The Health of the People
L: ^African
Regional
Health Report
RKIONAL OFFICE FOR
World Health
Organization
Africa
WHO Library Cataloguing-in-Publication Data
World Health Organization. Regional Office for Africa.
The health of the people : the African regional health report.
I. Public health 2. Development 3. Delivery of health care
4.Health status S.Africa I.Title.
ISBN929023 1033 (NLM classification: WA 541 HAI)
© World Health Organization. Regional Office for Africa, 2006
All rights reserved. Publications of the World Health Organization can be obtained from WHO Press. World Health Organization. 20 Avenue
Appia. 121 1 Geneva 27. Switzerland (tel.: +41 22 791 3264: fax: +41 22 791 4857: e-mail: bookorders@who.int). Requests for permission to
reproduce or translate WHO publications - whether for sale or for noncommercial distribution - should be addressed to WHO Press, at the
above address (fax: +41 22 791 4806: e-mail: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on
the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning
the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full
agreement.
The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World
Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However,
the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and
use of the material lies with the reader. In no eve-nt shall the World Health Organization be liable for damages arising from its use.
This report has been prepared by a core team from the African Regional Office of the World Health Organization (WHO) under the general guidance of
Dr. Luis G. Sambo and Dr. Paul-Samson Lusamba. The core team was coordinated by Drs. Derege Kebede. Amidou Baba-Moussa. and Doyin Oluwole:
and included Drs. Rufaro Chatora. Alimata J. Diarra-Nama. Antoine Kabore, Chris Mwikisa, and James Mwanzia. The following have also contributed to
the report: Drs. Djamila Cabral. Colette Dehlot. Abayneh Desta. Antonio Filipejr. Joses Muthuri Kirigia. Allel Louazani, Magda Robalo, Moeti Matshidiso.
Patience Mensah. Fidelis Morfaw. Seipati Mothebesoane-Anoh, Tigest Ketsela. Benjamin Nganda, Dosithee Ngo Bebe. Louis H. Ouedraogo. Martins
Ovberedjo. Thebe A. Pule. Edoh Soumbey-Alley. Thomas Sukwa, Prosper Tumusiime and Rui Gama Vaz. The assistance of the following staff from WHO'S
African Regional Office is gratefully acknowledged: Therese Agossou. Sam Ajibola, Doris Durao. Wenceslas H. Kouvividila. Jennifer Nyoni, Jean X. Ramde.
and. Khoko Soumahoro.
This report was edited and produced by the team from the Bulletin of the World Health Organization: Saba Amdeselassie, Diane d'Arcis. Fiona Fleck.
Laragh Gollogly. Sophie Guetaneh Aguettant, Gael Kernen, Hooman Momen, Brenda Morris, Ian G. Neil. Kaylene Selleck. Ramesh Shademani.
The following journalists contributed material to this report: Mawusi Afele (Ghana). Arthur Asiimwe (Rwanda), Judith Basutuma (Burundi), Lauren
Beukes (South Africa). Richard Brass (United Kingdom). Pam Chepki (United Republic of Tanzania). Phil Dickie (Switzerland). Anil Gundooa (Mauritius).
Karen Hey (Angola). Pushpa Jamieson (Malawi). Douglas Kimani (Kenya). Pelekelo Liswaniso (Zambia), Peter Masebu (Senegal). Rodrick Mukumbira
(Botswana). Helen Nyambura (United Republic of Tanzania). Paul Okunlola (Nigeria). Abiodun Raufu (Nigeria). Tsitsi Singizi (Zimbabwe). Sarah Venis
(Ethiopia). Charles Wendo (Uganda). Jacqui Wise (South Africa).
The assistance of the following WHO staff is gratefully acknowledged: Samira Aboubaker. James Bartram, Robert Beaglehole Michel Beusenberg
Zoe Brillantes. Jose Carlos Marlines. Carlos Corvalan. Timothy Evans. Michelle Funk. Maria Guraiib, Mie Inoue, Doris Ma Fat, Elizabeth Mason. Colin
Mathers. Zoe Matthews, Jane McElligott. Chandika Indikadahena. Quazi Monirul Islam. Federico Montero. Tunga Namjilsuren. Ariel Pablos-Mendez.
Gilles Poumerol. Thomson Prentice, Shekhar Saxena, Kenji Shibuya. Laura Sminkey. Nadia Soleman. Tessa Tan-Torres. Michel Thieren. Phyllida Travis.
Colin Tutuitonga. Nathalie Van de Maele, Mark van Ommeren, Jelka Zupan.
The assistance of Don de Savigny and Kamran Abbasi is also gratefully acknowledged.
Printed in Switzerland
More information about this publication can be obtained from:
WHO - Regional Office for Africa
Brazzaville / Republic of Congo
Contents
Message from the Regional Director ix
Foreword from the Chairperson of the African Union Commission xi
Executive Summary xiii
Introduction: The health of the people xxiii
The challenges confronting Africa xxiv
African Region of the World Health Organization xxv
Chapter 1 - Health and development in Africa 3
The cycle of poverty and ill-health 3
Putting health in the development context 6
Efforts to promote development in Africa 8
The Abuja Declaration 8
NEPAD 9
The United Kingdom's Commission for Africa 9
UN Millennium Development Goals 10
G8 Summit 2005 10
Conclusion: Making it happen 11
Bibliography 13
Chapter 2 - Maternal, newborn and child health 17
Africa's "silent epidemic" 17
Development goals for maternal and child health 18
Mothers: the causes and numbers of deaths 18
Newborns: the causes and numbers of deaths 19
Under-fives: the causes and numbers of deaths 20
Preventing millions of deaths 20
The obstacles 21
Conflict and emergencies 22
HIV/AIDS 23
Inadequate resource allocation 23
Weak health systems 23
Efforts to tackle the problem 24
Safe motherhood 24
Prevention of mother-to-child transmission of HIV 25
Repositioning family planning 26
Managing childhood illnesses 26
Increasing skilled attendance at birth 27
Immunizing more women and children 27
Conclusion: scaling up success 30
Bibliography 33
ill
Chapter 3 - Infectious diseases in Africa 37
Major obstacle to development 37
HIV/AIDS, tuberculosis and malaria 38
Challenges for disease control 38
Diseases for which control has been successful 41
Leprosy 41
River blindness 42
Poliomyelitis 43
Diseases of major public concern 44
HIV/ AIDS 44
Tuberculosis 48
Malaria 51
Diseases that are prone to cause epidemics 55
Neglected diseases 56
Conclusion: Learning from past success 57
Bibliography 59
Chapter 4 - Noncommunicable diseases in Africa 63
An emerging threat 63
Africa's double burden 63
Africa's lesser known toll of ill-health 65
Cardiovascular diseases 65
Obesity and undernutrition: an African paradox 65
Cancer 66
Injuries, violence and disabilities 67
Blindness 69
Mental health problems 70
Genetic diseases 71
Oral diseases 72
Efforts to tackle the problems 73
Legislation and marketing 73
Mental health legislation 74
Promoting healthy diets and lifestyles 74
Low-cost management programmes 75
Closer collaboration 75
Traditional health practitioners 75
The challenges 76
Scarcity of resources 76
Inadequate awareness and commitment 77
Limited data 77
Conclusion: Africa can learn from others' experience 79
Bibliography 80
Chapter 5 - Health and the environment in Africa 85
Environmental health risks in Africa 85
Challenges in the environment 86
Water and sanitation 86
Pollution and industrial waste 87
Urbanization 89
IV
Food safety 90
Emergency situations 92
Tackling poverty and environmental risks 94
Poverty reduction 94
Conflict prevention and management 95
Sustainable, low-cost solutions: water and sanitation 96
Making food safer: a shared responsibility 98
Conclusion: tracking progress 100
Bibliography 101
Chapter 6 - National health systems — Africa's big public health challenge 105
Building and reinforcing health systems 106
Public and private health-care provision 106
Scaling up health systems 107
Vertical programmes 107
Sector-wide approach 109
Health information systems 110
Vital registration 111
Getting the numbers right 112
Essential medicines 113
Improving access 113
Blood safety 115
Human resources: a continent in crisis 117
Approaches to filling the gap 120
Health financing 121
Donor funding 123
User fees 124
Evidence for resource allocation 124
Conclusion: Health systems - the key to better health 125
Bibliography 127
Statistical Annex - Statistical Annex
Health statistics in the African Region 129
Introduction 131
Demographic and socioeconomic statistics 132
Health status: mortality 134
Health status: morbidity 136
Inequities in health 138
Risk factors 140
Health service coverage 142
Health workers 144
Health expenditure ratios, 1999-2003 146
Per capita expenditure on health, 1999-2003 148
Explanatory notes 149
Glossary
Index 163
Boxes
Box 1.1: Achieving MDG 1: Poverty (Figure) 6
Box 1.2: MDG 8: A global partnership for development 10
Box 2.1: Achieving MDG 4: Child health (Figure) 18
Box 2.2: Achieving MDG 5: Maternal health (Figure) 19
Box 2.3: Psychosocial support for HIV-positive mothers and families
Box 2.4: Caring for sick children in the United Republic of Tanzania 28
Box 2.5: Giving birth in Mauritius 31
Box 2.6: Innovative financing to provide maternal care in Mali and Mauritania 32
Box 3.1: Guinea-worm disease and leprosy in Nigeria 40
Box 3.2: Activists give hope to people with HIV in Burundi
Box 3.3: How Cameroon secured lower prices for antiretrovirals 47
Box 3.4: HIV and tuberculosis in South Africa 50
Box 3.5: Treating malaria in Ethiopia
Box 3.6: Achieving MDG 6: HIV/AIDS, malaria, and other diseases (Figures) 58
Box 4.1: Rehabilitation for landmine victims in Angola 68
Box 4.2: Making roads safer in Rwanda 70
Box 4.3: Ghana is drafting a new mental health law 74
Box 4.4: Togolese people with epilepsy reintegrated into community
Box 5.1: Clearing the air with smoke hoods in Kenya 88
Box 5.2: Tackling mountains of waste in Lagos 89
Box 5.3: Making street foods safer in Ghana 91
Box 5.4: Healing post-conflict societies by healing peoples' minds 92
Box 5.5: Environmental control of schistosomiasis in Malawi 97
Box 5.6: Achieving MDG 7 on water and sanitation (Figure) 98
Box 6.1: What is a health system? 106
Box 6.2: Delivering health care to isolated communities 108
Box 6.3: Tanzanian farmers grow their own Artemisia annua 115
Box 6.4: Malawi's health sector "brain drain" 118
Box 6.5: Community home-based care in Botswana 121
Box 6.6: Uganda leads the way in simplified AIDS care 122
Figures
Fig. 1.1: Life expectancy at birth, for males and females, in countries by WHO region, 2003 4
Fig. 1.2: Proportion of population living on less than US$ 1.08 per day at 1993 purchasing
power parity (PPP)
Fig. 1.3: Investments in health contribute to economic development 7
Fig. 2.1: Causes of maternal mortality in the African Region 18
Fig. 2.2: Global distribution, by region, of maternal deaths, world population and live births, 2000 19
Fig. 2.3: Causes of neonatal mortality in the African Region 20
Fig. 2.4: Neonatal mortality rate in the WHO regions (per 1000 live births) 20
Fig. 2.5: Causes of under-5 mortality in the African Region 21
Fig. 2.6: Patterns of reduction of under-5 mortality rates, 1990-2003 21
Fig. 2.7: Immunizaton coverage with EPI (Expanded Programme on Immunization) vaccines,
African Region, 1982-2003 29
Fig. 3.1: Regional progress towards 70% case detection of tuberculosis 38
Fig. 3.2: Mass drug administration for elimination of lymphatic filariasis 39
Fig. 3.3: Prevalence of leprosy in the African Region, by countries, 1985 and 2003 41
Fig. 3.4: HIV prevalence among 15-24-year-olds in selected sub-Saharan African countries, 2001-03 45
Fig. 3.5: Trends in incidence of malaria cases and distribution of insecticide-treated nets (ITNs),
Eritrea (1997-2004) 52
Fig. 3.6: Status of malaria drug policy change and implementation in the African Region
as of July 2005 54
Fig. 4.1: Burden of noncommunicable diseases and injuries in DALYs by cause in the
WHO African Region, estimates for 2001 64
Fig. 5.1: Sanitation coverage in the African Region 86
Fig. 6.1: Types of household surveys that have been conducted in the African Region 110
VI
Fig. 6.2: Coverage of death registration: mortality data (1995 onwards), by cause, available to WHO 111
Fig. 6.3: Member States with official national medicine policies, WHO African Region
Fig. 6.4: Total cost of malaria illness, Ghana, 2002
Fig. 6.5: Per capita government expenditure on health (US$), WHO African Region, 2003 124
Tables
Table 1.1: Burden of disease in the African Region 2002
Table 4.1: 20 leading causes of death in South Africa 66
Table 4.2: Leading causes of death in the African Region, 2002 69
Table 4.3: Mental health resources in selected countries in the African Region
Table 4.4: A stepwise approach for prevention and control of noncommunicable diseases
Table 5.1: Deaths and DALYs attributable to indoor air pollution from solid fuel
in the African Region, 2000 87
Table 6.1: Outflow of health workers from 16 African countries, 1993-2002 119
VII
REGIONAL OFFICE FOR
World Health
Organization
Africa
Dr Luis Gomes Sambo
Regional Director
WHO - Regional Office for Africa
^ ^ Much can be done to prevent
disease and disability through the
promotion of healthy lifestyles and health
education. ... We know which treatment,
diagnostic and preventive methods are
needed and what works in Africa. We
also have the institutions. This report
shows clearly that health systems are
the key to providing a range of essential
health care. African governments and
their partners need to invest more funds
to strengthen the continent's fragile
health systems. % %
Message from the
Regional Director
Every year millions of Africans are dying needlessly of diseases that are preventable and treatable.
The Health of the People: the African Regional Health Report provides vital reading for those who
want to understand why and what can be done about it.
The vast majority of people living in Africa have yet to benefit from advances in medical
research and public health. The result is an immense burden of death and disease that is
devastating for African societies. This report looks at: HIV/AIDS, tuberculosis and malaria, and the
pregnancy-related conditions that kill mothers and babies. It also highlights the lesser known
problems of chronic diseases, such as diabetes and hypertension, and other noncommunicable
conditions, such as mental illness and injuries.
The challenges are many, including: weak and fragmented health systems; inadequate resources
for scaling up proven interventions; limited access to the health services and technologies
that are available; poor management of human resources for health; recurrent natural and man-
made disasters and emergencies; and extreme poverty.
And yet these pages do not merely recount tales of misery, indeed, they describe in detail some
of Africa's public health success stories that may serve as a models for others in the continent. Much
can be done to prevent disease and disability through the promotion of healthy lifestyles and health
education. ... And when people become sick with malaria or suffer with other health problems, the
solutions are within our grasp. ... We know which treatment, diagnostic and preventive methods
are needed and what works in Africa. We also have the institutions. WHO is working tirelessly
with WHO'S 46 Member States in the African Region to help build and reinforce health systems
that are central to improving the health of the people across the Region.
This report shows clearly that health systems are the key to providing a range of essential
health care. African governments and their partners need to invest more funds to strengthen the
continent's fragile health systems.
The challenge for African governments and their partners is to coordinate the provision of health
care more effectively than ever before, and to ensure that all funds are used in an accountable manner
to the benefit of the African people. On behalf of the African Regional Office of WHO. I would like to
express our gratitude to the 46 Member States and our partners in the Region for their commitment
to improving the health of their people.
Dr Luis Gomes Sambo
Regional Director
WHO - Regional Office for Africa
IX
This report is an excellent
review of the public health situation
across the WHO African Region,
that includes 46 African countries
that are all Member States of the
African Union. ... The African
Union Commission fully supports
the central message of this report:
that African governments and
their partners need to do more to
build and reinforce health systems
to deliver essential health-care
interventions to people living
on this continent. %%
Foreword
Chairperson of the
African Union Commission
Public health in Africa has come under the international spotlight in recent years. The sheer enormity
of the disease burden in African countries and the often inadequate response has prompted many
regional and international initiatives. More funds than ever before have been pledged for health in
Africa, yet many problems prevail.
This report is an excellent review of the public health situation across the WHO African Region,
that includes 46 African countries that are all Member States of the African Union. The health of the
people: the African regional health report provides vital insight into why Africa has such a heavy
burden of premature death and disease, but also a valuable overview of the interventions that work
and need to be extended to everyone who needs them.
The African Union Commission has been working closely with WHO's African Regional Office
in several public health areas. In May 2006, the African Union Commission, in collaboration with
United Nations agencies and other development partners held a Special Summit on HIV/AIDS,
tuberculosis and malaria in Abuja, Nigeria, to look at progress so far and the way forward to achieve
universal access to treatment for these diseases by 2010.
In collaboration with WHO and other United Nations' agencies, the African Union launched a
campaign this year to prevent HIV/AIDS in Africa. We want to promote widespread awareness of HIV
and how it is caused through media campaigns and public health education. We want more Africans
to embrace HIV counselling and testing and we want governments to ensure that HIV prevention
services are available — along with antiretroviral therapy — for everyone who needs them.
Violence is a major public health problem in Africa. The African Union's 53 Member States
declared 2005 the African Year of Prevention of Violence, and the African Union and WHO are
working closely on violence prevention in Africa. The African Union supports key health partnerships
and initiatives, including the STOP-TB partnership and the Road Map on the Reduction of Maternal
and Newborn Morbidity and Mortality in Africa.
Much progress has been made in the fight against polio by the Global Polio Eradication Initiative,
but more efforts by African governments and their partners are needed to ensure that new outbreaks
are quickly brought under control and that high immunity levels are maintained in all populations
through vaccination. The African Union has been working closely with WHO and other partners on
a preparedness and response plan to reduce the risk of bird flu and human pandemic influenza.
The African Union Commission fully supports the central message of this report: that African
governments and their partners need to do more to build and reinforce health systems to deliver
essential health-care interventions to people living on this continent.
r;
H.E. Prof. Alpha Omar Konare,
Chairperson of the African Union Commission
XI
Executive summary
This report comes at a crucial time, when much attention is being devoted to Africa
and when African countries are finding their own voice and their own solutions to
their problems. The health of the people: the African regional health report provides
an overview of the public health situation across the 46 Member States of the African
Region of the World Health Organization. This report charts progress made to date
in fighting disease and promoting health in the African Region. It reviews the success
stories and looks at areas where more efforts are needed to improve people's health.
The central message of the report is clear: African countries will not develop
economically and socially without substantial improvements in the health of their
people. The health-care interventions — treatments, diagnostic and preventive
methods — that are needed in this Region are known. The challenge for African
countries and their partners is to deliver these to the people who need them, and the
best way to do this is to establish well-functioning health systems.
Table a
Burden of disease in the African Region 2002
Malaria
Respiratory infections
Perinatal conditions
Diarrhoea
Top five subtotal (1 - 5)
Other communicable diseases
Communicable diseases (6 and 7)
Noncommunicable diseases
Injuries
Total (8 - 10)
The Member States of the Region have been divided into mortality strata on the basis of their levels of mortality in
children under five years of age and in males aged 1 5-59 years as described on pp. 1 56-7 of the 2004 World health report.
* See glossary for explanation.
Source: The world health report 2004. Geneva. World Health Organization; 2004.
Chapter 1 : Health and development in Africa
Economic development is impossible without major investments to apply tried-
and-tested health-care interventions that work. This chapter shows how much the
severe burden of disease hampers social progress and economic development in
many African countries. Ill-health pushes people into the poverty trap. Poverty is a
major factor determining ill-health, as well as being both a cause and an outcome of
ill-health. Several studies have sought to quantify the macroeconomic impact of the
disease burden (see Table a).
Governments in the African Region and their development partners need to invest
more in health care. Recent rapid economic growth in some African countries provides
an opportunity to do this. Their partners need to increase donor funds to scale up
tried-and-tested public health interventions. A
paradigm shift is needed: African countries and
their partners need to address the underlying
factors that determine ill-health. Investing in
health, therefore, means investing in water,
sanitation, environment, education, women's
empowerment, governance and other related
sectors.
WHO's African Region lags behind
other regions of the world in terms of human
development. This limited development is
largely attributable to the Region's immense
burden of infectious diseases, particularly that
of HIV/AIDS, tuberculosis and malaria. This
chapter describes the macroeconomic impact of
the Region's heavy burden of infectious diseases
as well as of unhealthy environments; maternal,
newborn and child death and disease; and the
growing burden of noncommunicable diseases.
There are positive indications that things
are changing as Member States of the Region
and their partners continue to demonstrate
the will to address poverty and development
by bringing health issues to the forefront. This
is demonstrated by regional initiatives, such as
the New Partnership for Africa's Development
(NEPAD) and efforts by the C8 and global
financial institutions to cancel debt and
encourage least-developed countries to channel
The African Regional Health Report
the resulting savings into health and related sectors. Chapter I reviews these and
other current initiatives to combat high mortality and morbidity in Africa, including
regional efforts, such as the Abuja Declaration and international efforts, including
the United Kingdom's Commission for Africa and the UN Millennium Development
Coals (MDCs). More needs to be done to encourage African nations to honour
the pledge they made in Abuja to allocate 15% of their national budgets to health.
Similarly, developed countries should honour the pledge they made to committing
0.7% of their gross domestic product (GDP) to development assistance.
The challenges for public health in the African Region are enormous. But with
true commitment and resolve by governments in the Region and their development
partners, these challenges can be overcome, helping countries in the Region to move
closer to achieving the MDCs.
Chapter 2: Maternal, newborn and child health
This chapter describes Africa's "silent epidemic", the tragedy that millions of mothers,
newborn babies and children die every year from preventable, treatable causes. It
summarizes the trends of death and disease among mothers during pregnancy and
childbirth, and of their children in the African Region. Progress in this area of health
was made in the 1970s and 1980s, as African states established health-care systems
providing antenatal and emergency obstetric care. Improved child survival became a
global phenomenon during those years, largely due to immunization and the success
of oral rehydration therapy for diarrhoeal diseases. But since the early 1990s, little or
no progress has been made in maternal, newborn and child health in many parts of
the Region largely due to the HIV/AIDS epidemic and armed conflicts. In some parts
of the Region, progress in maternal, newborn and child health has been reversed.
Major global efforts to address the situation have so far produced limited results.
Few countries in the Region are likely to achieve MDC 4 on child health and MDC 5
on maternal health (see Fig. a and Fig. b). The obstacles and challenges are many:
conflict and emergencies, HIV/AIDS, inadequate resource allocation and weak health
systems. Renewed efforts are now under way to make motherhood safer; prevent
mother-to-child transmission of HIV; provide family planning services; and manage
childhood illness.
This chapter looks at some success stories, for example, in the countries and
districts that have improved maternal, newborn and child health in the Region.
It reviews the tried-and-tested interventions, such as skilled birth attendance,
immunization and family planning, that need to be scaled up and replicated
throughout the Region. Furthermore, women need to receive better education to
improve their economic and social status and, in turn, their own health and that of
Fig. a
Under-5 mortality (deaths per 1000
live births) in the African Region
200
180
160
140
120
.183 Benchmark
171 Most recent
Progress made
Progress needed
to achieve goal
61 Goal
1990 2002 2015
Based on data from: Tfte world health report,
2005. Geneva:World Health Organization; 2005.
Fig.b
Maternal mortality (deaths per
100000 live births) in the African Region
1000
900
800
700
600
500
400
300
200
100
0
Benchmark
870
910 Most recent
Progress needed
to achieve goal
228 Goal
1990
2000
2015
Based on data from: The world health report.
2005. Geneva: World Health Organization; 2005.
The health of the people
Executive summary
their families. Governments in the Region have committed themselves to improving
the health of mothers, newborn babies and children. Now they need to act by
allocating more funds to this vital, but neglected area of public health.
Fig.c
HIV prevalence among 15-24-year-olds in selected sub-Saharan African
countries, 2001-03
20
8 is
10
> 5
z
Niger Mali Burundi Kenya Zambia South Africa Zimbabwe
(2002) (2001) (2002) (2003) (2001-02) (2003) (2001-02)
Sources: Burundi (Enquete Nationale de Seroprevalence de I'infection par le VIH au Burundi. Bujumbura, Decembre
2002). Kenya (Kenya Demographic and Health Survey 2003). Mali (Enqueue DSmographique et de Same". Mali
2001 ). Niger (Enquete Nationale de Seroprevalence de I'infection par le VIH dans la population generate agee de
1 5 a 49 ans au Niger (2002)). South Africa (Pettifor AE, Rees HV, Steffenson A, Hlongwa-Madikizela L, MacPhal C,
Vermaak K, Kleinschmidt I: HIV and sexual behaviour among young South Africans: a national survey of 1 5-24 year
olds. Johannesburg: Reproductive Health Research Unit, University of Witwatersrand, 2004). Zambia (Zambia
Demographic and Health Survey 2001 -2002). Zimbabwe (The Zimbabwe Young Adult Survey 2001-2002) .
Chapter 3 Infectious diseases in Africa
Infectious diseases are a major obstacle to human development in the African Region.
This chapter recalls that people in Africa suffer from a vast range of preventable and
treatable infectious diseases. It reviews the challenges for infectious disease control
in the Region and shows how factors, such as climate, geography and parasites,
make this task especially difficult.
Chapter 3 charts the Region's successes in controlling certain infectious diseases,
such as river blindness and leprosy, as well as vaccine-preventable diseases, such
as polio. It looks at the diseases in the Region that are prone to epidemics, such as
cholera, meningitis, Lassa fever and yellow fever, and the neglected diseases, such as
Buruli ulcer and sleeping sickness.
The chapter also takes a detailed look at three diseases of major public health
concern: HIV/AIDS, tuberculosis and malaria,
which kill more than three million people in
the Region every year. HIV/AIDS prevalence is
particularly high in southern African countries
(see Fig.c). This high prevalence increases the
occurrence of other infectious diseases, particularly
tuberculosis. However, the shortage of health
workers is hampering efforts to provide health care
for this and other problems.
Chapter 3 describes the devastating effect
of these three infectious diseases on society
hardship, impoverishment, countless
lives lost and reduced productivity - - and
how governments are forced to divert scarce
resources to tackle these diseases, spinning
countries on an inescapable cycle of poverty
and ill-health. But it also charts the progress
made in the Region in rolling out antiretroviral
treatment for HIV/AIDS in recent years.
It outlines some of the solutions that work
in the Region. Tried-and-tested public health
interventions — for example the provision
The African Regional Health Report
of universal HIV testing and counselling and simplified treatment for HIV/AIDS
— need to be applied more widely.
These simplified, low-cost approaches to treatment need to be scaled up so
that they are available to all the people in the Region who need them. Research
and development is needed to find more effective medicines for diseases such as
tuberculosis and other neglected diseases and vaccines for malaria and HIV/AIDS.
Meanwhile, countries in the Region need to promote safe sex and more countries
need to provide HIV testing and counselling to prevent further HIV infections and
reverse the AIDS pandemic. Political will backed by financial support is crucial to
scaling up tried-and-tested control methods that are specific to each disease.
Chapter 4: Noncommunicable diseases in Africa
Noncommunicable diseases and injuries constitute a growing public health problem
in the African Region, but at the same time represent one of the most neglected areas
of public health. Although the noncommunicable diseases and injuries burden repre-
sents 27% of the Region's total disease burden (see Table b), African countries and
their partners do not devote resources that are adequate to address the problem. The
risk factors for noncommunicable and chronic diseases — such as unhealthy diet
and lack of physical exercise, are on the rise in many African countries. The result is
that stroke, diabetes, cancer and heart disease — diseases that are seen as affecting
mainly wealthy industrialized countries — are becoming increasingly prevalent in
Africa and represent an emerging threat.
Chapter 4 looks closely at Africa's growing "double burden" of infectious and
noncommunicable disease. It charts Africa's lesser known toll of ill-health, including a
growing burden of cardiovascular diseases, malnutrition and obesity, cancer, injuries,
blindness, mental illnesses, genetic and oral diseases. Some of these conditions are
a consequence of infectious diseases, such as cervical cancer, while others, such as
noma, are specific to this Region.
There is a huge unmet need in terms of addressing noncommunicable diseases,
mental health and injuries in the African Region. This state of affairs must be
rectified. The challenges are many and include a scarcity of resources; inadequate
awareness and commitment to this area; and limited data. Donor agencies and
research institutions, too, are neglecting the growing burden of noncommunicable
diseases and injuries in the Region.
The chapter gives an overview of tried-and-tested solutions for tackling the problems.
These include: legislation and marketing which can be particularly effective to control
tobacco; mental health legislation; promotion of healthy diets and lifestyles is also an
effective, low-cost solution; and low-cost disease management programmes.
Table b
Leading causes of death in the African Region, 2002
HIV/AIDS
Malaria
Lower respiratory infections
Diarrhoeal diseases
Perinatal conditions
Cerebrovascular disease
Tuberculosis
Ischaemic heart disease
Measles
Road traffic crashes
Violence
Whooping cough
Chronic obstructive pulmonary disease
Protein-energy malnutrition
Nephritis and nephrosis
Syphilis
War
Tetanus
Diabetes mellitus
Drowning
Source: Global Burden of Disease 2002.
The health of the people
Priority should be given to primary prevention of noncommunicable diseases
by tackling risk factors, such as diet, physical activity, alcohol consumption and
tobacco use. Secondary prevention should focus on controlling risk factors among
those affected, with special emphasis on obesity, high blood pressure, high blood
sugar and high blood lipid levels. The third approach is tertiary prevention through
proper clinical management of cardiovascular disease, chronic obstructive respiratory
disease, diabetes, and cancer. Similar approaches are needed for mental health
disorders and oral health.
Government departments, such as health, transport and education, need to work
together to introduce measures to reduce the risk of injuries and noncommunicable
diseases, such as seat-belt laws and promotion of healthy diets. There also needs to
be more collaboration between government, nongovernmental organizations and
the media.
Many developed countries are only now realizing the value of health promotion
strategies, such as tobacco control. African countries have the opportunity to learn
from the mistakes made in developed countries and to act early before the growing
epidemic of noncommunicable disease gets out of control.
Fig.d
Improved water source (% of population
without access) in sub-Saharan Africa
Benchmark
50
40
30
20
10
Most recent
Progress needed
to achieve goal
1990
2002
2015
Source: WHO/UNICEF Joint Monitoring Programme
for Water Supply and Sanitation - Water for life:
make it happen. 2005.
Chapter 5: Health and the environment in Africa
People living in the African Region face a number of environmental health risks. High
levels of air pollution, both within and outside the home, unsafe water supplies,
inadequate sanitation and unhygienically prepared food are widespread in many
parts of the Region. There are also emerging environmental risks to health in the
African Region, such as ecosystem degradation and climate change.
Rapid urbanization has forced millions of people to live in shanty towns without
basic services, meanwhile day-to-day environmental threats to people's health are made
worse by armed conflict and natural disasters. There is a growing problem of industrial
pollution, the management of solid and liquid waste, and of medical waste.
This chapter summarizes trends in the environmental risk factors for health
in the Region, it outlines the efforts to tackle them and underscores areas where
more needs to be done to tackle these factors. Wider coverage of clean water and
sanitation, and wider provision of sewage and waste disposal would be major steps
towards a healthier environment (see Fig. d).
The challenges for governments are immense. Widespread poverty limits people's
ability to address environmental problems. Success in tackling environmental heath
problems depends very much on collaboration between ministries and agencies.
Chapter 5 describes some success stories, where communities have used locally
developed technologies and innovations that are effective, affordable and sustainable.
The African Regional Health Report
Low-cost, sustainable solutions for water and sanitation need to be scaled up.
Countries in the Region and international organizations need to work more closely
together to prevent and resolve conflicts. Governments in the Region also need to
scale up food safety and hygiene education. Closer cooperation between government
ministries and sectors in those countries is also key to making the environment more
healthy.
WHO has several strategies to address these issues. For example, WHO'S
strategy on health and the environment urges governments to develop environmental
health policies and to make communities more aware of the relationship between the
environment and public health.
Community-management programmes run by WHO and other agencies using
the Participatory Hygiene and Sanitation Transformation, Demand-Responsive
Approach and Ecological Sanitation, along with the Africa 2000 Water and Sanitation
programme, have all shown results. Through the Healthy Settings approach, several
countries in the Region are for the first time, addressing complex urban health
problems in a holistic way.
WHO programmes aim at empowering people and improving conditions at
community and workplace level to prevent and reduce factors that prevent communities
and individuals from achieving better economic and positive health outcomes. In this
way, WHO helps countries to improve their capacity to plan, implement and evaluate
their programmes to inform policies and implementation plans.
The challenges for
governments are immense.
Widespread poverty limits
peoples ability to address
environmental problems.
Success in tackling
environmental heath
problems depends very
much on collaboration
between ministries and
agencies.
Chapter 6 National health systems —
Africa's big public health challenge
One of Africa's major public health challenges is building and reinforcing health
systems capable of delivering essential health care to the population. Countries
in the African Region have weak and dysfunctional health systems. Several key
elements are required for health systems to function properly: adequate numbers of
skilled health workers, basic infrastructure and equipment; essential medicines and
supplies; and health financing systems. It is also important to establish effective
health information systems, including vital registration, to measure the scale of a
given health problem in order to gauge the appropriate response.
Health care in these countries is provided by a mix of public and private
providers, often resulting in "vertical" or single-disease/issue programmes. Funds
for health care come from a variety of public and private sources, including donor
funds. Some governments have started to take a "sector-wide approach" to improve
i health of the peopli
Executive summary
Stronger health systems
can act as a bridge to
social stability, peace and
prosperity throughout the
Region.
the coordination of those funds so that they can be used more effectively and to
avoid duplication.
The chapter closes with one of the report's key messages: that establishing
well-functioning health systems is essential to addressing the many health problems
described throughout this report. Furthermore, health systems need to be tailored to
their specific setting, whether urban or rural.
To strengthen health systems, governments of Member States need to forge
strong collaboration with other partners at national and local level, including the
private sector, civil society and communities. Universal access to health care can
only be achieved by scaling up essential health system interventions. This will be
difficult to achieve without adequate investment and without taking the delivery of
essential health services as close to the communities as possible through strong and
effective district health systems. Stronger health systems can act as a bridge to social
stability, peace and prosperity throughout the Region. •
The African Regional Health Report
Improving the health of the 738 million people in the 46 Member States
of the African Region of the World Health Organization (WHO) is
absolutely essential, along with education, good governance and sound
economic policy. Improvements in health can spur social progress and
economic growth, but cannot be achieved without increasing current levels
of investment in health in this Region.
The health of the people
The first African Regional Health Report comes at a crucial time for Africa, a
time when the continent has come into sharp focus. Major international efforts
have recently got under way to reduce poverty and achieve other Millennium
Development Goals (MDCs) in Africa. In July 2005, the Group of Eight (G8)
industrialized nations provided debt relief and increased aid to African countries. In
December 2005. the 148 Members of the World Trade Organization (WTO) agreed
on a package of trade and aid measures intended to help the world's poorest
countries. The package is a small first step towards the "trade-for-aid" goal of the
Doha Development Round: to abolish tariffs on African products and subsidies paid
to farmers in wealthy countries, tariffs and subsidies that make it difficult if not
impossible for African farmers to compete internationally.
This report shows that improving the health of the 738 million people (in 2005) in
the 46 Member States of the African Region of the World Health Organization (WHO) is
absolutely essential, along with education, good governance and sound economic policy.
Improvements in health can spur social progress and economic growth, but cannot be
achieved without increasing current levels of investment in health in this Region.
The need to invest more in health is not only a moral imperative to alleviate
suffering and to address a basic human right to health, but — in today's intercon-
nected, globalized world — it also makes economic sense, and can help pave the
way to a more prosperous and secure future for all. At the same time, efforts to im-
prove health need to be closely coordinated and monitored as never before to ensure
that funds are used to optimal effect and in an accountable way.
This report provides an overview for governments, civil society and health pro-
fessionals in Africa, as well as for donors and other members of the international
community. It reviews how the health of the people in the African Region has devel-
oped over the last 10-15 years and tracks progress — or lack of it — towards achiev-
ing the health-related MDGs by 2015. Outlined are the main public health challenges
this Region faces as well as the initiatives and programmes intended to tackle these,
and their successes to date.
The solutions described in this report draw on the advances in diagnosis, treat-
ment and prevention of major diseases that have led to greater life expectancy in the
rest of the world, but from which most people in Africa have yet to benefit. The path
to success in providing people in Africa with these basic services is in implementing
the solutions and strategies outlined in these pages: strategies that are known to work
in this Region, strategies that invest in the welfare of the African people.
The starting point for improving public health is firm political resolve on the part
of Member States of the African Region (see map and definition on p. xxv) andtheir
partners. In order to make progress, some Member States could increase spending
on health, while donor countries could seek ways to provide a more reliable and
sustainable flow of aid. In this way, health can be a bridge to economic prosperity
for every African nation.
The challenges confronting Africa
Success in improving public health in Africa depends on renewed efforts and deter-
mination to overcome a number of challenges in the African Region.
A child born in Africa faces more health risks than a child born in other parts
of the world. Such a child has more than a 50% chance of being malnourished, a
high risk of being HIV-positive at birth, while malaria, diarrhoeal diseases and acute
respiratory diseases account for 51% of deaths. A child born in the African Region
is more likely to lose his or her mother due to complications in childbirth or to HIV/
AIDS, while that child has a life expectancy of just 47 years, and is very likely — at
least once in his or her short life — to be affected by drought, famine, flood or civil
war, or to become a refugee.
People living in the African Region are more exposed to a heavy and wide-
ranging burden of disease partly because of this Region's unique geography and
climate. These factors make malaria, for instance, more intractable in Africa than it is
elsewhere. At the same time, noncommunicable diseases and injuries are emerging
as significant contributors to the disease burden.
Nowhere has HIV/AIDS killed such large proportions of the population as it
has in Africa. Nowhere has the old scourge of tuberculosis re-emerged to fuel the
HIV/AIDS epidemic as it has in the African Region. No other region has witnessed
so many armed conflicts and other humanitarian emergencies.
Nowhere is poverty so prevalent. The population of the African Region repre-
sents about 10% of the world's population, but an estimated 45% or more of its
people live below the poverty line, on less than US$ I a day. About 330 million
people in this Region — one-third of the world's I . I billion poor — are caught in this
poverty trap, in which low household incomes lead to low household consumption
and, in turn, the countries in which they live have low capacity and low productiv-
ity. Agricultural productivity is lower than in other regions due to unreliable water
supply, inadequate irrigation and poor soil quality. High transportation costs for the
continent's interior, due to the lack of navigable rivers and the slow diffusion of
technology, also hamper development.
The African Regional Health Report
Nowhere has life expectancy reversed so sharply as in the African Region. Life
expectancy at birth in this Region was 45 years in 1970. This rose to 49.2 years in
the late 1 980s but fell during the 1 990s and early 2000s to just 47 years. Overall life
expectancy for people born in the African Region in 2002 would be 54 years, if it
were not for about six years of life lost due to the sole impact of HIV/AIDS.
The African Region faces some of the same constraints as other regions. In-
ternational trade agreements that benefit the world's wealthier countries make it
difficult for poorer countries to compete in international markets. Only about 10%
of research and development funds for medicines and vaccines go into diseases that
account for 90% of the global disease burden.
The challenge confronting public health in the African Region today is that most
diseases and conditions described in this report are preventable, treatable or both.
Most deaths in this Region could be avoided if basic health care — vaccines, drugs,
diagnostic methods and the health systems to deliver them — were widely available.
This report is about how to make this happen. •
African Region of the World Health Organization
Cape
Verde
A
Senegal /
Gambia
Guinea-Bissau
Guinea
Sierra Leone
Liberia
Burkina Faso
Cote d'lvoire
Sao Tome and Principe
Cameroon
Equatorial Guinea
Gabon
WHO African Region
B Outside WHO African Region
Zambia
Namibia
Botswana
Uganda
Rwanda
Burundi
United Republic of Tanzania
Seychelles
— Comoros
Mozambique
- Mauritius
This report is about the 46 Member
States of the African Region of the
World Health Organization (WHO), as
illustrated in this map. The African
Regional Office of WHO is based in
Brazzaville, the Republic of the Congo.
When this report refers to "Africa", it
is referring to the continent and islands
as a whole. When the report refers to
"the African Region" or "the Region", it
is as defined by WHO.
It is important to note that the
WHO African Region does not include
all the countries on the African continent
and the Region itself is not limited to
all of sub-Saharan Africa.
Please note: the World Bank
divides the continent into two regions:
North Africa and sub-Saharan Africa,
while UNICEF divides it into three
regions: Eastern and South Africa,
West and Central Africa, and the
Middle-East and North Africa.
The health of the people
I
•',
-.
Key messages
a Health can drive social progress and economic growth
• Ill-health pushes people into the poverty trap
Severe burden of disease in Africa hampers development
Current investment in health is inadequate
Solutions
African governments need to invest more in health
Africa needs more development support from outside
Scale up tried and tested public health solutions
Paradigm shift is needed: need to address underlying
determinants of ill-health, such as poverty
Health and
development in Africa
The cycle of poverty and ill-health
^^ eople living in the African Region face a heavy and wide-ranging burden of
• J disease, which takes its toll on social and economic development and short-
ens their life expectancy. The HIV/AIDS epidemic as well as the resurgence of
malaria and tuberculosis have swept away improvements in life expectancy in some
sub-Saharan countries (see Fig. I.I). Other infectious diseases and — increasingly
— noncommunicable conditions are also a severe burden, while the complications of
pregnancy and childbirth take millions of lives every year.
The health services that have evolved in countries in Africa are often not able
to address adequately this severe burden of disease. These health systems are weak,
reflecting the overall state of the economies in the African Region. In many countries
out-of-pocket payments are high in proportion to household incomes and are a major
factor driving poverty. The cost of treatment for an adult with HIV/AIDS, in addition to
lost income due to time off work, can drag a whole household below the poverty line.
Therefore, just as health can drive economic growth, ill-health can push people into
poverty and make it very difficult for them to escape the poverty trap.
This vicious cycle of poverty and ill-health can be seen in many countries in Africa.
Some 76% of the population of sub-Saharan Africa live on less than US$ 2 a day, and
46.5% on less than US$ 1.08 a day (see Fig. 1.2). While poverty has declined in other
parts of the world, such as East and South Asia, over the past 20 years, in sub-Saharan
Africa the trend has been strongly in the other direction. Between 1981 and 2001 the
gross domestic product (GDP) of sub-Saharan countries decreased by 13%. resulting in
a doubling in the number of people in the Region living on less than US$ I a day from
1 64 million to 3 1 4 million. While Africans represented only 1 6% of the world's poor in
1985. by 1998 this proportion had risen to 31%. The trend is likely to continue, with
poverty expected to decline over the next 20 years in every part of the world except
sub-Saharan Africa, where a dramatic increase is expected.
Health and development in Africa
Fig. 1.1
Life expectancy at birth, for males and females, in countries by WHO region, 2003
80
70
60
30
Countries in other regions
Countries in African Region
30 40 50 60 70
Male life expectancy (years)
Figure shows low life expectancy in countries in the African Region.
Source: World Health Statitstics 2005. Geneva: World Health Organization: 2005.
Progress in human development made by some African countries in the 1970s
and 1980s has been sharply reversed by HIV/AIDS and by armed conflict. On top of
that, countries in the Region continue to suffer from other emergencies, large-scale
migration, famine and economic decline.
Chronic diseases are becoming increasingly prevalent in middle-income coun-
tries of the African Region, such as South Africa and Kenya. Furthermore, road traffic
collisions place a heavy burden on households and, in turn, regional and national
economies. For instance, road traffic collisions cost the Ugandan economy around
(JS$ 101 million per year, which is 2.3% of the country's gross national product
(GNP). In addition mental health is one of the most under-resourced areas of public
health in the African Region, even though mental health problems are on the rise and
mental health services are desperately needed in post-conflict societies to help them
achieve stability. In many countries of the Region this area of public health requires
more attention than it is currently receiving.
The African Regional Health Report
Fig. 1.2
Proportion of population living on less than US$ 1.08 per day at 1993 purchasing power parity (PPP)
60
50
40
30
20
10
Sub-Saharan Africa
South Asia
Middle-East and North Africa
Latin America and the Caribbean
Eastern Europe and Central Asia
East Asia
1981 1984 1987 1990 1993 1996 1999 2001
Source: Chen S, Ravallion M. How have the world's poorest fared since the early 1980s?
World Bank Policy Research Working Paper 3341 Washington, DC: World Bank; June 2004
Outside the African Region, about two-thirds of deaths are due to noncommu-
nicable diseases. In Africa, by contrast, according to 2002 estimates. 72% of deaths
are caused by communicable diseases such as HIV/AIDS, tuberculosis, malaria, re-
spiratory infections, other infectious diseases, and complications of pregnancy and
childbirth. These are largely preventable deaths, which account for about 23% of
mortality in other regions.
The WHO Commission on Macroeconomics and Health made a powerful case
in favour of investment in health — by scaling up known, cost-effective interventions
— as an important driver of economic growth. No other region of the world has so
much potential to benefit from such investment in health as the African Region.
African economies are growing fast, but not fast enough to achieve the UN
Millennium Development Goals (MDGs). The economies of sub-Saharan countries
need to grow at an average annual rate of 7% over the next decade to achieve the UN
Millennium Development Goal I of cutting poverty in half by 20 1 5 (see Box. I.I).
according to the International Monetary Fund. At current rates some countries may
succeed, but many will fail. Economic growth and more investment in health will not
help countries attain the improvements envisaged by the MDGs alone. More efforts
are needed to achieve greater peace and security, good governance, gender equality
and sustainable management of the environment.
Health and development in Africa
Achieving MDG 1: Poverty
MDG 1 aims to halve by 201 5 the number of people who were
living on less than US$ 1 a day in 1990. The poverty rate and
number of poor increased in the 1990s, making sub-Saharan
Africa the region with the largest proportion of people living
on less than US$ 1 a day. World Bank economists say that
projected economic growth over the 2006-15 period marks
a reversal of the region's long-term decline but is far short of
the growth needed to reduce poverty to half the 1990 level.
Bank economists say, however, that a few countries,
such as Uganda and Ghana, have sustained remarkable growth
and achieved some progress in poverty reduction and other
MDGs. They say there are indications that Cameroon is mak-
ing progress in achieving the poverty target.
Proportion of the population living
on less than US$1 a day
(sub-Saharan Africa)
k48 Benchmark
46 Most recent
24 Goal
Progress needed
to achieve goal
1990 2002
Source: World Bank.
2015
Some countries in the African Region are not far off achieving the MDG targets
and may need increased overseas development support to help bridge the gap in
economic growth rates. Sub-Saharan countries reported their best economic per-
formance for years in 2004. with an average 5% growth in real GDP, while average
inflation fell to below 10% for the first time in 25 years. Oil producers, such as
Nigeria and Equatorial Guinea, and post-conflict countries, such as Burundi and
Sierra Leone, have seen some rapid though often sporadic growth in recent years.
Economic growth has not always led automatically to improvements in public
health in the African Region. Current growth rates are an opportunity for African
governments to invest more in health, an investment that would lead to more social
and economic stability.
Increased investment in public health can reduce the burden of preventable and
treatable diseases that — on macroeconomic level — can be a drag on national econo-
mies and — on microeconomic level — a drain on household and individual incomes.
Health must, therefore, constitute a central pillar of any coherent vision of
African development, while increased investments in health should include those in
health-related sectors, such as water and sanitation, education and environmental
protection (see Fig. 1.3)
Putting health in the development context
Development experts have long recognized health as an important moral and social
goal. Health is also a key component of a sound development strategy, along with
education, economic growth and good governance. As a form of human capital,
health is essential to a productive society. Furthermore, the MDG project of the United
Nations fully endorses the central role of health in development.
Fig. 1.3
Investments in health contribute to economic development
Enhanced labour
productivity
Improved
educational
attainment
Increased
savings &
investment
Demographic
dividend: lower
dependency ratio
Source: adapted from: Saunders MK, Gadhia R. Connor C. Investments in health contribute to economic development. Publisher: Partners for
Health Reformplus (PHRplusI E-version: http://www.phrplus.org/Pubs/sp12.pdf
Several studies have sought to quantify the macroeconomic impact of the disease
burden (see Table I.I ). The prevalence of HIV/AIDS for adults aged 1 5-49 years in the
African Region is estimated at about 7.2%. In every other WHO region the average
was less than l%. There is general agreement that the economic and social impact of
HIV/AIDS in the African Region has been devastating. The epidemic has drastically re-
duced the workforce in many countries, while the cost of caring for the growing genera-
tion of AIDS orphans could slowdown long-term GDP growth by as much as I -1. 5%
in countries with high prevalence of HIV/AIDS, such as Kenya and South Africa.
Exacerbated by HIV/AIDS, the older scourge of tuberculosis has made a
comeback in many parts of the world. Southern Africa has become the epicentre
of the dual epidemic and both diseases are causing untold human suffering and
reducing household income, in turn slowing economic growth in southern
African countries.
Malaria has been dubbed "an African disease" because 90% of cases occur in this
continent. Estimates show that countries with endemic malaria have 1 .3% less econom-
ic growth per annum compared with similar non-endemic countries, and that in Africa
the annual cost of lost productivity and providing treatment is US$ 1 2 billion.
lealth and development in Africa • •
Table 1.1
Burden of disease in the African Region 2002
Burden of disease in DALYs* by cause and mortality stratum in the African Region
Mortality stratum
High child, high High child, very
adult high adult
(000) (000)
AIDS
Malaria
Respiratory infections
Perinatal conditions
Diarrhoea
Top five subtotal (1 - 5)
Other communicable diseases
Communicable diseases (6 and 7)
Noncommunicable diseases
Injuries
Total (8 - 10)
Efforts to promote development in Africa
There have been many regional and international initiatives to promote development
in Africa. Some have focused on health as well as education, governance and sound
economic policy, while others have focused entirely on health. In recent years both
governments in Africa and donors have pledged to provide more money for health
and development.
African governments pledged to raise their spending on health to 15% of their
annual national budgets at a meeting in the Nigerian city of Abuja in 200 1 . A year lat-
er, the United Nations called on developed countries to increase their overseas devel-
opment assistance to 0.7% of their GDP by 2015. European countries have pledged
to do this, but only a few have done so. By early 2006, Denmark, Luxembourg, the
Netherlands, Norway and Sweden had actually honoured that commitment.
The debt forgiveness granted by the G8
industrialized countries in 2005 to 23 countries
in Africa presents an opportunity for the lat-
ter countries to invest more in health, as well
as in water, sanitation and education. Fol-
lowing pledges by governments in Africa to
invest more in health and health-related sec-
tors, mechanisms need to be set up to moni-
tor spending. Below are some of the major re-
gional and international initiatives to promote
development in Africa.
14620
20070
18976
10869
11548
76083
39234
115317
30124
14974
160 415
49343
20785
16619
10485
11689
108 921
41484
150 405
34727
15829
200 961
The Member States of the Region have been divided into mortality strata on the basis of their levels of mortality in
children under five years of age and in males aged 1 5-59 years as described on pp. 1 56-7 of the 2004 World health report.
* See glossary for explanation.
Source: The world health report 2004. Geneva. World Health Organization; 2004.
The Abuja Declaration
Leaders of African countries gathered in the
Nigerian city of Abuja in April 2001 to declare
their continent to be in a "State of Emergency"
over the HIV/AIDS pandemic. Governments
declared that "containing and reversing the
HIV/AIDS epidemic, tuberculosis and other in-
fectious diseases" should constitute their "top
priority for the first quarter of the 21st cen-
tury". Their declaration said that tackling these
epidemics was an integral part of poverty reduc-
tion and sustainable development as well as
peace and security, and that the fight against
HIV/AIDS was "the highest priority issue in
our respective national development plans". In
The African Regional Health Report
the Declaration, the governments in Africa called for the lifting of all tariff and economic
barriers to funding AIDS-related treatment and medicines. For their part, the governments
pledged to increase spending on health to at least 15% of their annual budgets.
NEPAD
The New Partnership for Africa's Development (NEPAD) was launched in 2001 by
the Organization of African Unity (OAU) to eradicate African poverty, promote sus-
tainable growth and development, help countries in Africa take a more active part in
the global economy and improve the status of women in African society.
In NEPAD's 2002 Health Strategy. African governments identified the "huge
burden of potentially preventable and treatable disease" as causing "unnecessary
deaths and untold suffering". According to NEPAD. the burden of disease in Africa
"continues to block economic development and damages the continent's social fabric".
NEPAD recognizes the central role of building and reinforcing health systems to
assist in improving health in Africa, but also that health-care services are "too poorly
funded". The NEPAD health strategy calls on African governments to honour their
pledge to raise health spending to a level of 1 5% of their annual national budgets.
NEPAD argues that peace and security are vital for development and acknowl-
edges the devastating impact of war on human health and development.
The United Kingdom's Commission for Africa
According to a report released by the UK's Commission for Africa in March 2005.
Africa and its partners have a unique opportunity to act now to promote social and
economic development in the continent. The report argues that Africa should drive
its own development and that it is already doing so through the African Union and
NEPAD. The report states that it is in the interests of the rich countries to support
Africa's development agenda to create a more prosperous and secure world.
The one-year Commission brought together by the United Kingdom — mainly
made up of African political leaders, public servants and private entrepreneurs —
sought wide consultation. The Commission calls for more investment in education and
the rebuilding of health systems. To achieve this end. it recognizes that the top priority
in health care is scaling up services to respond to the human tragedy of HIV/AIDS.
The Commission for Africa report argues that a stronger investment climate is
required to boost the economies of Africa and reduce poverty, and suggests that
such a boost might be achieved through stronger public-private partnerships. In
addition, it suggests that donors should double their spending on infrastructure
— including both rural development and slum upgrading — so that Africa's poor-
est people will also be able to participate in economic growth. Corruption, customs
procedures, bureaucracy and trade tariffs must be minimized to boost trade between
African nations, it says.
NEPAD recognizes the
central role of building
and reinforcing health
systems to assist in
improving health in Africa.
Health and development in Africa
UN Millennium Development Goals
The United Nations Member States agreed in 2000 to work towards eight Millennium
Development Goals (MDGs). These goals set a number of targets to be achieved by
2015. The targets include halving extreme poverty and providing universal primary
education. The health goals are to reduce the number of deaths of under-five-year
olds by three-quarters, to reduce maternal deaths by two-thirds and to reverse epidemics
of HIV/AIDS, malaria, tuberculosis and other infectious diseases. The MDG project has
galvanized a global effort to meet the needs of the poorest people in the world.
In 2005, a UN report identified four main reasons why some regions are not
making enough progress towards the MDGs. The first was poor governance. The
second was national poverty traps, a particular problem in the African Region. The
third was the presence of pockets of poverty within countries. The fourth was politi-
cal neglect. The UN report recommends that every government should adopt and
implement a national strategy — with the help of bilateral and multilateral donors
and organizations — to help each country achieve the MDGs.
MDG 8: A global partnership for development
MDG 8 calls for international trade and finance
that are more equitable and give a fair chance to
poor countries. It calls for sustainable development
and youth employment as well as better access
to essential drugs and communication technology
in developing countries. Progress in these areas
depends not only on developing countries them-
selves, but also hinges on policy changes made
by wealthy countries, such as debt forgiveness,
commitments to increased aid, freeing of market
restrictions and relaxing patent protection for life-
saving technology. Some progress has been made
in these areas. For example, partial debt relief has
been offered to Burkina Faso, Mali, Mauritania,
Mozambique, the United Republic of Tanzania and
G8 Summit 2005
The Group of Eight industrialized countries (G8) agreed to cancel the debt of 18
of Africa's poorest countries and to increase aid to developing countries by US$ 50
billion at a summit in Gleneagles, Scotland, in July 2005. Of those, 23 are in Africa.
The G8 lamented declining life expectancy in Africa and pledged to continue to sup-
port African strategies to improve health, education and food security. The G8 also
pledged to support investment in
improved health systems, includ-
ing the training and retraining of
health workers to tackle the major
Uganda. Thirty-four of a total of 42 countries in the diseases affecting Africa, such as
heavily-indebted poor countries initiative are in the
African Region. Donor countries have also agreed
to harmonize aid and respect development priori-
ties in recipient countries. However, official devel-
opment assistance declined in sub-Saharan Africa
from US$ 34 per capita in 1990 to US$21 in 2001.
The goal reminds rich nations of their commitment
to give 0.7% of their annual income in aid. By early
2006, only Denmark, Luxembourg, the Netherlands,
Norway, and Sweden had actually honoured that
commitment. However, increased aid can only lead
to progress on the rest of the goals if recipient
countries improve governance and commit them-
selves to a policy of poverty reduction.
HIV/AIDS, malaria, tuberculosis,
polio and other neglected diseases.
The G8 pledged to give support
for investments in water and sani-
tation and to comprehensive food
security and famine prevention
programmes. It also pledged to
support African countries in build-
ing peace and security, promoting
good governance, investing in
people, and promoting growth
and development.
The African Regional Health Report
Conclusion: Making it happen
What should be done to ensure that health development in the African Region plays
its rightful role in national development efforts? The answer is that there are tried and
tested health-care interventions that work, interventions that enable safe childbirth,
treat acute respiratory and diarrhoeal illnesses, and prevent HIV transmission and
early death from AIDS. There are established methods of preventing malaria trans-
mission and treating tuberculosis. The results of a public heath experiment called the
Tanzania Essential Health Interventions Project (TEHIP) suggest that it is possible
to achieve dramatic gains in maternal, newborn and child health at little additional
cost. Mauritius achieved some of the best reproductive health indicators in WHO's
African Region through providing family planning services, strong political commit-
ment to tackling HIV/AIDS, health promotion, public health education and accurate
recording of statistics to gauge changes in health indicators.
African governments can avoid some of the burden of noncommunicable dis-
eases that wealthy, developed countries now face. While the greatest focus is on the
diseases that kill the most people, more efforts are needed to improve on outdated
methods of control and cure for neglected diseases, such as sleeping sickness, which
also hamper development in African countries.
Some countries are already linking public health and economic interests to tack-
le shortages of essential medicines, while others may follow suit.
For example, some African countries are already using new ways to purchase
drugs at reduced prices, such as negotiating low prices for patented antiretrovirals
for HIV/AIDS. Other countries are hoping to purchase cheaper generic antiretrovi-
rals from other developing countries, making use of a waiver in international trade
law for poor countries that was made permanent at the WTO
meeting in December 2005. Farmers in the United Republic of
Tanzania are growing the Artemisia annua plant to improve
domestic supply of antimalarial medicines.
Empowering women is crucial to lifting countries out of
poverty and improving the health of the people in the Region.
Health systems cannot function without the talents of suffi-
cient health workers. Successful development reform, such as
disbursing and spending aid in a more accountable manner,
is more likely to happen if it is driven by local priorities.
A concerted effort by African governments and their
partners is gathering momentum for change and to help the
Region come closer to achieving the MDGs (see Box 1.2).
Five key elements are vital for success. First, stronger political
will and commitment is essential to ensure solutions are
implemented. Second, African nations need to allocate a
Health and development in Africa
If the African Region is to
achieve peace, prosperity
and health for all, African
nations and their
partners need to act now
to implement the many
known solutions.
higher percentage of their national expenditure to health and their partners need to
increase aid to Africa to address the lack of financial resources. Third, to draw full
benefit from that additional donor aid, African nations need good governance to
use it wisely. Fourth, adequate numbers of health-care staff are required across the
African Region to provide health care, and governments and their partners need to
implement adequate programmes to train, retain and utilize these resources better.
Fifth, governments and their partners — domestic and international — need to
translate good policies into action.
If the African Region is to achieve peace, prosperity and health for all, African
nations and their partners need to act now to implement the many known solutions.
