African Health Monitor - Health systems and reproductive health in

Transcription

African
iSSN 2077 6136
·
the
Health systems and
reproductive health
in the African Region
march 2011
·
special issue 14
·
A serial publication of the World Health Organization regional office for africa
Health
monitor
REGIONAL OFFICE FOR
I N S I D e:
Communicable
Diseases
epidemiological
Report
Africa
African
the
Health
monitor
REGIONAL OFFICE FOR
Africa
·
march 2011
special issue 14
A serial publication of the World Health Organization regional office for africa
contents
Editorial: Health systems and primary health care in the African Region
Luis Gomes Sambo
—2—
Renforcement des systèmes de santé dans les pays de la région africaine de l’OMS :
Répondre au défi
Amidou Baba-Moussa, Saidou Pathé Barry and Kandjoura Drame
—4—
Health systems in sub-Saharan Africa: What is their status and role in meeting the
health Millennium Development Goals?
Prosper Tumusiime, Andrew Gonani, Oladapo Walker, Eyob Z Asbu, Magda Awases and Pierre C Kariyo
— 14 —
Assessing the efficiency of hospitals in Malawi: An application of the Pabón Lasso
technique
Eyob Z Asbu, Oladapo Walker, Joses M Kirigia, Felicitas Zawaira, Francis Magombo, Patrick Zimpita, Gerald Manthalu,
Dominic Nkhoma, Cynthia Eldridge and Edward Kataika
— 25 —
Improving access to quality care in family planning: Assessment of the Medical
Eligibility Criteria Wheel for contraceptive use in Ghana
Andrew Kosia, Charles Djoleto-Fleischer, Mongi Pyande and Triphonie Nkurunziza
— 34 —
Implementation of the Global Strategy on Infant and Young Child Feeding at
national level in the African Region: Challenges and way forward
Charles Sagoe-Moses, Kasonde Mwinga, Phanuel Habimana and Tigest Ketsela
— 39 —
Leveraging eHealth to improve national health systems in the African Region
Emil Asamoah-Odei, Derege Kebede, Chris Zielinski, Edoh-William Soumbey-Alley, Miguel Peixoto and Matshidiso Moeti
— 46 —
Data quality and information use: a systematic review to improve evidence,
Ethiopia
Gebrekidan Mesfin, Hajira Mohamed, Habtamu Tesfaye, Negusu Worku, Dereje Mamo and Nafo-Traoré Fatoumata
— 53 —
Communicable Diseases Epidemiological Report
— 61 —
News and events
— 69 —
1
t h e A f r i c a n h e a lt h m o n i t o r
editorial
Health systems and primary health
care in the African Region
A
weak national health
system can be viewed as
an important contributor
to poverty and inequity in the
African Region. Persons who are
in poor health less frequently
move up and more frequently
move down the social ladder
than healthy persons. The role
of the health system becomes
particularly relevant through
the issue of access to preventive
and curative health services.
The health system can directly
2
address inequities not only by
improving equitable access to
care, but also in the promotion
of intersectoral action to improve
health status. The health system
is also capable of ensuring that
health problems do not lead to a
further deterioration of people’s
social status and of facilitating
sick people’s social reintegration.
Equitable and sustainable
access to properly functioning
health systems, however, has
not been attained across the
Region. There have always
been geographical disparities
and these have worsened over
the last decade. Many people,
particularly those in rural
areas, often have to travel long
distances to receive basic health
care. Once they reach a hospital
or a clinic, they may only receive
health care if they pay for it.
Inevitably, many people may
forego treatment because
they cannot afford it, while
those who pay may find the
cost ruinous and the quality of
service limited. Rapid turnover
of people in key positions, lack
of continuity in policy, lack of
resources, poor management
of available resources and
poor implementation are seen
in many countries as major
c o n s t ra i n t s to i m p rov i n g
the health systems. Most
c o u n t r i e s i n t h e Re g i o n
inherited a colonial, European
model of health care that was
primarily intended for colonial
administrators and expatriates,
with separate or second class
provision made – if at all – for
Africans.
H EALT H S Y STEMS AN D RE P RO D U CTI V E H EALT H • s p e c i a l i s s u e 1 4
In spite of various constraints,
tangible progress has been made
by governments, communities
and partners towards improved
health outcomes; nevertheless,
many challenges lie ahead.
Health systems are weak and the
Region still faces an increasing
burden of communicable and
noncommunicable diseases, high
child and maternal mortality,
re c u r re n t e p i d e m i c s a n d
humanitarian crises aggravated
by the global financial crisis.
At the end of my first five-year
term, the WHO Secretariat,
together with Member States
and partners, have taken stock
of achievements made and
challenges faced; we have learnt
lessons and gathered additional
evidence for a renewed vision of
the work of WHO in the African
Region for the period 2010–2015
in line with the WHO Eleventh
General Programme of Work
2006–2015. The result of this
effort is a new set of strategic
directions for the Region.
The new strategic directions
build on the achievements in
the previous five years and
focus on the evolving and
specific context of the Region,
which continues to evolve. The
Strategic Orientations (2005–
2009) strengthened institutional
capacity and enhanced
partnerships and leadership
for health. Furthermore, the
adoption of various declarations
and calls for action has provided
consensus for the health agenda
in the Region. Building on these
and other achievements, the
current strategic directions were
formulated to sustain gains made
and to tackle current, emerging
and re-emerging priorities. They
are, therefore, more actionoriented and aimed at improving
the health outcomes in the Region.
An important focus of the current
strategic directions is to continue
supporting the strengthening
of health systems based on the
Primary Health Care Approach.
The platform created by the
Ouagadougou Declaration on
Primary Health Care and Health
Systems in Africa along with the
Algiers Declaration on Research
for Health and the Libreville
Declaration on Health and
Environment will be implemented
to further strengthen health
systems. WHO will advocate for
sustained commitments with
a special focus on the human
resource gaps, taking advantage
of new and effective technologies
to accelerate the attainment
of the MDGs. Countries will be
supported to strengthen national
research systems and shape their
research agenda. To support
countries, an African Health
Observatory aimed at analysing
data and providing information
on health outcomes and trends
will be established at the Regional
Office. Technical support will be
provided to establish similar
An important focus of the
current strategic directions
is to continue supporting
the strengthening of
health systems based on
the Primary Health Care
Approach
structures at country level.
Guidance will be provided for the
establishment and networking of
centres of excellence on health
research in order to generate
evidence to support service
delivery and inform policy action.
This issue of the Monitor includes
several articles on health systems
strengthening. There is a paper
on how national health systems
could be strengthened in the
Region. The role of health systems
as key determinants of progress
on the Health MDGs is detailed
in another paper. Country
experiences are also described in
three papers: health financing in
Malawi; an innovative method for
assessing family planning needs
that could be useful for health
workers in Ghana; and health
information systems in Ethiopia.
Leveraging eHealth to improve
health systems in the African
Region is a topic for the last paper
in this issue of the Monitor. All
the articles deal with important
issues of health systems and
thus would be useful reading
to all health workers and policy
makers. z
Luis Gomes Sambo
Regional Director
3
Renforcement des
systèmes de santé dans
les pays de la région
africaine de l’OMS :
Répondre au défi
Amidou Baba-Moussa
Saidou Pathé Barry
Kandjoura Dramé
Bureau régional de l’OMS pour l’Afrique, Brazzaville
4
a b s t r ac t
L’enjeu du bon fonctionnement du système
de santé est d’améliorer la qualité de vie des
individus, des familles et des communautés.
C’est pour cette raison que la performance du
système de santé doit figurer en tête des priorités
de l’action gouvernementale. Cependant, les
systèmes de santé des États Membres de la Région
africaine de l’OMS peinent à remplir efficacement
leurs fonctions, du fait de leur faiblesse et de
leur fragmentation.1 La faiblesse des systèmes
de santé s’explique par un certain nombre de
facteurs, à savoir : des insuffisances au niveau de
la planification et de la prévision; la pénurie des
ressources humaines, financières et matérielles;
l’insuffisance des données pour informer de
manière éclairée la prise de décision; les lacunes
des processus institutionnels; et les faiblesses
du suivi de la performance et de l’impact des
interventions. Le renforcement des systèmes de
santé constitue donc une condition préalable à
toute avancée significative en matière de santé
dans la Région africaine et même à l’échelle
mondiale. Les États Membres de notre Région en
sont pleinement conscients et saisissent de plus
en plus les occasions offertes par les initiatives
mondiales pour exprimer leurs besoins en la
matière.2 Le présent article trouve sa justification
dans ce besoin de renforcement des systèmes de
santé des pays, et se propose de contribuer à la
réflexion engagée pour la recherche de solutions
adéquates aux problèmes identifiés.
The environment for the smooth functioning of
health systems is the lives of people, families
and communities. Consequently, health systems
performance should be a top priority in the
national agenda. However, health systems
in countries of the Region are struggling to
operate effectively, because they are weak and
fragmented.1 Their failure stems from factors
such as managerial weaknesses in planning
and forecasting; lack of human, financial and
material resources; inadequate data to inform
decision-making, gaps in institutional processes
and weakness in monitoring the performance
and impact of interventions. Strengthening
health systems is therefore a precondition for any
significant progress in health in the African Region
and even in the world at large. Countries in this
Region are aware of this and are taking increasing
advantage of the opportunities provided by global
initiatives to express their need for health systems
strengthening.2
This article, prompted by a need for health
systems strengthening in countries, seeks to
contribute to the brainstorming in the quest for
appropriate solutions to the identified challenges.
Resumo
Auteur correspondant
Amidou Baba-Moussa
E-mail : [email protected]
A verdadeira questão subjacente ao bom
funcionamento do sistema de saúde é a vida
dos indivíduos, das famílias e das comunidades.
Nesse âmbito, o seu desempenho deverá ser
a prioridade cimeira da agenda dos governos.
Contudo, os sistemas de saúde dos países da região
têm dificuldade em cumprir eficazmente as suas
funções, pois apresentam muitas deficiências e são
fragmentados.1 As deficiências estão associadas a
determinados factores tais como deficiências na
gestão ao nível do planeamento e da previsão,
à escassez de recursos humanos, financeiros e
materiais, à insuficiência de dados para informar,
de forma clara, a tomada de decisão, às lacunas
dos processos institucionais e às debilidades de
monitorização do desempenho e do impacto
das intervenções. O seu reforço é portanto uma
condição de base, se quisermos conseguir avanços
significativos em matéria de saúde na Região
Africana e mesmo à escala mundial. Os países
da região estão conscientes disto e aproveitam
cada vez mais as oportunidades oferecidas
pelas iniciativas mundiais para expressarem a
necessidade de um tal reforço.2 O presente artigo
encontra a sua justificação nessa necessidade dos
países, e visa contribuir com ideias para a pesquisa
de perspectivas promissoras relativamente aos
desafios que lhes estão associados.
ProblÉmatique du renforcement
des systèmes de santé
L’effort de renforcement des systèmes de santé des pays
implique pour les acteurs, au moins deux préalables que sont
une compréhension partagée du concept de système de santé
et le contenu de son renforcement.
Selon l’Organisation Mondiale de la Santé (OMS) 3,4 un
système de santé comprend l’ensemble des organisations,
des institutions et des ressources dont le but principal est
d’améliorer la santé. Mais par delà cet objectif principal, il
doit répondre aux attentes des populations et assurer leur
protection financière contre les coûts liés à la défection de la
santé (équité financière).
A
fin de mieux cerner
la problématique du
renforcement des
systèmes de santé, il faut
envisager son concept dans une
optique systémique. Ainsi, un
système de santé s’entend comme
un ensemble interdépendant de
composantes organisées en vue
d’atteindre un but commun, en
l’occurrent et principalement
l’amélioration de la santé. Les
composantes d’un système
se distinguent en plusieurs
catégories : les entrées qui sont
en quelques sorte les matières
premières, les processus qui
assurent la transformation de ces
matières premières, et les sorties
qui sont constituées par les flux
de prestations fournies par le
système, comme produits de son
activité. En outre, le système est
doté d’un mécanisme de rétro-
information qui permet de suivre
constamment le niveau d’atteinte
des objectifs.
Dans cette acception, le système
de santé doit être appréhendé
Figure 1. Le Système de santé selon l’OMS
de façon holistique et approché
dans sa totalité et non élément
par élément. Faute d’une telle
vision, la plupart des initiatives
mettent uniquement l’accent sur
les ressources, en rapport avec
des affections particulières ou
des groupes cibles particuliers,
laissant habituellement pour
compte les composantes relatives
aux processus organisationnels.
Or c’est au niveau de ces processus
que se joue la structuration du
système, c’est-à-dire l’articulation
des moyens matériels et humains,
celle des fonctions des divers
organes et les modalités de leur
collaboration.
C’est de cette logique que
s’inspire le cadre conceptuel de
l’OMS qui approche le système
de santé comme un ensemble
reposant sur six piliers, comme
indiqué sur la figure 1.
Fonctions
Objectifs du système
Gouvernance
Définition de stratégies nationales
et sectorielles, clarification des rôles,
gestion de demandes conflictuelles
Réactivité des services
Traiter les gens avec dignité; garantir la
confidentialité
Ressources humaines
Avoir une force de travail adéquate
Information
Génération et utilisation d’information
et de connaissances
Financement
S’assurer d’un financement durable et
d’une protection financière pour les
populations
Médicaments, vaccins et
technologies
S’assurer d’une quantité suffisante de
médicaments, et d’une infrastructure et
équipements adéquats
Prestation de services
Améliorer l’organisation, la gestion et
l’offre des services de santé
Couverture
Qualité & sécurité
Amélioration
de la santé
Efficience
Protection financière
S’assurer que les gens ne soient pas
précipités dans la pauvreté à cause de
dépenses en santé
Distribution equitable
5
Dans ces conditions, renforcer le
système de santé consiste à agir
sur ses six piliers, afin d’améliorer
de façon durable et équitable
les services de santé et la santé
des populations. Cette action,
permettant ainsi de changer
de paradigme, doit être menée
à travers une vision globale et
de façon équilibrée au risque de
compromettre le succès.
Défis qui se
posent aux pays
de la region
africaine de l’OMS
Malgré des succès tangibles tels
que l’éradication de la variole,
et des progrès encourageants
dans la lutte contre certaines
maladies comme la poliomyélite,
la dracunculose, l’onchocercose
et la rougeole, les systèmes
de santé des pays de la région
montrent des faiblesses dans
la prestation des services, qui
soulèvent des défis multiples
qui peuvent être regroupés sous
cinq thèmes majeurs : leadership
et gouvernance ; organisation ;
information sanitaire ; financement ; ressources humaines et
matérielles.
Défis liés au
leadership et à la
gouvernance
Une consultation organisée par
l’OMS en 20075 a relevé que les
6
capacités en matière de leadership
et de gestion sont actuellement
insuffisantes, tant dans le secteur
privé que publique, et que rares
sont les pays à revenus faibles
qui se préoccupent de façon
systématique de la problématique
gestionnaire.
A cet égard, des défis complexes
se posent aux pays de la région
africaine :
• Définir une vision stratégique
pour le système dans sa
globalité, et obtenir l’adhésion
de toutes les parties prenantes
y compris le secteur privé ;
• Accorder une haute priorité,
à la conception du système de
santé fondée sur une approche
holistique qui implique pour
les autorités nationales, la
capacité d’agir à la fois de
façon équilibrée sur tous les
aspects du système de santé ;
• Refléter cette vision dans un
cadre stratégique qui sert
de creuset pour la définition
des politiques et stratégies
sectorielles ;
• I n s t a u re r u n e g e s t i o n
efficiente, dans le respect de
l’exigence de transparence
et de l’obligation de rendre
compte et ;
• Fo r m u l e r u n p l a n d e
renforcement du système de
santé.
Défis liés à
l’organisation
Les lacunes des prestations
de services sont souvent dues
à un dysfonctionnement de
l’organisation du système de
santé, même lorsque les apports
nécessaires sont fournis et l’appui
financier suffisant.3
Un défi organisationnel de taille
se pose tant pour la configuration
d’ensemble des systèmes de
santé que pour la structure
des prestations des services. Il
s’agit alors pour les autorités
nationales de :
• P r e n d r e
conscience
de l’importance vitale
de la structuration
organisationnelle pour en
faire une question prioritaire ;
• Faire preuve d’innovation
organisationnelle et opérer
des choix stratégiques en
répondant aux questions
clé telles que : comment
combiner les trois modalités
organisationnelles de base
d’un système de santé
(pyramidale hiérarchisée ;
contractuelle ; et centrée
sur les transactions
marchandes) ? Quelles
formes de décentralisation
appliquer et comment les
rendre effectives, grâce à une
répartition réelle de l’autorité
et des pouvoirs de décisions,
et un environnement de
travail incitatif par exemple ?
Comment combiner les
modalités hiérarchisées et
décentralisées d’organisation
des prestations de service ou
les alternatives d’intégration ?
Comment promouvoir la
contractualisation ? Comment
créer des liens structurels et
fonctionnels avec le secteur
privé souvent occulté ?
Comment promouvoir la
recherche sur les systèmes de
santé ?
Défis relatif à
l’information
sanitaire
L’information sanitaire est vitale
pour la prise de décision, le suivi/
évaluation des programmes, des
progrès, et de la performance
du système de santé. Mais, rares
sont les pays de la région où le
système d’information sanitaire
est assez performant pour le suivi
des progrès dans l’atteinte des
OMD, pour diverses raisons6 :
• caractère fragmenté et peu
cohérent de ces systèmes,
coordination difficile des
parties prenantes ;
• surcharge des agents de
santé ;
• faible degré de synthèse,
analyse et utilisation des
données collectées.
Quant à la mesure de la
performance du système de
santé, sa conception en est encore
au stade expérimental.7
Le système d’information
sanitaire est alors confronté à
plusieurs défis :
• Etablir un cadre d’évaluation de
la performance du système, et
instaurer un processus continu
suivi-évaluation-révision ;
• Sélectionner une série
limitée d’indicateurs adaptés
et conformes aux normes
internationales ;
• Développer l’expertise requise
en conception, gestion,
utilisation de l’information et
en recherche sur les SIS ;
• Créer un environnement
de travail incitatif pour
promouvoir une culture de
prise de décision fondée sur
des bases factuelles ;
• Mettre en place un mécanisme
efficace de mesure de la
performance du système de
santé.
Défis relatifs au
financement de la
santé
Dans le domaine du financement
de la santé, les pays de la région
africaine se heurtent à d’énormes
difficultés. Les ressources
financières sont insuffisantes,
mal gérées, affectées de façon peu
stratégique, et mal coordonnées
pour la part fournie par l’aide
extérieure.8
Les défis suivants se posent alors:
• A d o p t e r l a m e i l l e u r e
combinaison des quatre modes
d’organisation classiques
(Régime unique financé
par l’Etat, Sécurité sociale,
Organismes communautaires
et Caisses privées d’assurance
maladie), de façon à mieux
satisfaire les exigences d’équité
et d’efficacité ;3
• A c c r o î t r e l e s f o n d s
publiques en respectant les
engagements des Chefs d’Etat
et en mobilisant plus d’aides
extérieures ;
• Afficher la volonté politique
nécessaire pour instaurer
des règles de gestion et
d’allocation rigoureuses, en
mettant à profit les bases
de données constituées par
l’OMS à cet effet.8
Défis relatifs aux
ressources humaines
et matérielles
Un système de santé, pour être
performant, doit disposer d’une
masse critique de ressources
humaines et matérielles. Or dans
les pays de la région africaine,
celles-ci sont insuffisantes 8
dans un contexte de
déséquilibre entre les dépenses
d’investissement trop élevées
(40 à 50% du budget de la santé
dans le secteur public, contre
5% dans les pays riches) et les
dépenses de fonctionnement. 3
De la sorte, après les dépenses
salariales, soit 2/3 des dépenses
renouvelables, il reste peu de
fonds pour les consommables
y compris les produits
pharmaceutiques dont l’accès
est limité pour plus de la moitié
de la population dans certains
pays. Ce déficit de ressources
est particulièrement ressenti
concernant le capital humain
qui est la pierre angulaire d’un
système de santé performant.
L’ampleur du problème place
l’Afrique à l’épicentre de la crise
7
mondiale du personnel de santé,
comme le montrent les éléments
suivants.8
Fa c e à c e t te s i t u a t i o n
préoccupante, les défis relatifs
aux ressources humaines et
matérielles consistent, pour les
autorités nationales, à :
• E t a b l i r u n m e i l l e u r
équilibre entre les dépenses
d’investissements et celles
liées à l’entretien et au
fonctionnement du capital
tant humain que physique ;
• Affirmer la volonté politique
d’appliquer les résolutions
et recommandations prises
par les pays eux-mêmes,
notamment sur la crise du
personnel, à travers l’OMS
et le NEPAD par exemple, ou
celles émanant des instances
internationales partenaires
tels que « Global Health
Workforce Alliance » (GHWA),
GAVI et Banque Mondiale ;
• Renforcer le dispositif des
comptes nationaux de la
santé pour disposer d’une
information plus fiable sur les
ressources et mieux guider les
choix budgétaires ;
• A m é l i o r e r l ’ e f f i c a c i t é
des
mécanismes
d’approvisionnement, de
distribution et d’utilisation
des produits pharmaceutiques
et des équipements, tout en
développant la production
locale des produits de la
médecine traditionnelle ;
• Améliorer l’efficacité en
8
matière de planification et
d’allocation des ressources
et rendre leur gestion plus
rigoureuse et transparente.
Réponses des
pays de la region
africaine de
l’OMS
Face aux nombreux défis du
renforcement des systèmes de
santé dont les gouvernements
affirment avoir pleinement
conscience, les pays de la région
africaine ont pris des initiatives
très variables d’un pays à l’autre,
en fonction du contexte national
et des opportunités. Elles ont
toutes un trait commun : leur
caractère limité au niveau
local, leur expansion difficile à
l’échelle nationale et leur manque
de pérennité. Toutefois, elles
constituent autant d’expériences
acquises sur lesquelles il est
possible de bâtir l’avenir, et
certaines sont porteuses de
perspectives prometteuses. A
cet égard, les expériences à citer
à titre d’illustration, portent
sur l’approche sectorielle et la
réforme du système de santé.
Approche sectorielle
L’ a p p r o c h e s e c t o r i e l l e
communément appelée « SWAp »
en anglais (sector-wide approach),
peut être définie comme une
situation de coopération entre
gouvernements et partenaires,
où « tous les financements
importants du secteur appuient
une seule politique sectorielle
et un seul programme de
dépenses sous la direction des
gouvernements, qui optent pour
une approche commune du
secteur, et [où] les procédures
nationales sont progressivement
adoptées pour le décaissement
et la comptabilisation de tous les
fonds ».9
Toutefois, il faut souligner qu’une
SWAP dépasse la seule mise en
commun de fonds, et implique
aussi un dialogue soutenu entre
toutes les parties prenantes sur
les aspects clés.
Cette approche a vu le jour comme
moyen de renforcer l’efficacité
de l’aide, face au constat que
les efforts des donateurs « ont
systématiquement été incapables
de produire des résultats durables
dans le système de santé.10 Les
composantes clés d’une approche
sectorielle sont :
•Une politique et une stratégie
sectorielle claires que le pays
s’est approprié ;
•Un programme de dépenses
à moyen terme reflétant la
stratégie sectorielle ;
•Un système de suivi des
performances permettant de
mesurer les progrès réalisés
et de renforcer l’obligation de
rendre compte ;
• D e s m é c a n i s m e s d e
consultation larges impliquant
toutes les principales parties
prenantes ;
• Un processus formalisé et
conduit par le gouvernement
de coordination de l’aide et
de dialogue au niveau du
secteur ;
•U n p ro c e s s u s c o nve n u
permettant d’avancer sur la
voie de l’harmonisation des
systèmes d’établissement des
rapports, de budgétisation,
de gestion financière et
de passation des marchés
publics.11
Les appréciations suivantes
faites en 2007, dans un rapport
de l’institut « HLSP Institute »12
permettent de se situer par
rapport au bilan de l’application
des SWAps en Afrique. De
ce rapport qui porte sur les
expériences dans six pays (Ghana,
Malawi, Mozambique, Tanzanie,
Uganda et Zambie), il se dégage
ce qui suit :
• Tous ces six pays ont
mis en place les piliers
fondamentaux de la SWAp :
Un plan stratégique sectoriel ;
un budget pluriannuel ou
un cadre des dépenses à
moyen terme CDMT (sauf
le Mozambique) ; des
processus pour une gestion
commune sous la direction
du gouvernement ; des
indicateurs communs pour le
suivi des progrès sectoriels ;
un mécanisme de fonds
commun sous des formes
variables selon le pays ; la
mise en œuvre des outils
pertinents leur permettant
d’appliquer les principes de
la déclaration de Paris.
• Tous ces pays ont connu une
amélioration significative
en matière de coordination
de l’aide et des échanges
d’information ; un
re n fo rc e m e n t d e l e u r s
capacités dans des domaines
tels que la planification et la
gestion. Ils ont pu élaborer des
stratégies sectorielles axées
sur les problèmes majeurs du
secteur ; de plus il y a eu un
accroissement significatif des
fonds injectés dans le secteur
santé.
• Cependant, dans quelques uns
de ces pays, la SWAp a perdu
son élan initial. On a assisté à
une baisse des fonds canalisés
à travers les mécanismes de
la SWAp tandis que les coûts
de transaction sont demeurés
élevés. Des contraintes
subsistent dans le domaine de
la mise en œuvre, notamment
en raison de la faible capacité
au niveau des districts.12
• « Finalement, il est difficile
de démontrer l’impact de
la SWAp à ce stade de son
développement , car les
succès sont mitigés, avec
des progrès dans certains
aspects et des stagnations
dans d’autres. Ce constat
est loin de signifier que les
SWAps n’ont pas fonctionné.
Au contraire il reflète
l’essence même des SWAps,
qui ont vocation de jeter
les bases d’un développent
sectoriel durable, tout en
permettant l’amélioration de
la performance du système de
9
prestation des services dans
son état actuel ».12
Reforme du système de
santé
La reforme du système de
santé peut être définie comme
un processus de changement
fondamental des dispositions
de politique et institutionnelles,
conçu par le gouvernement en vue
d’améliorer le fonctionnement
et les performances du secteur
santé dans le but d’aboutir à des
résultats meilleurs sur le plan
de la situation de santé.13 Les
réformes en cours en Afrique
sont souvent des réponses à
des problèmes spécifiques et
développées sous forme de
projets de santé parfois limitées
à des espaces géographiques
choisis dans le pays. Ces
modèles d’expériences, bien
que permettant d’obtenir des
résultats, se trouvent néanmoins
confrontés à des défis liés à leur
généralisation et à leur pérennité.
Perspectives
d’avenir
Comment aller de l’avant pour
faire des progrès significatifs
dans la marche des pays de la
région africaine pour relever les
nombreux défis du renforcement
de leurs systèmes de santé ?
Autrement dit, quelles sont les
opportunités et comment les
exploiter de manière optimale ?
10
Des opportunités intéressantes
s’offrent aujourd’hui dans le
domaine du renforcement des
systèmes de santé des pays. Elles
se résument ainsi :
=Opportunités politiques
dans les pays eux-mêmes
et dans les organismes
régionaux
Dans les pays de la région
africaine de l’OMS, la prise de
conscience des gouvernements
est grandissante et s’exprime
de diverses manières. Les Chefs
d’Etats ont maintes fois inscrit
la question de la promotion de
la santé et particulièrement le
renforcement des systèmes
de santé dans l’agenda de
leurs sommets, pour souligner
combien la santé est un facteur
de développement qui mérite
d’être élevée à un haut rang
de priorité, pour prendre des
résolutions qui les engagent à
agir concrètement en terme de
gouvernance et de leadership,
mais surtout à travers des
efforts financiers conséquents.
A cet égard, il faut rappeler la
déclaration d’Abuja en 2001 au
Nigéria dans laquelle les Chefs
d’Etats s’engagent à consacrer
à la santé, au moins 15% des
budgets nationaux de leurs pays
respectifs, engagement renouvelé
à Gaborone au Botswana en 2005
puis à Ouagadougou au Burkina
Faso en 2006.
Le bureau régional de l’OMS
pour l’Afrique, s’appuyant sur
les orientations des Assemblées
mondiales de la santé, stimule la
réflexion des pays de la région
en la recentrant davantage sur la
problématique des systèmes de
santé dans ses diverses facettes.
Ce fut le cas au cours des comités
régionaux en 1998, 14 2001, 15
2004, 16 et 2007. 17 En 2006, le
rapport sur la santé dans la
région africaine a consacré
un volet conséquent sur les
systèmes nationaux de santé
comme « le grand défi pour la
santé publique en Afrique ». 8
Dans le rapport 2008 de l’OMS,
sur la santé dans le monde
« les soins de santé primaires :
Maintenant plus que jamais »,
la Directrice générale, après
avoir tiré les leçons du passé,
a mis l’accent sur les défis et
les voies que les systèmes de
santé devraient suivre pour
« combler le fossé intolérable
qui sépare les aspirations de la
réalité ». Ces voies sont définies
à travers « (i) les réformes de la
couverture universelle qui font en
sorte que les systèmes de santé
contribuent à l’équité, à la justice
sociale et à la fin de l’exclusion,
essentiellement en tendant vers
l’accès universel aux soins et à la
sécurité sociale ; (ii) les réformes
des prestations de services qui
réorganisent les services de santé
autour des besoins et des attentes
de la population, afin de les rendre
plus pertinents socialement et
plus réactifs aux changements
du monde, tout en produisant
de meilleurs résultats ; (iii) les
réformes des politiques publiques
qui rendent les collectivités plus
saines, en combinant mesures
de santé publique et soins de
santé primaires, en menant des
politiques publiques saines dans
tous les secteurs et en renforçant
les interventions de santé publique
sur le plan national et transnational ; et (iv) les réformes du
leadership qui remplacent à la
fois la quête disproportionnée
de résultats à court terme
d’un côté et le laisser-faire du
désengagement des pouvoirs
publics de l’autre, par l’autorité
dirigeante inclusive, participative
et négociatrice qu’appelle la
complexité des systèmes de santé
contemporains ».18
Par ailleurs, en 2008, deux
