relative performance is good for ▶ Country utilization is higher than the regional average for quality of care and system resilience service availability, health security and service responsiveness ▶ Tangible system investments are higher than regional averages for health products, outcome areas but lower for health workforce and health infrastructure ▶ Compared with other low-income countries, the country ▶ Tangible system investment levels are too low for eectiveness of system processes utilization is higher for service availability, health security and (service delivery, nancing, governance, information) service responsiveness outcome areas

Implications ▶ Accelerate ongoing interventions to address service availability, ▶ Explore areas for sharing lessons in setting up system resilience measures for the SDGs health security and service responsiveness outcomes focusing ▶ Accelerate strategies improving access to services, quality of care and system on the hard to reach populations resilience specically targeting hard to reach populations ▶ Introduce innovative approaches to improve SDG 3 service cov- ▶ Introduce innovative strategies to improve eective demand for the whole popula- erage, nancial risk protection and non-SDG 3 service coverage tion, focusing on scaling up investments in health workforce and infrastructure for all populations

122 Nigeria State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 47.7 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 11.9 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 847.1 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 582.7 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 189.5 177.6 234.9 190.6 180.3 170.6 Due to injuries 74.7 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income country with the largest total GDP in the WHO African Region ▶ Health status too low compared with that needed for the attainment (representing 28.72% of the total GDP) but only the 12th highest GDP per capita (US$ 2655.2 in of the SDGs current prices) based on 2015 estimates ▶ Explore innovative approaches to reduce the burden of communicable ▶ It has the largest population in the Region (18.24% of total population), and the 10th largest diseases, noncommunicable diseases and injuries land area (3.86% of the region), leaving it with the eighth highest population density (198.93 persons/km ) ▶ Health status is commensurate with that of a low-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional averages

1.00 0.90 0.80 0.80 0.70 0.67 0.70 0.60 0.62 0.50 0.49 0.45 0.44 0.40 0.39 0.40 0.35 0.30 0.30 0.20 0.21 0.21 0.14 0.10 0.10 0.08 - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A lower-middle-income country with system performance close to that of its the SDGs is 44% of what is feasible in the Region, lower than classication the regional average (48%). ▶ A large landmass country with high population ▶ Country utilization is higher than the regional average for ▶ Across system performance monitoring domains, relative performance is highest health security and non-SDG 3 services coverage for eective demand for services and quality of care, while it is lowest for system ▶ Compared with other lower middle-income countries, the resilience country utilization is higher for health security and non-SDG 3 ▶ Tangible system investment levels are too low for eectiveness of system processes services coverage outcomes (service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address health security ▶ Accelerate strategies improving access to services, quality of care and eective for the SDGs and non-SDG 3 services coverage outcomes focusing on the demand for services specically targeting hard to reach populations hard to reach populations ▶ Introduce innovative strategies to improve system resilience for the whole popula- ▶ Introduce innovative approaches to improve service availability, tion, focusing on scaling up investments in health products and health infrastructure service responsiveness, SDG 3 services coverage and nancial risk protection for all populations

123 Rwanda State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 56.6 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 6.4 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 413.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 187.9 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 156.9 177.6 234.9 190.6 180.3 170.6 Due to injuries 68.5 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 30th largest total GDP in the WHO African Region (representing ▶ Health status low compared to that needed for the attainment of the 0.49% of the total GDP) and the 31st highest GDP per capita (US$ 710.3 in current prices) based SDGs on 2015 estimates ▶ Accelerate ongoing eorts to reduce burden of communicable ▶ It has the 25th largest population in the Region (1.17% of total population), but with the eighth diseases and noncommunicable diseases targeting hard to reach smallest land area (0.10% of the Region) leaves it with the second highest population density populations (471.4 persons/km ) ▶ Explore innovative approaches to reduce the burden of injuries ▶ Health status is commensurate with that of a middle-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average ▶ However, mortality due to injuries is higher than that of the Region.

1.00 0.90 0.80 0.70 0.69 0.70 0.65 0.64 0.66 0.60 0.54 0.56 0.55 0.50 0.46 0.44 0.40 0.39 0.42 0.30 0.25 0.20 0.17 0.10 0.08 - ND - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance at its level of classication the SDGs is 56% of what is feasible in the Region, higher than ▶ Across system performance monitoring domains, relative performance is highest for the regional average (48%). quality of care and lowest for access to services ▶ Country utilization is higher than the regional average for all ▶ Tangible system investments are too low compared to the regional averages outcome areas apart from health security ▶ Tangible system investment levels are too low for eectiveness of system processes ▶ Compared with other low-income countries, the country (service delivery, nancing, governance, information) utilization is higher for all outcome areas assessed apart from health security

Implications ▶ Accelerate ongoing interventions to improve service availabili- ▶ Accelerate strategies improving quality of care, eective demand for services and for the SDGs ty, responsiveness, SDG 3 and non-SDG 3 service coverages, and system resilience specically targeting hard to reach populations nancial risk protection targeting hard to reach ▶ Introduce innovative strategies to improve access to services for the whole popula- ▶ Introduce innovative approaches to improve health security for tion, focusing on scaling up investments across all health system all populations

124 Sao Tome and Principe State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 59 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 6.5 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 410.5 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 206.7 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 159.9 177.6 234.9 190.6 180.3 170.6 Due to injuries 43.6 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income small island state with the smallest total GDP in the WHO African ▶ Health status low compared with that needed for the attainment of Region (representing 0.02% of the total GDP), but the 14th highest GDP per capita (US$ 1615.3 the SDGs in current prices) based on 2015 estimates ▶ Accelerate ongoing eorts to reduce burden of communicable ▶ It has the second smallest population in the Region (0.02% of total population), the second diseases, noncommunicable diseases and injuries focusing on hard to smallest land area (0.00% of the region) and the fth highest population density (203.7 reach populations persons/km ) ▶ Health status is commensurate with that of an upper-middle-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

1.00 0.90 0.80 0.80 0.75 0.70 0.71 0.68 0.62 0.61 0.60 0.57 0.53 0.53 0.50 0.50 0.52 0.49 0.40 0.30 0.33 0.20 0.18 0.10 - ND - ND - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A lower-middle-income country with system performance of an upper-middle-in- the SDGs is 53% of what is feasible in the Region, higher than come country the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average for SDG eective demand for services 3 and non-SDG 3 service coverages and nancial risk protection ▶ Tangible system investments are higher than regional averages, particularly for (no service availability/responsiveness data) health workforce and products ▶ Compared with other lower-middle-income countries, the ▶ Information is suggestive of some eective system processes (service delivery, country utilization is higher for SDG 3 and non-SDG 3 service nancing, governance and information), high system investment scores with an av- coverages and for nancial risk protection erage ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Share lessons with other countries in improving SDG 3 service ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs availability and nancial risk protection ▶ Accelerate strategies improving quality of care, and system resilience, specically ▶ Accelerate ongoing interventions to address non-SDG 3 service targeting hard to reach populations and focusing on scaling up investments in coverages focusing on the hard to reach populations health infrastructure ▶ Introduce innovative approaches to improve health security for all populations ▶ Improve information availability, particularly for service availability, and service responsiveness

125 Senegal State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 58.3 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 7 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 406.7 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 217.4 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 140.8 177.6 234.9 190.6 180.3 170.6 Due to injuries 47.6 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 18th largest total GDP in the WHO African Region (representing ▶ Health status still low compared with that needed for the attainment 0.81% of the total GDP) and the 23rd highest GDP per capita (US$ 910.8 in current prices) based of the SDGs on 2015 estimates ▶ Accelerate ongoing eorts to reduce burden of communicable ▶ It has the 21st largest population in the Region (1.51% of total population), the 29th largest diseases, noncommunicable diseases and injuries focused on the hard land area (0.82% of the Region) and the 18th highest population density (77.79 persons/km ) to reach populations ▶ Health status is commensurate with that of an upper-middle-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

1.00 0.90 0.80 0.70 0.73 0.68 0.67 0.60 0.64 0.50 0.49 0.48 0.40 0.39 0.34 0.30 0.29 0.30 0.30 0.32 0.20 0.24 0.22 0.10 0.11 0.13 0.06 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A lower-income country with system performance in line with its classication the SDGs is 39% of what is feasible in the Region, lower than ▶ Across system performance monitoring domains, relative performance is highest for the regional average (48%). quality of care, lowest for system resilience ▶ Country utilization is higher than the regional average for SDG ▶ Tangible system investments are markedly lower than regional averages for health 3 service coverage and non-SDG 3 service coverage outcome workforce and health infrastructure areas ▶ Tangible system investment levels are too low for eectiveness of system processes ▶ Compared with other low-income countries, the country (service delivery, nancing, governance and information) utilization is higher for SDG 3 service coverage and non-SDG 3 service coverage outcome areas

Implications ▶ Accelerate ongoing interventions to address SDG 3 service cov- ▶ Accelerate strategies improving access to services, quality of care and eective for the SDGs erage and non-SDG 3 service coverage outcome areas focusing demand for services specically targeting hard to reach populations on the hard to reach populations ▶ Introduce innovative strategies to improve system resilience for the whole ▶ Introduce innovative approaches to improve nancial risk population, focusing on scaling up investments in health workforce and health protection, health security and service responsiveness for all infrastructure populations

126 Seychelles State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 65.5 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 6.7 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 309.3 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 43.9 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 234.9 177.6 234.9 190.6 180.3 170.6 Due to injuries 30.3 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ The only high-income country that is also a small island state but with the fth smallest total ▶ Health status close to that needed for the attainment of the SDGs GDP in the WHO African Region (representing 0.09% of the total GDP) but the highest GDP per ▶ Explore innovative approaches to reduce the burden of noncommuni- capita (US$ 15 390 in current prices) based on 2015 estimates cable diseases ▶ It has the smallest population in the Region (0.01% of total population), the smallest land area ▶ Focus on identifying remaining pockets of hard to reach populations, (0.00% of the region) but with the sixth highest population density (203.08 persons/km ) sharing best practices and exploring alternative institutional service ▶ Health status is commensurate with that of its economic classication delivery models that improve sustainability for the low burden of ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional communicable diseases and injuries average ▶ However, mortality due to noncommunicable conditions is marginally higher than that of the Region

1.00 0.90 0.94 0.87 0.85 0.87 0.80 0.75 0.70 0.72 0.68 0.67 0.70 0.60 0.62 0.63 0.60 0.54 0.56 0.55 0.50 0.40 0.41 0.30 0.33 0.20 0.10 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Highest performer in the Region for service ▶ Highest performer in the region for overall system performance, and quality of responsiveness and non-SDG 3 services coverage care dimension (health determinants) dimensions of outcomes ▶ The only high-income country in the African Region, dening the expectations for high-in- ▶ Overall utilization of health and health-related services come countries in the Region to reach the SDGs is 68% of what is feasible in the ▶ Across system performance monitoring domains, relative performance is highest for quality Region, higher than the regional average (48%). of care and eective demand for services, and lowest for system resilience ▶ Country utilization is higher than the regional average ▶ Tangible system investment levels are higher than the regional average for all areas of the across all outcome domains assessed system ▶ Information is suggestive of functional and eective system processes (service delivery, nancing, governance, information), with high levels of investments in tangibles coupled with high ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Share lessons with other countries in improving service ▶ Explore areas for sharing lessons in establishing eective system processes and investing in for the SDGs availability, SDG 3 and non-SDG 3 services coverages, system tangibles (workforce, infrastructure and products) nancial risk protection, health security and service ▶ Accelerate strategies improving access to services, quality of care and eective demand for responsiveness services, specically targeting hard to reach populations

