REPORT ON THE REVIEW OF PRIMARY HEALTH CARE IN THE … · 2019-08-05 · report on the review of primary health care in the african region report on the review of primary health care

R E P O R T O N T H E R E V I E W O F P R I M A R Y H E A LT H C A R E I N T H E A F R I C A N R E G I O N

PB

REPORT ON THE

REVIEW OF PRIMARY HEALTH CARE

IN THE AFRICAN REGION

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AFRO Library Cataloguing-in-Publication DataReport on the Review of Primary Health Care in the African Region1. PrimaryHealthCare2. QualityAssurance,HealthCare3. RegionalHealthPlanning4. TechnicalReport[PublicationType]5. Africa

ISBN: : 92 9 023 126 2 (NLM Classification: W 84.6 )

©WHORegionalOfficeforAfrica,2008

Publicationsof theWorldHealthOrganizationenjoycopyrightprotectioninaccordancewiththeprovisionsof Protocol2of theUniversalCopyrightConvention.Allrightsreserved.Copiesof thispublicationmaybeobtained fromthePublicationandLanguageServicesUnit,WHORegionalOffice forAfrica,P.O.Box6,Brazzaville,Republicof Congo (Tel: +4724139100; Fax: +4724139507;E-mail:[email protected]).Requestsforpermissiontoreproduceortranslatethispublication–whetherforsaleorfornon-commercialdistribution–shouldbesenttothesameaddress.

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All reasonable precautions have been taken by the World Health Organization to verify theinformation contained in this publication. However, the published material is being distributedwithoutwarrantyof anykind,eitherexpressorimplied.Theresponsibilityfortheinterpretationanduseof themateriallieswiththereader.InnoeventshalltheWorldHealthOrganizationoritsRegionalOfficeforAfricabeliablefordamagesarisingfromitsuse.

PrintedintheRepublicof Mauritius

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Table of Contents

ACRONYMS iv

EXECUTIVESUMMARY 1

CHAPTER1: INTRODUCTION 5

CHAPTER2:METHODOLOGY 7 2.1 MAINOBJECTIVE: 7 2.2 MAINISSUESTOBEREVIEWED 7 2.3 PROCESS 8

CHAPTER3: ECONOMIC,SOCIALANDPOLITICAL ENVIRONMENTSINCEALMAATA 9 3.1 ECONOMICENVIRONMENT 9 3.2 SOCIO-POLITICALENVIRONMENT 13

CHAPTER4: PHCANDNATIONALHEALTHPOLICYFORMULATION 19

CHAPTER5:PHCSTRATEGYIMPLEMENTATION 23

CHAPTER6:PHCRESOURCES 37 6.1: HEALTHINFRASTRUCTURE 37 6.2 HUMANRESOURCES 39 6.3 FINANCIALRESOURCES 42

CHAPTER7:PHCMONITORINGANDEVALUATION 45

CHAPTER8: HEALTHTRENDSANDCHALLENGES 47

8.1 DISEASE-SPECIFICMORBIDITYANDMORTALITY 47 8.2 HEALTHSTATUSINDICATORS 56 8.3 CONSTRAINTSANDOPPORTUNITIES 61

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CHAPTER9: CONCLUSION 65

CHAPTER10:RECOMMENDATIONS 69

ANNEX1: PHCREVIEW:COUNTRYFRAMEWORK 71

REFERENCES 86

List of Tables

TABLE1: GROWTHOFOUTPUT(1980-1999)– SELECTEDAFRICANCOUNTRIES 11

TABLE2: SELECTEDSOCIALINDICATORSINSELECTEDCOUNTRIES 14

TABLE3: POPULATIONGROWTHINCOUNTRIES OFTHEAFRICANREGION,1980-1999 17

TABLE4: EVOLUTIONOFDOCTOR/POPULATIONRATIOS INFIVEAFRICANCOUNTRIESFROM1970TO2003 40

TABLE5: HEALTHPERSONNEL/POPULATIONRATIOS INTHEPUBLICSECTORINBANGUICOMPARED TOTHERESTOFTHECOUNTRY 41

TABLE6: DISTRIBUTIONOFHEALTHWORKERS BYGENDERANDBYZONEINNIGER 41

TABLE7: HEALTHEXPENDITUREINTHEAFRICANREGION,2000 43

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List of Figures

FIGURE1: GDPAVERAGEGROWTHRATES,1980-99(SELECTEDAFRICAN COUNTRIES) 10

FIGURE2: AFRICA’STOTALDEBT($BILLION)1977-1998 12

FIGURE3: GLOBALREFUGEESSTATISTICS,2000ESTIMATEDNUMBEROF PERSONSOFCONCERN,BYREGION 16

FIGURE4: HIERARCHICALHEALTHCARESYSTEM 24

FIGURE5: WATERSUPPLYCOVERAGEINAFRICA,2000 31

FIGURE6: SANITATIONCOVERAGEINAFRICA,1990AND2000 32

FIGURE7: IMMUNIZATIONCOVERAGEWITHEPIVACCINES INTHEAFRICANREGION,1998-2001 33

FIGURE8: MOHRECURRENTHEALTHEXPENDITUREBYLEVEL OFCAREINTHEPUBLICHEALTHSECTOR:1997/98 38

FIGURE9: ALLOCATIONOFEXPENDITUREBYLEVELOFCARE: HOSPITALANDNON-HOSPITALCARE,1997/98. 38

FIGURE10: TRENDINTHEPOPULATIONTOHEALTH PERSONNELRATIOS1979-1999INBURKINAFASO 40

FIGURE11: DISTRIBUTIONOFENDEMICMALARIA 48

FIGURE12: CUMULATIVEREPORTEDAIDSCASES–SUB-SAHARAN AFRICA,1982-2000 49

FIGURE13: ADULTHIV/AIDSPREVALENCERATES2001 INSELECTEDCOUNTRIES 50

FIGURE14: ADULTHIVPREVALENCEINSELECTED COUNTRIES,1997&1999 51

FIGURE15: REPORTEDTBCASESINAFRICA,1980-2001 52

FIGURE16: PROGRESSTOWARDSPOLIOMYELITIS ERADICATION,1988–END2000 54

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FIGURE17: GUINEAWORMCASETREND INTHEAFRICANREGION,1991-2000 54

FIGURE18: INFANTMORTALITYRATES(PER1,000LIVEBIRTHS), 1970AND2000-SELECTEDAFRICANCOUNTRIES 57

FIGURE19: UNDER-FIVEMORTALITYRATES(PER1,000LIVEBIRTHS), 1970AND2000-SELECTEDAFRICANCOUNTRIES 58

FIGURE20: TRENDSINALL-CAUSE,UNDER-FIVEMORTALITYINAFRICA 59

FIGURE21: MATERNALMORTALITYRATIOSREPORTED (PER100,000LIVEBIRTHS)FOR2001 59

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Acronyms

AFRO WHORegionalOfficeforAfrica

AMREF AfricanMedicalandResearchFoundation

CBHC CommunityBasedHealthCare

CBOs CommunityBasedOrganizations

CDD Controlof DiarrhoeaDiseases

CEDHA CentreforEducationalDevelopmentinHealthArusha

CHWs CommunityHealthWorkers

DHMBs DistrictHealthManagementBoards

DHMTs DistrictHealthManagementTeams

DMO DistrictMedicalOfficer

DPT Diptheria,PertussisandTetanus

FCFA CentralAfricanFrenchFrancs

FGM FemaleGenitalMutilation

FHI FamilyHealthinternational

FP FamilyPlanning

HCMTs HealthCentreManagementTeams

HIPCs HeavilyIndebtedPoorCountries

IDPs InternallyDisplacedPeople

IMCI IntegratedManagementof ChildhoodIllness

IRC InternationalRedCross

LGAs LocalGovernmentAreas

NIDs NationalImmunizationDays

PHMTs ProvincialHealthManagementTeams

RDC RuralDevelopmentCommittee

RHMTs RegionalHealthManagementTeams

UNAIDS JointUnitedNationsProgrammeonHIV/AIDS

VHCs VillageHealthCommittees

VHWs VillageHealthWorkers

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EXECUTIVE SUMMARY

With theadoptionof theAlma-AtaDeclaration in1978,which identifiedPrimaryHealthCare(PHC) as the strategy for health for all, countries embarked on implementing PHC in the lasttwo decades. Since then, there has been considerable diversity in country experiences in PHCimplementation.Dissatisfiedwithprogress,andwithpressurefrominternationalinstitutions,mostcountries embarked on implementing health sector reforms such as decentralization in order toprovideanenablingenvironmentforPHCimplementation.Whileusefullessonscanbedrawnfromcountryexperiences,itisevidentthatnoneof thecountrieshasfullyachievedhealthforall.

Recognizing that major interventions are needed in the 21st century to refocus on PHC, theWorldHealthOrganization(WHO)hasidentifiedtheneedtocarryoutaglobalreviewgiventheinstitutional,socio-economic,andotherchangesthathaveoccurredsincetheAlmaAtaDeclaration.EachWHORegionwouldundertakeareviewthatwouldbeusedtocontributetotheglobalreport.Thepurposeof thereviewwouldbetoexaminetheimplementationof primaryhealthcareandidentifystrategicinterventionsneededtocopewiththenewchallengesfacingthehealthsystems,asacontributiontodevelopinganagendaforstrengtheningPHCinthe21stcentury.Inparticular,thereviewwouldaddressthefollowing:

i. PHCpolicyformulation:HowwasthePHCpolicyformulated?

ii. PHCpolicyimplementation:HowhavethePHCpoliciesbeenimplemented?

iii. PHCresources:WhatresourcesareavailableforPHCimplementation?

iv. PHCmonitoringandreview:HowarethePHCpolicyandstrategiesbeingmonitoredandreviewed?

v. Healthtrends:Whatarethehealthtrendsincountriesof theWHOAfricanRegion?

vi. Whatisthewayforward?

ThePrimaryHealthCarereviewprocess, intheAfricanRegion,startedwithatwo-daymeeting(3-4July2001,Harare,Zimbabwe)whoseobjectivewastodeterminetheprocessandcontentof thecontributionof theAfricanRegiontotheglobalreviewof thePHCPolicy.TheparticipantsthatsupportedthereviewintheRegionincludedofficialsfromWHO/HQandfromallthetechnicaldivisionsof AFROaswellasrepresentativesof thethreeresourceinstitutions,namelyCentreforEducational Development in Health, Arusha (CEDHA), Iringa PHC Institute, Iringa (IPHCI),both in Tanzania and Institut de Santé et Développement (ISED), Dakar, Senegal). SpecificallythemeetingproposedaprocessforPHCimplementationreviewandidentifiedfiverelevantreviewareas in the African Region. These were Health Trends, PHC Policy Formulation, PHC PolicyImplementation,PHCMonitoringandReview,andPHCResources.

Itwasagreedthatallthe46countriesof theRegionwouldbeinvolvedinthereviewtoassurepoliticalownership.TheDivisionof HealthSystemsandServicesDevelopment (DSD)of WHOAfricanRegionalOffice,collaboratingwiththethreeresourceinstitutions,workedoutaguidelineforthe

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countryreviewof PHC.ThecountrieswererequestedtoidentifyanexpertwhowouldworkcloselywiththeMinistryof Healthtoundertakethereviewandproduceacountryreport.Meanwhiletheresourceinstitutionsundertookathoroughdesktopreviewoncountriesandexaminedinputsfromthecountryreports.FinancialsupporttotheinstitutionsandthecountriesfortheassignmentwasprovidedbyWHO.CEDHAandPHCI-IringaconductedthereviewinEnglish-speakingcountries,while ISED covered the French-speaking countries. The review relied on documented literaturefromvariouscountriesandavailableliteraturefromonlinelibrariesof theWHO,UNICEF,WorldBank and universities, among others. The final report is based on the reports produced by theresourceinstitutions,reviewof otherreportsavailableinAFROandotherUNorganizations,aswellasseventeenindividualcountryreportsonPHCpolicyreview.Usingtheinformation,AFROthenundertookthefinalreviewandsynthesisof thereport.

The review found thatPHCpolicy formulationhadbeenwell articulated in thenationalhealthpoliciesbymostcountries.Fiveprinciplesandtheeightelementsof PHCwereaddressed,althoughthe extent to which PHC policies encompassed equity, community participation, inter-sectoralcollaborationandaffordabilityisstillquestionable.AlthoughallcountriessaythattheyarecommittedtoPHC implementation, theprocess has laggedbehind due to a combinationof factors. Theseinclude weak structures, inadequate attention to PHC principles, inadequate resource allocationand,inmostcases,inadequatepoliticalwill.Periodicmonitoringandevaluationof PHCactivitiesinmostcountriesiseitherlackingordoneirregularlyand,asaresult,mostcountryPHCpolicieshavenoallowanceforfeedbackmechanisms.

Some health trends that showed initial improvements over time have regressed. The pace of improvementhasbeenslow,as shownby infantandchildmortalityrates.Therehasalsobeenaregressionasshownbythehighmaternalmortalityratesanddeclininglifeexpectancyatbirthinsomecountries.ThisisassociatedwithfallingGDPpercapitaovertheyears,coupledbythehighdebtburden,decliningproductionanddeterioratingtermsof trade.Financialresourcesallocatedtohealthand,especially, toPHChavedeclined.Inaddition, thesocialsituationhasdeterioratedduetotherisingnumberof conflictsandtheresultantdisplacementof peopleaswellasseverefoodshortagesresultinginnegativehealthimpactonthecommunities,suchasincreasedmalnutrition,particularlyamongthechildren.Furthermore,thepopulationhasbeengrowingdisproportionatelytotheprovisionof basicsocialservices.

Thekeyrecommendationsof thereviewhighlightthat1. Thereisneedto lookintowaysof harmonisingthehealthsectorreformswiththePHCin

ordertoensurethattheinitiativespromotebothequityandqualityof healthservices.

2. Foracommonunderstandingof theRegionalHealthPolicy,itwouldbeappropriatetobringallthecountriesintheRegiontogetherforbriefingontheorientationsandstrategiesof Agenda2020orotherregionalstrategiesbeforeembarkingondevelopmentof countrypoliciesandstrategicplans.

3. TheRegionalHealthPolicyshouldbediscussedatthehighestlevelof theStateandsharedwidelywithallnationalandinternationalpartnersinthehealthsectorinthecountry.

4. There isneed topromotemore inter-sectoral collaborationamong,andcoordinationwith,

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thediversestakeholdersinvolvedinPHCimplementation,especiallyatthedistrictlevelwherePHCimplementationisbeingadvocated.Forattainmentof betterinter-sectoralcollaboration,thenecessaryinteractionsof thehealthsystemwithothersystemsshouldbebetterandproperlydefined and appropriate mechanisms for inter-sectoral collaboration clearly designed on acountry-by-countrybasis.

5. Future efforts should be made to address challenges such as effective involvement of thecommunity in health planning and decision-making through the establishment of effectivelinkages,likeboardsandcommittees,betweenhealthfacilitiesandcommunitystructures.Inaddition,this involvementneedstobestrengthenedinareassuchasproblemidentification,prioritysetting,datacollectionandanalysis,evaluation,andplanning.

6. Financing policies and strategies should aim at improving equity and fairness in order toimproveservicecoverageforthepoor.

7. ResourceallocationstoPHCshouldbereviewedandwaysof sustainablefinancingof PHCshould be sought. In addition, greater efforts should be made in the countries to increaseefficiencyintheutilizationof themeagreresourcesavailable.

8. Countriesshouldbesupportedtoaddresstheirparticularhumanresourceneedsthroughcleararticulationof humanresourcespolicyandplans,developmentandstrengtheningof nationalmanagementsystemsandemploymentpolicies.

9. Thereisurgentneedtosupportcountriestoidentifyandputinplacemechanismsforattractingandretaininghealthpersonnel.

10. Intervention at inter-country level or even at the level of theAfrican Union is required toaddressthebraindrainproblem.

11. Thereisneedtoreformhealthscienceseducationandreorienthealthworkerseducationandpracticetoincorporateemergingtrendsandequipmajorstakeholderswithskillsinplanning,financialandpersonnelmanagement,whichisimportantinpromotingPHCandcommunityhome-basedcare.

12. WHOshouldfacilitatethedevelopmentandadoptionof guidelinesandmethodsonPrimaryHealthCaremonitoringandevaluationforusebythecountries.Thisshouldbeintegratedintothemonitoringof progresstowardsachievingtheMillenniumDevelopmentGoals.

13. WHOshould strengthen its support tomember countries to institutionalizeon-goinggoodpracticesandeffectivemeasuresbeforeintroducingnewinitiatives.

14. WHOshouldsupportmembercountriesincapacitybuildingthatwillenhanceimplementationof healthprogrammesandactionsthroughPHCandwithintheframeworkof Healthfor-Allpolicyforthe21stcenturyintheAfricanRegion:Agenda2020.

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INTRODUCTION

ByintroducingthePrimaryHealthCare(PHC)strategy,theAlmaAtaDeclarationin1978provedtobe a turningpoint in thehistoryof health carepolicy.PHCwas definedas “essential healthcarebasedonpractical,scientificallysoundandsociallyacceptablemethodsandtechnology,madeuniversallyaccessibletoindividualsandfamiliesinthecommunitythroughtheirfullparticipationandatacostthatthecommunityandthecountrycanaffordtomaintainateverystageof developmentinthespiritof self-relianceandself determination”.PHCwasexpectedtoformanintegralpartof both thecountry’shealth system,of which it is thecentral functionandmain focus, and theoverallsocialandeconomicdevelopmentof thecommunity.Itwouldbethefirstlevelof contactof individuals,thefamilyandcommunitywiththenationalhealthsystem,bringinghealthcareascloseaspossibletowherepeopleworkandlive,andconstitutethefirstelementof acontinuinghealthcareprocess.PHCcompriseseightelements: (i)educationconcerningprevailinghealthproblemsand the methods of preventing and controlling them, (ii) promotion of food supply and propernutrition,(iii)adequatesupplyof safewaterandbasicsanitation,(iv)maternalandchildhealthcare,including familyplanning, (v) immunizationagainstmajor infectiousdiseases, (vi)preventionandcontrolof locallyendemicdiseases,(vii)appropriatetreatmentof commondiseasesandinjuries,and(viii)provisionof essentialdrugs.

TheideologyandprinciplesbehindPHCcloselymatchwhatwasandhassincebeenadvocatedinhumandevelopmentsuchassocialjustice,equity,humanrights,universalaccesstoservices,givingprioritytothemostvulnerableandunderprivileged,andcommunityinvolvement.AtAlmaAta,itwasrecognizedthatthepromotionandprotectionof thehealthof thepeopleisessentialtosustainedeconomic and social development and contributes to better quality of life and to world peace.Attainmentbyallpeoplesof theworldbytheyear2000of alevelof healththatwouldpermitthemtoleadasociallyandeconomicallyproductivelife(HealthforAll)wasidentifiedbytheThirtiethWorldHealthAssemblyin1977asamainsocialtargetof governments,internationalorganizationsandthecommunityand,itwasreaffirmedbytheInternationalConferenceonPrimaryHealthCareatAlmaAtain1978thatPHCwasthekeytoattainingthetarget.

SincetheAlmaAtaDeclaration,MemberStatescommitmentinthePHCprocesshasbeenevidencedinthedevelopmentof healthpolicydocumentsanddevelopmentplans.TheseprioritizedPHCasthemainstrategyforachievinghealthforall.Despitethiscommitmentand25yearson,notmuchhasbeenachieved.PHCinthe21stcenturyis,andwillcontinuetobe,challengedbycomplexscenariosintheRegion,suchasrapidurbanization;theemergenceandre-emergenceof bothcommunicableandnoncommunicablediseases,especiallythehighprevalenceratesof HIV/AIDS;andthedecliningnationaleconomicperformanceaccompaniedbyhighdebtburdenanddeterioratingtermsof trade.Moreover, the social situationhascontinued todeterioratewith increaseddisparities inaccess tobasic social services among theurbanand rural population. In addition, increased conflicts andexceptionalfoodcriseshaveresultedinalotof resourcesbeingdivertedtoaddressemergenciesandhenceexhausting the resourcesoriginallyearmarked forPHC. It isagainst thisbackground thatAFROcommissionedtheCentreforEducationalDevelopmentinHealth,Arusha(CEDHA)andIringaPrimaryHealthCareInstitute(IPHCI),Tanzania,toconductaregionalreviewinEnglish-

CHAPTER 1:

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speakingcountriesandtheInstitutdeSantéetDéveloppement(ISED),Senegal,toconductinFrench-speakingcountries.Theobjectivewastoidentifythestrengths,weaknesses,opportunitiesandthreatsinPHCimplementation.Further,theoutcomeof thereviewwouldbeusedtoguideWHOonthewayforwardinsupportingMemberStatesonPHCimplementationinthe21stcentury.

ThemainmotivatingfactorforreviewingPHCpolicyimplementationintheRegionwasthegreatconcernbyallstakeholdersandpartnersinvolvedinhealthsectordevelopmenttofindappropriatewaystostrengthenPHCimplementationinordertodealwithcurrentandanticipatedhealthandhealth-relatedchallenges.

Thepurposeof thereviewwastoexaminetheimplementationof primaryhealthcareandidentifystrategicinterventionsneededtocopewiththenewchallengesfacinghealthsystems,asacontributiontodevelopinganagendaforstrengtheningPHCinthe21stcentury.

Themainissuesaddressedbythereviewwere:

PHCpolicyformulation:HowwasthePHCpolicyformulated?

PHCpolicyimplementation:HowhavethePHCpoliciesbeenimplemented?

PHCresources:WhatresourcesareavailableforPHCimplementation?

PHCmonitoringandreview:HowarethePHCpolicyandstrategiesbeingmonitoredandreviewed?

Healthtrends:Whatarethehealthtrendsincountriesof theWHOAfricaRegion?

Whatisthewayforward?

Thereportpresentsthemethodologyusedforthereview,describestheeconomic,socialandpoliticalenvironment since Alma Ata, and provides the review findings on PHC policy formulation andimplementation,itsresources,monitoringandevaluation,aswellashealthtrends,challengesandconsequences.Itendswithconclusionsandrecommendationsforthefuture.

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METHODOLOGY

TakingtheopportunityofferedbytheglobalPHCpolicyreview,initiatedbytheDirectorGeneralof theWorldHealthOrganization,ameetingwasheldinHarareon4–5thJuly2001todefinetheRegion’scontribution.ParticipantsweredrawnfromallthetechnicaldivisionsinAFRO,WHO/HQ,andtheinstitutionsidentifiedtosupportthereviewprocess,namelyCEDHA,Tanzania,PHCI-Iringa,TanzaniaandISED,Senegal.Followingthismeetingtheinstitutions,workingtogetherwiththeteamatAFRO,discussedtheprocessforthePHCPolicyImplementationReviewintheAfricanRegionandagreedtoconductthereviewattwolevels,namelycountry-specificreviewsandaregionalreview. To ensure consensus on issues for review, a framework for PHC review in countries (seeAnnex1)wasprovided.Itdescribedtheprocessandprovidedguidelinesfortheinterviews,analysis,focusgroupdiscussionandgaveanoutlineof reports tobeproduced.Theseweredisseminatedtoallcountries.ThecountrieswerealsogivenanopportunitytoidentifyaconsultantthatwouldworkcloselywiththeWHOcountryofficeandauthoritiesintheMinistryof Healthtocarryoutthecountryreview,withfundingfromAFRO.Meanwhile,CEDHA,PHCI-IringaandISEDwerecontractedtocarryouttheregionalreview.Thisconsistedof adeskreview,basedonanalysisof availableregionaldocuments,country-specificreviewreportsand,wherenecessary,casestudiesof countrieswithbestpractices.BothCEDHAandPHCI-IringawerecontractedtocovertheEnglish-speakingcountriesandproduceareport.Similarly,ISEDwastocoverFrench-speakingcountriesandthecountrieshavingPortugueseasworkinglanguage.

