WHO country cooperation strategy 2009–2013: Angola

ÚBLICA DE ANGOLA REP

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OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA O G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN LA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA OLA O G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN AN A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A OL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL GOL 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WHO COUNTRY COOPERATION STRATEGY 2008-2013

ANGOLA

WHO COUNTRY COOPERATION STRATEGY

2009–2013

ANGOLA

WHO Country Cooperation Strategy, 2009–2013 Angola 1. Health Planning 2. Health Plan Implementation 3. Health Priorities 4. Health Status 5. International Cooperation 6. World Health Organization

ISBN: 978 929 023 1592

(NLM Classification: WA 540 HA6)

©

WHO Regional Office for Africa (2010)

Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Publication and Language Service Unit, WHO Regional Office for Africa, P. O. Box 6, Brazzaville, Republic of Congo (Tel.: +47 241 39100; Fax: +47 241 39507; E-mail: afrobooks@afro.who.int.). Requests for permission to reproduce or translate this publication - whether for sale or for non-commercial distribution - should be sent to the same address. The designations employed and the presentation of the materiel 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 they may not yet be full agreement. The mention of specific companies or of certain manufacturer’s 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. 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 expressed or implied. The responsibility for the interpretation and use of the material lies with the readers. In no event shall the World Health Organization or its Regional Office for Africa be liable for damages arising from its use.

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CONTENTS ABBREVIATIONS .......................................................................................................... vi PREFACE ....................................................................................................................... ix EXECUTIVE SUMMARY ................................................................................................ xi SECTION 1: INTRODUCTION ................................................................................... 1 SECTION 2: DEVELOPMENT AND HEALTH CHALLENGES IN THE COUNTRY ......... 2.1 General Demography ........................................................................ 2.2 Economic and Human Development ................................................ 2.3 Health Financing ............................................................................... 2.4 Health Profile .................................................................................... 2.5 National Health Priorities .................................................................. 3 3 4 5 7 8

SECTION 3: SUPPORT FOR DEVELOPMENT AND PARTNERSHIPS…… ................... 9 3.1 Flow of Aid/Assistance ...................................................................... 9 3.2 Main Partnerships ............................................................................. 9 3.3 Coordination Mechanism ................................................................ 10 SECTION 4: WHO COOPERATION POLICY FRAMEWORK: GLOBAL AND REGIONAL GUIDELINES ...................................................................... 4.1 Mission .......................................................................................... 4.2 Main Functions ............................................................................... 4.3 Health Agenda ................................................................................ 4.4 Global Priority Areas ....................................................................... 4.5 Regional Priority Areas .................................................................... 4.6 A More Effective WHO at Country level ......................................... SECTION 5: CURRENT WHO COOPERATION ........................................................ 5.1 WHO’s Current Programme in the Country ..................................... 5.2 Strengths, Weaknesses and the Way Forward .................................. 5.3 Opportunities and Challenges ......................................................... 11 11 11 12 12 12 13 14 14 18 19

SECTION 6: THE WHO STRATEGIC AGENDA 2009–2013 ........................................ 20 6.1 Maternal and Child Health .............................................................. 20 6.2 Disease Control ................................................................................ 21 6.3 Organization and Management of the Health System ..................... 24 SECTION 7: IMPLEMENTING THE STRATEGIC AGENDA: IMPLICATIONS FOR WHO .......................................................................................... 7.1 Matching WHO interventions with the Country Cooperation Strategy .......................................................................................... 7.2 Main Problems Identified ................................................................ 7.3 Recommendations .......................................................................... 27 27 27 28

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SECTION 8: MONITORING AND EVALUATION ....................................................... 29 SECTION 9: CONCLUSION ...................................................................................... 30 ANNEXES 1. Strategic Objectives ............................................................................... 30 2. Table 8 —Areas of Work and Budget, WHO/Angola, 2002–2007 ......... 31 3. Angola —Some Basic Indicators ............................................................ 32

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ABBREVIATIONS ACT ADB AEC AFP AFRO AIDS ARV CCS CDC CDTI CIDA CPI CPLP DOTS EHA EMRP EPI EU GAVI GNP GFATM GoA GNI GSM HDI HIV HRH HSD : : : : : : : : : : : : : : : : : : : : : : : : : : : : Artemisinin-based Combination Therapy African Development Bank African Economic Community Acute Flaccid Paralysis WHO Regional Office for Africa Acquired Immune Deficiency Syndrome Antiretroviral Medicine WHO Country Cooperation Strategy Centres for Disease Prevention and Control Community-directed Treatment with Ivermectin Canadian International Development Agency Consumer Price Index Communidade dos Países de Língua Portuguesa (Community of Portuguese-speaking Countries) Directly-Observed Treatment, Short Course Emergency and Humanitarian Action Emergency Multi-Sector Recovery Programme Expanded Programme on Immunization European Union Global Alliance for Vaccines and Immunization Gross National Product Global Fund to Fight AIDS, Tuberculosis and Malaria Government of Angola Gross National Income Global Management System Human Development Index Human Immune deficiency Virus Human Resources for Health Health and Sustainable Development v

HSS ICC IEC IHR IMCI IOM IPT IRS LDC MDG MDR & XDR-TB MINSA MIS MNC MPS MSF MTSP NCM NEPAD NHPD NIDs NGO PALOP PASS PER PSO PVT UK SC-UK TB TRIP UNDP UNFPA

: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :

Health System Strengthening Interagency Coordination Committee Information, Education and Communication International Health Regulations Integrated Management of Childhood Illnesses International Organization for Migration Intermittent Preventive Treatment Indoor Residual Spraying Least Developed Countries Millennium Development Goals Multidrug-resistant and Extensively Drug-resistant Tuberculosis Ministry of Health Malaria Indicator Survey Mechanism for National Coordination Making Pregnancy Safer Médecins sans Frontières Medium Term Strategic Plan National Coordination Mechanism New Partnership for Africa’s Development National Health Development Plan National Immunization Days Nongovernmental Organization African Countries using Portuguese as official language Health Sector Support Project Public Expenditure Report on Health Planning and Statistics Office Prevention of Vertical Transmission United Kingdom of Great Britain and Northern Ireland Save the Children, United Kingdom Tuberculosis Trypanosomiasis United Nations Development Programme United Nations Population Fund vi

UNICEF USAID USD VCTC WHO

: : : : :

United Nations Children’s Fund United States Agency for International Development United States dollar Voluntary Counselling and Testing Centre World Health Organization

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PREFACE The Executive Board of the World Health Organization (WHO) approved a Corporate Strategy in 2000 to guide the work of the WHO Secretariat. The Strategy highlights the central role played by countries in the work of WHO. As a result, the general strategy was revised and adapted to the needs of each country. These measures led to the WHO Country Cooperation Strategy. The Country Cooperation Strategy sets forth WHO’s strategic priorities for each country to assist in providing an integrated response at the following three levels: country office, the Regional Office and headquarters. The CCS clearly expresses what the WHO deems best for the country: this strategic agenda will guide cooperation between the WHO and its Member States in the medium-term. The CCS serves as a reference for WHO work plans and for the allocation of resources, whether these are from the countries, the Region, the headquarters or from other sources such as collaborating centres. The WHO Country Cooperation Strategy was prepared after a long process of consultation that involved all levels of the Organization, the ministries of health, other governmental departments, the private sector and civil society organizations, training and research institutions, development partners and other health players. The process involved the use of questionnaires, detailed analyses of the major challenges to the health and development of each country and the study of WHO’s comparative advantages. An exhaustive process led to the preparation of this document and we would like to thank the Government of Angola and all those involved in the health sector for their work and participation. The CCS process will, no doubt, help countries in their effort to address priority health problems and coordinate the work of the different partners and players. Our challenge now is to translate these strategies into specific actions to improve WHO’s performance in the country and to contribute to improving the health status of the populations in greatest need.

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EXECUTIVE SUMMARY In recent years, the working methods of WHO have changed considerably and are continuing to change, with a view to providing more effective WHO support to efforts by Member States to address major health and development problems. This reform process is based broadly on the WHO Corporate Strategy. The Country Cooperation Strategy (CCS) is a strategic approach to the work of WHO at national level, in the medium term. The CCS sets forth the manner in which the three levels of WHO will work at the country level and takes account of WHO expected results and regional and national guidelines. It aims to harmonise the work of WHO with national priorities, bearing in mind international commitments such as the Millennium Development Goals (MDGs) and the New Partnership for Africa’s Development (NEPAD). Implementation of the first Country Cooperation Strategy (2002–2005) helped provide structured support to the Ministry of Health in several areas: policy development and strategic planning, monitoring and evaluation, and implementation of priority programmes, the objective being to reduce the disease burden and provide effective response to epidemics. Despite efforts made, the health situation in the country is still worrying: estimated life expectancy is 41[1] years, mortality rate for children under five is estimated at 260 per 1000 live births and maternal mortality rate was estimated at 1400 per 100 000 live births in 2005(HDR/UNDP-2007/2008). Only 40% of the population has access to health services. Furthermore, the risk of epidemics remains high due to inadequate access to safe drinking water and basic sanitation. This new CCS (2009–2013) seeks to improve the results expected during the implementation of the 2002–2005 country cooperation strategy and is based essentially on the 13 WHO strategic objectives set out in section IV. The objective is to increase WHO support to the Ministry of Health to address the major health and development challenges. The new CCS was prepared by the main players in the health sector under the leadership of the Ministry of Health. In so doing, in disease control where the technical and mobilization skills of WHO are globally recognized, WHO will put special emphasis on development of a coherent policy, development of strategies for prevention and control of communicable diseases and strengthening of surveillance and integrated response. It will also carry out advocacy for the implementation of the International Health Regulations (IHRs). As regards noncommunicable diseases, WHO will focus its interventions on developing a surveillance system based on control of risk factors, advocacy and capacity building for human resources and case management structures. WHO will help increase equitable access to safe and quality interventions for the prevention, early detection, diagnosis and treatment of neglected diseases. 1

National Health Policy.

