Health Services in Africa : Overcoming Challenges, Improving Outcomes 9781282030916, 9781905068654

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HEALTH SERVICES IN AFRICA Overcoming Challenges, Improving Outcomes

Edited by Chinua Akukwe

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Published by Adonis& Abbey Publishers Ltd P.O.BOX 43418 London SE11 4XZ http://www.adonis-abbey.com E-mail: [email protected]

First Edition, February 2008 Copyright 2007 © Chinua Akukwe British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library ISBN: 9781905068647 (HB)/ 9781905068654 (PB) The moral right of the author has been asserted All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted at any time or by any means without the prior permission of the publisher

Printed and bound in Great Britain

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HEALTH SERVICES IN AFRICA Overcoming Challenges, Improving Outcomes

Edited by Chinua Akukwe

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DEDICATION This book is dedicated to all individuals, organizations and agencies that work everyday to improve access to quality health services in Africa

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Table of Contents Acknowledgements

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Foreword ix ………………………………………………………………………………. Introduction Chapter: Healthcare Delivery in Africa: Issues, Challenges and Opportunities for Better Health 1 ……………………………………………………………………..……………..….

Section 1: Overarching Issues of Health Services in Africa ……………………………………………………………………………………….. Chapter 2 African Union and Healthcare Challenges in Africa: Strategies and Initiatives on Healthcare Delivery 13 ……………………………………………………………………..……………….. Chapter 3 Financing Health Services in Africa 25 ………………………………………………………………………………………. Chapter 4 Human Resources for Health in Sub-Saharan Africa: Addressing a Growing Crisis 37 ……………………………………………………………………………………… Chapter 5 Strengthening Health Systems in Africa 57 ……………………………………………………………….…………………

Chapter 6 Health-For-All as the Foundation for Better Health Services in Africa

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…………………………………………………………………… Section 2: Specific Health Service Issues in Africa Chapter 7 Organizing and Managing Health Services in Africa 75 ………………………………………………………………………………… Chapter 8 Clinical Health Services in Africa: The Special Role of Teaching Hospitals 85 ……………………………………………………………………………….. Chapter 9 Africa: The Role of Laboratory Services in Health Care Delivery 99 ………………………………………………………………………………… Chapter 10 Information, Education and Communication (IEC)Campaigns for Better Health in Africa: The Role of Indigenous Knowledge and Technologies 109 ………………………………………………………………………………….. Chapter 11 Maternal and Child Health Services in Africa 119 ………………………………………………………………………………… Chapter Twelve Mental Health Services in Africa 129 …………………………………………………………………….…………… Chapter 13 The Role of National Army Medical Corps in Helping African Nations Meet Health Care Delivery Challenges 145 …………………………………………………………………………………. Chapter 14 A Roadmap for Building and Maintaining National Emergency Medical Services in Africa: The Ethiopian Experience 157 ………………………………………………………………………………….. Chapter 15

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Community Oriented Primary Care 171 …………………………………………………………………………………..

…………………………………………………………………………………. Chapter 16 Health Services Research in Africa 185 …………………………………………………………………………………. Chapter 17 National Governments and International Development Partnerships for Better Health Services in Africa 197 ………………………………………………………………………………….

Section 3: A Glimpse of the Future ……………………………………………………………………….…………. Chapter 18 Organising Africa’s Diaspora for Health Care Interventions in Africa 207 ……………………………………………………………………………….…. Chapter 19 Hope Therapy: the Missing Modality in Africa’s Health Care Response 223 ………………………………………………………………………………….. Chapter 20 Health Services in Africa: A New Business Model for Change for United States Universities Actively Engaged in Healthcare Delivery in Africa 233 ………………………………………………………………………………….. Chapter 21 The Future of Healthcare Services Will Depend on Lessons Learned from Successful Programs and Sharing Ideas on Best Practices 245 ………………………………………………………………………………….. About the Chapter Authors ……………………………………………………………………………..…… Index 263 …………………………………………………………………………………..

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Acknowledgement I thank Jideofor Adibe and his colleagues at Adonis & Abbey Publishers, London, United Kingdom for the wonderful work on publishing this landmark book. Jideofor Adibe and his colleagues worked closely with me in every step of the process. They displayed tremendous tact, commitment and discipline during the entire publication process. I thank my family and friends who endured the time consuming process of editing this book and during the time it took for me to write some of the chapters in the book. Finally, I thank the chapter authors of this book for their wonderful articles and deep insights. These authors worked under very tight deadline, and, amidst a grueling professional and personal schedule. I will always remain indebted to them for their understanding and support.

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FOREWORD Achievements in the field of health over the past 50 years are threatened by factors within and outside the health sector such as: (I) HIV/AIDS epidemic (which is reversing all the development gains made over decades in sub-Saharan countries: (2) development of anti microbial resistance, leading to unexpected outcomes such as the recent sharp increase in the incidence of tuberculosis; (3) the steady rise in substance abuse; (4) the explosion of non communicable diseases; and (5) the further degradation of the environment with direct consequences for peopleʹs health. All these impact Africa, disproportionately. As inhabitants of the common hut ʺEarthʺ we are all already confronted with the negative consequences of preventable man-made disasters that aggravate health inequalities within and between countries. In this era of astonishing technological advances, globalization, increasing economic prosperity in some parts of the world, and the growing interconnectedness of peoples and nations in the nascent global village, we are faced with health challenges that are rooted deeply in poverty, social inequalities and lack of opportunities. Added to this mix are issues of ill health, diseases and weak health system responses. I welcome the initiative by the Chairman of the Technical Advisory Board of the Africa Center for Health and Human Security, George Washington University, Washington, DC, Dr Chinua Akukwe, for editing this book ʺHealth Services in Africa - Overcoming Challenges, Improving Outcomesʺ. This is a timely initiative. It comes at a time when the Ministers of Health of African Union during their meeting in Johannesburg, South Africa in April 2007 committed themselves to strengthening health systems for equity and development in Africa. In July 2007, the African political leadership gathered in Accra on the 50th anniversary of Ghanaʹs independence, and, reflecting the will and aspiration of the African people, engaged in a ʺGrand Debate on the Union Governmentʺ for Africa and agreed to accelerate the economic ix

and political integration of the African continent, including the formation of a Union government of Africa with the ultimate goal of creating the United States of Africa. This is a timely book since policymakers, technical experts, the business community and the civil society in Africa now believe that health is at the center of any serious development effort. The book examines issues that affect the delivery of health services in Africa. The book is very relevant because it addresses factors that impact negatively on the delivery of health services in Africa. The book also suggests ways to improve the delivery of health services. The impressive and eminent group of chapter authors of this 21 chapter book provides concise, overarching discussion of key heath services issues in Africa. The authors show an understanding of how the health systems operate in Africa as well as in the West. This is not surprising since the editor and most of the authors have experience of healthcare delivery mechanisms in Africa and in the West. As noted in one of the chapters of the book, the delivery of health services in all parts of the world faces major obstacles and challenges. There is a lot that health policymakers, technical experts and stakeholders can learn from each other in the delivery of health services as noted by one of the authors. In my nearly 35 years experience as medical doctor, I have come to understand that we can learn from each other on how best to solve healthcare delivery issues. I have come to understand that health is intricately linked to equity and sustainable development. You cannot have better health in midst of poverty. You cannot improve personal health in the face of injustice and political marginalization. You cannot improve the state of personal economic circumstances without improving health status. An important first step in addressing the delivery of health services in Africa is to conduct reliable needs assessment of specific health problems. Accurate needs assessment aimed at reducing health inequities will facilitate the development of verifiable baseline and trend data. Verifiable data will aid policymakers to make informed decisions. Reliable data will also positively influence the work of academics and the civil society. Better informed policymakers and stakeholders can then identify health priorities and mobilize both domestic and international resources to address identified problems. Providing direct medical care and serving as district Chief Medical

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Officer in my country, Mozambique 30 years ago, I realized a powerful lesson emphasized throughout this book: the critical importance of policymakers becoming aware of the felt rather than perceived needs of target populations. Throughout my subsequent career, maybe because I had the good fortune of starting public management at the local government level, I always kept the perspective that one must identify and respond to the needs of target populations in order to better serve them. The book draws attention to the “silent epidemic” that causes unacceptable high maternal mortality ratios in sub-Saharan countries. Worldwide, each year half a million women die not from disease but from pregnancy related complications while striving to perpetuate life; the right to life is a human right and women should not be denied this right, considering their immense contribution to the development of nations, both as mothers, caregivers, citizens and productive members of their community. Reducing maternal mortality ratio in Africa requires improvement of access to emergency obstetric services. The implementation of equitable health systems requires resources and leadership to overcome policy barriers to innovative approaches that seek to increase access to cost-effective surgical services. The book also discusses the magnitude of human resources for health crisis. To address the crisis there is need to correct imbalances in workforce structure to provide cost-effective essential healthcare. In my current assignment of promoting health research partnerships between Africa and Europe, with special emphasis on accelerating the development of new clinical interventions in the fight against poverty related diseases (HIV/AIDS, TB and Malaria in the first phase) and building health research leadership in developing countries (http://www.edctp.org), I am aware of ongoing national, regional and continental efforts to improve health systems and enhance the delivery of health services in Africa. African political leaders and technical experts are providing necessary leadership in organized efforts to improve the delivery of health services in Africa. The leadership is already having results as various continental platforms on specific health issues are now being developed. The major African institutions – the African Union, the African Developing Bank, the World Health Organization/African Region, and the UN Economic Commission for Africa – are working closely together to provide leadership on various healthcare issues. There is now a clear sense that xi

Africa can overcome some of its major health issues. This book serves both as a reminder of challenges ahead regarding the delivery of health services in Africa as well as the infinite possibilities of better health for Africans irrespective of geography, social station or economic circumstances. _______________________________________ Honorable (Dr.) Pascoal Mocumbi High Representative, European & Developing Countries Clinical Partnership (EDCTP), The Hague, Netherlands; Former Prime Minister of Mozambique, 1994-2004.

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Chapter 1 Introduction HEALTHCARE DELIVERY IN AFRICA: ISSUES, CHALLENGES AND OPPORTUNITIES FOR BETTER HEALTH CHINUA AKUKWE

Introduction Africa is always in the news. Continental and international news on the continent may include information on emerging democracies, the role of young and aggressive entrepreneurs, community development projects self financed by poor communities and the commissioning of gleaming infrastructure projects. However, for the most part, continental and international news about Africa are not flattering. It is often about conflicts, the ravages of AIDS, the deadly impact of Tuberculosis (TB), Malaria and other infectious diseases. Or the continued menace of childhood vaccine preventable diseases and high levels of maternal mortality rates. I and a group of individuals who have worked many years on healthcare issues in Africa sought recently to analyze the root causes of the often “bad” news about Africa as it relates to health. Why do we often have “bad” news coming out of Africa? Are healthcare systems in Africa meeting national expectations? Are African health policy makers effective in their work? Are Africans, especially target populations, involved in setting healthcare priorities in their countries? To provide answers to some of these questions, as the editor of the special edition of the African Renaissance journal devoted to healthcare issues in Africa, I invited expert contributors to write articles on key aspects of the healthcare system in Africa (1). The contributors to the special July/August 2006 edition of the African Renaissance included the 1

Healthcare Delivery in Africa: Issues, Challenges and Opportunities for Better Health

top official responsible for healthcare in the African Union Commission; a former First Lady now running a grassroots women organization; two young medical experts from Africa who have more than 25 years career ahead of them; the head of an African Diaspora organization based in the United States; a private health sector expert; the head of a national trade union organization; the head of a new continental research organization; and, an expert on Military Health Systems in the continent. These contributors exhaustively reviewed healthcare delivery systems in Africa. In the work of these experts and other major continental reviews on the healthcare system in Africa, a troubling pattern emerges: Africa’s healthcare delivery system is at worst, reeling and ineffective, and at best, a work in progress. All experts agree that the healthcare delivery system in Africa requires continuous, comprehensive, long term attention. Before going into details on why the healthcare delivery system in Africa is on such a shaky foundation, it is important to briefly review the state of health in the continent. The state of health in Africa? Unlike the usual practice of reciting horror statistics, it is critical to contextualize the state of health in Africa. Today, according to annual statistics from leading international organizations such as the World Health Organization Regional Office in Africa, the World Health Organization (WHO) Secretariat in Geneva, the United Nations Development Program (UNDP), the World Bank and UNAIDS, Africa ranks poorly compared to Asia, Latin America, the Caribbean, North America and Europe in almost all health indicators (2-5). In every known development index today, African countries dominate the laggards. According to the UNAIDS, life expectancy in 9 African countries is now less than 40 years due to AIDS. The healthcare worker crisis in many African countries shows no signs of abating: the doctorpatient ratio is one doctor to 30,000 or more patients in Ethiopia and Uganda. The burden of communicable and non communicable diseases is very high in the continent. The WHO Africa Region describes a “silent epidemic” that claims the lives of millions of mothers, children and infants every year in Africa due to eminently preventable and treatable causes (5).

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Despite these unfavorable indices of health, there are notable improvements in many African countries. The WHO Africa region reports that at least 50 percent of all Ugandans living with HIV/AIDS have access to antiretroviral therapy and social support (5). Rwanda achieved a 25 percent drop in the incidence of road traffic accidents in a year due to aggressive preventive programs. River blindness is no longer considered a public health problem by experts and 33 out of 42 Malaria endemic countries have adopted Artemisinin-based combination therapy to combat the growing problem of Chloroquine resistant Malaria infections. Polio, leprosy and guinea worm, according to the WHO Africa region (5), are now close to “elimination.” These areas of proven success, however, do not allay the fears of experts on the precarious state of health in Africa (1-8). At least 19 of the 20 countries with the highest maternal mortality rates in the world are in Africa. The continent has the highest rates of deaths from AIDS, TB, and Malaria. It also has the highest rates of neonatal, infant and under-5 mortality rates in the world. A comprehensive overview of the healthcare delivery system in Africa should include a critical review of over-arching obstacles. What are the major obstacles to better healthcare delivery in the continent? I briefly review these obstacles to better healthcare delivery in Africa. Obstacles to healthcare delivery A) Ineffective Health Systems: In Sub-Sahara Africa, at all levels of care, the health system leaves much to be desired. In many parts of Africa, teaching hospitals or tertiary health systems are shadows of their glorious days in the 1980s (1-5). There is very little real time coordination of primary, secondary and tertiary services in many African countries. B) Dilapidated Healthcare Infrastructure: This is one of the sorry spectacles of healthcare delivery in Africa (1-5). In many African countries, the infrastructure of primary health services, general hospitals and teaching hospitals need urgent repairs. Some of these facilities have not been rehabilitated or revamped since they were built in the 1980s. C) Healthcare Financing is Still Precarious: The average per capita spending on health in Africa, according to the African Union, is US$10 instead of the WHO recommended US$27 a year (4). In 2006, according 3

Healthcare Delivery in Africa: Issues, Challenges and Opportunities for Better Health

to the African Union, only two African countries met the declaration by Heads of State in 2001 to devote 15 percent of national budget to healthcare issues (4). D) Africa is in Throes of a Crippling Health Crisis: Throughout Africa, the health workforce crisis is crippling the delivery of basic health services. The health workforce crisis is also shortchanging the fight against AIDS, TB, Malaria and other infectious diseases (6, 8). Although Africa accounts for 10 percent of the global population and 25 percent of the global disease burden, the continent’s health workforce represents only 3 percent of the global health workforce. E) Poverty is Alive and Well in Africa: Most African countries are in the World Bank lowest income group of countries earning less than US$767 Gross National Income (GNI) per person per year (2, 4, 7). Africa is the only continent where the level of individuals living on less than one dollar a day is on the increase since 1990. In addition, it is highly unlikely that poverty rates in Africa will be reduced by 50 percent in 2015 as required in the UN Millennium Development Goals (MDGs). F) Risk Reduction and Preventive Health Programs have Mixed Results: Despite billions of dollars spent on information, education and communication (IEC) campaigns, preventive health programs in Africa have mixed results (1, 5). IEC campaigns in Africa often have problems with the type and method of delivering health messages; with the credibility of messengers; and, lingering questions about the relevance of preventive health messages to the needs and priorities of target populations. G) Governance Issues in the Health Sector Remain Unresolved: The tug of war on accountability and due process between host African countries and their international development partners is now a fact of life in the health sector (1, 6). Disagreements over governance reforms in the health sector remain unresolved in many African countries. Continued donor support may be at risk if these unresolved issues, linger. H) Private Sector Involvement is still Minimal: Africa is the only continent where out-of-pocket spending on healthcare is very high (80% of all private spending and 50% of overall spending) and the proportion of privately financed health system is very low (less than 10 percent) (4, 5). Government financed healthcare is very common in Africa, and, often inadequate. The African Union estimates that the

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continent needs to have a resource mobilization of between US$20 to US$70 billion a year to implement credible and effective healthcare delivery. This resource mobilization should be in place until 2015 to meet the MDG targets (3, 4). Currently, about US$10 billion a year is spent on healthcare in Africa. The private sector needs to become a very important partner in healthcare financing in the continent. I) Limited Role of Target Population in the Design and Implementation of Health Programs: This is a fundamental problem in the healthcare delivery framework in Africa (1, 5, 6-8). Despite attempts to organize “stakeholder meetings or consultations” the typical target population in Africa has little say in the design and implementation of health programs executed on their behalf. There is very little evidence that the felt rather than perceived health needs of target populations drive the decisions of policy makers and program managers in the continent. J) External Development Partners and Donor Are Highly Influential: The healthcare delivery system of many African countries depends heavily on donor finance and expertise (1-5). This has unwittingly created a situation where bilateral and multilateral organizations wield extraordinary influence on health programs and services in host African countries. The aforementioned issues and challenges cut across health discipline, national or regional boundaries. Health systems throughout Sub-Saharan Africa face fundamental challenges. I briefly discuss these challenges. Challenges of healthcare delivery in Africa First, few continental platforms and benchmarks for health exist in Africa (1, 6, 7). Any domestic or international organization can decide on a narrow set of interests and begin implementation activities in the continent. African governments, principally due to limited resources, have no choice than to agree with the priorities set by organizations with financial or technical resources. There is limited continental platform to serve as a benchmark or as a guide. Whoever has the money, today, can pretty much dictate the type and mode of health intervention in many parts of Africa. Second, Africa continues to lose its trained health expertise to Western countries and from poor African countries to richer ones (1-5). 5

Healthcare Delivery in Africa: Issues, Challenges and Opportunities for Better Health

Healthcare professionals in Africa are leaving for a variety of reasons, including poor working conditions, dilapidated infrastructure, non payment of salaries, fear of personal and professional safety, and, to better the economic circumstances of themselves and their families. Third, national health policies in many African countries remain weak or inconsistent, especially in the areas of regulations, personal and community health (1, 4, 5, 6). Regulating healthcare practices and delivery mechanisms in Africa is rarely time sensitive and corrective as a result of limited number of experts on clinical reviews, compliance and enforcement. Africans in general have limited assurances regarding key pillars of personal and community health. These pillars of health protection include guaranteed access to quality care; human rights protection as a client in the healthcare system; privacy and confidentiality of personal health records; due process in the provision of health services; elimination of gender inequities in the delivery of health services, and, the end to stigmatization and discrimination. In many health settings in Africa, especially in rural areas, patient confidentiality and informed consent are not enforced. Fourth, few African countries have taken advantage of the health expertise in the African Diaspora (1, 9). It is often stated that you have more African immigrant doctors in Western capitals and major cities than are in practice in Africa capitals and major cities. African countries have been slow to reach out to their native sons and daughters based in the West who are experts in healthcare. In addition, few African countries are benefiting from the expertise of African Americans, Blacks in Europe, Latin America and the Caribbean. Despite these challenges, there are emerging opportunities for better health in Africa. These emerging opportunities appear poised to address the aforementioned challenges and to lay a solid framework for quality healthcare delivery initiatives in the continent. Some of these emerging opportunities are driven by domestic political and economic interests in African countries. Others are driven by international solidarity concerns about the state of health in Africa. In addition, external donor concerns regarding the impact of development assistance are also driving the need to consider innovative strategies for better health. I briefly discuss some of these emerging opportunities for better health in Africa.

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Emerging opportunities for better health in Africa 1. African continental and regional institutions are working more closely together. The African Union, the African Development Bank, the World Health Organization Regional Office for Africa and the United Nations Economic Community for Africa are working more closely together at the highest political and technical leadership levels to develop or refine continental platforms for better health (1, 6, 7). This is still a work in progress, especially on technical issues. In addition, regional economic communities in Africa are working closely with continental organizations and with Member States to provide strategic technical leadership on health issues and to regionalize pools of expertise for priority health problems in member states. 2. The need for better coordination and consolidation of donor financed health projects in Africa is now receiving the highest political attention in Africa and also in donor countries. UN agencies operating in African countries now have coordinating offices, usually managed by the UNDP country office in recipient countries (1, 2, 6, 7). African continental organizations and regional economic communities are now working on external donor coordination and consolidation issues. 3. There is a growing influence of public/private/civil society partnerships for better health in Africa. These burgeoning partnerships are emerging at all levels of governance and are becoming increasingly influential in national policy making and program design (1). The emerging partnerships are also responding to the growing clout of well financed international partnerships and alliances dedicated to specific health conditions and initiatives. 4. There is now a momentum to resuscitate and revamp primary health care systems in many African countries. After more than two decades of benign neglect, policy makers are now revamping primary health care (PHC) systems as the foundation of national response to HIV/AIDS, TB, Malaria and other communicable diseases (1, 2, 3, 5, 6). The PHC system is now favored as the fulcrum of community-sensitive information, education and communication campaigns for better health. 5. Regional economic communities and expert professional associations and colleges are leading efforts to organize regional approaches to health expertise and resources sharing. This regional 7

Healthcare Delivery in Africa: Issues, Challenges and Opportunities for Better Health

approach will benefit African countries with limited expert health workforce and will also benefit countries emerging from long term conflicts and wars (1). In West Africa, the various medical specialty colleges are working closely to improve the quality of care in the region. 6. African immigrants living in the West are becoming more engaged in the provision of basic health services for their kith and kin in Africa. African immigrants in the West pay for timely, quality care for their relatives and family members. African professional organizations based in the West organize regular health missions to specific African countries where the assembled health expertise provide free services to individuals in need (1, 9). There are ongoing, sustained efforts to organize a strong African Diaspora for better health in Africa. African continental and regional institutions are now engaging Africans in the Diaspora on technical assistance services and consultancies. African governments are also increasingly reaching out to their native sons and daughters living in the West. African Diaspora organizations in the West are actively working on healthcare issues in Africa, organizing seminars, conferences and workshops. The World Bank, the African Union and other donors are now working closely to develop and implement a comprehensive Africa Diaspora initiative in multiple sectors, including health. 7. African health experts are taking advantage of emerging niche in healthcare delivery. One of the most impressive examples is the growing medical tourism practice in South Africa where clients from Western countries and affluent clients from other African countries come to South Africa for less expensive but high quality elective surgery and clinical consultations (1). Already in Southern Africa, most countries in the region rush their senior policy makers to South African health centers rather than send them to Western Europe or North America as was the case in the past. The medical tourism industry in South Africa is reportedly on its way to becoming a billion US dollar industry. Other emerging niche include national health insurance programs that often start with salaried government employees, and, private rural health schemes where pools of target populations get together and buy affordable health insurance in return for access to local health services, public or private (1). Looking into the future, Africa’s healthcare delivery systems face major obstacles. However, these obstacles as already discussed are not

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insurmountable. The future for Africa’s healthcare delivery system, in my view, revolves around six important “keys” for better health. Six keys to better healthcare delivery systems in Africa 1. National health policies in Africa should be strengthened to reflect national priorities, to safeguard consumer health and to meet minimum international standards. Africans should never accept a national health policy in their countries that does not meet continental and international standards. 2. Africa should have continental platform or guideline for better health. This platform will serve as benchmark for national health policies and also serve as a guide to development partners on continental priorities in health. 3. African leaders should accelerate the move towards regionalization of expertise and technical resource sharing so that African countries with limited expertise can benefit without delay. This regional approach should also extend to training and re-training programs for the health workforce. 4. Governments in Africa should strengthen the burgeoning public/private/civil society partnership for better health at all levels. This partnership should encourage more private sector financing of healthcare delivery in Africa, to relieve the current excruciating burden on cash-starved African governments. 5. African governments and institutions should work towards a robust African Diaspora response to better health in the continent. The key is to attract African Diaspora expertise for both short and long term participation in organized efforts to improve healthcare delivery systems in the continent. 6. The future of healthcare delivery system in Africa lies in a comprehensive, well financed, and, well managed community-based health services. The revival of the primary health care system is a step in the right direction. What is even more crucial is the need for target communities to become involved in the design, implementation, monitoring and evaluation of community-based systems of care.

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Healthcare Delivery in Africa: Issues, Challenges and Opportunities for Better Health

References 1. Chinua Akukwe (2006a) (Editor). Healthcare Delivery in Africa: Issues, Choices, Challenges and Opportunities. Special Edition. African Renaissance l, Volume 3, Number 4, July/August edition. 2.World Bank, World Health Organization, United Nations Development Program, UN Economic Commission for Africa annual reports and indices that includes information on Africa and African countries, 2005 and 2006 data. 3. African Union (2006a). Progress Report on the Implementation of the Plans of Action of the Abuja Declaration on Malaria (2000), HIV/AIDS and Tuberculosis. Special Session of the African Union on HIV/AIDS, Tuberculosis and Malaria (ATM), Abuja, Nigeria, 2-4 May 2006. Sp/Ex.CL/ATM/4 (I). Addis Ababa: Author. 4. African Union (2006b). Health Financing in Africa. Prepared for the Special Summit of African Union on HIV/AIDS, Tuberculosis and Malaria (ATM), Abuja, Nigeria, 2-4 May 2006. Sp/PRC/ATM/5 (1). Addis Ababa, Ethiopia: Author. 5. World Health Organization Africa Regional Office (2006). The Health of the People. The African Regional Health Report. Brazzaville, Republic of Congo: Author. 6. Chinua Akukwe (2006b). Don’t Let Them Die: HIV/AIDS, TB, Malaria and other Health Crisis in Africa. Adonis &Abbey Publishers, London, United Kingdom. 7. Chinua Akukwe (2006c). Beyond the Rhetoric: Essays on Africa’s Development Challenges. Adonis &Abbey Publishers, London, United Kingdom. 8. Rhoi Wangila and Chinua Akukwe (2006). Africa, AIDS Orphans and their Grandparents. Benefits and Preventable Hidden Dangers. TSEHAI Publishers, Los Angeles, United States. 9. Save the Children, Africa Recruit and Africa Diaspora Healthcare (2006). One Million More. Mobilizing the AFRICAN Diaspora Healthcare Professionals for Capacity Building in Africa. Karl Blanchet, Regina Keith and Peter Shackleton (editors). Save the Children, London, United Kingdom.

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SECTION 1: OVER-ARCHING ISSUES THAT IMPACT ON THE DELIVERY OF HEALTH SERVICES IN AFRICA

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Chapter 2 AFRICAN UNION AND HEALTH CARE CHALLENGES IN AFRICA: STRATEGIES AND INITIATIVES ON HEALTH CARE DELIVERY BIENCE GAWANAS Background/Introduction During the 70’s, the World Health Organization (WHO) Declaration of Health for All (HFA) was adopted as well as the Primary Health Care Strategy in Alma-Ata in 1978 as the strategy for meeting the objectives of HFA. It was recognized that stronger health systems must be based on Primary Health Care (PHC) principles which today is still regarded as the best approach to sustainable access to prevention, treatment and care. As such, African countries developed HFA strategies with a view to address some urgent health needs such as the development of human resources for health; promotion of environmental health; control of communicable diseases; and, strengthening of health systems. Promotion of access to universal primary health services remains an important goal although the target of achieving this by 2000 was not attained. This was due to various constraints experienced in the health delivery systems. These constraints include weak health infrastructure, limited tools, inadequate human resource capacity, limited public financing, poor program management and planning, lack of integrated health systems, and, misapplication of human, technical and financial resources. Nevertheless, there have been some improvements in healthcare which should be intensified. This would include amongst others, improving equitable and affordable access to health care services by investing in the strengthening of health systems with the primary intent of improving the health status of populations, especially child and maternal health and also by addressing issues of inequality and social exclusion. As such, countries will recognize that such an investment is a moral, social and economic imperative.

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African Union and Health Care Challenges in Africa

Throughout the years, the Organization of African Unity, OAU (now the African Union, AU) focused on health issues in the continent as borne out by the actions taken over time, including convening of meetings and development of various policy instruments. However, the challenge of implementing the major thrust of these instruments and platforms, still remains. The AU Commission has developed a Strategic Plan (2005-2007) which places emphasis on controlling the disease burden and promoting good health in the Continent. The AU Commission’s primary role is the harmonization and coordination of social development programs, policies and activities on the continent within the context of socio-economic development and regional integration. Africa’s Health Challenges (1) Disease burden Africa bears the heaviest burden of disease, mainly due to HIV/AIDS, Malaria and Tuberculosis as well as other communicable diseases such as pneumonia, meningitis, Ebola, and other diseases that greatly impact on the continent’s resource. African children die in high rates from preventable diseases such as respiratory infections, diarrhea diseases, measles, malaria, polio and malnutrition which are preventable but account for a high rate of child mortality. Women also die in high proportions from pregnancy and childbirth, resulting in the highest maternal mortality in the world. Africa accounts for 20 percent of the world births but contributes 40 percent of maternal deaths. Non communicable diseases such as mental illness, hypertension and injuries from conflicts, accidents and other mostly preventable causes contribute disproportionately to the disease burden in the continent. Other related health issues include environmental concerns; poor infrastructure; personal behavior and lifestyle issues; conflicts and migration; and, worsening protein energy and micronutrient malnutrition. (2) Poverty and Health Good health is linked to the human capacity to contribute to development. In this regard, controlling diseases and investing in health is critical in achieving poverty reduction within the framework of the Millennium Development Goals (MDGs). In spite of efforts by

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Member States to invest in health and to implement health strategies, the burden of disease continues to increase due to poverty experienced by the majority of the population, especially in rural areas and the urban vulnerable groups who cannot afford the cost of basic health services – even those that were once previously affordable and are also at high risk of food and nutrition insecurity. It is not surprising that HIV/AIDS, Malaria and TB have been identified as diseases of poverty by the WHO Commission on Macro Economics of Health. Similarly, the African Union Extra-Ordinary Summit on Employment and Poverty Alleviation held in Burkina Faso in 2004 acknowledges the link between health, development and poverty and adopted a Declaration and Plan of Action to promote a multi-sectoral approach to poverty reduction in the continent. (3) Health System factors Health systems factors that undermine efforts to reduce the disease burden in Africa include the following: (a) Limited financing for health Health care systems in Africa have borne the brunt of imbalances between resource and needs. Whereas Africa carries the highest burden of diseases and therefore needs adequate and effective health systems, limited or inadequate financial resources have led to weak health systems. This also includes the lack of social protection mechanism which will greatly enhance people’s access to services. As a result, the Heads of State and Government of the African Union committed themselves in the Abuja Declaration (2001) to allocate 15 percent of their national budget to health. Progress on this commitment reveals that 4 countries are allocating less than 5 percent, 25 countries between 5 and 10 percent and 13 countries between 11 and 14 percent. Presently only two countries have reached or surpassed the 15 percent target. (b) Lack of integrated health systems and cohesion in sectoral policies Whilst health systems in Africa have been stretched to the limit by diseases such as the HIV/AIDS pandemic, many countries failed to look at the wider institutional context and continued to implement disease specific programs. Consequently, priority continues to be given to specific diseases such as HIV infection or Malaria but not to the strengthening of the entire health sector. This approach, ironically, 15

African Union and Health Care Challenges in Africa

weakens any effort to fight a specific disease. There is also a lack of effective health policies to address integrated health sector issues in a holistic and integrated manner rather than through fragmented disease specific interventions. Such an integrated approach will also create synergy with other sectoral issues such as infrastructure development, sanitation, nutrition, and so on. (c) Human Resource Crisis in the Health Sector The crisis of the health sector workforce has been a major constraint to the improvement of health status in most communities in Africa. In this regard, although African governments invest in human capacity development, the need is so overwhelming that the capacity to meet national and international development goals is under threat. This is further exacerbated by various factors such as the misapplication of human resources, limited technological knowledge, and the continuous migration of health workers to pursue better prospects elsewhere in and out of the continent. The migration is fuelled largely by low pay and poor working conditions, and, the untimely death of health workers from AIDS. (d) Access to Essential medicines Lack of access to essential medicines prevents governments from effectively dealing with the burden of disease. Lack of access issues includes the affordability and accessibility of essential medicines. The concept of essential medicines emphasize that within the context of functioning health systems, essential medicines should be available at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford. This inability to afford and to have access to essential medicines are due to high prices of drugs; anticompetitive restrictions such as patent protection and restriction of generic medicines; limited research and development capacity in Africa; limited pharmaceutical production capacity; outdated patent laws and regulations; and, the dependency of African countries on imported pharmaceutical products. The affordability and accessibility issue is further jeopardized by transportation and distribution problems which in turn lead to a higher probability of essential medicines not being available on time and on a regular basis.

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(e) Health information management systems As a result of the relegation of the health sector to the periphery of national policy making in Africa, health research was not considered a vital aspect of national development. Research and Development is essential in designing and implementing best practices for the delivery of cost-effective, timely and efficacious health services. It is therefore important to strengthen health research capacity and also find the proper nexus between research and policy making. Paucity of data and inadequate use of available evidence and information to guide action including the use of ICT further hampers effective policy making and appropriate interventions in the continent. Key strategies for Achieving Universal Access to Health Care Strategies for promoting access to health care should focus on building an effective linkage between preventive care through primary health care approaches and curative care through greater accessibility to treatment, including timely access to drugs. In Africa, health care systems usually fail whenever a disconnect exists between preventive and treatment protocols. The following are summarized key strategic issues for the African Union and it’s Member States: 1. Political Will and Commitment The AU Health Ministers and the AU Heads of State and Government have debated on a number of major health issues and have taken a number of decisions and adopted Declarations and Plans of Action on disease control and effective health care delivery in the continent. In this context, the AU Department of Social Affairs ‘s mission is to promote a holistic and human-centred approach to development for the benefit of improving the life of the African people, especially the most vulnerable and marginalized. Major debates and actions include the debate on actions to improve health status in Africa (4th Ordinary Session of the AU Assembly in Abuja, Nigeria in January 2005); Accelerated Action for Child Survival with particular focus on MDG 4 (5th Ordinary session of the AU Assembly, Sirte, Libya in July 2005); Progress since the 2001 Abuja Declarations on HIV/AIDS, Malaria and Tuberculosis (AU Special Summit in Abuja in 2006), and; Launch of the Africa Malaria 17

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Elimination Campaign by building on the WHO Roll Back Malaria Campaign. The Secretariat of the AIDS Watch Africa (a committee of African Heads of States dedicated to providing political leadership on HIV/AIDS advocacy and resource mobilisation) has also been established within the Department of Social Affairs. Major policy instruments and actions adopted by AU include the African Union Commission (AUC) Strategic Framework 2005-2007 which focuses on HIV/AIDS, Malaria, TB and Polio and health systems strengthening; the AU Commission’s Strategic Plan on HIV/AIDS aims to promote AU leadership, mobilise resources and promote accountability; the Africa Health Strategy, 2007-2015; the Pharmaceutical Manufacturing Plan for Africa; the AU Continental Framework on Human Rights and People Living with HIV/AIDS; the Abuja Call for Accelerated Action; the Brazzaville Commitment on Universal Access to HIV/AIDS Prevention, Care, Treatment and Support based on four key areas, including human resources, public health goods and commodities, sustainable financing and human rights. It is essential to periodically review these instruments and actions to assess their level of implementation and impact on target populations, to identify their shortcomings, and, to share lessons learned as a guide to the way forward. 2. Promoting Primary Health Care and Health System Strengthening Countries will need to revitalize their PHC strategy, including the Bamako Initiative which enhances community participation and incorporates some measures for ensuring sustainability. Issues of selfcare, compliance with care and the role of traditional medicine should also be re-examined. The African Union has to promote change in health policies and the promulgation of new legislation where applicable. It should also promote the need to re-examine organizational and management arrangements for PHC, including human resource development issues, performance issues, and advocate for increased investment in health in line with the U$34-40 per capita target of the WHO Commission of Macroeconomics and Health within the health sector. This process, should involve governments, nongovernmental organizations, private sector development agencies and communities. It must be emphasized at this point that sustainable policy change will

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result from strategies that assure ownership of the process at community level. Improving performance in health systems should also involve enhanced efficiencies in strategic management of resources, the effective performance of the civil service and the quality of governance. Improved governance will include better coordination between sectoral ministries and the decentralization of services. The principle of stewardship makes clear that governments retain the ultimate responsibility for health system performance and the updating and costing of their national health plans which must take into minimum agreed packages of core interventions. Governments have at their disposal many potential levers for change which include enabling, specifying, monitoring or rewarding performance. 3. Affordability, Accessibility and Quality Health Care Service In order to provide timely, accessible and quality care, Member States should provide quality medicines, including generics. They should also make available insecticide treated mosquito nets, conduct indoor residual spraying, and promote the increased use of traditional medicines. AU Assembly of African Heads of State and Government through it’s decision (Assembly/AU/Dec.55 (IV) urged Member States to take all necessary measures to produce, with the support of the international community, quality generic medicines in Africa. In the implementation of this decision, the AU Commission developed a Pharmaceutical Manufacturing Plan for Africa which was adopted by the AU Ministers of Health in 2007. It provides for the establishment of a technical committee of experts to further study the major recommendations of the Plan including the new opportunities to effectively remove constraints to improving the health status of the people of Africa. These new opportunities include local production of drugs by taking advantage of the World Trade Organization TRIPS flexibilities, updating patent laws and regulations. 4. The Critical Role of Traditional Medicine Linked to the issue of affordable, accessible and quality health services in the continent, the AU and its Member States recognize the critical importance of traditional medicine, a mainstay of healthcare delivery in Africa. Traditional medicine is increasingly seen as a vehicle for achieving universal access to health services. At its Summit in July 2001 in Lusaka, Zambia, the OAU Heads of States and Government 19

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declared 2001-2010 as the OAU Decade for African Traditional Medicine. Subsequently, the OAU in collaboration with WHO and other interested stakeholders elaborated a Plan of Action adopted by the First AU Session of the Conference of African Ministers of Health held in April 2003 in Tripoli, Libya. The Plan provides a general framework to guide Member States in formulating respective national strategies for the implementation of the Decade Plan of Action. A midterm review of the Plan will be conducted during 2007/2008. 5. Enhancing Human Resource Capacity in Health Development of human resources plans and proper utilization of available capacity is necessary in health systems reforms. This will include addressing issues such as proper policies, plans, recruitment and retention, training and deployment, and working and living conditions of health workers. The newly adopted Africa Health Strategy elaborates a number of action steps which governments can take in this regard. The AU Migration Policy Framework for Africa as well as the Joint Africa/European Union (EU) Declaration on Migration and Development 2006 address the issues of brain drain, ethical recruitment within the Continent and by developed countries and how to enhance the role of the Diaspora in contributing towards Africa’s development efforts in the areas of reducing disease burdens and ensuring access to affordable and quality health care for all. 6. Sustainable Health Systems Financing The challenge of bridging the financing gap between needs and available funds would require that Member States increase national expenditure on health priorities in line with the AU Assembly decision of 2001 to allocate 15 percent of their national budget to health. It is estimated that even if the countries reach the Abuja targets of 15%, this might not be sufficient to meet the MDGs and other development targets by 2015. Therefore, new and innovative ways must be found to improve funding of health services in the continent. It would be necessary to advocate for the implementation of the recommended WHO Commission on Macro Economics of Health target of US$34 per capita required to provide essential health care. It is also important to promote private public partnerships including private health insurance. It also necessary to advocate for increased overseas development assistance (ODA) in line with the Paris Principles.

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7. Social protection Social protection systems have the advantage of promoting equity, solidarity and affordability. As such, a holistic approach to social protection would include social health insurance schemes, social pensions, poverty reduction strategies, reviewing of user fees and putting in place national solidarity mechanisms. 8. Promoting positive cultural practices There is a need not only to construct sustainable health systems which are equitable and effective in health care delivery but which also take into account the cultural context within which health systems operate. As such, positive cultural practices which support social development in general and health in particular should be promoted, including the increased use of traditional medicine. However, harmful traditional practices must be discouraged or eliminated as required in the protocols and cultural instruments adopted by AU organs. 9. Gender and Equity It is a well known fact that that health for all will remain meaningless unless countries address gender inequality issues which deny women access to health care. It should be recognized that women carry the heaviest burden of diseases such as HIV/AIDS because of their vulnerable situations. They are also the main care givers to the sick and marginalized. The AU Protocol on the Rights of Women reinforced by the AU Solemn Declaration on Gender Equality are important instruments in creating an enabling environment in which women can participate and benefit from and play a leadership role in health service delivery. The Africa Union is committed to quality healthcare delivery strategies for the continent that promotes universal access to every African no matter the geographical location and station in life. AU will continue to work with Member States to ensure that every African receives the best quality, timely health services.

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Notes Most of the Africa Union documents are either available at the organization’s website (http//:www.africa-union.org) or available on demand by contacting the Office of the Commissioner of Social Affairs. 1. African Union Declarations, Decisions and Continental Frameworks on social Development. 2. African Union Commission Strategic Plan 2005 -2007 3. Papers presented at the Special Summit of the African Union on HIV/AIDS, Malaria and Tuberculosis held in Abuja, May 2006. 4. Africa Union Migration Policy Framework for Africa 5. Africa Union Abuja Call for Accelerated Action on Universal Access 6. African Common Position on HIV/AIDS, 2006. 7. Africa Union 2006 Brazzaville Commitment on Universal Access to Prevention, Care and Treatment 8. Report of the Africa Union Expert Consultative Meeting on the Bamako Initiative on Essential Medicines and the Decade of Traditional Medicines, Addis Ababa, Ethiopia, 5-7 September 2005. 8. Gaberone Declaration on a Roadmap towards Universal Access to Prevention, Treatment and Care, adopted at the 2nd AU Conference of Ministers of Health, Gaberone, Botswana, October 2005. 9. Africa Health Strategy as adopted by the AU Ministers of Health, 2007 References 10. World Health Organization (2003). The World Health Report 2003: Shaping the Future, Chapter 2. Millennium Health Goals: Paths to the future, Geneva, Switzerland: Author. 11. World Health Organization Regional Office for Africa (2002). Health for All Policy for the 21st Century in the Africa Region: Agenda 2020, Harare, Zimbabwe: Author. 12. Abt Associates Inc (2005). Enhancing the Organization and Management of Health Services Around the World. Bethesda, Maryland, USA: Author. 13. AHPSR (2004). Strengthening Health Systems: the Role and Promise of Policy and Systems Research. Geneva, Switzerland: Author.

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14. European Observatory in Health Care Systems (2002). Policy Brief: Hospitals in a changing Europe. No. 1. 15. World Health Organization (2005). Health Systems Performance Assessment. Geneva, Switzerland: Author. 16. Mills A, Hanson K (2003). (Eds.) Expanding Access to Health Interventions in Low and Middle Income Countries: Constraints and Opportunities for Scaling-Up. Special Issue of the Journal of International Development, 2003, Volume 15, Number 1. 17. Helman, C. G. (1995). Culture, Health and Illness. Heinemann Publishers, London, United Kingdom. 18. Lankester, T. (2000). Setting Up Community Health Programmes: A Practical Manual for Use in Developing Countries. Macmillan Publishers, Oxford, United Kingdom. 19. Witter, S, Ensor T, Jowett M, Thompson R (2005). Health Economics for Developing Countries. Macmillan Publishers, Oxford, United Kingdom.