127 Sierra Leone State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 44.4 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 16.8 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 969.6 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 631.3 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 243.0 177.6 234.9 190.6 180.3 170.6 Due to injuries 95.1 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 34th largest total GDP in the WHO African Region (representing ▶ Health status too low compared with that needed for the attainment 0.25% of the total GDP) and the 34th highest GDP per capita (US$ 587.5 in current prices) based of the SDGs on 2015 estimates ▶ Explore innovative approaches to reduce the burden of communicable ▶ It has the 29th largest population in the Region (0.73% of total population), the 34th largest diseases, noncommunicable diseases and injuries land area (0.31% of the region) and the 14th highest population density (100.26 persons/km ) ▶ Health status is commensurate with that of its economic classication ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country recently recovered from a major disruption of the system due the SDGs is 43% of what is feasible in the Region, lower than EVD outbreak the regional average (48%). ▶ System performance is lower than that of other low-income countries ▶ Country utilization is higher than the regional average for ▶ Across system performance monitoring domains, relative performance is highest for health security and service responsiveness outcome areas system resilience, and lowest for access to services ▶ Compared with other low-income countries, the country utili- ▶ Tangible system investments are lower than regional averages for health workforce zation is higher for health security and service responsiveness and health products investments outcome areas ▶ Tangible system investment levels are too low to provide information on eectiveness of system processes (service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address health security ▶ Explore areas for sharing lessons in establishing resilient systems, learning from EVD for the SDGs and service responsiveness outcomes, focusing on the hard to experiences reach populations ▶ Accelerate strategies improving access to services and eective demand for care ▶ Introduce innovative approaches to improve service availability, specically targeting hard to reach populations SDG 3 service coverage, nancial risk protection and non-SDG 3 ▶ Introduce innovative strategies to improve quality of care for the whole population, services coverage for all populations focusing on scaling up investments in health workforce and health products

128 South Africa State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 54.4 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 11.1 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 506.3 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 253.8 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 204.2 177.6 234.9 190.6 180.3 170.6 Due to injuries 47.3 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ An upper-middle-income country with the second largest total GDP in the WHO African Region ▶ Health status too low compared with that needed for the attainment (representing 18.96% of the total GDP) and the sixth highest GDP per capita (US$ 5744.3 in of the SDGs current prices) based on 2015 estimates ▶ Accelerate ongoing eorts to reduce the burden of communicable ▶ It has the fourth largest population in the Region (5.57% of total population), the seventh larg- diseases and injuries focusing on hard to reach populations est land area (5.14% of the Region) and the 29th highest population density (45.58 persons/ ▶ Explore innovative approaches to reduce the burden of noncommuni- km ) cable diseases ▶ Health status is commensurate with that of a low to lower-middle-income country ▶ Overall healthy life expectancy marginally better, but morbidity and mortality rates worse than regional average ▶ Mortality due to noncommunicable diseases is higher than that of the Region.

1.00 1.00 0.90 0.80 0.81 0.70 0.66 0.67 0.60 0.63 0.62 0.61 0.56 0.53 0.50 0.48 0.47 0.44 0.40 0.39 0.30 0.20 0.10 0.13 - ND - ND - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Highest performer in the region for health security dimension ▶ An upper-middle-income country with system performance similar to its of outcomes classication ▶ Overall utilization of health and health-related services to reach the ▶ Across system performance monitoring domains, relative performance is SDGs is 66% of what is feasible in the Region, higher than the regional lowest for quality of care average (48%). ▶ Tangible system investments are average compared to the regional average, ▶ Country utilization is higher than the regional average for nancial being higher for health workforce risk protection, health security and non-SDG 3 service coverage out- ▶ Information is suggestive of some eective system processes (service delivery, come areas (there is no data for service availability or responsiveness). nancing, governance and information) – average levels of tangible invest- ▶ It forms the performance frontier for health security in the Region ments coupled with high ratio of overall performance score to consolidated ▶ Compared with other upper middle-income countries, the country uti- tangible investments scores lization is higher for health security and non-SDG 3 services coverage

Implications ▶ Share lessons with other countries in improving health security ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs ▶ Accelerate ongoing interventions to address nancial risk protection ▶ Accelerate strategies improving access to services, and eective demand and non-SDG 3 services coverage, focusing on the hard to reach specically targeting hard to reach populations populations ▶ Introduce innovative strategies to improve quality of care for the whole ▶ Introduce innovative approaches to improve SDG 3 services coverage population, focusing on scaling up investments in health products and health for all populations infrastructure ▶ Improve information availability, particularly for services availability and responsiveness

129 South Sudan State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 49.9 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 11.1 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 734.5 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 483.3 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 166.8 177.6 234.9 190.6 180.3 170.6 Due to injuries 84.1 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 26th largest total GDP in the WHO African Region (representing ▶ Health status too low compared with that needed for the attainment 0.54% of the total GDP) and the 27th highest GDP per capita (US$ 758.7 in current prices) based of the SDGs on 2015 estimates ▶ Accelerate ongoing eorts to reduce burden of noncommunicable ▶ It has the 24th largest population in the Region (1.20% of total population), but the 16th largest diseases, focusing on hard to reach populations land area (2.62% of the Region), leaving it with the 37th highest population density (19.17 ▶ Explore innovative approaches to address the high burden of commu- persons/km ) nicable diseases and injuries ▶ Health status is commensurate with that of its income classication ▶ The country has faced protracted civil unrest, straining its capacity for sustainable development ▶ Overall healthy life expectancy, morbidity and mortality rates are lower than the regional average ▶ However, mortality due to noncommunicable diseases is marginally higher than that of the Region.

1.00 0.90 0.80 0.70 0.69 0.60 0.56 0.50 0.50 0.52 0.45 0.43 0.40 0.38 0.37 0.30 0.30 0.20 0.16 0.10 - ND - ND - ND - ND ----ND ND ND

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with major conict in the recent past and persisting insurgen- the SDGs is 38% of what is feasible in the Region, lower than cy making real-time health system assessment dicult the regional average (48%). ▶ From available information system performance is average compared to the Region ▶ Country utilization is higher than the regional average for none ▶ Across system performance monitoring domains, relative performance is highest for of the outcome areas assessed (there is no data for service quality of care, lowest for access availability, and responsiveness) ▶ No information on tangible system investments ▶ Compared with other low-income countries, the country ▶ No assessment of eectiveness of system processes (service delivery, nancing, utilization is higher for all outcome areas assessed governance and information)

Implications ▶ Introduce innovative approaches to improve SDG 3 services ▶ Introduce innovative strategies to improve access, quality, resilience and demand for for the SDGs coverage, nancial risk protection, health security and non-SDG services for the whole population, focusing on investments across the health system 3 services coverage for all populations – through a dedicated health system recovery programme ▶ Improve information availability, particularly for services availability and responsiveness

130 Togo State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 52.8 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 9.6 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 597.2 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 351.5 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 181.6 177.6 234.9 190.6 180.3 170.6 Due to injuries 63.8 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 35th largest total GDP in the WHO African Region (representing ▶ Health status is too low compared with that needed for the attain- 0.24% of the total GDP) and the 37th highest GDP per capita (US$ 551.1 in current prices) based ment of the SDGs on 2015 estimates ▶ Accelerate ongoing eorts to reduce the burden of communicable ▶ It has the 28th largest population in the Region (0.75% of total population), the 35th largest diseases, noncommunicable diseases and injuries focusing on hard to land area (0.23% of the Region) but with the 11th highest population density (136.36 persons/ reach populations km2) ▶ Health status is commensurate with that of a lower middle-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are at the regional average

1.00 0.90 0.80 0.83 0.74 0.70 0.64 0.60 0.61 0.55 0.56 0.54 0.50 0.53 0.40 0.43 0.40 0.30 0.33 0.30 0.20 0.14 0.10 0.08 - ND - ND - ND -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values ND No data Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance closer to that of a lower-middle-in- the SDGs is 55% of what is feasible in the Region, higher than come country the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average for SDG eective demand for services 3 services coverage, and health security outcome areas (no ▶ Tangible system investments are lower than region-al averages for health workforce data for service availability and responsiveness) and health prod-ucts investments ▶ Compared with other low-income countries, the country ▶ Tangible system investment levels are too low to provide information on eective- utilization is higher for all outcome areas assessed ness of system pro-cesses (service delivery, nancing, governance and information)

Implications ▶ Accelerate ongoing interventions to address SDG 3 services ▶ Accelerate strategies improving quality of care and eective demand, specically for the SDGs coverage, nancial risk protection, health security and non-SDG targeting hard to reach populations 3 services focusing on the hard to reach populations ▶ Introduce innovative strategies to improve access to services for the whole popula- ▶ Improve information availability, particularly for service tion, focusing on scaling up investments in health workforce and health products availability and responsiveness

131 Uganda State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 54 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 9.2 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 528.3 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 307.0 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 157.9 177.6 234.9 190.6 180.3 170.6 Due to injuries 63.0 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 12th largest total GDP in the WHO African Region (representing ▶ Health status low compared with that needed for the attainment of 1.62% of the total GDP) but only the 32nd highest GDP per capita (US$ 674 in current prices) the SDGs based on 2015 estimates ▶ Accelerate ongoing initiatives to reduce the burdens of communicable ▶ It has the seventh largest population in the Region (4.04% of total population), but only the diseases and noncommunicable diseases focusing on hard to reach 28th largest land area (0.85% of the Region) leaving it with the seventh highest population persons density (200.2 persons/km ) ▶ Health status is commensurate with that of a lower middle-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are marginally better than the regional average

1.00 0.90 0.80 0.70 0.73 0.65 0.60 0.57 0.59 0.50 0.52 0.46 0.43 0.45 0.43 0.40 0.38 0.34 0.30 0.30 0.30 0.29 0.25 0.20 0.23 0.10 0.10 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance lower than that of other low- the SDGs is 46% of what is feasible in the Region, marginally income countries lower than the regional average (48%). ▶ Across system performance monitoring domains, relative performance is lower than ▶ Country utilization is higher than the regional average for the regional average in all areas, being lowest for access to services health security ▶ Tangible system investments are lower than regional averages for all areas of ▶ Compared with other low-income countries, the country investments utilization is higher for service availability and health security ▶ Tangible system investment levels are too low to provide information on outcome areas eectiveness of system processes (service delivery, nancing, governance, information)

Implications ▶ Accelerate ongoing interventions to address health security ▶ Accelerate strategies improving access to services, quality of care and system for the SDGs and non-SDG 3 services coverage focusing on the hard to reach resilience specically targeting hard to reach populations populations ▶ Introduce innovative strategies to improve eective demand for services for the ▶ Introduce innovative approaches to improve service availability, whole population, focusing on scaling up investments in all health system areas SDG 3 services coverages, nancial risk protection and service responsiveness for all populations

132 United Republic of Tanzania State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 54.2 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 7.8 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 511.9 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 298.9 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 154.5 177.6 234.9 190.6 180.3 170.6 Due to injuries 58.2 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the seventh largest total GDP in the WHO African Region (repre- ▶ Health status low compared with that needed for the attainment of senting 2.72% of the total GDP) but only the 24th highest GDP per capita (US$ 872.3 in current the SDGs prices) based on 2015 estimates ▶ Accelerate ongoing eorts to reduce burdens of communicable ▶ It has the fth largest population in the Region (5.42% of total population), the 11th largest diseases, noncommunicable diseases and injuries focusing on hard to land area (3.75% of the Region) and the 24th highest population density (60.83 persons/km ) reach persons ▶ Health status is commensurate with that of a lower-middle-income country ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average

1.00 0.90 0.80 0.70 0.67 0.66 0.60 0.61 0.56 0.59 0.50 0.50 0.48 0.46 0.48 0.45 0.40 0.40 0.39 0.39 0.30 0.33 0.33 0.27 0.20 0.10 0.07 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance lower than that of other low- the SDGs is 50% of what is feasible in the Region, marginally income countries higher than the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average for eective demand for services nancial risk protection, health security and non-SDG services ▶ Tangible system investments are lower than regional averages for health workforce coverage outcomes and health products investments ▶ Compared with other low-income countries, the country ▶ Tangible system investment levels are too low to provide information on utilization is higher for SDG 3 and non-SDG 3 services coverage, eectiveness of system processes (service delivery, nancing, governance and nancial risk protection, and health security information)