�.� MAIN OBJECTIVE:

Thegeneralobjectiveforcarryingoutthereviewwastoexaminetheimplementationof primaryhealthcarepolicyimplementationandidentifystrategicinterventionsneededtocopewiththenewchallengesfacinghealthsystems,asacontributiontodevelopinganagendaforstrengtheningPHCinthe21stcentury.

�.� MAIN ISSUES TO BE REVIEWED

Fivebroadareaswereidentifiedforreview.Theseare:

1. PHC policy formulation:HowwasthePHCpolicyformulated?Whatwastheprocessof formulatingPHCpolicy,thecontentof thePHCpolicyetc..

2. PHC policy implementation:HowarethePHCpoliciesbeingimplemented?Aspectstoexamineincludeadvocacyandmarketing,actorsandpartners,structuresandprocessesetc..

CHAPTER 2:

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3. PHC resources: WhatresourcesareavailableforPHCimplementation,forexamplehumanandfinancialresources,aswellasPHCphysicalresourcesandstructures.

4. PHC monitoring and review:HowarePHCpolicyandstrategiesbeingmonitoredandreviewed?

5. Health trends:Whatarethetrendsof themainhealthandhealth-relatedchallenges?

�.� PROCESS

The process of reviewing PHC at the regional level was carried out at two levels, country andregional.

Atcountrylevel,seventeenof theforty-sixcountries1intheRegionreviewedtheirownexperiencesinPHC implementationand submitted reports for inclusion in the regional report.Data for thereviewwasalsoobtainedfromthefollowingsources:

Unstructuredinterviewswithinterviewees/informantsthathaveintimateknowledgeof PHCimplementation, such as policy makers, implementers at all levels, other sectors involved,WHOandotherpartners.

Discussions with a wider audience of people who have intimate knowledge of PHCimplementation.Theseincludedpolicymakersimplementers,NGOs,privatesector,health-relatedinstitutions,WHOandotherpartners

A desk analysis of available documents and reports specific to the country and extensiveanalysisof allavailablepublishedandunpublisheddocumentsandmaterials.

Atregionallevel,bothCEDHAandPHCI-IRINGAproducedareviewreportwhileISEDproducedonly an inception report. The departure of the Director of ISED from the institution caused abreakdown in the compilation and analysis of the review in the French-speaking countries andcountrieswithPortugueseastheworkinglanguage.Thoughthiswassubsequentlyrectified,itwastoolatetofullycompletethetaskinthisgroupof countries.

Consequently,documentedandonlineliteratureonPHCfrom,forexampletheWHO,UNICEF,WorldBankanduniversities,Internetsearches,andindividualcountryreviewsfromtheseventeencountrieswereusedtocompletethereviewandthefinalreport.However,thiswasfurtherconstrainedbytheinadequateinformationreceivedontheissuesunderreviewinallcountries.

1 Algeria,Botswana,BurkinaFaso,Cameroon,CapeVerde,CentralAfricanRepublic,Congo,DemocraticRepublicof Congo,Kenya,Liberia,Madagascar,Malawi,Mauritania,Niger,SaoTome&Principe,TogoandZambia

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ECONOMIC, SOCIAL AND POLITICAL ENVIRONMENT SINCE ALMA ATA

�.� Economic En�ironment

Theimplementationof PHCassumedgoodeconomicperformance.Unfortunately,mosteconomiesinsub-SaharanAfricahavenotperformedwell.

Declining economic growth. Economiesinsub-SaharanAfricahavebeenperformingpoorlyduringthe1980stotheearly1990swhensomepositivegrowthwasregistered(fig.1).GDPgrowthincreasedin1994toreach1.6percentfromalow0.8percentrecordedin1993.Itcontinuedto2.2percentand 4.7 percent in 1995 and 1996 respectively (World Bank & UNDP data series). Improvedmacroeconomicmanagementandmorefavorableexternalconditionshelpedsub-SaharanAfricatoachievesignificanthighgrowthlevelsin1996(IrishAid,1998).Thensince1996,fallingcommodityprices and, especially, world oil prices progressively slowed the growth from 4.7 percent to 3.5percentin1997,furtherdecliningto2.1percentin1998(WorldBank,2000).The1997-99oilcrisescontinuedtodepresseconomicactivitiesinmostcountriesintheyear2000,asnon-oilcommoditypricescontinuedtodecline.Intheyear2000,theAfricaRegionaveragegrowthacceleratedto2.7percentfrom2.1percentin1998-99.

In terms of proportion of GDP dedicated to health, there are variations between countries.However,itisclearthathealthspendingremainscriticallylowasapercentageof GDPintheRegioncomparedtootherregionsintheworld.Forinstance,in1997and1998theaveragepercentageof GDPdevotedtohealthintheAfricanRegionwas4.1%and4.2%respectively(WHO,2001).Thehighestwas10.3%inSouthAfricain1997and9.2%inZimbabwein1998whilethelowestwasintheDemocraticRepublicof Congoat1.6%in1997and1.7%in1998(WHO,2001).

CHAPTER 3:

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Fig. 1: GDP Average Growth Rates, 1980-99 (Selected African Countries)

Source: World Bank, 2001

Poor performance of the main economic sectors – agriculture, industry, manufacturing and service. The poorperformance of the agricultural and industrial sectors, which form the backbone of Africaneconomies,hasbeenchallengingthesustainabilityof growthanddevelopmentof mostcountries.Most of the sectors including agriculture, industry, manufacturing and service declined over theperiods1980-1990and1990-1999(seeTable1)andveryfewcountriesshowedpositiveimprovements.Manufacturingoutputdropped inmost countriesdue toa combinationof factors including lowlevelsof investment,highproductioncostsandinherentstructuralweaknesses.Duringtheperiod1999to2000countrieslikeKenya,SierraLeone,ZambiaandZimbabwecontinuedtoexperienceindustrialdeclinesandexcesscapacity,amongothers.Thedecliningagriculturegrowthresultedindecliningpercapita foodproductionand this trend threatensAfrica’s food security.Lowexportsprices coupled by increasing world oil prices, and the subsequent diminishing market share of Africanproduce,especiallyinthe1990s,resultedindeterioratingexportsearnings.Conflicts,floodsandlowcommoditypriceshaveagainheldbackeconomicgrowthinAfricaanditisevidentthatmostcountriesdidnotmatchtheirmajorsectorsoutputinthe1990sascomparedtothe1980s.EvenforcountrieslikeMalawi,Namibia,LesothoandUgandathatareregisteringincreasedgrowthforsomesectors,thegrowthhasbeenveryminimal.

2.72.5

10.33.63.3

1.10.9

34

4.24.6

1.12.5

0.81.8

1.3-0.1

1.63.1

1.211.7

3.62.9

1.64.7

4.33.8

-0.54.6

3.24.3

2.24.4

1.73.6

3.64.2

3.42.4

3.43.3

-4.71.9

2.42.8

7.2

0.3

-10 -5 0 5 10 15 20

AlgeriaBenin

BotswanaBurkina Faso

CongoEthiopia

GabonGhana

Guinea BissauKenya

LesothoMadagascar

MalawiMali

MauritaniaNamibia

NigerNigeria

SenegalSierra LeoneSouth Africa

TogoZimbabwe

Uganda

average annual growth rates (%)

1980-901990-99

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Table 1: Growth of Output (1980-1999) – Selected African Countries

Extracted from: World Bank (2001), World Development Indicators 2001

High external debt burden.Highexternaldebtremainsasevereobstacletoeconomicdevelopment.By1998,thetotalexternaldebtowedbysub-SaharanAfricarosetoaboutUS$350billion,comparedto1994and1982whenthetotaldebtburdenwasUS$210andUS$80billionrespectively (seefigure2).ManyAfricancountriesarestillborrowingmorethantheycanrepayanddebtservicingnowexceeds30percentof theexportsearningsformostcountries(UNDP,2001).Thislimitstheamountof resourcesavailableforallocationtobasicsocialservices.ThehighdebtburdenhashadasignificantnegativeimpactonhealthspendinginAfrica,withmostcountriesallocatinglessthanUS$10perpersonperyeartotheirhealthbudgets.

The effects of the heavy debt burden have resulted in worsening balance of payments, fiscalimbalances,rampantinflation,whichmakesitdifficultforcountriestoinvestinpriorityissueslikehealthcare,foodproduction,housingandeducation.The$13billionannuallyrepaidbyAfricangovernmentstoNortherncreditorsfordebtservicingrepresentsmorethandoubletheirspending

Country Agriculture Industry Manufacturing Services Averageannual% Averageannual% Averageannual% Averageannual% growth growth growth growth

1980-90 1990-99 1980-90 1990-99 1980-90 1990-99 1980-90 1990-99

Algeria 4.6 3.0 2.3 1.0 3.3 -5.7 3.6 2.7Benin 5.1 5.3 3.4 3.8 5.1 5.6 0.7 4.4Botswana 3.3 0.3 10.2 2.8 8.7 3.9 11.7 6.3BurkinaFaso 3.1 3.3 3.8 4.0 2.0 4.2 4.6 3.6Congo 3.4 1.7 5.2 -0.2 6.8 -1.9 2.1 -1.4Gabon 1.2 -1.9 1.5 2.6 1.8 0.6 0.1 4.5Ghana 1.0 3.4 3.3 2.4 3.9 -4.5 5.7 5.8GuineaBissau 4.7 3.4 2.2 2.3 - 4.1 3.5 -7.3Kenya 3.3 1.4 3.9 1.9 4.9 2.4 4.9 3.5Lesotho 2.8 2.0 5.5 6.3 8.5 7.9 4.0 5.2Madagascar 2.7 1.5 0.9 1.9 2.1 0.6 0.3 1.9Malawi 2.0 7.5 2.9 1.2 3.6 -2.7 3.3 3.5Mali 3.3 2.8 4.3 6.5 6.8 3.2 1.9 2.7Mauritania 1.7 5.0 5.9 2.6 -2.1 -0.9 0.4 4.7Namibia 1.9 3.8 -0.6 2.5 3.7 4.3 2.3 3.4Niger 1.7 3.6 -1.7 1.8 -2.7 2.3 -0.7 1.6Nigeria 3.3 2.9 -1.1 1.7 0.7 2.0 3.7 2.8Senegal 2.8 1.4 4.3 4.4 4.6 5.0 -2.7 -10.8SierraLeone 3.1 1.0 1.7 -4.6 - 3.7 2.8 3.6SouthAfrica 2.9 1.0 0.7 0.9 1.1 1.1 2.4 2.4Tanzania - 3.2 - 2.5 - 2.3 - 2.4Togo 5.6 4.5 1.1 2.5 1.7 2.4 -0.3 0.6Uganda 2.1 3.7 5.0 12.7 3.7 14.2 2.8 8.1Zambia 3.6 9.4 1.0 -3.9 4.0 0.7 0.5 0.3Zimbabwe 3.1 4.6 3.2 0.7 2.8 0.7 3.1 3.5

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inhealthandprimaryeducationcombined(WorldBank,1997).MostcountriesintheRegionarespending less onhealth andallocatingmore resources todebt repayments. Uganda for examplespendsapproximately$2.50percapitaonhealthcomparedto$30percapitaondebtrepayments.

Fig. 2: Africa’s Total Debt ($ Billion) 1977-1998


In1996,33of the41countriesclassifiedas“Heavily IndebtedPoorCountries (HIPC)”were inAfrica.In1998,theHIPCinitiativestartedtoreviewcountriesfordebtrelief.However,itisnotablethatfewcountriesincludingUganda,NigerandTanzaniahavequalifiedfordebtrelief.Whilstthisinitiativeiscommendable,thedebtrelief measuresarestillmarginalandtoolimited.

Low investments. Africahascontinuedtoseeitsshareof theworld’smarketeconomydiminishandwhenevertherehasbeenmeaningfulgrowthithasnotbeenbackedupwithinvestment.Thiswaspartlyduetohighdebts,highinflation,persistentdroughtsandsignificantreductionsindevelopmentexpenditures and savings. In addition, the HIV/AIDS epidemic is having devastating effects oneconomicgrowth(WHO,2000a)andhencediscouragingfurtherinvestment.InSouthAfrica,forexample,theHIV/AIDSepidemicisprojectedtoreducetheeconomicgrowthrateby0.3to0.4%annually,resulting,bytheyear2010,inagrossdomesticproduct(GDP)of 17%lowerthanitwouldhavebeenwithoutAIDSandwipingUS$22billionoff theeconomy(UNAIDS,2000a).Further,projectionsshowthat,althoughBotswanahasthehighestpercapitaGDPinAfrica,AIDSwillslice20%off thegovernmentbudget,erodedevelopmentgains,andbringabouta13%reductionintheincomeof thepooresthouseholdsinthenext10years(UNAIDS,ibid).

Adverse external conditions.Adverseexternalconditionsinmostcountrieshavecontinuedtonegativelyaffect regional development, by stagnating external resource flows and decreasing commerciallending.Officialbilateralandmultilateralassistanceaccounting for thebulkof resource flows tomostcountrieshasalsodeclinedovertheyears.IrishAid1998notesthattheshareof theOfficialDevelopmentAssistance (ODA) inSub-SaharaAfricadeclined from40% in1989 toabout34%

0

50

100

150

200

250

300

350

400

1977 1982 1994 1998Years

$ B

illio

n

Africa's Total Debt


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in the late 1990s. Inadequate budgetary allocations coupled with poor governance, crumblinginfrastructure, and pilferage of public resources has adversely affected investor confidence andreducedexternalfundstomostcountries.Thishascontributedtohighpovertylevels,withabout50percentof thepopulationlivingbelowthepovertyline,andhasadverselyaffectedthedeliveryof basicsocialservicestothepoor,especiallychildrenandwomen.

Poverty

Povertyisoneof themajorconstraintsinallhumandevelopmentprocessesinAfrica.Ithasbeenclearlyestablishedthatthereisa“cycleof causalitybetweenbeingpoorandpoorhealth,confiningtheindividualinaspiralof poverty”(Fairbanketal.2001).Povertyisbothahindrancetohealthdevelopmentandaconsequenceof poorhealthandlackof accesstohealthservices.

Sub-SaharanAfricahasthehighestproportionintheworldof peoplelivinginpoverty,withnearlyhalf of itspopulationbelow the internationalpoverty lineof US$1aday.Between1990-1999,thenumberof thepoorintheRegionincreasedbyonequarterorover6millionperyear.Muchaseconomicmeasureswere taken incountries in theRegion to fightagainstpovertyandreduceinequities, it appears that theRegion’sweakeconomicperformanceduring the1980’s andearly1990sasnotedabovehinderedthesuccessof theseefforts.

�.� Socio-political En�ironment

Thesocialsituationhascontinuedtodeteriorateinsub-SaharanAfrica.Thishasbeenattributedtotheinequityinaccesstobasicsocialservices,increasingfoodshortagesleadingtohighmalnutritionlevels,risingconflictlevelsandinfluxof refugeesoverburdeningcountrieswhichalreadyhavehighpopulationgrowthrates.Thesectionbelowbrieflygivesanoverviewof thesocialsituationinthecountriesduringtheperiodunderreview.

Access to basic social services. TheRegioncontinuedtofaceinequalitiesinaccesstoservicessuchashealthfacilities,housing,safewaterandsanitation,withmorethan50percentof theAfricanpopulationlackingaccess.

Datafrommanycountriesindicatethattheruralpopulationisseriouslydisadvantagedintermsof accesstohealthandhealth-relatedservices.Theresultisthespreadof infectiousdiseases,includingchildhooddiarrhoea,whicharemajorcausesof malnutrition.Eachyear,dehydrationduetodiarrhoeaclaimsthelivesof 2.2millionchildrenunderfiveyearsof ageinthedevelopingcountries(UNICEF1998).

Access to safe water and basic sanitation remains limited though there was some improvementbetween1982-1985and1990-1996.Whereasaccesstosafewaterrangedfrom14%inBeninto52%inZimbabwein1982-1985,intheperiod1990-1996itrangedfrom29%inMadagascarto77%inZimbabwe.Asforbasicsanitation,accessrangedfrom9%inBurkinaFasoandNigerto60%inMalawiin1982-1985,comparedto9%inCongoto77%inKenyain1990-1996.However,in13of the23countriesintable2below,lessthan50%of thepopulationhadaccesstobasicsanitation.

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Table 2: Selected Social Indicators in Selected Countries

Source: Extracted from: World Bank, World Development Indicators 2001 & UNDP, Human Development Indicators 2001.

Increasing food shortages. Sub-Saharan Africa has been experiencing exceptional food emergencies.About17countriesfacedifficultweatherconditions,persistentcivilstrifeandinsecurity(FAO,2001).Unusually dry weather conditions that characterized most African countries over the years havecausedhugecroplossesthroughoutandhaveaffectedcerealproduction,resultinginreducedaccesstofoodforlargesegmentsof thepopulation.IncountrieslikeBotswana,SouthAfrica,ZambiaandZimbabwe, themaizeoutput,whichaccounts forover90percentof thesub-region’s totalcerealproduction, is estimatedat13.7million tons in2001,26percent lower than in2000andbelowaverage.

Increased levels of malnutrition.Mostcountrieshavewitnessedincreasedlevelsof malnutritionduetodecliningfoodpercapita.Thishascontinuedtoweakenthecopingmechanismsof mostcommunitiesand increasevulnerabilityof womenand, especially children, todiseases, child labourandearly

Country%of populationwith

accesstoimprovedwatersource

%of populationwithaccesstosanitation

%1-yearoldfullyimmunized

Contraceptiveprevalencerate

(%)AgainstTB Against Measles

1982-85 1990-96 1982-85 1990-96 1997-99 1997-99 1995-2000

AlgeriaBeninBotswanaBurkinaFasoCongoGabonGhanaGuineaBissauKenyaMadagascarMalawiMaliMauritaniaNamibiaNigerNigeriaSenegalS.AfricaTanzaniaTogoUgandaZambiaZimbabwe

-14-

25----

273132-

37-

373644-

5235164852

-5070-

47-

56-

532945376457533950704963344377

-10369--

26-

44-

6021--9----

14134726

-2055189-

42-

771553313234153658468626572366

97100987239608825966692847680362790979363838788

9892744623307319794690575665252660827847537279

5216-

12--

20-

3919227-

298613691824152648

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marriages.Thedecliningfoodpercapitahasresultedinincreasedbasicfoodprices,withthepoorbearingthebruntof theburden.Malnutritionhasincreasedinmostcountriesasevidencedbythehighpercentagesof malnourishedchildrenduringtheperiod1995-2000(UNDP,2001)asfollows:Benin(29%),Botswana(17%),BurkinaFaso(36%),Burundi(37%),CentralAfricanRepublic(27%),Democratic Republic of Congo (34%), Kenya (22%), Mauritania (23%), Namibia (26%), Niger(50%),Nigeria(31%),Rwanda(27%),Tanzania(27%),Uganda(26%)andZimbabwe(15%).Slowgovernmentresponsetofooddeficitsandinadequateallocationof fundsfortimelyfoodpurchasesfor,ortransportto, theneedyareashascausedserioussufferinginmostpartsof thesecountries.Thishaserodedcopingmechanismsamongthemostvulnerablecommunities.Thusthenumberof childreninneedof specialprotection(CNSPs)hasgrownrapidlyduetoincreasedvulnerabilityof manyAfricanhouseholds.Nefarious traditionalandculturalpractices suchasFemaleGenitalMutilation (FGM) have also overburdened the girl child and subjected them to serious healthconsequences.CountrieslikeKenyaandSierraLeonehaverecordedFGMratesabove50percent(WHO,1998a).

Increased conflicts and political crises.Africa’ssocialsituationhascontinuedtodeterioratewithincreasedarmedconflictandpoliticalcrisesincountrieslikeNigeriaandSierraLeone.Inaddition,countrieslikeKenya,Tanzania,Uganda,ZambiaandZimbabwearerecordingincreasedinfluxof refugeesfromneighboringcountries,namelyBurundi,theDemocraticRepublicof CongoEritrea,Ethiopia,Rwanda and Sudan. These countries have thousands of internally displaced persons who havesoughtrefugeinneighboringcountries,therebyincreasingtheburdenonfoodrequirementsof thehostcountries.UNHCR(2000)globalrefugeestatisticsindicatethatAfricasharesalargeproportionof theworldrefugees(29%)(seeFig.3).Conflictescalationandongoingcivilwarshavedisruptedproduction and health delivery in countries already without adequate structures, experiencingpersistentdroughtandfamine.Inmostof thewar-torncountries,healthpostsandhealthpersonnelhavebecometargetsof savageattacksbyrebelsandterroristsgroups,therebyhamperingeffortsinhealthcaredelivery.

WHOestimatesthatthenumberof civilianlossesincurrentconflictsborderson90%,themajorityof whicharewomenandchildren.Violenceagainstwomenandchildrenandthedamagethatresultsfromitareunacceptable.Theseconflicts increaseall formsof violenceincludingsexualviolence,resultantunwantedpregnancies,forceddisplacementsandfamine.ThesearmedconflictsarenowmajorchallengesconfrontingPHC,amajormeansof achievingHealthForAll.

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Fig. 3: Global Refugees Statistics, 2000 Estimated number of persons of concern, by region

Source: UNCHR (2001),Refugees by Numbers 2000 Edition

Education levels. The worsening economic crisis has jeopardized progress achieved in the socialsectorsespeciallyineducation,withabout110millionprimaryschool-agechildrenindevelopingcountriesoutof school(WorldBank,2001).Adultliteracylevelshavevariedfromcountrytocountry.Intheperiod1985to1990,adultliteracyinAfricawasbelow30%in8countries;between30%and50%in4countries;between50%and70%in10countriesandabove70%in5countries(WHO,1994a).Therateof adultliteracy,whichwasverylowinthe80s,improvedsharply,especiallyinthe90s.Itwas,onaverage,46%formalesand25%forfemalesin1980andby1995ithadreached60% formales and39% for females.Poor familieshavehad tobear theaddedburdenof theintroductionof cost-sharingfacilities,andhencehavelimitedaccesstoeducation,especiallyforgirls.Lowliteracylevelsamongwomenhaveseverelyaffectedthenutritionalstatusof thechildren.

Itshouldbenotedthateducationandliteracylevelshaveagreatinfluenceonpeoplesknowledge,skills,aptitudeandattitudesandhencebehaviors,whichareveryimportanthealthdeterminants.

Population growth rates. TheAfricanpopulationgrowthhascontinuedtoriseovertheyears(Table3),withalmosttwo-thirdsof thecountrieshavingratesabove3percent.

29%

33%

34%

2% 2%

Africa 6,250,540

Asia 7,308,860

Europe 7,285,800

Latin America &Caribbean 90, 170Oceania 80,040

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Table 3: Population Growth in Countries of the African Region, 1980-1999

Extracted from: World Bank (2001b), African Development Indicators, 2001.

