Compendium On Health, Nutrition and POpulation

TABLE OF CONTENT
FOREWORD
THE AFRICAN UNION ABUJA +12 SPECIAL SUMMIT ON HIV/ AIDS, TUBERCULOSIS AND MALARIA
1ST INTERNATIONAL CONFERENCE ON MATERNAL NEWBORN AND CHILD HEALTH
27
INTERNATIONAL CONFERENCE ON POPULATION AND DEVELOPMENT BEYOND 2014
67
DELIVERING THE DEMOGRAPHIC DIVIDEND IN AFRICA: INVESTING IN NUTRITION AS A FIRST STEP
91
ACKNOWLEDGEMENT
The Department of Social Affairs greatly values evidence driven programming which supports policymakers and key stakeholders in formulating or influencing policy. This publication, a compilation a number of policy briefs which the Department of Social Affairs with support from various partners have been able to put together over the past two years is predicated on evidence and focused on results. The Department therefore wishes to appreciate the United Nations Population Fund, Partnership for Maternal Newborn and Child Heath, Aids Accountability International, Elisabeth Glaser Pediatric AIDS Foundation and Childrens Investment Fund Foundation for the support availed in the publication of this compilation. We appreciate as well partners such as the UNAIDS, UNICEF, WHO, UNECA, ALMA, UNIDO, RBM, Save the Children and AfriDev, who provided technical assistance to the development of the policy briefs.
FOREWORD
The African Union Commissions Department of Social Affairs has worked tirelessly over the past two years in collaboration with partners to document concise and action oriented policy briefs focused on health and the social development of Africa. The realization that Policymakers are often busy and are probably not specialists in all developmental issues have been the driving force for the development of these briefs. The use of the policy briefs therefore can help policymakers, programme managers and others stakeholders in grasping the key issues and formulating or influencing appropriate policy. Evidence in these briefs suggests that Africas development pathway should centre on livelihoods and social security, especially as it affects poor and vulnerable. It should address specific areas such as climate change, food and nutrition security, gender equality, decent employment, natural resources, technology, education, health and promotion of local industries and that culture must remain a cross cutting issue and the cornerstone of facilitating sustainable development across the continent. I am therefore pleased that this collection of policy briefs focuses on specific themes that promote and address contemporary issues that touch on the lives of the African people - Family planning, the demographic dividend, immunization, nutrition, integration of health services, health financing, HIV and AIDS, Tuberculosis, Malaria and several others. These briefs review their situation with regards to developmental challenges on the continent and makes concrete, targeted recommendations. The compilation is presented against the background of relevant select activities in which the Department of Social Affairs, has actively participated in over the last two years. The African Union Commission continues to provide a platform for all stakeholders on the continent to express their views, backed up with evidence as we define our continents priorities within the evolving global agenda. As our AU celebrates 50 years of its existence and seeks to define the vision for the next 50 years, I therefore call on all stakeholders on the continent to rally round and ensure that Africa indeed seizes the moment.
H.E Dr Mustapha .S. Kaloko Commissioner for Social Affairs
DAYS TO MAKE A DIFFERENCE
The African Union Abuja +12 Special Summit on HIV/AIDS, Tuberculosis and Malaria
MALARIA CONTROL
With just 900 days left to achieve the Millennium Development Goals (MDGs), strategic decisions need to be made about investing in initiatives that yield high economic, social and health benefits. Malaria control has proven to be a highly cost-effective public health strategy to save lives, improve maternal and child health and lift obstacles to economic development and children's education. Malaria-endemic countries in Africa are highly committed to reducing the disease burden and have been working together through platforms offered by the African Union (AU), the World Health Organization, the Roll Back Malaria (RBM) Partnership and the African Leaders Malaria Alliance (ALMA). The AU has framed a compelling vision for the future of the continent and has developed powerful health policy frameworks that have resulted in a substantial reduction of the malaria burden.
MALARIA FACTS Malaria is an entirely preventable and treatable vector-borne disease. Disease transmission affects 99 countries around the world, with an estimated 3.3 billion people at risk. Worldwide, WHO estimates that 219 million cases and 660,000 deaths occur each year, inflicting a heavy economic and social burden on families, communities and nations;90% of all malaria-related deaths occur in sub- Saharan Africa, mainly among children under five years of age. The 17 most affected countries account for over 80% of malaria cases. The highest malaria mortality rates are being seen in countries that have the highest rates of extreme poverty. At present, 25 countries are en route to eliminating malaria and many more have declared elimination as a national goal. PROGRESS IN REDUCING MALARIA DEATHS AND CASES HAS BEEN SUBSTANTIAL In the course of the last decade, the global effort to control and eliminate malaria expanded significantly. As a result of a scale-up of control interventions including an expansion of access to long- lasting insecticidal nets, indoor residual spraying programmes, diagnostic testing and quality-assured treatment more than a million lives have been saved.Malaria mortality rates decreased by an estimated 26%globally and by 33% in Africa between 2000 and 2010.Worldwide,50countries(of which 9 are in Africa) are now on track to reduce their malaria case incidence rates by 75%, in line with World Health Assembly and RBM Global Malaria Action Plan targets for 2015.However, these 50 countries make up only 3% of estimated global cases of malaria. SHORTFALL IN FINANCING THREATENS FURTHER PROGRESS In order to move closer to 2015 targets, and to achieve wider economic and social benefits across Africa, malaria investments need to be expanded markedly between 2013 and 2015. Recent years have witnessed a gradual levelling off of international funding, staying well below the US$ 5.1 billion that would be needed each year to achieve universal access to life-saving prevention and control measures. In 2013, the funding gap for malaria control in Africa stood at US$ 3.6 billion for the period 2013-2015. Should efforts to maintain high levels of coverage fail, malaria will resurge in areas where commodities cannot be provided to at-risk populations in time. 2013 is therefore a critical year for malaria financing. With sustained funding and commitment, endemic countries can continue to progress towards ending malaria deaths, but without it, gains could be quickly reversed, putting millions of lives at risk.
Abuja +12: 900 Days to make a difference
WHAT CAN BE DONE? Maintain high-levels of cover- Greater Mekong subregion of South-East Asia. A furage with malaria interventions ther spreadof resistantstrains, or the independent emerIt is critical that malaria-endemic countries continue gence of artemisinin resistance in otherregions, could scaling up interventions to achieve universal coverage of threaten the success ofmalaria control efforts in Africa all prevention, diagnostic and treatment interventions, and around the globe.Resistance to at least one insectiin line with WHO policy recommendations. Together cide has been reported from 64 endemic countries globwith the UN Special Envoy for Financing the Health ally, with the majority of these countries being in Africa. MDGs and for Malaria, the RBM Partnership is roll- It is critical that national malaria control programmes ing out a strategy to mobilize financial resources to help implement the recommendations contained in the endemic countries meet the 2015 targets. This includes Global plan for artemisinin resistance containment and supporting the replenishment of the Global Fund to the Global plan for insecticide resistance management. Fight AIDS, Tuberculosis and Malaria, which currently Sectors outside of Health provides approximately 60% of all international financ- Engage In order to be effective, cost-efficient and sustainable, ing for malaria. malaria control efforts should be better integrated in Increased domestic financing for malariaand the devel- the work of key non-health sectors, and be considered opment of innovative financing mechanisms are also in the context of the broader economic, environmental key elements of this strategy. Possible innovative financ- and social challenges faced by endemic countries. Facing tools include airline ticket levies and financial trans- tors such as climate change, urbanization, industrial and action taxes; private sector financing through bonds; infrastructural investments, and natural resources manpooled or bulk procurement; and improved local manu- agement can substantially influence patterns of malaria facturing -- as called for previously by RBM and ALMA. transmission.Changes in demographic and population RBM partners are also working closely with national dynamics and ecosystems alsohave an impact on the epmalaria control programmes to resolve key logistics and idemiology of malaria and the required package of contechnical challenges at regional and country level. trol measures that need to be rolled out. With all these elements considered, malaria control should become an Strengthen malaria surveillance and response systems integral part of national development strategies. Currently, only around one-tenth of the estimated global case count is detected by surveillance systems. Without Completing the unfinished business effective surveillance systems, it is impossible to reliably In the remaining two and half years, the international measure progress towards malaria targets. Strengthened community and malaria-endemic countries should insurveillance would enable Ministries of Health to direct tensify malaria control and elimination efforts and scale financial resources to populations most in need, to re- up cross-border activities to prevent re- introduction spond effectively to disease outbreaks, and to assess the of the disease into areas that have become malaria-free. impact of control measures. RBM partners therefore Malaria should remain a high priority in the post-2015 urge and support endemic countries to strengthen their agenda, together with efforts to strengthen maternal malaria surveillance and response systems in line with and child health services and expandcommunity health WHO and RBM guidance released in the 2012. Malaria worker programmes. A strong focus on health system surveillance is a critical foundation of WHOsT3: Test. strengthening is also key to making visible progress Treat. Track.approach. against this disease. Prevent drug and insecticide resistance The double threat of emerging drug and insecticide resistance poses an urgent challenge that should be addressed at the national level, with support from the global malaria community. Parasite resistance to artemisinin thekey component of recommended combination treatments for malaria has already emerged in the To sustain the gains made to date, national malaria control programmes need predictable international donor funding, increased domestic investment and innovativefinancingmechanismsthatcantapintonew resources.Coordinated action through regional inter- governmental mechanisms, such as the African Union, will be critical for fostering national support for strong multisectoral
collaboration, improving surveillance and fighting drug and insecticide resistance. Finally, sustained political commitmentand an effective global partnership under
the umbrella of Roll Back Malaria will be fundamental to future progress.
Photo:World Bank Photo Collection
LOCAL PRODUCTION OF PHARMACEUTICALS IN AFRICA

INTRODUCTION In Africa we bear a disproportionate burden of disease with for example, 75% of the worlds HIV/AIDS cases and 90% of deaths due to malaria. 50% of global deaths under five occur on our continent largely due to neonatal causes, pneumonia, diarrhea, measles, HI V, TB and malaria. As well as communicable diseases, the incidence of non- communicable diseases such as cardiovascular disorders, cancer and diabetes are on the rise and are already very significant public health issues especially in the North of our continent. It is estimated that by 2020 Africa will have 60 million people suffering from hypertension and nearly 19million people living with diabetes. To date we have been overly reliant on imports for our essential medicines needs. It is often estimated that 70% of essential medicines used in Africa are imported from other continents. This situation leaves us vulnerable in terms of security of supply, is not long term can explicitly help us in meeting our medicine needs medicines that live up to the acceptable international standards of quality, safety and efficacy and that are affordable. The African Union Commission (AUC) with support from the United Nations Industrial Development Organization (UNIDO) has developed a Business Plan for the accelerated implementation of the Pharmaceutical Manufacturing Plan for Africa (PMPA). The plan recognizes the different contexts that our countries and regions face as well as the complexity of the pharmaceutical industry. It sets out a practical approach to developing the industry on our continent so that, first and foremost, it can serve to improve access to quality medicines to our people.Through implementation of this plan we will become less dependent on importsand improveour selfreliance. A stronger and reliable local pharmaceutical industry would also contribute to the economic development, job creation, human resource development and associated industrial development. The PMPA Business Plan Key Pillars In order for our pharmaceutical industry to develop there is a need to create a conducive environment which can be achieved through: enhancing the talent pool for the pharmaceutical industry facilitating access to investment capital and providing well-tailored but time limited incentives strengthening the regulatory control of our pharmaceutical markets and industry facilitating our companies to access know how and technoloy facilitating market access and improving the availability of market data. Human Resource Development The pharmaceutical industry is knowledge intensive and requires a workforce of highly skilled professionals. We have the skills on our continent but we need to expand this talent pool and equip our pharmaceutical industry with the practical knowledge of how to produce medicines of international standard at competitive cost. Investment Capital and Time limited Incentives Pharmaceutical companies need to make significant investments and require access to capital with long term maturity and at affordable rates. Demonstrable commitment from African leaders will increase the appetite for the sector amongst the investment community but there is a need to facilitate and support investment through initiatives such as context specific and time limited incentives. For example India supported the development of its industry over decades through incentives such as interest subsidies, working capital credits and export incentives. Many of the products that we import still benefit from export incentives and there is a need to level the playing field if our manufacturers are to be competitive and be able to invest.
11
Increased Regulatory Control For our companies to be able to invest they need to be protected from the unfair competition of, sometimessub-standard and even counterfeit products requiring greater oversight of the market place. To assist our companies to develop and to mitigate risk to public health it is necessary to implement a roadmap towards international quality standards that they will be supported to and required to follow, and this should be enforced by our vigilant and strengthened regulatory authorities. Access to Know How and Technology In the short term it will be necessary to enable companies to access the requisite skills and know how to develop and implement upgrading plans in accordance with the road map to international quality standards. We also need to expand the range of products manufactured in Africa and to realize the opportunity for improving access to for example second line ARVs that could be achieved through the TRIPS flexibilities. Facilitating Market Access and Improving the Availability of Market Data The Business Plan is closely aligned with the African Medicines Regulatory Harmonisation (AMRH) initiative. Through defragmenting our regional markets the business environment for our manufacturers will improve as they will be able to serve a larger market with the efficiencies in production that can then materialize. There is limited market data available such that it is difficult for companies to make informed decisions and
for investors to properly assess the risk and opportunity that the industry presents. The PMPA Business Plan Implementation The development of the industry requires coordination and collaboration of a number of different players at national and regional levels. Therefore political will is essential as is establishing policy coherence across ministries to support our companies and establishing a sound multi stakeholder strategy. The Business Plan recommends that a consortium of development partners must work together to provide technical assistance and capacity building across the different dimensions of pharmaceutical sector development. The nucleus of the consortium which is being convened under the authority of the African Union will be made up of the African Development Bank, UNAIDS, UNIDO and the World Health Organization (WHO). Other partners such as the New Partnership for Africas Development (NEPAD), the Federation of African Pharmaceutical Manufacturers Associations (FAPMA), the African Network for Drug and Diagnostic Innovation (ANDI) and the United States Pharmacopeial Convention (USP), amongst others, also have an important role to play.Subject to invitation from the AUC, the consortium of partners is open to contributions from yet other agencies who are interested in supporting local production in Africa.
CONCLUSION Developing the pharmaceutical industry on our continent can contribute to improved access to essential medicines, sustainability of treatment programmes and to economic development. The PMPA Business Plan sets out a practical approach that recognizes the complexity of the pharmaceutical industry and the different situations that our countries face. A consortium of African and International Partners is being convened to provide coordinated technical assistance and capacity building so that we reduce our reliance on imports, are able to provide high quality affordable products for our people, can sustain treatment programmes in the post MDG era and contribute to economic development through import substitution and exports to international markets.
12
TUBERCULOSIS
Overview: the situation of TB in Africa TB is one of the top 10 causes of deaths in the world and is second only to HIV/AIDS as the biggest killer among infectious diseases. In 2011, 8.7 million people fell sick with TB and 1.4 million died from the disease equivalent to three people every minute.The African continent is particularly affected by the TB epidemic. In 2011, 40% of all deaths associated to TB, i.e. 548 000 people, were in Africa.Without accelerated action, 23 million people will fall sick with TB and 5.5 million will die of TB in Africa in the next ten years. In 2005, 46 African ministers of health called for urgent extraordinary actions to address the TB emergency in Africa. Nine African countries have since declared TB as a national emergency. But this has not been followed by the dramatic scale-up of services that is needed to end the epidemic in Africa The reasons for acting now are compelling. A recent report identified TB as the most cost-effective health intervention. EveryUS$ 1 spent on TB generates US$ 30 through improved health and increased productivity. This presents an incredible opportunity to spur economic growth, end extreme poverty and improve the livelihoods of their people. 1. Fighting TB is a prerequisite for fostering economic growth, ending poverty and improving livelihoods - addressing TB must therefore be prioritized in national government programs 2. We are at a critical time in the fight against TB but we are facing a major funding crisis domesticand international financingmust bescaledupimmediately 3. Accelerated action to integrate TB and HIV services in African countries where co- infection rates are highest will lead to substantial cost-savings and improved health and economic outcomes.
Resolution of the WHO Africa Regional Committee in Maputo, Mozambique, on 25 August 2005 Report of the HighLevel Panel of Eminent Persons on the Post-2015 Development Agenda (31 May 2013), page 39.
13
Background 1. Fighting TB is a prerequisite for fostering economic growth, ending poverty and improving livelihoods - addressing TB must therefore be prioritized in national government programs At a macro-economic level, TB significantly hampers the economic development of middle- and low- income countries. According to the recent report of the HighLevel Eminent Panel on the post-2015 development agenda, investment in TB will yield a 30- fold return. TB is a disease that worsens poverty and disproportionately affects poor communities. Studies suggest that TB patients are out of work for an average of 3 4 months; that household incomes decrease by up to 80% as a result of a family member contracting TB; and that each TB death deprives a family of 15 years of income. TB creates a vicious cycle, with TBpatients remaining poor because of the devastating impact it has on their families life. The 2012 SADC Heads of State Declaration on TB in the Mining Sectoris a response to the economic impact of TB on a prominent African industrial sector. The recent Swaziland Statement highlights solutions for a multi- sectoral, regional and international response to the problem of TB in Africa. 2. We are at a critical time in the fight against TB but we are facing a major funding crisis domestic and international financing must be scaled up immediately In the last 13 years, critical progress has been made in the development of new tools, i.e. diagnostics and drugs, and in identifying the right approaches to fight the disease. TB is curable and can be defeated, but there are three challenges that underpin the TB emergency. The emergence of drug-resistant TB, which can cost up to 100 times more to treat in comparison to drug-sensitive TB, makes timely investments more critical: 1. Domestic financing for TB in Africa is low. On average, African governments contribute 30% of their national TB budgets, whereas in the rest of the world governments contribute 70% on average. This makes many African governments highly dependent on external financing and extremely vulnerable to any international aid fluctuations.
2. 88% of external donor financing for TB is from one source: the Global Fund. This provides US$ 440 million each year for the fight against TB globally. However, most of this money is not going into Africa. For every $100 going to Sub-Saharan Africa from the Global Fund, only 6% is for TB. This small amount still represents half of Africas available TB funding (54%). 3 Much greater ambition is needed in terms of providing diagnosis and access to treatment for all TB patients in most African countries. It is time for an emergency response.This need for scale-up should be reflected in ambitious national strategic plans, aiming at universal coverage and zero-TB related deaths. 3. Accelerated action to integrate TB and HIV services in African countries where co- infection rates are highest will lead to substantial cost-savings and improved health and economic outcomes A key stumbling block to progress in the fight against TB in the region is the extremely high co-infection rate of TB-HIV. In 2011, 80% of all new TB-HIV cases in the world were in Africa. 75% of all 435,000 people with HIV who died of TB in 2011worldwide were from Africa. The impact of what can be achieved through integrated TB and HIV services is remarkable: between 2005 and 2011, 1.5 million lives were saved due to TB and HIV integration. While this is notable progress, much remains to be done.Enhanced collaboration between HIV- and TB-services is required, too often patients are still going to different sites, but patients who have both diseases should be seen and treated by one health worker. The objective must be that every HIV patient is tested for TB and every TB patient is tested for HIV, and that treatment is easily provided. Conclusions We are the closest we have ever been to defeating TB forever. Impressive progress over the last five decades shows that TB can be stoppedwith strong political will and adequate financial resources. New tools are now available with which to accelerate progress. We must set ambitious targets against TB if we are to overcome poverty, foster economic growth and save millions of lives. Health Financing in Africa
14
15
HEALTH FINANCING IN AFRICA

The Heads of States' commitment to increase government funding for health has been emphasizedin the Abuja Declaration of 2001.The same commitment by Heads of state has been reiterated inthe Africa Health Strategy: 2007-2015; the 2008 Ouagadougou Declaration on Primary Health Care and health systems strengthening; the World Health Assembly resolution 68.5 on sustainable health financing structures and universal coverageand the 2012 Tunis Declarationof the Ministers of Health and Finance on value for money, sustainability and accountability in the health sector. There is broad agreement that sustainable,adequate and fair financing for health is one of the prerequisite to achieving country and international health goals and MDGs. Keys messages: Member states of the African Union are onaverage still far from meeting key health financing targets of the Abuja Declaration. In 2010,only 5 countriesreachedthetargetof allocating at least 15% of their annual budget to health. Twenty eight countries out of fifty spent the minimum of US$ 44 per capita as estimated by the High Level Task Force on Innovative Financing for Health Systems (HLTF). Only three countries in Africa reached the targets set in both the Abuja Declaration and the HLTF report; Out-of-pocket payments (OOP) still represent more than 20% of total health expenditure (THE) in 40 countriesin Africa.. Only one country has managed to spend more than 15% of their annual budget, the minimal level of US$ 44 per capita expenditure and OOP less than 20% of THE as shown in figure 1. A key challenge for member states and their partners is to ensure effective and efficient use of availableinternational and domestic resources, improved predictability,alignment to national priorities and use of government mechanisms; The reinforced dialogue between Ministers of Health and Finance, as spelt out in the Tunis forum organized
by HHA in 2012, has shown increased engagement towards financing for health and improving the effectiveness of available resources. Member States are often challenged by conflicts, natural and man-made disasters with significant public health Current Situation Total health expenditure The 2001 Abuja Declaration urging African Union Members States to allocate at least 15% of national budgets to the health sector was an important landmark. This target hadbeen achieved by only five countries by 2010, as shown in figure 1. The allocation to the health sector as a percentage of total government budgetsranged from 2% to 20%.In 22
consequences calling for provision of funds to address these threats; in this regard financing of the African Public Health Emergency Fund (APHEF) by member states should be prioritized.
countries, the level of funding for health is below US$ 44 THE per capita and this highlights the need for governments to allocate more money for health from domestic sources. It is important to note that only three countries have managed to meet both the Abuja Declaration target and the US$ 44 per capita THE recommended by the HLTF as shown in the table 1
Financial risks and barriers to access to health services As shown in Figure 1, although 29 countries have reached the level of US$ 44 THE per capita, 22 of these haveOOP payments exceeding 20%of THE. This level is higher than the ceiling at which financial risk protection can be ensured. Countries that have reached the US$ 44 per capita but have a high level of OOP payments still need to focus on developing and strengthening pooled prepayment mechanisms. The potential to identify new sources of tax revenue such as sales taxes and currency transaction fees can also be further explored. Ghana, for example, has funded its national health insurance scheme (NHIS) partly by increasing the value- added tax (VAT) by 2.5%.
Domestic funds for health Many African countries have limited capacity to raise public revenue mainly because of the informal nature of their economies. This makes tax collection difficult including payroll tax collection for social health insurance.The performance, accountability and administration of the tax system are often an additional problem for many countries. The extent to which countries will mobilize public financial resources for health will depend on the level of economic development in that, countries with a high GDP percapita will do better. This explains to a large extent why countries, with comparable GGE as a percentage of GDP will have significantly different levels of THE
17
per capita. Gabon is an example here with a government expenditure of US$ 2410 per capita while others, with a similar share of GGE over GDP (28%) for example Malawi, spend only US$ 110 per capita on health. The capacity of countries to generate public financial resources lies outside of the health sector to a large extent. Health advocates wishadditional revenue streams to be earmarked for health but very often they are not. In general however, raising more public revenues should indirectly benefit the health sectorwhose share, even it is not increased, will be from a larger resource envelope. External funds for health Although external sources play a significant role in financing health services in low income countries, the current level of funding still falls below commitments. It would be possible to achieve a significant increase in international resources for health, if donor countries would fulfill their promise to allocate 0.7% of their gross national income (GNI) to official development assistance (ODA). In 2009 only 5 out of the 22 donors met this requirement. Key recommendations Reinforce financing for health through national strategy emphasizing appropriate policies for revenue collection; using sound methods and approaches such as sharing
financial risks and ensuring equitable and efficient use of resources. . Concretize engagement toimplement Universal health coverage through strong and sustainable health systems based on PHC. Increase funding for health from innovative financing, prepaid mechanisms and pooled sources for health. Sustain the current process of dialogue between ministries of health and financethroughinter-ministerial committees, strategic alliances, and the presence of senior health officials in bilateral and multilateral discussions between government and development partners. Prioritize funding of the African Public Health Emergency Fund, which was established by Ministers of Health and endorsed by the AU head of state of the AFRO region. Improve effectiveness of external funding through addressing identified challenges among such as unpredictability and fragmentation of health systems.
18
Photo: US Army Africa
HEALTH SYSTEMS
INTRODUCTION Africa is confronted by a heavy burden of communicable and non-communicable diseases despite the existence of effective interventions to improve health outcomes.Most countries of the region are not on track to meet the health MDGs.The main reason for this situation is the weak ability of the health systems to deliver health interventions to those in greatest need in a comprehensive way, and on an adequate scale. The six building blocks of the health system are shown in figure 1 and there are weaknesses in all the pillars. Weaknesses are seen in leadership and governance, community engagement, financing, the health workforce, access to essential medicines, new vaccines and health technologies, fragmentation in partner support, as well as missed opportunities to use information and innovation to improve services. The Africa Health Strategy (2007 2015) and the Framework for the implementation of the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa (2010) over emphasize the need to prioritize health system strengthening, providing overall guidance to member states. Key messages Many member states of the African Union are not on track to achieve the health MDGs and other health outcomes. If health systems are not strengthened,countriesare less likely to scale up interventions by 2015. Sustainable and strong health systems are necessary to attain universal health coverage and people-centered care, thereby improving health and development outcomes. There are commitments and opportunities for this to happen. Health System Strengthening should be based on the principles of primary health care (PHC) , as proposed in the Framework for the implementation of the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa 2010. There should be a strong and evident country ownership and leadership of the health system strengthening process which, should be based on sound national health policies, strategies and plans. There should be a systematic involvement of all the key development sectors whose actions have a bearing on health at the highest level of government - healthinall policies, as well as the alignment of donor funds to country priorities.
The WHO Health Systems Framework
19
Burden of disease The African Region has a high disease burden, with only 10% of the world population, the Region's contribution to the global burden of HIV/AIDS, TB and malaria is 66%, 26% and 80% respectively. In general it contributes24% of global DALYS. It accounted for 46% of Under-five deaths in 2011; 55% of the maternal deaths; 22% of AIDS-related and 90% of the malaria deaths. Thirteen countries are on track to meet MDG 4, while 24 are making progress, though insufficient. Only two countries (Eritrea and Equatorial Guinea) are on track to meet the MDG 5 target. Issues and challenges related to health systems The goal of a health system is to improve the health of people in a manner which is equitable, efficient, responsive and financially fair. A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction to function. Strengthening health systems thus, means addressing key constraints in each of these areas. Some of the weaknesses and challenges identifiedinclude weak policies and guidelines; low public expenditure on health with only five countries reaching the Abuja 15% target; shortage of adequately trained and motivated health workers; inadequate supply and regulation of essential medicines, medical products, and technologies; fragmentation of the health information system which is not fully utilized and, low coverage of health services. In addition, health systems are sensitive to weak governance, accountability, political instability, natural disasters, underdeveloped infrastructure, and economic and financial instability. Opportunities for Health Systems Strengthening There is a strong and growing political willingness at various levels to strengthen health systems. Governments have increased the proportion of their national budget allocated to health. Regional initiativesundertaken include the Abuja Declaration to increase government funding for health, the Ouagadougou Declaration on Primary health care and health systems in Africa, the Africa Health Strategy 2007-2015 of the AU and, the Tunis Declaration on value for money, sustainability and accountability in the health sector. The region has shown innovation through increased and structured participation of communities to improve the coverage
of essential services through Community Extension Workers as seen in Ethiopia, Rwanda and Mali. The amount of Overseas Development Aid to the health sector has increased. Some global health initiatives such as the Global Fund and the GAVI Alliancehave opened financial windows for health system strengthening. Global and regional partnerships such as the International Health Partnership (IHP+) and the Harmonization for Health in Africa(HHA) have the objective to move towards better coordination and alignment of donor funds to country priorities. These are all important conditions for effectively strengthening health systems to meet the MDGs and move towards universal health coverage.
Recommendations Governments should provide political leadership with effective regulation, oversight and governance for health through formulation of national policies, strategies and plans. Governments investment plans should focus on building institutional capacity, promoting equity in access to services by decentralizing health systems and, enhancing community empowerment to participate in the management of health services through a high commitment to PHC approaches. Increase investment in health by allocating more funds to health from national budgets whilst ensuring efficient utilization of all available funding. In addition, there is need to reinforce advocacy for sustainable financing of health systems. Countries should seize the opportunity of resources provided by global health initiatives to strengthen the health system in a comprehensive manner. Through independent bodies, countries should develop a scorecard on health system performance and regularly high authorities on the progress made in health system strengthening. Strengthen all the building blocks of the health system; increase the quantity and quality of the health workforce, ensure availability and rational use of essential medicines and other health commodities, improve and expand available infrastructure, improvehealth information management systems and IT innovation.
Conclusion Effective public health interventions are available to curb the heavy disease burden in Africa. Unfortunately, health systems are often too weak to efficiently and equitably deliver those interventions to people who need them, when and where needed. Strong health systems are an effective means of improving the health of the people of Africa.In addition to health being a human right, the dividend of a healthier population in Africa is very high given the fact that healthy individuals are more productive, and have a positive impact on the gross domestic product (GDP) of a Nation. Therefore, investing in African health systems is an opportunity to accelerate economic development, contribute to saving millions of lives, prevent life-long disabilities, and move countries closer to achieving objectives of national poverty reduction strategies, the Millennium Development Goals (MDGs) and prepare them to move towards meeting the challenges of the post 2015 development agenda
21
ELIMINATION OF MATERNAL TO CHILD TRANSMISSION