A paradigm shift is needed. While delivering interventions to prevent and treat dis-
ease, governments also need to shift their focus to addressing the underlying factors
that determine health, such as poverty and education.
The development challenge that Africa faces is evident from the sheer magni-
tude of human death and disease that is outlined later in this report. These are not
simply catalogues of despair or tales of woe. Within the African Region, solutions to
the continent's challenges exist. Africa can overcome its problems through partner-
ships and political will. •
The African Regional Health Report
Bibliography
• Ainsworth M, Fransen L. Over M. editors. Confronting AIDS: evidence from the developing world: Selected background papers
for the World Bank Policy Research Report Brussels: European Commission; 1998.
• Abuja Declaration on HIV/AIDS, tuberculosis and other related infectious diseases. 27 April 2001. Available from: http://www.
uneca.org/adf2000/Abuja%20Declaration.htm
• Barro RJ. Health and economic development Washington, DC: World Bank; 1996. Available from: http://www.paho.org/
English/DPM/SHD/HP/barro.pdf
• Bloom DE, Canning D, Sevilla J. Health, human capital, and economic development Commission on Macroeconomics and
Health Working Paper Series, Paper No. WG1: 8. 2001. Available from: http://www.cmhealth.org/docs/wg1_paper8.pdf
• Bryce J. Boschi-Pinto C, Shibuya K, Black RE, WHO Child Health Epidemiology Reference Group. WHO estimates of the
causes of death in children. Lancet 2005:365:1147-52.
• Our common interest report of the Commission for Africa London; Commission for Africa: 2005.
• Global indicators. In: World development indicators 2005. Washington, DC: World Bank, 2005. Available from: http://www.
worldbank.org/data/wdi2005/wditext/Section6J.htrn
• Global Partnership to Roll Back Malaria. World malaria report 2005. Geneva: World Health Organization and UNICEF; 2005.
• Health Economics: getting value for money. African Health Monitor Jan-June 2005. Brazzaville: World Health Organization,
Regional Office for Africa; 2005.
• Human development report 2004: cultural liberty in today's diverse world New York: United Nations Development Programme; 2004.
• Macroeconomics and health: investing in health for economic development Report of the Commission on Macroeconomics
and Health. Geneva: World Health Organization; 2001.
• Our common interest report of the Commission for Africa. London; Commission for Africa: 2005.
• Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, et al. World report on road traffic injury prevention. Geneva:
World Health Organization; 2004.
• Ranis G, Stewart F, Ramirez A. Economic growth and human development. World Development 2000;28:197-219.
• Regional economic outlook sub-Saharan Africa Washington, DC: International Monetary Fund; 2005. Available from: http://
www.imf.org/external/pubs/ft/AFR/REO/2005/eng/01/SSAREO.htm
• Regional HIV and AIDS estimates 2005. Geneva: UNAIDS; 2005. Available at: http://www.unaids.org/epi2005/doc/report.html
• Report on the International Conference on Financing for Development Monterrey. Mexico. 18-22 March 2002. New York:
United Nations; 2002. UN document A/CONF.198/11. Available from: http://www.un.org/esa/ffd/aconf198-11.pdf
• Sachs J, Malaney P. The economic and social burden of malaria. Nature2QQ2; 415:618-85.
• Saunders MK, Gadhia R, Connor C. Investments in health contribute to economic development Bethesda (MD): Partners for
Health Reformp/us (PHRp/us). Available from : http://www.phrplus.org/Pubs/sp12.pdf
• Subbarao K, Coury, D. Reaching out to Africa's orphans: a framework for public action. Washington, DC: World
Bank; 2004. Available from: http://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1103037153392/
ReachingOuttoAfricasOrphans.pdf
• The world health report 2004: changing history. Geneva: World Health Organization, 2004.
• /Tie world health report 2005: make every mother and child count. Geneva: World Health Organization, 2005.
• 7776 state of the world's children 2005. New York: UNICEF. Geneva: World Health Organization, 2005.
• UNAIDS epidemic update 2004. Geneva: UNAIDS; 2004. Available from: http://www.unaids.org/wad2004/EPI_1204_pdf_
en/EpiUpdate04_en.pdf
• United Nations Development Programme. Human development report 2002: deepening democracy in a fragmented world
New York: Oxford University; 2002. Available from: http://hdr.undp.org/reports/global/2002/en/
• World health statistics 2005. Geneva: World Health Organization; 2005.
• World report on knowledge for better health: strengthening health systems. Geneva: World Health Organization; 2004.
tealth and development in Africa
, newborn
and child health
Key messages
• Millions of women, newborns and children die every year in
Africa needlessly
• Most deaths are from treatable, preventable causes
• Little or no improvement in maternal, newborn and child health
over the last 20 years
• Major global effort to address the situation is needed
Solution*
• African governments must take more action to save these lives
• Allocation of resources to this area of public health is needed
• Scale up tried and tested public health solutions
• Educate women and improve their economic and social status
Maternal) newborn
and child health
Africa's "silent epidemic"
4 * illions of women, newborns and children in Africa are dying from preventable
^^i causes every year. Millions more suffer ill-health or disability related to preg-
I j nancy and childbirth. African women risk death to give life and their offspring
have the smallest survival chances in the world. It is the sheer magnitude of this death,
disease and disability that constitutes Africa's "silent epidemic". High-level political
commitment is vital, but not enough, to make a difference in the lives of these women,
newborns and children. More needs to be done to save these lives.
A concerted effort is under way to remedy this situation. The World health
report 2005: make every mother and child count and World Health Day 2005 were
devoted to maternal and child health. Both of these focused on the tragedy that so
many mothers, newborns and children die of preventable, treatable causes. In 2004,
all 46 Member States of the African Region agreed to improve maternal and newborn
health through the adoption and implementation of the Road Map for accelerating
the attainment of the Millennium Development Goals (MDGs) relating to maternal
and newborn health in Africa. The Region is also making progress in implementing
the Integrated Management of Childhood Illness (IMCI) to improve child health.
Nearly 20 years after the launch of a major global campaign, the Safe Mother-
hood Initiative, there have been pockets of improvement in maternal, newborn and
child health in the African Region but no overall reduction in pregnancy- and child-
birth-related death and disease.
During the 1990s, the countries with the highest tolls of maternal, newborn and
childhood disease and death made the least progress in reducing them, while advances
in some countries, such as Botswana, South Africa and Zambia, have been reversed by
the spread of HIV/AIDS. In I960, countries in the African Region accounted for 14%
of deaths of children aged under five years globally. In 1 980, the proportion was 23%
and by 2003 this had increased to 43%.
Maternal, newborn and child health
Achieving MDG 4: Child health
MDG 4 on child health set the target of reduc-
ing by two-thirds the 1990 level of mortality
of children aged under five by 201 5. The child
health goal is measured by three indicators;
the under-five mortality rate, the infant mor-
tality rate and the proportion of one-year-old
children immunized against measles. Mortal-
ity of children aged under five years has im-
proved slightly in sub-Saharan countries, ac-
cording to the World Bank. The world health
report 2005 found that child mortality in the fol-
lowing 1 0 countries in the Region had increased:
Botswana, Cameroon, Cote d'lvoire, Kenya,
Rwanda, South Africa, Swaziland, the United
Republic of Tanzania, Zambia and Zimbabwe.
These countries are unlikely to achieve the
child health goal.
Under-5 mortality (deaths per 1000
live births) in the African Region
200
180
160
140
120
183 Benchmark
• 171 Most recent
Progress made
"Z....
Progress needed
to achieve goal
61 Goal
60
40
20
0
1990 2002 2015
Based on data from: The world health report,
2005. Geneva:World Health Organization; 2005.
Fig. 2.1
Causes of maternal mortality in the African Region
Severe bleeding
Infection
Source: African health monitor 2004; vol. 5(1).
A few countries in the African Region, such as Cape Verde,
Mauritius and Seychelles, have very low maternal, neonatal and child
mortality rates that are comparable with those in industrialized countries.
If progress is going to be made in improving maternal, newborn and
child health in this Region, these successes need to be replicated where
possible and primary health-care systems in these countries need to be
revived as conduits to deliver essential care and treatment.
Development goals for maternal and
child health
In recognition of the importance of maternal and child health, an MDC
has been devoted to each of these. Many countries in the African Region
have a long way to go to achieve MDG 4 on child health (see Box 2.1
and Figure) and MDC 5 on maternal health (Box 2.2 and Figure).
In 2000, when UN Member States unanimously adopted the
Millennium Declaration agreeing on eight MDGs, some countries in the
African Region faced the daunting task of having to catch up with 1 990
levels before they could contemplate moving beyond them. Some coun-
tries in this Region are still struggling to catch up with those levels of
maternal and child health mainly due to HIV/AIDS, which has reversed
advances made in the 1970s and 1980s.
Mothers: the causes and numbers
of deaths
The main causes of maternal death are severe bleeding (haemorrhage),
infection (sepsis), eclampsia, obstructed labour and unsafe abortion, but
increasing numbers of mothers in this Region die from indirect causes,
such as HIV/AIDS, tuberculosis, malaria and anaemia (see Fig. 2.1 ).
Of the 20 countries with the highest maternal mortality ratios in
the world, 1 9 are in Africa and one — Afghanistan — is in Asia. The
African Region accounts for about one-tenth of the world's popula-
tion and 20% of global births, yet nearly half of the mothers who
die globally as a result of pregnancy and childbirth are in this Region
(see Fig. 2.2).
Pregnancy- and childbirth-related complications were the second-
leading cause of death and disability for women aged 15-49 years in
this Region in 2002 with an estimated 23 1 000 deaths, according to
WHO data. The leading cause was HIV/AIDS with 866 000 deaths.
Apart from the personal tragedy for the children and families concerned,
the deaths of so many mothers in pregnancy and childbirth is a disaster
for communities and a major setback for the economic and social devel-
opment of countries.
African Regional Health Report
During the 1970s and 1980s, maternal mortality fell across the
Region as countries started establishing primary health care, including
antenatal services and emergency obstetric care. Millions more lives
could be saved if health systems were capable of ensuring that good
quality services are available to everyone who needs them. It is clear,
however, that maternal mortality in this Region has hardly improved
over the last 1 5 years. Many women in this Region face an even greater
risk of dying as a result of pregnancy or childbirth than they did 1 5 years
ago. A woman in sub-Saharan Africa faces a I -in- 1 6 risk of dying due to
pregnancy or childbirth during her lifetime compared with I in 2800 in
developed countries.
African women are more likely to suffer debilitating complications
linked to pregnancy and childbirth. A study in West Africa showed that
for each maternal death, a further 30 women may suffer long-lasting
disabilities due to a range of conditions, such as chronic anaemia, infer-
tility and obstetric fistula.
Harmful traditional practices such as female genital mutilation and
nutritional taboos also contribute to poor maternal health. Female geni-
tal mutilation, which is the partial or total removal of external genitalia
is practised in 27 Member States of the 46 in this Region,
Newborns: the causes and numbers
of deaths
The main causes of neonatal death in this Region are: severe infections,
birth asphyxia (the inability to breathe normally after birth), preterm
birth, neonatal tetanus, congenital anomalies and other conditions (see
Fig. 2.3). In developing countries, the children of mothers who die dur-
ing the first six weeks of their babies' lives are up to 10 times more
likely to die within two years than children with two living parents. The
reason is that the babies do not get breastfed, the family food supply
is threatened and there is no direct care for those children. The dead
woman's children are also less likely to get adequate health care and
education as they grow up.
While progress was made in improving the health of children
aged one month to five years in the 1 970s and 1 980s. the health of
neonates — babies in their first 28 days of life — remained a neglect-
ed area of public health. Recent data show that neonates represent
about 40% of children who die before their fifth birthday and that
29% of global neonatal deaths occur in Africa. The African Region's
neonatal mortality rate is the highest in the world (see Fig. 2.4). For
every newborn baby that dies, another 20 face illness or disability
from conditions such as birth injury, infection and the complications
of premature birth.
Achieving MDG 5: Maternal health
MDG 5 on maternal health set the goal of re-
ducing the 1990 level of maternal mortality by
three-quarters. It is measured by two indica-
tors: the maternal mortality ratio (MMR). which
is the number of maternal deaths per 100 000
live births, and by the average proportion of de-
liveries by skilled birth attendants. The differ-
ent values of MMR for 1990 and 2000 are due
to differences in methodology and not because
there has been an increase in MMR since 1 990.
Estimates for 1 990 and 2000 suggest that there
has been little change in the levels of maternal
mortality ratios in the African Region.
Maternal mortality (deaths per
100000 live births) in the African Region
1000
900
800
700
600
500
400
300
200
100
0
UONMmtf
P-o£-sis -eece:
to achieve goal
1990
2000
2015
Based on data from: The world health report,
2005. Geneva: World Heal* Organization; 2005.
Fig- 2.2
Global distribution, by region, of maternal deaths, world
population and live births, 2000
100
Maternal
deaths
• Africa
Source: World Heal* Organization.
World's Live
population births
n Other world regions
Maternal, newborn and child health
Fig. 2.3
Causes of neonatal mortality in the African Region
Birth asphyxia
24% ,
Congenital
anomalies
6%
The percentages do not add up to 100% due to rounding.
Source: World health report 2005. Geneva: World Health Organization:
2005
Fig. 2.4
Neonatal mortality rate in the WHO regions
(per 1000 live births)
50
40
8 30
i
a 20
10
ion
of the
Americas
South-East
Asia
Region
European Eastern Western
Region Mediteranean Pacific
Region Region
Source: World health statistics, 2005. Geneva: World Health Organization; 2005.
The first global estimates for neonatal deaths were made as late as 1983,
while more rigorous estimates were made in 1 995 and 2000. There are scant vital
data on newborn babies but even less is known about stillborn babies. WHO
estimates that the African Region has the highest proportion of stillbirths in the
world: 30% of an estimated 3.3 million stillborn babies globally in 2000.
Under-fives: the causes and numbers of deaths
The vast majority of deaths of children aged under five years in this Region are due
to preventable causes. Fig. 2.5 shows that the chief causes are neonatal conditions,
acute respiratory infections, malaria, diarrhoeal diseases, HIV/AIDS and measles, all
complicated by malnutrition.
The importance of malnutrition as an underlying cause of death for children
aged under five years has been recognized for many years and has recently been
reconfirmed: 53% of all of these child deaths could be attributed to underweight
and 35% of deaths are due to the effect of undernutrition on diarrhoea, pneumonia,
malaria and measles.
Deaths of children under five years of age are increasingly concentrated in the
African Region, at 43% of the global total in 2003, up from 31% in 1990. Of an
estimated 10.6 million children under five years of age who died each year during
2000-03, some 4.4 million died in the African Region, according to WHO estimates.
Every day an estimated 1 2 000 children die in sub-Saharan Africa from easily prevent-
able or treatable illnesses and conditions, such as pneumonia, diarrhoea, measles,
malaria and malnutrition.
Fig. 2.6 shows that mortality of children aged under five stagnated
between 1 990 and 2003 in 29 countries globally, and that 23 of these
countries were in Africa. This lack of change occurred in Africa partly
because modest reductions in death rates due to improved health care
were offset by population growth and the increasing number of births.
Lesotho, Malawi, Mozambique and Namibia made slow progress in
reducing child mortality, while under-five child mortality fell in a fur-
ther 10 countries in this Region. However, the number of under-five
deaths has since increased, and during the 13-year period there has
been no overall reduction in child mortality in this Region.
Preventing millions of deaths
The tragedy of maternal, neonatal and child mortality today is that
the vast majority of these deaths can be prevented by making sure
pregnant women and children have access to good quality health care.
Considerable progress has been made across much of the African
Region in terms of providing antenatal care. In the 1 990s, the level of
African Regional Health Report
i\
antenatal care rose by 4% to a currently estimated 70% of women in sub-
Saharan Africa receiving at least one antenatal consultation. Millions more
lives could be saved if health systems were developed to ensure that services
are of high quality and extended to everyone who needs them. This means
providing every woman with skilled care during childbirth and emergency
obstetric and neonatal care if complications arise. It also means ensuring
children's access to quality services for prevention and treatment of child-
hood illnesses.
The obstacles
Inadequate education, illiteracy and the women's lack of economic power
compounded by their low social status contribute to women's low utilization
of available health services. Other major factors that have led to inadequate
coverage of maternal health services are poverty, weak health systems
and the shortage of skilled health workers. According to the latest estimates,
Fig. 2.5
Causes of under-5 mortality in the African Region
~:.'.r "r:: ":'.'•
ifectiOR
21%
The percentages do not add up to 100% due to rounding.
Source: WortdheaHh repcrtXm Geneva: World Heal* Organization:
2005.
Fig 2.6
Patterns of reduction of under-5 mortality rates, 1990-2003
^_^ On track
U Slow progress
^H Reversal
H Stagnation
• No data
* More than 2 years of humanitarian
crisis between 1992 and 2004
Source: World health report 2005 Geneva: World Health Organization; 2005.
Maternal, newborn and child health
• • •
Women displaced by conflict, in a
camp in Freetown, Sierra Leone.
skilled attendants assist in only 43% of the deliveries in the African Region. The
remaining births are assisted by traditional birth attendants, relatives and neigh-
bours, while some mothers give birth alone.
In some parts of the African Region, about one-third of pregnant women are
adolescents. Adolescent mothers face a greater risk of death in pregnancy and
childbirth than women aged 20 or over. Their babies are particularly vulnerable
to premature birth, low birth weight and risk dying in the first month of life. In
some countries in this Region, adolescents represent 40-60% of mothers who die
in pregnancy and childbirth. If these adolescents had access to family planning
services many deaths and much ill-health could be avoided.
Conflict and emergencies
Over the last two decades, the African Region has seen more armed conflict and
humanitarian emergencies than any other. Between 1992 and 2004, 22 of 33 hu-
manitarian crises globally that lasted two or more
years occurred in Africa alone, according to the
Consolidated Appeals Process for humanitarian
disasters. These crises have taken a major toll on
human life and disrupted routine health services.
Conflict situations fuel sexual violence and rape,
which have reproductive and mental health re-
percussions and which require specialized clini-
cal and psychological care.
Pregnant women and their infants are often
the most vulnerable members of displaced and
refugee populations. Emergencies, such as floods
and other natural disasters, and armed conflict
also result in the destruction of hospitals and
loss of medical staff.
In humanitarian emergencies, pregnant
women still need routine antenatal care and
skilled assistance when they give birth, and if
there are complications they need back-up services, including emergency obstetric
and neonatal care. After giving birth, women need access to child care and family
planning services. In the vast majority of cases these services are not available.
A bitter testament to the impact of conflict on maternal and child health is the
example of Sierra Leone. After a devastating 1991-2001 civil war, the West African
country was estimated to have the highest maternal mortality ratio in the world with
2000 deaths per 1 00 000 live births in 2002. It also had a stillborn rate of 50 per 1 000
births and a neonatal mortality rate of between 42 and 56 per 1000 live births. Since
2000, Sierra Leone has been at the top of the list of the 20 countries worldwide with
the highest maternal mortality ratio.
African Regional Health Report
HIV/ AIDS
HIV/AIDS has had a dire impact on maternal and child health over the last two decades.
In some African countries an estimated 20-30% of pregnant women are infected with
HIV, while transmission rates from mother to child range from 25% to 40%.
In Botswana, South Africa, Zambia and Zimbabwe, the spread of HIV/AIDS has
in part reversed progress made in maternal, newborn and child health. HIV/AIDS
has, in turn, spurred the re-emergence of tuberculosis and complicated forms of
malaria, and all three diseases have become the biggest indirect causes of maternal
and neonatal death in this Region.
Inadequate resource allocation
Despite numerous maternal and child health campaigns, political commitment in the
African Region has not been sufficient to make a difference to the lives of mothers
and their children. Many governments in this Region are aware of the magnitude of
the problem but are prevented from allocating adequate resources to maternal, new-
born and child health care by poverty, indebtedness, armed conflict or humanitarian
emergencies.
Also donors are not always prepared to provide substantially more aid for this
area of public health. As a result, efforts to reduce the toll of maternal and child
death and disease in this Region have had limited success.
Weak health systems
Public health experts broadly agree that widespread exclusion from good quality
health care and the absence of well functioning public and private health systems -
whether through the absence, destruction or neglect of those health systems — are
at the root of the problem: that millions of mothers, newborns and children aged
under five die every year of preventable causes.
It is vital to scale up health-care services, but if the resulting services are of in-
sufficient quality people will not benefit from improved coverage. In some parts of
this Region antenatal care has been scaled up and extended to a large proportion of
pregnant women, but the quality of this care is so poor that it barely makes a differ-
ence. For instance, Chad and Zimbabwe are among the 12 countries with the world's
highest maternal mortality rates. Each has a rate of 1 100 maternal deaths per 100 000
live births, yet Zimbabwe's antenatal services have a 82% coverage rate compared with
only 51% in Chad. The indicators of the quality of antenatal care reflect how well this
care screens for major complications of pregnancy and childbirth, and prevents them.
Health systems also serve to gather reliable data. One of the main challenges for
improving the health of women, newborns and children is gathering data to measure
progress. Many countries with the highest burden of maternal, newborn and child
death and disease lack reliable data which they need to gauge an adequate response.
WHO helps such countries develop information systems to collect reliable data.
Many countries with the
highest burden of maternal,
newborn and child death
and disease lack reliable
data which they need
to gauge an adequate
response.
aternal, newborn and child heal
Efforts to tackle the problem
Breastfeeding is one of the
best ways to ensure the
baby's survival.
More than a decade of research has shown that modest, low-cost measures can sig-
nificantly reduce the health risks that women face when they become pregnant; for
instance, educating the woman to look after herself and recognize danger signs that
indicate when she should seek help at a health facility. These measures also include
providing basic and regular antenatal care to check blood pressure, weight gain and
renal function, diagnose anaemia and treat infections. Breastfeeding is one of the
best ways to ensure the baby's survival.
Safe motherhood
The Safe Motherhood Initiative, launched in Nairobi, Kenya, in 1 987 by international
agencies, placed maternal health — previously regarded as a private or family matter
- firmly on the global public health agenda. The initiative has succeeded in drawing
more attention to maternal health over the last two decades. Critics, however, argue
that it failed to bring about a broad-based improvement in this area of public health
because countries were not given the technical assistance they needed to translate
its recommendations into practice. Moreover, donors and humanitarian agencies
failed to coordinate efforts well enough to fill the gaps in public health services in
the African Region, leading to a patchwork approach.
Another major initiative, the UN International Conference on Population and
Development in Cairo, Egypt, in 1 994 urged all countries to address the human rights
issues relating to maternal and child health. It called on them to provide public infor-
mation on sexual and reproductive health, to protect pregnant women and to crimi-
nalize violence against women, and it condemned the harmful traditional practice of
female genital mutilation. The most important outcome of this conference was the
commitment by governments to provide universal access to reproductive health care
including family planning information and services by 2015.
WHO launched the Making Pregnancy Safer (MPS) initiative in 1999 to as-
sist countries to strengthen their health systems to improve access to skilled care,
including access to emergency obstetric and newborn care. The aim is to ensure
that mothers and their newborns have timely access to the care they need through
strengthening the health system and appropriate community involvement. WHO
started working with Ethiopia, Mauritania, Mozambique, Nigeria and Uganda in
2002 to implement the MPS initiative and later that year 34 more Member States in
the African Region requested similar assistance.
To advocate more effectively for the continuum of care that is needed for im-
proved Maternal and newborn and child health, the three initiatives that address
newborn and child health (the Healthy Newborn Partnership established in 2000,
the Child Survival Partnership created in 2004; and the Safe Motherhood and New-
born Health also created in 2004) were merged in 2005 to form the Partnership for
Maternal, Newborn and Child Health.
African Regional Health Report
Prevention of mother-to-child transmission of HIV
Countries in the African Region started introducing the Prevention of Mother-to-
Child Transmission of HIV (PMTCT) programme in 2002. This programme aims to
prevent HIV-positive mothers from infecting their babies during pregnancy, delivery
and afterwards. Its goal is also to prevent men and women from becoming infected
with HIV and to prevent unwanted pregnancies in HIV-positive women.
A successful pilot project conducted in a clinic in Zimbabwe in 2001 showed that
PMTCT programmes are more effective if clinical treatment given to HIV-positive mothers is
combined with psychosocial support for those mothers and their families (see Box 2.3).
Psychosocial support for HIV-positive mothers and families
The modest two-room Zengeza clinic in the Zimbabwean
city of Chitungwiza is playing a pioneering role in helping
expectant mothers and their families cope with the dis-
covery that they are HIV positive. This is one of a growing
number of antenatal clinics in the African Region that
have started to provide counselling and psychosocial
support to HIV-positive mothers in addition to clinical
treatment as part of their programmes to prevent trans-
mission of HIV from mother to child.
A recent study found that mothers who received
counselling and psychosocial support at Zengeza were
better equipped to cope with being HIV positive than
those who did not. Staff and activists are now calling for
all antenatal clinics in Zimbabwe to adopt this approach.
They say it has led to an increase in voluntary HIV/AIDS
counselling and testing, and higher awareness levels in
the community at large — a major step to curbing the
spread of HIV/AIDS. The only problem, they say, is that
not enough men participate in the counselling sessions.
Gladys Nyamunokora, 35, said the programme
had helped her to build up the courage to disclose her
HIV-positive status to her husband and to discuss this
openly with him. The study showed that mothers like
Gladys are better informed about HIV/AIDS than those
who do not receive counselling.
"When I found out I was HIV positive I was shat-
tered, ashamed and afraid," said Gladys. Like other
mothers in Zimbabwe and other African countries, Gladys
discovered she was HIV positive when she sought ante-
natal care. She was four months pregnant with her third
child.
"I had a lot of questions. 'How will I disclose
my status to my husband? Who will look after my
children and my unborn baby? How long will I live?'
I isolated myself and felt hopeless. Every day I con-
templated suicide."
An HIV-positive diagnosis is devastating for pregnant
women, leaving them feeling even more vulnerable, but
Gladys was lucky enough to attend the clinic in 2002. when
it started offering counselling and psychosocial support.
The clinical treatment was a success and Gladys's
daughter was bom free of HIV. Two years later after
regular counselling sessions and receiving psychoso-
cial support at the clinic, Gladys said: "The pain and
sadness will never go away completely, but now I
know how to cope with them when they resurface. The
counselling and social support from the caregivers and
counsellors gave me hope".
ping strategies are important for women
who are at risk of becoming infected with HIV.
Maternal, newborn and child health
Developed in
the 1990s by WHO
and UNICEF, the
Integrated Management
of Childhood Illnesses
(IMCI) strategy is being
implemented in 44 of
the 46 countries of the
African Region to reduce
the growing number of
child deaths attributable
to a few preventable,
treatable illnesses.
The idea of IMCI is to
improve the prevention or
early detection
and treatment of the
main childhood
killers in developing
countries.
Repositioning family planning
The African Region has some of the highest fertility rates in the world — 4.9 chil-
dren per woman on average — and a low prevalence of contraceptive use of 17%.
In contrast, global fertility has dropped from 4.5 to 2.8 children per woman since
the 1970s. The low use of contraception is not the only reason for this. High fertil-
ity rates drop in societies where people are convinced that their children have good
chances of survival. The high fertility in this Region increases the life-time risk a
woman faces of dying from pregnancy and childbirth-related complications
In the African Region, where women are at greater risk of dying in pregnancy or
childbirth than anywhere else in the world and where they have some of the high-
est fertility rates in the world, family planning is essential. However, over the last 10
years it has become a neglected area of public health because of conflicting priorities,
insufficient high-level political commitment and lack of donor interest. One of the
challenges here is overcoming religious barriers and cultural beliefs that encourage
high fertility and create misconceptions that prevent men and women from using
effective family planning methods or prevent providers from suggesting certain
family planning methods as options.
Countries need to address reproductive health to come closer to achieving the
Millennium Development Goals on maternal and child health. In 2004, the 46 minis-
tries of health in the African Region adopted a 10-year framework called Repositioning
Family Planning. This aims to provide guidance on how to revitalize the family plan-
ning component of national reproductive health programmes. WHO'S Regional Office
for Africa is working with countries to help strengthen their family planning services.
Managing childhood illnesses
Improved child survival became a global phenomenon largely due to the success
of oral rehydration therapy for diarrhoeal diseases and immunization. Another key
strategy for improving child health is the Integrated Management of Childhood
Illnesses (IMCI). Developed in the 1990s by WHO and UNICEF, this strategy is
being implemented in 44 of the 46 countries of the African Region to reduce the
growing number of child deaths attributable to a few preventable, treatable illnesses.
The idea of IMCI is to improve the prevention or early detection and treatment of
the main childhood killers in developing countries. Six conditions account for about
70% of all deaths. These are: acute respiratory infections — mostly pneumonia
— as well as diarrhoea, malaria, measles, HIV/AIDS and neonatal conditions.
IMCI training guidelines are designed to be adapted to the situation in each
country. In addition, some countries are training health workers to address the prob-
lem of HIV/AIDS in children. Health workers have also been trained to support and
counsel HIV-positive mothers on appropriate infant nutrition in over 20 countries in
this Region. It is estimated that 6% of deaths of children aged under five years in
Africa are due to HIV/AIDS.
African Regional Health Report
There have been reductions in child mortality in some countries that have imple-
mented IMCI. Malawi and Mozambique have managed to lower their child mortality
rates over the last 10 years. The United Republic of Tanzania reduced the mortality
of children aged under five years by 1 3% over the two-year period from mid-2000
to mid-2002 in two districts, where IMCI was part of a comprehensive strategy to
improve access to health care (see Box 2.4).
The Global Strategy on Infant and Young Child Feeding (GSIYCF) adopted by
the World Health Assembly in 2002 is also a step towards addressing malnutri-
tion in children under five years of age. WHO is supporting 17 countries in this
Region in developing and implementing a GSIXCF plan to address the problem of
malnutrition.
Increasing skilled attendance at birth
Traditional birth attendants, who have no formal training, are often the only people
available to assist with a birth in the African Region. These women can play an
important role in educating mothers about nutrition, breastfeeding and childcare,
but studies show that in countries where births are increasingly attended by skilled
health workers, maternal and newborn deaths decline.
WHO has developed a set of technical and managerial guidelines and tools
for the Integrated Management of Pregnancy and Childbirth (IMPAC). Coun-
tries can adapt these guidelines to provide better access to quality maternal and
newborn care services. The tools can be used to improve the health workers'
skills, fine tune the organization of maternal, newborn and child health-care
service delivery and promote health education and community involvement in
pregnancy and childbirth.
Maternal mortality in Botswana has declined since independence in 1962 with
the training of skilled birth attendants and implementing other recommended guide-
lines. In 2000, 94% of births in this southern African country were attended by
skilled health workers compared with an estimated level of 43% across the African
Region. The prevalence of contraceptive use in Botswana was 39% compared with
an average of 1 7% in this Region. The maternal mortality ratio in Botswana was 100
deaths per 100 000 live births — one of the lowest in this Region — and neonatal
mortality was 40 per 1000 live births.
Immunizing more women and children
Immunization can do much to improve child, newborn and maternal health, but its
potential has still not been exploited to the full in the African Region, where vaccine-
preventable diseases remain a major cause of death and disease. In 2001, WHO and other
partners from the Global Alliance for Vaccines and Immunization (GAVI) launched a new
initiative. Reaching Every District, to make routine immunization more widely available.
So far the approach has been implemented in 26 countries in this Region.
Immunization can do
much to improve child,
newborn and maternal
health, but its potential
has still not been exploited
to the full in the African
Region.
Maternal, newborn and child heal
Caring for sick children in the United Republic of Tanzania
The Tanzanian district of Morogoro introduced free child health care
and the Integrated Management of Childhood Illness strategy as
part of the Tanzania Essential Health Interventions Project (TEHIP) 10
years ago. Since then, fewer children are dying of preventable and
treatable causes, but challenges remain.
Zena Juma first took her sick child, Abduli Yahya, to a private
clinic believing she would get better service there than in a public
clinic. The boy showed no improvement, so she brought him to
Morogoro Regional Hospital. On arrival at the clinic where health
workers use the IMCI guidelines to manage sick children, Zubeda
Dihenga, paediatric nursing officer, immediately diagnosed the little
boy with severe dehydration after pinching his tummy. His skin
remained bunched where she had pinched it. The child had a listless
unblinking stare, and the sides of his mouth were cracked.
The child was then given an oral rehydration solution, and put
on a drip while some tests were done to give a diagnosis of what
was ailing him. "I just hope he will be better. I hope this hospital does
something for my child," Juma said.
Meshack Massi, head doctor at Morogoro Regional Hospital,
said that there were many benefits to using the Integrated Management
of Childhood Illness (IMCI) approach. "IMCI is a strategy where
children are treated immediately according to symptoms that they
exhibit," Dr Massi said. "In the rural areas where they don't have
access to laboratories, the doctors or medical personnel know that
the biggest child killers are diseases with symptoms and signs of
fever, diarrhoea or a cough. I am happy to say that we have since
seen a reduction in child morbidity and mortality."
Habiba Ramadhani did not know about the free medical
care for children under five years. Her son, Juneydi Maulidi,
fell sick with malaria at the beginning of the month. She took
him to the village dispensary, which is about 40 km away from
Morogoro town. Medical personnel at the dispensary pre-
scribed antibiotics and paracetamol for the four-year-old boy
although tests showed he had malaria.
"They didn't have medicine and asked us to buy
some from the pharmacy," 22-year-old Ramadhani
said. "He got worse over the month and we decided to bring him to
the bigger hospital."
When they got to the clinic at Morogoro, where IMCI is imple-
mented, Ramadhani's child was immediately seen by a clinical offi-
cer, and was diagnosed as having anaemia and admitted to hospital.
As she waited for a relative to donate some blood so that her son
could get a transfusion, Ramadhani said she was not aware of any
free medical services for children aged under five years.
Ramadhani had to get a relative to donate some blood to re-
place the blood that her son would use up. There is a perennial short-
age of blood in most Tanzanian hospitals and family or friends have
to give blood if their sick relative is to receive any.
A woman in the same ward as Ramadhani had not been so lucky.
Nineteen-year-old Geroda Robert's baby had just died a few minutes
earlier. She and her family live in a remote village in Morogoro. Her
one-year-old child fell sick but they could not get her to a doctor quickly
because a neighbouring river had flooded and was impassable. They
were marooned in their village until the river subsided. They came as
quickly as they could to the dispensary where they were referred to
Morogoro Regional Hospital, but the baby died soon after arrival.
Sifa Juma is a 27-year-old mother of four children whose ages
range between nine years to four months. She stays at home to care
for them while her husband buys tomatoes from village farmers and
sells them in Morogoro town. Her two youngest children have ben-
efited from the recent introduction of free medical care in the
district.
"With the first two children, you had to pay for
everything: medicine, tests, to see the doctor and
if your child needed to sleep a few nights in hospi-
tal, then that would mean a lot of money. But now,
as long as the child is below five, you get all that for
free," Juma said, adding: "Another good thing is
that there is now a clinic set aside for sick
children. Before, we had to sit in the queue
to see the doctor even with children who
were there for routine check-ups."
Zena Juma watches her sleeping son
Abduli Yahya.
African Regional Health Report
As a result, routine vaccination coverage, as measured by coverage of DPT3
(diphtheria toxoid, tetanus toxoid and pertussis vaccine) improved from 2002 to
2005. This can be seen in overall national immunization coverage as well as in the
numbers of districts that have achieved DPT3 coverage of 80% and higher. WHO/
UNICEF data for 2005 show that coverage continued to improve and that the average
regional DPT3 coverage was 69% at the end 2003 (see Fig 2.7)
By the end of 2004, hepatitis B vaccine was introduced in the routine immuniza-
tion programme in 24 countries in the African Region, Haemophilus influenza type
B (Hib) vaccine in 1 1 countries and yellow fever vaccine in 2 1 countries. Thirty-four
countries in this Region have been granted immunization system support (ISS) by
CAVI. The ISS fund has provided them with resources to strengthen their immuniza-
tion systems, so that they can introduce new vaccines. The countries also received
ISS to improve injection safety by providing autodisable syringes for three years as
well as safety boxes for the collection of the syringes once they have been used.
Routine immunization plays a role in the prevention of vitamin A deficiency.
Thirty-two countries in the African Region have a policy on using vitamin A in rou-
tine immunization, while 36 countries have used vitamin A supplementation during
polio and/or measles supplemental immunization activities.
The African Region's accelerated measles control initiative has seen significant
success over the last five years. The average rou-
tine measles vaccination coverage for the Region
stood at 69% in 2003, up from 54% in 1999.
Thirty-seven countries in this Region reported
routine measles coverage of 60% or more. Since
2001. at least 26 countries have conducted mass
immunization campaigns and instituted case-
based measles surveillance.
Since 1999, countries that have conducted
these accelerated measles control activities have
documented a more than 95% decline in measles
cases. The overall reduction in measles deaths
for the African Region is estimated to be more
than 50% compared with 1999 estimates. If the
project continues in current areas and expands
into new ones, it will help to achieve the 2005
World Health Assembly (WHA) goal of a 90%
reduction in global measles deaths by 2010.
A total of 139 million children in 31 coun-
tries were vaccinated between January 2001
and December 2004. An additional 75 million
children were targeted for vaccination in 2005.
These campaigns will help the African Region
achieve its goal of vaccinating 200 million chil-
dren by the end of 2005. From the beginning
Fig 2.7
Immunizaton coverage with EPI (Expanded Programme on Immunization) vaccines,
African Region, 1982-2003
100
0,60
ttfl
CD
03
o 40
o
20
1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2003
Figure shows coverage for BCG (tuberculosis), DPT3 (diphtheria, pertussis or whooping cough, and tetanus),
TT2 (tetanus toxoid) and measles.
Source: Communicable diseases in the WHO African Region 2003. Division of Prevention and Control of Communicable
Diseases. WHO Regional Office for Africa; 2004
Maternal, newborn and child health
Chapter
of 2006, all countries in this Region — except Liberia and Nigeria — were due to conduct
nationwide catch-up measles campaigns targeting children aged 9 months to 1 5 years.
Most countries have integrated their supplemental measles immunization ac-
tivities into their measles immunization strategy, such as the provision of vitamin
A supplementation, de-worming medicines, insecticide-treated nets for malaria
control and oral polio vaccine. The savings that resulted have allowed health au-
thorities to spend more on expanding the reach of these important public health
interventions. The efficiency and success of integrating supplemental activities
in immunization programmes has increased donor interest, and it has helped to
boost multisectoral collaboration and partnerships on an unprecedented scale.
Conclusion: scaling up success
In much of the African Region, there has been little or no improvement in maternal,
newborn and child health since the end of the 1980s. In some parts, some of the
gains of the post-independence years have been reversed. However, there are inter-
ventions that work in the African setting and the key to success is scaling these up
effectively.
Cape Verde, Mauritius (see Box 2.5) and Seychelles have improved ma-
ternal and newborn health through public health education including education
for girls, family planning and strong political commitment to HIV/AIDS prevention
and care. Similar best practices implemented in Uganda's Soroti district in 2001
with the adoption of the Making Pregnancy Safer initiative have also reaped
positive results. There, community involvement, improved communications and
transport, training to produce more skilled birth attendants and upgrading of
health facilities led to a reduction in maternal and neonatal deaths over a period
of 18 months.
Some countries in the African Region have found successful ways to address
the challenges they face in financing health care for maternal, newborn and child
health. For example, Mali and Mauritania have both developed community financing
schemes to subsidize maternal health-care services (see Box 2.6).
Another success story is improved access to antenatal care. Many countries
reached the relatively high level of 70% of women in sub-Saharan Africa receiving
at least one antenatal consultation in the 1990s. Some African countries are already
building on this by using antenatal consultations not only to prepare the mother for
the birth but as a platform to provide other essential screening and care, such as for
HIV/AIDS, tuberculosis and malaria.
A further key to success in the African context is boosting commu-
nity involvement. Many people in African countries do not go to
a health facility when they need care. Increasing the
quality of care at health facilities alone would
not reduce the maternal, neonatal and child
mortality rates significantly. Essential health
African Regional Health Report
Giving birth in Mauritius
Gone are the days when deliveries were performed at
home by traditional midwives in the Indian Ocean island of
Mauritius. Now, 99% of births are carried out by skilled
attendants, many in hospitals or clinics. Mothers like
Geeta Ramdin, a 25-year-old mother from the island, re-
ceive a high standard of antenatal and postnatal care,
and if complications arise, emergency obstetric care is
available.
Geeta went to her local clinic in the fourth month
of pregnancy to begin monthly checks of her weight and
blood pressure, and for blood and urine tests. Testing for
HIV is recommended, but only done with the patient's con-
sent, which Geeta readily gave. She was advised to have
a balanced diet and take regular exercise. In the seventh
month she was referred to a hospital for more comprehen-
sive tests, including an ultrasound scan of her baby.
All was going fine. When her contractions started
three days before the birth was due. doctors at the hos-
pital said she was not dilated enough and eventually de-
cided to do an emergency Caesarian. Obstructed labour
can result in the death of the baby, the mother or both.
and accounts for 12% of maternal deaths in the African
Region. Geeta was fortunate enough to have access
to a well-equipped hospital, able to provide her with a
straightforward Caesarian delivery.
Nurses helped her to express breast milk to feed
Shaksh immediately after the birth. Once Geeta recovered,
she started breastfeeding Shaksh herself: "I was over-
joyed to be able to hold my baby in my arms," she said. Six
weeks later, Geeta took Shaksh to the health centre for a
check-up. Shaksh, who is now a healthy one-year-old tod-
dler, has had a full course of routine vaccinations.
Over the last four decades the infant mortality rate
— that of babies aged less than one year — has dropped
sharply in Mauritius from 60 per 1000 live births in 1962 to
12.4 in 2003. The maternal mortality ratio in 2003 was 21
per 1 00 000 live births, on a par with the level in developed
countries.
A WHO report found that Mauritius owed this success
to strong political commitment to building health systems,
providing primary health care and having an efficient drug
supply system. The report also found that free education
— resulting in today's 95% literacy rate — and free health
care were also key. Public health experts believe that health
districts in other African countries that are the same size as
Mauritius can emulate some of these successes.
Geeta Ramdin and one-year-old Shaksh
care needs to be brought closer to the community. One way to do this is to deliver
more services through community providers, for example by supporting community-
based family planning services to improve utilization of contraception.
Scaling up health systems is vital but will not be effective if many people —
particularly girls and women — remain uneducated about their health. Lack of edu-
cation and illiteracy are major challenges in this Region and can be overcome by
taking a multisectoral approach that calls for investment in girls' education as well as
an improved public health infrastructure.
Governments and international agencies need to deliver essential and sustain-
able maternal, newborn and child health care to the people who need them. Unless
current efforts are stepped up, most countries in the African Region will have little or
temal, newborn and child healt
Chapter
Innovative financing to provide maternal care in Mali and Mauritania
Families in the African Region cannot always afford
antenatal, delivery and postnatal care, and their lack
of financial access to these sometimes life-saving
services contributes to the high rates of maternal and
newborn deaths. Mali and Mauritania have developed
community cost-sharing schemes to relieve poor fami-
lies of this financial burden and to subsidize care in
a bid to reduce high rates of maternal and neonatal
mortality. Mali introduced a community-funded scheme
in 2002 to provide 35 of 57 community health centres
with staff trained to deliver babies and perform emer-
gency obstetric surgery as well as to supply the centres
with emergency kits, containing anaesthetic and other
medicines for mothers who need a Caesarian. The cost
is shared between community health associations,
development partners and the government, while pa-
tients also make a small contribution.
WHO and Malian officials have praised people's
willingness to contribute financially to improve their
own maternal, newborn and child health and say the
scheme needs to be extended to general hospitals and
villages, where the majority of maternal and newborn
deaths occur. Such deaths often result from delays in
transportation and seeking help from traditional heal-
ers before taking mothers to a clinic.
Mauritania has introduced a health insurance
scheme called the Obstetric Package in the capital,
Nouakchott, and several other districts, to cover the
costs of antenatal, delivery and postnatal care. Each
pregnant woman and her family contribute US$ 0.26
to cover the costs of antenatal, delivery and postnatal
care. The remaining costs are covered by French devel-
opment aid, WHO and the Nouakchott health district.
The scheme has helped to finance the training of nurs-
es in emergency obstetrics and the hiring of doctors to
perform Caesarians. Community members are trained
to manage funds to cover the cost of ambulances.
Mauritania was one of the five countries in WHO'S
African Region to join the Making Pregnancy Safer pro-
gramme in 2002 in a drive to halve its high maternal death
rate by 2010. This year the authorities plan to extend the
cost-sharing system to four other regions of the country.
no chance of substantially reduc-
ing the toll of avoidable maternal,
newborn and child death and dis-
ease in the foreseeable future. Rapid
progress is needed to come even
close to achieving the target reduc-
tions envisaged by the MDGs on
maternal and child health. The Road
Map and the IMCI strategy are there
to accelerate progress towards these
goals. This ambitious MDG project
can only succeed in the African
Region if governments and donors
pledge substantially more funds and
if their joint efforts to improve ma-
ternal, newborn and child health are
tightly coordinated in a way that can
be sustained in the long-term. •
The future prospects for children
depend on decisions made today.
'African Regional Health Report
Bibliography
• Black RE, Morris SS. Bryce J. Where and why are 10 million children dying every year? Lancet 2003:361:2226-34.
• Communicable Diseases in the WHO African Region 2003. WHO Regional Office for Africa. Brazzaville: 2004.
• Family and reproductive health: 2002 in brief. Making the difference throughout the lifespan Brazzaville: WHO Regional Office
for Africa; 2004. WHO Regional Office for Africa document AFR/RHR/04/01.
• Hyder AA, Wali SA, McGuckin J. The burden of disease from neonatal mortality: a review of South Asia and sub-Saharan
Africa. &70G1 10:894-901.
• Lawn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal
deaths. Bulletin of the World Health Organization 2005:83:409-17.
• Maruping A. Policy interventions for reducing maternal and newborn mortality in adolescents. African health monitor
January-June 2004:11-4.
• Maternal mortality in 2000: estimates developed by WHO. UNICEFand UNFPA Geneva: Department of Reproductive Health
and Research. World Health Organization; 2004.
• Murray C and Lopez A. Health dimensions of sex and reproduction, the global burden of sexually transmitted diseases. HIV.
maternal conditions, perinatal disorders, and congenital anomalies, Harvard School of Public Health. Cambridge (MA), 1998.
• Phumaphi J. Fighting the "silent epidemic". Bulletin of the World Health Organization 2005;83:247-8.
• Prual A. Bouvier-Colle MH. de Bernis L, Breart G. Severe maternal morbidity from direct obstetric causes in West Africa:
incidence and case fatality rates. Bulletin of the World Health Organization. 2000:78:593-602.
• Road map for accelerating the attainment of the Millennium Development Goals relating to maternal and newborn hearth in
Africa Brazzaville: WHO Regional Office for Africa. Document AFR/RC54/R9.
• Schellenberg JRA, Adam T, Mshinda H. Masanja H, Kabadi G, Mukasa 0, et al. Effectiveness and cost of facility-based
Integrated Management of Childhood Illness (IMC!) in Tanzania. Lancet 364;2004:1 583-94.
• The world health report 2002. reducing risks, promoting healthy life. Geneva: World Health Organization; 2002.
• The world health report 2005: make every mother and child count Geneva: World Health Organization; 2005.
• World health statistics 2005. Geneva: World Health Organization; Geneva: 2005.
Maternal, newborn and child health
• • •
Key messages
Infectious diseases are a major obstacle to development
Geography and climate are conducive to infectious diseases
HIV/AIDS increases occurrence of other infectious diseases, particularly
tuberculosis
Health worker shortage is hampering health-care efforts
Solution*
Wider application of tried and tested public health interventions
Scale up simplified, low-cost approaches to treatment
Research and Development to find more effective medicines and vaccines
Promotion of safe sex, and HIV testing and counselling to prevent further
HIV infections and reverse AIDS pandemic
Infectious diseases
in Africa
Major obstacle to development
I A anV people in Africa have yet to benefit from the improvements in diagno-
nr* sis, prevention, treatment of common diseases and of living standards that
I * have contributed to greater life expectancy in most of the rest of the world
over the past half century. Unlike other regions of the world, the African Region still
largely attributes its slow progress in terms of human development to the ravages of
infectious diseases.
People in Africa suffer from a vast range of preventable and curable infectious
diseases. HIV/AIDS, tuberculosis and malaria alone are estimated to kill about three
million people every year in the Region. Africa's children bear the brunt of ill-health
caused by measles, waterborne infections and parasitic diseases. The result is hard-
ship, impoverishment, countless lives lost and reduced productivity. The diversion of
scarce resources into tackling these diseases spins countries on an inescapable cycle
of poverty and ill-health.
One reason for limited progress in the control of infectious diseases in Africa is
cost. Many African countries cannot always afford to diagnose and treat common
infections adequately. Expenditure on health is rarely as much as 5% of a country's
gross domestic product, and often is as little as 2%. Average public spending on
health is about US$ 10 per person per year, while patients and their families must
cover the remaining costs, and these can be substantial. A realistic estimate of the
cost of providing minimum health care to people in Africa is about US$ 34 per person
per year. In contrast, high-income countries spend US$ 2000 per person, or more.
ifectious diseases in Africa
Chapters
Fig 3.1
Regional progress towards 70% case detection of tuberculosis:
Europe low, SEAsia acceleration, Americas high
70
-!£-
0
4— '
CD
60
50
40
& 30
o>
T3
0)
</)
co
o
20
10
0
HIV/AIDS, tuberculosis and malaria
The devastating impact of HIV/AIDS, tuberculosis and malaria — known as the "big
three" — on people in developing countries has earned them their own Millennium
Development Goal: MDC 6. Meeting this goal in the African Region is proving dif-
ficult and may be impossible without adequate funding.
Of the major contributors to short lifespans in the Region, more than six are
infectious diseases: HIV/AIDS, tuberculosis, malaria, diarrhoeal diseases, acute re-
spiratory infections and vaccine-preventable diseases. Concerted efforts to control
infectious diseases in Africa have resulted in some spectacular gains against leprosy,
river blindness (onchocerciasis), poliomyelitis and guinea-worm disease (dracuncu-
liasis), while other efforts — such as those targeting the "big three" • - have had
little impact, despite recent improvements in prevention and treatment techniques.
HIV/AIDS is the leading cause of death and disease for adults in the Region,
while malaria is the leading cause of death and disease for children aged under five
years. The HIV/AIDS epidemic affects southern African countries most.
Malaria has been a constant scourge in countries south of the Sahara for centu-
ries and, despite decades of control efforts, Africa has more than 90% of the global
disease burden. Young children and pregnant women in rural areas suffer most from
the complications of malaria and are most likely to die from the disease. Despite
intense efforts and increased funding, the populations that are most at risk still lack
adequate access to effective prevention and treatment.
With the advent of curative drugs over
50 years ago, tuberculosis came to be per-
ceived in wealthy industrialized countries as
a disease of the past. Yet, tuberculosis is on
the rise in the Region with over one million
new cases notified in 2003. To achieve MDG 6,
case detection (Fig. 3.1) and treatment for tu-
berculosis need to reach many more people,
particularly those who are also infected with
HIV. MDG 6 will not be reached until HIV/
AIDS transmission is almost interrupted in
the 24 high-burden countries of the African
Region. Under the "3 by 5" initiative, there
are 34 high-burden countries globally.
Americas
Africa
Europe
1994
1996
1998
2000
2002
2004
2006
Source: Communicable diseases in the WHO African Region 2003. Division of Prevention and Control of
Communicable Diseases. WHO Regional Off ce for Africa; 2004.
Challenges for disease
control
Infectious diseases continue to exact a heavy
toll on African countries for a number of rea-
sons. Vectors, such as mosquitoes and flies,
The African Regional Health Report
have developed resistance to insecticides and this has reduced the impact of control
measures for vector-borne diseases. For many diseases — notably HIV/AIDS and ma-
laria — there are no vaccines. Another reason why control strategies may not succeed
is that some pathogens quickly become drug resistant. Also, the type and severity of
infectious diseases in Africa are altering due to changes in human behaviour. Outbreaks
of lethal viral fevers are examples of the unpredictable consequences of changing pat-
terns of land use. People are thrown into close contact with infectious agents by urban-
ization, conflict, migration, tourism and trade.
Africa's climate and geography are conducive to the spread of infectious dis-
eases. Mosquitoes that transmit malaria breed all year round in the hot, humid cli-
mate that dominates large swathes of the continent. In areas of scrubland, sandflies
transmit leishmaniasis. Blackflies that transmit river blindness (onchocerciasis) breed
on the rocks of fast-running river water. Tsetse flies transmit sleeping sickness (try-
panosomiasis) and ordinary flies transmit trachoma, which causes blindness. Dogs,
cats and bats transmit rabies, which can be fatal for humans. Freshwater snails carry
schistosomes, the parasites that cause schistosomiasis (bilharziasis).
People living south of the Sahel region and in parts of the Great Lakes region
and southern Africa are at risk of epidemic meningitis. Forests harbour rare but head-
line-grabbing haemorrhagic fever viruses,
such as Marburg and Ebola. By cutting down
the trees surrounding a village, people can
expose themselves to an outbreak of one of
these highly fatal diseases. Mosquitoes that
transmit malaria are capable of breeding in a
footprint filled with water. Other mosquitoes
transmit yellow fever, lymphatic filariasis (see
Fig. 3.2) and some of the haemorrhagic fever
viruses. Hepatitis, typhoid and diarrhoeal
diseases — including cholera and bacillary
dysentery — are also frequent in cities.
Schistosomes are transmitted via fresh-
water snails, while worms such as round-
worm, hookworm and tapeworm are soil-
transmitted. Schistosomiasis has a major
impact on the healthy development of chil-
dren and the quality of life of adults. Some
1 60 million people in Africa are infected with
schistosomes. Schistosomiasis also contrib-
utes to anaemia among pregnant women.
Worms of all species are particularly prob-
lematic for children aged 5- 1 4 years. Studies
show that heavy infestations may impair the
cognitive function of these children.
Fig 3.2
Mass drug administration for elimination of lymphatic filariasis:
Population targeted versus number treated
50
45
c
40
0
1
35
c
30
0
5>
25
Q.
o
20
Q.
15
10
5
0
Target
Treated
2000
2001
2002
2003
2004
2005
Year
Source: Roungou JB. Mubila L. Dabire A. Kinvi EB. Kabore A. Progress in lymphatic filariasis elimination in the
African Region. Communicable Diseases Bulletin for the African Region 2005 Mar; 3:10-1.
Infectious diseases in Africa
Chapters
The good news is that highly effective and affordable de-worming drugs
exist that are safe for all groups at risk, including pregnant women. Large-scale
control is technically feasible, but sustaining this control is a challenge. Worms
have proved hard to combat where water supplies are poor and sanitation inade-
quate. Intestinal worms tend to persist as long as people live in extreme poverty.
Guinea-worm disease and leprosy in Nigeria
Guinea worm eradication: a major public health success
Control of dracunculiasis, also known as guinea-worm disease, in the African Region has been hailed as a major public health success, but sus-
taining this success remains a challenge. People become infected with guinea worm by drinking water containing water fleas that are infected
with guinea-worm larvae. These larvae are reintroduced into water sources
by people who are infected with the disease and who dip their feet in water.
Guinea-worm disease can be prevented by filtering water with simple material,
such as cloth. Global control efforts have been successful, with an estimated
97% reduction in cases from 1986 to date. Most remaining cases are in 13 Afri-
can countries, where the final phase of eradication is proving difficult.
Despite years of control efforts and a measure of progress, residents in
the village of Ikija in south-western Nigeria are still becoming infected, though
not as much as in the past. "There was a time when we had people removing
hundreds of worms from their legs. Now, the situation has really improved," said
village head Isaiah Sobowale.
"Our river is basically stagnant water. We fetch water there around 5 am.
After that, there is nothing left until the next morning. Officials treat the water
regularly, but we need a better water supply," said farmer Lekan Fabowale, add-
ing that shallow wells become infected quickly and what the village needed was
a deep borehole.
; drinking-water supply is
necessary for the control of guinea worm.
Curing and reintegrating people with leprosy
There are 90% fewer cases of leprosy today than 20 years ago globally, but it is proving hard to reach the last remaining cases. In the African
Region seven countries have not yet reached the global elimination target of less than one case per 10 000 people. Nigeria reached that target
in 2003, but is still struggling to overcome discrimination against people with obvi-
ous signs of the disease and to address the disability it causes.
"Attempts to treat leprosy in Nigeria are hampered by stigma, socioeconom-
ic problems and physical disability, which makes it difficult for many patients to
seek help despite the fact that treatment is free," said Dr MO Lawal, the Leprosy
Programme Manager in the Ministry of Health in Oyo State.
The Nigerian Government established a National Tuberculosis and Leprosy
Control Programme in 1988. Lawal said that there is a long-term government plan
to close down leprosy colonies and to provide a community-based treatment pro-
gramme. Many people with leprosy have already left the colonies. Some live in
roadside huts and beg passing motorists for alms. "My father said I could not leave
education. I said, 1 must go and beg because I am a leper'. Later, I tried to get an
education, but they would not accept me because I had leprosy," said Alhaji Shedu
Abdullah!, the chairman of Integration, Dignity, Economic and Advancement, a non- People with leprosy can
governmental organization which supports people with leprosy in Nigeria. lonq-lastinq disability
suffer
and improvements in nutrition and sanitation could be more effective than drug
treatment in the long run.
Lessons from the successful efforts to control infectious diseases elsewhere in the
world can be applied in Africa, although the continent faces different obstacles. Africa's
geography, climate and political turmoil complicate the task. However, there are parts
of the African Region where some infectious diseases are being tackled successfully.
Diseases for which control has been successful
Infection control has been successful in African countries where diseases have char-
acteristics that make them easier to control and where these characteristics have
been countered with timely and effective interventions. Diseases that are transmitted
by an insect vector can be controlled as long as an effective insecticide exists and/or
humans can protect themselves from contact with the vector. One simple method
is sleeping under a mosquito net to avoid the night-biting mosquitoes that transmit
malaria. A cheap, effective and easily administered vaccine is an invaluable tool that
can render a viral pandemic, such as polio, within reach of complete eradication as
is the case today.
It has proved possible to limit the spread of diseases that follow a long course but
that are not easily transmissible, such as leprosy, and to limit the spread of diseases
that can be controlled by simple measures, such as filtering drinking-water to prevent
guinea-worm disease. These simple solutions need to
be tirelessly applied to make disease control sustain-
able and to lead to long-lasting improvements in public
health (see Box 3. 1). 1985 2003
Leprosy
Leprosy is close to being eliminated — reduced to a
prevalence of below one case per 10 000 people — in
Africa despite traditional perceptions that it is both
incurable and highly infectious. Since the disease is
so disfiguring, people with leprosy have traditionally
suffered social stigma and exclusion. Effective treat-
ment exists, but case-finding can be difficult and. even
today, the remaining patients scattered over large areas
of the African Region have poor access to diagnosis
and treatment. The Regional Strategy for Leprosy Control
is a simple and effective approach, relying on early
detection of cases and cure with multidrug therapy.
The prevalence of leprosy has dropped sharply
because of successful application of this strategy (Fig.
3.3). Patient numbers reported to WHO'S African
Reported cases per 10 000 inhabitants
D Countries outside the African Region D 1-2 cases
D Unknown • >2 cases
• < 1 case
Source: tte database of the World Health Organization. Regional Office for Africa. Brazzaville.
ifectious diseases in Africa
Chapters
Regional Office declined by over 60% from 127 500 in 1991 to 51 200 in 2003.