Averageannualpercentagegrowth

Millionsof people

Country

AngolaBeninBotswanaBurkinaFasoBurundiCameroonCapeVerdeCentralAfricanRepublicChadComorosDRCCongoCoted’IvoireEq.GuineaEritreaEthiopiaGabonGambiaGhanaGuineaGuineaBissauKenyaLesothoLiberiaMadagascarMalawiMaliMauritaniaMauritiusMozambiqueNamibiaNigerNigeriaRwandaSaoTome&PrincipeSenegalSeychellesSierraLeoneS.AfricaSwazilandTanzaniaTogoUgandaZambiaZimbabwe

1980

7.023.460.916.964.138.660.292.314.480.3427.011.678.190.222.3837.720.690.6410.744.460.8016.631.351.888.876.186.591.550.9712.101.035.5971.155.160.095.540.063.2427.580.5718.582.6212.815.747.01

1990

9.234.741.288.885.4611.470.342.945.750.4337.362.2211.640.353.1451.180.960.9214.875.760.9723.551.722.4411.638.518.462.031.0614.151.357.7396.206.950.127.330.074.0035.200.7725.473.5116.337.789.75

1991

9.594.881.319.095.6011.800.353.015.890.4438.602.2812.000.363.2252.950.990.9615.315.930.9924.281.762.4811.898.748.702.081.0714.421.397.9998.987.150.127.500.074.0935.930.7926.283.6416.898.0210.02

1992

9.945.031.359.315.7512.130.353.086.060.4639.872.3512.370.373.3154.791.021.0015.766.101.0124.981.802.5412.208.998.952.141.0814.691.428.26

101.887.350.127.690.074.1936.690.8227.103.7517.468.2610.28

1993

10.295.181.399.535.8912.470.363.156.250.4741.162.4212.750.383.3953.301.051.0416.206.261.0325.661.842.6012.559.249.202.201.1015.011.468.54

104.897.540.137.900.074.2937.470.8527.943.8718.038.5010.53

1994

10.635.331.439.766.02

12.8230.373.226.460.4842.492.4913.130.393.4854.891.071.0816.646.431.0626.311.892.6612.929.499.452.261.1115.421.508.84108.06.230.138.110.074.4038.280.8728.793.9918.608.7410.78

1995

10.975.481.469.996.1613.180.383.296.710.4943.852.5613.530.403.5756.531.101.1117.086.591.0926.921.932.7313.309.769.712.331.1215.821.549.15

111.276.400.138.330.084.5139.120.9029.654.1119.178.9811.01

1996

11.325.631.5010.236.2913.550.393.356.890.5045.252.6313.890.413.6758.231.131.1517.526.761.1127.541.972.8113.7210.029.992.391.1316.231.589.47

114.506.730.148.560.084.6339.910.9330.494.2319.749.2111.24

1997

11.665.791.5310.476.4213.920.403.427.090.5246.712.7114.210.423.7759.751.151.1817.986.921.1428.162.012.8814.1510.2810.292.461.1516.631.629.80

117.687.900.148.790.084.7540.670.9631.324.3520.329.4411.47

1998

12.005.951.5610.736.5514.300.423.487.280.5348.222.7814.490.433.8861.271.181.2218.467.081.1628.792.062.9614.5910.5310.602.531.1616.951.6610.14120.828.110.149.040.084.8541.400.9932.134.4620.909.6711.69

1999

12.356.111.5911.006.6814.690.433.547.490.5449.782.8614.730.443.9962.781.211.2518.957.251.1829.412.113.0415.0510.7910.912.601.1717.261.7010.49123.98.310.149.290.084.9542.111.0232.924.5721.489.8811.90

75-84

2.72.93.62.42.52.81.02.42.4-

3.12.93.92.42.62.83.23.12.31.73.73.82.53.22.63.22.22.51.42.72.73.33.13.31.52.91.42.02.33.23.22.82.43.43.1

85-89

2.83.23.52.42.92.91.92.42.42.63.42.93.43.43.03.23.44.13.52.82.33.72.52.32.83.42.72.80.81.02.83.23.03.02.82.80.72.22.53.23.23.02.63.03.3

90-MR

3.32.92.62.42.32.82.52.13.02.63.22.92.83.52.72.32.63.62.72.62.22.52.32.52.92.72.92.81.12.22.93.42.91.42.62.71.52.42.02.92.93.03.12.72.3

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During the last three decades, fertility rates decreased sharply worldwide, save for sub-SaharanAfrica.The22French-speakingcountriesintheRegionhad,forexample,anaveragegrowthrateof 5.27%in1999.ThehighestwasinNiger(6.6%)andthelowestinMauritius(1.9%).Youngpeopleconstitutethemajorityof thepopulationinthesecountries,withthosebelowtheageof 18years,onaverage,makingup52.8%of thepopulation.

Thistrendhascontinuedtothreatentheabilityof countriestoprovidefortheirpopulation,giventhedisproportionateslowgrowthinGDP.Thehighpopulationhasbeenattributedtopersistentlyhighlevelsof fertility,whichshownosignof abating,duetoearlychildbearing,lowliteracylevelsandlowlevelsof contraceptionuse(seetable3).Theincreasedinfluxof migrantsfromruralareasto urban centers, coupled with the high influx of refugees from neighboring countries, has alsocontributedtoincreasedburdenonthesocialservices.Asaresult,manycountrieshaverecordedincreaseddiseaseoutbreaks,especiallywaterbornediseasesduetoinadequatesanitaryfacilitiesandunsafedrinkingwater.

However, the annual growth rate of the 1990’s has declined in some countries. This is partlyexplainedbythehighHIV/AIDSprevalencerates,withabouteightAfricancountrieshavingatleast15percentof adultsinfected.TheincreasingHIVprevalenceratesareenvisagedtofurtherreducethepopulationgrowthrates.However,asalargeproportionof thepopulationof mostdevelopingcountries is in peak reproductive years, thenumber of children born each yearwill continue toincrease,albeitatalowerpercentileratethaninpreviousyears.Thisdisproportionatepopulationgrowthcomparedtotheavailabilityof basicsocialserviceshascontinuedtochallengetheprovisionof PHC.

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PHC AND NATIONAL HEALTH POLICY FORMULATION

PHCpolicyformulationinAfricahasbeenstimulatedbythreeimportantevents:(i)theadoptionin1977bytheWorldHealthAssemblyof “HealthforAllbytheYear2000”2,(ii)theadoptionof theAlma-AtaDeclaration3bythe1978InternationalConferenceonPHCinwhich“PrimaryHealthCare”wasseenasthestrategyforachieving“HealthforAll”,and(iii)theadoptionin1981bytheWorldHealthAssemblyof the“GlobalStrategyforHealthforAllbytheYear2000”.MostAfricancountries’healthpolicydocumentsandnationaldevelopmentplansindicatehavingaddressedsome,if notall,elementsof theprimaryhealthcareapproach,andthiswasdonemuchbeforeitsformalintroductionandadoptionin1978bytheinternationalcommunity.

National Health Policies and PHC

Areviewof thegovernments’policydocumentsandnationaldevelopmentplansindicatesthattheadoptionof PHCstrategieshasbeengivenpriority.InBotswana,thecountry’sfive–yearnationaldevelopmentplanclearlysetsthegoalof achievinghealthforallthroughtheprimaryhealthcarestrategy.BurkinaFasoadoptedPHCasacorestrategyforhealthdevelopment,andPHCwasanentrypointforthenationalhealthdevelopmentplansdevelopedin1986-90and1991-95.InKenya,thegovernment’scommitmentinreinforcingPHCwasemphasizedinthedevelopmentplan(1980-84)aswellasinsubsequentplansof 1984-88and1989-93.Inparticular,theKenya1989-93nationaldevelopment plan provides a general framework for PHC development. The effective launch of PHCintheDemocraticRepublicof Congotookplacein1985,whilethePHCapproachinMalawiwasemphasizedinthecountry’sdevelopmentplans.Thecountry’snationalhealthplan(1986-1995)integratesthePHCapproachasthemainstrategyof achievinghealthforall.In1984,theMinistryof HealthinGuineadevelopedaNationalHealthPolicyadaptingPHCtonationalandregionalspecificity.TheRepublicof CongoinitiatedthePHCapproachin1979andemphasisontheessentialPHCcomponentswasexpressedinthehealthplanfor1982-1986.InNamibia,thePHCapproachwasclearlyarticulatedinthehealthpolicydocumentsandthelaunchof thePHC/CBHCguidelinesin1992,increasinglyindicatethegovernment’scommitmenttoPHC.TheTanzaniahealthpolicyiscommensuratewithPHCandthisisclearlyindicatedinitslong-termdevelopmentplanfor1980to2000.

Policy formulation process

Thelevelof commitmentinformulatingPHCpoliciesinmostcountriesof theAfricanRegionhasbeenhigh.

2 InMay1977,thethirtiethWorldHealthAssemblyadoptedresolutionWHA30.43inwhichitdecidedthatthemainsocialtargetof governmentsandof WHOinthecomingdecadesshouldbetheattainmentbyallthepeopleof theworldbytheyear2000of alevelof healththatwillpermitthemtoleadasociallyandeconomicallyproductivelife,whichispopularlyknownas“healthforallbytheyear2000”.

3 InternationalConferenceonPrimaryHealthCareheldinAlma-Ata,U.S.S.R,6-12September1978

CHAPTER 4:

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InZambia,forexample,initialattemptsinpolicyformulationstartedbyestablishingtheNationalCoordinatingCommitteewhichdrewmembersfromtheUnitedNationalIndependenceParty,thechurches’medicalassociation,andrelevantgovernmentministriessuchasAgricultureandWaterDevelopment;Education;InformationandBroadcasting;Finance;andCommunityDevelopment(Kasondeet.al.1994).Althoughthisprocess failed,thegovernment’scommitment indevelopingdialogue in policy formulation was evidenced in the formation of the Primary Health CareCommittee,whichspearheadedtheprocess.Healthpersonnelatnationalandprovinciallevelswerechosentoinitiatetheprocess.

FollowingtheAlmaAtaDeclarationin1978,thegovernmentof BurkinaFasoadoptedin1979thestrategyof PHCasthemeansforhealthdevelopment.Adhesiontothestrategywasmanifestbythedevelopmentin1979of thenational5-yearstrategichealthplan(1979-1981)thattookintoaccountthePHCstrategywhichhas,amongotherprinciples,communityparticipationintheorganizationand management of health services and inter-sectoral collaboration. In September1993, withinthe framework of Bamako Initiative implementation, they developed a national document onstrengtheningPHC.Realtechnicaldecentralizationstartedwiththecreationof 53healthdistrictsandprovisionof autonomyforthemanagementof hospitalsandperipheralhealthfacilities.TheNationalHealthPolicyof 1980servedasthereferenceframeworkforPHCimplementationforaperiodof 20years.Anewonewasdevelopedin2000toguidethemanagementof PHC

KenyalaunchedapilotprojectinKakamegain1977inordertoassessthepotentialforcommunityparticipation in health care delivery. Drawing on experiences of the pilot project, it concludedthat community participation was a feasible approach of formulating and implementing PHC.Thecommunitiescanbeactivelyinvolvedindecision-makingconcerningtheirprioritiesinhealthpromotionanddiseaseprevention.By1986,theMinistryhadstartedCBHCprojectsin14districtsandestablishedaCBHCunitwithintheMinistrytocoordinatealltheCBHCactivitiesinKenya.

AttheRegionalCommitteeMeetinginBamako,Mali,in1987,theMinistersof HealthadoptedaninnovativestrategyforintensifyingPHC.TheBamakoInitiative(BI)aimedatrevitalizingprimaryhealthcareatthedistrictlevel.Itfocusedonfourissues,namely(i)theneedforPHCself-financingmechanismsatdistrictlevel;(ii)encouragementof socialinitiativetopromotecommunityparticipationinpoliciesonessentialdrugsandchildhealth;(iii)ensuringregularsupplyof essentialdrugsof goodqualityatlowestcostinsupportof PHC;and(iv)introductionof self-fundingmechanismsatdistrictlevel,especiallybysettinguprevolvingfundforessentialdrugs.

InNamibia,thefirststepinformulatingPHCpolicieswasthroughholdingthefirstinter-sectoralworkshop in Oshakati in February 1991. The workshop adopted a participatory approach toreaching a consensus on the concepts, processes and implementation of PHC at national level,raisingawarenessof decisionmakersontheconditionsof communitiesinruralareas;developingactionplansfortheregionsanddistricts;anddevelopingadraftguidelinefortheimplementationof PHC/CBHC(Ministryof HealthandSocialservices(MOHSS),Namibia,1992).Thefollow-upregionalanddistrictworkshopsheldinRundu,Oshakati,WindhoekandOkakararasoughttodevelopasharedunderstandingof PHCconceptsat theregionalanddistrict levels. Inaddition,theworkshopsmanagedtotrainatotalof 217trainers (TOTs);developedtrainingcurriculaandmodules for TBAs and HCWs; and designed district plans of action for the implementation of PHC/CBHCprogrammes.

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Marketing process

VirtuallyallcountrieshavemadeconsiderableefforttomarketthePHCpolicyformulationprocessasindicatedinthehealthpolicydocuments.CommitmentinformulatingandmarketingthePHCpolicyhasbeenwitnessedinmostcountriesthroughextensiveconsultationswithnationalofficials,regionalhealthdirectors,districthealthmanagers,NGOsandprivateproviders.Extensivepublicconsultationswereheldatthebeginningandduringthepolicyformulationprocess.Majoractorsinvolvedintheconsultationprocesshaveincludedministriesof,forexample,health,planning,water,education, finance and community development. The ministries of health also liased a lot withothermajorstakeholderssuchasthecommunities,regionalandinternationalorganizationsactiveinthefieldof PHC,forexampleAMREF,AgaKhanFoundation,InternationalRedCross(IRC),UNDP,UNICEF,WHOetc..Oneof thecommendableachievementsof theseconsultationsistheformationof PHCcommitteesatalllevels,inthecommunitiesandatthenationallevel.

Regional and district workshops and consultations have provided countries the opportunities toexaminethePHCpoliciesandmakeappropriaterecommendations.Theyhavealsoraised inter-sectoralawareness.InternationalagencieslikeWHO,UNICEFandSIDAgavesupporttoministriesof health inmostcountries in theorganizationof seriesof workshops forconsensusbuildingonPHCpolicyformulation.Theseworkshopshavebroughttogetherawiderangeof experiencesof stakeholders, including theprivateandpublic sectors,NGOs,donorsand thecommunities.Therecommendations emerging from these consultations are providing the basis in developing andimprovingguidelinesfortheimplementationof PHC.

Incorporation of PHC principles and elements

FollowingtheAlmaAtaDeclarationin1978,mostcountriesreviewedtheirnationalhealthpolicies,andthereviewof nationaldevelopmentplansindicatethatthesecountrieshaveincorporatedtheprinciplesandelementsof thePHCapproach.Kenyawasnotedtohaveintroducedandintegratedtwoadditionalelementstomakeatotalof tennamely,mentalhealthanddentalhealth.

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PHC STRATEGY IMPLEMENTATION

Theadoptionof thePHCstrategymeantthatattentionshouldbegiventotheprinciplesof universalaccess,equity,communityparticipation,appropriatetechnologyandinter-sectoralcoordinationasimportantconsiderationsindevelopinghealthsystems.Althoughcountriesdevelopedtheirrespectivenationalguidelinesfortheimplementationof PHC,literaturereviewpointstoadiscrepancybetweenpolicyformulationandimplementation.MakingPHCthecentralfunctionandthemainfocusof health systems has remained a big challenge for most countries (Macdonald, 1993). Macdonaldfurtherpoints out that the challengepresentedby PHCwas so great that almost as soon as theapproachwasdeclaredandprogrammestoimplementitwerelaunched,oppositiontoitbecameinstitutionalizedand‘selectivePHC’wasborn.

Principles of PHC.

Universal access:

Manycountriesdevelopedatwo-,three-orfour-levelhierarchicalhealthcaresystem.Acommonhierarchicalhealthsystemstructureispresentedinfigure4.Thestructurecomprisestheministryof healthasthetutelagestructure,teachingorreferralhospitals,regional/provincialhospitals,districthospitals andhealth centres.Theministryof health setspolicies anddirects the strategichealthsystem management. The provincial/regional level acts as the intermediary between the centrallevel and the districts. The provincial/regional healthmanagement teams and boards (PHMTs/PHMBs)were constituted tooversee the implementationof healthprogrammes in theprovince.Thedistricthealthmanagementteamsandboards(DHMTs/DHMBs)wereconstitutedtooverseehealth activities in each district. The district level is the main PHC operational unit, led by thedistrictmedicalofficer(DMO)whospearheadstheDHMT.Thehealthcentres,dispensariesandvillagehealthpostssupportPHCimplementationatthelocallevel.Inmostcountries,thestructuresfor working with the communities are the village health committees (VHCs) and health centremanagementteams(HCMTs).

Countrieshavesetdifferentguidelinesforestablishinghealthcentresanddistricthospitals.Insomecases,thehealthcentresareestablishedsuchthateachservesaspecifiedpopulationlike5000to10000peopleorpeoplewithinaradiusof eightkilometers,orsuchthatpeoplewithinthecatchmentareacanreachthehealthcentrewithinonehourtraveltime.Districthospitalsaresetupsuchthateachservesadistrictorapopulationvaryingbetween100000and500000.

Inordertoensurecosteffectiveness,thereisastrongadvocacyforuseof thereferralsystem,rightfromthemostperipheral level (community level)orprimarycarelevel (healthpostsandcentres),throughtheintermediatelevel(district,regionalorprovincial)tothecentrallevel.

CHAPTER 5:

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Service delivery was expected to be in an integrated manner in all health facilities, rangingfrom treatment of common ailments to disease control, antenatal care, care of the sick child toimmunizationandotherpreventive care. Itwasmeant to ensure that therewouldbenomissedopportunities.Thishaspresentedspecialchallengesintermsof theneedforhealthworkerswithgeneralistskills,especiallyathealthcentreanddistrictlevels.

However,itisevidentthatministriesof healthinthecountriesdidnotsharethesamevision.WhilesomeviewedPHCasprovidingforservicedeliverythroughthealreadyexistingreferralstructures,othersvieweditasaverticalprogrammethathadtobeimplementedinparalleltootherexistingprogrammesandcoordinatedbyPHCcommitteesattheministerial,provincial,districtandlocallevels. However, these PHC coordinating structures have been criticized as having resulted inunnecessaryduplicationof efforts.

Fig. 4: Hierarchical Health Care System

Level of Care Management Structure Inter-sectoral Coordination Body

Teaching Hospital Hospital Management Team

National Inter-sectoral Coordination Body

Provincial Hospital Provincial Health Management Team

Provincial Development Committee

District Hospital District Health Management Team

District Development Committee

Health Centre Area Development Committee

Health Centre Management Team

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Equity:

Equityinhealthwasunderstoodtomeanfairshareof,andopportunitiesin,distributionandaccesstohealthresourcesandservices.Thiswasespeciallypertinent,consideringtheinequitablehealthsystemsmostcountrieshadinheritedatindependence.Countriesdevelopednationalhealthpoliciesstatingequityasoneof theobjectivesandindeedtheinfrastructuredevelopmentinitiativesfocusingontheruralareasweremeanttooperationalizethisobjective.Unfortunately,itmeantareallocationof limited resources,which led to takingaway resources from thealreadyunder-funded servicesservingtheurbanelite,whowerethenewdecisionmakers.Theequitypolicyobjectivewasthereforenotfullyimplemented.

Therearehugedisparities inallocationof resourcesbetweentheruralandurbanarea,accesstoservicesissimilarlyskewedandthehealthoutcomesasshownbyinfantandmaternalmortalityratesconfirmthedisparities.Insomecountries,indigenousNGOshavebeensetupsuchasEQUINETandtheHealthSystemsTrustinSouthernAfricatospearheadtheequityagenda.

Thoughcountriesindicatedcommitmenttoequity,thishasnotbeenrealizedandalotmoreneedstobedone.

Community participation

Communityparticipationwasseenasaprocessof involvingthecommunitybypromotingdialoguewith,andempowering,communitiestoidentifytheirownproblemsandsolvethem.Participationof thecommunityinPHCwasevidencedinmostcountriesthroughtheformationof communityhealthcommittees,villagehealthcommitteesandhealthcentreorareahealthcommitteesandtheselectionof communityhealthworkersfortraining.Furthermore,communityrepresentativeswereincluded inhealth facilityor inter-sectoralmanagement structures suchasdistricthealthboards,districtdevelopmentcommitteesandhospitalmanagementboards.

Themanagementcommitteesrepresentaveryimportantelementintheinstitutionalsettingof thesysteminregardtotheirmainroleinplanning,managementandcontrolof healthservices.Theyformaninterfacebetweenthehealthsystemandthepopulationandhencerepresentandpromotethe people’s participation and ownership. Unfortunately in some countries, as was the case of Mauritania,lessthan10%of thesecommitteeswerefoundtobeoperational.Thisproblemmaybeassociatedwiththewayinwhichthemembersof thecommitteewerechosen,whichwasoftenbasedoncriteriaotherthanconsiderationof therequiredexpertise.Moreoftenthannot,thechairpersonof thecommitteeisthepoliticalleaderwhomaynotevenbestayinginthelocality.

A major challenge with community participation has been the capacity of the communityrepresentatives and relevant national structures to support it. Some countries responded bydevelopingguidelinesonwhatwasexpectedof thecommunitiesandcommittedtotrainandsupportthecommunities.Nonetheless,communityinvolvement,beyondpayingforservicesandprovidinglabourforworkcarriedoutathealthfacilities,hasbeenoneof themostchallenginganddifficultaspectsof PHCimplementation(JarretandOfosu-Ammah,1992).

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Communityhealthworkers (CHWs)havecontributedsignificantly toprogrammeeffectiveness inmanycommunity-basedprogrammes.Despitethestructuresinplacetomanagetheworkof CHWs,theiroperationhasbeenhamperedbytheweakmanagerialcapacitiesof thecommunityandthehighilliteracyrates.Althoughcommunityparticipationhasbeenarguedasthecoreof PHCpolicies,ithaslargelyremainedproblematic,callingformorereviewanddefinition.

Whilsttheroleof communityhealthworkersinachievinggreaterandquickerservicecoverageiswellrecognized,thevillagehealthworkerprogrammesinmanycountrieshavedisintegrated.Theconceptof traditionalbirthattendants(TBA)stillexistsbutisstillnotwidelypromoted,giventhenewemphasisontheneedforskilledattendants.

Besides,theroleof thetraditionalhealthpractitioners,whoareprovidingalotof servicestothecommunity,doesnotseemtobewellintegratedintonationalhealthsystems.

Althoughensuringqualifiedpersonnel-assisteddeliveriesisoneof thepillarsof theSafeMotherhoodInitiative,thecontributionof unassisteddeliveriestomaternalmortalitystillremainssignificant.Thepromotionof thetraditionalbirthattendantsprogrammeswaslaunchedinthe1970s,supposedlyas a transitory measure. However, qualified personnel to assist deliveries are limited and, oftenconcentratedinbigcities.Studieshaveshownlimitedcapacitytodetectsignsthatpredictunwantedoutcomes of pregnancy by traditional birth attendants. It was also noticed that the antenatalcareprovidedwasnotof adequatequality.Subsequently, it isnot surprising tonoticeenormousdisparitiesinthematernalmortalityratesbetweentheurbanandruralpopulations.Somecountriesaresignificantlydependentoncommunityhealthworkers(CHWs)andtraditionalbirthattendantstoassistchildbirth,especiallyinruralareas.

Inrevisitingcommunityparticipation,Davidet.al(1998)highlightthreemaindifficultieswiththeconceptualization and evaluation of community participation. These are (i) the great variety of health indicators using community participation as a strategy, (ii) the complexity of communityparticipationand(iii)whatcommunityparticipationitself isunderstoodtomean.Thesameauthorsrecommendtheneedtodevelopcommunitystructuresthattakeintoaccounttheneeds,resources,socialstructuresandvaluesof thecommunity.

Inter-sectoral collaboration

The need for the health sector to play a leading role in health and to coordinate and establishsynergicrelationswithothersectorsthathaveanimpactonhealthwasseenasoneof themajorcontributionsof thePHCstrategyinhealthdevelopment.Thiswasbecausetherewerenoexistinginstitutionalmechanismstoguaranteethathealthobjectiveswereprioritizedandmadeanintegralpartof policiesandprogrammesinothersectors.

Reviewof nationaldevelopmentplansof allcountriesnowshowthatinter-sectoralcollaborationisbeingwidelyadvocatedasoneof thekeyprinciplesof PHCimplementation.InBotswana,forexample,theRuralDevelopmentCouncils(RDC)wereorganizedwiththeobjectiveof promotinggreaterinter-sectoralcollaborationbyintegratingothersectorssuchasplanning,ruraldevelopment,financeanddevelopmentplanning.

