AFR/RC57/8 5 July 2007
REGIONAL COMMITTEE FOR AFRICA Fifty-seventh session Brazzaville, Republic of Congo, 27–31 August 2007 Provisional agenda item 7.6
ORIGINAL: ENGLISH
HEALTH SYSTEMS STRENGTHENING IN THE AFRICAN REGION: REALITIES AND OPPORTUNITIES
CONTENTS Paragraphs BACKGROUND ............................................................................................................................... 1–7 ISSUES AND CHALLENGES ....................................................................................................... 8–17 ACTIONS PROPOSED................................................................................................................. 18–31 CONCLUSION.................................................................................................................................... 32
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BACKGROUND 1. The world health report 2000 defines health systems as comprising all the organizations, institutions and resources that are devoted to producing health actions whose primary purpose is to improve health. It identifies four functions of health systems, namely stewardship; health financing; generating human and physical resources; and provision of health services. 2. In the last thirty years, many initiatives have been undertaken at country, regional and global levels for strengthening health systems and improving the quality of health services. The World Health Assembly (WHA) and the WHO Regional Committee for Africa adopted various documents and resolutions which provide guidance for strengthening health systems in the African Region. 3. In 1978, the World Health Assembly adopted the Health-for-All policy and Primary Health Care (PHC) as a strategy for attaining it. In 1998, the World Health Assembly renewed this commitment by requesting Member States to ensure the essentials of PHC.1 The Fifty-second World Health Assembly, in 1999, also resolved to put emphasis on strengthening health systems in developing countries. The world health report 2000 focused exclusively on health systems and improving their performance. 4. The Regional Committee for Africa adopted, in 1985, a three-phase health development scenario which emphasized district health systems. In 1987 and 2000, the Regional Committee adopted, respectively, the Bamako Initiative and the Health-for-All Policy for the 21st Century in the African Region: Agenda 2020. Further sessions of the Regional Committee held in 1999, 2000 and 2006 adopted resolutions2 to improve equity and universal access to quality health services in order to achieve the Millennium Development Goals. 5. Various other documents and resolutions were adopted over time and specifically pertain to human resources for health, health financing, essential medicines, health information and hospitals.3 In the document Strategic orientations for WHO action in the African Region 2005-2009, one of the five orientations is strengthening health policies and systems. In 2006, The African regional health report: The health of the people emphasized strengthening health systems to properly deliver priority health interventions. 6. Despite the adoption of various strategies and resolutions, health systems in the African Region remain too fragile and fragmented to deliver the required volume and quality of services to those in
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Resolution WHA51.7, Health-for-all policy for the twenty-first century. In: Fifty-first World Health Assembly, Geneva, 11–16 May 1998. Volume 1: Resolutions and decisions, and list of participants. Geneva, World Health Organization, 1998 (WHA51/1998/REC/1). Resolution AFR/RC49/R2, Health sector reform in the African Region: Status of implementation and perspectives. In: Fortyninth session of the WHO Regional Committee for Africa, Final Report, pp. 5–7, Harare, World Health Organization, Regional Office for Africa, 1999; Resolution AFR/RC50/R1, Health-for-all policy for the 21st century in the African Region: Agenda 2020. In: Fiftieth session of the WHO Regional Committee for Africa, Final Report, pp. 7–9, Harare, World Health Organization, Regional Office for Africa, 2000; Resolution AFR/RC56/R6, Revitalizing health services using the Primary Health Care approach in the African region. In: Fifty-sixth session of the Regional Committee for Africa, Final Report, pp. 19– 20, Brazzaville, World Health Organization, Regional Office for Africa, 2006. Resolutions AFR/RC48/R3, AFR/RC52/R5, WHA57.19 and WHA59.27 on HRH; AFR/RC56/R5 on financing; AFR/RC38/R19 and AFR/RC49/R5 on medicines; AFR/RC54/R3 and document AFR/RC54/12 Rev.1 on health information systems; and Resolution AFR/RC53/R2 on hospitals.