Treatment coverage soared from 28% to 98% during this period. Over this 12-year
period, a total of more than 800 000 cases were cured using multidrug therapy
and no resistance has been reported. The Central African Republic, Comoros,
the Democratic Republic of the Congo and the United Republic of Tanzania are
approaching the elimination target. Angola, Madagascar and Mozambique still have
areas that are highly endemic. Twenty-four-month multidrug therapy is effective and
in routine programmes the relapse rate is only 0.1% per five-year period.
People with leprosy are no longer as stigmatized as they used to be, while medical
treatment is now available to them. After these people have been cured, it is easier
for them to integrate back into the community. However, in countries that are ap-
proaching elimination, it is difficult to reach the last few patients living in isolated
communities. Active surveillance is needed to ensure that these people are diag-
nosed and treated.
River blindness
Abandoned villages along valuable stretches of river bear silent testimony to the di-
lemma people face between having enough to eat and being able to see. River blind-
ness, or onchocerciasis, is a parasitic disease caused by worms that are transmitted
by a blackfly that breeds in turbulent river water. Seventeen million people living in
West and Central Africa are estimated to be infected. Chronic infection gradually
causes skin changes and blindness. People who become blind with onchocerciasis
have a life expectancy only one-third of that of sighted people in the same area.
The Onchocerciasis Control Programme began in 1974 by using chemical
and biological larvicides to kill blackfly larvae on virtually every infested river
in I I West African countries. It has become one of the Region's biggest and
most successful public health campaigns. A total of 1.2 million square kilome-
tres in West Africa are now completely free of onchocerciasis. Fertile land
has been resettled and about 40 000 new cases of blindness per year
have been prevented. As the adult worms responsible for the dis-
ease live for 10-15 years, control measures have to continue for at
least this time. Large-scale vector control — using aircraft to spray
larvicides on rivers — has been replaced by mass treatment of
people living in endemic areas with ivermectin, once or twice
a year to prevent blindness and reduce residual transmission.
The African Programme for Onchocerciasis Control — which
was launched in 1995 — has treated 34 million people in 16
countries to date. These programmes are exemplary cases of
scale matching needs in terms of infectious disease control.
The African Regional Health Report
with three decades of sustained efforts tackling this persistent parasitic disease
and achieving measurable gains. By helping to eliminate river blindness as a public
health problem, WHO and other partners have made a major contribution to re-
ducing poverty in the African Region. Sustaining this historical success, however,
remains a challenge.
Poliomyelitis (polio)
When the Global Polio Eradication Initiative was launched in 1988, wild poliovirus
was endemic in 125 countries and paralysed more than 1000 children a day. By
vaccinating two billion children against the disease, this enormous public health
campaign has reduced the number of cases to less than 1 000 per year globally, most
of which are in Africa.
In 2004. there were 935 cases of polio across over 12 countries in the African
Region. 84% of which occurred in Nigeria. This was a 100% increase in the
number of cases recorded in 2003. This setback, however, has to be seen in
the context of tremendous progress overall. Despite outbreaks in Angola, Cape
Verde and the Democratic Republic of the Congo in 2000, 31 countries have
maintained a polio-free status for more than three years. Polio vaccination
resumed in 2004 in Nigeria after 1 1 months' suspen-
sion, and cases are subsequently decreasing. In addi-
tion to mop-up campaigns following sporadic cases,
routine immunization is needed to prevent the wild
poliovirus from re-establishing itself.
Each country must continue surveillance for cases
of acute flaccid paralysis, which can be caused by
other viruses, and test stool specimens to rule out polio as
a cause. This surveillance also helps to assess the cov-
erage of other immunizations, and measure progress
towards eradication of polio. Countries must show
they are continuing surveillance and stool testing to
confirm that there have been no cases of polio for
three consecutive years, the point at which eradica-
tion can be declared and the countries certified polio
free. In 2005, 35 of the 46 countries in the African Re-
gion achieved certification surveillance standards. The
eventual eradication of polio in the Region depends very much on the quality of
work performed by the 16 laboratories in the Regional Polio Laboratory Network
in the African Region. All members of the network kept their WHO accreditation
status in 2005 — a necessary step towards a polio-free Region.
It has been an uphill struggle
to eradicate polio.
Infectious diseases in Africa
Chapters
Diseases of major public concern
In contrast to the diseases which have been controlled with relative success, some
diseases have persisted despite control measures and are of major public concern.
HIV/AIDS, tuberculosis and malaria have become more prevalent in Africa during the
last 20 years. In the case of HIV/AIDS, the failure to control the epidemic is largely
due to the lack of a vaccine and the inability to change human behaviour. Tuberculosis
is re-emerging where it is spurred by the HIV epidemic. The persistence of malaria is
due to inadequate vector control and drug resistance.
HIV/AIDS
Africa is the region of the world most affected by the HIV/AIDS pandemic. It has
about 1 1 % of the world's population but is home to more than 60% of all people in
the world living with HIV infection. In 2005, an estimated 25.8 million people were
living with HIV/AIDS, 3.2 million people became infected with the virus and 2.4
million people died of AIDS in the Region. In 16 countries in Africa, at least 10% of
the population is infected.
Heterosexual transmission of HIV is the predominant mode in Africa. Some
5.7% of infected adults are women. Of young people who are infected, 75% are
women and girls (see Fig. 3.4). Many factors contribute to the spread of the virus,
namely commercial sex, sexual violence, population mobility, poverty, social in-
stability, lack of education, high levels of sexually transmitted infections, stigma
and discrimination.
The HIV epidemic has had disastrous ef-
fects on African society through its destruction
of individuals, families, health systems and the
public sector. Nevertheless, countries in the
Region have made efforts to prevent the spread
of HIV. Most countries are mounting an inter-
sectoral response to the epidemic, in which
different ministries and agencies are working
together. These responses are led by national
AIDS councils many of which are chaired by
heads of states, such as in Angola and Burundi.
Mass media and information campaigns for the
general public are also being implemented in
many countries, including programmes target-
ing young people and other vulnerable groups,
The past decade has seen real advances in
Girl weeping after their mother died of HIV/AIDS the treatment of HIV/AIDS and its complications.
Antiretroviral (ARV) drugs lower the level of HIV in the blood and postpone the
development of opportunistic infections, allowing people to regain a good quality
of life. ARV medicines are also extremely effective in preventing mother-to-child
transmission of HIV during pregnancy and birth, and — as the price of these
drugs has decreased — their widespread availability is a realistic target even for
poor countries.
WHO and UNAIDS declared the lack of access to ARV medicines to treat HIV/
AIDS in developing countries a public health emergency in 2003. Since then, the
two agencies and their partners have campaigned to scale up ARV treatment as part
of the "3 by 5" initiative to put three million people with HIV/AIDS on antiretroviral
therapy (ART) by the end of 2005. By December 2005, the number of people living
in sub-Saharan Africa receiving ART had increased more than eight-fold to 810 000
from 100 000 over the two-year period. Of the three million people targeted by
"3 by 5", 2.3 million live in sub-Saharan Africa. WHO and its partners have
Fig. 3.4
HIV prevalence among 15-24-year-olds in selected sub-Saharan African countries, 2001-03
20
15
f,
1
Men
Women
Niger
(2002)
Mali
(2001)
Burundi
(2002)
Kenya
(2003)
Zambia
(2001-02)
South Africa
(2003)
Zimbabwe
(2001-02)
Sources: Burundi (Enquete Nationale de Seroprevalence de I'infection par le VIH au Burundi. Bujumbura, Decembre 2002). Kenya (Kenya Demographic and Health
Survey 2003). Mali (Enqu&e Dgmographique et de Santa Malt 2001). Niger (Enqueue Nationale de Seroprevalence de I'infection par le VIH dans la population
generale agee de 1 5 a 49 ans au Niger (2002)). South Africa (Pettifor AE, Rees HV, Steffenson A. Hlongwa-Madikizela L, MacPhal C. Vermaak K, Kleinschmidt
I: HIV and sexual behaviour among young South Africans: a national survey of 15-24 year olds. Johannesburg: Reproductive Health Research Unit, University of
Witwatersrand, 2004). Zambia (Zambia Demographic and Health Survey 2001-2002). Zimbabwe (The Zimbabwe Young Adult Survey 2001-2002) .
fectious diseases in Africa
Chapters
Activists give hope to people with HIV in Burundi
Testing positive for HIV in the 1980s or 1990s in Burundi was like a
death sentence. In the absence of treatment and with the common
belief that it was a punishment sent by God, many people succumbed
to despair, abandoned by their families, who were unaware of the
reality that HIV/AIDS is a treatable and preventable disease.
Three associations have been set up in Burundi to educate
people more about the disease, to fight discrimination against people
with HIV/AIDS and to provide support for them: the Burundian Society
for Women Against AIDS in Africa (SWAA) formed in 1 992, the Asso-
ciation for the Support of HIV Positive People (ANSS) and the Reseau
Burundais des Personnes vivant avec le VIH/SIDA (RBP+ Network of
HIV-positive people). These associations encourage Burundians to be
tested for HIV, give hope and strength to HIV-positive people to stand
up for their rights and, among their many other public health activi-
ties, raise awareness about the dangers of HIV.
Years of lobbying has produced results. Activists have started dis-
cussing on television what it means to be HIV positive — which had
been a major taboo. The Burundian Government responded by propos-
ing a new law against discrimination of HIV-positive people. This was
adopted by the national assembly in March 2005. Adrienne Munene,
who is in charge of counselling with RBP+, said that the law would
help people such as an HIV-positive nurse, who was hired in 2000 by
a private health centre in Bujumbura but never given a contract. "They
kept telling her that she was not like others," Munene said.
Activists have also lobbied hard for treatment for people with
HIV and persuaded the government to waive taxes on antiretroviral
drugs. The government has also agreed to subsidize these drugs with
help from the Global Fund to Fight AIDS, Tuberculosis and Malaria,
and it has also negotiated with pharmaceutical firms to reduce the
cost of therapy from US$ 96 to US$ 30 per person per month.
Today more than 4000 Burundians receive free antiretrovirals.
HIV-positive people in that country expect to live longer thanks to
support they receive from their associations and to subsidized treat-
ment. But despite their achievements, these associations are over-
stretched. Dr Marie Jose Mbuzenakamwe, ANSS Coordinator, said
they cannot cope with increasing demand for testing and support.
She believes that all health facilities should provide HIV services so
that these patients have access to treatment without travelling long
distances.
The National AIDS Council has already identified hospitals and
associations to help with distribution of antiretrovirals and related
services but not all have adequate facilities and human resources.
There is a shortage of diagnostic kits and associations fear that if
donor funding dries up patients will be cut off from a drug supply.
This kiosk is run by the Burundian Society of Women Against AIDS in
Africa (SWAA). People come here to buy condoms and booklets on HIV.
They can also watch videos on HIV/AIDS here at certain times of the day.
helped 24 high-burden countries in the Region to train more staff to deliver ART.
ART coverage is expected to increase further due to solid commitment from those
involved, in particular, people living with HIV/AIDS and their governments (See Box
3.2). Rapid expansion of treatment to many more people with HIV/AIDS is expected
to contribute further to the lowering of ARV prices (See Box 3.3).
At least 90% of people living with HIV/AIDS across the African Region do not
know that they are HIV-positive, and HIV tests are often expensive and not always
available. But now that ARVs are becoming more widely available, more people
will be encouraged to come forward to be tested for HIV. To encourage people to
do this and to make testing services more widely available, WHO and UNAIDS
have developed regional guidelines on voluntary counselling and testing (VCT)
How Cameroon secured lower prices for antiretrovirals
and have issued a policy statement on the provision of HIV testing and counsel-
ling services.
Twenty-eight countries — including 21 high-burden countries — have
developed plans to scale up ART with the support of WHO and its partners, and 20
countries have developed plans to monitor
and evaluate ART as they roll out the treat-
ment. Botswana. Cote d'lvoire and Lesotho
are expanding people's access to treatment
by taking the logical first step of providing
universal HIV testing and counselling. VCT
guidelines have been developed in at least
29 countries, including all 24 high-burden
countries. These are the countries where
HIV prevalence of women attending ante-
natal clinics is above I % and where preva-
lence of HIV/AIDS among high-risk groups
is 5% or more.
The Region is also making progress in
rolling out a simplified public health ap-
proach to ART delivery based on the Inte-
grated Management of Adult and Adoles-
cent Illness (IMAI) approach. Thirty-three
countries have developed and adapted their
own simplified guidelines, based on the IMAI
model, for delivering and rolling out ART to
more people in need. These tools are con-
tinuously being updated based on the best
available international evidence. Moreover,
Regional Knowledge Hubs for HIV/AIDS
Treatment and Technical Resource Networks ^^^—^^^^.^^^^^^^B
of experts in ART have been established for
East/Southern and West/Central Africa.
WHO and partners are helping at least 1 6 countries in the Region to improve
laboratories to provide HIV testing and CD-cell count services. With an increase in
demand for ARV medicines. WHO and its partners are training staff in 3 1 countries
in the Region to develop procurement and supply management plans and helping
countries across the Region to monitor HIV drug resistance, as part of efforts to
provide appropriate treatment and care for everyone in need.
While progress has been made in the fight against HIV/AIDS in the African Region,
significant challenges remain. The scarcity of diagnostic services and surveillance mecha-
nisms makes it difficult to measure the incidence and prevalence of opportunistic
infections. The most widespread opportunistic infection is Pneumocystis jiroved
Negotiating more affordable prices for anti-
retrovirals has helped many poor countries
deliver more of these life-saving drugs to
more people who need them. Meanwhile,
generic pharmaceutical companies who
manufacture copies of the original pat-
ented drugs have helped to push prices
further down.
UNAIDS. WHO and other UN agen-
cies established the Accelerating Access
Initiative in 2000 with seven pharmaceu-
tical companies: Abbott Laboratories,
Boehringer Ingelheim, Bristol-Myers Squibb,
GlaxoSmithKline, Gilead Sciences, Merck
& Co., Inc. and Roche.
The combination of the UN initiative
and pressure from generic manufacturers
of antiretrovirals has helped Cameroon
obtain these drugs at prices that have de-
creased from USS 10 000 per patient per
year to about USS 300 in the space of a
few years.
Cameroon has also removed import
duties and taxes on essential medicines.
a further obstacle to providing the life-
saving medicines. The Cameroon experi-
ence shows the simple steps that can be
taken to provide antiretrovirals to people in
need even with limited resources.
First. Cameroon negotiated with drug
manufacturers to lower the price of anti-
retrovirals to USS 50 per patient per month in
earty 2001 . then the country won a further re-
duction to USS 40 in mid-2002. By early 2003
— with generic competition growing — the
price dropped further to about USS 30 per
month for the first-line regimen. If a patient
does not respond to the first-line regimen,
they are given second-line treatment
Some countries — including Botswana,
Burkina Faso, Burundi, Ethiopia, Mali,
Mauritania, Senegal and Zambia — pro-
vide first-line treatment free to patients,
while others such as Cameroon charge
USS 8-9 a month and the government
covers the remaining costs. Since October
2004, Cameroon has been able to offer its
citizens first-line regimen at USS 6-9 per
month and second-line at USS 14-20 per
month.
Infectious diseases in Africa
Chapters
pneumonia, which is responsible for the vast majority of AIDS-related deaths in children.
Following studies in Cote d'lvoire, UNAIDS has recommended trimethroprim-
sulfamethoxazole prophylaxis for HIV-infected adults and children.
Some people have called for universal prophylaxis for HIV-positive children to
prevent deaths from opportunistic pneumonia. Plans are also under way to imple-
ment preventive programmes for children in Senegal and Uganda. A vaccine for HIV
and an effective microbicide gel to protect women have yet to be developed. The
most powerful rallying point for HIV activists has been their campaign for access to
ARVs, as these drugs are the only way to reduce complications of HIV/AIDS, prolong
life and prevent mother-to-child transmission.
WHO's African Regional Office declared 2006 "the year of HIV prevention in the
African Region". The aim of the campaign is to make media, governments and people
in the Region as well as development partners, other stakeholders, and the global HIV
prevention and control community more aware of the HIV/AIDS epidemic.
The need for further rapid scale-up of HIV/AIDS treatment and prevention in
the Region raises many issues: how do countries sustain rapid expansion of treat-
ment in the long-run without neglecting overall health system development?
How can prevention be better funded and scaled up to make testing and
counselling services more widely available? How can countries galvanize
support from all government sectors for these public health efforts
S to prevent and treat HIV/AIDS, a disease that affects all public and
private sectors.
A Tuberculosis
Tuberculosis is one of the world's oldest infectious diseases.
Although there has been an effective, affordable and acces-
sible cure for the disease since the 1950s, the disease still
*V kills over 1.6 million people every year globally. In the
, African Region alone, there are an estimated 2.4 mil-
lion new tuberculosis cases and half a million tuber-
culosis-related deaths every year. In 2003, the Region
— which is home to I 1% of the world's population
— accounted for 24% of notified cases. Nine of
the 22 high-burden countries that are responsible for
80% of all new tuberculosis cases are in this Region:
the Democratic Republic of the Congo (DRC), Ethiopia,
Kenya, Nigeria, Mozambique, South Africa, Uganda, the
United Republic of Tanzania and Zimbabwe. Eleven of the 15
countries with the highest incidence are also in the Region: Botswana,
Kenya, Lesotho, Malawi, Namibia, Sierra Leone, South Africa, Swaziland,
Uganda, Zambia and Zimbabwe.
The incidence of tuberculosis in the Region has increased in tandem
with the HIV/AIDS epidemic. People with HIV easily contract tuberculosis
infections because of their weakened immune systems and go on to develop active
tuberculosis. People with healthy immune systems recover easily from primary
tuberculosis infection and have only a 10% chance of re-developing tuberculosis in
their lifetime. In contrast, it is estimated that one-third of people who died of tuber-
culosis in 2003 in the African Region, were HIV positive.
On average, about one-third of tuberculosis patients notified in countries in the
African Region are co-infected with HIV, and in most countries in southern Africa —
such as Lesotho. Malawi, South Africa. Swaziland, Zambia and Zimbabwe — over two-
thirds of children and adults with tuberculosis are co-infected with HIV. Tuberculosis is
increasingly occurring in younger, economically productive members of society in this
Region, especially girls and women, closely resembling the trend of HIV prevalence.
The recommended method for diagnosing tuberculosis is through sputum
smear microscopy. The need for specialized equipment and skilled personnel to per-
form this test places limitations on the availability of diagnostic services. This has
been complicated further by the fact that sputum microscopy in tuberculosis/HIV
co-infected people is not as effective in picking up tuberculosis as in people who are
not infected with HIV. With an increasing number of tuberculosis cases that are due
to co-infection with HIV, more and more cases of tuberculosis are not being picked
up. As a result of co-infection, tuberculosis is occurring increasingly in people aged
1 5-49 years. Children under five years of age are the most susceptible members of
a population to tuberculosis due to HIV infection, while those aged 3-15 years are
relatively resistant. The risk of an HIV-positive mother transmitting HIV to her child
is 25-48% in the absence of treatment to prevent mother-to-child transmission and
these HIV-positive children have a high risk of contracting tuberculosis.
Unfortunately, tuberculosis is difficult to diagnose in children, as its signs and
symptoms are not specific. Also, because the tuberculin test in HIV-positive children is
often negative, many children with tuberculosis are not diagnosed and do not receive
treatment. Furthermore, children do not produce much sputum on demand, and mi-
croscopy tends to yield negative results due to relatively small numbers of active bacilli.
It is estimated that only half of existing infectious tuberculosis cases in Africa are being
detected and put on treatment. Among those put on treatment, about a fifth of them
are lost to follow up before completing treatment.
The DOTS strategy, the most effective approach for combating tuberculosis,
has been successfully implemented in the African Region. The strategy depends
on government commitment, high-quality microscopy for diagnosis, reliable supply
of high quality short-course anti-tuberculosis drugs administered under appropriate
conditions, including direct observation of drug taking at least for the initial intensive
phase of treatment as well as a system to monitor and evaluate case-finding and
treatment outcomes.
Close supervision means better cure rates, fewer relapses and prevents drug
resistance. However, the growing shortage of trained health workers in the African
Region is making this very difficult to achieve. A course of treatment lasts six to eight
months. This lengthy time frame is a burden on both patients and the health-care
provider system. New shorter-course drugs are urgently needed.
With an increasing
number of tuberculosis
cases that are due to
co-infection with HIV,
more and more cases of
tuberculosis are not being
picked up.
ifectious diseases in Africa
Chapters
BCG (bacille Caimette-Guerin) vaccination is routinely given to newborns in
the African Region. However, even though the BCG vaccine protects people against
severe forms of tuberculosis, it has only a minimal effect in preventing pulmonary
tuberculosis and therefore does little to reduce the global burden of tuberculosis. A
new more effective vaccine is clearly needed.
Multidrug-resistant strains are not yet a significant problem in the African Re-
gion, but occur nevertheless in some places. Thus multidrug-resistant tuberculosis
needs to be contained and treated, and the interaction with the HIV epidemic needs
to be studied further. Interventions for people infected with both tuberculosis and
HIV and tuberculosis in South Africa
HIV/AIDS and tuberculosis are compounding one another to devastat-
ing effect in parts of the African Region. The realization that it will be
impossible to curb the spread of HIV and reduce mortality from AIDS
without tackling tuberculosis has led to an upsurge in initiatives to treat
the two diseases in tandem and to support people infected with both.
It was estimated that in 2003 more than 100 000 people were
co-infected with HIV and tuberculosis in South Africa, the highest
number in any country in the world. The country has the thirteenth-
highest prevalence of tuberculosis cases globally and an estimated
61% of these people in South Africa with tuberculosis are also in-
fected with HIV.
The Massive Effort Campaign, a non-profit organization, tries to
combine efforts to combat tuberculosis, HIV and malaria. "Tuberculosis is
now the most important killer of people with HIV/AIDS in South Africa.
Yet, it is an easily treated and curable disease: the drugs and diagnosis
are free and accessible everywhere in the country," said the campaign's
regional coordinator, Patrick Bertrand.
The ProTEST Initiative, sponsored by WHO-UNAIDS, has provided
the anti-tuberculosis drug isoniazid to HIV-positive people to prevent them
from developing active tuberculosis. ProTEST has run pilot programmes
in the Eastern Cape, KwaZulu-Natal and the Central and Western Cape.
Another initiative, the Raphael Centre in Grahamstown, Eastern Cape, was
set up and is run by volunteers. The centre provides residents of the local
townships with counselling, support and practical assistance to help them
comply with treatment and come to terms with the diagnosis of both dis-
eases. The Raphael Centre also provides on-the-spot HIV testing, one of
the first steps recommended by ProTEST to combat the dual epidemic.
Xoliswa Mjuleni, who visits the centre regularly, found out she
was HIV positive in 1999. Initially she was terrified but after she started
going to the centre she gained confidence, new friends and "a reason to
live". "We support each other. It doesn't always help having someone
who has not experienced it telling you HIV is not the end of the world. It
is so much better to have someone who knows exactly what it is like to
live with HIV, someone who has the same problems, the same pain."
The challenges in treating the dual infection are many. The stan-
dard tuberculosis smear test is often negative in HIV patients which can
delay starting treatment under tuberculosis protocols. Delays in test re-
sults can prove fatal and many tuberculosis patients are reluctant to be
tested for HIV because of the stigma associated with the disease. WHO
and national guidelines recommend first treating patients with the six-
month course of directly observed tuberculosis treatment before moving
on to antiretroviral (ARV) drugs for HIV/AIDS. For tuberculosis patients
with advanced clinical symptoms of AIDS, the alternative is to give two
months of tuberculosis treatment then start on ARV drugs. But for some
patients the only option is to begin tuberculosis and ARV treatment
simultaneously, which can mean taking 10 to 12 pills three times a day.
Skilled microscopists are an essential
part of tuberculosis control efforts.
HIV, such as chemoprophylaxis with isoniazid for 6-12 months, have proved to be
effective in reducing the incidence of tuberculosis in HIV-positive people. This inter-
vention is being provided in some countries, but has not yet been implemented on
a wide enough scale for significant impact (see Box 3.4). The battle against tubercu-
losis has not yet been won in the African Region and was declared a public health
emergency by the Regional Committee in 2005.
Malaria
Malaria causes untold human misery as well as economic and social devastation in
the African Region, where it is endemic in 42 of the 46 Member States. Estimates
show that countries in Africa with endemic malaria have 1.3 percentage points less
economic growth per annum compared with similar non-endemic countries, and
that the annual cost of lost productivity and providing treatment for malaria in the
Region is about US$12 billion.
Africa accounts for over 90% of an estimated 300-500 million clinical cases of
malaria that occur in the world every year. Children in Africa account for some 90%
of nearly one million malaria-related deaths estimated to occur annually in children
worldwide. Malaria contributes significantly to anaemia in pregnant women, and
malaria-related anaemia is estimated to cause 10 000 maternal deaths each year. In
addition, malaria contributes to low birth weight in newboms.
At a meeting in Abuja. Nigeria, in 2000, African heads of state and govern-
ment acknowledged the heavy disease burden due to malaria and agreed to reduce
its impact through universal implementation of tried and tested interventions. They
pledged to provide access to treatment to at least 60% of people with symptoms of
the disease within eight hours of onset by 2005 and to halve the number of malaria
deaths in the Region by 2010. Also by 2005, they pledged to provide at
least 60% of pregnant women in endemic areas with preventive doses of
antimalarial drugs and to ensure access to insecticide-treated nets for at
least 60% of vulnerable population groups, particularly children aged less
than five years and pregnant women. This concerted effort, however,
faced major challenges and these goals were not met. Among those chal-
lenges, climate change has helped to expand mosquito habitats, insecti-
cide resistance has made it more difficult to control the vectors, and the
emergence and spread of drug-resistant parasites has rendered affordable
treatments that were once effective, completely useless.
Other factors also make it difficult to overcome malaria. Concur-
rent infections with HIV have also increased the overall malaria disease
burden. Malaria has re-emerged in areas where conflict and civil unrest
have destroyed health systems and/or driven refugees from non-endemic
areas into areas that are highly malarious, sparking epidemics.
Treating mosquito nets with
insecticide increases their
efficiency.
factious diseases in Africa
Chapters
Environmental control, such as the removal of standing water, and the use of
bednets are two effective means of controlling malaria, but the scale of the need for
simple interventions such as these is daunting. Insecticide-treated nets have been
shown to reduce transmission of malaria by 50% and the need to re-apply the insec-
ticide has been circumvented by development of nets with insecticide incorporated
into the fibres and which do not require re-treatment. Eight and a half million insecti-
cide-treated nets were distributed in 2003,
bringing the total number in Africa to 20
million. But with 650 million people at risk
of infection, and the fact that most insec-
ticide-treated nets only last up to about
three years, many people are still not be-
ing protected from the malaria-bearing
mosquitoes that bite at night.
It seems unlikely that all the Abuja
targets will be met as fewer than 5% of the
population at risk and only 3% of children
under five years old were sleeping under
ITNs, according to the \Vor/d malaria
report 2005.
Studies done in Kenya showed insec-
ticide-treated nets significantly improve
the health of pregnant women and chil-
dren, and that the benefits were extended
through decreased transmission to house-
holds that did not have nets. The best
argument for persisting with this simple
but effective means of malaria control is il-
lustrated in countries such as Eritrea, where
nets are distributed free of charge (Fig 3.5).
Since the Second World War, at-
tempts to control mosquitoes have been less successful in Africa than in the Ameri-
cas. Indoor residual spraying with DDT and other insecticides can be an effective
method for mosquito control, especially during epidemics and emergencies. WHO
recommends that countries select insecticides according to local needs. At least 10
African countries include indoor residual spraying as part of their malaria control
efforts.
From the 1 970s to the 1 980s, malaria was reasonably well controlled in much of
East Africa, as cheap and affordable drugs such as chloroquine and sulfadoxine-
pyrimethamine were readily available. Today cheap and effective treatment for malaria
with one drug — known as monotherapy — is no longer an option for most countries
in Africa because of drug resistance. Chloroquine, amodiaquine and sulfadoxine-
Fig. 3.
Trends
nets (1
700
•y 600
1 500
§
5 400
| 300
3
Z 200
100
0
Source:
in incidence of malaria cases and distribution of insecticide-treated
FNs), Eritrea (1997-2004)
- ITNs distributed
Malaria cases
/
/
/
7_ y^—^
.^ -^^
1997 1998 1999 2000 2001 2002 2003 2004
Year
the database of the World Health Organization, Regional Office for Africa, Brazzaville.
The African Regional Health Report
pyrimethamine are still effective medicines for malaria in other parts of the world
but now fail widely in Africa. That leaves many countries with little choice but to
purchase drugs that are more effective but also more expensive (see Box 3.5).
No resistance to artemisinin combination medicines has been reported to date,
but many African countries simply cannot afford the US$ 2 per adult it costs for a
Treating malaria in Ethiopia
Like many countries in the African Region, Ethiopia faces a
malaria treatment crisis due to increasing resistance of the
malaria parasites to common drugs. Recent experience shows
the benefits of switching from old drugs to new effective com-
bination therapies, which are currently more expensive.
When Ethiopia adopted the antimalarial artemether-
lumefantrine for first-line treatment, the impact on the remote
district of Kafta Humera Wereda was dramatic. "The people
were fed up taking the old drugs and them not working, again
and again," said Seyoum Dejene, an Ethiopian doctor working
there. "The people like it: they call Coartem a 'miracle drug'." he
said, referring to one brand name of artemether-lumefantrine.
More than 100 000 migrant workers pour into Kafta
Humera Wereda every year from August to November to help
with the harvest, adding
to a resident population
of 65 000. These months
coincide with the peak of
the malaria season, which
starts as the rains end in
September. Many migrants
from the highlands — where
malaria is not endemic — do
not have natural immunity to the
disease. They sleep outside with
no protection from the mosquitoes
and have poor access to health
services, and so many get sick. The
presence of so many migrant work-
ers can trigger a malaria epidemic,
as these people are more susceptible
than the resident population.
In 2003. about 45 000 people
died in a malaria epidemic in Ethiopia
largely because of parasite resistance
to old antimalarial drugs. Jo Mesure,
former medical coordinator of Mede-
cins Sans Frontieres (MSF) in northern
Ethiopia, recalled how until 2004, when the government ap-
proved artemether-lumefantrine for first-line treatment, staff
had to give people two drugs, sulfadoxine-pyrimethamine and
chloroquine, to treat suspected falciparum malaria, knowing that
these drugs were ineffective. Artemether-lumefantrine is one of
a group of drugs, known as ACTs or artemisinin-based combina-
tion therapies, which are the only antimalarials that currently
face no resistance. But at US$ 0.60 to treat a child and US$ 2 to
treat an adult, these cost 10 times more than the older drugs.
According to Mesure, the effect of the change in drug
policy was immediate and dramatic. Manica Balasegaram, who
led an MSF study to inform the Ethiopian national drug policy,
agreed: "Before we started the project we had reports from the
health staff of people being treated seven to eight times with SP
(sulfadoxine-pyrimethamine) — it just was not working."
Patient in Kafta Humera Woreda receiving
artemether-lumefantrine for treatment of malaria.
ifectious diseases in Africa
Chapters
Fig 3.6
Status of malaria drug policy change and implementation in the African
Region as of July 2005
Adopted and implementing
ACT* policy
Adopted but not implementing
ACT policy
Implementing other policies
Countries outside the WHO
African Region
* Artemisinin-based combination therapy drugs (ACTs).
18 countries in the African Region have switched their malaria drugs policy to ACTs
Source: the database of the World Health Organization, Regional Office for Africa, Brazzaville.
course of artemether-lumefantrine, the only fixed-dose artemisinin-based combi-
nation currently on the WHO Essential Medicines List. A recent trial in Mbarara,
Uganda, showed that unsupervised administration of artemether-lumefantrine was
as efficacious as directly supervised treatment, offering some hope for the feasibil-
ity of widespread use in a Region where public health efforts are often hampered
by a shortage of trained health workers. Drug resistance and the change in drug
policy (Fig. 3.6) in about 1 8 countries all at once in 2004 has led to a surge in
global demand for artemisinin and some efforts are under way to increase supply.
For example, farmers, in the United Republic of Tanzania have started to grow the
shrub from which artemisinin is obtained. The active ingredient is being extracted,
made into pills abroad and being shipped back to the United Republic of Tanzania
and other African countries. The plan is eventually to produce tablets locally to meet
domestic demand.
Another area of concern for malaria
control is drug quality and regulations.
Countries in Africa are improving drug
regulations to adapt to the use of the
new antimalarial drugs and meet inter-
national standards. Countries are also
working on their pricing policies as ex-
pensive drugs could be re-sold on the
street or counterfeited. When the street
value is high, deaths increase either way.
This is because the malaria parasites de-
velop resistance when some patients fail
to complete their course of treatment
and because hoarding or reselling drugs
encourages incorrect use. People unsus-
pectingly buy counterfeit drugs because
they may be cheaper.
In areas where malaria is endemic,
fever is often attributed to malaria and
people often take antimalarial drugs without
being diagnosed properly. It is essential
to balance the provision of timely access
to drugs with specific diagnosis, but this
balance is difficult to achieve when coun-
tries lack sufficient numbers of adequately
trained health workers in communities
where the burden of disease is greatest.
The African Regional Health Report
Intermittent preventive treatment — in the form of two or three doses of
sulfadoxine-pyrimethamine during pregnancy — reduces maternal anaemia and the
risk of low birth weight in newborn babies. Intermittent preventive treatment of preg-
nant women has been implemented in Kenya. Malawi, Uganda, the United Republic
of Tanzania. Zambia and Zimbabwe.
Insecticide-treated nets, intermittent preventive treatment during pregnancy and
artemisinin combinations for diagnosed infections cost US$ 2-8 per person per year,
depending on how many of these three simple antimalarial measures are applied,
according to WHO's Regional Office for Africa. In many African countries, some
people cannot afford to pay this much for only one of the many health problems they
encounter, and that is why subsidized treatment is needed to make progress. Fewer
than 5% of the population at risk and only 3% of children under five years old were
sleeping under ITNs, according to the World malaria report 2005.
Coverage for intermittent preventive treatment for pregnant women in the
Region is low, and the number of people receiving effective antimalarial medicines
within 24 hours of onset of symptoms also remains low and is made worse by in-
creasing drug resistance. A total of 33 of the 42 malaria-endemic countries in the
Region have adopted artemisinin combinations as first-line treatment, but only nine
of these are currently implementing such treatment policies.
Diseases that are prone to cause epidemics
The last two decades have seen the re-emergence in Africa of diseases that are prone
to cause epidemics as well as new diseases, all of which require rapid and appropri-
ate response. Countries of the African Region started implementing integrated disease
surveillance and response (IDSR) systems as an important step to tackling outbreaks of
diseases — such as cholera, meningitis. Lassa fever, yellow fever, hepatitis E, dysentery,
plague, malaria and leptospirosis — that can trigger epidemics. These surveillance
systems have led to improved epidemiological reporting and outbreak detection, as
well as better laboratory confirmation, data analysis and use of information.
Thirty-nine of the 46 Member States have developed integrated disease sur-
veillance and response guidelines. A review of 15 countries in the Region in 2004
showed that a median of 82% of districts were submitting epidemiological reports on
time and that 50% of districts notified suspected disease outbreaks within two days.
These initial findings show significant progress.
WHO'S Office for the African Region is helping countries build and reinforce
these systems. A comprehensive regional database for communicable diseases has
been set up and by the end of 2004. 26 countries were submitting monthly disease
surveillance reports on time. WHO has established a rapid response network of 54
experts to provide technical support to countries in the event of an outbreak or epi-
demic. Emergency stocks of drugs, vaccines, equipment and reagent have also been
made available to countries in need.
JJje last two decades have
seen the re-emergence in
Africa of diseases that are
prone to cause epidemics
as well as new diseases, all
of which require rapid and
appropriate response.
Infectious diseases in Africa
Y
Raising the profile
of neglected diseases
is the first step towards
curing them.
WHO has in recent years helped to establish a network of national public health
laboratories in Member States to improve each country's outbreak investigation and
report those to the Region's central epidemiological database. In 2004. all major
outbreaks in the Region were confirmed through this regional public health labora-
tory network. WHO has also helped train staff from Member States to run integrated
disease surveillance and response systems. The main challenge in future will be to
scale up these systems to every district in every Member State and to ensure the
delivery of timely analysis of data and use of surveillance information as the basis
for effective health interventions. Another challenge is to sustain the commitment
of national authorities and partners to providing adequate resources and funding for
these systems.
Neglected diseases
Neglected diseases — such as sleeping sickness, visceral leishmaniasis and Buruli
ulcer — continue to take their toll in the African Region, but they no longer figure
on the disease-control agenda of the developed world. Progress has stalled on drug
research and development to treat these diseases, but they still have a considerable
impact on human development in the Region and have become worse while efforts
have focused on other diseases.
Raising the profile of neglected diseases is the first step towards curing them.
Renewed awareness of these diseases and their devastating impact is as badly need-
ed in the Region as the final stages towards attaining the much-publicized goal of
eradicating polio. The Drugs for Neglected Diseases Initiative was launched in 2003
to promote the development of drugs for diseases such as sleeping sickness, which
affects 500 000 people in 36 African countries, but for which the only effective drug
is highly toxic and must be given intravenously. Buruli ulcer is another disease that
does not attract adequate funds to fight it but happens to be the most common
mycobacterial infection after tuberculosis and leprosy. Buruli ulcer cases have been
found in 30 countries worldwide, 1 7 of which are in the African Region, according to
the Global Buruli Ulcer Initiative. Surgery can be used to treat Buruli ulcer, but it has
recently been shown that the drugs used for treating other mycobacterial diseases,
such as leprosy and tuberculosis, have some effect on the ulcers. Of 1450 new drugs
that have gone on the global market since the 1 970s, only 13 target the diseases that
mainly affect poor people in the tropics of which Africa has by far the greatest share,
according to the Drugs for Neglected Diseases Initiative.
Conclusion: Learning from past success
The examples of successful disease control: smallpox, leprosy, polio, guinea-worm
disease and river blindness show that the huge burden of infectious diseases in
Africa can be reduced by better use and wider application of current knowledge and
techniques. Political will backed by financial support are the crucial prerequisites
to scaling up the tried and tested control methods that are specific to each disease.
Effective disease control is eminently feasible given a judicious mix of environmental
control, mass chemotherapy, vaccination, case detection, treatment and prevention
strategies. For HIV/AIDS, there has been significant progress in improving access
to ARV medicines. In the first half of 2005. most African countries reported that
demand for ARV treatment was outstripping their capacity to supply it, and stressed
their urgent need for increased resources and technical support to maintain their
momentum in scaling up this treatment.
Interventions need to be implemented on a large scale and be above critical
levels of coverage; they also need to be sustained in order to have an impact. More
research and development leading to good vaccines for malaria and HIV and to a
more effective vaccine for tuberculosis would prevent the greater part of infectious-
disease-related deaths in the African Region and go a long way to meeting MDG 6
(see Box 3.6). More aid is needed for this research and development, as well as for
capacity building in public health. The World Bank estimates that it will take a ten-
fold increase in current aid levels to bridge the financing gap of US$ 25-40 per person
per year it estimates are needed for basic public health in the low-income countries
of Africa. Meanwhile, more use of available solutions is also an imperative: better
distribution of insecticide-treated nets; very high coverage of routine immunization
with recommended vaccines; effective drugs for malaria where and when they are
needed; universal testing for HIV; prevention of mother-to-child transmission; and
targeted HIV prevention for high-risk and vulnerable groups, such as sex workers.
Finally, more collaboration is needed to provide adequate food and clean
water, and to promote safe sex. This combined effort would bring the African
Region closer to achieving the Millennium Development Goals than any disease-
specific intervention. •
MDG 6: HIV/AIDS, malaria, and other diseases
The MDG 6 target for HIV/AIDS — the leading cause of morbidity
and mortality in the African Region — is to halt and reverse the spread
of the virus by 2015. Progress is measured by HIV prevalence among
pregnant women aged 15-24 years, condom use and the number
of children orphaned by the epidemic. The MDG 6 target for malaria,
tuberculosis and other major infectious diseases is also to halt and
reverse their spread by 201 5. Progress is measured by prevalence and
deaths associated with malaria and the proportion of the population
in endemic areas using effective malaria prevention and treatment
measures. For tuberculosis, progress towards the target is measured by
prevalence and deaths due to tuberculosis and the proportion of cases
detected and cured under the DOTS strategy.
The HIV/AIDS epidemic is most severe in southern Africa, with
more than 15% prevalence among pregnant women aged 15-24 years
Incidence of tuberculosis* (rate) by WHO Region
Western Pacific
South-East Asia
Europe
Eastern Mediterranean
Americas
Africa
L 12004
D 1990
100
200
300
400
* Estimates for incidence of smear positive tuberculosis cases include
patients with HIV. Estimates for all years are re-calculated as new information
becomes available and techniques are refined, so they may differ from those
published previously. See Explanatory notes on page 149 for further details.
Data can be downloaded from www.who.int/tb
Source: WHO report 2006 Global tuberculosis control - surveillance, planning,
financing
in eight countries in 2003-2004. According to the World Bank, the
epidemic in sub-Saharan Africa has risen steadily from a prevalence of
just under 3% in 1990, taken as the baseline for measuring progress on
the MDGs, to just over 7% in 2000. In 2005, HIV prevalence of adults
aged 15-49 was estimated at 5.8%. This lower estimate for the African
Region is partly due to an expansion of surveillance in rural areas where
prevalence is lower. There are no clear signs that HIV prevalence is
declining in southern Africa, where exceptionally high infection levels
continue in some countries.
A major obstacle to tracking progress towards achieving the target
of reducing the burden of malaria is the limited availability of data. Most
people with malaria in Africa are treated at home. Therefore, reported
cases from countries are not a reliable way to measure prevalence. Better
data collection is needed to measure progress in fighting malaria.
Estimates and ranges for adult HIV prevalence
(ages 15-49) in 2005 by WHO Region
Western Pacific j 0.1% 2%]
South-EastAsia [J 0.7% [0.5'
Europe Qj 0.5% 1 0.3% -0.7%]
Eastern Mediterranean I 0.2% [0.1% - 0.3%]
Americas H 0.6% [0.5% - 1.1%]
Africa I
5.8% 15,1% -6.5%]
01 234567
Figures in brackets are the range.
Source: UNAIDS/WHO, May 2006.
Bibliography
• 2004 report on the global AIDS epidemic 4th global report Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS)
2004. UNAIDS document UNAIDS/04.16E. Available from: http://www.unaids.org/bangkok2004/GAR2004Jitrnl/
GAR2004_00_en.htm
• 2006 report on the global AIDS epidemic a UNAIDS 10th Anniversary Special. Geneva: Joint United Nations Programme on
HIV/AIDS (UNAIDS) 2004. Available from: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp
• Africa malaria report 2003. World Health Organization/UNICEF 2003. http://www.rbm.who.int/amd2003/amr2003/amr_toc.htm
• AIDS in Africa: three scenarios to 2025. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2005. UNAIDS
document UNAIDS/04.52E. Available from: http://www.unaids.org/en/AIDS+in+Africa_Three+scenarios+to+2025.asp
• Ainsworth M. Fransen L, Over M, editors. Confronting AIDS: evidence from the developing world: Selected background papers
for the World Bank Policy Research Report Brussels: European Commission; 1998.
• Ait-Khaled N. e Enarson D. Tuberculose Manuel pour les etudiants en Medecine. World Health Organization et L'Union
Internationale Contre la Tuberculose et les Maladies Respiratoires. Available from: http://www.tbrieder.org/publications/
students_fr.pdf
• Anti-tuberculosis drug resistance in the world report no. 3. Available from: http://www.who.int/tb/publications/who_htm_
tb_2004_343/en/
• Bide L, Regional Advisor, Leprosy Elimination Programme, DDC Division, AFRO. Annual leprosy situation reports.
m Chitsulo L, Engels D, Savioli L, Montresor A. The global status of schistosomiasis and its control. Acta Tropica 2000;77:41-51
• Cohen D. Human capital and the HIV/AIDS epidemic in sub-Saharan Africa. Geneva: International Labour Organization; 2002.
• Communicable diseases in the WHO African Region 2003. Division of Prevention and Control of Communicable Diseases.
WHO Regional Office for Africa; 2004.
• Global tuberculosis control: surveillance, planning, financing. Geneva: World Health Organization; 2005. WHO document
WHO/HTM/TB/2005.349.
• Global Partnership to Roll Back Malaria. World malaria report 2005. Geneva: World Health Organization and UNICEF. 2005
• HIV/AIDS Epidemiological Surveillance Report for the WHO African Region. 2005 Update. Harare, Zimbabwe; December
2005. World Health Organization, Regional Office for Africa.
• HIV/AIDS and work global estimates impact and response 2004. Geneva: International Labour Organization; 2004.
• Human development report 2003. Millennium Development Goals: a compact among nations to end human poverty. UNDP.
New York: Oxford University Press; 2003. Available from: http://hdr.undp.org/reports/global/2003/
• Interim Policy on Collaborative JB/HIV activities. WHO/HTM/TB/2004.330; WHO/HTM/HIV/2004.1 . Geneva: World Health
Organization; 2004. Available from: http://whqlibdoc.who.int/hq/2004/who_htm_tb_2004.330.pdf
• Macroeconomics and health: investing in health for economic development Report of the Commission on Macroeconomics
and Health. Geneva: World Health Organization; 2001.
• Piola P, Fogg C, Bajunirwe F, Biraro S, Grandesso F, Ruzagira E, et al. Supervised versus unsupervised intake of six-dose
artemether-lumefantrine for treatment of acute, uncomplicated Plasmodium falciparum malaria in Mbarara, Uganda: a
randomised trial. Lancet 2005,365:1467-73.
• Progress on global access to HIV antiretroviral therapy: an update on "3x5" Geneva: UNAIDS and World Health Organization; 2005
• Progress on global access to HIV antiretroviral therapy: A Report on ~3x 5" and Beyond Geneva: UNAIDS and World Health
Organization; 2006
• Roungou JB, Mubila L, Dabire A, Kinvi EB, Kabore A. Progress in lymphatic filariasis elimination in the African Region.
Communicable Diseases Bulletin for the African Region. 2005 Mar; 3: 10-1.
• Roungou J. Regional Advisor Annual Reports, Other Tropical Diseases (OTD) DDC Division, WHO Regional Office for Africa.
Annual reports, other tropical diseases.
Infectious diseases in Africa
Chapters
Sachs J, Malaney P. The economic and social burden of malaria. Nature 2002:415:618-85.
Steketee RW, Nahlen BL, Parise ME, Menendez C. The burden of malaria in pregnancy in malaria-endemic areas. American
Journal of Tropical Medicine and Hygiene 2001 ;64:28-35.
Stephenson LS, Latham MC, Ottesen EA. Global malnutrition. Paras/fo/og/2000;121 Suppl:S5-22
Strategic Framework to reduce the burden of TB/HIV. Geneva: World Health Organization: 2002. Available from http://www.
who.int/docstore/gtb/publications/tb_hiv/2002_296/pdf/tb_hiv_2002_296_en.pdf
TB/HIV 'Clinical Manual. Second Edition. Geneva: World Health Organization: 2004. Available from http://whqlibdoc.who.
int/publications/2004/9241546344.pdf
Treatment of Tuberculosis. Guidelines for National Programmes. Geneva: World Health Organization: 2003. Available from
http://www.who.int/tb/publications/cds_tb_2003_313/en/
UNAIDS/WHO AIDS epidemic update: December 2005. http://www.unaids.org/epi/2005/doc/EPIupdate2005_html_en/
epi05_05_en.htm
UNECA Compact For African Recovery: Operational/zing the Millennium Partnership for the African Recovery Programme. Addis
Ababa: United Nations Economic Commission for Africa. Available from: http://www.uneca.org/cfm/compact_for_african_
recovery.htm
Ntincommunicabl'
diseases in Africa
Key messages
Noncommunicable diseases and injuries constitute a growing public
health problem in the African Region
African countries do not devote adequate resources to address
noncommunicable diseases
Donor agencies and research institutions are neglecting the growing
burden of noncommunicable diseases and injuries
Risk factors for noncommunicable and chronic diseases are on the
rise in many African countries
Solution/
African governments should act fast to avoid the mistakes of wealthy
industrialized countries
Scale up key, low-cost health solutions, particularly prevention and
health promotion to whole population
Legislation can improve mental health care and control of
noncommunicable diseases
All government departments and nongovernmental organizations
should work together to ensure a comprehensive approach to the
problem
Noncommunicable
diseases in Africa
An emerging threat
f | oncommunicable diseases such as stroke, diabetes, cancer and heart disease
^k I - usually thought of as "Western diseases" -- are becoming increasingly
/ TJ common throughout the African Region. Injuries have also become a sig-
nificant public health problem. But these chronic diseases and injuries tend to be
overshadowed by other headline-grabbing illnesses such as HIV/AIDS and are given
low priority and few resources (Fig. 4-1).
In fact, twice as many deaths from cardiovascular disease now occur in de-
veloping countries as in developed countries. In South Africa noncommunicable
diseases were the number one cause of death in 2000, accounting for 37% of deaths
and 21% of years of life lost due to premature death (see Table 4.1).
Furthermore, complications — especially stroke, cardiac and renal failure — and
certain forms of cancer, such as cervical cancer, occur at younger ages and in larger
numbers in the Region than in developed countries. The average age at death from
cardiovascular disease is at least 10 years younger in low-income settings than in
developed countries and as a result adults are hit in their most productive years.
Africa's double burden
Health systems in the African Region are straining under a double burden: a high
mortality and morbidity due to communicable diseases coupled with increasing rates
of noncommunicable diseases including mental illness and injury. Health systems
developed to provide acute, episodic care in some countries are inadequately de-
signed and resourced to care for people with chronic conditions.
Noncommunicable disease in Africa
The most common noncommunicable diseases are linked to a few common
and modifiable risk factors: high blood pressure, high cholesterol levels, tobacco
use, excessive alcohol use, inadequate intake of fruit and vegetables and being over-
weight, obese or physically inactive. Indeed, 75-85% of new cases of coronary heart
disease can be explained by these risk factors. In the African Region these risk factors
are increasing and they are linked to urbanization and globalization. As people move
out of villages into towns and cities, a traditional diet rich in fruit and vegetables is
gradually being replaced by one rich in calories from animal fats and low in complex
carbohydrates.
This dietary change is combined with a decrease in physical activity as people
move away from traditional farming into sedentary jobs. Global marketing of
tobacco, alcohol, and fatty, sugary and salty foods has reached into all but the most
remote parts of the Region.
Fig 4.1
Burden of noncommunicable diseases and injuries in DALYs* by cause in the WHO African Region, estimates for 2001
Noncommunicable diseases and injuries represented 27% of the total burden of disease in the WHO African Region in 2001
Unintentional injuries
Intentional injuries
Oral diseases
Skin diseases
Diabetes mellitus -*
Nutritional/endocrine disorders
Musculoskeletal diseases
Diseases of the genitourinary system
Congenital abnormalities
Sense organ disorders
Injuries
Noncommunicable conditions
Neuropsychiatric disorder;
Digestive diseases
Cardiovascular diseases
Neoplasms Respiratory diseases
Source: The world health report 2002: reducing risks, promoting healthy life. Geneva: World Health Organization: 2002.
* Disability-adjusted life years
The African Regional Health Report
A survey carried out in Algeria in 2003 illustrates the extent of the problem.
Of the 4000 people surveyed from both urban and rural areas: 12.8% were current
daily smokers, 5.1% were current alcohol consumers. 55.8% consumed less than
five servings of fruit and vegetables per day, 25.6% were mostly inactive, 1 6.4% were
obese, 29.1% had high blood pressure, 2.9% had high blood sugar and 36.5% had
high cholesterol.
Other surveys done in Cameroon, the Republic of the Congo, Eritrea and
Mozambique have produced similar results, though alcohol consumption is much
higher in these countries.
Africa's lesser known toll of ill-health
Cardiovascular diseases
The world health report 2001 showed that cardiovascular diseases alone accounted for
9.2% of the total deaths in Africa in 2000 compared with 8.15% in 1990. More than 20
million people have hypertension in the African Region — with a prevalence ranging
from 25% to 35% in adults aged 25-64 years and a clear upward trend over time.
In general, people living in urban areas are more likely to be at risk of cardiovas-
cular diseases than those in rural areas. A study of more than 1000 men and women
in Ghana found that the prevalence of hypertension was 33% in semi-urban villages
compared with 24% in rural areas. Detection, treatment and control of high blood
pressure was found to be poor overall, but was particularly bad in rural areas.
If hypertension is left untreated it increases the risk of stroke and cardiovascular
disease. Globally 15 million people suffer a stroke every year. Of these, five million
die and another five million are left permanently disabled. The African Region is one
of the most heavily affected areas in this respect. For example, mortality rates from
stroke were up to 10 times higher in the United Republic of Tanzania than in the
United Kingdom. This high incidence of stroke is believed to be due to untreated
hypertension. The ageing of populations in the Region may lead to a large increase
in incidence of stroke in the coming years.
Obesity and undernutrition: an African paradox
Africa is a vast continent containing extremes of poverty and wealth. Undernutrition
is still the most important underlying factor causing high infant and child mortality
in the Region. According to the Demographic and Health Surveys published in the
10-year period 1988-99. the prevalence of low birth weight in sub-Saharan Africa
ranges from 1 1 % to 52%. Between 30% and 40% of children suffered from stunting
due to chronic undernutrition, and 10% suffered from emaciation or wasting due to
acute undernutrition. Half of the children aged under five years were iron deficient
and a quarter were deficient in vitamin A. Between 4% and 40% of women of child-
bearing age were underweight. The highest prevalence of undernutrition in adults
was found among displaced people, including refugees.
Young smokers are at risk
throughout the Region.
Noncommunicable disease in Africa
Table 4.1
20 leading causes of death in South Africa
HIV/AIDS
Ischaemic heart disease'
Homicide/violence
Stroke
Tuberculosis
Lower respiratory infections
Road traffic accidents
Diarrhoeal diseases
Hypertensive heart disease
Diabetes melitus
COPD"
Low birth weight
Nephritis /nephrosis
Trachea/bronchi/lung cancer
Asthma
Suicide
Septicaemia
Oesophageal cancer
Cirrhosis of liver
Protein-energy malnutrition
Source: South African Health Survey 2000.
a Text in italic indicates noncommunicable disease.
b Chronic obstructive pulmonary disease.
Surveys carried out in Nigeria show that the situation there is not really improv-
ing. In 1 990, 43% of children under five years old were found to be stunted or short
for their age. A repeat study in 2003 found that 38% of children were stunted, 19%
were severely stunted, almost one in every 10 children was wasted and almost one
in three children was underweight with 9% being severely underweight.
Early childhood undernutrition may be a risk factor for noncommunicable dis-
eases in adulthood, particularly when coupled with lifestyle changes such as high
consumption of sugars, fats and reduced physical activity. The African Region has
seen an alarming increase in obesity since the early 1990s. The trend towards an
unhealthy diet rich in saturated fat, sugar and salt and poor in fruit and vegetables
means that in some countries, such as South Africa and Kenya, children are over-
weight but malnourished because they are receiving more than enough calories but
not enough necessary nutrients to grow into healthy adults.
In South Africa, according to a survey undertaken in 1998, 29% of men and
56% of women were overweight. Almost one in 10 men and three in 10 women
were obese with the general tendency towards being overweight increasing with
age. Urban men and women were more likely to be obese than rural men and
women. The proportion with a body mass index (BMI) greater than 30 reached 46%
in women aged 45-64.
Obesity is a major risk factor for type-2 diabetes, which is increasing rapidly in
the Region. In wealthier African countries such as Mauritius and Seychelles almost a
quarter of middle-aged people are affected.
Cancer
Cancer is the second leading cause of morbidity and mortality due to noncommu-
nicable diseases. Tobacco use is the single largest causative factor, accounting for
about 30% of all cancers in developed countries and an increasing number in the
developing world. Smoking causes 90% of lung cancer and is a major risk factor for
at least I I other types of cancer as well as causing heart disease, stroke and chronic
lung diseases such as bronchitis and emphysema. In Africa, there were 200 000
tobacco-related deaths in 2000. The prevalence of tobacco use was 29% in males
and 7% in females in 2000. The Global Youth Tobacco Survey showed that smoking
in 13-15-year-olds ranged from 13% in Kenya to 33% in Uganda.
Dietary factors account for around 20% of the burden of cancer in developing
countries. Being overweight or obese is a serious risk factor for cancer, particularly
for cancers of the stomach, colon, breast, uterus and kidney. Diets high in fruit and
vegetables may reduce various types of cancer, while high consumption of preserved
and/or red meat increases cancer risk. Eating a regular diet of highly salted foods
doubles the risk of stomach cancer.
Some cancers are linked to infectious diseases. If these diseases were prevented
or identified early enough then the associated cancers would not develop. For
example, primary liver cancer is one of the top three causes of cancer death in much
The African Regional Health Report
of Africa, Asia and the Pacific Basin but is relatively rare in the West. The major risk
factor is infection with hepatitis virus B or C. Another risk factor is exposure to afla-
toxin: a toxic substance present in mouldy peanuts, wheat, soybeans, groundnuts,
corn and rice. People who eat these contaminated foods over a long period of time
are at increased risk of developing liver cancer. This problem is more common in
Africa and Asia than in other parts of the world.
Human papillomavirus (HPV) causes cervical cancer and is the fifth-leading
cause of cancer death among females worldwide with some 239 000 deaths a year.
About 68 000 cases of cervical cancer are reported each year in Africa. Cervical
cancer offers a unique public health opportunity. Unlike most other cancers it is
cost-effective to screen for precursor lesions and then treat them before they develop
into cancer. The highest-risk lesions are most common among women in their
thirties and forties, with the cancer that develops when the lesions are left untreated
being most common among women in their forties and fifties. Countries that have
a well managed cervical cancer screening service can achieve dramatic results in
terms of treatment and prevention. For example, the age-standardized incidence
for cervical cancer is 68.6 cases per 100 000 women in the United Republic of
Tanzania compared with 7.7 cases per 100 000 women in North America.
Injuries, violence and disabilities
Injury is a leading cause of death and disability in the African Region, particularly in
those aged 5-29 years. Three of the top five causes of death for this age group are
injury related. Armed conflict is a frequent occurrence in many African countries and
is a major cause of ill-health and mortality. Five of the world's 10 most serious
conflicts during the 1990s took place in the African Region. In addition to the
deaths and injuries occurring on the battlefield, there are health consequences
resulting from the displacement of populations, the breakdown of health and
social services and the heightened risk of disease transmission. Even in countries
that have not experienced armed conflicts there is a heavy toll from firearm injuries
and other types of interpersonal violence which can lead to physical disability.
This presents a special challenge for rehabilitation and contributes to poverty in
the affected communities (see Box 4.1). Drowning is a leading cause of death
in children. Burns are another common injury, especially for people with epilepsy
who may fall into cooking fires when they have a fit. Because of inadequate care
for the injured, all these conditions lead to more deaths and more severe disabili-
ties than would be the case if trauma care systems and rehabilitation services were
more developed (see Table 4.2).
Road traffic deaths in the African Region are 40% higher than in all other
low- and middle-income countries and 50% higher than the world average. The
epidemic of road traffic injuries in developing countries is still in its early stages
but it threatens to grow exponentially with the rapid increase in the number of
vehicles. Some countries, including Algeria, Benin, Kenya and Rwanda, are taking
Armed conflict is a
frequent occurrence in
many African countries
and is a major cause of ill-
health and mortality.
Even in countries that
have not experienced
armed conflicts there is a
heavy toll from firearm
injuries and other types
of interpersonal violence
which can lead to physical
disability.
Noncommunicable disease in Africa
Rehabilitation for landmine victims in Angola
"I thought my life was over. I wanted to die," said Jose Antonio,
as he recalls the day he stepped on an anti-personnel mine while
fighting on the front line during Angola's civil war. The blast ripped
off much of his left leg.