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Thedevelopmentcommittees setupatdifferent levels inmostcountrieshad the sameobjective.However,WHO(1994b)4notesthattheenvisagedinter-sectoralcollaborationhasremainednon-functionalpartlyduetolackof fundsaswellaslackof clarityof rolesandresponsibilities.InMalawi,inter-sectoral collaboration both within the public sector and with the private sector has beenextensivelyexploredfortwomainreasons,namely(i)dwindlingresourcesandincreasingdemandsonthesector,and(ii)realizationthatthedualhealthcareprovisionsystemispromotinginequitiesbyleavinglargeareasunderservedby“free”publicfacilitiesintroducedatindependence.

Ingeneral,itisevidentthatmostcountrieshaveestablishednationalhealthcouncilsandprimaryhealthcarecommitteesatalllevelstopromotebothinter-sectoralandintra-sectoralcollaboration.Despitethesecommittees,however,collaborationhasbeendoneinanadhocbasisratherthaninaformalwaywithclearlydesignatedstructuresandwell-definedmotives.Asaresult,thereseemstobealackof generalunderstandingamongthedifferentstakeholdersof theirrolesinPHC.WHO(ibid)evaluationcitedimportantconstraintsininter-sectoralcollaborationinhealthtoincludethefollowing(i)thelackof apermanentmulti-sectoralcollaborationinthefield,(ii)closeorganizationalstructures and the specialized nature of public health services, (iii) low financial resources, (iv)underestimationbyhealth care authorities of thepotential of other sectors in addressinghealthproblems(v)increasingsocialandeconomicdifficulties(vi)frequentpoliticalinstabilitiesand(vii)thedifferingdonorexpectationsandrequirements.

Appropriate Technology:

Adherencetotheprincipleof usingappropriatetechnologyof proveneffectivenessandsafetywasintendedtobeacost-containmentmeasure.Limitedsuccesswasreportedinthisarea.Perhapsthegreatest achievement is the incorporation of generic drugs concept into national drugs policies.Otherexamplesincludeattemptsatstandardizingequipmentpurchasedforuseinhealthinstitutions,useof the cheapestbut effective technology likebasic radiologicalunits, useof locally-preparedsugarandsaltsolutionfortreatmentof diarrhoeaand,recently,thedevelopmentof ruralorbushambulancesusingdonkeydraughtpower,bicyclesandmotorcycleengines.

Despitethesedevelopmentsand,perhaps,duetopressurefromtheglobalpharmaceuticalindustry,medical equipment manufacturers, the health professions and indeed the populations at large,countrieshavehadtospendlargesumsof moneyonhighlysophisticatedtechnologywhencheaperoptionsareavailable. Thischallengecontinuestogrowespeciallyasglobalizationtakesrootandhealthprofession’seducation, trainingandpracticecontinues tobedrivenby themedicalmodelinsteadof thehealthmodel

The Bamako Initiative

Disappointed by progress towards Health for All, African health ministers adopted the BamakoInitiativein1987asastrategyforacceleratingPHCimplementation(WHO/UNICEF/Governmentof Mali,1999)andensuringaccess toessentialhealthservices to themajorityof thepopulation.

4 SeeWHO(1994b),Implementationof theGlobalStrategyforHealthforAllbytheYear2000.Eighthreportontheworldhealthsituation.

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Theinitiativeplacedemphasison(i)thepromotionandimplementationof aminimumpackageof services;(ii)accesstodrugsataffordablecost;(iii)cost-sharingbetweengovernmentandusersand,(iv)effectiveparticipationof thecommunityinthelocalmanagementof thehealthsystem.

The implementation of this initiative gave a second breath of life to the PHC implementationprocess.Itallowed,inallcountrieswhereitwasappliedrigorously,toscaleupPHCimplementation,resultinginanet improvementintheavailabilityof resourcesand,consistently, itsmoreeffectivefunctioning.Forexample,inCentralAfricanRepublic,65.2%of thepopulationhadaccesstohealthserviceswithinaradiusof 5kmintheyear2000ascomparedto45%in1995(RCA1994-1995),though leavingapproximately20.4%of thepopulationhaving to travelmore than10-15km toreachahealthfacility.

ExperiencefromtheBamakoInitiativeorsimilarnumerousprojects,suchasthecost-sharingschemeinBotswana,Ghana,Kenya,Niger,Nigeria,Tanzania,ZambiaandZimbabwe,havebeendiverse.Thereportonthereviewof BamakoInitiativeimplementationinAfricaheldinBamako,Mali,in1999indicatedthatcountrieswereatdifferentstagesof implementation.WhilecertaincountriesappliedBIinalltheirdistricts,theotherswereabletoexpandtoonlysomedistrictsof thecountry.Eighteenof the22French-speakingcountriesintheRegion,whichbenefitedfromthesupportof UNICEFin1991toimplementtheBI,coveredonly34%of 1048districts.ExceptforBeninandGuinea,theothercountriestooklongtostartimplementationof BI.Thegovernmentof Guinea,incollaborationwithUNICEF,WHO,WorldBankandtheItalianGovernment,initiatedin1988theimplementationof BamakoInitiativeinordertostrengthenPHC.Burundi,Cameroon,Mali,Mauritania,SenegalandTogointegratedBIonlyin1991(UNICEF,1992).OtherFrench-speakingcountrieslikeCôted’Ivoire,CentralAfricanRepublicandCongoBrazzavillewereabletoeffectivelystartonlyin1992.

Theuserfeesystemreceivedmostattentionasanalternativesourceof financing,duetoitsperceivedroleinmobilizingresources,promotingefficiency,fosteringequity,increasingdecentralizationandsustainability.Somesurveys(Nolan&Turbat,1993)indicatethatmostcountriesinAfricathattriedtoofferfreehealthserviceslaterintroducedsomeformof feesystemforgovernmentfacilities,forexampleKenya,TanzaniaandZimbabwe.

Asurveyof healthinsurancein23Africancountriesbetween1971and1987indicatedthatonlysevencountries(30%)hadformalhealthinsurancesystems(Vogel,1990;ShawandGriffin,1995).Arecentstudyonfifteencountriesrevealthathealthinsurancecoveragerangesfromlessthan10%of thepopulationinmostcountriestoabout15%inBurundiand25%inKenya(NolanandTurbat,1993).

AchievementswiththeBamakoInitiativehavebeennotableinthefollowingareas:promotionandimplementationof aminimumpackageof activities(MPA);revitalizationof healthcentres,constantavailabilityof essentialdrugsataffordablecost;costsharing;andaneffectiveparticipationof thepopulation. The availability of essential drugs at an affordable cost in Kenya, for example, wasachievedbythesaleof essentialdrugsthroughcommunitypharmacies,whichclearlyreducedbothfinancialandgeographicalbarrierstoaccess(Kara&Mcpake,1993).

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Health Sector Reforms

InordertomeetgrowinghealthneedsandsupportedbyinstitutionsliketheWorldBankaspartof theeconomicstructuraladjustmentprogrammes,countrieshaveembarkedonhealthsectorreforms.Much effort targeted rationalization of the ministry of health, decentralization of the planning,managementandimplementationof healthservicestothedistricts,introductionof newmechanismsforhealthcarefinancingandrecognitionof theroleof theprivatesector,NGOsandotheractorsinhealthcareprovision.

TheWHORegionalOfficeforAfrica(AFRO)hastriedsince1978tohelpMemberStatesimplementPHC,basedonthedistricthealthsystemsapproach.Itorganizedseveralorientationsonthesubjectanddevelopedmanydocumentstopopularize,orientandgivemethodologicalguidanceinordertopromotetheimplementationof theapproachinthecountriesof theRegion.

AFROalsofacilitateddialogueamongactorsinthehealthsector,puttingattheirdisposalmanuals,brochuresandguidelinesonthePHCapproach.WHO’sleadershipinPHCpromotionwasneverfoundtobewanting.However, innovativemeasuresweresometimes introducedtoofrequentlytocountriessuchthattheirhealthsystemshadproblemsinapplyingthemcorrectly.

Intheearly1990s,Ghanabegantakingaseriesof actionstowardsrestructuringitshealthsector,includingdevelopingabasicminimumpackageof services;refocusingemphasisonPHCincludingreproductivehealth;decentralizinggreatermanagementandfinancialresponsibilitytodistricts;de-linkinghealthservicedeliveryfromtheCivilService;andreviewingtheorganizationalstructureof MOHtoreflectashiftfromverticalsystemstoamorefunctionalhorizontalsystem(Dovlo,1998).InZambia,themainstreamsof decentralizationinvolveddecentralizationtolocalgovernmentsaspartof thepublichealthsectorreformprogrammeandthesecondstreamof decentralizationpolicyisspecifictothehealthsectorassetoutinthegovernmenthealthreforms(Chongo&Milimo,1996).

Comparingtheverticaldecentralizationof Zambiawhereonlythehealthsectorwasdecentralizedwith the holistic decentralization of Uganda, it has been concluded that neither form of decentralizationhassofarledtoaclearandappreciableimprovementinhealthservices(OkuonziandJeppsson,2000).InNigeria,thedecentralizationof healthresponsibilitieswithinthethree-tiersystemof governmenthasfacilitateddistributionof human,materialandfinancialresources.

Theseinitiativesaimedtoachievegreaterequityof accesstoservices,improvedefficienciesinresourceutilization,developmentof widerlinkageswithcommunitiesandotherpartners,aswellasimprovedqualityof healthservices.Yet,therehasbeennoimprovementinhealthsystemsperformance.Infact,evidenceavailableshowsthatinmanycountriesthehealthstatusof thepeoplehasworsened.

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Elements of PHC.

Education on prevailing health problems and control and prevention methods

Education on health problems and the methods for controlling and preventing them addressesthebroaddeterminantsof diseaseandill-healthintheRegion,withtheaimof promotinghealth.Countrieshaveadoptedvaryingmixesof healtheducationandpromotionapproaches.AccordingtoaWHOsurvey,5outof 37countries,15hadhealtheducation;11hadinformation,educationandcommunication;5hadhealthpromotion;2had information,educationandcommunicationandhealtheducation;1hadinformation,educationandcommunicationandsocialmobilization;while2hadnospecificapproach.

Since 1986, WHO and her key partners have convened at least five global health promotionconferences.IntheconferenceinMexico, inJune2000,theparticipantsfromAfricacalleduponAFRO to develop a regional health promotion strategy adapting the Mexico framework for thedevelopmentof healthpromotionwithintheAfricancontext.Inresponse,theRegionalCommitteein2001adoptedthehealthpromotionstrategyfortheAfricanRegion.Thestrategyaimedtofosteractionsthatenhancethephysical,socialandemotionalwell-beingof thepeopleandcontributetothepreventionof themaincausesof disease,disabilityanddeath.

Promotion of food supply and proper nutrition

Manyof thepoliciespursuedbyAfricancountriesduringthe1970sand1980ssuccessfullyachievedaggregatenationalfoodsecuritybutdidnotachieveadequateconsumptionbyallindividualsandgroupswithinthecountry(FAO1992e).Tomeetdomesticdemand,maximizefoodproductionandincreasemarketedsuppliesof food,manyAfricancountriesembarkedonfoodsecuritystrategiesfocusedonachievingfoodself-sufficiencyduringthelate1970sandearly1980s,usingpoliciesdesignedtomaximizedomesticoutputof staplecrops.(FAO1997,Agriculture,foodandnutrition).

Consequently,sincethe1980stheavailabilityof basicstaplefoodforconsumptionhasexpandedby30%forcerealsandcerealproducts,40%forrootsandtubers,35%forpulses,and35%foroilcrops. (FAO,1995f).However, the estimatedannual rateof populationgrowth for the last threedecadeswasabout3percentcomparedtotherateof foodproductiongrowthof around2percent(FAO1995f).

DatafromFAOshowthattheproportionof chronicallyundernourishedpeopleinAfricarosefrom38 to 43 percent between 1969 and 1992. It is estimated that about 215 million people in sub-SaharanAfrica suffer fromchronicunder-nutrition.Anaemiaaffects another206millionpeoplewhile181millionand52millionareatriskof iodinedeficiencydisordersandvitaminAdeficiency.

5 AquestionnairewassenttocountriesandtheseweretheresponseswhichwerereceivedbySeptember2000.

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HealthymarketplacesinitiativewasintroducedintheRegiontopromotesafetyandwholesomenessof foodssoldinthemarkets.AfewcountrieslikeTanzania,NigeriaandMozambiqueareundertakingtheinitiativeanditistoexpandtoothercountries.

Adequate supply of safe water and basic sanitation

Over the past twenty years water and sanitation coverage increased markedly from 32% watercoverage in 1980 to 56% in 1999, and from 28% sanitation coverage in 1980 to 55% in 1999.However,therewasadeclinefrom56%coveragein1990to55%coveragein1999forsanitation(AFR/WSH/00.3).

Althoughallcountriesof theRegionhadsome typeof guidingpolicies forwaterandsanitationdevelopment,manydidnothavelegalenactmentsorformalwrittenstatementsforthesector.Themajorityof countriesintheRegionmerelydrewtheirwaterandsanitationpolicyguidancefromgeneraldevelopmentpolicies,nationaldevelopmentplans,orinsomecaseswaterActs.However,during the InternationalDrinkingWaterandSanitationDecade (1981-1990),decadeplanswerepreparedforwaterandsanitationplanninginnearlyallcountriesof theRegion,settingouttheirnationalneeds,priorities,goalsandtargets.

ThemapandthefigurebelowshowthewatersupplyandsanitationcoverageinAfricafor1990and2000.

Figure 5: Water Supply Coverage in Africa, 2000

Source: Global Water Supply And Sanitation Assessment 2000 Report. WHO and UNICEF Joint Monitoring Programme For Water Supply And Sanitation. 2000. Page 43.

ThemajorconstraintsforwaterandsanitationsectordevelopmentintheAfricaRegionare,intheorder of importance, as follows: limited funding; inadequate logistics; inadequate operation andmaintenance;inadequateoroutmodedlegalframework;andinappropriateinstitutionalframework

WATER SUPPLY COVERAGE IN AFRICA, 2000

9 1% - 10 0 %M is s in g d a t a

W a te r s u p p ly c o v e r a g e

7 6 % - 9 0 %

0 % - 2 5 %2 6 % - 5 0 %5 1% - 7 5 %

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Figure 6: Sanitation Coverage in Africa, 1990 and 2000

Source: Global Water Supply And Sanitation Assessment 2000 Report. WHO and UNICEF Joint Monitoring Programme For Water Supply And Sanitation. 2000. Page 43.

Maternal and child health care, including family planning

Thematernalmortalityrate (MMR) in theRegion is thehighest in theworld,averagingaround1000deathsper100.000livebirths,withdisparitiesamongcountriesandbetweenurbanandruralareas.ThehighMMR,combinedwithlowcontraceptiveprevalencerateof 13%andhighfertilityrate-estimatedat5.6childrenperwoman, increasesthelifetimeriskof maternaldeath-estimatedat1:14.Insomecountriesof theRegion,25%to27%of firstbirthoccursamongadolescents.Adolescentchildbearingcontributessignificantlytomaternaldeathrisk,accountingforupto40%insomecountries.Lackof accesstoreproductivehealthservices,includingcounselingandfamilyplanning,contributestothehighincidenceof post-abortioncomplications.

The47thsessionof theRegionalCommitteeof WHOinSeptember1997,inthebidtoacceleratereduction of maternal and peri-natal mortality and disability, adopted the Regional Strategy onReproductive Health. The strategy focuses on critical issues, which include access to efficientantenatal care; provision of hospital-based treatment for pregnant women with life-threateningcomplications; transport and communication; and strengthening of the health care system. Toaddress theadolescenthealthproblems, the51stsessionof theRegionalCommitteeadoptedtheAdolescentHealthStrategyfortheAfricanRegion.Thestrategyaimedtoidentifyandrespondtothehealthneedsof adolescentsaswellaspromotetheirhealthdevelopment,throughtheirinvolvementandthatof theirparents,familiesandcommunities.

Inaddressingthehighinfantandchildmortalityrates,mostcountriesincludingBenin,Botswana,theDemocraticRepublicof Congo,Ghana,Kenya,Madagascar,Malawi,Niger,Tanzania,Togo,Zambia and Zimbabwe, have adopted an integrated approach to child health programmes thataddresstheoverallhealthof achild.Recentmeasuresandstrategiesadoptedintheareaof childhealthincludethecontinuationof nationalimmunizationcampaignstoeradicatemajorchildhooddiseasesinallcountries;promotionof breastfeeding;formulationandimplementationof anutrition

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policy;freehealthcareforpregnantmothersandchildrenundertheageof sixandfreetreatmentformalnutritionanddiarrhoealdiseases.Theadoptionof theWHO/UNICEFapproach foranintegrated management of childhood illness (IMCI)6 is seen as a great achievement in reducingchildhooddeathandillnesses.

Immunization against the major infectious diseases

Childimmunizationcoveragehasincreasedremarkablyinmostcountries,withtheimmunizationof almosttwo-thirdsof allchildrenunderoneyearof age.UNICEF(2002)notesthatthreemillionfewerchildrenunderfiveyearsof agenowdieeachyear,duelargelytoimmunizationprogrammesandthededicatedeffortsof familiesandcommunities.Figure7givesthetrendintheimmunizationcoveragewithEPIvaccinesintheAfricanRegionfrom1982to2001.Thecountrieshoweverexhibitdifferenttrendsduringthesameperiod.Immunizationprogrammeshaveimprovedaccessibilitytoimmunizationthroughincreasedpubliceducationonthevalueof PHC.Inaddition,communityhealth workers (CHWs) have been trained to promote immunization. Many countries haveindicatedthatimmunizationisseenasagoodwayof introducingPHCandbeginningtoworkwithcommunities.

Fig. 7: Immunization coverage with EPI vaccines in the African Region, 1998-2001

Source: AFRO, 2002

Immunizationagainsttetanusamongwomenof childbearingageisfarbelowexpectedcoverage.ForexampleintheCentralAfricanRepublic,thecoverageof pregnantwomenwith2ormoredosesof tetanustoxoidduringtheperiod1991to2001rangedbetween14%and32%only(EnquêteCVOMS

6 RefertoWHO/UNICEF(1999),IntegratedManagementof ChildhoodIllness(IMCI)–WHO/CHS/CAH/98.1B

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1990-1991;EDS1994-1995;EnquêteMICS1996;Donnéesderoutinede1997à1999;MICS2000;RevuePEV2002).InNigerbetween1994and1999itrangedfrom27%to42%(Rapportsannuelsd’activitésDNPEV).Casesof neonataltetanusthereforestillexist.Itwasconvenientlydecidedtouseantenatalconsultationstomaketheseinoculations.Thelowratesof antenatalcarevisitstohealthfacilitiesaswellaslateattendancefurtherreducesthechancesforimmunizationof womenagainsttetanus.Thefailuresof suchprogrammeswouldinmostcasesbeduetothedysfunctionof healthsystems.Thesesystemscontinuetosufferfromseriousgapsintheirorganizationandmanagement,asreflectedinfrequentshortagesof vaccines,defectivecoldchainequipment,infrequentorientationof the staff charged with the responsibility for immunization (WHO, World Health Forum,Vol. 8 , 1997).

Prevention and control of locally endemic diseases

Inthepast,thepreventionandcontrolof endemicdiseasesintheAfricanRegionlargelyfocusedoncommunicablediseases.Butinthelastdecadeorso,noncommunicablediseaseslikecardio-vasculardiseases,cancers,andmentalillnesseshavebeenincluded.

TheRegionalCommitteehasadoptedstrategiesforpreventionandcontrolof communicableandnoncommunicablediseaseswiththeaimof strengtheningthecapacityof MemberStatestodrawuppoliciesandimplementprogrammesusingcomprehensivemulti-sectoralapproaches.

However,communicablediseasesstillaccountforalargeproportionof thediseaseburdenandvariousstrategiesandeffortshavebeenmadetoaddressthem.TheAfricanRegionadoptedaframeworkforimplementationof RollBackMalaria(RBM)in2000.In1996theHIV/AIDSstrategyintheAfricanRegionwasadoptedtocombattheepidemicandaframeworkforitsimplementationwasadoptedin2000.Forcontrolof tuberculosis,thedirectlyobservedtreatmentshortcoursestrategy(DOTS)isbeingimplemented.Thenumberof countriesusingDOTShasbeenincreasingsincetheearly1980sreaching41outof 46by1998.Fifty-sixpercentof thecountrieshaveattained100%coverageof theirpopulation.Technical,managerial and financial supportwas given to countries towardseliminationof leprosyandmeasles,anderadicationof polioandguineawormdisease.ThroughtheRegionalStrategyonIntegratedDiseaseSurveillanceadoptedbytheRegionalCommitteein1998,andregionaleffortstobuildcapacityforepidemicpreparednessandresponseinthecountries,therehasbeenimprovementinprioritysetting,planning,resourcemobilizationandallocation,predictionandearlydetectionof epidemicsandmonitoringandevaluationof interventionprogrammes.Inaddition, collaborating with countries and other partners, new and under-utilized vaccines likeyellowfever,hepatitisBandpneumococcalmeningitisvaccineshavebeenintroducedandaremoreeffectivelyusedtoreducemortalityandmorbidityintheRegion.Appropriate treatment of common diseases and injuries

WHOhascontinuedtosupportcountriestoimprovethediagnosisandtreatmentof diseasesandinjuriesinaccordancewithimprovingtechnologyandintheefforttoimprovethemanagementof patients.Guidelinesandtoolstofacilitateidentificationof standardequipmentandotherapplicabletechnologieswereprovidedtocountries.Mostcountrieshavedevelopedtheirstandardtreatmentguidelines and, given the resource-limited context, have adapted the syndromic managementapproachinareaslikesexuallytransmittedinfections.

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TheRegionhasfacedproblemsof multi-drugresistanceintreatmentof tuberculosisandresistanceto first-line anti-malarial drugs. The DOTS approach has, to a great extent, ensured observedtreatmentandhencereducedthepotentialformulti-drugresistanceforanti-TBdrugs.Anumberof countrieshavehadtorevisetheirfirst-andsecond-linedrugsfortreatmentof malaria.

Provision of essential drugs

The‘‘provisionof essentialdrugs’’wasincludedastheeighthelementof PHCattheAlma-AtaConferenceonPrimaryHealthCare(PHC)in1978.In1981,theWHODirector-GeneralestablishedthethenActionProgrammeonEssentialDruginaccordancewithresolutionWHA32.41.

Concernedwiththecontinuedproblemof inequitableaccesstoessentialdrugs,Africanministersof healthtookmeasuresaimedatimprovingaccesstoessentialdrugs.Oneof themostimportantwastheBamakoInitiativethatwaslaunchedin1987.

Inordertofurtherincreaseaccessandpromoteequityof accesstoessentialdrugsinthecontextof nationalhealthpolicies,WHOwasrequested toassistMemberStates in the formulationandimplementationof comprehensivenationaldrugpolicies.Inresponsetothisrequest,thedocument‘WHOGuidelinesforFormulatingNationalDrugPolicies’wasproducedin1988.TheseguidelineswerefirstadaptedfortheAfricanRegionin1993anditscurrentversion(WHO/AFRO/EDP/01.5)waspublishedin2001.

Thirty-eightMemberStateshaveusedtheseguidelines,withWHOassistance,tostarttheprocessof formulatingorreviewingtheirnationaldrugpolicies,and33of themhaveofficialnationaldrugpolicies.Despitetheseefforts,over50%of thepopulationinsomepartsof theAfricanRegiondonothave regularaccess to themostbasic essentialdrugs, according toWHOestimates in1999.Thereasonsforthisincludeinadequatefinancingforhealthingeneralandfordrugsinparticular.Evenwhendrugsareavailable,weakregulatorycapacitymaymeanthattheyaresubstandardorcounterfeit,andthattheyarenotrationallyused.