Implications ▶ Accelerate ongoing interventions to address SDG 3 and non- ▶ Accelerate strategies improving access to services, eective demand for services and for the SDGs SDG 3 services coverage, nancial risk protection and health system resilience specically targeting hard to reach populations security focusing on hard to reach populations ▶ Introduce innovative strategies to improve quality of care for the whole population, ▶ Introduce innovative approaches to improve service availability, focusing on scaling up investments in health workforce and health products and service responsiveness for all populations

133 Zambia State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 53.7 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 9.7 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 554.2 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 356.5 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 144.0 177.6 234.9 190.6 180.3 170.6 Due to injuries 53.4 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A lower-middle-income country with the 13th largest total GDP in the WHO African Region ▶ Health status low compared with that needed for the attainment of (representing 1.26% of the total GDP) and the 19th highest GDP per capita (US$ 1313.9 in the SDGs current prices) based on 2015 estimates ▶ Accelerate ongoing initiatives to reduce the burden of communicable ▶ It has the 19th largest population in the Region (1.62% of total population), the 14th largest diseases, noncommunicable diseases and injuries focusing on hard to land area (3.15% of the Region) and the 36th highest population density (22.35 persons/km ) reach persons ▶ Health status is commensurate with that of its income classication ▶ Overall healthy life expectancy, morbidity and mortality rates are similar to the regional average

1.00 0.90 0.92 0.80 0.75 0.70 0.74 0.60 0.56 0.50 0.52 0.53 0.54 0.52 0.47 0.44 0.44 0.40 0.41 0.32 0.30 0.29 0.28 0.30 0.20 0.10 0.12 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A lower-middle-income country with system performance closer to that of an the SDGs is 53% of what is feasible in the Region, higher than upper-middle-income country the regional average (48%). ▶ Across system performance monitoring domains, relative performance is highest for ▶ Country utilization is higher than the regional average for quality of care and eective demand for services health security outcome area ▶ Tangible system investments are lower than regional averages for health workforce ▶ Compared with other lower middle-income countries, the and health products investments country utilization is higher for health security outcome area ▶ Tangible system investment levels are too low to provide information on eectiveness of system processes (service delivery, nancing, governance and information)

Implications ▶ Share lessons with other countries on improving health security ▶ Accelerate strategies improving access to services, quality of care, eective demand for the SDGs outcomes for services and system resilience specically targeting hard to reach populations ▶ Accelerate ongoing interventions to address SDG 3 services ▶ Scale up investments in health workforce and health products coverage, focusing on the hard to reach populations ▶ Introduce innovative approaches to improve service availability, nancial risk protection, service responsiveness and non-SDG 3 service coverage for all populations

134 Zimbabwe State of health and well-being Country African Region equivalent value value Average HICs UMICs LMICs LICs Healthy life expectancy 52.1 53.8 65.5 58.6 52.9 52.5 Crude death rate per 1000 population 9.8 9.7 6.7 8.2 10.1 10.0 DALYs lost per 1000 population – Total 591.8 592.2 309.3 441.4 618.4 630.6 Due to communicable diseases 367.4 352.9 43.9 207.1 374.8 393.0 Due to noncommunicable conditions 160.3 177.6 234.9 190.6 180.3 170.6 Due to injuries 63.7 61.2 30.3 43.2 62.7 66.5 Comments Implications for the attainment of the SDGs* ▶ A low-income country with the 14th largest total GDP in the WHO African Region (representing ▶ Health status low compared with that needed for the attainment of 0.97% of the total GDP) and the 22nd highest GDP per capita (US$ 1033.4 in current prices) the SDGs based on 2015 estimates ▶ Accelerate ongoing eorts to reduce the burdens of communicable ▶ It has the 20th largest population in the Region (1.59% of total population), the 21st largest diseases, noncommunicable diseases and injuries focusing on hard to land area (1.64% of the Region) and the 32nd highest population density (40.78 persons/km ) reach populations ▶ The country has faced a protected economic contraction leading up to the SDGs ▶ Health status is commensurate with that of its income classication ▶ Overall healthy life expectancy, morbidity and mortality rates are better than the regional average ▶ Mortality due to noncommunicable conditions is marginally higher than that of the Region

1.00 0.90 0.80 0.74 0.70 0.70 0.68 0.69 0.60 0.60 0.59 0.60 0.60 0.52 0.55 0.52 0.50 0.49 0.48 0.40 0.40 0.37 0.40 0.30 0.20 0.20 0.10 -

UHC Access Health Health Health Health Health

Service Service Quality

security Demand products coverage average

Average Average Average

workforce Resilience protection availability Financial risk Financial determinants infrastructure SDG 3 services responsiveness Regional average Country values Service outcomes System performance and investments Comments ▶ Overall utilization of health and health-related services to reach ▶ A low-income country with system performance of an upper-middle-income the SDGs is 60% of what is feasible in the Region, higher than country the regional average (48%). ▶ Extended economic crisis ▶ Country utilization is higher than the regional average across ▶ Across system performance monitoring domains, relative performance is highest for all outcome domains assessed eective demand and quality of care ▶ Compared with other low-income countries, the country ▶ Tangible system investments are above average as compared to the regional average utilization is higher for all outcome areas ▶ Information is suggestive of some eective system processes (service delivery, nancing, governance, information), with higher than average tangible investments coupled with a high ratio of overall performance score to consolidated tangible investments scores

Implications ▶ Accelerate ongoing interventions to address service availability, ▶ Explore areas for sharing lessons in establishing eective system processes for the SDGs SDG 3 and non-SDG 3 services coverage, nancial risk ▶ Accelerate strategies improving access to services, quality of care, eective demand protection, health security and service responsiveness focusing for services and system resilience specically targeting hard to reach populations on the hard to reach populations ▶ Scale up investments in health infrastructure

Annex 1: Indicators Health outcomes – health and essential services ...... 139 Outcome area 1: Attributes to monitor availability of essential services across age cohorts ...... 139 Outcome area 2: Indicators or coverage of essential health interventions by public health functions ...... 140 Outcome area 3: Indicators for financial risk protection ...... 140 Outcome area 4: Attributes for health security ...... 141 Outcome area 5: Attributes for service responsiveness ...... 141 Outcome area 6: Indicators for coverage of essential non-SDG 3 targets across determinants ...... 142 Health outputs – Health system performance measurements ...... 144 Health inputs – Health system investment measurements ...... 146 Annex 2: Data by indicator used to generate indices Health nancing data ...... 147 Health investments data ...... 149 Health workforce ...... 149 Health products ...... 150 Health systems performance data ...... 152 Access to essential services ...... 152 Quality of Care ...... 154 Effective demand for essential services ...... 155 System resilience ...... 156 Health and related service outcomes data ...... 157 Service availability ...... 157 Coverage with interventions addressing SDG 3 targets ...... 159 Health security ...... 160 Service responsiveness and satisfaction ...... 161 Coverage with interventions addressing non-SDG 3 targets influencing health and well-being ...... 163 Health impact data ...... 166

Annex 1: Indicators

Health outcomes – health and essential services Outcome area 1: Attributes to monitor availability of essential services across age cohorts

COHORT ESSENTIAL SERVICES Pregnancy and newborn Antenatal care services Perinatal care services Care for the newborn Postnatal care services Childhood Childhood immunization Child nutrition (under- and overweight) Integrated childhood services Primary school health services

Promotion of childhood healthy lifestyles Adolescence Adolescent sexual and reproductive health services Adolescent/youth friendly health services Secondary school health services Harm reduction services for prevention of drug and alcohol use Promotion of adolescent healthy lifestyles Adulthood Screening for common communicable conditions Screening for common noncommunicable conditions and risk factors Reproductive health services including family planning Promotion of adulthood healthy lifestyles Adult nutrition services Clinical and rehabilitative health services Elderly Annual screening and medical exams Elderly persons social support services Clinical and rehabilitative services for the elderly

139 Outcome area 2: Indicators or coverage of essential health interventions by public health functions

SDG TARGET INDICATOR RELATED PUBLIC HEALTH FUNCTION Maternal mortality ratio (per live births) Impact level indicator . Proportion of births attended by skilled health personnel () Curative Under-ve mortality rate (per live births) Impact level indicator . Neonatal mortality rate (per live births) Impact level indicator New HIV infections among adults – years old (per uninfected population) Communicable disease prevention TB incidence (per population) Communicable disease prevention . Malaria incidence (per population at risk) Communicable disease prevention Infants receiving three doses of hepatitis B vaccine () Communicable disease prevention Reported number of people requiring interventions against NTDs Communicable disease prevention Probability of dying from any of CVD, cancer, diabetes, CRD between age and exact age Noncommunicable disease prevention . () Suicide mortality rate (per population) Noncommunicable disease prevention . Total alcohol per capita (> years of age) consumption, in litres of pure alcohol Health promotion . Road trac mortality rate (per population) Noncommunicable disease prevention Proportion of married or in-union women of reproductive age who have their need for Health promotion . family planning satised with modern methods () Adolescent birth rate (per women aged – years) Health promotion Mortality rate attributed to household and ambient air pollution (per population) Noncommunicable disease prevention . Mortality rate attributed to exposure to unsafe WASH services (per population) Communicable disease prevention Mortality rate from unintentional poisoning (per population) Noncommunicable disease prevention

Outcome area 3: Indicators for nancial risk protection

INDICATOR General government health expenditure (GGHE) as of Total health expenditure Out of pocket expenditure (OOPS) as of Private health expenditure (PvtHE) Social security funds as of General government health expenditure (GGHE)

140 Outcome area 4: Attributes for health security DOMAIN CORE CAPACITY AREA National legislation, policy and nancing IHR coordination, communication and advocacy Antimicrobial resistance (AMR) Zoonotic disease Prevention Food safety Biosafety and biosecurity Immunization Points of entry (PoE) * National laboratory systems Real-time surveillance Detection Reporting Workforce development Preparedness Emergency operations centres Response Linking public health with law and multisectoral rapid response Medical countermeasures and personnel deployment Risk communication Chemical events Other Radiation emergencies

Outcome area 5: Attributes for service responsiveness

DOMAINS ATTRIBUTES Dignity Patients/clients are treated with respect during the care process The rights of patients/clients with conditions that may potentially be associated with stigma are eectively safeguarded Patients/clients are encouraged to discuss their concerns and needs freely, during the process of care Respect is shown for patients/clients desire for privacy during the examination or management process Autonomy Patients/clients are provided with information on alternative management options Patients/clients are consulted and their views considered in relation to their management preferences Patient consent is explicitly sought before testing or management is commenced Condentiality Consultations between patients/clients and providers is carried out in a manner that protects condentiality Condentiality of information provided by patients/clients is preserved, except if needed by other providers to further the care process Medical records are preserved in a manner that ensures there is limited/no chance of their leaking to unauthorized users Prompt attention Patients/clients are able to get to a facility oering services they need in under minutes Patients/clients will usually spend under minutes at a facility before they receive services Patients/clients will usually complete all the services they need within hours of arriving at a health facility Patients/clients will usually spend an unnecessarily long time waiting for elective procedures Access to social support Patients/clients are allowed to receive guests during the care process networks Families and friends of patients/clients are allowed to cater for their personal needs during the care process Patients/clients are allowed to involve themselves in religious activities during the care process Quality of basic amenities Health facilities are usually clean Food for Patients/clients is usually adequate for their nutrition needs Water and sanitation services for patients/clients are usually adequate in the health facilities The linen and other personal items provided to patients/clients is usually clean and appropriate Choice of care providers Patients/clients usually have a choice of providers in a given health facility Patients/clients usually have a choice of facilities providing their required services Patients/clients have the opportunity to freely seek a second opinion without fear of penalisation, if they desire Patients/clients have the opportunity to see specialists, if they desire to