After recovering from his above-knee amputation Jose moved
to Luanda, Angola's capital, for better medical care. There, he
heard about the Centra Neves Bendinha, a rehabilitation centre for
amputees, run by the provincial health authority and supported by
the International Committee of the Red Cross (ICRC).
"I've been very lucky," said the father of seven, as he waded
through a sand pit and climbed nimbly up and down steps, testing
his new artificial limb. "For years after the accident I was nervous. I
would jump at loud noises and was scared to leave the house. But
my wife persuaded me I needed a job. Our family was growing and
we were all relying too heavily on her. I could walk, so there was
no reason not to work. I just needed courage."
Now spray-painting cars for a living, Jose believes that work
stopped him from feeling sorry for himself. "Of course, I can't do all
the things I used to do, but I'm alive, I have a job so I feel useful,
and I have a good woman who made me see that there was more
to life than me and my leg," he laughed.
An estimated six million landmines — a legacy of the
country's brutal 27-year conflict — are littered around Angola's
countryside. They have left a trail of physical destruction and one in
every 415 Angolans disabled, according to UNICEF.
When available, rehabilitation services tend to be located
in cities and provincial centres and are often inaccessible for
people from rural areas. Beneficiaries of the few services
available, like Jose, can lead productive lives. But the lack
of post-trauma support services and life-skills training is
hampering the integration of landmine victims into
society. Many amputees think they are only fit to
beg on the street.
"Physical rehabilitation is just one piece
of the puzzle. Assistance to landmine
survivors is much more complex," said
Tracy Brown, country representative
of the Viet Nam Veterans of America
Foundation (WAF), a nongovernmental
organization that runs rehabilitation
programmes for landmine survivors in
eastern Angola.
Brown argues that post-trauma support
and life-skills training are critical to social reinte-
gration through training opportunities and
employment. But they are expen-
sive. Materials and assem-
bly of an average limb
already cost between
US$ 300 and US$ 800,
but that leaps to some
US$ 2000 when post-
trauma rehabilitation
services are included.
Jose Antonio tests his new leg
at the Centra Neves Bendinha.
steps to reduce crashes involving pedestrians, cyclists, and passengers on public
transportation (see Box 4.2).
Uganda has an annual road traffic fatality level of 1 60 deaths per 10 000
vehicles, one of the highest in the Region. Road traffic collisions cost the Ugandan
economy around US$ IOI million per year, which is 2.3% of the country's gross na-
tional product. Road crashes not only place a heavy burden on national and regional
economies but also on households. A study in Kenya showed that more than 75% of
road traffic casualties were economically active young adults, and that those most at
risk of death were pedestrians and users of motorized two-wheelers, who accounted
for 80% of the deaths.
The death toll is only the tip of the iceberg with 20-50 million people injured
or disabled each year in road traffic crashes worldwide. Pedestrians and users of
motorized two-wheelers, who tend to be from lower-income groups, are most at risk
of injury and death on the roads.
The African Regional Health Report
Table 4.2
Leading causes of death in the African Region, 2002
Rank 0-4 years
5- 14 years
15-29 years
Malaria
Lower respiratory infections
HIV/AIDS
HIV/AIDS
Lower respiratory infections
HIV/AIDS
Tuberculosis
Malaria
Diarrhoeal diseases
Road traffic crashes
Violence
Lower respiratory infections
Perinatal conditions
Measles
Lower respiratory infections
Diarrhoeal diseases
HIV/AIDS
Trypanosomiasis
Road traffic crashes
Perinatal conditions
Measles
Fires
War
Cerebrovascular disease
Whooping cough
Drowning
Maternal haemorrhage
Tuberculosis
Protein-energy malnutrition
Tuberculosis
Abortion
Ischaemic heart disease
Tetanus
Malaria
Malaria
Measles
Congenital anomalies
Violence
Maternal sepsis
Road traffic crashes
Syphilis
Meningitis
Hypertensive disorders
Violence
Tuberculosis
Poisoning
Drowning
Whooping cough
Fires
Falls
Obstructed labour
Chronic obstructive pulmonary disease
Road traffic accidents
Upper respiratory infections
Syphilis
Protein-energy malnutrition
Vitamin A deficiency
Hepatitis B
Self-inflicted injuries
Nephritis and nephrosis
Anaemia
Epilepsy
Trypanosomiasis
Syphilis
Drowning
Protein-energy malnutrition
Epilepsy
War
Poisoning
Lymphomas, multiple myeloma
Poisoning
Tetanus
Endocrine disorders
Anaemia
Cerebrovascular disease
Diabetes mellitus
Meningitis
Leishmaniasis
Rheumatic heart disease
Drowning
Source: Global Burden of Disease 2002.
Alcohol is an important factor in causing crashes. A study in South Africa
found that around 29% of non-fatally injured drivers and over 47% of fatally injured
drivers had been drinking. A later study found excess alcohol levels in over 52% of
trauma patients involved in road crashes.
Blindness
The major causes of blindness in the Region are cataract, trachoma, glaucoma, on-
chocerciasis and childhood blindness. The number of blind people in sub-Saharan
Africa is expected to increase from about 9 million to 15 million by 2020 unless
measures are taken to counter the problem. Some 80% of the causes of blindness
are avoidable.
The most important cause of blindness in sub-Saharan Africa is cataract, which
accounts for about 50% of blindness in this part of Africa. Trachoma is the most
Noncommunicable disease in Africa
Making roads safer in Rwanda
Liliane Uwamahoro can still walk, but only with the help of crutches. She was one of six
passengers in a public taxi who survived when it crashed in Rwanda's capital, Kigali, in
2002. Liliane lost her right leg, and has an artificial one. Eight fellow passengers lost their
lives. She complains of pain in her left leg and still can't come to terms with the loss of
her right leg. Liliane broke off her studies for three years and spent the first in hospital.
Her family scraped their money together to pay for her treatment. This year she plans to
return to college, but it won't be easy. "I have to do everything slowly now," she said.
Road traffic deaths in the African Region are 40% higher than all other low- and
middle-income countries and 50% higher than the world average. Rwanda — a country
of eight million people — is one of a growing number of African countries taking steps
to combat this high mortality. Police spokesman Tony Kuramba said the number of traffic
collisions reached unprecedented levels in 2002 and 2003. "We were doing a lot, but we
realized that we had to double our efforts to bring discipline to the roads".
In 2003, Rwandan police launched a public awareness campaign. They told trans-
port unions to make sure their staff were driving safely and used the media to reinforce
the message that motorists and pedestrians must obey traffic regulations. As part of the
campaign, primary and secondary schools started teaching road safety.
The number of people killed in road traffic collisions in the following year, 2004,
fell by nearly a quarter compared with the previous year to 324 deaths, and the number
of people injured on the roads fell by 10% to 331 0, Kuramba said. "But we realize that
losing over 3000 people in collisions ... is still a big number," he said.
Under legislation passed since then, passengers who do not wear a seat belt and
people on motorbikes or mopeds who do not wear a helmet face US$ 1 0 fine, one-fifth of
a Rwandan civil servant's monthly salary. The number of traffic police in the capital has
doubled to check for drunken or reckless driving, speeding and violations such as driving
a vehicle with mechanical defects. Police posts have been created in rural provinces to
monitor the highways leading to Kigali, where most crashes take place.
Road traffic injuries in developing countries
threaten to grow exponentially with the
rapid increase in the number of vehicles.
common infectious cause of blindness in the world,
and is endemic in 48 countries, mostly in Africa.
The Alliance for the Global Elimination of Tracho-
ma by 2020 (GET 2020) adopted the SAFE strategy
(Surgery for eyelids affected by trachoma, Antibiot-
ics, Facial cleanliness and Environmental improve-
ment) as the means of achieving this goal, but most
countries are still failing to ensure widespread imple-
mentation of this strategy.
In order to achieve sustainable control and
elimination of trachoma, all four SAFE components
must be implemented together. Likewise, all three
essential components to the global initiative for
elimination of avoidable blindness; disease control
interventions, human resource development, and
infrastructure development, must be addressed, and
built upon the essential foundation of community
participation.
Following the 1 999 launch of the global initia-
tive, VISION 2020: the Right to Sight, by WHO and
key partners, several countries in the Region have
stepped up blindness prevention and care efforts. The
goal was to eliminate avoidable blindness worldwide
by the year 2020. Yet at the beginning of 2005, only
22 of the 46 Member States in Africa had endorsed
the global initiative, VISION 2020, by signing the
Global Declaration of Support, and only 1 5 countries
in the Region had formed a national committee for
the prevention of blindness (NCPBL).
Mental health problems
Mental health problems have been increasing
throughout the African Region partly as a result of
conflicts and post-conflict situations.
In 2002, mental disorders accounted for 5% of
the total burden of disease in the Region. Moreover,
despite a high burden of physical disease, mental
disorders accounted for 1 9% of all disability in Africa.
The burden of depression is particularly onerous, ac-
counting for 5% of all disability.
In addition to conflicts, the increase in mental
and neurological disorders is linked to the high preva-
lence of communicable diseases such as meningitis,
African Regional Health Report
cystircercosis, sleeping sickness (trypanosomiasis) and HIV/AIDS. The breakdown of
traditional family structures and values is a further contributing factor since it can result
in youth and adults who are poorly prepared to cope with life and who may turn to
alcohol and illicit drugs. Indeed, reducing consumption of alcohol and illicit drugs has
become a major challenge for the Region.
Poverty, exacerbated by difficult socioeconomic conditions, can lead to isola-
tion and loneliness and, in turn, to depression, especially among vulnerable persons.
There has been an increase of depression and acute psychotic disorders among ado-
lescents, adults and the elderly. Without early diagnosis and appropriate care these
conditions can become chronic.
Unfortunately, the financial and human resources in the African Region are insuf-
ficient to address adequately the burden of men-
tal health disorders (see Table 4.3). The Region
has fewer mental health professionals than other
WHO regions. For example, the median number of
psychiatrists per 100 000 people is only 0.04.
A similar trend is seen in the availability of psy-
chiatric beds, whose median number per 10 000
population is 0.34. Also, only 56% of African
countries have community-based mental health
facilities and only 37% of countries in the Region
have mental health programmes for children, while
only 1 5% have programmes for the elderly.
People trying to access mental health care
are also thwarted by its cost. In 18 countries in
the Region the most common method of financ-
ing treatment involves out-of-pocket payments.
Similarly, only 20 of these countries provide dis-
ability benefits. As a result most individuals with
mental disorders in the African Region do not re-
ceive any medical treatment at all despite the fact
that effective therapies exist for many of these
conditions.
Healthy children can become healthy adults.
Genetic diseases
The most prevalent genetic diseases in Africa are ones that alter the population's sus-
ceptibility to malaria. The main ones are: sickle cell, thalassaemia, elliptocytosis and
glucose-6-phosphate dehydrogenase (C6PDH) deficiency. Sickle cell disease causes
great suffering, frequent absenteeism in school and is a cause of premature death
among children affected by it. Although there is no cure for the disease, a lot can be
done in terms of management and prevention of symptoms. Unfortunately, even the
more basic interventions, such as intravenous fluids and pain killers, are not always
available to the majority of affected children in the Region.
Noncommunicable disease in Africa
Chapter
Table 4.3
Mental health resources in selected countries in the African Region
Resources
Angola
Cameroon
Ethiopia
Mali
South Africa
••••^^^^•^^••i^^^^^^^^^^H^^l^Hi^HMMMMR^B^H^^^^^^^^^H^^^^^^^^^H^^^^HBBHHHiHHHM
Presence of mental health policy
Absent
Present
Present
Present
Present
Presence of substance abuse policy
Present
Present
Absent
Present
Present
Specific budget for mental health as a proportion of total health budget
Not available
0.1%
Not available
0.02%
2.7%
Presence of treatment for severe mental disorders in primary health care
Absent
Absent
Present
Present
Present
Number of psychiatric beds/ 10 000 population
0.13
0.08
0.07
0.2
4.5
Number of psychiatrists/ 100 000 population
0.07
0.03
0.02
0.06
1.2
Source: Project Atlas: A project of the Department of Mental Health and Substance Dependence, WHO, Geneva.
Oral health is a lifelong asset.
Much more could be done to screen children in Africa for these genetic abnor-
malities, prevent the complications of severe disease, educate the families of patients
and provide advice on family planning for affected adults.
Oral diseases
The African Region faces a number of serious oral diseases including noma, oral
cancer, oral manifestations of HIV/AIDS and maxillofacial trauma. Dental caries and
periodontal diseases are increasing in many African countries due to change of diet
with growing consumption of sugars, increasing tobacco use and the high preva-
lence of oral manifestations of HIV/AIDS. Access to oral health services
is limited in most African countries and oral health problems are left un-
treated or teeth are extracted because of pain and discomfort. Tooth loss
and impaired oral function are therefore expected to increase. Oral cancer
is closely related to the use of tobacco and excessive consumption of
alcohol. The prevalence of oral cancer is particularly high among men. Ac-
cording to WHO estimates, oral and pharynx cancer represent the tenth
leading cause of cancer in terms of incidence globally
Since many oral diseases have the same modifiable risk factors as car-
diovascular disease, diabetes and cancer, a common risk factors approach
has been developed by oral health programmes in the Region.
Noma — a gangrenous disorder that destroys the soft and hard
tissues of the mouth and face — has been termed "the face of poverty"
as it affects people in the very poorest parts of Africa. It mainly afflicts children
aged under six years, with 70-90% of children with noma dying, while the
survivors are disfigured for life, unable to eat, speak or breathe normally.
An estimated 140000 children contract noma each year, many of these live in
the Sahelian region. The exact cause of noma remains unknown though it is
believed to be bacterial. It has been linked to a combination of factors: malnutrition,
African Regional Health Report
compromised immune system, poor oral hygiene and infection with several bacteria.
If noma is recognized early enough treatment with antibiotics and nutritional sup-
port can halt the progression of the disease. However, the emphasis should be on
prevention rather than treatment.
Efforts to tackle the problems
Governments, donor agencies and research institutions in the African Region have
sadly neglected the growing burden of noncommunicable diseases, although many
of the causes are preventable. In contrast, cardiovascular diseases are now in decline
in the industrialized countries. This decline is largely a result of the successes of pri-
mary prevention and, to a lesser extent, treatment. Many of the successful strategies
that have worked in richer countries can, however, be just as effective in their poorer
counterparts. In this context, ministers of health in the Region have adopted a num-
ber of strategies to address noncommunicable diseases, such as those on Noncom-
municable Diseases in 2000, Health Promotion in 2001 and Mental Health in 1999.
Legislation and marketing
One of the most effective measures that governments can take is to control the mar-
keting of tobacco, alcohol, and salty, sugary and fatty foods. The modest amount of
progress made in controlling the tobacco industry in recent years shows what can
be achieved.
South Africa, for example, has some of the most stringent anti-tobacco legisla-
tion anywhere in the world and as a result the prevalence of smoking across most
groups is declining. In 1994. the government imposed a tax increase on tobacco
products amounting to 50% of the retail price. This action, combined with overall
price increases, has doubled the price of tobacco products over the past decade.
Along with other tobacco control interventions, tax increases have contributed to
a 33% reduction in tobacco consumption. A survey carried out in October 1996
in South Africa showed that 34% of adults smoked. However, by 1998, following
implementation of the Tobacco Products Control Act. only 24% of adults reported
being current smokers. Significantly, fewer children are starting to smoke. In 1 999,
18.5% of schoolchildren reported first smoking cigarettes before the age of 10 but
this proportion had dropped to 16.2% in 2002.
The WHO Framework Convention on Tobacco Control has been signed by 39
of the 46 Member States of the African Region. By early 2006, 23 of those 39 African
countries had ratified it. The next step is for these governments to pass appropriate
anti-tobacco legislation.
The most effective intervention is a combination of tobacco taxation, comprehen-
sive bans on advertising and dissemination of health information on the dangers of
smoking. All of these strategies can be affordable and cost-effective in the Region.
One of the most
effective measures that
governments can take is
to control the marketing
of tobacco, alcohol, and
salty, sugary and fatty
foods. The modest amount
of progress made in
controlling the tobacco
industry in recent years
shows what can be
achieved.
Noncommunicable disease in Africa
Mental health legislation
Ghana is developing a new mental health law with the help of WHO that is expected
to be a model for African countries. The idea is to provide a high standard of mental
health care by protecting vulnerable groups and the rights of people with mental
illness (see Box 4.3). This law also includes provisions to regulate the activities of
traditional healers, to whom people with mental conditions often turn.
Promoting healthy diets and lifestyles
Government-led action at the population level is needed to regulate marketing of
unhealthy foods and to promote healthy lifestyles. One success story is a national
healthy lifestyle intervention programme carried out in Mauritius between 1987 and
1992. The programme included extensive use of the mass media, community health
promotion activities and, probably most importantly, legislation to change the com-
position of cooking oil from largely palm oil — which is high in saturated fatty acids
— to soya bean oil. After five years there was a reduction in the prevalence of high
blood pressure in men, from 15% to 12.1%, and the mean population total serum
cholesterol concentration fell appreciably from 5.5 mmol/l to 4.7 mmol/l. Increased
leisure exercise and decreased smoking and alcohol consumption were also seen.
Ghana is drafting a new mental health law
Mr A. 67, has spent 40 years at the Accra Psychiatric Hospital, more
than half his life. "We have many such in-patients whose families
refuse to accept them back into their fold," said Ethel Lartey, Deputy
Director of Nursing Services. "They have made this place their home".
While industrialized countries have been shifting from
institutionalized mental health care to a care-in-the-community
approach, many developing countries still keep patients with
mental disorders in institutions. Shunned by their families and
stigmatized by society, patients like Mr A. are still the luckier ones.
Psychiatric services are in short supply and Ghanaians who suffer
from depression, trauma, schizophrenia or the effects of substance
abuse often seek help from unregulated religious or traditional
practitioners.
At a religious healing camp in Ghana, some patients are con-
strained in chains. After four days 17-year-old Ms B. was still waiting
to start treatment with "the Prophet". Meanwhile, her sister used
severe coercive methods to stop Ms B. from stripping herself naked.
Under a new mental health law which Ghana is drafting in
consultation with WHO's Department of Mental Health and Sub-
stance Abuse and the WHO Regional Office for Africa, such camps
will have to be registered and supervised by working committees
headed by a psychiatrist. Patients are to be treated with respect
for their human rights and they should, when possible, remain
integrated in the community while receiving care from psychiatric
units attached to general hospitals. The law, which replaces a
1972 law, is expected to be passed in the next two years. It has
gained the support of doctors, nurses and traditional healers and
could serve as a model for other African countries wishing to
develop progressive mental health laws that respect international
human rights standards.
Dr Samuel Allotey, the psychiatrist in charge of Pantang
Hospital outside the capital, said the current law only covers
institutional care: "The current law . . . does not make provision for
community psychiatric programmes. It does not cover traditional
and spiritual healers and does not emphasize the rights of mental
patients". One of the country's 16 psychiatrists in the country of
20 million people, Dr Allotey said that the new law will provide
for the establishment of a National Mental Health Advisory Board
and visiting committees that would have oversight and regulatory
responsibilities of ensuring the rights of patients.
The African Regional Health Report
As far as alcohol consumption and its many negative public health conse-
quences are concerned, the Regional Strategy for Mental Health 2000-10 and reso-
lutions adopted by the World Health Assembly in May 2005 — notably resolution
WHA58.26 on public health problems caused by harmful use of alcohol — show
the way for governments to take appropriate measures.
The WHO Global Strategy on Diet, Physical Activity and Health, published in
2004, also provides guidelines for governments.
One obvious course of action is to regulate the amount of salt and sugar in
foods, particularly those heavily marketed towards young people. Improved labelling
of foods can also be beneficial.
For example, the Nigerian Heart Foundation has been successful in raising
awareness about healthy eating habits and has recently started an initiative to label
foods with a heart-friendly logo. Fortification of staple foods with micronutrients
such as vitamin A is another key strategy.
Low-cost management programmes
As well as action at the population level, strategies need to be developed for indi-
viduals at high risk such as setting up a recall system for patients who already have
diabetes and hypertension. This can be achieved even in resource-poor settings such
as rural South Africa, where a nurse-led noncommunicable disease management pro-
gramme for hypertension, diabetes, asthma and epilepsy has been established within
the primary health-care system for an overall population of around 200 000 people.
This disease management programme includes use of clinic-held treatment cards and
registries; diagnostic and management protocols; self-management support services,
and regular, planned follow-up with a clinic nurse. Using this programme, nurses
were able to achieve good disease control among most of the patient population:
68% of patients with hypertension; 82% of those with diabetes, and 84% of those
with asthma.
Closer collaboration
Collaboration between governments and nongovernmental organizations is vitally
important. A global campaign for epilepsy, a joint initiative between WHO and leading
nongovernmental organizations to raise awareness and develop national programmes
on epilepsy, is being conducted in several countries, such as the Republic of the Congo,
Senegal and Zimbabwe. The community-based approach to rehabilitating people with
epilepsy that has been adopted in Togo is also interesting (see Box 4-4).
Traditional health practitioners
The debate about conventional versus traditional medicine is often cast in "either/
or" terms. But in the mental health field many African communities and even some
Fruit and vegetables
are vital components of
a healthy diet.
Togolese people with epilepsy
reintegrated into community
Sotoba district in northern Togo has
worked hard to prevent people with
epilepsy from becoming marginalized
by society. Its approach to rehabilitation
of these people is an example of good
practice for intersectoral collaboration
to integrate people living with epilepsy
back into society. The Togolese Associa-
tion against Epilepsy, community workers
and members of the national mental
health programme set up a programme in
the district to provide essential care for
people living with epilepsy. These people,
who were mainly living on the streets,
were given medication and psychosocial
care as well as support for the families.
After 18 months of such care social inte-
gration was possible in 35 adult cases.
About 180 children and adolescents were
monitored and around 60% of them were
found to be seizure free.
ncommunicable disease in Africa
• • •
More studies are needed
into the potentially
harmful effects of
traditional approaches to
mental health, and into
how these approaches
compare with practices
such as psychotherapy.
specialists are happy for conventional and traditional health practitioners to treat pa-
tients at the same time. Mental health resources are limited and many Africans have
little choice but to turn to traditional health practitioners.
Traditional health practitioners are highly respected in many communities be-
cause they share the same beliefs and perceptions on health care as members of
those communities. African traditional healers are often the first point of care for
people who are bereaved. These healers may guide people through rituals to help
reduce their fear and depression. In some cases, however, clients with mental health
problems are treated cruelly and physically mistreated by these practitioners.
More studies are needed into the potentially harmful effects of traditional ap-
proaches to mental health, and into how these approaches compare with practices
such as psychotherapy. A number of African governments allow traditional health
practitioners to register formally. Box 4.3 describes how healers in Ghana will soon
be required to register under a mental health law that was drafted in 2005.
The challenges
Scarcity of resources
Money is a major constraint. Member States of the African Region have so many
pressing issues, such as HIV/AIDS and tuberculosis, that swallow up limited health
budgets and so it is easy to see why noncommunicable diseases are overlooked. But
there is a ready source of new funds available if governments place a special tax on
tobacco products and use the proceeds for disease prevention programmes. In South
Africa, for example, government revenue from tobacco taxes has more than doubled
in the last 10 years.
Not all interventions are costly. For example, giving aspirin to people with chest
pain would prevent a quarter of the deaths associated with heart attacks and is
more cost-effective on a population basis than interventions such as revasculariza-
tion procedures. However, aspirin is strikingly underused when indicated. A study
of diabetic patients in the United Republic of Tanzania found that 71.9% had high
blood pressure (systolic pressure >I40 mmHg or diastolic pressure >90 mmHg) and
12.2% were obese. All the other patients had at least one other indication for taking
aspirin but only 39% were taking it regularly.
The lack of infrastructure in many parts of the African Region is a stumbling
block. In many areas health care tends to be provided by nurses working in isolated
clinics with limited access to drugs and equipment. First-class hospitals with hi-tech
equipment do exist — the first heart transplant operation took place in South Africa
— but often only a small number of wealthier citizens benefit. Certainly, more re-
search is needed to examine what is feasible in low-resource settings.
The African Regional Health Report
Setting up a traditional cervical cancer screening service, for example, can
be costly. However, visual approaches using acetic acid or Lugol's iodine to iden-
tify suspicious precancerous cervical lesions are promising low-cost screening
techniques.
Three centres have been set up to assess alternative approaches to screening
and treatment of precancerous cervical lesions: in Guinea, Angola and the United
Republic of Tanzania. As a result a screening programme has been put in place
in 14 countries. More than 25 000 women have been screened and successfully
treated for precancerous and cancerous cervical lesions over the last five years.
Inadequate awareness and commitment
Inadequate awareness is a big problem. For example, many political leaders in the
African Region are not fully aware of the magnitude and severity of road
traffic injuries and that this is indeed a public health issue. A number
of interventions can reduce road traffic crashes and minimize injuries.
For example, setting and enforcing speed limits and seat-belt laws, requir-
ing helmets to be worn on bicycles and motorbikes and setting and
enforcing blood alcohol concentration limits. Using speed bumps
and rumble strips to slow down traffic at crash-prone locations has
proved highly successful in Ghana where fatality per 10 000 vehicles
is about 30-40 times higher than in high-income countries. During the
16-month period between January 2000 and April 2001 when these
measures were introduced, traffic collisions were reduced by 35%, fa-
talities by 55% and serious injuries by 76%.
There have been a number of WHO initiatives to raise awareness.
For example the noncommunicable diseases strategy for the African
Region, which was passed by the WHO Regional Committee for Africa
in September 2000, aims to highlight the high and growing burden of
noncommunicable diseases and galvanize governments into action.
Helmet laws can reduce deaths.
Limited data
The limited data on noncommunicable diseases in Africa and shortage of sur-
veillance systems are important challenges. Surveillance systems play a key role
in informing prevention and control programmes. The implementation of STEPS
- a surveillance method based on risk factor approach — in Algeria, Eritrea,
Cameroon and the Republic of the Congo shows that this method is feasible and
affordable. A further six countries were being technically and financially supported
to conduct STEPS surveys in 2005 (see Table 4.4).
Noncommunicable disease in Africa
Table 4.4
A stepwise approach for prevention and control of noncommunicable diseases
Resource level National level
Population appproaches
Community level
Step 2:
Expanded
WHO Framework Convention on
Tobacco Control (FCTC) is ratified in the
country.
Tobacco control legislation consistent
with the elements of the FCTC is
enacted and enforced.
A national nutrition and physical activity
policy consistent with the Global
Strategy is developed and endorsed at
Cabinet level; sustained multisectoral
action is evident to reduce fat intake,
reduce salt (with attention to iodized
salt where appropriate), and promote
fruit and vegetable consumption.
Health impact assessment of public
policy is carried out (for example:-
transport, urban planning, taxation and
pollution).
Tobacco legislation provides for
incremental increases in tax on tobacco,
and a proportion of the revenue is
earmarked for health promotion.
Food standards legislation is enacted
and enforced; it includes nutrition
labelling.
Sustained and well-designed national
programmes (counter-advertising) are
in place to promote non-smoking
lifestyles.
Country standards are established that
regulate marketing of unhealthy food
to children.
Capacity for health research is built
within countries by encouraging studies
on noncommunicable diseases.
Local infrastructure plans include the
provision and maintenance of accessible
and safe sites for physical activity (such as
parks and pedestrian-only areas).
Health-promoting community projects
include participatory actions to cope
with the environmental factors that
predispose to risk of noncommunicable
diseases: inactivity, unhealthy diet,
tobacco use, alcohol use, etc.
Active health promotion programmes
focusing on noncommunicable diseases
are implemented in different settings:
villages, schools and workplaces.
Sustained, well-designed programmes
are in place to promote:
• tobacco-free lifestyles, e.g. smoke-free
public places, smoke-free sports;
• healthy diets, e.g. low-cost, low-fat
foods, fresh fruit and vegetables;
• physical activity, e.g. "movement" in
different domains (occupational and
leisure).
Recreational and fitness centres are
available for community use.
Individual high-risk approach
Context-specific management guidelines
for noncommunicable diseases have been
adopted and are used at all health-care
levels.
A sustainable, accessible and affordable
supply of appropriate medication is
assured for priority noncommunicable
diseases.
A system exists for the consistent, high
quality application of clinical guidelines
and for the clinical audit of services
offered.
A system for recall of patients with
diabetes and hypertension is in
operation.
Systems are in place for selective and
targeted prevention aimed at high-risk
populations, based on absolute levels
of risk.
Opportunistic screening, case-finding
and management programmes are
implemented.
Support groups are fostered for tobacco
cessation and overweight reduction.
Appropriate diagnostic and therapeutic
interventions are implemented.
Source: The world health report 2003. Geneva: World Health Organization: 2003.
e African Regional Health Report
Conclusion: Africa can learn from others' experience
Despite all the obstacles, a unique opportunity exists for governments in the African
Region to produce and implement bold policies that can have large health benefits.
The greatest gains would be in some of the poorest nations, where perhaps 10
more healthy life years might be achievable at relatively low cost. In order to achieve
these gains, governments need to shift their main public health focus from a mi-
nority of high-risk individuals to include preventative measures that can be applied
to the whole population. A coherent government-led strategy including legislation,
regulation, protection of human rights, and education of the public is needed. It
is imperative that the various government departments such as health, transport
and education work together to ensure comprehensive interventions. In addition,
collaboration between government, nongovernmental organizations, the media and
others should be encouraged and expanded. The world health report 2003 recom-
mended a stepwise framework for the prevention and control of noncommunicable
disease. Focusing on increased taxes on tobacco, legislation to reduce salt levels
and stronger health safety and promotion alone would produce impressive results.
Many developed countries are only now realizing the value of health promotion
strategies, such as tobacco control. African countries have the opportunity to learn
from the mistakes made in developed countries and to act early before the growing
"epidemic" of noncommunicable disease gets out of control. •
Despite all the obstacles,
a unique opportunity
exists for governments
in the African Region to
produce and implement
bold policies that can have
large health benefits.
Noncommunicable disease in Africa
Bibliography
• Atlas: country profiles of mental health resources. Geneva: World Health Organization; 2001. Available from: http://
whqlibdoc.who.int/hq/2001/WHO_NMH_MSD_MDP_01.3_P1.pdf
• Barker DJP, Osmond C, Winter PD, Margetts B, Simmonds SJ et al. Weight gain in infancy and death from ischaemic heart
disease. Lancet 1989,2:577-80.
• Beaglehole R, Yach D. Globalisation and the prevention and control of non-communicable disease: the neglected chronic
diseases of adults. Lancet 2003:362:903-8.
• Bradshaw D, Groenewald P, Laubscher R, Nannan N, Nojilana B, Norman R, et al. Initial estimates from the South African National
Burden of Disease Study, 2000. Pretoria: South Research Council 2003. Available from: http://www.mrc.ac.za/bod/bod.htm
• Cappuccio FP, Micah FB, Emmett L, Kerry SM, Antwi S, Martin-Peprah R, et al. Prevalence, detection, management, and
control of hypertension in Ashanti, West Africa. Hypertension 2004:43:1017-22.
• Coleman R, Gill G, Wilkinson D. Noncommunicable disease management in resource-poor settings: a primary care model
from rural South Africa. Bulletin of the World Health Organization 1998:76:633-40.
• Department of Health, Republic of South Africa and Measure DHS+. South Africa Demographic and Health Survey 1998: Full
Report. Pretoria: Medical Research Council; 2002.
• Dowse GK, Gareeboo H, Alberti KG, Zimmet P, Tuomilehto J, Purran A, et al. Changes in population cholesterol
concentrations and other cardiovascular risk factor levels after five years of the non-communicable disease intervention
programme in Mauritius. Mauritius Non-communicable Disease Study Group. BMJ 1995;31 1:1 255-9.
• Eriksson GJ, Forsen T, Osmond, C, Barker DJP et al. Early growth and coronary heart disease in later life: longitudinal study.
BMJ. 2001:322:949-53.
• Foster A. Vision 2020: The Cataract Challenge. Community Eye Health 2000,13:17-9.
• Guindon GE, Boisclair D. Past current and future trends in tobacco use. Washington, DC: The International Bank for
Reconstruction and Development/The World Bank; 2003. Economics of Tobacco Control Paper No 6. Available from: http://
www1.worldbank.org/tobacco/pdf/Guindon-Past,%20current-%20whole.pdfhttp://www.measuredhs.com/
• Kolawole BA, Adebayo RA, Aloba 00. An assessment of aspirin use in a Nigerian diabetes outpatient clinic. Nigerian journal
of medicine: journal of the National Association of Resident Doctors of Nigeria 2004:13:405-6.
• Magnus P, Beaglehole R. The real contribution of the major risk factors to the coronary epidemics: time to end the "only-
50%" myth. Archives of internal medicine 2001:161:2657-60.
• Mahy M, Gupta N. Trends and differentials in adolescent reproductive behavior in sub-Saharan Africa. Calverton (MA): ORC
Macro; 2002. DHS Analytical Studies No. 3.
• Murray CJ, King G, Lopez AD, Tomijima N, Krug EG. Armed conflict as a public health problem. BMJ 2002:324:346-9.
• Nigeria Demographic and Health Survey 1990. Lagos: Federal Office of Statistics and Colombia (MA): IRD/Macro
International, Inc; 1992. Available from: http://www.measuredhs.com/
• Nigeria Demographic and Health Survey 2003. Lagos; National Population Commission, Federal Republic of Nigeria and
Calverton (MA): ORC Macro; 2004. Available from: http://www.measuredhs.com/pubs/pdf/FR148/OOFrontMatter.pdf
• Odero W, Khayesi M, Heda PM.Road traffic injuries in Kenya: magnitude, causes and status of intervention. Injury Control
and Safety Promotion 2003:10:53-61 .
• Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, et al. World report on road traffic injury prevention. Geneva:
World Health Organization; 2004.
• Peden M, van der Spuy J, Smith P, Bautz P. Substance abuse and trauma in Cape Town. South African Medical Journal
2000:90:251-5.
• Peden MM, Knottenbelt JO, van der Spuy J, Oodit R, Scholtz HJ, Stokol JM. Injured pedestrians in Cape Town — the role of
alcohol. South African MedicalJournal 1996;86:1 103-5.
• Status of infant and young child feeding in sub-Saharan Africa, situation analysis. Brazzaville: WHO Regional Office for Africa; 2001 .
African Regional Health Report
Tsugane S. Sasazuki S, Kobayashi M, Sasaki S. Salt and salted food intake and subsequent risk of gastric cancer among
middle-aged Japanese men and women. British Journal of Cancer 2004:90:128-34.
Van Damme PA: Sokoto noma-team 19, September 2002. Noma. Lancet Infectious Diseases 2004;4:73.
Walker RW, McLarty DG, Kitange HM, Whiting D, Masuki G, Mtasiwa DM, et al. Stroke mortality in urban and rural
Tanzania. Adult Morbidity and Mortality Project. Lancet 2000:355:1684-7.
WHO Regional Office for Africa, Noncommunicable Diseases: A Strategy for the African Region. AFR/RC50/10, 2000.
WHO Regional Office for Africa, Health Promotion: A Strategy for the African Region, AFR/RC51/12 REV1, 2001.
WHO Regional Office for Africa, Mental Health: A strategy for Mental Health, AF/RC49/9, 1999.
The world health report 2001 Mental health: new understanding, new hope. Geneva: World Health Organization. 2001 .
Available from: http://www.who.int/whr/2001/en/index.html
The world health report 2002: reducing risks, promoting healthy life. Geneva: World Health Organization; 2002. Available from:
http://www.who.int/whr/2002/en/index.html
The world health report 2003: shaping the future. Geneva: World Health Organization; 2003. Available from: http://www.who.
int/whr/2003/en/index.html
The world health report 2004: changing history. Geneva: World Health Organization; 2004.
World report on violence and health. Geneva: World Health Organization; 2002. Available from: http://whqlibdoc.who.
int/hq/2002/9241 54561 5.pdf
Noncommunicable disease in Africa
Chapter 4
I
I , ' I i
Health an
environment in Africa
V
Key messages
Rapid urbanization poses major environmental health risks
Widespread poverty limits ability to address environmental problems
Inadequate access to safe water and sanitation exposes people to disease
Emergencies cause a deterioration in the environment and in the health of
people affected
Solutions
Scale up sustainable, low-cost solutions for water and sanitation
Countries and international organizations need to work more closely
together to prevent and resolve conflict
Scale up food safety and hygiene education
Closer cooperation between government ministries and other sectors to
make the environment more healthy
Health and the
environment in Africa
Environmental health risks in Africa
People living in the African Region face a number of environmental health risks.
High levels of air pollution, both within and outside the home, unsafe water
supplies, inadequate sanitation and unhygienically prepared food are wide-
spread in many parts of the Region. Rapid urbanization has left millions of people
living in informal settlements lacking basic services — in the kind of environments
that easily foster disease and high levels of stress and violence. In some parts of the
Region, these day-to-day environmental threats are exacerbated by armed conflict
and natural disasters. Apart from their direct impact, such events have an effect on
the environment of people beyond the immediately affected area.
One of the main factors that determine environmental conditions and ill-health
is the huge and seemingly intractable issue of poverty. Poverty limits people's ability
to address the environmental factors that cause ill-health.
Urbanization can mean more affluence but also more pollution and different en-
vironmental risk factors compared to those faced by people living in rural communi-
ties. Clean water and sanitation facilities and functioning health systems, including
immunization programmes and effective health education, need to be provided for
people in areas that have undergone rapid and unplanned urbanization. Electrical
power networks need to be constructed for these people to replace open fires. All of
this requires money.
There are also a number of emerging environmental risks to health in the
African Region such as ecosystem degradation and climate change. These are likely
to increase the impact of current risks related to water availability, food producing
ecosystems or changes in patterns of diseases, such as malaria.
Global efforts aimed at achieving the Millennium Development Goals (MDG) —
especially MDG I to halve the number of people living in extreme poverty — could
tealth and the environment in Africa
Fig. 5.1
Sanitation coverage in the African Region
% of population using
improved sanitation *
• Less than 50%
D 50-75%
• 91-100%
D Countries outside the
African Region
Source: Based on: Meeting the MDG drinking-water and sanitation target a mid-term assess-
ment of progress. Geneva; World Health Organization: New York; UNICEF; 2004. Fig.7, p.12.
* No countries in the African Region were included in the 76-90% category.
help to improve standards of living in the African Region. WHO and other agencies
are working to make the environment in African countries more healthy and to re-
duce factors that predispose people to poverty.
Challenges in the environment
Water and sanitation
Access to a safe water supply and proper sanitation are essential parts of a healthy
environment (see Fig. 5. 1). Without safe water for drinking and for use in food
preparation, populations are vulnerable to an array of waterborne diseases includ-
ing cholera, typhoid and other diarrhoeal infections as well as to parasites, such as
guinea worm and schistosomes.
The UNICEF/WHO Joint Monitoring Programme
for Water and Sanitation found that within developing
regions in 2002 the percentage of the population of sub-
Saharan Africa with access to a safe water supply was
58%, with only the Pacific region having a lower rate.
Coverage was low despite a concerted global effort. There
have been two international drinking-water decades. The
first was from 1 98 1 to 1 990, the second was launched in
2005. Global efforts have helped provide more than a bil-
lion people with safe water, producing a global coverage
of access to drinking-water of 83%. But while access to
safe water has improved, coverage for sanitation remains
low. Only 58% of the world's population has access to
adequate sanitation facilities, but sub-Saharan Africa has
the lowest proportion of all, at just 36%. These figures
show that the coverage of programmes to provide water
and sanitation is too low and that they need to reach
many more people.
Hundreds of thousands of Africans, particularly chil-
dren, die every year from diseases caused by microorgan-
isms, certain chemicals in the water supply, or diseases caused by poor sanitation.
Poor water and sanitation also bring with them a host of non-fatal but debilitating
diseases as well as severe problems of environmental degradation that have a further
impact on health.
However, great strides have been made in the last 10 years in developing low-
cost solutions and sustainable community-management approaches, such as the
participatory hygiene and sanitation transformation (PHAST) approach, ecological
sanitation and the AFRICA 2000 initiative to increase water supply and sanitation
coverage in Africa. The PHAST approach involves community participation, which
makes such projects more likely to be maintained and continued into the future.
The African Regional Health Report
Management of both solid and liquid waste is another environmental health
problem in the African Region. Uncontrolled dumping attracts salvaging, vermin and
vectors of diseases. Many communities inhabit old dump-sites, exposing themselves
to a range of toxic risks and burns from explosions of built-up gases, plus risk of in-
fections from the mixing of medical waste with other types of waste. Regular waste
collection is far from adequate in urban areas. Waste dumped into storm drains,
creeks, lagoons and other waterways also creates serious environmental problems
that can turn into disasters.
Pollution and industrial waste
Air pollution is one of the most serious environmental problems in the African
Region and a major threat to public health, especially in urban areas (see Table 5.1 ).
As cities grow, more vehicles, industries, homes and power stations are contributing
to the pollution load.
Children are more susceptible to the adverse
effects of indoor air pollution than adults. Indoor
air pollution has a direct impact on people's health.
Most people living in rural areas, informal settle-
ments and city slums in the African Region rely on
traditional fuels such as crop residues and fire-
wood for cooking and heating. These low-quality
fuels — combined with inefficient stoves and poor
ventilation — create high levels of pollutants inside
the home, often many times greater than outdoor
air pollution levels. Urban air pollution contrib-
utes to illnesses, such as lung cancer, heart disease,
asthma and bronchitis.
Cities may face many environmental prob-
lems, but rural areas have their problems too.
There is less provision of waste disposal in rural
areas than in urban areas. Indoor air pollution in
traditional mud huts has been linked to acute re-
spiratory infections, but in recent years some rural
communities have found innovative ways to tackle the problem, such as the instal-
lation of smoke hoods in Kenya (see Box 5.1 ).
Chemical pollution is another environmental source of damage to health in the
African Region. Exposure to certain chemicals can cause effects ranging from acute
intoxication to birth defects and cancer. Hazardous practices in agriculture or public-
health use of certain chemicals have had profound repercussions on health. The use
of DDT is a particular problem. Banned in much of the world because it remains in
the soil long after it has been applied and can travel great distances, this pesticide is
used in some parts of Africa in the absence of cheaper alternatives and because of
its effective role in vector control. DDT is only used at particular times of the year in
Table 5.1
Deaths and DALYs attributable to
indoor air pollution from solid fuel
in the African Region, 2000
Attributable
% of total in
the Region
Mortality
12318000 392000
3.4 3.5
" Please see glossary for explanation of DALYs
Source: World health report 2002
Children play on oil pipelines in
Okrika, Nigeria.
alth and the environment in Afric
Chapter b
Clearing the air with smoke hoods in Kenya
Happiness Lemuliet, 37, is delighted with the new smoke extrac-
tor that has been installed in her traditional hut. "This thing has
changed my life," says Lemuliet, a mother of six from Kenya's
Maasai community in Kajiado, a rural district near the capital,
Nairobi. "My children can now study in the evening, and they
don't get colds and coughs as often as they used to."
The hood clears at least 80% of indoor smoke, dramatical-
ly lowering health risks, according to Intermediate Technology
Development Group (ITDG), the nongovernmental organization
which developed it.
In Kajiado, where an initial 25 homesteads were involved
in the pilot project, the smoke extraction system consists of
a fireplace base, a smoke hood and a lightweight chimney
to take smoke out of the house. The smoke hood is a simple
frame made of sheet metal that is installed above the cooking
fire, drawing smoke towards the chimney. It can easily be
dismantled and transported on animals to the next homestead,
and costs from US$ 20 to US$ 70. The Maasai community were
closely involved in developing the ventilation systems, as the
smoke hoods, fireplace bases and chimneys were constructed
locally using old water drums, scrap metal and anthill soils.
Adaptability and low cost are essential in communities
where more than half the people live on less than US$ 1 a day
and rely on biomass — especially firewood, charcoal, dry dung
and crop waste — for heating and cooking. In urban areas,
the rising cost of wood is driving people to burn plastic, which
emits even more dangerous by-products.
The result is that indoor environments in many of the
country's households are highly polluted. Traditional hut
designs, such as the Maasai's windowless mud-and-dung
shelters, compound the problem through poor ventilation.
"Our research in Kajiado shows that the indoor environ-
ment in a traditional Maasai hut has particulate levels up to
100 times those accepted internationally," Dr Jacob Kithinji,
a consultant to the ITDG project and lecturer at the University
of Nairobi's Department of Chemistry says. "In western Kenya,
where hut design is circular with a thatched roof, particulate
levels are usually about 20 times higher than the international
standard — still very dangerous levels."
"Children from poorly ventilated households have an
especially difficult time coping with domestic chores and school
work," says Justin Nyaga, the Kenyan manager of ITDG's indoor
smoke programme. "These children have a high incidence of
coughs, upper respiratory infections and eye irritation."
"In Kajiado, the smoke hoods have made a good impact,"
says Nyaga. "The houses are cleaner and children are able to
study."
"The intervention should be participatory in all
aspects," says Nyaga. "It should take account of culture
and hut design, local sensibilities, available resources and
the traditional knowledge base, as well as sustainability
and cost-effectiveness."
Woman cooking on a fire under a
smoke hood in Kajiado, Kenya.
Africa when there are lots of mosquitoes, or for vector control in exceptional circum-
stances. For example, when a refugee population arrives in a malaria-endemic area,
the use of DDT is sometimes necessary to protect the refugees, who — coming from
an area where malaria is not endemic — are particularly vulnerable to the disease.
The accumulation of chemical waste is also becoming a serious problem,
and one which communities are facing as urban growth has brought residential
areas close to previously isolated chemical plants, and towns have been built
over former waste disposal sites. The long-term effect of exposure to compounds
The African Regional Health Report
such as polychlorinated biphenyls, potent pes-
ticides, accelerators and plasticizers has yet to be
studied and quantified. In addition to industrial
waste, there are problems associated with health-
care waste from medical facilities which pose a
risk to human health. This is because such waste
is often contaminated with infectious agents,
such as HIV and the hepatitis B virus. Efforts to
improve the situation have included the adoption
of low-cost incinerators and other technologies.
Many countries in the African Region also
have yet to enact regulations to control the levels
of lead in fuels used for road vehicles. Particularly
in urban areas, dispersed lead emissions from vehi-
cles that run on leaded gasoline, as well as indus-
trial emissions from smelters and battery recycling
plants, contribute to poor air quality.
Urbanization
From being an overwhelmingly rural part of the
world just 20 years ago, Africa is urbanizing rap-
idly and its population is well on the way to be-
coming primarily an urban one. The annual aver-
age urban growth rate in Africa is 3.6%, one-third
higher than in Asia and more than two-thirds
higher than in Latin America. Currently 37% of
Africans live in cities, but by 2030 this proportion
is expected to reach 53%.
Rapidly expanding cities are often charac-
terized by slum-dwelling, inadequate water and
sanitation services and wastewater problems.
Currently, 72% of city-dwellers in sub-Saharan
Africa live in slums. The lack of effective waste
disposal services is becoming a major problem.
Lagos, Africa's largest city with an estimated
population of 1 5 million people, is trying to crack
down on illegal waste dumping with mixed
results (see Box 5.2).
Informal urban settlements without adequate
sanitation, water, transport or health services
make very unhealthy environments. Microbes
flourish and infectious diseases become epidemic.
The overcrowding that always accompanies rapid
Tackling mountains of waste in Lagos
Taofeek Raheem earns his living by working as a household refuse collector
in Lagos. He fills his cart with household waste collected for a fee, and then
rummages through this waste in the hope of finding something he can sell.
Once he has finished, he pushes the waste to a legal dump site. Taofeek is
registered to take waste to this dump site, but the problem is that many cart
pushers are not registered and dump waste illegally in the city.
Lagos has been beset with the difficulties of clearing over 10 000
tonnes of solid waste generated daily. The city's population has grown
from 5.7 million people in 1991 to an estimated 15 million in 2005. Many
new arrivals, often unskilled youths like Taofeek, turn to the streets for
shelter and to the dumps for a livelihood.
During this rapid expansion, city officials have experimented with ev-
ery conceivable ploy to rid the streets of the mounds of refuse that often
squeeze pedestrian and road traffic routes into little more than narrow chan-
nels, including private sector participation (PSP), the use of highway manag-
ers and the registration of neighbourhood refuse cart pushers like Taofeek.
Gbolahan Sulaiman, spokesman for Lagos Waste Management
Authority, says that indiscriminate dumping is an added complication:
"It costs more to evacuate loose waste than bagged refuse". Sulaiman
blames the illegal operators for the dumping of refuse in the Lagoon, on
the strip of land in the middle of the road and on the side of motorways.
Despite several strategies adopted to address the menace, mountains
of refuse still litter the streets, public places, markets and bus stops, with
the side or middle of highways becoming the unofficial communal dump-
sites in most neighbourhoods. In many areas, a heavy pall of smoke emanat-
ing from these dunghills settles permanently over the surrounding areas.
Professor Jide Alo, an environmentalist from the University of Lagos,
says the state waste management authority is genuinely overwhelmed by the
volume of refuse generated in the city. He believes that until the environmen-
tal concept known as the "polluter pays principle" is effectively implemented
and various agencies working on refuse collection are empowered with funds,
the problem will persist.
Making a living from waste in
Lagos, Nigeria.
Health and the environment in Africa
Poor handling
and preparation
of staple foods are
of concern in both
urban and rural
communities, especially
when traditional food
preparation technologies,
such as fermentation,
are used.
urbanization contributes to a host of social and behavioural problems including
disintegration of families, homelessness, crime, violence, drug use and sexual abuse,
and each of these problems spawns its own set of health risks to the people living
within these settlements.
The WHO Regional Office for Africa is working with a number of countries to
help tackle the negative environmental consequences of urbanization as part of the
Healthy Cities project. So far, Cameroon, the Central African Republic, Ethiopia,
Kenya, Mozambique, Namibia, Niger, the Republic of the Congo, Togo, Zambia and
Zimbabwe have developed plans to address the poor environments in their cities
that are caused by inadequate water and sanitation, illegal refuse dumps and unsafe
handling of food.
Food safety
The shift in population throughout the African Region from rural communities to
largely informal urban settlements has brought a fundamental change in eating hab-
its. Whereas in the rural setting food is usually prepared and served in the home,
poorer city-dwellers frequently have neither the facilities nor space to store and pre-
pare food nor the time and resources to gather ingredients and ensure that prepara-
tion is adequate. As a result, the use of street food vendors and the consumption of
ready-to-eat food have soared.
Hygiene arrangements among vendors of cheap ready-to-eat food are often very
poor in most developing countries (see Box 5.3). Adequate running water, toilets
and washing facilities are rare, many vendors fail to disinfect surfaces or wash their
hands, food is not usually protected from insects and refrigeration is seldom avail-
able. Poor food-handling increases the transmission of microorganisms including
Campylobacter spp.. Salmonella spp., the hepatitis A virus and Escherichia coli (E.
coli). Practices such as using the same tools for cutting all ingredients, sharing tools
with other vendors and using the same water both for washing ingredients and for
dishwashing all add to the risk of food becoming contaminated.
Inadequate refrigeration and storage increase the incidence of food poisoning.
Contamination with pesticides, mycotoxins, other naturally occurring toxins, indus-
trial chemicals and heavy metals is an ongoing problem, as is the use of antibiotics
in animal husbandry, which brings with it the risk of transferring antibiotic-resistant
pathogens. The use of sewage sludge and animal manure as agricultural fertilizer is
another source of food contamination.
Poor handling and preparation of staple foods are of concern in both urban and
rural communities, especially when traditional food preparation technologies, such
as fermentation, are used. For example, konzo, a disease that causes paralysis, occurs
in rural Africa as a result of insufficiently processed cassava, a food staple in many
African countries. There are also concerns about the safety of some of the products
received as food aid.
Because of the informal, fragmented nature of much of the food-supply chain
in the Region, ensuring food safety is difficult. Outbreaks of disease are often well
The African Regional Health Report
Making street foods safer in Ghana
Street food vendors are important in die African Region. They
feed millions of people every day. But studies in Ghana show
that street food has often been prepared in an unhygienic way.
sparking concerns over the health risks.
Nine-year-old Setorwu eats breakfast at home before
leaving for school. For his lunch, his parents give him 2000
cedis (USS 0.25) to buy lunch from the street food vendor. His
father, Christian, a public servant, does not eat breakfast at
home. His only meal at home on weekdays is dinner. Both
Setorwu and his father patronize street food vendors. Many
Ghanaians like Setorwu and his father rely on street vendors
for many of their meals.
These vendors play a key role in providing as many as
three meals a day for schoolchildren, workers, families, travel-
lers, migrants and itinerant traders in Ghana. And they are
everywhere: from the street corners, where the food is sold
on tables, to the women who go from house-to-house car-
rying food in baskets on their heads to local canteens
known as "chop bars". Food vendors also operate
at work places and construction sites where they
are popular, as they open credit lines for workers.
Their menus range from beverages such as tea and
coffee to porridge and more substantial meals.
But Ghana's health authorities have been warning for
some time that some street food may be unsafe and calling for
more control over the ingredients that go into street food and
over the way this food is handled, prepared and stored.
Poor food-handling increases the
transmission of microorgan-
isms including Campylo-
bacterspp.. Salmonella spp..
hepatitis A virus and £ coli.
There are training programmes for food handlers and
consumers on safe food-handling and personal hygiene. Ghana
has adopted the hazard analysis critical control point (HACCP),
an internationally established system, which predicts for pre-
ventive action the points in the food chain where contamination
could occur.
But although Ghana has food safety regulations and has
adopted the HACCP system, officials there say these are not
being implemented rigorously enough. A survey conducted
among street vendors in the capital. Accra, shows that 18%
of them would associate diarrhoea with germs but none was
aware that dirty hands were a risk factor for diarrhoea.
ff.
Street food vendors often make
do with minimal equipment
advanced before they come to the attention of health authorities. In Kenya in 2004.
for example, an outbreak of acute aflatoxicosis due to consumption of contaminated
maize led to 3 1 7 reported cases and 1 25 reported deaths. The heavy toll of death and
disease associated with such outbreaks could be prevented by effective surveillance
and monitoring systems. During this outbreak, laboratories were improved to test for
food aflatoxins and other mycotoxins. and surveys were carried out to identify pre-
disposing factors and to assess the magnitude of the problem. The laboratory tests
allowed contaminated maize to be removed from the food supply system and from
households, destroyed and replaced with "clean" food.
merit in Afric
Chapter 5
Emergency situations
The African Region continues to struggle under the severest onslaught of man-made
disasters and disasters associated with natural hazard. In January 2006, of 46 coun-
tries worldwide that WHO'S Health Action in Crisis unit listed as experiencing a
crisis, 25 were in the African Region. In 2006, Southern Africa and the Horn of Africa
faced the "triple threat" of food shortage, increasing HIV/AIDS prevalence and natu-
ral hazards, while the Great Lakes region and West Africa faced complex humanitar-
ian emergencies. The impact on the environment in countries affected by these crises
— and to some extent on their neighbours' environment — is immense.
Civilians are more likely to suffer the most as a result of illness caused by com-
municable diseases, untreated chronic conditions, reproductive ill-health or violence
when there is no rule of law. There are also crises or emergency situations that de-
velop slowly and insidiously — such as those caused by HIV/AIDS — and these can
have a profound and long-term impact on society.
In health terms, the direct effects of war, civil conflict, floods, droughts, famine
and infectious disease are formidable. These factors reduce the resilience of people
and of health systems, and they are quickly compounded when shelter, water, nutri-
tion, security, sanitation and disease control are inadequate. The primary threat to
people's health is posed by common illnesses because these are made even more
dangerous by the crisis conditions. The most vulnerable people are the first to suffer
and die in crisis situations.
Healing post-conflict societies by healing peoples' minds
Mental health is often neglected in the places it is needed
most. There is a peace, of sorts, in Liberia. Former combat-
ants have faced each other across a cabinet table and an
election has been held. Psychiatrists say international donors
fail to realize that re-establishing a mental health system in a
country like Liberia is of vital importance and can contribute
to a stable society that is more able to develop socially and
economically.
WHO consultant Danish psychiatrist Dr S0ren Buus
Jensen assessed post-conflict mental health needs in Sierra
Leone to neighbouring Liberia. He says he could have reduced
his report on Liberia to four words: "Needs: immense.
Resources: none". He says that people with mental illness
are some of the most marginalized members of society and
providing care for them is not just a public health but also a
human rights issue. "They have their voices in their heads and
no voices speaking on their behalf," Buus Jensen says.
In Sierra Leone, the country's only psychiatrist Dr Edward
Nahim agrees: "Sierra Leone is a post-conflict and a low-income
country. Therefore mental health should be the number one prior-
ity, but unfortunately it is completely neglected".
The prevalence of mild and moderate common mental disor-
ders in any given general population is 10%, while that of severe
mental health problems, such as psychosis or severe depression,
typically affect 2-3% of any given population but can increase to
3-4% after a disaster. For the traumatized populations of post-
conflict states, the mental health needs are even greater.
When he arrived in Liberia in 2004 the consultant said that
"not one patient was in treatment" and the country's only psy-
chiatric hospital had long been destroyed. He argues that unless
people with mental disturbances in fragile societies are treated,
there is little hope of ending the cycle of violence that hampers
social and economic development.
"It doesn't take a lot of psychotic patients to terrorize a
village. If we don't do anything there is no chance to create a
healing environment where justice and democracy might grow.
We get a lot of sympathy, but no money. We can't pay a salary to
anyone, we can't set up a pilot project to show what is possible."
The African Regional Health Report
Common preventable and treatable illnesses such as diarrhoea, malaria, mea-
sles, malnutrition and respiratory tract infections claim a disproportionate number
of lives, while diseases such as meningitis and cholera can quickly flare into epidem-
ics, exacerbated by endemic malnutrition and malfunctioning health systems. The
conditions leading to epidemics are caused mostly by secondary effects and not by
the primary hazard, except in the case of flooding, which can cause an increase in
waterborne and vector-borne diseases. Disasters can result in the rupture of water
mains and sewerage systems or the interruption of electricity supplies required to
pump water.
In addition, in post-conflict situations mental health problems require special-
ized treatment (see Box 5.4).
Sudden, large-scale movements of people between and within countries often
produce emergency conditions. Dramatic loss of livelihoods and increased spending
due to emergencies can place people in a precarious situation. Epidemic diseases,
such as cholera, can easily overwhelm the capacity of an under-resourced health
service, triggering an urgent need for support.
The length of time that people spend in temporary unassisted settlements is
an important determinant of the risk of disease transmission. The prolonged mass
settlement of refugees in temporary shelters with only minimal provision of essential
services is typical of a situation that can cause outbreaks of infectious diseases.
In the Democratic Republic of the Congo, an estimated 3.3 million people died
as a result of the war between 1998 and 2002, according to the International
Rescue Committee (IRC) study on mortality in the Democratic Republic of
the Congo. Dubbed Africa's "first world war"
because at least six nations were involved,
the conflict was characterized by extreme vio-
lence, mass population displacements, wide-
spread rape, and a collapse of public health
services. The outcome has been a humanitar-
ian disaster, unmatched by any other in recent
decades.
Crises are often characterized by a high
level of sexual violence against women and
young children. WHO published guidelines
with UNHCR for health workers on best
practice in the care and treatment of victims
of sexual violence in 2004. WHO ran projects
in the Democratic Republic of the Congo and
in Liberia from 2004 to December 2005 to
address the health and psychological effects
of sexual violence. These provided specialized
training for health workers, counselling centres and medical supplies. As part of the
projects, lawmakers received advice on drafting legislation on sexual violence and
training was provided for community health leaders to fight sexual violence.