Inviewof theaboveandinresponsetoresolutionWHA54.11,theWHOMedicinesStrategy2000-2003wasdeveloped.Thestrategyaimstosavelivesandimprovehealthbyclosingthegapbetweenthepotentialthatcanbeofferedbythedrugsandtherealitythattheyareunavailableorunaffordableformillionsof people.Thestrategyaddressesfourobjectives:policy,access,qualityandsafety,andrationaluse.Of these,thegreatestemphasisisonsecuringaccesstoessentialdrugsforpriorityhealthproblemslikemalaria,childhoodillnesses,tuberculosisandHIV/AIDS.

Accessisthecentralpillarof thestrategyandfourfactorsarecritical inensuringandexpandingaccess:rationalselectionanduse,affordableprices,adequatefinancingandreliableprocurementandsupplysystems,usingapproacheslikegenericandbulkprocurement.Itisexpectedthatemphasisonaccesswillmakethegreatestcontributiontowardsachievingthefirstsevenelementsof PrimaryHealthCare.

Traditionalmedicinemaintainsitspopularityforhistoricalandculturalreasons.InBeninandSudanforexample,70%of thepopulationrelyontraditionalmedicinewhile,inUganda,usersof traditionalmedicinemakeup30%of thepopulation.InGhana,Mali,NigeriaandZambia,60%of children

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with fever were treated with herbal medicines at home in 1998. Some countries in the AfricanRegion are producing, locally and on a pilot scale, various plant-based preparations for chronicdiarrhoea, liver disorders, amoebic dysentery, constipation, cough, eczema, ulcers, hypertension,diabetes,mentalhealthandHIV/AIDS.Someof thesemedicineshavebeenregisteredandincludedinthenationalessentialdruglists.Furthermore,WHOhasdevelopedframeworks,guidelinesandprotocolsforinstitutionalisingtraditionalmedicineinnationalhealthsystems,andtofacilitatetherationalassessmentof traditionalherbalmedicines.

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PHC RESOURCES

�.�: Health infrastructure

Anetworkof infrastructure to support servicedelivery in theareaof PHChasbeendeveloped.Depending on the country, this includes health posts, dispensaries, rural maternities and healthcenters,whichconstitutethefirstlevelof thereferralsystem.Theyplaytheroleof interfacebetweenthepopulationandthehigher-levelfacilitieslikedistrictandotherreferralhospitals.Thesestructuresserveabout80%of thepopulationbutregrettablyreceiveatbestonly20%of thefinancialresourcesof thehealthsystem(DialloI.;WHO,1993).Figure8,showingconsolidateddatafromthenationalhealthaccountsof somecountriesineasternandsouthernAfricaconfirmsthispoint.Theseprimarycarefacilitiescannotbythemselvesmobilizesufficientresourcestooperatewell.Theyareveryoftenshort of equipment, qualified personnel and are unable to undertake appropriate managementprocedures.Thedysfunctionof thesestructurescontributessignificantlytothepoorperformanceof thehealthsystemsnoticedinalmostallthecountriesof theRegion.

Despite calls to governments to allocate more resources for primary care, it appears that moreresourcescontinuetobeallocatedtohospitals (1stand2nd levelsof care) inmostcountriesof theRegion.

Itcouldbearguedthatdonorandprivateresources(householdsandfirms)compensateforthelowallocationof recurrentexpenditurebyministriesof healthtoprimarycare.TheavailableevidencefromsomecountriesintheRegion,however,doesnotsupportthisargument.Figure9belowshowsthatevenwhentotalexpenditureonhealthisdistributedbetweenalllevelsof care,thebulkof theresourcesinmostcountriescontinuetobespentatthehospital level.Thoughitcouldfurtherbearguedthathospitalsalsoprovideprimarycare,andarehence justifiedtoreceivemorefinancialresources,itshouldbenotedthatmosthospitalsintheRegionarelocatedintheurbanareaswhereonlyabout30%of thepopulationlive.

Itisevidentthatfinancialresourceshavenotkeptpacewiththeincreasingdemandsonhealthcareaswellas the intentof healthpoliciesregardingexpansionof healthservices,especiallyprimarycare,tobothurbanandruralareas.However,whenfinancialresourcesareavailable,allocationof resourcesaremorebiasedtowardsurbanareasandtertiarycarehospitalsandinstitutions.Althoughanumberof alternativefinancingandcost-recoveryschemeshavetosomeextentyieldedrevenue,theireffectonincreasingPHCresources,promotingequityandaccessibilityisstillnotclear.

Theimportanceof hospitals,whicharepartandparcelof thehealthsystem,needstobeunderscored,nonetheless.Theirkeyroleinprovisionof referralcare,developmentof humanresourcesforhealthintermsof trainingandsupervision,andinformationandresearchneedstobehighlightedasavitallinkwiththelowerlevelsinhealthcaredelivery.Despiteseeminglyconsumingthegreatershareof healthbudgets,hospitalsintheRegionarecommonlyfoundtobedilapidated,withoutequipment,drugsandotheressentialsupplies.

CHAPTER 6:

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Human resources for proper hospital management are also lacking. Thus despite consumingaround70%of nationalhealthbudgets,hospitalsremainunder-fundedandfailtoplaytheirroleeffectively.

Fig. 8: MOH recurrent health expenditure by level of care in the public health sector: 1997/98

Source: Eastern and Southern Africa NHA Network (2001): National Health Accounts in Eastern and Southern African., A comparative Analysis (unpublished report)

Figure9:Allocationof expenditurebylevelof care:Hospitalandnon-hospitalcare,1997/98.

Source: Eastern and Southern Africa NHA Network 2001: National Health Accounts in Eastern and Southern African Africa: A comparative Analysis (unpublished report)

Tertiary23%

Primary Care (non hosp)

25%

Mid level (2nd and 1st)

52%

0%

10%

20%

30%

40%

50%

60%

70%

Kenya Rwanda Ethiopia Uganda Malawi Tanzania SouthAfrica

Hospitals Primary Care (Non Hospital)

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�.� Human Resources

Healthpersonnelconstitute50-75%of recurrenthealthbudgetsinmostAfricancountriesintermsof salariesalone(WHO,2003a).Whileestimatesof healthpersonnelhavebeendifficulttoobtain(WHO,1998b),humanresourcedevelopmenthasremainedacriticalchallengeinimprovinghealthcaresystems(MartineauandMartinez,1998).

AllcountriesintheRegionhavemadeprimaryhealthcarethecornerstoneof theirgoalof attainmentof healthforall.Yet,only15countrieshavepreparedhumanresourcedevelopmentplans.Someof theseplansarenotcomprehensivesincetheydonotalwaysarticulatetraining,distributionanddeploymentof healthworkersinPHCatalllevelsinthehierarchicalstructureof thehealthsystem.Mostof thesecountries,however,havetrainedandutilisedcommunityhealthworkers(CHWs)andvillagehealthworkerstopromotethedeliveryof basic,cost-effectiveservicestothemajorityof thepeople.

Inspiteof governments’effortsindevelopinghumanresourcesitseemstobeinadequateatalllevels,andparticularlyinPHC.

The PHC progressive philosophy has implications on health personnel training and health carepractises. The PHC approach requires that health workers both adapt and change a range of traditionalattitudes,expectationsandopinions(Walker,1995).Indeed,manyhealthsystemsarestillbasedonadisease-curingmodelof service,relyingmainlyonhospitalsandtechnicalhealthstaff thattrytoresolvespecificdiseaseandillnessevents.Asaconsequence,trainingandeducationof healthworkersareelitistandhospital-focused.

CadresarethereforeprimarilynotappropriatelyequippedtodealwithpromotiveandpreventivecareinlinewithPHC.Thereisclearlyaneedforashiftfromthe“medicalparadigm”toa“healthparadigm”whichismoregearedtopromotionof healthandwell-being.

Although insomecountries likeCapeVerde, thehumanresources/populationratios formedicaldoctorsandnursescanbeconsideredgood, the shortageof trainedandqualifiedhealthhumanresourcesinAfricacontinuestobeamajorimpedimenttoPHCdevelopment.Thestaffingrequiredforoptimumrunningof healthunitshavenotbeenmet(seefig.10andtable4),andthishashinderedtheintegrationof activities.Anothermajordrawbackisthescarcityof healthpersonnelinpublichealth delivery systems, although African governments have tried to introduce policies to retainskilled staff. In Lesotho and Zimbabwe, for example, governments have implemented bondingwherebyworkersareobligedtostayintheirpositionsforanagreedlengthof time,whileNigeriaandZimbabwehaveraisedpublicsectorsalaries.

Thesituationof migrationwithintheRegionandtoabroadhasreachedcrisislevels.Forexample,60%of medicalgraduatesfromonecountrymigratedwithinafewyearsaftergraduation.(BundredP.E.,LevittC,2000).AstudydonebytheWHORegionalOfficeforAfricain2002(AwasesM.etal.,2003)showedthat26to68%of healthworkersinterviewedintendtomigratetoothercountries.Themainfactorsformigrationwerepoorsalaries,poorworkingconditions,lackof opportunitiesforprofessionaldevelopment,unclearcareerpaths,conflictsandwars.Migrationof skilledhealthworkershascontributedsignificantlytodeterioratingaccessandqualityof careintheRegion.

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Fig. 10: Trend in the population to Health Personnel Ratios 1979-1999 in Burkina Faso

Source: Rapports annuels statistiques sanitaires, DEP/santé, Burkina Faso

Table 4: Evolution of doctor/population ratios in five African countries from 1970 to 2003

YEAR 1970 1990 1995-1997 2000-2003

COUNTRY

BurkinaFaso 97120 57320 29412(1995) 27200(2001)

Mozambique 18860 36225 N.A. 25200(2000)

Niger 60090 34850 28571(1997) 35600(2002)

Rwanda 59600 72990 N.A. 20100(2002)

Uganda N.A. 22399 20000(1996) 44300(2002)

Source: WHO-AFRO, 2001 and WHO-AFRO database

Inaddition to the shortageof humanresources forhealth, there isoften inequitabledistributionof availablehumanresourcesinfavourof urbanareas.Thesituationof CentralAfricanRepublic,showninthetablebelow,isagoodexample.

206642015621434

46235

3657 2643 2747 2974

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

Years

Num

ber o

f per

sons

per

hea

lth w

orke

rMedical Personnel

Paramedical Personnel

1979 1989 1994 1999

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Table 5: Health Personnel/Population ratios in the Public Sector in Bangui compared to the rest of the country

HealthPersonnel

Bangui Restof Country

Doctors 1/12,031 1/57,316

SeniorHealthTechnicians 1/9,466 1/19,105

StateCertifiedNurses 1/4605 1/18,857

Midwives/NurseMidwives 1/6,776 1/28,987

TraditionalBirthAttendants 1/7,462 1/31,923

Source: MSPP / DEP 1995, RCA

In Niger, the breakdown by zone demonstrates the important disparities and confirms theconcentrationof healthpersonnelinurbanareas(seetable6).Forexample,60%of alldoctors,50%of allmidwivesand30%of allnursesinthecountryarefoundonlyinNiamey,thecapitalcityof Niger.

Table 6: Distribution of Health Workers by gender and by zone in Niger

Agadez Diffa Dosso Maradi Tahoua Tillabéry Zinder Niamey Total%

M F M F M F M F M F M F M F M F

Urban 94 60 65 29 104 82 114 105 127 76 53 36 172 168 660 851 2796 65%

Country- 26 37 43 22 134 89 191 76 163 93 160 146 222 132 1534 35%

side

Total 120 97 108 51 238 171 305 181 290 169 213 182 394 300 660 851 4350 100%

Source: Développement des resources humaines pour la santé, plan stratégique: 2000-2010, septembre 1999

Attemptshavebeenmadetochangetheattitudeof healthpersonnel towardsPHC.Thedistrictmedical officers (DMOs) and the district health teams, who are charged with the responsibilityof coordinating the PHC activities in the districts, have received more training in countries likeTanzania,Uganda,Kenya,ZambiaandZimbabwe.However,themajorityof healthworkersdonotpossesstheappropriateskillsorconceptualawarenessof thePHCapproach(TarimoandWebster,1994).Theexistinghumanresourceisthereforeindireneedof reorientationinPHCapproach.Theefficientdeliveryof healthservicesisdependentontheavailabilityof professionallyqualifiedandmotivatedpersonnel.

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WHO(1996)notes thatalthoughmanyactivitiesand training topromotebetternationalhealthmanagementhavebeenundertakeninmostcountriesof theWHORegion,noevaluationsof theirimpactisavailable.Particularattentionshouldbegiventothisissuetoenablepolicymakerstodesignsoundpoliciesandplansforthedevelopmentof humanresourcesthatareabletofullyparticipateinachievementof PHCgoals.

�.� Financial Resources

ThemajorsourceforfinancinghealthcaregoodsandservicesintheRegionisthegeneraltaxrevenuefromgovernment,whichcontributesonaverage42.6%of totalhealthexpenditure.Households,throughdirectout-of-pocketpayments,arethesecondsourcecontributinganaverageof 36.7%of thetotalhealthexpenditure.Donorsonlycontributeanaverageof 15%of totalhealthspending(WHO2002).

TotalhealthspendingremainscriticallylowintheRegionaveragingUS$32percapitain2000.ThiscomprisesonaverageUS$12.5governmentexpenditure,US$1.2donorfundstogovernmentandUS$16.8fromprivateexpenditure,whichincludedout-of-pocketsources.

Thetotalexpenditurerangesfromalowof US$3percapitainLiberiaandBurunditoahighof US$440percapitainSeychellesin2000.Only10countriesspendmorethanUS$30asrecommendedbytheCommissiononMacroeconomicsandHealthReportof 2001fortheprovisionof essentialhealthinterventions.

Much as there is inefficiency and inequity in resource allocation and utilization in most of thecountriesasnotedbythefewresourcesallocatedtoPHC,mostcountries’nationalhealthsystemsaresufferingfromabsoluteinadequacyof financialresourcesascanbeseenfromTable7.

Mostcountries inAfricaarecurrentlyfacinganarrayof healthcarefinancingandmanagementproblems. Increasingly, countries have been found to rely on direct out-of-pocket payments as ameansforpayingforhealthcaregoodsandservicesintheRegion(anaverageof 36.7%of totalhealthspendingin2000rangingfromahighof 73%of totalhealthspendinginNigeriatozeroinAlgeria).Althoughsuchalternativefinancingandcost-recoveryschemeshavebeenimplementedinmanyAfricancountries,theireffectonpromotingequityandaccessibilityof PHCisstill limited.Evidenceshowsthatdirectout-of-pocketspendingdissuadestheverypoorfromutilizinghealthcareservices(Creese1990,WHO2000a)andthemajorityof thepeopleintheAfricanRegionarepoor.Inaddition,53%and50.3%of totalhealthexpenditureonhealthin2000respectively,wasprovidedthroughdonorsupportinafewcountrieslikeMozambiqueandRwanda,whichraisesquestionsof sustainability.

Thus, unless massive resources are mobilised both from domestic and other sources, the poorhealthsystemsperformance in theRegionwillcontinueandtheachievementof theMillenniumDevelopmentGoalswillremainadream.

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Table 7: Health expenditure in the African Region, 2000 Country Per capita total Per capita general Per capita external Per capita private expsenditure on health government revenue resources for health to expenditure at average exchange expenditure on health* government at average on health** (US$) rate (US$) (US$) exchange rate (US$)

Seychelles 440 278 17 146SouthAfrica 255 108 0 148Botswana 191 118 2 71Mauritius 133 73 2 58Namibia 128 76 5 48Gabon 120 78 5 38Algeria* 64 19* 0 11Swaziland 56 39 1 16EquatorialGuinea 54 29 7 18Zimbabwe 47 20 3 25CapeVerde 30 16 5 9Lesotho 28 21 2 5Kenya* 28 3* 2 22Cameroon 24 5 1 18Angola 24 12 1 11Congo 22 15 0 7Senegal 22 10 2 9Zambia 18 8 4 7Côted’Ivoire 17 6 1 10Mauritania 14 6 5 3Guinea 13 6 1 6Comoros 13 5 4 4UnitedRepublicof Tanzania 12 4 2 6Rwanda 12 3 3 6Benin 11 4 1 6Malawi 11 1 5 6Gambia 10 5 3 2Mali 10 3 1 5Ghana 10 4 1 5Uganda 10 1 3 6Guinea-Bissau 9 4 2 3Eritrea 9 2 4 3Mozambique 9 2 3 3DemocraticRepublicof theCongo 9 6 0 2Nigeria 8 2 6 0BurkinaFaso 8 4 2 2Togo 8 3 1 4SaoTomeandPrincipe 8 2 4 3CentralAfricanRepublic 8 2 1 4SierraLeone 6 3 1 2Chad 6 2 3 2Madagascar 5 2 1 2Ethiopia 5 1 1 3Niger 4 1 1 2Burundi 3 1 1 2Liberia 3 2 1 0African region (Population weighted average) 32.1 12.5 1.2 16.8

Notes* Does not include social security/social health insurance in Algeria at US$33 and in Kenya at US$1 per capita. The population-weighted average for social security/social health insurance in the Region is US$1.6/capita.** Includes expenditure on health by Non-Governmental Organizations (NGOs), households (through direct out-of- pocket spending), private health insurance and firms/enterprises reimbursements to their employee and provision of health care in their own health facilities. Source: WHO NHA Data Base 2002 (WHO, 2003b).

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PHC MONITORING AND EVALUATION

Most countries have health policy documents emphasizing the importance of monitoring andevaluationof PHC.Theyoutlinetheneedtodefineclearhealthobjectivesandtargetsandtheneedforbaselinesurveys.Mostcountriesseemtohavedevelopedmonitoringsystemsatalllevelsof thehealthcaresystem.However,thedegreetowhichthesesystemsmonitorperformancecomprehensivelyatalllevels,fromthecentralleveltothecommunities,isquestionable.Inmanydevelopingcountriesreliabledataonhealthservicesarescantyand,whenavailable,areoftennotused(Kippet.al,1994).Engelkes(1993)notesthatmostPHCprojectshaveinternal,sometimesverticalmonitoringsystems,andthatcomprehensiveandfunctionalhealthinformationsystemswerenotpresent.

InNiger,theorgansforfollow-up,monitoringandevaluationenvisagedinthehealthdevelopmentplanof 1994-2000include(1)thenationalhealthcommitteeandthenationalinter-sectoraltechnicalcommittee forhealthatnational level, (2) two inter-sectoral organs at regional level, namely theDepartmentalTechnicalCommitteeand theDepartmentalTechnicalCommittee forHealth, (3)theDistrictHealthCommitteeandthetechnicalcommitteeatdistrictlevel,(4)HealthManagementCommitteeatthehealthcentreleveland(5)theVillageHealthCommittee.

ThreePHCevaluationshavebeencarriedout inBotswanaduring1985,1991and1994 (WHO1994b). Progress is monitored at the facility, health district or national levels. However, majorproblemsinherentinthemonitoringandreviewprocessinBotswanainclude:-(i)untrainedstaff intheresearchandstatisticalunits;(ii)resignationortransferof relativelywell-trainedpersonnel;and(iii)shortageof datamanagementfacilitiesatthefacility,districtandnationallevels.

AnationalhealthinformationcentrehasbeeninplaceinNigeriaatthefederallevelsince1988.ThiscentrewasdevelopedbytheDepartmentof Planning,ResearchandStatistics.Inaddition,thePrimaryHealthCareDepartmentof theFederalMinistryof Healthhassetupamonitoringandevaluationdivision(WHO,ibid).Theobjectivesof themonitoringandevaluationdivisioninclude:(i)toassesscurrenthealthstatusinallLGAsinthecountry;(ii)todevelopthesystemof datacollectionforusenationwide,atthecommunity,LGAs,Stateslevels;(iii)tomonitorprogressinimplementationof PHCinNigeria;and(iv)toprovidedatatohealthsectordecisionmakersforallocationof fundsandrunningof effectiveprogrammes.

InTanzania,PHCreviewshavebeendonejointlywithDANIDA,SIDA,UNICEF,SCF,andWHO(InformationfromMinistryof Health,Tanzania).Theobjectivesof thereviewsinTanzaniawere:(i)toassessprogressandpresentstatusof PHCimplementation;(ii)todeterminetherelevanceof thepresenthealthpolicies,plansandprogrammes;(iii)toidentifytheprioritiesforappropriatesupportof each sector toPHCand (iv) todetermine the relevanceof support fromabroad.Apart fromthesereviews,itisevidentthatTanzaniadoesnothaveaPHCmonitoringandevaluationsysteminplace.

CHAPTER 7:

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Literaturereviewindicatesthatalthoughcountrieshavebeencarryingoutreviews,inmanyinstancestheywereinitiatedbyinternationalagenciessuchastheWHO(WHO,1994b;WHO,1996).Thelack of systematic baseline data or information to conduct evaluations has also hampered theprocess.TheliteraturereviewfurtherindicatesthatWHOhasdevelopedguidelinesforPHCreviews(HammadandSmith,1992).7However,thestandardapplicationof theseguidelinesinevaluatingPHCisnotevident.

Engelkes(1993)reviewedthelessonslearntfromevaluatingPHCprojectsbasedonthreesources:areviewof 83evaluationreportsfrom18donors;casestudyof threesuccessiveevaluationsof onePHCproject;andtheauthor’sownexperienceinevaluatingPHC.Fromthesehemadethefollowingconclusions:

Evaluationteammemberswererarelydescribed,asresultnoclearideacouldbeobtainedof their background, expertise or nationality. In addition, representatives of the recipientcountrywereincludedintheevaluationteamsinonly11of the43reportssubmitted.

Manyevaluatorscomplainedaboutalackof baselinedata,whileprojectobjectivesweretoovagueortooambitioustouseasacriteriaforevaluation.

Fewof theevaluatedprojectshad inbuilt systems forevaluationandmonitoring,althoughthesehadoftenbeenplannedwhentheprojectswereformed.

Donorsusuallydrawmostof thetermsof referenceforPHCevaluationsandthusevaluationcriteriaaremainlydonor-oriented.Evaluationshavebeentooconcernedwiththeformatof reportingthanwithmethodology.Inaddition,notalldonorshaveguidelinesforevaluations.

Key members of two major European bilateral aid agencies, which fund numerous evaluationsof PHCprojects indevelopingcountries,revealedthat it is likelythatexpensive, ill-designedandinappropriatehealth impactevaluationswillcontinuetobe implemented.This isduetopoliticalpressures,whichignoretheconceptualandmethodologicalproblemsassociatedwithsuchevaluations(ScrettenbrunnerandHarpham,1993).

7 Bindari-HammadA.&SmithD.L.(1992),PrimaryHealthCareReviews.GuidelinesandMethods.WHOPublication.

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HEALTH TRENDS AND CHALLENGES

Inthemajorityof Africancountries,healthreformshavebeenimplementedanddecentralizationhas strengthened district-level capacity to manage health services. Participatory structures withcommunity involvementhavebeencreated,and theconceptof healthcarepackagesdeveloped.Countrieshaveachievedsomeresultssuchasimprovementtoaccesstohealthservicesandinsomehealth indicators such as life expectancy and under-five mortality. However, the socioeconomicenvironmentsuchastheincreasingpoverty,growingimpactof theHIV/AIDSepidemic,increasedburden of care on the health system, communities and households, has not been conducive toachievinggreatsuccessinthepeople’shealthstatus.Inaddition,lackof accesstoeducation,water,sanitation,andincreasedfoodshortagesandsocialconflictshaveresultedinworseningthehealthstatusof thepeople,particularlyof womenandchildren.

Theeffortsputinhealthsectorreformshaveyettoshowsubstantialimprovementsinthedeliveryof services. Access to quality health services remains an overriding concern especially for poorhouseholdsandruralcommunities.

Thesectionbelowattemptstogiveageneraloverviewof thehealthtrends,includingtheleadingcausesof morbidityandmortalityfrombothcommunicableandnoncommunicablediseases,andgivessomeindicatorsrelatedtothepopulation’shealthstatus.

�.� Disease-specific morbidity and mortality

Thetenleadingcausesof morbidityinmostcountriesareattributabletocommunicablediseases,somenoncommunicablediseasesandtoperi-natalcauses,mostof whicharepreventable.