141 Outcome area 6: Indicators for coverage of essential non-SDG 3 targets across determinants DOMAIN AREA SDG SDG TARGET HEALTH RELATED INDICATOR USED End poverty in all its forms . Implement nationally appropriate social protection Coverage () – All Social Assistance everywhere systems and measures for all, including oors, and by achieve substantial coverage of the poor and vulnerable End hunger, achieve food . By , end all forms of malnutrition, including Prevalence of stunting in children under () security and improved achieving, by , the internationally agreed targets Prevalence of wasting in children under () nutrition and promote on stunting and wasting in children under years of Prevalence of overweight in children under sustainable agriculture age, and address the nutrition needs of adolescent girls, () pregnant and lactating mothers and older persons Ensure inclusive and . By , ensure that all girls and boys complete free, Primary education, duration (years) equitable quality education equitable and quality primary and secondary education Lower secondary completion rate, total ( of and promote lifelong leading to relevant and eective learning outcomes relevant age group) learning opportunities Primary completion rate, total ( of relevant for all age group) Secondary education, duration (years) . By , ensure that all girls and boys have access to Pre-primary education, duration (years) quality early childhood development, care and pre- School enrolment, pre-primary ( gross) primary education so that they are ready for primary education Social determinants Social determinants Achieve gender equality, . Eliminate all harmful practices, such as child early and Female genital mutilation prevalence () and empower all women forced marriage and female genital mutilation and girls Ensure availability and . By , achieve universal and equitable access to safe Proportion of population using improved sustainable management of and aordable drinking water for all drinking-water sources v () water and sanitation for all . By , achieve access to adequate and equitable Proportion of population using improved sanitation and hygiene for all and end open defecation, sanitation v () paying special attention to the needs of women and girls and those in vulnerable situations . By , improve water quality by reducing pollution, People practicing open defecation ( of eliminating dumping and minimizing release of population) hazardous chemicals and materials, halving the proportion of untreated waste water and substantially increasing recycling and safe reuse globally Ensure access to aordable, . By , ensure universal access to aordable, reliable Annualized average growth rate in per capita reliable, sustainable and and modern energy services real survey mean consumption or income, total modern energy for all population () Promote sustained, inclusive . Sustain per capita economic growth in accordance with GDP growth (annual ) and sustainable economic national circumstances and, in particular, at least per growth, full and productive cent gross domestic product growth per annum in the employment and decent least developed countries work for all . By , achieve full and productive employment and Unemployment, total ( of total labour force) decent work for all women and men, including for (modelled ILO estimate) young people and persons with disabilities, and equal pay for work of equal value Build resilient infrastructure, . Develop quality, reliable, sustainable and resilient Access to electricity ( of population) promote inclusive and infrastructure, including regional and trans-border sustainable industrialization infrastructure, to support economic development and and foster innovation human well-being, with a focus on aordable and

Economic determinants determinants Economic equitable access c Signicantly increase access to information and Individuals using the Internet ( of communications technology and strive to provide population) universal and aordable access to the internet in least developed countries by Reduce inequity within and . By , empower and promote the social, economic, Proportion of seats held by women in national among countries and political inclusion of all, irrespective of age, sex, parliaments () disability, race, ethnicity, origin, religion or economic or other status

142 Outcome area 6: Indicators for coverage of essential non-SDG 3 targets across determinants DOMAIN AREA SDG SDG TARGET HEALTH RELATED INDICATOR USED Make cities inclusive, safe, . By , reduce the adverse per capita environmental Annual mean concentrations of ne particulate resilient and sustainable impact of cities, including by paying special attention to matter (PM.) in urban areas x (µg/m) air quality and municipal and other waste management Take urgent action to . Strengthen resilience and adaptive capacity to climate- Average death rate due to natural disasters combat climate change and related hazards and natural disasters in all countries (per population) determinants Environmental Environmental its impacts Promote peaceful and . Signicantly reduce all forms of violence, and related Mortality rate due to homicide z (per inclusive societies for deaths population) sustainable development, Estimated direct deaths from major conicts aa provide access to justice (per population) for all and build eective, . End abuse, exploitation, tracking and all forms of Children in employment, total ( of children accountable and inclusive violence against and torture of children ages – ) institutions at all levels . By , provide legal identity for all, including birth Completeness of birth registration () registration Strengthen the means . Strengthen domestic resource mobilization, including of implementation and through international support to developing countries, revitalize the global to improve domestic capacity for tax and other revenue partnership for sustainable collection

Political determinants Political development . Enhance the global partnership for sustainable Net ocial development assistance received development, complemented by multi-stakeholder (current US) partnerships that mobilize and share knowledge, expertise, technology and nancial resources, to support the achievement of the SDGs in all countries, in particular developing countries

143 Health outputs – Health system performance measurements

DOMAIN INDICATORS USED Access to essential services Hospital beds per population Total density per population: Hospitals Total density per population: Health posts Total density per population: Health centres Physicians density (per population) Nursing and midwifery personnel density (per population) Dentistry personnel density (per population) Pharmaceutical personnel density (per population) Laboratory health workers density (per population) Environmental and public health workers density (per population) Community and traditional health workers density (per population) Health management and support workers density (per population) Diagnostics readiness Essential medicines readiness Pharmaceutical expenditure as percentage of Total Health Expenditure Pharmacists per population Average number of medicines prescribed per patient contact in public health facilities Percentage of medicines prescribed in outpatient public health facilities in the national Essential Medicines List Percentage of medicines prescribed in outpatient facilities prescribed by international non-propriety names Percentage of patients in outpatient public health facilities receiving antibiotics Percentage of adequately labelled medicines in outpatient public health facilities Blood donation rate per persons Quality of care TB treatment success Service readiness score Patient-centred care (PCC) score (dignity, condentiality, prompt attention) Diabetes mellitus, deaths per (age-standardized estimate) – (Data source: WHO, ) Age-standardized suicide rates (per population) Demand for essential services ANC – ANC dropout rate DTP – DTP dropout rate BCG – MCV dropout rate TB treatment dropout rate

144 RESILIENCE AREA ATTRIBUTES ASSESSED There is up to date (under year old) data mapping the health system assets – HR, infrastructure, commodities – that can be mobilized in the event of a stress event There is an up to date (under year old) mapping of potential health risks at the lowest level of the health system – health centre or community unit There is a functional epidemiological surveillance network regularly (weekly) reporting on status of potential disease events

Awareness The health sector is conducting regular (at least annual) predictive modelling of major health risks facing dierent populations and sharing this information with concerned parties The health sector is conducting simulation exercises to mimic the logistics of the response to the stress events of highest risk of occurrence Primary care facilities are providing at least of the essential services they are expected to provide Physical, nancial and/or social barriers hindering access to available essential services are minimized There is a clear strategy to scale up the provision of essential services currently not being provided Health facilities have basic capacities needed for provision of a broad range of essential services: . basic amenities: reliable power, water, sanitation,

Diversity . basic equipment, . standard precautions for infection prevention, . diagnostic capacity, . essential medicines Sta are appropriately skilled, and supervisory systems functional enough to identify rare/uncommon events when they occur The primary care facilities have the needed capacity to identify and isolate a health threat There are mechanisms at the management level supporting health facilities to target local resources to an identied health threat without need for bureaucratic authorizations Health facilities are aware of, and able to put in place contingency mechanisms that allow continued essential service provision even when responding to a threat Sources of additional HR capacities that may be needed to respond to the threat are identied, and procedures to bring these on board are known and agreed There are agreed protocols to guide absorption of resources and skills mobilized during a response to an event into the routine

Versatility and self-regulating and self-regulating Versatility system There are functional mechanisms for communication and engagement with non-public health partners working within the areas of responsibility of primary care facilities – such as private sector, NGOs, CSOs and others There are functional mechanisms for communication and engagement of primary care facilities with communities they are working within There are functional mechanisms for communication and engagement with health-related sectors working within the areas of responsibility of primary care facilities – such as agriculture, transport, education, and others integrated There are pre-agreed mechanisms for sharing of personnel, funds and capacities amongst stakeholders working within their areas of responsibility of primary care facilities

Mobilization, adaptive and adaptive Mobilization, There are mechanisms to regularly (annually) monitor performance of the health system and ensure it is constantly adapting to changing health needs

145 Health inputs – Health system investment measurements

DOMAIN INDICATOR Health workforce Physicians density (per population) Nursing and midwifery personnel density (per population) Dentistry personnel density (per population) Pharmaceutical personnel density (per population) Laboratory health workers density (per population) Environmental and public health workers density (per population) Community and traditional health workers density (per population) Health management and support workers density (per population) Health products, and technologies Diagnostics readiness Essential medicines readiness Pharmaceutical expenditure as percentage of Total Health Expenditure Pharmacists per population Average number of medicines prescribed per patient contact in public health facilities Percentage of medicines prescribed in outpatient public health facilities in the national Essential Medicines List Percentage of medicines prescribed in outpatient facilities prescribed by international non-propriety names Percentage of patients in outpatient public health facilities receiving antibiotics Percentage of adequately labelled medicines in outpatient public health facilities Blood donation rate per persons Health infrastructure and equipment Health infrastructure readiness Availability of basic amenities Availability of basic equipment Total density per population: Hospitals Total density per population: Health posts Total density per population: Health centres Total density per population: District/rural hospitals Hospital beds (per population)

146 Annex 2: Data by indicator used to generate indices Health nancing data MEMBER STATE TOTAL HEALTH EXPENDITURE (THE) PER CAPITA IN INT (PURCHASING POWER PARITY)      Algeria . . . . . Angola . . . . . Benin . . . . . Botswana . . . . . Burkina Faso . . . . . Burundi . . . . . Cabo Verde . . . . . Cameroon . . . . . Central African Republic . . . . . Chad . . . . . Comoros . . . . . Congo . . . . . Côte d’Ivoire : : : . . Democratic Republic of the Congo . . . . . Equatorial Guinea . . . . . Eritrea . . . . . Eswatini . . . . . Ethiopia . . . . . Gabon . . . . . The Gambia . . . . . Ghana . . . . . Guinea . . . . . Guinea-Bissau . . . . . Kenya . . . . . Lesotho . . . . . Liberia . . . . . Madagascar . . . . . Malawi . . . . . Mali . . . . . Mauritania . . . . . Mauritius : : : : . Mozambique . . . . . Namibia . . . . . Niger . . . . . Nigeria . . . . . Rwanda . . . . . Sao Tome and Principe : : : : : Senegal . . . . . Seychelles : : : . : Sierra Leone . . . . . South Africa . . . . . South Sudan : : . . . Togo . . . . . Uganda . . . . . United Republic of Tanzania . . . . . Zambia . . . . . Zimbabwe . . . . .