I
A refugee family carrying their
belongings out of reach of the
water when the first heavy rains
near Bahai, Chad, flooded the
seasonal riverbed.
Health and the environment in Afric
Chapter 5
Determined efforts to
make the environment
in the African Region
healthier are frequently
hampered by the nature of
the underlying problems,
not least of which is
poverty. The challenges
of tackling poverty are
considerable, but there are
tried and tested solutions
that are achieving results
and need to be scaled up.
As many as two million people have been displaced after two decades of con-
flict in northern Uganda. A study of internally displaced people in three districts in
northern Uganda showed that in the first six months of 2005 a cumulative excess
mortality of 25 694 persons was calculated. Malaria and HIV/AIDS were the two top
causes of death reported by people surveyed, while violence was found to be the
third most frequent cause of death. The crude mortality rate and under-five mortality
in two of the districts were four times the overall levels in non-crises areas of sub-
Saharan Africa.
Thousands of farmers lost their crops during an invasion of locusts in West
Africa from April to December 2004 leading to food shortages across the region. In
parts of some countries, including Burkina Faso, Chad, Mali, Mauritania, Niger and
Senegal, the price of food — especially millet — doubled.
Angola's recent history also demonstrates the links between crisis situations
and outbreaks of infectious disease. In April 1999, Angola suffered one of the larg-
est polio outbreaks ever recorded in Africa. The outbreak came after 30 years of
war and destruction of health services, massive population displacement that had
resulted in overcrowding, poor sanitation and inadequate water supply — an ideal
environment for the spread of the poliovirus. In March 2005, an outbreak of Marburg
haemorrhagic fever in Angola led to 329 deaths, making it the most deadly outbreak
of Marburg fever to date. There is no cure or vaccine for Marburg. Neither the source
of the outbreak nor the reservoir has been identified to date.
WHO and other UN agencies have many roles to play in crises. One is to evalu-
ate past and current social protection programmes that target vulnerable people.
Another is to support countries in the recovery process. WHO is providing this sup-
port to Angola, Burundi, the Central African Republic, Cote d'lvoire , the Democratic
Republic of the Congo, Eritrea, Ethiopia, Liberia, Mozambique, Niger and southern
African countries among others. This type of assistance represents a shift in focus,
from saving lives to restoring livelihoods. Experience shows that it is possible to
transform disaster into an opportunity to develop the health sector.
Tackling poverty and environmental risks
Poverty reduction
Determined efforts to make the environment in the African Region healthier are fre-
quently hampered by the nature of the underlying problems, not least of which is
poverty. The challenges of tackling poverty are considerable, but there are tried and
tested solutions that are achieving results and need to be scaled up. One initiative
is WHO's strategy on poverty and health in the African Region. Its core idea is that
health is vital for poverty reduction, economic growth and human development.
The strategy aims to promote health system reform that provides poor people with
access to basic health services and to advise non-health sectors on how to factor
The African Regional Health Report
heath issues into policies and practices. The strategy also seeks to shift the focus
of health systems away from the dominance of a curative approach to more health
prevention and promotion.
Conflict prevention and management
The conflict-based emergencies that have been so widespread in the African Region
bring with them a multifaceted set of problems for the environment. As with poverty,
these emergencies can only be tackled by a large and sustained international effort,
or by countries solving conflicts in a peaceful way.
That means improving the management of government incomes from natural
resources, using aid in a better way to tackle the causes of conflict, implementing
international agreements on how to control the conflict resources that fuel or finance
hostilities, and controlling the trade in small arms.
International and African organizations can help prevent and resolve conflict
when tensions cannot be managed at the national level through effective early warn-
ing, mediation and peacekeeping. Coordination and funding of post-conflict peace-
building and development must be improved to prevent states that emerge from
violent conflict from sliding back into it.
WHO'S African Regional emergency and humanitarian strategy urges Member
States to develop or strengthen their capacity to manage emergencies. The recom-
mended methods are focusing on country or areas vulnerable to emergencies through
emphasis on prevention, preparedness and readiness, and capacity-building. Other
recommended methods are training staff and strengthening institutional capacities,
including early-warning systems, and allocation of appropriate resources to create
- where this does not already exist — a National Emergency Fund. Countries are
also urged to integrate emergency and humanitarian programmes and activities
into their national health development plans. Also countries are encouraged to
strengthen community involvement in emergency preparedness and response, and
to identify, classify and map potential sources of emergencies. Effective and well-
prepared relief efforts can transform the most daunting of crises. As a result of this
strategy, several countries have improved their capacity for emergency prepared-
ness and response.
In emergency situations, whether due to human or natural causes, insufficient
resources and preparation render many governments in the Region incapable of miti-
gating the impact on the environment. Humanitarian organizations are often required
to underwrite and administer health interventions in emergencies. But reliance on
outside help inevitably delays the arrival of assistance and increases the period of risk
for the affected population.
Along with other agencies, WHO has also responded by taking a more proactive
role in helping countries to prepare for the health impact of emergencies and put-
ting systems in place to alleviate health problems caused by crises as quickly as
possible.
A key to an effective
response to emergencies
in the African Region is
improving coordination
and technical support
between the people and
governments receiving
relief as well as the
organizations providing it.
Health and the environment in Afric
Chapter 5
WHO's emergency and humanitarian strategy for the African Region, launched
in 1997, contains a series of measures countries can take to be better prepared for
emergencies. WHO is helping Member States to assess health risks and vulnerability,
build technical support for response and improve coordination during crises. WHO
has developed a minimum health package for emergencies, guidelines for action and
other tools for technical support. WHO also helps countries to rebuild destroyed
health systems after a natural disaster or armed conflict.
A key to an effective response to emergencies in the African Region is improving
coordination and technical support between the people and governments receiving
relief as well as the organizations providing it. Crises such as the famine in Ethiopia and
Eritrea and the conflicts in the Central African Republic, the Democratic Republic of the
Congo, Liberia and other West African countries have had an impact on the environ-
ment well beyond the borders of any one country, and coordinated action by govern-
ments in the Region and international agencies is crucial to controlling that impact.
Sustainable, low-cost solutions: water and sanitation
The crucial area of water and sanitation is one where progress has been made, even
if it is slower than hoped. The last 10 years have seen the development of low-cost
solutions and sustainable community-management approaches to this central prob-
lem. Decentralizing responsibility and ownership and providing a choice of service
levels to communities have proven to be particularly effective in improving access
to safe water.
Community-management programmes
run by WHO and other agencies have
shown results. Eor example, schemes using
the PHAST demand-responsive approach
for water and sanitation as well as
ecological sanitation projects. The AFRICA
2000 water and sanitation programme
has also galvanized efforts to improve
safe water supplies and sanitation in the
African Region.
Several countries in the Africa Re-
gion have adopted WHO's healthy set-
tings approach, which focuses on making
cities, schools, villages and food markets
healthier and which is based on the idea
that health depends on a supportive envi-
ronment as well as good health services.
By adopting the healthy settings approach,
these countries are addressing complex ur-
' ban health problems in a holistic way for
Fresh water is an invaluable resource. the first time.
The African Regional Health Report
The tools and expertise needed to run cost-effective programmes for improved
water supplies and sanitation facilities are now readily available, and as awareness
of those tools spreads so too should solid results, in turn, making the environment
more healthy to live in.
One example of an environmentally friendly solution to water-supply problems,
and of the kind of creative thinking that holds the key to solving the problems in this
area, is the play pump: a merry-go-round that also functions as a pump, allowing
children to pump water for their communities while they play.
Water supplies sometimes harbour diseases. One way of tackling waterborne
disease is through environmental control. For example, public health workers in
Malawi are controlling snail populations that carry schistosome parasites in rivers
and lakes to reduce transmission of schistosomiasis (see Box 5.5).
Environmental control of schistosomiasis in Malawi
Around 85% of the estimated 200 million people globally who
suffer from schistosomiasis and the 600 million people at risk
of contracting the disease live in Africa. Africa is now the focus
of considerable international and national efforts to lessen the
ravages caused by this infection.
Most of this effort is going into locating sufferers and pro-
viding them with treatment, but in Malawi, promising research
is being conducted into controlling populations of snails that
transmit the parasites responsible for schistosomiasis, also
known as bilharziasis, in humans.
The country's Bilharzia Control Programme coordinator
Samuel Jemu said environmental control was as important as
identification, treatment, nutrition and sanitation to tackle schis-
tosomes and other intestinal parasites.
His teams give priority to finding what they call "infection
hot spots". These are the snail-rich environments where snails are
passing parasites to water and where the parasites may be picked
up by people collecting water, washing, fishing or playing.
"We look at the habitat and see if it is good for the snail,"
Jemu said. "We try to mobilize communities in those areas to
make sure they clear the waterways," Mr Jemu said. "The water
can then move a little faster and that way no transmission can
take place. We also build footbridges so people have less con-
tact with the water in those areas."
In the past pesticides were used to control snail popula-
tions but this practice was abandoned because of the disastrous
environmental consequences, according to snail expert Dr Henry
Madsen of DBL-lnstitute for Health Research and Development
(Danish Bilharziasis Laboratory).
Peter Furu, Senior Adviser at the institute who was in-
volved in setting up and evaluating the trial programmes in 28
villages on Nankumba Peninsula, leading to conference papers
in 1998 and 1999. said the project was "innovative in its imple-
mentation because it was a health project integrated in a biodi-
versity conservation project in Lake Malawi".
A full evaluation could not be completed after Danish aid
to Malawi was reduced in 2001 , scientists said. The research
linked schistosome transmission and snail numbers to the de-
clining populations of mollusc-eating fish: Lake Malawi's cel-
ebrated cichlids.
Madsen said even if more fish turns out to mean fewer
snails, it will not provide a complete answer to the schistoso-
miasis problem in Malawi or anywhere else. Where funds are
limited and cost-effective drugs are available, it makes sense
to treat people as the first priority. "However, I do believe that
once prevalence has been reduced there will be a great need for
environmental control to get rid of the disease," Madsen said.
Unavoidable contact with snail-infested
water puts many people at risk of
contracting schistosomiasis.
ilth and the environment in Afri
Chapters
Making food safer: a shared responsibility
Improving food preparation and storage can reduce the health risks of unsafe food.
Targeting hygiene practices at a localized level, monitoring the level of hygiene and
disease transmission and educating food handlers have yielded good results.
Through the integrated disease surveillance strategy developed by the WHO
Regional Office for Africa in 1 999, all countries in the Region are now providing data
on cholera, typhoid and infections due to Salmonella spp., Shigella spp. and other
microorganisms. A major constraint is the lack of well trained technical staff, but this
lack is being addressed. Training of such staff in foodborne disease surveillance and
microbiological monitoring has been going on in 10 francophone countries since
2002. There are plans to cover the rest of the countries in the Region in the future.
In the francophone countries of the African Region, there is also an ongoing
project to monitor antibiotic resistance in Salmonella hadar as a result of the Global
Salm-Surv workshops, an international Salmonella surveillance programme initiated
in 2000. Other research activities include microbiological monitoring of food from pro-
duction to consumption as well as imported food products such as infant formula.
MDG 7 on water and sanitation
One of the targets of MDG 7, which is concerned mainly with
environmental sustainability, is to halve the number of people who
do not have sustainable access to safe drinking-water and basic
sanitation by 2015. This target requires coverage of 75% of the
population by improved water sources. In sub-Saharan Africa, that
proportion only rose from 49% to 58% between 1990 and 2002, well
short of the progress needed to reach the 201 5 target.
In the area of sanitation, the target is 66% coverage by im-
proved services by 201 5, but here sub-Saharan Africa is even further
from the goal. From 32% in 1990, coverage had risen to only 36% by
2002. To be on track, it should have reached 49% by that time. There
are some bright spots, however, such as Cameroon, where coverage
was only 21 % in 1 990 but had reached 48% by 2002; Senegal, where
coverage rose from 35% to 52%; and Ghana, rising from 43% to
58%, but progress in general is far too slow.
Improved water source (% of population
without access) in sub-Saharan Africa
Benchmark
50
i Most recent
z
Progress needed
to achieve goal
Goal
1990
2002
2015
Source: WHO/UNICEF Joint Monitoring Programme
for Water Supply and Sanitation - Water for life:
make it happen. 2005.
The African Regional Health Report
Benin and the Republic of the Congo have been working to strengthen surveillance
and microbiological monitoring of foods. The Global Environment Monitoring Sys-
tem/Food Contamination Monitoring and Assessment Programme (GEMS/FOOD)
has been introduced in about 10 francophone African countries through the Third
International Total Diet Study Workshop held in May 2004. A project on the chemi-
cal contaminants in food, in the form of a total diet study — these are the primary
sources of information on the levels of various chemical contaminants and nutrients
in the diet — is planned in Cameroon.
The rising incidence of foodborne disease and the emergence of new microbial
threats to the food-chain prompted the WHO Regional Committee to make food
safety a priority area of work in 2003. The establishment of the Codex Trust Fund in
the same year has allowed many countries in the Region to commit themselves to
implementing international food safety standards.
The food safety resolution endorsed by the Regional Committee for Africa in 2003
calls on Member States to develop or update food safety policies and legislation based
on scientific risk assessment and prevention along the entire food-chain. The idea is
to harmonize national food safety regulations with international food standards and
guidelines, including those set out by the Codex Alimentarius Commission. Under
the 2003 resolution. Member States are also encouraged to integrate food safety in
the curricula from primary school level to higher learning institutions; to incorporate
food safety education and information into training programmes for food handlers at
all levels — consumers, producers, and farmers; to provide functional labora-
tory facilities with adequate resources as part of national surveillance systems; and to
ensure national, subregional and regional coordination and networking.
Botswana, Ghana, and the United Republic of Tanzania have adopted the haz-
ard analysis of critical control points (HACCP), an internationally established system
of food safety management. This system anticipates points in the food chain where
contamination could occur and promotes voluntary controls to prevent them.
Activities are also under way in Burkina Faso, Guinea-Bissau and Kenya to as-
sess the quality and safety of street foods, to educate food handlers and consumers
on safe food-handling and personal hygiene, and to train food control inspectors.
The concept of healthy food markets has been applied in a number of countries, in-
cluding Mozambique, the Republic of the Congo and the United Republic of Tanza-
nia, to improve the safety of food sold in markets. The WHO Five keys for safer food
poster, Bringing food safety home, is being implemented in Botswana, Mozambique
and the Republic of the Congo to educate schoolchildren on food hygiene.
The food safety resolution
endorsed by the Regional
Committee for Africa in
2003 calls on Member
States to develop or
update food safety policies
and legislation.
Health and the environment in Afric
Chapter 5
Conclusion: Tracking progress
Member States, WHO
and partners should work
more closely together to
apply these tried and
tested methods and
knowledge to make the
environment more healthy.
People in the African Region are faced with a wide range of health risks, many of
which are of environmental origin. There are high levels of air pollution, both within
and outside the home, unsafe water supplies, inadequate sanitation and unhygieni-
cally prepared food in most communities in the Region. The Region is also charac-
terized by disparity in health outcomes. The result is poverty, poor transportation,
inadequate housing, poor access to services, especially clean water and sanitation
(see Box 5.6), and stress due to poor social and environmental conditions. Emergen-
cies caused by man-made and natural disasters often result in huge displacement of
populations, which in turn may trigger a deterioration in living conditions and in the
immediate environment.
WHO has been working with its partners in the African Region to improve the
health of the people by applying tried and tested solutions. For example, the PHAST
approach has been applied to tackle problems with water supply and sanitation.
By taking a healthy settings approach, much is being done to improve sanitation in
cities and improve food safety in food markets. Improving food hygiene in the food
industry has largely been achieved through the application of HACCP, while the
WHO Five keys for safer food helps to provide consumer education and has been
particularly useful for educating school children.
WHO has implemented a number of strategies in the African Region to help
Member States make their environments more healthy, notably WHO's 2002
Strategy on Environment and Health, which stresses the development and imple-
mentation of environmental health policies in the health sector. The strategy also
seeks to encourage communities to improve their knowledge and awareness of the
crucial link between the environment and health.
Other strategies include: Poverty and Health: A strategy for the African Region:
Microeconomics and Health: the Way Forward in the African Region; Emergency
and Humanitarian Strategy in the African Region, and others on Food Safety and
Occupational Health. All these strategies provide clear directives on how to alleviate
poverty and reduce contamination of the environment.
These strategies draw on a wealth of knowledge on how to enable the poor to get
the food and health care they need. There is plenty of evidence on how to make sure
food is safe at every point from the farm to the table, and to ensure safety in the work-
place. Methods for preventing and managing emergencies are also known. Member
States, WHO and partners should work more closely together to apply these tried and
tested methods and knowledge to make the environment more healthy and reduce the
burden of diseases of environmental origin in the African Region. •
The African Regional Health Report
Bibliography
• Africa Statement - Water and Sanitation Africa Initiative. Africa Consultative Forum. Abidjan, 17-20 November 199& Geneva: Water
• African Ministerial Conference on Housing and Urban Development 2005. Available from: http://www.housing.gov.za/
amchud/top.html
• AIDS epidemic update December 2004. Geneva: Joint United Nations Programme on HIV/AIDS; 2004. Available from: http://
www.unaids.org/wad2004/EPIupdate2004_html_en/epi04_00_en.htm
• Azziz-Baumgartner E, Lindblade K, Gieseker K, Schurz Rogers H, Kieszak A. Njapau H, et al. Case-Control Study of an Acute
Aflatoxicosis Outbreak, Kenya. 2004 Environmental Health Perspectives 2005.113:1779-83.
• Chitsulo L, Engels D, Montresor A, Savioli L. The global status of schistosomiasis and its control. Acta tropica 2000:77:41 -51.
• Clinical management of rape survivors: developing protocols for use with refugees and internally displaced persons. World
Health Organization, United Nations High Commissioner for Refugees; 2004. Available from: http://www.who.int/
reproductive-health/publications/clinical_mngt_survivors_of_rape/clinical_mngt_survivors_of_rape.pdf
• Coghlan B, Brennan R, Ngoy P, Dofara D, Otto B, Clements M, et al. Mortality in the Democratic Republic of the Congo: a
nationwide survey. Lancet 2006:367:44-51.
• Environmental health in emergencies and disasters: a practical guide. Geneva: World Health Organization, 2002. Available
from: http://whqlibdoc.who.int/publications/9241545410.pdf
• Food Safety and Health: Situation Analysis and Perspectives ( AFR/RC53/R5). Brazzaville: WHO Regional Office for Africa,
Brazzaville, Republic of the Congo; September 2003.
• Health and Environment A Strategy for the African Region (AFR/RC52/10). Brazzaville: WHO Regional Office for Africa,
Brazzaville, Republic of the Congo; 2002.
• Health and mortality survey among internally displaced persons in Gulu. Kitgum and Pader districts. Northern Uganda. Study
partnership: WHO, UNICEF, WFP, UNFPA and IRC under the auspices of the Ministry of Health of the Republic of Uganda,
July 2005). Available from: http://66.102.9.104/search?q=cache:ZWu60LwAeWMJ:www.theirc.org/resources/N-20Uganda-
20MOH-20Survey-20Report-20July-202005-20FINAL.pdf+health+and+mortality+survey+among+internally+displaced+pers
ons+in+Gulu&hl=en
• IASC (Inter Agency Standing Committee) Early Warning-Early Action Report for the IASC WG (3rd Quarter - 20051 Available from:
http://www.humanitarianinfo.org/iasc/
• Meeting the MDG drinking water and sanitation target. New York and Geneva: UNICEF and World Health Organization; 2004.
Available from: http://www.who.int/water_sanitation_health/monitoring/jmp04.pdf
• Mensah P, Yeboah-Manu D, Owusu-Darko K, Ablordey A. Street foods in Accra, Ghana: how safe are they? Bulletin of the
World Health Organization 2002;80:546-54.
• Occupation Health and Safety in the African region: Situation Analysis and Perspectives (AFR/RC54/10) WHO Regional
Office for Africa, Brazzaville, Republic of the Congo; September 2004.
• Our common interest report of the Commission for Africa. London; Commission for Africa; 2005.
• Outbreak of Poliomyelitis -Angola 1999, MMWR, 1999;48:327-9
• Poverty and health: a strategy for the African Region (AFR/RC52/11). WHO Regional Office for Africa, Brazzaville, Republic
of the Congo 2003.
• Regional strategy for emergency and humanitarian action, Report of the Regional Director, AFR/RC47/7. Brazzaville: World
Health Organization, Regional Office for Africa; Brazzaville, Republic of the Congo; 1997. Available from http://www.afro.
who.int/hac/pdf/strategieregional.pdf
• Strengthening the coordination of emergency humanitarian assistance of the United Nations; report of the Secretary General.
Draft from June 2005.
Health and the environment inAfric
Chapters
Supply and Sanitation Collaborative Council. Available from: http://www.wsscc.org/dataweb.cfm?edit_id=164&CFID=82774
2&CFTOKEN=59731633
Technical Guidelines for Integrated Disease Surveillance and Response in the African Region. Brazzaville: WHO Regional Office
for Africa, Brazzaville, Republic of the Congo and Centers for Disease Control and Prevention Atlanta, Georgia, USA; 2001 .
The world health report 2005: make every mother and child count Geneva: World Health Organization; 2005.
T. Tylleskar. The association between cassava and the paralytic disease konzo. ISHS Acta Horticulturae 375: International
Workshop on Cassava Safety. http://www.actahort.org/books/375/375_33.htm
Van Ommeren M, Saxena S, Saraceno B. Aid after disasters. S/WJ 2005:330:1160-1.
WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation. Water for life: make it happen. Geneva: UNICEF/
World Health Organization; 2005.
World urbanization prospects: the 2003 revision. New York: United Nations; 2004.
The African Regional Health Report
-JB
National health systems
— Africa's big public
health challenge
'
Key messages
Health-care delivery is hampered by shortage of health workers and
inadequate infrastructure
Out-of-pocket payments for health care drag people into cycle of poverty
and ill-health
Better health information needed to gauge appropriate public health
response
Half the population in parts of the Region have no access to medicines
Solutions
African governments and their partners should allocate more funds for
health systems
Subsidized health care and social health insurance schemes are needed
Sector-wide approach would allow for effective coordination of domestic
and external resources
Strong health systems would be an effective platform for delivering all
essential health care
National health systems
— Africa's big public
health challenge
^ost countries in the African Region have carried out health sector reforms to
^'f improve their health service delivery. Despite these efforts, health systems
* in many countries of the African Region are weak and not fully functional.
The major constraint on governments is inadequate financial and human resources.
Inevitably these governments welcome international support for their efforts to con-
trol diseases and alleviate suffering. Some "vertical" or single-disease programmes,
provided and funded by external donors, have achieved dramatic results; for exam-
ple, smallpox eradication and progress in the control of polio, guinea-worm disease,
onchocerciasis and measles. However, vertical programmes tend not to address a
major underlying cause of ill-health: weak health systems (see Box 6.1 ). This chapter
is about Africa's big public health challenge — strengthening these weak and dys-
functional health systems.
People get sick and die in many cases because the systems for disease preven-
tion and control are not in place or — if they are — they do not function properly.
Some may argue that building health systems in Africa is prohibitively expensive.
But a groundbreaking experiment in the United Republic of Tanzania proved the
contrary: that it is possible to strengthen health systems at little additional cost with
spectacular public health improvements. It has yet to be seen whether these gains
can be sustained in the two Tanzanian districts where the experiment was carried
out and whether the same approach can be applied successfully in other Tanzanian
districts or in other countries in the Region. The experiment, however, shows that
improved health systems performance can lead to progress in disease control.
Health syste
Chapter6
What is a health system?
A health system includes all actors, organizations, institutions
and resources whose primary purpose is to improve health.
Health systems have several goals. Their primary goal is to pro-
mote, restore or maintain health, but they also aim to be respon-
sive to people's legitimate expectations and financially fair.
Progress towards these goals depends on how well
systems carry out four vital functions. One, service provision
which involves delivering personal and non-personal health
services; two, resource generation which means investing
in people, buildings and equipment; three, financing which
involves raising, pooling and allocating the revenues to
purchase the services; and four, stewardship to provide
oversight and guidance for health.
When these basic components function well together
people tend to live healthier and longer lives. In contrast,
when a society does not provide these basic components,
people are at greater risk of becoming ill or dying needlessly.
Health systems are a means to ensure that health-care
practice responds closely to the burden of disease in an
equitable and sustainable manner.
Building and reinforcing health systems
In countries where many of the basic ingredients of a health system — skilled health
workers, information and knowledge, funds, infrastructure, as well as essential medicines
and medical equipment — are either absent or limited, the outlook can be bleak.
Many people living in the African Region, particularly those in rural areas, often
have to travel long distances to receive basic health care. Once they reach a hospital
or clinic, they may only receive health care if they pay for it out of their own pock-
ets. Inevitably, many people forego treatment because they cannot afford it, while
those who pay may find the costs ruinous and the quality of services limited. Either
way, people face impoverishment through incapacitating
illness or catastrophic expenditures. Some countries, in-
cluding Ghana, Kenya, Nigeria and Zambia, are developing
national social health insurance schemes to help people
cover their health costs.
One long-term solution to these problems, which are
common in the African Region, lies in further health sec-
tor reform, calling for increased financing and more effec-
tive use of funds combined with better governance and
improved access to affordable interventions that are known
to work. A key element of this reform is to establish health
districts as the basis for health service delivery. Once es-
tablished as such, health districts across the Region need
be made fully functional so that they can deliver essential
health-care services to people in an appropriate, affordable
and effective manner.
Public and private health-care
provision
The private sector plays an important role in the provision
of health care in Africa. This is partly because governments
have been unable to provide basic health care for a popula-
tion who — in the absence of state-subsidized health care — has no choice but to
seek alternatives. Private providers complement the public sector, stepping in where
the state fails to provide essential services. But the private sector suffers from a lack
of regulation and it may discriminate against people who cannot afford its services.
The private sector includes nongovernmental and charitable agencies that provide
free or subsidized care. In some countries, the private sector provides a significant
proportion of the health care that is available, whether subsidized or fee-based.
As medical goods and services flow between public, commercial, philanthropic,
traditional and informal providers, the distinction between private and public health
sectors is becoming increasingly blurred. Some doctors charge fees for services that
are supposed to be free in the public sector. Some drugs and medical equipment
The African Regional Health Report
purchased for public hospitals are sold on the black market. Some health workers
earn so little they have two jobs — one in the private and one in the public sector
— to make ends meet. Vet both sectors are needed. The private sector tends to allow
more competition, flexibility and innovation, while the public sector is responsible
for ensuring more equitable access to essential health care.
Scaling up health systems
Scaling up health systems means increasing human resources, improving infrastruc-
ture and training, and working on all fronts to make quality health-care services
more widely available. No region needs to scale up its health
systems more than Africa. Improved health systems are the
only coherent solution to the scale of public health problems
confronting the African Region. In the absence of functioning
health systems, HIV/AIDS has taken hold and spread rapidly
to create one of the biggest public health problems in history.
Today, the HIV/AIDS pandemic has reversed hard-won gains
in life expectancy. This reversal is a telling indictment of the
inadequacy of health systems to cope with the enormous
burden of the pandemic.
There are affordable and effective interventions to coun-
teract the diseases that are taking away the lives of people
in Africa, but the health workforce has dwindled so much
- partly as a result of the HIV/AIDS pandemic — that there
is often no one left to deliver them. Health-care delivery in
the Region is often piecemeal, with some tried and tested interventions provided free
of charge in small-scale projects in one clinic or hospital. These projects need to be
scaled up first to health district level and then to the whole country. But scaling up
is more easily said than done.
There are increasing efforts to help countries in the African Region achieve the
health-related Millennium Development Goals (MDGs), such as the "3 by 5" initiative
to deliver HIV/AIDS treatment, the Global Fund to fight AIDS, Tuberculosis and Malaria
and the US president's Emergency Plan for AIDS Relief. The challenge is to muster
enough funding for countries to build and reinforce their health systems as the overall
conduit not just to fight HIV/AIDS but for all disease control and treatment efforts.
Vertical programmes
By any measure of health systems function — immunization coverage, skilled birth
attendance, malnutrition, and maternal and child mortality — the African Region
is in poor shape. The challenge is to expand access to and coverage of basic health
services, although efforts have been made in this regard (see Box 6.2). Specific pro-
grammes focusing on particular health conditions have been implemented as vertical
or single-disease programmes, with varying success.
People visit big HIV/AIDS clinic in
Gaborone, Botswana, in order to
receive antiretroviral (ARV) treatment.
lealth systems
Delivering health care to isolated communities
For the last 11 years, the Phelophepa health-care train has
been bringing health care and education to communities
across South Africa.
The train stops mainly in isolated farming areas, where the
railway stations often have no platform and there isn't a hospital
for 100 km. About 42% of South Africa's population of 44.8 mil-
lion live in rural areas like these.
But Phelophepa, which means "good clean health" in the
Sotho and Tswana languages, also brings health care to towns,
such as Malmesbury in the Eastern Cape, where many people
are too poor to pay for health services that are available. The
response is overwhelming.
"I work until about 8 pm but sometimes there are still
people waiting to be seen. Some of them sleep on the platform
because they don't want to lose their place. It's heartbreaking,"
said optometrist Emma Rapoo, 27, one of train's staff members
who are mainly final-year and post-graduate medical students.
Phelophepa started as an eye clinic in 1 994 and has since ex-
panded to 16 wagons housing a primary care centre, dental clinic,
counselling team and education unit. They are limited, however, to
conditions and illnesses that can be treated on the spot. If a pa-
tient appears with symptoms of a serious disease, such as malaria,
cancer, HIV/AIDS or tuberculosis that requires long-term treatment
that person will be referred to the nearest clinic or hospital.
The train does try to address these needs, however, by train-
ing local community volunteers in home-based health care, which
may include the DOTS strategy for tuberculosis or basic AIDS care.
These volunteers are then placed under a local coordinator from
the department of health, usually a nurse in the area.
To date, the train has provided health care to 500 000
people and health screening and education to a further
800 000 people.
Every year, Phelophepa stops for a week at a
time at one of 36 destinations in four of the country's
nine provinces. Train Manager Lillian Cingo says that,
by providing education, "hopefully" it also leaves
something behind to sustain the community "to the
extent that some people will no longer need its ser-
vices when it returns".
Phelophepa's marketing team works closely with
communities months in advance to discuss their
needs and identify patients who cannot
afford the US$ 0.50-1 .00 fee.
The project requires plan-
ning and coordination. Its annual
operating costs are about
US$ 4.0 million, 60% of which is
provided by the Transnet Foundation
and the rest by corporate and
other private donors. Organiz-
ers plan to build a second train
in the next two years, for which
they are raising US$ 6million.
Dr Cingo's dream is to extend the
health train's route into the rest of
Africa. Further information can be
obtained from the following v
site: http://www.mhc.org.za/
Weziwe Rholowa, from Grahamstown, South Africa,
attended a five-day training course in basic health run
by Phelophepa staff.
These programmes tend to focus on one disease or one target group. They may
achieve great success in these terms, but they cannot be expected to address the
population's health needs as a whole. This vertical approach to public health care
can result, for example, in lost opportunities for delivering more comprehensive care
to isolated communities. Lack of coordination between vertical programmes can lead
to duplication of effort, poaching of skilled staff from essential health-care services
as well as unsustainable and short-term services.
Individual programmes that focus on one area or disease of interest, such as
HIV/AIDS or malaria, inevitably fail to provide people with the full range of the basic
health services they need.
The African Regional Health Report
Another problem with single-disease programmes is that they are short-term.
Often when they cease operating, recipients seek the same services from their local
health system, which may have deteriorated in the meantime. As a result of the fail-
ure to build and reinforce health systems, while providing vertical programmes, and
the failure to coordinate such programmes, many people in Africa have no reliable
health care at all.
Sector-wide approach
One way to improve the coordination of donor, government and other funding for
health-care programmes is to adopt a sector-wide approach (SWAP). This approach
means that all significant funding agencies support a shared policy and strategy that
applies to the whole health sector, i.e., that is sector-wide. The approach allows
governments to agree on health policies and strategic plans, and on where resources
should be allocated, with donors and other development partners. By adopting a
sector-wide approach, funding and other development partners commit themselves
to greater reliance on government financial management and accountability systems.
Ghana. Mozambique, Uganda, the United Republic of Tanzania and Zambia are just
some of the countries in the African Region that have adopted a sector-wide ap-
proach in recent years.
Identifying the key constraints to scaling up health systems was a key factor when
the MDGs were formulated. The 1 990 baseline picture of health systems function in the
African Region underscores just how far there is to go in terms of achieving these goals.
In 1998, countries in the African Region agreed to review their national health
policies and strategies and to monitor their progress towards the goal of health for
all. This pledge, made in a Regional Committee resolution, covers all facets of health
systems, from district services, hospitals, health research and information systems
to financing, essential technology, blood safety, essential and traditional medicines,
and human resources. The resolution also includes goals to give district health sys-
tems more of a community focus, and to provide an essential package of care and to
broaden access to this care.
Almost all countries in the African Region have taken different approaches to devel-
oping national health policy. Only a few. however, have recently developed or reviewed
these policies, with WHO support, to make their health-care services stronger, more
efficient and more widely available. For example, Burundi, the Central African Republic,
Mauritania. Gabon and the United Republic of Tanzania did such reviews in 2004.
A great deal of work has yet to be done across much of the Region in terms of
developing national health policy, a key step towards taking a sector-wide approach.
In 2004. WHO increased the number of staff working in the Region to help coun-
tries build up and reinforce their health systems. WHO's Regional Office for Africa
has also produced technical guidelines to help Member States draw up their own
national health policies and development plans.
Many countries, however, face key constraints for improving the health services
that are available to their people, such as rapid turnover of staff in key positions; lack
A great deal of work has
yet to be done across much
of the Region in terms
of developing national
health policy, a key step
towards taking a sector-
wide approach.
Health systems
of continuity in policy; lack of resources; poor management of available resources;
and poor implementation.
Health information systems
Fig. 6.1
Types of household surveys that have been conducted in the African
Region
D
Countries outside the African Region
MICS** and DHS*+ (12 countries)
MICS** (11 countries)
DHS*+ (14 countries)
No recent survey/no information
(9 countries)
*DHS •
**MICS:
Demographic and Health Surveys
Multiple Indicator Cluster Surveys
Please refer to the glossary for an explanation of DHS+
Source: WHO Regional Office for Africa.
Governments need reliable evidence based on population health data to develop a
public health policy that responds to the needs of the people in their country. These
data are vital for planning public health programmes and for monitoring and evaluat-
ing progress made by these programmes. Furthermore, population health data can be
used to ascertain whether the burden of disease has changed and whether resource
allocation needs to be adjusted. This approach enables a government to be more
accountable in the way it spends public money on health care.
Such a system provides basic, timely information on a number of factors: how
many people die and of what causes; what are the chief causes of disease; who is
treating patients; how many people can access care; how much does it cost; what
treatment outcomes are; and where the gaps in coverage are shifting. Patient registra-
tion, keeping medical records and running an appointment system not only make it
possible to manage patients but also enable health authorities to collect data that
can be collated and used to set priorities.
Despite limited resources Eritrea, the Gambia, Niger and the United Republic of
Tanzania have managed to develop information system policies, national health in-
dicators and integrated data collection forms over the last
decade. Some countries in the African Region have also
developed and maintained user-friendly databases that are
models of efficient health data collection from the level of
primary care to the ministry of health. However, efforts in
the Region to use information technology effectively have
been hampered by the lack of computer hardware; poor
internet connections; inadequate system maintenance; the
lack of sustainable energy sources; and a shortage of ade-
quately trained personnel. In addition, countries often use
different definitions, sources and methods for collecting
data, rendering international comparisons difficult. There
is, however, increasing support for unified methods of
providing improved population health data which can be
converted into evidence or knowledge for policy-making,
such as Multiple Indicator Cluster Surveys (MICS), and
demographic and health surveys (DHS) (see Fig. 6.1).
Most countries in the African Region do not have a
health information system that is capable of collecting,
storing, analysing, using and reporting these types of data.
.:
The African Regional Health Report
That means that governments and global agencies have to compensate for the lack
of information by employing other methods, such as mathematical models to pre-
dict possible trends and best-guess scenarios based on estimates or extrapolations.
Sometimes these methods provide the only available source of information, but they
are clearly inadequate. A lack of reliable population health information can result in
misdirected funds or the failure on the part of donors to renew aid in spite of con-
tinuing need.
In response to the inadequacies of national health information systems in the
African Region, global initiatives such as the Health Metrics Network (HMN) have
started to help countries improve and align their health information systems, includ-
ing the quality of vital registration, which is a crucial prerequisite to a more respon-
sive and appropriate use of health systems resources. By April 2006, 25 countries
had applied for funds and help as part of the HMN in the African Region and 19 of
those applications had been approved.
Vital registration
The critical baseline for judging a population's health
is derived from the registration of births and deaths,
but these vital events go unrecorded for the vast ma-
jority of people in Africa. Less than 10% of deaths
are registered in the African Region and even when
deaths are registered, often the causes are either not
attributed reliably or not reported at all. This low cov-
erage plus the fact that decision-makers are forced
to work with presumed causes of death can result in
wide margins of error.
Only a few of the 46 countries in WHO'S African
Region have some form of vital registration data and
only one country has complete current vital registra-
tion data, while others have reported incomplete data —
including no mortality data collected since 1 990 — and
some have never reported such data (see Fig. 6.2).
There are, however, alternatives to vital registration.
Verbal autopsy is the reporting of the circumstances
surrounding a death by interviewing relatives or others
who are familiar with the death but who have no medi-
cal expertise. Sample registration — another method
- tries to capture the causes of mortality of a defined
portion of the population. Also, sentinel demographic
surveillance involves monitoring a representative group
for the vital events of interest.
Fig 6.2
Coverage of death registration: mortality data (1995 onwards), by
cause, available to WHO
o
rj Countries outside the African
Region
• 100
• <50
D no information
Source: Mathers CD, Ma Fat D, Inoue M, Rao C, Lopez AD. Counting the dead and what they died of:
an assessment of the global status of cause of death data. Bulletin of the World Health Organization
2005:83:171-7
tealth systems
.
Sudanese refugees from the Darfur
region of Sudan. Mother and son in
their shelter in Iridimi. They were due
to move to a proper tent in the camp.
Iridimi, Eastern Chad.
Getting the numbers right
For health information systems to measure how effectively a health system is working,
it is important to get reliable data. Some data — immunization coverage, health-care
facility attendance and antenatal care coverage — may be generated by the routine
health information system. Other data, especially on long-term indicators such as
maternal and child mortality, life expectancy and fer-
tility rates of a given population, may require other
sources of data. These other sources include popula-
tion censuses, and demographic and health surveys.
Such data, however, are not sensitive to short-term
changes in health service provision, nor are they spe-
cific enough to distinguish the impact of a change
in policy from other factors, such as civil unrest or
natural disasters, which are common in the African
Region. On the other hand, disease-specific interven-
tions aimed at preventing and controlling diseases
require reliable data to show changes in incidence
of the disease in question. However, gathering reli-
able incidence data is dependent upon research ca-
pacity and/or valid reporting systems, both of which
are among the first casualties when health systems
decline.
The quality of data is often not given adequate
attention and yet it is crucial for deriving reliable in-
formation from that data. There are various methods
for checking data quality, including health facility pa-
tient/client satisfaction surveys, supervisory visits and community surveys. The data
obtained from these surveys allow for cross-checking and validation of data obtained
routinely. In addition, these data would complement those routinely collected.
Some countries in the Region have developed tools to monitor key indicators of
health system performance. The Health Systems Trust, a nongovernmental organiza-
tion in South Africa, established the District Health Barometer. The aim of this tool
is to compare the health data in the country's 53 districts and make the information
accessible to the public, thereby improving transparency and accountability. It shows
how districts are performing relative to one another and relative to their province
and the national average. It is designed to help managers identify gaps and deficits
in data collection, so that they can improve the quality of the health indicators they
use in decision-making.
Despite some countries' efforts to strengthen their national information systems,
much remains to be done. WHO and its partners are providing support to Member
States in the African Region to implement priority interventions to strengthen na-
The African Regional Health Report
tional health information systems. WHO has helped Kenya, Rwanda, Uganda and
Zambia to compile inventories of their health facilities, human resources and health
interventions — plotting them on maps in a process known as service availability
mapping. These maps show the coverage of health services and give a clear picture
of current facilities and staff, and help to identify gaps in services more easily.
Essential medicines
o
.a
E
In some parts of the African Region, over half of the population do not have
access to essential medicines and are unable to benefit from proven treatment for
common diseases.
Thirty Member States now have national medicine polices (Fig. 6.3), including
traditional medicine. These policies have been
drawn up with WHO's help to improve equitable
access to quality medicine at affordable prices
and to promote their rational use. That is an en-
couraging increase from three countries in 1991.
Full implementation of these policies, however, is
hampered by many factors, including: the short-
age of skilled workers; insufficient funding; poor
planning and management; and conflict and
poverty. These factors are crucial to the long-
term improvement of the pharmaceutical sector
in the countries of the African Region.
Medicines account for the second-largest
share of the health budget after salaries in coun- ^™™«.««B™.— — — ^— —
tries in the African Region. Government resourc-
es allocated to medicines are insufficient to provide for the whole population. There
is a need to improve the efficiency of the medicines supply system, including rational
selection, procurement, effective distribution and use. Furthermore, prices for new
medicines for the most prevalent diseases — HIV/AIDS, tuberculosis and malaria
— are often high.
Improving access
According to WHO's Medicines Strategy, equitable access to essential medicines
can only be ensured by meeting several criteria: rational selection and use; affordable
prices; adequate and sustainable financing; and reliable supply systems.
WHO has helped several countries in the African Region carry out medicine
price surveys in 2004. The surveys in Algeria. Chad. Ethiopia, Ghana, Kenya, Mali,
Nigeria, South Africa. Uganda, the United Republic of Tanzania and Zimbabwe
30 30
Fig 6.3
Member States with official national medicine policies, WHO African Region
35
30
25
20
15
10
5
...Mill
, i i i
0 — — — i
1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005
Source: WHO/AFRO/EDM
Health systi
The Leserian family tending their valuable
sweet wormwood crop in Arusha, the United
Republic of Tanzania (see Box 6.3).
found that prices of similar medicines vary considerably and are often unaffordable.
In many countries in the Region, medicine prices are not regulated; even in countries
that have medicine pricing policies, these policies are not always enforced.
In the absence of affordable and good quality medicines, some people in the
Region unwittingly resort to poor quality or cheap counterfeit medicines. It is illegal in all
countries in the Region, but common practice in most, to sell pharmaceutical products
on the street often, these medicines are counterfeit. In most cases these are more harmful
than no medication at all. Only four countries in the Region have comprehensive medi-
cine regulatory capacity. Inadequacies in this capacity can be ascertained
by quality screening of commonly used medicines. For example, a 2002
WHO survey found that chloroquine and sulfadoxine-pyrimethamine
for the treatment of malaria in Gabon, Ghana, Kenya, Mali, Mozambique
and Zimbabwe failed standard quality tests. Moreover, samples of rifam-
picin and isoniazid, essential medicines for the treatment of tuberculosis,
collected in Chad, Ethiopia, Ghana, Rwanda, Senegal, Uganda, and the
United Republic of Tanzania in 2004 were found to be substandard when
tested for quality.
Local production of traditional medicines is one solution to the lack
of availability of essential medicines, but only when there is evidence
to show that the medicines are safe and effective. The best example is
provided by artemisinin derivatives for malaria. The plant Artemisia an-
nua was introduced from China to the United Republic of Tanzania in
1 990, where it is now cultivated commercially. The Tanzanian National
Institute for Medical Research showed that rather than exporting the
plant to Europe for processing, then re-importing the artemisinin-based medicines to
Africa at US$ 6-7 per dose, domestic production could reduce costs to US$ 2 per dose
(see Box 6.3).
Some countries in Africa are trying to foster innovation in traditional medicines
as a long-term way of providing more affordable medicines to address public health
needs. But to do this, countries need to build a research and development capacity,
create gene banks and they need patent protection. For example, scientists in South
Africa are conducting research to find a vaccine for HIV that addresses the country's
specific health needs. The aim is to produce a vaccine for subtype C of the virus,
which accounts for more than 90% of HIV infections in southern Africa. Most HIV
vaccine research aims to develop a vaccine for virus subtype B, the dominant strain
in the United States and Europe.
WHO has developed a number of policies and standards to help Member States
address the problems with safety and quality, supply, management and rational use
of essential medicines. The illicit trade in pharmaceuticals needs to be controlled,
and the rights of pharmacists to sell generic medicines — which are cheaper than
their patented originals — need to be upheld. Member States should collaborate to
produce affordable essential medicines in the Region, and negotiate bulk purchases
wherever possible to reduce medicine prices.
The African Regional Health Report
Tanzanian fanners grow their own Artemisia annua
Cultivation of Artemisia annua. or sweet wormwood, in the United
Republic of Tanzania is the first step to improving people's access
to antimalarial medicines, and it has economic advantages too.
Farmers in Arusha say that growing Artemisia is more profitable
than growing vegetables and will raise their living standards.
Joseph Leserian uproots sweet wormwood seedlings from a
nursery and transplants them to his main garden, taking care not
to damage their roots. The 64-year-old hopes that the miniature
plants will provide him with a better income than his vegetables.
A bumpy unpaved road leads to his simple bungalow in Arusha, a
poor area near Africa's tallest peak. Mount Kilimanjaro.
Until recently Artemisia annua. was grown mainly in China and
Viet Nam. The plant is the source of artemisinin, which is the active
ingredient in the most effective antimalarial medicines available
today. These drugs — known as artemisinin-based combination
therapies (ACTs) — are badly needed in Africa because malaria par-
asites have become resistant to former mainstays of antimalarial
treatment, such as chloroquine. A global shortage of artemisinin.
however, means that not all countries can obtain sufficient quanti-
ties of ACTs. That is where farmers like Leserian come in. Artemisia
thrives in Tanzanian soil, which makes local production of artemis-
inin a viable commercial proposition. Now WHO is coordinating the
efforts of a nongovernmental organization called TechnoServe and
African Artemisia Ltd to produce the crop locally.
"We help farmers with cultivating, harvesting and selling
their crop. We hope that by producing artemisinin in East Africa,
we are helping to provide an African solution to an African prob-
lem," said TechnoServe 's project director, Michael Baddeley.
Leserian was the first of 300 farmers in Arusha to start culti-
vating the plant in February 2004. His three-quarter hectare plot —
part of his two-hectare farm — now boasts leafy well tended Arte-
misia shrubs. An optimistic Leserian says he switched from growing
tomatoes and potatoes to cultivation of Artemisia annua after being
convinced that the new venture could change his life. He points out
that the Artemisia shrubs are easier to tend than vegetables, and
easier to sell. "We had to struggle and to sell our vegetables, unlike
Artemisia, sweet wormwood, which has a ready market". African
Artemisia Ltd will purchase the crop: extract the artemisinin and sell
it to international pharmaceutical companies. Farmers will be paid
for the weight and quality of the crop; TshBOO (US$ 0.5) per kilogram
of leaves, with a bonus for higher artemisisin content. Each hectare
is expected to produce an average of two tonnes of Artemisia.
"Once I sell the crop and venture into other projects ... I shall
improve the living standards of my family," Leserian said.
Blood safety
Ensuring that blood supplies are safe is one example of the challenges health systems
face in Africa. Blood transfusions save many lives each year, but many people also die
when blood supplies are inadequate or unsafe. Women and children are particularly
affected. Women receive transfusions to replace blood lost during pregnancy and
delivery. Children often need transfusions because they are prone to life-threatening
anaemia caused by the all-too-common problems of severe malnutrition and malaria.
An unsafe blood supply can be worse than no blood supply, as the long-term risk of
being infected with and dying from HIV/AIDS or viral hepatitis B or C can outweigh
the risks of dying from anaemia in the short term.
In 1994, WHO'S Regional Committee for Africa noted with concern that only
10 of the 46 Member States could guarantee the safety of blood transfusion in their
hospitals. Countries were urged to enact blood safety policies and improve hospital
transfusion services. Yet by 1999, only 14 countries had a national blood transfu-
sion policy, and even these were not always fully implemented. Haphazard practices
exposed many patients and health-care staff to potentially fatal risks. The rest of the
countries in the Region have since developed a national blood policy, but due to lack
Health syst
Healthy blood donors are a
vital resource.
of funds, inadequate infrastructure and shortage of skilled personnel, implementa-
tion has been slow.
The way blood banks are run and transfusions are handled are problems. The
source of the blood is another. The safest blood source is from regular, unpaid,
voluntary donors, as their blood is the least likely to be infected with HIV or the
hepatitis viruses. In the absence of adequate supplies, patients are asked to find a
family member who will donate blood for their transfusion or an unrelated person
who will replace the units of blood taken from the hospital's short supplies. Cases of
paid donations have been reported by a few countries.
In 1999, only Botswana, Cote d'lvoire, Namibia, Rwanda, South Africa
and Zimbabwe were collecting 100% of blood supplies from voluntary non-
remunerated donors. Four additional countries, Benin, Burundi, Swaziland and
Togo, have reported using this source exclusively. In 2002, only half of the entire
blood supply in the Region came from unpaid donors, while about 44% came
from family or replacement donors and 4% from paid donors.
However, it is often hard to tell how much of so-called family or
replacement donations have been purchased. In the early years of
the HIV/AIDS epidemic some paediatric cases of HIV/AIDS were
caused by transfusion with contaminated blood. Well organized
blood donation programmes in Cote d'lvoire. South Africa and
Zimbabwe have shown that it is possible to find a population of
willing, unpaid blood donors with uninfected blood, even in areas
with a high prevalence of HIV.
Selecting donors is the first step to ensure a safe blood supply.
Screening the blood is the second. Despite progress made in HIV
screening — 99.9% of blood is screened compared with 75% in 1999
— less than 60% of the African Region's blood supply is currently
screened specifically for the four major transfusion-transmissible
infections (HIV, viral hepatitis B and C, and syphilis). Reliable blood screening is im-
possible without high quality reagents and test kits, properly trained and skilled staff,
and regular quality assurance. Twenty countries in the African Region still struggle
with irregular or incomplete supplies of reagents and test kits, with the result that
patients are given transfusions with potentially infected blood. This is doubly tragic
when patients who could have survived without a blood transfusion are given one
and when, on top of that, those patients die from an infection transmitted through
blood that they did not need in the first place.
Despite WHO courses — 200 quality managers were trained between 2000 and
2003 — national blood quality systems have since been established fully in only 12
countries, and partially in 1 5 countries. Twelve countries in the Region currently have
no quality assurance of blood transfusions.
Ensuring a safe blood supply is a long and costly exercise, but countries in the
African Region are making progress in improving transfusion practices. More funds
The African Regional Health Report
are needed to train staff, build and equip blood transfusion services, purchase re-
agents and implement quality assurance programmes. Patients in need should have
equitable access to safe blood, and HIV should not be transmitted through blood
transfusions. The medical indications for transfusion also need to be critically ex-
amined to make sure that patients are only given blood when there is no viable
alternative treatment.
Human resources: a continent in crisis
A major gathering of experts in human resources for health in Addis Ababa, Ethiopia, in
January 2002 put the African Region's health workforce crisis firmly on the international
agenda. Delegates at the meeting reported alarming figures; for example, 50% of doc-
tors in Namibia were expatriates, and medical doctor vacancy rates in the public sector
in 1998 were reported to be 43% in Ghana and 36% in Malawi. Nurse vacancy rates in
the public sector in Lesotho were reported to be 48% in !998.The meeting heard that
for 15 years there had been no public recruitment of health personnel in Cameroon,
while Ghana, Zambia and Zimbabwe estimated losses of 1 5-40% of employees in the
public sector every year. This underscores the instability of the health workforce and
the lengths some countries must go to fill vacancies (see Box 6.4).
Many factors have contributed to the growing shortage of health workers across
the Region — Africa's human resources for health crisis. A high disease burden
means that more health workers are needed to take care of the sick. Another factor
is the loss of many health-care workers due to death, migration and poor conditions
of service. Human resources for health policies and plans have not been able to
address the increasing demands of health service delivery, while weak or stagnant
health system infrastructures have not adapted to population growth. The devastat-
ing impact of the HIV/AIDS pandemic has drastically cut large swathes of the health
workforce in some African countries and made working conditions more intolerable
in the health sector. But even before the HIV/AIDS pandemic, the human resources
for health sector — a key element of a well functioning health system — was already
badly neglected. Until recently, scant attention was paid to the remuneration, de-
ployment and continuing education of health staff in Africa. To draw more attention
to the problem, WHO devoted the World health report 2006 and World Health Day
2006 to this issue. Increased awareness at national and global level is only the first
step to fixing the problem.
A WHO survey, published in 2004 of trends in Cameroon, Ghana, Senegal,
South Africa, Uganda and Zimbabwe over the period 1 99 1 -2000, found that although
the absolute numbers of health professionals had increased, the overall doctor: popu-
lation ratio had fallen. Health workers migrate within countries from rural to urban
practices, from the public to the private sector, and between countries, in search of
better working conditions, higher salaries, and opportunities for training and recog-
nition. It is difficult to gather reliable data on the scale of this migration.
Until recently, scant
attention was paid to the
remuneration, deployment
and continuing education
of health staff in Africa.
Health systems
Malawi's health sector "brain drain"
The growing shortage of doctors and nurses across parts of the African Region is one of
the greatest obstacles to tackling the heavy burden of disease, particularly in countries
with a high prevalence of HIV/AIDS. Malawi is one of the Region's worst hit countries. It is
often said that more Malawian doctors work in the English city of Manchester than in the
whole of Malawi. But there is more than just anecdotal evidence to suggest the drift.
"We have a critical shortage of nurses. We need 10 to 12 nurses to a ward. At the mo-
ment we have about five to a ward of 70 or 80 patients," said Chief Nursing Officer Fannie
Kachale at Kamuzu Central Hospital, one of Malawi's largest state referral hospitals. The
hospital in the capital Lilongwe needs 532 nurses to be fully staffed, but in March 2005 had
only 188. More than half the nurses' posts were vacant. Many had left to work in Malawi's
private sector or the United Kingdom, attracted by better pay and work conditions.
At Kamuzu Central, work conditions are grim and staff, who divide their time between
this and another hospital, are barely able to cope. Wards are overflowing as patients spill out
on to the verandah and most patients have relatives helping to look after them. Their condi-
tions are serious, ranging from tuberculosis to pneumonia, often related to HIV/AIDS.
Dr Damsom Kathyola, the director of the hospital, said the shortage of nursing staff
was "a crisis, which, if not reversed, could lead to the collapse of the entire health delivery
system in Malawi". Development agencies have started to respond to the crisis. The UK
' Department for International Development doubled its development aid to Malawi in 2005
to US$ 176 million (£100 million) over the following six years. Just over half will be spent
on human resources for health.
The idea is not only to train double the number of nurses and doctors currently being
trained in Malawi but once they start working to offer them higher salaries and additional
incentives to stay in Malawi. The aid would also cover the costs of paying nurses and doc-
tors from other countries to fill gaps, while the Malawians are being trained.
Nurse talking to mothers about childcare at a
rural health clinic in Malawi.
The African Regional Health Report
However, regulatory bodies in developed countries have data on health workers
registered to work in their countries. While this information is inevitably partial, it
provides an overview of foreign-trained health workers in developed countries. Table
6.1 shows the number of doctors and nurses from African countries working in devel-
oped countries. They represent more than 30% of the stock of doctors in the source
countries. Rough estimates can also be made based on the numbers of requests for
certificates of good standing from national licensing bodies as well as from the number
of expatriate doctors employed to fill in the gaps and the number of vacant posts.
Table 6.1
Outflow of health workers from 16 African countries, 1993-2002
Country No. of Main destination
health workers
reported migrated
Burundi
127
Belgium, Benin, France, Rwanda
Cameroon
82
Canada, Central African Republic, France, Namibia, Senegal,
UK, USA
Central African Republic
176
Cameroon, Cote d'lvoire, France, Senegal
Cote d'lvoire
641
Canada, France
Democratic Republic of the Congo
337
Canada, Cote d'lvoire, France, Senegal, USA, Zambia
Gabon
128
Canada, France
Gambia
233
UK, USA
Ghana
1169
Gabon, Saudi Arabia, South Africa, UK, USA
Kenya
1734
Saudi Arabia, UK. USA, Zambia
Madagascar
341
France, Zambia
Malawi
484
UK, USA
Mali
93
Cameroon, Canada, Cote d'lvoire, France, USA, Zambia
Nigeria
213
France, Gambia, Kenya, Namibia, UK, USA, Zambia
Sao Tome and Principe
103
Gabon, Namibia, Portugal
United Republic of Tanzania
446
Botswana, Comoros, Equatorial Guinea, Kenya, Mauritania,
Namibia, UK, United Arab Emirates, Zimbabwe, USA
Zambia
974
Botswana, UK, USA
Total
7281
Source: Survey on migration of health workers in the African Region.
Brazzaville: WHO Regional Office for Africa, 2003
Health systems
WHO and its partners
are working closely
with Member States in
the African Region to
find ways to motivate
and retain their
health workers.
Hospital development needs to complement other levels of the health sys-
tem, and improve referral patterns while ensuring that poor people have access
to services. Hospitals also need to develop their role in the provision of medical
care to include more specialized training and to promote research and the use of
information systems.
Approaches to filling the gap
To address growing shortages of health workers, some countries are testing models where
certain tasks are re-assigned from highly qualified health workers to less qualified staff
under further orientation and supervision. Botswana has tested community home-based
care as a way of involving families and other members of the community in caring for
people with HIV/AIDS (see Box 6.5). Likewise, Uganda has led the way in terms of train-
ing health workers to deliver simplified HIV/AIDS treatment, (see Box 6.6).
Like Uganda, the Eastern Cape region of South Africa has adopted simplified
guidelines to deliver antiretroviral (ARV) treatment to people with HIV/AIDS. Re-
searchers have called on the government to roll out the approach to the rest of the
country by giving more nurses greater responsibility to dispense ARVs, permission to
screen HIV-positive patients to determine whether they were eligible for treatment,
and permission to monitor patients' adherence to medication. They argue that with
adequate orientation and supervision, nurses can prescribe ARVs.
In rural Tanzanian districts, assistant medical officers often work as medical doc-
tors, and those with specialist training are in charge of clinical disciplines such as the
department of anaesthesiology and ophthalmology when no specialists are available
in these disciplines. In Zanzibar, an island in the Indian Ocean, where the shortage
of medical doctors is more serious, and in the mainland of the United Republic of
Tanzania, assistant medical officers work as district medical officers.
International efforts are under way to address Africa's growing health workforce
crisis. The World Health Assembly passed a resolution on migration and human
resources for health in 2004 and the High Level Forum meeting to discuss progress
towards the health-related Millennium Development Goals in 2004 also recognized
human resources for health as vital for achieving the goals.
WHO and its partners are working closely with Member States in the African
Region to find ways to motivate and retain their health workers. WHO has been
helping countries develop and implement motivation and retention strategies with
the support of development partners as part of these countries' national health plans.
This support includes scaling up training — especially of mid-level cadres — to fill
in staffing gaps. Various methods, including distance learning and continuing medi-
cal education can also help to achieve better staffing coverage.
Countries have tested different ways of preventing health workers from migrat-
ing. These include allowing health workers to engage in private practice while work-
ing in the public sector, raising salaries and improving working conditions. These
also include retaining certificates of graduates until they have returned to their coun-
try of origin, allowing communities in decentralized systems to directly recruit their
The African Regional Health Report
Community home-based care in Botswana
Banyefudi Sampora is full of praise for the community home-
based care (CHBC) programme, which has taught her how to look
after her sick daughter at home and emerged as a powerful tool
in Botswana's response to HIV/AIDS.