Scientific advances and their implementation have brought the world to a tipping point in the fight against AIDS. The science guiding interventions that address HIV risk reduction, prevent transmission, and reducemorbidity and mortality is now clear and established. Enhanced country and programme capacity, improved efficiencies, increased community engagement and participation, and innovative application of new technologies are helping scale up the accessibility and utilization of programme interventions, and achieving an 'AIDSfree generation' is now within reach. Eliminating new HIV infections in children and keeping mothers alive is critical to achieving this goal, and the Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, endorsed by Africa leaders, UN agencies, and development partners and launched in 2011, has set a goal of reducing new infections among children by 90% from baseline 2009 levels. Of the world's 34 million people living with HIV, 23.5 million are in Sub-Saharan Africa, and 21 of the Global Plan's 22 focus countries are in Africa. Africanwomenbearthemajorityofthe world'sepidemic. 92%ofallpregnantwomen living with HIV are in Sub-Saharan Africa, and 60% of Africa's infections are among women. Without intervention, up to 40% of these women would pass infection on to their babies. Much progress has been made, particular in eliminating new infections among children, with a 24% reduction in new infections among children between 2009 and 2011, and a 40% reduction since 2003. In Africa, 7.1 million people are now receiving treatment, and 57 per cent of pregnant women living with HIV received efficacious antiretrovirals (ARVs) for prevention of mother to child transmission (PMTCT). Access to early infant diagnosis (EID) for HIV within the first few weeks of life by infants born to women with HIVinfection has increased to 35% in 2011, and while paediatric ART coverage has steadily increased only 28% of children needing treatment received it in 2011.
The global, regional, and country plans for eliminating new infections among children highlight and detail critical actions and recommendations for implementing partners, national partners, governments, UN agencies, and donors. Bringing these plans to fruition will require bold national leadership, external and domestic resource mobilization, and enhanced national ownership and accountability. A recent midterm review of progress, synthesis of country level bottleneck analyses, and reviews of best practices, have highlighted the need to; a) Urgently develop strategies and plans in countries where performance and coverage is lagging; b) Develop approaches to accelerate progress against milestones; c) Strengthen monitoring, evaluation and the use of data for decision making; d) Advocate for political and administrative support, enabling policy and the service delivery environment; e) Address bottlenecks affecting supply chain management, human resources for health, and early infant diagnosis; f) Strengthen the role and participation of civil society; g) Strengthen resource mobilization efforts and the investment case for elimination; h) Complete the costing of national plans and select high impact eMTCT investments; and i) Ensure the application of the human rights based approach to future programme development. Three critical high level commitments, in line with the global plan, are needed to achieve country, regional, and global targets and address current gaps and shortfalls. These include: Ensuring universal access to optimal prevention and treatmentthat is grounded in the best interests of mother and child; Leveraging synergies, linkages and integration for improved sustainability Strengthening country ownership and accountability 1) Universal access: Ensuring womens access to optimal treatment regimen reflecting the most recent guidance available remains the cornerstone of efforts to eliminate new infections
22
Percentage of pregnant women living with HIV who received antiretroviral medicines to prevent transmission to their child, preliminary results, 2012
among children. National plans must be updated to reflect current guidance,andremaingroundedinthebestinterestsoft hemotherandchild. Renewed efforts to reach the unreached, simplify prevention and treatment regimens, maximized human resource capacity, scale up technological innovation, and strengthen supply mechanisms are paramount. Elimination plans that have focused primarily on ensuring testing, counseling, and treatment for HIV positive pregnant women should make concerted efforts to fully address other programme components needed to achieve elimination goals, including primary prevention among women of reproductive age,family planning and birth spacing and treatment for the health of the mother It remains essential to include women, their partners, PLHIV networks, communities, civil society, and the private sector in the design and implementation of programmes scaling up access to care, treatment, and support services. Efforts must be pursued to ensure that health service delivery mechanisms for both MNCH and care and treatment platforms are responsive to the needs of pregnant and postnatal women living with HIV, and to the ongoing needs of these mothers, their partners, and families. Universal access depends on communities supporting adolescent and family friendly HIV testing and counseling, without stigma and discrimination, and concerted national and subnational leadership is needed to make universal access a reality. 2) Leveraging synergies, linkages and integration for improved sustainability. Integrating HIV prevention and treatment for mothers and children into existing platforms for maternal, newborn, and child health, antenatal care, and family planning, will strengthen synergies, optimize outcomes for all women, and increase cost effectiveness and sustainability. Prevention and treatment should not be stand- alone, one time interventions, and more effective integration should not only increase access but also promote entry into a continuum of care across multiple health services, ensuring that HIV interventions contribute to global maternal and child health goals and strategies. This is particularly true in Africa, where the AIDS epidemic accounts for significant proportions of maternal and child mortality and morbidity. Integration is essential for improving loss to follow-up, strengthening referral linkages, effectively linking primary health care and treatment, increasing maternal and child access to longer term treatment, and promoting community mobilization and engagement. 3)Country ownership and accountability. Because countries have diverse epidemics and are at different stages of implementation in their efforts to eliminate new infections among children, it is essential that the leadership and development of context specific elimination plans rest at the country level. Strategic planning, priority setting, and performance monitoring must be led and coordinated at both national and decentralized levels, in collaboration with all critical stakeholders. Efforts to improve monitoring and progress reporting should also promote more active use of data for programme planning, priority setting, and decision making at decentralized levels. Country programs and their development partners must make adequate human and financial resources available and adopt evidence-informed policies. The sharing of best practices and lessons learned across countries needs to be improved, and additional support provided at regional levels to promote effective frameworks for cooperation and accountability. The roles, responsibilities, and contributions of all stakeholders need to be clear, specific, and transparent, and to ensure the efficient and effective use of resources, as well as address agreed upon gaps, bottlenecks, and capacity building needs, national leadership is needed to ensure the adoption and utilization of clear monitoring and evaluation frameworks and indicators to promote accountability and routinely assess programme progress.
23
ACCOUNTABILITY
INTRODUCTION Accountability has been identified as a key factor in improving the response to AIDS, TB and Malaria and the broader health and development agenda in Africa and worldwide. Accountability and transparency plays a key role in promoting health policy development and health care service delivery.Accountability is ensured through information provision on set targets and commitments, ensuring feedback mechanisms, consultation and participation of key stakeholdersat all levels. AIDS, TB and Malaria have remained high on the African Union political agenda with several commitments to address the challenge since the 2000 and 2001 (Abuja Declaration). Over the past twelve years, AIDS Watch Africa has served as an African-led advocacy and accountability platform to press for the urgent acceleration of continental action to combat AIDS with a broadened mandate in 2012 to also address TB and Malaria. Timeline of the African Union and AIDS Watch Africa key commitments
2001: AbujaSummitonHIV/AIDS,TBandOther Related Infectious Diseases, eight Heads of State and Government; AIDS Watch Africa (AWA) created as an advocacy platform at Head of State level to monitor the African response and mobilize resources. 2003 Maseru Declaration on HIV and AIDS/ Maputo Declaration on Gender Mainstreaming/ Maputo Declaration on HIV/AIDS, TB, Malaria 2004: AWA Secretariat was relocated to the AU Commission 2003 The Protocol Relating to the Peace and Security Council (PSC) of the African Union (especially around violence) 2004-2005 Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa (Maputo Women Protocol) 2004 Solemn Declaration on Gender Equality in Africa (SDGEA) 2005: Continental HIV/AIDS Strategic Framework and AWA Action Planapproved 2006: Maputo Plan of Action for implementing the Continental Policy Framework on Sexual Reproductive Health and Rights (SRHR) 2006: Continental Policy on Sexual and Reproductive Health and Rights, (Maputo Plan of Action related) 2006: Brazzaville Commitment on Scaling Up Towards Universal Access to HIV and AIDS prevention, treatment, care and support in Africa by 2010 2006: Reaffirmation of Abuja Declaration Plan of Action Special Summit of the AU on HIV/AIDS, TB, and Malaria (ATM) adopted 2006 Maputo Plan of Action, Plan of Action on Sexual and Reproductive Health and Rights 2007-2010 (renewed till 2015) 2007: African Union Ministers of Health adopt Africas Health Strategy; 2010: AU Heads of State and Government approve A Partnership For The Elimination of Mother-Child Transmission of HIV in Africa 2010: African Union launches Campaign for the Accelerated Reductionof Maternal Mortality in Africa (CARMMA) 2011: AU adopts Common Position on HIV/AIDS in activities pertinent to the prevention and resolution of conflict and post-conflict peace- building 2012: AU Heads of State and Government adopt the African Union Roadmap on AIDS, TB and Malaria (2012-2015)
24
Translating political commitments into action While political commitments play a vital role in delivering results, critically important is the need to translate commitments into action. To ensure that that this is achieved accountability mechanisms need to be institutionalised to hold all stakeholders accountable to set targets. The revitalisation of AIDS Watch Africa in 2012 is a significant step in ensuring that there is High Level Accountability on the three diseases. The Alliance of African Leaders on Malaria in Africa has taken key steps in ensuring that governments remain on track on their Malaria commitments. Various civil society organisations have developed scorecards on AIDS, TB and malaria related to the African commitments and haveemployed various engagement strategies including lobbying and advocacy at various levels to ensure implementation of commitments.
costed to adequate monitoring and evaluation. -Commitments have no teeth without the money to back them up-Funding is required by governments in order to roll out commitmentsIf a commitment is left unfulfilled and unattained they become toothless, and this has a knock on effect for other commitments. Every commitment that is made and then ignored and not attained undermines the entire process of having commitments.
-Government needs to be involved more in the drawing up of the recommendations early in the process.In many countries government still sits with more knowledge of what is really happening on the ground and what can be realistically rolled out than any other group, including civil society and funding partners. They need to be consulted and their political buy-in secured from the early stages of the design of the commitments. -Tracking mechanisms for various commitments do not exist- There is need to ensure that the impact and roll out of commitments is monitoring and evaluation systems exist to track progress, outcome and impact. -The roles of implementing partners in the commitment should be clearly spelled out to ensure clear division of labour for greater accountability. -Civil society should not undermine thelong term accountability mechanisms or capacity of government and development partners- governments are ultimately accountable government to provide services.
Accelerating the implementation of African Commitments on AIDS, TB and Malaria Over the years, quantitative and qualitative approaches to measure the performance of various stakeholders against their commitments have generated some recommendations to improve the implementation of these commitments. -Need to ensure that sets targets are measurable- there is need to ensure that commitments arequantifiedand
25
Photo by Nena Terrell/USAID
Photo: MamaYe
26
ICMNCH
1-3 August 2013
1st International Conference on Maternal, Newborn and Child Health
27
ICMNCH
COMMUNITY ENGAGEMENT AND REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH BACKGROUND Most causes of maternal, newborn, and childhood mortality are preventable using an evidence-based, cost-effective set of essential interventions. Proven best practices for reproductive health are also widely promoted by global agencies and African governments. Still, poor access to, and utilization of, such interventions are major barriers to RMNCH in Africa. Women and children continue to die from three key delays: seeking care, reaching the health facility, and receiving appropriate case management by health workers. Uptake of reproductive health services remains low. Improving utilization and eliminating delays requires communities to be empowered and engaged to participate in RMNCH. Communities should help to define and prioritize relevant RMNCH problems, understand the shortand long-term consequences of women and childrens health, feel ownership of interventions and outcomes, and participate in planning, implementing, monitoring, and feedback. Not only should African governments make a commitment to engage communities, communities likewise must have mechanisms by which to engage the state. Community engagement is necessary for gains in equity and sustainability. Many African countries experience regional disparities in women and childrens health. Equity issues are masked when RMNCH data is aggregated at national level, and centralized planning is prioritized. National RMNCH targets may be reached, yet whole regions left behind. Community engagement helps guarantee a countrys RMNCH gains are distributed fairly. Lastly, many RMNCH initiatives in Africa are financed by external sources and carried out within time-bound project cycles. Community engagement is essential to ensure that achievements are sustainable beyond the duration of projects and programs. Community engagement also can illuminate potential grassroots sources of funding and resource mobilization.
Photo: Heinrich Boell
28
ICMNCH, August 2013
CHALLENGES Social conditions and cultural beliefs contribute to a communitys sense of engagement in the health of women and children. Changes to attitudes and behaviors are challenging to implement, incentivize, sustain, and measure. RMNCH interventions must target male change agents and other male community members to succeed. A strong advocacy climate is critical to engaging local communities, as community organizations are vital stakeholders in defining and demanding appropriate services, as well as ensuring accountability. Outreach and advocacy to community organizations is still under-funded and under-coordinated in many African countries. Indirect costs of care-seeking (e.g. transport costs, loss of income, lack of child care) play a major role in the unwillingness of community members to make use of health facilities. These are key areas around which communities can be mobilized to provide support, but such factors are sometimes given less attention than more easily measured facility-based interventions. When successful MNCH projects are chosen for scaleup, the technical components of such interventions may be prioritized for scale up over community engagement components. Community health workers (CHWs) have sometimes lacked coordination, clearly defined roles and supervisory structures, and incentivization. Their training may be fragmented and infrequent. CHWs represent the front line of the health system, and should be critical agents in community mobilization, health promotion, and referral. In some instances, CHWs are not being utilized efficiently.
STRATEGIES AND BEST PRACTICES Involve communities in the identification of RMNCH problems, as well as in the planning, financing and implementation of solutions. Community systems (e.g. community-built maternity waiting homes, community emergency transport, pooled financing mechanisms for emergencies, community-led construction of health worker housing) are activities that can be funded, built, and administered at grassroots levels, creating a degree of community ownership of women and childrens health and a potential for sustainability (e.g. Malawi, Nigeria, Zambia). Involve communities in the creation of accountability mechanisms and quality assurance. Community scorecards and other social auditing mechanisms allow communities to provide feedback to health administrators as to the performance of local health facilities (e.g. Ethiopia, Sierra Leone, Tanzania, Rwanda). Utilize community- and facility-based maternal and perinatal death reviews and maternal near miss audits to expose any avoidable factors that contributed to a maternal death. Community engagement in identifying community-level gaps, as well as relevant strategies and responses to address those gaps and stimulate action is critical (e.g. Sierra Leone, Malawi, South Africa). Support womens participatory learning and action groups. Studies show these groups to be a cost-effective way to improve maternal and neonatal survival in rural, low-resource settings, even when the proportion of pregnant women participating is only 30 per cent. Interventions can reduce newborn deaths by one third and maternal deaths by 55 per cent, and prevent up to 283,000 neonatal deaths per year. Such groups improve care practices (e.g. hygiene, breastfeeding, bed net use), build social support for mothers, improve decisionmaking for care seeking, and help women hold health services accountable (e.g. Malawi). Leverage new digital technologies to bridge the gap between communities and states. For example, mobile phones, Internet, and social media platforms can be used by citizens to access evidence, hold governments accountable, and carry out RMNCH advocacy. SMSbased alert systems to improve antenatal health visits, phone-based incentivization or information platforms for CHWs, and SMS systems for surveillance and vital event reporting can all improve the flow of information and resources to/from communities (e.g. Kenya, Nigeria, South Africa, Uganda). Focus on change agents, including male change agents.
29
ICMNCH, August 2013
Tap into local leadership networks, existing womens groups, religious institutions, and other forums in which community key opinion leaders congregate (e.g. Egypt, Ghana, Nigeria, South Africa, Zambia). Develop, cost, ratify, budget, and implement Roadmaps for Maternal, Newborn and Child Health to ensure strategies for RMNCH advocacy and community engagement are institutionalized at national level. Roadmaps extend Ministry of Health focus beyond facilitylevel, and guide both government and other stakeholders (e.g. Senegal, Tanzania, Uganda, Zambia). Ensure National Health Policies and Strategic Plans build community engagement into their mission or vision statement to enable a policy platform from which to justify and develop community-based activities (e.g. Uganda, Zambia). Commit to recruiting, training, and retaining quality human resources for RMNCH at the community- and
primary-levels (e.g. Malawi, Nigeria, Uganda, Zambia). For example: CHWs can be taught basic case management and recognition of key danger signs in maternal and child health, to boost referral systems and avoid delay in careseeking. Community-sponsored mother-shelters or maternity waiting homes can provide a place for women near delivery to reside in order to avoid delays in reaching facilities. Health facility workers can be trained in midwifery skills, including a continuous emphasis on respectful care, to encourage facility-based births and avoid delays in receiving care. These efforts, however, will go to waste, if health workers cannot be retained.
CASE STUDY NIGERIA The Program for Reviving Routine Immunization in Northern Nigeria-Maternal, Newborn and Child Health (PRRINN-MNCH) is a six-year maternal, newborn, and child health initiative in Northern Nigeria. Originally focused on improving routine immunization uptake, PPRIN now includes demand generation for MNCH services. Political sensitivities in Northern Nigeria previously led to a drop off in service utilization for immunization and facility-based births. Collaboration with the Ministry of Religious Affairs (MoRA) and Islamic scholars helped promote women and childrens health services. State ministries include funds for demand-side issues in their budgets, and are active in community engagement activities. Information systems collect information on equity, including gender disaggregated human resources data, to help plan human resources for health. MNCH volunteers are identified by community members and trained in identifying danger signs. Indirect costs of care seeking are addressed through the creation of emergency transportation systems and emergency savings plans. The program has started working on social accountability systems and feedback mechanisms to allow health facility data to flow back to the community. Routine immunization and antenatal clinic visits have improved markedly.
CASE STUDY:
30
ICMNCH, August 2013
KEY OPPORTUNITIES The Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) is an African Union initiative intended to speed up progress on reducing maternal and infant mortality on the continent. CARMMA prioritizes communities by promoting the mobilization of key opinion leaders at community level, and by disseminating community advocacy messages. http://www.carmma.org The Maputo Plan of Action is an African Union plan that encourages its signatories to promote, strategize, and cost universal access to sexual and reproductive health services. The Maputo Plan, like CARMMA, prioritizes community-based services for sexual and reproductive health, and community engagement and involvement. MamaYe! is a public action campaign which engages the wider public in five African countries on maternal and newborn survival (Ghana, Malawi, Nigeria, Sierra Leone, Tanzania). It uses evidence strategically to stimulate and inform advocacy and enable strengthened accountability. http://www.mamaye.org There is technical support available from WHO, UNFPA, and other agencies to help national governments develop/improve roadmaps for maternal, newborn, and child health. These include integrating best practices in community engagement, including advocacy messaging and accountability mechanisms. Community-led total sanitation (CLTS) is a model for participatory community engagement in health-related water and sanitation. Communities targeted by CLTS collectively identify the extent of water and sanitation problems, then generate resources and implement solutions. CLTS addresses women and childrens health and safety in terms of proximity of water and toilets to the household (e.g. Kenya, Nigeria, Sierra Leone, Zambia). http://www.cltsfoundation.org/ There is a renewed interest in integrated management of childhood illness. Integrated Community Case Management (iCCM) represents a reboot of older models but strongly emphasizes building on existing initiatives, peer supervision and mentoring of CHWs, use of digital technologies, and improved use of evidence. CCM Central is a product of the iCCM Task Force and includes tools for costing, advocacy, programming, and monitoring. www.CCMCentral.com
REFERENCES
1. African Union. 2006. Maputo Plan of Action on Sexual and Reproductive Health and Rights. Special Session of the African Union. Sp/ MIN/CAMH/5(1). 2. Bradford C and Dobson D. 2011. PPRIN-MNCH Midterm Review. London: DFID-HDRC. 3. Prost A. 2013. Womens Groups Practicing Participatory Learning and Action to Improve Maternal and Newborn Health in Low-Resource Settings. Lancet. 381:1736-46. 4. WHO. 2007. Report of the Panel Discussion The Role of the Community in Improving Maternal, Newborn and Chidl Health in the WHO Africa Region. 57th Session of the Regional Committee for Africa. 31 August 2007. AFR/RC57/16 (b). 5. WHO/UNICEF. 2012. WHO/UNICEF Joint Statement on Integrated Community Case Management (iCCM): An Equity-Focused Strategy to Improve Access to Essential Treatment Services for Children. Geneva: WHO. 6. Zulfiqar A et al. 2005. Community-Based Interventions for Improving Perinatal and Neonatal Health Outcomes in Developing Countries: A Review of the Evidence. Pediatrics. 115(2): 519 -617. doi:10.1542/peds.2004-1441.
31
ICMNCH, August 2013
Photo: DFID - UK Department for International Development
32
ICMNCH, August 2013
ICMNCH
REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH IN AFRICA: PROGESS, OPPORTUNITIES, CHALLENGES W ith fewer than 1,000 days remaining until the 2015 deadline for the Millennium Development Goals (MDGs), Countdown to 2015 data shows the progress that African countries are making and the challenges that are preventing progress in scaling up health interventions that save womens and childrens lives. MODELS OF SUCCESS: AFRICAN COUNTRIES ARE REDUCING MORTALITY RATES 17 Countdown countries in Africa reduced their ma- Egypt, Liberia, and Rwanda cut child mortality by 65% ternal mortality ratios by 50% or more between 1990 or more. and 2010. Equatorial Guinea, Eritrea, and Egypt re Progress is accelerating: approximately 30 African duced maternal mortality by more than 70%. Countdown countries have achieved faster reductions 14 Countdown countries in Africa reduced their un- in both maternal and child mortality since 2000 than in der-5 mortality rates by over 50% from 1990 to 2011. the previous decade. MORE PROGRESS NEEDED: AFRICA FACES SUBSTANTIAL CHALLENGES Nearly half of the worlds child deaths, and more than half of all maternal deaths, take place in Africa (excluding north Africa). 36 of the 40 countries with maternal mortality ratios of 300 deaths per 100,000 live births or higher, and 23 of the 24 countries with under-5 mortality rates over 100 per 1,000 live births, are in Africa (excluding north Africa). In 2011, more than 1.1 million African newborns did not survive their first month of life, and 1 in 9 children in Africa (excluding north Africa) dies before the age of five. 9 Countdown countries in Africa all of which have struggled with high HIV prevalence or civil war experienced increases in maternal mortality between 1990 and 2010. (However, 8 of those 9 countries reduced maternal mortality during the 2nd decade of that period).
THE TIME IS NOW: WE KNOW WHAT WORKS TO PREVENT MATERNAL AND CHILD DEATHS More than half of maternal deaths are caused by haem- the time to scale-up these interventions and provide orrhage or hypertension. Undernutrition, in a synergis- high quality services to all population groups. tic relationship with infectious diseases like pneumonia, diarrhoea, malaria, and HIV, accounts for almost half of By 2050, 1 in 3 births will take place in Africa (excluding north Africa), and almost 1 in 3 of the worlds chilall child deaths. dren will live there. Efforts to reach women and children Most maternal and child deaths can be prevented with equitable, high-quality family planning, childbirth, through cost-effective, available interventions. Now is and child health services must be intensified.
33
ICMNCH, August 2013
FOCUS ON COVERAGE: THE KEY TO PROGRESS For 6 of 8 key RMNCH interventions across the continuum of care (Figure 1), the median coverage level for African Countdown countries with recent data available is 50% or lower; median coverage exceeds 80% only for DTP3. The wide ranges in coverage for these life-saving interventions show that progress varies across the African Countdown countries. For each intervention, except for postnatal care for baby, at least one country achieved coverage of at least 70%; for every intervention, there is at least one country with unacceptably low coverage below 25%. Countdown to 2015 tracks coverage levels for health interventions proven to reduce maternal, newborn and child mortality, together with data on maternal, newborn, and child survival, equity of coverage, health financing, policy and health system factors, and other determinants of coverage. It calls on governments and development partners to be accountable, identifies knowledge gaps, and proposes new actions to reach Millennium Development Goals 4 and 5, to reduce child mortality and improve maternal health. Countdowns data and analysis cover the 75 countries 47 of them in Africa (including 46 of the 54 Member States of the African Union)* that account for over 95% of global maternal and child deaths. Countdown to 2015 country profiles enable countries to track progress, identify key areas where more progress is needed, and compare data between countries and over time. They are a valuable accountability tool for countries efforts to achieve Millennium Development Goals 4 and 5 by the 2015 deadline. Country-level Countdown activities including Country Countdowns and in-depth case studies help stimulate the use of evidence by decision makers and key partners to take stock, identify areas of success and remaining challenges, and catalyse actions to accelerate progress. (See page 4.)
MEETING THE DEMAND FOR FAMILY PLANNING High fertility contrib- reducing unintended and utes to population pres- high-risk pregnancies and sures and health care chal- unsafe abortions, and by lenges in many countries: enabling women to space 35 Countdown countries their pregnancies. in Africa (excluding north Africa) have fertility rates The majority of Afriof 4 children per woman can Countdown countries with available data or higher. are meeting less than half Access to contraception of their populations deprevents maternal, new- mand for family planning born, and child deaths by (Figure 2). Undernutrition, in a synergistic relationship with infectious diseases, accounts for almost half of all child deaths. Stunting, the key indicator for assessing child undernutrition (Figure 3), reflects chronic exposure to inadequate diets and infections, especially in the first two years of life. Africa is the only major world region where the absolute number of stunted children increased in the last decade, because of continued high population growth.
ADDRESSING NUTRITION SAVES LIVES Stunting is often rooted in poverty and limited educational and income-earning opportunities for women. In all African Countdown countries, children of mothers with less education are at higher risk of stunting (Figure 4). African countries must continue to prioritize multisectoral efforts to improve the nutritional status and life chances of women and children.
34
RAPID GAINS FOR PMTCT: WHAT ABOUT OTHER INTERVENTIONS In 2005, most countries had low coverage both for prevention of mother-to-child transmission of HIV (PMTCT) and for careseeking for pneumonia. Today, PMTCT coverage has risen dramatically, but still far too few families seek appropriate care for childhood pneumonia (Figure 5). The message is clear: Advocacy, political commitment, and financial investment can bring rapid increases in coverage. The same level of attention that has been devoted to HIV services must be extended to other leading killers of women and children, including pneumonia and diarrhoea, which together account for 15 times more child deaths than AIDS.
to increase over time as child mortality levels continue to drop. Among African Countdown countries, this percentage ranges from 25% in Burkina Faso to 56% in Morocco. The leading killers of Africas newborns are preterm birth (see box), complications at or around childbirth, and infection, including sepsis and meningitis. And many African babies are born with a low birth weight, putting them at increased risk of poor health outcomes. TURNING THE TIDE: SCALING UP SERVICES FOR MOTHERS AND NEWBORNS Most newborn deaths can be prevented through available, cost- effective interventions including family planning and high- quality antenatal, intrapartum, and immediate postnatal care services. Yet coverage for these interventions remains too low across African Countdown countries representing missed opportunities to reach women and babies with needed care (Figure 1). A baby not breathing at birth will die within minutes, but a skilled birth attendant can resuscitate her and save her life. Neonatal sepsis can kill in hours, but an infection recognized at a postnatal visit can be effectively treated with antibiotics. Health care workers at the facility and community levels must be adequately trained and equipped with supplies to perform these life-saving services.
SAVING AFRICAS NEWBORN: AN URGENT IMPERATIVE In 2011, 1.1 million African babies did not survive their first 4 weeks of life more newborn deaths than occurred in 1990. This increase in the total number of newborn deaths is related to continued high birth rates and too little progress in reducing newborn mortality. Approximately 43% of all child deaths occur during the first month of life, and this percentage is expected
35
ICMNCH, August 2013
REACHING THE UNREACHED: EQUITY FOR WOMEN AND NEWBORN Countries that have rapidly increased coverage for key requiring a functioning health system, such as skilled atRMNCH interventions have accomplished this mainly tendant at birth, are particularly inequitable. by improving coverage for the poorest and most vulnerable. Focusing on equity is essential to achieving pro- In all African Countdown countries, women with secondary or higher education are more likely to give birth gress on MDGs 4 and 5. with a skilled attendant than women with only primary Coverage of interventions around the time of birth, or no education (Figure 6). Initiatives to improve the when the risk of maternal and newborn mortality is status of women, including girls and womens access to highest, tends to be substantially higher among women education, must be prioritized. and newborns from wealthier households. Interventions
36
ICMNCH, August 2013
Investing in care around the time of birth: a triple return on investment Around the time of birth, there is a stark survival and care gap between low- and high-income countries. But effective care before, during, after, and between pregnancies can prevent intrapartum stillbirths and save maternal and newborn lives a triple return on countries investments to close this gap by training skilled birth attendants and equipping facilities with needed supplies. An estimated 1 million third- trimester stillbirths occur each year in Africa; many of these happen during labour. The risk of an intrapartum stillbirth is 24 times higher for an African woman than for a woman in a high-income country, yet stillbirth is often invisible in African country policies, plans, and programmes. Interventions proven to reduce stillbirths and improve birth outcomes for both mother and newborn include high-quality childbirth services, supportive policies protecting women from harmful conditions during pregnancy, comprehensive family planning and antenatal care services, and induction of post-term pregnancies at 41 weeks and later. Of African babies who survive childbirth, far too many are born too soon or too small. Approximately 4 million preterm births occur every year in Africa. About 12% of all births in sub- Saharan Africa are preterm. Of 11 countries with preterm birth rates over 15%, 9 are African Countdown countries. Preterm birth increases the risk of death and disability, exacting a heavy toll on families and health systems. Feasible and low-cost interventions, such as antenatal corticosteroids, kangaroo mother care, breastfeeding support, and antibiotic treatment for infections, can save and improve the lives of preterm babies.
Momentum for action to end preventable newborn deaths There is growing hope for Africas newborns. Widespread use of 4 commodities and devices prioritized by the UN Commission on Life Saving Commodities (antenatal steroids, resuscitation devices, chlorhexidine cord cleansing, and antibiotics for neonatal sepsis treatment), as part of the delivery of high-quality services, could save millions of newborn lives each year. Success stories notably in Botswana, Malawi, and Rwanda, where impressive reductions in newborn mortality have been achieved in recent years offer examples that can be applied in other African countries. Every Newborn is a movement, linked to Every Woman Every Child and A Promise Renewed and initiated by African and Asian countries, to accelerate progress for newborn survival and health and end preventable newborn deaths by 2035. A process of country consultation and sharpening of national plans will contribute to the global Every Newborn action plan, which will be launched at the World Health Assembly in May 2014. More information is available at www.globalnewbornaction.org These actions, at the national, regional, and global levels, hold real promise for newborns and their families. Because newborn survival is so closely linked with maternal and child health, progress in scaling up interventions that save newborn lives will contribute to countries efforts to fulfill the promise of MDGs 4 and 5, strengthen their health systems, and improve living conditions for millions of families in thousands of communities in Africa and around the world. The time for action is now.
37
ICMNCH
MULTI-SECTOR DETERMINANT OF REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH BACKGROUND Snce 2000, the Millennium Development Goals (MDGs) have provided a framework for prioritizing and accelerating initiatives aimed at improving the health and welfare of the global population. Improvements to reproductive, maternal, newborn, and child health are the focus MDGs 4 and 5, but other MDGs (e.g. eradication of poverty and hunger, access to primary education, promotion gender equality, and prevention of HIV and other infectious diseases) have indirect influence on RMNCH, and progress towards health and development are closely linked. With the deadline for the MDGs fast approaching, there has been extensive consultation on the development of a Post 2015 Sustainable Development Agenda. Building on the MDGs, the development community has proposed a framework based on the four core dimensions of sustainable development: inclusive economic development; environmental sustainability; inclusive social development; and peace and security. nourished children have better cognitive development, educational attainment and, as adults, higher productivity and lifetime earnings. Environment Environmental degradation also has consequences for RMNCH. Lack of clean drinking water increases the burden of diarrhoeal disease in children under five. Changing weather patterns may lead to food insecurity and malnutrition. Women are exposed disproportionately to environmental hazards such as pesticides and solid fuel contaminants due to higher participation in the agriculture, cooking, and household work. Poverty Reduction These core dimensions are also critical determinants of RMNCH, and improvements in RMNCH contribute to improvements in these areas as well. For example, studies show that poverty reduction leads to increased uptake of contraception, decreased fertility rates, reduced incidence of infectious disease, and higher rates of child survival. Increasing womens income can improve family health since women tend to spend a greater proportion of their income on healthcare, food, and education. Healthy, wellSocio Cultural Inequities Women and children are also vulnerable to sociocultural inequities that exclude them from political representation, legal protection, educational opportunities, and reproductive choice. A higher level of education and literacy has been associated with positive health outcomes among both sexes, as well as greater political and economic participation. Without civil registration and other information systems, data to support policy, legislation and programs for women and children remains incomplete.
38
ICMNCH, August 2013
Conflict & Insecurity Lastly, conflict and insecurity are often associated with increased sexual violence. Health consequences include unwanted pregnancy, obstetric fistula, increased prevalence of STIs and HIV, and mental health issues. The disruption of girls schooling also has been proven to have cross-generational health consequences, while conflict-related environmental degradation has been shown to impact access to clean water, food security, and female livelihoods.
are often quickly eroded. Population growth is partly dependent on family planning, the uptake of which has been slow in Africa. African countries are struggling to meet their MDG 1 on reducing the proportion of people suffering from hunger, as not all food shortages can be anticipated, and infrastructure for the storage and marketing of foodstuffs is still weak. This also affects progress on maternal and child nutrition. Inclusive social and economic development is often dependent on changing strongly-held attitudes and behaviour related to women and children at the grassroots level. Such initiatives are often difficult to implement, incentivize, sustain, and measure. Mechanisms and institutions for redistributing economic resources in a more equitable and inclusive manner as well as targeting them toward health - are often weak at national level. This is especially true in countries reliant on mineral resources, as are many of the fastestgrowing economies in Africa.
CHALLENGES Political insecurity not only create the conditions that exacerbate RMNCH-related health conditions, but also can prevent policies, services and interventions to ameliorate such conditions from reaching vulnerable populations. High population growth, especially in urban areas, means that gains in water, sanitation, livelihoods support, human resource development, and food security
CASE STUDY: GHANA Achieving post-2015 sustainable development goals will require integrated strategies, a focus on strengthening systems and cross-sectoral partnership. In many instances, inputs targeted at one core area such as environmental sustainability can be leveraged to support other Wareas. For example, Ghana has been working toward rehabilitating and expanding its water infrastructure by investing in small town water supply, irrigation, and hydropower infrastructure. Between 2003- 2008, Ghana increased the proportion of population with access to improved drinking water from 83% to 93% in urban areas, and 55% to 76.6% in rural areas. Improving access to potable water can reduce water-borne disease in children under 5 years, as well as lessen the distances travelled by women and children for water collection thereby increasing physical safety. Irrigation improves access to water by small farmers many of whom are women. This, in turn, may improve rural female livelihoods, food security and household nutrition. Hydropower can lead to rural electrification, and therefore support better health service delivery.
39
ICMNCH, August 2013
STRATEGIES AND BEST PRACTICES Universal access to quality healthcare and other social protection schemes can mitigate the effects of poverty and social inequality, and shield families from catastrophic health expenditures. Free RMNCH services encourage service utilization and can lead to improved health outcomes for women and children (Burundi, Ghana, Kenya, South Africa). Universal access to education, the abolishment of school fees, investment in educational infrastructure and human resources, and schemes for promoting and incentivizing school attendance, can improve childrens attendance and completion rates, especially those of girls (Ghana, Tanzania, Zambia). Adopting legal frameworks can help guarantee 8-10 years of uninterrupted education, and reduce the incidence of child marriage and early pregnancy. Community-led total sanitation (CLTS) is an integrated methodology aimed at achieving open defectation free (ODF) status in communities. CLTS utilizes upon a combination of participatory research and monitoring, sustained attitude and behaviour change, and community mobilization for research and project implementation. Evidence has shown that CLTS can achieve rapid, and highly cost-effective, progress in community sanitation indicators, including those related to child health (Ghana, Kenya, Sierra Leone, Zambia). Creative means of integrating RMNCH with economic development by engaging the private sector in service delivery, information systems, and commodity supplychains can support entrepreneurship and economic development, as well as lead to improvements in maternal and child health indicators. Examples include social franchising of health clinics, value chain initiatives for essential medicines, and innovation labs for eHealth and other mobile technologies (Uganda, Kenya, Zambia).
KEY OPPORTUNITIES Environmental Sustainability Financing is now available for climate resilient agriculture initiatives from many donors (e.g. the World Bank, IFAD, the ADB). Technical support is also available (e.g. IFPRI, FAO). Many of these initiatives support closer integration of agriculture with both gender issues and nutrition for RMNCH. The Global Water Forum is the key forum for stakeholder dialogue, capacity building, and information dissemination on global clean water issues. The Forum has not yet been fully engaged on MNCH issues, but it could be an important future platform. www.globalwaterforum.org. The IDS-supported CLTS resource centre - http:// www. communityledtotalsanitation.org/resources - now provides a central portal for access to and sharing of resources on best practices in sanitation. World Toilet Day is a primary advocacy platform at national and community level for integrating sanitation and MNCH. Economic Development A new global investment framework based on recommendations by the independent Expert Review Group is being coordinated by PMNCH, WHO and the University of Washington. This framework will help guide national investments in a way that is more strategic, aligned, accountable, and targeted toward MNCH. The African Unions Comprehensive Agricultural Development Programme is seeking to integrate food security with poverty alleviation and employment generation via the development of agricultural value chains. This effort should help improve overall availability of foods, but also could tie in to improvement in womens livelihoods. Social Development The African Union already supports women and childrens health across a number of polices, conventions and statements - in particular those focusing on the rights of women and children, and advocacy for improving maternal and child health. Regional efforts, such as the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA), as well as acts of legislation by national parliaments, have also helped establish a policy frame for MNCH in African countries. African Union Heads of States have committed to a
40
ICMNCH, August 2013
second decade of education with the aim of increasing access to education, improving the quality and relevance of education, and ensure equity. The plan calls in particular for the attainment of full gender equality in primary and secondary education which will have a strong impact on health outcomes. The Scaling Up Nutrition (SUN) movement was launched in 2010 to campaign for improved coordination and leadership on nutrition. In Africa, 26 countries are involved in SUN.a SUN seeks to ensure that donors, governments, industry, and civil society invest in scaling up a package of nutrition-specific and sensitive, cost-effective, evidence-based interventions, such as the promotion of exclusive breastfeeding, access to supplements and fortification, and therapeutic feeding for severe undernutrition. Peace and Security Regional Peace and Security Initiative Policy Frameworks such as the African Union Post-Conflict Reconstruction & Development Programme seeka to improve timeliness, effectiveness and coordination of activities in post conflict countries and to lay the foundation for African Union Multi-Sector Framework on MNCH Ensures continental, sub-regional and country level integrated policy and budget action across all health and social determinant sectors that impact on RMNCH.
sustainable development in line with the reconstruction and stabilization of national governments. The African Union Continental Early Warning System (CEWS) collects and analyses data in collaboration with UN agencies, other relevant international organizations, research centres, academic institutions and NGOs in order to advise the Peace and Security Council on potential conflicts and threats to peace and security in Africa and recommend the best course of action. The Transitional Solutions Initiative (TSI) is an initiative by bi- and multi-lateral agencies and those national governments with large internally-displaced populations (IDPs) to improve livelihoods in areas affected by conflict. In Africa, TSI is working with the Government of Sudan to promote sustainable livelihoods, access to financial services, and self-reliance among refugees and IDPs. The initiative has led to an increase in refugees income in eastern Sudan. Opportunities exist to extend the TSI framework to other conflict areas, improve gender responsive programming, and to integrate MNCH issues into IDP livelihoods strategies.
FRAMEWORKS FOR MULTI-SECTORAL ACTION Dialogue on post-2015 Sustainable Development Will be driven by five transformative shifts: 1) ending extreme poverty in all its forms, 2) put sustainable development at the core of all efforts; 3) transform economies for jobs and inclusive growth; 4) recognize peace and good governance as core elements of wellbeing and 5) a new partnership to promote cooperation, and mutual accountability to underpin the post-2015 agenda.
Based on Paris Declaration and Accra Agenda on Aid Effectiveness, facilitate alignment of Global Strategy commitments and resources with pre-existing intersectoral African MNCH continental, sub-regional and country policies. REFERENCES
1. African Development Bank. 2013. Assessing Progress in Africa toward the Millennium Development Goals. MDG Report 2013. Tunis: African Development Bank. http://www. afdb.org/en/knowledge/publications/ millennium-development-goals-mdgs-report/
doi: http://dx.doi.org/10.2471/BLT.13.125146 6. Toure, K et al. 2012. Position Womens and Childrens Health in African Union Policy Making: A Policy Analysis. Globalization and Health. 8:3. 7. Sanitation and Water for All. 2012. Ghana Country Profile. Briefing prepared for the 2012 Sanitation and Water for All High Level Meeting. http:// www.wsmp.org/downloads/ country-summary-sheet-09.pdf Accessed July 7 2013. 8. UNHCR. 2012. Sudan 2012 Global Country Report. http:// www.unhcr.org/cgi-bin/texis/ vtx/home/opendocPDFViewer. html?docid=51b1d634a&query=TSI 9. WSMP. 2009. Status of Ghanas Drinking Water and Sanitation Sector. http://www.wsmp. org/downloads/country-summary-sheet-09.pdf Accessed July 7 2013.
2. Kuruvilla S et al. 2013. Strategies that High-Performing countries Used in Their Efforts to Reduce Maternal and Child Mortality: A Multi-Pronged, Multi-Method Study of Success. Manuscript Draft. 3. PMNCH. 2012. The Economic Case for Women and Childrens Health. Knowledge Summary 24. Geneva: PMNCH. 4. PMNCH. 2013. Healthy Populations at the Heart of Sustainable Development: Strengthening a Mulit-Sector Approach to Provide Essential Health and Development Services. July 2, 2013. Working Draft. 5. Presern C. 2013. Placing Populations Health at the Heart of the Post2015 Agenda. Bulletin of the World Health Organization. 91:467-467A.
41
ICMNCH
FAMILY PLANNING AND THE DEMOGRAPHIC DIVIDEND IN AFRICA BACKGROUND The demographic dividend refers to the opportunity foraccelerated economic growth that results from changes in a countrys age structure combined with favorable social and economic policies. The demographic dividend can be achieved during the middle stage of the demographic transition. The demographic transition refers to the transition from high birth and death rates to low birth and death rates as a country develops from a pre-industrial to an industrialized economic system. This is a four phase process where in the first phase death rates and birth rates are high; in the second phase where death rates drop rapidly due to various improvements in social and economic development; in the third phase birth rates fall in part due to access to family planning and the fourth phase where both birth rates and death rates are low. During the middle stage when fertility falls, countries have a window of opportunity for economic growth through an increase in the working-age population, decrease in the number of young people to support and without, yet an ageing population. For instance, an estimated 30-50% of East Asias dramatic economic growth in 1965-1990 can be attributed to reduced child mortality and subsequent lower fertility rates that created a baby-boom cohort and decreased the dependency ratio. This demographic dividend boosted economic growth. This effect is particularly important for women, as reduced fertility increases their participation in the workforce. GDP per capita is increasing by 1.0% per year in China and 0.7% per year in India as a result of the effect of lower fertility on age structures. A reduction in fertility of one child per woman in Nigeria would lead to a 13% increase in GDP per capita in 20 years, and 25% in 50 years. An estimated US$ 1.40 is saved on maternal and newborn health care for every dollar invested in family planning and another US$ 4 is saved on treating complications of unplanned pregnancies. Almost a quarter of girls in Africa (excluding north Africa) drop out of school because of unintended pregnancies. Providing girls with just one extra year of education beyond the average boosts their eventual wages by 10 to 20 percent. Family planning is a highly-cost effective investment in the health and livelihood of both women and children, and can strongly reduce numbers of preterm births, especially in regions like Africa with high rates of adolescent pregnancy. To achieve their full potential for economic growth, countries will need to address their extremely young age structure through investments in development, education, and a health and family planning strategy to contribute to smaller and healthier families and realize the demographic dividend. CHALLENGES There have been challenges to attaining demographic dividends in Africa: The majority of countries in Africa (excluding north Africa) have fertility rates of more than three children per woman, and couples still desire large families. These fertility rates, coupled with declining mortality rates, have led to youthful age structures, where younger age groups comprise a larger share of the population than older age groups. Today, 43 percent of Africas population (excluding north Africa) is under the age of 15. This has led to great demands on education and job creation. The window of opportunity presented by the demo-
42
ICMNCH, August 2013
graphic dividend is short, and will close over the next 10 to 20 years for most developing countries. Countries must enable fertility decline through strong investments in family planning in order to see the economic benefits of a demographic dividend. In many countries, improvements in child mortality have outpaced declines in fertility leading to a very youthful population age structure. In many of these same countries, women want to delay childbearing or have less or no more children, yet many are not using modern contraception. Globally the unmet need for family planning has decreased slightly between 2008 For countries to attain the demographic dividend, rapid fertility decline must occur. This will allow population growth to slow, and the ratio of working-age adults relative to young people to increase. Improved access to and use of voluntary family planning is a key intervention to address unintended pregnancy and, thereby, high fertility. (e.g. Malawi, Rwanda, Ethiopia, Ghana, Tanzania). Demographic dividends are not automatic. In addition to investments in health, governments must invest in human capital through education, health, and workforce training to prepare for the window of opportunity that the demographic transition presents (e.g. Burundi, Mozambique, South Africa). Demographic dividend is a time sensitive opportunity that requires immediate preparatory action. As populations age due to lower fertility, the resources required to support the elderly increase. To address this, policies such as strengthening social security systems to prepare the large working age group for their inevitable aging as well as promoting private savings as a means for old age security with incentivizing economic policies should be put in place, allowing the future generation to finance their consumption needs when older. (e.g. Ghana, South Africa).
and 2012, from 226 to 222 million. However in Africa (excluding north Africa), the unmet need for contraception has increased from 31 million in 2008 to 36 million in 2012. While many countries in Africa (excluding north Africa) have achieved significant economic growth in recent years, this growth has not improved the living standards of most people. Pro-poor economic and governance policies that will allow the most disadvantaged people to access family planning, health care, education and employment opportunities to can help ensure the demographic dividend yields equitable results. Government policies to encourage economic growth should also emphasize gender equality, allowing women to access voluntary family planning and contribute to the familys economic well- being. When women earn income, they reinvest 90 percent of their earnings into their families. (e.g. Mozambique, Rwanda, South Africa, Uganda, Zimbabwe). Investments in girls education are crucial for achieving lower family size and fertility decline, as evidence shows that education delays marriage and first pregnancy. Girls who marry at a later age tend to have fewer children than those who marry earlier (e.g. Burkina Faso, Ethiopia, Ghana, Nigeria). Through investments in reproductive, maternal and child health, smaller family size can be encouraged. Families will often choose to have fewer children when they know that their children will survive. To benefit from the demographic dividend, countries must have a healthy, productive workforce. For children and adolescents to succeed in school and prepare to contribute to the workforce, they must be provided with comprehensive health services (e.g. Botswana, Ethiopia, Namibia, Rwanda, South Africa).
STRATEGIES AND BEST PRACTICES
In Rwanda, modern contraception use has increased fourfold over the past decade, and the total fertility rate has fallen to 4.6 children per woman. If the impressive progress continues, Rwanda will, by 2030, have achieved the demographic conditions necessary for accelerated
CASE STUDY - RWANDA
economic growth. This rapid progress has been in part, as result of the Governments role in supporting family planning practices which have been promoted through a number of key policies. One such policy has been the strengthening of public sector service provision (govern-
43
ICMNCH, August 2013 ment health centres, hospitals and other public entities), which now serve almost 90% of all family planning users. The Rwandan Government has also taken steps to promote Public- Private Partnerships (PPP) to support contraceptive commodity security. Its Pharmacy Task Force, which is responsible for supervising the effectiveness and quality of pharmaceutical products, also provides free contraceptives through pharmacies and drug shops.
KEY OPPORTUNITIES The pledges made at the London Family Planning Summit in 2020 will bring voluntary family planning information, contraceptives, and services to 120 million more women and girls by 2020. In Africa, 53% of women of reproductive age have an unmet need for modern contraception. This investment can pave the path for a fertility decline and any ensuing demographic transition. The launch of the UN Commission on Life-Saving Commodities for Women and Children in 2012 will lead to increase access to affordable life-saving medicines and health supplies to this vulnerable population. Africa (excluding north Africa) accounts for 38% of global neonatal deaths. Efforts to end preventable child deaths under A Promise Renewed and Every Newborn will result in healthier children who have the opportunity to grow into productive adults, who both contribute to and benefit from the economic growth of their countries.
REFERENCES
1. Population Reference Bureau. 2012. Achieving a Demographic Dividend. Washington: PRB. 2. United Nations Economic Commission for Africa, African Union Commission. 2013. Creating and Capitalizing on the Demographic Dividend for Africa. Issue Paper. Abidjan: ECA and UAC. 3. Aspen Global Health Development. 2011. Family Planning Promotes the Democratic Dividend. Policy Brief. Washington: Aspen Global Health Development. 4. The Gates Institute- John Hopkins Bloomburg School of Public Health. 2011. A Primer on Demographic Dividend. Baltimore: The Gates Institute. 5. Population Reference Bureau. 2012. The Challenge of Attaining the Demographic Dividend. Washington: PRB. 6. Population Reference Bureau. 2012. Attaining the Demographic Dividend. Fact Sheet. Washington: PRB. 7. Borges, Phil. 2007. Women Empowered: Inspiring Change in the Emerging World. 8. WHO, UNICEF. 2012 . Countdown to 2015. Maternal, newborn and child survival. Building a future for women and children: the 2012 report. Geneva: WHO, UNICEF: Geneva. 9. Women Deliver. 2010. Promote Gender Equality and Empower Women. http://www. womendeliver.org/knowledge-center/facts-figures/gender-equity Accessed July 12 2013. 10. WHO, Aspen Global Health Development. 2011. Accelerating Access to Global Health. Rwanda. http://www.who.int/reproductivehealth/publications/monitoring/Rwanda _ access _ rh.pdf Accessed July 12 2013. 11. http://www.londonfamilyplanningsummit.co.uk/about.php Accessed July 12 2013 12. Save the Children. 2013. Surviving the First Day. State of the Worlds Mothers 2013. UK: Save the Children. 13. http://transition.usaid.gov/our _ work/global _ health/pop/alliance.html Accessed July 12 2013. 14. http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae432c9bd0df91d2eba74a%7D/ MATERNAL,%20NEONATAL,%20 UNDER5%20AND%20STILLBORN%20DATASHEET.PDF Accessed July 12 2013 15. PMNCH. Knowledge Summary Series. Geneva: PMNCH. 16. DFID. 2007. Gender Equality At the heart of development. London. DFID. 17. UN Millennium Project. 2005. Taking action: achieving gender equality and empowering women. New York. UNDP.
44
ICMNCH
MORE MONEY FOR HEALTH/ MORE HEALTH FOR MONEY: IMPROVING DOMESTIC FINANCING FOR REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH BACKGROUND Improving health outcomes for women and children requires sufficient funding to implement proven quality interventions that span the continuum of care from pre-pregnancy to delivery, the postnatal period, and childhood. The global economic crisis has led to a slowdown in the growth of international development assistance for health Many countries have also been unable to meet the High Level Task Force on Innovative International Financing for Health Systems (HLTF) recommended target expenditure on health of US $44 per capita. While official development assistance for maternal and child health is increasing in a number of African countries, funding gaps still exist. There is now an increased focus on what African countries can do to raise public and private resources for health (more money for health) and to improve value for money of existing resources for health (more health for money). Additionally, there is increased interest in creating systems through which women and children are able to access quality health services without suffering financial hardship. CHALLENGES Though the average per capita total health expenditure Enforcement of tax revenue collection is challenging, for Africa (excluding north Africa) has more than dou- especially in countries with large informal sectors and/ bled, increasing from US$32 in 1995 to US$84 in 2010, or rural populations. Taxation policies often end up rehealth care financing in Africa still is highly dependent gressively affecting the poor through sales taxes and/or on out-of-pocket payments, as well as assistance from consumption of basic commodities. Presently tax revbi- and multi-lateral donors. This creates issues for long- enues are not being efficiently earmarked toward either term, sustainable financing for reproductive, maternal, health in general, or RMNCH more specifically. newborn and child health (RMNCH) initiatives. Evidence-based decision-making is increasingly com Twelve years after the 2001 Abuja Declaration on mon in African countries, but much of this evidence is health expenditure, very few African countries have used to assess safety and effectiveness of interventions managed to allocate 15 per cent or more of their nation- and technologies, as opposed to comparative cost-efal budget to the health sector. fectiveness. Many countries do not have mechanisms or human resources in place to evaluate interventions and Management of existing financial resources for health technologies based on cost-effectiveness criteria. is still sometimes weak, fragmented, and not consistently aligned to national health strategies. STRATEGIES AND BEST PRACTICES More Money for Health Raise the priority of RMNCH and health on the national development agenda by increasing national budget allocation for health and per capita expenditure on health to US $44 or more (e.g. Botswana, Rwanda, Zambia). Increase government revenues from taxation by im-
45
ICMNCH, August 2013
proving the efficiency of tax collection, as well as by considering Sin taxes (e.g. tobacco tax increases) as a means of financing RMNCH (e.g. Cape Verde, Comoros, Gabon, Ghana). Implement country-appropriate models of Universal Health Coverage (UHC), such as social health insurance or micro- insurance schemes (e.g. Chad, Ghana, South Africa, Rwanda). Take steps to ensure RMNCH is included in benefits packages. Engage in public-private partnerships-for-health that leverage private sector financing or services (e.g. Kenya, Zambia). Consider innovative financing mechanisms such as diaspora bonds (e.g. Ethiopia), international bonds (e.g. Senegal, Zambia), and impact investing for health (e.g. Tanzania). More Health for Money Efficiency and Effectiveness Improve effectiveness and efficiency of RMNCH interventions through health technology assessment, local priority setting, utilization of international evidence on cost effectiveness, gap analysis, and costing exercises (e.g. Burkina Faso, Ghana, Malawi, Senegal, Sudan). Increase donor coordination, harmonization and alignment with national priorities to reduce transaction costs (e.g. DRC, Ghana, Rwanda, Ethiopia, Malawi, Niger, Nigeria, Sierra Leone, Tanzania, Zambia, etc). Reform drug procurement procedures and logistics to reduce prices, ensure access and improve quality control (DRC, Uganda, Zimbabwe). Utilize credit guarantees backed by pending aid commitments to address volatility of donor funding (e.g. Ethiopia, Zambia).
Implement performance based financing (PBF), including the establishment of incentive systems to reward facilities, health workers, and district health administrations for improved outputs and outcomes (e.g. Burundi, DRC, Ghana, Ethiopia, Rwanda, Tanzania, Zambia, Zimbabwe). Enact quality improvement strategies such as clinical audits, to ensure that health investments lead to value for money (e.g. Ethiopia, Kenya, Malawi, South Africa). Adopt task-shifting to midwives and other health workers to improve RMNCH outcomes in the face of human resources constraints and better incentivize health workers to remain in rural areas (e.g. Ghana, Ethiopia, Uganda). Equity Introduce vouchers where appropriate to entitle the bearer to obtain free or subsidized RMNCH health goods or services from a contracted provider (e.g. Kenya, Uganda, Tanzania). Mobile transactions can be used where appropriate. Subsidize RMNCH-related medicines or commodities to reduce consumer prices for these commodities, (e.g. the reduction in price of malaria treatment in Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania and Uganda as part of the Affordable Medicines Facility). Create equitable coverage of health facilities and health human resources to ensure that women and children have access to care and to enable systems of referral to function efficiently. Removal of fees at the point of accessing health care for women and children (e.g Sierra Leone, Uganda, Kenya)
Rwandas performance-based financing (PBF) program links rewards to a clearly defined output (services delivered) and quality indicators related to a basic package of health center services, determined in part by business plans developed by the facilities. Rewards are monthly bonus payments to top up provider salaries and provide support for health center administration and training. Most indicators are RMNCH-related, with an emphasis on increased antenatal visits, institu-
CASE STUDY - RWANDA
tional deliveries, vaccinations, growth monitoring, and family planning. Rwanda saw a marked improvement in some, but not all, RMNCH indicators after adopting PBF including institutional deliveries, preventive care visits for children, and growth monitoring. In one study, institutional deliveries increased in project intervention districts by 23%, preventive care visits for children under 23 months increased by 56%, and preventive
46
ICMNCH, August 2013 visits for children aged 24 to 59 months increased by 132%. PBF added value to health systems by reforming human resources management structures as well as improving decentralization processes by empowering health centers to make decisions relevant to their own needs and that of the communities they serve. PBF was also used as a mechanism for inter-sectoral cooperation by scaling up performance-related contracting to non-health ministries and district councils.
KEY OPPORTUNITIES There is now a clear set of globally-recognized essential makers to monitor the resource flows in their countrys interventions, commodities and guidelines for RMNCH health system for a given period as well as make finanthat have been demonstrated to achieve both significant cial projections and compare their experiences to the and rapid progress in RMNCH outcomes. http://www. past or with those of other countries. http://www.who. who.int/pmnch/topics/part_ publications/201112_es- int/nha/en/ sential_interventions/en/index.html The Pledge Guarantee for Health (PGH) is a public A number of tools exist to help governments in prior- private partnership launched in 2010, and backed by itizing, costing, and phasing interventions. For example, guarantees from the United States and Swedish governthe LiST tool facilitates comparisons between alternate ments. PGH provides access to short-term credit for investment strategies over a specified period for child reproductive health and essential health commodity survival outcomes. The OneHealth tool enables coun- procurement on the basis of pending aid commitments. try-level planning, costing, impact analysis, budgeting, /pledge-guarantee-forand strategic financial planning for all major health sys- http://pledgeguarantee.org health-2-0/ tem components: www.futuresinstitute.org/onehealth. aspx The Impact Economy Innovations Fund (IEIF) There are now a number of platforms to improve harmonization of aid for greater effectiveness and efficiency. These include Sector-wide approaches (SWAps), the Health Systems Funding Platform, the Harmonization of Health in Africa mechanism, and country compacts under the International Health Partnership (IHP+). The Joint Learning Network for Universal Health Coverage is a platform for countries to exchange experiences and information about the implementation of health financing reforms. www.jointlearningnetwork.org http://www. thegiin.org/cgi-bin/iowa/ieif/index.html was launched in South Africa in 2013 to introduce the entrepreneurial community in Africa to impact investing. Health is not yet a focus of this fund. Hosted by the Global Impact Investing Network (GIIN) and the Tony Elumelu Foundation, there is now an opportunity to encourage the Fund in its earliest stages to include health markets - especially those related to RMNCH - in its investment portfolios and working groups, as well as develop RMNCH-relevant indicators within its metrics, ratings and reporting systems. http://iris.thegiin.org/
National Health Accounts (NHA) allow decision REFERENCES

