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Comprehensive Analytical Profile: WHO African Region

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This analytical profile provides a health situation analysis of the WHO African Region and, coupled with the Atlas, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:
1. Introduction to Country Context
2. Health Status and Trends
3. Progress on SDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants
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Statistical profile
Introduction to Country Context

Africa is the world's second largest continent in both area and population, after Asia. At about 30 244 050 km², including its adjacent islands, it covers 20.3% of the total land area on Earth. Broad to the north (7400 km wide), Africa straddles the equator and stretches about 8050 km from the northern tip of Algeria in the north to Cape Agulhas (South Africa) in the south.

Most of Africa is a series of stable, ancient plateau surfaces, low in the north and west and higher (rising to more than 1830 m) in the south and east. Africa's six climatic zones are largely controlled by the continent's location astride the equator and its almost symmetrical extensions into the northern and southern hemispheres. These climatic zones are: the tropical rainforest climate around the equator; the savannah climate north and south of the equator; the semi-arid and arid climate around the Sahara and Kalahari; and the Mediterranean-type climate at the north and southern tip of the continent.

Health Status and Trends

In recent decades, the WHO African Region has fallen behind world averages in respect of health and human development, with sobering effects on health status and trends. The heavy burden of infectious disease, particularly the HIV/AIDS pandemic, is without doubt a major factor accounting for lowered life expectancy at birth in recent decades, coupled with steadily increasing rates of noncommunicable diseases as countries make economic and social transitions to modern lifestyles.

With up to 62% of Africans living in slum conditions where traditional and modern lifestyle hazards intersect, it is hardly surprising that the WHO African Region leads the world not only in dropping life expectancy rates but also in mortality and burden of disease ratios.

Progress
Progress on SDGs
Progess on SDGs



The Health System
Health system outcomes

Health systems have multiple goals.[1] The world health report 2000[2]defined overall health system outcomes or goals as improving health and health equity in ways that are:

  • responsive
  • financially fair
  • make the best, or most efficient, use of available resources.

There are also important intermediate goals: the route from inputs to health outcomes is through achieving greater access to, and coverage for, effective health interventions without compromising efforts to ensure provider quality and safety.

Leadership and governance

Leadership and governance involves the responsibility of providing oversight across all national institutions through policy-making and health planning, organization and management, and regulation of health services. In all 46 countries of the WHO African Region, the ministries of health are mandated to provide this oversight function. Some country health policies contain additional mandates in respect of population and social welfare. Increasingly, in order to address upstream social and environmental key determinants of health, ministries of health work in close collaboration with other government sectors responsible for agriculture, water supply and sanitation, other environmental issues, education, and women’s empowerment.

Community ownership and participation

The concept of community ownership and participation is key to the implementation of the primary health care renewal. Countries of the WHO African Region have advanced primary health care revitalization through the adoption of the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa and its related implementation framework.

The primary health care approach empowers communities so that they can be involved in processes to help ensure that health services are people centred. This means that they should meet people’s identified health needs, encompassing physical, emotional and social concerns beyond disease categories. Services that meet people’s health needs have to be comprehensive, including health promotion, prevention, diagnosis, treatment, referral, long-term care and social health services. These services also need to be consistently available until the health problem is resolved or the risk factor has disappeared.

Partnerships for health development
Health information, research, evidence and knowledge

In the last decade, understanding has been reached that creating an adequate knowledge, information and research infrastructure, and the means for managing it, is a powerful means of addressing the challenges of health status in the WHO African Region.

High-level summits have been held to this end, recognizing that health research in Africa requires an African perspective if present knowledge gaps are to be appropriately filled. Stronger commitment has been given to supporting health research, accelerating efforts to develop and implement appropriate research policies at national and regional levels, and fostering leadership and collaboration to these ends (see figure).

Health financing system

Health care financing in the WHO African Region is inadequate to the needs. This is indicated by the fact that the Region has access to only 1% of the world’s financial resources for health, despite accounting for more than 24% of the global burden of disease.

Per capita health spending has doubled to US$ 472 since the year 2000 at regional aggregate level. However, in more than half of the low-income countries, per capita expenditure on health is below the US$ 34 recommended by the WHO Commission on Macroeconomics and Health to provide an essential package of health services in low-income countries.

Service delivery

Despite clear policies on decentralization in most countries, the ability to provide comprehensive, equitable, continuous and people-centred health services at district level continues to be limited.[3] Most countries in the WHO African Region organize health service delivery in accordance with the level and size of health facilities.

These are normally categorized as primary, secondary and tertiary health facilities. Nomenclature of the health facilities in each category may differ from country to country, depending on organizational method and historical influences.

Health workforce

Health workforce management systems are one of the weakest components of human resources for health development, as evidenced by:

  • ill-equipped health workforce departments in ministries of health
  • huge imbalances between rural and urban areas and in skill mix
  • lack of incentives
  • sometimes an adverse working environment.

