/, WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA
ORGANISATION MONDIALE DE lA SANTE BUREAU REGIONAL DE L'AFRIQUE
ORGANIZAÇÂO MUNDIAL DE SAUDE SEDE REGIONAL AFRICANA
REGIONAL COMMIT TEE FOR AFRICA Forty-ninth session Windhoek. Namibia 30 August - 3 September 1999 Provisional agenda item 10
AFRIRC49fTDIl 10 February 1999 ORIGINAL: ENGLISH
DISEASE CONTROL IN THE AFRICAN REGION IN THE 21ST CENTURY
Technical Discussions EXECUTIVE SUMMARY 1. Even on the dawn of the 21st century, communicable diseases continue to be the major cause of morbidity and mortality in the African Region. Because of changing lifestyles, noncommunicable diseases which up till now were found rnainly in the developed world, have substantially added to the disease burden.
2. The choiee of the tapie ''Disease Control in the African Region in the 21st Century" for the Technical Discussions reflects the desire ofMember States to address major public health issues of concern in the next century. 3. While the overal1 goal of disease control in the African Region in the 21 st century wil1 be ta promote health, the main objective is to prevent diseases and reduce their incidence and ill-effects by establishing efficient disease control programmes in al1 countries of the Region. 4. Priority should be given ta the control of endemic and commonly-occurring infections, noncommunicable diseases, injuries and violence and ta epidemic preparedness. 5. Environmental services should be adequately developed ta ensure a healthy environment.
6. Disease reduction goals need ta be based on scientific evidence derived from the epidemiological profiles of diseases in each country and in each district. The identification of diseases should be based on the existence of an active surveillance system. An integrated system of active surveil1ance and monitoring of the health situation as a whole needs ta be put in place. 7. In arder to reduce variations in diagnoses and outcomes, it would be desirable !hat health care systems focus on incorporating scientific evidence into clinical and public health practice, with emphasis on the quality of care provided. 8. A number of prerequisites are necessary for disease control programmes ta succeed. These include development of sustainable health systems; promoting the use of science and technology; poverty al1eviation; developing and maintaining human resources; and securing adequate funding for disease control. 9. Regional and national priorities of disease control should be based on the epidemiology of diseases, morbidity and mortality rates, financial implications for control, and sustainability of efforts.
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CONTENTS Paragraphs
INTRODUCTION .......... ....... .... .... . ....... . ..................... . ..... , 1-7 HEALTH FOR ALL IN THE 21ST CENTURY .............. ...... ............ .... 8-12 Disease control gains in the 20th century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9-10 The disease control continuum and health .. ..... ... , ......... , ............. .. ... 11-12 DISEASE CONTROL IN THE 21ST CENTURY .... .. ............................ 13-34 Objectives ........................... . ................ ... ............... " 13-16 Reduction of disease .......................... . .. . . .. ..... . ........ , . . . . . . .. 17-18 Identification ofdiseases ................................... .. ............... 19-20 Quality management of disease .......... . ....... . .......................... , .... 21 Prerequisites for the success of disease control in the 21st eentury , , . , . . , , . , . , ... , .. ,. 22-29 Sustainable health systems . , , ... , , . , , . , , . , , .... , , , .. , , . , , .. , .... , .... , .......... 22 Fostering the use of science and technology ..................................... 23-24 Poverty alleviation .......... , ............ . ...... . .................. , .. .... .... 25 Developing and maintaining human resources for disease control .................... 26-28 Securing adequate financing for disease control ................... .. .... , ...... . .. ,. 29 Regional priorities for disease control in the 21 st century ...... , .......... . ............ 30 Communicable diseases ....... , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 31-32 Noneommunicable diseases .. ....................... , ........................ 33-34 DISEASE CONTROL IN MEMBER STATES OF AFRICAN REGION . ... . ....... , .. 35-38 Determination of national priorities ........................ , .. . ................... Peace and health .. , ... , . . ... , . . , .... ' , ............ . .... , ...... , .•. , ... , ....... Research and development ...... , . . ............... . ....... , ..................... Tools and targets ..... , ............ ... ......... . ............................... 35 36 37 38
CONCLUSION . . ...... . ........................ , ............... ... .......... 39-41 Questions .................. . . , ... . ....... . ..................... . ...... .. .... 41