�.�.� Communicable diseases

Whilethenumberof reportedcasesforsomediseaseslikemeasles,bilharzia,dracunculosis,leprosy,onchocerciasisandpoliohasdecreased,significantincreaseswerenotedformalaria,HIV/AIDS,TB,choleraandotheremergingdiseases.

Theseincreasesarethoughttobepartlyduetotheweaknessof thehealthsystemandunfavorablesocial,environmentalandeconomictrendsaswellasarmedconflictsandnaturalandman-madedisasters.Consequently,communicableandhighlyinfectiousdiseasesstillremaintheleadinghealthprobleminAfrica,accountingfornearly70%of thediseaseburden(WHO,2000a).8

CHAPTER 8:

8 SeeAnnexTable4inWHO(2000),TheWorldHealthReport2000.HealthSystems:Improvingperformance.

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Thisreportfocusesontheleadingcausesof morbidityandtheirtrends.Althoughtherearesomevariationsfromcountrytocountry,theleadingcausesof morbidityaremalaria,HIV/AIDS,TB,cholera,respiratorydiseases,diarrhoea.

Malaria

Malariaremainsoneof thetoptwocausesof mortalityandmorbidityinAfrica,withmorethan500millionclinicalcasesrecordedannually.Thediseasekillsonemillionpeopleannually,mostlychildrenandpregnantwomen

Figure 11: Distribution of Endemic Malaria

Source: MARA/ARMA collaboration (Mapping Malaria Risk in Africa), July 2002

About90%of allmalariadeaths in theworldoccur inAfrica, southof theSahara (TheAfricaMalariaReport2003).WHOnotes thatmalariaaccounts forabout30-50%of fevercases,30%of all outpatient consultations and 10-15% of hospital admissions in endemic countries (WHO,2000b).

AccordingtoUNDP(UNDP2001),malariacasesregisteredper100,000peoplein1997wereashighas37,458inZambia,26,217inNamibiaand11,941inGhana.Accordingtotheresultsof theMultipleIndicatorClusterSurvey (MICS) intheCentralAfricanRepublic (MPCI/UNICEF,Bangui2001),theprevalenceof malariawas25.8%in1996and31.8%in2000atthenationallevel,whilerangingfrom24.1%and42%fromonehealthdistricttoanother.However,inruralareaswithlittleaccesstoadequatetreatment,theratesmightbeevenhigher.Sincethe1980s,therehasbeenanotableincreaseinthenumberof casesanddeathscausedbymalaria,whichispartlyattributedtotheemergenceof newstrainsof theparasitethatareresistanttodrugssuchaschloroquineaswellasineffectivecontrolmeasures.

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Asaresult,chloroquinehashadtobereplacedwithmoreexpensivedrugssuchasSulfadoxine/Pyrimethamine,thustakingtreatmentoutof reachof themajoritypoorpopulations.Thistrendhascontinuedtochallengecountries’abilitytotacklemalaria,giventhelowlevelsof resourcesavailableforhealth.Ananalysisof datafrom31Africancountriesduringtheperiod1980to1995showedthattheannuallossof economicgrowthduetomalariawasashighas1.4percentperyear(WHO,ibid).InAfricasouthof theSahara,thedecreaseinall-causeunder-5mortalityseeninthe1970sand1980sleveledoff inthe1990s.

Countries such as Botswana, Kenya, Malawi and Zambia have updated their anti-malaria drugpolicy,whilecountriessuchasDemocraticRepublicof Congo,Namibia,Nigeria,Rwanda,Tanzania,UgandaandZimbabweareintheprocessof doingso(WHO,2000c).

Theincreasingincidenceof malariacasesandtheresistantstrainsof malariaposeabigchallengeinPHCimplementationinAfricancountries.Malariahascontinuedtoproduceconsiderableadverseimpactonthehealthof themajorityof thepopulationandconsumesalotof governmentresources.Consequently, all countries in the Region are committed to the Roll Back Malaria programme,whichaimstohalvethemalariaburdenby2010.

HIV/AIDS

Theoutbreakof HIV/AIDSintheearly1980sdrasticallychangedtheepidemiologicalprofileof countriesinAfrica,especiallythoseineasternandsouthernAfrica,withthepandemicbecominganunprecedentedthreattoregionaldevelopment.Currently,about25.3millionadultsandchildreninAfricaarelivingwithHIV/AIDS,outof theworldtotalof 36.1million(UNAIDS,2000).Figure12showsthecumulativereportedAIDScasesinsub-SaharanAfricaduringtheperiod1982-2000.SouthernAfrica (SouthAfrica,Botswana,Zimbabwe,Malawi,Lesotho,Swaziland,NamibiaandMozambique)accountedfor38.3%of theinfectionsinthecontinentin1999,whileUganda,Kenya,Tanzania,Ethiopia,Rwanda,CameroonandDemocraticRepublicof Congocontributed37.8%,andNigeria,Ghana,Coted’IvoireandBurkinaFasocontributedanother16.9%.

Figure 12: Cumulative Reported AIDS Cases – Sub-Saharan Africa, 1982-2000

Source: HIV SurveillanceReportforAfrica2000,WHO/AFROSource: HIV Surveillance Report for Africa 2000, WHO/AFRO

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Africa has also registered the highest adult prevalence rates in the world with countries such asBotswana, Zimbabwe, Swaziland and South Africa having higher prevalence rates averaging ataround38%,34%,33%and20%respectively,ascomparedtocountriesincentralandWestAfricawhoseprevalencerangedfrom0.1%inAlgeriato12.9%inCentralAfricanRepublic(Fig.13).HIV/AIDShascontinuedtohaveasubstantiallynegativeimpactonanumberof countries.Seventeenof theeighteencountriesinsub-SaharanAfrica(SSA)thatexperiencedadecliningorstagnatinglifeexpectancyduring1990-1995weredescribedtohaveageneralizedHIV/AIDSepidemic,withHIVprevalencerateof morethan5percentamongadultpopulation.

Fig. 13: Adult HIV/AIDS Prevalence Rates 2001 in Selected Countries

Inthesameyear,about530,000HIV-infectedchildrenwereborninsub-SaharanAfrica,causinghighchildmortalityrates.UNAIDS(ibid)estimatesindicatethat,by2005-2010,infantmortalityincountriessuchasSouthAfricawillbe60percenthigherthanitwouldhavebeenwithoutHIV/AIDS.InZambiaandZimbabwe,25percentmore infantsarealreadydyingthanwouldhavebeenthecasewithoutHIVandUNAIDSestimatesindicatethatby2010,Zimbabwe’sinfantmortalityrateswouldhavedoubled.However,countriessuchasKenya,Senegal,SouthAfrica,Uganda,Tanzania,Zambia,andZimbabwehavedevelopedandadoptednationalHIV/AIDScontrolprogrammestoensureeffectivecontrolandpreventionof thespreadof thevirus.Forexample,Uganda,whichhadthehighestHIVprevalenceratein1993,hasmadecommendableprogress,withratesdroppingfrom

Source: UNAIDS, UPDATE 2002 by country

0.1

3.6

38.8

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12.93.6

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33.4

7.8

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33.7

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Togo

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Prevalence rate (%)

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30%in1992,to14%in1995andreachingabout8%in2000,whileSenegalhasmaintainedthelowrateof infection(UNAIDS,ibid).Figure14demonstratesthetrendof adult(15-49years)HIVprevalenceinaselectednumberof countriesintheRegionbetween1997and1999.

Figure 14: Adult HIV Prevalence in Selected Countries, 1997 & 1999

Data source: UNAIDS/WHO Report on the Global HIV/AIDS Epidemic June 1998 & UNAIDS Report on the Global HIV/AIDS epidemic June 2000

The results of the 2000 MICS survey in Central African Republic show that the prevalence of HIV/AIDSatnationallevelwas14%;therateamongpregnantwomenvariedfrom5.3%to22%;inBanguiitvariedbetween12%and30%.Whereasstudiesconductedasearlyasthe1980sfoundHIV prevalence among sex workers to be over 30%, sex workers in Cote d’Ivoire had an HIVprevalenceof 83.8%in1992;thoseinBurkinaFasohadHIVprevalenceof 59.2%and31%-55%in1994and2000respectively.InBeninin1996sexworkers’HIVprevalencerangedfrom38.5%to85.4%.AUNAIDSmulti-centrestudyin1997/1998foundanHIVprevalence,amongsexworkers,inYaounde,CameroonandCotonou,Beninof 33%and57%respectively.

The increasing HIV/AIDS prevalence rates are threatening the commendable achievements of PHC.Asover80percentof deathshaveoccurredamong20-49yearolds,theepidemicisoffsettingdecadesof improvementinlifeexpectancyinseveralAfricancountries(UNAIDS,1998).HIV/AIDSfeaturesnowamongthefirsttwotothreecausesof morbidityandmortalityinmanycountries.Thechronicnatureof theproblemandlackof curehaveposedabigproblemtothehealthsystems,whichalreadyareunabletocopewiththemanagementof acuteinfections.AIDScasesareabigworryfortheservices,staff,familiesandthecommunities.Measurestomobilizeresourcesfromdifferentsectorsandinstitutionsshouldbetargetedinordertocontroltheepidemic.Inthisregard,AFROadvocates a multi-sectoral involvement through the HIV/AIDS Strategy in the African Region:Strengtheningthehealthsectorresponse.Thisisduetotherealizationthatthehealthsectoralonecannotcopewiththeburden.

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Tuberculosis

TuberculosishasbecomeamajoropportunisticinfectionamongpeoplelivingwithHIVinfection,becauseHIVhasbeenthemainthrustbehindtheupsurgeof tuberculosisincidenceandmortalityindevelopingcountries inrecentyears (Path,1999).Although tuberculosiswasonceregardedasvirtuallyundercontrol,reportedcasesinAfricahaveincreasedfrom219,802in1980to811,172in2001, as shown in figure15 (WHOReport2003GlobalTuberculosisControl,WHO/CDS/TB/2003.316).Themortalityassociatedwithtuberculosishasreachedabout3.1millionpeopleayear(WHO,1996).

Figure 15: Reported TB Cases in Africa, 1980-2001

Data source: WHO Report 2003 Global Tuberculosis Control (WHO 2003c)

CountriessuchasKenya,Nigeria,SouthAfrica,Tanzania,UgandaandZimbabweareamongthe22highest-burdencountriesintheworld,accountingfor80percentof allnewTBcases.Thedualepidemicsof HIVandtuberculosishaveaddedtothediseaseburdenof peoplelivingwithHIV/AIDS.Approximately40percentof allHIV/AIDSdeathsinAfricaresultdirectlyfromtuberculosis.In Zambia, for example, tuberculosis admissions have doubled since 1994 due to its associationwithHIVinfection(Kasonde,et.al1994).ItisalsoevidentthatcountriesthathadhighHIV/AIDSprevalenceratesby2001(Fig.13)alsoregisteredincreasedcasesof tuberculosisper100,000peopleinthesameyear.Forexample,Namibiarecorded628cases,Zimbabwe437caseswhileBotswana,SwazilandandSouthAfrica recorded619,653, and339 casesper100,000 respectively.On theotherhand,countrieswithrelativelylowerprevalencerateslikeAlgeriaandSenegalreportedonly59and89casesper100,000people, respectively. Incidenceof resistance todrugs is challengingdiseasecontrolmeasures.ConcertedeffortsarethereforenecessarytoaddressHIV/AIDSaswellastuberculosisinPHCimplementation.

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Cholera

Cholerahas re-emergedas a result of environmental degradation and breakdown of water andsanitationinfrastructure.

Increasingoutbreaksof cholerawerenotedinthe1990sinmostcountriessuchasBenin,Botswana,BurkinaFaso,Comoros,Ghana,Kenya,Madagascar,Niger,Tanzania,UgandaandZambia. Intheyear2000,theglobalnumberof casesofficiallynotifiedbyAfricancountriesdecreasedby42%comparedto1999(WHO,2000b).However,thesamereportnotesthattheofficiallynotifiedcasesdonotreflecttheoverallburdenof thedisease,owingtounderreporting.

TheWHOepidemiologicalrecordshowsdeclineincholeracasesreportedfromeastAfricancountriesand,comparedto1999,and85%decrease incumulativecholeracases forMalawi,ZambiaandZimbabwe.While thenumberof reportedcases remainedstable inGuineaand theDemocraticRepublicof Congo,therewasanincreaseinComorosandMadagascar.SouthAfrica,forexample,whichhadnothadanoutbreaksince1987,recordedamajoroutbreakinKwazulu-Natal,whichstartedinAugust2000.

Acute Respiratory Infections (ARI)

Acute Respiratory Infections are one of the principal causes of morbidity and mortality amongchildrenbelowageof 5.Ataprevalenceof 15.4%inCentralAfricanRepublic,accordingtotheresultsof theDemographicandHealthSurveyof 1994-1995,ARIisoneof thetopcausesof deathsamongchildrenbelowtheageof 3.Childreninruralareasaremoreaffected(11.7%)comparedtothoseintheurbanareas(8.0%).

Diarrhoeal DiseasesDiarrhoealdiseasesarestillamongthetopcausesof childhoodmortalityandmorbidityincountriesintheAfricanRegion.TheprevalenceintheCentralAfricanRepublicwas25.7%atnationallevel,27%inruralareasand23.8%intheurbanareas(MPCI/UNICEF,Bangui2001).Thelevelof useof OralRehydrationSalts(ORS)incasesof diarrhoeawasfoundtobeverylow,32.4%onaverageintheRegion(15.1%inBurkinaFaso,21.9%inCameroon,22.7%inCôted’Ivoire,17.1%inTogo,26.6%inSenegal(Barréreertal.1999).

Poliomyelitis

Considerable progress has been made in the control of poliomyelitis worldwide. In the AfricanRegion,thenon-polioAcuteFlaccidParalysis(AFP9)rate,whichistheproportionof AFPcasesthatarenotcausedbypolio,improvedfrom0.3in1998,to0.8in1999.

9 AcuteFlaccidParalysisreferstoacuteonsetof focalweaknessorparalysischaracterizedasflaccid(reducedtone)withoutotherobviouscauseinchildren<15yearsold.Itisanindexusedtomeasuresuccessof poliodiseasesurveillance.

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Figure 16: Progress towards poliomyelitis eradication, 1988 – end 2000

Source: Global Polio Eradication Progress 2000, WHO/POLIO/01.03

Thirteenof the46countriesintheRegiondetectedwildpoliovirusincirculationin2000,reporting1,763poliocasesof which144hadlaboratoryconfirmation.Byendof 2000,polioviruscirculationwasconfinedtowestandcentralAfricaandtheHornof Africa,asshowninfigure16.

Dracunculiasis (Guinea worm)

Countries in theAfricanRegionachievedanoverall reduction in incidenceof Guineawormof almost80%intheperiod1992-2000(seefigure17).However,in2000allreportedcaseswerefromsub-Saharan Africa, totaling 75,223 of which 20,333 were from the African Region. The mostendemiccountriesintheRegionremainNigeriaandGhana.

Figure 17: Guinea Worm Case Trend in the African Region, 1991-2000

Data Source: Weekly Epidemiological Record No.18. 2001,76

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Emerging Diseases

Emerging diseases constitute a serious challenge to PHC implementation because their causes,mechanismof transmission,preventionandtreatmentareunknown.Thisthereforecallsforahealthsystem thatcanadjust rapidly inorder to respond.Unfortunately,however,mostnationalhealthsystemsareresource-weak,withdilapidatedinfrastructure,andunabletoplaytheirproperpublichealthroles.

Therehavebeenepidemicsof EbolahemorrhagicfeverinCôted’Ivoire,Gabon,theDemocraticRepublicof Congo,theRepublicof Congo,SouthAfricaandUganda.TheepidemicintheRepublicof Congoreached143casesbyMay2003,including128deaths.TheepidemicinGabonin1997was60cases,including48deathswhilethe2002epidemictollreached60cases,claiming50deaths;andbetweenAugust2000andJanuary2001,atotalof 396caseswith150deathswerereportedinUganda.

Theotherepidemicwasmeningococcalmeningitis.Thedistributionof meningococcalmeningitiscasesismainlylimitedtothe“MeningitisBelt”of Africa,anareathatextendsfromSenegal,ontheWestAfricancoast,toEthiopiaintheHornof Africa.Inthelastdecade,itisestimatedthatover700,000casesof epidemicmeningococcaldiseaseoccurredwithanoverallcasefatalityrateof over10%.Duringthefirst8monthsof 2000,36,194caseswerereportedwiththehighestnumberof casesrecorded inBurkinaFaso (CommunicableDiseasesEpidemiologicalReportN°0003September,2000,WHO/AFRO)

In1989,HepatitisCwasidentifiedasthemostcommoncauseof hepatitisfollowingbloodtransfusion,whichisestimatedbyWHOtobeinfectingupto3%of theworldpopulation.

�.�.� Noncommunicable diseases

Apart from the acute microbial and parasitic diseases, the health sector has been challenged bytherisingburdenof noncommunicablediseases,includinginjuriesandaccidents,mentaldisorders,cancer,cardiovasculardiseases,respiratorydiseases,diabetesandotherdegenerativediseases.ThishasbeenpartlyattributedtochanginglifestylesinAfricancountriescombinedwithunhealthylivingconditions,violenceandwars,whichhaveprovidedasolidbaseforincreaseinincidencerates.Theincreasingburdenof NCDshasseverelyinflictedagreatburdenonPHC.AFRO(2000)estimatesthatif noncommunicablediseasesarenotcontained,theywillaccountforsixtypercentof deathsinAfricabytheyear2020,comparedtoforty-onepercentin1990(WHO2000d).

CancerouspathologyisalsoapublichealthproblemintheAfricaRegion.Cervical,liverandbreastcancersarecommonamongwomenwhileliver,prostateandstomachcancersarecommonamongmen.Cancerof thelungsandesophagusarealsofrequent,especiallyinsouthernAfrica,wheretheyarelinkedtotobaccouse.

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Arterial hypertension is the most common form of cardiovascular disease, with prevalence ratesexceeding10%,incertainurbanareas.Onepercentof theruralpopulationand2to3percentof theurbanpopulationinsomecountriesinAfricasufferfromdiabetes.

InAfricaasawhole,rheumaticfeverandrheumaticheartdiseasearemajorcausesof prematuremortalityandaccountforone-thirdof allcardiacdiseasesadmittedtohospitals.

Theprevalenceof malnutritioninWestAfricaaveraged17.91%amongchildrenunderfiveyearsof agein1998-1999(EnqûetesdémographiquesetdeSantéenAfriquedel’ouest,1999;Senegal1997).Interventionsinthisareaareverylimitedandoftencoveronlysmallportionsof thepopulation.

Accordingtoadraftpaper“AfricaBureauResultsPackage:nutrition,October,1998”producedbytheAfricaBureau’sOfficeof SustainableDevelopment (AFR/SD), it is currently estimated thatmalnutritionisanunderlyingcauseof nearlytwomillionchilddeathseachyearinAfrica.Accordingtothesamereport,micronutrientdeficienciesaffectmillionsof sub-SaharanAfricanmen,women,andchildren.Approximately,23%of thetotalpopulationwasatriskof iodinedeficiencydisordersin1997.Aboutone-thirdof allchildrenunder-five,nearly40%of allwomeninreproductiveage,andhalf of allpregnantwomen suffer fromanemia.Overall,malnutrition isalsoanunderlyingfactor in three out of the five major causes of maternal death in Africa. Malnutrition increasesillnessfrequencyandseverity,theneedforhealthcare,andsubsequentmortality,especiallywhenappropriateservicesandtreatmentarenotavailableorutilized.Theshort-andlong-termimpactsof childmalnutritionincludeunacceptablelevelsof diseaseanddeath,poorschoolperformance,andstuntedphysicalandmentaldevelopment.

�.� Health Status Indicators

�.�.� Infant mortality

Healthindicatorsinmostcountrieshaveshowntremendousimprovementswithcertainindicatorssuchasinfantmortalityshowinglowerfiguresin1999comparedtothirtyyearsago.Althoughtheinfantmortalityrateshavecontinuedtodropovertheyears,thepaceof declinehasbeenlaggingbehind,comparedwithotherRegions.

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Fig. 18: Infant Mortality Rates (per 1,000 live births), 1970 and 2000 - Selected African Countries

Source: UNDP, Human Development Indicators, 2002

Infantmortalityratesarestillhighandaveragingabove100per1,000livebirthsincountrieslikeMalawi,Nigeria,SierraLeoneandZambia.Theabovetrendscouldbepartlyexplainedbypoorenvironmentalconditions,scarceresourcesforcareduringpregnancyandchildbirthandthehighprevalence of communicable diseases. WHO (ibid) estimates that HIV/AIDS is likely to negateanysignificantprogressmadeininfantmortalityreduction.IncountrieslikeMalawi,SouthAfrica,Zimbabwe,Tanzania,Uganda,andZambia,theestimatedinfantmortalityrateshaveincreasedby40percentasaresultof HIV/AIDS(UNICEF,1998).

�.�.� Under-fi�e year old mortality

The most noted improvement is the decline in mortality among the under-fives in the majorityof countries over the years. This could be attributed to increased coverage of immunizationprogrammes, enhanced environment programmes such as safe water and sanitation and otherhealth-relatedaspects.

143180

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Sierra LeoneSouth Africa

SwazilandTogo

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Infant mortality rates per 1,000 live births

1 970 2000

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Fig. 19: Under-five Mortality Rates (per 1,000 live births), 1970 and 2000 - Selected African Countries

Source: UNDP, Human Development Indicators, 2002

Between1970and2000thereisnosignificantimprovementinreductionof under-fivemortalityinSierraLeone,AngolaandRwandawhile,forthesameperiod,countriessuchAlgeria,Benin,Congo,Ghana Kenya, Namibia and South Africa have experienced some progress and their under-fiveinfantmortalityhasdroppedsignificantly.

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Under-f ive mortality rates per 1,000 live births1 970 2000

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Figure 20: Trends in all-cause, under-five mortality in Africa

Themostimportantdeclineinunder-fivesmortalityisobservedinsouthernAfrica,followedbytheCentralandEasternRegions.Eventhough, there isan improvement, theratesarestillhighandunacceptable.

�.�.� Maternal mortality

Figure 21: Maternal Mortality Ratios reported (per 100,000 live births) for 2001

Source: MOH of Member States, Update 2001

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Maternal mortality ratios per 100, 000

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Maternalmortalityrateseitherremainedthesameorincreasedinallsub-SaharanAfricancountries.CountrieslikeSierraLeone,Angola,andMalawihaveamaternalmortalityratioper100,000of upto1,000(1800and1500respectivelyforSierraLeoneandAngola).Onlyfewcountries(Algeria,SouthAfrica,Namibia,andSwaziland)havelessthan300deathsper100,000livebirths).

Despite recent gains such as thedecline in fertility and increase in contraceptiveuseprevalencerate in many African countries, reproductive health eludes many women in the continent. Thehigh maternal mortality is essentially due to complications related to pregnancy and childbirthsuchashemorrhage, sepsis,eclampsia,obstructed labour,unsafeabortion,anemia,etc.Shortageof qualified health workers, basic supplies, equipment and drugs limit ability of health facilitiesto provide effective services, especially in handling obstetrics complications. In addition, accesstoyouth-friendlyservices is limited.Thereproductiverightsof womenandyouthcontinuetobehinderedbyharmfultraditionalpracticesinmanyAfricancountries.FemaleGenitalMutilationisamajorhindrancetotheempowermentof women.

�.�.� Life Expectancy

ThepoorhealthinvestmentsaremirroredinthelowlifeexpectancyintheAfricanRegion.Theaveragelife expectancy in sub-SaharanAfrica isonly48.7yearsalthough thenumbers vary significantly(SierraLeone39years,CapeVerdealmost69years)anditisover50yearsinafewcountries,forexample Ghana 57, South Africa 56, Benin 54, Kenya 52, Lesotho, Congo, and Swaziland 51,Cameroon50,accordingtotheUNDPHumanDevelopmentReport,2001.Accordingtothesamereport, life expectancy has declined most dramatically in Zimbabwe falling from 56 to 43 yearssincetheendof the70s.BotswanaandZambiahaveexperienceddeclinesof nineandsevenyearsrespectively,whilesmallerreductionsareevidentinNamibia,BurundiandMalawi.Themainfactorforfallinglifeexpectancyis,of course,HIV/AIDS.