1. Hsu, J et al. 2013. Countdown to 2015: Changes in Official Development Assistance to maternal, Newborn and Child Health in 200910, and assessment of progress since 2003. The Lancet. http://dx.doi. org/10.1016/S0140-6736(12)61382-8 2.PMNCH. 2012. Strengthening National Financing for Womens and Childrens Health. Knowledge Summary 21. Geneva: PMNCH. 3.PMNCH. 2012. Financing Access to RMNCH Interventions for Universal Health Coverage. November 2012. Paper for the Asia-Pacific Leadership and Policy Dialogue for Womens and Childrens Health. Geneva: PMNCH. 4.PMNCH. 2012. More Health for Money. November 2012. Paper for the Asia-Pacific Leadership and Policy Dialogue for Womens and Childrens Health. Geneva: PMNCH.
5. PMNCH. 2012. More Money for Womens and Childrens Health. November 2012. Paper for the Asia-Pacific Leadership and Policy Dialogue for Womens and Childrens Health. Geneva: PMNCH. 6.WHO. 2012. The State of Health Financing in the Africa Region. July 2012. WHO African Regional Office. 7. PMNCH. 2012. Knowledge Summary series. http://www.who.int/ pmnch/knowledge/publications/summaries/en/ 8.The World Bank. 2013. Health Financing and Fiscal Health in Africa: Bridging Collaboration between Ministries of Finance and Health. Paper produced for the: Africa Health Forum: Finance and Capacity for Results. http://siteresources.worldbank.org/ INTAFRICA/Resources/AHF-health-financing-and-fiscal-health-in-africa.pdf
47
ICMNCH, August 2013
48
ICMNCH
THE GIRL CHILD AND REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH
BACKGROUND A Focus on the health of the girl child is essential for reproductive, maternal, newborn, and child health efforts. Girls under the age of 15 are five times more likely than older women to die in childbirth. Infants are 60% more likely to die in their first year of life if their mothers are under 18. Among female adolescents, maternal conditions are responsible for 15% of all deaths. In Africa (excluding north Africa), women under the age of 20 have the least access to skilled birth attendance, highest rates of hospitalization due to unsafe abortion, and lowest access to reproductive and sexual health services. Of the 2.1 million adolescents living with HIV (most of them in Africa), 62 per cent are adolescent girls. Maternal morbidity including obstetric fistula is also higher amongst adolescents due to complications from labor and delivery. In many instances, child marriage exacerbates these statistics. In Africa (excluding north Africa), studies have shown that, among 15-19 year olds, those who are married are 75% more likely to have HIV than those who are unmarried. Two-thirds of those newly infected with HIV are girls. They are eight times more likely to have HIV than their male counterparts. Only 15 per cent are using contraception. The adolescent girls are also more vulnerable to gender-based violence and sexual exploitation. Globally, the lifetime prevalence of intimate partner violence among ever-partnered women for girls age 15-19 is 29.4 per cent. In Africa, the proportion of women reporting intimate partner violence and/or non-partner sexual violence ranges regionally from 29.7 per cent (Southern) to 65.6 per (Central), the highest in the world. The prevalence of sexual abuse before the age of 15 is also high in some areas; a study in urban Namibia cited a prevalence rate of 21 per cent. Health effects include sexually-transmitted infections, induced abortion, alcohol use, depression and suicide, injuries, and death from homicide. In spite of efforts to eradicate female genital mutilation (FGM), the practice is still pervasive in many areas. Approximately 3.3 million girls are at risk of FGM each year. Nutritionally, girls are at risk of anemia and iron deficiency due to menstruation. Girls are also more likely to leave school prematurely than boys. As a womans level of education is linked to delayed age of first sex, marriage and childbearing, as well as to improved health outcomes for her own children, girls participation in education has farreaching, long-term health implications. CHALLENGES There have been a number of challenges to improving the health of the girl child in Africa: Youth-friendly reproductive health services often remain in pilot form, or dependent on the participation of non-governmental partners. These services have not been consistently scaled up across the public sector. Social conditions, economic factors, and cultural beliefs contribute strongly to the persistence of child marriage and young girls decision to become sexually active. These factors also influence the prevalence of coerced sexual relations. Changes to attitudes and behaviors are challenging to implement, incentivise, sustain, and measure.
49
ICMNCH, August 2013
Human and financial resource constraints may prevent governments from effectively and consistently enforcing health education and marriage policies. Girls are often most vulnerable when living in areas with ongoing armed conflict, where health and education services do not reach. Girl child initiatives often require cross-ministerial coordination. Countries vary as to the degree to which
different ministries are able to work efficiently and effectively with one another. Gender equality is fundamental to attaining human rights, thus an approach that emphasizes accountability and seeks to assist participatory policy formulation is critical. The lack of a human rights-based approach prevents promotion of mutually empowering relationships between boys and girls, both in the public and private sphere.
STRATEGIES AND BEST PRACTICES Countries have initiatied a number of initiatives aimed at improving the health and welfare of the girl child. For example: Legislation has raised the national minimum age of marriage of girls to 18 years, so as to protect against the physical and mental health consequences of child marriage and young motherhood (e.g. Burundi, Lesotho, Namibia, Togo). Civil registries have been established to better track the age of a woman at marriage and/or the age when she gives birth to a child (e.g. Malawi, South Africa, Togo). National child or adolescent health policies and strategic plans help provide guidance for both the public sector and its partners as to program development and implementation (e.g. Ghana, Kenya, Uganda, Zambia). There is increased investment in and scale up of adolescent- friendly reproductive and sexual health services (e.g. Ethiopia, Ghana, Malawi, Mozambique, Namibia, Senegal, Tanzania, South Africa, Zambia, Zimbabwe). Outreach on girl child issues now targets community change agents both male and female - to support grassroots attitude and behavior change (e.g. Ethiopia, Senegal, Zambia). HPV vaccination of 9-13 year old girls to prevent cervical cancer in adulthood is an important entry point for delivery of additional interventions. There is increasing investment in and promotion of girls education, through outreach campaigns to parents, elimination of school fees, and re-entry policies to allow girls to return to school after delivering a child (e.g. Kenya, Liberia, Malawi, Zambia). Vocational and literacy support is being provided to girls who have left school early, including married girls and young mothers (e.g. Ghana, Malawi). Countries are approaching these issues from a multi-sectoral perspective, bringing in stakeholders from Ministries of Health, Youth, Education, and Women (e.g. Mozambique).
CASE STUDY - MOZAMBIQUE