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Maternal and child health will be improved by developing a strategic partnership and specific interventions to speed up the reduction of maternal, newborn and infant mortality in an attempt to achieve the Millennium Development Goals (MDGs). Support will be provided for the implementation of the Angolan Roadmap to Reducing Maternal and Child mortality in the context of revitalising municipal health services. Regarding environmental health and health promotion, the focus will be on providing support for preparing policies and strategic plans including areas such as nutrition and food safety. In health system organization, WHO will centre its support on developing a National Health Policy, a National Health Development Plan (NHDP), human resource development norms and standards, essential medicines, health financing and a health information system to improve the quality and provision of services. Particular attention will be paid to coordinating these interventions. As regards emergencies, WHO will continue to coordinate partners in the health sector within a framework of consultation with the United Nations system. In general, WHO will provide technical assistance in preparing technical tools, standards and guidelines and will strengthen its role as adviser at the highest level for the development and implementation of policies and strategies to help the Government in carrying out its responsibility of guiding the sector. Implementing this new CCS requires the close collaboration of the Ministry of Health and the players in the health and development sector. Increased collaboration is expected among the different levels of WHO: headquarters, Regional Office, the intercountry support team in Libreville and the WHO Country Office in Angola.

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SECTION 1 INTRODUCTION The advent of peace in Angola in 2002 heralded a process of national reconciliation, economic recovery and political stability. The burden of disease and the current phase of national reconstruction raise the major challenges of development of a coherent, up-to-date national health policy, the reconstruction and rehabilitation of the entire network of health services delivery and the recruitment, training and redistribution of health personnel. In collaboration with the Ministry of Health and other partners, WHO has identified new challenges and responsibilities in providing technical support to the country in the present context. This process of consultation led to the definition of a WHO Country Cooperation Strategy (CCS) as a frame of reference for the work of WHO in Angola during the period 2009–2013. The CCS is aligned with the National Medium Term Plan for Economic and Social Development 2009–2013. It is also aligned with the Long Term Development Strategy for Angola (2025) and the United Nations Development Assistance Framework for Angola (UNDAF) 2009–2013. Through the proposals presented in this document, WHO will seek to strengthen its cooperation with the Government to respond better to the country’s current challenges and needs. This document is the product of a vast process of participation and dialogue bringing together the Ministry of Health, representatives of other sectors of the Angolan Government, such as the Ministries of Planning, Family and Women’s Promotion, Social Reintegration, provincial governments, national and international NGOs, bilateral cooperation partners and United Nations agencies. In line with the mandate and the main functions of WHO, the WHO country office in Angola has been supporting the Government to improve health indicators related to the Millennium Development Goals, namely, Maternal and Child Health, Malaria, HIV/AIDS, Tuberculosis and Health System Strengthening as well as equitable access to services that are key priorities in the health sector. In addition, WHO has been supporting the Government to formulate policies, strategies, norms and standards for the health sector including National Health Policy, Health Sector Development Plan, National Health Accounts, National Strategic Plan for the Reduction of Maternal and Child Mortality, Control of Malaria, HIV/AIDS and Tuberculosis and Monitoring and Evaluation of national health programmes. The outcome of the evaluation of the WHO Country Cooperation Strategy for the period 2002–2005, the emerging health priorities in the country and the new WHO strategic directions have been helpful in preparing a second generation CCS (WHO Country Cooperation Strategy for 2009–2013) based on the following national health priorities: 1. Maternal and child mortality reduction; 2. Control of communicable and noncommunicable diseases; 3. Organization and management of the national health system: capacity building at municipal health system level, primary health care approach (process of revitalizing municipal health services); 1

4. Human resources development; 5. Strengthening national health information system, implementation of the International Health Regulations and creating a regional centre of excellence for integrated disease control; 6. Health financing; 7. Research and new technologies; 8. Logistics, material and equipment supply. The WHO strategic approach is in line with national health priorities and the strategic directions and objectives of the World Health Organization. To address national health challenges and priorities, the current CCS will focus on the following strategic thrusts: organisation and management of the health system, improving maternal and child health, and control of diseases.

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SECTION 2 DEVELOPMENT AND HEALTH CHALLENGES IN THE COUNTRY After nearly four decades of civil war, Angola signed a Peace Agreement on 4 April 2002. The war seriously affected all sectors of society and the lives of Angolans, causing massive displacement of populations, accelerating the process of disorderly urbanization and worsening the social and health situation. Despite the stability and the growing economic prosperity in the country, Angola still belongs to the group of “Least Developed Countries” (LDCs), according to United Nations criteria for LDC classification, based on three main factors: • • • Gross National Income per capita; Economic vulnerability; Human Development Index.

Countries are assessed every three years, according to the thresholds established for each factor. In the most recent assessment in 2006, Gross National Income per capita actually exceeded the threshold and the country’s rating for economic vulnerability almost reached the set threshold. There was a marked improvement in these two factors compared to the 2003 assessment. However, little progress was made in the third factor i.e. human development index. The low life expectancy in Angola is largely due to the high under-five mortality, estimated in 2005 at 260 deaths per 1000 live births — one of the highest rates in the world. Achieving the MDGs, which requires a two-third reduction in this rate between 1990 and 2015, will be extremely difficult. Similarly, the MDG summary report admits it is unlikely that the goal of reducing maternal mortality in Angola by three quarters by 2015 will be achieved. Maternal mortality in Angola is high: 1400 per 100 000 live births (UNDP 2007–2008).

2.1 GENERAL DEMOGRAPHY Angola covers an area of 1 246 700Km2, and in 2005 it had an estimated population of 16.1 million,2 and an average population density of 13 inhabitants per Km.2 Fertility rate is 6.7 children per woman, and 46.4% of the population are under the age of 15. In 2007, average annual population growth was 2.9%.3

2 3

UNDP Human Development Report, 2007-2008. idem

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The Angolan population is characterized by a diversity of ethnic groups, with diversified cultures, traditions, local languages and customs. The majority (53.3%) of the population are concentrated in urban areas.

2.2 ECONOMIC AND HUMAN DEVELOPMENT Although revenue from petroleum and diamond has helped increase per capita income from US$ 510 in 2002 to US$ 1980 in 2006 (World Bank, 2008), human development indicators continue to be low. Thanks to some measure of economic stability4 in the country, the Angolan economy has shown recent improvement in macroeconomic development, particularly: • • • • Growth in GDP which, estimated at 9% on average since 1995, rose to around 20% in 2006. Crude oil production exceeded 1.5 million barrels a day at the end of 2006. An annual economic growth rate of 26% in 2006 as agricultural production began to recover with the return of the displaced populations to their communities of origin. Gradual fall in annual inflation. The average rise in the consumer price index (CPI) in 12 months fell to 31% in 2004, 18.5% in 2005 and 12.2% in December 2006. The situation of the national budget has also improved lately as a result of the rise in the price of crude oil, such that a budget surplus of 16% of GDP was recorded in 2006.

Despite the progress in macroeconomic stability and structural reform, Angola still has a long way to go to improve fiscal discipline and governance. Fiscal discipline is weakened by poor capacity in the management of public spending, the Ministry of Finance’s limited control over oil revenue and the limited control over diamond revenues by the State Diamond Company, ENDIAMA. Angola is a potentially rich country with vast natural resources such as crude oil, gas and diamonds and considerable hydroelectric energy resource potential, arable land and adequate rainfall. Table 1: Economic Trends in 2005 Budget Planned Results GDP 16.1 20.6 Crude Oil 21.4 26.0 Diamonds 20.4 16.2 Farming 15.6 17.0 Transport 15.0 24.9 Construction 16.0 16.9 Energy 13.0 17.4 General Service 13.5 8.5

Source: Outcome of the implementation of the Government’s General Programme 2005–2006 (2005).