Theobjectiveof 60yearslifeexpectancyatbirth,thatwastoberealizedineverycountryin2000,wasachievedonlyinCapeVerdeandAlgeria(WHO,WorldHealthReport2000).

Theimplementationof PHCcertainlycontributedtothereductionof someof thediseaseburdeninasignificantway,butthisreductionremainsstillveryinsufficientand, insomecases,hasbeenreversed.Mostof thehealthindicatorshavenotachievedtheHFAtargetsfortheyear2000,andinfant,childandmaternalmortalityareregisteringhighfigures.

Recognizingthechallengesthatthehealthsectorisfacinginthecountriesof theRegion,aHealth-For-Allpolicyforthe21stCenturyintheAfricanRegion:Agenda2020wasadoptedbythe50thsessionof theRegionalCommittee.Itsvisionwastoovercomediseasesrelatedtopoverty,exclusionandignorancewithinacontextof goodgovernanceandautonomousdevelopmentof apro-activehealthsystemfordecentandworthyliving,bytheyear2020.AchievingthisvisionisabigchallengefortheAfricanRegion.

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�.� Constraints and Opportunities

Although the PHC approach has led to many interpretations in policy development and itsimplementation,itisevidentthattheinitiativeshavenotbeenwellintegrated.Thereviewdemonstratesthatcountriesarefacingsimilarconstraints,regardlessof thedevelopmentof PHCpoliciesortheinstitutionalframeworksinplace.Thesectionbelowbrieflydiscussessomeof theconstraintsandopportunitiesthatareevidentinthedevelopmentandimplementationof PHC.

Constraints

Thereseemstobeagenerallackof sharedunderstandingof thePHCconceptsamongthepolicymakers,healthworkersandthecommunityatlarge.Despitetheexistenceof PHCpolicyformulationmechanismsinmostcountries,nocommonfronthasbeenevolvedfortheimplementationof thestrategies. In somecases, therewereno institutionalized legal frameworksgoverningPHCpolicyformulationthatrequiredparticipationof thehealthandallhealth-relatedsectors.

Thesuccessivecrisesof the80sand90saggravatedthecapacitiesandlimitationsof thepublicsectortorespondtotheneedsof thepopulations.Itthusbecameinevitabletoidentifyotherpartnersinhealthcaredelivery,notablythenon-profitprivatesector,whoseknow-how,determination,ingenuityand flexibilitymade themtoaccumulate spectacularlypositive results.The involvementof otherpartnershoweverdidnotgowithoutproblems.TheNGOs,forexample,thoughverydynamicinthehealthsector,veryoftendidnothavetherequiredresourcesandhadlimitedcapacitytoinfluencethedecisionsof politicalandtechnicalauthorities.

Despitegovernments’commitmenttoimplementhealthsectorreforms,suchasdecentralizationof healthservices,thedecentralizationof resourceallocationandplanningtothedistrictshasnotbeenfullyachieved,leavingthelowerstructuresasmererecipientsof guidelinesandinstructions.

The right to health mentioned in the constitutions of the concerned countries were very oftenconfusedwithfreehealthcare.Oneof thefundamentalresponsibilitiesof anygovernmentiscertainlythe settingupof ahealth systemable toguaranteeuniversalaccessof thepopulation toqualityhealthcare.Thisdoesnothowevermeanthatthecarehastobefree.Worsestill,theregulationsinforceinthesecountriesrequiredthatmoneycollectedbyandfromStatestructuresbepaidbacktothetreasuryandthatexpendituresweretobefromapprovedbudgets.Intheseconditions,revenuelocallygeneratedcouldnotbeuseddirectlyatthepointof collection.

Despite having developed mechanisms for inter-sectoral collaboration within the ministries,poor coordination among different health providers such as donors, NGOs, private sector andthe communities remained evident. Furthermore, collaboration with other ministries such asenvironment, water, and agriculture, was not fully realized, resulting in fragmentation of effortsthroughmanyverticalprogrammes.

AlthoughdonoragenciescontributedinimplementingPHC,sometimestheireffortswerenotwellcoordinated.Insomecountries thedonors ‘dictated’ their involvement inhealthworkand,more

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oftenthannot,wereseentodriveselectivePHC.Theconcentrationonafewselectiveelementsof PHCcontributedtofailuretopromotethecomprehensivenessof PHC.

Often if different donors supported a programme, there were risks of a slow down or evenabandonmentof effortsintheprogrammeinfavourof another,evenwhereanationalplanand/orastakeholders’coordinationcommitteeexisted.Uponarrivalof newprogrammeswithsubstantialresourcesandbenefitingfromparticularattentionof nationalandinternationaldecision-makers,theearlierprogrammeswereoftenneglected.

Lackof effectiveownershipof PHCprojects inhostcommunities iscommon,probablybecausethese communities were not properly involved in the decision making process. The PHC policyformulationprocessdidnotclearlyseemtohaveinvolvedpeople’sparticipationatgrass-rootlevelsandmanagersof lowerstructuresinthehealthcarehierarchy.Thistopdownapproachweakenedthe policy formulation content and jeopardized the effective ownership of PHC projects by thecommunities.Althoughmostcountrieshaveinplacecommunitystructuressuchasthevillagehealthcommittees(VHCs),theiroperationandlinkagetotheoverallhealthstructuresisoftenweakandsometimesinformal.

ItisevidentthatbothhumanandfinancialresourceallocationprioritiesarenotinaccordancewiththePHCobjectivesbothatthenationalanddistrictlevels.Morehumanandfinancialresourceshavecontinuedtobenefitthelargerhealthinstitutions,whichareoftenfoundintheurbanareas,leavingtheruralpopulationunderserved.

Healthservicesforcommonchildhoodillnesses,namelyrespiratoryinfections,diarrhoealdiseases,malariaandmalnutritionand,of recent,AIDS-relatedillnessesarehamperedbytheineffectivenessof healthsystemsof mostcountries.Theadventof HIV/AIDShashadconsiderablenegativeimpactonresourcesandtheirutilizationinthehealthsector.HealthfacilitiesarefilledmoreandmorewithHIV/AIDSandAIDS-relatedcasesliketuberculosis,attheexpenseof theothercommonailments.Thesecasesconsumethelargerportionof themeagrebudgetsof healthfacilitiesandhaveledtoburnoutof thehealthpersonnelthatattendtothesecases.Thisalsomeansthatfewerandfewerresourcesareavailableforessentialmedicinesandsupplies.

Opportunities

ItisimportanttosummarizetherealopportunitiesthathaveariseninPHCimplementation,astheseopportunitiescanbeof greatvalueinpromotingPHC.

Majorstakeholdersincludinggovernments,NGOs,privatesector,internationalorganizationsandcommunity-basedorganizations(CBOs)arekeentocontributetoaddresscurrenthealthchallenges.Thislargenetworkof actorsisagreatassetforaddressingthehealthchallengesof,andexpandinghealthservicesto,themajorityof thepopulation.

ThecurrentWHO/UNICEFapproachof promotingIntegratedManagementof ChildhoodIllness(IMCI)isabroadstrategy,encompassinginterventionsathomeandinthehealthsystem.Itadvocatesforanintegratedapproachtomanagementof majorchildhoodillnessesthusremovingtheneedforverticalprogrammes.Thislessoncouldbereplicated.

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CurrentinitiativesbymostcountriestostrengthendistricthealthsystemsthroughdecentralizationareagreatopportunityforimplementingPHC.Thestructure,modeof functioningandresourcesof theoperationallevelhavebeendefined.ThedistrictisdeclaredtobetheoperationalunitforPHC,whichpresupposesarealdecentralizationof decision-makingauthoritytothelevelof thedistricts.

ManystructuresincludingthePHCcommitteeshavebeenformedatall levelsof nationalhealthsystems, intheregions,districtsandvillages.This isaverygoodframework, if strengthenedandmonitored,forfacilitatingdecision-making,implementationandmonitoringof PHCactivitiesatalllevels.

A number of health programmes utilize community resource persons, such as community drugdistributors,communityhealthworkers,traditionalbirthattendants,andtraditionalpractitioners.Thepossibilityof buildingonsuchalongtraditionof communityorganizationsisagreatopportunityinmitigatinghealthproblems.Itisthereforepossibletostrengthenthelinkswithcommunitystructures.However, the dangers of reinforcing internal links within the communities without developingrelationsorlinkswiththerestof themainstakeholdersshouldbeavoided.

TheAfricanRegionhasawiderangeof institutionssuchasuniversities,researchandtrainingcentres.These institutions canbeutilized to enhance capacitybuildingof key stakeholders inPHCandresearch.Throughresearch,interregionalcooperationamongmemberstatesshouldbeencouragedtosharePHCinterventionpackages;researchfindingsandbestpractises.

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CONCLUSIONIt is evident thatPHCpolicy formulationand implementationhasbeenahighly complex issue.PHC strategy implementation requires fulfillment of the five principles of equity, communityparticipation, universal access, appropriate technology and inter-sectoral collaboration. PHCintroducesamanagementchallengeof combiningcentralpolicydirectionwithsignificantdegreeof decentralization.

ThehealthsystemsintheRegionhaveundergonemajorreformsinmanagement,administrationand financing, including their decentralization. However, these reforms have not been sustainedduetotheimplementationof structuraladjustmentprogrammesandthedeclineinsocio-economicdevelopmentthatcharacterizedtheperiodafterAlmaAta.Consequently, lowhealthspendinginassociationwithpoorandinequitableaccesstobasicsocialserviceslikewater,sanitationandhousing,andhighpopulationgrowthrates,haveaggravatedtheviciouscycleof povertyandill-health.

MostcountrieshavemadeconsiderableachievementsindevelopingahealthcaresystembasedonthePHCmodel.Areviewof thenationaldevelopmentplansof countriesintheRegionindicatesthatthecountrieshaveaddressedsome,if notall,of theelementsof PHC.Despitethiseffort,therehasbeenadiscrepancybetweenthePHCpolicyanditsimplementation.Implementationof PHChasalsovariedacrosscountries.WhereasallcountriesmadeconsiderableefforttointegratePHCprinciplesandelementsintotheirhealthsystems,thebroad-basedPHCapproachof ensuringthatPHCwasthecentralfunctionandmainfocusof thehealthsystemshadbeenabandonedinmostcasesinfavourof “selectivePHC”informof verticaldisease-specificprogrammes.

Thereareemergingopportunitiesinpromotingthedevelopmentof structuresandsystemsinlinewiththeimplementationof somePHCprinciples.Theadoptionof theBamakoInitiativeandothercommunityhealthfundapproachesandthecreationof healthboardsaresomeof thegoodinitiativesthatarecreatinganenvironmentforthepromotionof communityparticipation.Decentralizationto thedistrict levels, currentlybeing implemented throughhealth sector reforms, is envisaged topromotebottom-upapproachesandcontributetothemobilizationof additionalresourcesforPHC.Mostof these initiativeshoweverare still in their infancyand theextent towhich theycan fullymobilizesupportforPHContheirownisstilltobeseen.Inaddition,multi-sectoralcollaborationhasbeenlargelyneglectedintheplanningandimplementationof programmes.

Theperiodof thelate80sandearly90ssawthebreakdownanddysfunctionof thenetworkof healthinfrastructurethathadbeenestablished.Thiscontributedsignificantlytothepoorperformanceof healthsystemsnoticedinmostcountriesof theRegion.

Financialresourceshavenotexpandedtocopewiththeincreasingdemandforhealthcare.Totalhealthspendingremainedcritically lowwithonly10countries intheRegionabletospendmorethanUSD34, theminimum figure recommendedby theCommission for Macroeconomics andHealth Report of 2001 for the provision of essential health care package. It is clear that unless

CHAPTER 9:

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massiveresourcesaremobilizedbothfrominternalandexternalsources,thepoorperformanceof thehealthsystemswillcontinueandtheachievementof theMillenniumDevelopmentGoalswillbethreatened.

Sincethe1990stheproblemof shortageof humanresourcesforhealthhasbecomeasignificantfactor in theperformanceof health systems in theRegion.Therehasbeenahighattrition rateof healthworkersasaresultof deathormigrationinsearchof betterremunerationandtermsof service,furtherreducingthecapacityof healthsystemstodeliverhealthcaretothepopulation.

Althoughinmostcountries,theimplementationof PHChasinvolvedcommunityhealthworkers,humanresourcepoliciesinthecountrieshavenottakencommunityhealthworkersintoaccountintermsof organization,management,integrationinthehealthsystemandintermsof considerationof proper procedures for selection, career development, motivation and remuneration, andsupervision.Theyarenotyetseenaspartnersandhencetheirinvolvementinhealthcaredeliveryisnotadequatelypromoted.

Veryfewcountriesdefinedclearpoliciesormechanismsandproceduresforcollaborationwiththeprivatesectorinhealthservicesdelivery,ingeneralandinparticular,intheapplicationof PHC.Theinvolvementof theprivatesectorandallcommunityinterestgroupsinPHCsuffersmainlyfromlackof coordination,integration,regularfollow-upandevaluation.

Yet,theinvolvementof thelucrativeprivatesectorpresentscertainpotentialadvantages.Theofferof goodqualitycurativecare inprivatehospitals in thebigcapitalscanallowtheState todivertitsattentionandresourcestothecareforthepooranddeprived.Theirlarge-scaleinvolvementinhealthservicesdeliveryandPHCinparticularrequiresadefinitionof newrolesfortheState,whichwouldconsistespecially indirecting, regulating,monitoringandqualitycontrolmore thandirectinvolvementinthedeliveryof services.

Healthcommitteesexistatthelevelof eachhealthfacilityinthedistrictsinmostcountriesof theRegion. In certain countries, their organization and operation was given huge importance suchthattheywereinstitutedbypresidentialdecree.Nevertheless,determinationof theirmembership,internalstructures,andrelationshipswithhealthservicesandstaff motivationposedanumberof problems.Thevoluntarismthatwasthereinitiallyseemedtohavewaned.

Thereviewshowsthatperiodicmonitoringandevaluationof PHCiseitherlackingorerraticandthat theextent towhichmostcountrieshaveprogressed in implementationhas largelyremainedunknown.Thishaslimitedcriticalreviewinthisarea.Reliabledataonhealthservicesisscantyand,moreoftenthannot,therearenocomprehensiveandfunctionalhealthinformationsystemsinplace.Theproblemiscompoundedbyshortageof appropriatelytrainedpersonneltohandleandinterpretdata.

The 1970s to mid-80s witnessed achievements in terms of quality of life as evidenced by thereductionininfantandchildmortalityrates.Therehasalsobeenconsiderableprogressmadetowardseradicationof polioandguineawormdiseases.However,subsequentperiodhasbeenassociatedwithdeterioratinghealthtrends,decreasinglifeexpectancyatbirth,highmaternalmortalityrates,andincreasinghealthchallenges.Therehasbeenemergenceandre-emergenceof bothcommunicable

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andnoncommunicablediseases,increasingpoverty,foodshortagesaswellasinadequateaccesstobasicsocialservices.

TheadoptionbyMembersStatesof theHealthforAllStrategyinthe21stcentury,Agenda2020,providesaframeworkfordevelopmentof healthsystemsrespectingtheprinciplesof PHCadoptedinAlmaAtaandtheimplementationof healthpackagesthatrespondtocurrentandchangingneedsof thepopulationsinthecountries.

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RECOMMENDATIONSGiventheabove,therecommendationsareasfollows:

1. Thereisneedtolookintowaysof harmonizinghealthsectorreformswithPHCinordertoensurethattheinitiativespromotebothequityandqualityof healthservices.

2. Foracommonunderstandingof theRegionalhealthpolicy,itwouldbeappropriatetobringallthecountriesintheRegiontogethertobebriefedontheorientationsandstrategiesof Agenda2020,oranyotherregionalstrategybeforeembarkingonthedevelopmentof countrypoliciesandstrategicplans.

3. TheRegionalhealthpolicyshouldbediscussedatthehighest levelof theStateandsharedwidelywithallnationalandinternationalpartnersinthehealthsectorinthecountry.

4. Thereisneedtopromotemoreinter-sectoralcollaborationandcoordinationwiththedifferentstakeholdersinvolvedinPHCimplementationand,especially,atthedistrictlevelwherePHCimplementation is advocated. For the attainment of better inter-sectoral collaboration, thenecessaryinteractionsof thehealthsystemwithothersystemsshouldbebetterstudiedanddefined,andappropriatemechanismsforinter-sectoralcollaborationshouldbeclearlydefinedonacountry-by-countrybasis.

5. Efforts shouldbemade in futureefforts toaddresschallenges suchaseffective involvementof thecommunity inhealthplanninganddecision-makingbyestablishingeffective linkagesbetweenhealthfacilitiesandcommunitystructures,suchasboardsandcommittees.Inaddition,community involvement needs to be strengthened in areas such as problem identification,prioritysetting,datacollectionandanalysis,evaluation,andplanning.

6. Financingpoliciesandstrategiesshouldaimatimprovingequityandaffordabilityinordertoimproveservicecoverageforthepoorpopulations.

7. Resource allocations to PHC should be reviewed and ways of sustainable PHC financingshouldbe sought.However, it is important thatgreatereffortsbemade in thecountries toincreaseefficiencyintheutilizationof themeagreavailableresources.

8. Countriesshouldbesupportedtoaddresstheirparticularhumanresourceneedsthroughcleararticulationof humanresourcespolicyandplans,developmentandstrengtheningof nationalmanagementsystemsandemploymentpolicies.

9. Thereisurgentneedtosupportcountriestoidentifyandputinplacemechanismsforattractingandretainingqualityhealthpersonnel.

10. Thebraindrainproblemrequiresinterventionatinter-countrylevelorevenatthelevelof theAfricanUnion.

11. There is need to reform health sciences education and reorient health workers educationandpracticesoastoincorporateemergingtrendsandequipmajorstakeholderswithskillsinplanning,financialandpersonnelmanagement,whichareimportantinpromotingPHCandcommunityhome-basedcare.

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12. WHOshouldfacilitatethedevelopmentandadoptionof guidelinesandmethodsinPrimaryHealthCaremonitoringandevaluationforusebythecountries.Thisshouldbeintegratedintotheprogress-monitoringframeworkfortheMillenniumDevelopmentGoals.

13. WHO should strengthen its support to member countries to institutionalize ongoing goodpracticesandeffectivemeasuresinapplicationbeforenewinitiativesareintroduced.

14. WHOshouldsupportmembercountriesincapacitybuildingthatwillenhanceimplementationof healthprogrammesandactionsthroughPHCandwithintheframeworkof Healthfor-Allpolicyforthe21stcenturyintheAfricanRegion:Agenda2020.

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PHC Re�iew: Country FrameworkTakingtheopportunityofferedbytheglobalPHCpolicyreview,requestedbytheDirectorGeneralof theWorldHealthOrganization,thecontributionof theRegionwasdefinedatthemeetingheldinHarareon4–5thJuly2001.Thereviewof thepolicyintheAfricanRegionwillfocusRegion-specificPHCimplementationissues,involveallcountries,thoughcountriesthemselveswillreviewtheirownPHC.WHOwillprovidetechnicalandfinancialsupport.

TheAfricanRegioncontributiontotheglobalPHCpolicyreviewwillgivehighattentiontohowtostrengthenimplementationof PHCwithintheoverallframeworkof theHealthfor-AllPolicyforthe21stCenturyintheAfricanRegion.

A Primary Health Care Review is being undertaken at the regional level in response to manyinstitutional,economic,socialandotherchangesthathaveoccurredintheworldsinceAlmaAta.ThePHCreviewisintendedtoaddressthreecorequestions,namely:

WhatshouldbethemainstrategyforimplementingPHCinthenewcontext?

WhatrolesshouldWHOplay insupportingMemberStates to implementprimaryhealthcare?

WhatresourcesandcapacitieswillcountriesandWHOneedinordertoplaythoseroles?

�.0 MAIN OBJECTIVE:

The general objective for carrying out this review is to identify major issues concerning PHCimplementationinordertoformulatepertinentrecommendationsonthewayforward.

�.0 MAIN ISSUES TO BE REVIEWED

Fivebroadareasaretobereviewedbothinthecountryreportsandintheregionalanalysis.Theseare:

1. Health trends:Whatarethetrendsof themainhealthandhealth-relatedchallengesinthecountry?

2. PHC policy formulation: How was the PHC policy formulated in the country? Otherissuesincludetheprocessof formulatingPHCpolicy,contentof thePHCpolicy,reviewof policyformulationandsoon.

3. PHC policy implementation:HowarePHCpoliciesbeingimplementedinthecountry?Aspectstolookatshouldincludeadvocacyandmarketing,actorsandpartners,structuresandprocesses,andsoon.

4. PHCresources:Whatare the resourcesavailable forPHC implementation in thecountry?(Humanandfinancialresources,PHCphysicalresourcesandstructures)

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5. PHC monitoring and review: How are PHC policies and strategies being monitored andreviewed? (Information system for PHC implementation, research activities, utilization of availableinformation,monitoringandevaluationsystems)

�.0 PROCESS

�.� Principles

Themainprinciplegoverningthereviewof PHCimplementationisthatithastobeasrepresentativeof theRegionaspossibleandbasedonownershipbycountries.Thiswillbeensuredusingseveralapproaches.AllMemberStatesintheRegionwillbeincludedinthereview,activeinvolvementof stakeholdersincountrieswillbeensured,andvalidationanddisseminationof thereviewreportbycountrieswillbecarriedout.

Otherprinciplesinclude:Thereviewprocesswillbethoroughandsystematic.

Reviewwillbebasedon:

Involvementof actorswithextensiveknowledgeof PHCimplementation.

Definitionof thewayforwardforPHCimplementationand,

Allowance,asmuchaspossible,forglobalcomparability,usingtheformatprovided.

�.� Consensus on and selection of issues for re�iewTo ensure consensus on issues for review, internal WHO/AFRO meeting(s) will be convened torefineissues/questionsforeachstageof thereviewanddiscussionsheldwithcountries(e-mails&telephone).

Method of conducting the re�iew:

Theprocessof reviewingPHCintheAfricanRegionwillbecarriedoutattwolevels,countryandregionallevels.

Country-specific re�iews:

Each country will review its own experiences in PHC implementation and submit a report forinclusion intheregionalreport.Foreachcountry,aconsultantwillbe identifiedtocarryout thereview and prepare the country review report. The consultant will work closely with the WHOcountryofficeandauthoritiesintheMinistryof Health.

Dataforthereviewwillbefromthefollowingsources:Unstructured interviewswith interviwees/informantswithan intimateknowledgeof PHCimplementation.Thesecouldcomprisepolicymakers,implementersatalllevels,othersectorsinvolved,WHOandotherpartners.

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Discussionswithawideraudienceof peoplewithintimateknowledgeof PHCimplementation.Thefollowingcouldbeinvolved:policymakersimplementers,NGOs,Privatesector,health-relatedinstitutions,WHOandotherpartners

Adesktopanalysisof availabledocumentsandreportsspecifictothecountry.Anextensiveanalysis of all available published and unpublished documents and materials will also beundertaken.

Thediscussionof theconsultant’sreportwillbebasedonacompilationandanalysisof datafromtheabove-mentionedsources.TheconclusionsonPHCimplementationandwayforwardwillbebasedonlogicaljudgments/assertionsderivedfromthedata.Thereportwillbereviewedanddiscussedbyawidernationalaudienceinorderto:

furthersubstantiatethefindings.

gainconsensusandvalidatetheinformationpresentedinreport

fosterownershipof thereport

ensuretheuseof therecommendationsof thereview

Regional re�iew:

Threeinstitutions,CEDHA,PHCI-IRINGAandISEDwillbecontractedtocarryouttheregionalreview (refer to the ToRs). A desktop review, based on a compilation and extensive analysis of availableregionaldocuments,country-specificreviewreportsand,wherenecessary,casestudiesof countrieswithbestpracticeswillbedone.TheconclusionsonPHCimplementationandthewayforwardwillbebasedonlogicalassertions/assertionsderivedfromthedata.