These issues prevail all over Africa, exacerbated by low economic status throughout the continent. Human resource shortages are compounded by recent decreases in investment in health, freezes in recruitment of health workers, poor remuneration and incentives, and the migration of skilled staff. Effectively, the health workforce in Africa (see figure) is in crisis.

Medical products, vaccines, infrastructures and equipment

Nine countries still have to develop a national medicines policy. It is important for countries to systematically revise, update and harmonize their medicines policies with those of other countries and to integrate traditional medicine policies and strategies where these are used. Regulatory systems for medicines are inadequate in many countries, which is an issue of serious public health concern.

A recent survey showed that only 4% of countries have an acceptable level of regulatory capacity. All countries need to take measures against the entry and circulation of medicines of unacceptable quality, which occurs all too frequently with limited and complex registration procedures. A limited number of quality control institutions are operational, but more are needed.

General country health policies
Universal coverage
Specific Programmes and Services
HIV/AIDS

Two thirds of all people living with HIV and AIDS live in sub-Saharan Africa. Encouragingly, new infection rates are now dropping, due to scaling-up of antiretroviral therapy treatment and more effective preventive interventions.

Forty-four out of the 46 countries of the WHO African Region have policies in place, while 38 have policies on HIV testing and counselling. However, the human resources needed to deliver on these policies fall short of requirements. This shortfall is in the region of 1.5 million throughout Africa, leading to increasing use of task shifting. This strategy is now used by 33 countries and is seen as successful in scaling-up the rate of antiretroviral therapy delivery (see figure).

Tuberculosis

Up to 30% of the global tuberculosis (TB) disease burden occurs in Africa, with incidence doubling between 1990 and 2007. Death rates also doubled during this period. At present rates of progress, most countries are unlikely to reach the Millennium Development Goal target, despite significant progress in expanding DOTS (the basic package that underpins the Stop TB Strategy) coverage since 1990.

Health system weaknesses are considered mainly responsible for slower than desirable improvement in TB identification and care. Limited local-level diagnostic capacity, poor patient follow-up and shortages in drug supplies are contributing factors. Multidrug-resistant and extensively drug-resistant forms of TB, are emerging concerns attributed mainly to poor DOTS performance.

Malaria

The greatest disease burden from malaria occurs in the WHO African Region, where 89% of all malaria deaths worldwide took place in 2008. Over the past 20 years, malaria has been rising in importance on the public health agenda, following a number of high-level measures at national and international level.

The most commonly used intervention policies and strategies for prevention and treatment include use of:

Immunization and vaccines development

Four million unnecessary deaths occur annually from diseases for which vaccines are available. The root of this problem is distribution and supply systems on the one hand, and the difficulty of accessing hard-to-reach and mobile populations on the other. Despite much progress, goals are not yet reached and the absolute numbers of those not consistently immunized remain high. One mechanism adopted to readdress the situation is a strong focus on district-level immunization.

Approaches to improving routine immunization include:

  • prioritizing countries with the largest numbers of non-immunized or under-immunized children
  • using the district-level approach
  • improving data for programme monitoring
  • introducing new vaccines as appropriate
  • enhancing training of health staff
  • resource mobilization.

However, while governments are spending more on buying vaccines, expenditure on routine immunization implementation appears to have changed little over the past 10 years.

Child and adolescent health

Sub-Saharan Africa has the lowest rate of improvement in child survival in the past 20 years, despite the highest rate of reduction in under-five mortality. To meet Millennium Development Goal 4, child mortality must be reduced by 8% per year, whereas the present rate is 1.4%. The leading causes of childhood deaths, in order, are neonatal conditions, diarrhoea, pneumonia, malaria, measles and HIV/AIDS. A total of 25% of under-fives are underweight and one third are stunted.


The challenges in nutrition faced by most African countries include:

  • the need to meet the energy needs and strengthen the immune systems of people with infectious diseases such as HIV/AIDS and tuberculosis;
  • increasing household food security and increasing dietary intake across the life cycle;
  • addressing the high consumption of sugars and fats that contribute to diet-related disorders.
Maternal and newborn health

Most maternal deaths occur during or after childbirth, and most are preventable. The lifetime risk for maternal mortality in African women is 1 in 26, compared with 1 in 7300 in the developed world. Leading causes are bleeding (haemorrhage), hypertension, abortion-related problems and sepsis. Other risks are due to undernutrition, anaemia, tuberculosis, malaria and HIV/AIDS.

The WHO African Region is making little progress in reducing maternal mortality, although to achieve Millennium Development Goal 5 requiring a reduction in maternal mortality of three quarters by 2015, a decline of at least 5.5% a year is needed. The Region has the highest rate of newborn deaths in the world at 41:1000 live births.

Gender and women's health

Women’s health is broader than reproductive issues only, and should be seen in this wider context. It is best understood in terms of life phases, ranging from infancy to old age. Each phase, due to its specific risks and conditions, has the potential to influence outcomes in the following phase, due to women’s specific roles and bodies.