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INTRODUCTION 1. While great strides have been made during this century in the control of communicable diseases, these diseases still constitute major public health problems for most countries in the WHO African Region. Acute respiratory infections, diarrhoeal diseases, malaria, HIVIAIDS, sexually transmitted diseases and tuberculosis are on the increase. Also, diseases with epidemic potential such as cerebrospinal meningitis, yellow fever, haemorrhagic fevers, cholera and vaccine-preventable diseases (measles, neonatal tetanus and poliomyelitis) are common in the Region. 2. Poverty, high illiteracy rate, conflicts and population movements leading to large-seale concentration of populations around big cities result in lifestyles which foment harmful nutritional and behavioural patterns. Thus, noncommunicable diseases such as diabetes, obstructive respiratory diseases, cancers and cardiovascular diseases as weIl as injuries and disabilities caused by land mines and other forms of armed conflicts are also increasing. There is, therefore, a cumulative double burden of communicable and noncommunicable diseases in the African Region as we approach the next century. 3. In addition, natural disasters, wars and other forms of violence and social disruption are major causes of growing psychosocial problems which include alcohol consumption, drug abuse, prostitution, the phenomenon of street children and domestic and social violence. 4. Most countries in the African Region do not possess functional disease surveillance systems and are thus unable to accurately determine disease priorities, monitor and evaluate disease control programmes and detect changes in disease patterns. Therefore, they lack the information they need to enable them to plan, mobilize and allocate resources. At the forty-eighth session of the Regional Committee for Africa in September 1998, Member States adopted a regional strategy for integrated epidemiological surveillance of diseases. 5. The choice of"Disease Control in the African Region in the 21st Century" as topic for the Technical Discussions retlects the desire of Member States to start addressing major foreseeable public health issues of the next century. This document defines relevant strategies and actions to be implemented in the 21st century, particularly in its first Iwo decades, and is addressed to governments, schools ofhealth sciences, public health experts and international and national development partners. 6. The beginning of the 21st century will be intluenced to a great extent by the HIV/AlDS epidemic. Indeed, in sorne countries, the AIDS epidemic has already brought life expectancy down from 65 t!l 40 years in less than ten years, putting them behind in development by about 30 years. The HIV prevalence rates in the different subregions are as follows: Central Africa: 8.2%; East Africa: 15.8%; Southern Africa: 25 .6%; West Africa: 8.5%; and the Indian Ocean 0.1%. The HIV/AIDS epidemic in the African Region deserves most serious attention. 7. Considering that health development is a key component of, and a prerequisite for, overall socioeconomic and human development, effective disease control requires a multisectoral approach involving communities and sectors such as health, finance, social welfare, education, agriculture and industry.
HEALTH FOR ALL IN THE 21ST CENTURY 8. The overall goal of disease control in the African Region in the 215t century will be to promot\: health in order to create conditions for increased life expectancy, universal and equitable access to quality care, disease prevention and rehabilitation.
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Disease control gains in the 20th century 9. There have been significant gains in disease control in the Region, especially in the past 50 years. These gains have been due not only to advances in science, technology and medicine, but also to expanded infrastructures, higher incomes, irnproved nutrition, better sanitation, higher literacy and greater opportunities for women. Political, administrative and operational integration have proved to be an important factor in the equitable provision ofhealth care. Average Iife expectancy at birth increased from46 years in 1975 to 53 years in 1997. The overall age-and-sex standardized death rates per 100 000 population dropped from 2670 in 1955 to 2013 in 1975 and then to 1645 in 1995. 10. Disease prevention through vaccination has been very successful. Smallpox has been eradicated globally and the overall vaccination coverage in the Region has increased from below 10% in 1975 to 60% in 1997. Thus, diseases such as measles (vaccination coverage: 60%), poliomyelitis (vaccination coverage: 75%), diphtheria (vaccination coverage: 60%) and tuberculosis (vaccination coverage: 70%) have been substantially controlled, leading to a significant reduction in child mortality. The death rate in the 0-4 age group dropped by nearly 50% between 1955 and 1995. Nevertheless, in most of the countries affected by the HIV pandemic in Africa today, Iife expectancy is less than 50 years. Furtherrnore, due to poverty and widespread sociopolitical unrest, a significant number of children in many countries in Africa will not celebrate their fifth birthday.