Data source: WHO Global Health Observatory, accessed December

147 Health investments data Health workforce MEMBER STATE YEAR OF MOST INDICATORS AND VALUES (PER POPULATION) INDICATORS AND VALUES (PER POPULATION) NORMALIZED SCORE MEMBER STATE RECENT DATA Physicians density Nursing and midwife- Dentistry personnel Pharmaceutical Laboratory health Environmental and Community and tradi- Health management’s (INDEX) ry personnel density density personnel density workers density public health workers tional health workers support workers density density density

Algeria . . . . . . . . . Algeria Angola . . . Angola Benin . . . . Benin Botswana . . . Botswana Burkina Faso . . . . . . . . Burkina Faso Burundi . . . . . . . . Burundi Cabo Verde . . . . . . . . Cabo Verde Cameroon . . . . . Cameroon Central African Republic . . . . . . . . . Central African Republic Chad . . . . Chad Comoros Comoros Congo . . . . . . . Congo Côte d’Ivoire . . . . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . . . . . Democratic Republic of the Congo Equatorial Guinea . . . . . . . . . Equatorial Guinea Eritrea . . . . . . . . Eritrea Eswatini Eswatini Ethiopia . . . . . . . Ethiopia Gabon . . . . . . . . Gabon The Gambia . . . . . . . . . The Gambia Ghana . . . . . . . . . Ghana Guinea . . . . . . . . Guinea Guinea-Bissau . . . . . . . Guinea-Bissau Kenya . . . . . Kenya Lesotho . . . . . . . . Lesotho Liberia . . . . . . . . Liberia Madagascar . . . . . . Madagascar Malawi . . . . . . . Malawi Mali . . . . . . . . . Mali Mauritania . . . . . . . . . Mauritania Mauritius . . . . . . . . . Mauritius Mozambique . . . . . . . . Mozambique Namibia . . . . . . . Namibia Niger . . . . . . . . Niger Nigeria . . . . . . . . Nigeria Rwanda . . . . . . . . Rwanda Sao Tome and Principe . . . . . . . . . Sao Tome and Principe Senegal . . . . . . . . Senegal Seychelles . . . . . Seychelles Sierra Leone . . . . . . . . Sierra Leone South Africa . . . . . . . South Africa South Sudan South Sudan Togo . . . . . . . . Togo Uganda . . . . . . . Uganda United Republic of Tanzania . . . . . . . . United Republic of Tanzania Zambia . . . . . . . . Zambia Zimbabwe . . . . . . . . Zimbabwe Regional average . . . . . . . . . Regional average Data source: WHO Global Health Observatory, accessed December Data source: WHO Global Health Observatory, accessed December

148 Health investments data Health workforce MEMBER STATE YEAR OF MOST INDICATORS AND VALUES (PER POPULATION) INDICATORS AND VALUES (PER POPULATION) NORMALIZED SCORE MEMBER STATE RECENT DATA Physicians density Nursing and midwife- Dentistry personnel Pharmaceutical Laboratory health Environmental and Community and tradi- Health management’s (INDEX) ry personnel density density personnel density workers density public health workers tional health workers support workers density density density

149 Health investments data Health products MEMBER STATE INDICATORS AND VALUES INDICATORS AND VALUES NORMALIZED MEMBER STATE READINESS Basic amenities Basic equipment Total density per Total density per Total density per Total density per Hospital beds SCORE (INDEX) population: population: population: population: (per population) Hospitals Health posts Health centres District/rural hospitals Algeria . Algeria Angola . Angola Benin . . . . . Benin Botswana . . . Botswana Burkina Faso . . . . . Burkina Faso Burundi . . . . . Burundi Cabo Verde . . . . Cabo Verde Cameroon . . . . . Cameroon Central African Republic . . . . . Central African Republic Chad . . . . . Chad Comoros . . . . . Comoros Congo . Congo Côte d’Ivoire . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . Democratic Republic of the Congo Equatorial Guinea . Equatorial Guinea Eritrea . . . . . Eritrea Eswatini . . . . Eswatini Ethiopia . . . . . Ethiopia Gabon . . . . . Gabon The Gambia . . . . . The Gambia Ghana . . . . . Ghana Guinea . . . . . Guinea Guinea-Bissau . . . . . Guinea-Bissau Kenya . . . . . . Kenya Lesotho . Lesotho Liberia . . . . . . Liberia Madagascar . . . . . Madagascar Malawi . . . . . Malawi Mali . . . . Mali Mauritania . . . . . Mauritania Mauritius . . . . . . Mauritius Mozambique . Mozambique Namibia . . . . . Namibia Niger . . . . . Niger Nigeria . Nigeria Rwanda . Rwanda Sao Tome and Principe . . . Sao Tome and Principe Senegal . . . . . Senegal Seychelles . . . . Seychelles Sierra Leone . . . Sierra Leone South Africa . . . . . South Africa South Sudan - South Sudan Togo . . . . Togo Uganda . . . . . . Uganda United Republic of Tanzania . . United Republic of Tanzania Zambia . . . . . . Zambia Zimbabwe . . . . . Zimbabwe Regional average . . . . . . . . . Regional average Data source: WHO Global Health Observatory, accessed December Data source: WHO Global Health Observatory, accessed December

150 Health investments data Health products MEMBER STATE INDICATORS AND VALUES INDICATORS AND VALUES NORMALIZED MEMBER STATE READINESS Basic amenities Basic equipment Total density per Total density per Total density per Total density per Hospital beds SCORE (INDEX) population: population: population: population: (per population) Hospitals Health posts Health centres District/rural hospitals Algeria . Algeria Angola . Angola Benin . . . . . Benin Botswana . . . Botswana Burkina Faso . . . . . Burkina Faso Burundi . . . . . Burundi Cabo Verde . . . . Cabo Verde Cameroon . . . . . Cameroon Central African Republic . . . . . Central African Republic Chad . . . . . Chad Comoros . . . . . Comoros Congo . Congo Côte d’Ivoire . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . Democratic Republic of the Congo Equatorial Guinea . Equatorial Guinea Eritrea . . . . . Eritrea Eswatini . . . . Eswatini Ethiopia . . . . . Ethiopia Gabon . . . . . Gabon The Gambia . . . . . The Gambia Ghana . . . . . Ghana Guinea . . . . . Guinea Guinea-Bissau . . . . . Guinea-Bissau Kenya . . . . . . Kenya Lesotho . Lesotho Liberia . . . . . . Liberia Madagascar . . . . . Madagascar Malawi . . . . . Malawi Mali . . . . Mali Mauritania . . . . . Mauritania Mauritius . . . . . . Mauritius Mozambique . Mozambique Namibia . . . . . Namibia Niger . . . . . Niger Nigeria . Nigeria Rwanda . Rwanda Sao Tome and Principe . . . Sao Tome and Principe Senegal . . . . . Senegal Seychelles . . . . Seychelles Sierra Leone . . . Sierra Leone South Africa . . . . . South Africa South Sudan - South Sudan Togo . . . . Togo Uganda . . . . . . Uganda United Republic of Tanzania . . United Republic of Tanzania Zambia . . . . . . Zambia Zimbabwe . . . . . Zimbabwe Regional average . . . . . . . . . Regional average Data source: WHO Global Health Observatory, accessed December Data source: WHO Global Health Observatory, accessed December

151 Health systems performance data Access to essential services MEMBER STATE INDICATORS AND VALUES INDICATORS AND VALUES NORMALIZED MEMBER STATE Hospital beds Total density Total density Physicians Nursing and Dentistry Pharmaceutical Laboratory Environmental Community Health manage- Diagnostics Essential Pharma- Pharmacists Avg. number  of medicines  of medicines  of patients  of Blood SCORE (per   (per   (per   density midwifery personnel personnel health workers and public and traditional ment & support readiness medicines ceutical per   of medicines prescribed in prescribed in out- in outpatient adequately donation (INDEX) popn) popn): popn): Health (per  personnel density (per density (per density (per health workers health workers workers density readiness expenditure population prescribed per outpatient PH patient facilities public health labelled rate per  Hospitals posts popn) density (per  popn)  popn)  popn) density (per density (per (per  popn) as  of THE patient contact facilities in the prescribed by facilities medicines in persons  popn)  popn)  popn) in public health national Essent. international non receiving outpatient PH facilities Medicines List propriety names antibiotics facilities Algeria . . . Algeria Angola . . . . . . . . . . . . Angola Benin . . . . . . . Benin Botswana . . . . . . . . Botswana Burkina Faso . . . . . . . . . . . Burkina Faso Burundi . . . . . . . . . . . . . . . . . . Burundi Cabo Verde . . . . . . . . . . . Cabo Verde Cameroon . . . . . . . . . . . . . Cameroon Central African Republic . . . . . . . . . . . . Central African Republic Chad . . . . . . . . . . . . . . . . . . . . . Chad Comoros . . . . . . . . . Comoros Congo . . . . . Congo Côte d’Ivoire . . . . . . . . . . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . . . . . . . . . . . Democratic Republic of the Congo Equatorial Guinea . . . . . . . . . . Equatorial Guinea Eritrea . . . . . . . . . . . . Eritrea Eswatini . . . . . Eswatini Ethiopia . . . . . . . . . . . . . . . . . . . . Ethiopia Gabon . . . . . . . . . . . . . . . Gabon The Gambia . . . . . . . . . . . . . The Gambia Ghana . . . . . . . . . . . . . . Ghana Guinea . . . . . . . . . . . . . . . Guinea Guinea-Bissau . . . . . . . . . . . . . Guinea-Bissau Kenya . . . . . . . . . . . . . . . . . . . Kenya Lesotho . . . . . . . . . . . . Lesotho Liberia . . . . . . . . . . . . . . Liberia Madagascar . . . . . . . . . . . . . Madagascar Malawi . . . . . . . . . . . Malawi Mali . . . . . . . . . . . . Mali Mauritania . . . . . . . . . . . . . . . Mauritania Mauritius . . . . . . . . . . . . . . . . . . . . Mauritius Mozambique . . . . . . . . . . . . . . Mozambique Namibia . . . . . . . . . . . . . . . . . Namibia Niger . . . . . . . . . . . . . . . . . . . Niger Nigeria . . . . . . . . . . . . . . . . . . Nigeria Rwanda . . . . . . . . . . Rwanda Sao Tome and Principe . . . . . . . . . . . . . Sao Tome and Principe Senegal . . . . . . . . . . . . . . . . . . . Senegal Seychelles . . . . . . . . . . . . . . . . . . . Seychelles Sierra Leone . . . . . . . . . . . . . . . . . Sierra Leone South Africa . . . . . . . . . . . . . . . . South Africa South Sudan . . . . . . . . . . . South Sudan Togo . . . . . . . . . . . . . Togo Uganda . . . . . . . . . . . . . . . . . . Uganda United Republic of Tanzania . . . . . . . . . . . . . . . . . . . . United Republic of Tanzania Zambia . . . . . . . . . . . . . . . . . . Zambia Zimbabwe . . . . . . . . . . . . . . . . . . . . Zimbabwe Regional average . . . . . . . . . . . . . . . . . . . . . Regional average Data source: WHO Global Health Observatory, accessed December Data source: WHO Global Health Observatory, accessed December 152 Health systems performance data Access to essential services MEMBER STATE INDICATORS AND VALUES INDICATORS AND VALUES NORMALIZED MEMBER STATE Hospital beds Total density Total density Physicians Nursing and Dentistry Pharmaceutical Laboratory Environmental Community Health manage- Diagnostics Essential Pharma- Pharmacists Avg. number  of medicines  of medicines  of patients  of Blood SCORE (per   (per   (per   density midwifery personnel personnel health workers and public and traditional ment & support readiness medicines ceutical per   of medicines prescribed in prescribed in out- in outpatient adequately donation (INDEX) popn) popn): popn): Health (per  personnel density (per density (per density (per health workers health workers workers density readiness expenditure population prescribed per outpatient PH patient facilities public health labelled rate per  Hospitals posts popn) density (per  popn)  popn)  popn) density (per density (per (per  popn) as  of THE patient contact facilities in the prescribed by facilities medicines in persons  popn)  popn)  popn) in public health national Essent. international non receiving outpatient PH facilities Medicines List propriety names antibiotics facilities Algeria . . . Algeria Angola . . . . . . . . . . . . Angola Benin . . . . . . . Benin Botswana . . . . . . . . Botswana Burkina Faso . . . . . . . . . . . Burkina Faso Burundi . . . . . . . . . . . . . . . . . . Burundi Cabo Verde . . . . . . . . . . . Cabo Verde Cameroon . . . . . . . . . . . . . Cameroon Central African Republic . . . . . . . . . . . . Central African Republic Chad . . . . . . . . . . . . . . . . . . . . . Chad Comoros . . . . . . . . . Comoros Congo . . . . . Congo Côte d’Ivoire . . . . . . . . . . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . . . . . . . . . . . Democratic Republic of the Congo Equatorial Guinea . . . . . . . . . . Equatorial Guinea Eritrea . . . . . . . . . . . . Eritrea Eswatini . . . . . Eswatini Ethiopia . . . . . . . . . . . . . . . . . . . . Ethiopia Gabon . . . . . . . . . . . . . . . Gabon The Gambia . . . . . . . . . . . . . The Gambia Ghana . . . . . . . . . . . . . . Ghana Guinea . . . . . . . . . . . . . . . Guinea Guinea-Bissau . . . . . . . . . . . . . Guinea-Bissau Kenya . . . . . . . . . . . . . . . . . . . Kenya Lesotho . . . . . . . . . . . . Lesotho Liberia . . . . . . . . . . . . . . Liberia Madagascar . . . . . . . . . . . . . Madagascar Malawi . . . . . . . . . . . Malawi Mali . . . . . . . . . . . . Mali Mauritania . . . . . . . . . . . . . . . Mauritania Mauritius . . . . . . . . . . . . . . . . . . . . Mauritius Mozambique . . . . . . . . . . . . . . Mozambique Namibia . . . . . . . . . . . . . . . . . Namibia Niger . . . . . . . . . . . . . . . . . . . Niger Nigeria . . . . . . . . . . . . . . . . . . Nigeria Rwanda . . . . . . . . . . Rwanda Sao Tome and Principe . . . . . . . . . . . . . Sao Tome and Principe Senegal . . . . . . . . . . . . . . . . . . . Senegal Seychelles . . . . . . . . . . . . . . . . . . . Seychelles Sierra Leone . . . . . . . . . . . . . . . . . Sierra Leone South Africa . . . . . . . . . . . . . . . . South Africa South Sudan . . . . . . . . . . . South Sudan Togo . . . . . . . . . . . . . Togo Uganda . . . . . . . . . . . . . . . . . . Uganda United Republic of Tanzania . . . . . . . . . . . . . . . . . . . . United Republic of Tanzania Zambia . . . . . . . . . . . . . . . . . . Zambia Zimbabwe . . . . . . . . . . . . . . . . . . . . Zimbabwe Regional average . . . . . . . . . . . . . . . . . . . . . Regional average Data source: WHO Global Health Observatory, accessed December Data source: WHO Global Health Observatory, accessed December 153 Health systems performance data Quality of Care MEMBER STATE INDICATORS AND VALUES NORMALIZED TB TREATMENT Service PCC score (dignity, Diabetes mellitus, deaths Age-standardized SCORE (INDEX) SUCCESS readiness score condentiality, per , (age-stand- suicide rates (per prompt attention) ardized estimate) population) Algeria . . . Angola . . . . Benin . . . . Botswana . . . Burkina Faso . . . . Burundi . . . Cabo Verde . . . . Cameroon . . . . Central African Republic . . . . Chad . . . . . Comoros . . . Congo . . . . Côte d’Ivoire . . . . Democratic Republic of the Congo . . . . . Equatorial Guinea . . . Eritrea . . . . Eswatini . . . . Ethiopia . . . . . Gabon . . . . The Gambia . . . . Ghana . . . . Guinea . . . . Guinea-Bissau . . . . Kenya . . . . . Lesotho . . . Liberia . . . . . Madagascar . . . Malawi . . . . Mali . . . . Mauritania . . . Mauritius . . . Mozambique . . . . Namibia . . . Niger . . . . Nigeria . . . Rwanda . . . . Sao Tome and Principe . . Senegal . . . . Seychelles . . . Sierra Leone . . . . South Africa . . . South Sudan . . . Togo . . . Uganda . . . . . United Republic of Tanzania . . . . Zambia . . . . . Zimbabwe . . . . Regional average . . . . . . Data source: WHO Global Health Observatory, accessed December