Table 1 shows an increase in actual revenue compared to planned revenue from overall production excluding diamond and general services. Despite these favourable conditions, the economic performance of the country beside these mineral sectors (diamonds and crude oil) has not yet achieved its potential due to decades of war, multiple challenges facing the industrial sector and weak institutional development. Furthermore, despite the economic growth, most of the Angolan population (62.2%) continue to live below the poverty line (Poverty Control, 2007).

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European Union and World Bank: Angola Public Expenditure and Health Sector, January 2007.

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Another major challenge is the continuing weakness of the medium-term fiscal and financial framework that remains relatively weak due to over-dependence on the oil sector which accounts for more than half of GDP.

2.3 HEALTH FINANCING As shown in Table 2, from 2001 to 2006, health spending varied from 2.78% to 3.40% of GDP — a very low percentage. However, over the same period, health spending on average accounted for 4.54% of total public spending. There is also a substantial increase in health spending in absolute terms, from US$ 213 million in 2002 to US$ 447 million in 2005, representing more than double the amount in 2002. Spending in the health sector was expected to total US$ 1 billion in 2006. This increase in spending is a major opportunity for the Government to improve the health of the population significantly. Table 2: GDP, Total Public Spending and Health Spending (expressed in US$ millions and in percentage). 2001 Nominal GDP Total Public Spending Health Spending Health Spending as % of GDP Health Spending as % of Total Public Expenditure Public Expenditure as % of GDP 9474 4386 263.6 2.78% 6.01% 46.3% 2002 11 204 5401 213.1 1.90% 3.95% 48.21% 2003 13 826 6141 298.6 2.16% 4.86% 44.42% 2004 19 915 7095 313.8 1.58% 4.42% 35.63% 2005 23 226 10 159 447.2 1.93% 4.40% 43.74% 2006a 30 051 23 110 1.020.9 3.40% 4.42% 769 %

Source: Study on Public Spending on the Health Sector, 2007

As indicated in Table 3 covering the period from 2000 to 2005, implementation of the State Budget remained low at around 70%. In the past, this situation was attributed to the high priority given to other sectors such as Defence. Today, this low level of health spending is probably due to the following factors: (i) weak absorption capacity of the health sector; (ii) inadequate quantity and quality of human resources to implement and manage programmes and (iii) non-transfer of funds to the primary level. There are substantial disparities in the rate of spending on the different levels of health care and on the different economic categories. Table 3: Budget and Total Public Health Spending per capita (USD ‘000)*. 2000 Budget Execution Budget per capita Execution per capita Execution Rate *

2001 337 950 26 570 24.5 19.1 78%

2002 244 297 213 110 17.2 15.0 87%

2003 398 586 298 579 27.2 20.4 75%

2004 509 383 313 799 33.8 20.8 62%

2005 663 598 447 245 42.7 28.8 67%

254 127 179 014 19.0 13.4 70%

The exchange rate used for amounts budgeted and executed: official exchange rate and informal rate during the year of execution.

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2.3.1 CONTRIBUTION BY DONORS TO THE HEALTH SECTOR During the armed conflict, the donor community played a major role in providing emergency health services to many provinces in the country. After the war ended, their support diminished and, according to recent studies by the European Union (EU), donor contributions amounted to US$ 59 million in 2005. Furthermore, it is expected that agencies of the United Nations and the Global Fund will provide US$ 15-20 million annually, making up a total of US$ 75-80 million from 2000 to 2005.This sum represents around 14% of total public health spending. Health was the sector that benefited the most from the donor contributions, accounting for 16% of total foreign aid. In coming years, donor contributions are expected to remain stable in absolute terms and to drop in relative terms, while Government contributions are expected to increase. Aid from the donor community is provided in three different forms: (i) Funds for vertical programmes to control specific diseases such as malaria and HIV/ AIDS. There has been growing support for more integrated approaches such as support for the national strategic plan for maternal and child mortality reduction. (ii) Institution development and implementation capacity building. This aid is provided to the Ministry of Finance and to provincial governments through technical assistance and capacity building to help develop policies and strategies for implementation. (iii) Direct provision of services, mainly in remote areas, with donor funds channelled essentially through NGOs. The provision of services should be coordinated with municipal and provincial authorities and, to a much lesser extent, with the Ministry of Finance. Should donor support for the health sector continue, it is important for coordination mechanisms to be strengthened and for the Ministry of Finance to play a leading role. As much as possible, donors should align the planning and the budget for their interventions with the cycle and structure of the national budget.

2.3.2 FAMILY CONTRIBUTIONS TO HEALTH Families contribute to health financing through direct payments or pre-payments (insurance) but the amount contributed is not yet known. In 2005, a study was carried out on the population’s participation in health financing, covering a sample of 22 units. The study concluded that cost recovery policy accounted for 4.1% of total costs and 22.7% of goods and services (non-salary recurrent expenditure). In the case of health centres, user payments represented 53.2% of the cost of goods and services. How this revenue should be used (e.g. to improve the quality of services or working conditions) has not been specified by law. Table 4 shows that the estimated average expenditure by families during a full episode of a common disease such as malaria or diarrhoea is about US$ 40. Data collected in five provinces shows that 62% of total spending in the health sector were allocated to public health facilities, 51% of which were for medicines.

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Table 4: Average Spending by Individuals on one Episode of a Common Disease (in Kwanzas) Category of Spending Direct Spending Medicines Private services Hospitalisation services Indirect spending Transport Meals Average Cost 366 1.023 3.757 710 661 3.350 200 291 1.491 329 270 2.535 200 1.483 4.253 382 850 3.359 11% 25% 100% 1.762 393 214 1.853 64 62 715 169 115 1.536 327 73 2.202 232 136 1.709 275 142 51% 8% 4% Luanda Benguela Bié Huambo Huíla Average %

Source: MOH – GEPE – PASS “Study on the rate of payment in health facilities in Angola”.

On the whole, the rate of payment by users of health services has not increased primary health care financing. There was no correlation between the introduction of user payment and the change in the volume of resources allocated to each level of health care. User payments have given municipal hospitals and health centres greater autonomy as such revenue is put in a management fund for contingencies and procurement of supplies and equipment, when necessary.

2.4 HEALTH PROFILE The health status of Angolans is characterized by low life expectancy estimated at 41 years5 and high morbidity and mortality rates. Under-five mortality is estimated at 260 per 1000 live births. In 2005, maternal mortality was estimated at 1400 per 100 000 live births. Chronic under-nutrition affects 45% of children under the age of five. Health service coverage remains low. Only 40% of the population have access to health services and only 40% of births are assisted by a qualified health worker. Communicable and parasitic diseases such as malaria, AIDS, tuberculosis and trypanosomiasis account for 70%6 of total deaths. Malaria prevalence is 146/1000 inhabitants according to routine data (MOH-2007). Around 24% of cases of fever in children under the age of five are due to malaria. Data from the same source indicate that 35% of demand for curative care, 20% of hospitalisations, 40 of peri-natal deaths and 25% of maternal mortality are due to malaria. Data on the HIV/AIDS pandemic are based solely on studies on specific population groups, seroprevalence and risk factors. That is how it was found that HIV in pregnant women rose from 3.4% in 1999 to 8.6% in 2001 (INLS/MOH/2001). HIV prevalence in adults (15–49) was estimated at 2.1% in 2007. It is estimated that around 200 000 people live with HIV. The reported cases of AIDS totalled 24 798 of which 7859 were being treated with ARV. Concerning the modes of HIV transmission, available data7 shows that 62% of transmission are via the sexual route (bisexual and homosexual), 19% through the use of unsterilized equipment, 10% through vertical transmission and 9% through blood transfusion (Ministry of Health, Strategic Plan for HIV/AIDS Control, 20032008). 5 6

7

National Health Policy Poverty Eradication Strategy: Social Reintegration, Rehabilitation, Reconstruction, and Economic Stability, Luanda, Angola, 25 February 2007, p. 76. Angola, a Country with a Future: Sustainability, Equality, Modernity, Long-Term Development Strategy for Angola (2025), Ministry of Planning, Luanda, Angola, February 2007, III-48.