Tbe disease control continuum and health II. Although health is not merely the absence of disease, the establishment of an effective disease control programme is crucial to health delivery. Such a programme should be an integrated one. Integrated disease control should involve the prioritization of disease control interventions based on country-specifie evidence, more rational utilization of exisling human and financial resources and evidence-based planning and monitoring of the overall health stalUs of the population. Although diseases are not necessarily similar, this approach has the advantage of combining the common aspects of disease control such as surveillance, case management, monitoring and evaluation, training and supervision, and continuing education. 12. Disease control which is an essential function of a health system may be regarded as a continuum which starts with the reduction of the incidence of a disease, its morbidity or mortality to a predeterrnined level through a conscious effort requiring continued interventions (control). The continuum then progresses to the reduction to zero of the incidence of a specific disease in defined geographical areas still through a conscious effort requiring continued intervention measures (e1irnination). The continuum progresses further until the incidence of a specific disease is perrnanently reduced to zero to the extent that intervention measures are no longer needed (eradication). DISEASE CONTROL IN THE 21ST CENTURY
Objectives 13. The main objective of disease control is 10 reduce the incidence and adverse effects of disease by establishing an efficient disease control programme in ail countries of the Region. The programme should be community-based and population-oriented and consist of the institution of methods for health promotion and disease prevention; early identification and diagnosis of diseases; proper management of diseases; and proper rehabilitation of persons with sequelae of diseases. 14. Priority should be given to endemic, epidemie-prone and commonly-oceurring infections, noncommunicable diseases, injuries especially those caused by domestie and road traffic accidents, violence
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inc1uding armed conflicts and public health practice. Environmental services should be adequately developed to ensure a healthy environment, which will include services to ensure access to safe water and sanitation, clean air and safe food, management of hazardous chemicals and wastes, and control of disease vectors and pollution. Il should be noted that disease prevention and health protection services in the workplace are essential components of occupational health. 15. Laboratory should be given adequate attention as part of the health care delivery system through an organizational scheme. A network of laboratories should be established at national and regional levels and he able to provide services according to specific needs and national health priorities at each level of the health system. Their public health function should be linked with the clinical function. Schemes should be established to improve the quality of health care services. 16. The maintenance of disease control services and their eventual extension to health promotion should he decentralized, as much as possible, when the comparative advantage of decentralization overrides that of centralization. It is however necessary to recognize that successful decentralization requires competent human resources and adequate materials and technologies at the locallevel. Reduction of disease 17. Disease reduction goals need to be based on scientific evidence derived from the epidemiological profiles of diseases in district and country. The values and assumptions underlying the determination of disease reduction goals and policies need ta be made explicit in order to ensure the endorsement of these goals and policies by ail stakeholders. Major continental and global initiatives should also receive appropriate consideration by the countries. 18. Diseases of global importance require worldwide efforts for surveillance and control. For certain diseases such as poliomyelitis and leprosy, global eradication is feasible and desirable and aIl countries must strive to meet their commitrnents in that respect. The global burden of HIV infection, malaria, tuberculosis, tobacco-related diseases and trauma are likely to become even more important in the Region in the first quarter of the 21st century. For sorne of the poorest countries and communities, including those where armed conflicts are a regular feature, the burden of childhood infections, zoonoses, maternaI mortality, and undernutrition would remain a priority. Although microbial and parasitic infections are common in the Region, rational use of antibiotics and antiparasitics and the monitoring of drug resistance have to be given high priority. Identification of diseases 19. The identification of diseases should be based on an active system of surveillance and monitoring. Global, regional, national and local surveillance, monitoring and early waming systems should alert health officiais and the public to impending threats, allowing time for appropriate action. 20. An integrated system of active surveillance and monitoring for health should, at least, focus on the following areas: communicable diseases, noncommunicable diseases, and health status and trends, including birth and death rates. Quality management of disease 21 . In order to reduce variations in diagnoses and their outcomes it would be desirable that health care services focus on ineorporating scientific evidence into clinieal and public health practice as weil as training health workers in problem-solving and quality-improvement methods. Telematics in health,
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including the Internet, teleconference, telediagnosis and other means should be used to provide a wider range of care and specific services in remote community settings. Long-term care should be provided, particularly in the 'community, through non-hospital institutional care and home-based services. Integration of health, social and environmental services, including school health and workers' health programmes, will be necessary.
