Africa's health problems remain a major obstacle to the continent's development. But the Special Initiative's multi-sectoral approach gives African countries new impetus to strengthen their health systems as an important part of an overall remedy for the interconnected ills afflicting the region. The Initiative aims to expand Africa's primary health facilities, with a particular emphasis on combatting the most debilitating illnesses: malaria, sexually transmitted diseases (including HIV/AIDS), tuberculosis and the major childhood diseases.
The lead agencies for the health component of the Special Initiative are the World Health Organization (WHO) and the World Bank, which are expected to help African countries mobilize the resources they need to carry out health sector reforms over the Initiative's 10-year period. The UN Children's Fund (UNICEF) is also deeply involved in strengthening preventive health care. But whatever assistance these international institutions and other donors may provide, notes Dr. Tayo Lambo of WHO's Africa regional office, "we do not implement the Special Initiative in New York, not even in Brazzaville, where we had a regional office. Implementation and the effects of implementation will only be seen at the country level."
Photo: UN / E. Debebe
Due to severe constraints on public spending in Africa, expenditure in the health sector rarely exceeds an average of 5 per cent of gross domestic product, or $10 per person per year, and is more likely to be allocated to salaries and to curative services in urban hospitals than to preventive and primary care. In many countries, more than 50 per cent of the population has no access to health facilities, 51 per cent has no access to safe drinking water and 56 per cent lacks sanitation -- services that could prevent the spread of some diseases.
According to a 1997 World Bank progress report, some $3.5 bn is being mobilized to support health sector development in 10 countries. More than half of this total will come from the countries themselves, with the donor community mobilizing the remaining $1.5 bn, of which about $500 mn will provided by the World Bank. Presenting the report to WHO's African Regional Committee of health ministers last September, Dr. A. Edward Elmendorf, the World Bank's lead health specialist for Africa, said the report's main message is that "if countries come forward with credible programmes, prepared in consultation with their external partners, filling the external financial requirements is not a problem."
The 10 countries are among 15 considered by the World Bank as being "positioned to execute the type of reform programmes outlined in the Initiative." The 15 -- Benin, Ethiopia, Ghana, Guinea-Bissau, Lesotho, Mali, Mauritania, Mauritius, Mozambique, Niger, Senegal, Tanzania, Uganda, Zambia and Zimbabwe -- all have either ongoing World Bank-sponsored sector investment programmes (SIPs) or are in the process of preparing one. The Bank deems most other African countries as currently lacking "readiness" for such sector-wide programmes, because of macroeconomic or institutional difficulties, certain major health sector issues that must be addressed before a SIP is feasible, or civil strife.
However, Dr. Ebrahim Samba, Director of WHO's Africa regional office (see interview), believes that the Special Initiative should not limit its activities to those countries that are in a better position to carry through sector-wide programmes. "We should on the contrary select the poorest countries," he told Africa Recovery, "the countries that are not qualified for sector investment programmes."
National
effortsThe Initiative's implementing agencies, Mr. Alieu Sallah, Deputy Assistant Administrator of the UN Development Programme (UNDP) Africa bureau, told Africa Recovery, must play an advocacy role within their respective sectors. "The idea is not for the Special Initiative to generate resources to supplement the budgets of UN agencies, but to support African government programmes in governance, water, health and education," he said.
Ethiopia gets high praise from Mr. Sallah for its commitment to the Special Initiative goals. According to Mr. Sallah -- until recently UNDP Resident Representative in that country -- what is exemplary about Ethiopia is the emphasis on national ownership of the reform process. The government already had prepared its programme for the health sector and was ready to use the forum of a World Bank-chaired donors' Consultative Group meeting to seek support. So impressed were the donors that in late 1996 they pledged $2.5 bn for Ethiopia's programmes (including in the health sector), although the government had sought only $2 bn. Mr. Sallah said that the best feature of Ethiopia's health sector reform is the government's effort to provide health facilities across the country, an effort launched before the Special Initiative began. It is expected that by June this year, the facilities will be completed, equipped and operational.
In Mozambique, the government's national health strategy serves as a framework for all donor contributions and is the basis on which a five-year rolling investment programme has been developed. The estimated cost for the period 1996-2000 is $356 mn, of which the government plans to provide $116.5 mn, according to the World Bank progress report. The programme is structured so that the country assumes an increasing share of financing, although external support is likely to be necessary to sustain health and other services for some years after this period.
Donor pooling arrangements have been set up in Mozambique for technical assistance, pharmaceuticals, medical supplies and infrastructure, with a pool for training under discussion. According to Mr. Emmanuel Dierckx de Casterle, UNDP Resident Representative in Mozambique, the government has rebuilt the infrastructure, half of which was destroyed during the civil war that ended in 1992. However, the full 10-year period of the Special Initiative will be needed to establish new buildings, systems and drug production facilities, as well as to train more quality health personnel, in a country where the population has doubled since independence in 1975.
The impact of weak preventive health care is felt most severely by Africa's children, who continue to fall ill or die most often from preventable and/or treatable afflictions -- acute respiratory infections, diarrhoea, malaria and measles -- in addition to protein-energy and micronutrient malnutrition. Accordingly, the UN Children's Fund (UNICEF) is one of the cooperating agencies of the Special Initiative's health component.
UNICEF was one of the first UN bodies to put money -- about $500,000 a year since 1996 -- into Zambia's "Basket Fund," which supports the implementation of a "minimum package of essential health services at the district level," says Dr. Kasa A. Pangu, Senior Health Adviser to UNICEF. In Ghana, UNICEF and other agencies are involved in an "Aid Donor Pool Account" programme to ensure that their pooled contributions benefit government-defined priority programmes for children and women. These include immunization campaigns against measles, polio and pertussis (whooping cough), as well as efforts to reduce infant, under-five and maternal mortality. UNICEF has set aside $400,000 for this programme, which begins this year.
Photo : UNICEF / John Isaac
UNICEF is concerned, however, that the Special Initiative seems to give low priority to multi-sector problems, Dr. Pangu said. While health issues are seen only through the Ministry of Health, others like nutrition are not confined to a single sector and there is no single "cross-cutting" agency that can tackle them. "We are very interested in the community level, which is our main focus, so we want to ensure that things are going on at that level in terms of capacity and skills," said Dr. Pangu.
According to Dr. Lambo of WHO, an initiative known as Integrated Management of Childhood Diseases provides for children attending clinics to be examined for an entire range of ailments instead of simply the one afflicting the child. "Right now," he told Africa Recovery, "I think about 10 or 12 countries are really implementing the initiative."
While malaria remains Africa's major cause of death and incapacitation, says Dr. Lambo, its negative impact on development is being surpassed by that of HIV/AIDS. By killing men and women in their most productive years -- the ages 15 to 45 -- the disease is taking a devastating toll on households and the national economy. However, over the past five years, progress has been made in introducing epidemiological surveillance systems, and in slowing the spread of HIV in some communities by successful prevention campaigns.
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