Very early in life there is a need to avoid parentally transmitted HIV, as this influences health for the rest of an infant’s life. As a child, obtaining adequate nutrition is essential, together with education and appropriate levels of parental support, which in some cultures is not invariably present for girls. Education is a strong predictor of women’s future health. However, many health indicators for girls are poorer in Africa than in other parts of the world.

Epidemic and pandemic-prone diseases

Factors that increase the vulnerability of many African communities to epidemics include weak health systems, high level of women’s illiteracy, poverty, inadequate water and sanitation systems, and poor general hygiene levels. These are compounded by limited public awareness, together with natural and man-made disasters.

The WHO African Region is regularly affected by epidemics sweeping through its countries, leaving already fragile health systems struggling to cope. In 1998, the Integrated Disease Surveillance and Response (IDSR) framework was adopted, with the aim of integrating and streamlining common surveillance activities and their human and financial resource costs.

Neglected tropical diseases

Neglected tropical diseases are, in the main, parasitic diseases that thrive in conditions of poverty and low environmental standards. These diseases impose a heavy burden on populations in the WHO African Region, not only because they are neglected, but also due to the high levels of disability and hence lost productivity they represent to already vulnerable communities. In addition, the chronic nature of neglected tropical diseases places a perpetual burden on weak and overstretched health systems.

Neglected tropical diseases account for 25% of all disability-adjusted life years attributable to infectious and parasitic diseases, and for 10% of mortality. While these diseases constitute a significant public health problem in the communities where they are endemic, their restriction to particular geographic areas and/or environmental conditions often prevents them from acquiring priority status at national level.

Non-communicable diseases and conditions

Noncommunicable diseases are now responsible for an increasing share of Africa’s disease burden, with about 62% of older Africans dying from this cause. This double burden with communicable diseases (infectious diseases) requires coordinated approaches.

Noncommunicable diseases principally affecting the WHO African Region are cancers, diabetes mellitus, cardiovascular disease, and chronic lung and respiratory diseases. Violence, injury and disabilities also contribute a high proportion of morbidity and mortality.

Key Determinants
Risk factors for health

Recent decades have seen significant increases in noncommunicable diseases in the WHO African Region, in addition to the long-standing burden of infectious disease. This can be attributed to three main factors, namely population ageing, rapid urbanization and globalization.

Alcohol abuse, drug abuse and tobacco use are high on the list of critical health risk factors in the Region. Only a small number of countries have alcohol control policies or advertising regulation in place and very few have any in-depth understanding of the nature and extent of drug use. Health services and interventions for those affected are few.

The physical environment

Air, water, land, geography and climate all exert a powerful impact on disease patterns and the health of humans and other species on which they depend. Although environmental factors take their toll on both rural and urban dwellers, the rapid but unplanned urbanization process that has overtaken the WHO African Region has had significant impact on health.

The natural elements serve as vectors for a wide variety of infectious and noncommunicable diseases in African countries, from malaria to malnutrition, and pneumonia to poisoning. Where environments are degraded, a disease or health issue once vanquished can appear again, wiping out gains previously made at high cost. This is exemplified in the resurgence of indoor spraying to control vectors, and in particular to reduce the high malaria disease burden.

Food safety and nutrition

Food output per capita has not increased over the past 50 years in the WHO African Region and 20 countries are reported to be in food crisis. The traditional African diet comprising largely cereals, roots, fruits and vegetables with some animal protein has now shifted towards more fats and processed foods, adding noncommunicable diseases and obesity to the chronic problem of undernutrition in many countries.

As agriculture remains the backbone of the African economy, a strong food safety/food control system is essential to protect both the import and export food markets. However, the required human capacity and resources for this are lacking in most African countries, and food law is often incomplete or outdated. The broad intersectoral nature of food safety, with the resultant difficulty in coordinating effective policies and actions across many government departments, is one major reason for the lack of coherent action.

Social determinants

Understanding the significance of broad health determinants is essential, given the wide range of potential risk factors in African countries and the increasing numbers exposed to them. The population of Africa is likely to double by 2036. At present, life expectancy is below 50 years in many countries, while the population on average is increasing at around 2.5% annually. With 10% of the world’s population, Africa can claim almost 30% of the global poor, most of whom live in sub-Saharan Africa.

Urbanization has occurred very rapidly in the past 30 years, with projections that by 2025, 60% of the population of Africa will live in cities. However, due to natural, social and political phenomena, urbanization has been largely unplanned and has failed to contribute significantly to economic growth. Infrastructural deficiencies have also hampered economic development.



References
  1. Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
  2. The world health report 2000. Health systems: improving performance (pdf 1.65Mb). Geneva, World Health Organization, 2000
  3. Health systems strengthening: improving district health service delivery, and community ownership and participation (pdf 229.52kb). Brazzaville, World Health Organization Regional Office for Africa, 2010 (AFR/RC60/7)