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need.4 Consequently, most countries are lagging behind in achieving the health-related Millennium Development Goals. 7. The purpose of this document is to propose actions that support integrated health systems and reinforce the effective implementation of already-existing global and regional orientations for improving health system performance. ISSUES AND CHALLENGES 8. Since the late 1990s, 37 countries in the WHO African Region have formulated or revised national health policies, and 27 have prepared national health strategic plans. However, only five countries developed comprehensive health plans that are costed and consistent with broader development processes, poverty reduction strategy papers, sector-wide approaches or medium-term expenditure frameworks.5 The implementation of these policies and plans has yet to show substantial improvement in the delivery of services. 9. Appropriate care requires that caregivers recognize symptoms and use health services for correct diagnosis and treatment. Unfortunately, many people do not have confidence in their health care services due to the low quality of care resulting from human resource shortages, low staff morale, poor access to quality medicines and lack of basic diagnostic equipment. 10. One of the objectives of decentralization is to move authority and responsibility from the centre to the local level. Decentralization of management of health services to the district level does not, however, always increase the autonomy or overall authority of managers regarding personnel management, budgetary control, quality, sustainability and accountability in health service delivery. District health services still lack capabilities in key areas such as workforce management, health information, health financing, and medicine and equipment supply. 11. In 2005, 13 countries reported having policies and plans on human resources for health.6 Key challenges include under-investment in training; difficulties in maintaining and retaining staff, particularly in remote areas; poor working conditions; migration of health workers; and unequal distribution of existing staff in urban and rural areas.7 These problems have been exacerbated by budget restrictions on recruitment and work overload due to increasing prevalence of HIV/AIDS, which also directly impacts on the health status of the workforce.8 12. In the Region, all 46 countries are committed to allocating at least 15% of their national budget to health; however, only one country has reached that level, and 27 countries spend less than US$ 10
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Travis P et al, Overcoming health systems constraints to achieve the Millennium Development Goals, The Lancet 364 (9437): 900–906, 2004. WHO, African Health Monitor: Health economics: Getting value for money 5(2), various articles, Brazzaville, World Health Organization, Regional Office for Africa, 2005. WHO, Status of human resources for health in the Africa Region: Survey report, Brazzaville, World Health Organization, Regional Office for Africa, 2006. WHO, Strengthening the health workforce, Geneva, World Health Organization, a draft technical framework, 2005. MSH and WHO, Tools for planning and developing human resources for HIV/AIDS and other health services, Cambridge, MA, Management Sciences for Health and World Health Organization, 2006.
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per person per year.9 It is a concern that in some countries, even when the 15% funding level is reached, the available funds will not be sufficient. Countries face challenges such as slow economic growth rates; small tax base; weak tax collection systems; heavy debt servicing and repayment burdens.10 In 2002, direct out-of-pocket expenditures constituted over 50% of the private health costs in 38 countries.11 13. To date, 30 countries have formulated or reviewed their national medicine policies. One of the objectives of these policies is to increase access to essential medicines. However, most African countries face serious challenges in ensuring that essential medicines are available, accessible, affordable, of high quality and used rationally.12 14. There is gross inequity in the distribution of health infrastructure and equipment within and across countries in the African Region. In many cities, there is an over expansion of health infrastructure beyond what is sustainable while the few existing health facilities in rural areas stand empty and underused due to disrepair, inadequate design or lack of equipment. 15. WHO technical reviews on community involvement in health development indicate positive contribution when communities are perceived as a resource and hence are appropriately supported.13 However, health workers are often not trained in community participation approaches. 16. Poor governance, stagnation or decline of economic growth, and natural and man-made disasters have negative impacts on health systems. Some cultural practices, traditional behaviours and beliefs about diseases lead to decreased demand and utilization of health services. Other issues include increased prevalence of noncommunicable diseases, emergence of new diseases and excess donor influence in decision-making in the African Region. 17. Emerging opportunities exist to address the above issues and challenges. They include the renewed commitment of Member States to strengthen health systems; increased willingness of vertical health programmes to sustain health system development; poverty reduction strategies; health-related Millennium Development Goals; the Paris Declaration on donor harmonization and aid effectiveness; and increased financial commitment from the Global Fund to Fight AIDS, Tuberculosis and Malaria; Global Alliance for Vaccines and Immunization; Alliance for Human Resources; Health Metric Network; Multilateral Debt Relief Initiative.
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WHO, Health financing: A strategy for the African Region (AFR/RC56/10), Brazzaville, World Health Organization, Regional Office for Africa, 2006. 10 Mwabu G, Mwanzia J, Liambila W, User charges in government health facilities in Kenya: Effect on attendance and revenue, Health Policy and Planning 10(2): 164–170, 1995. 11 WHO, National health accounts data, Geneva, World Health Organization, 2002. 12 WHO, The African regional health report: The health of the people, Geneva, World Health Organization, 2006. 13 Kahssay HM, Oakley P (eds), Community involvement in health development: A review of the concept and practice (Public health in action no. 5), Geneva, World Health Organization, 1999.