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Chapter 3 FINANCING HEALTH SERVICES IN AFRICA CHINUA AKUKWE Introduction The financing of health services in Africa present unique challenges (1). First, the level of poverty is so high, with more than two of every five African living in poverty. Second, the provision of health services in Africa is often inadequate, sporadic and too little, too late for many Africans, who endure chronic illnesses and die with limited health service. Third, government support for individual health services is either stagnant or waning, leaving many Africans to forego healthcare, except in dire emergencies. Fourth, the cost of healthcare in Africa is disproportionately borne by individuals and families, many of whom are either living in poverty or become poor from escalating cost of health care. As the cost of care escalates for poor African families, their kith and kin living outside the continent are contributing money and time to take care of their relatives living in Africa (1). A serious discussion of the financing of health services in Africa will require an exhaustive review of some of the complex factors that impact on payment of health services, especially in resource constrained environment. This is beyond the scope of this book that is focusing on the provision of health services. However, a growing body of work on healthcare financing issues in Africa concludes that there are no quick fixes, magic wands or populist strategies that can dramatically remove the constraints that poor families face in Africa in paying for health services (2, 3, 4, 5, 6, 7, 8). Many countries in Africa have limited financial resources and are unable to adequately provide the financial backbone needed to ease the burden of health care cost on poor families. It is necessary to briefly review the goals of healthcare financing, the major forms or avenues available for financing health services, and, end by recommending possible strategies for improving the financing of health services so that poor families in Africa can have access to timely and quality care. 25

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Real and Perceived Goals of Healthcare Financing As I had noted in another forthcoming publication (1), the aim of any serious effort to finance healthcare programs no matter the geographical location and political ideology is to alleviate the burden of direct payments for health and at the same time keep the target population, healthy and productive. This view is collaborated by the work of others (2, 3, 4, 6, 9, 10). Although this is often a stated goal of healthcare financing, in reality, stakeholders have different motivations and interests regarding the ultimate goal of healthcare financing mechanisms. The motivation of the government or the public sector may be different from the interests of the private sector or the civil society. The public sector may want to stretch public dollars to “reach” as many people as possible. The organized private sector may want to shift the burden of healthcare costs as much as possible to the public sector. The civil society, even in the face of scarce resources may vigorously pursue the twin objectives of “reach” and highest possible quality of care. Thus in both resource rich and resource constrained environments around the world, an ideological and strategic tug-of-war often exists between real versus perceived motivations of partners and stakeholders in health care financing. This tug-of-war can be intense between those that control the levers of limited financial resources and those that advocate for increased access to care and for better quality of care. In most cases, target populations do not have the opportunity to participate in debates and discussions on how best to resolve ideological and strategic differences over healthcare financing mechanisms. Another major stated goal of healthcare financing is to create opportunities for a “reasonable” access and use of health services by sick and at risk populations. What constitutes “reasonable” access to and use of health services and who determines when it is no longer reasonable is at the heart of many major political battles in both rich and poor countries (3, 4, 6, 7, 8). It is also the subject of extensive research and literature (1-10). The third major goal of healthcare finance is to use legal and morally acceptable strategies and mechanisms to encourage target populations to adopt healthy behaviors and reduce the risk of illness so that the cost of care becomes “low, stable, and manageable” from a

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financial point of view (1-7). This goal assumes that a predictable pattern of healthcare costs will allow policymakers and managers of health services to plan for the long term, to estimate cost of care, and to prepare for exigencies. As expected, fierce debate rages on how to achieve “low, stable and manageable” cost of care and how to achieve inevitable tradeoffs acceptable to all stakeholders. The fourth major goal of healthcare financing, and also controversial, is the attempt to “recover” certain costs of care (1-4, 6-8). This cost recovery in Western countries and affluent societies of the South may include third party payments by insurance companies. It may also include reimbursement of already paid cost of care to the health consumer, especially public and private sector workers. In resource poor environments, cost recovery is almost always borne at the point of care by the health consumer. One of the author’s early responsibilities in his medical career in Nigeria was the review and management of reimbursable medical expenses of thousands of workers in the public sector of what is now three state governments. These workers often spend considerable resources to obtain healthcare, and there is no guarantee that these health expenses will be refunded in full or on time. There are few effective and functional national health insurance systems in Africa that can consistently shield the poor from direct payment for health services. Government financial support for health services in Africa rarely includes direct cash support, even for health consumers living in abject poverty. Consequently, in Africa, “user fees” in the healthcare system is a fact of life. Most current health systems in Africa are set up to pass on the cost of user fees and sundry payments directly to the consumer irrespective of socioeconomic status. What are the major types of health services financing in Africa? Major Types of Health Financing The African Council of Ministers during their April 2007 meeting in Johannesburg, South Africa adopted a new “Africa Health Strategy: 2007-2015.” This new Africa Health Strategy includes a section on financing, resource allocation and purchasing of health services (11). In this document, African health ministers note that governments alone cannot finance health services.

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Critical partners of government financing mechanisms for health include the organized private sector, national professional organizations, the civil society and international development partners. The African Union Health Strategy document also calls for healthcare financing to be treated as an “exceptional case” in national government fiscal mechanisms and in the relationship with international development partners since poverty levels remain unacceptably high in the continent. As I noted earlier (1) and as collaborated by various reports (2, 3-7, 9-14), the major types of healthcare financing include: 1. 2. 3. 4. 5. 6. 7.

Government or public sector health financing mechanisms; Individual spending in public or private health settings; Individual spending on healthcare but managed by the public sector, and, in some instances, the private sector such as user fees; Employment-based financing with or without co-pays; Pooled spending according to defined characteristics and motivations; Community-based health insurance (CHI) schemes; and, “Free” health services either to the general population or to a defined segment of the population. However, the while the cost of care is “free” to the recipient or end user, the cost of care is borne by the government or the entity managing the “free” health program.

The type of health financing in place at any point in time in an African country may reflect past and current political ideologies, the size of the middle class, and, the sophistication of the civil society (111). In Africa, the rich always have access to quality health services either by making direct payment to health practitioners or through employee sponsored programs. The rich in Africa also have access to private health services, including upscale and expensive health facilities. When these upscale services are believed to be inadequate, the rich in Africa also have access to better services in South Africa, India or in the West (15). For the poor in Africa, access to health services can be a daunting task. Inability to make direct payments creates barriers to health services in rural clinics and health centers. It can also lead to non receipt of health services in general hospitals and teaching hospitals. In addition to payment issues, the poor may not have access to health

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services as a result of the unavailability of health personnel, crumbling and dilapidated health facilities, lack of medicines, and disgruntled health workers who may be owed back pay for several months. The plight of the poor is also complicated by the fact that they often consult traditional medical practitioners. Although traditional medicine is readily available to the poor, it is not cheap. No matter the type of healthcare financing in Africa, poor families often have to make choices on whether they put food on the table or use meager resources to access increasingly expensive health services. Special Issues in the Financing of Health Services in Africa As earlier noted, the type of healthcare financing mechanism in Africa does not remove a formidable obstacle to health in Africa: lack of access to available health services by poor families. The situation is further complicated by the increasing reliance of government managed health services on direct fees and payments by clients (11). Poor households in Africa increasingly pay for health services while they have no social or economic protection during a major, expensive illness (1-4). Another important special issue is the uneven role of the private sector in the provision of health services in Africa (2-6, 11). Multinational corporations and large domestic private companies organize the best possible care for their employees and immediate families in Africa. However, these corporations rarely provide health services to non company related families living in their operational areas. Large domestic and international private companies are rarely involved in the provision of comprehensive community-based health services. They are also rarely involved in organized efforts to revamp existing health services at local, provincial and national levels. At national levels in Africa, functional, effective public-private collaboration on healthcare financing rarely exists. In addition, health professional organizations in Africa are yet to assume their natural role as indispensable partners in national efforts to improve the financing of health services. These professional organizations often remain preoccupied with agitation for the salary and fringe benefits of their members in the public sector. They are also focused on creating stable regulatory environment for private health practice and the additional professional training of members. The issue 29

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of healthcare financing is not on the radar screen of many health professional organizations in the continent. Civil society organizations in Africa remain a work in progress. Very few African countries have powerful labor unions for both junior and senior public officers that have in-house intellectual heft sufficient enough to engage the government in the technical aspects of health care financing. Very few civil society organizations have enough national and community political creed to mobilize support for specific health care issues, including equitable health care financing. However, civil society organizations have the critical role of serving as vigilant watchdogs of public policy. It is hoped that the issue of healthcare financing will eventually become a strategic objective of civil society organizations in Africa. The poor in Africa have a particularly difficult time organizing themselves, politically and organizationally. Limited opportunities for political discourse and the domineering role of central governments with enormous powers make it difficult for the poor to organize themselves in Africa. The daily grind for survival in abject conditions takes precedence over organizing. However, as grim conditions become worse, spontaneous violence may erupt in urban slums over lack of health and social services. The poor in Africa face tremendous logistics and financial odds to organize themselves politically at national or regional levels. Recommendations The key to an improved financing mechanism for health services in Africa is a good understanding of the dynamics of the cost of healthcare and a disposition by all stakeholders to correct noted deficiencies. As I note in a forthcoming publication (1) and as collaborated by other publications (2-7, 11, 12), it is important for stakeholders to understand that the success of financing mechanisms for health depends on the following factors: a) b) c)

The age-old dynamics of healthcare demand and supply; The availability of health and non health infrastructure to support adopted healthcare financing mechanisms; The immediate, short term and long term cost of health care for the designated target population;

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d)

e) f) g)

The ability of healthcare financing managers and healthcare regulators to work harmoniously to achieve positive cost-benefit efficiencies and effectiveness in health; The state of baseline indicators before the commencement of the healthcare financing mechanism-good, fair or poor; The level of macroeconomic, social and political stability in the designated area of operations; The level of participation of informed consumers in the design, implementation, monitoring and evaluation of health services.

In each of the aforementioned issues, Africa as of today appears to be in a disadvantaged position due to poor personal and community health status, lack of consensus on financing mechanisms, limited national expenditure on health and the lack of target population involvement in discussions about healthcare financing mechanism. However, this apparent disadvantage could be turned into a major strength if national governments, professional associations, the civil society and international development partners work together. In this envisaged harmonious and effective relationship, all stakeholders will focus on how to minimize the heavy financial burden of healthcare borne by the poor in Africa. The partnership should also work together to create verifiable mechanisms where the rich and the middle class pay an equitable share of the cost of health services. For the envisaged partnership to be very effective, I recommend that each country should adopt a NATIONAL HEALTHCARE FINANCING INTERVENTION PERIOD whereby poor countries receive both domestic and international technical and financial assistance to realign national policies, train staff, create necessary infrastructure, and organize target populations to become effective partners in the search for better health services. This intervention period may last between three and five years with dedicated financial, technical and logistics support for the establishment of health financing mechanisms that meet national priorities. An important activity during the intervention period is the need to train and re-train indigenous staff on various aspects of healthcare financing and management. This process will not be easy, especially in African countries with significant shortages of health workers. One of the most important strategies for improving the financing of health services is to dramatically raise the proportion of national 31

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expenditure spent on health. In this regard, all African countries should meet the African Union Heads of State agreement to devote 15 percent of national expenditure to healthcare (11). The African Council of Health Ministers in their April 2007 meeting recommended that African governments should target at least US$34-40 per capita in order to provide basic health services to all citizens (11). This recommendation is however a major leap from the current national health expenditure levels of less than US$5 per capita in Africa (11). To be better prepared for sustainable health financing mechanisms, African governments would have to invest in management information systems so that each country can have reliable baseline health indicators and can link health outcomes with stated program objectives. Each country should set up epidemiological surveillance and monitoring operations that would allow for the collection of valid baseline and trend health data. In this way, decisions about healthcare financing mechanisms will be based on valid baseline and trend health data. The engagement of the organized private sector in Africa by national governments is important. The organized private sector in Africa have experience in healthcare financing since they provide some type of health coverage to most of their workers and immediate family members. They also have experience with managing cost of care and navigating logistics of care, especially in large domestic and international corporations. The civil society in Africa has an indispensable role to play in ensuring that the less privileged in the society receive a fair shake of healthcare expenses. Civil societies have unique roles to play as independent watchdogs of national policies and programs on healthcare financing. In particular, civil society organizations have important roles to play in national debates about “rationalization” of health services, a diplomatic word for reduction in service. Since the poor is often at the wrong end of “rationalized” health services, civil society organizations have a powerful role to play in ensuring that cost saving measures in healthcare does not disproportionately affect the poor. One of the most important issues that must be resolved by stakeholders in regards to the financing of health services is the sustainability of financing mechanisms. Africa is home to abandoned health clinics, health centers and other health projects. Once these

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projects become abandoned, the local population suffers, as they have to travel long distances to reach next available health facilities. The planning of health services financing mechanisms must include a strategy for the continuation of health coverage beyond government funding cycle support, private sector support or external donor support. Finally, each African government should seek ways to involve their African Diaspora in the quest for the best financing mechanisms for health services. Citizens from African countries living in the West and outside of their native homelands are already actively involved in the financing of health services (1, 15). These individuals send money back home to support their family members, including payment of medical services and surgical procedures. Africans in the Diaspora have unique contributions to make in the search for health services financing mechanisms since they have personal and sometimes professional experiences with healthcare financing mechanisms of their adopted countries. Some Africans in the Diaspora work in health financing organizations in the West and understand the strengths and weaknesses of these organizations. African governments should engage their citizens living in the West and other more affluent countries regarding the design and implementation of health financing mechanism. It is important to note that the involvement of the African Diaspora in organized efforts to improve the financing of health services should not in any way compromise the inherent rights and obligations of national governments to make final decisions regarding modalities of healthcare delivery in each country, including health financing mechanisms. Conclusion As shown by the experience of Western democracies, there are no quick fixes or short cuts to effective financing mechanisms for health services. In Africa, the poor bear a disproportionate burden of the cost of healthcare. African governments and other stakeholders such as the organized private sector, the civil society and international development partners need to come up with strategies for ensuring an equitable healthcare financing mechanism in the continent.

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References 1. Chinua Akukwe (2006a). Healthcare Financing in Africa: Issues, Choices, Challenges and Opportunities. Institute of African Development, Cornell University International Conference Proceedings. Forthcoming. 2. African Union (2006). Health Financing in Africa. Special Summit of African Union on HIV/AIDS, Tuberculosis and Malaria (ATM), Abuja, Nigeria, 2-4 May, 2006. Sp/PRC/ATM/5 (1). Addis Ababa, Ethiopia: Author. 3. World Health Organization, Africa Region (2006). The Health of the People. The Africa Regional Health Report. Brazzaville, Republic of Congo: Author. 4. United Nations Economic Commission for Africa (2003). ProPoor Growth Strategies in Africa. Financing for Pro-Poor Health Policies: An Inquiry into Making Financing Health Policies Work for the Poor. Addis Ababa, Ethiopia: Economic Policy Research Center. 5. Lola Dare, Eric Buch (2005). The Future of Health Care in Africa. Editorial. British Medical Journal 2005, July 2nd, Volume 331, pages 1-2. 6. World Bank (2006). Health Financing Revisited: A Practitioner’s Guide. May 25, 2006. Available at http://worldbank.org/ Accessed May 31, 2006. 7. World Health Organization (2007). Health Financing. Available at http://www.who.int/trade/glosaary/story047/en/print.html 8. R. Smith, R. Beaglehole, D. Woodward, N. Drager (2003) (Editors). Global Public Goods for Health: Health Economics and Public Health Perspectives. Oxford University Press, Oxford, United Kingdom. 9. Ronald Vogel (1993). Financing Health Care in Sub-Saharan Africa. Greenwood Press, West Port, Connecticut, United States. 10. Charlotte Leighton (1995). 22 Policy Questions about Healthcare Financing in Africa. Bureau of Global Health Programs, USAID. Washington, DC: USAID. 11. African Union (2007). Africa Health Strategy: 2007-2015. Third Session of the African Union Conference of Ministers of Health, Johannesburg, South Africa. April. CAMH/MIN/5(III). Addis Ababa, Ethiopia: Author.

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12. Lucy Gibson, D. McIntyre (2005). Removing User Fees for Primary Care in Africa: The Need for Careful Action. British Medical Journal, Volume 331, pages 702-5. 13. United Nations Development Program (2005). Human Development Report. New York: Author. 14. World Bank (2005). Africa Development Indicators. Washington, DC. Africa Region. Washington, DC: Author. 15. Chinua Akukwe (2006a). Healthcare Delivery in Africa: Issues, Choices, Challenges and Opportunities. Special Edition. Volume 3, Number 4, July/August. 16. Chinua Akukwe (2006b). Don’t Le Them Die: HIV/AIDS, TB, Malaria and the Healthcare Crisis in Africa. Adonis &Abbey Publishers, London, United Kingdom. 17. Chinua Akukwe (2006c). Beyond the Rhetoric: Essays on Africa’s Development Challenges. Adonis &Abbey Publishers, London, United Kingdom. 18. Rhoi Wangila, Chinua Akukwe (2006). Africa, AIDS Orphans and their Grandparents. Benefits and Preventable Hidden Dangers. TSEHAI Publishers, Los Angeles, United States. 19. African Union (2006b). Progress Report on the Implementation of the Plans of Action of the Abuja Declarations on Malaria (2000), HIV/AIDS and Tuberculosis (2001). Special Session of the African Union on HIV/AIDS, Tuberculosis and Malaria (ATM), Abuja, Nigeria, 2-4 May 2006. Addis Ababa, Ethiopia: Author. 20. World Health Organization Regional Office for Africa (2006). The Health of the People. The African Regional Health Report. Brazzaville, Republic of Congo: Author.

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Chapter 4

HUMAN RESOURCES FOR HEALTH IN SUB-SAHARA AFRICA: ADDRESSING A GROWING CRISIS TAMARA A. HOWARD, ROSHELLE M. PAYES

Introduction According to the World Health Organization (WHO), healthcare workers are “all people primarily engaged in actions with the primary intent of enhancing health (1).” Although this definition encompasses untrained caretakers, for the purposes of this discussion, the definition will be limited to doctors, nurses, midwives, as well as health management and support workers, who have received formal training. These workers are at the core of health services provided to populations, especially vulnerable and high-risk groups. There is a direct relationship between the ratio of health workers to a designated population and the survival of women during childbirth and children in early infancy (1). As the number of health workers declines, survival declines proportionately (2). Unfortunately, health systems in many developing countries are facing critical shortages of human resources for health (HRH). Of the 57 countries identified as having a “critical shortage” of healthcare workers as defined by the Joint Learning Initiative (JLI) – less than 2.5 health workers per 1000 people – 36 of these countries are in subSaharan Africa (1). Currently, there are only about 750,000 health workers in Africa, or 0.8 health workers for every 1000 people (3). This shortage of skilled professionals in the midst of so much unmet health need places sub-Saharan Africa at the epicenter of the global health workforce crisis. Several factors contribute to the poor state of HRH in sub-Saharan Africa, including: inadequate worker training and placement; unequal distribution of health workers across urban and rural divides; insufficient compensation; poor working environments; the heavy work burden associated with tuberculosis, Malaria and particularly 37

Human Resources For Health In Sub-Sahara Africa: Addressing A Growing Crisis

HIV/AIDS; increasing incentives to exit the local workforce; and, overwhelmingly weak health infrastructures. In sum, health systems across the continent are unable to train, sustain and maintain the necessary staff to meet community health needs. WHO assesses the current human resources crisis in the health sector as an issue of deficiencies at three levels: entry, workforce and exit (4). Entry refers to a health system’s ability to prepare the health workforce in terms of planning, education, and recruitment; workforce encompasses a system’s capacity to enhance worker performance, such as supervision, compensation, support systems and lifelong learning; and lastly, exit includes attrition management in terms of migration, career choice, health and safety, and retirement. In sub-Saharan Africa, multifaceted problems in these key areas transcend the health sector and are often influenced by negative economic, political and social factors that operate at national, regional and international system levels. Within the context of the entry, workforce and exit framework, we review the current state of knowledge about the HRH crisis in subSaharan Africa; identify gaps in the knowledge; and, discuss steps for addressing these gaps. The discussion will close with recommendations for addressing the HRH crisis in the continent. Current State of Human Resources for Health in Sub-Saharan Africa Africa bears more than 24 percent of the global burden of disease but has access to only 3 percent of health workers and access to less than 1 percent of the world’s financial resources, even when loans and grants from abroad are included (5). In comparison, the WHO Region of the Americas has 10 percent of the global burden of disease, 37 percent of the world’s health workers and spends more than 50 percent of the global financial resources on health (6). It is estimated that Africa will require one million additional health workers to meet human resources needs for the delivery of basic health services. Besides staff shortages, recent trends in migration of highly trained professionals result in direct and indirect financial losses to poor developing countries that invested in the education and training of these professionals, including those in the health sector (7). The African Union (8) estimated that given the cost of $60,000 for training a general practice physician, low income developing countries

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“subsidize” developed countries with US$500 million annually (8). The United Nations Economic Commission for Africa (UNECA) also estimates that Africa lost $1.2 billion from the 60,000 professionals that migrated between 1985 and 1990 alone (9). The United Nations Commission for Trade and Development estimates that each professional leaving Africa costs the continent $184 000, or $4 billion a year – one third of official development aid to Africa (10). Nonetheless, the HRH crisis in sub-Saharan Africa is more than an issue of overall numbers or density of workers. It is also characterized by poor recruitment, training, placement and weak infrastructures (11). Weaknesses at the Entry Level: Poor Training, Recruitment and Placement of Health Personnel Throughout Africa, national governments are primarily responsible for recruiting, training and posting health workers in the community. However, in the last two decades, increasing fiscal pressures and national budget stringency have significantly constrained governments’ capacity to effectively meet these responsibilities. WHO reports that only 66 medical and 288 nursing institutions exist in sub-Saharan Africa, ranking it the lowest and second-lowest in these institutions, respectively (1). Besides the limited number of training facilities, existing training policies also impact on the production of health workers. The practice in many African medical and nursing schools is learning by rote with little opportunity for hands-on experience. The underinvestment in programs has also prevented many health worker candidates from fulfilling curriculum intentions for field practice outside of urban hospitals. As such, recent graduates are often poorly trained, lacking the skills to work on the front lines of public health. For example in Kenya – a country with fairly developed health training programs – a 2004 survey regarding blood safety for laboratory technicians revealed that only 211 were trained in blood safety techniques, but 660 were actually providing the service (12). Furthermore, national training policies for health workers focus heavily on preparing highly skilled workers, such as doctors, registered nurses and specialists. Training these cadres of workers has high unit costs and the needed number to be trained has presented a costly and unsustainable investment for most African governments (1). A majority 39

Human Resources For Health In Sub-Sahara Africa: Addressing A Growing Crisis

of health professionals’ training focuses on clinical care rather than preventive systems, and occurs in tertiary care facilities with only a minimum of community based components (13). Numerous examples exist of ways in which the skills of health workers or the skill mix within the workforce are inefficiently used. Commonly, tasks do not match an individual worker’s skills – for example, skilled nurses doing clerical tasks because there are no ward clerks, or management tasks being carried out by scarce medical personnel who have no expertise in that area (14); or untrained personnel carrying out skilled tasks such as birth delivery and other interventions. A study in Tanzania estimates that 40-50 percent of a district medical officer’s time was spent on report writing and 20 percent on hosting domestic and international missions (15). In Uganda, district managers estimated that they spend 70-80 percent of their time on planning, reporting and training workshops, leaving little time for activity implementation (16). Besides these training challenges, many African health systems are notorious for cumbersome hiring procedures and the misallocation of health workers. In many countries, the hiring process is centralized and the lack of hiring managers makes the process extremely time consuming and characterized by bureaucratic red tape and political interference (1). Filling vacant health worker positions can take anywhere from 12-18 months in some countries as noted in Kenya. Meanwhile, those workers that are successfully hired are too often sent to urban areas instead of rural communities where need is greater. Consequently, there is a significant imbalance throughout the continent between health workers posted in urban versus rural areas. This imbalance also exists in regards to the availability of training facilities, opportunities for career advancements and standards of living. Urban areas offer more opportunities for lucrative private practice, better schools for the children and better security of lives and properties (17). Furthermore, overstaffing in urban areas can lead to underutilization of skilled personnel while increasing the total cost of health care systems. For example in Kenya in the late 1990s, about 80 percent of doctors and dentists were practicing in urban areas despite the fact that only 20 percent of Kenya’s population live in urban communities (18). Similar imbalances are present in Ghana, Guinea and Senegal, where more than 50 percent of physicians are concentrated in the capital city where less than 20 percent of the population live.

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Consequentially, rural communities have less access to health care service than their urban neighbors and are forced to travel long distances for care. The Workplace: Poor Compensation, Inadequate Support Systems, Lack of Supervision Upon entering the workforce, health workers inevitably face another set of barriers to providing adequate care to patients. In general, health workers in the public sector are poorly paid and many workers receive only subsistence level salaries. The starting salary for a highly-trained doctor in Botswana is approximately $2,500 per year, while a physician with comparable training may earn a starting salary of $120,000 in the United States (19). Meanwhile, the yearly salary for a nurse in Malawi is about $1,900, but she could earn anywhere from $40,000 to $50,000 per year in the US or UK (20). As such, many workers that stay within their local health labor markets often supplement their salaries with private practice or other supplemental work. Poorly paid workers may be fortunate enough to receive any salary at all, as it not uncommon for many African governments, such as Uganda and Nigeria, to not pay health workers for months at a time. Health workers also lack non-financial support in the workplace. Budget crises have limited health systems’ capability to purchase the necessary equipment for health workers to properly do their jobs. Essential support systems are weak or nonexistent, with facilities in need of clean water, vehicles, stationary, drugs, personal protection equipment and other essential supplies. In Zambia, patients may not receive referrals or prescriptions for lack of stationary and fees go uncollected for lack of receipt books (21). Additionally, without adequate equipment and internationally accepted safeguards, health workers are even more vulnerable to contracting the illnesses they are attempting to treat, especially HIV/AIDS. Lastly, lack of supervision and effective management has also been cited as causes for low morale among health workers. Supervision that is supportive, educational and consistent and helps to solve specific problems can improve performance, job satisfaction and motivation (22). Nurses in South Africa for example working in maternal health services were asked about the most important characteristics of the workplace and presented with 16 theoretical 41

Human Resources For Health In Sub-Sahara Africa: Addressing A Growing Crisis

workplace profiles. The most significant finding was that good management (e.g. clearly defined responsibilities, supportive attitude when mistakes are made, rewarding ability and not seniority) outranked salary as a preference, unless the remuneration was dramatically higher. These results reinforce other research demonstrating the effect of good management on employment choices and job satisfaction among health workers (23). Increasing Worker Departure: “Push and Pull” Factors for Migration Push and pull factors are also substantial risk factors for health worker shortages and the poor state of HRH in sub-Saharan Africa. Push and pull factors refer to the circumstances that pressure a worker to leave his or her local workforce, resulting in unplanned migration and ultimately the further erosion of the local health workforce. Examples of push factors include: political and civil instability, low wage and promotion potential, poor working environments, the heavy burden associated with high caseloads of HIV/AIDS patients, and poor living standards. Pull factors revolve around influences such as significantly higher wages abroad, lucrative recruitment deals from high income health systems and the opportunity for career advancement. While the most publicized unplanned migration is that of African health workers (especially nurses and doctors) to high-income countries such as the United States and the United Kingdom, exit rates are also affected by worker movement from less developed countries to more developed neighbors (i.e. Kenya to South Africa), rural to urban areas and public to private practice. Exit rates, especially among African nurses and doctors, are astounding. In 2001, less than one-third (360 of 1200) of physicians trained in Zimbabwe in the 1990s continued to practice in the country. In 2003, more than 3,000 nurses trained in South Africa, Zimbabwe, Nigeria, Ghana, Zambia and Kenya registered in the United Kingdom (24). Furthermore, recent statistics demonstrate that Ethiopia’s public health sector is losing about 9.6 percent of their physicians every year, both to other countries and the private sector. For the United States, where health systems are struggling to find sufficient personnel to care for aging populations, Africa has proved to be a significant source of health labor. More than 23 percent of Americaʹs 771,491 physicians received their medical training outside the United States, the majority

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(64 percent) in low-income or lower middle-income countries. A total of 5,334 physicians from sub-Saharan Africa are in that group, a number that represents more than 6 percent of the physicians currently practicing in sub-Saharan Africa. Nearly 86 percent of these Africans practicing in the USA originate from only three countries: Nigeria, South Africa and Ghana. Furthermore, 79 percent were trained at only 10 medical schools (25). The push and pull factors contributing to brain drain extend beyond the health sector. Their impact upon the workforce is undeniable. The Multi-Dimensional Impact of HIV/AIDS on the African Health Workforce The HIV/AIDS epidemic has significantly affected the African health workforce in the entry, workforce and exit dimensions, and merits special attention in this discussion. The epidemic has impacted the health workforce in both direct costs – labor loss, disability, death benefits and increasing medical aid costs, and indirect costs – increased absenteeism, reduced productivity, and stressed workplace (26). As part of the adult, sexually active population, healthcare workers have not escaped infection and it is estimated that in Africa between 19-53 percent of all deaths of government health employees is due to AIDS (27). If the epidemic continues on its same course, 6-9 percent of health workers in Africa could be living with HIV by 2010. Such levels have already been reached in some countries, such as Botswana where it is estimated that cumulative AIDS deaths among health workforce could reach 40 percent by 2010 (28). Meanwhile in Swaziland, there is a 7 percent net loss of health workers with 50 percent of those losses attributed to HIV infection. Nevertheless, this possibly detrimental impact to the health workforce has received relatively little attention among policymakers (29). Overall, there is inadequate support for workers infected living with HIV/AIDS. If a worker becomes HIV positive, they often lack confidentiality, counseling, clinical care and drug treatment opportunities. In addition, health workers who are not living with HIV/AIDS may succumb to the overwhelming work load and pressure associated with caring for patients and their colleagues dying of AIDS. In Malawi, up to 800 qualified nurses exited the system due to frustrations and burnout associated with HIV/AIDS case load (30). 43

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Many health staff also has no choice but to leave in order to provide proper care to sick and dying relatives. Surveys reveal that African health workers cite the need for support related to dealing with the increased number of deaths, grief counseling, and the increased workload (exacerbated by the worker shortage) (31). The HIV/AIDS epidemic is moving through the continent at such a rapid pace that the damage done is outstripping efforts to change personal behaviors, provide care, jump start development and accelerate policy initiatives to address identified gaps in remedial actions (32). Current Policies Addressing the HRH Crisis Current policies to address the HRH crisis are the focus of recent international attention, in response to the realization that global health goals such as Millennium Development Goals (MDGs), the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFTAM) cannot be achieved in sub-Saharan Africa, without a sufficient number of skilled health workers to facilitate the delivery of services. Insufficient funding and lack of political will are at the root of failing health systems and HRH shortages in sub-Saharan Africa. Training and human-resource management do not compete well for policy attention with elite science or macroeconomic issues. The reform of the health sector has not fully addressed the necessary human infrastructure needs and is often based on the assumption that workers will be available, motivated and able to undertake newly assigned functions (33). In many countries, progress has been made in recent years to develop national policies for HRH, but the implementation, monitoring and evaluation of these policies have often been slower and more difficult to quantify (34). In Africa, few countries have comprehensive policies on human resources for health. Fewer have plans of action. Even where national policies or plans exist, funding does not always follow, and issues of retention and remuneration remain unaddressed (35).

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Gaps in Current Knowledge of HRH Crisis in Sub-Saharan Africa Available Health Human Resource Data is Questionable Accurate, reliable statistics on human resources for health in Africa are scant and those that are readily available are difficult to standardize and compare internationally (36). Provider to population ratios are often based on government reported information that may be dated or poorly sourced. Most documents use WHO’s principal indicator of proportion of health workers among total population, which seems like a fairly straightforward indicator. Nonetheless, there are a number of issues that require careful consideration when using this common indicator, especially for cross country and international comparisons. First, occupational categories are country specific and may not translate across different national health systems (37). Second, methods vary for calculating the quantity of workers in a given position. Third, the validity of this indicator is strongly contingent upon the denominator – total population (38). In many African countries, reliable census data does not exist or is outdated, with the most notable example being Nigeria. The 2006 national consensus data of Nigeria is already a subject of agitation and disputes. Although the frequently used provider-to-population ratio is a fair starting point for reviewing health worker distribution, the abovementioned caveats must be considered when using such data. There are questions related to the estimates of health workers needed to fill the shortage as well. Figures regarding the number of needed health workers for Africa vary between 1 and 1.5 million. However, there is an urgent need for more definitive data regarding the types of workers required (doctors, nurses, midwives, community health workers, health managers) and the priority areas for these workers. Moreover, more accurate data is needed regarding disparities at regional and national levels, especially between urban and rural communities within countries. Producing 1 or 1.5 million new doctors or nurses will not provide a long-term solution to Africa’s HRH situation. Efforts should be made to identify the breakdown of the different cadres of worker required to meet current and future community health needs.

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Individual Country Needs Yet to be Determined International donors and technical agencies seem to approach SubSahara Africa as a single entity with broad overarching problems. A look at current available information reveals that the magnitude of the HRH crisis varies significantly both within and between countries. For example, the Kenyan health labor market presents a paradox of a shortage of workers coinciding with a surplus of unemployed health workers, principally nurses (39). Meanwhile, Malawi has traditionally had low numbers of health workers. Currently, about 50 percent of nursing posts are unfilled in Malawi. In comparison to regional neighbors Kenya and Zambia, Malawi has the lowest provider-topopulation ratios. In addition to noted variations in national capacities for health workers in Africa, information on each country’s financial resource need for HRH is overwhelmingly missing. African health ministers have committed to prepare and implement costed human resources requirements for health development plans so as to achieve universal access to care and treatment by 2015 (40). To reach this goal, detailed cost information related to national needs is required immediately. Training Priorities are still Unknown While African governments and many organizations (domestic and international) have deployed substantial resources in increasing training opportunities for African health workers, there does not appear to be consensus on what type of training should be a priority. Should training focus on producing more doctors and nurses? Should it focus on producing more highly trained professionals with internationally recognized skills that could increase the supply of these workers in the global labor market? Should lower and mid-level cadres be the focus of training initiatives to alleviate the immediate health workforce situation? Current literature reveals a lack of agreement on this approach as well. In fact, many national professional groups are often threatened by these types of initiatives and organize heavy opposition to empowering lower-level cadres of health workers. In the end, we are still left to wonder: How can we most effectively improve training opportunities for health workers at the entry level if there is little consensus on who should be trained?

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Comprehensive National Human Resource Plans are still lacking at the Country Level A January 2006 workshop coordinated by the USAID funded Capacity Project which partners with African ministries of health, NGOs, private practitioners and other health system stakeholders to implement new approaches to HRH, revealed that despite the increased attention on HRH crises in Sub-Sahara Africa, most countries lack comprehensive national plans. Lesotho, Rwanda, Uganda, Zambia, Malawi and even Southern Sudan reported the development and early stages of HRH strategic plans, with some countries working on second and third versions of their models. The status of national plans in other countries around the continent is not readily known. Such plans are critical tools for building the human infrastructure required to support national health systems (41). National health human resource plans are also critical for donors and technical agencies to provide the most appropriate support. The Role of Remittances and Migrant Health Workers is Vague Much of the available literature hint at the distorting affect that migrant health worker remittances may be having in the national response to the HRH crisis. Further research is necessary to determine the extent of the remittances, which countries are benefiting the most from exporting workers, the explicit or implicit position of national authorities on worker remittances and the impact on country level efforts to quell worker migration. Additionally, while remittances are commonly used to supplement family incomes, their possible contribution to the health sector or local human development needs to be determined. Other financial contributions (investments, bank transfers, portfolios) by migrant workers as well as from the African Diaspora community should also be explored. More Information still Needed on Reasons for Worker Exit While various push and pull factors are offered as reasons for worker exit, additional data is still needed to better understand the brain drain phenomenon. This will certainly prove difficult because most workers that leave their local labor markets do not report their intention to emigrate. They simply resign from their posts and move on to external positions. While civil instability, economic constraints and poor career prospects certainly contribute to worker exits, further 47

Human Resources For Health In Sub-Sahara Africa: Addressing A Growing Crisis

information is needed regarding other reasons for migration. Information relating to what type of incentives would motivate a worker to stay is also required. Similar to market studies that assess “willingness to pay” for new products, it would be useful to do a “willingness to stay” study among skilled health workers. Way Forward National governments, the donor community and technical agencies are unlikely to stem the HRH crisis unless more reliable evidence becomes available regarding specific shortages of health workers, direct and remote causes of the crisis, and the short and long term remedial efforts that will stabilize the situation. Each country needs to provide critical information regarding the possible cause-andeffect relationships that lead to HRH crisis. We examine some of the needed action steps by African countries. Need for Improved Monitoring and Evaluation of Health Workforce Although the health worker shortage and health sector deficiencies are undeniable, there is still substantial need for better information regarding human resources for health (42). With the assistance of international agencies, national governments should develop and implement country specific policies and strategies, inclusive of cost components that provide baseline and trend data on HRH. There should be a concerted effort to collect more specific data related to health workforce implications of education, skills mix, retention, remittances and worker incentives. Examine Aspects of HRH beyond Medical Providers The production of doctors and nurses, as well as their compensation, working conditions and exit rates, are frequently the main focus of HRH assessments. However, greater attention should be directed to the impact of public administration, health management and health financing on the HRH crisis. Providers are not trained to manage or keep track of facility finances, nor should they be. However, the health workforce depends on these capabilities to function properly. The interdependency of different sectors and skills within the health workforce need to be further examined to determine priority areas.

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Continued Advocacy will be Essential for Maintaining Momentum on Addressing HRH Issues HRH research and current policy initiatives will require continued advocacy at both the national and international levels. Stakeholders, particularly professional groups, should actively promote the need for national long term commitment to ending health workforce crisis. In particular, stakeholders for HRH should ensure that financial and technical support is available at country levels for addressing current and future health work force crises. Recommendations The human resource crisis in Africa is a multifaceted issue which requires an integrated approach inclusive of both short and long-term strategies. However, there is not one country, international donor or technical agency with the capacity and resources to comprehensively address all the contributing risk factors for the poor state of health personnel in the continent. Overcoming worker shortages and deficiencies at the entry, workforce and exit levels require strategic actions at the country level in partnership with the international community’s financial, technical and political expertise. As the characteristics of each country’s health personnel situation varies, it is ultimately the duty of national officials to carefully balance each partner’s contribution so as to adequately meet local needs and realities. Current policy momentum on the issue is promising, but additional actions are still needed. The following recommendations aim to complement those initial steps already taken by both the international community and national governments. Recommendations for a Global Response The global community needs to follow through with commitments to HRH in Africa or be held accountable Countless alliances, partnerships, communities, forums, and initiatives are now forming to tackle the continent’s HRH crisis. In light of the magnitude of the crisis, there should be little room for failed programs or initiatives with no results. Moreover, developing countries should hold industrialized countries accountable for not fulfilling their 49

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global promises, such as the repeated promise to increase overseas development assistance (ODA) to 0.7 percent of gross national income. Developed countries should address their own HRH issues in order to aid the crisis in Africa Countries such as the UK and US, which absorb significant numbers of African healthcare workers, are struggling to provide care for aging populations. As such, lucrative recruitment packages are often offered to African health workers to migrate to these countries. However, developed countries should use the entry, workforce, and exit framework to assess their HRH situation as opposed to luring workers from health systems where they are desperately needed. Moreover, the WHO, the International Labor Organization (ILO) and the International Office on Migration (IOM) should advocate for more ethical recruitment strategies or bilateral agreements that are beneficial for both the provider and recipient country. Significantly increased funding should be provided to countries in early stages of addressing HRH crisis It may be useful for agencies such as the World Bank and the International Monetary Fund (IMF) to devise strategies to provide significant increases in funding to the African health sector to expand human resources for health, support salary increases, commodity purchases, or worker retention incentives such as provision of training and growth opportunities. This may require a heavy investment in the beginning, but would gradually taper off once health systems became self-sufficient and can support its workforce. Technical bodies should address the skill mix by assisting in curriculum development and prioritization of health support workers To address the skill mix, the WHO AFRO region proposes reevaluating school curriculum to ensure that all cadres of health workers are being generated, including health support workers and health managers. Recognizing the influence of traditional medicine practitioners and faith healers on populations in SSA, WHO AFRO recommendation to include community health workers and other village representatives in public health prevention campaigns and other basic health services should be embraced, to act as the continuum to nurses and doctors when advanced health assistance is required.

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Recommendations for Country-Level Action Countries need to take ownership of initiatives to resolve the HRH crisis To best fulfill its own needs, individual countries need to acknowledge the HRH crisis and decide collectively to tackle identified problems. Significant efforts are needed to determine the extent of the crisis within each country and identify disparities between urban and rural communities, public and private practices, and gender. Once national assessments are prepared, comprehensive national human resources for health plans need to be developed by all countries. Reliable cost analyses of the crisis are also required. Most sub-Saharan countries have yet to develop comprehensive national HRH plans, despite being faced with a shortage of workers or even a paradox of unemployed workers amidst high health labor demand. Regional organizations in Africa should increase efforts to assist in the development of HRH mobilization plans. Utilize currently available financial and human resources more strategically Countries currently possess resources that can be utilized more strategically. The concentration of health workers in urban centers should be redistributed to rural areas where they are most needed. This may require providing financial or non-financial incentives to workers, but nonetheless governments should explore possible options. In addition, national governments should work with professional groups to determine how best to train and utilize lower and middle cadres of health workers. If professional health workers associations and groups are involved in the strategic planning than they may feel less threatened by shifts in roles and tasks. Assess the impact of HIV/AIDS on the health workforce and provide safer working environments African Ministries of Health should obtain additional information regarding the impact of HIV/AIDS among health staff. Areas to explore include: how are workers becoming infected? What are the occupational hazards and how can these hazards be removed or minimized? What type of support services exist to workers that become 51

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infected? What services should exist? This information should help address issues at the workplace and exit levels. Increase transparency in the health sector and promote good governance throughout Countries can improve the entry aspect of the health workforce by improving the hiring and recruitment process. Transparency and accountability are also required in areas such as professional regulation and ensuring the highest ethical standards. Both health workers and the donor community would place greater trust in systems with improved governance. Create policies at workforce entry to address the mal-distribution of health workers between rural and urban divides Initiatives should specifically reference experiences from comparison countries such as Thailand, which shared similar problems in its early years targeting HRH issues. National governments with endorsement from the Africa Union should implement rural field placements in medical and nursing school curricula for a period of at least two years, prior to graduation. In this manner, students will be investing in their country before having the option to graduate and possibly relocate to higher-income countries. In Nigeria, the compulsory one year National Youth Service Corp program for university graduates provides needed health workforce in underresourced parts of the country. This system would help alleviate some of the financial loss caused by the brain drain, while at the same time, endorsing a consistent flow of workers to rural health locations and thus building up a social infrastructure in remote regions. References 1. World Health Organization (2006). World Health Report 2006: Working Together for Health. Available at: www.who.int. 2. World Health Organization (2006). The Global Shortage of Health Workers and Its Impact. Factsheet No. 302. Available at: http://www.who.int/mediacentre/factsheets/fs302/en/print.html . 3. World Bank (2005). High-Level Forum on the Health MDGs. Addressing Africa’s Health Workforce Crisis: An Avenue for Action. Available at

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http://info.worldbank.org/etools/docs/library/206812/AfricasWorkforce HLF%20Abuja.pdf 4. See number 1. 5. The World Health Organization (2006). Ten Statistical Highlights in Global Health, World Health Statistics 2006. Available at: http://www.who.int/whosis/whostats2006.pdf 6. See number 1. 7. Martineau T, Decker K, Bundred P (2002). Briefing Note on International Migration of Health Professionals: Leveling the Playing Field for Developing Country Health Systems. Liverpool School of Tropical Medicine, Liverpool, England. Available at http://www.liv.ac.uk/lstm/research/docu ments/InternationalMigrationBriefNote.pdf 8. Africa Union (2003). Investing in Health for Africa’s Socioeconomic Development. Experts Meeting. Human Resource Mobilization for Health. Conference of the African Ministers of Health. Seventh Session. CAMH/16 (VII) Tripoli, Libya. 26-30 April. Addis Ababa, Ethiopia: Author. 9. United Nations Economic Commission for Africa (2000). Aide Memoire: Regional Conference on Brain Drain and Capacity Building in Africa. Addis Ababa, Ethiopia: Author. 10. Marchal B, Kegels G (2003). Health Workforce Imbalances in Times of Globalization: Brain Drain or Professional Mobility? Int J Health Plann Manage 2003, 18 Suppl Volume 1, pages 89-101. 11. Ibid. 12. Support for Analysis and Research in Africa (2004). The Impact of HIV/AIDS on the Health Workforce in Kenya. Academy for Educational Development, Washington, DC. Available at: http://sara.aed.org/publications/hiv_aids/aids_briefs/Kenya%20workfo rce%20brief_2.pdf 13. WHO, World Bank, Rockefeller Foundation (2004). Global Health Trust. The Health Workforce in Africa: Challenges and Prospects. A report of the Africa Working Group of the Joint Learning Initiative on Human Resources. March. Burlington, Vermont: Joint Learning Initiative. 14. Jaffre Y, de Sardan, O (2003). Inhospitable Medicine: Difficult Relations between Carers and Cared for in Five West African Capital Cities. Karthala Press, Paris, France. .