154 Health systems performance data Eective demand for essential services MEMBER STATE INDICATORS AND VALUES NORMALIZED ANC - ANC DROP OUT DTP - DTP drop out BCG – MCV drop out TB treatment drop out SCORE (INDEX)

Algeria . . . Angola - . . Benin . . . Botswana . . . Burkina Faso . . . Burundi . . . Cabo Verde . . . Cameroon . - . . Central African Republic . - . . Chad . . . Comoros . . . Congo . . . Côte d’Ivoire . . . Democratic Republic of the Congo . . . Equatorial Guinea . . . Eritrea . . . Eswatini . . . Ethiopia . - . . Gabon . . . The Gambia . . . Ghana . . . Guinea . . . Guinea-Bissau . . . Kenya . . . Lesotho . . . Liberia . . . Madagascar . - . . Malawi . . . Mali . . . Mauritania . . . Mauritius - . . Mozambique . . . Namibia . . . Niger . . . Nigeria . - . . Rwanda . . . Sao Tome and Principe . - . . Senegal . . . Seychelles - . . Sierra Leone . . . South Africa . - . . South Sudan . . . Togo . - . . Uganda . . . United Republic of Tanzania . . . Zambia . . . Zimbabwe . . . Regional average . . . . . Data source: WHO Global Health Observatory, accessed December

155 Health systems performance data System resilience MEMBER STATE PROPORTION OF RESPONDENTS REPORTING POSITIVE PERCEPTION OF ATTRIBUTE NORMALIZED AWARENESS Diversity Versatility and self Mobilisation, adaptive and integrative SCORE (INDEX) regulating

Algeria Angola . . . . . Benin . . . . . Botswana Burkina Faso Burundi Cabo Verde . . . . . Cameroon . . . . . Central African Republic . . . . . Chad . . . . . Comoros Congo . . . . . Côte d’Ivoire . . . . . Democratic Republic of the Congo . . . . . Equatorial Guinea Eritrea . . . . . Eswatini . . . . . Ethiopia . . . . . Gabon . . . . . The Gambia . . . . . Ghana . . . . . Guinea . . . . . Guinea-Bissau . . - . . Kenya . . . . . Lesotho Liberia . . . . . Madagascar . . . . . Malawi . . . . . Mali . . . . . Mauritania . . . . . Mauritius Mozambique - . - - . Namibia Niger . . . . . Nigeria . . . . . Rwanda . . . . . Sao Tome and Principe Senegal . . . . . Seychelles . . . . . Sierra Leone . . . . . South Africa South Sudan Togo Uganda . . . . . United Republic of Tanzania . . . . . Zambia . . . . . Zimbabwe . . . . . Regional average . . . . . Data source: WHO Global Health Observatory, accessed December

156 Health and related service outcomes data Service availability MEMBER STATE NUMBER OF KEY INFORMANTS REPORTING TRACER SERVICES AVAILABLE IN NORMALIZED COUNTRY SCORE (INDEX) Pregnancy / Childhood Adolescence Adulthood Elderly Newborn

Algeria Angola . Benin . Botswana Burkina Faso Burundi Cabo Verde . Cameroon . Central African Republic . Chad . Comoros Congo . Côte d’Ivoire . Democratic Republic of the Congo . Equatorial Guinea Eritrea . Eswatini . Ethiopia . Gabon . The Gambia . Ghana . Guinea . Guinea-Bissau . Kenya . Lesotho Liberia . Madagascar . Malawi . Mali . Mauritania . Mauritius Mozambique . Namibia Niger . Nigeria Rwanda . Sao Tome and Principe Senegal . Seychelles . Sierra Leone . South Africa South Sudan Togo Uganda . United Republic of Tanzania . Zambia . Zimbabwe . Regional average . Data source: WHO Global Health Observatory, accessed December