"These people have been like the second mother to my
daughter, she eats well and gets medicine," said the 68-year-
old grandmother referring to the community health workers who
visit Sampora and her family every month.
Sampora has been taking care of her HIV-positive daughter
since 2002 at her rural home at Mmopane village, 20 km north-
west of Botswana's capital, Gaborone. She is the only breadwin-
ner as her daughter is too ill to work. She also has to care for her
daughter's four children who are still in school.
Sampora was given a basic education in HIV/AIDS. Com-
munity health workers explained how to care for her daughter,
prevent transmission of the virus to other members of the family
and monitor that her daughter is taking her medicine every day.
Every month they deliver a package to each home containing
basic medical supplies and food. If her daughter gets an infection,
the family must go to the village health post 2 km away.
Botswana has one of Africa's most developed health sys-
tems. But with the rapid spread of HIV/AIDS over the last decade
that system is badly overstretched. The community home-based
approach is a way of making scarce health resources go a long
way and of delivering health care to patients in the comfort of
their homes.
The village of 5000 was selected in 2002 by the Depart-
ment of Nursing and Midwifery at the University of Botswana,
a WHO Collaborating Centre, to develop CHBC teaching and
learning material for the rest of English-speaking Africa. The
department also created a day centre for patients, which gives
the home-based caregivers time to get on with their own lives.
Sampora tends a vegetable garden and sells her produce to sup-
port the family.
Director Dr Esther Seloilwe said the village was chosen
because it is underdeveloped despite being close to the capital.
It has a health post staffed by a nurse but no telephone, which
makes referring patients to hospital very difficult.
"The Botswana family structure is ideal for the CHBC pro-
gramme because the culture dictates that families support and
care for the sick and the dying," said Seloilwe. "Home-based
care has been in our tradition for years, it was just a case of us
now placing the emphasis on caring for those with HIV/AIDS."
MoOTe heaffli educator teaching a Tamily
about HIV/AIDS.
health workers and pay them. While recognizing the right of individuals to migrate,
governments can also use this to mutual benefit through, for example, bilateral ex-
changes of specialists.
Health financing
African countries spent on average 5% of their gross domestic product (GDP) on health
in 2003, 5 1% of which were expenditures by the government. The median share of
government expenditure on health funded by external resources is 26%, with a wide
range of countries' share of government expenditure on health funded by external
resources, from less than 1% (e.g. Algeria) to over 75% (e.g. Rwanda). Expenditures
on health by the private sector (households, nongovernmental organizations, private
enterprises, insurance) on average made up 49% of total expenditure on health.
Health syste
Uganda leads the way in simplified AIDS care
Few countries in the African Region can afford the "gold stan-
dard" package of HIV/AIDS chronic care that is routinely pro-
vided in industrialized countries. Botswana, one of the Region's
wealthiest countries, adopted this approach and by the end of
2004 it was the only African country to have reached the 50%
treatment target level. But Uganda hopes that a new, simplified
approach to delivering HIV/AIDS treatment will help it overcome
the lack of cash and health workers and be just as effective as
Botswana. So far Uganda has started delivering treatment to a
third of the people who need it. It hopes this new approach will
help it reach the rest over the next few years.
The idea is to train nurses to do some of the work of doctors
and for lay health workers and community workers to carry out
some nurses' tasks. Patients are prescribed combination pills to
be taken twice daily, rather than several different medicines. As
long as a doctor diagnoses a patient or endorses the diagnosis
of a nurse, and as long as the doctor writes the prescription,
the counselling and supervision of drug intake can be done by
others.
"If you can make a good diagnosis, the counselling is good
and the patient adheres to the drugs, I don't see how the level of
qualification can be a problem," said Elizabeth Madraa, manager
of Uganda's National AIDS Programme, adding that simplified
treatment guidelines were key not only to delivering HIV/AIDS
treatment but basic health care in general. "Unless we do things
differently to address the human resource capacity gap, we shall
never deliver even the basic health-care services, let alone ART
(antiretroviral therapy)".
The approach called Integrated Management of Adult and
Adolescent Illness (IMAI) is a health services delivery model
characterized by simplified guidelines and training material. It
is based on full involvement of nurses, lay health workers and
— in the case of HIV/AIDS chronic care — HIV-positive patients
who help to train health workers.
The approach has been inspired by successes elsewhere in
Africa, Latin America and the former Soviet Union where rela-
tives, friends or other community volunteers have been trained
to help treat tuberculosis patients in poor settings.
One of the principles is community home-based care -
which has already proved a success in Botswana (see Box 6.5)
— to ease congestion in health facilities. If complications arise,
the nurses and others who visit the patients at home can refer
them to a doctor or a health facility.
More than 1400 health workers in Uganda have completed
HIV training across the country. Ethiopia, the Eastern Cape Prov-
ince of South Africa, Swaziland and Zambia have also started
training health workers in this simplified approach. If successful,
they could serve as a model for other low-income countries.
with households representing the largest share (80%). Fig. 6.4 shows a breakdown
of expenditure on malaria in Ghana, illustrating the disproportionate burden on
households.
The WHO Commission for Macroeconomics and Health estimated that a mini-
mum expenditure of US$ 34 per person per year was required to provide an essential
package of public health interventions in order to achieve both the relevant MDGs
and the New Partnership for Africa's Development (NEPAD) targets. Thus, govern-
ments in the 35 Member States that are currently spending less than US$ 34 on
health per capita per year will need to increase their budgetary allocations to reach
the recommended minimum health spending (Fig. 6.5).
Heads of state of countries in Africa made a commitment in Abuja to allocate
at least 1 5% of their annual budgets to the health sector. By the end of 2003, only
one country's government had spent 1 5% or more of its national budget on health,
including spending funded by external resources. The other 45 Member States in the
African Region will need to take appropriate steps to honour the commitment made
by their heads of state.
The African Regional Health Report
In 2005, the Abuja pledge to allocate 15% of their national budgets to health
was reconfirmed by African heads of state in the Gaborone Declaration at the October
2005 session of the Conference of African ministers of health in Botswana.
WHO has devised a method called National Health Accounts, a system which
23 of the Region's 46 Member States have already used to track their health expen-
diture. This system can also be used to analyse the financial flows within national
health systems to see where funds are adequate or in short supply. Health authorities
can use this to allocate finances more effectively to improve the overall performance
of health systems.
Donor funding
Donor funding, on average, represented 16% of overall health-care spending in the
African Region in 2003. In the Maputo Declaration, African heads of state urged
donor countries to honour their pledge to allocate 0.7% of their gross national
product as official aid to developing countries to
boost funds for health and development.
There is little coordination between internation-
al donors, who tend to focus on different diseases
in an unsystematic way. Donors may, for example,
insist on using different drugs from one another.
They may demand different delivery methods. They
may fail to live up to their funding pledges, and they
may provide funds over short time-frames. The UK's
Commission for Africa called upon health develop-
ment partners to harmonize and align their support
with recipient countries' national health policies and
strategic plans to make aid more effective.
Where aid is ineffective, donors can be to blame
Fig 6.4
Total cost of malaria illness, Ghana, 2002
Households indirect cost
US$ 23.89m
Ministry of Hearth direct cost
US$ 7.75m
Households direct cost
US$ 18.41m
Source: WHO Regional Office for Africa.
as much as the recipient countries themselves. There is broad agreement — and
this is one of the demands of the UK's Commission for Africa — that donor coun-
tries change their approach to funding, but there is less consensus on how.
Ideally, donors should all work to a single agreement drawn up by the gov-
ernment of each recipient country and they should be legally bound to pay as
promised. They should pledge aid over a longer time frame to allow African gov-
ernments to plan the use of those resources better. One way governments in the
Region have started to improve coordination of external and domestic funds for
health is by taking an intersectoral approach to streamline the efforts of all the
sectors involved.
Health is determined by a number of factors that lie outside the health sector's
direct influence, such as water, sanitation and other environmental factors as well as
food availability, education, political and social environment. These social determi-
nants of health can be addressed by strengthening inter-sectoral collaboration.
Fig 6.5
Per capita government expenditure on health (US$), WHO African
Region, 2003
Seychelles 382 ^•••^^^^^•1
B°Gab7n |® ^J
User fees
South Africa 114 i^^M
User fees charged by public facilities are often around
Mauritius 105 •••
5% of total government recurrent health expenditure.
Namibia 101 ^^H
However, analysis in the United Republic of Tanzania
Algeria 71 ••
showed that the abolition of primary health care fees
Equatorial Guinea 65 ••
would cost only US$ 13 million per year. Rich nations
Swaziland 61 ••
should support poor countries to offset the financial
CapeVerde 57 ••
loss arising from the removal of direct out-of-pocket
Sao Tome and Principe 29 •
payments for basic health care until governments in Af-
Lesotho 25 •
rica can afford to take on these costs themselves. Basic
Angola 22 •
health care should be subsidized for the poorest mem-
Zimbabwe 14 1
bers of society. User fees may be entirely covered by al-
Mauritania 13 |
ternative financing methods, but many providers prefer
Congo 12 1
charging a minimal, symbolic fee to ensure that services
Senegal 12 |
are appreciated and not used unnecessarily.
Cameroon 11 1
There are many types of social protection schemes,
Zambia 11 1
such as social health insurance, voluntary-based insur-
Benin 9 1
ance, cash transfers to carers, social pensions, and child-
Burkina Faso 9
care grants. These can be of great benefit to many people,
Mali 9
especially the most vulnerable: the elderly, the young and
Cote d'lvoire 8
the disabled.
Gambia 8
Kenya 8
Evidence for resource allocation
Chad 7
Once governments have collected and pooled from vari-
Mozambique 7
United Republic of Tanzania 7
Comoros 6
ous sources their scant public revenues, policy-makers
face the task of having to decide how to allocate them
to buy health services. Often policy-makers do this with
Nigeria 6
Central African Republic 5
Ghana 5
very little evidence to guide their choice of the many pos-
sible public health interventions. This lack of evidence
sometimes results in decisions being made to invest in
Madagascar 5
Malawi 5
expensive interventions that benefit few people rather
than in low-cost interventions which potentially benefit
Niger 5
Uganda 5
more people. To guide such priority-setting, WHO runs a
uguuuu
Eritrea 4
project called Choosing Interventions that are Cost Effec-
Guinea 4
tive — also known as WHO CHOICE — to help coun-
tries in this task. WHO has compiled databases, which
Guinea-Bissau 4
Liberia 4
can be found under http://www.who.int/choice/links/re-
latedjinks/en/index.html of the evidence of cost-effec-
Sierra Leone 4
tiveness on over 500 public health interventions address-
Togo 4
Ethiopia 3
ing broad categories of problems: unsafe water, addictive
Rwanda 3
drugs, sexual health, malnutrition, malaria, tuberculosis,
Burundi 1
Democratic Republic of the Congo 1
100
200
300
400
Source: WHO/ World Health Report, 2006.
The African Regional Health Report
maternal and neonatal diseases, iron deficiency, unsafe injections, mental illness and
blindness. Information on 200 interventions for cardiovascular diseases and cancer
will be added to the databases.
Once resources have been allocated to pay for various health-care services, it is
important to monitor the efficiency of the use of those resources. There is also grow-
ing evidence in the African Region that hospitals and health centres can attend to
more patients if the resources available to them are better managed. Since hospitals
and health centres consume a significant proportion of development and recurrent
budgets of ministries of health, there is a need for vigilance in monitoring the use of
those resources.
Conclusion: Health systems - the key to better health
The countries of the African Region need to build and reinforce their health sys-
tems as a platform to provide a broad range of essential health-care services to their
people. There is no "one-size fits all". These health systems must be tailored to the
needs of each country, each region and each community — whether rural or urban,
affluent or poor. Health systems must provide services that address key public health
needs and these must be delivered in an effective and accountable way. There is an
urgent need to establish accountable and transparent systems to monitor and evalu-
ate health expenditure as health spending from public and private sources increases.
Getting this right is one of Africa's big public health challenges.
Several key elements need to be in place for health systems to function prop-
erly: adequate human resources and infrastructure, reliable evidence on public
health needs, as well as health financing systems. Governments, working together
with all partners, need to make a deliberate effort to build and reinforce health
systems to make them responsive to public health needs and to be more effective.
Governments — in the African Region and elsewhere in the world — need also
to be more involved in research into the health problems that affect their people
most and engaged in the quest for sustainable public health solutions to those
problems.
In view of the significant role being played by the private sector and civil society
in health services delivery, it is imperative that governments strengthen their col-
laboration with them and also create the right regulatory and legal environment for
the private sector and civil society to effectively play that role.
As we have seen, building, reinforcing and scaling up health system interventions
are vital steps towards the goal of equitable health care in the spirit of the 1978 Dec-
laration of Alma-Ata on primary health care to achieve the goal of health for all. There
is widespread recognition among African governments and in the donor community
that the African Region has little chance of achieving the health-related MDGs if it can-
not strengthen and operate such systems effectively. Health systems have enormous
untapped potential to contribute to economic and social development.
There is no "one-size fits
all". These health systems
must be tailored to the
needs of each country,
each region and each
community — whether
rural or urban.
Health systems
The challenge is to make governments more aware that health has a crucial role
to play in the social and economic development of their countries. Health needs to
be placed higher on the political agenda of countries in the Region and their lead-
ers need to develop policies and strategies to strengthen their health systems. That
means providing sufficient resources to make health systems work effectively and to
sustain them into the future.
Governments in the Region and donors need to make health systems a top priority
in national and international development agendas. This is vital for establishing inte-
grated primary health care at district level and to strengthening the overall public health
infrastructure. These vital health system elements require long-term political commit-
ment and substantial additional funds. Those involved must also accept that results
will be slow, but solid. The health systems that result would provide a much needed
platform for delivering all the necessary services for the health of the people. •
} I
The African Regional Health Report
Bibliography
• African Union: Maputo declaration on Malaria, HIV/AIDS. Tuberculosis, and other related infectious diseases. Addis Ababa; 2003.
• Asbu EZ, Mclntyre D. Addison T. Hospital efficiency and productivity in three provinces of South Africa. South African
Journal of Economics. 2001,69:336-58, .
• Awases M, Gbary A, Nyoni J, Chatora R. Migration of health professionals in six countries: a synthesis report Brazzaville;
WHO Regional Office for Africa; 2004
• Brown A. Current issues in sector-wide approaches for health development Mozambique case study. Geneva: World Health
Organization; 2000. WHO document WHO/GPE/00.4. Available from: http://whqlibdoc.who.int/hq/2000/WHO_GPE_00.4.pdf
• Brown A. Current issues in sector-wide approaches for health development Tanzania case study. Geneva: World Health
Organization; 2000. WHO document WHO/GPE/00.6. Available from: http://whqlibdoc.who.int/hq/2000/WHO_GPE_00.6.pdf
• Brown A. Current issues in sector-wide approaches for health development Uganda case study. Geneva: World Health
Organization; 2000. WHO document: WHO/GPE/00.3. Available from: http://whqlibdoc.who.int/hq/2000/WHO_GPE_00.3.pdf
• Chatora R. Health financing in the WHO African Region. African Health Monitor. 2006;5:13-6.
• Commission for Africa. Our common interest an argument London: Penguin Books; 2005.
• Documenting Best or "Promising" Practices In Human Resources For Health Development In The Who African Region.
• Evans D, Edejer TT. Choice: an aid to policy. African Health Monitor. 2005;5:27-9.
• Foster M, Brown A, Conway T. Sector-wide approaches for health development a review of experience. Geneva; World Health
Organization; 2000. WHO document WHO/GPE/00.1. Available from: http://whqlibdoc.who.int/hq/2000/WHO_GPE_00.1.pdf
• Freedman LP, Waldman RJ, de Pinho H, Wirth M E, Chowdhury AMR, Rosenfield A. Transforming health systems to improve
the lives of women and children. Lancet 2005;365:997-1000.
• Guidelines for evaluating traditional medicines in WHO African Region. Regional Office for Africa. Brazzaville.
• Kirigia JM, Emrouznejad A, Sambo LG, Measurement of technical efficiency of public hospitals in Kenya: Using data
envelopment analysis. Journal of Medical Systems, 2002;26:29-45.
• Kirigia JM, Emrouznejad A, Sambo LG, Munguti N and Liambila W. Using Data Envelopment Analysis to Measure the
Technical Efficiency of Public Health Centers in Kenya. Journal of Medical Systems, 2004;28:155-66.
• Kirigia JM, Sambo LG, Scheel H. Technical efficiency of public clinics in Kwazulu-Natal province of South Africa, East African
Medical Journal, 2001;78:S1-S13.
• Marmot, M. Social determinants of health inequalities. Lancet 2005;365:1099-104.
• Masiye F, Ndulo M, Roos P, Odegaard K. A comparative analysis of hospitals in Zambia: a pilot study on efficiency
measurement and monitoring. Chapter 7, pp. 95-107. In: Seshamani V. Mwikisa CN, Odegaard K. Zambias, Health Reforms
Selected Papers 1995-2000. Lund: Sweden; 2002.
• Mathers CD, Ma Fat D, Inoue M, Rao C, Lopez AD. Counting the dead and what they died from; an assessment of the global
status of cause of death data. Bulletin of the World Health Organization 2005;83:171-7.
• New WHO Regional Director for Africa pledges to do better for Africa. Bulletin of the World Health Organization 2005:83:9.
• Organization of African Unity: Abuja declaration on HIV/AIDS, tuberculosis and other related infectious diseases. Addis Ababa; 2000.
• Osei D, d'Almeida S, George MO, Kirigia JM, Mensah AO, Kainyu LH. Technical efficiency of public district hospitals and
health centres in Ghana: a pilot study. Cost Effectiveness and Resource Allocation 2QQ5;3:3. Article URL: http://www.
resource-allocation.com/content/2/1/9.
• Regional Committee for Africa fifth session. International migration of health personnel: a challenge for health systems in
developing countries. An information document. AFR/RC55/inf/Doc.2 2005.
• Renner A and Kirigia JM. Technical efficiency of health centres in Sierra Leone. African Health Monitor. 2005;5:39-42.
Health systems
Report on the Consultative Meeting on Improving Collaboration between Health Professionals, Governments, and Other
Stakeholders in Human Resources for Health Development, Addis Ababa, 29 January - 1 February 2002. Brazzaville; WHO
Regional Office for Africa: 2002. Available from: http://www.afro.who.int/hrd/consultative_meeting_report.pdf
Tools for institutionalizing traditional medicine in health systems in WHO African Region. Regional Office for Africa.
Brazzaville. http://www.prometra.org/Documents/ToolsforlNstitutionalizingTraditionalMedicineinHealth.pdf
WHO Regional Office for Africa (2004) Priority Interventions for Strengthening National Health Information Systems. WHO
Regional Office for Africa (2004) AFR/RC54/12.
Commission for Macroeconomics and Health Report. Geneva; World Health Organization 2001.
World health report 2004: Changing history. Geneva; World Health Organization 2004.
World health report 2005: Make every mother and child count. Geneva; World Health Organization 2005.
World Health Report 2006: Working together for health. Geneva; World Health Organization 2006.
World development indicators 2004. Washington, DC: World Bank; World Health Organization 2004.
World Health Organization: Sustainable health financing, universal coverage and social health insurance. Geneva; WHO; 2005.
The African Regional Health Report
Health
y
African Region of the World Health Organization
Cape
Verde
Senegal . =
Gambia / .,
Guinea-Bissau
Guinea
Sierra Leone
Liberia
Burkina Paso-
C6te d'lvoire •
Sao Tome and Principe
Cameroon
Equatorial Guinea
Gabon'
WHO African Region
H Outside WHO African Region
Central African
Republic
Democratic
Republic of
the Congo
Botswana
Angola
Uganda
Rwanda
Burundi
United Republic of Tanzania
Seychelles
Comoros
Malawi
Zambia
Mozambique
Madagascar
Zimbabwe
Swaziland
Lesotho
Mauritius
This report is about the 46 Member States of the African Region of the World Health Organization (WHO), as illustrated in this map. The
African Regional Office of WHO is based in Brazzaville, the Republic of the Congo. When this report refers to "Africa", it is referring to
the continent and islands as a whole. When the report refers to "the African Region" or "the Region", it is as defined by WHO.
It is important to note that the WHO African Region does not include all the countries on the African continent and the Region itself
is not limited to all of sub-Saharan Africa.
Please note: the World Bank divides the continent into two regions: North Africa and sub-Saharan Africa, while UNICEF
divides it into three regions: Eastern and South Africa, West and Central Africa, and the Middle East and North Africa.
1 30 The African Regional Health Report
Introduction
These tables include some of the most recent statistics since 1 997. based on health indicators
from the African Region's 46 Member States. All of these tables have been selected from
World Health Statistics 2006. In addition, historical data for some of these indicators have
been reproduced from the World health report 2006: Working together for health. The statistical
tables cover the following categories: mortality, morbidity, health service coverage, risk factors,
health systems, inequities in health, and demographic and socioeconomic status.
World Health Statistics 2006 includes an expanded set of statistics from all 192 WHO
Member States, with a particular focus on equity between and within countries. It was collated
from publications and databases of WHO's technical programmes and regional offices. The core
set of indicators was selected on the basis of relevance for global health, availability and quality of
data, and accuracy and comparability of estimates. The statistics for the indicators are based on
an interactive process of data collection, compilation, quality assessment, and estimation between
WHO technical programmes and its Member States. In this process, WHO strives to maximize
accessibility, accuracy, comparability, and transparency of country health statistics.
In addition to national statistics, this publication presents statistics on the distribution of
selected health outcomes and interventions within countries, disaggregated by gender, age, urban/
rural setting, wealth/assets, and educational level. Such statistics are primarily derived from the
analysis of household surveys and are only available for a limited number of countries. The number
of countries reporting disaggregated data is expected to increase during the next few years.
The core indicators do not aim to capture all relevant aspects of health, but to provide
a comprehensive summary of the current status of population health and health systems at
country level: I) mortality outcomes: 2) morbidity outcomes: 3) risk factors: 4) coverage of
selected health interventions; 5) health systems; 6) inequalities in health; and 7) demographic
and socioeconomic statistics.
All statistics have been cleared as WHO official figures in consultation with Member States,
unless otherwise stated. The estimates published here should, however, still be regarded as the best
estimates by WHO rather than the official view of Member States.
As demand for timely, reliable, and consistent information on key health statistics continues to
increase, users need to be well informed on definitions, quality, and limitations of health statistics.
More detailed information is available from the WHO Statistical Information System (WHOSIS) at:
http://www.who.int/whosis.
The health of the people • • • Statistical annex 131
lo
Population
annual
growth rate
Total fertility
rate3
Algeria
Angola
Benin
Botswana
Burkina Faso
32854
15941
8439
1765
13228
1.4
2.3
2.8
0.9
2.7
60
37
46
53
19
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
7548
16322
507
4038
9749
1.7
1.9
2.1
1.6
3.0
11
53
58
44
26
Comoros
Congo
Cote d'lvoire
Democratic Republic of the Congo
Equatorial Guinea
798
3999
18154
57549
504
2.5
2.9
1.9
2.2
2.1
36
54
46
33
50
Eritrea
Ethiopia
Gabon
Gambia
Ghana
4401
77431
1384
1517
22113
3.2
2.3
2.0
2.9
2.0
21
16
85
26
46
Guinea
Guinea-Bissau
Kenya
Lesotho
Liberia
9402
1586
34256
1795
3283
2.0
2.6
2.1
0.6
4.2
37
36
42
18
48
Madagascar
Malawi
Mali
Mauritania
Mauritius
18606
12884
13518
3069
1245
2.6
2.2
2.6
2.6
0.9
27
17
34
64
44
Mozambique
Namibia
Niger
Nigeria
Rwanda
19792
2031
13957
131 530
9038
2.1
2.0
3.1
2.2
5.0
38
34
23
48
22
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
South Africa
157
11658
81
5525
47432
1.8
2.2
0.6
2.6
1.2
38
51
50
40
58
Swaziland
Togo
Uganda
United Republic of Tanzania
Zambia
1032
6145
28816
38329
11668
0.8
2.9
2.9
2.0
1.8
24
36
12
38
37
(per woman)
2004
2.5
6.7
5.7
3.1
6.6
6.8
4.5
3.6
4.9
6.7
4.7
6.3
4.9
6.7
5.9
5.4
5.7
3.9
4.6
4.2
5.8
7.1
5.0
3.5
6.8
5.3
6.0
6.8
5.7
2.0
5.4
3.8
7.8
5.7
5.6
3.9
4.9
2.1
6.5
2.8
3.8
5.2
7.1
4.9
5.5
fertility proportion
13.9
14.7
12.3
8.1
9.4
16.9
8.3
14.7
11.7
14.5
13.0
13.7
8.9
9.6
16.2
10.5
14.5
11.1
4.6
13.6
12.2
13.7
1999
2002
2003
2003
1997
2000
1998
1998
2002
1997
2002
2002
1998
2000
1999
2000
2002
1999
1997
2002
1999
1999
1998
2000
Zimbabwe
13010
0.9
36
3.4
13.3
1997
African Region
738 083
2.2
38
5.3
11.7
... Data not available or not applicable.
a World Population Prospects: The 2004 Revision. Population database. Population Division. Department of Economic and Social Affairs. United Nations Secretariat, (http://
esa.un.org/unpp)
b Population Division. Department of Economic and Social Affairs. United Nations Secretariat.
0 United Nations Educational, Scientific and Cultural Organization, (http://gmr.uis.unesco.org/selectindicators.aspx)
1 32 The African Regional Health Report
Adult
literacy rate0
Net primary school
enrolment ratio11
Gross national
income
per capita6
Population living
below the poverty line
(%)
2000-2004
Males (%) Females (%)
1998-2004
(PPP lnt.$)
2004
(% with <$1
a day)
Year
69.8 |
66.8
33.6
96
66
69
94
47
6260
2030
[ 1 120
78.9
79
83 ||
8920
12.8
42
31
1220
44.9
1998
58.9
62
52
660
54.6
1998
67.9
^^2090
17.1
2001
75.7
100
98
5650
48.6
| 1 110
25.5
72
49
1420
56.2
59
50
1840
82.8
48.1
55
67
53
54
750
1^1 390
...
2002
10.8
65.3
680
84.2
91
78
7400
49
42
1050
41.5
55
47
[^ 810
23.0
1999-00
IjHi
I^B78
5600
mn^m
79
78
| 1900
59.3
1998
54.1
64
62
2280
44.8
1998-99
73
58
2130
53
37
690
73.6
66
66
^^1050
22.8
1997
81.4
83
89
3210
55.9
79
61
70.6
78
79
830
61.0
2001
64.1
| 620
41.7
1997-98
19.0
50
39
980
51.2
68
67
| 2050
25.9
2000
84.3
96
98
11870
46.5
58
53
1 160
85.0
76
81
6960
14.4
45
31
| 830
66.8
74
60
930
70.2
1997
64.0
85
88
1300
51.7
1999-00
139.3
91.9 &$,
29.6 I
82.4
100
71
100
89
94
IHB^^HBBHM^B^H
66
99
89
1^^1720
15590
[^ 790
10960
^^^^^^^^"*^^^^^^^
10.7
2000
79.2
53.0
68.9
69.4
75
99
83
75
83
81
4970
1690
[^ 1520
660
84.9
1999
67.9
69
68
890
63.7
1998
90.0
79
80
2180
60.1
70
63
2074
44
ed Nations Educational, Scientific and Cultural Organization. (hrtp^/www.uis.unesco.org/ev.php?URLJD=5187&URL_DO=DO_TOPIC&URL_SECTION=201)
World Bank Group. (http://siteresources.worldbank.org/DATASTATISTICS/Resources/GNIPC.pdf)
World Bank Group. (http://devdata.worldbank.org/wdi2005/Table2_5.htm)
The health of the people • • • Statistical annex 1 33
Country
Life
expectancy
at birth3
(years)
Healthy life
expectancy
(HALE)
at birth"
(years)
Probability of dying Probability Infant Neonatal Maternal
per 1000 population of dying per mortality mortality mortality
between 15 and 1000 live rate0 rated ratio11
60 years3 births under 5 (per 1000 (per 1000 (per
(adult mortality rate)
live births) live births) 100000
live births)
mortality rate)
Females Both sexes Both sexes Both sexes Females
m Algeria
I Angola
I Benin
I Botswana
Efl Burkina Faso
69 72
38 42
52 53
40 40
47 48
60
32
43
36
35
62
35
45
35
36
153
591
388
786
472
124
504
350
770
410
40
260
152
116
192
35
154
90
75
97
20
54
38
40
36
140
1700
850
100
1000
I Burundi
• Cameroon flHHHH
I Cape Verde
• Central African Republic
HM Chad
42 47
50 51
67 71
40 41
45 48
33
41
59
37
40
37
42
63
38
42
593
444
209
667
497
457
432
139
624
422
190
149
36
193
200
114
87
27
115
117
41
40
10
48
45
1000
•1 730
150
1100
1 100
I Comoros
1 Congo
1 Coted'lvoire
1 Democratic Republic of the Congo
•£• Equatorial Guinea
62 67
53 55
41 47
42 47
42 44
54
45
38
35
45
55
47
41
39
46
254
442
585
576
577
182
390
500
446
522
70
108
194
205
204
52
79
118
129
123
29
32
65
47
40
480
| 510
690
990
880
1 Eritrea
1 Ethiopia
58 62
49 51
49
41
50
48
49
51
42
53
51
50
345
451
411
344
349
281
389
344
263
319
82
166
91
122
112
52
110
59
89
68
25
51
31
46
27
630
•i 850
420
540?
540
I Gabon
1 Gambia
K9 Ghana
55 59
55 59
56 58
• Guinea
I Guinea-Bissau
1 Kenya
1 Lesotho
52 55
45 ' 48
51 50
39 44
44
40
44
30
34
46
41
45
33
37
364
482
477
845
596
319
413
502
728
477
155
203
120
82
235
101
126
78
55
157
48
48
29
28
66
740
1100
1000
550
760
• Madagascar
1 Malawi
1 Mali
55 59
41 41
44 47
47
35
37
43
60
50
35
38
46
65
338
663
490
325
217
270
638
414
246
112
123
175
219
125
15
76
109
121
78
12
33
40
55
70
12
550
1800
1200
1000
I Mauritania
•HI Mauritius
55 60
69 75
• Mozambique
1 Namibia
I Nigeria
« Rwanda
44 46
52 55
42 41
45 46
44 47
36
43
36
41
36
38
44
35
42
40
627
548
506
513
518
549
489
478
478
435
152
63
259
197
203
102
42
152
103
118
48
25
43
53
45
300
800
1400
1 Sao Tome and Principe
I Senegal
1 Seychelles
1 Sierra Leone
vm South Africa
57 60
54 57
67 78
37 40
47 49
54
47
57
27
43
55
49
65
30
45
301
358
232
579
667
236
288
83
497
598
118
137
14
283
67
75
78
12
165
54
38
31
9
56
21
690
2000
230
Swaziland
1 Togo
1 Uganda
I United Republic of Tanzania
^B Zambia
36 39
52 56
48 51
47 49
40 40
33
44
42
40
35
35
46
44
41
35
823
401
525
551
683
741
327
446
524
656
156
140
138
126
182
102
79
81
78
104
38
40
32
43
40
370
| 570
880
1500
750
| Zimbabwe
37 34
34
33
857
849
129
78
33
1 100
... Data not available or not applicable.
a World health report 2006: working together for health. Geneva, World Health Organization, 2006. (http://www.who.int/whr/2006/annex/en)
b World health report 2004: changing history. Geneva, World Health Organization, 2004. (http://www.who.int/whr/2004/en/index.html)
c (i) WHO Mortality Database. World Health Organization, (http://www.who.int/healthinfo/morttables/en/index.html);
(ii) United Nations Children's Fund. State of the World's Children 2006. New York: United Nations Children's Fund, 2005.
11 World health report 2005: make every mother and child count. Geneva, World Health Organization, 2005. (http://www.who.int/whr/2005/en/index.html)
e UNAIDS 2004 report on global HIV/AIDS epidemic: 4th global report. Geneva, Joint United Nations Programme on HIV/AIDS 2004.
(http://www.unaids.org/bangkok2004/GAR2004_pdf/UNAIDSGIobalReport2004_en.pdf)
f These are classified as deaths from tuberculosis (A15-A19, B90) according to the ICD-10. Source: Global tuberculosis control: surveillance, planning, financing. WHO report 2006. Geneva,
World Health Organization (WHO/HTM/TB/2006.362). (http://www.who.int/tb/publications/globaLreport)
1 34 The African Regional Health Report
Cause-specific mortality rate
(per 100 000 population)
Age-standardized mortality rate by
cause1" (per 100 000 population)
Years of life lost
by broader causes'1'' (%)
Causes of death among children under 5 years of age'
Both sexes
1 Both sexes
Both sexes
Both sexes
2003 1
2004
2004
I 2002 1
2002
1 2002
2002
1 2002
2002 I
2002 1
2000
2000
2000
2000
2000
2000
2000
2000 1
<10
2
<1
598
314
103
85
50
30
20
48.0
0.0
11.9
0.9
0.5
13.7
5.0
20.0
140
25
7
982
486
179
231
84
8
8
22.2
2.2
19.1
4.8
8.3
24.8
1.4
17.2
73
14
2
852
432
154
116
82
10
••P
25.0
2.2
17.1
5.3
27.2
21.1
2.1
0.0
: 1863
37
58
653
338
124
72
93
4
3|
40.3
53.8
1.1
0.1
0.0
1.4
3.3
0.0
234
38
16
901
459
162
149
87
7
7
18.3
4.0
18.8
3.4
20.3
23.3
1.5
10.4
355
59
33
843
439
146
301
81
7
12
23.3
8.0
18.2
3.0
8.4
22.8
1.8
14.6
311
19
12
848
436
150
118
81
11
••P
24.8
7.2
17.3
4.1
22.8
21.5
2.2
0.0
35
1
692
356
127
39
51
37
12 I
25.9
3.7
12.2
4.4
4.3
13.3
3.5
32.6
584
55
58
863
445
154
146
84
9
••P
27.2
12.4
14.7
6.5
18.5
18.7
2.0
0.0
197
60
22
869
443
156
131
85
8
7
24.0
4.1
18.1
7.0
22.3
22.8
1.8
0.1
...
7
<1
736
381
128
83
70
18
12
37.3
3.7
13.6
5.9
19.4
16.3
3.4
0.5
257
52
18
762
393
134
147
79
11
11
30.9
9.3
11.2
6.6
25.7
13.6
2.6
0.0
267
67
37
873
436
160
179
78
11
10
34.9
5.6
14.8
2.5
20.5
19.6
2.2
0.0
184
57
21
909
465
161
273
82
7
11
25.7
3.7
18.1
4.7
16.9
23.1
1.6
6.3
30
27
864
438
155
144
79
12
9
27.5
7.4
13.6
7.4
24.0
17.3
2.5
0.3
155
52
9
762
398
133
92
81
11
8
27.4
6.2
15.6
2.5
13.6
18.6
3.0
13.0
163
60
19
859
435
147
104
82
12
6
30.2
3.8
17.3
4.2
6.1
22.3
1.7
14.3
224
33
22
813
410
158
103
72
18
9
35.1
10.1
8.8
4.4
28.3
10.7
2.5
0.0
42
38
2
805
413
144
109
75
15
10
36.6
1.3
12.2
2.5
29.4
15.5
2.6
0.0
141
40
10
786
404
138
97
74
16
10
28.5
5.7
12.2
2.9
33.0
14.6
3.0
0.0
100
44
12
853
432
156
147
80
11
9
28.8
2.3
16.5
5.5
24.5
20.9
1.4
0.0
33
9
883
449
159
138
86
8
6
24.1
2.6
186
3.4
21.0
23.4
1.4
5.5
458
90
43
782
401
139
95
81
11
8
24.2
14.6
16.5
3.2
13.6
19.9
2.7
5.3
1611
41
58
785
404
139
88
90
7
3
32.8
56.2
3.9
0.1
0.0
4.7
2.2
0.0
223
46
27
955
485
169
270
83
7
10
29.1
3.6
17.3
6.0
18.9
23.0
1.7
0.3
43
37
6
837
430
147
112
79
12
9
25.6
1.3
16.9
5.0
20.1
20.7
2.4
8.0
681
48
49
835
430
150
105
89
6
5
21.7
14.0
18.1
0.3
14.1
22.6
1.7
7.6
94
62
11
909
456
166
145
86
8
6
25.9
1.6
18.3
6.1
16.9
23.9
1.4
5.9
17
57
3
884
451
158
138
79
12
9
39.4
0.3
16.2
1.7
12.2
22.3
1.9
5.9
11
<1
701
434
79
42
11
75
13
66.0
0.0
1.2
0.0
0.0
3.9
5.2
23.6
577
62
67
720
371
124
66
91
7
2
29.0
12.9
16.5
0.3
18.9
21.2
1.0
0.1
806
44
41
754
385
146
93
83
10
6
38.5
53.0
2.5
0.1
0.0
3.0
3.0
0.0
37
31
3
916
456
169
163
87
HH
6
16.7
0.6
19.8
7.3
14.3
25.1
1.4
14.8
246
56
27
889
452
157
132
83
10
7 |
26.1
5.0
15.7
6.3
24.1
20.1
1.9
0.8
251
69
33
831
425
150
126
85
8
7
21.7
5.0
18.5
1.6
4.6
23.2
1.8
23.7
28
<1
764
396
133
87
67
21
12
32.1
3.7
16.0
4.8
0.6
21.2
3.5
18.1
31
49
3
832
426
146
125
76
13
11
22.8
1.0
17.1
8.1
27.6
20.7
2.6
0.2
6
<1
657
336
131
69
16
64
21
27.2
0.0
0.0
0.0
0.0
10.1
12.3
50.3
92
13
1017
515
181
250
86
6
8
21.9
1.3
19.7
5.3
12.4
25.5
1.2
12.7
'. 789
56
78
808
410
154
120
77
15
8
35.1
57.1
0.8
0.0
0.0
0.9
5.0
1.1
1643
93
176
732
364
162
72
91
5
4
26.8
47.0
9.6
0.2
0.2
11.8
3.8
0.5
171
77
21
831
427
147
117
79
12
9
29.0
5.8
13.8
6,6
253
17.1
2.5
0.0
290
71
22
824
422
146
154
84
8
8
23.6
7.7
17.2
3.0
23.1
21.1
2.2
2.1
433
47
31
847
435
151
115
85
8
6
26.9
9.3
16.8
1.3
22.7
21.1
2.0
0.0
788
70
68
700
359
122
58
92
6
2
22.9
16.1
17.5
1.2
19.4
21.8
1.0
0.1
1322
62
685
347
122
103
90
28.1
40.6
12.1
2.9
0.2
14.7
1.2
0.3
313
53
28
800
404
144
133
59
26.2
6.8
16.6
4.3
17.5
21.1
1.9
5.6
I These deaths are classified under "HIV disease resulting in tuberculosis (B20.0)" according to the ICD-10. They are already counted in the number of deaths from HIV/AIDS (B20-B24).
! Source: Global tuberculosis control: surveillance, planning, financing. WHO report 2006. Geneva, World Health Organization (WHO/HTM/TB/2006.362).
l!http://www.who.int/tb/publications/global_report)
t Mortality and burden of disease estimates for WHO Member States in 2002. World Health Organization, December 2004.
rhttp://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls)
I Rates are age-standardized to the WHO world standard population. Source: Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJL, Lozano R, Inoue M. Age standardization of rates: a new WHO
I standard. GPE Discussion Paper Series: No.31. EIP/GPE/EBD. World Health Organization. 2001. (http^/www3.who.int/whosis/discussion_papers)
j Sum of individual proportions may not add up to 100% due to rounding.
I 'Communicable diseases" include maternal causes, conditions arising in the perinatal period and nutritional deficiencies.
JNeonatal causes include diarrhoea during the neonatal period. Sources: (i) Bryce J, Boschi-Pinto C, Shibuya K. Black RE; WHO Child Health Epidemiology Reference Group. WHO estimates of
(the causes of death in children. Lancet, 2005:365:1147-52; (ii) WHO mortality profiles, (http://www.who.int/whostatistics/mortality)
The health of the people •
Statistical annex 135
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Congo
Cote d'lvoire
Democratic Republic of the Congo
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Kenya
Lesotho
Liberia
HIV
prevalence
among adults3
(15-49)(%)
Both sexes
2003
3.9
1.9
37.3
4.2
2.7
4.4
8.1
1.2
3.1
3.2
6.7
28.9
5.9
prevalence
(per 100 000
population)
Both sexes
2004
54
310
142
553
365
564
227
314
549
566
95
464
651
551
322
437
533
339
329
376
410
306
888
544
447
IB
incidence11
(per 100 000
population)
Both sexes
2004
54
259
87
670
191
343
179
172
322
279
46
377
393
366
239
271
353
280
233
206
240
199
619
696
310
Number of
confirmed polio
Both sexes
2005
0
10
0
0
0
1
22
0
0
0
... Data not available or not applicable.
a UNAIDS2004 report on global HIV/AIDS epidemic: 4th global report. Geneva, Joint United Nations Programme on HIV/AIDS 2004.
(http://www.unaids.org/bangkok2004/GAR2004_pdf/UNAIDSGIobalReport2004_en.pdf)
b All forms of TB, including TB in people with HIV infection. Source: Global tuberculosis control: surveillance, planning, financing. WHO report 2006. Geneva, World Health
Organization (WHO/HTM/TB/2006.362). (http://www.who.int/tb/publications/global_report)
0 World Health Organization, Polio Eradication Initiative. Data as of 25 April 2006. (http://www.who.int/immunization_monitoring/en/diseases/poliomyelitis/case_count.cfm)
1 36 The African Regional Health Report
HIV
prevalence
among adults3
(15-49) (%)
Both sexes
2003
prevalence
(per 100 000
population)
Both sexes
2004
I
Zimbabwe
* Imported cases of malaria
24.6
(update 2004)
7.1
673
518
IB
incidence
(per 100 000
population)
Both sexes
2004
674
356
Number of
confirmed polio
Both sexes
2005
Madagascar
1.7
351
218
1
Malawi
14.2
501
413
0
Mali
1.9
578
281
3
Mauritania
0.6
502
287
0
_____ ^^^^^^^^^^H^g^g^^M
Mauritius
...
135
64
0
Mozambique
12.2
635
460
0
Namibia
21.3
586
717
0
Niger
1.2
288
157
10
Nigeria
5.4
531
290
801
Rwanda
5.1
660
371
0
Sao Tome and Principe
...
253
107
0
Senegal
0.8
451
245
0
Seychelles
...
83
34
0
Sierra Leone
...
847
443
0
South Africa
21.5
670
718
0
Swaziland
38.8
1120
1226
0
Togo
4.1
718
355
0
Uganda
4.1
646
402
0
United Republic of Tanzania
8.8
479
347
0
Zambia
16.5
707
680
0
854
The health of the people • • • Statistical annex 1 37
Probability of dying per 1000 live births under 5 years
(under- 5 mortality rate)
Place of residence
Wealth quintile
Educational level
of motherb
Children under 5 years stunted for age
Place of residence Wealth quintile
Benin
2001
175.5
133.6
1.3
198.2
93.1
2.1
174.5
80.8
2.2
33.4
24.2
1.4
35.4
18.2
1.9
Botswana
1988
55.2
55.3
1.0
62.0
46.3
1.3
Burkina Faso
2003
201.5
136.4
1.5
206.0
144.0
1.4
198.4
108.0
1.8
41.4
19.8
2.1
45.7
20.6
2.2
Burundi
1987
184.2
163.7
1.1
191.2
80.7
2.4
48.6
27.1
1.8
Cameroon
2004
168.8
119.3
1.4
189.0
88.0
2.1
185.7
93.3
2.0
38.2
23.1
1.7
40.9
12.3
3.3
Central African Republic
1994-95
178.4
128.6
1.4
192.9
98.3
2.0
175.2
83.1
2.1
37.2
28.6
1.3
42.3
25.0
1.7
Chad
2004
208.0
179.0
1.2
176.0
187.0
0.9
200.0
143.0
1.4
43.0
32.3
1.3
50.7
31.7
1.6
Comoros
1996
122.6
80.7
1.5
128.9
86.6
1.5
120.6
74.5
1.6
35.0
29.9
1.2
44.8
23.3
1.9
Cote d'lvoire
1998-99
196.8
125.2
1.6
192.7
79.4
2.4
28.6
18.3
1.6
Eritrea
2002
117.1
86.1
1.4
100.0
65.0
1.5
120.6
58.5
2.1
42.6
27.8
1.5
44.8
17.6
2.5
Ethiopia
2000
192.5
148.6
1.3
159.2
147.1
1.1
197.4
89.2
2.2
52.3
41.6
1.3
52.9
43.2
1.2
Gabon
2000
99.9
88.4
1.1
93.1
55.4
1.7
112.0
87.1
1.3
29.0
17.4
1.7
32.8
11.5
2.9
Ghana
2003
118.3
92.7
1.3
128.0
88.0
1.5
124.9
84.5
1.5
34.0
19.9
1.7
41.8
13.2
3.2
Guinea
1999
210.6
148.7
1.4
229.9
133.0
1.7
203.8
104.2
2.0
29.4
18.2
1.6
32.4
15.7
2.1
Kenya
2003
U6.9
93.5
1.3
149.0
91.0
1.6
126.5
62.9
2.0
32.0
23.8
1.3
38.1
19.2
2.0
Liberia
1986
239.7
217.8
1.1
242.1
176.1
1.4
Madagascar
2003-04
120.0
73.3
1.6
141.8
49.4
2.9
148.6
65.4
2.3
48.9
40.9
1.2
50.5
38.2
1.3
Malawi
2000
210.3
147.9
1.4
230.8
149.0
1.5
214.5
118.0
1.8
51.3
34.2
1.5
57.8
33.5
1.7
Mali
2001
253.2
184.6
1.4
247.8
148.1
1.7
246.9
89.6
2.8
42.1
23.2
1.8
44.8
19.7
2.3
Mauritania
2000-01
96.2
110.7
0.9
98.1
78.5
1.2
110.5
85.5
1.3
37.9
30.2
1.3
38.7
23.4
1.7
Mozambique
2003
192.0
143.2
1.3
196.0
108.0
1.8
200.5
85.7
2.3
45.7
28.5
1.6
49.3
20.0
2.5
Namibia
2000
66.1
49.5
1.3
55.4
31.4
1.8
83.6
47.1
1.8
23.0
21.7
1.1
26.7
15.3
1.7
Niger
1998
327.4
178.1
1.8
281.8
183.7
1.5
314.0
129.6
2.4
43.0
31.2
1.4
41.9
32.3
1.3
Nigeria
2003
242.7
152.9
1.6
257.0
79.0
3.3
269.4
107.2
2.5
42.9
28.9
1.5
48.8
17.9
2.7
Rwanda
2000
216.2
141.3
1.5
246.4
154.1
1.6
232.7
116.7
2.0
44.9
27.8
1.6
49.4
26.9
1.8
Senegal
1999
171.2
92.1
1.9
159.9
80.1
2.0
South Africa
1998
71.2
43.2
1.6
87.4
21.9
4.0
83.8
45.6
1.8
Sudan
1990
144.0
117.0
1.2
151.9
84.3
1.8
Togo
1998
157.4
101.3
1.6
167.7
97.0
1.7
159.1
82.5
1.9
23.9
14.8
1.6
29.0
11.0
2.6
Uganda
2000-01
163.8
100.5
1.6
191.8
106.4
1.8
186.9
93.0
2.0
39.9
26.5
1.5
43.3
25.1
1.7
United Republic of Tanzania
1999
165.9
141.6
1.2
160.0
135.2
1.2
165.4
62.6
2.6
46.5
24.5
1.9
49.5
23.4
2.1
Zambia
2001-02
182.3
140.0
1.3
191.7
92.4
2.1
197.8
121.1
1.6
51.1
37.1
1.4
54.1
31.6
1.7
Zimbabwe
1999
99.7
69.0
1.4
99.5
62.2
1.6
118.8
78.7
1.5
29.2
20.6
1.4
32.7
18.6
1.8
Statistics by gender are presented elsewhere in this report.
... Data not available or not applicable.
3 Source: Demographic and Health Surveys, (http://www.measuredhs.com)
b Lowest and highest mother's educational levels are "no education" and "secondary or higher", respectively.
c Data correspond to births in 3 years preceding survey, not 5 years.
1 38 The African Regional Health Report
Births attended by skilled health personnel1
Measles immunization coverage among 1 -year-olds'
EdBC3t)ondl level
Place of residence
Wealth quintile
Educational level
of mother
Place of residence
Wealth quintile
Eitocational level
33.0
17.1
1.9
68.4
82.9
1.2
99.3
49.6
2.0
67.6
98.6
1.5
75.3
64.1
1.2
83.1
56.9 1.5
88.6 63.4
1.4
71.7
93.5
1.3
53.6
96.6
18
65.4
*'--
09
630 6T.S
09
40.8
12.4
3.3
30.5
87.7
2.9
90.8
38.8
2.3
32.7
94.7
2.9
73.1
53.3
"
71.3
48.3 1.5
80.4 543
1.5
49.0
24.6
20
16.8
85.2
51
—
15.6
"5 '
49
51 \
47.8
1.1
_
56.3 45.2
1.2
M :
21.0
1.9
44.2
84.2
1.9
••MM^HM
94.5
29.3
3.2
229
91 "
U
72.5
58.3
12
83.2
52.1 1.6
79.3 46.1
1.7
37.2
24.1
1.5C
23.7
77.7
3.3
817
14.3
5.7
29.4
\-\
2.9°
68.4
40.5
1.7
79.8
31.3 2.5
79.2 386
2.1
10
22.1
2.0
6.4
45.6
7.1
55.4
3.6
15.4
9.3
66.7
7.2
37.5
19.2
2.0
38.1
8.2 4.6
53.7 182
3.0
38.2
2; :
i- I
78.9
1.8
84.8
2-: 2
32
« 9
:2r
2.0=
S3 :
63 :
1 0
86.0
51.1 1.7
75.5 58.7
1 :
au
14.2
2.0
32.1
79.1
2.5
...
-
-
37.9
83.6
2.2
82.0
58.8
1.4
...
-
94.6 57.8
1.6
44.6
16.2
2.8
114
-:- -
6.2
81.0
6.7
12.1
12.0
87.9
~;
93.8
78.5
1 2
-- 4
83.8 1.2
95.6 77.1
1.2
52.8
32.5
Li
2.3
34.5
15.0
25.3
0.9
28.1
2.5
45.0
18.0
63.1
22.3
2.8
52.2
18.2 2.9
61' 221
2 :
22.5
16.5
1.4
; 1 '
92.9
1.3
97.1
67.2
1.4
83.9
92.9
: ;
61.1
37.1
1.6
71.3
34.1 2.1
63.9 42 •
1.5
38.0
23.7
1.6
30.9
79.7
2.6
90.4
20.6
M
29.7
67.9
2.3
85.8
81.8
1.0
88.8
75.0 1.2
89.3 78.2
1.1
::• •
2 :
21.3
75.6
3.5
81.5
12 :
6.7
:- :
S3 :
2.9
:: '-
46.7
14
73.0
•31 22
82.3 48.4
:?
36.4
19.0
: --
34.5
72.0
2.1
75.4
17.0
4.4
15.8
72.0
4.6
85.9
69.7
1.2
88.0
54.8 1.6
84.9 51.1
1.7
44 :
76.7
1.7
49.3
86.6
1.8
30.2
28.0
42.7 24.9
1.7
49.1
38.0
1.3
39.6
70.6
1.8
939
29.9
3.1
21.9
80.5
3.7
73.9
55.9
1.3
84.0
38.4 2.2
85.2 36.1
2.4
54.2
27.1
2.0
51.9
81.6
1.6
83.0
43.0
} 9
4: !
87.7
1 •-
90.6
82.0
1.1
90.4
'9.8 1 1
93.4 79.2
1.2
13.6
2.9
26.6
80.8
3.0
81.9
8.1
10.1
34.4
90.8
2.6
70.8
41.3
1.7 j
76.5
39.7 1.9
78.7 44.9
1.8
21.4
1.7
28.9
85.8
3.0
92.8
14.7
6.3
40.4
91.6
2.3
74.3
53.0
HI
86.2
42.0 2.1
79.8 55.4
1.4
47.7
14.5
3.3
34.1
80.7
2.4
88.6
24.8
•e
31.4
94.8
.: :
50.8
".c
1.3
96.4
60.8 1.6
991 -.-'.
1.5
28.5
17.9
1.6
66.3
93.1
; :
97.1
55.4
1.8
« •
89.1
1.9
84.3
78.4
i :
85.7
76.2 1.1
83.3 69.5
12
-
23.6
1.8C
8.1
68.7
8.5
62.8
4.2
15.0
13.8
68.5
5.0C
67.1
27.8
2.4
65.8
23.0 2.9
73.9 31.8
2.3
50.5
20.0
25
271
58.8
22
84.5
13.0
6.5
13 8
"52
5.4
521
28.!
IS
159 4.4
665 156
4.3
47.9
26.1
1.8
19.9
65.7
3.3
59.6
17.3
3.4
13.9
689
5.0
•99
•:.•
1.0 1
:::
83.8 1.1
93.2 82^
1.1
75 7
95.6
: :
": :
:~ ;
1.2
78.7
:": :
14
-'.- •-:
1.7
75.5
93.4
1.2
98.1
67.8
: -
59.7
9.4
1.5
85.1
79.3
1.1
84.5
73.5 1.1
85.6 64.0
1.3
59.3
85.9
1.4
52.6
95.5
1.8
69.9
56.3
\2 1
84.8 50.3
L7
25.5
12.0
2.1C
39.8
86.4
2.2
91.2
25.1
3.6
36.7
86.8
2.4C
58.0
38.2
1.5
63.2
34.5 1.8
63.7 36.5
1.7
28.9
; -_
33.1
':'. '-
2.4
77.3
19.7
3.9
21.5
": ;
3.5
-\-
55.3
1.2
64.5
49.1 1.3
69.4 54.1
1.3
-:"
16.6
2.8
34.7
83.3
2.4
•I:
289
2.9
25.3
81.5
3.2
90.3
75.3
1.2
•9 :
63.4 1.4
Y- ; i; ;
1.5
53.8
36.1
1.5
27.6
79.0
29
9i :
19.7
4.6
17.3
77.8
4.5
«: 5
83.9
10
88.4
81 2 11
87.2 79.8
1.1
3,3
22.5
1.6
64.2
89.4
1.4
93.5
56.7
1.6
42.8
85.6
2.0
86.2
75.7
1.1
85.8
80.2 1.1
85.2 69.4
1.2
The health of the people • • • Statistical annex 1 39
a
2002
2001
2001
200G
2003
2002
2001
2001
2000
2003
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Congo
Cote d'lvoire
Democratic Republic of the Congo
Equatorial Guinea
Eritrea
2002
2000
2000-01
2000
2003
2002
2000
2000-01
2000
2003
2002
2000
2000-01
2000
2003
Ethiopia
Gabon
Gambia
Ghana
Guinea
1999
2000
2003
2000
1999-00
1999
2000
2003
2000
1999-00
1999
2000
2003
2000
1999-00
Guinea-Bissau
Kenya
Lesotho
Liberia
2003™
2000"
2001"
2000-01"
1998'
Madagascar
Malawi
Mali
Mauritania
Mauritius
2003-04
2000
2001
2000-01
2003-04
2000
2001
2000-01
Mozambique
Namibia
Niger
Nigeria
Rwanda
2003
2000
2000
2003
2000
2003
2000
2000
2003
2000
2003
2000
2000
2003
2000
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
South Africa
1998
Swaziland 30.2 2000 10.3 2000 9
Togo 21.7 1998 25.1 1998 1.5 1998 15 ...
Uganda 39.1 2000-01 22.9 2000-01 2.6 2000-01 12 MM
United Republic of Tanzania 43.8 1999 29.4 1999 1.7 1999 13 4.4 2004-05"
Zambia 46.8 2001-02 28.1 2001-02 3.0 2001-02 12 3.0 2001-02"
Zimbabwe
26.5
1999
13.0
1999
1999
7.5
1999"
14 f^
... Data not available or not applicable.
a Global Database on Child Growth and Malnutrition. World Health Organization.
(http://www.who.int/nutgrowthdb/database/en/)
b United Nations Children's Fund and World Health Organization. Low Birthweight: Country, regional and global estimates. UNICEF, New York, 2004.
(http://www.who. int/reproductive-health/publications/low_birthweight/low_birthweight_estimates.pdf)
c WHO Global Database on Body Mass Index (BMI). World Health Organization. (http//www.who.int/bmi). Comparisons between countries may be limited due to differences in definitions, sample
characteristics, or survey years.
d World Health Organization and United Nations Children's Fund. Joint Monitoring Programme for Water Supply and Sanitation. Online database.
(http://www.wssinfo.org/en/wecome.html)
e Programme on Household Energy and Health, Department for Public Health and Environment. World Health Organization, (http://www.who.int/indoorair/en/)
' In adolescents, data relate to daily or occasional tobacco use, while in adults they relate to daily or occasional tobacco smoking. Comparisons between countries may be limited due to differ-
ences in definitions, sample characteristics, or survey years.
8 Global NCD InfoBase/Online Tool. World Health Organization. (http;//www.who.int/ncd_surveillance/infobase/en)
1 40 The African Regional Health Report
Access to improved
Access to improved
Population using Prevalence of current tobacco use (%)'
J Condom use by young people
(aged 15-24
n
water sources
sanitation11
solid fuels'
at higher risk sex' (
U
(%) (%) | (%) | Adolescents (1 3-1 5)E | Adults (>15)h j J
Urban
2002
Rural
2002
Urban
2002
Rural
2002
1 Urban
2003
20*03 s^s "" — [*•*"
Year
Males Females
Year
1
92
80
99
82
--
40
56
16
n
60
58
12
BB
99 14.5 2003
•HBBBBf 19
2001
100
90
57
25
| _ '• _ | 11.3 2001
| 88 75
2000
82
44
45
5
9J
100
24.2 11.1
2003
67 54
2003
90
78
47
35
98
100
^^^^^^^^^^^^^^^^^^^^^^
84
41
63
33
62
98 HBBBI
2004
86
73
61
15
...
1
93
61
47
12
•BBBlBBBBHi
...
40
32
30
O
H
98
18.3 3.7
2003
25 17
::.-
90
%
38
15
46
90-
27.5 17.0
20031
72
17
14
2
84
98"
16.5 1.7
2003'
98
74
61
23
63
95' BIBB
20.7 3.2
20031
...
•BBS
83
29
43
23
45
42
60
46
72
54
34
3
31
97 6.6 I :
81
11
19
•B
78
100
7.3 0.6
2003'
RBBRP^ff 17
2000
4^
37
30
14
81
_
48 33
2000
••••BH
95
93
68
46
75
96 11.7 201
K 9.9 1.3
2003
52 33
2003
78
38
25
6
"
49
57
23
1 _ —
89
46
56
43
17 94 12.7 2001 27.2 1.9 20031
2003
88
74
61
32
| 20.3 2002
53 53
2004
72
52
49
7
75
34
49
27
12 5
2003
96
62
66
42
50
99 iHHB
| 25.3 5.8
2003'
47 35
2004
76
35
59
38
99
100
24 7 3 D
2003
| 30 14
2001
63
45
54
9
BH
•4 24.7 2001 29.6 4.7
20031
100
100
100
99
0 2 | 13.2 2003 42.7 2.8
2003
76
24
51
14
33 29
2003
98
72
66
14
24 84 | 25.8 2004 28.3 12.4
2003
69 48
2000
80
36
43
4
•1
98 18.4 2001
72
49
48
30
0 0
2003"
, 46 24
2003
92
69
56
38
98
100
41 28
2004
89
73
32
20
90
54
70
34
BI
80 16.6 2002 24.1 1.9
2003'
...