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15. Bill and Melinda Gates Foundation, McKinsey and Company (2005). Global Health Partnerships: Assessing Country Consequences. Seattle, Washington: Bill & Melinda Gates Foundation. 16. See number 1. 17. Zurn P (2002). Imbalances in the Health Workforce: Briefing Paper. Geneva, Switzerland: World Health Organization. 18. Kimalu, P, et al. (2004). A Review of the Health Care Sector in Kenya. KIPPRA Working Paper No.11. Nairobi, Kenya 19. Hilts, R. (2005). Chapter 4, Changing Minds. In the book Rx for Survival. Penguin Press 2005. New York. 20. The New York Times (2004). An Exodus of African Nurses Puts Infants and the Ill in Peril. Available at: http://query.nytimes.com/gst/fullpage.html?res=9D03E1D7113BF93 1A25754C0A9629C8B63&sec=health&pagewanted=print . 21. Support for Analysis and Research in Africa (2004). The Health Sector Human Resource Crisis in Africa: An Issues Paper. Academy for Educational Development. Available at: http://www.aed.org/ToolsandPublications/upload/healthsector.pdf 22. See number 1. 23. Blaauw D, Penn-Kekana L (2003). Socio-Economic Inequalities and Maternal Health in South Africa. Presentation to the 22nd Conference on Priorities in Perinatal Care in Southern Africa. 24. HealthGap.Org (2005). Factsheet: Health Worker Crisis in Africa (2005). Available at: http://www/healthgap.org/camp/hcw_docs/HCWfactsheet.pdf . 25. Amy Hagopian, et al (2006). The Migration of Physicians from Sub-Saharan Africa to the United States of America: Measures of the African Brain Drain. Available at: http://www.eldis.org/static/DOC19757.htm 26. World Bank (2004). The State of the Health Workforce in subSaharan Africa: Evidence of Crisis and Analysis of Contributing Factors. Available at: http://siteresources.worldbank.org/AFRICAEXT/Resources/No_75. pdf 27. Ibid. 28. Ibid. 29. British Medical Journal (2006). Doctors and Nurses with HIV and AIDS in sub-Saharan Africa. Available at:

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http://bmj.bmjjournals.com/cgi/content/full/329/7466/584(access rquired) 30. See number 12. 31. Ibid. 32. HealthGap.Org (2006). Factsheet: Health Worker Crisis in Africa. Available at: http://www.healthgap.org/camp/hcw_docs/HCWfactsheet.pdf 33. Rigoli F, Dussault, G (2003). The Interface between Health Sector Reform and Human Resources in Health. Hum Resour Health, Volume 3, Number 1, page 9. 34. Egger, D. and Adams, O (1998). Imbalances in human resources for health: Can policy formulation and planning make a difference? The Human Resources for Health Development Journal 1998, Volume 2, page 1. 35. World Health Organization, Africa Region (2002). Building Strategic Partnership in Education and Health in Africa: Consultative Meeting on Improving Collaboration between Health professionals, Governments, and other Stakeholders in Human Resources for Health Development. Brazzaville, Congo: Author. 36. See number 26. 37. Ibid. 38. Ibid. 39. See number 5. 40. See number 1. 41. The Capacity Project (2006). HRH Action Workshop. Available at: http://www.capacityproject.org/action_workshop/ 42. The World Bank (2004). High Level Forum on the Health MDGs – Addressing Africa’s Health Workforce Crisis: An Avenue for Action. Available at: http://info.worldbank.org/etools/docs/library/206812/AfricasWorkforce HLF%20Abuja.pdf

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Chapter 5

STRENGTHENING HEALTH SYSTEMS IN AFRICA CHINUA AKUKWE Introduction The World Health Organization (WHO) defines health systems as the sum total of all the organizations, institutions and resources whose primary purpose is to improve health (1). To be effective, a health system in any part of the world should have adequate complements of trained personnel, financial resources, logistics capacities, political support, target community support and a set of operating principles that allow for transparent monitoring and evaluation of supported health services. An effective health system should also provide opportunities for timely access to health services by all potential clients. An effective health system should also be based on ethics that meet national and international standards. Two recent landmark publications recognize the major role of health systems in any organized effort to improve health services in Africa. The report by the World Health Organization Regional Office in Africa (2) indicated that strengthening national health systems across Africa is indispensable in national efforts to improve health services. In adopting a new African Health Strategy (2), the African Council of Health Ministers at their April 2007 meeting in Johannesburg, South Africa focused on how to strengthen health systems in Africa 2007 through 2015. African governments, regional institutions, continental organizations and the international community can strengthen health systems by mobilizing technical, financial and logistics resources to improve the regulation, implementation, monitoring and evaluation of health services. To establish and sustain effective health systems in Africa, it is important to understand the health and non-health factors that influence the state of a health system in a defined geographical area or jurisdiction.

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Health Issues that Influence the State of a Health System First, the national health policy established in each country affects the state of the health system operational in that country. A national health policy that favors a clinical care approach will have a health system organized in such a way that treatment is favored over preventive services. A national health policy skewed towards healthcare for urban areas and the middle class will have health systems that are not realigned to provide rural health services. A national health policy that provides medical treatment overseas for its leaders and elites is unlikely to produce a health system with enough expertise to manage complex health problems. A national health policy should provide a road map for the national health system with specific support for technical, fiscal and logistics resources needed to provide quality health service. Vague national health policies often lead to health systems that are unresponsive to the needs of the target population. Second, health workers are the engine room of health systems. As shown in an earlier chapter, the scarcity of health workers in Africa is jeopardizing health systems throughout the continent. The number of health professionals and their functions are important to the smooth running of health systems. The training and morale of health workers are also important. As noted by the two recent publications on health systems in Africa (2, 3), shortage of health workers represent a formidable challenge to ongoing initiatives to strengthen health systems. Third, the state of healthcare infrastructure impacts heavily on the existing state of health systems. In Africa, the state of healthcare infrastructure is poor in many countries due to years of official neglect. In particular, the deterioration of primary health care systems in Africa further contributed to the poor quality of health systems in Africa (4). The only evidence of PHC glory days in many parts of Africa are dilapidated or abandoned healthcare infrastructure. Fourth, the state of healthcare financing impacts on the state of health systems in a specific country or jurisdiction. The high out-ofpocket payments by the poor in Africa and the relatively low rate of government support for direct health services created a terrible situation where national health systems were no longer sustainable (2,

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3, 4, 5, 6). The poor, no matter their geographical location, can never sustain national health systems. Fifth, lack of medicines and other medical and public health goods is hollowing out national health systems from within (2, 3, 5, 6, 7). It is not uncommon for health facilities in some parts of Africa to serve just as dispensing outposts, with little chance of patients obtaining drugs in such facilities. Prospective patients and in-patients already know that they must be ready to buy medicines, surgical equipment, and other medical goods for their care. They are also aware of the “obligation” to pay “unauthorized” fees if they wish to receive medical attention. Patients are also aware that their attending health workers may be owed months of arrears of salaries and emoluments. In some parts of Africa, the existing health system might as well be a shell. Sixth, health information systems in Africa are still evolving (2, 3). The dream of integrated health systems that link all health services in a defined geographical location or jurisdiction is still many years away in many African countries. The lack of integrated health information systems also negatively impacts on efforts by health managers to keep track of baseline and trend data. It also stymies efforts to enforce transparency and accountability in the health system since real time data is rarely available to program managers and their supervisors. In addition, health services research is still in its infancy in many parts of Africa due to lack of integrated health information systems. Seventh, individuals continue to die needlessly in Africa as a result of ineffective health systems available for disease prevention and clinical care (2, 3). Most health systems can rally round to provide acute care. However, when a patient needs sub-acute or chronic care, then the inadequacies of the health system kicks in, ranging from lack of medicines and equipment to scarcity of trained health personnel. An acute oriented health system is grossly inadequate for preventive health services. The existing health system is rarely adequate for disease prevention efforts such as health education, risk reduction activities, and community-based information, education and communication campaigns against infectious diseases. Eight, Africa’s health systems often support vertical or single disease/health condition strategy (2, 3). This approach is favored due to lack of technical capacity, undue dependence on donors and their priorities, and, the political pressure to achieve quick results. However, a vertical health system approach is not conducive for a comprehensive 59

Strengthening Health Systems in Africa

health strategy that meets the needs of target populations. It is also ineffective when seeking to improve overall health behaviors in target populations. In addition, vertical programs are often operational silos with limited interaction with other initiatives in the same target population. Vertical health systems can also draw existing staff away from their undermanned positions in other health programs. Ninth, the provision of health services at local, rural areas of Africa has suffered greatly from the breakdown of national and district health systems. Africans living in rural areas have seen a gradual erosion of health services provided in health dispensaries, health clinics and primary health care centers. In these first lines of defense against ill health and disease, health systems are at its weakest in Africa. Non Health Related Issues that Influence the State of a Health System The most important non-health related issue is the gradual but consistent erosion of political support for ministries of health in Africa. The prestige which national ministries of health held in national affairs is now occupied largely by Ministries of Finance, Defense and Internal Affairs/Interior. Today in Africa, most African countries spend less than US$5 per capita on healthcare every year when at least US$30 or more will be adequate (2, 3). In addition, only two African countries in April 2007 met the 2001 African Union Heads of State mandate for member states to set aside 15 percent of their national expenditures for healthcare programs (2, 3). Second, the organized private sector is yet to become a major source of healthcare financing in African countries (3, 4, 5, 6). This has led to a situation whereby poor African countries foot the enormous cost of health programs and poor Africans pay the bill for direct health services. The organized private sector, especially large external conglomerates and domestic organizations focus on the health needs of their workers and their immediate families. These corporate healthcare programs for employees and family members rarely extend to individuals and families living in the operational areas of the affected corporations. Third, attempts to scale up health systems in Africa often fail due to the inability of ministries of health to manage the political process in a democracy (2, 3, 4, 5, 6). Ministries of health are rarely major players

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in the appropriation process for establishing funding priorities and statutory budgets. Ministry of health officials often spend considerable amounts of time dealing with donor funding budget and program priorities. Ministries of health must deal with fluctuating power supply in rural health facilities. They must also deal with the reluctance of staff to deploy to unsafe and sometimes dangerous health outposts. There is very little Ministries of health can do about the inability of central governments to provide portable water and basic sanitation, two important strategies for preventing communicable diseases. Poor urban and rural road networks are not in the Ministry of health docket. In addition, ministries of health need resources to scale up successful programs, re-train existing staff and hire and retain new workers. Fourth, as money for health becomes scarce, the health sector is slow to adopt a sector-wide approach (SWAP) to healthcare services so that all funding decisions reflect a shared national development strategy (2). A SWAP approach allows resource poor countries to collectively agree on national strategies for development; reach agreement on possible sources of funding; decide on how financial resources will be allocated; and, determine which programs and services will be made available for international donor support. Health ministries across Africa struggle with SWAP because it will require a major strategic shift: the need for verifiable multi-sectoral collaboration and coordination of services instead of vertical, disease oriented programs and services. Finally, the pervasive role and impact of poverty in Africa creates special challenges for health systems in Africa. Poverty prevents African families from accessing health services. Poverty can also deny these families access to further healthcare if they pay for direct services, including expensive catastrophic care. Africa’s health systems are squeezed for money and currently cannot provide significant subsidized care. Some African health systems are significantly donor dependent, both for recurrent and capital expenditures. It is difficult for health system managers in Africa to plan for the long term when money is in short supply, needs are growing in exponential proportions, and external donor priorities can change with limited advance notice.

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The Fundamentals of an Effective Health System The World Health Organization, Africa Region (2) lists four vital functions of an effective health system: 1. 2.

The health system should deliver quality personal and nonpersonal health services; The health system should invest on qualified personnel, buildings and equipments; The health system should address immediate and long term financing issues, including who pays for care, when and at what level; The health system should be run transparently, with monitoring and evaluation information readily available to stakeholders, and, with accountability as the rule rather than the exception.

3.

4.

The WHO Africa Region underscores the need for all health systems to be proficient in the above listed vital functions in order to better serve target populations. A target-population focused health system should respond in a timely fashion to the clinical, preventive and psychosocial needs of its target populations. Such a health system should respond at personal, family and community levels. It is also important for the health system to respond to the target populations in their neighborhoods and communities, and in consonance with shared cultural and religious experiences. An effective and sound health system should be part of a national solution to non-health issues that impact on the state of health at both personal and community levels. An effective health system should also have built-in mechanisms for protecting the safety of patients through training and re-training programs of staff; by ensuring that health facilities meet the stipulations of relevant laws and regulation; by the vigorous enforcement of professional practice laws and speedy prosecution of criminal violations; and, by the provision of regular feedback to stakeholders, including patients and at-risk populations. In addition, an effective health system must be an ethical oasis of fair play and equity, ensuring protection of patient rights. An effective health system should have a health research program that meets domestic and international standards, including issues of informed consent, patient confidentiality and the right to continue receiving services if a patient declines to participate in research activities.

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Ten Recommended Components of an Effective Health System Each country will have to decide how to organize their health system so that it meets the four fundamentals earlier discussed. In Africa, the challenge of developing an ideal health system is compromised by endemic poverty, limited financial and technical resources, and the pressure of responding to external donor funding. No matter the situation, no African country should adopt and implement a national health system that is not responsive to the needs of target populations and does not reflect national objectives. Various ideal configurations of health systems have been suggested (1-3, 5-8). At the core of these suggestions is the need for a flexible health system that responds to the present needs of target populations while contingently prepared to respond to future needs and challenges. Reform of health systems should be driven by domestic needs and considerations. Health sector reforms should be continuous, based on valid assumptions and exigencies, and focused on meeting the evolving needs of target populations and communities. In recommending the components of an effective health system, I am aware that each national government will have to decide on the best way forward, in consultation with domestic stakeholders. However, I believe that an effective national health system should at the barest minimum have the following components: 1. 2.

3. 4. 5. 6.

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A Service Delivery component focused on both preventive and clinical care, and, delivered at personal and community levels; A national health system that seeks to understand the Knowledge, Attitude and Perception of Patients and At-Risk populations regarding the quality of the contact/interaction with health services and healthcare delivery mechanisms; An Ethical and Equity-based health system that seeks to meet the needs of citizens; A trained, motivated Health Workforce that provides timely, quality health services; A Multi-Sectoral national health system that responds to both health and non health needs of patients and at risk population; A Financing Mechanism that shares the risk of healthcare delivery, drastically reduces the burden of health services on the poor, and ensures continuity of health care;

Strengthening Health Systems in Africa

7.

A national health system that values Information Technology and gradually moves towards an Integrated Information Management system for health; 8. A national health system that provides quality Drugs and Medicines, working Equipment, functioning Infrastructure and Conducive Environment for the provision of health services; 9. A national health system that utilizes Public-Private Partnerships to improve the quality, access and cost of health services. 10. A national health system that is Domestically Driven by the needs of target populations and utilizes International Development Assistance as a part of the national effort to meet the health needs of citizens.

References 1. World Health Organization (2007). Health Systems. Available at http://www.who.int/healthsystems/about/en/ 2. World Health Organization, Africa Region (2006). National Health Systems – Africa Big Public Health Challenge. In the African Regional Report on Health, 2006. Brazzaville, Republic of Congo: Author. 3. African Union (2007). Africa Health Strategy: 2007-2015. Third Session of the African Union Conference of Ministers of Health, Johannesburg, South Africa, 9-13 April. Addis Ababa, Ethiopia: Author. 4. Chinua Akukwe (2006) (Editor). Healthcare Delivery in Africa: Issues, Choices, Challenges and Opportunities. African Renaissance, July/August. 5. World Health Organization (2007). WHO Strategy on Health Systems. Available at http://www.who.int/healthsystems/topics/en/ 6. Dan Kaseje (2006). Health Care in Africa: Challenges, Opportunities and an Emerging Model for Improvement. Presented at the Woodrow Wilson International Center for Scholars Meeting, November 2. Washington, DC: Woodrow Wilson International Center. 7. Jessie McGowan, Vivian Robinson, Peter Tugwell (2006). High Priority Health Challenges in Sub-Saharan Africa: Is There Good Evidence? Ontario, Canada: Center for the Advancement of Health.

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.

8. World Health Organization (2006). A Global Health Agenda. Engaging for Health: Eleventh General Programme of Work 2006-2015. Available at http://www.who.int/gpw/GPW_En.pdf

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Chapter 6

HEALTH-FOR-ALL AS THE FOUNDATION FOR BETTER HEALTH SERVICES IN AFRICA CHINUA AKUKWE

Introduction The 1978 international health conference in Alma Ata, in then Russia, is widely considered as a landmark gathering that finally linked basic health services with social development responsibilities. The Alma Ata declaration (1) set forth brilliant health concepts and practices that would have led to Health-For-All to individuals worldwide by 2000. Although the Alma Ata declaration failed to lead to Health-For-All to individuals worldwide by 2000, it provided glimpses on what could be done to dramatically improve access to quality care, even in resource challenged environments. It also showcased how to mobilize stakeholders to work together and achieve hitherto unexpected outcomes. The Alma Ata declaration could be divided into three basic concepts (1, 2). The first concept reaffirmed the inalienable right of every individual to the best possible state of health. The second concept reconfirmed the need for collaborative alliances and partnerships focused on creating health systems that respond to the needs of target populations. The third concept is the role of primary health care systems as the basic foundation of a just and equitable healthcare program. I briefly discuss these concepts and conclude by indicating how the concept of Health-For-All can become the foundation of a revitalized health service delivery in Africa. The Right of Every Individual to the Best Possible State of Health The Alma Ata declaration reaffirmed that health, in accordance with the World Health Organization (WHO) definition is a state of complete physical, mental and social well being, and not merely the absence of diseases or infirmity. The Declaration further defined health 67

Health-For-All As The Foundation For Better Health Services In Africa

as a “fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires action of many other social and economic sectors in addition to the health sector.” This reaffirmation challenged all national governments and the international economic and political order to rise to the challenge of providing healthcare to all citizens of the world. It also linked conclusively in the health arena, the intricate relationship between international economic order and state of personal health. The Declaration foreshadowed the concept of globalization by more than a decade. The Declaration indicates that a “New International Economic Order” based on justice and equity can be the building blocks of a world where disparities in health status between rich and poor nations are drastically minimized. The Declaration also set in motion one of the most fundamental challenges of healthcare delivery in any part of the world: the need for health stakeholders to collaborate and work together as partners. The Alma Declaration in declaring as unjust, gross inequalities in the state of health between individuals living in rich and poor nations, creates a moral burden whereby governments in the North should work closely with their counterparts in the South with a shared goal of improving access to better health services and creating conditions for individuals to attain the best possible state of health. The inalienable right to health also reaffirms the central role of national governments to organize and manage health services in their jurisdictions. Every national government should design and implement health services that meet the needs and priorities of its citizens. No matter the level of resource constraints in each country, national governments have the cardinal role to conceive, design and implement health strategies that can lead to improved health status in their countries. The right to health also comes with responsibilities. The Alma Ata Declaration reaffirms the responsibility of target populations to participate as individuals and in groups in the planning and implementation of health services intended for their use. Thus, optimal health systems and programs should have verifiable mechanisms for assuring the participation of target populations in the conceptualization, design, implementation, monitoring and evaluation of health services. In addition, target population should take charge of personal health status and that of their families. In doing so, target

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populations will prod governments to make quality health services accessible and affordable. The Need for Collaborative Alliances and Partnerships in Health The Alma Ata Declaration laid a firm foundation on the need for all stakeholders to work together in organized efforts to improve health throughout the world. Today, national governments work with domestic private sector and civil society partners. The national governments also work closely with international development partners. The ultimate goal is to create enabling environments that would allow individuals to assume responsibilities for their own health. Another major goal is to create opportunities for at-risk individuals to have access to consistent, timely access to quality and affordable health services. The Central Role of Primary Health Care The Alma Ata Declaration define primary health care (PHC) as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.” PHC as envisaged in the Alma Ata declaration is the vehicle for linking all citizens to a national health system. PHC is also the primary interface between clients seeking health services and the health care system. PHC serves as the foundation of the three-tiered system of care, linking general hospitals as secondary level of care and teaching/specialist hospitals as the tertiary level of care with basic health services. PHC as noted in the Alma Ata declaration is not an inferior system of care. It is not a healthcare strategy for the poor. Rather it is a roadmap for bringing top quality health services closer to those in need irrespective of their income or social status. By emphasizing a continuous referral system that starts at the PHC level to the secondary and tertiary levels and loops back to the PHC level, there is an expectation that the quality of care provided at each level will be at

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optimum, with full complements of staff, infrastructure and equipment. The Alma Ata Declaration recognized PHC as the strategy that will lead to Health-For-All by 2000. To reach this goal, the Alma Ata declaration recognized the need for the full deployment and better use of global resources. This deployment and better use of global resources never happened. By the 2000, not every individual had access to health services. However in many African countries, the late 1970s and the 1980s witnessed unprecedented commitment of resources to PHC, including training of health professionals and construction of health centers and clinics. Individuals with both frontline and policy making experience in PHC strongly believe that the Health-For-All concept anchored on a community-based system of healthcare is still very relevant in today’s search for answers. The former Director General for the World Health Organization, late Lee Jong-wook remarked that the Health-For-All movement made it possible for individuals and organizations to think the impossible and to aspire for unprecedented goals and objectives (3). He noted that although the challenges of the new millennium is vastly different from the Cold War days of 1978 and the fact that more than 2 billion people are now added to the global population since 1978, leading to new set of challenges, the inspiring role of the Health-ForAll movement cannot be overemphasized. The long term former prime minister of Mozambique, Pascoal Mocumbi recognizes the role of the Health-For-All concept as the foundation for assuring equity in access to health services (4). Dr. Mocumbi observed that the noble idea of Health-For-All to citizens of the world or each country should be an inspiration for policy makers and program managers as they make decisions on the best possible healthcare delivery mechanisms for target populations. The May 1998 World Health Assembly (2) adopted the new global health policy known as “Health for All in the 21st Century.” The new global health policy ensured a continuation of the Alma Ata HealthFor-All process and duly recognized newer challenges and obstacles. The new thrust of the Health-For-All in the 21st century has commitments in the following areas:

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•

To provide the highest attainable standard of health as a fundamental right;

•

To strengthen application of ethics to health policy, research and service provision;

•

To implement equity-oriented policies and strategies that emphasize solidarity; and

•

To incorporate gender perspective into health policies and strategies.

Health-For-All as the Foundation of Revitalized Health Services in Africa Authors of earlier chapters of this book provide information on the major challenges of healthcare delivery in Africa. The need is extensive and resources are limited. The envisaged renewal of health services in Africa requires a firm foundation of principles and concepts that should guide the role of policy makers, program managers and all stakeholders as they search for the best possible way to provide health services to all Africans. The Health-For-All Concept provides a firm foundation that has been tried and tested (2-5). The concept has also been modified to reflect current challenges and emerging threats. The concept is also the subject of extensive expert reviews and analyses. Health Services in Africa should be anchored on the following Health-For-All Concepts:

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•

Health is an inalienable and fundamental human right. Every effort should be made to provide health services that allows patients and at risk populations attain the highest possible state of health;

•

Health services should be provided under the highest possible ethical standards with verifiable assurances for informed consent, patient confidentiality and the integrity of health records and data. Health services research, policy making and service provision should be conducted in a transparent, accountable and ethical way;

•

The basic foundation of a three tier health service delivery system (primary, secondary and tertiary levels of care) should

Health-For-All As The Foundation For Better Health Services In Africa

be community-based and community-focused system of care that provides timely, consistent quality care; •

Health services in Africa should perspectives in all phases of care;

•

Collaboration and goal oriented partnerships should be a major component of health services in Africa. It would be ideal to have public/private/civil society/professional organizations/external donor collaboration and partnerships in health care delivery mechanisms;

•

Target communities and at-risk populations should be actively involved in the design, implementation, monitoring and evaluation of health services. This active involvement should be measurable and verifiable.

incorporate

gender

References 1. World Health Organisation (1978). Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 612 September. Available at http://www.who.int 2. World Health Organization (1998). Health for All in the Twenty-First Century. Geneva, Switzerland: Author. 1. Lee Jong-wook (2003). International Seminar on Primary Health Care 25 Years of Alma-Ata. Speech at the International Seminar, Brasilia, Brazil. Available at http://www.who.int/dg/lee/speeches/2003/brazilia_almaata/en/print.ht ml 2. Pascoal Mocumbi (2006). Equal Opportunities to Health for All. Vision for the World Health Organization. Maputo, Mozambique: Author. 3. World Health Organisation (2007). WHO Called to Return to the Declaration of Alma-Ata International Conference on Primary Health Care. Available at http://www.who.int/social_determinants/links/events/alma_ata/en/prin t.html

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SECTION 2: SPECIFIC ISSUES THAT IMPACT ON THE DELIVERY OF HEALTH SERVICES IN AFRICA

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Chapter Seven

THE ORGANIZATION AND MANAGEMENT OF HEALTH SERVICES IN AFRICA CHINUA AKUKWE

Introduction As noted in the previous chapters of this book, the provision of health services depends on: (1) A sound health policy, whether at national or continental levels; (2) A talented and committed workforce; (3) A strong foundation to provide Health-For-All; (4) A transparent and equitable financing system; and (5) A responsive health system that meets the needs of the target population.

The organization and management of health services in Africa reflects how various countries have tackled, resolved or deferred the aforementioned issues. It may also reflect how far African countries have improved upon inherited health systems from the colonial era. In addition, the management and organization of health services reflects upon government expenditure on health, the state of infrastructure, the level of training of existing work force, and the extent of external donor impact. I review the basic organization and management of health services. Organization of Health Services in Africa The apex entity for the organization and management of health services in African countries is the National Ministry of Health (MOH). Depending on the political arrangement in each country, you may have state ministries of heath, provincial or regional ministries of health and prefecture health departments. At the grassroots level, you have the 75

Clinical Health Services in Africa: The Special Role Of Teaching Hospitals

District health system, the oldest supervisory level of health management in Africa (1, 2). The District health system supervises healthcare delivery in designated geographical areas, including local general hospitals, health centers, health clinics and dispensaries (3). In some countries, you have community health workers that live in the service area and provide door-to-door preventive and basic clinical services. In this configuration of organized health systems are traditional medical practitioners, traditional birth attendants and faith healers (15). These practices are patronized significantly by Africans. They are often the first port of call in the health seeking behavior in many rural isolated areas or in urban slums in the continent. Their services are also not cheap. From a clinical point of view, there are three traditional levels of care in most African countries. The primary level of care includes health services provided in dispensaries, health clinics and health centers. Primary care facilities are structured to provide basic clinical care, including antenatal and maternity services, elective surgery, and, uncomplicated emergency care. This level also provides preventive health services. The primary care level is also expected to serve as epidemiological sentinels and as the first line of defense against emerging epidemics and disasters (natural and man made). Most primary care services in Africa are controlled by local authorities at District health levels, local governments or township governments (3, 4). The secondary level of care includes non specialist or general hospitals that provide more complicated clinical care, receive clinical referrals from primary level centers, and may provide training opportunities for new doctors and other health professions during their compulsory internship training programs. Management of secondary level health programs is under the supervision of state governments and their equivalent. Secondary level care systems provide more robust epidemiology and surveillance services and are expected to liaise closely with primary level care systems. In many communities in Africa, secondary levels of care provide both acute and chronic care, and are often the apex hospital covering large geographical areas. Tertiary level of care represents specialist and teaching hospitals. The specialist hospitals include national institutions that specialize in

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various clinical areas such as eye, ear/nose/throat, orthopedics, dentistry and other forms of specialized care. Teaching hospitals not only provide training for medical students, residents and other health professionals but also have wide range of specialist components compared to other forms of clinical facilities. Some teaching hospitals have special designations of “excellence” reflecting concentration of clinical competencies and expertise. Some teaching hospitals are designated cardiac center of excellence, pediatric center of excellence, neurology center of excellence and so on. In some African countries, national specialist hospitals and teaching hospitals are managed by the national government through the national ministries of health. In other countries, state governments and their equivalent manage these hospitals, especially if they are part of a state university. In some situations, religious organizations and external organizations manage specialist and teaching hospitals. Tertiary level health systems in Africa provide acute and chronic health care. They also run outpatient clinics for clinical and preventive health consultations, including clients who bypassed the primary and secondary levels of care. These outreach services provide important training opportunities for medical students and residents. In addition to the public configuration of health services in Africa, there are growing proportions of privately managed health systems (1, 2, 4-6). Some of the private managed health systems provide primary, secondary, or in some cases as earlier noted in this document, specialized health service. There are also private health services that cater to the employees of large business organizations and their families. These health programs may be very sophisticated, especially in the area of acute care. For multinational companies, their own health care facilities or those retained by them often have highly regarded acute care services so that expatriate staff could be stabilized before being medically evacuated to their homeland hospitals. Religious organizations run large, dispersed health systems in some African countries. These health systems often operate in remote locations and can be the mainstay of health services in these areas. The range of services provided may include primary, secondary and tertiary levels of care.

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Management of Health Services in Africa The National Ministry of Health is the apex health management entity in Africa. The leader of the National Ministry of Health is the Minister of Health who is appointed by the President or head of government. As a member of the President’s cabinet, the Minister of Health is the chief health policy maker of the country. The Minister of Health is also responsible for domestic and external health initiatives that require the participation of national governments. The Minister is supported in most ministries of health by the following line officers: • • • •

•

•

A director general/permanent secretary who is often the chief operating and chief accounting officer of the Ministry; A director of medical services who is the chief scientific officer of the ministry; A director of personnel or human resources who is responsible for work force recruitment and retention issues; A director of supplies/procurement who is charged with logistics and management of public health facilities, goods and services; A director of hospital services and training who is the management oversight official for national specialist and teaching hospitals, including doctors, nurses and other health professionals; and, increasingly A line director for public health or epidemiology/surveillance services with the major function of providing leadership on national readiness issues against epidemics and other emerging health threats.

The Ministry of Health may have various categories of staff that deal with domestic and international issues, including those that liaise with international development partners. Most MOH have dedicated officers responsible for communications and interaction with the general public. They may also have dedicated officers that provide national leadership in nursing, pharmacy, laboratory technology and other specific areas of health service. State ministries of health and their equivalent are often aligned managerially as their colleagues in the national ministry of health. The only major exception is that state ministries of health have dedicated senior officials for community-based services, nursing, pharmacy, and

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allied health professions. State ministries of health may also have state health management boards with quasi-independent mandates to run hospitals in that state. However, these officials report to the head of the health ministry or the deputy. District health officers usually are at the apex of District health systems. This is a powerful post in many African countries since they are responsible for the provision of health services in wide geographical areas. They may or may not be medical doctors. District health officers include nurses, sanitary officers and public health workers. Head of District health systems also have senior officers responsible for public health, clinical care, management, nursing, personnel, procurement/logistics, and data collection. District health officials need to visit health facilities under their jurisdiction on a regular in order to sharpen operational readiness and performance. They are also the first line of defense in epidemics and other disasters. In rural, underserved communities, district health officers have enormous clout and respect, often based on long years of meritorious service. Regarding direct operations of health services at primary, secondary or tertiary levels, the basic organization and management structure is similar to the situation in district health offices, with a major difference: At the most basic levels of care, one person may wear multiple hats as the head of the health facility, head nurse or community health worker, and head of facilities management. This individual with multiple administrative hats is often assisted on finance and supply issues by a clerk or mid level accounting officer. The head of primary care centers often have to sign off on time sheets and make payroll at least once a month. They have to sign off on received supplies and make requisition for new supplies. The head of a primary health center or clinic in Africa is a very busy person. For secondary level of care, the head of the hospital, usually a medical doctor is also the chief executive officer. This individual is supported by heads of various clinical services offered in the hospital (clinical medicine, surgery, pediatrics, obstetrics and gynecology, nursing, pharmacy, laboratory services and others) and the head of non clinical services (finance/supplies, personnel, facilities, and transport, and other services). The heads of these departments supervise the clinical activities in their departments.

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At the tertiary level of care, health services are under the leadership of the chief medical director or equivalent who is usually a medical doctor. This individual is supported by directors of clinical services, personnel, finance/supplies, facilities management, and security. The director of clinical services supervises heads of medical specialties, nursing, pharmacy, laboratory technology, pathology and other specialties, way beyond what is available at secondary levels of care. The management of health services is a major challenge in resource constrained environments as the internal capacity to respond to emerging health threats is compromised by limited financial resources, limited number of health workers and large proportion of clients who are awaiting care (4-9). The brain drain of health workers is significant as highly skilled health practitioners leave for richer African countries and the West. Poor remuneration is also a problem. In addition, training and re-training opportunities may not be readily available. Lack of equipment and crumbling infrastructure represent additional challenges. Basic Attributes of Effectively Organized and Manage Health Services The indispensable attribute of health services management is an effective and functional national ministry of health. The national ministry of health sets the right tone and direction for health in each country. The national ministry of health requires an effective minister of health that commands the respect of politicians, policy makers, technocrats and professional organizations. The minister of health should be an active part of appropriation and budgeting process so that enough resources are reserved for health services. The minister should have the capacity to run a professional ministry and at the same time build viable and sustainable partnerships with health stakeholders. The national ministry of health needs to have fully competent staff with fair and commensurate remuneration. The national ministry of health should be organized in such a way that it becomes the fulcrum of the national government efforts to effectively engage domestic and international stakeholders on health care issues.

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National ministries of health need to be sufficiently organized and deployed in order to: • • •

•

•

• • • •

•

Set and help shape national health policies and programs; Recruit and retain competent and knowledgeable staff; Provide knowledge leadership on content issues of health and development, including Health-For-All concepts and social justice issues; Set norms, standards of practice and training, professional ethical behaviors/practices and establish verifiable mechanisms for enforcing them; Establish replicable mechanisms for monitoring and evaluating the health status of defined population at primary, secondary and tertiary levels of care; Manage first class epidemiology and surveillance program that meet World Health Organization standards; Enforce national health laws and practices, and, reform outdated regulations and practices; Establish transparent health service operations with verifiable accountability mechanisms; Implement in consultation with local professional organizations a high level of technical assistance to stakeholders at state and district levels; Engage external partners with clearly articulated health goals based on objective needs assessment and the active engagement of stakeholders

Other important attributes of an effectively organized and managed health service include: •

• • •

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The organization and management of health services should have a strong community-based orientation. The challenge of African governments is to re-establish community-based health programs that respond to the felt needs of target populations and provide a basic minimum of care to all citizens. The organization and management of health services should eschew bureaucracy, redundancy and wastage of scarce resources; Health services should be run in a cost effective basis, and should be based on transparent and ethical allocation of resources; Health services should adopt sector wide approaches so that multisectoral cooperation could be utilized to enhance the delivery and effectiveness of care;

Clinical Health Services in Africa: The Special Role Of Teaching Hospitals

•

Health sector reforms should be embraced and be driven by domestic needs and priorities; The provision of health services should ensure the availability and delivery of affordable drugs and other medical goods; Health services should be accessible, affordable and of consistent high quality; Vertically and fragmented provision of health services should be minimized; Managers of health services should focus on performance and outcomes of care. In particular, managers of health services and policy makers should obtain regular feedback from patients and at-risk populations regarding the efficiency and effectiveness of care. This is a fundamental weakness in many African countries since feedback from consumers are rarely sought or recognized; Management information systems and platforms should form the backbone of health services. This is a difficult task in resource challenged environments. However, national governments can deploy management information systems in phases with the ultimate goal of having an integrated management and health information system within a stipulated time frame.

• • • •

•

Organizing and managing health services in Africa remains a daunting challenge. In addition to the organizing and management issues of the work force, the World Health Organization identifies two critical issues that should be addressed (9, 10). These issues are: 1) The need for adequate management of resources and support networks. This includes appropriate attention and action on human resources issues; financial resources; information systems; drugs and supplies; equipment, vehicles and buildings; procurement systems; referral systems; and, waste management. The key is to have an integrated management and support services network; 2) The need to focus on quality of care irrespective of the type of care. Whether it is in dispensaries, health clinics, health centers or hospitals, individuals responsible for the organization and management of health services in Africa should pay close attention to quality assurance issues, patient safety, user satisfaction and standards of care. Standards of care should meet or exceeded client and stakeholder expectations.

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Conclusion Managers of health services in Africa need to focus closely on the felt needs of patients and their families. A functional health system should ensure that health services respond to the health needs and priorities of consumers. In particular, managers of health services in Africa should ensure that quality care is provided in all health facilities. In particular, the poor in Africa should have access to quality health services that provides access to essential medicines and other public health goods (11). The high quality health service should be provided in an ethical, fair and equitable manner so that citizens irrespective of financial status or geographical location can benefit maximally from available health services, whether it is clinical or preventive care. References 1. World Health Organization, Africa Region (2006). Health of the People. The African Regional Health Report 2006. Brazzaville, Congo: Author. 2. African Union (2007). Africa Health Strategy: 2007-2015. Third Session of the African Union Conference on Ministers of Health, Johannesburg, South Africa, 8-13 April. Addis Ababa, Ethiopia: Author. 3. World Health Organization (1998). District Health Facilities: Guidelines for Development and Operations. WHO Regional Operations, Western Pacific. Geneva, Switzerland; Author. 4. World Health Organization (2007). Management for Health Services Delivery. Leadership and Management in Health Systems. Available at http://www.who.int//management/en/ 5. Dominique Egger, Phyllida Travis, Delanyo Dovio and Laura Hawken (2005). Strengthening Management in Low-Income Countries. Making Health Systems Work: Working Paper No. 1. WHO/EIP/healthsystems/2005.1. Geneva, Switzerland: World Health Organization. 6. George Dorros (2006). Building Management Capacity to Rapidly Scale Up Health Services and Health Outcomes. Geneva, Switzerland: World Health Organization.

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7. Centers for Disease Control and Prevention (2007). Core Management Competencies for Public Health Managers. Available at http://www.cdc.gov/smdp/corecomp.htm 8. World Health Organization (2000). Health Information Systems Developing and Strengthening. Guidance on Needs Assessment for National Health Information Systems Development. WHO/EIP/OSD/00.6. Geneva, Switzerland: Author. 9. World Health Organization (2007). Management of Resources and Support Systems. Available at http://www.who.int/management/resources/en/ 10. World Health Organization (2007). Management of Quality of Care. Available at http://www.who.int/management/quality/en/ 11. World Health Organization (2007). WHO Model List of Essential Medicine. 15TH List, March 2007. Geneva, Switzerland: Author.

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Chapter Eight

CLINICAL HEALTH SERVICES IN AFRICA: THE SPECIAL ROLE OF TEACHING HOSPITALS CECILIA CHUKWU Introduction I entered the University of Nigeria Medical School, Enugu, Nigeria in 1979. For nearly three decades, I have had professional affiliations with teaching hospitals in Nigeria and the United States. These affiliations include my time as a medical student, a resident physician, a chief resident, an attending physician and now as a professor. I have spent most of my adult life observing the operations of teaching hospitals. Over the years, I have come to realize the significant role of teaching hospitals in the healthcare delivery system of a country. I have also come to understand the enormous potential of a teaching hospital in reshaping the delivery of health systems through its role as innovators of care and as leading citadels of learning. In this article, I discuss teaching hospitals as the tertiary level of health services that train generations of health providers, provide health service, and conduct health research. By this definition, teaching hospitals train doctors, nurses, dentists, pharmacists, laboratory technologists, physiotherapists and other health professionals. This training program may commence at undergraduate level, proceed to clinical internships, and continue with post graduate and resident programs, including fellowship and post-fellowship opportunities. The role of preparing the next generation of health practitioners is sacrosanct in any healthcare delivery system. Nations without medical schools or teaching hospitals spend fortunes sending their citizens for further training in other countries. Equally notable is the unique role of teaching hospitals in the provision of health services. Teaching hospitals provide direct care to individuals and families. These patients may have bypassed the primary and secondary levels of care. In Africa, clinical services as discussed in earlier chapters of this book face the problems of limited financial and technical resources. Clinical services in Africa also face problems of brain drain, crumbling 85

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infrastructure, poor staff morale and shortages of drugs and equipment. At the apex of clinical services in Africa sits teaching hospitals. Concerns about the vital role of teaching hospitals have engaged policy makers in Africa at national and continental levels (1, 2, 3, 4). The World Health Organization, Africa Region in 2002, 2003 and 2006 organized conferences that reviewed ways of strengthening the role of hospitals in national health systems (1, 2, 3, 4). The World Health Organization landmark 2006 World Health Report on the growing human resource crisis in health also reviewed the role of hospitals at all levels in ameliorating the shortage of skilled manpower in the health sector (3. 4). Teaching Hospitals in any part of the world standout because they are expected to train and qualify doctors, nurses and other health professionals that are not only competent but are also expected to do no harm to their patients. In this regard, teaching hospitals bear high burdens of expectation and responsibility. Teaching hospitals no matter their location and no matter the level of resource constraints should have certain attributes to be recognized and respected as citadels of medical education (5-15). Generic Attributes of Teaching Hospitals The number one attribute is that a teaching hospital must be professionally accredited. In this regard, a teaching hospital must met professional standards of teaching and practice set by competent professional authorities and the government of each country. The accreditation process is a continuous exercise, with the convening authorities reserving the right to “visit” the teaching hospital at any time to verify standards of care. The convening accreditation authority can withdraw recognition of medical education status if the teaching hospital is found wanting on specific professional standards and practice. As part of the accreditation process, teaching hospitals are expected to not only meet national standards of care but to also be in congruence with recommendations from respected international organizations. It is important to state explicitly that the World Health Organization does not convey accreditation to teaching hospitals or

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medical schools in any country (10). National governments and professional organizations in each country establish accreditation standards for teaching hospitals. However, these standards are expected to meet international standards. The second attribute is that teaching hospitals provide health service to patients. This health service provision is made possible through the outpatient facilities of the teaching hospital and also through referrals from primary and secondary level health facilities and also from private funded health systems. Teaching hospitals are also major providers of acute and emergency medical care since they are likely to have the full complements of staff to provide such services. The third attribute is that teaching hospitals engage in health research. Teaching hospitals are expected to conduct basic and clinical research. They are also expected to participate in public health research, including community-based research efforts. No matter the state of financial and logistic support, teaching hospitals are expected to engage in research activities. The fourth attribute is that teaching hospitals should have faculty members that are not only terminally trained in their respective fields but are also qualified to impact specialist medical knowledge. Teaching hospitals in Africa should attract the best qualified health practitioners who are academically prepared to teach in various medical disciplines. Support staff members of teaching hospitals are also expected to achieve or exceed mandatory professional qualifications. The fifth attribute is that teaching hospitals should provide leadership on innovative ways to improve the delivery of health services through their evidence-based approach to care. Policy makers and other stakeholders increasingly look toward teaching hospitals to devise creative ways of enhancing the quality of health services, especially in clinical care. As part of academic institutions, teaching hospitals operate under the ambiance of academic freedom. Faculty members consequently have the responsibility of conducting unencumbered research on how to solve pressing national and local health problems. The sixth attribute is that teaching hospitals in Africa usually receive direct budgetary support from national governments. The budgetary support almost always covers recurrent costs. The budget support also takes care to varying degrees of significant capital expenditures. In addition to direct national government budget 87

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support, teaching hospitals receive assistance from private organizations and external donors. The seventh attribute is that various components of the infrastructure of a teaching hospital should meet or exceed recognized professional standards. This is critical in resource challenged environments since no component of a teaching hospital infrastructure can afford to drop below accepted standards. Leaders of teaching hospitals often spend considerable time shoring up the state of the infrastructure in their medical centers. The eight attribute is that teaching hospitals focus relentlessly on quality improvement initiatives. These initiatives may include customer satisfaction surveys, independent reviews of training programs and services, and, internal peer reviews. The ultimate goal is to maintain high standards of professional education, service and research. The ninth attribute is the focus on professional education in teaching hospitals. These hospitals aim to produce well trained health workforce that meet the health needs of the citizens of that country. Even when teaching hospitals take in international students, the primary focus is still on national health needs and priorities. As a result, professional education in teaching hospitals is always in evolution, ready to meet new or emerging challenges. The tenth attribute is that teaching hospitals in Africa now must have presence in local communities. This is often realized through community medicine and public health programs of medical schools and teaching hospitals. In Nigeria, teaching hospitals have affiliations with Federal comprehensive health centers situated in the local community. A major difference between teaching hospitals in Africa and the West, especially in the US, is the role of hospice services for the terminal ill. In the United States, teaching hospitals often have links with top quality hospice centers where terminal ill patients in agreement with family members, significant others or caregivers are transferred for terminal care. In the hospice center, the aim is to keep the patient as comfortable as possible, reduce pain and allow for visits and interactions with family members and friends. In this setting, patients spend their last days in dignity and with their families and friends. Hospice care is not common in Africa.