157 Health and related service outcomes data Health and related service outcomes data Coverage with interventions addressing SDG 3 Coverage with interventions addressing SDG 3 targets targets MEMBER STATE HEALTH PROMOTION INTERVENTIONS COMMUNICABLE DISEASES CONTROL INTERVENTIONS NONCOMMUNICABLE DISEASE CONTROL INTERVENTIONS MEDICAL CARE INTERVENTIONS NORMALIZED MEMBER STATE Total alcohol Propor. married or Adolescent Proportion DTP  New HIV TB incidence Malaria Infants Reported number Mortality rate Probability of Suicide Road traffic Mortality rate Mortality rate Proportion Caeserian TB HIV mortal- Deaths due SCORE (INDEX) per capita (> in-union women birth rate o of mother coverage infections g (per incidence h receiving of people requiring attributed to dying from any mortality mortality attributed to from uninten- of births section rate treatment ity rate per to malaria  years of age) of reproduct. age (per  Exclusively among adults   (per  three doses interventions against exposure to of CVD, cancer, rate k (per rate m (per household tional poisoning attended () success rate , (per , consumption in who have their need women aged breastfeeding - years population) population at of hepatitis B NTDs j unsafe WASH diabetes, CRD     and ambient (per   by skilled population) litres of pure for family planning - years) old f (per  risk) vaccine i () services (per between age  popula- population) air pollution p population) health alcohol projected satisfied with modern uninfected   and exact age  tion) (per   personnel estimates l methods n () population) population) k () population) () Algeria . . . . . . . - . . . . . . . . . . . . Algeria Angola . . . . . . . . . . . . . . . . Angola Benin . . . . . . . . . . . . . . . . Benin Botswana . . . . . . . . . . . . . . . Botswana Burkina Faso . . . . . . . . . . . . . . . . . Burkina Faso Burundi . . . . . . . . . . . . . . . . Burundi Cabo Verde . . . . . . . . . . . . . . . . . Cabo Verde Cameroon . . . . . . . . . . . . . . . . . . Cameroon Central African Republic . . . . . . . . . . . . . . . . . Central African Republic Chad . . . . . . . . . . . . . . . . . . . Chad Comoros . . . . . . . . . . . . . . . Comoros Congo . . . . . . . . . . . . . . . . Congo Côte d’Ivoire . . . . . . . . . . . . . . . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . . . . . . . . . . . . . . Democratic Republic of the Congo Equatorial Guinea . . . . . . . . . . . . . . . . . Equatorial Guinea Eritrea . . . . . . . . . . . . . . . . . . Eritrea Eswatini . . . . . . . . . . . . . . . . . . Eswatini Ethiopia . . . . . . . . . . . . . . . . . Ethiopia Gabon . . . . . . . . . . . . . . . Gabon The Gambia . . . . . . . . . . . . . . . . . The Gambia Ghana . . . . . . . . . . . . . . . . . Ghana Guinea . . . . . . . . . . . . . . . . . . Guinea Guinea-Bissau . . . . . . . . . . . . . . . . . Guinea-Bissau Kenya . . . . . . . . . . . . . . . . . Kenya Lesotho . . . . . . . . . . . . . . . . Lesotho Liberia . . . . . . . . . . . . . . . . . Liberia Madagascar . . . . . . . . . . . . . . . . . . Madagascar Malawi . . . . . . . . . . . . . . . . Malawi Mali . . . . . . . . . . . . . . . . Mali Mauritania . . . . . . . . . . . . . . . . . . Mauritania Mauritius . . . . . - . . . . . . . . . . Mauritius Mozambique . . . . . . . . . . . . . . . . . Mozambique Namibia . . . . . . . . . . . . . . . . Namibia Niger . . . . . . . . . . . . . . . . . Niger Nigeria . . . . . . . . . . . . . . . . Nigeria Rwanda . . . . . . . . . . . . . . . . Rwanda Sao Tome and Principe . . . . . . . . . . Sao Tome and Principe Senegal . . . . . . . . . . . . . . . . . . Senegal Seychelles . . . - . . . . Seychelles Sierra Leone . . . . . . . . . . . . . . . . . Sierra Leone South Africa . . . . . . . . . . . . . . . . South Africa South Sudan . . . . . . . . . . . . . . South Sudan Togo . . . . . . . . . . . . . . . . Togo Uganda . . . . . . . . . . . . . . . . Uganda United Republic of Tanzania . . . . . . . . . . . . . . . . . . . United Republic of Tanzania Zambia . . . . . . . . . . . . . . . . . Zambia Zimbabwe . . . . . . . . . . . . . . . . . Zimbabwe Regional average . . . . . . . . . . . . . . . . . . . . . . Regional average Data source: WHO Global Health Observatory accessed December Data source: WHO Global Health Observatory accessed December 158 Health and related service outcomes data Health and related service outcomes data Coverage with interventions addressing SDG 3 Coverage with interventions addressing SDG 3 targets targets MEMBER STATE HEALTH PROMOTION INTERVENTIONS COMMUNICABLE DISEASES CONTROL INTERVENTIONS NONCOMMUNICABLE DISEASE CONTROL INTERVENTIONS MEDICAL CARE INTERVENTIONS NORMALIZED MEMBER STATE Total alcohol Propor. married or Adolescent Proportion DTP  New HIV TB incidence Malaria Infants Reported number Mortality rate Probability of Suicide Road traffic Mortality rate Mortality rate Proportion Caeserian TB HIV mortal- Deaths due SCORE (INDEX) per capita (> in-union women birth rate o of mother coverage infections g (per incidence h receiving of people requiring attributed to dying from any mortality mortality attributed to from uninten- of births section rate treatment ity rate per to malaria  years of age) of reproduct. age (per  Exclusively among adults   (per  three doses interventions against exposure to of CVD, cancer, rate k (per rate m (per household tional poisoning attended () success rate , (per , consumption in who have their need women aged breastfeeding - years population) population at of hepatitis B NTDs j unsafe WASH diabetes, CRD     and ambient (per   by skilled population) litres of pure for family planning - years) old f (per  risk) vaccine i () services (per between age  popula- population) air pollution p population) health alcohol projected satisfied with modern uninfected   and exact age  tion) (per   personnel estimates l methods n () population) population) k () population) () Algeria . . . . . . . - . . . . . . . . . . . . Algeria Angola . . . . . . . . . . . . . . . . Angola Benin . . . . . . . . . . . . . . . . Benin Botswana . . . . . . . . . . . . . . . Botswana Burkina Faso . . . . . . . . . . . . . . . . . Burkina Faso Burundi . . . . . . . . . . . . . . . . Burundi Cabo Verde . . . . . . . . . . . . . . . . . Cabo Verde Cameroon . . . . . . . . . . . . . . . . . . Cameroon Central African Republic . . . . . . . . . . . . . . . . . Central African Republic Chad . . . . . . . . . . . . . . . . . . . Chad Comoros . . . . . . . . . . . . . . . Comoros Congo . . . . . . . . . . . . . . . . Congo Côte d’Ivoire . . . . . . . . . . . . . . . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . . . . . . . . . . . . . . Democratic Republic of the Congo Equatorial Guinea . . . . . . . . . . . . . . . . . Equatorial Guinea Eritrea . . . . . . . . . . . . . . . . . . Eritrea Eswatini . . . . . . . . . . . . . . . . . . Eswatini Ethiopia . . . . . . . . . . . . . . . . . Ethiopia Gabon . . . . . . . . . . . . . . . Gabon The Gambia . . . . . . . . . . . . . . . . . The Gambia Ghana . . . . . . . . . . . . . . . . . Ghana Guinea . . . . . . . . . . . . . . . . . . Guinea Guinea-Bissau . . . . . . . . . . . . . . . . . Guinea-Bissau Kenya . . . . . . . . . . . . . . . . . Kenya Lesotho . . . . . . . . . . . . . . . . Lesotho Liberia . . . . . . . . . . . . . . . . . Liberia Madagascar . . . . . . . . . . . . . . . . . . Madagascar Malawi . . . . . . . . . . . . . . . . Malawi Mali . . . . . . . . . . . . . . . . Mali Mauritania . . . . . . . . . . . . . . . . . . Mauritania Mauritius . . . . . - . . . . . . . . . . Mauritius Mozambique . . . . . . . . . . . . . . . . . Mozambique Namibia . . . . . . . . . . . . . . . . Namibia Niger . . . . . . . . . . . . . . . . . Niger Nigeria . . . . . . . . . . . . . . . . Nigeria Rwanda . . . . . . . . . . . . . . . . Rwanda Sao Tome and Principe . . . . . . . . . . Sao Tome and Principe Senegal . . . . . . . . . . . . . . . . . . Senegal Seychelles . . . - . . . . Seychelles Sierra Leone . . . . . . . . . . . . . . . . . Sierra Leone South Africa . . . . . . . . . . . . . . . . South Africa South Sudan . . . . . . . . . . . . . . South Sudan Togo . . . . . . . . . . . . . . . . Togo Uganda . . . . . . . . . . . . . . . . Uganda United Republic of Tanzania . . . . . . . . . . . . . . . . . . . United Republic of Tanzania Zambia . . . . . . . . . . . . . . . . . Zambia Zimbabwe . . . . . . . . . . . . . . . . . Zimbabwe Regional average . . . . . . . . . . . . . . . . . . . . . . Regional average Data source: WHO Global Health Observatory accessed December Data source: WHO Global Health Observatory accessed December 159 Health and related service outcomes data Health security MEMBER STATE AVERAGE OF JOINT EXTERNAL EVALUATION SCORE NORMALIZED IHR CORE SCORE (INDEX) JEE prevention score JEE detection score JEE response score JEE average score CAPACITY SCORES – – Algeria . Angola . Benin . . . . . Botswana . Burkina Faso . Burundi . Cabo Verde . Cameroon . Central African Republic . Chad . . . . . Comoros . . . . . Congo . Côte d’Ivoire . . . . . Democratic Republic of the Congo . Equatorial Guinea . Eritrea . . . . . Eswatini . Ethiopia . . . . . Gabon . The Gambia . Ghana . . . . . Guinea . . . . . Guinea-Bissau . Kenya . . . . . Lesotho . . . . . Liberia . . . . . Madagascar . . . . . Malawi . Mali . . . . . Mauritania . . . . . Mauritius . Mozambique . . . . . Namibia . . . . . Niger . Nigeria . . . . . Rwanda . Sao Tome and Principe . Senegal . . . . . Seychelles . Sierra Leone . . . . . South Africa South Sudan . Togo . Uganda . . . . . United Republic of Tanzania . . . . . Zambia . . . . . Zimbabwe . Regional average . Data source: WHO Global Health Observatory, accessed December

160 Health and related service outcomes data Service responsiveness and satisfaction

MEMBER STATE DIGNITY AUTONOMY CONFIDENTIALITY PROMPT ACCESS TO SOCIAL QUALITY OF BASIC CHOICE OF CARE NORMALIZED ATTENTION SUPPORT AMENITIES PROVIDERS SCORE (INDEX)

Algeria Angola . . - . . - . . Benin - . . . . . . . Botswana Burkina Faso Burundi Cabo Verde . . . . . . . . Cameroon . . . . . - . . Central African Republic . . . . . - . . Chad . . . . . . - . Comoros Congo . . . . . . . . Côte d’Ivoire . . . . - . . . Democratic Republic of the Congo . . . . . - . . Equatorial Guinea Eritrea . . . . . . . . Eswatini . . . . - . . . Ethiopia . . . . . . . . Gabon . . . . . . . . The Gambia . . . . . . . . Ghana . . . . . . . . Guinea . . . . . . . . Guinea-Bissau . . . . . . . . Kenya . . . . . . . . Lesotho Liberia . . . . . . . . Madagascar - . . . . . . . Malawi . . . . . . . . Mali . . . . . . . . Mauritania . . . . . . . . Mauritius Mozambique . - . . . - - . Namibia Niger . . . . . . . . Nigeria . . . . . . . . Rwanda . . . . . . . . Sao Tome and Principe Senegal . - . . . . . . Seychelles . . . . . . . . Sierra Leone . . . . . . . . South Africa South Sudan Togo Uganda . . . . . - . . United Republic of Tanzania . . . . . . . . Zambia . . . . . . . . Zimbabwe . . . . . . . . Regional average . . . . . . . . Data source: WHO Global Health Observatory, accessed December