Prerequisites for the success of disease control in the 2Ist century Sustainable bealtb systems 22. Member States are encouraged to continue the process of health sector reform which iliey have endorsed. The process starts with the drawing up of a comprehensive national policy for health. The health sector is responsible for developing policies and priorities that reflect people' s needs by setting standards and norms, ensuring that supportive legislation and regulations are adopted, informing the public about their rights and responsibilities and establishing sustainable financing mechanisms. A legislation that promotes health should include measures to ensure environmental standards, food safety restrictions on tobacco advertising and sponsorship, restrictions on the promotion of alcoholic drinks and access to weapons, measures to protect consumers, and providing people access to health care. Fosterlng the use of science and technology 23 . Health bas benefited ITom advances made in science and technology in the past, and this is likely to continue in the 21st century. Communications and electronic information technologies, for instance, offer opportunities for researchers everywhere to participate fully and contribute to scientific progress. Health personnel would also be able to manage patients in remote places without having to transfer them to referral hospitals. 24. Appropriate and affordable technology should be available in ail health facilities according to need and relevance. Regional research priorities should he complemented by country-specific research priorities and actions through which the countries will work towards improved national, regional and global health. In view ofthe rapidly growing incidence of lifestyle-related diseases in African countries, research should he conducted on both noncommunicable and communicable diseases. Particular attention should be given to research to develop vaccines and strategies for vaccine delivery since the rising incidence of HIV infection in the Region raises concerns about large-scale use of live vaccines. Poverty aUevlatlon 25. Poverty can be broadly defined as lack of resource availability for individuals and families to enable them to satisfy their basic needs. It is multidimensional in nature and covers various forrns of deprivation. The link between poverty and health is twofold: poor health retains the poor in poverty, while poverty keeps people in poor health. One strategy for poverty alleviation is to direct special efforts at breaking this chain and releasing people ITom the vicious circle ofiIl-health and poverty. Developlog and malntaining human resources for dlsease control 26. A we\l-trained and motivated workforce is essential to sustain health systems for disease control programmes. Therefore, training institutions should be involved in overall planning and goal setting to ensure that these realistically reflect the need for ongoing and comprehensive capacity-building for health.