conférences internationales
ont été organisées, l’une à
Ouagadougou sur les soins de
santé primaires et les systèmes
de santé en Afrique et l’autre à
Alger sur la recherche pour la
santé dans la région africaine.
Elles ont toutes formulées des
déclarations qui ont été dotées de
cadres de mise en œuvre, comme
outil permettant de mener les
actions concrètes, de mesurer et
de suivre les progrès.
D’autres instances et
organismes au niveau régional,
en collaboration avec l’OMS,
se sont également engagés
dans le combat en faveur du
santé. C’est le cas de la conférence
des ministres africains de la
santé19 et aussi du NEPAD.20
=Opportunités liées aux
partenariats internationaux
Un consensus grandissant
émerge actuellement au sein de
la communauté internationale
pour reconnaître que les
systèmes de santé défaillants
constituent un obstacle majeur
à la réalisation des Objectifs du
millénaire pour le développement
et qu’en conséquence il est
bénéfique d’investir dans leur
renforcement de façon innovante
et coordonnée. 18 C’est autour
de cette vision partagée que de
nouveaux partenariats mondiaux
connaissent un véritable essor
avec des parties prenantes
fortement engagées tels que GAVI
Alliance,18 le partenariat “Health
8”,21 le Partenariat international
pour la santé et Initiatives
apparentées.22
=Opportunités d’ordre
technique
Les savoir et savoir-faire dans
le domaine des systèmes de
santé ont connu un niveau de
développement appréciable en
offrant aux systèmes de santé,
des outils nécessaires pour
obtenir des résultats. C’est le cas,
à titre d’illustration : (i) du projet
“CHOICE” en anglais (Choosing
Interventions that are CostEffective), initié par l’OMS en
1998 afin de fournir aux décideurs
les bases factuelles pour
sélectionner les interventions et
programmes ayant un meilleur
rapport coût-efficacité ; (ii) de
l’initiative pour l’amélioration de
la performance des systèmes de
santé (Initiative EHSPI) dont le
but est de permettre aux pays
de développer une meilleure
capacité en matière d’analyse de
la performance des systèmes de
santé, de mise en œuvre et de
sui-évaluation des actions visant
à améliorer cette performance ;23
(iii) du cadre OMS pour le
santé « WHO’s framework for
action » publié en 2007, qui
fournit un cadre conceptuel
qui approche le système de
santé dans une perspective
systémique, le décompose ses
six piliers fondamentaux, et
offre finalement un creuset
commun pour sa configuration
ou son renforcement selon le
contexte de chaque pays ;4 (iv)
du cadre du Réseau de métrologie
sanitaire pour la mise en place
et le renforcement des systèmes
d’information sanitaire des pays
(Cadre-HMN) assortis d’une
série d’outils d’évaluation,
de planification, et d’aide à la
formulation et la soumission des
requêtes en vue de l’obtention
d’un appui technique ou d’un
financement du réseau ; 6 (v)
de la série de boîtes à outils
mises au point par l’OMS, la
Banque Mondiale et d’autres
partenaires en 2008, et qui décrit
un ensemble d’indicateurs ainsi
que des stratégies pertinentes,
afin de permettre aux pays de
11
disposer d’un cadre cohérent
et unifié pour le monitorage du
santé.24
=Une question essentielle
se pose alors, au vu de ces
opportunités
Comment en tirer le meilleur
bénéfice possible et capitaliser
au maximum les expériences
accumulées par les pays pour
faire des avancées décisives dans
le domaine du renforcement des
systèmes de santé ? Cette question
constitue elle-même un défi qui
interpelle les gouvernements
des pays eux-mêmes à qui il
appartient d’assumer pleinement
leurs responsabilités pour entrer
en possession de cet immense
trésor de potentiels qui est
maintenant à leur portée. C’est
alors que l’accompagnement
des partenaires engagés à leurs
côtés, pourra démonter toute son
efficacité.
Toutefois, il faut reconnaître, à
la suite du rapport de la Banque
mondiale, édition 2006, sur le
financement de la santé, que
« toute réforme du secteur de
la santé, dans quelque pays
du monde que ce soit, est une
opération complexe ». 25 Les
dirigeants des pays de la région
africaine se doivent de répondre
à cette interpellation avec un
engagement à la mesure des
enjeux vitaux que recouvre le
santé dans leurs pays.
Conclusion
Malgré leur importance vitale
reconnue, les systèmes de
santé des pays de la région
africaine de l’OMS ne jouissent
pas de l’attention méritée de
la part des gouvernements, en
termes de priorité d’action et
d’allocation de ressources. Aussi
connaissent-ils généralement de
graves dysfonctions en rapport
avec leurs multiples défaillances
au regard des structures, des
infrastructures, et des moyens
humains et matériels. Toutefois,
la prise de conscience est
grandissante au sein des pays
concernés quant à la nécessité
impérieuse d’intensifier les
actions dans la perspective
d’atteindre les OMD relatifs
à la santé à l’heure du bilan.
Les défis à relever à cet égard
sont immenses et complexes et
touchent à plusieurs domaines :
leadership et gouvernance ;
aspects organisationnels et
institutionnels ; information
sanitaire ; financement ;
ressources humaines et
matérielles.
Plusieurs initiatives ont été
engagées dans les pays selon
le contexte et les opportunités,
mais elles restent généralement
localisées et leur expansion
à l’échelle nationale difficile.
Certaines sont néanmoins
suffisamment prometteuses,
comme les approches sectorielles
12
développées dans quelques pays.
Il y a lieu de capitaliser les acquis
de ces initiatives pour faire des
avancées significatives, surtout
que les opportunités immenses
s’offrent aux pays de la région
africaine, et qui sont soit d’ordre
politique au sein de ces pays, soit
liées aux partenariats mondiaux
qui se sont développés, soit
d’ordre technique.
Mais cela ne suffit pas pour
relever les défis du renforcement
des systèmes de santé. Dans
tous les cas, un changement
de paradigme s’impose afin
de pouvoir, dépasser la simple
notion que le système de santé
peut être construit uniquement
autour des maladies ou des
interventions verticales, pour se
convaincre que la clé n’est pas
dans les outils techniques mais
dans le processus politique et
les valeurs de société.4 Armés
d’une telle vision nouvelle,
ils pourront et devront alors
inscrire le renforcement des
systèmes de santé dans le cadre
d’un plan stratégique qui devrait
s’exécuter graduellement dans
une perspective à long terme,
selon des priorités clairement
définies. z
Références bibliographiques
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la lutte contre le paludisme, le VIH/sida et la tuberculose, 10–12
octobre 2005, Botswana. Union africaine, 2005.
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les systèmes de santé : le processus de réforme peut-il être fondé
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13/Taskforce/Johansbourg/JA.pdf. IHP+, 2011.
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hspa15_pertinence.pdf, OMS, 2011.
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13
Health systems
in sub-Saharan
Africa: What
is their status
and role
in meeting
This paper reports on an assessment conducted in 2007 of the global progress
towards achieving the health Millennium Development Goals (MDGs) which
showed disparities, with sub-Saharan Africa trailing the rest of the developing
the health
world. This situation exists despite the existence of cost-effective interventions
for addressing the targeted health problems. It is increasingly assumed that the
Millennium
missing link has been ineffective use of the interventions and the weakness of
health systems that are unable to scale up implementation of the interventions.
a health systems review was conducted in five countries of subDevelopment Consequently,
Saharan Africa, namely Kenya, Malawi, Namibia, Uganda and Zambia. The
countries were purposefully selected on the basis of the availability of country
Goals?
reports. A literature review was carried out, focusing primarily on country health
Prosper Tumusiime
Andrew Gonani
Oladapo Walker
Eyob Z Asbu
Magda Awases
Pierre C Kariyo
Intercountry Support Team, South and East Africa, WHO
African Region
Corresponding author
Prosper Tumusiime
E-mail: [email protected]
14
sector reports and United Nations data on MDG indicators complemented by on-line
literature. The status of health systems was assessed using WHO’s six health system
building blocks, covering the period up to 2007. Whereas Malawi, Namibia and
Zambia are likely to achieve the measles immunization targets, only Malawi and
Zambia are likely to meet the under-five mortality targets. However, in considering
the maternal mortality rate (MMR), where approximately 5.5% annual average
reduction is required in order to meet the MDG target, all countries are not on track,
although Namibia has made progress in the provision of skilled birth attendance.
In all the countries reviewed, there is a weakness in health policies and guidelines,
and a shortage of human resources and medicines, while public expenditure on
health has not risen as expected towards the 15% Abuja target. Health information
systems are fragmented and not fully utilized and health service coverage is not
adequate. Overall, there is inadequate progress towards achieving the selected
MDG impact indicators in the five reviewed countries, against a background of
non-conducive health sector policy environment and inadequate resources and
service coverage. Achieving the MDGs will require timely national refocusing of
health sector policies and commitment to health systems strengthening.
Sumário
résumé
Eight MDGs were adopted by
189 countries following the
signing of the United Nations
Millennium Declaration in
2000.1,2
En 2007, l’évaluation des progrès réalisés vers l’atteinte
des objectifs du Millénaire pour le développement
(OMD) dans le monde a révélé bien des disparités,
et montré que les pays d’Afrique subsaharienne
demeurent à la traîne par rapport aux autres pays en
développement, en dépit de l’existence d’interventions
d’un bon rapport coût-efficacité qui permettent de
résoudre les problèmes de santé ciblés. L’on est
porté à croire que le «chaînon manquant» demeure
l’utilisation inefficace des interventions proposées et
la faiblesse des systèmes de santé, qui ne parviennent
pas à passer les actions à l’échelle. En conséquence,
un examen des systèmes de santé a eu lieu au Kenya,
au Malawi, en Namibie, en Ouganda et en Zambie, 5
pays d’Afrique subsaharienne sélectionnés à dessein
sur la base de la disponibilité de rapports pays. Une
revue de la littérature a été effectuée, avec un accent
marqué sur les rapports sectoriels de la santé produits
par les pays et sur les données des Nations Unies
relatives aux indicateurs des OMD, complétée par
la documentation en ligne. En utilisant les six blocs
constitutifs du système de santé de l’OMS, l’état des
systèmes de santé a été évalué jusqu’en 2007. Il en
ressort que si le Malawi, la Namibie et la Zambie
réussiront probablement à réaliser les objectifs de
vaccination antirougeoleuse, seuls le Malawi et la
Zambie pourront atteindre les cibles relatives à la
mortalité des moins de cinq ans. D’autre part,
s’agissant de la mortalité maternelle, dont le taux
doit baisser annuellement de 5,5 % environ pour
atteindre la cible de l’OMD, il convient de relever
qu’aucun des cinq pays n’est en bonne voie sur cet
indicateur, même si la Namibie a fait des progrès sur
le plan de la disponibilité d’accoucheuses qualifiées
pendant l’accouchement. Tous les pays évalués se
caractérisent par une absence de nombre de politiques
et lignes directrices sanitaires et par une pénurie de
ressources humaines et de médicaments. En outre, la
dépense publique de santé n’a pas augmenté comme
prévu pour atteindre l’objectif d’Abuja, qui est de 15
% du budget national. Les systèmes d’information
sanitaires sont fragmentés et ne sont pas utilisés
comme il convient, et la couverture des services
sanitaires demeure insuffisante. En général, les
progrès vers l’atteinte des indicateurs d’impact des
OMD demeurent lents dans les cinq pays examinés, qui
évoluent au demeurant dans un contexte de politiques
sectorielles de la santé peu propices, de ressources
insuffisantes et de couverture sous-optimale des
services. Pour atteindre les OMD, il faudra recentrer
comme il convient les politiques sectorielles de la santé
et renouveler l’engagement en faveur du renforcement
des systèmes de santé.
A avaliação dos progressos em relação à consecução
mundial dos Objectivos de Desenvolvimento do
Milénio (ODM) em 2007 revelou disparidades, com
a África Subsariana a ficar atrás do resto dos países
em desenvolvimento. Esta situação verifica-se apesar
da presença de intervenções custo-eficazes para os
problemas de saúde visados. Assume-se cada vez
mais que o elo em falta tem sido a utilização ineficaz
dessas intervenções e a fragilidade dos sistemas de
saúde, que se mostram incapazes de as implementar
adequadamente. Consequentemente, foi feita uma
análise dos sistemas de saúde em cinco países da
África Subsariana, nomeadamente no Quénia, no
Malawi, na Namíbia, no Uganda e na Zâmbia. Os países
foram deliberadamente selecionados com base na
disponibilidade de relatórios nacionais. Foi feita uma
análise da literatura incidindo sobretudo nos relatórios
nacionais do sector da saúde e nos dados das Nações
Unidas sobre os indicadores dos ODM, complementada
por literatura online. O estado dos sistemas de
saúde foi avaliado utilizando as seis componentes
essenciais do sistema de saúde da OMS, abrangendo
o período até 2007. Embora o Malawi, a Namíbia e a
Zâmbia consigam provavelmente atingir as metas de
imunização do sarampo, apenas o Malawi e a Zâmbia
conseguirão provavelmente alcançar os objetivos em
termos da taxa de mortalidade em menores de cinco
anos. Por outro lado, a redução da taxa de mortalidade
materna (TMM), que requer uma redução anual de
cerca de 5,5% para alcançar a meta dos ODM não
está no bom caminho em todos os países, embora
a Namíbia tenha registado progressos na prestação
de assistência especializada durante o parto. Em
todos os países analisados, faltam algumas políticas
e linhas de orientação sanitárias, recursos humanos
e medicamentos, não tendo as despesas públicas
na saúde aumentado como previsto no sentido do
objectivo de Abuja de 15%. Os sistemas de informação
sanitária estão fragmentados e não são totalmente
utilizados, e a cobertura do serviço de saúde não é
adequada. Em termos gerais, o progresso registado
foi inadequado para a consecução dos indicadores
de impacto dos ODM selecionados nos cinco países
analisados num contexto de uma política do sector
da saúde desfavorável, assim como de recursos e
cobertura de serviço inadequados. A consecução dos
ODM requer um reenquadramento nacional oportuno
das políticas do sector da saúde e um compromisso no
sentido de reforçar os sistemas de saúde.
MDGs 4, 5 and 6 directly relate
to health namely; reducing
under five child mortality by
two thirds, reducing maternal
mortality by three quarters and
to halt and begin reversing the
spread of HIV/AIDS, malaria
and other major diseases,
using 1990 as the baseline
and 2015 as the target year for
achievement.3,4
However, assessment of progress in
2007 showed uneven results globally
with sub-Saharan Africa trailing
behind the rest of the developing
world not withstanding that proven
and cost-effective interventions
to implement against the targeted
health problems are known and
well understood.3,5 The interventions
are not effectively used and health
systems are not always capable
of implementing them to scale.3 It
was with this background that a
literature review was conducted
to gain an insight into the current
status and role of health systems
in meeting the health MDGs in subSaharan Africa.
15
A desk review of the literature
on health systems and MDGs was
performed between the months
of July and September 2009 for
five countries from Eastern and
Southern Africa, namely Kenya,
Malawi, Namibia, Uganda and
Zambia. The countries were
selected purposefully based
on the availability of national
health sector reports. The review
primarily focused on country
health sector reports that are
in the public domain and data
from the United Nations on MDG
indicators.6,7 These sources were
complemented by literature
search in the following electronic
databases: national ministry of
health websites, WHO’s Global
Information Full Text, Pub Med
and Google Scholar. The status
of country health systems was
assessed using the WHO’s six
health system building blocks’
selected desirable attributes as
outlined in the Framework for
Action for Strengthening Health
Systems to Improve Health
Outcomes.8 See Table 1.
Results
P rogress on
selected health
MD G impact
indicators
H e a l t h i m p a c t i n d i c a to r s
monitored through the United
16
Table 1. Assessment criteria using the six WHO health system building blocks
Health system building block
Leadership and governance
Sustainable financing
Health workforce
Medicines and vaccines
Information
Service delivery
Reviewed attribute
Availability of sector strategies
Collaboration
Accountability
Adequacy of funding for health
Out of pocket expenditure payments
Quantity
Distribution
Availability
Facility based data utilization and reporting
Package of integrated services
Coverage
Figure 1. Under five child mortality rate among the reviewed countries, 1990 to 2007
250
Deaths/1000 live births
Methodology
● Kenya
● Malawi
● Namibia
● Uganda
● Zambia
200
150
100
50
0
1990
1995
2000
2005
2007
Year
Source: United Nations MDG indicators official website.
Nations include MMR and under
five mortality rate.6 Among the
reviewed countries, the MMR
in 2005 was 210 maternal
deaths per 100 000 live births
for Namibia representing 6.7%
reduction from the 1992 level
translating into 0.5% average
annual decrease; in the same year
Uganda was at 435/100 000 with
a 13.9% reduction from 2000
level, a 2.8% average annual
decrease; so too was Kenya at
560/100 000, a 16.4% decrease
from 1990 making 1% average
annual decrease; 449/100 000
for Zambia in 2007 representing
a 30.8% decrease 1996 and 2.8%
average annual decrease; and
807/100 000 for Malawi in 2006,
a 30.2% increase from the 1992
level.6,9,10,11,12,13
The trend of under five mortality
rate from 1990 to 2007 among
the countries is shown in
Figure 1. Malawi and Uganda
show a declining trend in under
five mortality while the other
three countries seem to have a
generally stable trend.6
Leadership and
gov ernance
All reviewed countries have
incorporated the MDGs in
national policies and plans as
follows: through the national MDG
based planning process in Kenya;
the Growth and Development
Strategy in Malawi; Vision 2030 in
Namibia; the Poverty Eradication
Action Plan in Uganda; and the
Fifth National Development Plan
in Zambia. 9,10,11,12,13 They also
generate periodic reports on
national progress of achievement
of the MDGs.9,10,11,12,13
By the time of this review, all
countries except Malawi had
National Health Policies and
all of them except Namibia
had National Health Sector
Strategic Plans or Programmes
of Work. 14,15,16,17,18 By the year
2008 some national policies and
guidelines relating to the three
MDGs were either in draft form
or needed updating: in Namibia
on the minimum essential
package, health promotion,
patient referral, Expanded
Programme on Immunization
(EPI) and essential medicines
list; in Uganda on EPI, national
health laboratory and public
private partnership; in Kenya
the reproductive health strategy,
child health, communication
strategy and the immunization
policy; in Malawi the national
health policy; and the health
facility policy for Zambia in
2007.14,15,16,17,18
With the exception of Namibia,
all the reviewed countries
have a formal collaborating
arrangement with development
partners through the sectorwide approach (SWAp) whose
objective is to have all significant
health sector funding supporting
a single policy and expenditure
programme. 14,15,16,18,19,20 Since
inception of SWAp in these
countries, they hold annual
joint review meetings with
stakeholders as one form of
accountability; Namibia held its
first health and social services
system review in 2008.14,15,16,18,20
S u stainable
financing
General government expenditure
on health as a percentage of
total government expenditure
in 2006 compared with 2002
has generally been stable in
all reviewed countries except
Zambia where it has increased21
(see Table 2). Notable also is
that only Malawi and Zambia are
above the 15% target of the Abuja
Declaration 2001.22
Comparing the years 2006 and
2002 the per capita total health
expenditure (THE) has increased
in all countries varying from a
31% increase in Malawi to
over 100% for Namibia and
Zambia 21 (see Table 2). While
external resources for health
as a percentage of THE slightly
decreased between the years 2002
and 2006 in Kenya, it increased
for the rest of the countries with
Namibia experiencing over 100%
increase.21 Out of pocket (OOP)
expenditure as a percentage of
private expenditure on health,
varied from 5.7% in Namibia to
80% in Kenya in the year 200621.
See Table 2.
Table 2. Selected health expenditure indicators for the reviewed countries
Country
Kenya
Malawi
Namibia
Uganda
Zambia
General government
expenditure on
Per capita health as % of total
Year THE US$ government expenditure
2006
29
9.7
2002
18
8.9
2006
21
17.1
2002
16
17.6
2006
281
11.1
2002
105
11.1
2006
24
8.9
2002
17
9.8
2006
58
16.4
2002
23
13.6
External
resources for
health as % of
THE
14.9
16.4
59.6
44.4
22.4
3.2
31.2
21.5
38.1
26.0
OOP expenditure
as % of private
expenditure on
health
80.0
80.0
28.4
44.4
5.7
9.8
51.0
51.4
67.2
77.0
Source: WHO selected National Health Accounts indicators.
17
Kenya and Namibia’s public
health services have a policy of
applying user fees at the hospital
level with the former exempting
under five children.14, 23 Uganda
abolished the user fees in public
facilities in 2001 while Zambia
removed them in 54 selected
rural districts in 2004; Malawi
does not have a user fee policy
for public health facilities.16,24,25
Health workforce
Malawi, Namibia, Uganda and
Zambia have national human
resources for health (HRH)
strategic plans focusing on
training, recruitment, retention
and management; however, in
all cases implementation was
slow.14,15,16,18 Training institutions
have inadequate human and
infrastructural capacity; by
2008 Malawi and Zambia’s
comprehensive human resources
information systems were still
under development and Namibia’s
was paper based.14,15,16,18 Namibia
and Uganda were experiencing
lengthy recruitment processes
and implementation of HRH
rural retention schemes were
making slow progress because
of inadequate funding, while
Namibia abolished its rural
retention schemes in 1995.14,15,16,18
The density of public sector
medical doctors, nurses and
midwives combined per 1000
population was 0.18/1000 in
Malawi in 2006; 0.98/1000 for
Zambia in 2007; 1.4/1000 in
18
Table 3. Selected public HRH vacancy rates in four reviewed countries, 2006 and
2008
Country vacancy rates (%)
Workforce category
Malawi
Namibia
Uganda*
Zambia
Doctors
67
36
36
27
Nurses
77
24
29
42
Dental personnel
69ª
48
34
nd
Pharmacy personnel
79ª
41
43
44
Laboratory personnel
30ª
nd
nd
50
Environmental personnel
38ª
56
nd
50
Radiographers
69ª
34
nd
55
Source: country reports. nd = no data available. *data from general and regional hospitals only. ª 2006 data, the rest 2008.
Kenya in 2004; and 2.0/1000 for
Namibia in 2008.14,16,23,25 Overall,
public sector vacancy rates were
at 27% for Namibia and 49% for
Uganda in 2008; while Zambia
and Malawi reached 50% and
77% for laboratory personnel
and nurses respectively in 2006
and 2008.14,15,16,18,25 See Table 3.
The vacancy rates were worsened
by recruitment freezes in Kenya
and Uganda in 2005 and 2007
respectively.11,12
By 2008, the majority of doctors,
dentists and pharmacists and
close to half of registered nurses
in Namibia were working in
the private sector, serving an
estimated 15% of mostly urban
populations.14 The distribution
of HRH in favour of urban areas
was also experienced in Zambia
and Uganda.15,16
M edicines and
vaccines
A health system review in Namibia
in 2008, reported medical stock
outs in a number of regions of
the country with 50% of health
facilities in one region having had
a stock out of oral rehydration
salts (ORS) and 35% for Coartem
in a three-month period.14 In 2008
a Uganda national facility survey,
established that 72% of surveyed
health facilities had stock outs
of one or more of the six tracer
medical products that included
Coartem, Cotrimoxazole, ORS and
measles vaccine in the 2007/08
fiscal year; while in Kenya
33% of health facilities were
without national tracer drugs
for a period of more than two
weeks in the same fiscal year.15,17
A national survey in Kenya in
2004 established that first line
medicines that included antimalarial drugs and antibiotics
for the treatment of children’s
conditions were available in
83% of facilities and pre-referral
medicines were available in
25% of the facilities; it further
reported that 40% of the facilities
had all components for providing
quality child immunization.27
In Malawi a national review in
14 purposefully selected district
From demographic and health
surveys, skilled attendance
during delivery varies from
81% in Namibia to 42% for
Uganda in 2006.6,14 See Figure 3.
Namibia reported good progress
towards attaining the MDG goal
of providing skilled attendance
at births while the rest of the
reviewed countries reported
inadequate progress.9,10,11,12,13
Figure 2. One year old children measles immunization coverage, 1990 to 2007
100
90
● Kenya
● Malawi
● Namibia
● Uganda
● Zambia
80
70
60
2007 –
2006 –
2005 –
2004 –
2003 –
2002 –
2001 –
2000 –
1999 –
1998 –
1997 –
1996 –
1995 –
1994 –
40
1993 –
50
1992 –
In 2005–06 Namibia achieved
80% of timeliness and
completeness of national
reporting of disease surveillance
data from districts while in
All the reviewed countries except
Namibia are implementing health
services based on an integrated
essential health package by level
of health services; Namibia’s
policy towards developing this
package was in draft form in
2008.14,15,16,18,23 In 2008 40% of
Namibia’s population lived within
5 kilometres of a health facility;
46% for Malawi in 2004; 50%
for Zambia in 2008 and 75% for
Uganda in 2008.14,15,27
1991 –
All reviewed countries have
established health information
systems (HIS) as the main source
of routine health data.14,15,18,23,27
It was noted in 2008 that
Namibia has multiple stand alone
information systems managed
by different divisions of the
central Ministry of Health and
Social Services and running on
different software in addition
to the HIS.14 A similar situation
was reported in Malawi where
there are separate, individual
reporting systems particularly
for national disease control
programmes operating both at
national and district levels.18 The
private health sector in Namibia
and Malawi does not participate
in the routine HIS reporting.14,18
H e a l t h s e r v i c e p rov i s i o n
coverage, as exemplified by
measles immunization, antenatal
care (ANC) and the provision
of skilled attendance during
delivery, is shown in figures
2 and 3. The immunization
trends show stagnation or little
increase in coverage. However,
Malawi, Namibia and Zambia are
reported potentially likely and
Uganda unlikely to achieve the
measles immunization target by
2015.9,10,12,13
S erv ice deli v ery
1990 –
Information
Zambia it was 99% in 2007.27,28
Uganda reports that while 83%
of districts submitted the disease
surveillance weekly reports to
the national level, only 56%
submitted them on time.15 Local
utilization of the data through
trend analysis was reported at
66% of health facilities in Uganda
while in Zambia it was at 100%
in 2007.15,27
Percentage (%)
hospitals and 11 health centres
reported consistently higher
average stock out rates at health
centre level than district hospitals
with Amoxicillin capsules having
an average of 134 stock out days
as compared with 70 days for
hospitals in 2008.26 Stock outs
were also reported in Zambia
on some vaccines, anti-malarial
drugs and family planning
commodities in purposefully
selected facilities in the same
year.16
Year
Source: United Nations MDG indicators official website.
19
Figure 3. Antenatal visits at least four times and births by skilled
attendance coverage, 2002 to 2006
● ANC four visits ● Skilled attendance
90
80
Percentage (%)
70
81.4
70.4
71.6
60
57.1
50
40
53.6
43.4
52.3
47.2
41.6
42.1
Kenya
Uganda
30
20
10
0
Namibia
Zambia
Malawi
Source: United Nations MDG indicators official website. All Zambia’s data are from 2002 and Kenya’s from
2003. Malawi’s ANC data are from 2003; the rest of the data are from 2006.
The percentage of under
five children sleeping under
insecticide treated bed nets
was at 4.6% in Kenya in 2003,
and 9.7%, 22.8%, and 23% for
Uganda, Zambia and Malawi
respectively in 2006.6
Discussion
This review has shown that the
progress in meeting the health
MDG goals among the selected
countries is quite varied with
inadequate progress overall. The
reduction of MMR which requires
a 5.5% annual reduction to meet
the MDG target is not on track
in all countries. 7 Only Malawi
seems likely to meet the under
five mortality targets; the rest
of the countries are performing
below the required 4.3% average
annual reduction to meet the
20
target. 29 Only Namibia made
progress in the provision of
skilled attendance at birth; while
Malawi, Namibia and Zambia
were likely to achieve the measles
immunization targets. This
inadequate progress is against
a background of weak health
systems unable to effectively
deliver health services required
to reach the MDGs.
MDGs are meant to influence realignment of national priorities
towards human development;
effective national leadership
in this regard will ensure that
strategic policies and plans
are formulated or existing
ones aligned to the MDGs and
followed by effective oversight
and coalition building. 8,30 The
finding that all countries have
adapted the MDGs to national
policies and strategies is the
right step in this direction; and
this finding is in contrast to the
global survey finding of 2005 in
118 countries where only one
third of national strategies were
amended to reflect the MDGs.30,31
At health sector level, the
policy environment was not
conducive to effectively guide
the implementation of health
services towards meeting the
MDGs in the reviewed countries.
The finding that some health
policies and guidelines were in
draft form or needed updating
(and in some countries had
been that way for a number of
years), raises questions over the
sector’s stewardship in meeting
the MDGs. 14,15,16,17,18 Some of
the reasons advanced for this
situation include inadequate
institutional capacity for policy
analysis and development
in Namibia and the lengthy
legislation process in Uganda.14,15
The introduction of SWAp in
four of the reviewed countries
has the potential of promoting
collaboration in the formulation
of national health strategies and
plans, resources mobilization,
monitoring and bolstering
government leadership. 9,32,33
SWAp reduces the fragmentation
and duplication of planning
and programmes which is
quite prevalent in Namibia
where there were 36 parallel
agreements with individual
development partners by the
year 2008.14 Besides improving
donor collaboration, stronger
intersectoral collaboration would
assist countries in effectively
combatting other determinants
of health crucial to meeting the
MDG targets as indicated by
Malawi and Namibia.9,13
A good health financing system
raises adequate funds in ways
that allow people to use needed
services while being protected
from financial catastrophe and
impoverishment associated
with having to pay. 8 For lowincome countries, this requires
an optimized combination of
in-country equitable health
financing and funding from
donors. 3 Namibia and latterly
Zambia have shown higher per
capita expenditure, meeting the
US$ 34 recommended by WHO’s
Commission on Macroeconomics
and Health unlike the rest of the
countries.34 Indeed per capita
expenditure on health in subSaharan Africa is lower than any