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Tuberculosis prevalence was 333/100 000/year in 2005, and its incidence was 269/100 000/year. HIV prevalence among TB patients was 19%. In addition to these, there is a high burden of acute respiratory infections, diarrhoeal diseases and trypanosomiasis, among others, affecting the most vulnerable groups namely women and children. In 2004, 53% of the population had access to safe drinking water and, in the same year, 31% of the population had access to basic sanitation (UNDP 2007-2008). The country’s vulnerability is evidenced by the frequent occurrence of epidemics due to the high rate of poverty (68%), precarious water supply and sanitation system, limited access to health services and low coverage of routine immunization. In recent years, the country has had various epidemics: poliomyelitis in 1999 affecting 1117 children; meningitis, with 1263 cases and 152 deaths by October 2002 and; measles in some provinces, causing 7000– 15 000 deaths annually. In 2005, in the Uíge province, Angola experienced the worst epidemic of haemorrhagic fever ever recorded worldwide, with a total of 252 cases and 227 deaths. Since February 2006, Angola has been grappling with a cholera epidemic with 67 256 cases and 2722 deaths. In 2007, the cholera epidemic continued to wreak havoc with 18 390 cases and 515 deaths. By 31 May 2008,8 8788 cases and 209 deaths had been recorded. Also predominant in the epidemiological profile are acute diarrhoeal diseases, acute respiratory diseases, trypanosomiasis, and vaccine-preventable diseases such as measles and tetanus. Acute respiratory and diarrhoeal diseases account for nearly 80% of all deaths. Coverage of health service is still low. In 2004, 62% of all children were vaccinated against measles. In 2003, 22.5% of births were assisted by qualified health workers. Human resources are inadequate quantitatively and qualitatively. There is uneven geographical distribution of human resources in the health sector with major imbalances between regions and largest population concentrations in urban areas. These disparities raise the problem of equitable access to health services and deserve the attention of planners. In 2004, data on the main categories of qualified health workers showed ratios of 0.008 doctors per 10 000 inhabitants; 0.12 nurses per 10 000 inhabitants and 0.43 midwives per 10 000 inhabitants. In Angola, the proportion of health professionals per inhabitant is low as measured against the reference indicator of 2.5 qualified workers per 1000 inhabitants set by Joint Learning Initiative (2004) as the minimum to ensure access to essential services in line with the Millennium Development Goals.

2.5 NATIONAL HEALTH PRIORITIES In the light of the foregoing epidemiological profile and the prevailing challenges, the following national priorities were spelled out in National Health Policy Document: 1. Maternal and child mortality reduction. 2. Control of communicable and noncommunicable diseases. 3. Organisation and management of the health system. 8

Cholera in Angola Bulletins 2006, 2007, 2008 from the Data Processing Centre (CPD) of the National Directorate of Public Health (DNSP).

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SECTION 3 SUPPORT FOR DEVELOPMENT AND PARTNERSHIPS 3.1 FLOW OF AID/ASSISTANCE From 2004 to 2007, development aid dropped from Euros 953 million to Euros 242 million, representing a decrease of 19% as shown in the table below. The reduction in aid is mainly due to the cessation of the war in 2002 and the fact that the country has sufficient resources of its own. Table 5: General Trend of Development Aid to Angola (millions of Euros) Year Flow of development aid Variation n+1/n in % Sources: 2004 953 -60.9 2005 373 -3.8 2006 359 -32.6 2007 242

2004 data were calculated using the UNDP human development report based on an exchange rate of 1 Euro = $ 1.2. Data from 2005–2007 were gathered from UNDP statistics.

The health sector is the main beneficiary of development aid. Although foreign contributions account for only 14% of total public spending on the health sector, 16% of overall funding from abroad is reserved exclusively for health.

3.2 MAIN PARTNERSHIPS Many partners provide technical and financial support to the health sector in Angola. That support is channelled through the United Nations agencies or provided in direct cooperation with the Ministry of Health. The main partners providing bilateral or multilateral development aid for the health sector are Sweden, the Netherlands, USA, Spain, Portugal, Japan, CIDA, IOM, UNICEF, UNFPA, World Bank, GFATM, ADB, European Commission and WHO. Some NGOs, civil society, and national and international companies contribute actively to the sector particularly petroleum companies and Rotary International. Regional and subregional organisations such as NEPAD, African Union, the community of Portuguesespeaking countries (CPLP) and African countries using Portuguese as official language (PALOPs) also provide assistance to the country. Direct implementation of programmes by international NGOs is intended to fill a gap requiring technical skills appropriate to the needs of the country and to ensure access to remote or inaccessible areas. One of the major challenges to guaranteeing the sustainability of this type of partnership is adherence to national health policy to avoid fragmentation of interventions, which hampers impact assessment.

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Table 6: Partnership in Health in Angola 2002–2007. Partner EHA USA CDC/Atlanta Italy Spain EC Sweden UK Norway Belgium Netherlands France Portugal UNICEF UNFPA PSI China SC-UK World Bank GFATM Oxfam MSF ADB Petroleum Companies X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X EPI X X HIV X X X X X X X X X X X MAL X Areas of intervention TB HSS X HRH MPS X TRIP HSD

3.3 COORDINATION MECHANISM The recent improvement in access to populations previously not covered by public health interventions coupled with the hard accessibility of vast areas of the country have increased the needs of the health sector. The presence of numerous partners and national and international nongovernmental organizations underscores the importance of strengthening coordination mechanisms. Clear definition by the leadership of the Ministry of Health of guiding principles and methods for the entire health sector is therefore crucial. The establishment of the Interagency Coordination Committee (ICC) for immunization programme and the recent establishment of the National Coordination Mechanism (MNC) for the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria, the Global Alliance of Health Workers, the Global Alliance for Vaccines and Immunization (GAVI) and Health System Strengthening (GAVI-HSS) have increased the need for strong coordination. These coordination mechanisms operate by means of regular meetings. The Deputy Minister of Health chairs the ICC while the Deputy Minister of Planning chairs the MNC. Even so, there is need for more coordination among all partners.

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SECTION 4 WHO COOPERATION POLICY FRAMEWORK: GLOBAL AND REGIONAL GUIDELINES WHO has introduced significant changes and continues to revise its form of cooperation with “the ultimate objective of enhancing its performance in the provision of assistance to Member States to address the main health and development challenges and to help Member States to achieve the health-related Millennium Development Goals”. The framework underpinning this process of organisational change is the Country Corporation Strategy.9

4.1 MISSION The mission of WHO continues to be “the attainment by all peoples of the highest possible level of health” (Article 1 of the WHO Constitution). The cooperation strategy, the 11th General Programme of Work for 2006–201510 and the Strategic Orientations for WHO action in the African Region 2005–20093 set forth the main directions by which WHO intends to make its greatest possible contribution to health. The aim of WHO is to strengthen technical leadership in health and its own management capacity in addressing the needs of Member States including the attainment of the Millennium Development Goals (MDGs).

4.2 MAIN FUNCTIONS The work of WHO is guided by a series of functions based on its comparative advantages.11 The functions are: 1. Assume leadership of the health sector and build partnerships where joint action is required; 2. Secure the research agenda and promote the production, dissemination and application of valuable knowledge; 3. Establish norms and standards and promote and monitor their implementation; 4. Articulate policy options on the basis of evidence and ethics; 5. Provide technical support, catalysing change and building sustainable institutional capacity; 6. Monitor the health situation and assess its trends.

9 10 11

WHO EB 105/3 A Corporate strategy for the WHO Secretariat. Eleventh General Programme of Work 2006 –2015. A Global Health Agenda. Strategic Orientations for WHO Action in the African Region 2005–2009.

11

4.3 HEALTH AGENDA In order to correct existing gaps in social justice in all health policy and implementation documents, WHO identified the following seven priority areas at global level: 1. Investing in health to reduce poverty; 2. 3. 4. 5. 6. 7. Guaranteeing individual and public health; Promoting universal coverage, gender equality and human rights in health; Minimizing the negative impact of health decisions; Strengthening health systems and equity in access; Making use of new knowledge, science and technology; and Strengthening governance, leadership and accountability.

Furthermore, the WHO Director-General proposes an agenda with the following items: 1. 2. 3. 4. 5. 6. Health Development; Health Insurance; Health Systems; Evidence-based formulation of strategies; Partnerships; Improving WHO performance.

Lastly, the WHO Director-General has said that the success of the Organization should be measured in terms of improvements in the health of women and of the African people.

4.4 GLOBAL PRIORITY AREAS The Global priority areas are outlined in the 11th General Programme of Work. They include: 1. Supporting countries to achieve universal health coverage through effective public health interventions; 2. Guaranteeing global health security; 3. Identifying health sector actions/interventions capable of changing behavioural, social, economic and environmental determinants of health; 4. Building institutional capacity for better health service delivery under the management of ministries of health; 5. Strengthening WHO leadership at global and regional levels and supporting management improvements at country level.

4.5 REGIONAL PRIORITY AREAS Regional priorities take account of the different global documents and resolutions of WHO governing bodies, the Millennium Development Goals, the NEPAD health strategy, health-related resolutions adopted by the Heads of State of the African Union and WHO strategic objectives contained in the Medium Term Strategic Plan (MTSP) 2008–2013. These regional priorities are set forth in the “Strategic Orientations for WHO Action in the African Region 2005–2009”. These orientations include prevention and control of communicable and noncommunicable diseases, child survival and maternal health, emergency and 12

humanitarian action, definition of policies and health determinants. Other objectives include health and the environment, food safety and nutrition, health systems (policies, delivery of services, financing, technologies and laboratories), partnerships, management and infrastructures. In addition to the above-mentioned priorities, the Region is committed to supporting countries to achieve health-related Millennium Development Goals and address their human resource challenges. The identification of sources of funding for achieving these objectives is being negotiated in collaboration with other agencies, and under the leadership of the countries themselves. To address these challenges, one of the most important priorities in the Region will be decentralization and the establishment of Intercountry Support Teams to provide assistance to countries. In order to address these priorities effectively, the Region will be guided by the following strategic directions: 1. Strengthening WHO country offices; 2. Improving and expanding partnerships in the health sector; 3. Providing support for the planning and management of health systems at municipal and community levels; 4. Strengthening the main interventions related to priority health problems; 5. Increasing awareness of, and response to, major health determinants.