BBBB
100
75
100
... j 28.9 2002 | _ | -
i 75
46
53
30
...
98
73
86
44
40 23.6 2002 3" 3 11.2 2003
87
42
78
44
23
82 11.5 2001 :•: . 3.2
2003
80
36
71
15
16.1 2002
87
52
53
39
BB
99 nBBE99
25.2 3.3
2001"
55 53
2004
92
62
54
4!
.
46 34
2004
90
36
68
32
68
99
23.3 5.7
2003
42 33
2001
74
CQ
: '
26
94
26.2 3.1
2003
^^^^^^^^^^^^^__^_^_g_____
________
^K
•••
84
•Bi
4:
•••
58
••B
28
BHBI
••••••i
•••••BHHHH
••B
••••••••B
•BB
B
(i) Global NCD InfoBase/Online Tool. World Health Organization. (http7/www.wtio.mt/ncd_surveillance/infob3se/en): (ii) Ustun TB. ChaHerji S. Mechbal A. Murray OIL WHS Collaborating Groups. The World Health
Surveys in Health Systems Performance Assessment: Debates. Methods and Empiricism (eds. Murray CJL and Evans D). World Health Organization. Geneva. 2003: (iii) Results from the World Health Survey. World
Hearth Organization, (http-7/www.who.mt/healthinfo/survey/en/)
Multiple Indicator Cluster Survey (http-7/childinfo.org) and Demographic and Hearth Surveys (rtttpyAvww.measuredhs.com).
1 Self-reported data.
Sample is not necessarily nationally representative.
Lower age limit above 15.
* Upper age limit at 50.
* Cigarettes are the only smoked tobacco product under consideration.
The health of the people • • • Statistical annex 1 41
So
2
2m
2m
2001
2000
2m
2000
2001
2001
2000
2003
Algeria
Angola
Benin
Botswana
Burkina Faso
2000
2m
1998
2000
2004
2000
200H
1998
2000
2000
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Congo
Cote d'lvoire
Democratic Republic of the Congo
Equatorial Guinea
2002
2000
2000
2000
2003
2002
2000
2000
2000
2003
200\
2000
2000
2000
2003
Eritrea
Ethiopia
Gabon
Gambia
Ghana
1999
2001
2003
200\
200\
1999
2000
2003
2001
2000
Guinea
Guinea-Bissau
Kenya
Lesotho
Liberia
1997
2000
2001
2000-01
2003-04
2002
2001
2001
1998
2003-04
2000
2001
2000-01
Madagascar
Malawi
Mali
Mauritania
Mauritius
2003
2000
2000
2003
2000
2003
2000
2000
2003
2000
1997
2000
1998
2003
2001
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
South Africa
2000
2000
2000
2004-05
2001-02
2000
2000
2000-01
1999
2001-02
Swaziland
Togo
Uganda
United Republic of Tanzania
Zambia
1998
2000-01
1999
2001-02
African Region
66
66
35
... Data not available or not applicable.
a WHO/UNICEF estimates of national coverage for year 2004 (as of September 2005).
(http://www.who.int/immunization_monitoring/routine/immunization_coverage/en/index4.html)
b World health report 2005: make every mother and child count. Geneva, World Health Organization, 2005. (http://www.who.int/whr/2005/en/index.html)
c WHO Database on Skilled Attendant at Delivery. World Health Organization, (http://www.who. int//reproductive-health/global_monitoring/data. html)
World Contraceptive Use 2005 database. Population Division, Department of Economic and Social Affairs, United Nations.
e World malaria report 2005. Geneva, World Health Organization and United Nations Children's Fund. 2005. Values for Cameroon and Chad have been updated.
f Progress on global access to HIV antiretroviral therapy. A report on "3 by 5" and beyond. Geneva, World Health Organization and Joint United Nations Programme on HIV/AIDS, March 2006. Data for
high-income countries have been added to the original list which consisted of 152 low- and middle-income countries. Regional values relate to low- and middle-income countries only. (http://www.
who.int/hiv/fullreport_en_highres.pdf)
1 42 The African Regional Health Report
Children under- 5
sleeping under
insecticide-treated
nets'
D.7
Antiretrovtral
therapy
coverage
detection
rate under
DOTS1
Children Children Children under- 5 Children 6-59 months! Births
under-Swith under-Swith with fever who who received by
ARI symptoms diarrhoea received treatment vitamin A Caesarean
taken to facility' receiving ORT1 with any antimalarial* supplementation' section
2001 39.3 2001
2003 49.0 2003
48.6
: : : :
14.7
36
51
66
85
70
34
75
43.6
15.8
47.7
a:
2002
2000
2000
2003
38.2
34.9
52"
39.6
2002
2000
2000
2003
3.0
55.2
62.8
2002
2000
2000
2003
51.1
7.4
2003
2004
58.4
26.5
2000
2003
2.1
2000
2004
2003-04
73
65
58
87
47.9
26.7
35.6
40.7
2003-04
2000
2001
2000-01
34.9
35.4
53.5
2004
2000
2001
41.1
31.6
y e
33.4
2004
2004
2003
2003-04
95.0
85.8
68.3
89.0
1997
2000
2001
2000-01
2000
2003
2BM
2003
2000
2003
2000
17.3
2000
2000
2003
2000
96.4
76.6
79.0
36.2
1997
1992
1998
2003
52
106
36
83
70
100
83
1993
61.2
36.2
60.7
2000
2000
2000
73.9
1991
82.7
87.2
1997
1998
1999 ] 7
2001-02 26
1998
2000-01
1999
2001-02
49.0
51.0
1999
78.2
1999
17
48
72
I ' The number of new smear-positive cases notified to WO divided by the estimated number of new smear-positive cases. Source: Global tuberculosis control: surveillance, planning, financing. WHO report 2006.
Geneva. World Health Organization (WHO/HTWTB/2006.362).
* The percentage of new smear-positive patients registered for treatment under DOTS during 2003 who were cured (with laboratocy confirmation) or completed their course of treatment. Source: Global tuberculosis
control: surveillance, planning, financing.
• Demographic and Hearth Surveys, (http://www.measuredris.com)
1 UNICEF Global Database on Vitamin A Supplementation Coverage. The United Nations Children's Fund. (httpVAvww.childinfo.org/eddb/vita_a/framedb.htm)
| k Data do not exactly relate to "skilled health personnel* as defined in the document: Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO. ICM and F1GO. Geneva. World Hearth
Organization. 2004. Further information can be found on httpy/www.who.imVwhosis.
The health of the people.
Statistical annex 143
e
Human resources for health
Physicians
Algeria
35368
1.13
2002
68950
2.21
2002
799
0.03
2002
9553
0.31
2002
Angola
881
0.08
1997
13135
1.15
1997
492
0.04
1997
2
0.00
1997
Benin
311
0.04
2004
5789
0.84
2004
12
0.00
2004
Botswana
715
0.40
2004
4753
2.65
2004
38
0.02
2004
Burkina Faso
789
0.06
2004
5518
0.41
2004
1732
0.13
2004
58
0.00
2004
Burundi 200
0.03
2004
1348
0.19
2004
14
0.00
2004
Cameroon 3 124
0.19
2004
26042
1.60
2004
147
0.01
2004
Cape Verde 231
0.49
2004
410
0.87
2004
11
0.02
2004
Central African Republic
331
0.08
2004
1188
0.30
2004
519
0.13
2004
13
0.00
2004
Chad 345
0.04
2004
2387
0.27
2004
112
0.01
2004
15
0.00
2004
Comoros 115
0.15
2004
588
0.74
2004
29
0.04
2004
Congo 756
0.20
2004
3672
0.96
2004
12
0.00
2004
Cote d'lvoire
2081
0.12
2004
10180
0.60
2004
339
0.02
2004
Democratic Republic of the Congo
5827
0.11
2004
28789
0.53
2004
159
0.00
2004
Equatorial Guinea
153
0.30
2004
228
0.45
2004
43
0.08
2004
15
0.03
2004
Eritrea 215
0.05
2004
2505
0.58
2004
16
0.00
2004
Ethiopia 1 936
0.03
2003
14893
0.21
2003
651
0.01
2003
93
0.00
2003
Gabon
395
0.29
2004
6974
5.16
2004
66
0.05
2004
Gambia
156
0.11
2003
1 719
1.21
2003
162
0.11
2003
43
0.03
2003
Ghana 3240
0.15
2004
19707
0.92
2004
393
0.02
2004
Guinea 987
0.11
2004
4757
0.55
2004
64
0.01
2004
60
0.01
2004
Guinea-Bissau
188
0.12
2004
1037
0.67
2004
35
0.02
2004
22
0.01
2004
Kenya
4506
0.14
2004
37113
1.14
2004
1340
0.04
2004
Lesotho
89
0.05
2003
1 123
0.62
2003
16
0.01
2003
Liberia 103
0.03
2004
613
0.18
2004
422
0.12
2004
13
0.00
2004
Madagascar 5201
0.29
2004
5661
0.32
2004
410
0.02
2004
Malawi
266
0.02
2004
7264
0.59
2004
Mali
1053
0.08
2004
6538
0.49
2004
573
0.04
2004
84
0.01
2004
Mauritania
313
0.11
2004
1893
0.64
2004
64
0.02
2004
Mauritius 1 303
1.06
2004
4550
3.69
2004
54
0.04
2004
233
0.19
2004
Mozambique
514
0.03
2004
3954
0.21
2004
2229
0.12
2004
159
0.01
2004
Namibia
598
0.30
2004
6145
3.06
2004
113
0.06
2004
Niger
377
0.03
2004
2716
0.22
2004
21
0.00
2004
15
0.00
2004
Nigeria
34923
0.28
2003 j
210306
1.70
2003
2482
0.02
2003
Rwanda 401
0.05
2004
3593
0.42
2004
54
0.01
2004
21
0.00
2004
Sao Tome and Principe
81
0.49
2004
256
1.55
2004
52
0.32
2004
11
0.07
2004
Senegal
594
0.06
2004
3287
0.32
2004
97
0.01
2004
Seychelles
121
1.51
2004
634
7.93
2004
94
1.17
2004
Sierra Leone |
168
0.03
2004
1841
0.36
2004
5
0.00
2004
South Africa 34 829
0.77
2004
184 459
4.08
2004
5995
0.13
2004
Swaziland
171
0.16
2004
6828
6.30
2004
32
0.03
2004
Togo
225
0.04
2004
2141
0.43
2004
5
0.00
2004
19
0.00
2004
Uganda
2209
0.08
2004
16221
0.61
2004
3104
0.12
2004
363
0.01
2004
United Republic of Tanzania 822
0.02
2002
13292
0.37
2002
267
0.01
2002
Zambia 1 264
0.12
2004
19014
1.74
2004
2996
0.27
2004
491
0.04
2004
Zimbabwe
2 086 0.16 2004
9357
0.72 2004
310
0.02 2004
.. Data not available or not applicable.
World health report 2006: working together for health. Geneva, World Health Organization, 2006. (http://www.who.int/whr/2006/annex/en)
1 44 The African Regional Health Report
Human resources for health'
Public and
environmental
health workers
Community health
workers
Lab technicians
Other health
workers
Health management
and
support workers
6333
0.20
2002
2534
0.08
2002
1062
0.03
2002
8838
0.28
2002
5088
0.16
2002
60882
1.95
2002
24
D.OC
1997
11
0.00
2004
178
0.03
2004
88
0.01
2004
477
0.07
2004
128
0.02
2004
3281
0.47
2004
333
0.19
2004
172
0.10
2004
277
015
2004
829
0.46
2004
343
0.03
2004
46
0.00
2004
1291
0.10
2004
424
0.03
2004
975
0.07
2004
325
0.02
2004
76
0.01
:::-
657
: :?
2004
147
0.02
_::4
1 186
0.17
2: 14
2087
0.30
2004
700
0.04
2004
28
0.00
2004
1793
0.11
2004
IB 16
0.00
2004
5902
0.36
2004
43
3.09
2004
9
0.02
2004 ,
65
0.14
2004
78
0.16
2004
42
3.09
2004
74
0.15
2004
17
0.00
2004
55
0.01
2004
211
0.05
2004
4-
0.01
2004
367
0.09
2004
167
0.04
2004
37
: ::
2004
230
0.03
2004
268
0.03
2004
317
0.04
2004
153
0.02
2004
1502
0.17
2004
41
0.05
2004
17
0.02
2004
41
0.05
2004
63
0.08
2004
9
0.01
2004
272
0.34
2004
99
0.03
2004
9
0.00
2004
124
: 33
2004
554
3.15
2004
957
:.25
2004
987
3.26
2004
1015
0.06
2004
155
0.01
2004
1165
0.07
2004
172
0.01
2004
2107
0.12
2004
1200
0.02
2004
512
0.01
2004
1042
0.02
2004
15013
0.28
2004
130
0.26
2004
18
0.04
2004
1275
2.51
2004
75
0.15
2004
74
0.15
2004
107
0.02
;::-
88
0.02
2004
248
0.06
2004
56
0.01
2004
765
0.18
:: -
1343
0.02
2003
1347
0.02
2003
18652
0.26
2003
2703
0.04
2003
7354
0.10
2003
_.
63
0.05
2004
150
0.11
2004
276
0.20
2004
1
0.00
2004
144
D.ll
2004
48
0.03
2003
33
0.02
2003
968
0.68
2003
99
0.07
2003
3
0.00
2003
391
0.27
2003
1388
0.06
2004
b99
0.04
2004
7132
0.33
:::4
19151
0.90
2004
530
0.06
2004
135
0.02
2004
93
0.01
2004
268
0.03
2004
17
; ::
2004
511
0.06
2004
40
0.03
2004
13
3.01
2004
4486
2.92
2004
230
0.15
2004
61
: 34
2004
38
: :2
2004
30S4
0.10
2004
6496
0.20
2004
7000
0.22
2004
5610
0.17
2004
1797
0.06
2004
62
0.03
2003
55
D.03
2003
146
3.08
2003
23
0.01
2003
18
D.01
2003
35
0.01
2004
150
0.04
2004
142
0.04
2004
218
0.06
2004
540
0.15
2004
518
0.15
2004
175
0.01
2004
130
0.01
;::-
385
0.02
2004
172
0.01
2004
530
0.03
2004
6036
: •-
2004
...
26
0.00
2004
...
4;
0.00
2004
707
0.06
2004
_
...
351
0.03
2004
231
0.02
2004
1295
0.10
2004
264
0.02
2004
377
0.03
2004
652
0:5
2004
81
0.03
2004
429
0.14
2004
106
0.04
2004
«t
0.02
2004
1056
0.35
2004
1428
1.16
2004
238
0.19
;::-
236
0.19
2004
324
0.26
:::4
134
0.11
2004
2038
1.65
2004
618
0.03
:::-
564
0.03
2004
941
0.05
2004
1633
0.09
2; J4
9517
: 5C
2::4
288
0.14
2004
240
0.12
2004
4S1
024
2004
597
0.30
2004
7782
3.87
2004
20
0.00
2004
268
0.02
2004
...
294
0.02
2004
213
0.02
2004
513
0.04
2004
6344
0.05
2004
115761
0.91
2004
690
0.0 1
2004
1220
0.01
2004
278
0.03
::;:
101
0.01
2004
12000
1.41
;;C4
39
0.00
2004
521
0.06
2004
1419
0.17
20M
24
0-15
::•:-
19
0.12
2004
374
2.27
2004
51
0.31
2004
291
1.76
:::-
288
1.75
2004
C«
61
340
0.01
0.76
0.07
2004
2004
2004
705
77
136
0.07
0.%
0.03
2004
2004 .
2004
1227
0.24
2004
66
59
0.01
: ~4
2004
2004
704
35
0.07
0.44
2004
2004
564
m
0.05
0.00
2004
2004
12521
0.28
2004
2529
0.06
2004
9160
0.20
2004
1968
0.04
2004
40526
0.90
2004
28005
0.62
2004
70
0.06
2004
!'0
0.10
2004
4700
4.34
2004
78
: 17
2004
551
0.51
2004
374
0.35
2004
134
3.03
2004
289
0.06
2004
475
3.09
2004
528
0.11
2004
397
: DS
2004
1335
0 2'
2004
688
0.03
2004
1042
0.04
2004
1702
0.06
2004
3617
0.14
2004
6499
0.24
2004
365
0.01
2002
1831
: 55
2002
1520
3.04
2002
29722
0.82
2002
689
: 32
2002
1039
0.10
20M
1027
0.09
2224
1415
0.13
20M
3330
0.30
2C04
10853
0.99
2004
883
0.07 2004
1803
0.14 2004
917 0.07 2004
743 0.06 2004
581
0.04 2004
The health of the people • • • Statistical annex 1 45
Figures computed to assure comparability;3 they are not necessarily the official statistics of Member States, which may use alternative methods
26.7 22.6
17.8 15.4
55.5 53.1
42.8 49.6
19.2
19.1 15.8
56.5 56.9
46 41.8
55.8 53.2
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
73.3 77.4
82.2 84.6
44.5 46.9
57.2 50.4
42.4 39.5
78.9 80.8
80.9 84.2
43.5 43.1
54 58.2
44.2 46.8
2A 2.8
HJ HA
5.1 5.6
5.4 5.6
17.9 21.6
27.6
73.5 75.8
21 23.3
27.6 28.9
75.1 73.2
82.1 78.4
72 72.4
26.5 24.2
79 76.7
72.4 71.1
24.9 26.8
Cape Verde
Central African
Republic
Chad
Comoros
Congo
41.2 38.6
35.5 39.9
58.9 61.4
58 59.1
58.8 61.4
64.5 60.1
10 11.5
13.1 13.8
2.9 2.7
1.9 2
3.8 3.6
54.9 47.7
66.5 67
19.8 18.3
58 54.1
66.9 64.2
31.6 27.6
45.1 52.3
33.5 33
80.2 81.7
42 45.9
33.1 35.8
68.4 72.4
Cote d'lvoire0
Democratic Republic
of Congo
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Guinea
4.5 4.6
5.7 5.8
4.2 4.2
7.9 7,8
5.4 4.8
66.9 59.2
54.6 53.2
73.1 73
50.9 45.5
56.9 58.4
69.8 66.6
40.9 40
4.4 4.6
9.3 10.5
13.9 9.9
14.4
6.8
40.5 40.1
35.3 28.8
5.2 5.4
6.2 5.6
4.5 4.3
6.5 5.2
13.5
23.7 21.3
46.5 42.8
82
14.7 16.6
40.8 45.8
44
86.5 81.7
76.3 78.7
85.3 83.4
59.2 54.2
56 61.3
16.9 20.3
52.3 43.3
Guinea-Bissau
Kenya
Lesotho
Liberia
2.1 1.9
8.6 10.5
4.7 4.3
2.8 2.7
9.4 9.3
4.5 4.8
3.9 4.2
53 64.7
30.2 45.2
49.5 50.1
63.3 67 S
47 35.3
69.8 54.8
50.5 49.9
36.7 32.1
37 36.6
66 64.8
47.4 42.6
25.8 23.2
Madagasc
Malawi
Mali
Mauritania
Mauritius
63.4
35.2
52.6 57.4
74.2 76.8
Mozambique
Namibia
Niger
Nigeria
Rwanda
5.5 4.8
7 6.4
4.4 4.3
4.3 5.3
4.3 4.1
67.8 66.2
68.9 69.4
52.4 53.1
33.5 31.4
34.6 38.8
67.6 61.7
68.6 70
52.8 53
25.6 25.5
47 43.5
32.2 33.8
31.1 30.6
47.6 46.9
66.5 68.6
65.4 61.2
32.4 38.3
31.4 30
47.2 47
74.4 74.5
53 56.5
12.9 10.7
12.3 11.1
12.3 12
4.2 3.2
7.7
Sao Tome and
Principe
Senegal
Seychelles
Sierra Leone
South Africa
Swaziland
T d
Togo
Uganda
5 5.1
5.1 5.9
3.5 3.5
8.4 8.4
36.4 38.5
75 74.7
55.5 53.7
42.4 41.2
63.6 61.5
25 25.3
44.5 46.3
57.6 58.8
60.2 58.2
25.1 26.8
36.4 41.7
59.4 61.4
63.6 58.3
40.6 38.6
5.9 5.8
4.9 5.6
7.6 7.3
58.6 57.8
29 25.2
26.8 27.3
59.3 57.3
18.7 24.8
31.1 30.4
41.4 42.2
71 74.8
73.2 72.7
40.7 42.7
81.3 75.2
68.9 69.6
United Republic of
Tanzania
Zambia
Zimbabwe
50.6 56.5
48.3 38.6
56.7 51.4
37.7 35.9
43.3 48.6
62.3 64.1
Equatorial Guinea, Gabon, Guinea Bissau, Liberia and Sao Tome and Principe: estimates for these countries should be read with caution as these are derived from limited sources (mostly macro
data that are publicly accessible).
Burkina Faso, Guinea, Mauritius and Rwanda: new NHA reports, surveys, and/or country consultations provided new bases for the estimates.
' See explanatory notes for sources and methods.
In some cases the sum of the ratios of general government and private expenditures on health may not add to 100 because of rounding.
f The series was adjusted for the removal of social security expenditure on health, which could not be confirmed due to incomplete information.
Togo data on health research and development and training were adjusted to harmonize with the standard methodology used for World Health Reports.
n/a Used when the information accessed indicates that a cell should have an entry but no estimates could be made.
0 Used when no evidence of the schemes to which the cell relates exist. Some estimates yielding a ratio below 0.04% are shown as '0'.
1 46 The African Regional Health Report
External resources (or health as % of
total expenditure on hearth
Social security expenditure on health
as%of
general government
expenditure on health
Out-of-pocket expenditure as % ot Private prepaid plans as % of private
private expenditure on hearth expenditure on health
1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003
0.1 01 01 0
c 7 171: ic 7 03
it 13
99 :: :
3.4
7
:
c 7
-4
40.8 35.5 33.3
•••••
n/a n/a a/a
n/a n/a n/a
0.3 0.8 12
29.1 28.4
•••I
n/a n/a
n/a
0.7 1
97
100
91
30.3
96.7 96
100 100
9: 956
31.3 31.5
98.1 98.1
95.7 95.3
100 100
9;.:- 92. 3
29.7 28.8
98.1 98.1
2.9 3.1
••••I
8.4 8.4
22.7 20.6
29 0.9
3.8 4.1
44
8.7 9 9
20 19.6 21.8
59 : 9 0.9
10.7 8 10.6
5.2 6 6.9
8.4 13.5 15.1
20 20 15.4
29.1 36.6 33.8
10.3 14.1
2.3 32
HMB
13.4 2.9
17 11.8
n/a n/a n/a
0.1 01 01
36.9 36.1 35.1
n/a
n/a
n/a
n/a
n/a
n/a
n/a n/a 100
2; :.: 942
33.6 35.5 99.7
n/a n/a 95.1
n/a n/a 96.7
100 100
93.3 S3..!
99.6 99.5
100 100
93 6 98 3
99.8 99.7
95.5 95.5 95.5 95.3
96.5 96.6 96.5 96.3
n/a n/a
n/a n/a
0.3 0.4
n/a n/a
0.3 0.4
n/a n/a n/a
n/a n/a n/a
0.5 0.2 0.3
n/a
0.4
n/a
0.4
n/a
0.4
:oe 100 100 100
100 100 100 100
93.4 921 903 955
100 100 100 100
839
5C5 si:
20.2 30.6 24.1
1.6
6.4 12.8 20.7
22.5 19.6
2:' 26
0.7 fli
:•: 21.8
14.4 15.8
0
24
•
0
n/a
0
3.4
U
0
n/a
0
3.4
•
0
n/a
0
24
•
0
n/a
0
0.4
•
0
n/a
100
79.7
100
68.1
100
100 100
79.1 -98
100 100
692 595
100 100
100 100
-9; 78.7
100 100
692 67
100 100
5 5
•§_
13.3 132
3.6 10.8
55.7 43.6
58 10.5
16 15.8
17.2
31.2
6.3 ":
35.5 26.8
:54 15.3
6.4 8.2
25.5 32;
1.8 1.8
i-2 zMHl
16.7 11.7 14.8
1.5 1.7 1.5
92
0
0
99.4
• ••I
:: -92
•H
0 0 98.5
99.4 99.4
83.7 85.2
5: : 80.5
20 19.4
98.5 98.5
29: 994
84.1 80.2
SI 326
18.6 182
98.5 38.5
40.5 43.3 39.1
:-. : is.; 3:
18.8 24.1 20.8
31.6 22
23 2: 1
3.4 13.7
1.2 1.1 1.6 1.4
:
n/a n/a n/a
0 0 0
24 21.8 22.9
0 0 0
6.5 7.8 8.3
n/a n/a 89.7
0 0 423
27.7 26 893
0 0 100
8.3 8.7 100
90.5 87.1
41.7 42
88.6 89.1
100 luO
100 100
91.6 91.7
42.5 42"
89.2 89.3
132 13:
100 100
10.3 9.5 12.9 8.4 8.3
1.7 1.6 1.7 1.6 1.6
0 0 0 0
n/a n/a n/a n/a
:
n/a
39.6
2.4
28.6
13.8
4!-
429 4--;
3.8 4
466 23:
162 5.6
459 38.2
38.3 40.8
4.3 5.3
22- 32 S
6.1 5.3
45 9 54 5
0 38.5
39 343 3? 3U U U 06 06 05
182 20.1 20.4 192 74.7 773 75.1 74.9 76
88 K2 8M tU M 74 73 7 12 \
35.6 39.2 43.8 41.7 3.8 5.6 6.5 7.5
59.9 62.5 62.9 74.9 56
8.8
0.1
100 100 100 100 100
14 15.2
0.6 0.4
11.8 14.8
0.4 0.4
55 155
0.4 0.5
19 192
5.3 52
0
3.5
C
3.3
18.8
•§
0
3.1
:66 :58
BHH
o
4.6
0
3.8
96.7
62.5
IOC
17.1
96 6 96 5
61.8 62.5
100 122
18.9 17.8
954 955
62.5 62.5
122 100
16.8 17.1
0
2.1
0
22
0
22
0 0
35 54
0 0 0 0 0
77.4 75.6 76.7 77.7 77.7
10.3
27.6
29.3
8.9
15.7
7.1 4.8 11.4 2.3 8.1 13.4 11.6
28.3 2~ 4 29: 25: 0 I •
0 0 40.9 42.4 41.8 41.7 42.4 US US » 20 19.6
14.4 14.6 87 86.6 87.8 87.7 88 5.1 5.4 4.3 4.3 4.1
2 C 61.5 56" 5: S 5: 528 3.2 2: 2.2 0.2 52
11.7 5.6 1.4 6.8
82 81.1 74.9 72.7 682
n/a n/a n/a n/a n/a
44.9 46.7 50.7 51.7 56.7 39.6 31.1 29 25.9
21
The health of the people • • • Statistical annex 147
Figures computed to assure comparability;3 they are not necessarily the official statistics of Member States, which may use alternative methods
8
Per capita total expenditure on
health at average exchange rate
(USS)
Per capita government expenditure
Per capita total expenditure on on health at average exchange rate Per capita government expenditure
health at international dollar rate (US$) on health at international dollar rate
Member State
1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003
Algeria
61
63
68
75
89
137
132
149
174
186
43
46
53
60
71
99
97
115
137 H
Angola
15
16
21
18
26
43
34
48
41
49
m
13
18
15
22
20
28
41
33 t
Benin
16
15
16
16
20
34
34
38
37
36
7
7
7
7
9
15
15
18
16 1
Botswana
138
152
132
144
232
259
294
284
312
375
75
87
67
78
135
141
168
143
169 21
Burkina Faso
15
12
12
15
19
55
54
55
62
68
6
5
5
6
9
24
23
22
27 ;
Burundi
4
3
3
3
3
14
14
15
15
15
1
1
1
1
1
3
3
3
3
Cameroon
31
29
29
32
37
62
58
62
66
64
8
8
8
9
11
15
16
17
18 ]
Cape Verde
61
55
61
66
78
148
163
186
193
185
45
41
46
50
57
110
119
141
145 1-
Central African Republic
10
10
10
11
12
44
50
49
51
47
4
4
4
4
5
17
20
19
21 1
Chad
11
11
12
12
16
37
40
43
44
51
4
4
5
4
7
12
17
18
16 ;
Comoros
11
8
7
10
11
30
25
21
27
25
6
4
3
6
6
18
14
10
16 !
Congo
n
17
16
16
19
25
20
23
22
23
11
11
10
11
12
16
13
15
15 1
Cote d'lvoire
39
30
24
25
28
87
79
65
62
57
7
6
4
8
8
15
16
12
20 :
Democratic Republic
of Congo
8
10
4
•
|
.
13
10
11
14
1
1
<1
<1
1
•
•1
'
1
Equatorial Guinea
46
54
67
85
96
125
106
152
193
179
28
37
47
61
65
76
72
107
139 i;
Eritrea
8
8
8
7
8
47
48
53
51
50
6
5
5
4
4
33
32
31
26 ;
Ethiopia
5
5
5
5
5
17
19
21
21
20
3
3
3
3
3
9
10
11
12 :
Gabon
165
164
148
158
196
250
229
235
244
255
113
120
108
111
130
171
167
171
171 i;
Gambia
24
25
23
20
21
76
88
92
84
96
8
10
9
8
8
24
36
37
34 :
Ghana
22
13
12
14
16
100
102
94
95
98
8
5
4
4
5
35
36
27
29 :
Guinea
20
18
17
19
22
74
76
81
90
95
3
2
3
3
4
10
10
15
13
Guinea-Bissau
8
6
6
9
9
45
38
38
49
45
2
2
1
4
4
13
9
8
20 ;
Kenya
16
18
18
19
20
60
61
62
66
65
7
8
8
8
8
25
28
27
29 ;
Lesotho
28
28
24
25
31
91
100
103
125
106
23
23
20
21
25
74
83
84
104 1
Liberia
10
8
7
7
6
26
23
21
20
17
6
5
3
3
4
18
13
10
10
Madagascar
5
5
5
7
8
20
20
19
24
24
3
3
3
5
5
11
10
12
15
Malawi
16
13
15
15
13
47
41
48
44
46
6
4
7
5
5
17
12
22
15
Mali
11
11
11
12
16
27
32
32
35
39
5
5
5
6
9
11
16
16
is ;
Mauritania
10
9
10
14
17
32
32
38
53
59
7
6
7
10
13
21
20
26
39
Mauritius
113
127
132
143
172
281
331
373
398
430
70
74
80
87
105
174
194
226
242 21
Mozambique
11
12
10
11
12
34
40
39
45
45
7
8
6
7
7
21
27
26
30 :
Namibia
127
126
107
95
145
328
340
323
318
359
93
87
75
65
101
240
235
224
218 2!
Niger
8
6
6
7
9
27
25
26
27
30
4
3
3
4
5
14
13
14
15
Nigeria
n
18
19
19
22
48
39
50
49
51
•1
•1
6
5
6
14
13
16
12
Rwanda
11
10
8
9
7
33
32
31
35
32
5
3
3
4
3
16
11
12
17
Sao Tome and Principe
34
29
35
31
34
94
84
107
95
93
30
25
30
26
29
82
72
92
81
Senegal
21
18
20
23
29
44
45
51
55
58
8
7
8
9
12
16
16
19
22 i
Seychelles
431
405
403
456
522
548
555
535
554
599
322
304
301
342
382
410
417
400
415 4:
Sierra Leone
5
5
6
7
7
19
24
25
32
34
2
3
3
4
4
9
13
13
21 ;
South Africa
257
236
216
198
295
595
579
626
649
669
105
100
89
80
114
244
245
258
263 2!
Swaziland
87
83
73
68
107
305
302
308
315
324
51
48
42
40
61
180
177
178
187 11
Togo
16
11
13
13
16
59
49
58
54
62
mi
3
3
2
4
24
14
15
10
Uganda
16
16
17
18
18
55
60
70
75
75
5
4
5
5
5
17
16
19
23 ;
United Republic of
Tanzania
11
12
12
12
12
23
25
27
28
29
5
6
6
6
7
10
12
13
15
Zambia
17
17
19
20
21
45
46
51
53
51
8
9
11
11
11
22
23
29
30 ;
Zimbabwe
36 44 65 132 40 185 168 184 161 132 17 21 25 50 14 91
61
' See explanatory notes for sources and methods.
The currency now called Ariary is worth one fifth of the Francs previously used.
1 48 The African Regional Health Report
Explanatory notes
The following provides the definition of the health statistics categories included in this statistical annex, as well as the rationale for including them
and the estimation methods used to produce them.
1. Life expectancy at birth
Rationale for use: life expectancy at birth reflects the overall mortality level of a population. It summarizes the mortality pattern that prevails across
all age groups — children and adolescents, adults and the elderly.
Definition: average number of years that a newborn is expected to live if current mortality rates continue to apply.
Methods of estimation: WHO has developed a model life table based on about 1800 life tables from vital registration judged to be of good
quality. For countries with vital registration, the level of completeness of recorded mortality data in the population is assessed and mortality rates are
adjusted accordingly. Where vital registration data for 2003 were available, these were used directly to construct the life table. For countries where
the information system provided a time series of annual life tables, parameters from the life table were projected using a weighted regression model,
giving more weight to recent years. Projected values of the two life table parameters were then applied to the modified logit life table model, where
the most recent national data provided an age pattern, to predict the full life table for 2003. In case of inadequate sources of age-specific mortality
rates, the life table is derived from estimated under-5 mortality rates and adult mortality rates that are applied to a global standard (defined as the
average of all the 1800 life tables using a modified logit model.)
2. Healthy life expectancy (HALE)
Rationale for use: substantial resources are devoted to reducing the incidence, duration and severity of major diseases that cause morbidity but not
mortality and to reducing their impact on people's lives. It is important to capture both fatal and non-fatal health outcomes in a summary measure of
average levels of population health. Healthy life expectancy (HALE) at birth adds up expectation of life for different health states, adjusted for severity
distribution making it sensitive to changes over time or differences between countries in the severity distribution of health states.
Definition: average number of years that a person can expect to live in "full health" by taking into account years lived in less than full health
due to disease and/or injury.
Methods of estimation: since comparable health state prevalence data are not available for all countries, a four-stage strategy is used. Data from
the WHOGBD study are used to estimate severity-adjusted prevalence by age and sex for all countries. Data from the WHOMCSS and WHS are used
to make independent estimates of severity-adjusted prevalence by age and sex for survey countries. Prevalence for all countries is calculated based on
CBD. MCSS and WHS estimates. Life tables constructed by WHO are used with Sullivan's method to compute HALE for countries.
3. Probability of dying (per 1000) between ages 15 and 60 years (adult mortality rate)
Rationale for use: disease burden from noncommunicable diseases among adults — the most economically productive age span — is rapidly increas-
ing in developing countries due to ageing and health transitions. Therefore, the level of adult mortality is becoming an important indicator for the
comprehensive assessment of the mortality pattern in a population.
Definition: probability that a 15-year-old person will die before reaching his/her 60th birthday.
4. Life table (see life expectancy at birth).
Data sources: civil or sample registration: Mortality by age and sex are used to calculate age specific rates. Census: Mortality by age and sex tabulated
from questions on recent deaths that occurred in the household during a given period preceding the census (usually 1 2 months). Census or surveys:
Direct or indirect methods provide adult mortality rates based on information on survival of parents or siblings.
Methods of estimation: empirical data from different sources are consolidated to obtain estimates of the level and trend in adult mortality by
fitting a curve to the observed mortality points. However, to obtain the best possible estimates, judgement needs to be made on data quality and
how representative it is of the population. Recent statistics based on data availability in most countries are point estimates dated by at least 3-4 years
which need to be projected forward in order to obtain estimates of adult mortality for the current year. When no adequate source of age-specific
mortality exists, the life table is derived as described in the life expectancy indicator.
5. Probability of dying (per 1000) under age five years (under-five mortality rate)
Probability of dying (per 1000) under age one year (infant morality rate)
Rationale for use: under-five mortality rate and infant mortality rate are leading indicators of the level of child health and overall development in
countries. They are also MDG indicators.
Definition: under-five mortality rate is the probability of a child bom in a specific year or period dying before reaching the age of five, if subject
to age-specific mortality rates of that period. Infant mortality rate is the probability of a child bom in a specific year or period dying before reaching
the age of one. if subject to age-specific mortality rates of that period.
Methods of estimation: empirical data from different sources are consolidated to obtain estimates of the level and trend in under-five mortality
by fitting a curve to the observed mortality points. However, to obtain the best possible estimates, judgement needs to be made on data quality and
how representative it is of the population. Recent statistics based on data availability in most countries are point estimates dated by at least 3-4
years which need to be projected forward in order to obtain estimates of under-five mortality for the current year. Those are then converted to their
corresponding infant mortality rates through model life table systems: the one developed by WHO for countries with adequate vital registration data:
Coale-Demeny model life tables for the other countries. It should be noted that the infant mortality from surveys are exposed to recall bias, hence
their estimates are derived from under-five mortality, which leads to a supplementary step to estimate infant mortality rates
The health of the people • • • Statistical annex 1 49
6. Neonatal mortality rate (per 1000 live births)
Rationale for use: neonatal deaths account for a large proportion of child deaths. Mortality during neonatal period is considered a useful indicator of
both maternal and newborn health and care.
Definition: number of deaths during the first 28 completed days of life per 1000 live births in a given year or period. Neonatal deaths may be
subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal deaths, occurring after the seventh day but
before the 28 completed days of life.
7. Maternal mortality ratio (per 100 000 live births)
Rationale for use: complications during pregnancy and childbirth are leading causes of death and disability among women of reproductive age in
developing countries. Maternal mortality ratio (MMR) represents the risk associated with each pregnancy, i.e. the obstetric risk. It is also an MDG
indicator for monitoring goal 5 of improving maternal health.
Definition: number of maternal deaths per 100 000 live births during a specified time period, usually one year.
Methods of estimation: measuring maternal mortality accurately is difficult except where comprehensive registration of deaths and their causes ex-
ist. Elsewhere, censuses or surveys can be used to measure levels of maternal mortality. Data derived from health services records are problematic where
not all births take place in health facilities because of biases whose dimensions and direction cannot be determined. Reproductive-age mortality studies
(RAMOS) use triangulation of different sources of data on deaths of women of reproductive age including record review and/or verbal autopsy to ac-
curately identify maternal deaths. Based on multiple sources of information. RAMOS are considered the best way to estimate levels of maternal mortality.
Estimates derived from household surveys are usually based on information retrospectively collected about the deaths of sisters of the respondents and
could refer backup to an average 1 2 years and they are subject to wide confidence intervals. For countries without any reliable data on maternal mortality,
statistical models are applied. Global and regional estimates of maternal mortality are developed every five years, using a regression model.
8. Estimated rate of adults (15 years and older) dying of HIV/ AIDS (per 1000)
Estimated rate of children below 15 years of age dying of HIV/ AIDS (per 1000)
Rationale for use: adult and children below 15 mortality rate are leading indicators of the level of impact of HIV/AIDS epidemic and impact of inter-
ventions specially scale up of treatment and prevention to mother to child transmission in countries.
Definition: estimated mortality due to HIV/AIDS is the number of adults and children that have died in a specific year based in the modeling of
HIV surveillance data using standard and appropriate tools.
Methods of estimation: empirical data from different HIV surveillance sources are consolidated to obtain estimates of the level and trend in
adults and children mortality by using standard methods and tools for HIV estimates appropriate to the level of HIV epidemic. However, to obtain
the best possible estimates, judgement needs to' be made on data quality and how representative it is of the population. UNAIDS/WHO produce
country specific estimates every two years.
9. Tuberculosis mortality
Rationale for use: prevalence and mortality are direct indicators of the burden of tuberculosis (TB), indicating the number of people suffering from
the disease at a given point in time, and the number dying each year. Furthermore, prevalence and mortality respond quickly to improvements in
control, as timely and effective treatment reduce the average duration of disease (thus decreasing prevalence) and the likelihood of dying from the
disease (thus reducing disease-specific mortality).
Definition: estimated number of deaths due to TB in given time period. Expressed in this database as deaths per 1 00 000 population per year.
Includes deaths from all forms of TB, and deaths from TB in people with HIV.
Methods of estimation: estimates of TB incidence, prevalence and mortality are based on a consultative and analytical process in WHO and are
published annually. The methods used to estimate TB mortality rates are described in detail elsewhere. Country-specific estimates of TB mortality are. in
most instances, derived from estimates of incidence, combined with assumptions about the case fatality rate. The case fatality rate is assumed to vary
according to whether the disease is smear-positive or not: whether the individual receives treatment in a DOTS programme or non-DOTS programmes,
or is not treated at all: and whether the individual is infected with HIV.
10. Age-standardized death rates per 100 000 by cause
Rationale for use: the numbers of deaths per 100 000 population are influenced by the age distribution of the population. Two populations with the
same age-specific mortality rates for a cause of death will have different overall death rates if the age distributions of their populations are different.
Age-standardized mortality rates adjust for differences in population age distribution by applying the observed age-specific mortality rates for each
population to a standard population.
Definition: the age-standardized mortality rate is a weighted average of the age-specific mortality rates per 100 000 persons, where the weights
are the proportions of persons in the corresponding age groups of the WHO standard population.
11. Years of life lost (percentage of total)
Rationale for use: years of life are lost (YLL) take into account the age at which deaths occur by giving greater weight to deaths at younger age and
lower weight to deaths at older age. The years of life lost (percentage of total) indicator measures the YLL due to a cause as a proportion of the total
YLL lost in the population due to premature mortality.
Definition: YLL are calculated from the number of deaths multiplied by a standard life expectancy at the age at which death occurs. The standard
life expectancy used for YLL at each age is the same for deaths in all regions of the world and is the same as that used for the calculation of disability-
adjusted-life-years (DALY). Additionally 3% time discounting and non-uniform age weights which give less weight to years lived at young and older
ages were used as for the DALY. With non-uniform age weights and 3% discounting, a death in infancy corresponds to 33 YLL, and deaths at ages
5 to 20 to around 36 YLL.
12. The disability-adjusted-life-year or DALY
DALY is a health gap measure that extends the concept of potential years of life lost due to premature death (PYLL) to include equivalent years of
1 50 The African Regional Health Report
"healthy" life lost by virtue of being in states of poor health or disability ( I ). DflLXs for a disease or health condition are calculated as the sum of the years
of life lost due to premature mortality (Xli) in the population and the years lost due to disability (VLD) for incident cases of the health condition.
Methods of estimation: life tables specifying all-cause mortality rates by age and sex for 192 WHO Member States were developed for 2002
from available death registration data, sample registration systems (India. China) and data on child and adult mortality from censuses and surveys.
Cause of death distributions were estimated from death registration data for 107 countries, together with data from population-based epidemiologi-
cal studies, disease registers and notifications systems for selected specific causes of death. Causes of death for populations without useable death
registration data were estimated using cause-of-death models together with data from population-based epidemiological studies, disease registers and
notifications systems for 2 1 specific causes of death.
13. Causes of death among children under five years of age (percentage)
Rationale for use: MDG4 consists in the reduction of under-five mortality by two-thirds in 2015. from its level in 1990. Child survival efforts can be
effective only if they are based on reasonably accurate information about the causes of childhood deaths. Cause-of-death information is needed to
prioritize interventions and plan for their delivery, to determine the effectiveness of disease-specific interventions, and to assess trends in disease
burden in relation to national and international goals.
Definition: the cause(s) of death (CoD) as entered on the medical certificate of cause of death in countries with civil (vital) registration system.
The underiying CoD is being analysed. In countries with incomplete or no civil registration, causes of death are those reported as such in epidemio-
logical studies that use verbal autopsy algorithms to establish CoD.
Methods of estimation: CoD data from civil registration systems were evaluated for their completeness. Complete and nationally-representative
data were then grouped by ICD codes into the cause categories and their proportions to total under-five deaths were then computed. For countries
with incomplete data or no data, the distribution of deaths by cause was estimated in two steps. In the first step, a statistical model was used to
assign deaths to one of three broad categories of causes: communicable diseases: noncommunicable diseases: or injuries and external causes.
In a second step, cause-specific under-five mortality estimates from Child Health Epidemiology Reference Croup (CHERC). WHO Technical
Programmes, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) were taken into account in assigning the distribution of deaths to
specific causes. A variety of methods, including proportional mortality and natural history models, were used by CHERC and WHO to develop coun-
try-level cause-specific mortality estimates. All CHERG working groups developed comparable and standardized procedures to generate estimates
from the databases.
14. HIV prevalence among the population aged 15-49 years
Rationale for use: HIV and AIDS has become a major public health problem in many countries and monitoring the course of the epidemic and impact
of interventions is crucial. Both the Millenium Development Goals (MDG) and the United Nations General Assembly Special Session on HIV and
AIDS (UNGAS) have set goals of reducing HIV prevalence.
Definition: percent of people with HIV infection among all people aged 1 5-49 years.
Methods of estimation: HIV prevalence data from HIV sentinel surveillance systems, which may include national population surveys with HIV
testing, are used to estimate HIV prevalence using standardized tools and methods of estimation developed by UNAIDS and WHO in collaboration
with the UNAIDS Reference Group on Estimation. Modelling and Projections. Tools for estimating the level of HIV infection are different for general-
ized epidemics, and concentrated or low level epidemic.
15. Incidence of tuberculosis
Rationale for use: incidence (cases arising in a given time period) gives an indication of the burden of tuberculosis (TB) in a population, and of the
size of the task faced by a national TB control programme. Incidence can change as the result of changes in transmission (the rate at which people
become infected with M tuberculosis, the bacterium which causes TB). or changes in the rate at which people infected with M. tuberculosis develop
TB disease (e.g. as a result of changes in nutritional status or of HIV infection). Because TB can develop in people who became infected many
years previously, the effect of TB control on incidence is less immediate than the effect on prevalence or mortality. Millennium Development Goal 6.
Target 8 is "have halted by 2015 and begun to reverse the incidence of" TB. WHO estimates that in 2004 the per capita incidence of TB was stable
or falling in 5 out of 6 WHO regions, but growing globally at 0.6% per year. The exception was the African Region, where incidence is apparently
still increasing, but less rapidly each year. Implementation of the Stop TB Strategy, following the Global Plan to Stop TB 2006-20 1 5. is expected to
reverse the rise in incidence globally by 201 5.
Definition: estimated number of TB cases arising in a given time period (expressed as per capita rate). All forms of TB are included, as are cases
in people with HIV.
Methods of estimation: estimates of TB incidence, prevalence and mortality are based on a consultative and analytical process in WHO and are
published annually. Estimates of incidence for each country are derived using one or more of four approaches, depending on the available data:
1 . incidence = case notifications / proportion of cases detected
2. incidence = prevalence / duration of condition
3. incidence = annual risk of TB infection x Styblo coefficient
4. incidence = deaths / proportion of incident cases that die.
16. Prevalence of tuberculosis
Rationale for use: prevalence and mortality are direct indicators of the burden of tuberculosis (TB). indicating the number of people suffering from the
disease at a given point in time, and the number dying each year. Furthermore, prevalence and mortality respond quickly to improvements in control,
as timely and effective treatment reduce the average duration of disease (thus decreasing prevalence) and the likelihood of dying from the disease
(thus reducing disease-specific mortality). Millennium Development Goal 6 is "to combat HIV/AIDS, malaria and other diseases" [including TB].
This goal is linked to Target 8 - "to have halted by 201 5 and begun to reverse the incidence of malaria and other major diseases" - and indicator 24
- "prevalence and mortality rates associated with TB". The Stop TB Partnership has endorsed the related targets of reducing per capita TB prevalence
and mortality by 50% relative to 1990. by the year 2015. There are few good data with which to establish TB prevalence and mortality, particularly
for the baseline year of 1 990. However, current best estimates suggest that implementation of the Global Plan to Stop TB 2006-20 1 5 will halve 1 990
The health of the people • • • Statistical annex 1 51
prevalence and mortality rates globally and in most regions by 2015, though not in Africa and eastern Europe.
Definition: the number of cases of TB (all forms) in a population at a given point in time (sometimes referred to as "point prevalence") ex-
pressed in this database as number of cases per 100000 population.
Methods of estimation: estimates of TB incidence, prevalence and mortality are based on a consultative and analytical process in WHO and are
published annually. The methods used to estimate TB prevalence and mortality rates are described in detail elsewhere. Country-specific estimates of
prevalence are, in most instances, derived from estimates of incidence [please link to incidence page of compendium], combined with assumptions
about the duration of disease. The duration of disease is assumed to vary according to whether the disease is smear-positive or not: whether the in-
dividual receives treatment in a DOTS programme, non-DOTS programmes, or is not treated at all; and whether the individual is infected with HIV.
17. Number of poliomyelitis cases
Rationale for use: the 1988 World Health Assembly (WHA) called for the global eradication of poliomyelitis. The number of poliomyelitis cases is
used to monitor progress towards this goal and to inform eradication strategies. Countries implement strategies supplementing routine immunization
e.g. national immunization days and sub-national campaigns - or more targeted mop-up activities, depending on the levels of poliomyelitis cases.
Definition: suspected polio cases (acute-flaccid paralysis - AFP, other paralytic diseases, and contacts with polio cases) that are confirmed by
laboratory examination or are consistent with polio infection.
Methods of estimation: estimates of polio cases are based exclusively on unadjusted surveillance data.
18. One-year-olds immunized with:
one dose of measles (%)
three doses of diphtheria, tetanus toxoid and pertussis (DTP3) (%)
three doses of hepatitis B (HepB3 )(%)
Rationale for use: immunization coverage estimates are used to monitor immunization services, to guide disease eradication and elimination
efforts, and are a good indicator of health systems performance.
Definition: measles immunization coverage is the percentage of one-year-olds who have received at least one dose of measles containing vac-
cine in a given year. For countries recommending the first dose of measles among children older than 12 months of age. the indicator is calculated
as the proportion of children less than 24 months of age receiving one dose of measles containing vaccine. DTP3 immunization coverage is the per-
centage of one-year-olds who have received three doses of the combined diphtheria and tetanus toxoid and pertussis vaccine in a given year. HepB3
immunization coverage is the percentage of one-year-olds who have received three doses of Hepatitis B3 vaccine in a given year.
Methods of estimation: WHO and UNICEF rely on reports from countries, household surveys and other sources such as research studies. Both
organizations have developed common review process and estimation methodologies. Draft estimates are made, reviewed by country and external
experts and then finalized.
19. Antenatal care coverage (%)
Rationale for use: antenatal care coverage is an indicator of access and utilization of health care during pregnancy.
Definition: percentage of women who utilized antenatal care provided by skilled health personnel for reasons related to pregnancy at least once
during pregnancy as a percentage of live births in a given time period.
Methods of estimation: empirical data from household surveys are used. At global level, facility data are not used.
20. Births attended by skilled health personnel (%)
Rationale for use: all women should have access to skilled care during pregnancy and at delivery to ensure detection and management of complica-
tions. Moreover, because it is difficult to measure accurately maternal mortality and model-based maternal mortality ratio (MMR) estimates cannot be
used for monitoring short -term trends. The proportion of births attended by skilled health personnel is used as a proxy indicator for this purpose.
Definition: percentage of live births attended by skilled health personnel in a given period of time.
Methods of estimation: empirical data from household surveys are used. At global level, facility data are not used.
21. Contraceptive prevalence (%)
Rationale for use: contraceptive prevalence is an indicator of health, population, development and women's empowerment. It also serves as a proxy
measure of access to reproductive health services that are essential for meeting many of the Millennium Development Goals (MDG)s. especially the
child mortality, maternal health HIV/AIDS, and gender related goals.
Definition: contraceptive prevalence is the proportion of women of reproductive age who are using (or whose partner is using) a contraceptive
method at a given point in time
Methods of estimation: empirical data only.
22. Children under five years of age sleeping under insecticide-treated nets (%)
Rationale for use: in areas of intense malaria transmission, malaria-related morbidity and mortality are concentrated in young children, and the use
of insecticide-treated nets (ITN) by children under 5 years of age has been demonstrated to considerably reduce malaria disease incidence, malaria-
related anaemia and all-cause under-5 mortality. Vector control through the use of ITNs constitute one of the four intervention strategies of the Roll
Back Malaria Initiative. It is also listed as an MDG indicator.
Definition: percentage of children under five years of age in malaria endemic areas who slept under an ITN the previous night. ITN being denned
as a mosquito net that has been treated within 12 months or is a long-lasting insecticidal net (LLIN).
Methods of estimation: empirical data only.
23. People with advanced HIV infection receiving antiretroviral (ARV) combination therapy (%)
Rationale for use: as the HIV epidemic matures, increasing numbers of people are reaching advanced stages of HIV infection. ARV combination
1 52 The African Regional Health Report
therapy has been shewn to reduce mortality among those infected and efforts are being made to make it more affordable even in less developed
countries. This indicator assesses the progress in providing ARV combination therapy to everyone with advanced HIV infection.
Definition: percentage of people with advanced HIV infection receiving ARV therapy according to nationally approved treatment protocol (or
WHO/Joint UN Programme on HIV and AIDS standards) among the estimated number of people with advanced HIV infection.
Methods of estimation: the denominator of the coverage estimate is obtained from models that also generate the HIV prevalence, incidence
and mortality estimates. The number of adults with advanced HIV infection who need to start treatment is estimated as the number of AIDS cases
in the current year times two. The total number of adults needing ARV therapy is calculated by adding the number of adults that need to start ARV
therapy to the number of adults who are being treated in the previous year and have survived into the current year.
24. Tuberculosis: DOTS case detection rate
Rationale for use: the proportion of estimated new smear-positive cases which are detected (diagnosed and notified to WHO) by DOTS programmes
provides an indication of how effective national tuberculosis programmes are in finding people with tuberculosis and diagnosing the disease.
Methods of estimation: estimates of incidence are based on a consultative and analytical process in WHO and are published annually. The
DOTS detection rate for new smear-positive cases is calculated by dividing the number of new smear-positive cases notified to WHO by the estimated
number of incident smear-positive cases for the same year.
25 . Tuberculosis: DOTS treatment success
Rationale for use: treatment success is an indicator of the performance of national tuberculosis control programmes. In addition to the obvious ben-
efit to individual patients, successful treatment of infectious cases of TB is essential to prevent the spread of the infection. Detecting and successfully
treating a large proportion of TB cases should have an immediate impact on TB prevalence and mortality. By reducing transmission, successfully
treating the majority of cases will also affect, with some delay, the incidence of disease.
Definition: the proportion of new smear-positive TB cases registered under DOTS in a given year that successfully completed treatment, whether
with bacteriologic evidence of success ("cured") or without ("treatment completed"). At the end of treatment, each patient is assigned one of the
following six mutually exclusive treatment outcomes: cured: completed: died: failed, defaulted: and transferred out with outcome unknown. The
proportions of cases assigned to these outcomes, plus any additional cases registered for treatment but not assigned to an outcome, add up to 1 00%
of cases registered.
26. Children under five years of age with acute respiratory infection and fever (ARI) taken to facility
Rationale for use: respiratory infections are responsible for almost 20% of all under-five deaths worldwide. (Jnder-fives with ARI that are taken to
an appropriate health provider is a key indicator for both coverage of intervention and care-seeking and provides critical inputs to the monitoring of
progress towards the child survival related millennium development goals (MDGs) and strategies.
Definition: proportion of children aged 0-59 months who had presumed pneumonia (ARI) in the last two weeks and were taken to an appropri-
ate health provider.
Methods of estimation: empirical data.
27. Children under five years of age with diarrhoea who received ORT
Rationale for use: diarrhoeal diseases remain one of the major causes of under-five mortality, accounting for 1.8 million child deaths worldwide.
despite all the progress in its management and the undeniable success of the oral rehydration therapy (ORT). Therefore, the monitoring of the cover-
age of this very cost-effective intervention is crucial for the monitoring of progress towards the child survival related Millennium Development Goals
(MDGs) and strategies.
Definition: proportion of children aged 0-59 months of age who had diarrhoea in the last two weeks and were treated with oral rehydration
salts or an appropriate household solution (ORT)
Methods of estimation: empirical data.
28. Children under five years of age with fever who received treatment with any antimalarial (%)
Rationale for use: prompt treatment with effective anti-malaria drugs for children with fever in malaria risk areas is a key intervention to reduce mortal-
ity. In addition to be listed as a global MDG indicator under Goal 6. malaria effective treatment is also identified by WHO. UNICEF. and the World
Bank as one of the four main interventions to reduce the burden of malaria in Africa: (i) use of insecticide-treated nets (ITNs). (ii) prompt access
to effective treatments in or near the home, (iii) providing antimalarial drugs to symptom-free pregnant women in stable transmission areas, and
(iv) improved forecasting, prevention and response, essential to respond quickly and effectively to malaria epidemics. In areas of sub-Saharan Africa
with stable levels of malaria transmission, it is essential that access to prompt treatment is ensured. This requires drug availability at household or
community level and. for complicated cases, availability of transport to the nearest equipped facility. Reserve drug stocks, transport, and hospital
capacity are needed to mount an appropriate response to malaria cases and prevent the onset of malaria to degenerate to a highly lethal complicated
malaria picture.
Definition: percentage of population under five years of age in malaria-risk areas with fever being treated with effective antimalarial drugs:
Methods of estimation: for prevention, the indicator is calculated as the percentage of children under five years of age who received effective
anti-malaria drugs upon a fever episode. The information is obtained directly from household surveys. The empiric values are directly reported with-
out further estimation.
29. Children 6-59 months of age who received vitamin A supplementation
Rationale for use: vitamin A supplementation is considered a critically important intervention for child survival due to the strong evidence that exists
of its impact on child mortality. Therefore, measuring the proportion of children who have received vitamin A in the last six months is crucial for
monitoring coverage of interventions towards the child survival related MDGs and strategies.
Definition: proportion of children 6-59 months of age who have received a high dose vitamin A supplement in the last 6 months
Methods of estimation: empirical data.
The health of the people • • • Statistical annex 1 53
30. Births by caesarean section (%)
Rationale for use: births by caesarean section is an indicator of access to and utilization of health care during childbirth.
Definition: percentage of births by caesarean section among all live births in a given time period.
Methods of estimation: empirical data from household surveys are used.
31. Children under five years of age
- stunted for age (%)
- underweight for age (%)
- overweight for age (%)
Rationale for use: all three indicators measure growth in young children. Child growth is internationally recognized as an important public
health indicator for monitoring nutritional status and health in populations. In addition, children who suffer from growth retardation as a result of
poor diets and/or recurrent infections tend to have greater risks of illness and death.
Definition: percentage of children stunted describes how many children under five years old have a height-for-age below minus two standard de-
viations of the National Center for Health Statistics (NCHS)/WHO reference median. Percentage of children underweight describes how many children
under five years have a weight-for-age below minus two standard deviations of the NCHS/WHO reference median. Percentage of children overweight
describes how many children under five years have a weight-for-height above two standard deviations of the NCHS/WHO reference median.
Methods of estimation: empirical values are used. Several countries have limited data for recent years and current estimations are made using
models that make projections based on past trends.
32. Newborns with low birth weight (%)
Rationale for use: the low-birth-weight rate at the population level is an indicator of a public health problem that includes long-term maternal malnu-
trition, ill-health and poor health care. On an individual basis, low birth weight is an important predictor of newborn health and survival.
Definition: percentage of live born infants with birth weight less than 2500 g* in a given time period. Low birth weight may be subdivided into
very low birth weight (less than 1 500 g) and extremely low birth weight (less than 1000 g).
Methods of estimation: where reliable health service statistics with a high level of coverage exist : "Percentage of low birth weight" births.
For household survey data different adjustments are made according to the type of information available (numerical birth weight data or subjective
assessment of the mother).