In Mozambique, 41 per cent of girls 15-19 years have either already given birth, or are pregnant, while 80 per cent are sexually active. The maternal mortality ratio is presently 500 per 100,000 live births, of which 8 per cent are girls, adolescents and young women between the ages of 15-24 years. Girls, adolescents and young women are four times more likely to be infected with HIV than other age/gender categories. Since 1999, the Government of Mozambique has been partnering with UNFPA and the family planning association, AMODEFA, to integrate adolescents into sexual and reproductive health policy, and create and extend youth-friendly adolescent health services. Using a cross-sectoral approach, the Ministries of Health, Youth and Sports, Women and Social Action, and Education have partnered with technical agencies and NGOs to provide counseling and services both within and outside of schools. For example, Bancada Feminina discussion forums for girls, adolescents, and young women have been launched to create opportunities to discuss reproductive health issues, build self esteem, and link to mentors and positive role models.
50
ICMNCH, August 2013
KEY OPPORTUNITIES Many countries and organizations have increased efforts to improve the health of the girl child: The United Nations inaugurated the first International Day of the Girl Child on October 11, 2012. Global and national advocates now have a focal day on which to highlight girl child issues such as girls education, adolescent sexual and reproductive health, and child marriage. Many African countries have signed key global and regional charters on the rights and welfare of children, as well as on womens and human rights. These charters provide an advocacy platform for policies and initiatives in support of the health of the girl child. Many African countries have successfully legislated for an increase in the national age of marriage. A higher age of marriage removes legal barriers to initiatives aimed at raising age of first sexual activity and creates a basis for enforcement. Global and regional initiatives aimed at improving civil registration have opened up policy windows and
1. African Union. 2013. Documenting Good Practices in Maternal, Newborn and Child Health Interventions. Addis Ababa: AU. http:// www.who.int/pmnch/media/events/2013/ camh6 _ mnch _ good _ practices2013.pdf 2. IPPF. 2011. Girls Decide: Choices on Sex and Pregnancy. London: IPPF. 3. IWHC. 2008. Child Marriage: Girls 14 and Younger at Risk. June 2008. New York: IWHC. 4. Nour N. 2006. Health Consequences of Child Marriage in Africa. Emerging Infectious Disease. 12(11):1644-1649. 5. Plan International. 2012. The Status of the Girl Child in Africa. Woking, UK: Plan International. 6. Plan International. 2012. The State of the Worlds Girls: Learning for Life. Woking, UK: Plan International. 7. PMNCH. 2012. Reaching Child Brides. Knowledge Summary 22.
opportunities for financing for countries wishing to create better systems of marriage and birth registration. A wide range of resources exist to assist countries in advocacy and planning. For example: Plan Internationals Because Im a Girl campaign provides resources on a number of girl child topics, including school-based gender-based violence, urban and digital space, and conflict. The Elders Girls Not Brides campaign is a global partnership that supports advocacy, legislation, incentivisation, and community mobilization towards the prevention of child marriage. National affiliates of the IPPF provide youth-friendly services and help train public sector workers in service delivery. Population Council has extensive research on adolescent reproductive and sexual health in Africa, and is a source of epidemiological and social data.
REFERENCES
8. Save the Children. 2012. Every Womans Right: How Family Planning Saves Childrens Lives. London: Save the Children. 9. UNFPA. 2013. Child Marriage. http://esaro.unfpa.org/public/cache/ offonce/lang/en/ pid/1234 Accessed July 6 2013. 10. WHO. 2013. Adolescent Health Epidemiology. http://www.who. int/maternal _ child _ adolescent/epidemiology/adolescence/en/index.html Accessed July 6 2013. 11. WHO. 2013. Global and Regional Estimates of Violence Against Women. Geneva: WHO. http://apps.who.int/iris/bitstream/10665/85239/1/9789241564625 _ eng.pdf
51
ICMNCH
USING HUMAN RIGHTS TO ENHANCE ACCOUNTABILITY FOR WOMENS AND CHILDRENS HEALTH BACKGROUND A human rights-based approach to programming differs from the basic needs approach in that it recognizes theexistence of rights. It also reinforces capacities of duty bearers (usually governments) to respect, protect and guarantee these rights. Accountability is central to a human rights based approach to health and can be a powerful tool for improving the health and well-being of women and children in the African Region. Human rights-based accountability can have far reaching effects in the strengthening of health systems and transforming the rights discourse into practical health policy and programming.
There has been substantial progress in promoting human rights in womens and childrens health in Africa. Womens and childrens human rights, including their rights to health, are protected under international human rights law, as well as various regional human rights instruments such as the African Charter on Human and Peoples Rights; the Protocol to the African Charter on Human and Peoples Rights of Women in Africa (Maputo Protocol) and the African Charter on the Rights and Welfare of the Child. The adoption of the Principles and Guidelines on the Implementation of Economic, Social and Cultural Rights through the African Commission on Human and Peoples Rights, as well as initiatives such as the Campaign for the Accelerated Reduction of Maternal Mortality in Africa (CARMMA), are also important for clarifying accountability requirements, and pushing towards greater progress in this area.
CHALLENGES Maternal and child mortality and morbidity represent A human rights-based approach depends on the an ongoing human rights and accountability challenge. monitoring of core progress indicators to track what These deaths have their roots in the under-prioritiza- is happening where, to whom, and with what resourction of womens and childrens health services and comes. However, monitoring alone is not enough. Human modities, lack of accountability mechanisms to respond rights-based accountability must combine elements of to preventable maternal and child deaths, and a denial responsiveness, monitoring, independent review, anof human rights that exacerbate inequity and violence swerability, and remedial action by all relevant actors. against women and children. STRATEGIES AND BEST PRACTICES Facilitating rights-based planning, implementation, Create an enabling environment Eliminate all barriers that prevent women and chil- monitoring & evaluation dren from achieving the highest attainable standard of Planning health. These barriers include: Inform the planning process by carrying out a situ Legal barriers: such as the non-recognition of the right ational analysis of existing problems and structures, the to health in national laws main health needs of women and children, and the un Economic barriers: such as user fees or high costs of derlying socio-economic and cultural determinants of health. medicines Cultural barriers: such as gender discrimination or practices that are harmful to women and girls Social barriers: such as lack of information, education, and nutrition of women and children. Emphasize best practice evidence of required interventions and appropriate strategies. Ensure the planning process is transparent, participatory, and pays special attention to the most marginalized individuals and communities.
52
ICMNCH, August 2013
Implementation Ensure the elements of availability, accessibility, acceptability, and quality are at the center of the implementation of all programs and policies on womens and childrens health. Implement programs and policies on womens and childrens health that respect, protect, and fulfill the rights of children and women. Monitoring and evaluation Use both quantitative and qualitative indicators. Consult and ensure the active participation of all stakeholders, including women and children themselves. Assess how much is spent, where, on what, and on whom. Regional, national, and international accountability mechanisms Ensure international, regional and national accountability mechanisms hold all actors to account, identify
gaps and failures of institutions and programs, as well as provide remedies and redress for women and children whose rights have been violated. In April of 2012, the 126th Assembly of the IPU unanimously adopted a resolution: Access to health as a basic right: The role of parliaments in addressing key challenges to securing the health of women and children. The resolution highlights the human rights, political and socioeconomic imperatives against which parliamentarians can view and act on womens and childrens health as a priority. The resolution further enumerates the concerns of parliaments with respect to womens and childrens health, and the commitments parliaments have made in response. Promote functional, accessible and transparent accountability mechanisms including through ratification of the Maputo Protocol to ensure the respect, protection and fulfillment of womens and childrens right to health.
CASE STUDY - KENYA