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Organization and Management of Teaching Hospitals One of the most remarkable things about teaching hospitals all over the world is that the envisaged mission is always the same: to provide the best possible medical education, health services, and locally relevant research. Teaching hospitals are organized with this mission in mind. The management of teaching hospitals also reflects this basic mission. Organization of Teaching Hospitals

Teaching hospitals are organized around specific functional entities. First is the relationship of the teaching hospital with the medical school. This relationship may not be so distinct to the outside eye but it is a fact of life. The teaching hospital or medical center is often a part of the medical school or college of medicine. However, most teaching hospitals in Africa and other parts of the world also have quasiindependent status, with its own board of directors and officers that focus exclusively on running the teaching hospital. In Nigerian teaching hospitals, these individuals are known as Chief Medical Directors. Most of these chief medical directors have faculty affiliations with the medical school. At the George Washington University Medical Center, Washington, DC where I am currently affiliated, the head of the medical center was for a long time the dean of the medical school. Now, the head of the medical center is the vice president of health affairs for the entire university and the supervisor of the medical school and the school of public health. The medical center has a chief executive whose primary role is to run the George Washington University Hospital. No matter the role, the primary objective is for teaching hospitals to be linked to medical schools. Second, teaching hospitals have semi-autonomous or autonomous broad offices expected of a complex organization: the chief executive, head of clinical services, head of administrative services, head of finance and supplies, head of communications and external relations, and, head of audit and internal investigations. Third, teaching hospitals have direct administrative entities in the form of departments and sub-departments that reflect academic and teaching responsibilities. Most teaching hospitals have departments of 89

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internal medicine, surgery, obstetrics and gynecology, pediatrics, pharmacy & pharmacology, nursing/midwifery, pathology/ laboratory services, and, epidemiology/statistics. Teaching hospitals may also have sub-departments or full fledged departments in the areas of ear, nose and throat; psychiatry; psychology; various areas of internal medicine and surgery; community medicine; and, specialist units for women health issues. Fourth, teaching hospitals take special precautions on cleanliness of facilities and safe disposal of waste. Since teaching hospitals attract patients with complicated ailments and at various chronic levels, and have intensive care units where cleanliness is at a premium, the leadership is rightly preoccupied with cleanliness of staff, equipment, infrastructure and surroundings. In this regard, surgical theaters must be clean; delivery rooms must be clean; hospitals gowns must be thoroughly cleaned and secured; medical and surgical equipments must be sterilized and stored according to the best possible standards; and, staff must practice the highest levels of personal hygiene. Fifth, teaching hospitals all over the world must be flexibly organized in such as a way as to handle referrals from primary and secondary levels of care. A teaching hospital will quickly lose its professional standing and respect if it is unable to manage referrals and consistently provide the level of professional expertise beyond what is typically available in other levels of care. A major reason teaching hospitals in many parts of Africa appear full of patients is that hospital specialist staff are under pressure to handle all referrals and walk-ins from secondary and primary levels of care. Sixth, teaching hospitals in Africa have their own fair share of outpatient clients. As earlier noted, these clients may have bypassed primary and secondary levels of care to seek assistance in teaching hospitals. The outpatient clinics also serve as important teaching opportunities for students and residents of all health professions undergoing training. The outpatient clinics also provide a steady flow of patients for the surgical and other hospital units that predominantly engage in surgical care. Seventh, teaching hospitals usually have a process for conducting post mortality reviews. These reviews seek to allow peers of the affected medical team to critically evaluate all aspects of the medical care provided to the deceased while in the teaching hospital. The

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review also provides invaluable learning opportunities for medical students and residents. Eight, the support, non medical staff members of teaching hospitals are extremely important in the delivery of health services. Support staff members in teaching hospitals include cleaners, ambulance drivers, intake and discharge clerks, facility staff, security personnel and others. They play a critical role in maintaining the high standard expected of teaching hospitals. Ninth, teaching hospitals need to be actively engaged with local communities. In all parts of the world, teaching hospitals must now reach out to individuals and families that live in their operational areas. These outreach activities need to be both aggressive and long term focus, with emphasis on community medicine programs, public health services and organized efforts to elicit the input of target populations on the efficiency and effectiveness of health services provided in the teaching hospital. In Nigeria, the board of directors of teaching hospitals often includes representatives from local communities to ensure that the voice of the local community is heard in the highest decision making organs of these hospitals. Tenth, teaching hospitals provide some measure of academic freedom to its medical staff to practice the best possible standards of care. Boards of directors of teaching hospitals, rarely, interfere with the day-to-management of teaching hospitals. The national ministry of health rarely interferes with treatment protocols undertaken by health practitioners in teaching hospitals unless known breach of existing laws guarding practice in hospitals or specific professional standards come to light. Medical practice in teaching hospitals is expected to reflect the highest possible standards and in return, health practitioners have the relative freedom to do their best in the interest of their patients. Management of Teaching Hospitals

Management of teaching hospitals is based on hierarchy. The Board of Directors or equivalent authorities have broad powers to set policy regarding the management of teaching hospitals. The board of directors derives guidance from relevant national laws of each country that regulate the management of teaching hospitals. The board of directors represents a mix of health and non health stakeholders, including representatives of local communities. The national 91

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government or a state government of each country depending on relevant laws appoints members of the board of directors of teaching hospitals who serve for renewable fixed terms of office. The chief executive of the teaching hospital with titles ranging from chief medical director to medical director has the direct responsibility for the day-to-management of the hospital. This individual, often a distinguished medical practitioner, supervises the entire operations of the teaching hospital, including the administrative and training functions of the institutions. The next level of management is at the various departments in the teaching hospital (head of clinical services, head of administrative services, head of finance and supplies, head of communications and external relations, and, head of audit and internal investigations, at the barest minimum). Heads of various departments manage activities within their entities and also liaise directly with the head of the teaching hospital. At the next level are managers that deal with various issues under general management. The Clinical Services department is likely to have heads of the following departments: internal medicine, surgery, obstetrics and gynecology, pediatrics, dentistry, pharmacy and pharmacology, nursing/midwifery, pathology/laboratory services, and epidemiology/statistics. Increasingly teaching hospitals have departments of community medicine and public health. The heads of the various clinical departments can be very influential in teaching hospitals depending on national and international reputation of the department, the reputation of the head of department or the proportion of medical practitioners affiliated with the department. Other general departments such as administrative services, finance and supplies, communications and internal audit are also managed in such a way as to enhance efficiencies and economies of scale in the teaching hospital. One of the most formidable levels of management incidentally may appear to be at the totem pole of management activities in teaching hospitals. Committees that represent the interest of various health practitioners and support staff in teaching hospitals can be very powerful in terms of setting policies and influencing management of teaching hospitals. Committees that represent medical doctors are very powerful in any teaching hospital in any part of the world. They often engage the management of teaching hospitals on how best to improve

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quality of care, how to enhance remuneration of staff and how to improve the standard of medical education in the hospital. All professional groups in teaching hospitals often work closely with the management of teaching hospitals to address issues critical to their professional needs and aspirations. Support staff members of teaching hospitals also have committees that represent their interests before the management of their hospitals. They are often well organized and battle tested in labor-management relations issues. Journey So Far in My Experience with Teaching Hospitals In my experience with teaching hospitals in Nigeria and the United States, I have noticed that common problems exist. The first is the struggle to pay for the cost of running and maintaining teaching hospitals. Teaching hospital administrators work very hard to find additional sources of money to keep hospitals running and to fulfill the ever-growing need of the primary mission of medical education, service delivery and health research. Second is the need to continuously refine the comparative advantage of each teaching hospital in comparison to its peers. In Nigeria, you have various hospitals declared as centers of excellence in specific medical specialties. These centers of excellence are expected to provide technical leadership in chosen specialties and to provide the best post graduate training opportunities. In the United States, various teaching hospitals seek to be known nationally for their competence in select medical specialties and sub-specialties. These areas of competence often reflect the pioneering efforts of faculty in various medical areas, the national reputation of leading faculty members, the quantity and quality of research in the specific medical specialty, and the perception of medical students and residents of the quality of the specific medical specialty. Third, it is my experience that teaching hospitals can always do more. Managers and staff of teaching hospitals can always do more in the areas of maximizing financial resources, motivating existing staff, recruiting and retaining staff, and improving the enabling environment for health research. The key for doing more is to remain focused on the teaching, service and research primary missions of teaching hospitals. No teaching hospital in Africa can afford to neglect any of the three key missions no matter the scarcity of resources. 93

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Lessons Learned and Recommendations Lessons learned are plentiful on how local, national and international events impact on the ability of teaching hospitals to meet their primary mission of education, service and research. Teaching hospitals are never isolated from the political and economic realities of their operational areas. They are also not immune from international issues that impact on the quality of its work and staff. Building Political Support

I have learnt in Nigeria and the United States that teaching hospitals cannot remove themselves from political realities. Since most teaching hospitals receive significant proportions of their operating budgets from politicians, leaders of these hospitals should make the impact of their work known to local and national politicians. Teaching hospitals leadership should also utilize every opportunity to provide information on the positive contributions of teaching hospitals to the overall health care delivery system of their country as well as the potential for teaching hospitals to do more if given better support. In particular, teaching hospitals should find ways to reach out to politicians on how to consistently provide support for the very important mission of training future leaders in the health sector, saving lives through better healthcare delivery mechanisms, and, providing cutting edge health research that save lives and improve the efficiency and effectiveness of care. In the United States, political support for the prestigious National Institutes of Health, Bethesda, Maryland is assured because politicians clearly understand the special contribution of the Institute to basic and clinical research. Working with Public and Private Policy Makers

Policy makers, political or technical, depend on available information to make the best informed judgment on policy issues. It is not evident to me that teaching hospitals in Africa are focused on providing information from their work to policymakers in the public and the private sector. Policy makers in Africa need to know about the impact of the medical education in teaching hospitals. They need to know about the effectiveness of health services delivered in teaching hospitals. They also need to be aware of the immediate and long term

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impact of health research conducted in teaching hospitals and how these research efforts can help them make better decisions. Impact of Training and Re-Training Programs

Teaching hospitals have enormous capacity to influence the availability of skilled manpower in their countries. However, this realization must be tempered with the knowledge that lack of quality jobs will force their graduates to seek greener pastures in other countries. The most important lesson in my view is that teaching hospitals must now be at the forefront of organized efforts to mitigate the impact of brain drain in the health sector. Teaching hospitals should be at the forefront of national discussions on staff recruitment and retention in the health sector, reasonable salaries for health staff, and improved conditions of service for health workers. Otherwise, teaching hospitals will continue to produce health professionals who due to deteriorating professional standards at home will find sanctuary in the West and other African countries. The Importance of Community-based Health Services

Teaching hospitals of today are integral to the overall health status of their operational communities. A major lesson I have learnt is that teaching hospitals are important stakeholders in community-based efforts to improve the state of health in rural communities throughout Africa. As the tertiary level of care, teaching hospitals can deploy qualified staff to work on community medicine and public health issues in target communities. Teaching hospitals can also provide guidance on what works and what does not work on community-based healthcare through innovative research. Teaching hospitals can also lend their expertise to district and local governments in Africa as they seek answers to the major problem of how to provide basic health services in the midst of limited budget and massive need. Conclusion Teaching hospitals in Africa and in any part of the world command a unique perspective as the tertiary level of care. Teaching hospitals with their primary mission of professional medical education, quality health service and top-notch health research are indispensable to any country’s long term health plans. As the tertiary health level of care, 95

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managers and staff of teaching hospitals in Africa should provide leadership on better quality care. In my nearly three decades of knowledge about teaching hospitals in Nigeria and the United States, I am aware that the healthcare delivery system in these two countries, and in other parts of the world, require teaching hospitals to lead the way in the quest for better health services. References 1. World Health Organization, Africa Region, World Bank (2002). Building Strategic Partnerships in Education and Health in Africa. Consultative Meeting on Improving Collaboration between Health Professionals, Governments and other Stakeholders in Human Resources for Health Development. Addis Ababa, January 29-February IST. Harare, Zimbabwe: WHO Africa Region. 2. World Health Organization, Africa Region (2003). Towards Better Hospital Services in Africa. September 1st. Brazzaville, Congo: Author. 3. World Health Organization, Africa Region (2003). Meeting Suggests Ways to Strengthen the Role of Hospitals in National Health Systems. October 25th. Brazzaville, Congo: Author. 4. World Health Organization (2006). World Health Report 2006. Geneva, Switzerland: Author. 5. World Health Organization (2006). World Health Day 2006. Working Together for Health. An Advocacy Toolkit. Geneva, Switzerland: Author. 6. World Health Organization, World Federation for Medical Education (2004). Accreditation of Medical Education Institutions. Report of a Technical Meeting, Schaeffer garden, Copenhagen, Denmark, 4-6 October. Geneva, Switzerland: World Health Organization. 7. 7. World Federation for Medical Education (2003). Basic Medical Education. WFME Global Standards for Quality Improvement. WFME Office, University of Copenhagen, Denmark: Author. 8. World Federation for Medical Education (2003). Continuing Professional Development (CPD) of Medical Doctors. WFME Global Standards for Quality Improvement. WFME Office, University of Copenhagen, Denmark: Author.

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9. World Federation for Medical Education (2003). Post Graduate Medical Education. WFME Global Standards for Quality Improvement. WFME Office, University of Copenhagen, Denmark: Author. 10. World Health Organization (2007). World Directory of Medical Schools. Available at http://www.who.int/hrh/documents/wdms_upgrade/en/print.html 11. World Health Organization (2007). WHO/WFME Strategic Partnership to Improve Medical Education. Available at http://www.who.int/hrh/links/partnership/en/print.html 12. World Health Organization Regional Office for South East Asia (2000). Enhancing the Role of Medical Schools in STI/HIV and TB Control. Report of an Informal Consultation, Chennai, India, 5-7 July. New Delhi, India: Author. 13. Pavignani Enrico (2007). Module 9. Studying the Health Network. Available at http://www.who.int/hac/techguidance/tools/disrupted_sectors/module _09/en/print.html 14. Pascal Zum, Mario Dal Poz, Barbara Stilwel, Orvil Adams (2002). Imbalances in the Health Workforce. Briefing Paper. Evidence and Information for Policy, Health Service Provision. Geneva, Switzerland: World Health Organization. 15. Chinua Akukwe (2006) (Editor). Healthcare Delivery in Africa: Issues, Choices, Challenges and Opportunities. African Renaissance, July/August.

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Chapter Nine

THE ROLE OF LABORATORY SERVICES IN HEALTH CARE DELIVERY SERVICES IN AFRICA HENRY MBAH Introduction Clinical or medical laboratories and public health laboratories are involved in health care delivery. In clinical or medical laboratories, diagnostic or other screening procedures are done on biological specimens in order to get information about the health of patients. These specimens include blood, sputum, stool, urine, cerebro-spinal fluid, tissue biopsy or other potentially infectious materials. Public health laboratory operate as diagnostic and monitoring entities, which provide a first line of defense to protect the public against diseases and other health hazards. A United States Institute of Medicine committee report (1) on the future of public health stated that “Public health laboratories are an essential part of a robust and stable surveillance capability necessary to identify emerging threats, natural or intentional, to the health of the public and to track the effectiveness of interventions at multiple levels.” What are the Core Functions of a Laboratory in Health Care Delivery? A laboratory’s core functions are to provide: • • • • • • • • • • • •

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Appropriate diagnosis of common diseases; Patient safety testing for hematology, blood chemistry, liver function, kidney function, pregnancy, and so on; Testing for sexually transmittable diseases; Patient toxicity testing; Drug resistance testing and surveillance; Newborn screening for metabolic and genetic disorders; Safe blood transfusion; Epidemiological survey and surveillance; Control of local epidemics; Identification and characterization of emerging infections; Monitoring of zoonoses; Establishment of safe transport for diagnostic specimens;

The Role of Laboratory Services in Health Care Delivery Services in Africa

• • • • • • • • • • • •

Assurance of quality laboratory practice; Analysis of potentially dangerous substances; References and specialized testing; Environmental health protection; Food safety; Laboratory improvement and regulation; Policy development; Emergency response; Public health-related research; Training and education; Integrated data management; and, Partnerships and communication.

In summary, the role of the laboratory is to rapidly provide highly reliable data to support disease preventive measures. Another role is to facilitate prompt therapeutic decision-making, a cardinal principle of effective health services. Are Laboratories in Sub-Saharan Africa Adequately Performing These Key Roles? In developed countries, such as the United States, laboratories are functional and well organized to realize their core function. As part of national healthcare policy, developed countries promote the routine use of laboratory service to confirm disease diagnosis. Thus the decision to treat a patient is in most cases not based on empirical evidence but on scientific evidence. This close collaboration between doctors and laboratory professionals results in timely and accurate disease diagnosis, cost effective treatment, and better patient care overall. On the other hand, in most developing countries, even the most basic laboratory services are often lacking, unreliable or misused. This is especially true in sub-Saharan Africa, where laboratories cannot realize their core functions. It appears that diagnosis based on clinical symptoms alone, without the support of basic diagnostic tests, is the rule rather than the exception in most parts of Africa. This leads to inappropriate treatment, increased morbidity, and unnecessary loss of life (2). A 2006 study in Ghana concluded that doctors’ undervaluation of diagnostic testing is a major barrier to laboratory use, resulting in empirical diagnosis, non-judicious use of antimicrobials and increased

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cost to patients (3). Under these conditions, misdiagnosis, under diagnosis, and over diagnosis of diseases is rampant. The absence of laboratory support resulted in the misdiagnosis of Malaria in about 40 percent of children in Ghana when the underlying cause was bacterial sepsis (4). A rising epidemic of typhoid fever in Cameroon was dismissed because of the misuse of the Widal test (5). Another study in Botswana only found evidence of tuberculosis infection in about half of 229 patients suspected of tuberculosis (6). It has become apparent that laboratory services are the “Achilles heel” in global efforts to combat HIV infection, tuberculosis, and malaria, and the antimicrobial resistance that accompanies them (7). In Africa, where the disease burden is heaviest, laboratories are the most wanting. Why can’t Laboratories in Sub-Saharan Africa perform their Key Roles? Laboratory capabilities are undermined by major problems that can be grouped into: (1) Testing methods and poor routine practices; (2) Inadequacy of infrastructure; and, (3) Programs, policies and finance.

Testing methods and poor routine practices

Laboratory visits in Africa revealed some unacceptable routine practices and testing methods (personal observation, peer discussion and 8): • • • • • • •

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Halving of Western blot and urinalysis test strips to double testing capacity; Diluting and stealing of reagents to sell; Transporting, storing and exposing reagents in unapproved temperatures; Using expired reagents and test kits; Reusing of ELISA plates; Eating and drinking in the laboratory; Not disinfecting bench tops daily;

The Role of Laboratory Services in Health Care Delivery Services in Africa

• • • • • • • • • • • • •

Reusing disposable pipette tips and mouth pipetting; Sharing of a common pipette among different divisions of the laboratory; Reusing of blood and urine collecting tubes and disposable gloves; Not using protective clothing and gloves always; Taking protective clothing home for laundry; Separating blood with manual centrifuge; Using uncontrolled water sources and in some cases, having no running tap water; Handling of bio-hazardous and ordinary waste without discrimination; Not posting biohazard signs and marking restricted areas adequately; Working in a cramped, dusty environment without functional air conditioning; Not maintaining and calibrating equipments routinely; Not establishing proper screening and rejection criteria for specimen; and, Not maintaining adequate records.

Inadequacy of infrastructure

A recent published article in Clinical Infectious Diseases by Petti et al (2) asserts that laboratory infrastructures in sub-Saharan African are plagued by multiple problems including: • • • • • • • •

•

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Lack of basic essential equipment; Limited number of skilled personnel; Lack of laboratory consumables; Lack of educators and training programs; Having inadequate logistical support; Suffering from a de-emphasis of laboratory testing by clinical staff; Having insufficient monitoring of test quality; Having decentralized facilities that have been set up as parallel and competing infrastructures (where governmental, nongovernmental organizations and commercial (for-profit) organizations operate independent laboratories); and, Having no governmental standards for laboratory testing.

Henry Mbah

Programs, Policies and Finance

Laboratories in sub-Saharan Africa were not highly valued until 1979, following a World Health Assembly resolution (9). This resolution urged Member-States to give due attention to developing health laboratory technology for use in resource limited countries. Today, the majority of laboratory services at the intermediate and peripheral levels of care in Africa are limited because of urban bias in resource distribution. The urban bias applies to both facilities and health manpower. Another report (10) shows that in many African countries, although the development of infrastructure was a focus of national health policies, hospitals continued to consume the largest share of health budgets at the expense of other health sectors. There is also a tendency to allocate limited resources to health sectors where professional pressure is strongest (from doctors and nurses) and where needs are perceived to be most pressing (mother and child health). Through African government supported programs, including free medical consultation and even free medicine, health practitioners often do not order laboratory services, even when available. In addition, laboratory services are rarely included in free or subsidized health programs. International health policies appear to be shifting from the comprehensive primary health care approach to a more selective approach with emphasis on disease-oriented programs (11). Some current selective programs with laboratory focus include Adult AIDS Clinical Trials Group; International Maternal Pediatric Adolescent AIDS Clinical Trial Group; AIDS Vaccine Trials Network; Global Fund to Fight AIDS, TB and Malaria; WHO TB and Malaria Program for Africa; Global Alliance for Vaccines and Immunizations; US President’s Emergency Plan for AIDS Relief and so on. Citizens have only limited access to some of these programs. Furthermore, some of these programs have operating priorities that have little relevance to the needs of target populations. Opponents of these disease-oriented programs assert that that they further fragment the precarious laboratory service and divert limited resources especially human resources, away from other important non-targeted disease-related testing. However, others see these disease-oriented

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programs as an opportunity for laboratory services to develop as a more cost-effective approach, and as a quantitative success indicator. Since 2003, effort to scale up anti-retrovirus therapy services and strengthen laboratory support has often focused on developing appropriate technologies and providing equipment, supplies and technical training. However, insufficient concurrent strengthening of management and leadership responsibilities has made it impossible to improve and sustain the overall quality of laboratory services and performance. Effective management is absolutely essential in such a fragmented health service system. Yet the sub-Saharan African region has the lowest management ratio in the world. Only 17 percent of its total health workforce are employed as managers or support workers, compared with 43 percent in the Americas and 33 percent globally (12). What can be done to address some of the Challenges Facing Laboratory Systems in Sub-Saharan Africa? Sustained and holistic effort in capacity building is extremely important. Capacity building must not be limited to training, purchasing equipments and infrastructure development. It should include intangibles such as creating an enabling environment, developing leadership, managing change, creating a culture of respect, and ensuring information flow and accountability. Some of the proposed recommendations, including previous ones from Petti et al (2) for improving the availability and quality of laboratory services include:

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1) Emphasizing the importance of laboratory testing in overall health services; 2) Ensuring the adequate representation of laboratory scientists in the highest decision-making organs of the health system; 3) Balancing the allocation of financial resources in health to assure adequate and reasonable funding for laboratory services and non direct medical services; 4) Strengthening the existing laboratory infrastructure and creating more diagnostic services in underserved areas; 5) Establishing bulk procurement and commodity management schemes. 6) Creating a safe working environment to minimize risk of infection through occupational exposure; 7) Monitoring and testing diagnostic quality through peer evaluation and proficiency testing; 8) Establishing a system for laboratory accreditation in every country; 9) Implementing laboratory technical and management training programs; 10) Encouraging partnerships between public and private organizations; 11) Developing affordable, rapid diagnostic tests; 12) Establishing strong collaboration among laboratory professionals and clinicians.

Table 1 below provides an overview of a practical model to improve the quality of laboratory services. It is critical to improve the quality of laboratory services to strengthen the role of diagnostic tests in medical diagnosis and to assist public health workers in the field.

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Table 1. A practical model based on Total Quality Management to improve laboratory services in sub- Saharan Africa 1. PLAN 2. EXECUTE 3. ASSESS 4. ADJUST ™

™

™

™

™

™

Assess current situation and determine gaps. Form partnerships and networks. Ensure leadership involvement. Arrange meetings of laboratory workers. Establish policies and procedures. Secure finances and allocate resources.

™ ™

™ ™

™

™ ™ ™

Recruit, train and motivate staff. Develop standard operating procedures (SOP). Develop technical manuals. Purchase equipment and supplies. Establish maintenance contracts. Establish supply chains. Keep reports and records. Develop backup plans.

™

™ ™

™

™ ™

Establish selfassessment tools. Do internal audits. Participate in peer evaluation. Participate in proficiency testing Carry out investigation Discover faults.

™ Take corrective action. ™ Improve on systems.

References 1. Institute of Medicine, Committee on Assuring the Health of the Public in the 21st Century. (2002).The Future of the Public’s Health in the 21st Century. Washington, DC: The National Academies Press. Available at http://books.nap.edu/books/030908704X/html/ 2. Petti CA, Polage CR, Quinn TC, Ronald AR, Sande MA (2006). Laboratory Medicine in Africa: a Barrier to Effective Health Care. Clin Infect Dis, Volume 42, pages 377–82. 3. Polace CR, G Bedu-Addo G, A Owuso-Ofori A, Frimpong E (2006).Laboratory Use in Ghana: Physician Perception and Practice Am. J. Trop. Med. Hyg, Volume 75, Number 3, pages 526-531. 4. Evans JA, Adusei A, Timmann C, et al (2004). High Mortality of Infant Bacteraemia Clinically Indistinguishable from Severe Malaria. QJM; Volume 97, pages 591–7.

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5. Nsutebu EF, Ndumbe PM, Koulla S (2002). The Increase in Occurrence of Typhoid Fever in Cameroon: Overdiagnosis due to Misuse of the Widal test? Trans R Soc Trop Med Hyg, Jan-Feb, Volume 96, Number 1, pages 64-67. 6. Lockman S, Hone N, Kenyon TA, et al (2003). Etiology of Pulmonary Infections in Predominantly HIV-Infected Adults with Suspected Tuberculosis, Botswana. Int J Tuberc Lung Dis 2003, Volume 7, pages 714–723. 7. Berkelman R, Cassell G, Specter S, Hamburg M, Klugman K (2006). The ʺAchilles heelʺ of Global Efforts to Combat Infectious Diseases. Clin Infect Dis, May 15; Volume 42, Number 10, pages 15031504. 8. Theo Smart (2006). Monitoring Antiretroviral Treatment with Limited Laboratory Services. HIV & AIDS Treatment in Practice #69, 20th June. 9. World Health Assembly (WHA) (1979). World Health Assembly Resolution WHA32.16. Geneva, Switzerland: World Health Organization. 10. World Health Organization (WHO) (1998). World Health Report. Geneva, Switzerland: Author. 11. Koivusalo M, Ollila E. (1997). Making a Healthy World: Agencies, Actors and Policies in International Health. London, England: Zed Books. 12. World Health Organization (WHO) (2006). World Health Report 2006: Working Together for Health. Geneva, Switzerland: Author.

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Chapter 10

INFORMATION, EDUCATION AND COMMUNICATION (iec) CAMPAIGNS FOR BETTER HEALTH IN AFRICA: THE ROLE OF INDIGENOUS KNOWLEDGE AND TECHNOLOGIES NDUNGE KIITI Introduction With Africa’s diverse cultures and resources, the state of Information, Education, and Communication (IEC) campaigns in the continent elicits varying perspectives. In many ways, IEC campaigns have provided unique opportunities for learning especially with the use of various approaches and technologies. Increasingly, there is recognition that a population’s health is intricately linked to a nation’s economic growth and prosperity and vise versa. Traditionally, development policies and theories have tended to prioritize growth over social services such as health leading to increased disparities within and among countries. The health-development link has often not been reflected in policies and programs in the continent. Thus, the critical role of IEC campaigns can play in influencing personal and community health becomes even more essential. However, IEC campaigns have also posed many challenges for addressing health in Africa. Both across and within African countries, factors such as language, literacy rates, gender, cost, and urbanization all impact the implementation and effectiveness of IEC initiatives. Despite these diverse contexts, IEC campaigns are often designed to appeal to a wide spectrum of individuals and community groups. Additionally, IEC materials are frequently designed and disseminated by external health professionals based in urban settings who may not always be sensitive to the skills and knowledge of the audience, especially in rural settings (1). These situations perpetuate the technology divide or limit the use of indigenous knowledge, resources and technologies.

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From a theoretical standpoint, many IEC campaigns have been informed by individual-based and top-down approaches that often only focus on awareness and risk reduction. The assumption has been that exposure or access to IEC materials will lead to behavior change, ignoring the social, economic and political context. Research has shown that although information and awareness are critical components in health campaigns, they often do not lead to desired and sustainable change (2). The design, planning and implementation of IEC campaigns have also been scrutinized. Some health and development specialists have argued that IEC campaigns are designed hurriedly with no baseline to determine the relevance of chosen messages, channels and dissemination process to targeted audiences. Thus, relevance to local situations is called to question. Sustainability is another issue in the forefront of IEC campaigns in Africa. The expertise, skills and technologies that have often defined IEC campaigns are costly, relying heavily on external resources and methodologies. This often refocuses IEC priorities from the national or local levels to externally driven objectives. For example, the cost of equipment and technology to produce videos, films, billboards and other common IEC media are often absorbed into external funding grants. There are few partnerships or alliances that primarily focus their work on IEC campaigns to address health in Africa. One of the most well known internationally is the Health Communication Partnership housed and facilitated by the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs.. They partner with the Academy of Educational Development, Save the Children, the International HIV/AIDS Alliance, and Tulane University’s School of Public Health and Tropical Medicine, all based in the United States. These broad partnerships also have regional offices with programs in numerous African countries. Each month, their newsletter features IEC campaign materials that have presumably made an impact at the community level in Africa. The following programs are examples of recent successful IEC campaigns: •

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Speaking Books (South Africa): these books are culturally appropriate, straightforward and easy to understand to

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•

ensure clarity in communicating to readers at various levels of literacy. Topics include TB, Malaria, HIV/AIDS, and Diabetes; and, HEART Campaign (Zambia): The HEART (Helping Each Other Act Responsibly Together) Campaign mobilizes and involves youth in the design of IEC materials using print and television spots to communicate HIV/AIDS messages. Youth involvement includes a Youth Advisory Group (YAG) which consist of 35-40 young people and 11 youth organizations that advise the design and dissemination team.

After more than two decades of experience with information, education and communication campaigns for health in Africa, ranging from work in designing, implementing, monitoring and evaluating such campaigns, I know that it is a work in progress in Africa. In the next section, I share some of experiences and insights. The Journey So Far Building Institutional Capacity

Like many other individuals involved in IEC campaigns in Africa, my journey began with working in HIV/AIDS programs. In the late 80s and early 90s, Medical Assistance Program (MAP International), a global health, relief and development organization with offices in Africa, Asia and the Americas, began developing a comprehensive response to HIV/AIDS in Africa. With both international and national support, the goal was to increase the capacity of faith communities to design, implement, manage and evaluate effective, culturally appropriate and locally sustainable HIV/AIDS programs. Although the program was initially implemented in Kenya, MAP has facilitated this initiative and shared the lessons learned in many countries, within Africa and in international forums. The five main components of the program were: research, policy development, training, IEC material production and dissemination, and networking/partnership development. Qualitative and quantitative research activities were the foundation of our work. We conducted the baseline research to better understand knowledge, attitudes, beliefs and practices (KABP) of the various segments of the target audience. The research helped identify some of the gaps and needs which 111

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ultimately guided the design and implementation of the program. This also provided a framework for integrating a strong monitoring and evaluation system. An impact evaluation was carried out at the end of the program. The policy component of the project worked at two levels, involving local leaders and their communities as well as national and regional leaders. The emphasis was on each level informing the other so policies were well grounded in people’s realities. The training and networking objectives were to expand capacity through sharing and interacting with new and existing knowledge. Individual and group training paired with institutional capacity building deliberately targeted the grassroots levels. The training included a curriculum that allowed community members and leaders to design and implement their own HIV/AIDS programs. The beginning point was always the community and their realities. The subsequent response and engagement by the trainees was evidenced through their voluntary activities and initiatives in their respective communities. The IEC component was defined as a critical need. At the time, there were few materials that could be used for HIV awareness and education. Guided by the findings from the baseline, MAP worked with community members to produce and disseminate IEC materials using different formats to reach more segments of targeted population. IEC materials included a video, manuals, information packets (posters, brochures and leaflets), radio spots and placement of different advertisements in national newspapers at strategic intervals to coincide with World AIDS Day themes and other national events. These materials were produced and extensively field tested by or with the involvement of the end users to ensure relevance and appropriateness. This IEC campaign had tremendous impact and created unique partnerships. For example, the video was translated into film and was shown 683 times over two years in public areas through touring cinema vans, reaching approximately 2.8 million people in rural Kenya (3). MAP’s project regional coordinators, at the grassroots level, helped facilitate the showing of videos and subsequent discussions. Working in partnership with the Ministry of Health (National AIDS Control) and the national media groups, the video was also aired three times on national television during prime time viewing hours. In another instance, partnering with the private sector led to increased

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Ndunge Kiiti support and the production of more IEC materials for their workers and families. As MAP recognized the demand for these IEC materials beyond Kenya, regional and continental partnerships were developed and the materials were adapted and translated into three other languages--Kiswahili, French and Portuguese--for broader use throughout Africa. The experience working with MAP and exposure to other IEC campaigns, reinforced, in my mind, that for any health development initiative to be relevant and sustainable, it has to genuinely build on or complement the knowledge and resources that exist in communities. This began my second journey in the area of IEC. My doctoral dissertation research looked at the role of indigenous knowledge and resources in HIV/AIDS Communication and Education in Eastern Kenya. My main concern was that top down paradigms have sometimes perpetuated dependency on external resources to the point where individuals or communities fail to recognize, identify, tap and use their own local resources to address health problems (4). I believe that my research findings illustrate that few effective IEC campaigns can be developed or implemented without the involvement of the individuals most affected by the problem. The Role of Indigenous Knowledge and Resources

Communication that supports the full development of people must be participatory communication. Thus, anyone who comes to work with a community must first learn about the local culture and its ways of communicating. Non-disruptive, lasting change must come through a society’s own communication system (5). Many have argued that the limitation of available resources should lead us to channeling our energies into applying fundamental development principles of community mobilization and involvement at all levels (6, 7). This reinforces the claim made by MacLachlan and Carr in Malawi (8). They suggest that given the over-stretched health resources in many African countries, the use of ‘indigenous human resources’ would be both credible and economic (8). Nichter argues that far too much time, energy and too many resources have been spent identifying what a population does not know or do rather than in identifying what people do know and the way in which it is known (9). Growing evidence in international health literature shows that, if mobilized and supported, communities can make lasting contributions 113

Information, Education And Communication (Iec) Campaigns For Better Health In Africa

to their health and well being (10). Paulo Freire, a community activist and educator, suggests that a dialogical model of communication and education supports the mobilization of local resources by beginning with what people know and encouraging critical reflection so that solutions come from the specific context (11). Information, Education and Communication campaigns must increasingly focus on the “learner” or “receiver.” Freire argues that strategies must move beyond merely a “banking” model of educational practice in which education is little more than an act of depositing information to a collaborative, dialectical process where learners’ knowledge become a key component of addressing their own problems (11). There is evidence that the effective use of indigenous or local resources and knowledge can make a positive impact on a community’s health. In a joint study, the Zambian INDENI Petroleum Refinery Project, the Population Council and the Counseling Unit of the Ministry of Health set out to test the hypothesis that locally developed, culturally appropriate communication and education will improve the acceptability and enhance the adoption of appropriate prevention and care behavior at the community level. When evaluated, the program showed positive signs of sustainable change (12). Lessons Learned from IEC Campaigns in Africa IEC programs vary within communities, countries, and regions. It is the responsibility of each country to determine the modalities for their IEC campaigns in health. However, there few lessons learned from my journey working in various regions of the Africa. I will keep the lessons learned as simple as possible so that stakeholders in IEC programs can reflect on them without ambiguity. Policy Lessons

•

•

Policy development is a two way process. The process must be part of a long-term plan that includes research, analysis, dialogue and advocacy so that policymakers are continuously informed; and, There is often a gap between policies and the reality at the community level. Deliberations and formulations of policies must engage a broader audience than top level leadership.

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Ndunge Kiiti Grassroots reality must always inform the policy making process. Program Lessons

•

•

•

• •

In IEC, the relationship between the target audience, the communicator and the message is very important. The gap between those who design and implement IEC campaigns and the intended audience must be narrowed to increase the effectiveness of the message; Dissemination of IEC materials is a critical part of the process that has to be integrated into the planning, design and evaluation of a program; IEC programs must be more multi-sectoral to help broaden the health-development dialogue in a sustainable, holistic and integrated way; IEC campaigns are only one component of a complex process towards behavior change for better health; and, Monitoring and evaluation are essential components for measuring and understanding what difference IEC programs have made.

Health System Improvements

•

•

Community mobilization and involvement enables communities to identify and contribute resources to complement the existing health system; In many African countries, health care infrastructure requires support and often must be expanded and strengthened to deal with the health challenges which confront our people. The strengthening and development of appropriate health systems also plays a critical role in the hiring and retention of health care workers who have the option of taking advantage of better working conditions and experiences provided by other countries in the continent and in the West.

Education and Training of Health workers for IEC Campaigns

•

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Capacity building of health workers, at all levels—national, provincial, district, and local--are an essential part of transforming health systems in Africa. They are often a direct link to communities and are central in effecting social change;

Information, Education And Communication (Iec) Campaigns For Better Health In Africa

• •

•

National governments should invest in short-and-long term training programs for health workers; For health workers engaged in IEC programs, they should have access to re-training opportunities that expose them to modern techniques and strategies as well as familiarize them with local and other forms of indigenous knowledge; and, Training on field research and techniques for detecting change due to program impact is very important.

Building Political Support for IEC

•

•

•

Governments play a most critical role in the health sector. Institutions and communities involved in IEC must ensure that their goals align with national priorities; IEC leaders and managers should involve various government, private and non government agencies and organizations in their work; and, IEC staff must share with policy makers and politicians information about the impact of their activities. They should also suggest ways that policy makers and politicians can assist them with their work.

Sustaining International Partnerships

•

•

• •

Partnerships allow us to achieve that which we can not achieve on our own. They are essential and help reduce duplication; encourage good stewardship; broaden impact, influence and capacity, and; promote learning through exchange of ideas, skills, and experiences; Partnerships need to be nurtured through respectful and trusting relationships between domestic and international partners; The partnership should be consistently supported with financial, technical and logistics resources; Partnerships should be diverse, inclusive and transparent. Important stakeholders in the partnership include communities/civil society; NGOs (local, national, international); governments/public institutions; private sector (e.g. businesses; industries); financial institutions; academic institutions; networks; external bilateral and multilateral

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•

donors, external private donors, including foundations and philanthropies; and, Institutions and individuals actively engaged in IEC programs need to look beyond partnerships to form and reshape networks and communities of practice.

Recommendations For IEC to have a maximum impact on health in Africa, African governments, regional institutions, international/national organizations and civil society must make a genuine commitment through their practices, policies and resources allocation to reach and understand target communities, and, then implement programs that meet felt rather than perceived needs. More specifically, IEC stakeholders need to: 9

9 9

9

9

Provide a framework for developing and strengthening IEC components of current domestic and international development initiatives such as Millennium Development Goals (MDGs) and other such initiatives; Build health systems and train and retain health personnel—at all levels--to improve health and well being; Mobilize and involve all stakeholders (e.g. communities, media groups) in the IEC process, building on the resources, knowledge and technology that already exist; Establish and support research, IEC learning networks and communities of practice in IEC; Strengthen monitoring and evaluation mechanisms to help determine effectiveness and impact of IEC strategies for scaling up purposes.

References 1. Mbananga N, Becker, P (2002). Use of Technology in Reproductive Health Information Designed for Communities in South Africa. Health Education Research. Volume 17, Number 2, pages 195209. 2. Otieno, P (1996). Role of Youth in AIDS Education. Paper presented at the XI International AIDS Conference, Vancouver, Canada.

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3. Makinwa, B, O’Grady, M (2001). FHI/UNAIDS Best Practices in HIV/AIDS Prevention Collection. Geneva, Switzerland/Arlington, Virginia: Joint United Nations Programmme on HIV/AIDS (UNAIDS) and Family Health International (FHI). 4. Kiiti, N (2005). Indigenous Knowledge: An Effective Communication and Education Resource for Addressing HIV/AIDS among Young People in Eastern Kenya. The Journal of Development Communication, Volume 16, Number 1, pages 40-50. 5. Lundstrom K, Smith D, Kenyi S, Frerichs J (1990). Communicating for Development: A Practical Guide. Geneva, Switzerland: Lutheran World Federation. 6. Laver S (1998). African Communities in the Struggle against AIDS: the Need for a New Approach. New York: Alan R. Liss, Inc. 7. Atteh O (1992). Indigenous Knowledge as Key to Local Level Development: Possibilities, Constraints and Planning Issues in the Context of Africa. Ames, Iowa, USA: Iowa State University Research Foundation. 8. MacLachlan M Carr SC. (1994). Managing the AIDS Crisis in Africa: in Support of Pluralism. Journal of Management Medicine, Volume 8, Number 4, pages 45-53. 9. Nichter. (1991). Analogy in Health Education: Using the Familiar to Explain the New. Development Communication Report, Volume 74, pages 1-6. 10. Howard-Grabman L, Snetro G (2003). How to Mobilize Communities for Health and Social Change. Baltimore, MD: Media/Materials Clearinghouse. 11. Friere P (1984). Pedagogy of the Oppressed. New York: Continuum. 12. Lau C, Muula A (2004). HIV/AIDS in Sub-Saharan Africa. Croatian Medical Journal, Volume 45, Number 4, pages 402-414.