other region, averaging US$ 23.35
Government expenditure on
health as a percentage of total
government expenditure has
generally been stable between
2002 and 2006, whereas
(except for Kenya) financing has
increased. This raises questions
on the fungibility of public funds
in the face of favourable donor
support – increases in external
support do not seem to lead
to increases in the allocations
to health, but are absorbed
elsewhere. In all countries
except Namibia OOP expenditure,
though seemingly decreasing or
stable, was higher than the 15%
threshold that would protect most
households from catastrophic
expenditure.36 This situation is
probably linked to the countries’
user fees policies. Inadequate
health financing has adverse
implications for the other health
systems such as health worker
remuneration, the availability
of medicines and supplies and
health service coverage scale up.
A well performing health
workforce is the one that has
sufficient numbers and mix, is
fairly distributed, competent and
productive.8 The density of public
health sector medical doctors,
nurses and midwives combined
varied from 0.8/1000 population
in Malawi to 2.0/1000 in Namibia.
This is against a background of
high vacancy rates and national
maldistribution in favour of the
private sector and urban areas.
Even though there is no universal
norm for minimum HRH density
because it is context specific, it
has been estimated that a density
of less than 2.28/1000 generally
fails to achieve 80% coverage for
skilled birth attendance and child
immunization. 37 The shortage
of HRH has affected most subSaharan Africa countries; as
of 2001, only 360 of the 1200
physicians trained in Zimbabwe
in the 1990s were still practising
in the country; while in Swaziland
44% of posts of physicians and
19% of posts of nurses were
unfilled in the year 2004. 38,39
The maldistribution of HRH is
also the case in Ghana where the
Greater Accra Region has a doctor
density 30 times that of the
21
Northern Region.38 The shortage
of HRH will affect the quality
and availability of services, in
turn contributing to poor health
outcomes.
A well functioning health
system ensures adequate and
equitable access to essential
medical products, vaccines and
technologies.8 The findings have
reported medicine and vaccine
stock outs in all reviewed countries
with respect to ORS, anti-malaria
drugs, antibiotics, measles
vaccines and family planning
commodities, all of which are
crucial to meeting MDG targeted
services. Similar situations
pertain elsewhere in Africa. For
example, the unavailability of
medicines reported in South
Africa in 2003 was among the
factors contributing to health
service quality weaknesses in
three provinces.40 System issues
of procurement, management
and logistical challenges have
been identified as the primary
causes of the medicine and
vaccine stock outs in Malawi
and Zambia.16,41 The shortage of
medicines and vaccines makes
services unavailable to the people
that need them most, the poor,
who may be pushed to make
catastrophic expenditures as they
resort to purchasing necessary
products.
A well functioning health
information system will ensure
t h e p ro d u c t i o n , a n a lys i s ,
dissemination, and use of reliable
and timely data.8 All the reviewed
countries have established HIS
as a source of routine data;
however, they face challenges of
fragmentation, non-involvement
of the private sector, untimeliness
and incompleteness of data
and inadequate analysis. The
existence of parallel information
systems has also been reported
in Mozambique; and inadequate
utilization and untimeliness
in the United Republic of
Tanzania. 15,42 “Projectization”
of development assistance has
been advanced as one of reasons
for the fragmented HIS; and the
private sector’s non involvement
and lack of legislative provision
and noncompliance in Malawi
and Namibia.14,18 Untimeliness
and incompleteness have been
attributed to lack of feedback
on the submitted data; and
inadequate utilization to capacity
and motivation constraints in
Malawi, Uganda and the United
Republic of Tanzania.15,42 Health
information that is of poor quality
due to incompleteness and
untimeliness negatively affects
decision making at both policy
and operational levels which then
impacts the performance of the
health systems.
Good health services are those
that deliver health interventions
to those who need them, when
and where needed. 8 Malawi,
Namibia and Zambia reported
potentially likely and Uganda
unlikely to achieve the measles
immunization MDG target; while
only Namibia reported good
progress in providing skilled
attendance at birth. See figures
2 and 3. Under five insecticide
treated bed nets utilization varied
22
from 4.6% in Kenya to 23% for
Malawi; the reviewed countries
have quite a long way to go in
the fight against malaria. The
delivery of an integrated essential
package, a guaranteed minimum
of interventions by level of
health services in four of the five
countries would focus resources
to the most common local
causes of disease burden and the
integration would make services
more accessible and convenient to
users, increase service efficiency
through sharing of resources, and
reduce duplication in delivery and
administration.43 However, the
challenge is inadequate funding
of the packages as exemplified by
Uganda’s costing of the package at
US$ 28 per capita but by the year
2008 the country was spending
only US$ 8.2 per capita.15 It is
recommended that developing
countries invest US$ 34 per
capita per annum for delivering
basic essential health care
interventions.34 The application
of the user fees policies in three
of the five countries and the low
population density per health
facility could prove to be barriers
to accessing health services; the
abolition of user fees in Uganda in
2001 saw a rapid increase in health
service utilization especially for
the poorest populations.44
It should be recognized that all the
health system building blocks are
interdependent on each other and
therefore require an integrated
approach to improvement.8 For
example while skilled attendance
at birth is essential, maternal
outcomes will still be affected by
the systems in which they occur;
in 2005, Uganda had over three
times the skilled attendance rate
(39%) than Bangladesh (12%)
but still estimates of MMR were
higher in Uganda at 505 compared
with 322 for Bangladesh. 45
Explanations for this disparity
were systemic such as the quality
of hospital care; availability of
medicine and doctors to handle
complications and geographical
barriers to accessing health
service.45
Limitations of this review include
the use of data from multiple
sources that included routine data
in some instances whose quality
could not be ascertained; and the
unavailability of data from some
of the selected countries. The
strength of the review includes
the use of data from population
based and other country surveys.
There is need for further review
to assess the quality of the
adaptation of national health
sector policies to the MDGs;
to explore the operational
bottlenecks faced by the health
system building blocks; and to
consider the private sector’s role
in contributing to achieving the
MDGs in the face of public service
health system challenges.
In conclusion this paper has
highlighted varied and inadequate
progress towards achieving
selected MDG indicators in the
five reviewed countries against
a background of non conducive
health sector policy environment,
underfunding, shortage of HRH,
unavailability of medicines and
vaccines and inadequate service
coverage. Meeting the MDGs
requires an urgent refocus of
national sector policies and
commitment to improving all
health system building blocks
holistically. National health sector
leadership has to be displayed by
timely formulation of relevant
policies and guidelines and
sufficient funding of the sector
to sustainably complement the
increased donor funding. In
turn, health sector resources
should be effectively funded to
improve their availability. Health
information systems should
be strengthened so that they
provide reliable data for resource
planning, management and
improvement of service coverage.
The recently adopted
Ouagadougou Declaration on
Primary Health Care and Health
Systems seems to provide an
opportune framework to subSahara African countries to scale
up health interventions and
accelerate their progress towards
meeting the MDGs in 2015.46 z
23
Acknowledgements
The authors would like to thank all those who made contributions
during the draft and review stages of this article.
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Assessing the
efficiency of
hospitals in
Malawi: An
application
of the
Pabón Lasso
technique
Eyob Z Asbu
résumé
1 Family Health International,
Development 360, Washington, DC
2 World Health Organization, Regional Office
for Africa, Intercountry Support Team for East
and Southern Africa, Harare, Zimbabwe
3 World Health Organization, Regional Office
for Africa, Brazzaville, Congo
4 World Health Organization, Lilongwe, Malawi
5 Department of Planning and Policy
Development, Lilongwe, Malawi
6 East, Central and Southern African Health
Community, Arusha, United Republic of
Tanzania
Aucune enquête relative à l’utilisation des capacités basée sur la technique Pabón Lasso (PL)
n’a été conduite au Malawi jusqu’à ce jour. La présente étude examine l’efficacité technique
des hôpitaux publics et confessionnels au niveau du district. La technique Pabón Lasso est
appliquée en évaluant la performance relative d’un échantillon de 40 hôpitaux au niveau du
district (60 % d’hôpitaux publics et 40 % d’hôpitaux confessionnels) au Malawi. Le calcul des
taux d’utilisation des hôpitaux et l’élaboration du diagramme Pabón Lasso ont été effectués
à l’aide de STATA 10. Seulement 27,5 % des hôpitaux se situaient dans la zone souhaitable du
diagramme de Pabón Lasso (la zone la plus en haut à droite), alors que près de 50 % d’entre
eux se trouvaient dans la zone la plus en bas à gauche, qui correspond à la situation la moins
souhaitable et se caractérise par un faible ratio de rotation associé à un faible taux d’occupation
des lits. L’utilisation des capacités est meilleure dans les hôpitaux publics de premier niveau, en
comparaison avec les hôpitaux confessionnels. En dépit d’une faible densité de lits, le constat
d’une utilisation largement insuffisante de l’offre actuelle des lits de patients s’impose. Les
causes principales doivent être identifiées et des actions appropriées de génération de la
demande entreprises pour juguler ce problème. En outre, pour identifier les inefficacités liées
à l’échelle/taille, il faut mener une évaluation à l’aide de techniques de pointe pour mesurer
l’efficacité (par exemple une analyse d’enveloppement des données ou des modèles de pointe
stochastiques, incluant les fonctions de production et de coût).
Resumo
Eyob Z Asbu1
Oladapo Walker2
Joses M Kirigia3
Felicitas Zawaira4
Francis Magombo4
Patrick Zimpita5
Gerald Manthalu5
Dominic Nkhoma5
Cynthia Eldridge5
Edward Kataika6
Studies on capacity utilization, using the Pabón Lasso (PL) technique
have not been conducted in Malawi before. This study examines the
technical efficiency of district-level public and mission hospitals. The
Pabón Lasso technique is applied in assessing the relative performance
of a sample of 40 district hospitals (60% public and 40% mission) in
Malawi. The computation of hospital utilization ratios and construction
of the Pabón Lasso diagram was performed using STATA 10. Only 27.5%
of the hospitals were located in the desirable region of the Pabón
Lasso diagram (right upper region), while close to 50% were located
in the left lower region, which is the most undesirable situation,
characterized by a low turnover ratio and low bed occupancy rate.
Capacity utilization is better in public primary level hospitals compared
with the mission hospitals. Despite a low bed density, there is a
gross underutilization of the existing supply of inpatient beds. It is
essential that the underlying causes be identified and appropriate
demand-creating interventions be instituted to counter this problem.
Furthermore, in order to identify inefficiencies related to scale/size,
it is necessary to conduct an assessment using frontier techniques of
efficiency measurement (e.g. data envelopment analysis or stochastic
frontier models including production and cost functions).
Os estudos sobre a utilização das capacidades usando a técnica Pabón Lasso (PL) ainda não
tinham sido conduzidos anteriormente no Malawi. Estes estudos avaliam a eficiência técnica
dos hospitais públicos e dos hospitais missionários a nível distrital. A técnica Pabón Lasso
é aplicada na avaliação do desempenho relativo de uma amostra de 40 hospitais distritais
(60% públicos e 40% hospitais missionários) no Malawi. O cálculo das taxas de utilização
dos hospitais e a construção do diagrama Pabón Lasso foram efectuados utilizando o STATA
10. Apenas 27,5% dos hospitais encontravam-se localizados na região desejada do diagrama
Pabón Lasso (região superior direita), enquanto que cerca de 50% encontravam-se localizados
na região inferior esquerda, que é a situação menos desejada, caracterizada por um índice de
rotatividade e uma taxa de ocupação de camas baixos. A utilização da capacidade é melhor nos
hospitais públicos de nível primário comparativamente com os hospitais missionários. Apesar
de uma baixa densidade de camas, existe uma enorme subutilização do fornecimento existente
de camas hospitalares. É essencial que as causas subjacentes sejam identificadas e que sejam
instituídas intervenções apropriadas de criação de procura para contornar este problema. Além
disso, de forma a identificar as ineficiências relacionadas com a escala/tamanho, é necessário
conduzir uma avaliação utilizando técnicas de fronteira de medição da eficiência (por ex.:
análise de englobamento de dados ou modelos de fronteira estocástica incluindo funções de
produção e custos).
25
Inefficiency in the allocation and use of health sector resources is one of
the inherent problems of health systems in sub-Saharan Africa. Cognizant of
this fact, in 2006, at a special session of the African Union, health ministers
undertook to institutionalize efficiency monitoring within national health
management information systems.1
The few studies on the technical efficiency and productivity of hospitals conducted in Africa
indicate the pervasiveness of technical inefficiency and wastage of resources that could
have been used to improve access and quality of care.2,3,4 Zere et al (2001)2 in their study of the
technical efficiency and productivity of public sector hospitals in South Africa found technical
inefficiency levels ranging between 34–38%. The efficiency saving that could have been realized
was equivalent to the amount needed for the construction of about 50 clinics. This implies that
there is a significant potential to mobilize resources from within the system if technical efficiency
levels are improved.
A
s is the case in other
countries in sub-Saharan
Africa, per capita
spending on health in Malawi is
low despite a growing burden
of disease. In 2005/2006 per
capita spending on health in
Malawi was estimated at US$ 25,5
which is far less than the US$ 34
recommended by the WHO
Commission on Macroeconomics
and Health to provide a basic
package of services in lowincome countries. 6 Hence, to
provide health services with such
a low level of funding, it is very
important to avoid wastage in
the use of the meagre resources
available. Technical inefficiency
contributes to the shortage of
resources and adversely affects
governments’ initiatives to
26
improve access and bridge any
inequities in health care.
In sub-Saharan Africa,
hospitals account for the bulk
of government’s health sector
expenditure, ranging between
45–69%.7 Malawi is no exception
to this. Moreover, district/primary
level hospitals play a significant
role in providing support to
primary care teams to ensure
comprehensive responsibility for
their population8 and therefore,
facilitate the implementation of
the Primary Health Care approach.
The need to assess the technical
efficiency of district hospitals
cannot be overemphasized.
Studies on capacity utilization
using the Pabón Lasso9 technique
have not been conducted in
Malawi before. The current
exercise is therefore aimed at
bridging the information gap and
generating important evidence
on the state of capacity utilization
of district, community and rural
hospitals for the purposes of
planning and resource allocation.
This study seeks to examine the
technical efficiency of district,
community and rural hospitals
(henceforth called primary
level hospitals), including both
public and private with a view to
assessing efficiency and pave the
way for further detailed studies
of efficiency and its determinants
using more robust frontier
techniques.
Malawi
Country profile
Malawi is a low income country in Southern Central Africa. The total population is estimated at a little more than 13 million. 10
With a human development index (HDI) in 2005 of 0.437, the country is classified with the group of low human development
countries, most of which are in sub-Saharan Africa.11
The gross domestic product (GDP) per capita was US$ 154 (in constant 2000 prices) in 2005.12 About 52% of the population
is classified as poor, i.e. below a national poverty line of the equivalent of US$ 147.12
Health and development indicators of Malawi are those typical of
other low-income countries in sub-Saharan Africa, as depicted in
the Table 1.
Malawi, like many countries of sub-Saharan Africa, faces a growing
burden of disease. The epidemiological profile is characterized by
a high prevalence of communicable diseases including malaria,
tuberculosis and HIV/AIDS; high incidence of maternal and child
health problems; an increasing burden of noncommunicable
diseases and resurgence of neglected tropical diseases.
Table 1. Selected health and development
indicators
Indicator
Value
Life expectancy at birth, 2007 (both sexes)
50
Infant mortality rate, 2006 (per 1000 live births)
69
Under five mortality rate, 2006 (per 1000 live births)
118
Maternal mortality ratio (per 100 000 live births)
807
Total fertility rate
6.3
Sources: 13, 14, 15.
The per capita total expenditure on health (THE) that stood at US$ 25 in 2005/2006 falls short of the US$ 34 recommended by
the WHO Commission on Macroeconomics and Health to provide the basic package of services in low income countries.
The health expenditure per capita is also not adequate to cover the Malawi Essential Health Package (EHP) that is
estimated to cost about US$ 22 (it should be noted that this includes interventions not included in the EHP and health
system administration costs). The health system suffers from a critical shortage of human resources for health. In the
period 2000–2007 there were about 6 nursing and midwifery personnel per 10 000 population. The number of doctors per
10 000 was less than one.13
To address the health and health care challenges effectively the government adopted the sector-wide approach (SWAp)
in 2004 and designed an essential health care package that addresses the most common causes of morbidity and mortality
to be provided at community, primary and secondary levels of the health care system. The government in conjunction with
its development partners has formulated a six-year Emergency Human Resources Programme (2005–2010) at an estimated
cost US$ 272 million to ameliorate the chronic shortage of human resources for health.
The country’s health service delivery system is four-tiered, consisting of community, primary, secondary and tertiary care
levels. At the community level, service is provided through health surveillance assistants. The focus is on preventive
interventions. Primary care is delivered through clinics and health centres. District and central hospitals provide secondary
and tertiary care services respectively. The private not-for-profit sector plays a significant role in service provision. A
health facility survey conducted in 2002–2003 indicated that there were 14 612 inpatient beds giving a bed density of 13 per
10 000 population.15
27
The measurement
of hospital
efficiency:
basic issues
The performance of hospitals
can be evaluated using ratios
that mainly measure capacity
utilization or frontier techniques
such as data envelopment
analysis (DEA) and stochastic
frontier methods including
production and cost functions
that are more robust.16
Ratio analysis involves the
piecemeal examination of
different key ratios, such as
average cost per inpatient day,
bed occupancy rate or cost per
child immunized. Although
easy to use, ratios have some
pitfalls. First, the requirement
for identical measurement units
makes the identification and
measurement of inputs and
Performance indicator ratios commonly used by hospitals include:
Average length of stay (ALS): This measure refers to the average number
of days that a patient stays in a hospital. It is calculated using the following
formula:
1
2
Bed occupancy rate (OCC): The occupancy rate is a measure of utilization
of the available bed capacity. It indicates the percentage of beds occupied
by patients in a defined period of time, usually a year. It is computed using
the following formula:
Where,
; and
This is a method commonly used in assessing hospital performance.
Barnum and Kutzin suggest that hospitals would be operating efficiently at
an occupancy rate of 85–90 percent.17
Bed turnover ratio (BTR): The turnover ratio is a measure of productivity of
hospital beds and represents the number of patients treated per bed in a
defined period of time (usually a year). It is computed as follows:
3
Turnover ratio in acute care hospitals is expected to be higher than chronic
care hospitals.
28
outputs difficult. Second, ratios
are only meaningful and easy to
understand in single input, single
output situations. Comparisons
of multiple outputs by means
of ratio analysis require a priori
weights and/or a standardizing
measurement to get an overall
indicator. The arbitrariness
and pre-determination of these
weights and standardization has
often been questioned.
The Pab ó n L asso
(PL) techniq u e
It has to be stressed that an
assessment based on only one of
the ratios of hospital bed capacity
utilization (see box opposite)
may be flawed and misleading.
For example, bed occupancy
rate may be relatively high in
the presence of unnecessarily
high average length of stay
emanating from such factors
as poor nursing care, improper
scheduling of diagnostic and
therapeutic interventions and
the development of nosocomial
infections. Thus, although the
bed occupancy rate may indicate
that there is a good level of
capacity utilization, the reality
is that this is due to under
performance/inefficiency of
the hospital. Therefore, to avoid
such misleading conclusions,
it becomes necessary to make
use of all three indicators
simultaneously so as to have a
better picture. To this end, the
method devised by Pabón Lasso
to analyse the performance of a
group of hospitals in Colombia
is useful.9
The PL technique is a graphical
method that makes use of the
three indicators (BTR, OCC and
ALS) concurrently in assessing the
relative performance of hospitals.
In this method, the occupancy
rate (horizontal axis), is plotted
against the turnover ratio (on
the vertical axis), with vertical
and horizontal lines dividing
the diagram into four regions.
The horizontal and vertical
demarcations represent the
mean values of the turnover ratio
and occupancy rate. It follows
from the functional relationship
of the three measures that the
slope of the line linking the origin
to any of the observations (any
point on the graph) represents
the reciprocal of the ALS of the
hospital under consideration.
Figure 1 represents the possible
features of hospitals located in
each of the four regions.
The setting of the cut-off points
at the mean values of the BTR
and OCC may be contentious.
However, Pabón Lasso also
suggests using other cut-off
points (e.g. allowing a margin of
one standard deviation from the
mean).9
The size of a hospital may
sometimes be a cause for
inefficiency. 4 A hospital may
be too large for the volume of
activities that it undertakes;
and therefore, may experience
diseconomies of scale. On the
other hand, a hospital may be too
small for its level of operation,
and thus experience economies
of scale. In the presence of
diseconomies of scale, a hospital
is inefficiently large. Unit costs
increase as the scale of production
increases. Diseconomies of scale
may arise due to problems such
as red tape, poor communication
and poor labour relations that
are often encountered in large
organizations. In the presence
of economies of scale a hospital
is inefficiently small. Unit
costs decrease as the scale of
production increases, thus
an inefficiently small hospital
may improve its efficiency by
Figure 1. The four zones of the Pabón Lasso diagram
Bed turnover (patients/bed)
Occupancy rate
Region II (high BTR, low OCC)
Region III (high BTR, high OCC)
• excess bed capacity
• good quantitative performance
• unnecessary hospitalization
• small proportion of unused beds
• many patients admitted for observation
• predominance of normal deliveries
Region I (low BTR, low OCC)
• excess bed supply
• less need for hospitalization
• low demand/utilization
Region IV (low BTR, high OCC)
• large proportion of severe cases
• predominance of chronic cases
• unnecessarily long stays
increasing its size. Economies of
scale may occur as a result of staff
being able to specialize in their
areas of expertise, the ability to
spread overhead costs over a
larger number of output units,
discounts from bulk buying of
supplies and the ability to use
expensive diagnostic equipment
at full capacity. Hence, the
assessment of hospital efficiency
should also take into account
inefficiencies caused by a nonoptimal hospital size, which
may not necessarily be under
the control of the hospital
management.
Data and
methods
Sampling
Based on the availability of
usable data, a sample of 40 of
district level hospitals in Malawi
were included in the study. These
included both public sector
and mission hospitals. Nonpublic hospitals are of different
categories and therefore to
ensure comparability, the study
team deliberately selected
those that are comparable with
government district hospitals.
Data collection
Data for the financial year
2005/2006 was collected using
a questionnaire that included
information on inputs, outputs
and other factors that influence
29
the technical efficiency of
hospitals.
It is observed from Table 2 that
the primary level hospitals have
a wide variation in terms of size
and resource endowment. For
example, in terms of bed capacity,
the range is between 30 beds
for Kaluluma rural hospital to
450 beds for Mangochi district
hospital. The input and output
profile of the hospitals was
influenced by the ownership
type of the hospitals as can be
discerned from Table 3.
Data analysis
The computation of hospital
utilization ratios and construction
of the Pabón Lasso diagram was
performed using STATA 10.
Results
General
description
Analysis was performed on data
from 40 hospitals, 60% of which
were public and the rest were
mission hospitals. A descriptive
of the statistics of the relevant
input and outputs is depicted in
Table 2.
Public hospitals are larger than
the mission ones in terms of bed
capacity and have more staff.
Furthermore, public hospitals
produce more outputs as
measured by outpatient days and
inpatient visits. This is, however,
Table 2. Descriptive statistics: inputs and outputs
Standard
deviation
Minimum
171.5
90.1
30
450
Outpatient visit
84 709
119 699
7996
522 974
Inpatient day
34 660
26 395
1866
114 605
Variable
Mean
Bed
Maximum
Table 3. Summary statistics: inputs and outputs by hospital ownership
Doctor
Nurse
Bed
Outpatient
Inpatient days
Standard
Standard
Standard
Standard
Standard
Ownership Mean deviation Mean deviation Mean deviation Mean deviation Mean deviation
Mission
6
4.2
22
15.6
135
58.8
15 469
9619.1
21 321
16 658
Public
10
8.3
32
25.2
196
100
130 868
136 661
43 552
12 180
Total
8
7.2
28
22.2
171
90.1
84 708
119 699
34 660
26 395
Table 4: Capacity utilization measures by ownership type
Average length of stay (days)
Bed turnover ratio
Bed occupancy rate (%)
Ownership
Mean
Standard deviation
Mean
Standard deviation
Mean
Mission
4.3
1.7
34
14.3
40
21.2
Public
3.8
4.4
62
40.2
56
26.9
Total
4.0
3.6
51
35
50
25.6
30
Standard deviation
more than proportionate to their
relative resource endowment. For
example, while public hospitals
have about 1.4 times more beds
than the mission hospitals, their
output in terms of inpatient days
is about two times more than that
of mission hospitals.
Capacity
utilization ratios
There is a wide variation in the
performance of the hospitals as
measured by capacity utilization
measures: bed occupancy rate,
bed turnover ratio and average
length of stay. The bed occupancy
rate ranged from 14–105%, while
the bed turnover ratio fluctuated
between 15 and 204 (Table 4).
As can be seen from Table 4,
public hospitals had higher bed
occupancy rate and turnover ratio.
The average length of stay for both
types of hospitals was within the
range of 3–5 days recommended
for acute care hospitals. The
occupancy rates are far below the
conventionally accepted norm of
80–85% indicating the presence
of a significant proportion of
unutilized capacity. Hospital
capacity utilization measures for
each hospital are presented in
Table 5.
As discussed earlier, analysis
based on only one of the
above mentioned capacity
utilization ratios may not give a
comprehensive picture. Hence,
it is necessary to use the three
measures simultaneously using
the Pabón Lasso diagram as
shown in Figure 2.
In Figure 2A , the vertical and
horizontal lines are set at the
mean values of the bed occupancy
rate and bed turnover ratio, while
in 2B, the vertical line is set at the
accepted norm of 85% for bed
occupancy rate.
Table 5. Hospital capacity utilization measures, 2005/2006
Hospital ID
Hospital
Average length of
stay (days)
Bed turnover ratio
(patients per bed)
Bed occupancy
rate (%)
1
Balaka
2.3
118
74.0
2
Chikwawa
6.7
51
93.8
3
Chiradzulu
5.1
33
46.2
4
Chitipa
2.5
41
28.7
5
David Memorial
8.1
21
46.0
6
Dedza
1.7
205
95.1
7
Dowa
5.4
47
70.5
8
Dwambazi
1.7
31
14.2
9
Ekwendeni
2.6
32
23.0
10
Embangweni
4.2
26
30.3
11
Holy Family
5.7
35
54.6
12
Kaluluma
2
66
36.0
13
Karonga
4.3
55
65.3
14
Kasungu
2.4
61
40.7
15
Likuni
5.2
50
72.4
16
Machinga
3.8
91
93.7
17
Madisi
3
33
26.6
18
Mangochi
4
37
40.5
19
Mchinji
2.3
133
84.6
20
Montfort
3
27
22.6
21
Mponela
3.1
45
37.6
22
Mulibwanji
8
25
54.0
23
Mwanza
5
77
105.4
24
Mzambazi
3.7
21
21.3
25
Mzimba
5.1
52
72.4
26
Ngabu
2.6
60
42.2
27
Nkhamenya
4
52
56.8
28
Nkhatabay
1.7
55
25.8
29
Nkhotakota
6.2
15
26.2
30
Nsanje
3.8
38
39.4
31
Ntcheu
4.5
48
58.8
32
Ntchisi
5.7
51
79.3
33
Rumphi
4.9
38
50.3
34
Salima
5.4
12
17.9
35
Sister
4.1
18
20.5
36
St Anne's
3
50
41.5
37
St Gabriel's
4.8
70
91.7
38
St John's
3
36
29.7
39
St Martin's
4.4
34
40.6
40
St Peter's
2.8
21
15.6
From Figure 2A, it is observed
that only 27.5% of the hospitals
are located in the desirable region
of the Pabón Lasso diagram
(right upper region), while close
to 50% were located in the left
lower region, which is the most
undesirable situation that is
characterized by low turnover
ratio and low bed occupancy
rate. When the cut-off for the
bed occupancy rate is increased
to the conventionally suggested
benchmark of 85%, the number
of those hospitals located in
the desirable (efficient) region
decreases to only 12.5%, while the
proportion of those located in the
most undesirable region increases
to 65%. The distribution of
hospitals among the four regions
of the Pabón Lasso diagram is
depicted in Figure 3.
It is observed that even when
the mean occupancy rate of the
group of hospitals in the study
is used as the benchmark, most
of the hospitals lie in the region
which lies below the means of
the occupancy rate and turnover
ratio (left lower region). This