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27. Since the emphasis will be on ensuring that districts become functional, the current emphasis on training and retraining ofhealth personnel should be supplemented by putting in place a cadre of people capable of working in a multidisciplinary and collaborative context, with systematic use of quality assurance methods. The health sector should develop national health workforce policies that contribute to human resource development and deployment and emphasize increased participation of women. 28. Health personnel tend to be overworked and underpaid in most countries of the African Region. The strategies for disease control in the 21 st century willlead to an increase in their responsibilities. Member States should therefore ensure that the remuneration of health personnel is commensurate with their responsibilities. Securing adequate financing for disease control 29. Governments should invest adequately in health and disease control to ensure sustainability, equity of access, efficiency and cost containment. Health care financing approaches may differ among countries, but in many countries of the Region, resources will have to be mobilized from the communities and international donors and be coordinated by the government. WHO has a key role to play in working with countries to explore alternative fmancing possibilities. Financial mechanisms and insurance systems can be used to promote equal access and equity among the sick and the poor. In an equitable health care system, there is universal access to adequate level of care throughout the life span of an individual. Regional prlorities for disease control in the 21st century 30. WHO willlead efforts to control diseases ofregional or global importance. It will provide leadership in strengthening the global linkage of organizations and institutions working for better health and facilitate technical cooperation and mobilize resources for countries and communities in greatest need. Communicable diseases 31 . The following summarizes the priorities of the African Region in the control of communicable diseases:
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Malaria control: The strategie objective is that by 2025, malaria will neither be a major contributor to mortality and morbidity nor be of significant socioeconomic consequence. The targets are to reduce malaria-specifie mortality by 50% by the year 2010, by a further 30% by the year 2015, and by a further 20% by the year 2025' . Mycobacterial diseases: The priorities are elimination ofleprosy; control oftubercuJosis and Buruli. ulcer; and achieving 85% rate of cure of newly-detected tuberculosis cases.
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Vaccille-preventable diseases: Diseases targeted for eradication are poliomyelitis, yellow fever, and measles. Hepatitis B, meningitis, and haemophilus influenzae should be better controlled and neonatal tetanus should be eliminated.
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Integrated management of childhood illness: The priorities are that ail districts in ail countries will be implementing wcr covering diarrhoea, acute respira tory infections, measles, malaria, and malnutrition which will, together, account for less than 30% of the causes ofunder-five mortality.
, Provisional d.ta from Roll B.ck Malari., 1998
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Other tropical diseases: Priority will go to the elimination, eradication or control of schistosomiasis, Iymphatic filaria, onchocerciasis and intestinal parasites.
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HIVISTD: The priorities are to control HIV/STD and other opportunistic infections sa as to attain 25% reduction in prevalence, 10% reduction in mortality, 5% increase in life expectancy, 20% reduction in under-five mortality, 30% reduction in infant mortality, 40% reduction in mother-to-child transmission and 25% reduction in the number of children tumed into orphans.
32. From a practical point of view, the above-mentioned diseases may also be classified as:
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Epidemie-prone diseases: HIV/ AIDS, tuberculosis, sexually transmitted diseases, malaria, cholera, bacillary dysentery, meningococcal meningitis, haemorrhagic fevers. Vaecine-preventahle diseases: hepatitis. Yellow fever, measles, whooping cough, diphtheria, viral
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Diseases to he eradieated: Dracunculiasis, poliomyelitis, onchocerciasis. Diseases to he eliminated: Neonatal tetanus, leprosy. Other diseases: Plague, schistosomiasis, lymphatic filariasis, Buruli u1cer.
Noncommunicable diseases
33. The overall control of noncommunicable diseases in the Region will depend on a numher of principles which are the promotion ofhealthy lifestyles such as moderation in alcohol use and abstinence from smoking in Africa; the promotion of traditional remedies of proven efficacy as an alternative for the management of certain chronic diseases; provision of good mental health coverage; standardization of diagnostic and management procedures in relation to the capacity of health services (staff qualifications, available technology, etc.), which may lead not only to the identification and use of affordable and efficient diagnostic methods in the peripheral centres, but also to the availability in ail health facilities and at ail times of essential drugs for the treatrnent of common chronic diseases; and prevention of injuries due to land mines and violence and management of the sequelae of injuries and infectious diseases. 34. The following is a summary of the priorities of the African Region with regard ta noncommunicable diseases in the 21 st century:
Chronic diseases: The priority diseases will he cardiovascular diseases, chronic obstructive bronchopathies, diabetes, cancers, chronic liver disease and genetic disorders (e.g. sickle-cell disease). Nutrition and feeding: The priorities are to improve the nutritional status of the populations, especially those at risk. The indicators will be the elimination of iodine deficiency and acute protein energy malnutrition in children, and reduction of vitam in A deficiency and anaemia. Men/al health: The first priority is to reduce the burden, including the stigma associated with neurologica!, mental and psychosocial disorders. The key indicator will be to reduce the prevalence of childhood mental problems by 50% by the year 2020 as the tirst step. The second priority is to reduce problems related to the use ofpsychoactive substances (tobacco, alcohol, drugs), especially targeting young people. The key indicator will he 50% reduction in the prevalence of substance abuse among young people by the year 2020, as the first step.