4.6 A MORE EFFECTIVE WHO AT COUNTRY LEVEL The expected outcomes of the WHO Country Cooperation Strategy vary from country to country depending on the specific context and the health challenges. With regard to WHO’s mandate and comparative advantages, the six core functions of the Organization, as outlined in section 4.2, can be adapted to the needs and the specific situation of each country.

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SECTION 5 CURRENT WHO COOPERATION WHO is expected to provide leadership in technical assistance to the Ministry of Health and to coordinate partnerships in the health sector in accordance with the priorities set by the country. To achieve these goals, areas of work were regrouped into 13 strategic objectives as set out in Annex 1.

5.1 WHO’S CURRENT PROGRAMME IN THE COUNTRY In Angola, WHO has a central office in Luanda and a three-member support team in each of the 18 provinces in the country. These teams, set up in 2001, comprise a focal point for diseases surveillance, a driver and a secretary, and assist the Provincial Directorate of Health in epidemiological surveillance and the prevention of communicable diseases and epidemics. Currently, WHO is facing challenges in its operations. It has had a staff of around 189 since December 2007 and a budget of over US$ 47.65 million in the 2008–2009 biennium. However, it has needed partners particularly NGOs in order to implement the 2008–2009 biennium programme budget jointly with the Ministry of Health. After a situation analysis and definition of priority strategies to be supported by WHO, this document suggests administrative and operational changes. This process will keep the WHO offices at the services of the country without duplicating the work of the Ministry of Health and partners, while striving to create an enabling environment to make a real impact in morbidity and mortality reduction in the country.

5.1.1 WHO’s main areas of work and budget for the country The budget for the 2002–2007 period based on forecasts made since October 2002 included financial resources for the selected areas such as those described in Table 8, Annex 2. The following graph describes funding trends during the same period. Graph: Budget summary, 2002–2007 50000000 40000000 30000000 20000000 10000000 0 2002-2003 2004-2005 2006-2007 2008-2009 Regular Budget Voluntary Contributions

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Since 2002 WHO’s contribution to the Programme Budget has increased significantly from US$13.6 million to 47.65 million in 2008–2009. This amount does not include the funding made available by both the WHO headquarters and Regional Office to cover the technical assistance provided by the WHO Country Office in Angola. Major donors that provided funding to WHO in Angola in the past three years were: USAID, CDC Atlanta, United Kingdom, Rotary International, The Netherlands, Spain, Sweden, Norway, Italy, Belgium, European Commission, ADB, Global Fund and petrolium companies.

5.1.2 Main results achieved Over the period from 2002 to 2007, the main results achieved in the priority areas of work were:

5.1.2.1 Preparation of documents on health policies Notable among the main results are: • • • • • • Preparation of the National Health Policy document. Formulation of the new policy on malaria treatment with ACT. Preparation of the national blood transfusion policy and strategic plan. Preparation of the Angolan Roadmap for accelerated reduction of maternal and neonatal mortality. Preparation of the plan for revitalizing primary health care services and strengthening interventions in the context of child survival. Preparation of community-based policies and manuals for Integrated Management of Childhood Illnesses (IMCI).

5.1.2.2 Preparation of strategic plans WHO provided support for the preparation of the following documents: • • • • • • National Health Accounts; Strategic Plan for leprosy elimination and the new TB Strategic Plan for 2008–2012; MDR-TB (multidrug-resistant tuberculosis) control plan; National Malaria Strategic Plan 2008–2012; National Strategic Plan for the Reduction of Maternal and Child Mortality 2005– 2009; National Strategy for Infant and Young Child Feeding including those living with HIV and the Strategic Plan for Reproductive and Sexual Health and Contraceptive Safety; National HIV/AIDS Monitoring and Evaluation Plan.

•

5.1.2.3 Monitoring and evaluation The following evaluations were done with the support of WHO: • • • • Three studies on HIV prevalence in pregnant women and sex workers. Study on the prevalence of neglected diseases. Evaluation of the TB Strategic Plan for 2002–2007. Evaluation of the Pharmaceutical Sector in Angola. 15

• • • •

National needs assessment of emergency obstetric and newborn care. Assessment of the needs of the Procurement and Management System in Angola including the human resources component. Assessment of health needs in the Moxico province in the light of the Emergency Multisectoral Recovery Project (EMRP). Assessment of the situation regarding schistosomiasis and other helminthiases and filariasis.

5.1.2.4 Capacity building in health systems and services delivery WHO’s contribution to capacity building were in the following areas: • • • • • • • Laboratories for HIV testing. Managing TB-HIV co-infection and HIV-related diseases. Malaria case management as part of the implementation of the artemisinin-based combination therapy (ACT) for prevention and treatment. Intermittent treatment of malaria in pregnancy. Indoor residual spraying and distribution of mosquito nets. Supply of drinking water and improvement of basic sanitation as part of control of the cholera epidemic in 2006-2007. Emergency preparedness and response.

5.1.2.5 Emergency and humanitarian action WHO made significant contribution to the following: • • • Control of the Marburg epidemic in Uíge. Response to the cholera epidemic in 16 of the country’s 18 provinces. Control of the sodium bromide poisoning in the Cacuaco municipality, Luanda province.

5.1.2.6 Prevention and control of communicable diseases The focus of WHO support in communicable disease control was on the following areas:

5.1.2.6.1 Vaccine-preventable diseases • • • • • Holding of synchronized National Immunization Days and campaigns jointly with neighbouring countries: Democratic Republic of Congo and Namibia. Introduction of pentavalent vaccine in routine immunization in 2006. Increased routine immunization coverage for all EPI antigens. Increased coverage of DPT3/pentavalent 3 countrywide from 46% in 2005 to 67% by the end of 2007. Increase in non-polio AFP case detection rate countrywide from 2.1 in 100 000 children under the age of 15 in 2005 to 3.1 in 100 000 children under the same age in 2007. Certification of the elimination of leprosy as a public health problem in Angola. Implementation of the onchocerciasis eradication plan jointly with TIDC. 16

5.1.2.6.2 Neglected tropical diseases • •

5.1.2.6.3 HIV/AIDS • • • • Gradual expansion of access to ARV, PTV and CATV. Increase in epidemiological surveillance capacity. Strengthening of national capacity to manage cases of TB/HIV coinfection. Formulation of strategies as well as prevention and monitoring of resistance to ARVs.

5.1.2.6.4 Tuberculosis Notable among the main organization-related results are: • • • Establishment of 70 DOTS treatment centres; Establishment of 35 laboratories with functional notification system; Training of 96 laboratory technicians in TB case detection.

5.1.2.6. 5 Malaria • • • Introduction and expansion of ACTs and of the strategy of intermittent preventive treatment of malaria in pregnancy in all provinces; Indoor residual spraying in areas that have the potential for outbreaks of malaria epidemic. Increased coverage of long-lasting insecticidal nets through the innovative “Live a Healthy Life Campaign”.

Support was provided for the formulation of proposals to the Global Fund with regard to AIDS, malaria and tuberculosis.

5.1.2.7 Maternal and child health • National Committee for monitoring of maternal and child health interventions and committees for prevention and control of maternal and neonatal mortality in Luanda province. Launch of the IMCI strategy. Commencement of the process of revitalizing municipal health services with priority to maternal, neonatal and child health. Ratification of the Framework Convention on Tobacco Control. Preparation of guidelines and messages on health promotion at national and provincial levels. Strengthening of multisectoral coordination during the cholera epidemic. Technical assistance for the development of Primary Health Care policies. Strengthening of human resources for health through a vocational training programme and provision of fellowships. Establishment of the School of Public Health. Preparation of the National Health Accounts. Revision of the National Plan for the Development of Human Resources for Health. 17

• •

5.1.2.8 Environmental health and health promotion • • • • • • • •

5.1.2.9 Health system strengthening

5.1.2.10 Partnerships: The WHO Country Office in Angola strengthened and undertook advocacy for the establishment and strengthening of coordination mechanisms such as the Interagency Coordination Committee (ICC), the Country Coordination Mechanism (CCM) for AIDS, tuberculosis and malaria, and the partners forum for priority programmes such as malaria, HIV/AIDS and onchocerciasis. The actions above made it possible to gain access to financial allocation from Global Fund, the Interagency Coordination Committee (ICC) and from other donors including cooperation missions, USAID, Rotary International, petroleum companies, African Development Bank, World Bank, United Nations agencies and NGOs. Several Memoranda of Understanding were signed between WHO, United Nations agencies, bilateral cooperation agencies and the petroleum companies.