33. Prevalence of adults (15 years and older) who are obese (%)
Rationale for use: the prevalence of overweight and obesity in adults has been increasing globally. Obese adults (BMI = 30.0) are at increased risk of
adverse metabolic outcomes including increased blood pressure, cholesterol, triglycerides, and insulin resistance. Subsequently, an increase in BMI
exponentially increases the risk of noncommunicable diseases (NCDs), such as coronary heart disease, ischaemic stroke and type-2 diabetes mellitus.
Raised BMI is also associated with an increased risk of cancer.
Definition: percentage of adults classified as obese (BMI = 30.0 kg/m2) among total adult population (15 years and older).
Methods of estimation: estimates are still under development and will be published later in 2006. Only nationally representative surveys with
either anthropometric data collection or self-reported weight and height (mostly in high income countries) are included in the 2006 World health
statistics.
34. Population with:
- sustainable access to an improved water source (%)
- access to improved sanitation (%)
Rationale for use: access to drinking water and improved sanitation is a fundamental need and a human right vital for the dignity and health
of all people. The health and economic benefits of improved water supply to households and individuals (especially children) are well documented.
Both indicators are used to monitor progress towards the MDGs.
Definition: access to an improved water source is the percentage of population with access to an improved drinking water source in a given year.
Access to improved sanitation is the percentage of population with access to improved sanitation in a given year.
Methods of estimation: estimates are generated through analysis of survey data and linear regression of data points. Coverage estimates are
updated every two years.
35. Population using solid fuels (%)
Rationale for use: the use of solid fuels in households is associated with increased mortality from pneumonia and other acute lower respiratory dis-
eases among children as well as increased mortality from chronic obstructive pulmonary disease and lung cancer (where coal is used) among adults.
It is also a Millennium Development Goal indicator.
Definition: percentage of population using solid fuels.
Methods of estimation: the data from surveys and censuses are used as reported in the surveys and censuses. All countries with a Gross
National Income (GNI) per capita above US$ 10 500 are assumed to have made a complete transition to cooking with non-solid fuels. For low-
and middle-income countries with a GNI per capita below US$ 1 0 500 and for which no household solid fuel use data are available, a regression
model based on GNI, percentage of rural population and location or non-location within the Eastern Mediterranean Region is used to estimate
the indicator.
36. Prevalence of current tobacco use in adolescents (13-15 years of age)
Rationale for use: the risk of chronic diseases starts early in childhood and such behaviour continues to adulthood. Tobacco is an addictive substance
1 54 The African Regional Health Report
and smoking often suits in adolescence, before the development of risk perception. By the time the risk to health is recognized, the addicted indi-
viduals find it difficult to stop tobacco use.
Definition: prevalence of tobacco use (including smoking, oral tobacco and snuff) on more than one occasion in the 30 days preceding the
survey, among adolescent 13-15 year olds.
37. Prevalence of current (daily or occasional) tobacco smoking among adults (15 years and older) (%)
Rationale for use: prevalence of current tobacco smoking among adults is an important measure of the health and economic burden of tobacco, and
provides a baseline for evaluating the effectiveness of tobacco control programmes over time. While a more general measure of tobacco use. including
both smoked and smokeless products, would be ideal, data limitations restrict the present indicator to smoked tobacco. Occasional tobacco smoking
constitutes a significant risk factor for tobatco-related disease, and is therefore included along with daily tobacco smoking.
Definition: prevalence of current tobacco smoking (including cigarettes, cigars, pipes or any other smoked tobacco products). Current smoking
includes both daily and non-daily or occasional smoking.
Methods of estimation: empirical data only.
38. Condom use at higher risk sex among young people aged 15-24 years (percentage)
Rationale for use: consistent correct use of condoms within non-regular sexual partnerships substantially reduces the risk of sexual HIV transmission.
Definition: percentage of young people aged 15-24 years reporting the use of a condom during the last sexual intercourse with a non-regular
partner among those who had sex with a non-regular partner in the last 12 months.
Methods of estimation: empincal data only. Survey respondents aged 1 5-24 years are asked whether they have commenced sexual activity.
Those who report sexual activity and have had sexual intercourse with a non-regular partner in the last 12 months, are further asked about the num-
ber of non-regular partners and condom use the last time they had sex with a non-regular partner.
39. Number of:
-physicians per 1000 population
-nurses per 1000 population
-midwives per 1000 population
-dentists per 1000 population
-pharmacists per 1000 population
-public and environmental health workers per 1000 population
-community health workers per 1000 population
-laboratory health workers per 1000 population
-other health workers per 1000 population
-health management and support workers per 1 000 population
Rationale for use: the availability and composition of human resources for health is an important indicator of the strength of the health system.
Even though there is no consensus about the optimal level of health workers for a population, there is ample evidence that worker numbers and qual-
ity are positively associated with immunization coverage, outreach of primary care, and infant, child and maternal survival.
Definition:
Physicians: includes generalists and specialists.
Nurses includes professional nurses, auxiliary nurses, enrolled nurses and other nurses, such as dental nurses and primary care nurses.
Midwives: includes professional midwives. auxiliary midwives and enrolled midwives. Traditional birth attendants, who are counted as com-
munity health workers, appear elsewhere.
Dentists: includes dentists, dental assistants and dental technicians.
Pharmacists: includes pharmacists, pharmaceutical assistants and pharmaceutical technicians.
Laboratory health workers: includes laboratory scientists, laboratory assistants, laboratory technicians and radiographers.
Environment and public hearth workers: includes environmental and public health officers, sanitarians, hygienists. environmental and public
health technicians, district health officers, malaria technicians, meat inspectors, public health supervisors and similar professions.
Community health workers: includes traditional medicine practitioners, faith healers, assistant/community health education workers, com-
munity health officers, family health workers, lady health visitors, health extension package workers, community midwives. institution-based
personal care workers and traditional birth attendants.
Other health workers: includes a large number of occupations such as dieticians and nutritionists, medical assistants, occupational thera-
pists, operators of medical and dentistry equipment, optometrists and opticians, physiotherapists, podiatrists, prosthetic/orthetic engineers,
psychologists, respiratory therapists, speech pathologists. medical trainees and interns.
Hearth management and support workers: includes general managers, statisticians, lawyers, accountants, medical secretaries, gardeners, com-
puter technicians, ambulance staff, cleaning staff, building and engineering staff, skilled administrative staff and general support staff.
Methods of estimation: no methods of estimation have been developed.
40. Total expenditure on health as percentage of GDP
41. General government expenditure on health as percentage of total general government expenditure
42. Per capita total expenditure on health at international dollar rate
The health of the people • • • Statistical annex 1 55
Rationale for use: health financing is a critical component of health systems. National health accounts (NHA) provide large set of indicators based
on the expenditure information collected within a internationally recognized framework. NHA are a synthesis of the financing and spending flows
recorded in the operation of a health system, from funding sources to the distribution of funds across providers and functions of health systems and
benefits across geographical, demographic, socioeconomic and epidemiological dimensions.
Definition: total health expenditure as percentage of gross domestic product (GDP).
Percentage of total general government expenditure that is spent on health.
Per capita total expenditure on health at international dollar rate.
Data sources & Methods of estimation.
Only about 95 countries either have produced full NHA or report expenditure on health to OECD. Standard accounting estimation and ex-
trapolation techniques have been used to provide time series. The principal international references used are the International Monetary Fund (IMF)
Government finance statistics and International financial statistics: OECD health data and International development statistics: and the United
Nations National accounts statistics. National sources include: national health accounts reports, public expenditure reports, statistical yearbooks
and other periodicals, budgetary documents, national accounts reports, statistical data on official web sites, central bank reports, nongovernmental
organization reports, academic studies, and reports and data provided by central statistical offices and ministries.
43. General government expenditure on health as percentage of total expenditure on health
44. General government expenditure on health as percentage of total government expenditure
45. External resources for health as percentage of total expenditure on health
46. Social security expenditure on health as percentage of general government expenditure on health
47. Out-of-pocket expenditure as percentage of private expenditure on health
48. Private prepaid plans as percentage of private expenditure on health
49. Per capita total expenditure on health at average exchange rate (US$)
50. Per capita government expenditure on health at average exchange rate (US$)
51. Per capita government expenditure on health at International dollar rate
Rationale for use: health financing is a critical component of health systems. National health accounts (NHA) provide large set of indicators based
on the expenditure information collected within a internationally recognized framework. NHA are a synthesis of the financing and spending flows
recorded in the operation of a health system, from funding sources to the distribution of funds across providers and functions of health systems and
benefits across geographical, demographic, socioeconomic and epidemiological dimensions.
Definition: key indicators for which the data are available:
Level of total expenditure on health as % of GDP, and per capita health expenditures in US dollars and in international dollars.
Distribution of public and private sectors in financing health and their main components, such as:
- Extent of social and private health insurance
- Burden on households' through out-of-pocket spending
- Reliance on external resources in financing health
Associated terms:
Cross domestic product (GDP) is the value of all goods and services provided in a country by residents and non-residents. This corresponds
to the total sum of expenditure (consumption and investment) of the private and government agents of the economy during the reference
year.
General government expenditure (GGE) includes consolidated direct outlays and indirect outlays, such as subsidies and transfers, includ-
ing capital, of all levels of government social security institutions, autonomous bodies, and other extrabudgetary funds.
Total expenditure on health (THE) is the sum of general government health expenditure and private health expenditure in a given year,
calculated in national currency units in current prices. It comprises the outlays earmarked for health maintenance, restoration or enhancement
of the health status of the population, paid for in cash or in kind
General government expenditure on health (GGHE) is the sum of outlays by government entities to purchase health care services and
goods. It comprises the outlays on health by all levels of government, social security agencies, and direct expenditure by parastatals and public
firms. Expenditures on health include final consumption, subsidies to producers, and transfers to households (chiefly reimbursements for
medical and pharmaceutical bills). It includes both recurrent and investment expenditures (including capital transfers) made during the year.
Besides domestic funds it also includes external resources (mainly as grants passing through the government or loans channelled through the
national budget).
Social security expenditure on health (SSHE) includes outlays for purchases of health goods and services by schemes that are manda-
tory and controlled by government. Such social security schemes that apply only to a selected group of the population, such as public sector
employees only, are also included here.
External resources health expenditure (ExtHE) includes all grants and loans whether passing through governments or private entities for
health goods and services, in cash or in kind.
Private health expenditure (PvtHE) is defined as the sum of expenditures on health by the following entities:
Prepaid plans and risk-pooling arrangements (PrepaidHE): the outlays of private insurance schemes and private social insurance schemes
(with no government control over payment rates and participating providers but with broad guidelines from government)
Firms' expenditure on health: the outlays by private enterprises for medical care and health enhancing benefits other than payment to social
security or other pre-paid schemes.
Non-profit institutions serving mainly households: outlays of those entities whose status do not permit them to be a source of financial
gain for the units that establish, control or finance them. This includes funding from internal and external sources.
1 56 The African Regional Health Report
Household out-of-pocket spending (OOPS): the direct outlays of households, including gratuities and in-kind payments made to health
practitioners and to suppliers of Pharmaceuticals, therapeutic appliances and other goods and services. This includes household direct pay-
ments to public and private providers of health care services, non-profit institutions, and non-reimbursable cost sharing, such as deductibles.
copayments and fee for services.
Exchange rate: the annual average or year end number of units at which a currency is traded in the banking system.
International dollars: derived by dividing local currency units by an estimate of their Purchasing Power Parity (PPP) compared to the US
dollar, i.e. the measure which minimizes the consequences of differences in price levels between countries.
Data sources & methods of estimation: about 100 countries either have produced full national health accounts or report expenditure on health
to OECD. Standard accounting estimation and extrapolation techniques have been used to provide time series ( 1 998-2004). Ministries of Health have
responded to the draft updates sent for their inputs and comments.
For details on sources and methods see www.who.int/nha.
52. Coverage of vital registration of deaths
Rationale for use: health information is an essential component of health systems. The registration of births and deaths with causes of death, called
"civil registration (vital registration)", is an important component of a country health information system.
Definition: percentage of estimated total deaths that are "counted" through civil registration system
Methods of estimation: expected numbers of deaths by age and sex are estimated from current life tables, based on multiple sources. Reported
numbers are compared with expected numbers by age and sex to obtain an estimate of coverage of the vital registration system.
53. Number of hospital beds per 10 000 population
Rationale for use: service delivery is an important component of health systems. To capture availability, access and distribution of health ser-
vices delivery a range of indicators or a composite indicator is needed. Currently, there is no such data for the majority of countries. Inpatient beds
density is one of the few available indicators on a component of level of health service delivery.
Definition: number of inpatient beds per 100 000 population.
Methods of estimation: empirical data only with possible adjustment for underreporting (e.g. missing private facilities).
The health of the people • • • Statistical annex 1 57
Glossary
Terms used in the African Regional Health Report
Active surveillance: a method of using
outreach to identify cases that would be missed
by passive case detection and reporting.
Acute flaccid paralysis: loss of power
of voluntary movement in a muscle, with
a loss of muscle tone and reflexes; can
be associated with an infectious disease,
usually viral in origin, that causes fever, pain
and gastrointestinal symptoms; such as that
caused bythepoliovirus.
Acute respiratory infection: infection
of the lungs or airways, usually caused by
viruses or bacteria.
Aflatoxins toxic metabolites of some fungi,
which can cause disease in humans and
animals eating peanut meal and other food
contaminated by these fungi, and through
long exposure, play a role in the etiology of
acute hepatitis, and liver cancer in humans.
Amodiaquine: a drug used for treating malaria
Anaemia: insufficient concentrations of red
blood cells or the haemoglobin that they con-
tain; resulting in pallor, shortness of breath,
palpitations, lethargy.
Antenatal care: care provided to mothers
during pregnancy, which can include counsel-
ling about diet, hygiene, HIV status, birth pre-
paredness, care and feeding of the newborn,
and screening for, and treatment of, conditions
such as anaemia, malnutrition, tuberculosis,
malaria, hypertension and diabetes.
Antiretrovirals drugs that are used for
treating HIV infection; they work by prevent-
ing the virus from replicating.
Artemether-lumefantrine: an artemisinin
combination treatment used for malaria.
Artemisinin combination therapies
(ACTs): drugs used for the treatment of
malaria, one of the active ingredients of which
is extracted from the plant Artemesia annua
(also known as sweet wormwood or Qinghao).
Bacteria: a one-celled organism that usu-
ally multiplies by cell division; smaller than
parasites and bigger than viruses.
BCG vaccination (bacille Calmette-
Guerin): a suspension of a weakened strain
of Mycobacterium tuberculosis, which is in-
oculated into the skin to prevent tuberculosis.
Blood alcohol concentration: the amount
of alcohol present in the bloodstream, usually
measured in milligrams per decilitre (mg/dl).
Body mass index: a person's weight in ki-
los, divided by height in metres squared. Less
than 18.5 is considered underweight, 20-25
normal, 25.0-29.9 overweight, more than 30
obese, and more than 40, very obese.
Bronchitis: inflammation of the airways of
the lung.
Buruli ulcer: an ulcer of the skin with wide-
spread necrosis of subcutaneous fat, due
to infection with Mycobacterium ulcerans;
named after the Buruli district in Uganda
where it was first described.
Campylobacter bacteria that can cause
acute gastroenteritis in people with sudden
onset of diarrhoea, muscle and joint pains,
and headache.
Cancer: a general term for any of various
types of malignant growths, most of which
invade surrounding tissues, metastasize
to distant sites in the body, recur after
attempted removal, and cause death of the
patient unless adequately treated.
Cardiovascular diseases: diseases of the
heart and blood vessels that include strokes,
hypertension, heart attacks, etc.
Case management: treatment of the
individual patient, in contrast to population-
based approaches.
Cervical cancer: a malignant disease of
the neck of the uterus.
Chemoprophylaxis: prevention of a disease
by the use of drugs.
Child mortality rate: measured by the
probability (per 1000 live births) of a child
born in a specific year dying before reaching
5 years of age.
Cholera: an acute epidemic infectious disease
caused by Vibrio cholerae, causing profuse
watery diarrhoea, dehydration and collapse.
Choloroquine: a drug used for treating
malaria.
Conflict resources: natural resources such
as gold, oil, timber, diamonds, that provoke
and finance war.
Contagious: transmitted by contact
Corruption: the process of changing for the
worse, particularly in a moral sense, as by
bribing.
Cost-effectiveness: the amount of value for
money that a particular intervention gives.
Cysticercosis: disease caused by the larvae
of tapeworms encysting in humans.
DALY: Disability-adjusted life year; a unit for
measuring the burden of disease — calculated
as the sum of the years of life lost due to prema-
ture mortality and disability in the population.
Demography: the study of populations,
especially with reference to birth, death and
health of the people.
DHS: Demographic and health surveys, done
by the Opinion Research Corporation (ORC
Macro), are nationally-representative house-
hold surveys with large sample sizes (usually
between 5000 and 30 000 households) that
are used to obtain data on female popula-
tion, health, and nutrition indicators.
DHS+: Demographic and health surveys that
also collect data from men.
DOTS: a five-component strategy for tuber-
culosis control; including diagnosis by high-
quality microscopy, political commitment, an
assured supply of drugs, directly-observed
treatment and systematic monitoring and
accountability.
Dracunculiasis: guinea-worm disease: an
infection with Dracunculus medinensis, a
nematode similar to the filarial worms, that
is acquired by humans drinking water contain-
ing cyclopoid copepods (water fleas) infected
1 58 The African Regional Health Report
with guinea worm larvae. Human infection
can be prevented by filtering drinking-water,
preventing infected people from wading in
the water, or vector control, by using insecti-
cides to kill the water fleas.
Emphysema: an increase in the size of
the distal air spaces in the lung, causing
breathlessness.
Epidemic: an outbreak of an illness, or spe-
cific health-related behaviour in a community
or a region that is clearly in excess of that
normally encountered.
Epilepsy a chronic disorder comprising
seizures or fits due to bursts of neuronal
discharge in the brain.
Escherichia coli (E-coli} a species of
bacteria that is normally found in the intes-
tines, and can cause urinary tract infections
and diarrhoea, particularly in children, and
travellers.
Essential medicines drugs that are deter-
mined by the WHO Expert Committee on the
Selection and Use of Essential Medicines to
be required for the basic health needs of a
population.
Famine severe general shortage of food
usually caused by population explosion or
failure of food crops.
Fertility rate: the number of live births in
a year divided by the number of females of
child-bearing age.
Foodborne disease: infections or toxic
reactions that are spread by eating contami-
nated food.
Gender equality: a state of even balance
and access to societal rights and privileges
between men and women.
Generic drugs: drugs that not protected by
trademark or sold as a specific brand, non-
proprietary.
Governance: the exercise of political,
economic and administrative authority in the
management of a country's affairs at all levels:
the complex mechanisms, processes, relation-
ships and institutions through which citizens
articulate their interests, exercise their rights
and obligations and mediate their differences.
Health systems: the people, institutions
and resources that serve to improve the
health of the population, by helping people to
avoid ill-health and treating disease.
Health workers: people with specific train-
ing and a recognized role in the provision of
health care.
Health-for-all the attainment by all the
people of the world of a level of health
that will permit them to lead socially and
economically productive lives.
Heart disease: commonly used term that
encompasses diseases of the muscle, blood
vessels, or envelopes of the heart — includ-
ing ischaemia, myocardial infarction, angina
pectoris. arrhythmias, hypertension and heart
failure.
Hepatitis: inflammation of the liver, usually
caused by a viral infection, or toxic agents;
including alcohol and drugs. Hepatitis A virus
is spread by contact with faeces or blood,
most often through the ingestion of contami-
nated food. Hepatitis B virus is shed through
blood, semen, vaginal secretions and saliva;
symptoms can develop after an incubation
period that may be as long as six months;
and people may remain asymptomatic carri-
ers; a leading cause of chronic liver disease,
cirrhosis, and liver cancer. An effective vac-
cine exists. Hepatitis C virus is spread mainly
through blood transfusion and can cause
cirrhosis, liver failure, and liver cancer.
HIV/AIDS: human immunodeficiency virus is
the causative agent and acquired immuno-
deficiency syndrome is the disease that it
causes. A fatal, incurable disease of humans
that includes a constellation of relatively
specific infections and cancers that result
from the selective destruction of part of the
human immune system by the virus.
Hookworm: common name for bloodsucking
round worms of the family Ancyclostomatidae,
and the infection that it causes in humans,
with anaemia as its main consequence.
Human Papillomavirus certain types of
this virus cause cutaneous and genital warts
in humans, including verruca vulgaris and
condyloma acuminatum, other types cause
cervical intraepithelial neoplasia; account-
ing for about 80% of cervical cancer and
anogenital and laryngeal carcinomas.
Human resources: the people that make up
the workforce.
Humanitarian emergencies: a situation
in which the quality and/or continuation of
people's lives are gravely endangered.
Hypertension: blood pressure consistently
exceeding 160 mm Hg (systolic) and 95mm
Hg (diastolic).
Incidence: the number of instances of
illness commencing, or of persons falling ill,
during a given period in a specified popula-
tion; the number of new events, such as the
new cases of a disease in a defined popula-
tion, within a specific period of time.
Infectious: a disease that is caused by
transmission of a specific pathogenic agent
or its toxic products from an infected person,
animal, or reservoir to a susceptible host.
Infrastructure: the permanent services and
equipment such as roads, railways, bridges,
factories and schools, needed for a country
to be able to function properly.
Insecticide: any natural or manufactured
substance that is used to kill insects.
Insecticide-treated nets (UN): mesh
fabric that is soaked in a solution of chemi-
cals designed to kill the insects that land
on them; usually intended to be hung over
sleeping people to protect them from the
night-biting mosquito that carries malaria.
Intermittent preventive treatment: the
practice of giving drugs at regular intervals
to a defined population at risk in an area of
endemic disease (regardless of whether the
individual is already infected or not), in order
to prevent the worst effects of this disease.
Isoniazid: a drug used to treat tuberculosis
Ivermectin a drug used to decrease the
complications and transmission of filarial
diseases.
Know-do gap: the difference between
current knowledge on a subject and what is
actually done in practice.
Knowledge management: the handling of
a set of principles, tools and practices that
enable people to create, share, translate and
apply what they know in order to improve
effectiveness and create value.
Larvicide: a compound that is toxic to the
stage of the insects at which they are im-
mature, but capable of independent life
Macroeconomics: the study of econom-
ics on a large scale such as the nation as a
whole, taking into account trade, national
income, output and exchange rates, and
financial policy.
The health of the people • • • Glossary
Malaria: a parasitic disease caused by Plas-
modium species, transmitted to humans by
the bite of the female Anopheles mosquito;
fever and anaemia are its main signs.
Malnutrition: various disorders resulting
from inadequate food intake, an unbalanced
diet (lack of protein or vitamins) or an inabil-
ity to absorb nutrients from food.
Market restrictions: legislation covering
the amount and type of trading that a country
is allowed to legally pursue.
Measles: a contagious eruptive fever with
coryza and catarrhal symptoms, caused by
a virus, with about a two-week incubation
period. An effective vaccine exists.
Microbicide gel: a gel that is formulated to
destroy microbes, and designed to be used in
the vagina or rectum to prevent the transmis-
sion of sexually transmitted infections.
MICS: Multiple Indicator Cluster Surveys
— household surveys developed by UNICEF
specifically to gather information on the
status of women and children to measure
progress towards the World Summit for
Children goals.
Mop-up campaign: in immunization
programmes, when a case of the disease
is detected, a concerted effort is made to
immunize all susceptible individuals in the
immediate vicinity within a very short space
of time.
Morbidity: the condition of being diseased,
or sick; also the amount of sickness and dis-
ease caused by a particular agent or condition.
Mortality rate: the ratio of the number of
people dying in a year to the total mid-year
population in which the deaths occurred.
Multidrug-resistant tuberculosis: disease
caused by strains of M. tuberculosis that
are resistant to rifampicin and isoniazid,
irrespective of resistance to other standard
antituberculosis drugs.
Mycobacteria: slender, Gram-positive, acid-
fast microorganisms resembling, and includ-
ing, the bacillus which causes tuberculosis.
Neonatal mortality rate: the number of
deaths in infants under 28 days of age in a
given period, usually a year, per 1000 live
births in that period.
Noma (cancrum oris): a severe infection
causing gangrene of the oral and facial tissues,
usually occurring in debilitated patients or mal-
nourished children; has a very poor prognosis.
Noncommunicable disease: a disease
that is not transmitted to or between people,
and does not have an infectious cause.
Obesity: the condition of being overweight
to an unhealthy extent: for adults, a body-
mass index equal to, or greater than 30.
Onchocerciasis: also known as river blind-
ness; infection with filarial worms that live
and breed in the nodules under the patient's
skin, and can cause blindness. Transmitted
by biting blackflies that breed on rocks in
turbulent river water.
Oral rehydration therapy (ORT): a water,
salt and sugar mixture used for treating
dehydration.
Overweight: a body mass index equal to or
great than 25 in adults.
Pandemic: a widespread epidemic disease
Parasite: a plant or animal which lives upon
or within another living organism at whose
expense it obtains some advantage without
compensation.
Patent protection: an official licence from
the government granting a person or busi-
ness the sole right for a certain period, to
make and sell a particular article.
Pesticides: a compound used to destroy
pests of any sort; including fungicides, herbi-
cides, insecticides, rodenticides etc.
Performance indicators: (used for assess-
ing polio surveillance) all three of which need
to be reached for a region to be declared free
of polio:
1 . Every year, countries must report at
least 1 case of acute flaccid paralysis
that is not caused by polio, per 100
000 population aged <1 5 years.
2. Countries must collect adequate stool
specimens from at least 80% of re-
ported cases of acute flaccid paralysis.
3. All acute flaccid paralysis stool speci-
mens must be analysed in laboratories
accredited by WHO.
Philanthropic: practically benevolent
towards mankind.
Pneumocystis jiroveci: the microorgan-
ism that causes pneumocystis pneumonia in
debilitated patients.
Poliomyelitis (polio): an acute viral
disease characterized clinically by fever, sore
throat, headache and vomiting, often with
stiffness of the head and back, that may lead
to involvement of the central nervous system
with meningitis, destruction of the anterior
horn cells of the spinal cord, and paralysis.
An effective vaccine exists.
Poverty: poverty is pronounced deprivation
in well-being. It is associated not only with
insufficient income or consumption but also
with insufficient outcomes with respect
to health, nutrition, and literacy, and with
deficient social relations, insecurity, and low
self-esteem and powerlessness. Defined by
the World Bank as having an income of less
than US$ 1 per day.
Poverty reduction: actions — usually coun-
try's macroeconomic, structural and social
policies and programmes — to promote
economic growth and reduce poverty, as well
as associated external financing needs. The
Poverty Reduction Strategy Papers, prepared
by governments through a participatory proc-
ess involving civil society and development
partners, including the World Bank and the
International Monetary Fund (IMF) are pres-
ently the principal instruments for combating
poverty in many low-income countries.
Poverty trap: [Often] extreme poverty that
is pervasive and persistent, a situation from
which many cannot escape without external
assistance.
Prevalence: the number of cases of a
disease in existence at a certain time in a
designated area.
Prevalence of contraceptive use: the pro-
portion of acts of sexual intercourse in which
means to prevent conception and/or sexually
transmitted infection are used.
Psychosis: any mental disorder character-
ized by delusion and/or prominent hallucina-
tions to the extent that this disorder grossly
interferes with the capacity to meet ordinary
demands of life.
Public-private partnerships: arrange-
ments between governments and industry
to combine funding and skills in an effort to
address specific problems.
Rifampicin: a drug used for treating
tuberculosis.
1 60 The African Regional Health Report
n: members of the phylum
Nematoda; Ascaris is the genus that
causes the most infections in humans, and
is acquired by ingesting eggs of the parasite
in contaminated soil. The infection causes
damage to the lungs when the larvae migrate
through the body, intestinal colic due to large
masses of adult worms in the intestines,
these masses can also cause complications
such as volvulus, intestinal obstruction or
intussusception.
Rumble strips: a series of indented or
raised elements on a road to alert drivers to
reduce speed.
Salmonella rod-shaped. Gram-negative
bacteria that include the typhoid-paraty-
phoid bacilli, and that can cause violent
painful diarrhoea.
Saturated fat a fatty acid whose carbon
chain contains no double or triple bonds
between the carbon atoms. It is the main die-
tary cause of high levels of blood cholesterol.
Scaling up: growth in size, number and
activities of organized initiatives, particularly
to reach more people.
Schistosomiasis: a variety of infections
caused by blood flukes, which are transmit-
ted to humans by exposure to infested water.
The three main forms of infection — urinary,
intestinal or hepatosplenic — vary with the
species of schistosome but result mostly from
reactions to the eggs deposited in tissues.
Schizophrenia: a mental disorder which
tends to be chronic, impairs functioning
and includes psychotic symptoms involving
disturbances of thought, perception, feeling
and behaviour.
Screening: the systematic application of
a test or enquiry, to identify individuals at
sufficient risk of a specific disorder, who may
benefit from further investigation or direct
preventive action without having sought
medical attention on account of any symp-
toms of that disorder.
Shigella bacteria that are the usual cause
of dysentery with painful bloody diarrhoea
and fever; spread by the faecal oral route,
contaminated food and objects, and by flies
as mechanical vectors.
Sickle cell disease: a chronic haemolytic
anaemia, characterized by sickle-shaped red
blood cells due to homozygous inheritance of
haemoglobin S.
Skilled birth attendance: the practice of
having a specifically trained health worker
(doctor, nurse or midwife) to assist during
labour and delivery, irrespective of where the
birth actually occurs.
Smoke hoods a metal frame designed to
draw smoke away from an open fire towards
a chimney or other outlet as part of a passive
extraction system.
Social protection schemes: arrangements
for payment of an amount of money in the
event of illness, injury or death, particularly
for people too poor to be able to pay the
premium for individual insurance contracts.
STEPS: Stepwise approach to surveillance.
A simple standardized method for
collecting, analysing and disseminating
data for noncommunicable disease risk
factors (www.who.int/ncd_surveillance/
steps/riskfactor/en).
Stroke: a sudden and severe attack caused
by acute vascular lesions of the brain, such
as haemorrhage, thrombosis or embolism,
with functional consequences depending on
the location and the extent of the lesion.
Stunted: not having gained full growth or
development; used specifically to mean a
child that is less than two standard devia-
tions from the mean height for his or her age,
due to chronic malnutrition.
Sulfadoxine-pyrimethamine: a long-
acting sulfonamide used in combination with
pyrimethamine to reduce the relapse rate of
malaria.
Sustainable development: the use of natu-
ral resources to support human endeavour at
a rate, and by methods that do not irrepara-
bly deplete or damage the source.
Syphilis: a contagious systemic disease
caused by the spirochete Treponema pallidwn.
that can affect all organs; characterized by
three clinical stages, and years of asymptom-
atic latency. Easily prevented and treated in
its early stages by penicillin.
Tapeworm: a parasitic intestinal cestode
worm; most human infections are caused by
either Taenia solium (acquired by eating un-
dercooked pork) or Taenia saginata (aquired
by eating undercooked beef), only the former
can cause cysticercosis in humans, while
there are few symptoms that can be reliably
attributed to the presence of the adult worms
in the intestines.
Tetanus: an acute infectious disease caused
by a toxin produced in the body by the
bacteria Clostridium tetani. caused by soil
contaminating wounds; resulting in muscular
rigidity and spasms; when the respiratory
muscles are involved, patients die from
asphyxia. An effective vaccine exists.
Trade tariffs: the tax or duty to be paid on
a particular class of imported or exported
goods.
Traditional birth attendants: women
usually with no formal training, who act as
midwives; assisting women during labour
and delivery.
Trypanosomiasis: in Africa, a fatal
infection caused by Trypanosoma brucei
gambiense or T. brucei rhodesiense that is
transmitted by the bite of the tsetse flies;
also called sleeping sickness.
Tuberculin test: a test for tuberculosis,
consisting of the subcutaneous injection of
5 mg of tuberculin. The test has no effect in
healthy people, but usually causes inflamma-
tion at the site of the injection in people that
are infected.
Tuberculosis: an infectious disease caused
by Mycobacterium tuberculosis, spread by
inhalation, ingestion or inoculation, charac-
terised by an initial predilection for the lungs,
although tubercles may form in any organ
Typhoid: a disease with fever and rash due
to infection with Salmonella typhi.
Urbanization: the process of making a
district less rural and more town-like.
Vaccine: any preparation whose adminis-
tration is intended for the prevention, amelio-
ration or treatment of infectious diseases by
stimulating the formation of antibodies to
specific pathogens or toxins.
Vector control: control of the carrier,
especially an animal, (usually an arthropod;
mosquito, flea, fly, tick), which transfers an
infective agent from one host to another.
Vector-borne disease: a disease that is
transmitted by an animal, such as an insect,
that transfers the pathogen from one organ-
ism to another, for example, from animal to
The health of the people • • • Glossary
humans, usually without itself contracting
the disease.
Verbal autopsy: the recounting of events
that surrounded the death of a person, usu-
ally by someone who has no formal health
training, used as a means to attribute the
cause of death in places where traditional
postmortems are not practicable.
Virus: a minute infectious agent that can
only replicate within living host cells
Vital registration: the process of collect-
ing, by civil records, enumeration, or indirect
estimation, data on the frequency of the
occurrence of important events in human life
including birth, death, fetal death, marriage,
divorce, annulment, judicial separation,
adoption, legitimation and recognition.
Vitamin A supplements: doses of the
organic substance, usually present in minute
amounts in natural foodstuffs, given to treat
or prevent a deficit that can lead to night
blindness, xerophthalmia, dermatosis, sus-
ceptibility to infection and retarded growth.
Wasted: having lost flesh or strength, ema-
ciated; abnormally thin from extreme loss of
flesh; particularly a child who is less than 2
standard deviations from the mean weight
for height.
Sources:
Chalmers Dictionary. Larousse. 1995.
Borland's Illustrated Medical Dictionary 24th ed. W.B. Philadelphia and London: Saunders Company, Philadelphia and London; 1965.
Last JM (editor). A dictionary of epidemiology. 2nd ed. Oxford: Oxford University Press; 1 988.
Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. WHO Technical Report Series 894. Geneva: World Health
Organization, 2000.
World Health Organization. Health Promotion Glossary whqlibdoc.who.int/hq/1998/WHO_HPR_HEP_98.1.pdf
World health statistics 2006. Geneva: World Health Organization; 2006.
World health report 2001 — mental health: new understanding, new hope. Geneva: World Health Organization; 2001 .
1 62 The African Regional Health Report
Index
-
Page references to fexf figures, tables and boxesare shown in italics. References to the statistical annex (pages 129-148) are shown in bold.
As all countries in the WHO African Region are included in the annex, specific country references to the annex are not included in the index.
Definitions of the statistical categories used in the annex can be found in the "Explanatory notes" (pages 149-157). Definitions and explanation
of terminology used throughout the report can be found in the "Glossary" (pages 1 58-162).
Accelerated Access Initiative (2000) 47
acute flaccid paralysis 43
acute respiratory infection (ARI)
children under 5 143
adolescent mothers 22
aflatoxins 91
Africa 2000 initiative 86. 96-7
AIDS see HIV/AIDS
Abuja Declaration 51.122.8-9
alcohol abuse 69, 72, 75
Algeria
disease risk factors 65
essential medicines, pricing survey 113-14
health financing, external 121-3
per capita government expenditure, health 124
road traffic accident prevention 67-8
STEPS survey, noncommunicable diseases 77, 78
amodiaquine 52
Angola
cervical screening 77
emerge ncy recovery support, WHO 94
landmine victims, rehabilitation 68
mental health policies 72
per capita government expenditure, health 124
polio 94
antenatal care 27, 142, 20-1
antiretroviral (ARV) medicines 45, 50. 143
Accelerated Access Initiative (2000) 47
pricing 47, 46-7
Artemisia annua farming 1 1 , 54, 1 14, 7 15
artemisinin-based combination therapies (ACTs) 53, 54, 53-4
artemether-lumefantrine 54, 53
aspirin 76
BCG (bacillus Calmette-Guerin) vaccination, tuberculosis 50
Benin
blood supplies, safety 115-17
food safety 99
per capita government expenditure, health 124
road traffic accident prevention 67-8
bilharzia seeschistosomiasis
birth
attendants 27, 139, 142
by Caesarean section 143
blindness 69-70
blood supplies, safety 115-17
Botswana
blood supplies, safety 115-17
food hygiene, schoolchildren 99
food safety monitoring 99
HIV/AIDS 23
home-based health care 121
infant and maternal mortality 17,27
per capita government expenditure, health 124
tuberculosis prevalence 48
breastfeeding 24
Burkina Faso
first-line HIV/AIDS treatment 47
food safety monitoring 99
locust crop damage 94
per capita government expenditure, health 124
burns 67
Buruli ulcer 56
Burundi
Association for the Support of HIV Positive People (ANSS) 46
blood supplies, safety 115-17
emergency recovery support, WHO 94
first-line HIV/AIDS treatment 47
health-care review 109
health-care worker emigration 773
HIV prevalence 45
per capita government expenditure, health 124
poverty targets 6
Reseau Burundais des Personnes vivant avec le VIH/SIDA 46
Society for Women Against AIDS in Africa 46
Cameroon
food contamination research 99
health-care staffing crisis 1 17
health-care worker emigration 7 19
Healthy Cities project 90
HIV/AIDS medication 47
mental health policies 72
per capita government expenditure, health 124
poverty targets 6
sanitation improvements 38
STEPS survey, noncommunicable diseases 77
cancerfs)
age-standardized mortality rate 135
cervical 67, 77
intestinal 66
liver 66-7
lung 66
oral 72-3
The health of the people • • • Index 1 63
pharyngeal 72
Cape Verde, per capita government health expenditure 124
cardiovascular diseases 65, 76
age-standardized mortality rate 135
cataract 69
Central African Republic
emergency recovery support, WHO 94
famine 96
health-care review 109
health-care worker emigration / 19
Healthy Cities project 90
per capita government expenditure, health 124
Chad
antenatal service 23
essential medicines, pricing survey 113-14
locust crop damage 94
per capita government expenditure, health 124
tuberculosis drug quality 114
children
acute respiratory infection 143
antimalarial treatment 143
blindness 69
diarrhoea 135, 143
illness xviii, 28, 26-30
insecticide-treated nets, use by children 143
low birth weight 140
MDG 4: child health 18
overweight 140
stunted growth 140,138-9
underweight 140
vitamin A supplements 143
see also mortality
chloroquine 52, 114, 53
cholera 55
chronic disease 4
communicable diseases, years of life lost (YLL) 135
Comoros
per capita government expenditure, health 124
condom use, young people (1 5-24 years) 141
conflict
prevention and management 95-6
reproductive health 22
Congo
food hygiene, schoolchildren 99
food safety 99
health-care worker emigration 119
Healthy Cities project 90
healthy food markets 99
per capita government expenditure, health 124
recent war deaths 93
sexual violence 93
STEPS survey, noncommunicable diseases 77, 78
tuberculosis prevalence 48
contraceptives
condom use, young people (15-24 years) 141
prevalence 142
Cote d'lvoire
blood supplies, safety 115-17
emergency recovery support, WHO 94
health-care worker emigration 119
per capita government expenditure, health 124
UNAIDS study 48
n
data reliability 112-13
DDT 87-8
Democratic Republic of the Congo (DRC)
emergency recovery support, WHO 94
famine 96
demographic and health surveys (DHS) 1 1 0
diabetes mellitus, type-2 66
diarrhoea
children (under 5 years)
mortality 135
oral rehydration therapy (ORT) 143
diets, healthy 78,74-5
diphtheria toxoid, tetanus toxoid and pertussis vaccine (DPT3) 29
Directly-Observed Treatment Short-course (DOTS), tuberculosis strategy 49
disease control
cardiovascular diseases 65, 76
chronic diseases 4
epidemic diseases 93, 55-6
genetic diseases 71-2
infectious diseases 38-43
neglected diseases 56
noncommunicable diseases 63-79
oral diseases 72-3
sickle-cell disease 71-2
disease mortality rates 8
domestic waste 89
donor funding 123
drowning 67
Drugs for Neglected Diseases initiative (2003) 56
dysentery 55
Ebol
Ebola virus 39
economic development
and health investment 8, 7, 6-7
and HIV/AIDS 7
and infectious diseases 37-8
emergency situations 92-4
environmental health risks 85-6
epidemic diseases 93, 55-6
epilepsy patient integration 75
Equatorial Guinea
per capita government expenditure, health 124
poverty targets 6
Eritrea
emergency recovery support, WHO 94
famine 96
health information system 110
malaria, effectiveness of insecticide-treated nets, 52
per capita government expenditure, health 124
STEPS survey, noncommunicable diseases 77, 78
Ethiopia
emergency recovery support, WHO 94
essential medicines, pricing survey 113-14
famine 96
first-line HIV/AIDS treatment 47
Healthy Cities project 90
malaria treatment 53
mental health policies 72
per capita government expenditure, health 124
tuberculosis drug quality 114
tuberculosis prevalence 48
Expanded Programme on Immunization (EPI) 29
1 64 The African Regional Health Report
'5~
ferr
imily planning 26
female genital mutilation 19,24
fertility rates 26. 132
adolescent 132
food safety 90-1.98-9
food standards legislation 78. 74-5
of Eight) Summit 2005 lO.xvii
health-care review 109
health-care worker emigration 7 19
malaria drug quality 114
per capita government expenditure, health 124
Gaborone Declaration 122
Gambia
health-care worker emigration / 19
health information system 110
per capita government expenditure, health 124
genetic diseases 71-2
Ghana
essential medicines, pricing survey 113-14
food safety 91
food safety monitoring 99
healthcare, sector-wide approach (SWAP) 109
health-care staffing crisis 117
health-care worker emigration 7 19
health insurance scheme 106
malaria
drug quality 114
heath care costs 123
mental health legislation 74
per capita government expenditure, health 124
poverty targets 6
sanitation improvements 98
traditional health practitioners, registration 74
tuberculosis drug quality 114
glaucoma 69
Global Alliance for Vaccines and Immunization (GAVI) 27-30
Global Buruli Ulcer Initiative 56
Global Elimination of Trachoma by 2020 (GET 2020) 69-70
Global Environment Monitoring System/Food Contamination Monitoring
and Assessment Programme (GEMS/FOOD) 99
Global Fund to Fight AIDS, Tuberculosis and Malaria 46
global partnership for development, MDG 8 10
Global Polio Eradication Initiative (1988) 43
Global Salm-Surv workshops 98
Global Strategy on Diet, Physical Activity and Health 75
Global Strategy on Infant and Young Child Feeding (GSIYCF) 27
Global Youth Tobacco Survey 66
gross domestic product 3-4
Guinea
cervical screening 77
per capita government expenditure, health 124
Guinea-Bissau
food safety monitoring 99
per capita government expenditure, health 124
guinea-worm disease 41,57.40
u
Haemophii
<lus influenzae type B vaccine 29
haemorrhagic fevers 39
hazard analysis critical control point (HACCP) 99. 100. 91
health care
community involvement 727, 30-1
costs 3. 105
data reliability 112-13
health systems
future 125-6
weak 23, 105
health workers
community health workers 145
dentists 144
emigration 119
health management and support workers 145
lab technicians 145
midwives 144
nurses 144
pharmacists 145
physicians 144
public and environmental health workers 145
and HIV/AIDS 107
household surveys 7 10
isolated communities 108
national systems 105-26
definition 706
political awareness 77
public vs private 106-7
scaling up 107
sector-wide approach (SWAP) 1 09-1 0
staffing 12
vertical programmes 107-9
vital registration 111
health expenditure statistics 146-7
health information systems 110
health insurance schemes 106
Health Metrics Network (HMN) 1 1 1
health practitioners, traditional 75-6
health system finances 5, 121-5
donor funding 123
expenditure statistics 146-8
external funding 121-3
investment and economic development 7. 6-7
private expenditure 147
resource allocation 124-5
social security expenditure 147
user fees 124
WHO CHOICE 124-5
healthy life expectancy (HALE) 134
hepatitis B
blood supplies, safety 115-17
and liver cancer 67
vaccine 29
hepatitis C
blood supplies, safety 115-17
and liver cancer 67
hepatitis E 55
HIV/AIDS 7, 23, 38, xviii, 44-fl
antiretroviral (ARV) medicines 45, 46-7
Accelerated Access Initiative (2000) 47
pricing 47,46-7
Association for the Support of HIV Positive People (ANSS) 46
blood supplies, safety 115-17
childhood deaths 48
The health of the people • • • Index 1 65
1
and health system resources 107
incidence, WHO regions 58
life expectancy reversal xix
Massive Effort Campaign, South Africa 50
MDG 6: HIV/AIDS, malaria and other diseases 38, 58
mortality, children (under 5 years) 135
mortality rates 135
mother-to-child transmission 25, 48
Pneumocystis jiroveci pneumonia 47-8
prevalence 136-7,44-5
in young people 45
psychosocial support for HIV-positive mothers 25
Regional Knowledge Hubs 47
simplified AIDS care 722
"3 by 5" initiative 45, 107
and tuberculosis 50,48-9
human papillomavirus (HPV) 67
human resources 117-21
see also health workers
hypertension 65
immunization 27-30
coverage 29, 142
income, daily 5
industrial waste 87-9
infectious diseases
"big three" 38
disease control strategies 38-43
and economic development 37-8
insect vectors 39, 42
injuries
age-standardized mortality rate 135
fatal 67-8
mortality, children (under 5 years) 135
years of life lost (YLL) 135
insect vectors, infectious diseases 39, 42
insecticide-treated nets
effectiveness 52,51-2
use by children (under 5) 143
Integrated Disease Surveillance and Response (IDSR) 55
Integrated Management of Adult and Adolescent Illness (IMAI) 47
Integrated Management of Childhood Illness (IMCI) 17, 26-7
Intermediate Technology Development Group (ITDG) 88
international drinking water decades 86
iron deficiency 65
isoniazid 114, 50
Kenya
^essential medicines, pricing survey 113-14
food safety monitoring 99
health-care worker emigration 779
health data inventories 113
health insurance scheme 106
Healthy Cities project 90
indoor air pollution prevention 88
malaria, effectiveness of insecticide-treated nets, 52
per capita government expenditure, health 124
road traffic accident prevention 67-8
Safe Motherhood Initiative 17,24
tuberculosis prevalence 48
landmine victims, rehabilitation 68
Lassa fever 55
leprosy 57,40,41-2
Regional Strategy for Leprosy Control 41-2
leptospirosis 55
Lesotho
health-care staffing crisis 117
per capita government expenditure, health 124
tuberculosis prevalence 48
under-five mortality 20
Liberia
emergency recovery support, WHO 94
famine 96
per capita government expenditure, health 724
post-conflict mental health 92
sexual violence 93
life expectancy
at birth 134
healthy life expectancy (HALE) 134
HIV/AIDS reversal xix
male vs female 4
life table see life expectancy, at birth
lifestyle
change 78, 74-5
nutritional taboos 19
obesity and undernutrition 76, 65-6
literacy rates 133
locust crop damage 94
lymphatic filariasis 39
Madagascar
health-care worker emigration 779
per capita government expenditure, health 724
Making Pregnancy Safer (MRS), WHO initiative (1999) 24, 32
malaria 7, 38, 51-5
Abuja Declaration 51
antimalarial treatment, children under 5 years 143
Artemisia annua 11
drug policy change 54
drug quality 114
drug resistance 52-3
heath-care costs 123
insecticide spraying 52
insecticide-treated nets
effectiveness 52, 51-2
use by children (under 5) 143
Massive Effort Campaign, South Africa 50
MDG 6: HIV/AIDS, malaria and other diseases 38, 58
medication costs 54, 55, 57, 53
mortality, children (under 5 years) 135
prevalence 51
Malawi
health-care staffing crisis 117, 118
health-care worker emigration 779
per capita government expenditure, health 724
schistosomiasis control 39, 97
tuberculosis prevalence 48
under-five mortality 20
Mali
essential medicines, pricing survey 113-14
1 66 The African Regional Health Report
financing perinatal care 32
first-line HIV/AIDS treatment 47
health-care worker emigration 7 19
HIV prevalence 45
locust crop damage 94
malaria drug quality 114
maternal and newborn health 30
mental health policies 72
per capita government expenditure, health 124
Marburg haemorrhagic fever 39, 94
mass population displacement 93-4
maternity
adolescent mothers 22
maternal and newborn health 30. 31
MDG 5: maternal health 19
mortality 27, 18. 79,17-19,21-2
Mauritania
financing perinatal care 32
first-line HIV/AIDS treatment 47
health care
review 109
locust crop damage 94
per capita government expenditure, health 124
Mauritius
diabetes mellitus, type-2 66
healthy lifestyles 74
maternal and newborn health 30, 31
per capita government expenditure, health 124
reproductive health indicators 1 1
measles
immunization 139,29-30
mortality, children (under 5 years) 135
medical resources 54, 55, 57, 53, 76-7
medicines, essential
improving access 113-14
national policies 113
pricing 113-14
Medicines Strategy 113-14
meningitis 55
mental health 72, 70-1
legislation 74-6
Millennium Development Goals (MDG) 5, 10
MDG 1: poverty 6,85-6
MDG 4: child health 18
MDG 5: maternal health 19
MDG 6: HIV/AIDS, malaria and other diseases 38, 58
MDG 7: water and sanitation 98
MDG 8: global partnership for development 10
mortality
[causes, rates and probabilities are included below]
under 1 year 134
under 5 years 134,135,138
15-60 years (adult mortality rate) 134
age-standardized
cancer 135
cardiovascular diseases 135
injuries 135
noncommunicable diseases 135
causes, age related 69
cause-specific
HIV/AIDS 135
tuberculosis, HIV negative 135
tuberculosis, HIV positive 135
childhood 26, 48, 134, 135
data collection 777
infant 134
maternal 78,79,134,17-19,21-2
neonatal 79,134,135,19-20
rates 8
under-5 years 20, 26, 18, 21, 134, 17-18
Mozambique
emergency recovery support, WHO 94
food hygiene, schoolchildren 99
healthcare, sector-wide approach (SWAP) 109
Healthy Cities project 90
healthy food markets 99
malaria drug quality 114
per capita government expenditure, health 124
tuberculosis prevalence 48
under-five mortality 20
Multi Indicator Cluster Systems (MICS) 110
mycotoxins 90-1
A?
JL fbt
mibia
blood supplies, safety 115-17
health-care staffing crisis 117
Healthy Cities project 90
per capita government expenditure, health 124
tuberculosis prevalence 48
under-five mortality 20
national income, gross per capita 133
neglected diseases 56
New Partnership for Africa's Development (NEPAD) 9, 122
Niger
emergency recovery support, WHO 94
health information system 110
Healthy Cities project 90
HIV prevalence 45
locust crop damage 94
per capita government expenditure, health 124
Nigeria
domestic waste 89
essential medicines, pricing survey 113-14
guinea-worm disease eradication 40
health-care worker emigration 7 79
health insurance scheme 106
healthy eating targets 75
leprosy eradication 40
per capita government expenditure, health 124
poverty targets 6
tuberculosis prevalence 48
noma 72-3
noncommunicable diseases 63-79
age-standardized mortality rate 135
emergence 64, 63-5
mortality 135
risk factors 64
spectrum 64
STEPS surveys 77, 78
vs communicable 5
years of life lost (YLL) 135
see also specific diseases
nutritional taboos 19
The health of the people • • • Index 1 67
obesity 76, 65-6
adults (over 15 years) 140
vs undernutrition 65-6
onchocerciasis 57, 69, 42-3
African Programme Onchocerciasis Control (1995) 42
Onchocerciasis Control Programme (1974) 42
oral diseases 72-3
oral rehydration therapy (ORT), diarrhoea 143
Organization for African Unity 9
participatory hygiene and sanitation transformation (PHAST) 86, 100, 96-7
Partnership for Safe Motherhood and Newborn Health (2005) 24
per capita government expenditure, health 124
pesticides 90
plague 55
pneumonia
mortality, children (under 5 years) 135
Pneumocystis jiroveci 47-8
poliomyelitis (polio) 41, 43, 57, 94
confirmed cases 136-7
Global Polio Eradication Initiative (1988) 43
Regional Polio Laboratory Network 43
pollution 87-9
chemical 87-9
indoor air pollution 87, 87
polychlorinated biphenyls 89
populations 132
post-conflict mental health 92
poverty
and ill-health xviii, 3-4
MDG 1 : poverty ft 85-6
population below line 133
reduction 94-5
Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme (2002) 25
primary school enrolment 133
ProTEST Initiative 50
purchasing power, by region 5
rape 22, 44, 93
Regional Polio Laboratory Network 43
Regional Strategy for Leprosy Control 41-2
Repositioning Family Planning framework (2004) 26
Republic of the Congo see Congo
Reseau Burundais des Personnes vivant avec le VIH/SIDA 46
rifampicin 114
Right to Sight 70
river blindness (onchocerciasis) 57, 42-3
road traffic deaths 67-8
Rwanda
blood supplies, safety 115-17
health data inventories 113
health financing, external 121-3
per capita government expenditure, health 124
road traffic accident prevention 70, 67-8
tuberculosis drug quality 114
afe Motherhood Initiative 17,24
Salmonella 98, 90-1
salt intake 75
sanitation 86-7
improvement 86
Sao Tome and Principe
health-care worker emigration 1 19
per capita government expenditure, health 124
schistosomiasis 39, 97
Bilharzia Control Programme, Malawi 97
Senegal
first-line HIV/AIDS treatment 47
health-care staffing crisis 117
locust crop damage 94
per capita government expenditure, health 124
sanitation improvements 98
tuberculosis drug quality 114
sexual violence 22, 44, 93
Seychelles
diabetes mellitus, type-2 66
maternal and newborn health 30
per capita government expenditure, health 124
sickle-cell disease 71-2
Sierra Leone
per capita government expenditure, health 124
post-conflict mental health 92
poverty targets 6
tuberculosis prevalence 48
sleeping sickness 56
smallpox 57
smoking 66, 72-3
Society for Women Against AIDS in Africa, Burundi 46
solid fuel use 141
South Africa
blood supplies, safety 115-17
causes of death SB
District Health Barometer 112
essential medicines, pricing survey 113-14
health care, isolated communities 108
health-care staffing crisis 117
health data inventories 113
health insurance scheme 106
Healthy Cities project 90
HIV prevalence 45
HIV/AIDS 23
infant and maternal mortality 17
Massive Effort Campaign 50
mental health policies 72
per capita government expenditure, health 124
ProTEST Initiative 50
Tobacco Products Control Act 73
tuberculosis prevalence 48
tuberculosis/HIV co-infection 50
soya bean oil 74
sub-Saharan Africa
blindness increase 69
economic growth 5.6
HIV/AIDS 58
malaria 38
maternal mortality 19
water source improvement 98
see also specific countries
sugar intake 75
sulfadoxine-pyrimethamine 114, 53, 52-4
1 68 The African Regional Health Report
sustainable solutions, water and sanitation 96-7
Swaziland
blood supplies, safety 115-17
per capita government expenditure, health 124
tuberculosis prevalence 48
syphilis
blood supplies, safety 115-17
Tanzania see United Republic of Tanzania
.il"3 by 5" initiative 45
tobacco
marketing controls 73, 78
use 66, 72, 141
Togo
blood supplies, safety 115-17
epilepsy patient integration 75
Healthy Cities project 90
per capita government expenditure, health 124
trachoma 69-70
trimethoprim-sulfamethoxazole 48
tuberculosis 38, 48-51
BCG vaccination 50
case detection 38. 143
diagnosis 49
DOTS strategy 49,108,143
drug quality 114
HIV co-infection 50,48-9
incidence, WHO regions 58, 136
Massive Effort Campaign, South Africa 50
multidrug-resistant strains 50
prevalence 136
ProTEST Initiative 50
Uganda
essential medicines, pricing survey 113-14
health care, sector-wide approach (SWAP) 109
health-care staffing crisis 117, 120
health data inventories 113
mass population displacement 94
maternal and newborn health 30
per capita government expenditure, health 124
poverty targets 6
road traffic accidents 68
simplified AIDS care 122
tuberculosis drug quality 114
tuberculosis prevalence 48
young smokers 66
UN International Conference on Population and Development (1994) 24
UN Millennium Development Goals see Millennium Development Goals
(MDGs)
undernutrition 65-6
United Kingdom's Commission for Africa 9, 123
United Republic of Tanzania
Artemisia annua farming 11,54,114, 115
cervical screening 77
diabetes 76
essential medicines, pricing survey 113-14
food safety monitoring 99
health care
review 109
sector-wide approach (SWAP) 109
health-care worker emigration 120, 779
health information system 110
health system costs 105
healthy food markets 99
per capita government expenditure, health 124
stroke rate 65
Tanzania Essential Health Interventions Project (TEHIP) 1 1 , 28
tuberculosis drug quality 114
tuberculosis prevalence 48
urbanization 89-90
vaccination 27-9
coverage 29, 142
DPT3 29
Haemophilus influenzas type B 29
hepatitis B 29
measles 29
yellow fever 29
vertical programmes, health-care systems 107-9
violence 67-8
visceral leishmaniasis 56
VISION 2020 70
vital registration 1 1 1
vitamin A deficiency 29, 65
and civil conflict
Bte
domestic 89
industrial 87-9
see also pollution
water and sanitation 86-7
access to improved sanitation 141
access to improved water sources 141
Africa 2000 initiative 86
international drinking water decades 86
MDG 7: water and sanitation 98
participatory hygiene and sanitation transformation (PHAST) 86
sustainable solutions 96-7
'Western diseases' see noncommunicable diseases
WHO
African Region
introduction xvii-xix
member states xix, 130
Choosing Interventions that are Cost Effective (WHO CHOICE) 124-5
Commission on Macroeconomics and Health 5, 122
see also Global initiatives
World Health Day 2005 17
World health report 2001: Mental health: new understanding, new hope 65
World health report 2003: Shaping the future 79
World health report 2005: Make every mother and child count 17,78
World health report 2006: Working together for health 1 1 7
World health statistics 2006 131
World Trade Organization xvii
_j
ars of life lost (YLL)
communicable diseases 135
injuries 135
The health of the people • • • Index 1 69
noncommunicable diseases 135
yellow fever 55
vaccine 29
Zambi;
Gambia
first-line HIV/AIDS treatment 47
healthcare, sector-wide approach (SWAP) 109
health care worker e migration 1 19
per capita government expenditure, health 124
Zimbabwe
antenatal service 23
blood supplies, safety 115-17
essential medicines, pricing survey 113-14
health-care staffing crisis 117
Healthy Cities project 90
HIV/AIDS 23, 25
malaria drug quality 114
per capita government expenditure, health 124
prevalence 45
1 70 The African Regional Health Report
This is the first report to focus on the health of the
) 738 million people living in the African Region of the
\ World Health Organization. The Health of the People
L comes at a crucial time for Africa, when the continent
has come into sharp focus.
This report highlights the fact that millions
of Africans are dying due to preventable and
jr treatable diseases. It provides vital reading for
those who want to understand this situation better
• and what can be done.
\ Why — in this age of rapid communica-
tions and other scientific advances — is it so
difficult to deliver basic health care to people
in Africa? Why has HIV/AIDS spread faster and
killed more of the population in Africa than in other parts of
the world? Why does malaria still kill so many people when
treatment for this disease exists?
This report provides some answers and highlights the public health achievements that
have been made in the African Region to date. The message is clear: the solutions to Africa's
health problems are within our grasp.
These solutions can only be achieved by strengthening governments' stewardship role
in health and building on the lessons learnt from successful health-care interventions, and
through closer collaboration between all partners.
ISBN 92 9023 103 3
9" 789290 "231035
Live Music Archive
Librivox Free Audio
Metropolitan Museum
Cleveland Museum of Art
Internet Arcade
Console Living Room
Books to Borrow
Open Library
TV News
Understanding 9/11