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Chapter 11

MATERNAL AND CHILD HEALTH SERVICES IN AFRICA CHINUA AKUKWE Introduction The World Health Organization, Africa Region in its recent landmark report on the state of health in Africa (1) describes a “silent epidemic” of millions of mother, their infants and young children dying prematurely from preventive diseases and health conditions. In the last 20 years, earlier gains in maternal and child health in the continent is now lost (1). In every country in Africa, women and child continue to die needlessly due to lack of medical personnel and health services, vaccine preventable diseases, wars and conflicts, and ineffective information, education and communication campaigns against maternal and child health deaths and morbidities (1-4). Despite the major gains made in the late 1970s and 1980s on age-appropriate immunization, oral rehydration therapy and under-5 child health services, indices for mother and their children have remained precarious throughout the continent. The spread of HIV/AIDS, the growing rates of intractable poverty in many parts of the continent, declining government expenditure on health, the cut back on outreach nurse-midwives services, and, the decimation of maternal and child health programs have taken their toil (1, 2, 3). The urgent situation with maternal and child health services in Africa also reflects part of ongoing global struggles to meet the health needs of women and children. It is important to note that maternal and child health issues are of concern in all parts of the world, although the situation is precarious in Africa. Rich nations, including United States still have problems with maternal and child health services, especially for ethnic minorities and the poor (4). For example, the gap in maternal and child health indices between the White Caucasian population in the United States and their Black peers continues to persist despite local, state and national remedial initiatives (4, 5). Poverty is believed to be a major factor in the 119

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persisting Black-White differences in maternal and child health indices in the United States. Lack of timely access to available services is another factor. In Africa, and as known in other resource-constrained environments around the world, maternal and child health services face difficult challenges (1-8). I briefly discuss these challenges. Ten Challenges to Maternal and Child Health Services in Africa First, Africa is home to unacceptably high maternal mortality as well as very high infant and under five deaths. Most of these deaths are not only preventable they are also eminently treatable. As noted by the World Health Organization, Africa Region (1), a child born today in Africa is 50 percent more likely to be malnourished and 51 percent more likely to die of either Malaria, diarrhea diseases or acute respiratory infections compared to his or her peer in other parts of the world. This same child is more likely to lose his or her mother to child birth complications. The same child has a life expectancy of 47 years instead of 62 years principally due to AIDS. The same child in Africa is likely at least once in his or her life to be negatively impacted by drought, famine, flood or civil war. The odds against this child and her mother are high. Second, endemic poverty is a formidable foe of maternal and child health services in Africa. Women in Africa are more likely to live in poverty than men despite being the predominant producers of basic goods and services. Women with small children are particularly at risk if they are widows or live on their own. The HIV/AIDS epidemic has further compounded the problem. Third, the pre-pregnancy and inter-pregnancy health status of women living in poverty is often unfavorable. African women often have poor pre-pregnancy history and also are likely to have poor obstetrics history compared to peers in other parts of the world. African women often deliver at home. Skilled birth attendants are in short supply in the continent. Nurses and midwives are at premium in rural, poor parts of Africa where they are most needed. Fourth, access to health services is a major challenge. Lack of qualified health professionals, crumbling health infrastructure, and, lack of medicines and equipment are major concerns. Antenatal services do not reach many pregnant women. Financial, technical and

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Ndunge Kiiti logistics cutbacks by various levels of government have further reduced the capacity of maternal and child health services in Africa to reach intended target population. Services for children have also suffered, including startling reverses in age-appropriate immunization rates. Children under five years of age continue to die of vaccine preventable diseases. Fifth, the maternal and child health population is mobile and very busy with farm work and household chores. Basic health services in Africa are static, poorly funded and poorly managed. These health programs no longer support outreach forays into isolated villages and communities due to lack of funds and staff cutbacks. African women who are busy with petty trading at home or in markets rarely find time to seek health care in available health facilities. Sixth, community-based maternal and child health services are gradually disappearing in Africa. The decline of primary health care programs and the cutback on outreach services has led to the decline of health programs for women and children for the rural poor communities or in urban slums. This cutback has also affected the training and re-training programs for traditional birth attendants. Seventh, female gender inequities adversely impact on maternal and child health services. In areas where women work round-the-clock on farming, petty trading and child rearing activities, there is very little time for preventive health services. Cultural practices that deny widows inheritance rights may also push them further into poverty, making it more difficult for them to access health services. Eight, lack of political will is a major challenge of the maternal and child health population. This is true in both developed and developing regions of the world. Most publicly funded maternal and child health programs are located in poor neighborhoods. These programs are often the first to be closed due to budgetary pressures. Even when these services are closed there are little political repercussions since the maternal and child health population lack political will. Maternal and child health target population are rarely significant political stakeholders at local or national levels. The lack of political gravitas also makes it difficult to assemble viable and long term maternal and child health stakeholders that can consistently engage policy makers. Ninth, inadequate funding of maternal and child health services is a major challenge. A soft political constituency in a resource challenged environment is unlikely to fight against inevitable budget cutbacks and 121

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closure of existing services. It is not surprising that public health nurses are often the first in the budget chopping blocks. These nurses, often trained as midwives, are the backbone of maternal and child health services in poor communities. Tenth, the unique plight of children is a formidable challenge. Children must depend on parents, extended family and the entire community for their welfare and upkeep. In recent years, the traditional extended family system in Africa has come under strain from a deadly combination of HIV/AIDS and endemic poverty (10). In many parts of Africa, grandmothers are raising their grandchildren as result of their adult children dying of AIDS (10). The rise of poverty levels means that harried parent and grandparents must now pick and choose between food and healthcare or between school, food and healthcare. Basic Elements of Quality Maternal and Child Health Services A successful maternal and child health program in Africa should have basic attributes. These attributes should guide the design, implementation, monitoring and evaluation of health services for women and children (1, 5, 6, 8, 9, 10, 11-16). A quality maternal and child health program should take into consideration the changing needs of women and children at different stages of their lives. The basic element of a successful maternal and child health program includes several components. Policy makers and program managers need to be aware of these components in their evaluation and implementation of maternal and child health services. 1. The program should meet the physical, mental and emotional needs of women and children. Health services for women and children should be based on an understanding of the demographic, social, environmental and psychosocial issues that influence their state of health. 2. The program should have a nationally acceptable minimum standard of care and an essential package of care for women and children. Each country

should establish an essential package of services for women and children. Each maternal and child health facility should provide the essential package of care. The essential package of care will include specific preventive and clinical health services that should be available

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Ndunge Kiiti in each maternal and child health facility. It should also include provisions for acute and chronic management of health conditions at primary, secondary and tertiary levels of care. Each country should also establish a minimum standard of care for maternal and child health services. The minimum standard of care should address issues such as access and affordability of care; rights of patients when in health facilities; expected customer service by health workers; expected standard of care; and, ways to evaluate care received in health facilities. The twin strategies of minimum standard of care and essential package of care will address the uneven care provided in publicly funded maternal and child health programs. 3. The program should provide a continuum of care for both women and children. Maternal and child health programs should provide a continuum of care for women that links childhood health status to prepregnancy health status; links pre-pregnancy health status to the state of health during pregnancy, child birth and after child birth; links state of health during the inter-pregnancy period; links reproductive age state of health to peri-and-post menopausal periods. For children, pediatric health services should be linked to late teens and early adult years. The key is to organize a system of care that links every stage of women and children lives in a continuum. 4. The program should have a foundation of trained health professionals, functioning infrastructure and conditions of service that motivate employees. Anybody familiar with maternal and child health services in Africa is aware that the staff are perennially overworked. A human resource strategy for training and re-training obstetrics and gynecologists, pediatricians, nurse midwives, public health nurses/midwives, community health workers, and, traditional birth attendants is needed to build a foundation of health professionals that can respond to the health requirements of women and children in Africa. These health professionals should have access to regular in-service training programs and refresher courses. The infrastructure for maternal and child health services should meet national professional standards and should be functional enough to facilitate preventive health programs. 5. The program should be involved in organized grassroots and national efforts to end gender inequalities. This is a current weakness of maternal 123

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and child health services in Africa. Maternal and child health programs should be part of organized efforts to improve girl and women educational opportunities, end domestic violence, improve property and inheritance rights, and, help end cultural taboos and mores that negatively impact the socioeconomic development of women. In areas where boys and girls are not encouraged to attend age-appropriate schooling, it is important for maternal and child health programs to become an important part of the organized effort to end such practices. 6. The program should include comprehensive school health services, especially at primary and secondary school levels. From the age of six when African pupils begin their primary education, it is important for health policy makers and program managers to take advantage of their six years of primary schooling and another six years of secondary education to provide them with basic health services in school settings. School health services can provide preventive care and can serve as important referral networks for clinical care. It is also possible to reach parents with health messages at home through their kids in school. In many resource-poor countries, a school health program may start with a nursing staff and an outreach worker to cover a number of schools in a designated area. 7. The program should have sustainable, long term financial support from national governments. Maternal and child health services are often the first programs to be cut during national budgetary difficulties. It is crucial for national governments to pledge and maintain their long term financial commitments to maternal and child health services. In making this pledge, national governments should not create a situation whereby the sustainability of maternal and child health services become dependent on the continued support of external donors. Maternal and child health services should be at the core of basic health services in each country, with expressed and verifiable financial, technical and logistics support of national governments. 8. Maternal and child health services should involve men and “significant others” in their operational activities. Husbands and significant others of women and mothers should be part of organized efforts to improve maternal and child health in Africa. The support of men is particularly important in societies where men dominate leadership positions. The

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Ndunge Kiiti support of men is vital in local and national advocacy efforts to improve the availability and quality of maternal and child health services, and, to advance legislation on women and children rights. 9. Maternal and child health services should be the fulcrum of national immunization activities. This is already in practice in many African countries. However, the role of maternal and child health programs in immunization programs is to serve as a gateway to preventive health services for women and children. All pregnant women in Africa should receive their tetanus shots before delivery. Pregnant women should also know their HIV status during pregnancy. Children should receive all the age-appropriate immunizations through maternal and child health services. 10. The organized private, the civil society and health professional organizations should join the government as major stakeholders of maternal and child health services. To maintain regular financial and technical support for maternal and child health service, it is critical to develop and sustain a public/private/civil society/professionals partnership. This partnership should work together in the areas of public policy for women and children, poverty alleviation, program operations, financial support, and external donor relations. A very important function of the partnership is to develop strategies that empower women to improve their social and economic status, end gender inequities and provide a better future for their children. 11. Monitoring and evaluation should be an integral component of maternal and child health services. This is a tough responsibility in the face of overworked staff and unattended patients. However, it is important for maternal and child health managers to recognize the need to demonstrate the efficiency and effectiveness of funded programs. This demonstration of impact is very important since maternal and child health programs traditionally have weak political support. Target population should also be part of the monitoring and evaluation mechanisms so that program managers and policy makers can get time sensitive feedback. 12. All maternal and child health programs should find a way to obtain feedback from families that utilize services. Maternal and child health 125

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program managers need to be aware of the knowledge, attitudes and perceptions (KAP) of clients and target population. The KAP of clients will always change, and maternal and child health staff should adjust, accordingly. The felt needs of target population will also change and program managers should be ready for these inevitable changes. 13. External donor support for maternal and child health services should reflect national priorities. External donor support for maternal and child health services is often significant, reflecting widely held interest on the plight of women and children worldwide. However, each host country should as earlier suggested adopt a minimum standard of care and an essential package of maternal and child health services that should guide interaction with external donor partners. Each host country should work with external donor partners to provide long term support for maternal and child health services, especially in resource challenged environments. When external donor support comes to an end, national governments should have over time deployed alternative funding mechanisms so that maternal and child health services are not interrupted or drastically scaled back due to lack of resources. Conclusion Millions of women and child die needlessly from preventable and treatable health conditions in Africa. African governments need to adopt a minimum standard of maternal and child health service as well as adopt an essential package of services that should be provided in each health facility. African government, the organized private sector, the civil society, professional organizations and external development partners need to collaborate and forge strong partnerships that address obstacles that limit the provision of a continuum of care for women and children in the continent. Meeting the health needs of women and children is not an easy task, as shown by the operational challenges in rich nations, including the United States. However, it is an obligation for the leaders of each country to work diligently to meet the health needs of its mothers, mothers-to-be, their born children, and, their children yet unborn.

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Ndunge Kiiti References 1. World Health Organization, Africa Region (2006). Health of the People. The Africa Regional Health Report 2006. Brazzaville, Congo: Author. 2. World Health Organization (2005). World Health Report. Make Every Mother and Child Count. Integrating Maternal, Newborn and Child Health Programmes. Policy Brief One. Geneva, Switzerland: Author. 3. World Health Organization (2006). Engaging for Health. Eleventh General Programme of Work 2006-2015. A Global Health Agenda. Geneva, Switzerland: Author. 4. African Union (2007). Africa Health Strategy: 2007-2015. Third Session of the African Union Conference of Ministers of Health’ Johannesburg, South Africa. CAMH/MIN/5(111). Addis Ababa, Ethiopia: Author. 5. Global Health Council (2002). Making Childbirth Safer Through Promoting Evidence-based Care. Washington, DC: Author. 6. Save the Children, Population Reference Bureau (2006). Saving Newborn Lives. The Maternal-Newborn-Child Health Continuum of Care: A Collective Effort to Save Lives. Policy Perspectives on Newborn Health, March. Washington, DC: Population Reference Bureau. 7. Davidson Gwatkin (2006). IMCI: What can we learn from an Innovation that didn’t reach the Poor? Editorial. Bulletin of the World Health Organization, October, Volume 84, Number 10, page 768 8. Bureau for Africa, US Agency for International Development (1995). Setting Priorities for Research, Analysis, and Information Dissemination Safe Motherhood and Reproductive Health in Africa. Washington, DC: Author. 9. Centers for Disease Control and Prevention (1999). Achievements in Public Health, 1990-1999: Healthier Mothers and Babies. MMWR October 01, Volume 48, Number 38, pages 849-858. 10. Rhoi Wangila and Chinua Akukwe (2006). Africa, AIDS Orphans and their Grandparents. Benefits and Preventable Hidden Dangers. TSEHAI Publishers, Los Angeles, United States. 11. Akukwe, Chinua (1997). Perinatal and Infant Mortality: A Worldwide Issue. European Journal of Public Health, Volume 7, pages 223-225. 127

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12. Jane Otado, Chinua Akukwe, James Collins (2004). Disparate African American and White Infant Mortality Rates in the United States, pages 355-368. In Praeger Handbook of Black American Health. Policies and Issues Behind Disparities in Health. Second Edition. Ivor Lensworth Livingston (Editor). Praeger Publishers, Westport, Connecticut, USA. 13. Akukwe, Chinua (1996). Infant Mortality in the District of Columbia. Department of Health, Washington, DC: Office of Maternal and Child Health. 14. Akukwe, Chinua (1998). The Potential Impact of the 1996 Welfare Reforms on Intimate Partner Violence, Family and Community Health, Volume 20, Number 4, pages 54-62. 15. Akukwe C, Nowell A (1999). Essential Strategies for Achieving Durable Population-based Maternal and Child Health Service, Journal Royal Society of Health, March, Volume 119, Number 1, pages 42-49. 16. Akukwe, Chinua (2000). Maternal and Child Health Services in the Twenty-First Century: Critical Issues, Challenges and Opportunities. Health Care for Women International, Volume 21, pages 641-653.

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Chapter 12

MENTAL HEALTH SERVICES IN AFRICA FOR THE 21ST CENTURY: ISSUES, CHALLENGES AND OPPORTUNITIES FLORENCE BAINGANA Introduction Organization of Mental Health Services in Uganda

Health and mental health services in Uganda have been decentralized. In relation to the mental health services, there is one National Psychiatric Referral Hospital, Butabika Hospital, with 450 beds. Then there are 12 Regional Referral units with 22 to 30 beds. Each is supposed to have a psychiatrist. Presently, there are psychiatrists at 10 of the Regional Referral Hospital Mental Health Units. Uganda has 84 districts. Some of the district hospitals have four bed mental health units. District hospitals with mental health units have either a Psychiatric Clinical Officer (PCO) or a Registered Psychiatric Nurse in charge of the unit. Some district hospitals do not have mental health units and in these cases, people with mental disorders are admitted to the medical wards. Below the district hospital level, are the health centers which are Health Center IV, at least one in each sub county, and these have admission facilities for adult male and female patients, and children’s wards. People with mental disorders would be admitted with the general male or female patients. Health centers at levels lower than this may run outreach mental health clinics with the support of a specialist from the district hospital. Nurses who run these units have received orientation on how to recognize and manage common mental disorders. They can also can recognize side effects of medications and make referrals when necessary. At the policy level, a National Mental Health Coordinator was posted to the Ministry of Health in 1996 to set up a Mental Health Unit. The Unit now has a Principal Medical Officer, a Senior Medical Officer and one secretarial/administrative staff. The principal role of this Unit is to formulate policy and programs, develop standards and guidelines, develop and implement annual work plans, mobilize resources, 129

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provide regulatory oversight and support supervision. The Ministry of Health provides the resources for support supervision so that psychiatrists can travel from the National Referral Hospital to the Regional Referral Hospitals. The Ministry of Health also provides resources for the psychiatrists at the Regional Referral Hospital to travel to the district hospitals in the region. The districts are then supposed to provide the resources for the PCOs in the hospitals, to travel to the lower levels of care, the health centers, for support supervision. At the present time, Uganda has about 24 psychiatrists, 115 psychiatric clinical officers, and over 1000 psychiatric nurses. Training of mental health personnel has been carried out since the mid 1970s. In addition, all medical students have to do an orientation of ten weeks in the psychiatry department of Makerere University Medical School and Mbarara University of Science and Technology. All nurses and midwives trained in the Government training schools have an orientation in mental health. All health care services are provided “free of charge” to any person who walks into a health center or hospital in Uganda. The health system is organized such that all those who require mental health care should be able to receive it at any point of contact with the health care system. This care should be “free of charge”. The laboratory investigations and the drugs and other therapies required should all be provided free of charge. The mental health care system is set up so that those who are seen at the primary care level are managed at that level. If the primary health care worker is not able to effectively manage that person, then theoretically, a referral is made to the next level of care. This referral is then supposed to continue until the person gets to the highest level of care, Butabika National Referral Hospital. Traveling up this system of care is at the expense of the patient and their families. Sometimes, patients make a decision to go directly to Butabika Hospital, or to the nearest Regional Referral Hospital Mental Health Unit, without going through the levels of care as described above. In 1999, when the Health Policy was formulated, mental health was included as one of the components of the Essential Health Care Package of Uganda (1). A budget line for mental health was created, and mental health was allocated 0.7 percent of the Ministry of Health budget (2). Uganda allocates only 3 percent of GDP to the health sector,

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which translates to about US $8 per person per year in the current Health Sector Strategic Plan (HSSP II) (3). Out of pocket payments for health are approximately US $12 per capita. Competing priorities for these scarce resources include high maternal mortality rate, high infant mortality rate, high under-five mortality rate, and the high prevalence rates of HIV and AIDS. Other issues are the conflicts in northern Uganda and their impacts on health status and the health system, the challenge of poor remuneration, the mal-distribution of health workers, and other health system challenges. In 2000, Uganda received an African Development Bank (ADB) loan that provided US $17 million for the downsizing and rehabilitation of Butabika National Psychiatric Referral Hospital, from 900 to 450 beds; for the construction of six Regional Referral Mental Health Units; and, for support to training of all levels of health care providers, specialized and non-specialized, in mental health. The overall objective of this loan was the integration of mental health into primary health care. The first project is now ended and a second (ADB) loan has been approved that will construct 6 more Regional Referral Units, carry out a baseline assessment on mental health and train more health workers, specialized and non specialized. Mental health in Uganda is also provided through psychosocial interventions, provided to conflict-affected populations, mainly in the northern part of the country, as well as to those who are living with HIV/AIDS. Support for psychosocial services is financed through the Ministry of Gender, Labor and Social Development. In 1997, many non government organizations (NGOs) were carrying out psychosocial interventions in the northern part of the country, including UNICEFUganda. In partnership with two government sectors, this work of the NGOs eventually led to the Northern Uganda Psychosocial Needs Assessment carried out in 1998. As a result of this assessment, The Core Team on Psychosocial Issues was created, principles for psychosocial interventions programming were formulated and each of the 8 districts most affected by the conflicts were then facilitated to develop psychosocial components for the District Development plans. The Core Team was able to act very quickly to provide support to three additional districts in the southern part of the country that were affected by insecurity in 1999. The Core Team still meets regularly up to now.

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In Uganda, up to 80 percent of the patients who have mental disorders begin their help seeking with traditional healers compared to 4 percent of those in surgical wards (4). Traditional healers are found in every community in the country. Uganda has a formal working relationship with Traditional Birth Attendants (TBA), in relation to Safe Motherhood programs, and with traditional healers in the fight against HIV/AIDS. However, the Ministry of Health does not collaborate with traditional healers on mental health issues. Mbarara University of Science and Technology Department of Psychiatry had begun a program of training traditional healers so they would make referral to the ‘Western’ systems of care a lot faster. It is not clear what constitute traditional medicine healing methods, what the benefits are, and, whether there is self-regulation among the traditional healers. It is still not easy to determine whether there should be a formal collaboration with traditional healers in Uganda. Uganda has a very active mental health NGO sector. Some of the NGOs include Mental Health Uganda; Uganda Parents of Children with Learning Disability; The Epilepsy Support Organization; and; the Schizophrenia Support Organization, which are indigenous. International NGOs also operate in Uganda and some are affiliated with international NGOs such as the Transcultural Psychosocial Organization of Uganda (TPO-U), affiliated to HealthNet/TPO International, and, Basic Needs of the United Kingdom in Uganda. Continental and International Partnerships for Mental Health Each Sub-Saharan African country has a National Mental Health Coordinator. In Uganda, this is the Principal Medical Officer, Mental Health, in the Ministry of Health. The WHO Regional Office for Africa has a Regional Advisor of Mental health. Her role is to support the development of mental health policy in the Region, and to mobilize resources for mental health activities to be carried out in member countries. She does this through expert consultations with the National Mental Health Coordinators. Meetings are often organized by language groups and regions. The region has met and come to a consensus on alcohol and drugs, and on a mental health strategy for the region, to mention some recent developments. Other regional partnerships include the African Network of Psychiatrists and Allied Professionals, made up of members from all countries including the northern African countries that are often

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clustered with the Middle East by the World Bank and WHO. There is also the World Psychiatric Association, which has a Regional Committee for East Africa, including Ethiopia. These associations mainly collaborate to strengthen mental health research and publication in the continent. Regular meetings are held every year. At the international level, many countries in Sub-Saharan Africa have consumer and family organizations that are members of the World Federation for Mental Health (WFMH) and of the World Schizophrenia Fellowship. The roles of these organizations are mainly advocacy and lobbying for strengthened investment in mental health, for constant drug supplies and for the humane treatment of those with mental disorders. The Journey So Far I qualified as a psychiatrist in 1990, and began work at Butabika National Referral Psychiatric Hospital. In 1993, I joined Mulago National Referral and Teaching Hospital Department of Psychiatry, where I mainly worked as liaison psychiatrist, as well as teaching undergraduate and post-graduate students, and carrying out clinical work in the mental health out-patient department and the mental health ward. In 1996, I was posted to the Ministry of Health as the first National Mental Health Coordinator. I established and was head of the Mental Health Division, in the Ministry of Health, Kampala. I developed work plans for the Division, assessed mental health services in the districts and hospitals, advocated for mental health activities at the district level, facilitated the development of standards and guidelines for mental health and for the management of epilepsy. The position also involved networking, collaboration and liaison with other divisions in the Ministry of Health, other Ministries and with NGOs. I represented the Mental Health Division and the Ministry of Health at national and international meetings, workshops and conferences. I also developed strategic plans and discussed policy and work plans for mental health with donors such as UNICEF, WHO, United Kingdom’s Department for International Development (DfID) and others. I coordinated policy implementation both within government and between government and NGOs.

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My responsibilities included scheduling, supervising and training staff. A key activity carried out was participation and as co-lead in the Northern Uganda Psycho-social Needs Assessment. On completion of the assessment, we participated in facilitating affected districts to prepare work plans. As a result of this work, a system for monitoring and evaluation of psychosocial programs was established and implemented. The Core Team on Psychosocial Issues, made up of representatives of two government ministries, and key NGOs that work in the area of psychosocial interventions was formed at that time and is still in existence. I initiated and supported the formation of consumer NGOs such as the Mental Health Uganda, the Uganda Parents of Children with Learning Disabilities, and, the Epilepsy Support Organization. I was also a founding member and treasurer for the organization known as Hope after Rape; was Treasurer for Action for Development (ACFODE); and, was Chairperson of the Coalition for the Prevention of the Lowering of the Age of Consent to Sex as well the Coalition on the Prevention of Violence against Women. Major achievements during this period include the adoption of mental health as a component of the Essential Health Care Package in the Health Sector Policy and Health Sector Strategic Plan of Uganda. A mental health budget line was established, and the mental health law revised and integrated into the Health Services Bill. As a result, a major component of the US$17 million loan from the Africa Development Bank was committed to the rehabilitation and restructuring of mental health services. In 2000, I was seconded to the World Bank by the World Federation for Mental Health for a two year term. I was in the World Bank until 2006 as the sole, full time Mental Health Specialist. I provided operational technical assistance to World Bank teams preparing mental health components to projects in Africa, Middle East and South East Asia. I provided technical advice to the programs on refugee health, psychosocial interventions, mental health issues and gender issues. The Mental Health Specialist position also involved representing the World Bank at international meetings. As part of the knowledge management activities, I established the mental health web page which is still active; prepared a Mental Health Fact sheet; and, developed a

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Mental Health and Conflicts Discussion Paper and Toolkit, a Mental Health and HIV/AIDS Discussion Paper and Toolkit, and a Mental Health and Conflicts Social Development Note. I participated in the preparation of the World Mental Health Report 2001. While in Washington DC, I served as an Adjunct Professor in the Department of Global Health of the School of Public Health, George Washington University from 2003 to 2006. I developed the curriculum, taught classes and supervised class projects for the first ever graduate International Mental Health Course in the School of Public Health. Critical Challenges A major critical challenge is get policy makers to acknowledge the negative impact of mental health. Although globally, neuropsychiatry disorders are the leading cause of disability and account for 13 percent of the Global Burden of Disability (5) and even when Sub-Saharan Africa has a double burden of both communicable and noncommunicable disorders, there is no increased funding and program attention going to mental health issues in the continent. The evidence for the huge burden of mental disorders in SSA is now well established. In Butajira, Ethiopia, a demographic study site for the University of Addis Ababa and the Ministry of Health of Ethiopia, it was found that, using the DALY method, depression contributed 7 percent to the total disease burden (6). In Zimbabwe, depression was found to be second to HIV in the Global Burden of Disease study of 2001(7). Other studies found that estimated prevalence of depression in women in Harare, Zimbabwe, was 30 percent and the incidence rate of depression in the same population was estimated at 18 percent (8, 9). A study carried out in Lesotho found an estimate of a one-month prevalence rate of Panic Disorder to be 3.7 percent for males and 15.3 percent for females in a population age 19 to 93 years (7). This prevalence was substantially higher than that found in other regions of the world. Estimates for psychosocial and mental disorders resulting from conflicts were 15.5 percent in Rwanda five years after the genocide (10). Various studies carried out in conflict affected populations find rates of depression to be between 16 to 36 percent (11). In Uganda, point prevalence rates of depression range from 8

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percent to 50 percent with a mean of 30 percent. Conflict-affected districts were found to have higher rates of depression (12). A silent epidemic in Sub-Saharan Africa is that of alcohol abuse. Five of the 13 countries with the world’s highest increase in alcohol consumption from 1970–72 to 1994–96 are in Sub-Saharan Africa. Lesotho ranked 1st, with a 1,817 percent increase; Nigeria, 5th, with a 196 percent increase; Rwanda, 10th, with a 129 percent increase; Burkina Faso, 12th, and Sudan, 13th, with 116 percent and 108 percent increases, respectively (13). A worrying trend is that of alcohol consumption by children. In Namibia, 20 percent of schoolchildren and 75 percent of young people not in school abuse alcohol on weekends. In Zimbabwe, 31 percent of those aged 14 years and under report using alcohol. In Lesotho, 8.8 percent of children between the ages of 10 and 14 years and 4 percent of those between 5 and 9 years currently use alcohol (10). Even with this overwhelming evidence, it is still very difficult to convince donors to include mental health in their funding packages. When Uganda’s Health Policy (1999-2009) was being formulated, the Ministry of Health had to argue very strongly and repeatedly with the donors to make a case for the inclusion of mental health in the Essential Health Care Package. In Rwanda, although the country included mental health in the Poverty Reduction Strategy Paper and recognized the need for inclusion of mental health in the Poverty Reduction Strategy Credit (the document that actually identifies the areas that will be allocated donor and government funds), the donor community insisted that funding for mental health should not be included and won. Mental health policy makers are now beginning to realize that epidemiological burden alone is not enough to mobilize investment in mental health interventions. We also realize that another major challenge is the lack of economic evidence to support investments in mental health, such as: what is the most cost-effective intervention? How much does it cost to provide an essential package of mental health services?; and, what is the incremental cost to include mental health in the essential health care package? Mental health policy makers also need to be more creative in mobilizing resources for mental health services. With conflicts and with HIV/AIDS, a high number of orphans and vulnerable children are at more at risk of

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mental and psychosocial disorders. Mental health and psychosocial services could be provided through these funding channels. We should continue to ask questions regarding mental health services. What is the role of the health sector in mitigating the impacts of conflicts and HIV/AIDS? How and in what ways do we collaborate with the education and the social protection sectors? What are the best protocols for community-based mental health services? Mental health policy makers have not yet taken advantage of the opportunities in collaborating with the social protection and education sectors. Another challenge I noted, especially while at the World Bank, is that the inability to mention mental health explicitly as an MDG has made it impossible for multilateral, and bilateral donors, and even country governments, to provide financial support for the area. Yet it is clear that mental health is intricately linked to poverty; people with mental disorders are over represented among the poor and there is a link between mental health and socio-economic outcomes (14). Children with learning and mental disabilities are making it impossible to address the education-for-all goal of the United Nations. Violence against women is not included in the MDG gender goal. Advocacy for women’s health rarely takes into account gender issues of mental well being. Yet it is known that depression is not only a global phenomenon but affects women four times more frequently than men. Depression in women has a negative impact on the health, nutrition and educational outcomes of their children. Yet this is not taken into account when child health programs are being developed. People with mental disorders who are not recognized as such when they present at the primary care level take away scarce resources at that level due to poor clinical examination, poor prescription habits, and unnecessary laboratory and other diagnostic tests carried out on these individuals. Broad Lessons Learned From my work in Uganda, I learnt that it is possible to integrate mental health into a Health Policy and a Health Sector and Strategic Plan. I learnt that doing so goes a long way in mobilizing resources for mental health. Even if the Government/public funds allocated to mental health were only 0.7% of US $8 per capita per year, as a result of having mental health included as component of the Essential Health 137

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Care Package in the Health Policy and the Health Sector Strategic Plan, we were able to access donor funds, such as the ADB loan of US $17 million. Another broad lesson learned is that of taking advantage of every opportunity to make the case for mental health services. When the MOH was discussing HIV/AIDS, I was there and made a case for the inclusion of mental health. When the Ministry allocated funds to health education, I was there and accessed some of that funding for mental health services. When WHO-Uganda was developing the Safe Motherhood Program and the Adolescent Health Policy, I was there and made a case for the inclusion of mental health components. Another important lesson I learned is the need to work outside of the health sector. UNICEF-Uganda had resources for psychosocial interventions, I was in the meeting that discussed the situation of these services in the north, and eventually became a lead, with my partner in the Ministry of Gender, Labor and Social Development, in the subsequent study and the Core Team activities that followed. Policy makers in mental health need to be both creative and flexible in the quest to get additional financial and technical support for mental health programs. The important program lesson is that mental health must be integrated into general health. It is not sustainable to advocate for and develop silo (vertical) mental health programs. It is also very important to have a mental health point person in the Ministry of Health whose role is policy, planning, resource mobilization, regulation and supervision. This person does not have to be a psychiatrist. After I left the Ministry of Health to join the World Bank, a public health specialist, who had been working with me as Senior Medical Officer took over, and she has done an excellent job. Many Sub-Saharan countries have a shortage of specialized mental health personnel, and there is no need to take them away from clinical care, support supervision and teaching by putting them in the Ministry of Health. However, a mental health focal point in the MOH is very important as this person has the opportunity to attend high level meetings where decisions about money, technical resources and partnerships are made. In some countries, the chief psychiatrist at the national referral hospital takes on this role, and often advocates for funding for the institution alone, without taking into account the bigger burden of people with mental disorders who are at the primary

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levels of care. Only 1-3 percent of the total numbers of individuals living with mental disorders have severe mental disorders, and they are the ones utilizing mental institutions. It is possible to make health systems responsive to mental health issues. In Uganda, we developed a mental health curriculum for all entry level nurse training programs, as well as developed a curriculum and carried training sessions with as many primary health care workers as possible regarding the recognition and management of common mental health disorders. Mental health drugs are included in the essential drug list and so have to be included in purchases made by districts for their health units. Mental health issues are included in the clinical guidelines distributed to all health workers in Uganda. The PMO Mental Health also ensured that five mental health conditions are now added in the Health Management Information System of Uganda (HMIS). Education and training have to take into account where the biggest burden is known to occur, including the primary entry points into care, and the availability of resources. The biggest burden of mental disorders is in the community. The first entry point would be the interface with primary health care workers. However, we find that primary health care workers often do not recognize the signs and symptoms of common mental disorders. Our emphasis is on training primary health care workers so they are all able to recognize and manage common mental disorders. There is also training of other cadres of mental health workers, such as integrating mental health into the Comprehensive Nurse training curriculum. Comprehensive nurses are able to prescribe in Uganda. It is not realistic to expect that we shall have psychiatrists at the primary level. The role of psychiatrists is training, providing support to lower levels of care, research, and attending to the complicated patients who do not respond to treatment provided at lower levels. Presently, psychiatrists are only available at the National Teaching Hospital, the National Referral Psychiatric Hospital and at some of the Regional Referral Psychiatric Hospitals. It is also possible to address some of the major burden of mental and psychosocial disorders through developing or strengthening community mental health and psychosocial interventions. We can train teachers in “listening and helping skills”, so they are better able to help those children with emotional and behavioral problems. Community 139

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psychosocial programs include facilitating the formation of support groups for vulnerable populations such as women survivors of violence, former abductees from conflict zones and mothers living with HIV/AIDS, among others. If the MDGs are to be achieved, more studies on mental health and socio-economic outcomes as well as longitudinal studies that establish direction of causality need to be carried out. In relation to the education MDG, studies have shown that in SSA, up to 30 to 50 to percent of children are not enrolled in the education for all programs (15) and children with disabilities, including mental and emotional disabilities account for up to 35 percent of these children (16). In this situation, community wide, cost-effective public health interventions can be instituted to reach target populations. Some of these population-based interventions include the iodinization of salt to prevent mental retardation, de-worming all children at the beginning of each school term, and providing “Listening and Helping Skills” training to teachers as is being done in Rwanda. It is also important to invest in early childhood development where children are expected to meet age-appropriate cognitive and physical skills. In Burundi, community-based Early Child Centers (ECD) is now operational. Children who attended these centers have been found to perform much better (academically as well as retention in school) than those who did not. The Community ECD Centers are now a part of the Community Development Policy of Burundi. In relation to the gender MDG, violence against women, very rampart in Uganda and other parts of the continent, is a major cause of mental and psychosocial disorders. Sexual abuse of children is also known to lead to early sexual activity, increasing the risk of HIV transmission and death from AIDS. Survivors of violence against women are more at risk for depression, are more likely to abuse alcohol and drugs, are more likely to be promiscuous and as a result, lead to a huge economic burden to the nations where gender based violence is prevalent. How can this link between mental disorders and sexual violence be highlighted and what interventions are appropriate to the context of SSA? In relation to the child health and women’s health MDGs, a more holistic approach must be taken that involves consideration of mental health issues that affect women. In addressing the health of women, their mental health must be taken into account.

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Recommendations 1. All sub-Saharan African countries, if they have not yet done so, are encouraged to appoint an individual to be responsible for mental health issues in the National Ministry of Health. This position must be de-linked from the Director/chief psychiatrist of the National Psychiatric Hospital. It is hoped that in decentralized systems of Government, the districts will also create a position of district mental health coordinators. 2. All Ministries of Health, if they have not already done so, should create a budget line for mental health. In decentralized systems of governance, district planning committees are encouraged to create a budget line for mental health. 3. Consumers of mental health services and their caregivers are encouraged to create consumer organizations that will advocate for improved quality of services, as well as being the representatives of the consumers to policy makers. 4. Every effort must be made to increase funding of mental health services at the primary level of care. This may require conducting studies on how to efficiently allocate health spending at primary level facilities so that it covers mental health services. 5. It is important to strengthen the link between mental health and psychosocial interventions. Mental health professionals often provide support for interventions at the lower levels of care. There is a need to develop standards and guidelines at the policy and planning levels in order to streamline approaches and ensure quality. 6. Traditional healers cannot be ignored. All Sub Saharan African governments are encouraged to carry out assessments to determine the costs and the effectiveness, or the harmful features of their practices. Studies can also be carried out that will determine whether to collaborate or not and what the mode of collaboration will be. It is important to determine how regulation of their practices is to be carried out, should it be self-regulation by the traditional healers themselves, or will the Ministries of Health take on this role. Conclusion I look forward to the strengthening of the linkage between mental health practitioners (psychiatry) and public health, between the 141

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researchers and the policy makers and implementers, so that more and more, policy will be evidence based. There is a need for strengthening research in mental health policy, planning and financing. We need to get a better understanding of what the costs are of a basic mental health care package that can be integrated in the essential health care package of each nation in Africa. We need to understand what the costs are for a hospital bed at the different levels of care, and whether this is the best use of the scarce resources available to mental health. We need to get a better understanding of planning and implementation of mental health and psychosocial interventions for populations affected by HIV/AIDS and conflicts. What can we each do to make quality mental health care accessible to the whole population of Sub-Saharan Africa, beginning at the community level? This is the fundamental question for all health policy makers in Africa. References 1. Government of Uganda, Ministry of Health (1999). The Health Sector Policy 1999 – 2009. Kampala, Uganda. 2. Government of Uganda, Ministry of Health (1999). Health Sector Strategic Plan I 1999/2000-2004/05. Kampala, Uganda. 3. Government of Uganda, Ministry of Health (1999). Health Sector Strategic Plan II 2005/06 – 2009/2010. Kampala, Uganda. 4. Florence Baingana (1990). The Use Made of Ward 16, Old Mulago Hospital and Butabika Hospital and Patients Views of the Traditional Healer. M.Med. Thesis. 5. World Health Organization (2001). World Health Report. Mental Health: New Understanding, New Hope. Geneva, Switzerland: Author. 6 Abdulahi HD, Mariam H, Kebede D (2001). Burden of Disease Analysis in Rural Ethiopia. Ethiopian Journal, Volume 39, Number 4, pages 271-281. 7. Mathers CD, Stein C, Ma Fat D, Rao C, Inoue M, Tomijima N, Bernard C, Lopez AD, Murray CJL (2002). Global Burden of Disease 2000: Version 2 Methods and Results. Global Program on Evidence for Health Policy Discussion Paper No. 50. Geneva, Switzerland; World Health Organization.

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8. Abas M, Broadhead J (1994). Mental Disorders in the Developing World. British Medical Journal Volume 308, Number 6936, pages 10521053. 9. Abas, M., and J. Broadhead (1997). Depression and Anxiety amongst Women in an Urban Setting in Zimbabwe. Psychol Med, Volume 27, pages 59–71. 10. Bolton, P., R. Neugebauer, and L. Ndogoni (2002). Prevalence of Depression in Rural Rwanda Based on Symptom and Functional Criteria. Journal of Nervous and Mental Disease Volume 190, Number 9, pages 631–637. 11. Baingana F, Bannon I and Thomas R (2004). Mental Health and Conflicts: An HNP Discussion Paper. Washington, DC: World Bank. 12. Kinyanda E (2007). Epidemiology of Depression in 15 districts of Uganda. Presented at the seminar on Mental Health and Public Health, convened by Makerere University Institute of Public Health on 28th March, 2007, Grand Imperial Hotel, Kampala. Uganda. 13. World Health Organization (1999). Global Status Report on Alcohol. Geneva: Author. 14. Baingana, F., A. Dabalen, E. Menye, M. Prywes, and M. Rosholm (2004). Mental Health and Socio-Economic Outcomes in Burundi. An HNP Discussion Paper. Washington, DC: World Bank. 15. UNESCO Institute of Statistics (2005). Education for all 2005. Montreal, Quebec, Canada: Author. 16. UNESCO (2007). The Right to Education for Persons with Disabilities: Towards Inclusion. An EFA Flagship concept paper downloaded on 28th May 2007 from http://unesdoc.unesco.org/images/0013/001378/137873e.pdf

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Chapter 13

NATIONAL ARMY MEDICAL CORPS AND HEALTHCARE DELIVERY CHALLENGES IN AFRICA COLONEL ANTHONY AJEMBA

Introduction The National Army Medical Corps and its personnel have always played pivotal role in the development of healthcare system worldwide. It will be recalled that a French Army Surgeon called Captain Alphonsus Laveran serving in Algeria discovered the malaria parasite in the red blood cells of man in 1880 (1). In 1996, the ant-malarial drug Halofantrine was synthesized by the medical personnel of Walter-Reed Army Hospital, Washington DC, USA in conjunction with Smith-KlineBeecham pharmaceutical company (2). As recent as the year 2000, a Nigerian Consultant Anesthesiologist-Brigadier General O. Ovadjeinvented an emergency auto transfusion blood giving set known as EAT set for use in operating theatres in developing nations. For this he was given recognition and award by WHO, UNDP and the African union. In this chapter, I discuss the potential of Military health systems in Africa in organized efforts to improve healthcare delivery in the continent. I will use the Nigeria Army Medical Corps as the background for this discussion. However, the role of Military health systems in Africa is similar, especially in those countries that had to rapidly increase their armed forces due to domestic and international armed conflicts. Overview of Nigeria Army Medical Corps In Africa, the National Army Medical Corps have been involved in meeting many health care delivery challenges. Using Nigeria as a model, the Nigerian Army Medical Corps (NAMC) evolved out of the detachment of the British Army Medical Service that operated with 82 West African Division during the Second World War. After the war it was designated West African Army Medical Corps (WAAMC). At 145

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Nigeria’s independence in 1960, it became Nigerian Army Medical Service (NAMS). It became the Nigerian Army Medical Corps in 1976 (3). As of 1960, the NAMC could only boast of two military hospitals i.e. the 44 Army Hospital Kaduna and the 68 Army Hospital YabaLagos with less than 100 beds between them. The medical personnel were mainly foreigners and most of them left the country with the advent of self government. This left the Corps with acute manpower shortage in all departments and poor infrastructure. As of today, the NAMC has greatly increased in capacity with three standard five hundred bedded Reference (Specialist) Hospitals at Army Headquarter level, seven military hospitals with three hundred beds each at the divisional level and many medical centers and medical reception stations at the brigade and battalion levels. In addition there is an armed forces hospital jointly owned by the army, navy and air force at the Defense headquarters level. Thus its network of health facilities is widespread and it is able to render healthcare delivery to a wide range of people even in the remotest areas. The NAMC has continuously faced series of challenges starting from the time the Corps was about seven years in 1967 when it was suddenly faced with management of many casualties from the Nigerian Civil war of 1967 to 1970. The NAMC has also taken part in health care delivery in the Gambia, peace-keeping in former Yugoslavia, Lebanon, Western Sahara, Chad, Tanzania, Liberia, Sierra Leone, Darfur-Sudan, Eritrea, Ethiopia, Somalia and the Democratic Republic of Congo. The Corps has also participated in many disaster management operations, locally. In all these operational areas, the NAMC learnt valuable technical lessons in acute and chronic care, and, became more adept at customizing its medical services to the meet the health needs of the target population in its operational areas. The 1967 through 1970 Civil War in Nigeria led to an astronomical growth in the number of Corps personnel, expertise, deployment and readiness. The experience learnt in the Nigerian Civil War gave the NAMC the number one position in the field of trauma surgery and psychiatry in the country, and perhaps in the continent. Only Egypt Army Medical Corps could rival Nigeria in trauma surgery because of its experience in the Arab-Israeli wars. The NAMC deployment in the 1980s as part of the United Nations Peace Keeping contingent of the Nigerian Army in the former Yugoslavia brought noticeable adjustments in the technical and

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operational capacities of the officers and men regarding provision of healthcare in cold weather and chronic diseases not very common in Africa. The NAMC provided the hub of medical support throughout the Liberian civil war (1990-2002) by establishing several field hospitals across the war zone. The Corps in addition to their colleagues from Ghana, Guinea and Senegal took on the role of providing comprehensive healthcare for Liberians during a most brutal civil war. The war in Sierra Leone broke out some few years after the Liberian war had begun and the NAMC almost single-handedly intervened in the country’s healthcare delivery sector after the rebels destroyed the entire health infrastructure. In addition, the rebels raped a lot of women, amputated the hands and feet of able bodied men and the women that resisted them, and routinely cut off the limbs of innocent children. All the wounded and the sick were treated in the NAMC Field Hospital and Field Ambulance. At a point in time, the bulk of the NAMC medical personnel were tied up in Liberia and Sierra Leone. NAMC personnel suffered casualties in both Liberia and Sierra Leone wars. Many corps health workers died in the course of discharging their duties in the hands of the rebels who did not respect the Geneva Convention on health services and facilities (6). One of the very serious challenges facing the NAMC in the aftermath of the civil wars in Liberia and Sierra Leone is the large number of troops that contracted HIV and developed AIDS. This took a toll in the health facilities of NAMC and over time, was beginning to spiral out of control until recently when the American government and others intervened to provide antiretroviral free drugs for the affected individuals. Prior to this intervention, many young soldiers were dying daily as they could not afford to pay for the anti-retroviral drugs because of its high cost and only few benefited for the Federal government free anti-retroviral drugs. Even with the intervention, NAMC continues to face major challenges as new clinical wards had to be opened to admit those who require intensive treatment and close monitoring. This has led to employment of more medical personnel thereby increasing the overhead cost for the government. The NAMS role in other countries such as in Darfur-Sudan, Eritrea/Ethiopian border, Somali and Democratic Republic of Congo were highly commended by the international community. In all these countries, the NAMC had the extra responsibility of being the primary and at times the secondary health provider to the displaced citizens of 147

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these countries. The role of NAMC in Darfur was particularly daunting. The NAMC was drafted to Darfur under the auspices of the African Union (AU) to provide medical cover for the Nigerian troops who were part of the AU peace-keeping force. At Darfur, the NAMC had to take on the additional role of providing primary healthcare to thousands of citizens of Darfur who had no healthcare facilities whatsoever. More challenging was how to use NAMCʹs meager health resources and facilities to take care of many starving and malnourished children and adults who were daily succumbing to all kinds of infectious diseases. The NAMC had to carry out urgent immunization against hepatitis when a serious outbreak was noticed in refugee camps. As a result of the recognition accorded NAMC, its leadership and technical corps are on high demand in many African countries. The NAMC overhauled, trained and set up a new Gambia and Sierra Leone armed forces medical services. NAMS provided leadership for Military hospitals of these two countries for many years before handing them back for local oversight. Presently, NAMC is providing similar leadership and technical expertise to the fledgling Liberian army medical services. On the local scene, the NAMC has always been called upon by the Federal and State governments to provide healthcare services for the internally displaced people occasioned by flood, fire disasters and ethno-religious conflict. The Military is widely acknowledged as the only neutral body and location for those displaced or wounded in the ethno-religious crisis to seek shelter, food and treatment. The NAMC has through this avenue perfected the management of the public health disasters and the rapid deployment of personnel and equipment to meet non health exigencies in areas such as overcrowding, poor housing facilities, inadequate portable water supply, exposure to weather elements and insect vectors. NAMS has also become proficient in dealing with poor sanitary conditions in emergency situations and the problem of hasty or improper burial of the dead in emergency and refugee camps. In addition, NAMS has gained widely acknowledged expertise in the areas of management of large-scale outbreak of epidemics such as diarrhea from cholera, enteric fever, E.coli, shigellosis, and the management of large scale staphylococcus food poisoning. As the NAMC is regularly enlisted to work on civilian issues, the Corps has

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developed expertise on the management of severe malnutrition and dehydration especially among the very young and elderly and also in the clinical management of tetanus and other deadly infectious diseases. In addition, due to the strategic location of the NAMC medical facilities across the country and good knowledge of the countryside by the Corps, the NAMC is always among the first to arrive in the areas of mass casualties like plane crash, road traffic accident etc. Meeting the Needs of Beneficiaries and its Impact on the General Population One of the most important functions of national army medical corps throughout the world is the provision of quality care to its officers, rank and file and their beneficiaries. In some African countries, beneficiary care by Military medical corps is among the best available health systems. The situation is no different in Nigeria. Efforts to improve healthcare among Military personnel and their beneficiaries often lead to future health policy and health delivery initiatives in the general population. I discuss some these issues as it relates to Nigeria. The NAMC today is present in all formations of the Nigerian Army and offers primary, secondary and tertiary health services primarily to the members of the armed forces. Such services include clinical consultation, management of patients, teaching and medical research. Also it offers consultancy services for civilian and other interested institutions in the country. Primary heath care services rendered by the NAMC include health education, barracks inspection and sanitation, immunization, control of communicable diseases, maternal and child health services and family planning. Even before the recent advent of the National Health Insurance Scheme (NHIS) in Nigeria, the NAMC has always provided a comprehensive free medical care for the military personnel, their spouses and four children below the age of 18 years. The medical care is all encompassing and may involve treatment of very complicated cases in the best hospitals abroad such as in UK, USA, Germany, Israel and Egypt. At the height of the war in Liberia and Sierra Leone, many of the Nigerian Peace Keepers were wounded in action and Military Hospitals quickly became overwhelmed by these casualties. An

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arrangement was made to evacuate many of these casualties to Egypt and Israel for further treatment. In addition, the NAMC initiated the payment of hazard allowance to all medical personnel who are daily exposed to many infectious diseases such as HIV/AIDS, Tuberculosis and many others. This has gone a long way to reducing the financial burden that comes from paying for medical care. Although medical care is free, military personnel still have to pay for expendable materials that are not available in Military Hospitals and then make claims later for official reimbursement. The scourge of fake and adulterated drugs that flooded Africa from some Asian countries resulted in many morbidities and mortalities among the populace. The NAMC had to set up special task force headed by Military doctors and pharmacists to arrest, prosecute and stop the importers of these fake drugs and their collaborators. This is a work in progress. This effort is now complemented by the robust leadership and technical competence of the national drug regulatory agency, NAFDAC. To safeguard the lives of the military personnel and the general public, the NAMC set up its own drug manufacturing firm. The firm is headed by a Military pharmacist to produce basic drugs and intravenous infusions needed for Military hospitals. The production line has since evolved to the production of drugs for use by the general population Another by product of the continuous expansion of the role of the NAMC both locally and abroad is the inevitable growth of training and professional education programs. The Corps has since established a Nigerian Army Medical Training School that trains medical manpower for the Nigerian armed forces. The courses offered include nursing and midwifery, dental technology, physiotherapy, health services administration, peri operative and anesthetic nursing, radiography and environmental health. The three reference hospitals in Kaduna and Lagos have been certified by the Medical and Dental Council of Nigeria to train house officers and clinical interns. Also the National Postgraduate Medical College of Nigeria and the West African Postgraduate Medical College have since given these reference hospitals the approval to train resident doctors in internal medicine, surgery, pediatrics, family Medicine and obstetrics and gynecology.