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ACTIONS PROPOSED Countries 18. The focus will be on governing, steering and regulating the health sector by defining the vision and direction of health policy; providing integrated quality health services that are accessible and affordable; generating the necessary human and physical resources; and raising and pooling revenues to purchase services.14 19. Meeting the basic health needs of people requires setting policies at the highest level of government and ensuring their successful implementation at local level to improve the health status of people which is the legitimate goal of any health system. Thus, great emphasis is put on implementing integrated health services at district level. Updating policies and developing strategic plans 20. Each country should develop a comprehensive national health policy that is integrated into an overall development strategy and takes into consideration realistic allocation from multiple funding sources. The development of the national health policy should be a broad country-wide consultative process based on data that are relevant for strategic decision-making. Official approval of the policy at the highest political level will ensure long-term sustainability. 21. The National Health Policy should be implemented through a subsequent health strategic plan which is consistent with the overall budget framework. The Ministry of Health should participate in medium-term planning exercises coordinated by the Ministry of Finance in order to ascertain and fully appreciate issues of budget allocation and availability of resources anticipated in the National Health Strategic Plan, and participate in decision-making. These policies and plans should support service delivery, ensure access to health services and restore confidence in health systems. Integrating health services at district level 22. Countries should ensure that District Health Management Teams (DHMTs) prepare annual operational plans which are based on local priorities as well as national health policies and strategic orientations. These plans should be comprehensive and integrated rather than separate or singlepurpose. The DHMT should build strong and effective partnerships and networks with the private sector and non-health public sectors to enhance coordination, facilitate synergy and maximize the efficient use of resources. 23. An essential health package should be defined for each service level, including the district hospital, which should be seen as an integral part of the District Health System. Existing resources should be devoted to making the essential health package available to all. A system should be in place for monitoring and evaluation of service availability, coverage, human resources, financing, information systems, leadership and governance. 24. Countries should support capacity-building of DHMTs to ensure better integrated health services; improved referrals and prescribing practices; budget analysis and monitoring; procurement, 14
WHO, The African regional health report: The health of the people, Geneva, World Health Organization, 2006.
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distribution and transportation of medicines and supplies; health management information and research systems; laboratory support services; maintenance; and community participation. 25. Countries should strengthen the interaction between health services and communities, including traditional healers, to enhance community accountability and involvement in decisionmaking; defining health needs; planning, collecting, analysing and using data; fundraising; and linkages with the formal health services. They should promote the sustainability of community initiatives and improve community capacity to participate in service delivery. Mobilizing more financial resources for the poor 26. Countries should develop comprehensive national health financing policies and strategic plans which guide the monitored transition from the current situation of predominantly out-of-pocket payments to universal financial risk protection against costs of illness. Countries with user fee systems should ensure that vulnerable population groups and the poor are adequately protected by exemption policies; they should target health services for those in need and thus resolve any constraints to access to service delivery.15 27. Countries should make more efficient use of available resources by improving technical and allocative processes. Emphasis should be on interventions that best improve the population’s health. The Ministry of Health should oversee all available resources in the sector and work towards reducing the transaction costs of budgeting and planning. Investing in people 28. Countries should improve the availability of qualified health workers by training more staff; improving the quality of training; re-examining the competencies required to fit current and new responsibilities; eliminating ghost workers; setting appropriate retirement ages; treating health workers ill from HIV/AIDS; improving the motivation of health workers by ensuring better pay and payment mechanisms; improving work conditions; and setting up performance incentives, including housing, education and health benefits, and career advancement. Investing in infrastructure, equipment and medicines 29. Countries should rationalize investments through developing clear policies to support rational long-term planning for infrastructure and equipment, and establish a management system to guarantee maintenance. Countries should create specifications, norms and standards for infrastructure and equipment by level of facility. Countries should review requests for new facilities in terms of location, population covered, referral issues, service demand, linkage with medical and nursing staffing, and supply of medicine and equipment. 30. Countries should pursue their efforts in developing, implementing and monitoring medicine policies based on the concept of essential medicines; they should monitor the quality of essential medicines, including vaccines and traditional medicines, and ensure their continuous availability in the public and private sectors. 15
Masiye F, Analysis of health care exemption policy in Zambia: Key issues and lessons. In: Audibert M, Mathonnat J, de Roodenbeke E (eds), Le financement de la santé dans les pays d’Afrique et d’Asie a faible reven, pp. 139–159. Paris: Karthala, 2003.
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WHO and partners 31. WHO and partners should: (a) Harmonize their support for strengthening health systems by providing financial and technical support to countries for integrated health services; (b) Advocate for more resources and better partnerships under the leadership of national authorities; (c) Promote sharing of positive experiences in strengthening health systems and intercountry cooperation; (d) Strengthen capacity of countries to enable them to track progress of implementation of health systems reform and initiatives, including Primary Health Care; the three-phase health development scenario; and the Bamako Initiative; (e) Establish centres of excellence in health systems and use them to support countries.
CONCLUSION 32. The Regional Committee is requested to examine and encourage the actions proposed.