5.2 STRENGTHS, WEAKNESSES AND THE WAY FORWARD 5.2.1 Strengths The strengths of technical cooperation between WHO and Angola may be summarily presented as follows: • The strong partnership between the Government of Angola, civil society and partners as a whole gave the WHO Country Office in Angola an understanding of the political, social and health dynamic and humanitarian aid in Angola. The Government, partners and stakeholders countrywide recognize WHO’s global leadership in health. Decentralization of the WHO Country Office over the 18 provinces has created a strong WHO presence countrywide and enhanced the effectiveness of support to the country through the provincial and municipal directorates of health. WHO’s international credibility and its considerable capacity to mobilize resources in response to emergencies and other crises have been enhanced.

• •

•

5.2.2 Weaknesses: • The process of setting up provincial teams was slow or had no coherent administrative mechanisms set up to support them (mechanisms for accounts reporting and other instruments for resources management) as well as the necessary logistics (radio, communications, e-mail, vehicles, etc.). WHO should therefore consider establishing appropriate administrative instruments to give sustainability to a structured model with new characteristics and personnel distribution countrywide. Lack of continuity in staff presence due to the scheme of contract breaks for several months hampering the achievement of goals. Management of staff contracts and the resources for their extension should guarantee the continuity of work. Inadequate mobilization of resources for implementing the programme budget. Inadequate availability of human resources in the country.

•

• •

5.2.3 The way forward The management mechanism will be strengthened by increasing financial resources and the mechanisms of administrative decentralisation to the provincial level. Subsequently, but as soon as possible, there will be need to consider increasing the number of general service 18

staff, training staff in work procedures, having larger office space and better equipment (computers, vehicles, communication equipment, etc) and carrying out equipment maintenance.

5.3 OPPORTUNITIES AND CHALLENGES In order to achieve the strategic objectives defined in the Medium-Term Strategic Plan, the WHO Country Office in Angola will continue to strengthen results-based management in all areas of work with special emphasis on gender equality, equity in health, learning and collaboration, and joint planning. This reflects the strengths of WHO in the context of comprehensive health and community development. The challenge is to provide consistent and coherent technical support to the country through cooperation with the Government and partners in order to achieve the Millennium Development Goals.

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SECTION 6 THE WHO STRATEGIC AGENDA 2009–2013 The WHO strategic agenda 2009–2013 is based on the major lessons learnt from situation analyses, national priorities (sections II and III), and the strategic directions for WHO action in the African Region. These will be the thrust of the work of the WHO over the next five years in its major areas of work namely: • • • Maternal and child health; Disease control; Organization and management of the health system.

Nonetheless, WHO’s strategic action will be based on the comparative advantages of the Organization, the core functions set forth in section IV and the 13 strategic objectives listed in Annex 1.

6.1 MATERNAL AND CHILD HEALTH According to the strategic document on long-term national development12 (Angola 2025), the Government has set the following quantifiable objectives for the period 2008 • • • Significantly reducing maternal mortality from 1400/100 000 to 200/100 000 by 2015; Reducing infant mortality from 150 to 57 per thousand by 2015; Reducing under-five mortality from 260 to 96 per thousand over the period 2008– 2015.

To help the Angolan Government to achieve these objectives, WHO will focus its interventions over the next six years on the following areas: 6.1.1 Promoting safe motherhood, providing technical support for the strengthening and adoption of strategies and technical innovations with a view to reducing maternal and newborn mortality. Bearing in mind the direct relationship between child health, maternal health and health systems performance, WHO will help revitalise the current municipal health system and its future extension countrywide by providing technical support and making norms, standards, and the necessary guides and instruments available. Still in the context of the revitalization process, special attention will be given to the extension and strengthening of the integrated management of childhood illness (IMCI) strategy throughout the country and the implementation of the national roadmap to reducing maternal and newborn mortality. Capacity building and provision of quality services for both mother and child with specific attention to strengthening human resources, rational use of essential medicines and blood safety. Provision of technical support by WHO for drawing up and implementing effective

6.1.2

6.1.3 12

Ministry of Planning, Long Term Development Strategy for Angola (2025), February 2007, vol. III, p. VIII-66.

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policies and interventions with a view to harmonizing the technical content of programmes and creating synergies among the various areas including immunization, nutrition, HIV/AIDS, malaria and tuberculosis. 6.1.4 Strengthening innovative strategies, updating reproductive health strategies and implementing policies, norms and procedures to benefit children and adolescents (sex education programme on prevention of early pregnancies and sexually transmitted infections). Encouraging research, developing the necessary technologies and interventions, supporting capacity building in operational research and providing the evidence base for the underlying causes of maternal and child deaths and for the effectiveness of programmes implemented. Strengthening WHO’s technical support for supervision, monitoring and evaluation of the progress made towards achieving internationally-agreed goals endorsed by the country. Promoting the concept of gender and providing the necessary technical support for developing this concept and building it into reproductive health policies and strategies. Promoting best practices and healthy lifestyles and reducing the risk factors for the most frequent diseases. Undertaking advocacy, in the context of partnerships development, for strengthening joint ventures and, based on evidence, mobilizing the resources necessary for improving sexual and reproductive health as well as maternal, newborn, child and adolescent health. Furthermore, WHO will undertake advocacy for maternal and newborn health to be considered as a national priority and be integrated into national development plans.

6.1.5

6.1.6

6.1.7 6.1.8 6.1.9

6.2 DISEASE CONTROL Given the epidemiological context described in the chapter on health profile, the Government of the Republic of Angola has given special attention to disease control in its development strategy. The set objective is to define a comprehensive and coherent framework for disease surveillance and response and at the same time cultivate respect for the principle of equity. In addition, poverty eradication in which WHO is involved, jointly with the national authorities and development partners, would begin with the prevention and control of major diseases that continue to weaken the population. The fight against HIV/AIDS, tuberculosis and malaria will contribute considerably to reducing poverty, infant mortality and improving maternal and newborn health.

6.2.1 Control of communicable diseases 6.2.1.1 HIV/AIDS, tuberculosis and malaria With regard to HIV/AIDS, the set objective is to stop the spread of the disease and actually reverse the current trend by 2015. The planned strategic actions include accelerating the prevention of transmission, supporting diagnosis and treatment, combating stigma and strengthening the epidemiological surveillance system.

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Concerning tuberculosis the Government’s set objective is to reduce prevalence by 60% by 2015. Priority actions include improving laboratory diagnosis, promoting the DOTS strategy and extending it to all municipalities in the country, strengthening the skills and technical capacities of those in charge of tuberculosis management and mobilising more resources for the National Tuberculosis Control Programme. In malaria prevention and control, the National Malaria Control Programme plans to contribute to reducing the malaria burden by 50% by 2010, the target of the malaria sector being to reduce13 the current malaria morbidity by 60% by 2012. The priority measures to achieve these targets are vector control, health promotion measures with emphasis on health education and community participation and malaria case detection, management, supervision and evaluation. To help the country to achieve the set objective of controlling these three priority diseases, WHO will focus its work up to 2013 on the following areas: 6.2.1.1.1 Provide support to the Ministry of Health in developing, implementing and supervising national policies, strategies and norms for HIV/AIDS, tuberculosis and malaria. 6.2.1.1.2 Disseminate innovative prevention strategies for the control of HIV/AIDS, tuberculosis and malaria. 6.2.1.1.3 6.2.1.1.4 6.2.1.1.5 Facilitate the provision and adequate use of quality medicines and products. Strengthen research, supervision and evaluation capacities and provide incentives for assessing progress and producing evidence for decision making. Provide technical assistance and guidance for integrated surveillance of HIV/ AIDS sentinel surveillance sites including monitoring of ARV and tuberculostatic resistance (MDR, XDR-TB). Strengthen partnerships to support global, regional and intercountry initiatives for control of HIV/AIDS, tuberculosis and malaria and implement effective mechanisms of mobilization and efficient use of resources for controlling these diseases.

6.2.1.1.6

6.2.1.2 Control of other communicable diseases In order to assist the country to achieve its set objectives for controlling these three priority diseases, WHO intervention up to 2013 will focus on the following: 6.2.1.2.1 Continue to strengthen the Expanded Programme on Immunization in collaboration with other partners. This support will involve the provision of guides and norms for improving the quality of immunization services including injection safety and monitoring of the side effects of immunization;

6.2.1.2.2 Provide support for the Integrated Disease Surveillance and Response Strategy (IDSR) adopted by the Ministry of Health as well as technical support for expanding IDSR to all municipalities in the country including vertical programmes; 6.2.1.2.3 Disseminate innovative emerging and re-emerging diseases prevention strategies whereby surveillance will be integrated into the existing epidemiological surveillance system;

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Angola, a Country with a Future: Sustainability, Equality, Modernity, a Long Term Development Strategy for Angola (2025), Ministry of Planning, Luanda, Angola, February 2007, Volume III, VIII-70.