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The NAMC as a matter of policy gives free emergency medical treatment to all accident victims, all unconscious patients and the very ill and poor patients from local communities where the various military health systems are located. The residents of these contiguous communities also benefit from NAMC free health education programs and often benefit from the extension of such Military Barracks amenities as portable water supply. They are also encouraged to take advantage of free immunization for their babies in all Military hospitals. Where the community lacks medical facilities, they are given full treatment up to the tertiary level and pay only token fees to cover administrative charges and material use. The Nigerian Army Eye Centre is noted as one of the best in the country and offers its services to all at a very modest cost. One of the best equipped audiology centers in Africa is run by expert consultants from the NAMC. It was initially set up to cater for soldiers suffering from deafness which they acquired from the war zones in Liberia, Sierra Leone, Somalia and others but it is now a major referral centre for audiological problems in West Africa. In recognition of NAMC role in the provision of free healthcare to the general population and the high number of individuals living with HIV/AIDS in Nigeria, the Harvard University School of Public Health in conjunction with the US President’s Emergency Program For AIDS Relief (PEPFAR) chose the Nigerian Army Reference Hospital YabaLagos as one of its sites in the country to give free antiretroviral and antituberculosis drugs to all Nigerians living with HIV/AIDS. In addition, the U.S. Department of Defense is financing another HIV/AIDS program in the Nigerian Army Reference Hospital, Kaduna. These two programs have markedly reduced the mortality and morbidity associated with HIV/AIDS in the Military. Many extremely sick individuals living with HIV/AIDS who ordinarily would have died have made remarkable recovery after having started the highly active anti retroviral therapy (HAART) provided free of charge to these patients. Military Health Systems and National Health Policy Makers The NAMC has had an explosive growth over a short period. The growth in function has not equally been matched with commensurate increase in funding. This has been attributed to prevailing poor 151

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economic conditions in Nigeria. Consequently, NAMC is managing a lot of dilapidated infrastructures and equipment. In addition, regular professional training programs at home and abroad to update clinical, public health and management acumen have slowed down, considerably. Even those who obtained sponsorship for further training abroad through external organizations such as USAID,UNDP and UNICEF have to come back to work with the same outdated equipment. According to a recent WHO publication (7), Africa accounts for 10 percent of the global population but harbors 25 percent of the global disease burden while fielding only 3 percent of the global health work force. The same report noted that 4 million health workers are needed to combat the chronic work force shortage world wide, with Africa needing at least one million health workers as soon as possible. Out of the 57 countries that have serious shortage of health workers in the areas of childhood immunization, pregnancy care and access to treatment, 37 of these are in sub-Saharan Africa. In spite of these, the NAMC continues its training and retraining programs for its staff locally in teaching hospitals and abroad within its limited resources. The NAMC still parades an array of well trained personnel who have benefited from training programs at home and abroad. However, for less affluent African countries, it may be difficult to remain at the cutting edge of Military health services as well as contribute to the provision of health services to the general population due to chronic paucity of funds. This is a major dilemma that national health policy makers must contend with since Military health systems have the capacity to positively influence the provision of health services in the general population of a given country. Military health systems in Africa can be mobilized in short notice to provide healthcare to needy citizens. It is also interesting to note that brain drain appears not to be a major problem for NAMC. Unlike what obtains in the public medical system where many well trained medical professionals have drifted abroad seeking greener pastures and better practice opportunities, NAMC appears to retain most of its highly trained personnel. According to the Nigerian Federal Ministry of health publication (8), by July 2003, 10,000 of 35,000 registered medical doctors had left Nigeria in search of better employment opportunities abroad. The same report also noted that 20 percent of 10,364 registered pharmacists had left the

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country during the same period. The report also noted that 2,980 nurses left in 2001 and 5,937 in 2002. As of today, Nigeria has only about 7,500 environmental health officers. The limited impact of brain drain in NAMC has made the system one of the best in the country in terms of technical expertise and experience. In the area of emergency medical care, NAMC is almost indispensable. NAMC is also well regarded in multiple clinical specialties. In order to achieve the Millennium Development goal of 2-3 health workers per 10000 people in Africa, health policy makers in Africa should look toward stable Military health systems in Africa for expertise and experience. Military health system experts can play critical formalized roles in national programs such as childhood immunization campaigns, national health education programs, public health disaster management initiatives and health care training programs for various categories of medical personnel. These resident skills, experience and expertise in African Military health systems should be maximally utilized by national and continental organizations and institutions in Africa. In addition, Military health systems need to be a part of an integrated, comprehensive health delivery mechanism at national and continental levels. Policy makers in Africa need to adopt national health strategies that include African Military health systems as part of its overall plan for healthcare delivery. This will end the current practice whereby Military health systems are rarely at the table during serious national and continental efforts to improve health services. It will also end the present practice whereby Military health systems are only the burden of ministries of defense. As shown in this document, the reality is that Military health systems in Africa, at least in Nigeria, are already providing critical health services to the general population. It is necessary for ministries of defense and health to explore ways of working together at strategic, policy and operational levels. This working relationship may evolve into an arrangement where both ministries share administrative oversight of Military health systems and jointly coordinate the deployment of technical experts from both entities for specific tasks and assignments. For example in Nigeria, the Federal Ministry of Health has begun a comprehensive and phased rehabilitation of all the Federal Teaching 153

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Hospitals and Medical Centers but none of the Military hospitals is benefiting from this initiative due to lack of coordination and integration between the two ministries. It is obvious that the NAMC through its various activities nationally and abroad have affected the lives of far many more people than their civil hospital counterparts. There is a need to fund and integrate the NAMC into the federal structure for it to be more effective in carrying out various healthcare challenges in Nigeria, other parts of Africa and abroad. Apart from the need for adequate funding and integration into the federal health network, experts in NAMCS can rotate through civilian health institutions during peace time in order to transfer knowledge on certain medical condition peculiar to the armed forces. Such areas include the management of ballistic/missile injuries, nuclear, biological and chemical warfare. These specialized areas are peculiar to the Army Medical Corps and are hardly taught in medical school at undergraduate and postgraduate levels. Conclusion Military health systems in Africa do not operate in a vacuum or in isolation of other public medical systems. In addition to very effective beneficiary health programs for the men and women in the armed forces and their dependents, Military health systems in Africa play a critical role in the provision of routine health services, the provision of emergency services and the provision of healthcare during the time of war at home and abroad. Military health systems in Africa, as shown by the example of Nigeria, have some of the best complements of medical expertise in African countries, are better able than their civil counterparts to retain their experts at home and have tremendous experience in public health disaster managements, specialized clinical care and public health national campaigns against specific diseases and health conditions. What is glaringly missing is a formalized role for Military health systems in the rubric of health policy making at national and continental levels in Africa. It is time to integrate Military health systems with public and private health systems in organized efforts to improve healthcare delivery in Africa.

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References 1. Postiglione M (1998). Malaria and its present situation in the world. Medical Corps International 1988, Volume 3, pages 53-57 2. Smithkline-Beecham (2004). Pan African Meeting. Medicine Digest, Volume 20, pages 24-27. 3. The Nigerian Army Medical Corps and School (2004). Brief History of Nigerian Army. Available at http://www.nigeriaarmy.net/schools/namcs.htm.2004. 4. Adeloye A (1977). Missile Head injuries in Nigerian soldiers (with special study of Tangential wounds): Care of the Injured, Pages 122-127 5. Dick HJ (1989). Prevention of Cold Injury on Exercises with the Allied Military Force (Land) in North Norway. Medical Corps International, Volume 4, pages 41-47. 6. United Nations (1948). Geneva Convention. Geneva, Switzerland: Author. 7. Nigeria Sun Newspaper (2006). World Health Organization publication. Sunday, April 9, page 54. 8. Nigeria Sun Newspaper (2006). Federal Ministry of Health publication. April 11, page 26.

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A ROADMAP FOR BUILDING AND MAINTAINING NATIONAL EMERGENCY MEDICAL SERVICES IN AFRICA: THE ETHIOPIAN EXPERIENCE TENAGNE HAILE-MARIAM, KATE DOUGLASS, ANGELA LEE Introduction Low and middle income nations must bear the “dual burden of disease”. Health care systems have long struggled to prevent, diagnose and treat communicable disease. Today, demographic and socioeconomic shifts have added to the toll of death and disability from increasingly prevalent non-communicable diseases and injuries. A particularly poignant example of this “dual burden” is the disproportionately large human and material cost placed on low and middle income nations by the global epidemic of road traffic injuries (1). In 2003, the World Health Organization (WHO) recognized that the leading causes of global morbidity and mortality could be reduced with improved access to emergency health services and called for a “rapid and sustainable expansion of emergency services.”(2) Indeed, patients who present with acute medical and surgical problems such as injuries, cardiovascular events, dehydration, infection and complications with pregnancy and delivery are best served by a system that can provide timely, effective, cost-efficient and sustainable care. We agree that the time has come for a paradigm shift in the international health community’s approach providing for emergency healthcare services. Emergency services can no longer be viewed as “extras” or as limited to auxiliary services such as emergency medical systems (EMS). If emergency medical care is to be efficient, cost-effective and sustainable, it must be integrated into the healthcare systems of low and middle income countries (3, 4). Proper organization and planning can help reduce waste and lead to improved care and better outcomes (3, 5). In short, emergency medical services must be incorporated into the planning, funding and delivery of public and primary healthcare 157

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services to ensure that all persons who seek emergency care receive the best possible care in a humane and timely manner. In this chapter, we will explore some of the nascent but exciting work that is being done to improve emergency health care services in Addis Ababa, Ethiopia. We hope that this work will provide a “roadmap” for the development of such systems throughout Ethiopia and eventually Africa at large. It the first section, we address the question of “why emergency medicine” in a low income country context and describe what currently passes for emergency care in Addis Ababa, Ethiopia’s best served city. We then review the data that has already been collected and initiatives that have begun. Finally, we lay out our “road map” for the judicious and orderly introduction of a tiered and efficient emergency healthcare system as an essential piece of a broad based effort to improve the overall quality and delivery of healthcare services. Our effort is both highly focused on the specificities of care delivery in one extremely poor city – it is involves a collaboration among the Addis Ababa Heath Bureau, the Federal Ministry of Heath, the Addis Ababa University School of Medicine, Black Lion Hospital and the Ronald Reagan Institute of Emergency Medicine of The George Washington University Department of Emergency Medicine located in Washington, DC. This synopsis is meant to provide a model of how best to conceive and implement robust, sustainable emergency healthcare systems that will improve the outcomes of patients with acute healthcare needs in other, similarly challenged cities and countries. The Journey So Far Our experiences in helping set up an emergency medicine program in Addis Ababa, Ethiopia are very instructive. With some of the worlds’ most challenging health care indices, Ethiopia might, at first glance, not appear to be a nation that should be appropriating precious healthcare resources to emergency medicine (6). In the face of AIDS, Malaria, tuberculosis and a host of other communicable diseases, it is easy to see why current health funding for Ethiopia focuses on prevention and treatment. Health facilities in Ethiopia are preoccupied with the treatment of patients with communicable diseases. These health facilities place a premium on early recognition and swift

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treatment of presenting cases. In addition, health facilities also focus on the recognition and treatment of sentinel cases. A well-planned and managed acute care system can provide precious opportunities to provide preventive health services targeted at patients and their families. In addition to preventive health interventions, emergency medicine addresses the second health “burden” that Ethiopians face on a regular basis: the fact that their country has one of the highest fatality rates per vehicle in the world (7, 8). The significant morbidity and mortality alone from automobile accidents in Ethiopia is enough to justify the need for major investments in emergency medicine networks throughout the country. The need for emergency medicine in Ethiopia is straightforward. Without an effective emergency care system: ¾

¾ ¾ ¾

Tens of thousands of injuries, illnesses, complications of childbirth, and cardiac events leave patients unnecessarily disabled or dead, with terrible human and economic costs; There is no way to identify or track outbreaks of disease or epidemics such as avian flu, or to manage them if or when they occur. There exists no capacity to prepare for or manage mass casualties in the event of a natural disaster or terrorist attack. Existing health care resources are inefficiently deployed, as the emergency case load must be handled by units and systems not optimized for emergency care.

Current conditions in Ethiopia demonstrate the importance of these problems. In Ethiopia, medical providers from various backgrounds provide emergency medical care with limited supplies and inadequate training. Even in Addis Ababa, where per capita healthcare worker ratios are better than elsewhere in the country, there is no coordinated system of emergency care, either in the pre-hospital arena or in the formalized hospital and clinic system. On arrival to the hospital receiving area, a rudimentary triage system directs patients to services but does not adequately prioritize patients based on objective data collection or risk stratification. Although there are several mechanisms for disease surveillance in place, data that can be used to design an acute healthcare response system are clearly missing. The lack of a comprehensive understanding of the profile and burden of patients presenting with emergency 159

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clinical conditions results in inadequate patient care. Lack of primary data also decreases the ability of emergency departments to recognize and respond to dangerous infectious disease outbreaks. The emergency departments are also ill prepared for any potential disaster or mass causality incident. This is a common description of the current state of emergency medical services in most African countries, with even more dire situation in poor rural areas of the country. In addition, the lack of emergency medical services is a deficiency that is often underrecognized and under-appreciated by domestic and external donor agencies, administrators and policy makers. Over the past ten years, intermittent initiatives have taken place in Ethiopia concentrating on different components of emergency medical services, including pre-hospital care training and short courses in emergency medicine (9, 10). These efforts have been intensified and streamlined in the past three years, and a critical group of stakeholders committed to the development of a sustainable emergency medical system has emerged, including in-country representation from the Addis Ababa Health Bureau (AAHB), the World Health Organization (WHO), and the Addis Ababa University Medical Faculty (AAUMF). The rationale for emergency medical systems development has been recognized and embraced by the Federal Ministry of Health (FMOH) (11). In addition, external collaboration has been provided by various groups, including the Ronald Reagan Institute of Emergency Medicine of the George Washington University Department of Emergency Medicine (RRIEM), the Ethiopian North American Health Professionals Association (ENAHPA) and Students for International Medical Action (SIMA). Our shared vision is the development of a functioning emergency health care system for all people in Addis Ababa, Ethiopia, whereby emergency medical services will be available in a timely and equitable fashion. This committed group has undertaken several steps towards achieving our common vision including: Ongoing Volunteer Site Visits

A regular series of site visits has been conducted by teams from RRIEM, ENAHPA and SIMA since May, 2005. Visiting teams have included emergency physicians, emergency nurses, physicians’ assistants, wound care specialists, medical students, and public health

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professionals. Activities have included hands-on training of local physicians, nurses and allied health professionals on various courses including basic and advanced life support and the evaluation and treatment of minor and major trauma. Specific site visits have been made to receiving areas of hospitals in Addis Ababa, with evaluations and recommendations for improving processes and facilities. There have been numerous collaborative formal and informal investigations which have resulted in research endeavors, presentations, and projects. These investigations and site visits have provided valuable needs assessment information that is shaping ongoing projects. Collaborative Meetings

Stakeholders have met regularly to organize initiatives and ensure that projects are in alignment with Ethiopian national health goals. These meetings have provided a larger, more formalized format for discussing ongoing project planning and development. o

o

o

The Addis Ababa Health Bureau hosted the First Stakeholders meeting to Improve Emergency Medical Services in Ethiopia, Addis Ababa on May 29, 2006. The meeting was held at Menelik II hospital and included representatives from ENAHPA, RRIEM, AAHB, the Addis Ababa Police, several health related NGO’s and civil society organizations such as local women’s groups; Ethiopian Emergency Medicine Stakeholders Teleconference – December 9, 2006. This meeting included key representatives from AAHB, AAUMF, RRIEM, ENHAPA, the Federal Ministry of Health as well as experts from fields of Health Policy and program implementation;. Recurrent meetings continue amongst persons dedicated to project development, including the Core Working Group of physicians representing various specialties at the Black Lion Hospital that hold monthly meetings to discuss issues, updates, and initiatives.

Online Exchanges

Online exchanges have provided collaborators in Addis Ababa, Washington, DC and other parts of the United States to maintain continuing communication and discuss emerging issues. Cost-efficient use of modern telecommunications resources will be an increasingly important means for information transfer, education and training.

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Project Development

Working groups have collaborated in drafting a template for training healthcare workers to meet the increasing demand for emergency health care services in Addis Ababa. The draft has been constructed by the AAUMF, presented at the stakeholders teleconference in December, and is undergoing revision by all relevant stakeholders. Broad Lessons Learned and Identified Gaps The continuing collaboration has provided invaluable insight into the overall needs, existing capacities, and essential requirements on how to design and implement future interventions in emergency medicine. Given the limited amount of available data, a major focus of future operations will revolve around the need for valid baseline and trend data, and, the need for verifiable monitoring and evaluation protocols as progress is made in the design and operations of emergency care in Ethiopia. In general, effective emergency medicine development requires a systems approach to understanding how the delivery of emergency care fits into the established national health care system. Without a broad perspective, the concepts of sustainability and equity will not be achieved (3). Current Health Care System

One of the challenges of improving emergency medicine in Ethiopia is the lack of information regarding the frequency and distribution of emergency cases. Reasons for these limitations include inadequate surveillance mechanisms and a lack of uniformity or completeness of patient medical records. This is compounded by what we can only assume to be large number of missed presentations (due to pre-hospital mortality or the decision not to seek medical care). It is nearly impossible to accurately anticipate emergency department patient volume or types of care needed. The essentials of emergency care rely on a collaborative team effort focused on the implementation of acute resuscitation without delay for payment or definitive diagnosis. Such principles must be known and practiced by all healthcare workers and understood by administrators and policy makers. Currently, this mindset is not consistent with emergency care and resuscitation taught or practiced in Ethiopia.

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Clinical Obstacles Ethiopia faces significant barriers to the clinical practice of emergency medicine. The most critical needs relate to the availability of space, the prioritization of patients, and the availability of supplies. The outpatient department in a typical hospital is naturally overwhelmed by emergency visits by patients, adding to the normally congested outpatient services. We have identified the lack of dedicated acute care receiving areas and emergency triage personnel and guidelines as fundamental barriers to adequate and timely care. Another significant clinical barrier is the inadequate and insufficient medication for emergency patients. In emergency situations, these limited resources are not only frustrating but deadly. Healthcare Provider Training We do not believe that intermittent foreign-based training of healthcare providers in the concepts and practice of emergency medicine is a long term, sustainable strategy. Without local training and educational capacity building, the gap in the delivery of emergency care will persist. Our goal in training is to develop long term solutions in the form of train-the-trainer programs and creating a self-perpetuating Emergency Medicine residency program. Training will be offered to non-physicians such as technicians, nurses, and physician assistants. High standards of professionalism and credentialing will be vital in assuring the competence of trained health professionals and in ensuring the sustainability of emergency medicine programs in Ethiopia. We look forward to the establishment of a dedicated training center. This center will also serve as the fulcrum of community outreach efforts and serve as the venue for first responder training courses. The current deficiency in trained providers is complicated by the issue of retention, which must be openly addressed in concert with training initiatives. Establishing broad-based Support for Emergency Medicine If emergency medical services are to be successfully implemented in Addis Ababa, this will require “buy-in” from the general public, policy makers, healthcare providers and the international development community. Healthcare providers must understand the unique and essential role played by emergency health care providers, and work to 163

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incorporate the specialty into the medical system at large. The community should embrace the concept of emergency medical care, and participate by seeking emergency care only when appropriate and necessary. The international development community will also have to accept that building emergency medical systems is a critical health and human rights issues, especially in countries with dangerous rates of road traffic accidents, natural and man-made disasters. The impending threat of pandemic influenza and the epidemic of road traffic injuries have heightened the need to align funding priorities with developing viable and sustainable emergency care and response systems. In order to save lives and build strong foundations for emergency medical services, we recommend not only early investment in emergency systems development impact analysis to show potential cost savings at national and local levels. Policy Dialogue Although small scale training programs and recurrent site visits have provided for invaluable opportunities for teaching and information exchange, this cannot foster sustainable change. Sustainability can only be achieved by fundamental shifts in health policy and resource allocation. To this end, it is essential that policy makers are intimately involved in all phases of planning and implementation of new emergency medicine programs. If emergency medicine is to take root in Addis Ababa or any city in Africa, it will require on-going support and engagement at the highest levels of health policy makers and the national government. Given the multiple, complex mandates facing the Ministry of Health and the Addis Ababa Health Bureau, the expanded mandate to improve emergency medical access and care has lead to predictable gaps in resources. All stakeholders recognize this gap and are committed to finding means for its resolution. Program Management A common pitfall in international development is duplication of initiatives, leading to wasted resources and unnecessary competition. Management of emergency medicine programs should be based on broad national mandates so that a system of care could be developed to meet the needs of all citizens. The broad national mandate will also

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ensure the coordination of program efforts, the realignment of emergency medicine issues with national health goals and objectives, and, the integration of emergency medicine protocols into existing national health systems. A broad national mandate will also assure the delivery of similar quality programs throughout the country, through national professional standards and emergency medicine credentialing processes. It is very important that program design in emergency medicine should be flexible enough to accommodate future understanding of disease prevalence and distribution gained from ongoing surveillance efforts. Without adequate coordination of these programmatic issues, the overall effectiveness of emergency systems development will be jeopardized. Developing and fostering International Partnerships Finally, emergency medicine is a new specialty in every country. There have been critical lessons learned along the road of systems development that will be helpful as African countries begin to incorporate this new specialty. Dedicated international assistance with a focus on sustainability has already been of assistance to Ethiopian health care workers and policy makers and can continue to be utilized as a resource. In particular, Ethiopian nationals living in the West and organizations such as ENAHPA have important roles to play in the design, implementation and sustenance of emergency medicine initiatives in their homelands. Recommendations A. Emergency medical care should be developed as a system and integrated into existing preventive and primary health care systems

Countries interested in developing emergency medical services must consider both the big picture and the individual components when conceptualizing the appropriate integration of emergency medicine into existing health systems. A commitment to ongoing training, monitoring and evaluation strategies will create an emergency medicine program that is responsive to the needs of the population.

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To establish, operate, maintain and sustain an emergency medicine program in Ethiopia or any part of Africa, we believed the following issues should be considered. 1. Each country must establish its own standards of emergency medicine.

As a relatively new medical specialty, emergency medicine and responsibilities continues to evolve. Each national government should establish standards for the practice of emergency medicine. This standard will include accreditation, credentialing of the work force, facility/infrastructure standards, and career opportunities. The process of establishing standards will involve health professional organizations, relevant professional registration authorities, policy makers and the target population. 2. Ensure governmental support and ongoing policy dialogue Numerous policy issues exist around healthcare, including concerns about equity and allocation of limited resources. Emergency care should be made available and accessible to all. Cost cannot be a barrier to seeking emergency care. Healthcare providers trained in emergency medical care should find a place in the system of care operational in their country. They should also be appropriately compensated. Successful program implementation cannot occur without these elements being duly addressed. 3. Conduct careful needs assessments Qualitative and quantitative assessment of baseline and trend healthcare needs of the population should be used for planning and implementation purposes, to target training, to procure medical equipment and other essential supplies, and, to engage potential external donors and partners. 4. Implement ongoing data collection and surveillance systems A dynamic data collection and surveillance component will allow identification of changes in healthcare needs and alert policy makers and program managers to emerging health issues. Accurate data is critical in the preparation and response to disasters, epidemics and pandemics. Furthermore, data collection is essential to effectively guide allocation of human and material resources.

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5. Maintain information and communication infrastructure Cost effective use of appropriate information technologies is imperative to building an emergency medical system for the present and the future. For example, pre-hospital personnel must know how to discuss and alert healthcare facilities of the impending arrival of patients requiring immediate care. Field healthcare workers should have a transparent, easily updatable and accessible method for knowing the receiving capacity of local hospitals. The issue of an accessible and updatable patient healthcare record is one that is vexing, even in the most endowed and sophisticated healthcare systems. Fortunately for our collaborative project, the Ethiopian Ministry of Health is in the process of addressing this problem. 6. Address healthcare practitioner retention issues Trained professionals continue to leave Africa. Any training program must be accompanied by significant efforts to retain trained professionals within Africa. Healthcare worker retention is vital to maintaining a well-functioning healthcare system. B. Institute and Maintain Healthcare Provider Training and Credentialing Program

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Pre-hospital care training can be provided to lay-persons or the professional category of emergency medical technician/paramedic specifically tailored to the needs of a particular community. Basic first aid and primary interventions for common diseases such as dehydration can have significant impacts on morbidity and mortality.

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Incorporate non-physician healthcare providers training. Creative and versatile non-physician provider training programs should be tailored to the needs of individual communities. Physician training is a long and expensive process. Not all clinical care requires the expertise of a physician. Wound care technicians, midwives and other physician-extenders can have significant impacts on community health outcomes. Ongoing credentialing and training must be used to ensure quality of patient care.

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Institute Emergency Medicine post-graduate training. Ongoing training, evaluation and credentialing will ensure current, upto-date quality care. As with all training programs, quality of care must be monitored. This will ensure improved morbidity and mortality as well as maintain the public trust in the care that they receive. Emergency medical care as an independent, defined specialty is new to Africa, and rigorous program evaluation throughout process implementation is essential.

C. Invest in Medical Student Education and Exchange

A high yield but low-cost method of inspiring young physicians to choose professional career paths that incorporate service is to involve medical students in international collaborations. International student collaborations also foster professional pride and can form the basis for further research, educational and training initiatives. D. Engage in Injury Prevention/Community Based Interventions

Community involvement is essential in ensuring the success of healthcare initiatives. Ongoing community outreach and teaching on various topics such as disease prevention will lead to improved health outcomes. E. Maintain Equipment and Supplies

Maintaining perishable and non-perishable goods and supplies is an ongoing challenge to all healthcare systems. These challenges are made more apparent by the variety of medication and equipment sent from various sources to health care institutions in Sub-Saharan Africa. Ensuring that purchased and donated supplies and equipment are relevant, useful and cost-effective in the emergency care setting must be a priority. Conclusion Emergency medical care is a vital component of all healthcare systems and the systematic incorporation of such care is critical. Careful needs assessment and planning in concert with policy change are essential if emergency medical care is to be a sustainable, rational and cost-effective component of the healthcare system. With the successful incorporation of emergency healthcare services, every

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individual should have equitable access to life and limb saving interventions whether from acute disease presentations or traumatic injuries. References 1. World Health Organization (2006). World Health Report 2006: Working Together for Health. Geneva, Switzerland. Available at: http://www.who.int/whr/2006/en/ 2. World Health Organization (2003). World Health Report 2003: Shaping the Future. Geneva, Switzerland. Available at: http://www.who.int/whr/2003/en/index.html 3. Arnold JA, Hollman CJ (2005). Lessons learned from International Emergency medicine Development. Emergency Medicine Clinics of North America, Volume 23, pages 133 – 147. 4. Smith J, Haile-Mariam T (2005). Priorities in Global Emergency Medicine Development. Emerg Med Clin N Am, Volume 23, pages 1129. 5. Thomas TL (2005). Developing and Implementing Emergency Medicine Programs Globally. Emerg Med Clin N Am Volume 23, pages 177-197. 6. World Bank Groups (2006). World Development Indicators April 2006. Washington, DC. Available at: 7. http://devdata.worldbank.org/external/CPProfile.asp?CCODE= ETH&PTYPE=CP 8. World Health Organization (2007). Disability and injury prevention and rehabilitation.” Available at: 9. http://www.who.int/countries/eth/areas/violence/about/en/index.ht ml. 10. Jacobs, Goff and Amy Aeron-Thomas. Estimating global road fatalities. Global Road Safety Partnership. Available at http://www.grsproadsafety.org/. 11. Bayleygne T, et al (2000). An International Training Program to Assist with Establishing Emergency Medicine in Ethiopia. Annals of Emergency Medicine. Volume 36, Number 4, pages 378 – 382. 12. Pozner C et al (2003). Emergency Medical Services Capacities in the Developing World: Preliminary Evaluation and Training in Addis Ababa, Ethiopia. Prehospital Emergency Care, Volume 7, Number 3, pages 392-396. 169

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13. Federal Democratic Republic of Ethiopia Ministry of Health (2006). National Injury and Rehabilitation Strategy Draft. March. Addis Ababa, Ethiopia: Author. Appendix 1: Key Components for the Development of an Emergency Healthcare System 1. Integrate development of emergency care into the overall healthcare system to ensure coordinated, ongoing care 2. Government support and ongoing policy dialogue 3. Needs Assessment 4. Ongoing data collection and surveillance 5. Information and communication infrastructure 6. Healthcare worker retention- training and retaining qualified personnel is vital to maintaining a well functioning healthcare system 7. Healthcare provider training and credentialing - Prehospital provider training - Nonphysician provider training, credentialing - Emergency medicine post-graduate training 8. Medical student education and exchange 9. Injury prevention and community based interventions 10. Equipment and supply acquisition and maintenance

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Chapter 15

COMMUNITY ORIENTED PRIMARY CARE CHINUA AKUKWE Introduction Community Oriented Primary Care (COPC) originated from the rural areas of South Africa in the early 1940s (1, 2, 3). In Phoela, South Africa, a husband and wife team, Sydney and Emily Kark began operating an integrated clinical medicine and public health practice for a defined rural population. This integrated clinical and public health approach focused on getting to know the residents of Phoela and its environs, family members and other dependants, whether they had complaints of illness or not. By taking time to get to know their clients and family members in the clinic and within family settings, Sydney and Emily Kark began the process of involving the community in their own health care. The Phoela community-based integrated clinical and public health approach eventually evolved into community health centers in the country. The Karks however had to migrate to Israel following the increasing focus of the then South Africa Apartheid regime on racial discrimination and the blatant implementation of social and economic policies designed to provide inferior services to the Black majority population. In Jerusalem, Israel, Sidney and Emily Kark established the famous community oriented primary care (COPC) program at the Hadassah Teaching Hospital and the Hebrew University School of Community Medicine and Public Health, Jerusalem. Generations of physicians and other health practitioners from Israel, Palestinian Territories, Africa, United States, Europe, Latin America, South East Asia and Australia learnt the rudiments of COPC from Sydney and Emily Kark and other professors both had trained and mentored on COPC (1, 2, 3). The author as a graduate student of COPC in Jerusalem, Israel got to meet Sydney and Emily Kark in their retired but still active years and had the opportunity to benefit from their combined special lecture and consultation on COPC.

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As a methodology that started in rural settings and eventually became well known in urban centers of Israel before migrating to the inner cities and rural areas of the United States and metropolitan areas in United Kingdom and parts of Latin America, there are varied definitions of COPC. These varied definitions are important as I seek in this article to show the relevance of COPC in organized efforts to transform health systems in Africa. Definitions of COPC Sydney Kark (2) defines COPC as a form of integrated clinical care that brings together personal health and community medicine within primary care settings. This integrated system of care focuses on the target community as the foundation for needs assessment, health planning, service delivery and evaluation of defined services. Mullan and his colleagues define COPC as a primary care delivery strategy that relies heavily on established priorities of target populations in the design and implementation of services (4). In another slight variation, Plescia and Groblweski (5) define COPC as the application of public health principles in primary care settings to define and improve the health status of specific populations. Another definition by an academic center (6) indicates that COPC is a bridge between clinical medicine and public health with the target community as the focal point in the planning, delivery and evaluation of care. In this regard, COPC is both a theoretical and practice construct that provides rationale for healthcare delivery strategies that should meet identified needs of target populations, including maximization of available resources. Other definitions and discussions of COPC recognize the integration of clinical medicine and primary care services to meet identified needs and priorities of defined populations (7-10). COPC also links clinical and public health services to psychosocial issues, health behaviors and environmental concerns in target communities. For the purposes of this chapter article, I define community oriented primary care (COPC) as a community-based health strategy that unites the practice of clinical medicine with public health delivery mechanisms in defined communities and in response to the expressed needs and priorities of the target population. By this definition, COPC

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integrates clinical medicine with public health and epidemiology in mostly ambulatory settings and in response to verifiable needs and priorities identified by defined target populations. For this definition of COPC to be met, clinical medicine practitioners will have to work closely with public health experts to get to know their practice or target community and must collaborate with those familiar with epidemiology practices to get the target population to become actively involved in the design, implementation, monitoring and evaluation of health services. The felt needs and priorities of the target population in this definition of COPC remain central to program operations. In addition, COPC practitioners should have the flexibility to customize the delivery of health services to meet the priorities of target population. They should also have the capacity to detect and respond to changing needs and priorities of those they serve. In this instance, the “community” in COPC represents hamlets, villages and towns from where clients of health services come from or a subset of this population. This clarification is critical in developing country settings where rural populations and inhabitants of urban centers may not have a choice regarding which health service to attend. It is critical to define the ‘community’ in COPC so that baseline and trend data could be collected and health practitioners can get to know their target population. Steps in the COPC Process COPC is organized and implemented in six major steps, with minor modifications depending on local practice patterns and target population (2, 5, 6). These six steps form a circular loop of strategies that need to be revisited as often as possible in order to remain focused on the needs of the target population. The six steps include: 1) 2) 3) 4) 5) 6)

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Define target community or target population; Complete community characterization; Translate identified problems into priorities; Conduct detailed assessment or community diagnosis relying on epidemiological tools and other forms of analysis; Decide on intervention mechanisms and begin operations; Implement monitoring and evaluation protocols for chosen interventions.

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Each step requires the active participation of the target community or population. It also requires application of data protocols in such a way that the validity of program outcomes could be verified by independent third parties. The US Institute of Medicine in its review of COPC (11) suggests that interventions should be comprehensive, accessible, coordinated, continuous, sustainable and accountable. This is particularly important in settings where concerns for governance are genuine and reputation for active community engagement is limited. Rhyne and his colleagues (11) and Williams (12) argue strongly that the active participation of target community or population in all steps of COPC is a sine qua non for progress. For developing countries and resource constrained environments, the emphasis on data collection and analysis will task communitybased health systems since healthcare delivery at community levels do not usually have resources to assure reliable and valid data collection and analysis. The emphasis on community involvement and active participation will also represent a serious shift in emphasis since huge unmet needs of care at community levels are the immediate preoccupation of overworked health workers. However, the precarious state of health in many parts of Africa calls for serious debate on how best to meet the needs of target populations in the continent. Very few rural or community-based health systems in Africa can provide consistent, quality care due to issues already discussed in earlier chapters of this book. A logical question is what are the challenges of implementing COPC in Africa? Challenges of COPC in Africa The first challenge of COPC is that although it originated in Africa, experience with the concept is not common in the continent, at least according to the literature. However, most countries in Africa adopted the Alma Ata declaration of Health-For-All which anchored the delivery of care on primary health care (PHC) systems. The PHC approach recognizes community participation as a foundation of health. PHC is the preferred method of healthcare delivery in many parts of Africa where health clinics and health centers are among the first line of contact between the target population and the healthcare

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system. The PHC concept as noted in the Alma Ata Declaration is not an inferior system of care and should have the full complements of a quality health service. It would not be difficult to implement COPC in PHC institutions. The second challenge is that PHC infrastructure in Africa is in bad shape, reflecting more than two decades of financial and technical neglect. To implement integrated clinical medicine and public health services, these decaying PHC infrastructures will have to be rebuilt and some communities will benefit from new PHC infrastructure, a prospect beyond the means of many African countries. The third challenge of COPC is the belief by experts that it is expensive to integrate clinical practice with public health service (4, 5, 9, 10, 11, 12, 13, 14, 15). However, most of these publications failed to ascribe specific costs to COPC or to provide strict comparisons between COPC and other forms of care. In many African countries that run primary health care centers, clinical care and health education/outreach services are theoretically expected to run parallel, and often do. As a medical student and junior doctor in Africa, this author had experience of working in PHC facilities that ran integrated clinical and public health programs, especially in maternity and post natal services. The fourth challenge is that few African countries, perhaps with the exception of South Africa, have enough qualified epidemiologists, biostatisticians and data managers to provide roving services to clusters of COPC programs. Certainly, no African country is capable of fielding the full complements of data experts in each COPC program. However, health workers could be trained to collect and store data and make them available for analysis by trained experts. A COPC strategy would also force epidemiologists and statisticians in central government offices to become more involved in health surveillance issues in local communities. The fifth challenge of COPC is the impact of the ongoing health workforce crisis in the continent. An integrated clinical, public health and epidemiology practice in COPC requires appropriate staffing complements. Customers of Africa’s health systems often wait long periods or even days to see a doctor or receive routine care. Staff morale is not at optimum levels in many health facilities in Africa. However, a COPC strategy with defined target population and expected outcomes could become a morale booster for disaffected health personnel who yearn for better challenges. It could also become 175

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a motivating force for dedicated clinicians, public health experts and data experts to work together to define health needs of target populations and implement appropriate responses. The sixth challenge is the failing state of community-based health systems in Africa. I believe the PHC concept in Africa failed to become sustainable becomes of perception that it represented “inferior” systems of care and were designed expressly for “poor” target populations. A COPC strategy could be deployed in any part of the country and allows clinicians, public health experts and data experts to implement practice protocols that meet highest standards of care. The seventh challenge of COPC in Africa and perhaps the gravest is the reorientation that would have to take place to ensure the active participation of target populations in all facets of healthcare delivery. In COPC, there are no short cuts regarding the verifiable involvement of target populations in the six steps of the process. A comprehensive implementation of COPC requires evidence of verifiable benchmarks of community participation. COPC also mandates a structured process of constant interaction with target populations regarding their knowledge, attitudes and perception on current programs. Having briefly reviewed some challenges of implementing COPC in Africa, it is important to consider opportunities for COPC to assist in transformation efforts in Africa’s healthcare delivery. Opportunities for COPC to Transform Healthcare Delivery in Africa As noted in the previous section of this article, serious challenges await implementation of COPC in Africa. However, as noted, none of these challenges appear insurmountable if the expressed goal is to improve the health of defined communities and target populations. As healthcare delivery deteriorates in Africa, it is critical for policy makers and experts to explore best ways to meet the needs of target communities and populations in the continent. I briefly review opportunities that could transform Africa’s healthcare delivery systems through the implementation of COPC. 1. Reestablish the role of community-based health systems in Africa COPC will help reinvigorate currently moribund community health systems across many nations in Africa. COPC will force national policy

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makers and technocrats in Africa to go back to the drawing board in search of best strategies for implementing health programs that meet the needs of target populations. Reestablishing the role of communitybased systems of care in Africa will require domestic and international financial support to refurbish decaying health infrastructure, maintain health facilities in good shape and build new health facilities for communities in need. A functional community-based health facility is the meeting point for all stakeholders in the COPC process. 2. Integrate clinical medicine and public health practices in Africa

It is no secret that there are limited professional interaction between clinicians and public health experts in Africa. Clinicians are too busy and overwhelmed by massive numbers of clients that need care and public health experts are busy trying to implement population-based health programs. There are also lingering perceptions that public health experts practice “soft” or “inferior” medicine. An integrated clinical and public health practice under COPC will assist target communities to benefit maximally from the strengths of these two different but closely related professions. 3. Make data collection, analysis and dissemination the foundation of healthcare in Africa

Valid baseline and trend data are major problems of health systems throughout Africa. A COPC strategy would allow national health policy makers to implement a comprehensive, systematic collection, analysis and dissemination of health data. Valid data will become invaluable in local and national health planning and policy making efforts. It would also facilitate the coordination of national priorities that are anchored on verifiable data from target communities. Valid data from COPC will also become the backbone of local and national epidemiological surveillance systems. In addition, valid baseline and trend health data will become the backbone of the monitoring and evaluation protocols of domestic and internationally funded health initiatives. 4. Assure the verifiable participation of target populations and communities in the design, implementation, monitoring and evaluation of health programs

This will be a huge payoff of the COPC strategy since it would no longer be possible to sidetrack or ‘fast track’ community participation 177

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in local or national health planning or program design efforts. COPC practitioners recognize the connection between verifiable, active community participation in all phases of care and the improvement in personal, family and community health status. COPC raises the possibility that healthcare delivery in Africa will be become more responsive to the needs and priorities of target populations. The lack of strong community participation in healthcare delivery decision making in the continent is a major militating factor against robust continental response to deadly conditions such as HIV/AIDS, TB and Malaria (16, 17, 18, 19). 5. Create technical infrastructure for the rapid deployment of health interventions in Africa

In the heydays of primary health care centers, these facilities served as the hub and the first line of defense against epidemics and natural disasters. A COPC strategy will create opportunities for trained health workforce to be rapidly deployed during emergencies and to serve as valid sentinel of nationwide epidemiological surveillance systems. These well trained, integrated COPC teams could also become useful in rapid intervention programs for neglected but economically devastating diseases in Africa such as schistosomiasis, dracunculiasis, lymphatic filariasis and trachoma (17). 6. Create opportunities for comprehensive attention to the social roots of diseases and health inequities

COPC creates excellent opportunities for the implementation of health programs that focus on the demographic, socioeconomic, psychosocial and environmental determinants of health. As noted recently by the World Health Organization‘s Commission on Social Determinants of Health (16), health systems worldwide will continue to grapple with health disparities and inequities until they become responsive to the social roots of health and illness. The situation is particular dire in Africa where poverty and chronic illness negatively impact on the outcome of development initiatives (18, 19). COPC creates unique opportunities for policy makers and technical experts to conduct verifiable community needs assessment and diagnosis, and, to respond appropriately to identified needs and priorities of target population.