BothCEDHAandPHCI-IRINGAwillcovertheEnglish-speakingcountriesandproduceonereportwhileISEDwillberesponsible forproducingareportbasedonPHCreviewof French-speakingcountriesandcountrieswithPortugueseasaworkinglanguage.

�.� Suggested format for country and regional reports.

Thefollowingformatmaybefollowedinwritingcountryandregionalreviewreports.Ensuringclosefollowupof theformatwillensurecomparabilityof bothtypesof reportsatregionalandgloballevels.

I. Introduction 1. Historicalbackgroundof healthsystemsinthecountry 2. Goalandobjectivesof thereview

II. Implementation of the re�iew 1. Methodologyused 2. Processof datacollectionandanalysis

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III. Findings and discussions

1. Healthtrendsinthecountry - Healthchallenges - Health-relatedchallenges 2. PHCpolicyformulation - Processof formulatingthePHCpolicy - Contentof thePHCpolicy - Reviewof policyformulation 3. PHCimplementation - Advocacyandmarketing - Actorsandpartners - Structuresandprocesses - Opportunities - Constraints 4. PHCresources - Humanresources - Financialresources - PHCphysicalresourcesandstructures 5. Monitoringandreviewing - InformationsystemforPHCimplementation - Researchactivities - Utilizationof availableinformation - Monitoringsystems

IV. Major conclusions and recommendations

References Annexes

�.� Dissemination of the PHC re�iew:A programme of communication and briefing within WHO, with Member States and otherinternationalagenciestodisseminatetheoutcomesof thereviewwillbemade.Attheregionallevel,thereviewreportwillbeputontheagendaof ongoingmeetingswithdifferenthealthstakeholders,startingfromNovember2001.Atcountrylevel,ahalf-daymeetingwillbeconvenedtoreviewandendorse the consultant’s report. Opportunity will be taken to also disseminate the country andregionalreportsduringon-goingmeetingsinthecountries.

�.0 TERMS OF REFERENCE FOR COUNTRY CONSULTANTS

Objecti�es of the Consultancy:

Theobjectivesof theconsultancyaretoReviewtheexperiencesinPHCimplementationinthecountry

CompilethecountryreportonPHCimplementationreview.

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Scope of Work:Theconsultantisexpectedto:

Carry out a review of documents and reports on the country experiences in PHCimplementation.Thereviewshouldlookatallrelevantdocumentsconcerninghealthtrends,PHC policy formulation and implementation, PHC resources, and PHC monitoring andreview.ThisshouldnotberestrictedtoexperiencesinthepublicsectororexperiencesundertheMinistryof Health.Itshouldincludeallkeyactorsandstakeholders.

Hold in-depth interviews with professionals and people with extensive knowledge andinformationonthemajoraspectsof PHCpolicyandimplementationinthecountry.

AnalyzethedataandinformationgatheredaswellasprepareacountryPHCreviewreport.

Facilitateanationalmeeting togain consensuson,andvalidate, the countryPHCreviewreport.

Period of Work:

TheassignmentwillcovertheperiodfromAugusttoSeptember2001.

Reporting:

ItisexpectedthatadraftcountryPHCreviewreportwillbepresentedtoanationalmeetinginordertogainconsensusandvalidation.

Thefinalreport,whichshouldincorporatediscussionsatthenationalmeeting,shouldbesubmitted,notlaterthanthelastweekof September2001,throughtheWorldHealthRepresentativetoAFROwithacopytotherespectiveinstituteoverseeingthereviewinthespecificcountrygroup.English-speaking countries will be under CEDHA and PHCI-Iringa, Tanzania, while French-speakingcountriesandcountrieswithPortugueseasworkinglanguagewillbeunderISED,Senegal.

Mode of Payment:

40%downpaymentwillbemadeatthebeginningof theassignmentandtheremaining60%uponacceptanceof thefinalreport.

Qualifications and experience

TheconsultantmusthaveawideexperienceinresearchandPHCimplementation.He/sheshouldalsohaveagoodexposuretohealthpolicydevelopmentandevaluationmethodologies.He/sheshouldhaveagoodworkingrelationshipwiththeMinistryof Health.

Languages

TheconsultantshouldbefluentinEnglishorFrenchorPortuguese,asrequired.

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GUIDELINES

IN-DEPTH INTERVIEWS WITH INTERVIWEES/INFORMANTS

Thetargetinterviewees/informantsforthisreviewarepersonsinthecountryinthebestpositiontoprovideinterviewerswithadequateandpreciseinformationonmajoraspectsof thePHCpolicyandimplementationinthecountry.Theymaybedirector-generalsorheadsof departments,divisions,andotherservicesof theMOH,orcoordinatorof NGOsinvolvedinhealthorhealth-relatedactivities,orpartnersof MOH,multi-andbi-lateralagencies(WHO,UNICEF,UNDP,USAIDetc.).

The proposed guidelines have been developed to assist the reviewers in the review process and,particularly,intheinterviewcomponentaswellasinwritingthereport.Itsproperutilizationwillalsofacilitateacomparisonof allcountryreports.Theguidelines,nevertheless,havetobeconsideredassimplya“guide”thataimstofacilitatetheinterviewer’sworkandnotasacompleteandperfectsetof directivestoberigidlyfollowed.Agoodunderstandingof thegoalandobjectivesof thisreviewandthereviewer’sownabilityisthebestguidelinesforthiswork.

GENERAL RECOMMENDATIONS

Properutilizationof thecurrentguidelinesforinterviewingpeople/informantsrequiresnecessaryinterviewskillsbytheinterviewer.Herearesomeof theessentialelementstoberememberedwhenconductingtheinterview.(1)Theinterviewershouldadoptacarefulstep-by-stepapproachanddecideonhowandwhentorecordtheessentialinformationreceivedfromtheinterviewee/informant.(2)Theinterviewermustalwaysbearinmindthattheinterviewaimstodrawoutknowledge,opinionorjudgmentof theinterviewee/informantonmajorissuesrelatedtoPHCpolicyandparticularlyitsimplementationinthecountry.(3)Theinterviewershouldknowhowtoappropriatelypreventintervieweeselectiverecountof informationandalsoknowhowtodrawtheinterviewee/informantbacktothesubjectmatterif heorsheisdeviating.(4)Theinterviewershouldfindwaysandmeanstoengagetheinterestof theinterviewee/informantinthesubjectmatterinordertogetmaximumvaluableinformationandshouldfindwaystohavehimorheraccepttospendenoughtimeontheinterview.(5)Theinterviewermustavoidmakinganyjudgment,implicitlyorexplicitly,onwhattheinterviewee/informant is saying;andatall times (6) showcourtesyandopenness throughout theinterviewperiod.

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GUIDELINES FOR CONDUCTING THE INTERVIEW.

MAJOR AND RELATED AREAS FOR INVESTIGATION COMMENTSHEALTH TRENDS

What are the trends of the main health and health-related challenges in the country?

Emergingandre-emergingdiseases,

Economicconditions(poverty),

Demographicproblems,

Otherepidemiologicalproblems,

Socialconflictsetc.

PHC POLICY FORMULATION

1. How was the PHC policy formulated in your country?

Whatarethemajoractors?

People/institutionsinvolvedintheprocess?(NGOs,privatesector,civilsociety,communities)

Influencesof itsestablishment?

Principles,evidenceused?

Howcommitmentintheformulationof thePHCpolicycanbedemonstrated?(levelof participation,marketingstrategy,solicitingideasfromdifferentstakeholders,meetings,ownership,etc.),

TowhatextentdoesPHCpolicyaddressthestructures,resourcesandlegislationsof healthandhealth-relatedsystems?

2. Does the country review the formulation of its PHC Policy?

WhatisthetrendregardingthemajorpolicydecisionsonPHCinthelastfiveyears?

Isthereastructure/procedureforreviewing?

3. What is the country’s policy on PHC?

WhatisthecountrypolicystatementonPHC?

TowhatextentdidthePHCpolicyaddressthemainchallenges?

Whatarethemainprogrammes?

Towhatextentdoesthepolicymodeladdresscomprehensivenessof healthissues?

Whatistherelationshipwithotheron-goingreforms?

Thissectionaimstocapturethemajor health or health-relatedchallengesof thecountryinthepast,nowandintheforeseeablefuture. The focus shouldbeonthe ways they have or mightinfluence the development of PHCinthecountry.Thissectionalsomakesuseof thejudgementof the interviewee/informantregarding the situation in thecountry.

The concern here is to get themaximum information on theprocess undertaken to developand review the PHC policyin the country. It aims also todetermine the extent to whichthe PHC policy has addressedthechallenges.

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MAJOR AND RELATED AREAS FOR INVESTIGATION COMMENTSPHC POLICY IMPLEMENTATION

How are PHC policies being implemented in the country?

Whoarethemajoractors?

Howwasitadvocatedandmarketed?

Strategies for overcoming resistance, barriers andconstraintsforPHCimplementation(relatedtostructures,resources,politicsetc.)?

Does the implementation focuson the5principles andthe8componentsof PHC?

TowhatextentwasresourcesandcapacityappropriateforPHCimplementation(human,financial,physical,etc.)?

To what extent does the implementation focus oninvolvingotherpartnerssuchasthecivilsociety,privatesector,NGOs,otherpartnersinhealthdevelopmentetc?

To what extent has PHC implementation promotedpracticeanddevelopmentof traditionalmedicine?

TowhatextentandhowhaveexternalagenciesinfluencedPHC policy and strategy implementation (UNICEF,WHO,WorldBank,bilateralandmultilateral)?

HowarePHCpolicyandstrategiesbeing implementedatthedifferentlevelsof thehealthsystem?Howaretheselevelsconnected(referralsystem/continuityof care)?

TowhatextentdidPHCimplementationbringchangesin integration, decentralization and financing of healthcare?

How have other major initiatives improved the healthcare system (Bamako Initiative, poverty reductionprogrammes, Safe Motherhood/Making PregnancySafer, etc.)?Towhat extentare these in linewithPHCprinciplesandcomponents.

The aim is to identify allapproaches,methodsandactivitiesusedinthecountrytoimplementPHCpolicyandstrategiesaswellasthemajordifficulties,constraintsand resistances encountered andstrategiestoovercomethem.

GUIDELINES FOR CONDUCTING THE INTERVIEW (CONTD).

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GUIDELINES FOR CONDUCTING THE INTERVIEW (CONTD).

MAJOR AND RELATED AREAS FOR INVESTIGATION COMMENTSPHC RESOURCES

What resources are available for PHC implementation in the country?

• Towhatextentareresourcesappropriateandadequatefor sustainable implementation of PHC policy andstrategies?

• What major approaches are used to mobilize andreallocateresourcestoPHCpolicyimplementation?

• Towhatextentisthedevelopmentof humanresourcesincluding community health workers (policy, planning,training, management, etc….) in line with PHCprinciples?

• What structures (responsibilities, relationships,procedures and culture) of the health system and thefacilities are used to operationalize PHC policy andstrategies (hospitals, health centers, dispensaries, healthhuts,ruralmaternitiesandtraininginstitutions,includinguniversities)?

PHC MONITORING AND REVIEW

How are PHC policy and strategies being monitored and reviewed?

• StrategiesandapproachesformonitoringandreviewingPHCpolicyimplementation?

• Outcomesandtheirapplication,if any?

• Actorsatdifferentlevels?

• Howistherelationshipwiththeoverallmanagementof thehealthsystem?

• Howareresearchactivitiesandthehealthinformationsystemsupportedandused toreviewand improvePHCimplementation?

• TowhatextentarethemonitoringandevaluationresultsbeingusedtosetprioritiesinPHCactivities?

The aim is to identify theresources available in thecountry and the way they arebeing mobilized and allocatedfor effective and sustainableimplementation of PHC policyandstrategies.

The objective is to identify thesystematic approach (if any)thatexistsincountrytomonitor,evaluateandreviewperiodicallythe implementation of PHCpolicyandstrategies.

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GUIDELINES ON REVIEW OF DOCUMENTS AND REPORTS

�.0 Possible sources of information

Thefollowingarethemainsourcesof informationthatmaybeusedinthePHCreviewprocess:Individuals,groups,andorganizations;

Publishedinformation(books,articles,indexes,abstractjournals);and

Unpublishedinformation(otherresearchproposalsinrelatedfields,reports,records,computerdatabases)

�.0 Identifying the different sources

Differentsourcesof informationcanbeconsultedandreviewedatvariouslevelsof theadministrativesystemwithinthecountry.

Community and district or pro�incial le�els

Localsurveys,annualservicereports

Statisticsissuedatprovincialanddistrictlevels

Newspapers,books,articles,mimeographedreports,etc.

National le�el

Articlesfromnationaljournals,booksidentifiedduringliteraturesearchesatuniversityandothernationallibraries,WHO,UNICEFlibraries,etc.

Specialcollections,e.g.,newspaperclippings,archivalrecords,library.

Documentation,reportsandrawdatafrom:

TheMinistryof Health(e.g.5-yearplans)

Centralstatisticaloffices

Otherministries

Non-governmentalorganizations

International-le�el informationBilateralandmultilateralorganizations(e.g.,IDRC,USAID,UNICEF,WHO,WB);

Computerized searches for international literature (from national library or internationalinstitutions).

Someagencieswillassistwithliteraturesearch,if requestedbytelephoneorinwriting.Therequest,however,shouldbeveryspecific.Otherwiseyouwillreceivealonglistof references,mostof whichwillnotberelevant.If youarerequestingacomputerizedsearch,itisusefultosuggestkeywordsthatcanbeusedinlocatingtherelevantreferences.

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�.0 Accessing the sources of information.

You need to develop a strategy to gain access to each source and to obtain information in the most productive manner. It may include the following steps:

Identifying a key person (researcher, decision maker or community member) who isknowledgeableonthetopicandaskif heorshecangiveyouafewgoodreferencesor/andnamesof otherpeopleyoucouldcontactforfurtherinformation;

Lookingupthenamesof speakersonyourtopicatconferencesmightbeuseful;

Contacting and requesting relevant references from librarians in universities, researchinstitutions,andtheMinistryof Healthandnewspaperoffices;

Examiningthebibliographiesandreferencelistsinkeypapersandbookstoidentifyrelevantreferences;

Looking for references in indexes (e.g. Index Medicus) and abstract journals; which areavailableinlibrarieseitherashardcopiesorincomputerizedform.

Requestingacomputerizedliteraturesearch(e.g.Medline).

�.0 Possible biases in re�iewing documents and reports.

Biasinthereviewof documentsandreportsisthedistortionof theavailableinformationsuchthatitreflectsopinionsorconclusionsthatdonotrepresenttherealsituation.Itisusefultobeawareof varioustypesof biasinordertohaveacriticalapproachinconsideringexistingliterature.If youhavereservationsaboutcertainreferencesorif youfindconflictingopinionsintheliterature,discusstheseopenlyandcritically.Suchacriticalattitudemayalsohelpavoidbiases inyourownstudy.Commontypesof biasinliteratureinclude:

Playingdowncontroversiesanddifferencesinone’sownstudyresults;

Restrictingreferencestothosethatsupportthepointof viewof theauthor;and

Drawing far-reaching conclusions from preliminary or shaky research results or makingsweepinggeneralizationsfromjustonecaseorsmallstudy.

�.0 Ethical considerations

Thetypesof biasmentionedabovewouldputthescientificintegrityof theresponsibleresearcherinquestion.Moreover,carelesspresentationandinterpretationof datamayputreaderswhowanttouse the study’s findingson thewrong track.Thismayhave seriousconsequences, in termsof timeandmoneyspentanditmayevenleadtowrongdecisionsaffectingpeople’shealth.Asimilarlyserious act, for which a researcher can be taken to court, is the presentation of research resultsor scientific publications from other writers without crediting the actual author (s). Therefore,appropriate referencingprocedures shouldalwaysbe followed in researchproposalsaswellas inresearchreports.

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INTERVIEW GUIDE FOR INTERVIEWERS

�.0 HEALTH TRENDS

Whatarethetrendsof themainhealthandhealth-relatedchallengesinthecountry?• Emergingandre-emergingdiseases,• Economicconditions(poverty),• Demographicproblems,• Epidemiologicalproblems,• Socialconflictsetc.

�.0 PHC POLICY FORMULATION

�.� How was the PHC policy formulated in the country?Whoarethemajoractors?

People/institutionsinvolvedintheprocess?(NGOs,privatesector,civilsociety,communities)

Influencesof itsestablishment?

Principles,evidenceused?

How can commitment in the formulation of the PHC policy be demonstrated? (level of participation, marketing strategy, soliciting ideas from different stakeholders, meetings,ownership,etc.),

TowhatextentdoesPHCpolicyaddressthestructures,resourcesandlegislationsof healthandhealth-relatedsystems?

�.� What is the country policy on PHC?TowhatextentdidthePHCpolicyaddressthemainchallenges?

Whatarethemainprogrammes?

Towhatextentdoesthepolicymodeladdresscomprehensivenessof healthissues?

�.� Does the country re�iew the formulation of its PHC Policy?WhatisthetrendregardingmajorpolicydecisionsonPHCinthelastfiveyears?

Isthereastructure/procedureforreviewing?

�.0 PHC POLICY IMPLEMENTATION

�.� How are PHC policies being implemented in the country?Whoarethemajoractors?

Howwasitadvocatedandmarketed?

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Strategiesforovercomingresistance,barriersandconstraintstoPHCimplementation(relatedtostructures,resources,politicsetc.)?

Doestheimplementationfocusonthe5principlesandthe8componentsof PHC?

TowhatextentwereresourcesandcapacityappropriateforPHCimplementation(human,financial,physical,etc.)?

Towhatextentdoestheimplementationfocusoninvolvingothersectorssuchastraditionalmedicine,civilsociety,privatesector,NGOs,otherpartnersinhealthdevelopmentetc,

To what extent do external agencies influence the implementation of PHC policy andstrategies(UNICEF,WHO,WorldBank,bilateralandmultilateral)?

HowarePHCpolicyandstrategiesbeingimplementedatdifferentlevelsof thehealthsystem?Howaretheselevelsinterconnected(referralsystem/continuityof care)?

TowhatextentdidPHCimplementationbringchangesintheintegration,decentralizationandfinancingof healthcare?

What other major initiatives have improved the health care system (Bamako Initiative,financial,planning,qualityof services,equityetc.)?TowhatextentaretheseinlinewithPHCprinciplesandcomponents.

�.0 PHC RESOURCES

�.� What resources are a�ailable in the country for PHC implementation?Towhatextentareresourcesappropriateandadequate for sustainable implementationof PHCpolicyandstrategies?

What major approaches are used to mobilize and reallocate resources to PHC policyimplementation?

Towhatextentisthedevelopmentof humanresources,includingcommunityhealthworkers(policy,planning,training,management,etc….)inlinewithPHCprinciples?

Whatstructures(responsibilities,relationships,proceduresandculture)of thehealthsystemandthefacilitiesareusedtooperationalizePHCpolicyandstrategies(hospitals,healthcenters,dispensaries,healthhuts,ruralmaternitiesandtraininginstitutions,includinguniversities)?

�.0 PHC MONITORING AND REVIEW

�.� How are PHC policy and strategies being monitored and re�iewed?StrategiesandapproachesformonitoringPHCpolicyimplementation?

Outcomesandapplications,if any?

Actorsatdifferentlevels?

Whatistherelationshipwiththeoverallmanagementof thehealthsystem?

HowareresearchactivitiesandthehealthinformationsystemsupportedandusedtoreviewandimprovePHCimplementation?

TowhatextentarethemonitoringandevaluationresultsbeingusedtosetprioritiesinPHCactivities?

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GUIDE FOR COLLECTING INFORMATION FROM DOCUMENTS AND REPORTSThe proposed guidelines have been developed to assist reviewers in the review process and,particularly, in conducting the interview and writing the report. Its proper utilization will alsofacilitateacomparisonof allcountryreports.Theguidelines,nevertheless,havetobeconsideredas simplya“guide” thataims to facilitate the interviewer’sworkandnotasanexhaustive setof directives tobe rigidly followed. Thebest guidelines areagoodunderstandingof thegoal andobjectivesof thereviewandtheabilityof thereviewertoeffectivelyachievethem.

Information fromdocumentsandreportsmaybecollectedand sortedusing the formatoutlinedbelow.Guidingquestionsarepresentedbeloweacharea.Datafromdocumentsandreportsmaybeextractedtoanswerthesequestions.

1. HEALTH TRENDS: findings and conclusions

Whatarethetrendsof themainhealthandhealth-relatedchallengesinthecountry?

2. PHC POLICY FORMULATION: findings and conclusions

HowwasthePHCpolicyformulatedinthecountry?

WhatisthecountrypolicyonPHC?

Doesthecountryreviewtheformulationof itsPHCPolicy?

3. PHC POLICY IMPLEMENTATION: findings and conclusions

HowarethePHCpoliciesbeingimplementedinthecountry?

4. PHC RESOURCES: findings and conclusions

WhatresourcesareavailableforPHCimplementationinthecountry?

5. PHC MONITORING AND REVIEW: findings and conclusions

HowarePHCpolicyandstrategiesbeingmonitoredandreviewed?

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GUIDELINES ON GROUP DISCUSSION/MEETING ON COUNTRY PHC REVIEW REPORT AND ITS RECOMMENDA-TIONS.Thetargetparticipantsforthismeetingisanypersoninthecountryinthebestpositiontoprovideintimate, adequate and precise information on major aspects related to the PHC policy and itsimplementationinthecountry.Theymaycompriseof theDirectorGeneralsorHeadsof departmentsanddivisions,andotherservicesof theMOH,coordinatorof NGOsandprivatesectorsinvolvedinhealthorhealthrelatedactivities,partnersof theMOHmultiandbi lateralagencies (WHO,UNICEF,UNDP,USAID,WB).

Theproposedguidelineshavebeendevelopedtoassistthereviewersintheprocessof conductingameeting todiscuss andvalidate the countryPHCreview report. Theguidelines,nevertheless,havetobeconsideredassimplya“guide”thataimstofacilitatetheinterviewer’sworkandnotasacompleteandperfectsetof directivestobesolelyandcompletelyfollowed.Thebestguidelinesareagoodunderstandingof thegoalandobjectivesof thereviewandtheabilityof thereviewertoeffectivelyachievethem.

Formattobeusedtoguidethemeeting.

Thefollowingformatmaybeusedtoguidethediscussionsof themeeting.

1. HEALTH TRENDS: findings and conclusions

Whatarethetrendsof themainhealthandhealth-relatedchallengesinthecountry?

2. PHC POLICY FORMULATION: findings and conclusions

HowwasthePHCpolicyformulatedinthecountry?

WhatisthecountrypolicyonPHC?

Doesthecountryreviewtheformulationof itsPHCpolicy?

3. PHC POLICY IMPLEMENTATION: findings and conclusions

HowarethePHCpoliciesbeingimplementedinthecountry?

4. PHC RESOURCES: findings and conclusions

WhatresourcesareavailableforPHCimplementationinthecountry?

5. PHC MONITORING AND REVIEW: findings and conclusions

HowarePHCpolicyandstrategiesbeingmonitoredandreviewed?

6. RECOMMENDATIONS AND WAY FORWARD

Thereviewerwillbethefacilitatorof thediscussions,guidingthediscussionbasedontheareaslistedabove.He/shewillensureexhaustivediscussionandconclusionof eachtopic.Eachtopicwillendwithrecommendations thatwillbecompiledandutilized tomapout theway forward.ThewayforwardshouldaimatstrengtheningPHCimplementationinthecountry.

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