161 Health and related service outcomes data Coverage with interventions addressing non-SDG 3 targets inuencing health and well-being MEMBER STATE MEMBER STATE SOCIAL DETERMINANTS ENVIRONMENTAL DETERMINANTS ECONOMIC DETERMINANTS . . . . . . . . . . . . . . .c . Coverage Prevalence of Prevalence Prevalence of Primary Lower secondary Primary comple- Secondary Pre-primary School Female genital Proportion of Propor. of pop- People Annual mean con- Average death Annualized avg growth GDP Unemployment, Access to Individuals Proportion of () – All stunting in of wasting in overweight in education, completion rate, tion rate, total ( education, education, enrolment, mutilation population us- ulation using practicing centrations of fine rate due to nat- rate in per capita real growth total ( of electricity using the seats held by Social children under children under children under duration total ( of relevant of relevant age duration duration pre-primary prevalence ing improved improved open defe- particulate matter ural disasters survey mean con- (annual total labor force) ( of pop- Internet ( women in Assistance  u ()  u ()  u () (years) age group) group) (years) (years) ( gross) () drinking-water sanitation cation ( of (PM.) in urban y (per   sumption or income, ) (modeled ILO ulation) of popula- national parlia- sources v () v () population) areas x (µg/m) population) total population () estimate) tion) ments () Algeria . . . . . . . . - . . . . . . . . . . . Algeria Angola . . . . . - . . . . . . . . . . . Angola Benin . . . . . . . . . . . . . . . . . . . . . Benin Botswana . . . . . . - . . . . . . . . . . . Botswana Burkina Faso . . . . . . . . . . - . . . . . . . . . . . Burkina Faso Burundi . . . . . . . . . - . . . . . . . . . . . Burundi Cabo Verde . . . . . . - . . . - . . . . . . Cabo Verde Cameroon . . . . . . . . . . - . . . . . . . . . . . Cameroon Central African Republic . . . . . . - . . . . - . . . . . .. Central African Republic Chad . . . . . . - . . . . . . . . . . . Chad Comoros . . . . . . . . . - . . . . . . . . . . . Comoros Congo . . . . . . - . . . . . . . . . . . Congo Côte d’Ivoire . . . . . . . . . - . . . . . . . . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . . . . . - . . . . . . . . . . . Democratic Republic of the Congo Equatorial Guinea . . . . . . - . . . . - . (.) . . . . Equatorial Guinea Eritrea . . . . . . . - . . . . - . .. . . . . Eritrea Eswatini . . . . . . . - . . . . . . . . . . . Eswatini Ethiopia . . . . . . . . . - . . . . - . . . . . . Ethiopia Gabon . . . . . . - . . . . - . . . . . . Gabon The Gambia . . . . . . . . . - . . . . . . . . . . . The Gambia Ghana . . . . . . . . . - . . . . . . . . . . . Ghana Guinea . . . . . . . . - . . . . - . . . . . . Guinea Guinea-Bissau . . . . . . . . . . . - . . . . . . Guinea-Bissau Kenya . . . . . . . . . . . . . . . . . . . . . Kenya Lesotho . . . . . . . . . . - . . . . . . . . . . . Lesotho Liberia . . . . . . . . . - . . . . - . . . . . . Liberia Madagascar . . . . . . . - . . . . . . . . . . . Madagascar Malawi . . . . . . . - . . . . . . . . . . . Malawi Mali . . . . . . . . . - . . . . . . . . . . . Mali Mauritania . . . . . . . . . . - . . . . . . . . . . . Mauritania Mauritius . . . . . . - . . . . . . . . . . . Mauritius Mozambique . . . . . . . . - . . . . . . . . . . .. Mozambique Namibia . . . . . . - . . . . . . . . . . .. Namibia Niger . . . . . . . . . - . . . . . . . . . . . Niger Nigeria . . . . . . - . . . . . . . . . . . Nigeria Rwanda . . . . . . . . . - . . . . . . . . . . . Rwanda Sao Tome and Principe . . . . . . . . . - . . . - . . . . . . Sao Tome and Principe Senegal . . . . . . . . . . . . . . . . . . . . . Senegal Seychelles . . . . . . . . . - . . - . - . . .. . . . Seychelles Sierra Leone . . . . . . - . . . . . . . . . . . Sierra Leone South Africa . . . . . . - . . . . . . . . . . . South Africa South Sudan . . . . . . - . . . . . . . .. . . . South Sudan Togo . . . . . . . . . . . . . . . . . . . . . Togo Uganda . . . . . . . . . - . . . . . . . . . . . Uganda United Republic of Tanzania . . . . . . . - . . . . . . . . . . . United Republic of Tanzania Zambia . . . . . . - . . . . - . . . . . . Zambia Zimbabwe . . . . . . - . . . . . . . . . . . Zimbabwe Regional average . . . . . . . . . . . . . . . . . . . . . . Regional average Data source: WHO Global Health Observatory, accessed December Data source: WHO Global Health Observatory, accessed December 162 Health and related service outcomes data Coverage with interventions addressing non-SDG 3 targets inuencing health and well-being MEMBER STATE MEMBER STATE SOCIAL DETERMINANTS ENVIRONMENTAL DETERMINANTS ECONOMIC DETERMINANTS . . . . . . . . . . . . . . .c . Coverage Prevalence of Prevalence Prevalence of Primary Lower secondary Primary comple- Secondary Pre-primary School Female genital Proportion of Propor. of pop- People Annual mean con- Average death Annualized avg growth GDP Unemployment, Access to Individuals Proportion of () – All stunting in of wasting in overweight in education, completion rate, tion rate, total ( education, education, enrolment, mutilation population us- ulation using practicing centrations of fine rate due to nat- rate in per capita real growth total ( of electricity using the seats held by Social children under children under children under duration total ( of relevant of relevant age duration duration pre-primary prevalence ing improved improved open defe- particulate matter ural disasters survey mean con- (annual total labor force) ( of pop- Internet ( women in Assistance  u ()  u ()  u () (years) age group) group) (years) (years) ( gross) () drinking-water sanitation cation ( of (PM.) in urban y (per   sumption or income, ) (modeled ILO ulation) of popula- national parlia- sources v () v () population) areas x (µg/m) population) total population () estimate) tion) ments () Algeria . . . . . . . . - . . . . . . . . . . . Algeria Angola . . . . . - . . . . . . . . . . . Angola Benin . . . . . . . . . . . . . . . . . . . . . Benin Botswana . . . . . . - . . . . . . . . . . . Botswana Burkina Faso . . . . . . . . . . - . . . . . . . . . . . Burkina Faso Burundi . . . . . . . . . - . . . . . . . . . . . Burundi Cabo Verde . . . . . . - . . . - . . . . . . Cabo Verde Cameroon . . . . . . . . . . - . . . . . . . . . . . Cameroon Central African Republic . . . . . . - . . . . - . . . . . .. Central African Republic Chad . . . . . . - . . . . . . . . . . . Chad Comoros . . . . . . . . . - . . . . . . . . . . . Comoros Congo . . . . . . - . . . . . . . . . . . Congo Côte d’Ivoire . . . . . . . . . - . . . . . . . . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . . . . . - . . . . . . . . . . . Democratic Republic of the Congo Equatorial Guinea . . . . . . - . . . . - . (.) . . . . Equatorial Guinea Eritrea . . . . . . . - . . . . - . .. . . . . Eritrea Eswatini . . . . . . . - . . . . . . . . . . . Eswatini Ethiopia . . . . . . . . . - . . . . - . . . . . . Ethiopia Gabon . . . . . . - . . . . - . . . . . . Gabon The Gambia . . . . . . . . . - . . . . . . . . . . . The Gambia Ghana . . . . . . . . . - . . . . . . . . . . . Ghana Guinea . . . . . . . . - . . . . - . . . . . . Guinea Guinea-Bissau . . . . . . . . . . . - . . . . . . Guinea-Bissau Kenya . . . . . . . . . . . . . . . . . . . . . Kenya on next page) (continued Lesotho . . . . . . . . . . - . . . . . . . . . . . Lesotho Liberia . . . . . . . . . - . . . . - . . . . . . Liberia Madagascar . . . . . . . - . . . . . . . . . . . Madagascar Malawi . . . . . . . - . . . . . . . . . . . Malawi Mali . . . . . . . . . - . . . . . . . . . . . Mali Mauritania . . . . . . . . . . - . . . . . . . . . . . Mauritania Mauritius . . . . . . - . . . . . . . . . . . Mauritius Mozambique . . . . . . . . - . . . . . . . . . . .. Mozambique Namibia . . . . . . - . . . . . . . . . . .. Namibia Niger . . . . . . . . . - . . . . . . . . . . . Niger Nigeria . . . . . . - . . . . . . . . . . . Nigeria Rwanda . . . . . . . . . - . . . . . . . . . . . Rwanda Sao Tome and Principe . . . . . . . . . - . . . - . . . . . . Sao Tome and Principe Senegal . . . . . . . . . . . . . . . . . . . . . Senegal Seychelles . . . . . . . . . - . . - . - . . .. . . . Seychelles Sierra Leone . . . . . . - . . . . . . . . . . . Sierra Leone South Africa . . . . . . - . . . . . . . . . . . South Africa South Sudan . . . . . . - . . . . . . . .. . . . South Sudan Togo . . . . . . . . . . . . . . . . . . . . . Togo Uganda . . . . . . . . . - . . . . . . . . . . . Uganda United Republic of Tanzania . . . . . . . - . . . . . . . . . . . United Republic of Tanzania Zambia . . . . . . - . . . . - . . . . . . Zambia Zimbabwe . . . . . . - . . . . . . . . . . . Zimbabwe Regional average . . . . . . . . . . . . . . . . . . . . . . Regional average Data source: WHO Global Health Observatory, accessed December Data source: WHO Global Health Observatory, accessed December 163 Health and related service outcomes data Coverage with interventions addressing non-SDG 3 targets inuencing health and well-being MEMBER STATE POLITICAL DETERMINANTS NORMALIZED SCORE (INDEX) MEMBER STATE . . . . MORTALITY RATE DUE TO Estimated direct deaths Children in employment, Completeness of birth Net official development assistance Social determinants. Index Economic determinants Environmental determi- Political determinants index Overall determinants index HOMICIDE Z (PER   from major conflicts aa total ( of children ages registration () received (current US) nants index (per   population) -) POPULATION) Algeria . . . . . . . Algeria Angola . - . . . . . Angola Benin . - . . . . . . Benin Botswana . - . . . . . Botswana Burkina Faso . . . . . . . Burkina Faso Burundi . . . . . . . Burundi Cabo Verde . - . . . . . Cabo Verde Cameroon . . . . . . . . Cameroon Central African Republic . . . . . . . Central African Republic Chad . . . . . . . Chad Comoros . - . . . . . Comoros Congo . - . . . . . Congo Côte d’Ivoire . . . . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . . . . . . Democratic Republic of the Congo Equatorial Guinea . - . . . . . Equatorial Guinea Eritrea . . . . . . . Eritrea Eswatini . - . . . . . . Eswatini Ethiopia . . . . . . . Ethiopia Gabon . - . . . . . Gabon The Gambia . - . . . . . The Gambia Ghana . - . . . . . . Ghana Guinea . . . . . . . Guinea Guinea-Bissau . . . . . . . . . Guinea-Bissau Kenya . . . . . . . . Kenya Lesotho . - . . . . . . Lesotho Liberia . - . . . . . Liberia Madagascar . . . . . . . Madagascar Malawi . - . . . . . . . Malawi Mali . . . . . . . Mali Mauritania . . . . . . . Mauritania Mauritius . - . . . . . Mauritius Mozambique . . . . . . . Mozambique Namibia . - . . . . . Namibia Niger . . . . . . . Niger Nigeria . . . . . . . Nigeria Rwanda . . . . . . . . Rwanda Sao Tome and Principe . . . . . . . Sao Tome and Principe Senegal . . . . . . . . Senegal Seychelles . . . . . . Seychelles Sierra Leone . - . . . . . Sierra Leone South Africa . . . . . . . South Africa South Sudan . . . . . . . South Sudan Togo . - . . . . . . . Togo Uganda . . . . . . . Uganda United Republic of Tanzania . . . . . . . . United Republic of Tanzania Zambia . - . . . . . . Zambia Zimbabwe . . . . . . . . Zimbabwe Regional average . . . . . . . . . . Regional average Data source: WHO Global Health Observatory, accessed December Data source: WHO Global Health Observatory, accessed December

164 Health and related service outcomes data Coverage with interventions addressing non-SDG 3 targets inuencing health and well-being MEMBER STATE POLITICAL DETERMINANTS NORMALIZED SCORE (INDEX) MEMBER STATE . . . . MORTALITY RATE DUE TO Estimated direct deaths Children in employment, Completeness of birth Net oﬃcial development assistance Social determinants. Index Economic determinants Environmental determi- Political determinants index Overall determinants index HOMICIDE Z (PER   from major conﬂicts aa total ( of children ages registration () received (current US) nants index (per   population) -) POPULATION) Algeria . . . . . . . Algeria Angola . - . . . . . Angola Benin . - . . . . . . Benin Botswana . - . . . . . Botswana Burkina Faso . . . . . . . Burkina Faso Burundi . . . . . . . Burundi Cabo Verde . - . . . . . Cabo Verde Cameroon . . . . . . . . Cameroon Central African Republic . . . . . . . Central African Republic Chad . . . . . . . Chad Comoros . - . . . . . Comoros Congo . - . . . . . Congo Côte d’Ivoire . . . . . . . Côte d’Ivoire Democratic Republic of the Congo . . . . . . . . . Democratic Republic of the Congo Equatorial Guinea . - . . . . . Equatorial Guinea Eritrea . . . . . . . Eritrea Eswatini . - . . . . . . Eswatini Ethiopia . . . . . . . Ethiopia Gabon . - . . . . . Gabon The Gambia . - . . . . . The Gambia Ghana . - . . . . . . Ghana Guinea . . . . . . . Guinea Guinea-Bissau . . . . . . . . . Guinea-Bissau Kenya . . . . . . . . Kenya Lesotho . - . . . . . . Lesotho Liberia . - . . . . . Liberia Madagascar . . . . . . . Madagascar Malawi . - . . . . . . . Malawi Mali . . . . . . . Mali Mauritania . . . . . . . Mauritania Mauritius . - . . . . . Mauritius Mozambique . . . . . . . Mozambique Namibia . - . . . . . Namibia Niger . . . . . . . Niger Nigeria . . . . . . . Nigeria Rwanda . . . . . . . . Rwanda Sao Tome and Principe . . . . . . . Sao Tome and Principe Senegal . . . . . . . . Senegal Seychelles . . . . . . Seychelles Sierra Leone . - . . . . . Sierra Leone South Africa . . . . . . . South Africa South Sudan . . . . . . . South Sudan Togo . - . . . . . . . Togo Uganda . . . . . . . Uganda United Republic of Tanzania . . . . . . . . United Republic of Tanzania Zambia . - . . . . . . Zambia Zimbabwe . . . . . . . . Zimbabwe Regional average . . . . . . . . . . Regional average Data source: WHO Global Health Observatory, accessed December Data source: WHO Global Health Observatory, accessed December

165 Health impact data MEMBER STATE Crude death rate Healthy Life DALYS PER  POPULATION POPULATION () (per  popula- Expectancy,  All Causes Communicable, Noncom- Injuries tion),  maternal, perinatal municable and nutritional diseases conditions Algeria . . Angola . . , Benin . . Botswana . . Burkina Faso . . Burundi . . Cabo Verde . . Cameroon . . Central African Republic . Chad . . Comoros . . Congo . . Côte d’Ivoire . Democratic Republic of the Congo . . Equatorial Guinea . . Eritrea . . Eswatini . . Ethiopia . . Gabon . The Gambia . . Ghana . . Guinea . . Guinea-Bissau . . Kenya . . Lesotho . . Liberia . Madagascar . Malawi . Mali . . Mauritania . . Mauritius . . Mozambique . . Namibia . . Niger . . Nigeria . . Rwanda . . Sao Tome and Principe . Senegal . Seychelles . . Sierra Leone . . South Africa . . South Sudan . . Togo . . Uganda . United Republic of Tanzania . . Zambia . . Zimbabwe . . Africa . . Data source: WHO Global Health Observatory, accessed December

166