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Since COPC creates opportunities for community diagnosis of psychosocial or environmental concerns, these issues will require policy and program attention if they are identified as priorities by target populations. 7. Entice the private sector to become active in Africa’s healthcare delivery

COPC is likely to appeal to private sector policy makers with the program’s emphasis on defined populations, identification of needs and priorities, verifiable community participation, integration of clinical care with public health practices and epidemiology, reliance on monitoring and evaluation protocols, and, strict adherence to accountability and outcomes. For Africa’s health systems to scale up and meet expressed need, governments alone cannot bear the cost of care. The private sector has a huge role to play in this regard. COPC could become important entry points for the private sector. The initial strategy in many African countries is likely to be public/private partnerships in health for defined communities and for specific expected health outcomes. 8. Provide excellent opportunities to train the next generation of community health leaders in Africa

A generation ago, the primary health care concept inspired medical students in Africa, including the author of this article, to pursue public health careers. The COPC concept with integration of clinical care and public health and epidemiology has the capacity to inspire a new generation of community health leaders. In communities where COPC is practiced, teaching opportunities are important benefits of the program. To take advantage of the huge training potential of COPC, medical schools, nursing schools and schools of health technology in Africa should inculcate COPC principles in their curriculum and provide practicum opportunities for students to gain valuable experience. Graduate programs in health and clinical/public health fellowships in Africa should also include opportunities for training in COPC. Health policy makers in Africa need to set up dedicated physician resident programs in COPC to produce dedicated practitioners that will provide leadership on quality community-based system of care in Africa.

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9. Creates opportunities for seamless deployment of African Diaspora health professionals that seek work in Africa

COPC is a natural entry point for thousands of medical and nursing personnel trained in Western institutions to move seamlessly into healthcare delivery in Africa. For example, clinicians that belong to the National Medical Association and National Dental Association, organizations for African-American physicians and dentists, respectively, in the United States who wish to serve in Africa can train in various COPC programs in the country and be ready to deploy to Africa. Public health experts, nurses, physician assistants, epidemiologists, biostatisticians and other health workers can also train on COPC precepts and practices and be ready to join similar programs in Africa. African immigrant health workforce in the West can also retrain in COPC and be ready to assist in healthcare delivery programs in the continent. Retired health professionals in the West, professionals in the early stages of their careers and those seeking a change in careers and challenges may take advantage of COPC training programs and join their colleagues who are implementing COPC programs in Africa. Various schools that have established COPC programs such as those in Israel, US and UK can become critical training spots for Western-based health practitioners seeking opportunities to participate in Africa-based COPC programs. 10. Ends the mutual suspicion between international donors and African governments regarding transparency and governance issues in healthcare

COPC is built on transparency, accountability and a clear idea of expected outcomes. If expected outcomes cannot be met, the elaborate monitoring mechanisms of COPC will alert program managers so that corrective action could be taken. The rigorous evaluation framework of COPC allows for a transparent process of reviewing program operations. The relentless focus on reliable and valid data, verifiable benchmarks of active community participation, and, the searchlight on program accountability and prudent management of resources make COPC a win-win situation for international donors and African governments regarding concerns over the governance of supported health initiatives. The successful implementation of COPC strategies requires accountability and community participation in each step of the process. The monitoring and evaluation mechanisms of COPC are almost on

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autopilot, with obvious safeguards for individual patient data. COPC can end the mutual suspicion existing today between international donors and African governments regarding governance issues in externally supported health programs. This existing mutual suspicion must be addressed openly, honestly and in a speedy fashion to allow target populations access quality care in a timely manner (18, 19). Conclusion Community Oriented Primary Care is a paradigm that deserves close attention in Africa as national and continental policy makers consider options for transforming health systems in the continent. As health status deteriorate or stagnate in Africa, it is important for policy makers to search for healthcare delivery mechanisms that recognize the critical importance of target populations and communities as the foundation of healthcare delivery. The felt needs rather than perceived needs of target populations should be the guide of health planning and policy making. Opportunities to integrate clinical medicine with public health and epidemiology will create sustainable platforms for transforming healthcare delivery in Africa. Community Oriented Primary Care is an important strategy for transforming Africa’s health systems and delivery mechanisms. References 1. Kark S, Kark E (1999). Promoting Community Health: From Phoela to Jerusalem. Witwatersrand University Press, Johannesburg, South Africa. 2. Kark SL (1981). The Practice of Community Oriented Primary Health Care: Community Diagnosis and Health Surveillance in Primary Health Care. Appleton-Century Crofts publishers, New York. 3. Kark SL, Kark E (1983). An Alternative Strategy in Community Health Care: Community Oriented Primary Health Care. Israel Journal of Medicine, Volume 19, pages 707-713. 4. Mullan F, Phillips RL, Kinman EL (2004). Geographic Retrofitting: A Method of Community Definition in Community Oriented Primary Care Practices. Family Medicine, Volume 36, Number 6, pages 440-446.

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5. Plescia M, Groblewski M (2004). A Community Oriented Primary Care Demonstration Project: Refining Interventions for Cardiovascular Disease and Diabetes, Annals of Family Medicine, Volume 2, Number 2, pages 103-109. 6. Master of Public Health Program on Community Oriented Primary Care, George Washington University School of Public Health, Washington, DC (2006). Mission Statement, Goals and Background. George Washington University, Washington, DC. 7. Mullan F. Community Oriented Primary Care. New England Journal of Medicine, Volume 307, pages 1076-1078. 8. Mullan F, Epstein L (2002). Community Oriented Primary Care: New Relevance in a Changing World. American Journal of Public Health, Volume 92, pages 1748-1755. 9. Nevin JE, Gohel MM (1996). Community Oriented Primary Care. Primary Care, Volume 1996, pages 1-15. 10. Rhyne R, Bogue R, Kukulka G, Fulmer H (eds.) (1998). Community Oriented Primary Care: Health Care for the 21st Century. American Public Health Association press, Washington, DC. Williams RL (1998). Tools for Community Oriented Primary Care. Journal of the American Board of Family Practice, Volume 11, Number 1, pages 28-33. 11. Institute of Medicine (1984). Community Oriented Primary Care: A Practical Assessment (Volumes 1 and 2). Institute of Medicine Press, Washington, DC. 12. Williams RL (2002). Getting the Community into Community Oriented Primary Care. Abstract Number 49078. 130th Annual Meeting of the American Public Health Association. Available at http://apha.confex.com/apha/130am/techprogram/paper_49078.htm 13. Pathman DE (2004). The Strengths and Challenges of Excellence in COPC. Annals of Family Medicine. Electronic Letter published in the Journal online edition, 12th April 2004. 14. Murray SA (2004). Rapid Appraisal as a Participatory Approach to Community Oriented Primary Care (COPC). Annals of Family Medicine. Electronic Letter published in the Journal Online edition, 12th April 2004. 15. Bettigole CA (2004). Structural Barriers to Health and the COPC Model. Annals of Family Medicine. Electronic Letter published in the Journal Online edition, 12th April 2004.

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16. Commission of Social Determinants of Health Secretariat, World Health Organization (2006). Tackling the Social Roots of Health Inequities. PLos Medicine, Volume 3, Issue 6, e 106, pages 001-003. 17. Molyneux DH, Hotez PJ, Fenwick A (2005). Rapid Impact Interventions: How a Policy of Integrated Control for Africa’s Neglected Tropical Diseases Could Benefit the Poor. PLos Medicine, Volume 2, Issue 11, e336, pages 1064-1070. 18. Akukwe, C (2006). Don’t Let Them Die: HIV/AIDS, TB, Malaria and the Healthcare Crisis in Africa. Adonis-Abbey Publishers, London, United Kingdom. 19. Akukwe, C (2006). Beyond the Rhetoric: Essays on Africa’s Development Challenges. Adonis-Abbey Publishers, London, United Kingdom.

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HEALTH SERVICES RESEARCH IN AFRICA CHINUA AKUKWE Introduction The role of health services research, according to the World Health Organization (1) is to close the “know-to-do” gap in health care delivery by translating knowledge obtained from all phases of healthcare delivery into action to refine and enhance the quality of care. In 2004, the World Health Organization (WHO) and the Government of Mexico organized a landmark conference on health research. This conference sought to close the so called “10/90” gap whereby less than 10 percent of global health research resources are spent on finding solutions to 90 percent of health problems worldwide. The Mexico conference identified four major initiatives that are important in global efforts to improve the capacity to generate, disseminate and utilize knowledge from the delivery of health services. The four major initiatives include: 1. 2. 3. 4.

Establishing the priority role of research in health systems; Improving access to knowledge from health research in the developing world; Ensuring that national decision making on health is based on evidence from health research and practice; and Establishing a global clinical trials register.

In Africa, both the African Union and the Africa Regional Office of the WHO recognize the central role of health research in providing evidence for best informed decision making in health (2, 3, 4). The two continental organizations also recognize the role of health research in strengthening health systems, deploying new technologies, and integrating the role of domestic and international partners in healthcare delivery mechanism in the continent. African governments and institutions are also keen to utilize evidence from social, cultural and behavioral health research as part of coordinated efforts to understand

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determinants of health among at risk populations and target communities. A major impetus for the global effort to improve health research is the realization that the successful attainment of the Millennium Development Goals (MDGs) will require an understanding of the policymaking and health systems constraints that impact on healthcare delivery mechanisms (1, 5). Knowledge from health research is critical to the implementation of effective interventions that address the MDG related goals of reducing child mortality, improving maternal health and fighting HIV/AIDS, Malaria and other diseases. Information from health research is also important in the implementation of interventions for the other MDG goals of halving poverty levels, ensuring the sustainability of the environment, and, developing effective global partnerships for development. Health research represents a wide range of disciplines and scientific endeavors. Health policy research focuses on the policy implications for health decisions made by policy makers. Health systems research emphasizes the impact of strategies and activities that strengthen the efficiency and effectiveness of health systems. Biomedical research refers to clinical and basic medical research conducted to improve the efficacy of medicines, equipments and other medical goods. Health services research deals with evidence from all phases of healthcare delivery that impact on individual and target population health outcomes. This book is dealing with health services in Africa. This chapter is focusing on health services research in the continent. In the remaining sections of this chapter, I discuss the essential goals of health services research and the five program components of a research program (conceptualization, design, implementation, monitoring and evaluation). Essential Elements of Health Services Research First, health services research must be de-mystified in Africa (4). Today in Africa, health services research tend to take place only in teaching hospitals and academic institutions. Health services research is not yet an integral part of healthcare delivery mechanism in the continent. Primary, secondary and tertiary levels of care should engage in health services research. Policy makers and program managers

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should insist that health services research should be simultaneously managed with routine delivery of care in all health facilities. Second, health services research should aim at producing verifiable and replicable evidence of the efficiency and effectiveness of care (3, 610). This will allow for informed decision making on health issues at all levels of the public and the private sector. Health services research should also provide data on the cost-effectiveness of care. Third, health services research should address the need of patients and the target community (1, 2, 3, 5). Health services research should provide information to consumers of health on ways to improve their personal health behaviors and that of their families. In particular, health services research should address the ever changing knowledge, attitude and perception of consumers and the target population regarding the effectiveness and relevance of care they are receiving. Fourth, health services research should rely on adequate institutional capacity and support. A bane of health services research in non teaching hospitals in Africa and other parts of the world is the lack of “time, staff and equipment” for research activities (2, 3, 4). This is usually due to the heavy workload and the chronic shortage of financial and technical resources. However to meet the ever changing needs of patients and at-risk populations, institutional capacity for health research should be assured at all levels of care. Primary, secondary and tertiary levels of care should have designated persons and designated facilities for health services research. Fifth, each country should have unambiguous laws and regulations on the ethical conduct of health services research. Each country, bar none, should have national laws and professional standards regarding the ethical conduct of health services research and the participation of human subjects in research activities. It should also have relevant laws on informed consent, patient confidentiality, and lack of reprisals if patients and their families refuse to participate in health services research. African countries can benefit maximally from the expertise of the World Health Organization (8, 9, 11) and other similar technical entities. Sixth, health services research should address contemporary issues such as, intellectual property rights, access to patient records, sexual and other forms of abuse of patients, denial of care, rationing of care, financing of health services, direct payment of services, including user fees, and, the provision of health services to the poor and marginalized. 187

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Each country should address pressing urgent health issues through service delivery activities and also through health services research programs. The challenge is for national governments in Africa to work closely with other stakeholders to determine these contemporary issues and address them accordingly through multiple means, including a robust health services research agenda. Seventh, health services research programs should be designed to maximize the use of domestic and international collaborative networks. In each African country, health services research programs should collaborate with each other, linking public-based health services research with peers in the private and non government sector. National health services research efforts should maximize the use of financial, technical and logistics expertise of the WHO Africa Region, the WHO headquarters and other emerging global alliances focused on health services research. Eight, training and re-training of staff, the procurement and maintenance of equipments and the building of infrastructure that meet professional standards are key to health services research programs. National governments in Africa have a major role to play in ensuring that the technical and logistics resources for health services research are at optimum. National governments also have the responsibility of regulating the conduct of research in its jurisdiction. International development partners should assist national governments in maintaining the standard of health services research in the continent. Ninth, health services research in Africa should adopt key goals established at the landmark 2004 health services research summit in Mexico. The Mexican Statement on Health Research (10): ™

™

™

Reaffirmed the Commission on Health Research for Development recommendation in 1990 that “developing countries should invest at least 2% of national health expenditures in research and research capacity strengthening, and at least 5% of project and program aid for the health sector from development aid agencies should be earmarked for research and research capacity strengthening.” Recognized that high quality research is facilitated by a strong, transparent and sustainable national health research system that operates in transparent ethical standards and generates knowledge that inform better policy making; Reaffirmed the capacity of high quality health services research to contribute to the attainment of health targets within the MDGs, to

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™ ™ ™

improve the performance of health systems, to improve the role of a country’s social and economic development in enhancing health status, and, to achieve the goal of health equity; Recognized the need to build public confidence and trust in science; Recognized the need to establish a national health research policy and ensure its implementation; and Recognized the need to mobilize domestic and international stakeholders to support health services research.

Tenth, health services research should at the barest minimum have the following components: (1) Conceptualization of research activities; (2) design of research activities; (3) Implementation of research activities; (4) Monitoring of research activities; and (5) Evaluation of research activities.

I briefly review these components of health services research. Major Components of Health Services Research 1. Conceptualization Phase of Health Services Research

Every research effort must go through a conceptualization phase whereby the early outlines of the research effort is discussed and put in a concept format for further discussion. In the concept note, the author/s of the proposed research effort discuss their ideas in broad outlines, including information on the proposed research question, the anticipated outcomes, the process for carrying out the research, and a broad identification of partners and possible roles in the research effort. This is a very critical phase of research activity since individuals and organizations privy to the concept note will help shape the form of the research effort. The conceptualization phase ends when key stakeholders agree that the broad ideas shared in the concept note merit more specific consideration and work. A major concern of internationally funded health research effort is that domestic stakeholders may not have the opportunity to actively participate in the conceptualization of research intended for their own countries.

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2. The Design Phase of Health Services Research

At this stage, the health research effort moves from the broader outlines of the conceptualization stage to the design of a research effort that could receive government or external donor support. The design stage of a health research project could be in response to the request for application from a funding agency or it could be in response to directives from policy makers. The Design stage sets the entire roadmap for the health services research initiative, with the following procedures, in most cases: 9

9

The first phase of the design process is to set a research priority with specific information on research goals and objectives, the dependent and independent variables, method of data collection and analysis, the role of each participating partner and a clear delineation of who is responsible for each component of the research effort (12). The research priority may already be set by the funding agency. The organization writing for the grant will now have to discuss how to develop a research proposal that meets the parameters set out in the grant application document. This process often generates intense discussion among key participants in the proposed research effort regarding how best to provide specific responses to the criteria set forth in the call for applications. At the end of this process, there is an agreement with all stakeholders in the proposed research effort on how to move forward with a research proposal. The next phase of the design process is to write a grant proposal or a document that provides information on how the research effort will be implemented. Most research grant applications start with cover page and other identifying information; an abstract section; the major section of the application that describes the proposed research effort and the role of each major partner, the method of the research effort, and how to collect and analyze results from the research activity; information on the qualifications of proposed personnel; budget information on major proposed activities; monitoring and evaluation mechanisms; and, assurances on ethical issues, use of human subjects and informed consent. The design stage of a health services research effort should include information on monitoring and evaluation indicators and who will be responsible for that function; provide information on whether the research project will continue at the end of the proposed funding cycle and how, and; provide documentation on the contributions of the host institution during the funding cycle. The design stage of

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9

the research project should include an anticipation of various issues that may arise during the research effort and who should address these exigencies whenever the need arises. All stakeholders in the health service research effort should be actively involved during the design stage of a health services research effort. At the end of the design stage of a proposed health services research project, a single document should have information on the proposed research question/s and anticipated research answers; a clear outline on how the research effort will be carried out and by whom, when, where and how; an outline of budget information, personnel and non personnel issues as may be appropriate; a clear outline of monitoring and evaluation indicators and who will be responsible for managing that effort; and, an outline of other contingencies as may necessary or as directed by the prospective funding organization.

3) The Implementation Phase of Health Services Research

During this stage, funding is hopefully in place for the health services research effort. Staff members are also ready for work. Equipment, infrastructure and other logistic issues are also in place. The implementation of the research project will follow the outline set forth in the design document for the project and the final statement of approval from the funding agency, including restrictions and follow up issues. In some circumstances, the grant awarding institution may change the outline of work proposed in the design document. Relevant authorities in the recipient institution will have to decide whether to accept the modified plan of work established in the design document. This decision by the recipient institution is extremely important when human subjects are involved in research activities or when identifying information of any kind is included in the modified grant award. Throughout the implementation phase, responsible staff members of the health services research project collect data according to the outline established in the design stage document and the awarding documents. The staff also record data and analyze results according to prior established protocol in the design phase of the health services research effort. It is important to note that any change in the implementation phase of the health services research that is at variance with prior established protocols from the design phase will have to be

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resolved by the team or representatives of those that made decisions in the design stage. Nobody has the right in a health services research effort to unilaterally change the implementation outlines established in the design stage of the research project cycle. It is the joint responsibility of the donor and recipient institutions or agencies. 4) Monitoring Phase of Health Services Research

The protocol for the monitoring phase is already set during the design phase of the health services research program. The monitoring phase is operational throughout the implementation phase of the project. Monitoring indicators usually focus on the process of research with emphasis on meeting timelines, completing certain tasks at specific intervals, and resolving emergency problems and issues. Independent monitors or program leaders may be charged with the responsibility of ensuring that all monitoring milestones are met and on time. 5) Evaluation Phase of Health Services Research

As in the case of monitoring protocols, the outline of the evaluation mechanism and indicators are set during the design phase of the research project. Independent monitoring and evaluation experts review process and impact indicators from the health services research and determine whether the research effort has met its original goals and objectives. In resource challenged environments, it is often difficult to retain the services of independent evaluators. However, independent evaluators are indispensable in assuring third parties that the research effort was carried out according to plan and also provides assurances on the reliability and validity of data from the research effort. Collating, Disseminating and Ensuring that Data from Health Services Research Influence Policy Health services researchers often face the challenge of how to disseminate the findings of their research to the target population and policy makers. Even policy makers now realize that decision making in health should be evidenced based as shown in the Mexican Statement on Health Research (10).

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To reach health consumers and target populations, health services researchers should carry them along during all phases of the project cycle. Health consumers and target population should be kept abreast of major developments during research activities. They should also be informed of major findings from health services research efforts through multiple media. They could be reached by radio, television, through local medium of communication and through word-of-mouth. Target populations could also be reached through religious and cultural authorities, during major feasts and events, and through their children who are in school. In regards to policy makers, the situation is a bit complicated in that there are two major push-and-pull efforts (7): 9 9

Should priorities be set to produce health research that policy makers will want to use; or Should priorities in health research be set that will engage the interests and commitment of the research community?

Experts recommend that organized efforts should be made to increase the interface of health services researchers with policy makers (2, 3, 6, 7, 8, 10). This interface may include informational interviews of health policy makers by health researchers in order to have a first hand knowledge of issues that impact their decision making. The interface may also include focus group meetings, conferences that allow more one-on-one conversations, workshops and seminars where researchers and policy makers can interact closely. In addition, health services researchers need to become proficient in writing policy briefs favored by policy makers, making policy oriented presentations with key actionable items to policy makers and their staff, and providing background information to the senior aides of policy makers who can then brief their bosses. Ultimately, health services researchers face the challenge of translating their findings into policy making decisions that will improve the state of health of their target population (12, 13). Policy makers in Africa and other parts of the world need evidence of what works and what does not work, and will welcome assistance from health services researchers, including those working in Africa.

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References 1. World Health Organization (WHO) (2004). Ministerial Summit on Health Research. Geneva, Switzerland Available at http://www.who.int/rpc/summit/en 2. African Union (2007). Africa Health Strategy: 2017-2015. Third Session of the African Union Conference of Ministers of Health, Johannesburg, South Africa, 9-13 April. Addis Ababa, Ethiopia: Author. 3. World Health Organization, Africa Region (2006). The Health of the People. The Africa Regional Health Report 2006. Brazzaville, Congo: Author. 4. World Health Organization, Africa Region (2007). Health Systems Research. Geneva, Switzerland. Available at http://www.afro.who.int/hsr/ 5. World Health Organization (2005). The Millennium Development Goals will not be Attained without new Research Addressing Health System Constraints to Delivering Effective Interventions. Report of the Task Force on Health Systems Research. March. Geneva, Switzerland: Author. 6. World Health Organization (2006). Health Research, Policy and Systems 2006. Geneva, Switzerland: Author. 7. Stephen Hanney, Miquel Gonzalez-Block, Martin Buxton, Maurice Kogan (2002). The Utilization of Health Research in Policy Making: Concepts, Examples, and Methods of Assessment. A Report to the Research, Policy and Co-operating Department, WHO. Geneva, Switzerland: WHO. 8. World Health Organization (2006). Research for Health. A Position Paper on WHO’s Role and Responsibilities in Health Research. ACHR45/05.16 Rev. 1. Geneva, Switzerland: Author. 9. World Health Organization (2006). Research Ethics Review Committee (ERC). Research Policy and Cooperation. Geneva, Switzerland: Author. 10. World Health Organization (2004). The Mexico Statement on Health Research. Knowledge for Better Health: Strengthening Health Systems. Geneva, Switzerland. Available at http://www.who.int/rpc/summit/en/

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11. WHO Advisory Committee on Health Research (2007). Advisory Committee on Health Research. Geneva, Switzerland. Available at http://www.who.int/rpc/advisory_committee/en/ 12. World Health Organization (2005). Engaging for Health. WHO th 11 General Programme of Work, 2006-2015. Geneva, Switzerland: Author. 13. Chinua Akukwe (2006). Healthcare Delivery in Africa: Issues, Choices, Challenges and Opportunities. African Renaissance, July/August.

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NATIONAL GOVERNMENTS AND INTERNATIONAL DEVELOPMENT PARTNERSHIPS FOR BETTER HEALTH SERVICES IN AFRICA AMINA SALUM ALI Introduction As the Minister of Finance of Zanzibar, United Republic of Tanzania, I had the unique opportunity of working with international development organizations and bilateral agencies. These organizations included the United Nations System, development agencies of donor countries, and, also major international foundations. The role of these organizations in healthcare delivery is very critical in many African countries, especially in the areas of financing health services and enhancing the quality of implemented programs. In my former position as Minister of Finance and now as the Permanent Representative of the African Union to the United States, it is very clear to me that health is at the nexus of any serious development effort. As noted by the World Health Organization (1), health is integral to economic progress, social harmony and the future prosperity of defined populations. Healthy populations live longer, contribute better to the economic wellbeing of their community, and, allow parents and guardians to live long enough to nurture and prepare the future generation for leadership roles in their societies. Consequently, any serious discussion of healthcare issues should include a comprehensive understanding of the state of health of individuals and families on overall development goals. More than 190 nations adopted the Millennium Development Goals (MDGs) as a way of harmonizing international efforts on health and development (2). MDGs represent international commitment to drastically reduce poverty, minimize ill-health and its impact on development, tackle gender inequality, close the gap on educational attainment, improve access to clean water, and, end environmental degradation. As long as it is understood that health is integral to development, then serious efforts to improve the state of health of a defined target population should be multi-sectoral. This organized response should 197

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involve multiple stakeholders and constituents. Efforts to improve the health status of defined populations should extend beyond ministries of health to include other government agencies, professional bodies, civil society organizations and target communities. Another important consideration is the impact of poverty on the state of health. The World Health Organization (3) recognizes the critical role of the health-poverty link on individual and community health status. Poverty reduction strategies at national, continental and international levels articulate the role of ill health in making people poor, keeping them poor, and letting them die poor. National governments and their international development partners work jointly to reduce poverty rates among target populations and to provide incentives and opportunities for families to permanently escape poverty. The relationship between regional institutions, national governments and their international development partners often revolve around the efforts of national governments to improve quality of life for all citizens. A popular intervention strategy in this relationship is the need to encourage preventive health behaviors. Another strategy is to improve the accessibility and quality of healthcare services. Another strategy is to improve measurable health outcomes. Consequently in Africa and other developing regions of the world, one of the most important agenda of international development partnership is to improve the state of health of defined populations and communities. The Journey So Far Since the political independence of most African countries more than four decades ago, the continent has witnessed significant gains in economic development, rate of educational attainment and the provision of medical services. In my personal experience in Tanzania, I have grown up to see many communities have access to educational opportunities, health services and economic opportunities. National governments in Africa over the past 40 years have worked closely with their international development partners to improve the state of health in their countries. National governments have also invested heavily in the training of medical doctors, nurses and other health professionals. Schools of

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medicine, dentistry, pharmacy, nursing and other health professions are operational in many African countries. National governments in Africa and their international development partners have collaborated in the establishment and maintenance of these facilities. Thousands of African health professionals have received additional training in external donor country institutions. Tanzania and other African countries recorded significant increase in the number of health professionals and health facilities, and, also the availability and quality of care. Despite the noted significant improvement in the number of health professionals and the availability and quality of health services, significant challenges remain (3, 4, 5, 6). First, the negative impact of the World Bank/International Monetary Fund structural adjustment economic policies of the 1980s forced many poor African countries to reduce funding for basic health services. Second, the Cold War politics that existed until the early 1990s led to a situation whereby rich donors avoided providing assistance to citizens of countries that were not in their political orbit. Third, the brain drain of health professionals in Africa became a deluge, with thousands of health professionals leaving for the West and other more affluent African countries. This situation has led to acute shortage of qualified manpower in many African countries. Fourth, the primary health care system established in many African countries in the late 1970S and early 1980s went into decline due to lack of financial, political and logistics support from both national governments and their development partners. Finally, and perhaps the gravest challenge, had been the onslaught of HIV/AIDS and the resurgence of TB and Malaria in the continent. Africa is currently the epicenter of the HIV/AIDS pandemic. The continent is home to 90 percent of all malarial illnesses and deaths. TB and HIV/AIDS have formed a deadly partnership in Africa. In some African countries, life expectancy rates are 40 years or below largely due to the rise in HIV/AIDS. Some African counties have life expectancy rates last recorded 40 years ago. Despite the efforts of national governments in Africa and international development partners, the state of health in many African countries, significantly lag behind those in Latin America and the Caribbean. It is embarrassing to compare the state of health in Africa and that of Western countries.

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Lessons Learned in International Development Partnerships The relationship between national governments in Africa and their international development partners is complex and complicated. In my experience in the government of Tanzania and Zanzibar, I experienced this complex situation first hand. There is always a push-and-pull relationship between satisfying the needs of national governments and satisfying the priorities of donor agencies and countries. This situation is more precarious when national governments have limited resources amidst extraordinary need. Even under severe economic constraints, national governments in Africa strive to develop the best national health strategies for their countries. This tug-of-war around health strategies, policies and programs may drag on for a long time while the needs of expectant citizens go unmet. Policy Lessons

For me, the most significant policy lesson I learnt as a minister of finance is the need for national governments to develop policies that reflect the felt needs of citizens. In my present position as the Permanent Representative of the African Union to the United States, I have noted how American lawmakers and the executive branch work closely to ensure that national health policies address significant health concerns. As a rich nation, the United States is not under real or perceived pressure from external sources. This is not the situation in many African countries. In these African countries, national governments are under tremendous pressure to meet the needs of powerful, donor countries. This pressure may include meeting the different policy requirements of external support, the pressure to change national health policies in order to qualify for external funding support, and, the pressure to buy goods and services from commercial organizations operating in donor countries. Another important policy lesson is the need for national health policies in Africa to reflect measurable indicators so that trend data could be developed over the life of joint initiatives with international development partners. Another important policy lesson is the need for national governments in Africa to have national policies that show clearly national needs and priorities so that every partner is aware of the roles and responsibilities of each stakeholder.

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Program Lessons

The most important program lesson is the need for complete ownership of national health programs by national governments in Africa. National governments should CONCEPTUALIZE and DESIGN health programs for their people. Although many national governments may have serious financial difficulties, it is crucial that every aspect of national and local health program is under the control of the government. This situation may become tricky if the national government has limited technical capacity or financial controls to take charge of program operations. However, it is my experience that African governments can meet basic technical and operational control of health programs in their countries by reaching out to their citizens with requisite skills and having strong operational links with national professional organizations. Another important program lesson is the need for national governments to plan for local control of external funded programs during the design stage of external funded programs. Every externally funded program will eventually end. National governments in Africa should be prepared for that eventuality. National governments should make accountability and transparency in health programs a natural part of their responsibility. Accountability and transparency should be high on the agenda of national governments when dealing with both domestic and international stakeholders. It is also important to carry along target populations. In my view, it would be very helpful for international development partners to plan long term and commit resources early so that national policy makers can better plan for the long haul. It is a major problem for national governments when external funding cycles are short term, inconsistent or arbitrary. Lessons Learned on Training and Education of Health Workers

This is a very vital part of the relationship between national governments in Africa and international development partners. A major lesson is the need to train health workers in their home countries. African governments and their international development partners should develop national and regional fellowship programs at home or in neighboring African countries. These fellowship programs 201

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should meet the gold standards of learning and practice anywhere in the world but should be relevant to the delivery of health services at home. The training program should also prepare graduates to meet the health challenges of their communities. It is necessary to set aside more resources for in-service and re-training programs for both specialized and support staff in the health sector. Another important issue is the pay and incentives for health workers. National governments should provide conditions of service for health workers that reflect their many years of professional training and the complexity of their work. The provision of tools and equipment is also very important in the retention of trained health workers. Political instability, conflicts and economic turmoil often force health workers to vote with their feet, especially those with highly marketable skills. Lessons Learned on Building Political Support

In my experience the key to building and maintaining political support for international partnerships in health is accountability and transparency. National governments should create opportunities for citizens to be carried along on various aspects of international development partnerships. National governments should also be transparent in their dealings with international development partners. As citizens of donor countries mount pressure on their own governments to show evidence of the impact of external program support, it is crucial for national governments in Africa to insist on accountability and transparency in all external funded programs. It is also important for national governments to ensure that the terms and obligations of international development initiatives reflect both the letter and spirit of national legislation in each African country. In addition, international development initiatives should not be the exclusive preserve of the executive branch in African countries. International development initiatives should also be subject to the oversight of relevant committees of national parliaments. National governments should also engage professional organizations and the civil society in international development partnerships for health.

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Recommendations The most important recommendation is that African governments and peoples should have complete ownership of their health policies and health services. In particular, African governments should have complete ownership of health programs financed through international development partnerships. Every African government should conceptualize and design health policies that reflect national priorities and aspirations. These health policies should articulate the need for a national multi-sectoral response and action. It is important for all national governments and their international development partners to be on the same page regarding the health needs of target populations. In my view, no African country should accept foreign support for health programs that do not reflect the FELT needs of the target population. No African government, no matter the dire financial strait, should accept external donor support to implement programs that are not in its best national interest. It is also important for national governments in Africa and their international development partners to reach agreement on the roles and responsibilities of each partner. These rules and responsibilities should also be known to civil society and professional watchdogs. Regular updates on specific health initiatives and programs should be provided to the citizens of the African country. Transparency and accountability should be the hallmark of every partnership between national governments and their international development partners. Specific, measurable and verifiable indicators should be established before the commencement of each externally supported health initiative so that stakeholders can monitor and evaluate progress made in each stated program objective. Local stakeholders should be involved in this process. In particular, professional organizations, civil society organizations and community representatives should be actively involved. The Ministry of Health of each African country should adopt a multi-sectoral strategy on health. Each ministry of health should have complements of staff with training on how to work with international development partners. The ministry of health should also have staff members with strong training in program management, monitoring/evaluation, and community relations. Ministries of health in Africa should also work harmoniously with other government 203

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agencies that are responsible for finance, national planning and infrastructure development. African governments should take advantage of the technical resources and capacities available in African institutions. African governments should take advantage of the technical and logistics capacity of the African Union, the African Development Bank, the World Health Organization Africa Regional Headquarters and the UN Economic Commission for Africa. African governments should also take advantage of their citizens practicing as professionals in other countries to increase the pool of technical expertise. The training and retention of health workers is now an urgent necessity as the health workforce crisis deepens in many African countries. African governments should adopt a holistic, comprehensive health worker training and retention strategy. This strategy will include personnel incentives, local training opportunities, improvements in the political and economic situation in the country, and the procurement of tools and equipments. Finally, the state of health of citizens no matter their social or economic status should be at the heart and soul of any relationship between African countries and their international development partners. This is a very critical issue. The potential target population of each international development partnership initiative should loom large in this relationship. This target population should be defined precisely and known to both partners. Change in health status is both personal and collective. For individuals living in poverty, international development partnerships for health should also address the root causes of poverty. Abject poverty is closely related to ill health and poor health seeking behavior. The World Health Organization in a seminal study of the deep frustrations of poor people regarding their exclusion from the design of health policies and the implementation of health programs made several recommendations (6): ƒ

ƒ

First, poor places kill. There will not any improvement in health status of defined populations if individuals and families live in poor, decrepit neighborhoods and dwellings. Second, as long as the poor have no right or opportunity to speak, the health status of the poor will continue to remain imperiled. This is particularly true with respect to age, gender and allocation of health resources.

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ƒ ƒ

Third, health is the number priority of the poor. Until their health needs are met, the poor are unlikely to escape poverty. Fourth, the provision of health services for the poor is extremely inadequate. The poor in Africa are either excluded from mainstream health services or they receive ineffective or sometimes dangerous healthcare.

Conclusion African governments and their international development partners have worked together for more than 40 years in the continent. Significant strides have been made. Major challenges remain. The task ahead is to recommit to meeting the needs of target populations in Africa in the delivery of health services in the continent, whether it is through domestic or international development partnerships. References 1. World Health Organization (2007). Health and Development. Geneva, Switzerland. Available at http://www.who.int/hdp/en/index.html. . 2. World Health Organization (2007). Health and the Millennium Development Goals. Geneva, Switzerland. Available at http://www.who.int/mdg/en/. 3. World Health Organization (2004). PRSPs. Their Significance for Health: Second Synthesis Report. Poverty Reduction Strategy Papers. WHO/HDP/PRSP/04.1 Geneva, Switzerland: Author. 4. Chinua Akukwe (2006). Don’t Let Them Die. HIV/AIDS, TB, Malaria and the Healthcare Crisis in Africa. Adonis-Abbey Publishers, London, United Kingdom. 5. Chinua Akukwe (2006). Beyond the Rhetoric. Essays on Africa’s Development Challenges. Adonis&Abbey Publishers, London, United Kingdom. 6. Chinua Akukwe (2006) (Editor). Healthcare Delivery in Africa: Issues, Challenges and Opportunities. African Renaissance , July/August. 7. World Health Organization and World Bank (2005). Dying for Change. Geneva, Switzerland: Authors.

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PART THREE: A GLIMPSE OF THE FUTURE

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ORGANISING AFRICA’S DIASPORA FOR HEALTH CARE INTERVENTIONS IN AFRICA TITILOLA BANJOKO Overview of Health Issues in Africa One deleterious factor that affects Africa’s health systems is the migration of health workers from the continent to the developed world. There has been a massive migration of doctors, nurses, pharmacists, midwifes, radiographers and other allied healthcare professionals groups from the third world to the developed world. The loss of these skilled healthcare workers has severely affected health care delivery systems in Africa both in terms of quantity and quality and this loss has been compounded by the effects of HIV/AIDS and related diseases. Furthermore, although insufficient numbers of healthcare personnel are in employment, there are very many healthcare personnel and para-medical personnel who have been trained at great public expense who remain unemployed due to lack of adequate health structures to absorb them into existing health systems. Lack of funding has been linked to the policies of two international financial institutions, the International Monetary Fund (IMF) and the World Bank. Both institutions enforced fiscal policies on African government to the detriment of timely access to quality health services. Although both bodies have now recognised this failure, more than 20 years of under-funding health systems in Africa have left it reeling, with badly degraded infrastructure. Consequences of Poor/Lack of Funding for Health Services I will discuss the impact of poor and or lack of funding for health services in a simple format that attempts to eliminate ambiguities. Limited funding for health services in Africa has led to:

Organising Africa’s Diaspora For Health Care Interventions In Africa

9 9

9

9

9

9

9

A weak health infrastructure, with limited maintenance and lack of appropriate medical equipment; A dysfunctional medicines procurement system despite the fact that medicines account for 25 to 70 percent of overall health care budget in African countries; The poor financing of health systems. The available meager resources are not even allocated in an efficient and effective manner. This situation has negatively impacted on the availability, affordability and appropriateness of the health care services; The poor information system creates a situation where on time or real time data are not available to policy makers and program managers. More reliable information systems are important to the development and implementation of health policies and plans, and, in targeting the needs of target populations. African health information systems is far from the desired level regarding the type of information available, its collection as well as analysis, dissemination and use; The lack of sufficient human resources for health. This applies to countries that have developed human resources for health (HRH) policies and plans. Currently, 45 percent of the 46 countries in the WHO African Region have HRH plans. However, even where policies and plans exist, their implementation is limited; The continent still lagging behind with poor health indices, including high maternal and child mortality rates, frequent epidemics, declining life expectancy, emerging and re-emerging diseases. This situation exists despite success stories in some African countries; and The deterioration of health indicators. Most of the analyses of the economic impact of health worker migration simply count the cost of the schooling and tertiary education. What they miss is that, because health is a productive investment in development and growth, poor health care and personal health undermines development. This is costing African economies billions each year, sums which dwarf the outlay on health worker education and are not

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compensated for by the much-vaunted remittances from expatriate citizens living and working in foreign countries. Recent international agreements on alleviating poverty in Africa such as the Gleneagles G8 Summit in 2005, have paved the way for rebuilding health care systems and their infrastructure. Targets such as the Millennium Development Goals (MDGs) have been set, though these initiatives have so far had little impact on the ground. The last three years have heralded a new era whereby African countries and global partners are now in agreement that without addressing health workforce issues little progress will be made in achieving MDGs. Consequently, African governments and their international development partners have now placed HRH on their agenda as evidenced by the Second High Level Forum in Abuja, Nigeria in December 2004; the African Union Heads of State and Government Assembly in Abuja, Nigeria in January 2005; the African HRH Dialogue in Abuja, Nigeria in January 2005; the Oslo HRH Global Consultation in February 2005; the World Health Assembly 2004 and 2005; the African HRH Consultative Meeting in Brazzaville, Congo in July 2005; the Second Conference of African Ministers of Health in Gaborone, Botswana in October 2005; and, the Second Oslo HRH Consultation in March 2006. The World Health Day 2006 “Working together for health” devoted to HRH provides another opportunity to highlight the need to urgently address the shortage of the health work force in Africa. There have been many calls for an African Diaspora advocacy body to take up the issues of healthcare problems and solutions in Africa. The demand became overwhelming at the March 2006 meeting organized by Africa Recruit and supported by Save the Children U.K., The Commonwealth Secretariat, The New Economic Partnership for Africa’s Development (NEPAD), the Department for International Development (DFID) and the Royal African Society. Why the African Diaspora Should Intervene Prospects for Action

Owing to the variations in country situations, organized efforts to respond to the HRH crisis should emerge from country levels and this should be supported by political commitment, appropriate allocation 209

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of resources and international partnership solidarity. Regional, global responsibility and collective solidarity is vital if the Diaspora should play a significant role as dual stakeholders on a global platform. The emerging value of the Diaspora as transnational citizens has attracted the attention of policy makers globally. The NEPAD health strategy emphasizes the need to reduce the brain drain of essential human resources for health development. NEPAD’s strategic vision for health development can only be achieved through increased resource mobilization, strengthened management and more equitable distribution and allocation of financial and human resources that are underpinned by active collaboration and coordination at the global, regional and national levels. Approximately 40 percent of all African professionals have left the continentʹs shores over the decades. Approximately 3.8 millions Africans live outside of Africa mainly in Europe and North America. Africa Recruit recent survey of 3,000 plus African Diaspora indicated that: • • •

Approximately 75 percent had postgraduate qualifications; 54 percent left Africa for career and professional development; and, 67 percent would like to return to Africa within the next 5 years.