implies one or more of the
following scenarios:
• excess bed supply
• less need for hospitalization
• low demand for or utilization
of hospital services
It is also observed that when the
benchmark occupancy rate is
increased to 85%, the number
of hospitals with the above
31
Figure 2. Pabón Lasso diagram, 2005/2006
200 —
200 —
150 —
150 —
100 —
11
50 —
0—
l
20
Discussion,
conclusion and
recommendations
B
Bed turnover ratio
Bed turnover ratio
A
l
l
l
40
60
80
Bed occupancy (%)
100 —
11
50 —
0—
l
100
l
20
l
l
l
40
60
80
Bed occupancy (%)
l
100
Note: The numbers attached to the scatter plots are hospital IDs.
Figure 3. Distribution of hospitals among the four regions of the Pabón
Lasso diagram
A
B
20 —
25 —
26
15 —
10 —
11
7
5—
Number of hospitals
Number of hospitals
19
20 —
15 —
10 —
9
5—
3
0
0
Region I Region II Region III Region IV
mentioned scenarios increases.
Given the scope of the study, it
is not possible to identify the
exact nature of the problem.
However, whether due to less
need for hospitalization or low
demand for hospital services,
there is an excess supply of
hospital beds that merits further
investigation. Given the low bed
32
5
0
Region I Region II Region III Region IV
density in the country, we would
expect the presence of unmet
need for hospitalization and
therefore, the case for less need
for hospitalization may not be
a plausible explanation. Only a
few of the hospitals are located
at the right upper region, which
is the desirable state of capacity
utilization.
This study has assessed the
technical efficiency of primary
level hospitals using hospital
capacity utilization ratios and
the Pabón Lasso method. The
use of the Pabón Lasso technique
helps to draw more robust
conclusions by using the three
measures of hospital capacity
utilization (average length of
stay, bed turnover ratio and bed
occupancy rate) simultaneously,
as using each of the measures
separately may lead to misleading
conclusions.
The findings clearly indicate
the presence of excess bed
capacity given the current level
of utilization. It should, however,
be noted that this does not imply
the presence of excess capacity
relative to need. In fact, the bed
density in Malawi is far lower
than that recommended for the
size of the population. There
may possibly be demand-side
barriers of any type (e.g. financial,
geographical, cultural etc) that
negatively influence utilization of
hospital services.
The evidence indicates that
capacity utilization is better in
public primary level hospitals
compared with the mission
ones. Public hospitals have
more resources in terms of
staff and beds compared with
the non-public ones. However,
their output, as measured by
outpatient visits and inpatient
days, is more than proportionate
to their resource endowment.
Issues related to economies of
scale may also contribute to
capacity underutilization and
inefficiency. Some hospitals
may experience economies of
scale (inefficiently small size)
and others may be experiencing
diseconomies of scale due to
their inefficiently large size.
Identification of economies
or diseconomies of scale
is beyond the scope of the
analytical technique used and
calls for further study using
frontier techniques of efficiency
measurement.
In the light of the findings
discussed above, the following
recommendations are proposed
with a view to improve hospital
efficiency and capacity utilization:
1 Studies need to be conducted to
identify individual, household
and systemic level barriers
to utilizing hospital services
and institute appropriate
measures that will enhance
optimal use of the existing
hospital capacity. Demandcreating interventions have
to be instituted to counter
barriers related to healthseeking behaviour of
individuals and households.
Systemic bottlenecks need
tailor-made interventions
depending on the nature of
the problem. These, will in
the end, stimulate demand/
utilization.
2 Given the low bed density
in the country, the supply
of beds may not match
the population’s need for
hospital services. Therefore,
it is not desirable to reduce
the number of hospital beds.
However, in the interim, that
is until the demand-creating
interventions bear the
desired behavioural change,
innovative ways of using
the existing relative excess
capacity need to be explored.
3 I n o r d e r t o i d e n t i f y
inefficiencies related to
scale/size, it is necessary
to conduct an assessment
using frontier techniques of
efficiency measurement (e.g.
data envelopment analysis
or stochastic frontier models
including production and cost
functions). Furthermore, to
assess changes in productivity
over a period of time, efforts
must be made to collect panel
data.
4 As the Pabón Lasso technique
is a valuable tool that is easy
to use, it is recommended that
annual health management
information system (HMIS)
reports include this kind of
analysis in order to provide
evidence for management
decision-making purposes. z
References
1. African Union. Universal access to HIV/AIDS, tuberculosis and
malaria services by a United Africa by 2010. Addis Ababa, 2006.
Resolution Sp/Assembly/ATM/5(I) Rev. 3 of the Ministers of
Health on Health Financing in Africa.
2. Zere E, McIntyre D, Addison D. Technical efficiency and
productivity of public sector hospitals in three South African
Provinces. South African Journal of Economics. 2001; 69:
336–358.
3. Kirigia JM, Emrouznejad A, Sambo LG. Measurement
of technical efficiency of hospitals in Kenya: Using data
envelopment approach. Warwick, 2000.
4. Zere E, Mbeeli T, Shangula K, Mandlhate C, Mutirua K,
Tjivambi B, Kapenambili W. Technical efficiency of district
hospitals: Evidence from Namibia using data envelopment
analysis. Cost Effectiveness and Resource Allocation. 2006; 4: 5.
5. Ministry of Health, Malawi. Multi-country impact evaluation
of the scale up to fight AIDS, tuberculosis and malaria: Malawi
national health accounts – with sub-accounts for HIV and
AIDS, tuberculosis and malaria. Ministry of Health, Lilongwe,
Malawi, 2008.
6. WHO. Macroeconomics and health: Investing in health for
economic development. Commission on Macroeconomics and
Health, WHO, Geneva, 2001.
7. Kirigia JM, Fox-Rushby J, Mills A. A cost analysis of Kilifi and
Malindi district hospitals in Kenya. African Journal of Health
Sciences. 1998; 5: 79–84.
8. WHO. The World Health Report 2008: Primary Health Care: Now
more than ever. WHO, Geneva, 2008.
9. Pabón Lasso H. Evaluating hospital performance through
simultaneous application of several indicators. Bulletin of the
Pan American Health Organization. 1986; 20 (4): 341–357.
10. National Statistical Office of Malawi. 2008 population and
housing census: preliminary report. National Statistical Office,
Zomba, 2008.
11. United Nations Development Programme. Human
development Report 2007/2008: Fighting climate change:
human solidarity in a divided world. United Nations
Development Programme, New York, 2007.
12. National Statistical Office of Malawi. Integrated household
survey 2004–2005. National Statistical Office, Zomba, 2005.
13. WHO. World Health Statistics 2009. WHO, Geneva, 2009.
14. National Statistical Office of Malawi and UNICEF Malawi.
Malawi Multiple Indicator Cluster Survey: monitoring the
situation of children and women. National Statistical Office,
Zomba, 2008.
15. Japan International Cooperation Agency. Malawi health
facilities inventory survey. Lilongwe, 2003.
16. Smith P, Mayston D. Measuring efficiency in the public sector.
Omega, International Journal of Management Science. 1987;
15(3): 181–189.
17. Barnum H, Kutzin J. Public Hospitals in Developing Countries:
Resource use, Cost, Financing. Johns Hopkins University Press
for the World Bank, Baltimore, 1993.
33
Improving access to quality
care in family planning:
Assessment of the Medical
Eligibility Criteria Wheel for
contraceptive use in Ghana
Andrew Kosia1
Charles Djoleto-Fleischer2
Mongi Pyande1
Triphonie Nkurunziza1
1 WHO Regional Office for Africa, Brazzaville, Congo
2 WHO Ghana
Triphonie Nkurunziza
34
En 2004, pour relever le défi de l’amélioration de l’accès
à des soins de qualité en matière de planification
familiale, un certain nombre de partenaires du Ghana,
OMS en tête, ont mis au point un instrument de
travail, à savoir le disque pour le choix des méthodes
contraceptives selon les critères de recevabilité
simplifiés. Suite aux essais menés sur le terrain au
Ghana et en Érythrée, l’outil a été finalisé, produit et
distribué à des prestataires de services de planification
familiale de plusieurs pays, dont le Ghana. Puisque
l’outil était utilisé depuis plusieurs années, il a été jugé
opportun d’en déterminer la pertinence. Une enquête a
donc été commandée par le Bureau de Représentation
de l’OMS au Ghana pour évaluer l’utilité de la roue des
critères de recevabilité médicale, avec l’appui technique
et financier de l’OMS/AFRO. Le présent rapport décrit
l’évaluation et résume les résultats de l’étude, qui se
sont révélés très positifs.
Resumo
résumé
In order to address the challenge of improving access to quality care in family planning, a number of
partners in Ghana, led by the WHO, developed a work aid – the simplified Medical Eligibility Criteria
(MEC) Wheel in 2004. Following the field tests in Ghana and Eritrea, the tool was finalized, produced
and distributed to family planning providers in several countries including Ghana. Having been in
use for a few years, it was timely to determine the usefulness of the tool. A study was therefore
commissioned by the WHO Country Office in Ghana to evaluate the usefulness of the simplified Medical
Eligibility Criteria Wheel with technical and financial support from AFRO. The present report describes
the evaluation and summarizes the results of the study, which were strongly positive.
De forma a enfrentar o desafio de melhorar o acesso
aos cuidados de qualidade no planeamento familiar,
um número de parceiros no Gana, liderados pela OMS,
desenvolveram um auxiliar de trabalho – a «Roda»
simplificada do Critério de Elegibilidade Médica (CEM)
em 2004. Após os testes de campo no Gana e na Eritreia,
a ferramenta foi finalizada, produzida e distribuída aos
fornecedores de planeamento familiar em diversos
países incluindo o Gana. Dado que esta ferramenta
tem vindo a ser utilizada há já alguns anos, revelou-se
oportuno determinar a sua utilidade. Por conseguinte,
foi encomendado um estudo pela Representação
da OMS no Gana para avaliar a utilidade da «Roda»
simplificada do Critério de Elegibilidade Médica, com o
apoio técnico e financeiro da AFRO. O presente relatório
descreve a avaliação e resume os resultados do estudo,
os quais foram bastante positivos.
Family planning (FP) is recognized as a key intervention for reducing
maternal mortality and improving the health of women and children.
Over the past 40 years, there have been major advances in scientific knowledge as a result
of research. This has resulted in the development of a wider choice of new contraceptive
methods and improvements in the safety and effectiveness of existing methods. Unfortunately
the full range of modern family planning methods still remains unavailable to at least 350
million couples worldwide, many of whom want to space or prevent future pregnancies.
I
n 1996, WHO published a
document entitled “Improving
Access to Quality Care in Family
Planning: Medical Eligibility
Criteria” (WHO, 1996). A second
edition of this document was
published in 2000 (WHO, 2000).1,2
The document was intended to
be used by policy-makers and
family planning programme
managers to enable them prepare
guidelines for service delivery
of contraceptives. A number of
countries including Ghana had
used the document to develop
guidelines for use by service
providers. Unfortunately the
documents produced were often
too bulky, not user-friendly and
time consuming to use.
In order to address this challenge,
a number of partners in Ghana
led by the WHO used the WHO
guide to develop a work aid – the
simplified MEC Wheel in 2004
(see Figure 1).
The development of the tool was
an attempt to adapt the MEC
Wheel for utilization by service
providers especially those in
more remote settings where
information on the safety of
methods may be lacking.
Figure 1.
The Medical Eligibility Criteria Wheel
Following field tests in
Ghana and Eritrea, the tool
was finalized, produced
and distributed to family
planning providers in
several countries including
Ghana.
Having been in use for a few
years, it was timely to determine
the usefulness of the tool.
A study was therefore
commissioned by the WHO
country office in Ghana to
evaluate the wheel’s usefulness
with technical and financial
support from AFRO.
Objectives
The objective of the evaluation
is to provide WHO, Ghana Health
Services and partners evidence
that the MEC Wheel is an effective
tool for family planning.
Specific objecti ves
• T o
determine
the
completeness, accuracy, userfriendliness, usefulness and
handiness of the MEC Wheel.
• To ascertain whether there
are any sections of the wheel
culturally unacceptable
to family planning service
providers.
35
• To identify the most useful
and least useful sections of
the wheel.
• To determine the proportion
of family planning service
providers who would
recommend the regular use
of the MEC wheel.
Methodology
A survey involving family
planning service providers
in public health facilities
throughout the 10 regions of
Ghana was conducted. The main
data collection tools employed
were structured questionnaires
with open- and close-ended
questions.
Statistical analysis of the data
was performed using EPI-Info
(version 6). Qualitative responses
from open-ended questions were
analysed manually in terms of
emerging themes and related to
the study objectives.
Ethical approval was obtained
from the Director General of the
Ghana Health Service, the 10
regional directors and district
directors in the selected districts.
Key findings
A total of 121 health providers
responded to the questionnaires
giving a response rate of 81%.
They were made up of nurses
36
(59.5%), midwives (22.3%) and
Community Health Nurses (CHN)
(7.4%) among others. A majority
of them (38%) were working
in hospitals compared with
28.1% each in clinics and health
centres. (The headquarters of the
Ghana Health Service accounted
for 5%.)
Usefulness
Approximately 71% of medical
officers found the MEC wheel
useful while 83% and 73% of
midwives and nurse respectively
found the wheel very useful.
Difficulties in decision making
following the introduction of
the MEC Wheel
In terms of decision making on the
choice of method for the clients
(77.7%) of the respondents
reported having no difficulties
in deciding on whether a client
could use a particular method or
not following the introduction of
the MEC Wheel to them.
User-friendliness
The majority (94.2%) of
respondents described the wheel
as very friendly to use and 95%
also described it as extremely
useful to their operations. Most
(82.6% of the respondents)
found all four sections of the
wheel useful.
Accuracy
Almost all the respondents
(98%) described the MEC Wheel
as very accurate with only one
respondent describing it as not
very accurate.
Acceptance of the MEC Wheel
guidelines
A majority of the respondents
(98.3%) reported agreeing with
all the guidelines provided with
the MEC Wheel.
Comprehensiveness
On how comprehensive they
have found the MEC Wheel,
86% described it as most
comprehensive while about
11% felt it was somewhat
comprehensive. Only one
respondent found the MEC
Wheel totally incomprehensive.
About 92% of the respondents
reported to have found the
directions for the use of the
wheel to be very clear and easy
to understand. Though there
were differences in the level of
clarity and understanding among
the professionals interviewed, it
was not statistically significant
(X2 = 13.852, p = 0.537).
View on the size of the wheel
Most of the respondents (92%)
found the size of the wheel to be
just the right. While 5.8% of them
felt it was too big, the remaining
2.2% felt it was too small.
Handiness
About 94% of the respondents
were of the view that the MEC
Wheel was very handy while
5.8% felt otherwise.
Information provided
Though a majority (79.3%) of the
respondents felt the information
on the wheel was adequate,
nearly 20% of them reported that
there were times that they felt
they needed more information
in order to use the wheel. Some
of the additional information
needed included pictures, to
explain further to the clients, and
information on menstruation.
Cultural acceptability of the
wheel
Almost all respondents (112)
found the MEC Wheel to be
culturally acceptable. Only one
respondent reported to have
found sections of the wheel to
be culturally unacceptable. Most
(89.3%) indicated that they
never found it embarrassing
anytime they had to refer to the
MEC Wheel to find out whether
a patient could use a particular
method or not. Only 3 (2.5%)
of them, consisting of one CHN
and two nurses reported this
difficulty. On whether they would
recommend the use of the wheel
on a daily basis for family planning
Table 1. Respondents’ impression of the MEC Wheel
Impressions
Unsatisfactory
Needs improvement
Satisfactory
Very good
Excellent
No response
Total
Completeness
Frequency
%
0
0.0
3
2.5
9
7.4
46
38.0
60
49.6
3
2.5
121
100
Accurate
Frequency
%
0
0.0
1
0.8
10
8.3
44
36.4
63
52.1
3
2.5
121
100
User-friendliness
Frequency
%
0
0.0
1
0.8
6
5.0
29
24.0
82
67.8
3
2.5
121
100
service providers, almost
all the respondents (98.3%)
responded in the affirmative. An
overwhelming majority (97%) of
the respondents considered the
development of the MEC Wheel
as a “best practice” to improving
accessibility to family planning.
Only three respondents (three
CHNs) answered = negatively.
General
impressions of
the wheel
Table 1 presents the general rating
of respondents’ impressions
about the MEC Wheel. Nearly
50% of the respondents assessed
the completeness of the wheel
to be excellent while another
38% felt it was very good. In
this regard only 2.5% called
for further improvements. A
little over half of them scored
the accuracy of the wheel as
excellent. About 8% however felt
it was satisfactory. With regard to
its user-friendliness, the majority
scored either very good or
Usefulness
Frequency
%
0
0.0
0
0.0
6
5.0
33
27.3
79
65.3
3
2.5
121
100
Handiness
Frequency
%
0
0.0
5
4.1
6
5.0
34
28.1
73
60.3
3
2.5
121
100
37
excellent. Again, it was generally
described as incredibly useful.
Finally, about 60% assessed its
handiness as excellent, while 4%,
however, felt there was the need
for some improvement.
Conclusions
The evaluation results show
that the MEC Wheel was found
useful by all categories of staff
as it provided guidelines in
assisting their clients to choose
and use a family planning method
appropriate for them. In addition,
the MEC Wheel is regarded as
a good tool and should be
extended to all cadres of health
care providers including family
planning attendants in public
and private health facilities.
38
Currently, the training and use
of the MEC Wheel is limited to
only in-service training, as a
result only those providing family
planning services benefit from it.
The trainings should therefore
take into consideration preservice medical, midwifery and
nursing students in both public
and private institutions.
The evaluation also documented
some of the challenges in using
the MEC Wheel. They included
the absence of pictures. The
fact that some providers did not
recognize vital conditions on the
wheel such as sickle-cell diseases,
renal failure and, essentially, side
effects of contraceptives, which
are present on the wheel, has
serious implications for their
training in the use of the MEC
Wheel and should be carefully
addressed in future programmes.
Finally, the MEC Wheel is a
working tool and should be kept
safe at facility level for other
health providers in the FP field
to access and use. Related to this,
providers who are privileged
to have the opportunity to
participate in the training
programme should share their
new knowledge with colleagues
to make the whole programme
more useful and effective. z
References
1. WHO. Improving Access to Quality Family Planning – Medical
Eligibility Criteria for Contraceptive Use, WHO/FRH/FPP/96.9.
WHO. WHO, Geneva, Switzerland, 1999.
2. WHO. Improving Access to Quality Family Planning – Medical
Eligibility Criteria for Contraceptive Use, third edition. WHO,
Implementation of the Global Strategy
on Infant and Young Child Feeding at
national level in the African Region:
Challenges and way forward
The Global Strategy for Infant and Young Child
Feeding (IYCF) aims to address inappropriate infant
feeding practices. Although breastfeeding of infants
aged up to six months has increased in sub-Saharan
Africa over the last decade the regional average is
31% (as compared with a global average of 37%).
Numerous other problems impact upon child
feeding in the Region. To address this issue, over
30 of the 46 countries in the WHO African Region
are implementing national strategies. This paper
reviews the development and implementation
processes of national strategies, identifying
the challenges and proposing a way forward to
improve infant and young child feeding practices
in the Region. Effective coordination of all the
agencies concerned is identified as a key to effective
implementation. The under-six month breast
feeding rate has improved in most countries that
have implemented IYCF strategies. Capacity building
of health workers, and evaluation of strategies have
played an important role in this regard. However,
challenges remain – notably inadequate funding,
high turnover of staff and bureaucratic delays.
Establishing and sustaining community involvement
has also proved difficult. A key to making progress is
to enact the International Code of Marketing Breastmilk Substitutes into national law – as clearly shown
by Ghana. Implementing national communication
and capacity building plans also plays a vital role in
improving IYCF. Addressing this issue will be critical
to attaining MDG 4 on infant mortality.
résumé
Charles Sagoe-Moses
La stratégie mondiale pour l’alimentation du nourrisson et du jeune enfant (ANJE) vise à
résoudre le problème posé par des pratiques inadéquates d’alimentation de l’enfant. Certes,
le taux d’allaitement maternel des nourrissons âgés de 0 à 6 mois a augmenté en Afrique
subsaharienne au cours de la dernière décennie, mais la moyenne régionale est de 31 %,
contre 37 % dans le monde. De nombreux autres problèmes se répercutent sur l’alimentation
des enfants dans la Région. Pour traiter cette question, plus de 30 des 46 États Membres de la
Région africaine de l’OMS appliquent des stratégies nationales. Le présent document passe en
revue ces processus de développement et de mise en œuvre, en identifiant les obstacles et en
proposant des voies d’action susceptibles de contribuer à l’amélioration de l’alimentation du
nourrisson et du jeune enfant dans la Région. Une coordination efficace de toutes les institutions
concernées est identifiée comme un facteur clé de succès. Le taux d’allaitement maternel des
nourrissons de moins de six mois est en hausse dans la plupart des pays qui ont mis en œuvre des
stratégies ANJE. Le renforcement des capacités des agents de santé et l’évaluation des stratégies
ont joué un rôle important dans cette embellie. Cependant, des écueils subsistent, notamment
le financement inadéquat, une rotation élevée du personnel et des pesanteurs administratives.
Il s’est également avéré difficile d’obtenir et pérenniser l’adhésion des communautés. La solution
semble donc résider dans la promulgation dans le droit national du Code international de
commercialisation des substituts au lait maternel, comme l’a déjà fait le Ghana. La mise en
œuvre de plans nationaux de communication et de renforcement des capacités joue également
un rôle clé dans l’amélioration de l’ANJE. Relever ce défi demeure un enjeu crucial pour atteindre
l’OMD 4 relatif à la mortalité infantile.
Resumo
Charles Sagoe-Moses
Kasonde Mwinga
Phanuel Habimana
Tigest Ketsela
A Estratégia Global para a Alimentação dos Lactentes e das Crianças visa abordar práticas de
alimentação infantil não adequadas. Embora a amamentação dos lactentes com idades até
aos seis meses tenha aumentado na África Subsariana na última década, a média regional
é de 31% (comparativamente com 37% a nível mundial). Inúmeros outros problemas têm
impacto na alimentação das crianças na região. Para abordar esta questão, 30 dos 46 países na
Região Africana da OMS estão a implementar estratégias nacionais. Este relatório analisa esse
processo de desenvolvimento e implementação, identificando os desafios e propondo uma
forma de melhorar as práticas de alimentação infantil na região. A coordenação eficaz de todas
as agências envolvidas é identificada como um elemento chave para uma aplicação eficiente.
A taxa de amamentação nos primeiros seis meses de vida dos lactentes tem melhorado na
maioria dos países que implementaram as estratégias da IYCF (política nacional abrangente
para a gravidez, parto e alimentação de lactentes e crianças); o reforço das capacidades dos
profissionais de saúde e a avaliação das estratégias desempenharam um papel importante.
No entanto, os desafios permanecem – financiamento inadequado, elevada rotação do
pessoal e atrasos burocráticos. Desenvolver e manter a participação comunitária revelou-se
igualmente difícil. A chave para o progresso reside na promulgação do Código Internacional
de Comercialização dos Substitutos do Leite Materno na legislação nacional– conforme foi
claramente demonstrado pelo Gana. A execução de planos nacionais de reforço das capacidades
e comunicação desempenha também um papel fundamental na melhoria da IYCF. Abordar esta
questão será fundamental para atingir o ODM 4 em termos de mortalidade infantil.
39
Introduction
The Global Strategy for Infant
and Young Child Feeding
(GSIYCF) was endorsed by the
World Health Assembly (WHA)
in May 2002 through resolution
WHA 55.251 and by the UNICEF
Executive Board later in the
same year. This strategy takes
into account previous WHA
resolutions, building upon past
and continuing achievements
particularly the Baby Friendly
Hospital Initiative, the
International Code of Marketing
of Breast-milk Substitutes and
the Innocenti Declaration on
the Protection, Promotion
and Support of Breastfeeding.
The Global Strategy for Infant
and Young Child Feeding aims
to address the problems of
inappropriate infant feeding
practices through the promotion
and support of optimal feeding
to assure adequate growth and
development, nutritional status,
health and, thus, the survival of
infants and young children.
Malnutrition is a major public
health problem worldwide.
Globally, maternal and child
under nutrition contributes to
35% of the disease burden in
children younger than 5 years
and is the underlying cause of
3.5 million deaths. Twenty three
out of the 40 countries with child
stunting prevalence of 40% or
more are in Africa.2
40
In sub-Saharan Africa, the
proportion of infants 0–6 months
who are exclusively breastfed
increased by at least 20 to 50
percent over the last decade in
some countries, however, the
regional average is 31%, which
is lower than the global average
of 37%.3 There are a number of
socio-cultural practices in the
region which do not support good
nutrition and deprive infants
of the irreplaceable protection
that breast milk provides. Some
examples of such practices
include giving water, herbal teas
and porridge to babies less than
six months old.
Africa continues to face natural
and man-made disasters,
including civil conflicts, famine
and droughts, resulting in
increasing numbers of refugees
and internally displaced people.
Living under such precarious
situations compromises the care
and feeding of infants and young
children. The continent bears
the highest burden of the HIV
pandemic. The risk of motherto-child HIV transmission
through breastfeeding has
undermined the resolve of many
governments in Africa to promote
breastfeeding, even among
unaffected families.
As part of the efforts to address
the above problems, over 30
out of 46 countries in the WHO
African Region have developed
and are implementing their
national infant and young
child feeding (IYCF) strategies
in accordance with the global
strategy. Plans are under way to
support the remaining countries
in developing their national
strategies.
T h i s p a p e r re v i e w s t h e
development and implementation
processes for national IYCF
strategies in the African Region.
It also identifies the challenges
encountered and proposes the
way forward to improve infant
and young child feeding practices
in the region.
Development
process
Following the adoption of the
GSIYCF by the World Health
Assembly and the UNICEF
Executive Board in 2002, the
WHO Regional Office for Africa
(WHO/AFRO) organized three
separate planning meetings for
13 countries.4 The meetings came
up with a list of key activities and
elements for consideration in the
national strategy and developed
a framework for a detailed action
plan for implementation. They
also identified the monitoring
and evaluation tools for the
national strategy.
The lessons learnt from these
regional meetings led to the
development of the Infant and
Young Child Feeding: Guide for
national implementation of the
global strategy for infant and
young child feeding 5 by WHO.
This guide provides countries
with a systematic and step-wise
approach that translate the global
strategy’s aim, objectives and
operational targets into concrete,
focused national policy, strategy
and action plans. The guide was
used by a number of countries in
the process of developing their
national strategies.
At national level the process of
developing national IYCF strategy
started with the assessment of
the policies, programmes and
practices of IYCF in countries
using the WHO/LINKAGES
assessment tool.6 This process
was usually carried out by two
or three independent local
consultants working in close
collaboration with staff from
the Ministry of Health. In most
countries desk reviews of
existing data from demography
and health surveys (DHS), multiindicator cluster surveys (MICS),
recent national survey reports
or studies were carried out to
identify the status of various
indicators. Then guidelines from
the assessment tool were used to
rate the country’s performance
in a particular indicator. The
ratings ranged from poor to
very good. This information was
summarized into a report. The
report of the assessment was
shared at a national stakeholders’
meeting and the findings formed
the basis for the development
of a national strategy and
implementation plan.
A national IYCF strategy was
derived from the assessment
report and sets out priority
interventions to reverse gaps
identified in the situation analysis
of the assessment report, such as
seen in the example from Kenya.7
The strategy has clear targets
and provides a mechanism and
framework for various sectors to
contribute to the improvement of
the health and nutritional status of
children through improved infant
and young child feeding practices.
The strategy and implementation
plans usually have a timeframe of
about three years.
Implementation
of national
strategies:
country
experiences
The global strategy clearly states
that the primary obligation of
governments is to formulate,
implement, monitor and evaluate
a comprehensive national policy
and plan on IYCF. Adequate
resources – human, financial
and organizational – will have
to be identified and allocated
to ensure timely and successful
implementation of the strategy.8
The governments that have
41
successfully translated the
global strategy into national
strategies have done so by
effective national coordination
to ensure full collaboration of all
concerned government agencies,
international organizations and
other relevant stakeholders.
process of publishing and
launching their strategies and
plans. These final national
strategies have been widely
disseminated to all key
stakeholders at various levels
including the provincial and
district health administrations.
Currently over 30 countries 9