The Kenya National Commission on Human Rights in 2011 launched an independent public review into violations of sexual and reproductive health rights (SRHR) in Kenya. The review followed a complaint filed by Kenyas Federation of Women Lawyers and the US-based Centre for Reproductive Rights alleging systematic violation of womens reproductive health rights in Kenyan health facilities. The inquiry concluded that the SRHR of Kenyans were being violated in a number of ways. SRH services were unavailable or difficult to access due to distance or cost. Available services were of poor quality and service providers demonstrated a lack of sensitivity to cultural norms and beliefs. The inquiry concluded that the government had not complied with its obligation to dedicate its maximum available resources to progressively realize SRHR. The Kenya National Commission on Human Rights made a number of key recommendations that the state and other stakeholders should consider in programming, policy dialogue, and other measures aimed at enhancing the realization of SRHR in Kenya.
KEY OPPORTUNITIES There is technical guidance to assist policymakers in the implementation of policies and programmes to reduce maternal mortality and morbidity in accordance with human rights standards. http://www2.ohchr.org/ english/issues/women/ docs/A.HRC.21.22_en.pdf There is increasing evidence available to assist states comply with their binding national and international obligations and understand how human rights approaches help to improve womens and childrens health. http://apps.who.int/iris/ bitstre am/10665/84203/1/9789241505420_eng.pdf There is global consensus around accountability for results, with the Commission on Information and Accountability for Womens and Childrens Health spearheading the monitoring of core progress of resourcing and impact of human-rights based outcomes. A number of tools are being developed to assist states to strengthen national, legal, and policy accountability mechanisms for improving womens and childrens rights (e.g. Human Rights and RMNCH Rapid Assessment Tool).
53
ICMNCH
PROMOTING WOMENS AND CHILDRENS HEALTH INTEGRATING HIV, TB MALARIA REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH In many countries, RMNCH services represent the primary point of womens and childrens access to the health system. The stakeholders, messages and services for HIV, tuberculosis (TB) and malaria and for reproductive, maternal, newborn and child health (RMNCH) are closely interconnected. When integrated with prevention, care and treatment for other health concerns, coverage for these three priority diseases can be greatly enhanced. There are multiple entry points along the RMNCH continuum of care to integrate HIV, TB and malaria strategies, and opportunities exist to strengthen health systems and community structures. An appropriate approach will avoid duplication and maximise effectiveness, efficiency and quality. It will also promote human rights and accountability for shared indicators and results. Several initiatives currently support the integration of HIV, TB and malaria services with RMNCH services. Further expansion of these efforts could significantly improve the health of women and children. THE CONTEXT Women and children bear a heavy burden of HIV, TB ties relating to gender and poverty in accessing health and malaria, which interact with and exacerbate other services, early and forced marriage, as well as stigma, reproductive, maternal, newborn and child health (RM- discrimination and denial of legal rights exacerbate the NCH) problems (see Figure 1). Over two million wom- vulnerability of women and girls to these diseases and to en and children die every year from AIDS, TB and ma- other RMNCH problems.6 laria.1 AIDS and malaria combined contribute to 10% of all deaths in children under the age of five and are Integrating HIV, TB and malaria and RMNCH interassociated with around 20% of maternal deaths world- ventions together across the continuum of care can adwide.2 In 2011, an estimated 330,000 children were new- dress critical gaps in service delivery and greatly extend packages of care save lives and are ly infected with HIV, more than 90% of them through coverage. Integrated 7-9 Programme evaluations show that costeffective. vertical transmission from their mothers and there were antenatal care (ANC), provider-initiated HIV testing anestimated 0.5 million cases and 64 000 deaths among children3, 4 due to TB. It is not known how many still- and counselling (PITC), prevention of mother-to-child births (2.7 millionper annum) or preterm births might transmission (PMTCT)b and antiretroviral therapy be directly linked to HIV, TB or malaria, particularly. (ART) adherence all improve when an integrated apreproductive, maternal Malaria in pregnancy also has a negative impact, con- proach is adopted into routine 10 and neonatal health care. tributing to maternal anaemia, low birth weight and infant mortality and coverage of IPTp is very low.5 InequiKEY STRATEGIES Recognising the need to capitalise on lessons learned in this area, several initiatives support strategic integration and linkages with RMNCH (see Box 1).c Integrating HIV, TB and malaria strategies with RMNCH shows immense promise for making progress on universal access to prevention, treatment, care and support. Interventions that are based on national health priorities, strengthen health and community systems and integrate the continuum of care with HIV, TB and malaria strategies allow for the best use of limited human and ma-
54
ICMNCH, August 2013
terial resources and can improve health service delivery. To be as effective as possible, integrated interventions must also promote gender and human rights, give attention to creative and innovative approaches and strengthen accountability for results. The inclusion of RMNCH linkages in the Global Funds mandate and funding model requires attention to each of these areas.11 Integrate across the continuum of care There are multiple points across the continuum of care where essential interventions can be integrated with HIV, TB and malaria strategies (see Figure 2). There are evidence-based and well-documented successes in countries. Key entry points across the continuum of care to consider include sexual and reproductive health
services, antenatal and postnatal care, and providing nutritional, psychosocial and socioeconomic support for women and children who are especially vulnerable (see Box 2 for details and technical resources). It is estimated that more than 50% of development assistance for reproductive health activities in 2009 and 2010 was directed towards HIV prevention, treatment and care for women of reproductive age.12, 13 Strengthen health systems Inadequate health systems are a primary obstacle to scaling up interventions to improve womens and childrens health and to support HIV, TB and malaria control programmes.14 For health systems, having sufficient numbers of trained, qualified and motivated health workers in the right place, at the right time and with
Global Fund support for strengthening RMNCH linkages The Global Fund 20122016 Strategy: Investing for Impact states: A targeted initiative, focused on selected synergistic MNCH interventions in a limited number of high-burden countries where the Global Fund already has substantial investment could have a major impact on saving lives at a relatively modest incremental cost. This represents a very costeffective outcome, reflecting the leveraging effect of building on the platform already established to deliver aligned services. Source: The Global Fund. The Global Fund strategy 2012-2016: Investing for Impact. 2012. The Global Fund Board encourages: ...countries, where applicable, to strengthen the MNCH content of their Global Fund-supported investments, maximizing existing flexibilities for integrated programming. Source: The Global Fund. Twenty Second Board Meeting (December 2010).
55
ICMNCH, August 2013
the right resources is crucial to the provision of essential services.15 Strengthening health systems, such as in areas of procurement/regulation of drugs and commodities and competencies and innovative profiles of human resources, not only improves key disease-priority areas, but also ensures the system can provide the volume and quality of services needed for successful integration across the continuum of care.16 Promote community systems The promotion of community systems involves developing the role and capacity of a broad range of community actors in the design, delivery, monitoring and evaluation of health services and other interventions at the community level. Many synergies and overlaps within and between community and health systems can be reinforced. Robust community systems interact with the health system directly and improve RMNCH outcomes through building demand for appropriate services and
providing interventions related to prevention, treatment, care and support. Community systems also address issues that impact on health, such as sanitation, safe drinking water, malnutrition, gender equality and womens empowerment. The combined strengthening of health and community systems and integrated service delivery is increasingly prioritized in order to reach MDGs 4, 5 and 6.17 Emphasize effectiveness, efficiency and quality Synergising RMNCH with strategies for the three diseases by using innovative, cost-effective and evidencebased approaches, can improve the targeting of funds, increase efficiency and improve the quality of womens and childrens health interventions.17 Efforts towards quality improvement in maternal and health services also increase the likelihood of timely and appropriate treatment that is both equitable and consistent with current professional knowledge. RMNCH services which
56
ICMNCH, August 2013
are clinically effective, safe and a good experience for the patient not only strengthen the continuum of care but also facilitate action and enhance coverage for the three priority diseases. For example, when HIV, TB and malaria interventions are linked with RMNCH initiatives across the continuum of care model and consideration is given to cross- cutting issues such as gender-based violence prevention (GBV) and youth empowerment, they can demonstrate greater effectiveness than when implemented alone. Realize human rights, address inequities, combat stigma and prevent discrimination Promoting awareness of rights, advocating for equality of access to essential services, ensuring legal entitlements and mitigating stigma and gender inequity are essential elements of a human rights approach to promoting womens and childrens health.18 Successful integration of RMNCH interventions with HIV, TB and malaria strategies requires preventing discrimination across all dimensions of access to quality healthcare: accessibility, affordability, acceptability, appropriateness and quality of services. It also requires efforts to address the underlying risk factors and determinants of disease in vulnerable groups and to improve coverage and outcomes in underserved populations, such as reduced new infection rates and improvements in survival and health status. Promote accountability for results at all levels Shared indicators for monitoring and evaluating will help track progress towards MDGs 4, 5 and 6. The Commission on Information and Accountability for Womens
and Childrens Health (CoIA) provides a framework for strengthening health information systems and includes consensus on tracking11 core RMNCH indicators, which include antiretroviral prophylaxis among HIV-positive pregnant women, antenatal care coverage, children under five who are stunted, maternal mortality ratio and under five child mortality.18 Integrating monitoring and evaluation (M&E) for RMNCH and for HIV, TB and malaria programs will help ensure accountability for results at all levels, inform programme management and promote learning across contexts on addressing constraints and building on successes to promote womens and childrens health.
Resources to guide integration of HIV, TB and malaria and RMNCH services WHO Technical Guidance Note: Strengthening inclusion of maternal, newborn and child health in proposals to the Global Fund and other Partners. 2011. http://tip.populationaction.org/files/2012/08/WHO_ RH_ MNCHGuidance_July2011.pdf Integrating HIV/AIDS and RMNCH programmes: Best Practices. 2012. http://www.who.int/pmnch/ knowledge/ publications/strategybriefs Integrating Malaria in Pregnancy (MiP) and RMNCH Programs: Best Practices. http://www.rollbackmalaria.org/ mechanisms/mpwg.html No more crying, no more dying. Towards zero TB deaths in children. http://www.stoptb.org/assets/documents/resources/ publications/acsm/ChildhoodTB_report_singles.pdf
CONCLUSION An opportunity to accelerate progress towards MDGS 4, 5 and 6 An integrated approach to the health MDGs is consistent with the UN Secretary-Generals Global Strategy for Womens and Childrens Health,14 which builds on the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) and other initiatives. Better integration and coordination of RMNCH interventions with HIV, TB and malaria strategies offers a significant opportunity to accelerate progress towards MDGs 4, 5 and 6. The strategies for prevention are similar and the areas where systems require strengthening are also interconnected. There are less than 1000 days left to reach the MDG targets, but the effort will not stop in 2015. It is critical to expand the impact of global investments by integrating RMNCH interventions across diseases and sectors, and promoting equity and accountability within existing frameworks, such as the CoIA, to ensure women and their children can access sustainable, quality care when and where they need it.6, 15
57
ICMNCH, August 2013
REFERENCES
1. WHO. The Global Burden of Disease: 2004 Update; 2008. 2. WHO, UNICEF. Countdown to 2015. Maternal, newborn and child survival. Building a future for women and children: the 2012 report. 3. UNAIDS. UNAIDS Report on the global AIDS epidemic; 2012. 4. WHO. Global TB Report; 2012. 5. WHO, 2007. Malaria in Pregnancy. Guidelines for measuring key monitoring and evaluation indicators. 6. WHO. Womens health and human rights: Monitoring the implementation of CEDAW; 2007. and other Partners . 2011. 11.The Global Fund. The Global Fund strategy 2012-2016: Investing for Impact. 2012 12.Netherlands Interdisciplinary demographic Institute (NIDI). Financial resource flows for population activities in 2009. New York. United Nations Population Fund, 2010. 13.Patel P, Roberts B, Guy S, Lee-Jones L, Conteh L. Tracking official development assistance for reproductive health in conflict affected countries. PLoS Med. 2009; 6(6): e1000090. 14.WHO. The World Health Report. Health Systems Financing: The Path to Universal Coverage; 2010. 15.UN Secretary-General. Global Strategy for Womens and Childrens Health; 2010. 16.WHO, 2007. Everybodys Business. Strengthening Health Systems to improve health outcomes. WHOs Framewoek for Action. 17.The Global Fund. Community Systems Strengthening Framework; 2011. 18.OHCHR. International Law http://www2.ohchr.org/english/law/ index.htm#core 19.United Nations Commission on Information and Accountability for Womens and Childrens Health. Advance copy of the report of the Commission: Keeping Promises, Measuring Results; 2011.
7. LassiZS,HaiderBA,BhuttaZA.Community-basedinterventionpackagesforreducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2010; (11): CD007754. 8. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005; 365(9463): 977-88. 9. Pattinson R, Kerber K, Buchmann E, Friberg IK, Belizan M, Lansky S, et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet. 2011; 377(9777): 1610-23. 0.WHO. WHO Technical Guidance Note: Strengthening inclusion of maternal, newborn and child health in proposals to the Global Fund
58
ICMNCH
NUTRITION AND REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH BACKGROUND Nutritional status greatly influences an individuals growth, educational attainment, productivity, reproductive success,and susceptibility to disease. Children undernourished within their first 1,000 days of life have slower cognitive and physical development and are less likely to perform well in school. In 2001, the Commission on Macroeconomics and Health showed that higher income is associated with better health (wealthier is healthier), but also showed a link from improved health and nutrition to economic growth (healthier is wealthier). Thus, the macroeconomic consequences of malnutrition for low- and middle-income countries can be significant. Approximately 165 million children suffer from undernutrition. Presently, childhood malnutrition is responsible for up to 45 per cent of all deaths among children under five. African countries (excluding north Africa), in particular, have struggled to tackle malnutrition. Improvements in nutrition can be undermined by food insecurity; only three countries have been able to reduce hunger by 50 per cent or more (Ghana, Mauritania). In five countries, hunger has worsened over this time. African countries also face an uphill battle against Anaemia, with more than 70 million women of reproductive age suffering from it, increasing their likelihood of dying from a post-partum haemorrhage during childbirth. At current trends, it will take more than 150 years to resolve this problem in Africa. Stunting (low height-for-age) and Wasting (low weight-for-height) are two other major challenges for African development. 56 million children under five in the continent were affected by stunting in 2011, i.e. one third of the worlds stunted children. Stunted children have a greater risk of disease and may also have a retarded development, with consequences on schooling and employment. Studies in Ghana and Brazil have correlated each centimetre gain in height due to improved childhood nutrition with a wage increase of 8-10% in adulthood. Wasting, resulting from a combination of food insecurity, poor sanitation, and lack of access to clean water, is affecting 13 million children under five in Africa (2011). Poverty and marginalization exacerbate these conditions. Children from poor and rural households are more likely to be underweight, as are children born to mothers with low levels of education, or exposed to poor water and sanitation. Pregnant women who are malnourished are more likely to give birth to malnourished children (low birth weight), as are women who are undernourished during their own first 1,000 days of life. Global- and country-level interventions for improved nutrition have been proven to be effective and provide high economic and social returns. Thus, communities, national governments, donors, and global partnerships need to leverage multi-sectoral platforms to collectively prioritize women and childrens nutritional needs.
59
ICMNCH, August 2013
CHALLENGES Frequent droughts and other natural disasters have ment of severe malnutrition continues to be a challenge devastated Africas agricultural sector in recent years, in the Region. and constrained countries ability to build long-term emergency food stores. Along with global economic Population growth in Africa is rising at a faster rate factors, this has resulted in severe food price volatility in than agricultural productivity. Population growth is Africa. Adverse climate change in the future will likely also a key contributor to poverty and a key impediworsen. Price hikes affect poor peoples access to food, ment to providing water, sanitation, and health services. and create a vicious cycle of poverty in which the very Achievements in nutrition can be undermined if food assets that allow a family to produce food are liquidated production cannot meet the demands of a growing population, and if the growing population is both poorer in order purchase food. and sicker than previous generations. Nutritional disorders in Africa are often related to the prevalence of diarrhoeal disease and vitamin deficiency. Conflict, instability, and food insecurity are mutually Thus, programs that address undernutrition should be reinforcing conditions. Conflict in some countries in integrated with diarrhoeal disease control and vitamin Africa has led to internal displacement, declines in productivity, disruption in markets and health services, and supplementation. an increase in hunger and malnutrition. Food insecuri Low coverage of proven and effective nutrition inter- ty, in turn, drives conflict and instability as populations ventions such as exclusive breastfeeding, complemen- fight over scarce resources. During conflicts, mothers tary feeding, micronutrient supplementation, manage- and children are especially susceptible to malnutrition. STRATEGIES AND BEST PRACTICES African governments are demonstrating strong leader- care of diarrhoea. ship and political commitment to nutrition and food security issues. For example, food security has been Provision of Nutrients, Fortificants and Emergency Malawis top domestic policy issue since the 2004/05 Feeding drought. A number of strategies and best practices point Introduce supplementation and fortification of key nutrients via periodic supplementation through intethe way forward. grated campaigns (e.g. Child Health Weeks) or partnerPrevention of Hunger ships with food growers/ processers for fortification of Improve domestic financing for the agricultural sec- staple foods (e.g. iodization of salt, Vitamin A-enhanced tor. maize). Link national agricultural policy explicitly to country nutrition goals and interventions. Tie these to strategies to improve access to land and gender equality. Promote and provide individual/community support for nutrition-enhancing newborn and infant care strategies. Proven strategies include exclusive breastfeeding from delivery up to six months, kangaroo care, and complementary feeding for children 6-24 months. Strengthen national nutrition policy, financial allocation to nutrition interventions and implementation. Educate and provide support for auxiliary interventions such as hand washing and hygiene messaging. Promote and improve access to zinc for home-based Nutrient supplementation for pregnant and breastfeeding women (e.g. calcium and iron folate) through such channels as ante-/post-natal clinics or post-natal community health worker visits. Increase availability of therapeutic feeding interventions for severe acute malnutrition, if possible on an outpatient basis. Create a consistent supply of therapeutic foods in quantities appropriate for household use. Screen and treat accompanying medical conditions. Policy and Best Practice The World Health Assembly, in 2012, approved a comprehensive implementation plan on maternal, infant and young child nutrition. This also established six global nutrition targets on the reduction of stunting,
60
ICMNCH, August 2013
wasting, anaemia, overweight, low birth weight and on the improvement of breastfeeding rates. Adopt globally recognized growth-monitoring standards (e.g. multiple growth monitoring indicators, better record-keeping from the point of individual child health cards up to national surveillance systems, inclusion of growth monitoring in pre- service training).
Integrate nutrition components into other reproductive, maternal, newborn and child services, such as family planning initiatives, HIV-AIDS programs, and bednet distribution activities. Introduce food-related social safety nets such as early warning systems, targeted cash- or food-for-work programs and emergency response systems. Integrate nutrition education into these programs.
CASE STUDY: ETHIOPIA The Ethiopian government in partnership with the Food and Agriculture Organization (FAO) launched a comprehensive approach to food security following decades of famine. The project focused specifically on female-headed households, and integrated agriculture, health, education, and water and sanitation. Womens income-generating activities were prioritized (e.g. poultry raising, beekeeping, vegetable growing), as was health promotion for nutrition and safe water and sanitation. The project targeted 26,000 people in Southern Tigre and Northern Shao and resulted in a decline of acute malnutrition from 13.4% to 9.5% in two years.
KEY OPPORTUNITIES The African Unions Comprehensive Africa Agricul- among small farmers, including women. Opportunities ture Development Program (CAADP) was initiated in exist to ensure the Alliance commits to a gender per2003 to help member states boost agricultural produc- spective and a nutritional focus on a childs first 1,000 tivity by improving land and water management, rural days. market infrastructure, food availability, and agricultural research. Countries also agreed to commit at least 10% The Global Alliance for Improved Nutrition (GAIN) of national budgets to agriculture. More than 40 Afri- is a public- private partnership to increase access to can countries have completed CAADP-based National missing dietary micronutrients. Over 600 companies Agriculture and Food Security Investment Plans and and civil society organizations are involved, reaching are eligible for funding from the Global Agriculture and an estimated 667 million people with nutritionally enFood Security Program. Opportunities exist to ensure hanced food products. About half of the beneficiaries country-level CAADP implementation includes a gen- are women and children. GAINs goal is to reach one der-perspective and a prioritization of investment for billion people by 2015 with nutritious foods that have sustainable nutritional impact. maternal and child health. African governments and the G8 initiated the New Alliance for Food Security and Nutrition in 2012 to increase private investment in agriculture. The Alliances Global Agriculture and Food Security Programme will help improve information sharing among African countries. Food Security and Nutrition Cooperation Frameworks will be created to align and prioritize food security issues within CAADP national investment plans. Over US $3 billion has been raised to boost productivity The Scaling Up Nutrition (SUN) movement was launched in 2010 to campaign for improved coordination and leadership on nutrition.a In Africa, 28 countries are involved in SUN.a SUN seeks to ensure that donors, governments, industry, and civil society invest in scaling up a package of nutrition-specific and sensitive, cost-effective, evidence-based interventions, such as the promotion of exclusive breastfeeding, access to supplements and fortification, and therapeutic feed-
61
ICMNCH, August 2013
ing for severe undernutrition. Aligned with SUN, the Feed the Future (FtF) targets the root causes of hun1000 Days Partnership focuses on pregnancy through ger, poverty, and undernutrition, especially for women the first two years of life. These countries are adopt- and children. Twelve of the nineteen FtF focus couning multi-sectoral approaches to improving nutri- tries are in Africa. Through FtF and the Global Health tion: setting up multi-stakeholder nutrition platforms; Initiative, the United States supports country-owned adopting sound nutrition policies and laws; articulat- programs to address the root causes of undernutrition ing national commitments and aligning plans around and improve the future potential of millions of people. a single set of expected results; implementing specific In addition to its support for the first 1,000 days, FtF nutrition interventions (including the promotion of strengthens local capacity to bring programs to nabreastfeeding) and nutrition-sensitive approaches, tional scale and sustain them. across multiple sectors; mobilizing in-country and external resources to realize their commitments: The World Health Organizations Accelerating Numonitoring progress and demonstrating their achieve- trition Improvements project, supported by the Canaments. The SUN Movement provides a means through dian International Development Agency, is designed which donors, the UN system, business, and civil so- to support government efforts to strengthen nutrition ciety are harmonizing and aligning their in-country surveillance in eleven high-burden countries in Afby building on national and external support behind government-led national rica (excluding north Africa) b health information systems. nutrition plans and contributing to systems for mutual accountability. REFERENCES
1. African Union. 2013. Millennium Development Goals Report 2013. Addis Ababa. African Union. www.who.int/reproductivehealth/publications/linkages/HIV _ 05 _ 5/en/index.html 2. The Lancet. 2013. The Maternal and Child Undernutrition Series. 3. PMNCH. 2013. The Economic Benefits of Investing in Womens and Childrens Health. Knowledge Summary 24. http://www.who.int/pmnch/topics/part _ publications/ knowledge _ summary _ 24 _ economic _ case/en/index.html 4. PMNCH. 2012. Nutrition. Knowledge Summary 18. http://www. who.int/pmnch/topics/ part _ publications/knowledge _ summaries _ 18 _ nutrition/en/ 5. Save the Children. 2012. A Life Free From Hunger: Tackling Child Nutrition. 6. UNICEF. 2013. Improving Child Nutrition: The Achievable Imperative for Global Progress. April 2013. New York: UNICEF. 7. Black RE, Victora CG, Walker SP, and the Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013; published online June 6. http://dx.doi.org/10.1016/S0140-6736(13)60937-X
a. SUN African Countries include (2012) Benin, Burkina Faso, Burundi, Cameroon, Chad, Cte dIvoire, DR Congo, Ethiopia, Gambia, Ghana, Guinea, Kenya, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Sudan, Tanzania, Uganda, Zambia, Zimbabwe. b. Accelerating Nutrition Improvements Project (WHO/CIDA) Sub- Saraha African Countries: Burkina-Faso, Ethiopia, Mali, Mozambique, Rwanda, Senegal, Sierra Leone, Tanzania, Uganda, Zambia, Zimbabwe.
62
ICMNCH, August 2013
ICMNCH
PRIMARY HEALTH CARE AND REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH
BACKGROUND The 1978 Alma-Ata Declaration identified Primary Health Care (PHC) as the key means by which to guarantee all people a level of health sufficient to lead a socially and economically productive life. PHC is a set of principles focused on a) health and well-being; b) community ownership of, and participation in, health; c) locally-appropriate services, technologies, and resource use; d) equity-focused interventions; and e) a multi-sectoral approach. Based on a principle of equity, PHC is operationalized through a package of essential services: health education, nutrition, maternal and child health, basic sanitation and clean water, immunization, prevention and control of endemic diseases, treatment of common diseases and injures, and provision of essential drugs. While the Alma-Ata Conference was a groundbreaking moment for international health, the declaration itself was non-binding, and debates about the strategy continued through the 1990s. The struggles of many countries to achieve their health-related Millennium Development Goals (MDGs), and the recognition that social determinants of health must be addressed in the post- 2015 development agenda, have led to a renewed emphasis on the relevance of PHC for achieving countries RMNCH goals. In Africa, this renewed emphasis is particularly timely. Challenges, such as the HIV/AIDS crisis have led to varied progress towards health indicators, especially in countries that have had to reorganize their health systems around a response to the epidemic. Even among countries that have had success in tackling the HIV epidemic, access to healthcare especially among vulnerable populations - remains a challenge. Investing in health systems is a critical component to promote PHC and improve RMNCH indicators across African countries. CHALLENGES PHC is a holistic philosophy of health requiring a and demanding appropriate and equitable services, and committed multi-sectoral approach. It represents a con- ensuring accountability. Civil society in many African siderable investment in both financial and human re- countries remains uncoordinated and thereby unable to sources. Vertical approaches to health problems in Af- fulfill their full potential. rica need to be integrated into a comprehensive PHC Decentralized budgeting, decision-making, and planmodel. ning are vital aspects of the PHC model; communities, The majority of countries in Africa still have not im- clinics, and sub-national administrations must be inplemented many measures required to achieve universal volved in prioritizing locally relevant health problems access to health care such as social protection, without and services. Decentralization of the health sector in which the goals of PHC cannot be completely realized. many African countries, however, is often only partial. A strong civil society is critical to PHC, as community organizations are vital stakeholders in defining PHC involves multiple stakeholders including those outside the health sector - working in coordination, and
63
ICMNCH, August 2013
committing to a common set of shared principles. In some countries, inter- ministerial cooperation is not efficiently managed. Many countries still experience supply-chain bottlenecks including inefficient tendering procedures, and weak forecasting mechanisms for essential RMNCH supplies which can result in stockouts. The shortage of medicines and technologies in facilities discourages
people from utilizing the public health system, driving them instead to private providers. The human resources crisis in Africa is one of the biggest challenges to the realization of PHC on the continent. Without a clear strategy on the recruitment, training, retention, and incentivization of health workers especially in rural areas it will be difficult for African countries to achieve PHC goals and objectives.
STRATEGIES AND BEST PRACTICES Implement country-appropriate models promoting universal access to health care, such as social health insurance or micro- insurance schemes (e.g. Chad, Ghana, South Africa, Rwanda). Implement targeted, evidence-based, cost-effective essential interventions, commodities, and guidelines for RMNCH. These should span the continuum of care from adolescence and pre- pregnancy through infancy and childhood. They should cover community-level health promotion, services, and referral systems, as well as primary-level facilities and referral systems (e.g. Niger) Provide education subsidies for RMNCH trainees tied to enforceable agreements to serve in remote areas. Recruit students from rural communities and locate RMNCH training facilities nearby. Use incentives (e.g. hardship allowance, free housing, paid leave) to attract health workers with expertise to hardship posts. Create professional development opportunities and supportive supervision (e.g. Tanzania, Uganda). CASE STUDY: ETHIOPIA Ethiopia is fast registering impressive successes in extending affordable primary health-care services across the country. Through the Health Extension Programme (HEP), the government has worked to fill gaps in access to care throughout its extensive and often hard to reach rural communities by recruiting and training women as paid frontline health workers. These women, recruited from the local communities in which they will work, complete a 1-year training course, which includes fieldwork, before taking up their posts. They train families in hygiene and other public health practices, deliver a defined package of basic services, and serve as role models for girlsa vital service in a country where under-age marriage is still common. Nurses in the program provide additional and complementary services at local clinics. The HEP sought to deploy two salaried health extension workers at each village health post aiming at training 30,000 Health Extension Workers. Since its introduction, the HEP has surpassed its HEW target and has contributed significantly to the improvement of health outcomes. The HEP has yielded an increase in the proportion of women who have utilized family planning, antenatal care, and HIV testing. Coverage of publicly-funded health care has risen from 61% in 2003 to 87% in 2007, whereas total coverage including services provided by private health facilitieshas grown from 70% to 98% over the same period. Align national budgets, strategies, and partnership support to PHC goals. Prioritize a horizontal, integrated, health systems approach. Committing to provision of services and promotion of health as close to the household as possible is a primary mission of many national health strategies (e.g. Democratic Republic of Congo, South Africa). Restructure health governance to create closer ties to communities and greater engagement of civil society. Make national health data open access and disseminate it sub- nationally. Prioritize evidence-based decisionmaking, performance-based financing, participatory research methods, and priority setting. Social audits, scorecards and equity gauges help ensure the health sector is closely accountable to the community (e.g. Ethiopia, Rwanda, South Africa, Zimbabwe). Leverage non-health sector actors for equity gains in RMNCH. Provide platforms for multi-sectoral coordination, legislation, regulation, and planning and priority-setting processes (e.g. Sierra Leone).
64
ICMNCH, August 2013
KEY OPPORTUNITIES The Joint Learning Network for Universal Health Coverage is a platform for countries to exchange experiences and information about the implementation of health financing reforms. www.jointlearningnetwork.org There is now a clear set of globally-recognized essential interventions, commodities, guidelines, and training manuals for RMNCH that have been proven to achieve significant and rapid progress in RMNCH outcomes. http://www.who.int/pmnch/topics/part_publications/ essential_ interventions_18_01_2012.pdf CapacityPlus is developing tools to help governments cost out and plan for health worker training and retention schemes. iHRIS Retain is a software tool to cost retention strategies at different levels to determine the feasibility of interventions and budget for implementation. A rapid retention survey toolkit helps countries assess health worker satisfaction. Opportunities exist to ensure new tools are closely tied to RMNCH health human resources needs. http://retain.ihris.org/retain/ Between 2008-2013, the World Health Organization has provided a framework and toolkit for the monitoring and analysis of health systems strengthening, as well as a health systems digital library serving as a repository for evidence, tools, and guidelines on health systems strengthening. http://www.who.int/healthinfo/systems/ monitoring/en/index.html
REFERENCES
1. Amouzou A et al. 2012. Reduction in child mortality in Niger: a Countdown to 2015 country case study. Lancet. 380: 1169-1178. 2. ESCA. 2011. Documenting Best Practices for Retention of Health Workers: Report of a Survey and Case Studies from Rwanda Tanzania and Uganda. Arusha: ESCA-HC. 3. Lawn J et al. 2008. Alma-Ata 30 Years On: Revolutionary, Relevant, and Time to Revitalise. Lancet 372: 917-27. 4. PMNCH. 2011. A Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health. Geneva: PMNCH. 5. WHO. 2008. Primary Health Care: Now More than Ever. World Health Report 2008. Geneva: WHO. 6. UNDP.2013 Human Development Report 2013 - The Rise of the South: Human Progress in a Diverse World. New York. UNDP 7. Araya Medhanyie, Mark Spigt, Yohannes Kifle, Nikki Schaay, David Sanders, Roman Blanco, Dinant GeertJan and Yemane Berhane. The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study. BMC Health Services Research 2012, 12:352. 8. Wairagala Wakabi. Extension workers drive Ethiopias primary health care. The Lancet, Volume 372, Issue 9642, Page 880, 13 September 2008.
65
66
International Conference on Population and Development Beyond 2014
67
ICPD Beyond 2014