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6.2.1.2.4 6.2.1.2.5 6.2.1.2.6 6.2.1.2.7

Strengthen national capacity to update instruments and strategies for prevention, early detection, diagnosis and treatment of communicable diseases; Support the country to increase cost-effective health interventions that have been successful in other countries; Support the country to implement World Health Assembly resolutions on communicable diseases and the International Health Regulations 2005. Carry out advocacy among other players to increase their participation in integrated surveillance.

6.2.2 Control of noncommunicable diseases Noncommunicable diseases (cardiovascular diseases, high blood pressure, diabetes, smoking, mental disease, sickle cell anaemia) are on the increase. WHO technical support will focus on the following: 6.2.2.1 Provide support mainly for primary prevention through information gathering and national policy development; 6.2.2.2 Help the country to gather, analyse and use data on the magnitude and causes of chronic diseases and noncommunicable diseases. 6.2.2.3 Prepare technical guidelines and training materials for improving the management of noncommunicable diseases.

6.2.3 Management of emergencies and natural disasters Angola has regularly experienced outbreaks of epidemics: Marburg in Uíge in 2005, sodium bromide poisoning in Cacuaco province in 2007 and a cholera epidemic that is still rife in one endemic state. The country also experienced flooding due to heavy rains in the Kwanza Norte province in 2005; in Luanda, Moxico, Kuando Kubango, Bengo and Uige in 2007 and in the Cunene, Kuando Kubango, Benguela, Huíla and Namibe provinces in 2008. Risk reduction and emergency and natural disaster preparedness and response will be a cross-cutting element of the work of the WHO country office up to 2013 and will help reduce the health impact of emergencies, disasters and crises, through using the following strategies: 6.2.3.1 Building national capacity to assess the health impact and people’s needs in emergency situations to ensure better preparedness, coordination and organization of response using multisectoral and multidisciplinary approaches; 6.2.3.2 Supporting partnership building and establishing coordination mechanisms with networks of collaborators, civil society and centres of excellence to ensure rapid intervention whenever necessary; 6.2.3.3 Supervising and assessing environmental risks and building the capacity to define and implement health promotion and environmental policies including updating norms and criteria.

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6.2.4 Promotion of health including healthy environments Promoting health and healthier environments are key components of communicable and noncommunicable diseases prevention and control and reduction of risk factors. WHO will therefore focus its support on the following: 6.2.4.1 Supervision and assessment of environmental risks while strengthening the capacity to define and develop health and environment policies including the development of norms and criteria; 6.2.4.2 Reformulation and implementation of national health promotion policies and strategies as a main component of primary health care; 6.2.4.3 Conduct of advocacy for health promotion with a view to strengthening partnerships and formulating regulations on the importation and use of products posing health hazards including tobacco and alcohol in an attempt to reduce their consumption; 6.2.4.4 Provision of technical and financial assistance for the planning and organization of international meetings on health promotion.

6.3 ORGANIZATION AND MANAGEMENT OF THE HEALTH SYSTEM One of the major challenges to public health in Angola is to establish a health system capable of providing essential care for the population. Several elements are necessary for this purpose: development of a national health plan and a health development plan; availability of basic material, essential medicines, equipment and a financing system. A health and research information system should also be created for better monitoring and evaluation of interventions. Without a more effective and equitable health system, it will not be possible to develop the essential interventions needed to make any significant improvement in the health status of the populations whether in maternal and child health, or in the control of malaria, HIV/ AIDS and other major diseases of public health importance. The role of WHO will be to support countries to prepare a policy and a coherent strategic plan, as well as the instruments for its implementation. This will require the availability of human resources, an information system, funding and medicines.

6.3.1 Human resources: training and strategic management Human resources are a national priority and a key element in increasing universal health coverage by 2025. The number of births assisted by qualified health workers should increase from the current 45% to 60% by 2015. The human resource model that the country will adopt by 2015 will be based on three programmes: information and management of human resources; a training programme and; a programme for improving working conditions. For African countries using Portuguese as official language (PALOPs) including Angola, there is cooperation between the European Union and the World Health Organization to develop human resources for health (Project 9.ACP.MTR.004). There is also the ePORTUGUESE platform under which virtual libraries are set up for dissemination of knowledge, research and new technologies. There is the strategic plan for health cooperation 2009–2012 for the community of Portuguese speaking countries (CPLP), approved by the ministers of health of CPLP Member States.

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WHO’s role will be: 6.3.1.1 to support the National Directorate of Human Resources of the Ministry of Health in drawing up a human resources development policy and plan; and to provide technical assistance for implementing the CPLP agreement and the EC/WHO/ PALOPs agreement. 6.3.1.2 to support the health workforce training institutions and encourage and monitor the internal and external assessment process in order to prepare better training programmes and curricula, taking into account the country’s actual needs and international standards; 6.3.1.3 to provide health training institutions access to technical documentation and help national managers to attend international seminars with a view to facilitating continuing training; 6.3.1.4 to disseminate best recruitment and management practices that will help stabilize and retain technical health staff in peripheral areas;

6.3.2 Health information system and research Information, statistics and health research are crucial to the health system. They are indispensable for evaluation and supervision of policies and programmes. Over the next six years, WHO will strengthen: 6.3.2.1 Technical advice in designing a health information system and creating instruments for the respective subsystems by disseminating know-how and providing support for exchange of experiences with other countries; 6.3.2.2 Technical support for evaluating the existing system in order to identify dysfunctional areas of the health information system and for adopting corrective measures; 6.3.2.3 Assistance in organising a Demographic and Health Survey by 2010 in order to obtain basic demographic and health indicators; 6.3.2.4 Support for the formulation of a national health research policy (including research on health systems) and advocacy for the use of research results in decision-making; 6.3.2.5 Support for the development of a plan for monitoring and evaluation of public health programmes.

6.3.3 Medicines and technologies Quality medicines, vaccines and health technology are indispensable for the provision of quality health care. WHO will help increase access to care, technologies and medical products and help improve their quality and use by: 6.3.3.1 Providing support for the development of a policy and strategic plan for the pharmaceutical sector for the period 2009–2013; 6.3.3.2 Providing guidelines on the nomenclature of reference products and materials; 6.3.3.3 Inviting tenders for the design and implementation of programmes leading to good stock management, reliable procurement systems and rational use; 6.3.3.4 Supporting the implementation of a quality control system and establishing a network for pharmacovigilance and guaranteeing blood transfusion safety.

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6.3.4 Health financing Health financing is an essential determinant of the health and well-being of the population. Therefore, by 2025, Angola intends to set up a financing model that will evolve from a single source of public financing to multiple funding sources: public funding, private funding and donor funding. In this regard, WHO support will consist of: 6.3.4.1 Providing technical support to quantify funds allocated to the health sector and document their sources: national health accounts; 6.3.4.2 Assessing the financial magnitude of free care provided for certain social categories (the needy, vulnerable groups) and for certain diseases (HIV/AIDS, malaria, tuberculosis and trypanosomiasis); 6.3.4.3 Helping to create funding mechanisms that will make the resources of the health sector more predictable and sustainable, and forms of payment that gives incentives for better performance; 6.3.4.4 Facilitating, in collaboration with other partners, the introduction and expansion of economic assessment of health services (economic viability study of certain interventions, the economics of certain health actions, cost-benefit analysis, etc) to guide decision-making; 6.3.4.5 Supporting the development of funding proposals to mobilize resources from the Global Fund to fight HIV/AIDS, tuberculosis and malaria and the GAVI-RSS; 6.3.4.6 Preparing health investment plans for developing cost-effective interventions contributing to poverty reduction and achievement of MDGs.

6.3.5 Coordination and partnerships This component covers two main aspects: the need to strengthen community participation in creating a reference framework and; the need to improve coordination among all partners based on health programmes or on the sector-wide approach. This will be the central role of WHO, focusing mainly on: 6.3.5.1 Active participation of organs in health policy implementation and in advocacy among all stakeholders for concerted action and for aligning all national priority interventions to ensure greater coherence and synergy. 6.3.5.2 Formulation of a national policy on community participation and mobilization of the various actors for its implementation.

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SECTION 7 IMPLEMENTING THE STRATEGIC AGENDA: IMPLICATIONS FOR WHO 7.1 MATCHING WHO INTERVENTIONS WITH THE COUNTRY COOPERATION STRATEGY At the annual retreat of staff of the WHO Country Office in Angola from 23 to 24 May 2008, the staff took a critical look at WHO interventions in Luanda and in the provinces and did an analysis of health priorities as reflected in the Country Cooperation Strategy 2002– 2005. Competencies were discussed with a view to reflecting on them on the structure of the WHO Country Office in Angola. The current relevance of priority programmes defined in the CCS was analysed and, as a result, areas of work were selected. The relevance of the following areas were confirmed: (a) development of health systems; (b) prevention and control of communicable diseases; (c) reproductive health and; (d) health promotion. Humanitarian aid was considered an area of minor importance, considering the current context of reconstruction in the country. However, areas such as nutrition and environmental health were considered as a high priority.