have developed national IYCF
strategies with implementation
plans. These countries are at
various levels of development
and implementation of their
strategies. Some countries
are using draft strategies and
implementation plans though
these are not yet finalized and
published. Other countries 10
have gone through the entire
The national strategies form
the basis for a comprehensive
package and provide guidance
for subsequent interventions
and care in the countries. The
strategies have been used as
a tool for the planning and
implementation of IYCF activities
by all the levels of the health
ministries and by partners. In
some countries such as Nigeria
the strategy serves as a guide for
action in IYCF and a benchmark
for setting annual targets.11
Implementation of national
strategies has contributed
towa rd s i m p rove m e n t i n
the coverage of some key
breastfeeding interventions such
as exclusive breastfeeding rates.
Figure 1 compares the under six
months exclusive breastfeeding
rates of selected countries before
and after the development
and implementation of their
national IYCF strategies. Most
countries significantly increased
their exclusive breastfeeding
rate after their strategies were
developed. However, in countries
such as Nigeria, Madagascar,
Uganda and Zimbabwe the rates
100
90
89
80
84
70
67
60
50
40
30
32
20
19
17
14
13
0
40
32
25
11
13
13
12
8–2
006
aso
199
Bu
rkin
aF
er
Nig
a2
003
–20
eri
Nig
44
6
Source: Demographic and health surveys.
42
30 30
44
38
54
53
17
12
1
29
28
25
24
22
34
32
41
38
63
61
60
199
9–2
003
Zim
bab
we
199
9–2
006
Ca
me
roo
n1
998
–20
04
Na
mib
ia 2
000
–20
07
Gu
ine
a1
999
–20
05
Lib
eri
a1
986
Mo
–20
zam
07
biq
ue
199
7–2
003
Ke
nya
200
3–2
009
Se
neg
al 1
997
–20
05
Ma
Un
li 2
ited
001
–20
Re
pub
06
lic
of T
a
199 nza
9–2 nia
005
Be
nin
200
1–2
Ma
006
dag
asc
ar
200
4–2
009
Ma
law
i 20
00–
200
4
Ug
and
a2
001
–20
06
Zam
bia
200
2–2
007
Gh
ana
200
3–2
008
Rw
and
a2
000
–20
05
10
63
51
08
Under six month exclusive breastfeeding rates
Figure 1. Comparison of under six month exclusive breastfeeding rates of countries before and after development of national
IYCF strategy
● Before strategy ● After strategy
Country (DHS year)
decreased after their strategies
were put in place. The reasons
for the decreased rates are not
clear, and will require further
investigations. Other related
improvements include the
enactment of the international
code on the marketing of breast
milk substitutes (Code) into
national laws in Cape Verde, The
Gambia and Zambia, while Kenya,
Swaziland and South Africa are at
the final stages of the enactment
process. Implementation of the
Baby Friendly Hospital Initiative
(BFHI) in the context of HIV/
AIDS has been revitalized in12
countries12 with BFHI assessment
and reassessment conducted in
some of these countries. Capacity
building of health workers has
seen exponential increases in
countries with rapid cascading
and expansion of training at the
district level with over 6500
trainers available at national,
provincial and district level to train
health workers in countries.13
In most countries implementation
was aided by the accompanying
implementation plan, which
clearly outlines the strategic
areas, with objectives and
targets as well as, when and how
to reach the set targets. These
strategic areas included policies
and regulations; promotion
of appropriate IYCF practices;
IYCF in emergencies; HIV and
infant feeding; partnership and
coordination; capacity building;
research, monitoring and
evaluation; and advocacy and
communication.
Commitment from ministries of
health (MOH) has been crucial
for successful development and
implementation of the national
strategy. When the MOH is
in the driving seat, directing
and coordinating the entire
process, there is stability and
sustainability to keep the process
on course even if some members
of the working groups change.
The MOH is also able to revitalize
interest and commitment among
all stakeholders through active
dialogue and engagement with
key partners. Active involvement
of key partners to support the
initiatives of the MOH has kept
the process on course. Countries
have engaged in constructive
dialogue and active collaboration
with appropriate groups working
for the protection, promotion
and support of appropriate
feeding practices. Key partners,
such as WHO, UNICEF, USAID,
IBFAN etc., have made technical,
financial and materials support
available to the MOHs. Sharing of
best practices has been another
facilitating factor as peers share
their experiences on how they
have overcome challenges in
regional forums.
Challenges
The process of developing and
implementing national IYCF
strategies has not been without
challenges to countries. The
process can take from an average
of six months to three years,
meanwhile, principal actors
(within the various working
groups and task forces) may
change jobs or move on to other
programmes; funds voted for the
process may no longer be available
or reduced in value due to local
currency depreciation; and some
key stakeholders may no longer
be in the country or their focus
may shift to other issues.
The major inhibiting factors
include delays and the long
duration of the process. This is
mainly due to various bureaucratic
bottlenecks. The process of getting
permissions and clearance for
meetings, documents and approval
can be unduly lengthy (between
six weeks and three months); in
the meantime there are other
competing activities of equal
importance in which the same
people are expected to participate.
Where IYCF issues are not
prominent or high on the political
and development agenda, such as
featuring in national development
plans and strategies, and only
seen as a health issue, the lack
of high political stimulus needed
to drive implementation of a
national strategy is an issue.
The absence of a comprehensive
national communication and
social marketing strategy makes
43
advocacy and sensitization of
policy makers at all levels and
the general public challenging.
The lack of data driven advocacy
messages leads to ineffective
communication to the target
population.
Establishing and sustaining the
involvement of the community,
especially the motivation of
volunteers among mother
support groups and failing to
deal with some cultural norms
concerning the role of motherin laws, grandmothers and
fathers can make grassroots
implementation difficult.14 The
lack of a comprehensive national
capacity building plan which
addresses in-service, pre-service
and community workers’ training
is a hindrance.
Counselling skills are crucial in
IYCF support yet these are often
not taught in nursing and medical
schools. Bridging this knowledge
and skill gaps has not always been
easy. The high attrition rate of
health workers means that trained
and competent health workers are
constantly in short supply. Trained
health workers get attracted to
places and programmes with
better salaries; such a scenario
can sometimes make a well
thought out implementation plan
unachievable.
IYCF makes a huge contribution
towards child survival; about
19% of under five mortality can
44
be prevented if there is universal
coverage of breastfeeding and
c o m p l e m e n t a r y fe e d i n g 1 5 .
However, the size of budget
allocations that both governments
and partners commit to child
survival in general and IYCF in
particular is disproportionately
low and unrealistic. This is one
of the major challenges most
countries encountered achieving
the goals of their national IYCF
strategies.
Way forward
The enactment of the
International Code of Marketing
of Breast-milk Substitutes into
national law is an important
step forward. The existence of
a well informed and motivated
government agency responsible
for the laws and policies on
the marketing breast-milk
substitutes such as (the Food
and Drugs Board in Ghana
and the National Agency for
Food and Drug Administration
and Control in Nigeria) and an
oversight committee that ensure
the enforcement of the law is
important. Dynamic leadership
in the government ministries
(Ministry of Health, Labour and
Employment, Justice etc.) is
instrumental to the enactment
and enforcement of laws on the
Code and maternity protection
for working mothers and child
rights etc. Development partners,
particularly UN agencies such as
ILO, WHO and UNICEF, should
continue to serve as powerful
advocates and provide technical
support to governments for the
realization of key policy and
legislation in favour of child
survival including putting IYCF
programmes high on the political
and developmental agenda.
T h e a c t iv i t i e s o f s o c i o cultural structures existing in
communities – NGOs, community
based organizations (CBOs),
traditional leadership groups
– need to be harnessed for
advocacy and social mobilization
for IYCF.Technical and financial
support of development partners
should be invested in the skills
of locally available human
resources to ensure availability
and sustainability of competent
people in the communities.
There is a need to develop:
• A comprehensive national
communication and social
marketing strategy which
uses data driven advocacy
messages to create awareness
and behavioural change
among the target audience.
• Comprehensive national
capacity building plans which
include equipping training
institutions to facilitate
capacity development in IYCF
at pre-service and in-service
levels.
• Counselling in all areas dealing
with IYCF at every contact
point with mother and child.
To reduce the long development
process period, efforts to remove
bureaucratic bottlenecks need
to be intensified by ensuring
that advance preparations
for activities are done and
communication among the
various stakeholders is good.
Financial allocation to IYCF
activities should be proportionate
to the burden of disease and the
deaths that could be averted
by improved breastfeeding and
complementary feeding practices.
District health management teams
should develop need-based plans
and budgets for child survival and
appropriately fund IYCF activities
based on the contribution of IYCF
towards child survival in their
respective districts.
WHO, in collaboration with
other partners, should intensify
advocacy to countries without
national strategies to develop
one, while continuing to provide
technical support to countries
to scale up the implementation
of their strategies. The year
2012 will be ten years since the
adoption of the global strategy
and an opportune time to conduct
a comprehensive multi-country
evaluation to assess the effects
of the strategy on the support,
promotion and protection of
appropriate IYCF as well as its
contribution to reducing child
morbidity and mortality.
on IYCF revitalized enthusiasm,
national strategies emphasized
the strong coordination role
of the MOH and the roles and
responsibilities of government,
NGOs, UN agencies and other
partners were clearly stated.
National strategies are data
driven, more focused on specific
country needs and involve key
stakeholders ensuring ownership
and sustainability.
Promotion, protection and
support for IYCF in general and
breastfeeding in particular has
been going on actively since
the early 1990s; a lot of the
activities were done by different
and many parties without much
coordination. However, the
introduction of the Global Strategy
The development and
implementation of national
strategies has not been without
challenges. Overcoming the
challenges identified will
require concerted efforts from
government, partners and the
community to eventually ensure
that IYCF practices are taken
to scale to make a meaningful
contribution towards child
survival and the attainment of
Millennium Development Goal
(MDG) 4. z
assessing national practices, policies and programmes. WHO,
2003.
7. MOPHS/WHO/UNICEF. Kenya National Strategy on Infant and
Young Child Feeding. WHO, 2008.
8. WHO. Global Strategy for Infant and Young Child Feeding. WHO,
2003.
9. Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroun,
Cape Verde, Côte d’Ivoire, DRC, Ethiopia, Gabon, Ghana,
Gambia, Guinea Bissau, Lesotho, Kenya, Mali, Malawi,
Mozambique, Nigeria, Niger, Sao Tome and Principe, Rwanda,
South Africa, Swaziland, United Republic of Tanzania, Togo,
Uganda, Zambia and Zimbabwe.
10. Ethiopia, Ghana, Gambia, Lesotho, Kenya, Malawi, Nigeria,
Senegal, Sierra Leone, United Republic of Tanzania, Uganda,
Zambia and Zimbabwe.
11. Federal Ministry of Health, Nigeria. National Policy on Infant
and Young Child Feeding in Nigeria. Federal Ministry of Health,
Nutrition Division, Abuja, 2005.
12. Botswana, Lesotho, Madagascar, Malawi, Namibia, South
Africa, Swaziland, United Republic of Tanzania, Uganda,
Zambia, Zimbabwe.
13. WHO. Division of Family and Reproductive Health; 2006 – 2007
at a Glance. WHO Regional Office for Africa, 2007.
14. Holmes WR, Savage F. Exclusive breastfeeding and HIV. The
Lancet. 2007; 369: 1065–1066.
15. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS and the
Bellagio Child Survival Study Group. How many child deaths
can we prevent this year? The Lancet. 2003; 362: 65–71.
Conclusion
References
1. WHO, Global Strategy for Infant and Young Child Feeding. WHO,
2003.
2. Black RE, Allen L, Bhutta Z, Caulfield L, de Onis M, Ezzati M,
Mathers C, Rivera J. Maternal and child under nutrition: global
and regional exposures and health consequences. The Lancet.
2008; 371: 243–260.
3. UNICEF. State of World’s Children 2010.
4. Angola, Botswana, Burkina Faso, Cape Verde, Côte d’Ivoire,
Ethiopia, Ghana, Guinea Bissau, Mali, Mozambique, Sao Tome
and Principe, Senegal and Zimbabwe,
5. WHO, Infant and Young Child Feeding: Guide for national
implementation of the global strategy for infant and young child
feeding. WHO, 2004.
6. WHO/Linkages. Infant and Young Child Feeding: A tool for
45
Leveraging eHealth to improve
national health systems in the
African Region
Emil Asamoah-Odei
Derege Kebede
Chris Zielinski
Edoh-William Soumbey-Alley
Miguel Peixoto
Matshidiso Moeti
World Health Organization, Regional Office for Africa, Brazzaville,
Congo
46
résumé
The World Health Organization defines eHealth as
the cost-effective and secure use of information
and communication technologies (ICTs) for health
and health-related fields. ICTs provide a range of
technologies for gathering, storing, retrieving,
processing, analysing, transmitting and receiving
data and information. These include radio, television,
mobile phones, computer and network hardware and
software, as well as the services and applications
associated with them, including videoconferencing
and distance learning. eHealth is an umbrella term
that covers a variety of areas such as health informatics,
digital health, teleHealth, telemedicine, eLearning
and mobile health. The WHO Regional Committee
for Africa has called on Member States to adopt and
implement eHealth strategies to improve their health
systems. The Ouagadougou and Algiers declarations
and the Framework for Implementation of the
Algiers Declaration also underscore the importance of
eHealth in health systems. This paper highlights some
key issues that need to be addressed and proposes
concrete actions for adopting eHealth solutions as
tools for strengthening health systems in order to
accelerate progress towards achieving the Millennium
Development Goals and improving health outcomes in
the Region.
L’Organisation Mondiale de la Santé définit la cybersanté (eHealth) comme l’utilisation rentable
et sécurisée des technologies de l’information et de la communication (TIC) pour la santé et
les secteurs connexes. Les TIC fournissent une gamme de technologies destinées à rassembler,
stocker, récupérer, traiter, analyser, transmettre et recevoir des données et des informations.
Elles comprennent la radio, la télévision, les téléphones portables, les ordinateurs, le matériel de
réseau informatique et les logiciels, ainsi que les services et applications qui leur sont associés, y
compris la vidéoconférence et l’apprentissage à distance. La cybersanté est un terme générique
qui recouvre différents domaines tels que l’informatique de la santé, la santé numérique, la
télésanté, la télémédecine, l’apprentissage à distance et la santé mobile. Le Comité régional de
l’OMS pour l’Afrique a appelé les États Membres à adopter et à mettre en œuvre des stratégies de
cybersanté pour améliorer leurs systèmes de santé. Les Déclarations de Ouagadougou et d’Alger
et le Cadre pour la mise en œuvre de la Déclaration d’Alger soulignent également l’importance
de la cybersanté dans les systèmes de santé. Ce document met en lumière certaines questions
clés à traiter et propose des actions concrètes pour adopter des solutions de cybersanté, en
tant qu’outils visant à renforcer les systèmes de santé afin d’accélérer les progrès en vue de la
réalisation des objectifs du Millénaire pour le développement et de l’amélioration des résultats
sanitaires dans la Région.
Resumo
Derege Kebede
A Organização Mundial da Saúde define cibersaúde (eHealth) como a utilização segura
e rentável da informação e tecnologias da informação e comunicação para os campos
relacionados com a saúde e da saúde. As TIC fornecem uma gama de tecnologias para recolha,
armazenamento, recuperação, processamento, análise, transmissão e recepção de dados e
informação. Estas incluem rádio, televisão, telemóvel, computador e hardware e software de
rede, assim como os serviços e aplicações associados com estes, incluindo vídeo-conferência
e ensino à distância. Cibersaúde é um termo geral que abrange uma variedade de áreas,
tais como a informática médica, saúde digital, telesaúde, telemedicina, ciberensino e saúde
móvel. O Comité Regional Africano da OMS foi convocado pelos Estados Membros a adoptar e
implementar estratégias de cibersaúde para melhorar o seu sistema de saúde. As declarações
de Ouagadougou e Argel e o enquadramento para a implementação da Declaração de Argel
também sublinham a importância da cibersaúde nos sistemas de saúde. Este documento
destaca alguns problemas-chave que necessitam ser abordados e propõe acções concretas
para adoptar soluções de cibersaúde como ferramentas para reforçar os sistemas de saúde, de
modo a acelerar o progresso em direcção à consecução dos Objectivos de Desenvolvimento do
Milénio e à melhoria dos resultados da saúde na Região.
Introduction
The World Health Organization
(WHO) defines eHealth as the
cost-effective and secure use of
information and communication
technologies (ICTs) for health
and health-related fields.1 ICTs
provide a range of technologies
for gathering, storing, retrieving,
processing, analysing,
transmitting and receiving
data and information. These
include radio, television, mobile
phones, computer and network
hardware and software, as well
as the services and applications
associated with them, including
videoconferencing and distance
learning. eHealth is an umbrella
term that covers a variety of areas
such as health informatics, digital
health, teleHealth, telemedicine,
eLearning and mobile health.2
Recognizing the significant
developmental role and crosscutting impact of ICTs in
regard to all aspects of national
life, including health, an ICTrelated target was included
in Millennium Development
Goal number 8. 3 The World
Health Assembly resolution on
eHealth, WHA58.28,4 noted the
potential impact that ICT could
have on health-care delivery.
Subsequently the WHO Executive
Board endorsed a set of activities
to be implemented by the WHO
Secretariat aimed at, among
others, creating an environment
that ensures data privacy,
security and confidentiality, and
improves interoperability.5 This
included the establishment of the
Global Observatory for eHealth to
improve the evidence base and
guide policies for integrating
eHealth into health systems.6
Through Resolution AFR/RC56/
R8,7 Member States were called
on to adopt and implement
eHealth strategies to improve
their health systems. The
Ouagadougou 8 and Algiers 9
There are several ways in which eHealth can strengthen health
systems:
ûby
improving the availability, quality and use of information and
evidence through strengthened health information systems and
public health surveillance systems;
ûdeveloping the health workforce and improving performance by
eliminating distance and time barriers through telemedicine and
continuing medical education;
ûimproving access to existing global and local health information
and knowledge; and
ûfostering positive lifestyle changes to prevent and control common
diseases.
declarations and the Framework
for Implementation of the Algiers
Declaration10 also underscore the
importance of eHealth in health
systems strengthening.
Major eHealth projects in the
Region include the Telemedicine
Network for Francophone African
Countries (RAFT), 11 HINARI
Access to Research in Health
Programme, 12 ePortuguese
Network 13 and Pan-African
e-Network Project. 14 Several
countries in the Region are
implementing telemedicine and
eLearning projects, including
Algeria, Benin, Burkina Faso,
Burundi, Cameroon, Chad,
Republic of Congo, Cote
d’Ivoire, Ethiopia, Ghana, Kenya,
Madagascar, Mali, Mauritania,
Niger, Rwanda, Senegal and South
Africa. Some of these are using
mobile phones to support the
delivery of health care, awareness
and education; remote data
collection; remote monitoring
and home care; communicating
treatments to patients; and
reporting and responding to disease
outbreaks and emergencies. Others
are using satellite technologies to
broadcast health promotion to
patients and health workers in
hospitals and clinics.
While eHealth projects in the
Region continue to be on a small
scale and are fragmented, the
rapid advances in ICT have put
countries under intense market
pressure to adopt ICT-associated
47
services. There is a need to ensure
that the introduction of ICT in the
health sector is driven by country
needs and appropriate policies,
rather than by pressures from
technology producers.
This document highlights
some key issues that need to
be addressed and proposes
concrete actions for adopting
eHealth solutions as tools for
strengthening health systems
in order to accelerate progress
towards the achievement of the
MDGs and the improvement of
health outcomes in the Region.
Issues and
challenges
Some major issues in the Region
include the “digital divide,” i.e.
inadequacy of ICT infrastructure
and services and the limited
ability and skills to use them. It
is estimated that in sub-Saharan
Africa, access to fixed telephone
lines in 2007 was 1.5 per 100
population, access to mobile
phone subscriptions was 22.9
per 100 population, and the
level of internet use was 3.7 per
100 population. This contrasts
with the global average of 19.0
per 100 population, 50.3 per
100 population and 20.6 per
100 population, respectively.15
While mobile phone services are
booming, the African Region has
extremely little bandwidth, and
the costs of internet services are
48
beyond the reach of the majority
of the people.
Development and maintenance of
ICT infrastructure are expensive
and the costs are beyond the
budget of many institutions
in Africa, particularly when
technology is sought for largescale use. The ICT infrastructure
development needs of the
health sector are not within the
purview of ministries of health.
Economic situations and financial
constraints both countrywide and
in the health sector are such that
many health facilities and medical
training institutions are unable to
cater for their needs, including
computerization. Dependence
on external resources or donor
funding for the introduction of
eHealth in the Region has become
the rule rather than the exception.
The key challenges countries
need to address include limited
awareness about eHealth; lack of
an enabling policy environment;
weak leadership and
coordination; inadequate human
capacity; weak ICT infrastructure
and services; inadequate financial
resources; and weak monitoring
and evaluation systems.
L imited awareness
of e Health
Policy-makers, health authorities
and health practitioners are
not fully aware of the potential
benefits of the use of ICT for
health. Neither has the health
sector developed medium- or
long-term strategic plans for
developing eHealth infrastructure
and services.
Lack of an enabling
policy environment
Most countries in the Region
have not developed national
policies, strategies or regulatory
frameworks that are necessary for
establishing common technical
infrastructure, interoperability
and standardization protocols.
Countries also need to address
ownership, confidentiality,
security of data and quality of
information.
Weak leadership
and coordination
In several countries, there is
a multiplicity of players and
partners in several eHealth
projects being implemented
with limited capability for
interoperability. The challenge
is to strengthen coordination
and collaboration among all
stakeholders, partners and
donors as well as improve the
capacity of the health sector to
lead the process.
Inadeq uate hu man
capacity to plan
and apply e Health
solu tions
The number of health workers
capable of leveraging ICT in their
work remains limited. Health
workers are not systematically
trained in the use of ICT. There
are insufficient numbers of
health workers with the capacity
to design, deploy and effectively
manage eHealth projects and
programmes. The use of ICT
facilitated learning remains
limited in most health training
institutions.
Weak I CT
infrastru ct ure
and services within
the health sector
Existing eHealth projects within
the health sector are small scale
and fragmented, and their scope
and coverage are rather limited.
In most countries, the ministries
in charge of communications,
technology and finance are
primarily responsible for
national ICT infrastructure.
The challenge is for ministries
of health to ensure that ICT
needs and adequate coverage
of the health sector are taken
into consideration during the
preparation and implementation
of national ICT plans.
Inadequate
financial
reso urces
Financing eHealth infrastructure
and services requires
collaboration and coordination
between multiple partners from
both the private and public
sectors. The challenge is for the
health sector to partner with
other governmental sectors and
the private sector to mobilize the
resources required for eHealth.
Figure 1. Percentage of population who are cellular or mobile subscribers in the
African Region, by country, 2006 and 200016
● 2006
● 2000
African Region
Sierra Leone
0.0
0.3
Guinea
0.0
0.6
Ethiopia
1.1
0.0
Eritrea
1.4
0.0
Burundi
0.2
Central African Republic
0.1
Niger
0.0
Rwanda
0.5
Comoros
0.0
Chad
0.1
Malawi
0.5
Madagascar
0.4
Zimbabwe
2.6
2.7
3.4
3.4
4.5
4.7
5.3
5.5
0.5
Dem. Rep. of the Congo
0.0
Burkina Faso
0.2
Liberia
0.1
Guinea Bissau
0.0
Mali
0.1
6.7
7.4
7.5
8.3
9.6
10.9
0.0
Mozambique
0.3
11.5
11.6
Benin
0.9
Zambia
0.9
Angola
0.2
United Republic of Tanzania
0.3
Cameroon
0.7
Congo
Kenya
11.2
1.1
Sao Tome and Principe
Lesotho
12.1
14.0
14.3
14.8
18.9
20.0
1.2
20.9
0.4
22.0
3.2
Ghana
0.7
Nigeria
0.0
23.1
24.1
Swaziland
24.3
3.3
Senegal
25.0
2.6
26.0
0.5
27.2
1.1
Namibia
Mauritania
21.0
4.5
Côte d'Ivoire
Equatorial Guinea
19.4
2.4
Cape Verde
Gambia
6.5
2.3
Uganda
Togo
20.9
2.8 29.7
4.6
33.6
0.6
Botswana
Mauritius
Algeria
Gabon
South Africa
Seychelles
46.8
13.5
61.5
15.1
63.0
0.3
63.9
9.8
83.3
18.3
86.5
33.6
49
Weak monitoring
and e valuation
Figure 2. Percentage of the population who are internet users in the African
Region, 200717
African Region
Sierra Leone
0.22
Niger
0.28
0.32
Ethiopia
0.35
Democratic Republic of the Congo
0.37
Guinea
0.52
Liberia
0.53
Madagascar
0.58
Burkina Faso
0.59
Chad
0.60
Burundi
0.77
Mali
0.81
Mozambique
0.93
Mauritania
0.95
0.99
Malawi
1.00
Rwanda
1.08
Equitorial Guinea
1.55
Côte d'Ivoire
1.63
Benin
1.66
Congo
1.70
Cameroon
2.23
Guinea Bissau
2.26
Eritrea
2.47
Uganda
2.51
Comoros
2.56
Angola
2.93
Lesotho
3.49
Ghana
3.75
Swaziland
4.87
Zambia
5.03
Togo
5.07
Botswana
5.31
Gabon
6.16
6.62
Nigeria
6.75
7.68
Kenya
7.99
South Africa
8.16
Zimbabwe
10.12
Algeria
10.34
Sao Tome and Principe
Mauritius
Seychelles
50
5.87
Senegal
Cape Verde
Despite these challenges,
opportunities exist for planning
and deploying eHealth solutions.
These include the rapid advances
in ICT, increasing access to
mobile phones and broadband
connectivity, increasing interest
by donors and countries
in strengthening health
systems, and the partnerships
being built by agencies
such as WHO, International
Telecommunication Union,
World Bank, United Nations
Economic Commission for Africa
and others. The partnerships
seek to develop national road
maps for eHealth, facilitate
connectivity of health facilities
in districts, and p rov i d e
health workers access to a
suite of eHealth applications
and solutions for enhancing
professional capacity.
4.08
Namibia
Gambia
The majority of the eHealth
projects, initiatives, national
plans or frameworks
implemented so far in the
Region have not been adequately
monitored or evaluated. Indeed,
comprehensive frameworks
for monitoring and evaluation
have yet to be developed. The
challenge is to ensure the
availability of efficient systems
for monitoring and evaluation
and for sharing of experiences
and lessons learnt.
5.48
14.59
26.95
36.95
Proposed
actions
In order to strengthen national
health systems and improve the
health of the people, countries
should take actions leading to
increased access to eHealth tools
and services. Crucially, these
actions should be taken in the
context of the implementation
of the Algiers and Ouagadougou
declarations, and be integrated
with other efforts to strengthen
national health systems.
1 Promote national political
commitment and awareness
of eHealth: It is necessary to
raise the awareness of policymakers and the general public
on the benefits of eHealth,
including the identification
and use of champions (e.g.
celebrities within and outside
the health sector) for that
purpose. It is important to
develop health sector capacity
to advocate for eHealth
solutions, negotiate with
other ministries and lead the
national process.
2 Develop an enabling policy
environment: All countries
should carry out a national
needs assessment for
eHealth and follow this with
the development of longterm strategic plans and
frameworks for eHealth.
Countries should develop
policies on eHealth which
articulate the commitment of
the government to invest in
an ICT-based health system
that will improve access to
quality services at affordable
prices. The policies should
be based on the national ICT
policy. Countries should also
develop strategies, norms
and appropriate governance
mechanisms related to legal
liability, ethical standards, and
confidentiality and privacy
protection.
3 Strengthen leadership and
coordination: A multisectoral
and multidisciplinary
consultative process involving
all key stakeholders, including
the users and beneficiaries,
should be used to develop
national plans, policies,
strategies, and ethical and
legal frameworks. Each
country should consider
establishing multidisciplinary
and intersectoral support
mechanisms. The top
leadership in the health
sector should lead by
example in acquiring the skills
and utilizing the relevant
technologies.
4 B u i l d i n f r a s t r u c t u r e
and establish ser vices
for eHealth: Countries
should select appropriate
technologies and solutions
to be used within their
s p e c i f i c e nv i ro n m e n t s ,
bearing in mind the current
state of power supply
standards, health systems
and telecommunications
infrastructure. Health needs
should drive technology
acquisition and adoption.
Some of the key areas of
focus include building the
ICT infrastructure necessary
to support eHealth services;
establishing internet
connections for health
institutions; establishing web
sites for ministries of health;
building local area networks
and establishing telemedicine
facilities. The adoption of open
ICT platform technologies
should be encouraged, and
maintenance of adopted
technologies should be given
high priority.
5 Develop human capacity
for eHealth: Systematic
education in eHealth for
health personnel must be
at the heart of any strategy
designed to facilitate eHealth.
Countries need to introduce
ICT in the curricula of all