AFRICAS CHILDREN AND THE DEVELOPMENT AGENDA POST-2015 Childhood is a crucial phase in the life cycle of human beings, and the quality of life at this stage is crucial for survival and productivity in adulthood and old age. In Africa, socially and culturally, children are highly valued in society and important in the family where they usually grow. Yet the welfare and survival of children in Africa are highly compromised by complex issues of demography, malnutrition and stunting, food insecurity, low delivery and poor quality of social services, particularly health and education, and low income and high poverty. These issues need to be adequately addressed through national development policies and strategies, and priorities included in the post- 2015 development agenda. Determinants of the development and welfare of children Unlike the other stages of the human life cycle, development and welfare at childhood is usually determined by complex factors. At this stage the child is usually physically dependent on the parents and their social and economic status, as well as on the state and its capacity to provide quality resources and services in terms of employment, income, education, health, among others. The family and the state are therefore both crucial in playing important roles in the upbringing of children, and these roles are needed in the future development prospects of societies and countries. Any nation or country which aspires to develop and sustain progress in the future must invest in the development and welfare of its children and their mothers. Evidence from around the world shows that lack of resources and investment in children and women will result in multiple costs and negative impacts that are detrimental to development in the short and long term. Investment in child welfare and development must therefore be given priority in national development policies and strategies and in the post-2015 development agenda. This general statement can be supported by briefly studying some of the most important determinants of the development and welfare of children and their mothers in Africa. What are the critical issues and priorities for children in Africa that need to be reflected in the post-2015 development agenda? The Millennium Development Goals (MDGs) have proven to be a powerful framework for maintaining political support for development. They have had a positive impact on childrens welfare and contributed to reduction in income poverty and child mortality, and increased primary school enrolment, particularly for girls. As the year 2015 draws closer, the question on the minds of most development practitioners is: What next? How can the Post-2015 Development Agenda meet the needs and secure the rights of Africas children? Despite significant progress made in the past decade in many African countries, children, particularly those living in rural areas, still face an extremely high risk of material, social and economic deprivation. Although the continent achieved impressive economic growth during this period, very little of it reached children below the age of 18. This proves that although growth is a necessary condition for development, the poor socioeconomic status of the majority of Africas children is not about economic growth it is about how that growth is shared out and the choices we as Africans make in terms of development goals and policies. Much still needs to be done beyond 2015 to sustain the gains that have been made to date and to ensure more equitable levels of development across countries and population. As we approach the MDG target year, there is a need to recognize that achieving the goals is not a one-off event, but a dynamic process, subject to shocks and reversals. While achieving development goals is a critical step, consolidating and sustaining the hard-won progress on the MDGs may turn out to be an even more daunting challenge. There are a number of reasons for ensuring that children are at the centre of the post-2015 development agenda.
68
ICPD Beyond 2014
ICPD Beyond 2013
Demography Demographically children below the age of 18 in Africa constitute about 46 per cent of the total population in 2013 compared to an average of 50.3 per cent in the 1960s when most African countries gained independence. However, the number of children increased numerically from about 141 million in 1960 to 506 million in 2013. Future projections show that this number is likely to increase to 614 million in 2025 and 794 million in 2050, which is about three times the total population of the continent in 1960. Rapid increase in the number of children below 18 is primarily due to high fertility. There were about 7 children per woman in 1960. Fertility remained at a high level of more than 5 children per woman till 2000, and declined slightly to 4.3 children per woman in 2013. High fertility implies a young age structure and a high growth momentum, both of which explain the high increase in the number of children even with the expectation of fertility declining to 2.8 children by 2050. The main challenge of the continuing rapid increase in the number of children in Africa, is meeting their high demand for food, nutrients, medicines, education, among others. The above-mentioned numbers reflect the need for continuous and sustained efforts to register children at birth, report their causes of death, and to scale up immunization coverage. There is also a need to invest in the management of the demographic behaviour of people in such a way as to improve maternal and child health. Child poverty Childhood poverty is a persistent and enormous burden on Africas social and economic transformation, incurring huge costs for society. It remains the single biggest obstacle to meeting the needs, as well as protecting and promoting the rights of children. It also has a profound impact on their families, and on the rest of society. Poverty in early childhood affects physical, cognitive and social development and sets children on a lifelong trajectory of a low level of education and participation in economic activity, and poor physical and mental health. There is a strong correlation between poverty and child labour, which is still high in the region. Although by law child labour is prohibited, children contribute to production for and survival of their families. Laws are
often not implemented due to capacity and cultural constraints. Tackling child poverty can break long-term spells of poverty and enhance the intergenerational transmission of social and economic opportunities. Eradication of poverty and reduction of disparities must therefore be key objectives of development efforts. Health and survival Health and survival are important components of the development and welfare of children and their mothers. They are directly influenced by high fertility. The slow pace of decline in fertility in Africa is due to cultural reasons, low level of education of women and low use of modern contraceptive methods. The fertility situation in Africa makes it difficult for rapid progress to be made on the health MDGs, particularly in the areas of infant, child and maternal health. Available information indicates that fertility goes hand in hand with infant, child and maternal health. When fertility is high infant and child mortality are also high. High fertility is associated with higher pregnancy rates and the desire for a higher number of children. Evidence from Africa shows overwhelming support in favour of associating the health of the child with that of the mother. For the continent as a whole, an average of 6 or more children per woman is associated with infant and under-five mortality rates of above 105 and 170, respectively, per 1,000 live births. A drop in fertility to 4 children per woman will bring down infant and underfive mortality rates to about 63 and 97, respectively. Maternal and child health improved significantly in countries that have implemented deliberate policy interventions to reduce fertility and increase education of women. When such policy interventions were implemented in Tunisia, for example, they brought down the average number of children per woman from about 6 children in 1974 to 2.1 children in 2000. Infant and under-five mortality which were 109 and 137, respectively, per 1,000 live births in 1974, declined to 25 and 31, respectively in 2000. This evidence largely explains the impressive progress Tunisia has made in achieving the health MDGs. The same goes for a few other countries such as Algeria and Mauritius. The lessons to be learned from this evidence are that health targets are highly linked to demographic and epi-
69
Photo: UN Photo/Stuart Price
demiological transitions, and that policy interventions usually have multiple positive impacts on child and maternal health. Such linkages therefore need to be taken on board in the post-2015 development agenda. Malnutrition and stunting The nutritional status of women during pregnancy and of infants are important determinants of child development and welfare. Healthy life starts during the critical period of pregnancy through the first two years of life. Countries that are reaching mothers and infants with effective nutrition and health interventions are achieving results. Those that fail to provide adequate food and nutrients are likely to face a high prevalence of malnutrition and stunting. Research undertaken by UNICEF 1 on improving child nutrition estimated that there were about 165 million stunted children in 2011. These are children below the WHO Child Growth Standards. In Africa these children are estimated at around 54 million or 33 per cent of stunted children in the world. In Nigeria the number of stunted children is about 11 million and stunting prevalence is 41 per cent. In Ethiopia stunted children are estimated at about 5.3 million and the prevalence rate is 44 per cent. Other countries that rank next in terms of the number of stunted children are DRC (5.2 million), Tanzania (3.5 million), Egypt (2.6 million), Kenya (2.4
million), Uganda (2.2 million) and the Sudan (1.7 million). The World Economic Forum in 2013 highlighted food and nutrition security as a global priority. The World Health Assembly set the goal of achieving a 40 per cent reduction in the number of stunted children by 2025. This goal is achievable provided that countries implement the right policy interventions to address malnutrition and stunting. These interventions include improving womens nutritional status before, during and after pregnancy, breastfeeding and high quality and adequate food and nutrition for infants. Maternal nutrition will prevent low birth weight and ensure continued breastfeeding. Education Existing educational services are far below demand. Drop out from schools is highest in Africa, estimated by UNESCO at around 10 million children per year. Poverty and low family income are among the main reasons for low child welfare and drop out from schools in Africa. Poor children in many African countries are less likely to be enrolled in, or be able to regularly attend school. Children who must respond to the demands of family are particularly likely to leave school for the immediate rewards of jobs.
70
ICPD Beyond 2014
The centrality of education has featured in the ongoing discourse of the post-2015 development agenda globally and on the continent. It is argued that its catalytic role will provide a holistic approach in ensuring inclusive social and economic development, environmental sustainability as well as peace and security - all key components of the post- 2015 development agenda. Equity Reducing various forms of inequality such as those relating to income, geographical space and gender, constitutes a major challenge to achieving development goals in the region. While aggregated measures provide guidance on progress at the national level, this should not mask the importance of addressing the needs of the poorest and most vulnerable. In most African countries, there are more children from the poor households than from rich ones. Gender inequalities also remain deeply entrenched, posing serious hindrances to achieving development goals. Although considerable progress has been made in primary education for girls, increasing gender disparities at middle and higher levels seem poised to reverse the gains achieved. Females also continue to suffer unequal treatment when it comes to health, employment and participation in decision-making. An African Common Position on the Post- 2015 Development Agenda The success of the post-2015 development agenda greatly depends on how effectively it can reflect critical issues affecting children, such as those highlighted above. Ongoing consultations on the development of an African Common Position have revealed a strong commitment to ensuring that the agenda accounts for the needs and rights of children. Mandated by the African Union Heads of State, the United Nations Economic Commission for Africa (UNECA), the African Union Commission (AUC), the African Development Bank (AfDB) and the United Nations Development Programme Regional Bureau for Africa (UNDP/RBA) are undertaking a series of consultations to develop an African common position on the post2015 development agenda. This has included national, regional and continental consultations, and an electronic survey. Participation has been drawn from a wide range of actors including policymakers, civil society organizations (CSOs), womens organizations, parliamen-
tarians, academia, and youth groups from 53 African countries. The agreements from consultations, on what must be included in the post-2015 development agenda, can be summed up as follows: 1. Emphasize inclusive economic growth and structural transformation 2. Reorient the development paradigm away from externally-driven initiatives towards domestically-inspired and funded initiatives that are grounded in national ownership 3. Prioritize equity and social inclusion and measure progress in terms of both the availability and quality of service delivery 4. Pay greater attention to vulnerable groups such as women, children, youth, the elderly, people with disabilities, and displaced persons 5. Take into account the initial conditions of nation states and recognize the efforts countries have made towards achieving the goals as opposed to exclusively measuring how far they fall short of global targets 6. Incorporate the Rio+20 outcomes and the outcomes of Africa-wide initiatives, national and regional consultations as well as United Nations forums such as ICPD +20 7. Focus on development enablers as well as development outcomes. Four development outcomes were identified as priorities for the post-2015 development agenda: Structural economic transformation and inclusive growth; Innovation and technology transfer; Human development and; Financing and partnerships. On the human development priority the indicators identified by stakeholders were: eradication of poverty with special emphasis on vulnerable groups including children; education and capacity-building; universal and equitable access to quality health with special focus on vulnerable groups including children; gender equality and women empowerment; population and youth dynamics. These are to realize Africas demographic dividend with a specific focus on eliminating child mortality.
71
ICPD Beyond 2014
The consultations have underscored that achieving the development outcomes will require an enabling environment at national, regional and global levels. The following development enablers have been identified as prerequisites for the post-2015 development agenda: peace and security; good governance; strengthened institutional capacity; promoting equality and access to justice and information; human rights and gender equality. The success of the post-2015 agenda will also hinge on how effectively it tackles the data constraints faced by many African countries. Due attention must be paid to the availability and use of viable data to ensure effective monitoring of agreed indicators. The post- 2015 development framework must be grounded in robust data and evidence that assess the status of children and adequately reflect their needs, interests, and voices. Drawing on lessons from the MDGs in which a number of indicators were simply not monitored due to data limitations and weak institutional capacity for data gathering and analysis one of the significant contri-
butions of ECA to the post-2015 agenda will be generating data. ECA is realigning itself and has adopted a new strategic direction to respond to data challenges on the continent. It will undertake rigorous research, data collection and analysis to broaden the evidence base on critical development issues including those relating to children. It will also continue to support initiatives to strengthen national capacities for collecting and analysing viable data. Conclusion An outcome document that forms the basis of an African Common Position was endorsed by the Sixth Conference of African Finance, Planning and Economic Ministers in Abidjan in March 2013. The unified African position on the post-2015 development agenda has been considered and adopted at the Twenty- First Ordinary Session of the Assembly of Heads of State and Government of the African Union. It will inform the discussion of the Sixty-Eighth United Nations General Assembly in September. Let us continue to work together to ensure that Africas unified position thoroughly reflects commitments on children.
72
ICPD Beyond 2014
INTERNATIONAL MIGRATION AND DEVELOPMENT International migration is emerging as a mega trend in Africa and its resource potentials need to be harnessed to support development transformation on the continent. International migration has the potential of bringing significant contribution to the economic growth and social and human development in Africa. To achieve this, it should be tackled in a holistic manner and mainstreamed appropriately in development planning and strategies. Migration dynamics in Africa are complex and multifold. It highlights the fact that the continent is home to millions of refugees and persons in need of humanitarian assistance; and that a high percentage of migrants are women who may be in need of protection against Sexual and Gender-based Violence, and also in need of maternal health services including family planning. Furthermore, migration in Africa is characterized by the irregular flow of people during which migrants could be involved in smuggling or become victims of trafficking. The separation of families, which is a result of migration, is detrimental to the social fabric of society, as well as to the care systems, leading to vulnerability to human trafficking and exploitation. Contrary to common belief, there are more Africans who move within their own region than those who travel long distances to other parts of the world. Yet, African countries are not open to each other, and make travel within Africa difficult. Visa requirements for travelling to other African countries are stringent for Africans and more relaxed for non-Africans. Migration plays a vital role in regional integration and cooperation, policy dialogue and partnership with all stakeholders, namely countries of destination and development partners; the private sector, including diaspora entrepreneurs and investors; civil society, including migrants and diasporas. The multiplicity of stakeholders calls for coherence and coordination of policies and actions on migration and development in Africa. In recognition of this fact, African countries, under the auspices of the African Union have adopted a number of migration policies. These include the Migration Policy Framework for Africa, the African Common Position on Migration and Development and the Ouagadougou Action Plan to combat Trafficking in Persons, especially women and children. Mainstreaming migration in development Mainstreaming migration in development plans and strategies is a new concept that has recently gained interest and concern following the High-Level Dialogue in September 2006. It has been often discussed at the Global Forum on Migration and Development summits and Global Migration Group (GMG) meetings at the principal and working levels. According to the GMG1 mainstreaming migration in development plans and strategies is defined as the process of integrating the opportunities and challenges of migration at all stages of development planning. Mainstreaming has a number of advantages the most important of which are to: 1. Provide information for making right decisions on policy interventions that are most likely to maximize the benefits and outcomes of migration for development; 2. Promote the appropriate understanding of the migration challenges and adopt the right approach for addressing them; 3. Foster a coherent and comprehensive approach rather than piecemeal and uncoordinated actions; 4. Support better and coordinate management of migration, and of its resource potentials for development; 5. Identify information, data, and policy and research gaps and adopt theappropriate measures to address them. The current status of mainstreaming migration in Africa Despite its potential advantages, migration is rarely acknowledged in most development planning tools, and even when links are made they tend to remain at a conceptual rather than practical level. Some poverty reduc-
73
ICPD Beyond 2014
tion strategy papers refer to the benefits of remittances, while others refer to migration in a rather negative light, for example human trafficking, the loss of skilled professionals, health-related problems and the spread of diseases, increased poverty and problems relating to sanitation, and crime. Policy measures linking migration with development tend to focus on law enforcement activities (curbing irregular migration, trafficking and strengthening immigration and customs services) rather than harnessing the benefits such as remittances. Furthermore, when the benefits of migration are recognized, the focus tends to be on remittances and their associated economic effects. Migration has a great potential to improve development outcomes in a wider sense, including the social and cultural dimensions, but has received little attention. Challenges in mainstreaming migration into Africas development There are many reasons why migration has not featured in development plans in a concrete and/or comprehensive manner, to date: 1. Lack of data and indicators on migration is a major constraint in many countries; 2. Lack of capacity, expertise and/or financial resources to understand and address these linkages, especially beyond economic dimensions; 3. Lack of knowledge in particular, of the interlinkages between demographic trends and conditions and other economic and social variables (such as the availability of food and natural resources, health particularly sexual and reproductive health, employment, housing, the status of women, among others); 4. Lack of political will that could play an effective leadership role on Migration and Development beyond rhetoric. Migration is a fragmented portfolio, often falling under the responsibility of various government departments (for example ministries of finance, interior, labour, migration, health, foreign affairs). This makes the issue fall through the cracks or become the subject of rivalry between departments. The converse situation, in which responsibilities for migration are assigned to just one government department, has its own set of problems if migration is dealt with from a one-dimensional perspective. The issue of migration may not feature prominently in
74
donor priorities, making it difficult to mobilize funding. This may particularly be the case for programmes that address both migration and development, and not just migration. Migration is a complex cross-cutting issue which makes it difficult to formulate a coherent and common position. It could be both conceptually and politically challenging, since it brings together stakeholders with markedly different interests. Migration is a politically sensitive issue, often leading to a focus on border management and control rather than development. The multiplicity of development planning tools used by developing countries can complicate matters. Most countries employ several poverty reduction/ development frameworks, with different stakeholders, agendas, time frames and sectoral and geographical scopes. The guidance provided here should assist in dealing with some of these constraints. Some will remain challenging, however, and will require a pragmatic but determined approach. Such an approach will require drawing on the best and widest possible store of information and resources available to integrate migration into development plans, while recognizing that the mainstreaming exercise will never be perfect. Conditions for successful mainstreaming Experience from different countries on the continent indicates that for mainstreaming to be successfully undertaken the following conditions should prevail: 1. Strong political support at a high level. This ensures there is sufficient political will to move the Migration and Development agenda forward; 2. National ownership. The government must be the lead actor in a mainstreaming process, and government priorities must prevail over the priorities of external actors; 3. Early involvement of key stakeholders (such as migrant community groups, diaspora groups, civil society, academics, employers associations and development partners). The aim is to make key stakeholders and partners fully committed to the mainstreaming process. Stakeholders can offer different perspectives, new information and data, political and moral support, and funding, among many other resources. All these actors and resources need to be drawn upon if the mainstreaming exercise is to fulfill its potential;
ICPD Beyond 2014
4. A shared understanding of objectives. This is important to avoid divergent agendas being pursued. A clear vision, transparency and regular dialogue between stakeholders are keys in establishing and maintaining a mutually beneficial agenda. It is also vital when identifying priorities to devise concrete and achievable strategies; 5. Broad-based participation in identifying clear roles and responsibilities. As the process proceeds, it is vital that it is not monopolized by a single government in-
stitution, nor ownership confined to a few individuals. Policy implications Given the observations presented above, it is important to note that policy can play a key role in supporting the positive aspects of migration by favouring the contribution of migrants to development, facilitating the social integration of migrants, protecting their rights and curbing the negative impacts such as racism and xenophobia.
Photo: Kate Holt/IRIN
75
ICPD Beyond 2014
URBANIZATION AND DEVELOPMENT TRANSFORMATION IN AFRICA Urbanization, or the increasing urban share of total population, is one of the most significant population trends in Africa. Urban areas, whether megacities or small and mediumsized towns and cities, concentrate people, economic activity, industry, and indeed poverty. Urban transition is centrally linked to economic growth, particularly as part of the transformation of economies from ruralbased agriculture to urbanbased industries. Urban population growth is increasing rapidly in most African countries, driven both by natural increase (births over deaths) in urban areas and widespread rural to urban migration. The process of urbanization can provide countries with enormous opportunities to achieve sustainable development, including economic growth, poverty reduction, and service provision via economies of scale. At the same time, rapid urbanization can bring with it significant challenges depending on government capacity, planning and response, such as slum growth, inadequate provision of services and infrastructure, poor health and quality of life and environmental degradation. It is therefore imperative to study the challenges and potentials of the ongoing urban transformation in Africa, and to discern its consequences so as to inform the policies and actions for sustainable urban development, as well as implications for health, gender and service provision, on the continent. Though Africa is the least urbanized continent, its rate of urbanization is the fastest in the world. Urban inhabitants grew from 33 million persons in 1950 to 414 million in 2011, and are expected to reach 471 million by 2015, and 744 million by the year 2030. The share of urban inhabitants in total population increased from 14.4 per cent in 1950 to 39.6 per cent in 2011 and expected to reach 47.7 per cent by the year 2030. These increases in numbers show high urban growth rates of above 3 per cent per year, which will double urban population in 24 years, that is, in 2025 (UNPD World Urbanization Prospects, 2011 revision). Rapid urbanization implies that the urban settlements will progressively absorb the population growth in Africa. The continent will therefore witness an increase in population concentration in urban areas, as opposed to the wide dispersion pattern that was prevalent in the past. Consequently, it is important for development policy to carefully weigh changes in population distribution and their policy implications for both urban and rural development. There are varying levels of urbanization on the continent. Southern and Northern Africa are the most urbanized subregions on the continent. The urban proportion of the population in Southern Africa, which is one of the hardest hit by the HIV/AIDS pandemic in the world, was 53.7 per cent in 2000. It reached 58.9 per cent in 2011, and expected to reach 60.6 per cent by 2015. Southern Africa is experiencing a decline in its rural population because of the combined impacts of migration to urban areas and mortality caused by HIV/AIDS among other factors. The urban proportion in Northern Africa was 48.4 per cent in 2000, and went up to 51.5 per cent by 2011. It is projected that in 2015, the urban inhabitants of Northern Africa will constitute 52.6 per cent of its total population. Western Africa reports the highest annual urban incremental change, with growth rates near 4 per cent. In 2011, the region had 140 million urban inhabitants corresponding to 44.9 per cent of the population. Western Africa is expected to witness a convergence of the number of the urban and rural inhabitants at about 195 million persons per each group by the year 2020, with continued rapid urbanization (though slowing down) thereafter. Central and Eastern Africa are the least urbanized subregions on the continent. The share of the urban areas in the total population in 2011 reached 23.7 per cent in Eastern Africa and 41.5 per cent in Central Africa, up from 5.5 per cent for the former and 14.0 per cent for the
76
ICPD Beyond 2014
latter in 1950. By the year 2025 these shares will reach 51 per cent for 48.6 Central Africa and 29.7 per cent for Eastern Africa. Somehow, though it has the lowest rate of urbanization, Eastern Africa has the highest urban growth rate on the continent. The rapid pace of urbanization and the subregional variations in Africa are reflected in changes in the growth and size of urban settlements, and their progression on the scale of urban hierarchy. The bulk of the urban population in Africa lives in small urban settlements with populations under 500 thousand. However, the share of these settlements in the total urban population on the continent is declining, from 73.1 per cent in 1970 to 56.8 per cent in 2010, reducing further to an expected 47.1 per cent in 2025. Given the enormous overall growth in urban population, these declining percentages are accompanied by a significant increase in total population of smaller urban settlements. The declining proportional trend varies across the subregions. Rapid urbanization is accompanied by the emergence and rapid progression of cities with over one million inhabitants in Africa. Cities from one to five million in size increased from only 2 in 1950, to 7 in 1970, 34 in 2000, 47 in 2010, and expected to reach 81 cities by 2025. There was only one city of over five million (Cairo) in 1970, but this increased to 2 (Cairo and Lagos) in 2000 and to 3 (Cairo, Lagos and Kinshasa) in 2010. By 2015, there will be 5 cities such in Africa (Cairo, Lagos, Kinshasa, Khartoum and Mogadishu). Unlike the small urban settlements, the share of cities with over one million in total urban population increased from 17.8 per cent in 1970 to 33.5 per cent in 2010, and projected to reach 43.5 per cent by 2025. This increase in share is more pronounced in cities with populations between one and five million than in those with over five million, and also in subSaharan Africa more than in Northern Africa. The progression of human settlements from small urban centers to agglomerations and further to megacities is very fast, mainly because of rapid urbanization. This is seen in the progression of cities like Lagos, which grew from a small urban center with a population of about 325 thousand in 1950. It became an agglomeration with about 1.4 million inhabitants in 1970, 2.6 million inhab-
itants in 1980 and 4.8 million inhabitants in 1990. Lagos became a megacity with a population of 6.0 million persons in 1995, 7.3 million in 2000, 10.8 million in 2010, and is expected to reach nearly 19 million in 2025. By that year, Lagos would have exceeded Cairo by over 4 million inhabitants and become the 11th largest city in the world, up from the 28th position in 2000. The progression of an urban settlement on the urban hierarchy varies according to subregion, and Northern Africa has many more than subSaharan Africa. Rapid urbanization entails high levels of urban poverty. Most studies reveal that between 15 and 65 per cent of African city dwellers are living in poverty, very often in informal settlements with limited access to infrastructure, poor health and environmental conditions and little social or urban services. While cities continue to attract significant numbers of rural to urban migrants, primarily for economic opportunities, indicators for the urban poor in Africa are often the same or potentially worse than their rural counterparts. Significant inequalities have emerged in urban areas, with pockets of people who are quite wealthy and have strong connections to global production and consumption, while at the same time, inadequate infrastructure and high crime rates threaten poorer parts of cities. Wellinformed and statistically sound policies are needed to meet the demands of the growing numbers of urban poor, particularly to secure for them the benefits of urban living. Urban poverty in Africa must be tackled with sound urban development and management policies. Better governance, especially local governance (where capacity and resources are most often lacking), is key to dealing with urban poverty and related economic, health and social needs, as well as secure and environmentally safe shelter. Shifting authority from central governments to municipalities or local authorities could help to involve the urban poor in programmes that concern them, and make policies, plans and actions more responsive to their needs, such as housing. Donors and international agencies can focus more on strengthening the institutional capabilities needed to meet the challenges of rapid urban growth. Urban planning could also do more to address interrelated issues such as land use, slum upgrading, housing, improved water supply, electricity distribution, sanitation, waste management, and more efficient transportation.
77
ICPD Beyond 2014
Photo: UNHCR / F. Noy
78
ICPD Beyond 2014
BOOSTING YOUTH EDUCATION AND EMPOWERMENT TO REAP THE DEMOGRAPHIC DIVIDEND IN SUB-SAHARAN AFRICA: THE CASE OF WEST AND CENTRAL AFRICA Countries across Sub-Saharan Africa are confronted to the challenge of securing development and inclusive growth while dealing with an underlying fragile situation. In West and Central Africa, this situation is further compounded by two concurrent crises: (i) a baby boom of unprecedented proportions due to a delayed demographic transition resulting in 50 to 60% of its population below the age of 19 and child dependency ratios above 80 per 100 of the working age population; by comparison, at the end of their demographic transition, countries in South- East Asia had young dependency ratios below 40; and (ii) an education crisis due to education systems suffering from severe internal inefficiencies, resulting in 24% of school-age children never attending school, 55% only able to complete primary education, 24% completing lower secondary schooling, and a mere 14% attending upper secondary or higher education levels. There are large variations in trends and patterns of fertility, natural population increases and migration across Eastern, Southern, Central and Western Africa.1 This study focuses on five countries - Nigeria and the Democratic Republic of Congo, two of the most populous countries in sub-Saharan Africa, and Niger, Mali and Chad, three Sahelian countries which have the highest fertility and population growth rates in the world and seeks to contribute to the ICPD Plan of Action, in particular, the objectives related to adolescents and youths.2 Diagnostic A delayed demographic transition: Historically, sub-Saharan Africa is the last region in the world to embark on the so-called demographic transition with most countries still in the second phase of the transition, which is characterised by declining child mortality but persistently high fertility rates. As a result, countries are still characterised by extremely young age structures and high dependency ratios. The demographic bonus is still to materialize: High population growth rates and young age structures offer both challenges and opportunities. Rapidly growing populations strain countries capacities to provide quality social services. More teachers, classrooms, boreholes and health services are needed every year only to maintain the current coverage of basic social services. On the other hand, countries also stand at a turning point where they can convert their youthful age structure into a demographic bonus, which stems from increasing the number of the working age population relative to the number of dependents. Crucial for this demographic bonus to materialise is the speed at which the decline in the dependency ratio takes place. Demographic analyses indicate that the demographic window is still closed for Mali, Niger, and Chad, Nigeria, and DRC. This is because they have experienced either slow and irregular (fertility) transition (Nigeria) or very slow and incipient transition (Niger, DRC, Mali, Chad). A particularly challenging socio-economic and cultural environment: Since independence, Niger, Chad, Mali, Nigeria and DRC have experienced erratic economic growth rates which were in most cases too low to offset each countrys high population growth rate and other shocks to their economies. As a result, by 2010, GDP per capita (in constant 2000 US$) had severely declined to 32% and 57% of the 1960 level in DRC and Niger respectively, was barely above the level attained in 1960 in Chad, and was less than twice higher than in 1960 in Mali and Nigeria. Extreme poverty remains widespread with a half to two-thirds of the population living with less than US$1.25 a day and more than three-quarters living with less than US$2 a day. Chronic and acute malnu-
79
ICPD Beyond 2014
trition rates reach emergency thresholds year after year, notably in Sahelian countries. A large proportion of the children under the age of five are stunted, with stunting crossing critical levels. Severe inefficiencies and inequities affecting the education system exclude the majority of children from basic secondary education: In the past 20 years, West and Central African countries have achieved a remarkable increase in school enrolment. Average gross enrolment rates in the region increased from 77% in 2000 to 106% in 2012.3 The number of children enrolled in school increased by 60% from 37.8 million children in 1999 to 60.2 million in 2010. Key policies enabling such progress include making primary education compulsory in law and abolishing school fees. Major efforts in the supply of education were also undertaken. Communities were also mobilised to participate in school management. However, overall, countries are still struggling to provide quality education to a rapidly increasing number of children while having to improve the efficiency of their education systems. UNICEFs out-of-school studies show that on average across the region, 38% of schoolage children remain out of school (29% in DRC, 38% in Nigeria). Only 45% of a cohort has access to lower secondary school and 30% complete it. Retention rates are extremely poor with only a third of children completing the full primary cycle. Transition rates between primary and secondary school are extremely low with only 21% of children attending lower secondary school and a mere 8% completing lower secondary school.4 When children drop of schools, they may be offered alternative / non-formal education opportunities, which to date remain small-scale and scattered. Structural issues affecting education systems: Formal education systems are confronted to an array of structural issues. In summary, key factors affecting school attendance, and girls in particular, include: costs unaffordable to parents, distance to school, insecurity and violence in school, and social norms requiring that girls be married and have children early. Additional factors affecting school drop-out include poor school performances linked to cognitive deficits associated with stunting (due to lack of adequate nutrition during early childhood, notably between the ages of 0-3) and energy deficits during schooling time (due to lack of