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Oral health: The priority is to significantly reduce the incidence ofnoma, oral cancer, dental caries and the oral manifestations ofHIV/AIDS. Occupational health: The priorities are to prevent job-related accidents and occupational diseases. These should be reduced in each case by 60% by the year 2020 as the first step. Ageing and health: The priority will be to improve the health and well-being of the elderly and enhance their social integration in communities.
DISEASE CONTROL IN MEMBER STATES OF THE AFRICAN REGION Determination of national priorities 35 . National priorities will he determined according to surveillance data; morbidity and mortality data; ease of notification of diseases; available national resources; the availability of institutions (including appropriate tools for control); expressed needs of populations; and results ofhealth research. Peaee and health 36. Il is evident that without peace it will he impossible to have a healthy society. Besides, peace without development will not lead ta health. Disease control should therefore be a multisectaral enterprise involving ail development partners and should not be left to the health sector alone. It should also involve poverty alleviation programmes as weil as the provision of adequate remuneration ta health personnel. Research and development 37. In order to enhance research and development in the Region, it would be necessary to identify and strengthen reference laboratories to help confirm the of causes of disease; to facilitate linkages between ministries of health and research institutions, including universities, so that funds would be made available and that research conducted in institutions would reflect national health priorities; and to ensure that research carried out by both nationals and their partners adheres to basic ethical norrns and that govemments finance sorne aspects of rnedical research. Tools and targets 38. The following table would be useful in helping the countries identify the tools necessary for disease control in the 21 st century:
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Table: SUGGESTED TARGETS AND TOOLS FOR USE BY MEMBER STATES TARGET Clearly-defmed national policy for disease control Comprehensive disease surveillance Provision of quality Care TOOLSIRESOURCES National health policy needs to be defined by communities, govemment and parliament. Development of a national integrated surveillance system. Standard management guidelines; appropriate infrastructure; qualified personnel with problemsolving skills; and availability of essential drugs in ail places and at ail times. Qualified personnel and appropriate tools for data analysis. Determination of cut-off points; regular (timely and complete) reporting; and adequate training of personnel. Infrastructure; trained personnel; basic technology; and essential drugs. Conduct of essential health research to ensure regular improvement of the management process. None COMMENTS
None Policy for infrastructural, technological and personnel development must be in place.
Epidemiological mapping of diseases Problem (disease) identification
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None
Community-based rehabilitation of the disabled Research and development
None
Training and supervision
CONCLUSION 39. In conclusion, disease control in the 21 st century should he of concern to ail those involved in the development of the African continent because there can be no sustainable development without good health. The decentralization of services to the district level needs to be accompanied by the deployment of well-trained and motivated personnel, adequate technology and financial resources to permit the smooth functioning of services. 40. Disease control activities in the Region will be evaluated every five years.
Questions 41. Participants in the Technical Discussions will have to answer the following questions: (i) Wbat are the optimal policy commitrnents to be made by governments to ensure that both communicable and noncommunicable diseases are weil controlled in the 21 st century?
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(ii) What would be the optimal requirements for establishing an integrated surveillance and sereening programme within the countries, inc1uding preparedness to taclde emerging diseases? (iii) How should national priorities in disease control he determined? (iv) What should be the responsibilities of the various aetors (communities, governments, WHO, development partners) in the disease control initiative? (v) What are the conditions required to sustain the disease control programme? (vi) What are the mechanisms required to ensure that countries comply with the recommendations of the Technical Discussions?