7.2 MAIN PROBLEMS IDENTIFIED • Short-term contracts (11 months) do not provide staff the expected job security as they do not guarantee a professional career, thereby contributing to the departure of many staff members. Short-term contracts have an adverse impact on the continuity of activities and undermine the effectiveness and efficiency of the office. The physical infrastructure and space of the central office is limited and, to avoid overcrowding, technical staff are dispersed to different offices thereby hampering coordination. Many of these WHO suboffices with technical staff in the provinces do not meet the minimum requirements for adequate functioning. Communication, transport and logistic support should be improved. The provincial suboffices are assigned too many programmes and different activities for which the staff have not been adequately trained.

•

•

•

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7.3 RECOMMENDATIONS • Implement the process of reprofiling to improve efficiency, effectiveness and coherence in the work of the WHO Country Office in Angola, convert short-term contracts into fixed-term contracts and start implementing staff development and learning programmes; Provide the WHO Office in Luanda with adequate physical structure and space to accommodate all staff; Increase central support to the suboffices in the provinces particularly in terms of logistics and communication and create the enabling conditions for staff learning and development through continuing education and refresher courses; Ensure adequate technical and financial support for implementation of the Programme Budget.

• •

•

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SECTION 8 MONITORIING AND EVALUATION Country Cooperation Strategies monitoring and evaluation will be carried out using the biennial workplans monitoring and evaluation mechanism. At the end of the period covered by the CCS, an overall evaluation will be done, taking into account the outcomes of the evaluation of the three biennial workplans. Lessons learnt will help improve the definition of priority intervention strategies for the future generation of CCS. According to WHO, the main steps in the process of monitoring and evaluation of biennial workplans are: 8.1 Semi-annual monitoring (SAM), carried out after every six months of implementation and indicating the degree to which planned activities have been executed. An execution rate of 25% is expected by the time of the semi-annual monitoring. Mid-term review (MTR) carried out after the biennial workplan has been implemented for 12 months. The rate of execution expected at this stage is 50% of the biennial plan. The mid-term review should be submitted to the Ministry of Health and all technical and financial partners as well as key players in the health sector. This exercise indicates the extent to which the workplan has been implemented and is used to plan activities for the second year of the biennium. A third evaluation, done after 18 months of implementation of the biennial workplan and followed by a biennial report at the end of each two-year period. At this stage, it is expected that the biennial workplan would be fully implemented. The outcome of this end-of-biennium report is submitted to the Ministry of Health and partners for discussion.

8.2

8.3

Implementation of the Global Management System will enhance the ability of Divisional Directors and Programme Managers to monitor budget implementation and achievement of results. An external evaluation will be desirable if necessary.

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SECTION 9 CONCLUSION The strategic agenda for 2009–2013 consists in consolidating and strengthening the main achievements of cooperation with Angola in 2002–2005 and in responding to priorities according to the context, current challenges of the country and the WHO strategic directions and orientations. The main challenges of the health sector are to reduce maternal and infant mortality, control communicable diseases such as HIV/AIDS, TB and malaria, vaccine-preventable diseases and neglected tropical diseases. Epidemic preparedness and response, health system strengthening, promotion of health and healthy environments, also pose major challenges to the country. To address these challenges, WHO will support the Government of Angola over the next five years to achieve the Millennium Development Goals (MDG) in the following areas: maternal and child health, disease control, organization and management of the health system. In maternal and child health, the approach will be to implement the Angolan Roadmap to reducing maternal and newborn mortality and revitalise the municipal health system based on the primary health care approach. In disease control, interventions will centre on controlling the above-mentioned diseases and implementing the International Health Regulations. In organization and management of the health system, support will focus on development and management of human resources for health, strengthening the health information system, health sector financing, medicines and partnerships. For WHO support to the Ministry of Health to be effective, there will be need for collaboration among the different levels of WHO and for enhancing the service delivery capacity of the WHO country office.

Annex 1: Strategic Objectives 1. Prevent and control communicable diseases. 2. Combat HIV/AIDS, tuberculosis and malaria. 3. Prevent and reduce disease, disability and premature death from chronic noncommunicable conditions. 4. Reduce morbidity and mortality and improve health during key stages of life. 5. Strengthen response to emergencies, disasters, crises and conflicts. 6. Integrate comprehensive, multisectoral and multidisciplinary health promotion processes. 7. Address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive and human rights-based approaches. 8. Promote a healthier environment. 9. Strengthen nutrition, food safety and food security. 30

10. Improve health services through better governance, financing, staffing and management informed by reliable, accessible evidence and research. 11. Ensure improved access, quality and use of medical products and technologies. 12. Provide leadership, strengthen governance and foster partnership and collaboration with countries, the United Nations system and other stakeholders in order to fulfil the mandate of WHO. 13. Develop and sustain WHO as a flexible learning organization, enabling it to carry out its mandate and work efficiently and effectively in advancing the global health agenda as set out in the General Programme of Work.

Annex 2: Table 8: Areas of Work and Budget, WHO/Angola, 2002-2007 PROGRAMME 2002-200314 Making Pregnancy Safer Child and Adolescent Health Epidemic Preparedness and Response Health Promotion Environmental Health Control and Prevention of Communicable Diseases Tuberculosis HIV/AIDS Development of Health Policies Human Resources for Health WHO Presence in the Country Malaria Immunization and Vaccine Development Nutrition Essential Medicines Prevention and Management of Chronic Noncommunicable Diseases Reproductive Health Epidemic Alert and Response Essential Health Technologies Food Safety Health System and Services Delivery Mental Health and Drug Abuse Communicable Diseases Research Health Financing and Social Protection Violence, Accidents and Disability Prevention Information, Evidence and Research for Policy TOTAL 14

Budget Programme 2004-2005 250 000 2006-2007 2 235 000 1.390 000 1 160 000 180 000 1 545 314 85 000 1.819 000 855 000 705 000 1 470 000 220 000 731 000 589 942 270 000 382 425 61 000 300 000 1 254 000 2 080 000 5 286 350 1 758 000 6 463 829 5 992 000 2.100 000 989 000 1.260 000 405 000 850 000 2.913 000 2.105 000 6.800 000 300 000 600 000 800 000 1.305 000 1.500 000 625 000 200 000 490 000 314 848 944 000 450 000 550 000 600 000 500 000 700 000 13 571 350 17 712 358 33 500 000 400 000

The budget for 2002-2003 contains the most recent forecasts as at 31 Oct. 2002. However, the resources used in 2003 for emergencies and humanitarian assistance are not included. Resources made available by WHO headquarters and by WHO/AFRO for technical support from the WHO Country Office in Angola or from AFRO are not included either. Consequently,the budget does not include the 8 international experts and 40 national experts paid from funds for polio eradication directly by the WHO headquarters in Geneva.

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Annex 3: Angola – Some Basic Indicators Year Demographic and socioeconomic statistics Population (figures) * Population (annual growth rate) * Total area ** Population density ** Population aged 15 * Urban population * Total fertility rate (per woman) ** Primary school attendance rate (%)** Primary school attendance rate (%)** Adult literacy rate** Gross national income per capita ** Population living below the poverty line ** Health status – Health statistics Life expectancy at birth (years) * Under-five mortality per 1000 live births* Infant mortality per 1000 live births * Newborn mortality per 1000 live births ** Maternal mortality per 100 000 live births Prevalence of HIV among adults (15-49) (%)** Prevalence of tuberculosis (per 100 000 inhabitants) ** Incidence of tuberculosis (per 100 000 inhabitants) ** Number of confirmed cases of poliomyelitis ** Behavioral and environmental risk factors % Population with access to sanitation * % Population with access to improved water supply source * Health service coverage Immunization of children aged below 1 year (%) Measles DTP3 Coverage of antiretroviral treatment (%)** TB case detection rate under DOTS (%)** Successful TB treatment with DOTS (%)** Health System Statistics Total health spending as % of GDP ** Overall Government health spending as % of total health spending ** Private sector’s health spending as % of total health spending Public spending on health as % of total public spending ** Doctors (per 1000 inhabitants) ** Nurses (per 1000 inhabitants) ** 2003 2003 2003 2003 2004 2004 2.8 84.2 15.8 5.3 0.077 1.19 2007 2007 2005 2004 2003 79 67 6 94 63 2004 2004 31 53 Male & female Male & female Male & female Male & female Female Male & female Male & female Male & female Male & female 2005 2005 2005 2004 2005 2003 2004 2004 2005 41 260 154 54 1400 3.9 310 259 10 % (%) Per Km2 Per Km2 % % (%) Male Female (%) 2005 2005 2004 1998-2004 1998-2004 2000–2004 2006 2004 2005 2005 16.1 2.9 1 246 700 13 46.4 53.3 6.7 66 57 66.8 1980 68 Level

Source: *Human Development Report, UNDP 2007-2008 and ** World Health Statistics Report 2006 http://www.who.int/ whosis/en/

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