health training institutions.
Training in eHealth should
be included in continuing
education programmes for
health workers. The use
of eLearning programmes
for professional education
should be promoted in the
health sciences as well as
in ongoing professional
development. Local academics
51
and researchers as well as
external technical experts
should be involved in these
efforts. Countries should
consider establishing centres
of excellence to train eHealth
professionals and reach a
critical mass of expertise for
service, training and research.
Experts in eHealth are also to
be recruited.
to ensure integration of ICT
in all budgetary processes to
promote sustainability.
International partners and
donors should be encouraged
to support national efforts.
Governments should
establish an enabling policy
e nv i ro n m e n t t h a t w i l l
encourage the private sector
to seek funds for capital
investments that will allow
the introduction of new costeffective technologies.
6 M o b i l i z e
financial
resources for eHealth:
Countries need to make
the necessary investments
in ICT infrastructure and 7 M o n i to r a n d e va l u a te
services in the health sector,
national eHealth plans
using domestic and external
and frameworks: Countries
financing. Countries will need
should establish monitoring
and evaluation systems to
measure progress in the
implementation of national
eHealth strategic plans. This
is crucial to ensure delivery of
the expected benefits.
In conclusion, countries can
benefit from using eHealth
tools to strengthen their health
systems and improve the health
of their populations. They should,
however, tackle existing eHealth
challenges related to limited
awareness, policies, leadership,
infrastructure, human and
financial resources. z
References
1. WHO. Resolution WHA.58.28: eHealth. In: Fifty-eighth
World Health Assembly, Geneva, May 2005, World Health
Organization. http://apps.who.int/gb/ebwha/pdf_files/
WHA58/WHA58_28-en.pdf
2. Oh H et al, What is eHealth: a systematic review of published
definitions. Journal of Medical Internet Research, 2005, 7(1).
http://www.jmir.org/2005/1/e1/
3. Target 18F: In cooperation with the private sector, make
available the benefits of new technologies, especially
information and communications.
4. WHO. Resolution WHA58.28: eHealth; In: Fifty-eighth
World Health Assembly, Geneva, May 2005, World Health
Organization. http://apps.who.int/gb/ebwha/pdf_files/
WHA58/WHA58_28-en.pdf
5. WHO. eHealth: proposed tools and services (EB117/15).
In: Executive Board, 117th session, Geneva, January 2006,
World Health Organization. http://apps.who.int/gb/ebwha/
pdf_files/EB117/B117_15-en.pdf
6. WHO. Global Observatory for eHealth. http://www.who.int/
goe
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7. WHO. Resolution AFR/RC56/R8, Knowledge management in
the WHO African Region: strategic directions. In: Fifty-sixth
Session of the WHO Regional Committee for Africa, Addis
Ababa, Federal Democratic Republic of Ethiopia, 28 August–1
September 2006, Final Report, Brazzaville, World Health
Organization, Regional Office for Africa, 2006 (AFR/RC56/24),
pp. 22–24. http://afrolib.afro.who.int
8. WHO. Ouagadougou Declaration on Primary Health Care and
Health Systems in Africa: Achieving Better Health for Africa
in the New Millennium, a declaration by the Member States
of the WHO African Region, April 2008, Ouagadougou. http://
www.afro.who.int/declarations/DeclarationOuagadougouen.pdf
9. WHO. The Algiers Declaration, Ministerial Conference
on Research for Health in the African Region; Narrowing
the Knowledge Gap to Improve Africa’s Health, June
2008, Algiers. http://www.afro.who.int/declarations/
algiers_declaration_en.pdf
10. WHO. Framework for the Implementation of the Algiers
Declaration on Research for Health in the African Region. In:
Fifty-ninth Session of the WHO Regional Committee for Africa,
Kigali, Republic of Rwanda, September 2009. http://www.
afro.who.int/rc59/documents/AFR-RC59-5.pdf
11. Le Réseau en Afrique Francophone pour la Telemedicine
(RAFT). http://raft.hcuge.ch
12. WHO. HINARI. http://www.who.int/hinari/en/
13. WHO. ePortuguese Network. http://www.who.int/
eportuguese/en
14. Pan-African e-Network Project. www.panafricanenetwork.
com
15. ITU. Information Society Statistical Profiles 2009, Africa,
International Telecommunication Union. http://www.itu.int/
ITU-D/ict/material/ISSP09-AFR_final-en.pdf
16. International Telecommunication Union, September 2009.
17. United Nations Statistical Division, MDG database, June 2010.
1 World Health Organization, Ethiopia Country
Office
2 Monitoring and Evaluation Unit, Planning
and Policy Directorate, Federal Ministry of
Health, Addis Ababa, Ethiopia
Gebrekidan Mesfin
résumé
Gebrekidan Mesfin1
Hajira Mohamed2
Habtamu Tesfaye2
Negusu Worku1
Dereje Mamo2
Nafo-Traoré Fatoumata1
Les systèmes d'information de gestion de la santé (SIGS)
fournissent les données nécessaires aux systèmes de
santé pour suivre l’utilisation et la qualité des services
de santé et prendre des décisions fondées sur des
preuves. L’Ethiopie a entrepris une réforme et une
refonte extensives de son SIGS introduit en 2008, dans
six des neuf régions que compte le pays. Une évaluation
a été engagée: en général pour apprécier la gestion des
données et les systèmes de notification et pour vérifier
la qualité des données ainsi que le niveau d’utilisation
de l’information lié à la prise de décision et en particulier
pour identifier les marges de progrès. Le rassemblement
des données via des questionnaires permettra d’estimer
la collecte des données et le fonctionnement de la
notification. Six secteurs fonctionnels relatifs à la gestion
des données et des systèmes de notification ont été
évalués sur une échelle de 0 à 2. La précision des données
a été analysée en comparant les données de trois niveaux
de notification pour assurer la cohérence. Ces niveaux
étaient les suivants: site de prestation des services (SPS);
niveau intermédiaire d’agrégation (NIA) où les rapports
issus des SPS sont agrégés; suivi de programme et unités
d’évaluation au niveau national (S&E). La précision des
données des neuf indicateurs clés nationaux sélectionnés
a été mise en regard à chaque niveau.
Les données ont été réunies au sein de 17 districts de
santé et de 32 sites de prestation des services (26 centres
de santé et 6 hôpitaux). Une collecte de données intégrée
et des outils de notification ainsi que des directives et
des procédures de fonctionnement standard étaient en
place à tous les niveaux. La documentation et les sources
étaient à disposition pour tous les SPS. Toutefois, les
ressources étaient plus faibles pour SPS et NIA (résultats
de 0,5). Le traitement de la gestion des données a généré
un résultat moyen de 1,2. L’exhaustivité du contenu et
l’opportunité de la notification sont restées au dessus de
la cible nationale de 85% à tous les niveaux (SPS 76,7%
et 67,7%; NIA 62% et 39% et 29%, et 53% au niveau
national). La précision des données était de 76% pour
SPS et de 71% pour NIA. Les sites et districts avaient
quant à eux utilisé à hauteur de 37% des données issues
du SIGS dans des discussions et activités liées à la prise
de décision. Un suivi et une action durables afin de
préserver la qualité du SIGS et la précision des données
sont essentiels pour faire le bilan des progrès réalisés en
matière de résultats sanitaires.
Sumário
Data
quality and
information
use: A
systematic
review to
improve
evidence,
Ethiopia
Health information and monitoring systems (HMIS) provide necessary data to health
systems to monitor the utilization and quality of health services and make evidencebased decisions. Ethiopia has undertaken an extensive reform and re-design of its HMIS
introduced in six of Ethiopia’s nine regions in 2008. To assess the data management and
reporting systems, verify the data quality as well as the level of information use for
decision-making an assessment was undertaken to identify areas for improvement. Data
were collected via questionnaires to evaluate data collection and reporting functioning. Six
functional areas of the data management and reporting systems were assessed on a scale
of 0 to 2.0. Data accuracy was assessed by comparing data at the three reporting levels for
consistency. These levels were: service delivery site (SDS); intermediate aggregation level
(IAL) where reports from SDSs are aggregated; and programme monitoring and evaluation
units at national level (M&E). Data accuracy of the nine selected key national indicators
was compared at each level.
Data was collected from 17 health districts; 32 service delivery facilities (26 health
centres and 6 hospitals). Integrated data collection and reporting tools, standard operating
guidelines and procedures were in place at all levels. Documentation and sources were
available at all SDSs. However, resources were weakest at the SDS and IAL (scores of 0.5).
Data management processing had an average score of 1.2. Content completeness and
reporting timeliness remained below the 85% national target at all levels (SDSs 76.7% and
67.7%; IALs 62% and 39% and 29%, and 53% at national level). Data accuracy was 76%
for the SDS level and 71% for the IALs. At the facility and district levels, 37% had utilized
data from the HMIS in discussions and decision-making activities. Sustained monitoring
and action to maintain good HMIS and data accuracy are essential in evaluating progress
on health outcomes.
Os sistemas de monitorização e informação clínica (HMIS)
fornecem os dados necessários a sistemas clínicos para
monitorizar a utilização e qualidade dos serviços de
saúde e tomar decisões baseadas em evidências. A
Etiópia empreendeu uma reforma e uma reformulação
do design extensivas do seu HMIS introduzido em seis de
nove regiões da Etiópia em 2008. Para avaliar os sistemas
de gestão de dados e de informação, verificar a qualidade
dos dados, assim como o nível de informação utilizada na
tomada de decisões, foi empreendida uma avaliação para
identificar as áreas a melhorar. Foram reunidos dados
através de questionários para avaliar a recolha de dados
e o funcionamento da divulgação de informações. Foram
avaliadas seis áreas funcionais dos sistemas de gestão de
dados e de informação numa escala de 0 a 2,0. A precisão
de dados foi avaliada quanto à consistência através da
comparação de dados nos três níveis de divulgação de
informações. Estes níveis eram: local de prestação de
serviços (LPS); nível intermédio de agregação (NIA), onde
são agregadas as informações do LPS; e monitorização
do programa e unidades de avaliação a nível nacional
(M&U). A precisão dos dados dos nove indicadores chave
selecionados foi comparada a cada nível.
Foram reunidos os dados de 17 distritos de saúde; 32
instalações de prestação de serviços (26 centros de saúde
e 6 hospitais). As ferramentas de recolha de dados e de
informação integradas, as diretrizes e os procedimentos
operacionais standard estavam em vigor a todos os níveis.
A documentação e as fontes estavam disponíveis em
todos os LPS. No entanto, os recursos foram mais fracos
no LPS e NIA (classificação de 0,5). O processamento de
gestão de dados teve uma classificação média de 1,2. A
integridade do conteúdo e a pontualidade das informações
permaneceram abaixo dos 85% da meta nacional a todos
os níveis (LPS 76,7% e 67,7%; NIA 62%, 39%, 29%, e 53%
a nível nacional). A exatidão dos dados foi de 76% para o
nível de LPS e 71% para os NIA. Ao nível das instalações e
distrito, 37% utilizaram os dados do HMIS em discussões
e atividades de tomada de decisão. A monitorização e
ação sustentadas para manter um bom HMIS e exatidão
de dados são essenciais no progresso de avaliação nos
resultados da saúde.
53
Introduction
In 2008, to strengthen the HMIS
in Ethiopia, the Federal Ministry
of Health (FMOH) introduced a
new system. The newly designed
HMIS was implemented in
six of nine regions, namely
Benishangul-Gumuz, Dire Dawa,
Gambella, Harari, Amhara and
Southern Nations, Nationalities
and People’s Region. 1,2 The
objective of the new system is to
ensure improved measurement
and standardization to ensure
good quality data – enabling
better decisions and thus better
health outcomes.
The quality of reported data
and use of information is
dependent on the underlying
data management and reporting
systems. 3,4 Stronger systems
ought to produce better quality
data. In other words, for good
quality data to be produced
by and flow through a data
management system, key HMIS
functional components need to
be in place at all levels of the
system4 (see Figure 1).
An assessment was performed
to inform users and stakeholders
of the current status of the
functioning of the HMIS and
its ability to provide quality
monitoring and data to decisionmakers. Three areas of HMIS
were assessed:
• Six functional components
of the data management and
reporting systems:
– M&E capabilities, role and
responsibilities;
– inputs/resources;
– data management process;
– linkage with national system;
– d a t a c o l l e c t i o n a n d
reporting forms;
– indicator definition and
reporting guidelines;
Figure 1. Data management and reporting systems, functional levels and data
quality
Dimensions of quality
54
M&E unit
Intermediate aggregation
levels (e.g. districts, regions)
Service points
Data management and reeporting system
Reporting levels
Quality data
Accuracy, completeness, reliability, timeliness,
confidentiality, precision, integrity
Functional components of a data management
system needed to ensure data quality
I
M&E capabilities, roles and responsibilities
II
Training
III
Data reporting requirements
IV
Indicator definitions
V
Data collection and reporting forms/tools
VI
Data management processes
VII Data quality mechanisms and controls
VIII Links with the national reporting system
• The data quality in terms of:
– accuracy;
– timeliness;
– completeness.
• Information use.
methods and
materials
Study design
A cross-sectional design was
used and data were collected
through observation, interview
and data review at the various
respective critical levels of the
flow of information.
Selection of study
sites
Study sites where activities
supporting the indicators were
implemented were selected. The
selection of study sites involved
identifying regions, districts and
individual health facilities using
a multistage cluster sampling
technique. As the study units
have different volumes of service,
the sampling involved a stratified
random sampling of sites.
Data collection
procedures and tools
The assessment included three
protocols,4,5 with data collection
for all protocols occurring at all
sites.
Firstly, functional components
assessed six areas of the data
management and reporting
systems. Trained data collectors,
w i t h ex p e r i e n c e i n d a t a
management, visited each site
and collected observational data
using a standardized checklist
and a questionnaire. Scores were
generated for each functional
area at the three levels – SDS,
IAL and M&E. For each of the six
functional components questions
were asked, with responses
coded as follows:
0 – no, not at all;
1 – partly;
2 – yes, completely.
The scores were intended to be
compared across functional areas
as a means of prioritizing system
strengthening activities.
The second data verification
protocol evaluated two stages;
an in-depth verification at the
SDS and a follow-up verification
at the IAL and programme M&E
level (region or FMOH). The
relationship between the SDS
and IAS data was measured
to establish if the selected
i n d i c a to r s we re re p o r te d
accurately and on time. Nine
indicators were selected among
the key national indicators in
the HMIS.3,4 Selection was based
upon their relative application
for decision-making. Indicators
w e r e e va l u a t e d f o r t w o
months (May and June 2010).
The data quality assessment
determined if a sample of SDSs
had accurately recorded the
activity related to the selected
indicators via a documentation
r e v i e w, a n d t r a c e a n d
verification. Data accuracy
at the SDS was calculated by
comparing the verified numbers
to the site reported numbers
during the period specified.
Data verification at the IALs
was determined by dividing the
sum of reported counts from
all SDSs divided by the total
count contained in the summary
report prepared by the relevant
IAL. Likewise, data accuracy
at the M&E unit level was
calculated by dividing the sum
of reported counts from all IALs
by the total count contained in
the summary report prepared
by the relevant M&E unit.
Values under 85% represent
over reporting and over 130%
under reporting. Availability,
completeness and timeliness of
reports from all SDSs and IALs
were determined based on the
MOH guidelines.
The third protocol concerned
information use.
Data analysis
Data was entered and analysed
on SPPSS version 19 software.
results
A total of 17 health districts
(woredas) were randomly
selected from the six regional
states implementing HMIS
in Ethiopia. These districts
contributed a total of 32 SDSs of
which 26 health centres and 6
district hospitals were reviewed.
A HMIS was fully implemented
over the previous two years in
19 of the 32 (59.4%) SDSs, in 7 of
17 (41.2%) of IALs and in 1 of 6
(16.7%) of the regions.
Observations on the basic
infrastructure required for HMIS
showed that a card room was a
standard specification in 7 of 32
(21.9%) sites, and a standard
Master Patient Index (MPI) box
was available in 13 of 32 (40.6%)
sites. Moreover, standard
shelves were available in 15 of
32 (46.9%) of SDS (see Table 1).
HMIS reporting formats were
observed at 32 of 32 (100%) of
the SDSs.
An assigned focal person for
HMIS was observed at 25 of
32 (78%) facilities with 7 of
25 (28%) focal persons having
information technology training.
Regular budget allocation for
HMIS running costs were found
at 7 of the 32 (22%) facilities, 5 of
17 (29.4%) districts and 2 of 6
(33.3%) region level offices (see
Table 1).
Data management and
reporting systems
performance
SDS: The performance of the six
functional areas (see Figure 2)
of the data management and
reporting systems gave a mean
score of 0.5 for resources. Data
management processes and data
55
Table 1. Characteristics of service delivery sites (n=32), infrastructure and
resources status at time of survey, Ethiopia, September 2010
Study levels
SDS
(n=32)
N (%)
Description of characteristics
6 months
Duration of HMIS implementation
1 year
≥2 years
Availability of HMIS unit
Card room size
Availability of MPI box
Availability of standard shelves
Yes
Card room staff
Budget allocation to HMIS activities
4 (23.5)
3 (50)
19 (59.4)
7 (41.2)
1 (16.7)
NA
6 (35.3)
5 (83.3)
11 (64.7)
1 (16.7)
3 (50)
25 (78.1)
Within standard
5 (15.6)
Above standard
2 (6.3)
Yes
13 (40.6)
No
19 (59.4)
Not at all
17 (53.1)
2 (33.3)
8 (25)
7 (21.9)
Yes
25 (78.1)
13 (76.5)
No
7 (21.9
4 (23.5)
3 (50)
1 (4)
0
3 (50)
Statistician
Qualification of focal persons
6 (35.3)
3 (9.4)
Below standard
Below standard
Region
(n=6)
N (%)
10 (31.3)
No
Standard
Presence of trained focal persons
District
(n=17)
N (%)
HI/MPH
0
0
3 (50)
14 (56)
4 (28.6)
NA
Others
3 (12)
1 (7.1)
NA
Not at all
2 (6.3)
NA
NA
5 (29.4)
2 (33.3)
Nurse
Partially staffed
19 (59.4)
Fully staffed
11 (34.4)
Allocated
7 (21.9)
Figure 2. Data management and reporting performance (scoring): SDSs, Ethiopia,
September 2010
Resources
M&E structure, functions
and capabilities
Links with national
reporting systems
Indicator definitions
and reporting guidelines
Data collection and
reporting forms
Data management
process
56
quality controls scored 1.2 and
links with the national reporting
system scored 1.3. For SDSs the
system shows relative strengths
in the data collection and
reporting tools (score 1.5).
IAL and M&E: The IALs had
data collection and reporting
tools scores of 0.5 at district,
1.25 at regional and 1.5 at
national levels (see Figure 3).
For resources the mean score
value ranged between 1.5 at
district level to 2.0 at regional
and national levels. The M&E
structure and capabilities scored
1.0 at district level, 1.5 at regional
level and 1.6 a national level. Data
management processes and data
quality controls scored 1.0 at
district, 1.25 at regional and 1.1
at national levels. Furthermore,
links with the national reporting
system scored 1.0, 1.6 and 1.4,
at district, region and national
levels respectively, indicating the
presence of parallel reporting.
Documentation
and reporting
performance
SDS: Indicator source documents
were available in 31 of the 32
(95%) sites. Completion of
reporting forms was seen in
24 out of the 31 (77%) sites.
However, regarding the dates for
the indicator source documents
only 21 of 31 (68%) fell within
the agreed national reporting
period (see Figure 4).
Figure 3. Data management and reporting performance (scoring): IALs,
Ethiopia, September 2010
Figure 4. Reporting performance (%) by SDS,
2.0
100
95.3
80
1.5
76.7
67.7
60
1.0
40
0.5
0
20
SDS
District
Region
● Resources
● Links with national reporting systems
● Data collection and reporting forms
● Data management process
● Indicator definitions and reporting guidelines
● M&E structure, functions and capabilities
0
National
Availability
of source
document
Document
completeness
Reporting
fall within
the standard
period
Figure 5. Comparison of reporting performance at different levels,
100
100
90
80
71
70
IAL & M&E: reports were
available in 12 of 17 districts
(71%). Completion of the fields
of the key indicators were
seen in 7 of 12 (62%) available
district reports and in 6 of the
17 districts (39%) reports were
received on time at the district
level (see Figure 5). Furthermore,
the reporting performance
at regional and national
levels showed that though the
representative completeness
reached 87% and above for both
administrative levels, the content
completeness and timeliness of
reporting were as low as 39% and
73% at regional level. At national
level content completeness and
timeliness were at 29% and 53%
respectively.
87
National target: 85%
73
62
60
53
50
40
39
39
29
30
20
10
0
District
Region
FMOH
● Timeliness
● Content completeness
● Representative completeness
Data accuracy
The accuracy ratio was related
to over reporting at the SDS
and IAL and under reporting at
the M&E level. Accuracy of the
observed data in 24 of 32 (76%)
SDSs had an accuracy ratio that
fell within the accepted range,
11% had accuracy ratio less that
70% and 7% were above 130%
indicating under reporting.
Comparing services, under
reporting was more common for
voluntary counselling and testing
(VCT), proportion of deliveries
attended by skilled persons
(SBA) and tuberculosis case
detection rate (TBCDR). There
was over reporting for measles,
Pentavalent, antiretroviral
57
Figure 6. Data accuracy at service sites by indicator, Ethiopia, September 2010
32
Number of service sites
28
24
20
16
12
8
4
0
SBA
CAR
Penta
Measles
TBCDR
PMTCT
ART
VCT
● >130
● 115–129
● 85–114
● 71–84
● <70
Figure 7. Accuracy ratio at all levels by indicator, Ethiopia, September 2010
2.5
2.0
1.5
1.0
0.5
0
FMOH
● CAR
● SBA
● Penta 3
● Measles
● TBCDR
● PMTCT
● ART
● VCT
● ANC
58
Region
District
Health facility
ANC
therapy (ART) and contraceptive
acceptance rate (CAR) in the
majority of the SDSs (see
Figure 6).
Data accuracy within the
acceptable range in the IALs was
88% at the district and 71% at
the regional level; and below
70% in 8% of the districts and
in 13% of the regions. Between
indicators, the accuracy was
highest for antenatal care (ANC),
TBCDR and measles but lowest
for CAR,prevention of mother
tp child transmission therapy
(PMTCT) and ART (see Figure 7).
Information use
Data was compiled on quarterly
basis at 30 of 32 (94%) of
SDSs and 12 of 17 (71%) IALs.
Feedback reports based on HMIS
data was observed in 35.3% of
IAL and 50% of M&Es. Discussion
and decisions based on HMIS data
occurred in 37% of the facilities.
These included patient utilization
of services, service coverage and
medicine stock-outs. Routine
meetings to review managerial
or administrative matters were
conducted in 23.5% and 50%
cases for the studied IAS and
M&E levels respectively.
discussion
Results from the data
systems assessment enabled
t h e te a m to u n d e r s t a n d
qualitatively and quantitatively
the operationality as well as
the relative strengths and
weaknesses of functional areas
that affect the overall quality
of data in the health systems.
Findings showed that standard
data collection and reporting
tools were in place. However,
implementation was low.
Major factors were: inadequate
provision of the required
resources or inputs, including
lack of trained focal persons,
inadequate start-up costs that
including basic infrastructure,
such as the availability of card
rooms, standard MBI boxes
and shelves. The majority of
administrative levels tended to
allocate inadequate funding to
operationalize the new HMIS
on regular basis. A study done
previously on the implementation
progress of the country’s HMIS
had observed similar findings.6
Furthermore, though source
documents for the selected
indicators were available for the
reporting being verified, content
completeness and reporting
timeliness remained far below
the national 85% target. Accuracy
of reported data, moreover, was
generally inadequate. A tendency
to over report for the indicators
was a common finding in nearly
all of the reporting levels. Findings
indicated that the level of data
accuracy among the various levels
was over-reported in nearly all of
the health facilities, districts and
regions, and was under reported
at the M&E national level.
The study further acknowledged
the inadequacy of regular
supervision and feedback
from senior levels to address
the problems of inadequate
documentation, late and
incomplete reporting and
inaccurate reporting.
These findings indicate the
extent to which data quality can
be adversely affected by limited
investment in infrastructure and
human resource capacity as well
as by the performance of the data
aggregation and reporting units
of the system.
Furthermore, the study observed
a limited culture of using
information for decision-making
in planning and management
of implementing programmes.
Just 37% of the facilities had
exercised discussion and made
decisions using findings from
routine health information.
conclusion
The present study documents
the challenges and limitations of
the information systems to serve
as the foundation of decisionmaking and for monitoring
the quality of service delivery.
While achieving and maintaining
data quality requires ongoing
attention and a comprehensive
59
approach in addressing the
issues of data management and
reporting systems and data
accuracy, strengthening health
information systems is one of the
most powerful ways of improving
health outcomes. To this effect,
the assessment recommends
instigating:
• A favourable administrative
and legal environment
that ensures or reinforces
mandatory routine reporting;
• Sound data archiving;
• T h e d e s i g n a t i o n o f
institutional responsibilities
for the approval of national
data collection instruments
and methods;
• Infrastructure support to
enhance the efficiency and
quality of reporting as well as
building capacities of health
information experts. The
latter will enhance the use
of evidence based practices
during supervision, planning
and budgeting;
• Adopting procedures to
address late, incomplete or
inaccurate reports received
from sub-reporting levels
Acknowledgements
References
The authors are keen to express their appreciation to the WHO
country office for the technical as well financial support to
undertake this relevant and timely work. Thanks also go to
all experts at the M&E unit of the FMOH. The team offers its
appreciation to the service delivery facilities and the various tiers of
the health care system for their willingness and active participation
in this important endeavour.
1. Federal Democratic Republic of Ethiopia Ministry of Health,
Health Management Information Systems, Monitoring and
Evaluation. Information Use Guideline and Display Tools,
January 2008.
Health Management Information Systems, Monitoring and
Evaluation (M&E). HMIS Procedure Manual: Data recording and
reporting procedures, January 2008.
3. WHO. Monitoring the building blocks of health systems: a
handbook of indicators and their measurement strategies, WHO,
60
and corrections to earlier
discrepancies in reports
through regular integrated
supportive supervision.
This study recommends that
follow-up assessments on data
systems should be integrated
into the routine supervision
systems as a means identifying
and monitoring necessary
improvements. z
4. WHO. World Health Organization guideline on DQS and LQS,
2008, 2009.
5. USAID and Measure Evaluation. PRISM: Performance of
Routine Information System Management. PRISM Tools for
Assessing, Monitoring, and Evaluating RHIS Performance,
PRISM Tools Version 3.1, March 2010.
Health Management Information Systems, Monitoring
and Evaluation. Implementation status of HMIS and M&E in
Ethiopia, September 2009.
C o m m u n i c a b l e D i s e a s e s Ep i d e m i o l o g i c a l R e p o r t
CDER editorial
REGIONAL OFFICE FOR
Africa
Communicable
Diseases
Epidemiological
Report
data valid effective
march 2011
In this issue
CDER Editorial — 61
Virological epidemiology of influenza
infection in the African Region (2011) — 61
Cholera situation in the first quarter of 2011
in the African Region — 63
Clinical cases of yellow fever in the first
quarter of 2011 in the African Region — 65
I
ntegrated Disease Surveillance
and Response (IDSR) in the WHO
African Region now goes beyond
the scope of communicable diseases.
Noncommunicable health conditions
and events are also a priority in IDSR.
However, this March 2011 issue
attempts to provide information on
the burden of some of the regional
priority communicable diseases such
as cholera, cerebrospinal meningitis,
influenza and yellow fever in the
WHO African Region. The data
presented were collected through
the implementation of the Integrated
Disease Surveillance Strategy in the
region.
A number of questions remain
unanswered in this report. What do
the increased cholera and meningitis
case-fatality rates (CFR) in the region
tell us about the case management
capacities of Member States? Is the
apparent reduction in meningitis
cases due to N. Meningitidis A (Nm A)
in Burkina Faso, Mali and Niger a
result of the recent introduction of
the men A conjugate vaccine?
We hope you will find the contents
of this report useful. Your comments
and suggestions are most welcome
and should be addressed to the
Editor of the Communicable Diseases
Epidemiological Report.
Dr J B Roungou
Director, DPC Cluster
Cerebrospinal meningitis in the first quarter
of 2011 in the African Region — 66
CDER Editorial Board
Dr F Kasolo, Dr Z Yoti, Dr B Impouma,
Dr P Gaturuku, Dr A A Yahaya,
Dr F Tshioko, Mr C Corera, Dr N Bakyaita
Editor:
Dr J B Roungou, Director, DPC Cluster
Contact information
Virological epidemiology of
influenza infection in the African
Region (2011)
There are 29 national influenza laboratories in the 24 countries of the WHO African
Region responsible for providing information on the virological epidemiology of
influenza in the region. These are members of the African Influenza Laboratory Network.
The main goal of this network is to continue building the national laboratory capacity
of African countries to conduct virological surveillance of viral respiratory diseases
in general and influenza in particular. The primary laboratory diagnostic test used to
generate virological information is the reverse transcriptase polymerase chain reaction
(RT-PCR) technique. In addition to this test, 11 of the 24 countries also perform virus
isolation.
WHO/AFRO, DPC Cluster
Attention: IDS
BP 6, Cite du Djoué, Brazzaville, CONGO
Tel: (242) 241 39387/39412 or (47) 241 38000
Fax: (47) 241 38005/6
Email: [email protected]
61
Figure 1. Comparison maps of countries reporting at least one laboratory confirmed
case of influenza in the first quarters of 2010 and 2011
REGIONAL OFFICE FOR
Africa
Communicable
Diseases
Epidemiological
Report
2010
2011
valid: march 2011