adequate nutrition for schoolage children from impoverished families). These factors are further compounded by the lack of responsive parenting and stimulation during early childhood (especially before the age of 3). Proposed Strategies Two groups of adolescents are critical for the demographic dividend to materialise (i) The large number of adolescent girls and boys who are out-of school. Among them, particularly vulnerable teenagers include girls who are already mothers or at high risks of early pregnancy (ii) Adolescent girls and boys in primary and secondary school who are at high risks of dropping out. Among them, girls are confronted to high risks of child marriage and teenage pregnancy. Redefining the quality and relevance of education To keep children in school and ensure that education contributes towards the demographic dividend, we define quality and relevant education as follows: (i) The education system is mindful of the needs of communities and adaptive to their constraints. (ii) The school environment is responsive to adolescents needs by being learner-centered, rights-based and non-discriminatory, gender-sensitive, safe and protective, health promoting, academically effective, and by promoting mutual respect and equal opportunities for girls and boys. (iii) Education endows children not only with literacy and numeracy skills but also with life skills and competencies that enhance capabilities to fulfill their human potential and increase their employability. Designing education policies catered to the needs of adolescents in order to accelerate the demographic transition and trigger a virtuous cycle of human development and inclusive economic growth What policies can trigger the initial fall in fertility that would advance the demographic transition so countries can benefit from the demographic bonus and turn it into a dividend? Key factors driving fertility decline are child mortality, womens education, and female participation in the labour force and wages impacting the opportunity costs of motherhood. At the heart of population and growth dynamics are adolescent girls and boys, who rep-
80
ICPD Beyond 2014
resent an ever large proportion of the population. Our model highlights the multiple pathways through which providing equal education and learning opportunities for girls and boys contributes to accelerate the demographic transition while helping countries move towards a model of development based on inclusive and sustainable economic growth. The model is built around two major building blocks. The first block calls for renewed efforts to invest in an effective and inclusive education system so it can generate social returns. The second block is built on the recognition that concentrating efforts on the education sector alone will not be sufficient. An enabling environment for the empowerment of adolescent girls and boys needs to be established. It is particularly important that education policies create linkages between curricula taught in schools and current (and future) demands of the labour markets. In addition, girls and boys need to be equipped with skills and life competencies that improve their employability and productivity. For the demographic bonus to be translated into an economic dividend, all these reforms need to be associated with inclusive economic and labor market policies that stimulate labour- intensive and income-generating sectors. Finally, for this strategy to be truly inclusive of adolescents excluded from the current system, inter-sectoral linkages across key social sectors need to be made in order to address the special needs of adolescents and their families (e.g. health, nutrition, child protection, social protection, water and sanitation, early child development). Synergies with the existing momentum to accel-
erate child survival and reduce stunting under the aegis of A Promised Renewed in sub-Saharan Africa should be built upon to maximize the impact of the programme we propose below. Six types of reforms are necessary to ensure that all adolescent girls and boys receive quality and relevant education and are empowered to participate in the economic development and social cohesion of their country. 1. Structural reforms for an effective, inclusive and transformational education system. 2. Specific gender equality measures at both primary and secondary levels are necessary to ensure that girls complete the full cycle of basic education where social and economic returns to education are highest. 3. Bring to scale alternative education and youth empowerment programmes targeted at out-of-school girls and boys. 4. Empowering families (mothers and fathers), gate-keepers of prevailing social norms and local decision- makers to own and support equal opportunities for girls and boys to complete at least basic education and improve their health and livelihoods. 5. An integrated multi-sector package of interventions will be necessary to reach the adolescents currently excluded from education and employment opportunities. 6. Breaking the inter-generational cycle of education deprivation through early childhood interventions for teenage mothers and their children.
81
ICPD Beyond 2014
REDUCING MATERNAL MORTALITY IN AFRICA: ADDRESSING THE UNMET NEED FOR FAMILY PLANNING AND POST-ABORTION CARE Since the International Conference on Population and Development (ICPD) held in Cairo in September 1994, improving maternal health has been high on the continental agenda. The importance of the issue was further acknowledged during the millennium summit and included as the fifth of the eight Millennium Development Goals. Despite this strong international will and efforts by governments to improve the status of women and thus contribute to the reduction of maternal mortality, in most African countries it remains high, even though it has declined by 40 per cent in the region in the last two decades. The major causes of maternal mortality are known, and there is ample evidence of the linkage between family planning, unsafe abortion and maternal mortality and morbidity. All over the continent, millions of people, both adults and adolescents, are unable to control their fertility and sexuality, and enjoy their sexual and reproductive health and rights, because they face legal, social and economic barriers to access contraception, maternity care, abortion services, care for STIs and HIV prevention. Governments and other stakeholders have a unique opportunity in the ICPD Beyond 2014 review and the Post-2015 Development Agenda to continue addressing the issue of universal access to comprehensive sexual and reproductive health services, by putting at the centre, the health of young people and adolescents; gender equality and equity; empowerment and autonomy of women, couples and young people to make informed choices and health care decisions, which constitute the core foundations of human development. Family planning has direct and indirect effects on maternal mortality Addressing the unmet need for family planning is one of the few tangible and feasible policy and programme instruments that can prevent maternal mortality. Family planning is one of the four pillars of the safe motherhood initiative. Satisfying the unmet need for contraception contributes to nearly 33 per cent reduction in maternal mortality, thus averting at least 59,000 maternal deaths annually in sub-Saharan Africa and 750 maternal deaths in North Africai. Despite this recognized and strong role of family planning in reducing maternal death and improving womens sexual and reproductive health, in most African countries the national family planning programmes have not fully succeeded in putting in place efficient and accessible service delivery to meet the growing demand for family planning in order to reduce current levels of fertility. With an average of 500 deaths per 100,000 live births, the level of maternal mortality in sub-Saharan Africa is higher than anywhere else as per the UNFPA State of the World Population Report of 2012. The figures are 160 for Asia Pacific and 81 for Eastern Europe and the Caribbean. Failing to satisfy the unmet need for family planning is partly the cause of this situation. It affects the health and well-being of individuals, families and communities. The unmet need for family planning could increase maternal and infant mortality and morbidity, especially if births cannot be sufficiently spaced out (Ashford, 2003; Mackenzie Drahota and others, 2010), and cause an increase in unsafe abortions. The results of the most recent surveys, including those provided by Demographic and Health Surveys (DHS), confirm this relationship in many African countries. Out of the 44 countries for which data are less than ten years, 16 have a higher level of maternal mortality, at 500 deaths per 100,000 live births, and this ratio is less than 100 for only two countries (Cape Verde and Sao Tome). In a sample of 44 countries, the level of maternal mortality is correlated with the total contraceptive
82
ICPD Beyond 2014
prevalence. In addition to this is the fact that in some countries, the evolution of maternal mortality is not linked to contraception but dependent on other factors. This is the case in countries such as South Africa, Kenya, Malawi, Namibia, Tanzania, Rwanda, Swaziland and Zambia, located mainly in Southern and Eastern Africa, where the level of maternal mortality is greater than 100 deaths per 100,000 live births, even though female use of contraception is more than 30 per cent. Progress and setbacks in response to unmet needs Increasing the number of women who have access to modern contraception Over the last twenty years, the use of modern contraceptive methods has increased significantly among women in almost all regions of the world. In many developing countries however, access to family planning services is still limited. Available data show modern contraceptive use in Africa increased by 0.3 points annually over the period 2000- 2009ii. Consequently, there are still many sexually active women who want to avoid pregnancies but are not using contraception due to cultural constraints or disapproval of the community, costs of modern contraceptive methods, long distances to access family planning services, lack of access to information and the frequent shortages that providers face (Countdown, 2015, 2012; Sedgh, Hussain and others, 2007). In sub- Saharan Africa in particular, nearly 22 per cent of women used a modern contraceptive method in 2009, as against 67 per cent in Asia Pacific and 73 per cent in Latin America and the Caribbean (UNFPA, 2012). Increased government support to family planning African countries overwhelmingly support family planning. In 2010, all African countries provided support to family planning except for one. With the exception of two countries that provided indirect support and another that provided no support, all the governments in the region provided direct support to family planning. Region has a high level of unmet needs for contraceptives, thus compromising the reproductive health and right of millions of women Despite the undeniable progress made since 2000, studies confirm the existence of an even higher number of unmet needs in family planning among African women, regarding both the spacing out and limiting of the number of pregnancies that result in high levels of fertil-
ity (five children per woman on average across the continent). Over the years, the proportion of women able to decide they no longer want more children while they are still capable of reproducing is increasing in every country and every household wealth index quintile. Similarly, the disparities between countries in the same region have increased. Figure 1 below shows the levels of contraceptive use and the proportion of women with unmet needs in the five regions of Africa. Across the continent, there are women (at least one in four women aged 15 to 49 years) who wish to postpone their next pregnancy for at least two years, or stop childbearing, but do not use any family planning method. The level of unmet need for planning is highest in East Africa at 28 per cent of women. However, analysis of the survey data reveals that more than half (58 per cent) of women in Southern Africa use modern contraceptive methods and together with North Africa have the lowest levels of unmet needs on the continent. Political instability, civil and humanitarian crises in countries such as Cte dIvoire, Somalia, Democratic Republic of Congo(DRC) and more recently, the war in Mali have reduced the impact of the efforts made over the past decades in family planning, increasing the percentage of women with unmet needs.
Unsafe abortion and post-abortion care A high level of unmet need for family planning is also linked to a high proportion of unintended pregnancies and abortions.
83
ICPD Beyond 2014
According to the World Health Organization (WHO), unsafe abortions and limited access to post-abortion care are among the three causes of maternal death, as about 13 per cent and 14 per cent of maternal deaths worldwide and in Africa respectively, are caused by unsafe abortionsiii. According to WHO estimates the annual number of abortions in Africa increased from 5.5 million in 2003 to 6.2 million in 2008. Africa has the highest proportion of unsafe abortions: 97 per cent of all abortions registered in Africa in 1995- 2008 were unsafe compared to 40 per cent in Asia and 9 per cent in Europeiv. Women who are poor, live in rural areas and are young are particularly vulnerable to unsafe abortions as they are less likely to have the resources to obtain safe procedures. The risk of dying following an unsafe abortion is by far highest in Eastern, Central and Western Africa, where case fatality rates were about 500 deaths per 100,000 unsafe abortions. Given the causal link between unsafe abortion and maternal health, all African countries have set up legal grounds for abortion to save the lives of mothers. When access to safe legal abortion is limited and women and girls have no timely access to contraceptive methods, information on sexual and reproductive health or emergency contraception, they face unwanted pregnancies and resort to unsafe abortions, with devastating consequences for their health, lives and families. These restrictive laws and policies increase womens vulnerability to abuse, violence, health risks and further disempowerment.
Implications for policies and programmes Maternal mortality level though declining remains unacceptable: maintain commitment to action There is an urgent need for African leaders and development actors to act on the high maternal mortality level, and provide an adequate response to the many needs of family planning expressed by women. Appropriate family planning policies are important for the prevention of early pregnancies among teenage girls, as well as for spacing and limiting births, which can provide relief to women and be beneficial to the family budget and the national economy. Improve service delivery and access to sexual and reproductive health services particularly in rural areas Access to quality reproductive health services is essential for the reduction of maternal mortality, the fight against poverty and improving the standard of living. It is critical to improve accessibility to contraception through an efficient management of reproductive health commodities, removing barriers, and empowering women and girls, especially those in the poor and disadvantaged group. Increased partnership and collaboration to save lives Partnership and collaboration among the various stakeholders, including development partners, Non-governmental organizations (NGOs), the private sector, national governments and communities are important for the success of inclusive reproductive health programmes. There has been renewed partnership to protect womens health and lives and the Family Planning summit in London in 2012 provided a forum for countries, the private sector and civil society to commit themselves and the global community to addressing the unmet need for family planning Excerpts of commitment at the 2012 Family Planning Summit in London Kenya has enshrined the individuals rights to quality reproductive health care, including family planning information, services and supplies, in the Constitution and the target is to increase the contraceptive prevalence rate from 46 per cent to 56 per cent by 2015. Nigeria will increase her total commitment for the next four years from US$12 million to US$45.4 million.
84
ICPD Beyond 2014
Norway, the Bill and Melinda Gates Foundation and the UK will work together to increase the availability, access and use of quality, life-saving family planning commodities, each committing $200 million of their total Summit commitment until 2020, amounting to a combined commitment of $600 million. UNFPA will double the proportion of its resources allocated to family planning from 25 per cent to 40 per cent based on current funding levels, bringing new funding of at least $174 million per year from core and non-core funds. This will include a minimum of $54 million per year, from 2013-2019, in increased funding for family planning from UNFPA core resources. To make access to family planning universal; WHO, in collaboration with donors and partners, commits itself to among others: 1) Working with countries to integrate the WHO Medical Eligibility Criteria Family Planning wheel and related tools; 2) Scaling up the availability of high-quality contraceptive commodities; 3) Synthesizing and disseminating evidence on effective family planning delivery models and actions to inform policies, address barriers and strengthen programmes; and working with countries with highest levels of unmet needs to examine inequalities and vulnerabilities and reasons for unmet need. The World Bank will work closely with global partners in the Partnership for Maternal, Neonatal, and Child Health to see how support for these programmes can be expanded even further. The Bank will continue to do its part, working with Ministries of Finance and others in its partner countries, to help ensure that support for family planning and reproductive health is, and remains, a key element of country development strategies.
Addressing gender issues and scaling up male involvement Maternal mortality, family planning and sexual and reproductive health and rights are strongly affected by gender inequity and sociocultural factors. Addressing gender issues and improving involvement of men in sexual and reproductive health are effective strategies to improve womens health. Involvement of men still remains very limited and there is a need to scale up such programmes. Though most of these programmes are focused on women, decisions on these issues are taken in the family by men.
Strengthen capacity for evidence based programming. Strengthening capacity in in-depth data analysis and utilization to inform programme design, implementation and monitoring; taking advantage of the increasing availability of data from population census, large population surveys such as a Demographic and Health Survey, enhance the survey and health information system. Special emphasis should be on collecting and analysing available data on personal motivations for family planning and abortion, and post-abortion care particularly in disadvantaged areas.
85
ICPD Beyond 2014
SOCIAL AND ECONOMIC IMPACT OF CHILD UNDERNUTRITION: IMPLICATIONS FOR HARNESSING THE DEMOGRAPHIC DIVIDEND Child Nutrition, Social and Economic Development Maximizing the benefits for the demographic dividend requires that the increase in the working-age population in Africa is complemented by quality human growth. The Cost of Hunger in Africa (COHA) study highlights the economic and social implications of not addressing the nutritional issues of children in this agenda, as well as the losses in productivity and capacities that can directly affect the levels of youth employment. We must ensure that we understand the relationship between child nutrition and the demographic dividend, which the COHA points to by showing how much we stand to gain in terms of productivity, for our future demographic dividend, if we take action today. The Cost of Hunger in Africa The COHA is a project led by the African Union Commission (AUC) and the NEPAD Planning and Coordinating Agency, and supported by the United Nations Economic Commission for Africa (UNECA) and the World Food Programme (WFP). COHA is a multicountry study aimed at estimating the economic and social impacts of child undernutrition in Africa. Results from the countries in the first phase, namely Egypt, Ethiopia, Uganda and Swaziland, estimate the economic impact at values equivalent to between 1.9 and 16.5 per cent of GDP. Currently, the study is being implemented in Burkina Faso, Ghana, Rwanda and Malawi, and will be initiated in Cameroon, Kenya, Mauritania and Botswana before the end of the year. Results for the first phase have already been presented at country level, and the regional official publication will be launched at the African Day for Food and Nutrition Security event, to be organized by the AUC in the Niger, on 30 October 2013. This study aims at producing evidence to inform key decision makers and the general public about the cost African societies are already paying for not properly addressing the problem of child undernutrition, by analyzing its consequences on health, education and productivity. The results provide compelling evidence to guide policy dialogue and advocacy on the importance of preventing child undernutrition. Ultimately, it is expected that the study will encourage the revision of current allocation practices in each participating country to ensure the provision of the human and financial resources needed to effectively combat child undernutrition, specifically during the first 1,000 days of life when most of the damage occurs. Results of the Study in Egypt, Ethiopia, Swaziland and Uganda Health Sector The study estimated that child under nutrition generates health costs ranging from an equivalent of 1 to 11 per cent of the total public budget allocated to health. These costs are due to episodes directly associated with the incremental quantity and intensity of illnesses that affect underweight children and the procedures required for their treatment. Additionally, the study estimates that a large proportion of these episodes, 69 to 81 per cent, do not seek medical attention and are treated at home, increasing even further the risk of complications, evidencing an unmet demand for health care. Eliminating the inequality in access to health care is a key element of the social transformation agenda in Africa which requires, as a precondition, a reduction of the rural / urban gap in coverage. As the health coverage expands to rural areas, there will be an increase in people seeking medical attention, which can potentially affect the efficiency of the system to provide proper care services. This study illustrates that a reduction of child undernutrition could facilitate the effectiveness of this expansion by reducing the incremental burden created by the health requirements of underweight children.
86
ICPD Beyond 2014
Education Sector The study estimated that in schools, higher repetition rates ranging from 2 to 4.9 per cent were recorded among children who were stunted. Moreover, the model estimates that 7 to 16 per cent of all grade repetitions in schools are associated with the higher incidence of repetition that is experienced by stunted children, the bulk - 90 per cent - of which occurs in primary schools. These numbers suggest that a reduction in the stunting prevalence could also support an improvement in the quality of schooling, as it would reduce preventable burdens on the educational system. Increasing the educational level of the population, and maximizing the productive capacity of Africas population dividend, is a key element to increasing competitiveness and innovation on the continent. This presents a unique opportunity in sub-Saharan Africa where the population under 5 years is estimated to be 40 per cent of the total population. These children and youth must be equipped with the skills necessary for competitive labour. Thus, the underlying causes for low school performance and early desertion must be addressed. As there is no single cause for this phenomenon, a comprehensive strategy must be put in place to consider improving the quality of education and the conditions required for school attendance. The study demonstrated that stunting is one barrier to attendance and retention that must be removed to effectively elevate educational levels and improve an individuals work opportunities in the future. Labour Productivity The study estimated that 52 per cent of the workingage population in the analyzed countries is currently stunted. This population has achieved on average lower school levels of education than those who did not experience growth retardation, ranging from 0.2 to 1.2 years of lower schooling. The working-age population has diminished by 1 to 8 per cent due to child mortality associated with undernutrition. On the continent, more than half of the population is expected to live in cities by 2050. An important
component to prepare for this shift is ensuring that the workforce is ready to make a transition towards a more skilled labour force, and economies are able to produce new jobs to reduce youth unemployment. By preventing child stunting, and thereby avoiding the associated loss in physical and cognitive capacity that hinders individual productivity, people can be provided with a more equal opportunity for success. Potential Economic Savings The model estimates that a reduction to half of the prevalence level by the year 2025 can generate annual average savings from $3 million to $376 million, for the analyzed countries. An additional scenario estimates that a reduction to 10 per cent stunting and 5 per cent underweight could yield annual average savings from $4 million to $784 million. This economic benefit that would result from a decrease in morbidities, lower repetition rates and an increase in manual and non-manual productivity, presents an important economic argument for increase in investments in child nutrition. Policy Recommendations 1. Stunting is a useful indicator for effective social policies Chronic child undernutrition can no longer be considered a sectoral issue, as both its causes and solutions are linked to social policies across numerous sectors. Reduction of stunting will therefore require interventions from the health, education, social protection, and social infrastructure perspectives. Stunting can be an effective indicator of success in larger social programmes. The study encourages countries not to be content with acceptable levels of stunting; equal opportunity should be the aspiration of the continent. In this sense, it is recommended that ambitious targets are set in Africa for the reduction of stunting that go beyond proportional reduction, to establish an absolute value of 10 per cent as the goal for the region. 2. A multi-causal problem requires a multi-sectoral response This ambitious goal cannot be achieved by the health sector alone. In order to have a decisive impact on improving child nutrition, a comprehensive multi-sectoral policy must be put in place, with strong political com-
87
ICPD Beyond 2014
mitment and allocation of adequate resources for its implementation. 3. Sustainability requires strong national capacity To ensure sustainability of these actions, whenever possible, the role of international aid must be complementary to nationally led investments, and further efforts have to be made in ensuring the strengthening of national capacity to address child undernutrition. 4. Monitoring is needed for progress To measure short-term results in the prevention of stunting, a more systematic approach with shorter time intervals is recommended, such as two years between each assessment. As the focus on the prevention of child undernutrition should be children under two years of age, these results will provide information to policy-
makers and practitioners on the results being achieved in the implementation of social protection and nutrition programmes. 5. Long-term commitment is necessary to achieve results The COHA initiative presents a valuable opportunity for making nutrition part of the strategy for ensuring Africas sustainable development. As the post-MDG agenda nears, priorities and targets will be set that will serve as a guide for development policies in years to come. It is recommended that the prioritization of the elimination of stunting should not only be presented from the traditional forums, but also included in the discussions on broader aspects of development, as a concern for the economic transformation of Africa.
88
ICPD Beyond 2014
REDUCING MATERNAL MORTALITY IN AFRICA: ADDRESSING THE UNMET NEED FOR FAMILY PLANNING AND POST-ABORTION CARE INTRODUCTION Twenty out of the 25 countries with the highest adolescent fertility rates in the world are in Africa. In many African countries, adolescents make up to one-third of the population. Africa has recognized that population is an important resource for development. Deliberations are ongoing as to how to harness the forthcoming demographic dividend for Africa to reap the maximum benefit from its important resource population. The state of the continents demographic trends present a potential for economic growth and social development in the near future. Adolescents and the youth, hold the key to sustainable development in Africa. African countries will need to address key youth and adolescent issues such as universal access to education and health services in order to achieve their full potential for economic growth. Young people face a range of health and social challenges. For example, adolescent girls who engage in sexual activity before they have acquired adequate knowledge and skills to protect themselves are at a higher risk of unwanted pregnancies, unsafe abortions, and sexually transmitted infections, including HIV and AIDS. As a result of this, adolescent pregnancy, as well as the number of younggirls exposed to HIV is growing. Trends in Africa Africas Total Fertility Rate (TFR) has remained considerably higher than that of other regions, at 6.67 and 4.64 iin 1970- 1975 and 2005-2010 respectively. In 2010, Central Africa had the highest TFR of 5.9 on the continent, and Southern Africa had the lowest at 2.5. The medium projection series show that by the middle of the 21st century, Western Africa will have the highest TFR of 3.3, and Northern and Southern Africa will reach rates at or below the replacement level.ii Africa has experienced a decline in fertility rate albeit at a slow rate, attributed to a fall in GDP per capita and the AIDS epidemiciii, which has led to a shift in focus, as well as to low national and donor budget allocation to family planning programmes. Increasing economic performance, reducing the HIV/ AIDS burden and increasing allocation of funds to family planning, may result in a shift in the population structure, thereby raising Africas prospects of reaping the benefits of the demographic dividend, given the estimated population of 1.6 billion people in 2030 from just 1.0 billion in 2010. This will represent about 19 per cent of the worlds population as compared to Asia and Latin America that account for 58 per cent and 8 per cent respectively iv . Graph 1 below shows the trend from 1990 to 2030:
Investment should be centered on the youth and adolescents if the above trend is to serve as an opportunity for development. In order to end the transfer of the heritage of poverty and other socioeconomic challenges to the next generation, interventions to curb early/child marriages, teenage pregnancy, Gender Based Violence (GBV), school dropout, and HIV/AIDS must be prioritized. Furthermore, there should be access to vital information and the creation of an enabling environment for employment opportunities.
89
ICPD Beyond 2014
Disparities The current investments in population and the youth and adolescents are not commensurate with the rate of projected population structure and growth. Continued insufficient investment can render the population increase a disaster for Africa. It is worth noting that Africa south of the Sahara is the only region of the world where the number of adolescents continues to grow significantlyv; the region therefore needs to invest more in that sector. Challenges (i) African ancestral beliefs and religions value large families. Consequently, in rural communities there is a perceived need to have many children to assist in food and livestock production; (ii) Underage marriage and teenage pregnancy are detrimental to the health and social development of the African youth. Today, the practice places an estimated 37.4 million young girls at the risk of maternal mortality and of contracting Sexually Transmitted Infections (STIs) including HIV; (iii) Limited access to reproductive and sexual health services, as most services are not youth friendly; (iv) The concept of the demographic dividend may still not be well understood as an important resource for development in Africa, leading to the current low investments in the youth and adolescents; (v) Capturing of data on progress in countries is difficult due to the different tools, and disparities in definitions of youth and adolescents in countries.
The Way Forward In order to enhance the welfare of the youth and adolescents a number of policy frameworks have been developed and ratified by most countries in Africa. These include, The African Charter on the Rights and Welfare of the Child and The African Youth Charter. The State of Africa Population Report is produced biannually as a reference and planning guide for countries on the continent. However, these instruments are not an end in themselves and countries should therefore ensure their full implementation. Investing in youth programmes which include adolescent girls and boys is crucial. There is evidence that girls are less likely than boys to obtain a secondary education, more likely to be forced into child marriage with its attendant early sexual activity, less likely to use information and communication technologies and, more likely to contract HIV vi . Girls should therefore be treated as a special group. Countries must take advantage of the demographic dividend window by implementing concrete policies in the areas of family planning, health, education, gender equality, and the labour market. The International Conference on Population and Development (ICPD) is the current available resource for improving the lives of the youth and adolescents in Africa. Countries should therefore subscribe to the vision of the ICPD to benefit from it. The success of the ICPD Conference that took place in Cairo from 5 to 13 September 1994, which was a result of shifting population policy away from human numbers to human lives and human rights, is clear evidence of what prospects the ICPD has for Africa and the world.
org/root/au/Documents/Treaties/List/African%20Charter%20on%2 0the%20Rights%20and%20Welfare%20of%20the%20Child.pdf [Accessed: 20 August 2013] v African Union Commission (2009). African Charter on the Rights and Welfare of the Child. Available from: http://www.africa- union. org/root/ua/conferences/mai/hrst/charter%20english.pdf. [Accessed: 20 August 2013] vi United Nations Childrens Fund (UNICEF) (2012). Progress for Children: A report card on adolescents. Division of Communication. Available from: http://www.unicef.org/publications/ [Accessed: 20 August 2013]
REFERENCES
i Bongaats, J. (1982). The Fertility-Inhibiting Effects of the Intermediate Fertility Variables. Studies in Family Planning, 13(6/7), 179-189. ii Population Reference Bureau, (2010). 2010 World Population Data Sheet, Washington, DC. iii African Development Bank Group (2012). Africas Demographic Trends. Available from: http://www.afdb.org/fileadmin/uploads/afdb/ Documents/PolicyDocuments/FINAL%20Briefing%20Note%20 4%20Africas%20Demograp hic%20Trends.pdf [Accessed: 20 August 2013] iv African Union Commission (1999). African Charter on the Rights and Welfare of the Child. Available from: http://www.africa- union.
90
DELIVERING THE DEMOGRAPHIC DIVIDEND IN AFRICA: INVESTING IN NUTRITION AS A FIRST STEP
Delivering the Demographic Divident in Africa: Investing in Nutrition as a first step
91
DELIVERING THE DEMOGRAPHIC DIVIDEND IN AFRICA: INVESTING IN NUTRITION AS A FIRST STEP INTRODUCTION In the 1980s the ratio of Africans of working age to the number who were not of working age was one. By 2050 the projections tell us that this ratio will be two. This represents a halving of the dependency ratio. When death rates and birth rates converge, populations grows more slowly (Figure 1, Bloom 2011). The group of individuals born during the period in Africa when there was a big gap between birth and death rates (when death rates are low but birth rates are yet to follow suit) are now beginning to enter working age. When large groups of people enter labour force age and a smaller number of infants are born after them, the ratio of working age to non-working age population increases. This increasing ratio has the potential to act as a spur to economic growth. This potential is called the demographic dividend. Investment in nutrition can enhance harnessing of the demographic dividend in the following way: Job creation; Children who are adequately nourished do better in school, earn 20% more in the labour market, are 10% more likely to own their own sustainable business, and are 33% less likely to live in poor households as adults; Accelerate fertility declines; Children who are stunted are twice as likely to die as children who are not. Evidence suggests that the faster the child death rate declines the faster desired fertility will decline. Furthermore Investments in maternal nutrition can improve their labour force participation, further decreasing birth rates; Reduce the long term disease burden on the health system; Investments in nutrition in the first 1000 days after conception result in higher school attainment after 10 years and higher productivity after 20 years on, they also facilitate a lower rate of chronic disease such as diabetes, high blood pressure and heart disease after 40 years (Risnes et. al. 2011);
92
How does the demographic dividend work? There are two main pathways: simple arithmetic and not so simple human behavior. Arithmetic: (a) Large cohorts of young people entering the labour force, and if significant proportions are engaged in productive work, growth will be boosted; and (b) working age people on average save more than other categories of adults and increased savings rates stimulate growth via investment. Behavioural pathways: (a) the boost to saving rates as people plan for longer lives, (b) the rise in womens participation in the economy as birth rates decline and (c) the freeing up of some societal resources due to the need to invest in a fewer number of children (Bloom 2011).
top 20 cause (out of 176) of disability adjusted life years (Murray et. al. 2012). The treatment of these chronic diseases is much more expensive than their prevention and could serve as a drag on economic growth.
Why is investing in nutrition so central to the delivery of the dividend? Nutrition security in Africa still requires significant investment. Some evidence suggests that chronic malnutrition rates as measured by child stunting (low height for age) have been hovering at just below 40 percent for the past 20 years (De Onis et. al. 2011) on the continent.
CONCLUSION To deliver the demographic dividend in Africa, investing in nutrition is a first step. It is not guaranteed that the demographic changes happening in Africa will generate an economic dividend. However the steps enumerated above are part of conscious interventions that need to the implemented to deliver of an economic dividend from the demographic changes. Investing in nutrition supercharges the effects of these policies. Improved nutrition status facilitates (a) faster declines in fertility, (b) better school outcomes, higher earnings, more business creation and stronger growth, and (c) delayed onset of expensive chronic diseases. Therefore priority needs to be given to all available nutrition interventions opportunities such as breastfeeding but also in nutrition sensitive programmes and interventions such as agriculture, social protection, water and sanitation. Investment in nutrition can enhance the possibility of harnessing the demographic dividend.
So what needs to happen to deliver the dividend? 1. Make sure job creation expands rapidly Focus on job-intensive sectors in which the country has a competitive advantage or strong domestic market, improve infrastructure, expand access to financial services, less unnecessary regulation and, perhaps most importantly, a skilled workforce (Fine et. al. 2012). Broad based growth is best developed via wide access to education. This is thought to be one key factor for earlier onset of high growth rates in China compared to India (Bloom and Canning 2011). 2. Accelerate fertility declines The projected rate of the demographic change for Africa, excluding North Africa is slow compared to other regions. The main public policy actions to accelerate fertility decline are the expanded use of family planning services and the increased survival chances of newborns through improved public health provision (Cleland 2012). 3. Reduce the disease burden on the health system and the state from an aging population Non Communicable Diseases (NCDs), which usually occur in later life are expanding rapidly in Africa. High blood pressure, for example is a top 6 risk factor (out of more than 40) for the burden of disease in most parts of Africa (Lim et. al. 2012) and heart disease is now a
93
94
95
96