At least one case confirmed
No confirmed case
No data
Total confirmed Pandemic A (H1N1) cases: 1264
Total confirmed influenza cases: 2018
Total confirmed Pandemic A (H1N1) cases: 517
Total confirmed influenza cases: 1347
During the first quarter of 2010, the network laboratories tested 11 353 specimens
of which 2018 (18%) were positive compared with 9013 specimens tested in 2011 of
which 1347 (15%) were positive. 1264 (63%) of the positive specimens were pandemic
A (H1N1) in 2010 compared with 517 (38%) in 2011.
As shown in Figure 2, Pandemic A (H1N1) was the predominant influenza type during
the first quarter of 2010 as opposed to the same period 2011, where both Pandemic A
(H1N1) and seasonal influenza B were co-predominant. Overall there was a comparative
drop in the number of Pandemic A (H1N1) cases in first quarter of 2011.
Figure 2. Number of confirmed influenza by subtypes circulating in the region
during the first quarters of 2010 and 2011
First quarter 2010
Number of specimens positive
for influenza
350 —
300 —
250 —
200 —
150 —
100 —
50 —
0—
1



62
2
3
A (H1)
A (H3)
A (not subtyped
4



5
6
7
Weeks
Pandemic A (H1N1)
A (H5)
B
8
9
10
11
12
13
First quarter 2011
Number of specimens positive
for influenza
200 —
200 —
150 —
100 —
50 —
0—
1



2
3
A (H1)
A (H3)
A (not subtyped
4



5
6
7
Weeks
8
9
10
11
12
13
Pandemic A (H1N1)
A (H5)
B
Cholera situation in the first
quarter of 2011 in the African Region
By the end of the first quarter of 2011, 16 countries in the African Region had reported a
total of 20 394 cholera cases with 406 deaths compared with 18 countries, 20 882 cases
and 313 deaths in the corresponding quarter in 2010 as shown in Table 1 and Figure 3.
Figure 3. Countries reporting cholera cases in first quarters of 2010 and 2011
First quarter 2010
First quarter 2011



Countries reported cases
No reported case
No data
63
Table 1. Suspected and confirmed cholera cases reported in first quarters
2010 and 2011
REGIONAL OFFICE FOR
Africa
Communicable
Diseases
Epidemiological
Report
valid: march 2011
Country
Angola
Benin
Burundi
Cameroon
Chad
Côte d'Ivoire
Ethiopia
Ghana
Kenya
Liberia
Malawi
Mozambique
Niger
Nigeria
Togo
Uganda
Zambia
Zimbabwe
Total
First quarter 2010
Cases
Deaths CFR (%)
529
18
3.4
269
2
0.7
75
0
0.0
7
0
0.0
4
2
50.0
0
0
0.0
24
0
0.0
3462
38
1.1
1010
14
1.4
0
0
0.0
1401
25
1.8
252
0
0.0
686
11
1.6
5044
93
1.8
0
0
0.0
344
29
8.4
7
0
0.0
97
8
8.3
2361
19
0.8
4973
44
0.9
337
10
2.9
20 882
313
1.5
First quarter 2011
Cases
Deaths CFR (%)
116
2
1.7
11
1
9.1
158
0
0.0
2470
109
4.4
0.0
178
11
6.2
517
12
2.3
3363
59
1.7
0.0
5994
62
1.0
1
0
0.0
360
0
0.0
0
0
0.0
1001
0
0.0
96
10
10.4
4874
124
2.5
0
0
0.0
0
0
0.0
531
7
1.3
258
7
2.7
466
2
0.4
20 394
406
2.0
Source: Member States.
In 2011, countries reporting cases of cholera in the region continue to have an
unacceptably high case-fatality rate, above the 1% threshold. High case-fatality rates
may reflect the limited country preparedness to respond effectively to cholera outbreaks
or an inability to detect cholera circulation at district level in good time.
Combating cholera calls for the development of comprehensive response plans that
should include:
• Health education campaigns on the prevention of cholera especially when the season
or conditions are ripe for outbreaks;
• Pre-positioning of equipment and supplies to detect and respond in time to any
outbreaks;
• Health worker training and re-training on outbreak detection and response.
Recently, discussions have commenced on the possibility of using cholera vaccines as an
additional tool in the fight of this disease (ref: WER No. 13, 2010, 85, 117–128).
64
Clinical cases of yellow fever in the
first quarter of 2011 in the African
Region
In first quarter of 2011, 11 countries reported 282 clinical cases of yellow fever with
11 deaths compared with 16 countries, 350 cases and 12 deaths recorded during the
same period in 2010. The case-fatality rate for the suspected cases remained below the
4% threshold in both 2011 and 2010. Significant laboratory confirmed outbreaks were
reported in Côte d’Ivoire and Uganda in 2011. The Uganda outbreak was unusual in that
this was the first time in many years that yellow fever had been detected in the country.
Figure 4. Countries that reported clinical cases of yellow fever in the first quarters of
2010 and 2011
First quarter 2010
First quarter 2011