Compendium On Health, Nutrition and POpulation

Caricato da

Informazioni sul documento

Descrizione originale:

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Compendium On Health, Nutrition and POpulation

Caricato da

Copyright:

Formati disponibili

TABLE OF CONTENT

1ST INTERNATIONAL CONFERENCE ON MATERNAL NEWBORN AND CHILD HEALTH

INTERNATIONAL CONFERENCE ON POPULATION AND DEVELOPMENT BEYOND 2014

DELIVERING THE DEMOGRAPHIC DIVIDEND IN AFRICA: INVESTING IN NUTRITION AS A FIRST STEP

H.E Dr Mustapha .S. Kaloko Commissioner for Social Affairs

DAYS TO MAKE A DIFFERENCE

DAYS TO MAKE A DIFFERENCE

Abuja +12: 900 Days to make a difference

Abuja +12: 900 Days to make a difference

the umbrella of Roll Back Malaria will be fundamental to future progress.

Photo:World Bank Photo Collection

DAYS TO MAKE A DIFFERENCE

LOCAL PRODUCTION OF PHARMACEUTICALS IN AFRICA

Abuja +12: 900 Days to make a difference

DAYS TO MAKE A DIFFERENCE

Abuja +12: 900 Days to make a difference

Abuja +12: 900 Days to make a difference

DAYS TO MAKE A DIFFERENCE

HEALTH FINANCING IN AFRICA

Abuja +12: 900 Days to make a difference

Abuja +12: 900 Days to make a difference

Photo: US Army Africa

DAYS TO MAKE A DIFFERENCE

The WHO Health Systems Framework

Abuja +12: 900 Days to make a difference

Abuja +12: 900 Days to make a difference

DAYS TO MAKE A DIFFERENCE

ELIMINATION OF MATERNAL TO CHILD TRANSMISSION

Abuja +12: 900 Days to make a difference

DAYS TO MAKE A DIFFERENCE

Abuja +12: 900 Days to make a difference

Photo by Nena Terrell/USAID

1st International Conference on Maternal, Newborn and Child Health

Photo: Heinrich Boell

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013

Photo: DFID - UK Department for International Development

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013

STRATEGIES AND BEST PRACTICES

CASE STUDY - RWANDA

ICMNCH, August 2013

CASE STUDY - RWANDA

National Health Accounts (NHA) allow decision REFERENCES

ICMNCH, August 2013

ICMNCH, August 2013

CASE STUDY - MOZAMBIQUE

ICMNCH, August 2013

ICMNCH, August 2013

CASE STUDY - KENYA

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013

ICMNCH, August 2013