No reported case
No data
Table 2. Summary of yellow fever cases reported in the WHO Region, first quarters
2010 and 2011
Country
Benin
Chad
Congo
Côte d'Ivoire
Gabon
Ghana
Guinea
Liberia
Mali
Niger
Nigeria
Senegal
Sierra Leone
South Africa
Uganda
Total
First quarter 2010
Cases
Deaths CFR (%)
1
0
0.0
2
0
0.0
30
2
6.6
25
0
0.0
102
3
2.9
21
3
14.2
6
0
0.0
22
0
0.0
33
2
6.1
5
0
0.0
9
1
11.1
12
1
8.3
4
0
0.0
53
0
0.0
16
0
0.0
9
0
0.0
0
0
0.0
350
12
3.4
First quarter 2011
Cases
Deaths CFR (%)
0
0
0.0
0
0
0.0
22
2
9.1
0
0
0.0
65
3
4.6
35
1
2.8
10
1
10.0
69
1
1.4
29
0
0.0
7
0
0.0
14
1
7.1
3
1
33.3
0
0
0.0
0
0
0.0
16
0
0.0
0
0
0.0
12
1
8.3
282
11
3.9
65
REGIONAL OFFICE FOR
Africa
Communicable
Diseases
Epidemiological
Report
valid: march 2011
Cerebrospinal meningitis in the first
quarter of 2011 in the African Region
Figure 5 and Table 3 compare the burden of cerebral spinal meningitis during the first
quarters of 2010 and 2011. A total of 20 countries reported cases of cerebrospinal
meningitis in the first quarter of 2011 compared with 26 during the same period in 2010.
There were 9535 cases and 994 deaths attributable to cerebral spinal meningitis
reported in the first quarter of 2011 compared with 15 003 cases and 1739 deaths in
2010 (see Table 3).
Table 3. Suspected and confirmed cerebral spinal meningitis cases, first quarters
2010 and 2011
Country
Angola
Benin
Burkina Faso
Burundi
Cameroon
Chad
Congo
Côte d'Ivoire
Ethiopia
Gabon
Ghana
Guinea
Kenya
Liberia
Mali
Mozambique
Namibia
Niger
Nigeria
Senegal
Seychelles
Sierra Leone
Togo
Total
66
First quarter 2010
Cases
Deaths CFR (%)
116
4
3.5
159
29
18.3
3827
544
14.2
6
0
0.0
498
47
9.4
212
63
29.7
1705
162
9.5
11
0
0.0
58
18
31.0
2252
244
10.8
3
0
0.0
2
0
0.0
728
77
10.6
66
9
13.6
44
14
31.8
2
1
50.0
238
16
6.7
309
88
28.5
2
0
0.0
1453
126
8.7
2938
218
7.4
26
1
3.8
1
0
0.0
2
1
50.0
289
71
24.6
56
6
10.7
15 003
1739
11.6
First quarter 2011
Cases
Deaths CFR (%)
0
0
0.0
113
25
22.1
1903
340
17.9
18
1
5.6
258
29
11.2
0
0
0.0
2791
144
5.16
0
0
0.0
49
16
32.6
2321
214
9.2
2
0
0.0
11
3
27.3
433
69
15.9
110
6
5.5
16
1
6.3
2
0
0.0
153
7
4.6
0
0
0.0
6
1
16.7
676
78
11.5
424
22
5.2
0
0
0.0
0
0
0.0
2
0
0.0
226
32
14.2
21
6
28.5
9535
994
10.4
Figure 5. Countries reporting cerebral spinal meningitis cases in the first quarter of
2010 and 2011
First quarter 2010
First quarter 2011



No reported case
No data
Cerebral spinal fluid (CSF) samples were collected, tested and reported on in countries
with enhanced surveillance namely: Benin, Burkina Faso, Cameroon, Chad, Mali and
Niger. During the first quarter of 2011, of the 1889 CSF samples tested, 757 were
positive and overall the predominant pathogens were Streptococcus pneumoniae (47%),
Neisseria meningitidis W135 (30%) and Neisseria meningitidis A (14%). During the same
quarter of 2010, of the 1755 CSF samples tested, 843 were positive with Streptococcus
pneumoniae (25%), Neisseria meningitidis A (30%) and Neisseria meningitidis W 135
(29%). (Refer to tables 4 and 5.) A significant observation is that there has been a decline
in the overall confirmed cases of Neisseria meningitidis A in 2011. Of note is that before
the meningitis season, the men A conjugate vaccine was introduced in Burkina Faso,
Mali and Niger. Although it is early days, it is possible that this could be the reason for
the drop in Neisseria meningitidis A related cases.
Table 4. Pathogens1 identified by PCR, latex and culture, reported first quarter 2010
Country
Benin
Burkina Faso
Cameroon
Chad
Mali
Niger
Total
1
No. of
CSF
50
414
16
241
17
1017
1755
Results
Neg
Pos
17
33
193
221
8
8
165
76
11
6
518
499
912
843
Number of CSF positive by sero-type
Nm A
0
66
7
48
4
132
257
Nm X
0
41
0
0
0
2
43
Nm
W135
0
7
0
14
0
223
244
S.
Pneum
33
125
1
12
1
40
212
Proportions (%) of pathogens
Hib
0
7
0
2
1
13
23
Positive
samples Nm A
66.0
0.0
53.4
29.9
50.0
87.5
31.5
63.2
35.3
66.7
49.1
26.5
48.0
30.5
Nm
W135
0.0
3.2
0.0
18.4
0.0
44.7
28.9
S.
Pneum
100.0
56.6
12.5
15.8
16.7
8.0
25.1
Nm B, Nm C, Nm Y and other unknown pathogens were also screened for but are not shown in the table.
67
Table 5. Pathogens1 identified by PCR, latex and culture reported first quarter 2011
REGIONAL OFFICE FOR
Africa
Communicable
Diseases
Epidemiological
Report
valid: march 2011
No. of
CSF
Country
Benin
52
Burkina Faso2 857
Cameroon
147
Chad
228
Mali
121
Niger
484
Total
1889
1
2
Results
Neg
Pos
19
33
341
324
124
23
107
121
101
20
248
236
940
757
Number of CSF positive by sero-type
Nm A
0
2
6
98
0
3
109
Nm X
0
42
0
0
0
1
43
Nm
W135
0
16
5
6
11
187
225
S.
Pneum
31
257
10
13
8
38
357
Proportions (%) of pathogens
Hib
2
7
0
4
1
1
15
Positive
samples Nm A
63.5
0.0
37.8
0.6
15.6
26.1
53.1
81.0
16.5
0.0
48.8
1.3
40.1
14.4
Nm
W135
0.0
4.9
21.7
5.0
55.0
79.2
29.7
S.
Pneum
93.9
79.3
43.5
10.7
40.0
16.1
47.2
Nm B, Nm C, Nm Y and other unknown pathogens were also screened for but are not shown in the table.
192 samples from Burkina Faso were contaminated.
Country-specific reports on cerebral spinal meningitis
Burkina Faso, Mali and Niger located in the “meningitis belt” have been supported to
conduct enhanced meningitis surveillance that includes monitoring cases and deaths
as well as sero-typing the causative agents using polymerase chain reaction (PCR)
techniques. Below we examine in more detail country specific reports from Burkina
Faso, Niger and Mali using data in tables 3, 4 and 5.
Burkina Faso: The number of meningitis cases reported in the first quarter has
decreased by 50% in 2011 (1903 cases and 340 deaths) when compared with 2010
(3827 cases and 544 deaths). Despite this there has been an increase in the casefatality rates which went up slightly in 2011. In the first quarter 2011, Burkina Faso
tested 857 samples of which 324 (38%) were positive for S. pneumoniae accounting for
79% of positive samples and Nm A only 0.6%. In the corresponding quarter of 2010,
S. pneumoniae accounted for 53% of positive samples and Nm A 30%. There is a clear
drop in the proportion of cases due to Nm A in 2011 compared with 2010 possibly
related to the men A conjugate vaccine introduction.
Niger: Reported 676 cases and 78 deaths in the first quarter of 2011 compared with
1453 cases and 126 deaths in 2010, suggesting a 50% drop in both cases and deaths.
In the first quarter of 2011, of the 484 specimens received, 236 (49%) were positive
with the predominant pathogen being Nm W135 (79%), S. pneumoniae 16% and
Nm A 1.3%. In the corresponding quarter 2010, the predominant pathogen was still
Nm W135 (45%) followed by Nm A (27%). As is the case for Burkina Faso, the drop
in proportion of positive specimens due to Nm A can be attributed to the partial
introduction of men A conjugate vaccine.
Mali: In the first quarter of 2011 153 cases and 7 deaths were reported, compared
with 238 cases and 16 deaths in the corresponding quarter of 2010. Of the 121 CSF
samples received only 20 (16.5%) were positive with the predominant species Nm
W135. In the corresponding period in 2010, only 6 samples were positive of which 4
were Nm A. Given the small sample sizes, it is difficult to interpret the trends.
Conclusion
Burkina Faso, Mali and Niger have recently introduced the men A conjugate vaccine. The
first vaccination campaigns were conducted just before the beginning of the traditional
meningitis season before December. The introduction of this vaccine may be responsible
for the reduction in the number of Nm A cases in these countries. However, more data
and analysis are needed to confirm the apparent decline.
68
NEWS AND EVENTS
WHO African Region gets its own Strategic
Health Operations Centre
A Strategic Health Operations
Centre, known simply as the
AFRO SHOC Room, has been
established at the Brazzaville
headquarters of the WHO
Regional Office for Africa.
Built-in electronic storage
systems in the AFRO SHOC
will ensure storage of large
volumes of epidemiological
data as well as well as facilitate
detailed analysis of these data.
The facility will serve as the hub
for coordinating the response
to outbreaks, epidemics,
pandemics, natural or manmade disasters and other
public health emergencies in
the region.
Situated in a room on the first
floor of AFRO’s headquarters
in the Congolese capital,
the AFRO SHOC is fitted
with a dedicated V SAT
communication system and
satellite plasma television
screens which receive dozens
of TV channels in different
languages, thus enhancing
the collection, compilation,
verification, risk assessment
and monitoring of public health
events that could threaten
regional health security.
“We are witnessing a
very important moment
for WHO in the African
Region and for this office
in particular”, WHO
Regional Director for Africa,
Dr Luis Sambo, said during
the official commissioning
ceremony which took place
recently in Brazzaville.
“This state-of-the-art
facility, complete with
video and telephone
conferencing facilities
will ensure real-time
communication with
WHO Headquarters; other
WHO regions; our Country
Offices and Intercountry
Support Teams (ISTs)
at base locations in
Libreville, Ouagadougou
and Harare; partners,
and other rapid response
teams operating in the
field,” Dr Sambo said.
He added: “The AFRO
SHOC
Room
will
revolutionize our ability to
mount coordinated rapid
responses, and to save
lives more quickly.”
To support the process
of outbreak detection,
verification, risk assessment
and monitoring, WHO has
developed a web based
application called Event
Management
System
(EMS) which uses the latest
information technology and
acts as an early warning and
response system.
Management of the AFRO
SHOC Room
The centre is managed by WHO
AFRO’s Epidemic and Pandemic
Alert and Response Programme
whose primary mission is to
support Member States of the
African Region to establish and
implement functional integrated
early warning and epidemic
preparedness and response
systems that will result in
the improved prediction,
early detection and rapid and
effective response to epidemicand pandemic-prone diseases
that will be the foundation of
an integrated regional alert
and response system for
epidemics and other public
health emergencies.
Functionality of the SHOC Room:
ûProvide facilities for coordination of response to health emergencies within the region.
ûAbility to access satellite television broadcasts on multiple touch screens.
ûAbility to access political and geographical maps of the region’s 46 Member States, using sophisticated
software able to zoom into specific locations (city, village or site as much as possible).
ûCommunication via e-mail telephone, fax, video, satellite phone, high frequency radio using one or the
other as an alternative and backup.
ûAbility to access video-conferencing facilities.
ûConnection to situation rooms at HQ, regional and country offices as well as WHO AFRO’s ISTs.
ûAbility to function 24 hours a day 7 days a week.
The AFRO SHOC boasts an equipment room, a main operations room, two outbreak rooms and a control room.
69
African Health Ministers adopt Brazzaville
Declaration on Noncommunicable Diseases
The first Africa Regional
Ministerial Consultation on
noncommunicable diseases
(NCDs) ended in the Congolese
capital with the adoption of
the Brazzaville Declaration
on NCDs (available at http://
w w w. a f r o . w h o . i n t / e n /
clusters-a-programmes/dpc/
non-communicable-diseasesmanagementndm.html).
The Declaration urged urgent
action by various stakeholders
to address major NCDs and
priority conditions which
represent “a significant
challenge” to people in the
African Region: cardiovascular
diseases, diabetes, cancer and
chronic respiratory diseases,
diseases of blood disorder (in
particular sickle-cell disease),
mental health, violence and
injuries.
In the Declaration, the ministers
also committed to develop
national NCD action plans
and strengthen institutional
capacities for NCD prevention
and control; urged the United
Nations to include NCD
prevention and control in all
future global development
goals; and called on WHO,
partners and civil society
organizations to provide
technical support to Member
States for implementing,
monitoring and evaluating
recommendations contained in
the Declaration.
The Declaration specifically
requested heads of state and
governments in the Region to
endorse the Declaration and
present it to the September
2011 UN General Assembly
High-Level Summit on NCDs
as the position of the Region
on NCDs.
The ministers also requested
the UN Secretary General
to establish a mechanism
70
Highlights of the Declaration include commitment by the ministers to:
ûStrengthen
and standardize national health systems to
generate disaggregated data on NCDs, their risk factors
and determinants and monitor their magnitude, trends,
and impact.
ûUse
all appropriate means including information and
communication technologies to promote, intensify
and increase health awareness and empowerment
of individuals and communities.
ûDevelop
and implement NCD prevention and
control strategies, guidelines, policies, legislations
and regulatory frameworks including the WHO
Framework Convention on Tobacco Control
(FCTC) to protect individuals, families and
communities from unhealthy diets, harmful
use of alcohol, tobacco use and exposure
to tobacco smoke and unsafe food; and
from violence and injuries, advertising of
unhealthy products.
ûReorient national health systems towards the promotion
and support of healthy lifestyles by individuals, families and communities within the
primary health care context in order to effectively respond to complex social, cultural and
behavioural aspects associated with NCDs.
ûFurther
strengthen health systems with appropriate attention to, among other things, health
financing; training and retaining the health workforce; procurement and distribution of
medicines, vaccines, medical supplies and equipment; improving infrastructure; and, evidencebased and cost-effective service delivery for NCDs.
ûIdentify
and harness existing health initiatives, including global initiatives, to accelerate the
prevention and control of NCDs and address integrated care in the context of primary health
care and health systems strengthening.
ûSupport
and encourage partnerships, alliances and networks bringing together national,
regional and global players including academic and research institutions, public and private
sectors, and civil society in order to collaborate in NCD prevention and control and to conduct
innovative research relevant to the African context.
ûAllocate, from national budgets, financial resources that are commensurate to the burden of
NCDs to support NCD primary prevention and case management using primary health care
approach and establish sustainable innovative and new financing mechanisms at national and
international levels.
to monitor progress of the
commitments taken at the UN
High-level Summit on NCDs,
and called on the WHO Regional
Director for Africa to include the
regional NCD strategic plan in
the agenda of the 62nd session of
the WHO Regional Committee
for Africa and report progress
made in the implementation of
the declaration to the Regional
Committee in 2014.
Ministers launch pioneering initiatives to
tackle health and environment issues in Africa
The Second Inter-Ministerial
Conference on Health and
Environment, held from 25 to
26 November 2010 in Luanda,
Angola, adopted the Luanda
Commitment which outlines
the continent’s health and
environment priorities and
commits countries to take
actions to address them, and
accelerate the implementation
of the Libreville Declaration.
The conference was jointly
organized by WHO (World
Health Organization) and UNEP
(United Nations Environment
Programme) and hosted by the
Government of Angola.
The priorities listed in the
Luanda Commitment include
provision of safe drinking water;
provision of sanitation and
hygiene services; management
of environmental and health
risks related to climate change;
sustainable management of
forests and wetlands; and
management of water, soil
and air pollution as well as
biodiversity conservation.
Other priorities are vector
control and management
of chemicals, particularly
pesticides and wastes; food
safety and security, including
the management of geneticallymodified organisms in food
production; children’s health
and women’s environmental
health; health in the workplace
and the management of natural
and human-induced disasters.
With the Luanda Commitment,
countries pledge to accelerate
the implementation of the
Libreville Declaration, especially
because of the effect this
will have on the attainment
of Millennium Development
Goals 4, 5, 6 and 7 relating to
child health, maternal health,
communicable diseases and
environmental sustainability
respectively.
The ministers also agreed to
mobilize resources available
from government budgets
and the private sector, and
to advocate for and monitor
the allocation of 15% of
government expenditure to
the health sector, as stated
in the 2001 Abuja Declaration
by African Heads of State,
and a substantial increase in
government spending on the
environment sector.
WHO and the UNEP, the coorganizers of the conference,
are requested in the Luanda
Commitment to increase their
support for the implementation
of the Libreville Declaration;
broaden the participation of other
relevant inter-governmental
organizations, development
banks and regional economic
communities; and establish a
mechanism to facilitate access
by countries to existing financial
resources for health, the
environment and sustainable
development, especially climate
change funds.
The ministers also formally
established the Health and
Environment Strategic Alliance
(HESA), a novel mechanism
to stimulate policies and
investments in favour of
enhanced joint actions for
health and environment in
Africa. HESA, the first ever
collaboration framework of
its type between African
countries and two United
Nations agencies in Africa, was
adopted alongside the other
major conference outputs.
Building on the linkages
between the health and
environment sectors, HESA,
now institutionalized, will
develop and coordinate actions
to effectively protect and
promote public health and
ecosystem integrity with a view
to helping countries attain the
Millennium Development Goals.
It will concretely support country
efforts through advocacy,
resource mobilization, capacity
building, technical assistance
as well as progress monitoring,
as part of the implementation
of the Libreville Declaration,
adopted in 2008 to reduce
environmental threats to human
health and well-being.
Also, for the first time,
African ministers of health
and environment made their
strongest pronouncement ever
on climate change and health
in the region, with the adoption
of a Joint Statement on Climate
Change and Health.
The statement articulates
Africa’s common position on
climate change and health, and
calls for support for actions
aimed at reducing vulnerability
and building resilience in
the health sector in African
countries. It also captures
commitments by African
ministers to address climate
change in the continent,
particularly as its effects are
likely to be more severe than
originally anticipated and
may exacerbate the effects
of traditional and emerging
environmental risk factors
on human health, thereby
hampering Africa’s efforts
to attain the Millennium
Development Goals.
The Joint Statement on
Climate Change and Health
will be tabled before the 16th
Conference of the Parties to
the United Nations Framework
Convention on Climate Change
taking place from 29 November
to 10 December 2010 in
Cancún, Mexico.
Speaking at the closing
ceremony of the conference,
the Minister of Environment
of Angola, Ms Fatima Jardim,
said, “Angola can contribute
by setting the example and
through interaction and
information, consolidate the
mutual commitments set out
in the important tools we have
adopted at this meeting and
which will serve not only as a
link between the health and
environment sectors but also
to connect us in a commitment
as countries of a continent.”
The Regional Director and
Representative of UNEP
in Africa, Mr Mounkaila
Goumandakoye said, “The
Luanda Conference is a
milestone as the health
and environment sectors
become credible and
strategic partners. I leave
this meeting further
convinced that the future of
Africa is not cast anywhere.
It is we who determine this
by our commitments, our
determination and our
actions.”
Assessing the outcomes of
the conference, the WHO
Regional Director for Africa, Dr
Luis Sambo said, “The three
tools that we have adopted at
this conference are clear and
consistent and the decisions
we have taken will serve us
well in the implementation of
the Libreville Declaration.”
71
the
African
REGIONAL OFFICE FOR
Africa
Health
monitor
HEALTH SYSTEMS AND
REPRODUCTIVE HEALTH
special Issue 14
March 2011
The African Health Monitor is a magazine of the World Health Organization Regional Office for Africa
(WHOAFRO) published four times a year. It is a multilingual publication with peer reviewed articles in English,
French and Portuguese.
The aim of the African Health Monitor is to promote and facilitate evidence-based policy and decisions
to strengthen programmes for health promotion, protection, and restoration in the African Region. In
order to achieve its aim, the Monitor serves as a medium for publication of articles that monitor the health
situation and trends, and track progress toward the health-related Millennium Development Goals and other
internationally agreed-upon goals. It will publish and disseminate relevant and scientifically rigorous public
health information. It will also disseminate information on public health interventions carried out in the
Member States with the cooperation of AFRO technical programmes.
Prospective authors should follow the Monitor stylesheet, which can be obtained by sending an email
message to the Editorial Office at [email protected] or by using this intranet link http://intranet.afro.who.int/
guidelines/ahm.pdf
Editorial B oard
Paul Lusamba-Dikassa (Editor-in-Chief)
Uche Amazigo
Rufaro Chatora
Alimata J Diarra-Nam
Lucile Imboua
Tigest Ketsela
Matshidiso Moeti
Chris Mwikisa Ngenda
Jean-Baptiste Roungou
Bokar Toure
Oladapo Walker
Editorial office
Chris Zielinski (Managing Editor)
Samuel Ajibola (Production Manager)
Wenceslas Kouvividila
Angele Mandzoungou
Firmine Mavila
core Editorial group
Derege Kebede (Editor)
Chris Zielinski (Chief Language Editor)
Emil Asamoah-Odei (Deputy Editor, English)
Issa Sanou (Deputy Editor, French)
Carina Ferreira-Borges (Deputy Editor, Portuguese)
Edoh William Soumbey-Alley (Deputy Editor, Statistics)
Samuel Ajibola (News and Events Editor)
Aude-Armel Onlinouo (Photo Editor)
Associate Editors
Usman Abdulmumini
Olga Agbodjan-Prince
Bartholomew Akanmori
Abdikamal Alisalad
Ghislaine Conombo
Fernando Da Silveira
Jean-Marie Dangou
Babacar Drame
Phanuel Habimana
Bah Keita
Georges Alfred Ki-zerbo
Joses Muthuri Kirigia
Lucien Manga
Balcha Masresha
Peter Ebongue Mbondji
Patience Mensah
Kasonde Mwinga
Benjamin Nganda
Deo Nshimirimana
Louis Ouedraogo
Assimawe Paul Pana
Kweteminga Tshioko
Prosper Tumusiime
All reasonable precautions have been taken by the World Health Organization
to verify the information contained in this publication. However, the published
material is being distributed without warranty of any kind, either express or
implied. The responsibility for the interpretation and use of the material lies with
the reader. In no event shall the World Health Organization or its Regional Office
for Africa be liable for damages arising from its use.
The contents of this publication do not necessarily reflect official WHO views.
Some papers in this publication have not passed through formal peer review.
72
Expert Advisor
Dr Rosa Constanza Vallenas de Villar
Medical Officer, Child and Adolescent Health and
Development, WHO, provided expert advice for this issue.
The African Health Monitor
Office #345
P.O. Box 6
Brazzaville
Republic of Congo
[email protected]
Tel: + 47 241 39217
Fax: + 47 241 39509
D ESIG N & L AYOUT
The mention of specific companies or of certain manufacturers’ products does not
imply that they are endorsed or recommended by the World Health Organization
in preference to others of a similar nature that are not mentioned. Errors and
omissions excepted, the names of proprietary products are distinguished by
initial capital letters.
Cover © Shutterstock
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Vivien Stone
The designations employed and the presentation of the material in this
publication do not imply the expression of any opinion whatsoever on the part
of the World Health Organization concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its
frontiers or boundaries. Dotted lines on maps represent approximate border lines
for which there may not yet be full agreement.
photo credits
Co- ordinator
Articles may be reproduced for noncommercial purposes by citing at least the
authors’ names, title of article, year of issue and name of magazine (African
Health Monitor, World Health Organization Regional Office for Africa). For all other
uses, permission for reproduction could be sought by sending an email request to
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L’IV Com Sàrl, Villars-sous-Yens, Switzerland
© WHO-AFRO, 2011
REGIONAL OFFICE FOR
Africa
African Health Monitor
P.O. Box 6
Brazzaville
Republic of Congo
Tel: + 47 241 39217
Fax: + 47 241 39503
ISSN 2077-6128
Key title: African health monitor (Print)
Abbreviated key title: Afr. health monit. (Print)
ISSN 2077-6136
Key title: African health monitor (Online)
Abbreviated key title: Afr. health monit.
(Online)

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The Department of Health and Social Services, in conjunction with

At the Canadian Institute for Health Information (CIHI), exciting

Qui est éligible Quand est-ce que la couverture commence? Quand

CLA ALC

Notre mission

Vocabulaire - CPGE Dupuy de Lôme

age caused by experimental drugs or technologies are

Bios et résumés – Série 2

Fondations de la santé et l`environnement bâti

Belgium 1 Scotland 4 Appendix : Policy documents accessed and anal