Business Case for Engaging the Diaspora Diaspora should be perceived in very positive light as an effective integrating force to be reckoned with, and a key driver for sustainable development in Africa in the policy making circles of the continent. As a primary catalyst and a link between Africa and the rest of the world, the role played by the Diaspora can help redress the brain drain and skill shortages. Globalization and increasing context of migration is a reality that can be viewed as a process or a tool which if harnessed can be of immense benefit. Human resources for health (HRH) represent the core asset and the pillar of health systems anywhere in the world. While the health workers: population ratio required for the Millennium Development Goals (MDGs) is estimated at 2.5 health workers per 1000, the ratio in Africa is estimated at .08 health workers per 1000 corresponding to

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750,000 health workers for a population of 682 million1. The situation is worsening due to unprecedented migration and brain drain. For example, in 2004 alone, Zambia lost 2,000 nurses and midwives. There are currently more medical doctors from Bénin practicing in France than in Bénin. HRH development faces also the lack of evidence-based policies and plans as well as insufficient resources for sustainable implementation. Factors for migrating include amongst others poor wages and incentives, inadequate living conditions, lack of professional development, declining health services, lack of promotion and economic decline of countries. Africa Recruit survey of Healthcare professionals demonstrated that over 50 percent migrated for career professional reasons with 13 percent economic, 6 percent political and others 16 percent. The New Partnership for Africa’s Development (NEPAD) in March 2005 indicated that Africa will benefit from initiatives that rely on highlevel scientific, technological and managerial skills. The major question, according to NEPAD is where these skills will come from. The obvious answer, according to NEPAD, are Africans in the Diaspora. Since it will take African countries at least a generation or longer to achieve critical mass in needed skill sets, it would be prudent to look towards the African Diaspora. The rationale for the Africa Recruit project is to tap into the vast ready-made resources available to the Diaspora. The African Diaspora also cultural, ethnic and indigenous knowledge of health care delivery issues in Africa. It is known that the Diaspora at personal and institutional levels are already actively involved in skills and financial transfers to address the gaps in the current healthcare system in Africa. Human Capital

Of the 598 Africa Diaspora Healthcare professionals surveyed by Africa Recruit, 70 percent will consider going back to work on a permanent basis if conditions were conducive. At least 95 percent of the respondents indicate they are prepared to work as expert consultants and all are prepared to work outside their country of origin

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Financial Capital

The African Diaspora contribute over 45 billion US dollars to the economy of the continent annually of which a significant proportion goes to health care support for family or financing healthcare organizations. The African Diaspora is a significant donor to healthcare systems in Africa. Virtually every African country has benefited directly or indirectly from the contribution of its Diaspora. Ongoing Programs and Initiatives In the table on the next page, I provide an overview of some of the key ongoing Africa Diaspora health initiatives. These initiatives seek to link skill sets in the Africa Diaspora with specific needs and services in Africa. Challenges to Diaspora Mobilization and Engagement Multitude of challenges affects the mobilization and engagement of the Diaspora. These challenges include: o o

o o o o

o o o

Poor or limited knowledge on what, where and how to tap into the skills of Diaspora health professionals; Lack of or poor formal structures in both host and sending countries to facilitate and enable effective engagement of the skills e.g. institutions, government and private sector; Lack of access or limited information on opportunities in Africa to enable Diaspora engagement; Ineffective or poor assimilation of returning skills by host countries; Lack of resources by the Diaspora to ensure a continued engagement; Tailoring the ability of the Diaspora to engage, including utilization of options available in private, public, Not for Profit and self employment sectors; Harnessing the capital offered by the Diaspora -financial, intellectual, social, nostalgic and political potential; Recognizing diversity and the varying needs of the Diaspora; Understanding that the various reasons for leaving Africa by the Diaspora results in different perspective by the Diaspora on healthcare issues and solutions for the continent;

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o

o o

Recognizing the skepticism by the Diaspora of whether organizations or governments in Africa want to engage with the Diaspora; Understanding that host governments have difficulties engaging the Diaspora and political groups living abroad; and, Lack/poor or misinformation and communication.

Table 2 Organizations in receiving countries

THET-links programme The Tropical Health and Education Trust (THET) provides training for frontline health workers in the poorest settings, and developed the institutional capacity of local health

institutions.

This

is

achieved

through focusing on the goals of our overseas partners and offering specialist support and training from UK-based health professionals. Voluntary Service Overseas -Diaspora volunteering -VSO recognizes there are many Diaspora communities in the UK who have a particular interest in using their skills and contacts in their countries of heritage. Many people from Diaspora communities are already forming professional networks and organizations committed to developing worthwhile programs ʺback homeʺ. Diaspora volunteering is about VSO working with these organizations in creative, flexible and inclusive ways to see how we can increase the diversity of volunteers and the overall impact of volunteering. International Organisation for Migration (IOM) Migration for Development in

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Diaspora Organization, Associations or Individuals

Sending Countries

35% of the 598 African Diaspora Health care professionals surveyed respondents are currently involved in Africa’s health care system; Individual efforts to link, transfer and mobilize skills and other resources; Associations that conduct healthcare missions, mobilize and galvanize funds and support e.g. Independent Public Health Management Consultant; HIV Care of AIDS Orphans Networking off line and online ( Egroups); Developing links from healthcare or related institutions

• MOU and agreement with Diaspora organizations • Informal arrangements • Individual arrangements

Organising Africa’s Diaspora For Health Care Interventions In Africa

Africaʺ (MIDA) is a capacity-building programme, which helps to mobilize competencies acquired by African nationals abroad for the benefit of Africaʹs development. The programme ensures that the rights and status acquired by migrants in host countries are preserved by guaranteeing them freedom of movement to and from their countries of origin. Several modalities to transfer the competencies of the Diaspora are possible. The transfer of skills, financial and other resources of Africans in the Diaspora will be carried out through: Virtual / tele-work or satellite based information technology systems; Sequenced / repeated visits; Investment and Permanent relocation. In collaboration with Government and private sector employment institutions in participating African Countries, host countries and IOM the Diaspora are effectively engaged.

to similar organizations in Africa; Advocacy in health care; Donation of equipments, materials and training materials; Teaching and Research promoting medical leadership; Voluntary workorganizational/team and or individual effort; Registration of drugs and clinical trials in Africa

Fortunately, there is increasing evidence of the meeting of minds regarding the role of the African Diaspora by Africa institutions and national governments. There are now calls for action coming from Africa. All stakeholders agree that a mechanism needs to be put in place to attract skilled Africans in the Diaspora back to their countries and provide them an opportunity to support on-going efforts to address the HRH crisis in their countries. As one of the responses to the current HRH crisis, it is critical to implement Africa Diaspora initiatives as part of sustainable HRH development framework. Africa governments need to think about sustainable medium and long-term solutions that will not further destabilize the already fragile health system being built at high cost by countries. As noted in the World Health Organization Africa Region March 2006 Report at The Mobilising African Diaspora Healthcare Professionals for Capacity Building in Africa Conference, it is critical to implement solutions that complement rather than disrupt the flow of health services. Donor

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countries in the deployment of skilled Africans in the Diaspora must commit to releasing professionals from their jobs for extended periods without jeopardising their professional status in any way. This “no jeopardy” right needs to be entrenched in labour laws, like protection against any other discrimination as noted by NEPAD. Areas of Input by the Diaspora 1. Skills Circulation and Transfer

The Diaspora can contribute to the provision of health services, training and re-training of health professionals, and help finance support services. However, for this to happen, national governments should conduct needs assessment and develop national HRH priorities, short-and-long term. The Diaspora should only seek to add value to already identified national priorities. 2. Knowledge, Information and Research Support for Policymaking Process and Management

The Diaspora can provide expertise on different models of healthcare delivery to policy makers. For example, Diaspora health experts can advice on developing sustainable models of setting up hospital centres by demonstrating how these new models can build upon the utilization ratio of existing health facilities. Domestic policy makers may even have the opportunity to observe how these new models of care are implemented in few health facilities before committing to a national roll out. This would be a quick win-win strategy and ensures the local/regional government’s buy-in from the beginning. The focus of the Diaspora knowledge transfer, information and research support should be in urban slums and suburban communities as these are areas with greatest need, and the impact of the contribution should be easily measurable and evaluated. 3. Facilitating Support and Capacity Building in areas of Quality Control

The Diaspora can play important roles in facilitating ongoing efforts to improve governance structures, accreditation of healthcare organisations, and guideline development (protocols, algorithms) to facilitate high standards of care. Contribution in this area would go a long way in influencing policy making. The Diaspora can add great value by asking volunteers with quality control, clinical governance 215

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and risk management skills to contribute to already existing structures. The aim should be to audit and support local health facilities that need to augment their quality improvement efforts. 4. Training the Trainer in Urban Centres

The Diaspora can assist in providing training and re-training programs for local experts who will in turn train other health professionals, including those that work in rural areas or urban slums. Diaspora health experts can work with African governments to train, support and build capacity using accepted best practices. 5. Facilitate and Enable the Return of the Diaspora

The focus should be on the Diaspora health experts that seek return to the continent, perhaps permanently. This effort would likely require developing systems and structures to enable the Diaspora make an informed decision. Timely access to information about job opportunities will also be very important. 6. Establish and Refine Two-Way Exchange Programs

Mentoring and twinning are important strategies that have been shown to facilitate skills transfer³. African governments and Diaspora organizations need to establish mentoring and twinning programs that build individual and institutional support. 7. Diaspora Advocacy Group

Diaspora advocacy groups should work with national governments so that critical non health services and infrastructure are extending to target populations of health programs. The advocacy groups should support rural electrification projects, water and basic sanitation initiatives, rural road networks, and comprehensive public safety operations. They should also support local governance initiatives and the active participation of target populations in the design and management of health services. A Diaspora advocacy effort could be instrumental in the promotion of a two-way traffic for the training of medical and non-medical personnel for the purposes of providing access to modern medical care for African medical and para-medical personnel. This would allow both parties (medical professionals from Africa and the West) to experience the health realities applicable in each other’s environment.

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How to Engage the Diaspora Effectively This could be at individual or organizational levels. The challenge is to ensure that the best practice options for Diaspora professionals to contribute are identified and pursued. I discuss the next steps in simple terms. 1.

Develop a database or inventory of health professionals in Diaspora:

o o o o

How many nurses and doctors live in “magnet countries” Track Diaspora and develop database. Establish links with migrant professional network Support Diaspora to form networks and linkages.

2. Establish Diaspora desks and focal points in Ministries of Foreign Affairs or Ministry of Health:

o o o o o 3.

Health professionals often return home. Host countries should take advantage of the opportunity. Facilitate the short stay of the Diaspora by creating “Diaspora friendly” environment. Establish Diaspora desks or focal points. Be cautious of migrant health workers with feelings of privileged entitlements. Provide incentive to promote regular return and “circulation.” Utilize Diaspora skills:

o

o o

4.

Develop opportunities for health professionals who have left the continent to share their experience and skills with their colleagues ‘back home’ on a consultancy or shared approach basis, or in fact on a ‘virtual’ basis. Look at ways to harness the motivation and skills of the Diaspora in order to assist African countries. Focus on temporary return while improving chances for permanent return. Organize Media campaigns for positive image of the Diaspora:

o

o 217

View Diaspora as investors, welfare providers, knowledge communities and technology harbingers to the home countries. Counter negative media and government views of Diaspora.

Organising Africa’s Diaspora For Health Care Interventions In Africa

o o 5.

Work with leaders of the Diaspora to present a positive portrait. Market projects and achievements of the Diaspora. Link with host countries to mobilise the Diaspora:

o o o

Organize technical cooperation programs between countries to mobilise Diaspora. Develop and harness skills, talents, and resources of migrant health professionals. Explore dual citizenship and arrangements for Diaspora recognition that would contribute to more return and circulation.

5.

Market specific projects that would enhance knowledge and resource transfer

o o o o

Define priority needs and projects. Market projects aims and objectives. Involve Diaspora in project development and implementation. Consider prospects for self employment by the Diaspora or partnership ventures. Organize mobile libraries.

o

The Process of Mobilizing and Engaging the Diaspora o

o

o o o

Mobilize around themes. The interest and value factor of the Diaspora is wide ranging. It is important to tap into various structures and systems in the African Diaspora. Inform the Diaspora of the various ongoing changes in Africa that have impact on the socio-economic conditions and the state of healthcare in a timely manner. Provide timely access to job opportunities in Africa to enable those who want to return take action. Provide consistent platforms for the Diaspora to debate with stakeholders and policy makers in Africa. Build strategic alliances and partnership inside and outside of Africa.

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Recommendations o

o

o o

o

o

Foster an understanding of the Diaspora by the donor and host countries by facilitating a process that will harness their capacity to effectively engage in programs in their countries of origin e.g. labour and migration laws, tax concessions Enhance circular migration e.g. debt forgiveness for new and recent health graduates if they serve in Africa; sabbatical and extended leave of absence for experienced Diaspora health practitioners. Build strategic partnerships between other host countries and sending countries, e.g. African governments. Work with international and multilateral organisations to address the constraints on public spending- decent employment opportunities in the healthcare sector. Move from bilateral to multilateral agreements- so that economy of scale is achieved and integrated health programming could be undertaken. African governments need to adopt policies that enable assimilation of the critical skills deployed back from the Diaspora.

Conclusion Engaging the African Diaspora to participate in ongoing efforts to improve socioeconomic conditions and the state of health in Africa is not as simple as it may appear. The process of engagement requires continuous interface between stakeholders and policy makers in Africa, and, individual members of the Diaspora as well as organizations and institutions that promote Diaspora issues. The overall goal should be to harness the benefits of “brain circulation” between Africa and the West. African governments should shift from the “brain drain” concept to the need for “continuous brain exchange” and brain circulation so that the African Diaspora can participate in the healthcare delivery system in the continent through multiple entry points and platforms. In addition, the process of exchange will require extended cooperation and confidence building between source and host countries. 219

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It would also require a concerted effort to develop and implement retention strategies in Africa so that participating Diaspora experts can move permanently back to the continent. African governments need to establish national priorities on how to maximize the contribution of the Diaspora. National governments should also support networks of health professionals in the Diaspora whose members can deploy to Africa for immediate, mid term or long term commitments. The paramount importance of regional and international partners requires that they be engaged in the HRH participatory process to ensure its success. These partners are important in the coordination of a strong and visible global response. National governments in Africa should reinforce the commitment to Africa on HRH by global partners and provide transparent platforms for sector-wide approaches for external funding support for health services. As part of this effort, African governments should work with domestic and international stakeholders to ensure that commitments to double overseas development assistance made by rich nations are achieved, and, to ensure that development assistance is long term and dependable. Since resources are at premium in Africa, national governments should increase the national expenditure on health as agreed upon by African Heads of State at the Abuja 2001 summit. By meeting the Heads of State directive on allocating at least 15 percent of national expenditure on health, Africa will be sending a message to its international development partners that it means business. It is also important to put in place mechanisms by which African countries agree that they will not reduce domestic expenditure on health as donor funding increases African leaders and international development advocates need to put pressure on international financial institutions such as the IMF and World Bank to remove the crippling effects of unreasonably tight budget caps on recruitment and salaries of workers in Africa, including health personnel.

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Proportions of medical doctors from selected countries working in source countries or working Abroad Adapted from : General Medical Council, United Kingdom, 2004 ; Hagopian A et al 2004, The migration of physicians from sub-Saharan Africa to the United States of America: Measures of the African brain drain, Human Resources for Health, 2: 17, 2004, Canadian Institute for Health Information, 2004; Mullan F, A legacy of pushes and pulls: An examination of Indian physician emigration, Bethesda, George Washington University, 2004; Carrolo M, Ferrinho, P, Portugalʹs contribution to the brain drain from PortugUese-speaking African countries, Lisbon, 2004, unpublished; Bundesaertzkammer, Germany, 2003; WHO HRH database, 2005.

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References 1. A. Gbary (2006). Current focus on Africa Human Resources in Health care. Presentation made on behalf of Dr Luis G. Sambo, Regional Director WHO Office for Africa, Brazzaville, Congo. Conference on “ Mobilizing the African Diaspora for Capacity Building in Africa, 21-22nd March 2006, House of Commons, London, United Kingdom. Hosted by the Africa All Party Parliamentary Group. 2. Eric Buch (2006). Presentation at the Closing Reception for the Conference on Mobilizing African Diaspora Healthcare Professionals for Capacity Building in Africa, 22nd March 2006, The House of Commons, London United Kingdom. Hosted by the Africa All Party Parliamentary Group. 3. T Banjoko (2006). Assessing Policy Innovations to Date—Bilateral Agreements, Codes of Conduct; Diaspora Initiative. Presentation at the conference Promoting Global Solutions to Health Worker Migration: Policy Innovations for Sending and Receiving Nations September 12, 2006 New York USA. Co-hosted by Realizing Rights: The Ethical Globalisation Initiative, the WHO Global Health Workforce Alliance, the Commonwealth Secretariat and Physicians for Human Rights.

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Chapter 19

HOPE THERAPY: THE MISSING MODALITY IN AFRICA’S HEALTH CARE RESPONSE ANN L. CARTER-OBAYUWANA., ALPHONSUS O. OBAYUWANA

Introduction In 1948, the World Health Organization proposed that health is a complete state of physical, mental, and social well being and not merely the absence of disease (1). We extend this definition to state that health is not only the mere absence of diseases and epidemics, but a state of optimal physical, mental, social, and psychological well-being of the individual, buttressed and sustained by a strong feeling of Hope. It is our thesis therefore that anyone, in whatever capacity, who desires to be a serious partner in shaping Africa’s health and healthcare delivery in the 21st century, should subscribe to this comprehensive definition of Health, which emphasizes the role of Human Hope in the sustenance of individual well-being. Many glaring inadequacies can be found in the current health paradigms, upon which most of Africa’s healthcare philosophy had been based. These inadequacies can be traced to the fact that the above comprehensive concept of health has largely eluded the mostly foreign architects of current Africa’s healthcare response and delivery systems. It is important, therefore, in future planning of health programs or reviewing existing health policies to be cognizant of the above comprehensive definition of health, including the concept of Human Hope. It is important to recognize the concept of Human Hope in sustaining physical, mental, and psychological well being. We propose that serious considerations be given to the enhancement of Human Hope in the form of Hope Therapy in all responses to health crises especially in the on-going care for those who are living with HIV/AIDS.

Hope Therapy: The Missing Modality in Africa’s Health Care Response

Overview of HIV/AIDS Pandemic The annual report of UNAIDS and World Health Organization provides information on the state of HIV/AIDS worldwide (2). In this report, Africa remains the geographical region with the highest incidence and prevalence of HIV transmission. The 2007 update on AIDS indicate that 22.5 million people are living with HIV/AIDS in Africa (2). More than 20 million Africans have died of AIDS since the early 1980s. Africa with 10 percent of the global population is responsible for 64 percent of current HIV infections and more than 75 percent of AIDS deaths every year. African women bear the brunt of HIV/AIDS: 13 women for every 10 men living with HIV/AIDS in Africa. Two of the most prominent challenges to achieving HIV prevention are: (A) understanding the culture and context of people’s lives – especially the rights and status of women and young girls and (B) recognizing the stigma still associated with HIV/AIDS. For example, around the world – from sub-Saharan Africa and Asia to Europe, Latin America and the Pacific – an increasing number of women are infected with HIV. Those at most risk of infection are often women with little or no income. Additionally, the positions of women and girls are exacerbated by “widespread inequalities including political, social, cultural, and human security factors.”(2) The individual and community stigma and the consequential discrimination linked with HIV/AIDS are extremely difficult obstacles to overcome. These twin barriers of stigma and discrimination jointly reduce the effectiveness of efforts to control this global epidemic, thereby generating an ideal climate for its further growth (3, 4, 5, 6, 7, 8, 9, 10). In sub-Saharan Africa HIV/AIDS is the leading cause of premature death. It is estimated that over 12 million children have been orphaned by AIDS; and if trends continue, 20 million African children will be AIDS orphans by the close of this decade (11, 12, 13, 14, 15). Medical Response to HIV/AIDS Both local and foreign “experts” who are working in the various African communities, continue to focus mainly on the acquisition and

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delivery of “drug therapy” for those who cannot afford the high cost of antiretroviral medications. Lack of funding and insufficient international response has even made this approach a difficult goal to achieve (2, 16, 17, 18). While the priority of antiretroviral therapy is unquestionably important, it is a serious omission to pay very little attention to other determinants of health and well-being. This traditionally Western medical approach to health care fails to consider the multidimensional needs of the infirmed. These needs may include spiritual void, economic deprivations, low educational attainment, hunger for simple human touch, compassion and interaction, distorted self-concept, feeling of helplessness and the ultimate danger of hopelessness. Consider the case of AG: AG is a 32-year-old married African male who contracted HIV/AIDS through unprotected sex outside of marriage. His wife, who subsequently contracted the disease from him, has now left him in anger and has taken their two children with her to her own birthplace. He was employed in the city, but since losing his job, he too has returned to his own village of origin hoping to find empathy and understanding. Instead, he was met with rejection and now lives alone, depressed, and has very little contact with his fellow villagers. His maternal grandmother brings him a daily meal, and he receives free drug therapy delivery from the nearest HIV/AIDS clinic located 25 miles away from his village. He is full of guilt and anger and firmly believes that his disease is a punishment from God. Life has ceased to have any meaning and he frequently thinks of suicide as a means of ending his misery and total lack of relevancy. He takes his antiviral drug perfunctorily often without any firm idea and/or belief in the “desired” result.

AG is not an uncommon example of an African living with HIV/AIDS today in sub-Saharan Africa. It is our contention that although the pharmacologic needs of AG – an obvious medical priority – is being met, it is clear there is a missing modality in AG’s health plan, and this missing modality is Hope Therapy – a technique for enhancing Human Hope. Human Hope and Hope Therapy The devastating impact of HIV/AIDS in Africa, paradoxically, has also provided a rare opportunity to pause and take a critical look at what constitute essential human needs. What is a good life? What in 225

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fact is a disease as opposed to an illness? What is health in contrast to wellness? What is humanity? What nurtures the will to live and how does one acquire the courage to die a peaceful death? What is a soul? Finally, what is that “peace of mind called Human Hope”? Our personal on-going reflections on subjects such as these and our many years of scientific research and clinical practice have all greatly illuminated our own understanding of Human Hope and the efficacy of the Hope Therapy Model. To appreciate Hope Therapy and recognize its potential role when responding to health crises such as the current pandemic of HIV/AIDS in Africa, one must first understand the concept of Human Hope. Dictionaries define Hope as the feeling that what is desired is also possible or that things will turn out for the best (19) Stotland defined hope as an expectation greater than zero of achieving a goal (20). Through our own scientific research (21, 22, 23), we have determined that “the feeling that what is desired is also possible” arises as the product of “Ego Strength, Perceived Human Family Support, Education, Spiritual or Religious Beliefs, and Economic Assets.” These five components of Hope we have defined as follows: Ego Strength is the sum of the attributes of an individual which constitute the core of his or her personality, facilitate all desired adaptations, and serve the primary function of self gratification and/or preservation. Perceived Human Family Support is the degree of perceived availability of moral support, meaningful inspiration, and desired assistance which an individual senses in the process of interaction with the immediate family, relatives, friends, neighbors, and significant others. Education consists of all forms of awareness and knowledge acquired by the individual through formal learning or by experience, which provide a better understanding of the environment, one’s immediate plight, and the laws of nature or society.” Religious/Spiritual Beliefs are those value characteristics of an individual which represent or promote a meaningful and satisfying relationship with an omnipotent and loving deity, force or being that is believed by the individual to provide in perpetuity for one’s total

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welfare, especially when prescribed commandments and lifestyle doctrines are followed. Economic Assets comprise of money and property, real or anticipated, including all items, arrangements, or situations considered by the individual as contributory to wealth and material sufficiency because they either actually enhance potential buying power or merely confer a perceived relative degree of financial comfort. Therefore, Hope is defined as the positive outcome of (A) the Ego Strength of an individual, (B) the amount of Human Family Support she or he perceives, (C) his or her Spiritual/Religious beliefs, (D) the level of Educational awareness, and (E) his or her perceived sense of material sufficiency or Economic Assets. The role of Hope is essentially to decrease anxiety by allaying fears that arise from uncertainties. In the final analysis, Hope increases the ability of an individual to cope with stress. Hope can be enhanced by building on the strengths of an individual and instituting corrective step to effectively address the weaknesses and deficits found in each of the five indices of Hope. The assessment and enhancement of the indices of Hope are the essence of Hope Therapy. The literature is replete with scientific evidence regarding the role and import of self-concept, family support, education, employment, and religion – all indices of Hope – in the prevention and treatment of HIV/AIDS. For example, feelings of guilt, depression, suicide, and other mental illnesses reflecting deficits in Ego Strength are commonly reported diagnoses in HIV/AIDS patients (24, 25, 26). Similarly, the important role of Family Support for individuals living with HIV/AIDS is well-documented (27, 28, 29). Education and accurate information have been shown to be critical for both the person living with HIV/AIDS as well as the broader community in order to correct misunderstanding, faulty cognitions, and the elimination of stigma and discrimination (3, 30, 31, 32). The impact of lack of economic assets (e.g. unemployment, high cost of antiretroviral treatment, depressed economy) is undeniable and well reported in the literature (15, 33, 34, 35). Support is also found in the literature regarding the importance of religious/spiritual beliefs as a critical coping mechanism for people diagnosed with HIV/AIDS. (4, 36, 37). The concept of Hope Therapy, as a missing modality in the treatment of individuals with HIV/AIDS, is therefore well supported by the literature. 227

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In the case of A.G., it is glaringly evident that multiple deficits exist in his five indices of Hope, and he could greatly benefit from Hope Therapy. In the context and parlance of Hope Therapy, the free antiretroviral drug supply and the daily meal from his grandmother only partially address AG’s sense of economic insufficiency and hunger for human companionship, respectively. Ignored and unattended to are: (A) his feelings of guilt and depression (deficits in Ego Strength); (B) his isolation from the village and his immediate family (lack of human family support); (C) his understanding of HIV/AIDS as punishment (an educational deficit); (D) his lack of employment and sense of financial insecurity (an economic deficit); and finally, (E) his belief that he has been abandoned and punished by God. (a spiritual void). As documented in the literature review above, these unanswered needs of AG have a negative impact on his overall health and wellbeing. Hope Therapy for AG would begin with an assessment of his strengths and weaknesses in each of the five categories that comprise the components of Hope. Assessment is achieved through an in-depth interview (ideally with an instrument for assessing Hope – e.g. the Hope Index Scale) (38). Subsequent to assessment, active steps will be initiated to institute the appropriate corrective measures by a social worker, a counselor, a nurse, or other trained personnel working in conjunction with a multidisciplinary team. Corrective measures may involve individual counseling, the solicitation of volunteers, community-wide education, involvement of local pastor or imam, marriage/family counseling, and possible re-unification with his wife and children. Conclusions and Recommendations In addition to others who have made recent calls for the inclusion of mental health in all medical treatments (39, 40, 41), this chapter has presented a compelling rationale for including issues of mental hygiene in the formulation of medical treatment plans for HIV/AIDS patients in Africa. Today, in the United States and other countries, many hospitals and medical centers have designated rooms or chapels for meditation and/or spiritual reflections. Often, there is a resident chaplain. Some centers have programs that involve teenage as well as adult volunteers and the use of “visiting pets” to answer the need for companionship for

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lonely patients in hospitals, nursing homes, and long-term medical care facilities. Education pamphlets and informative videos on different diseases and other various health topics are available to patients and their families. There are also organized support groups and meetings to empower patients, provide camaraderie, and to boost individual feelings of selfefficacy and personal relevancy. Social service personnel are readily available to address issues of patients’ personal needs and economic sufficiency. Although not called Hope Therapy, these practices attest to the growing trend and belief that health is not the mere absence of disease but rather a state of optimal physical, psychological, mental, and social well being that is buttressed and sustained by a strong feeling of Hope. It is our recommendation that Hope Therapy be an essential part of the medical care plan for every patient living with HIV/AIDS anywhere, particularly in Africa. References 1. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. Available at http://www.who.int/ 2. UNAIDS, WHO. (2007). AIDS Epidemic Update. Geneva, Switzerland: UNAIDS. 3. Emlet C (2006). A Comparison of HIV Stigma and Disclosure Patterns between Older and Younger Adults Living with HIV/AIDS. AIDS Patient Care & STDs, Volume 20, Number 5, pages 350-358. 4. Farley M (2004). Partnership in Hope: Gender, Faith, and Responses to HIV/AIDS in Africa. Journal of Feminist Studies in Religion Volume 20, Number 1, pages 133-148. 5. Farmer P (2001).Community-based approaches to HIV Treatment in Resource-poor Settings. [MEDLINE] 6. UNAIDS (2000). AIDS Epidemic Update: December 2000, Geneva: Author 7. Mutangadura G (2001). Women and AIDS in Southern Africa: The case of Zimbabwe and its Policy Implications. Journal of Culture and African Women Studies, Volume 11, pages 1-11. 229

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8. Ntozi J (1997). AIDS Morbidity and the Role of the Family in Patient Care in Uganda. Health Transition Review, Volume 7(Suppl), S1_S22. 9. Parish C (2006). Women are the Answer. Nursing Standard Volume 20, Number 45, pages 20-22. 10. Rutledge S, Abell N (2005). Awareness, Acceptance, and Action: An Emerging Framework for Understanding AIDS Stigmatizing Attitudes among Community Leaders in Barbados. AIDS Patient Care & STDs, Volume 19, Number 3, pages 186-199. 11. VanBrakel W (2006). Measuring Health-related Stigma—A Literature Review. Psychology, Health & Medicine, Volume 11, Number 3, pages 307-334. 12. UN Economic Commission for Africa, (2005a).The HIV/AIDS Pandemic and the Governance Challenge in Africa. The Millennium Development Goals in Africa: Progress and Challenges. Available from http://www.uneca.org/mdgs/story10November05.asp 13. UN Economic Commission for Africa, (2005b). Controlling Diseases – Lessons from the Past. The Millennium Development Goals in Africa: Progress and Challenges. Available from http://www.uneca.org/mdgs/story9September05.asp 14. International Federation of Red Cross and Red Crescent Societies. (2000). World Disaster Report 2000. Geneva: International Federation of Red Cross and Red Crescent Societies 15. Joint United Nations Programme on HIVAIDS, (2000). AIDS Epidemic Update: December 2000, Geneva, Switzerland: Author 16. Farmer P et al (2001). Community-based approaches to HIV treatment in resource-poor settings. [MEDLINE] 17. Rosen S, Sanne I, Collier A, Simon J (2005). Rationing Antiretroviral Therapy for HIV/AIDS in Africa: Choices and Consequences. Public Library of Science Medicine, Volume 2, Number 11, pages 1098-1104. 18. Nursing Standard (2005). G8 Cash Shortfall Leaves AIDS Fund in Terrible Trouble . Nursing Standard, Volume 20, Number 13, page 6. 19. Webster Dictionary. Available at http://www.Webster.com and http://www.Dictionary.com, includes the dictionary definition of hope. 20. Stotland E (1969). The Psychology of Hope. San Francisco: Jossey-Bass

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21. Obayuwana AO, Carter AL (1982). The Anatomy of Hope. Journal of the National Medical Association, Volume 4, Number 3, pages 229-234. 22. Obayuwana AO, Collins J, Carter AL, Rao MS (1982). Hope Index Scale: An Instrument for the Objective Assessment of Hope. Journal of the National Medical Association, Volume 8, pages 761-765. 23. Obayuwana AO, Carter AL, Barnett RM (1984). Psychosocial Distress and Pregnancy Outcome: A Three Year Prospective Study. Journal of Psychosomatic Obstetrics and Gynecology, Volume 3, pages 173-183. 24. Judd F, Komiti A, Chua P, Mijch A et.al (2005). Nature of Depression in Patients with HIV/AIDS. Australian & New Zealand Journal of Psychiatry, Volume 39, pages 826-832. 25. Porche D, Willis D (2006). Depression in HIV-infected Men. Issues in Mental Health Nursing, Volume 27, Number 4, pages 391-401. 26. Shelton AJ, Atkinson J, Risser JMH, McCurdy S A et.al. (2006). The Prevalence of Suicidal Behaviors in a Group of HIV-positive Men. AIDS Care, Volume 18, Number 6, pages 574-576. 27. Smith J, Myer L, Middelkoop K, Seedat S et. al (2006). Mental Health and Sexual Risk Behaviors in a South African township: A Community-based Cross-Sectional Study. Public Health, Volume 120, Number 4, pages 534-542. 28. Ntozi J (1997). AIDS Morbidity and the role of the family in patient care in Uganda. Health Transition Review, Volume 7(Suppl), pages S1_S22. 29. Petersen I, Mason A, Bhana A, Bell C, McKay M (2006). Mediating Social Representations Using a Cartoon Narrative in the Context of HIV/AIDS: The AmaQhawe Family Project in South Africa. Journal of Health Psychology, Volume 11, Number 2, pages 197-208. 30. Santmyire A, Jamison M. (2006). Educating African Pastors on Mother-to-Child Transmission of HIV/AIDS. Journal of Nursing Scholarship. Volume 38, Number 4, pages 321-327. 31. Bermejo A. (2004). HIV/AIDS in Africa. New Economy, Volume 11, Number 3, pages 164-169. 32. Zolfo M, Lynen L, Dierckx J, Colebunders R (2006). Remote Consultations and HIV/AIDS Continuing Education in Low-resource Settings. International Journal of Medical Informatics, Volume 75, Number 9, pages 633-637.

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33. Flanelly LT, Inouye J (2001). Relationships of Religion, Health Status, and Socioeconomic Status to the Quality of Life of Individuals who are HIV positive. Issues in Mental Health Nursing, Volume 22, pages 253–272. 34. Pronyk P, Kim J, Bates B (2002). HIV/AIDS and Business in South Africa: Interventions, Opportunities and the Private Sector Response to the Epidemic .Johannesburg: Canadian Business, Alliance of South Africa. 35. Rajaraman D, Russell S, Heymann J (2006). HIV/AIDS, Income Loss and Economic Survival in Botswana. AIDS Care, Chapter 18, Number 7, pages 656-662. 36. Tarakeshwar N, Pearce M, Sikkema K. (2005). Development and Implementation of a Spiritual Coping Group Intervention for Adults Living with HIV/AIDS: A Pilot Study. Mental Health, Religion & Culture, Volume 8, Number 3, pages 179-190. 37. Prado G, Feaster D, Schwartz S, Pratt I et. al (2004). Religious Involvement, Coping, Social Support and Psychological Distress in HIV-seropositive African American Mothers. AIDS Behavior, Volume 8, pages 221–235. 38. Hope Index Scale, © Institute of Hope. Contact authors. 39. Freeman M, Patel V, Collins P, Bertolote J (2005). Integrating Mental Health in Global Initiatives for HIV/AIDS. British Journal of Psychiatry, Volume 187, pages 1-3. 40. Miranda J, Patel V (2005). Achieving the Millennium Development Goals: Does Mental Health Play a Role? Public Library of Science Medicine, Volume 2, Number 10, pages 962-965. 41. SAMHSA Supports Mental Health Care for HIV/AIDS. (2006). Mental Health Weekly, Volume 16, Number 38, page 7.

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Chapter 20

HEALTH SERVICES IN AFRICA: A NEW BUSINESS MODEL FOR UNITED STATES UNIVERSITIES ACTIVELY ENGAGED IN HEALTHCARE DELIVERY IN AFRICA JOHN F. WILLIAMS, FRANK J. CILLUFO, LEROY R. CHARLES, KRISTEN k. CAMPBELL

Overview In order to help promote change in Africa, United States universities working in the continent need to end the “business-asusual” relationships, encouraging a closer collaboration between Africans and their Western counterparts in shaping the development agenda. US universities should set an example by engaging African communities in a two-way dialogue in order to identify, understand, and respond to African priorities. Although it is imperative that US universities understand the challenges and help contribute to the solutions, Africans must be responsible for change on the continent. In other words, the challenges in Africa can be tackled if Africans have the opportunity to demonstrate strong technical and managerial leadership, and define research and policy priorities. The George Washington University Africa Center for Health and Human Security has embraced, and is promoting, a model for change that strengthens and empowers Africans to lead and manage their own development. This model also encourages the global community to reexamine what makes a person secure, thus making human security a key focus. This model can serve as a catalyst for a new paradigm “out of Africa”-- putting Africans in charge of deriving and implementing solutions, and taking ownership of the results related to improving health and human security on the continent. A New Business Model US universities can make enormous contributions towards the scientific, technological and intellectual capacity of Africa by 233

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establishing a model for partnerships that promotes enduring relationships and sustained involvement in Africa. For example, universities in Africa and richer nations of the world can play a critical role in creating neutral forums for discussing policy alternatives as well as program efficiencies and effectiveness. However, in order for these forums to be successful a new business model needs to be established that: o o o

o

harnesses the expertise of Africans to investigate possible Africanspecific solutions; engages Africans in defining priorities; provides Africans with training for self-sufficiency; and Integrates academic and policy agendas that drive programmatic action in Africa.

This model requires advancing a new paradigm for relationships between African-based institutions and organizations and their Western counterparts. To this end, Africans, African Diaspora communities, and faculty and students from Historically Black Colleges and Universities must be included in discussions from which they are often excluded. The GW Africa Center for Health and Human Security In November 2004, Dr. John F. Williams, The George Washington University (GW) Provost and Vice President for Health Affairs, created the Africa Center for Health and Human Security (Africa Center). The Africa Center distinguishes itself from other academic and advocacy groups by developing and promoting the above model as the guiding framework for the Center. The Africa Center provides a forum for multidisciplinary and multisectoral experts to brainstorm cross-cutting approaches to pressing problems on the African continent. It provides a neutral forum for convening African and American policymakers, academicians and representatives from the private sector. The Africa Center also serves as catalyst, clearinghouse, and a coordinating mechanism for Africa-related activities at GW. After deliberating with our African partners, the Africa Center identified three potential program areas within the context of health and human security on which to focus:

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1. 2. 3.

Human resource development; Economic impacts of neglected tropical diseases; and Health policy analysis and development.

First, the Africa Center is exploring a multidisciplinary and multisectoral workforce development initiative on Africa to assist the continent in dealing with the ongoing severe human resource crisis in the health and development sector. GW professor and chair of the US Institute of Medicine report on workforce issues in developing countries, Dr. Fitzhugh Mullan, will work with partners in Africa to help lead this effort. Second, the Africa Center is considering a major focus on neglected but economically devastating diseases in Africa. This effort would address the preventive, clinical, economic, cultural and other development issues related to neglected diseases in Africa. GW professor Dr. Peter Hotez, the principal investigator on the Human Hookworm Vaccine Initiative from the Sabin Vaccine Institute and the Gates Foundation, and a leader of the emerging global alliance to address neglected but economically devastating diseases, is working with experts in South America and Africa to help direct this effort. Finally, the Africa Center is focusing on a health policy initiative where, at the invitation of host governments, the Africa Center will mobilize health policy experts across various schools at GW to respond to identified needs and priorities. This effort will be lead by Dr. John G. H. Palen, Associate Dean for Academic Affairs and an Associate Professor in GW’s Departments of Health Policy and Global Health. The Africa Center will work closely with African-based leading researchers and policy makers to examine comprehensive health and development issues that impact on workforce, neglected diseases, and health policy issues in Africa. The Africa Center expects African institutions, the civil society, professional organizations, and governments to take the lead role in articulating the political, economic, social and cultural issues that influence workforce issues, the prevention and control of neglected diseases, and the formulation of analysis of health policies.

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Why Health and Human Security? The evolution of threats, especially over the last 10 years, has considerably altered our understanding of security. In particular, the events of September 11, 2001, in the US forced the global community to re-examine what makes a country “secure.” Today, people in Africa are threatened not only by war and conflict but also by terrorism, poverty, hunger, environmental degradation, and infectious diseases. These issues, combined with the new burdens of the rapid out-migration of healthcare professionals and a growing orphan population, have created enormous human security challenges for Africa. The global community is recognizing that endemic disease affects not only the health of a community, but over the long-term, it can contribute to the destabilization of governments and spur an environment where conflict and poverty flourish. Traditionally, “health” and “security” have been treated by academicians, policy makers, and practitioners as very distinct domains of activity. “Security,” in particular, is a term typically associated with a rather narrow set of questions related to national defense. The Africa Center supports the belief that to ensure the wellbeing of individuals, communities, and nations, we must consider the broader range of conditions encompassed by human security. Human security, as defined by the United Nations Commission on Human Security (1) is: “the protection of ‘the vital core of all human lives in ways that enhance human freedoms and fulfillment. Human security means protecting fundamental freedoms. It means protecting people from critical and pervasive threats and situations. It means using processes that build on peopleʹs strengths and aspirations. It means creating political, social, environmental, economic, military and cultural systems that, when combined, give people the building blocks for survival, livelihood and dignity. Human security is far more than the absence of violent conflict. It encompasses human rights, good governance and access to economic opportunity, education and healthcare.”

This concept is particularly significant for the people of Africa, where the challenges of “freedom from fear” and “freedom from want” are most pervasive, and where internal and external factors threaten

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human security. Health challenges are a critical component of human security. The principle of human security relies on developing a healthy population. Therefore, health and human security are intertwined, requiring a closer interaction between different disciplines such as public health, political science, geography, economics, agronomy, and anthropology to address human security issues. Linkages and cooperation among universities, governments, international organizations, non-governmental organizations, and faith-based organizations are also invaluable. Policy and Program Recommendations For US universities and other institutions working in Africa, health and human security should encompass a long-term investment in the global community. We identify policy and program recommendations where African institutions can collaborate with US universities to improve health and human security on the continent. Enhancing Healthcare Delivery and Management in Africa

Studies show that people in Africa face not only short life expectancies but that they also live a higher proportion of their lives in poor health. Therefore, much remains to be done in organized efforts to improve Africa’s healthcare delivery system to not only treat those afflicted with illness, but to institute preventive measures as well. Increased education and training of Africans can play an important role in enhancing healthcare delivery and management. By partnering with African institutions, governments, and other community-based organizations in-country, US universities can support a range of initiatives and serve as a catalyst for change. 1. Support health workforce initiatives According to a 2005 Institute of Medicine report, the single greatest obstacle to meeting health care needs in low income countries is the dearth of qualified health professionals (2). Experts estimate that subSaharan Africa currently needs one million new health workers to meet its essential health needs. Unprecedented partnerships will be required to address this problem. US universities should work with African partners to:

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o o

o o

develop a health workforce needs assessment in order to establish baseline data; recruit, train, support and effectively utilize health workers (including doctors, nurses, laboratory technicians, pharmacists, and mid-wives) to achieve universal access to clinical and treatment in Africa; increase medical-education opportunities in Africa; and Establish relationships with local organizations such as hospitals, universities, and non-governmental organizations in-country.

This work should be African-led and supported within the context of a comprehensive country and regional health strategy that addresses prevention, care, and treatment. AfricaRecruit, a program of The New Partnership for Africa’s Development (NEPAD), is an example of such an effort. AfricaRecruit has been at the forefront of mobilizing skills and human resource capacity in and outside of Africa since 2002. It is an innovative service delivery vehicle with its focus on capacity building through human resources using its various networks within and outside Africa (3). 2. Increase awareness about neglected tropical diseases While the world is focused on the “big three” diseases, AIDS, malaria, and tuberculosis, there are a number of other diseases, neglected tropical diseases, whose burden has been underappreciated. Neglected diseases include hookworm, leishmaniasis, trypanosomiasis, lymphatic filariasis, onchocerciasis, schistosomiasis, leprosy, Buruli ulcer, and trachoma. Recent data on neglected diseases indicate that there is geographic overlap with HIV/AIDS, Malaria, and tuberculosis, and that co-infections promote susceptibility to disease. According to Hotez and Sachs (4), neglected diseases share a high prevalence in rural and poor regions of low-income countries, an ability to promote poverty, and cause disabling stigma characteristics. For a less than $1 per person per year, a package can be developed to treat several neglected diseases. In addition to raising global awareness about neglected diseases, US universities can assist African institutions in developing a comprehensive disease control plan.

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3. Develop and implement health policy analysis training US universities can help develop and build health policy analysis capacity in support of a country’s healthcare goals. Potential activities include academic and professional educational program development, faculty and student exchanges, direct technical assistance by faculty and staff at US universities, clinical and public health research collaborations, continuing education programs via videoconferencing, and organizing stakeholder meetings on key public health and healthcare issues. These activities will result in the creation of a workforce that is skilled in health policy analysis and health services management. Additionally, they will enhance and expand academic and other professional endeavors within African governments and graduate medical and public health academic institutions. 4. Facilitate a dialogue between traditional African healers and those who practice modern medicine Another way to enhance healthcare delivery is for US universities and other organizations working in Africa to acknowledge and embrace the important role of traditional medicine in Africa. American academicians and scientists need to look beyond the traditional confines of modern science and medicine, and incorporate other ways of addressing health challenges. For example, meetings, conferences, and other public forums can help facilitate dialogue between traditional African healers and those who practice Western-based medicine. This discussion will allow for the incorporation of African traditional medicines and methods into efforts that address the crucial health challenges of our times. 5. Develop advocacy skills in students and generate evidence through research For decades, advocacy efforts in health care policymaking have been hamstrung by a lack of evidence-based practices. The credible and neutral forum inherently provided by universities creates a portal to fact-based advocacy. This forum, however, also creates an interesting dilemma when it comes to faculty members playing an advocacy role. For example, how do faculty members advocate for issues without losing credibility as providing factual and unbiased research and information for decision-making? US universities can play a key role in healthcare advocacy in Africa by building advocacy skills among students and by generating research supporting advocacy efforts (5). 239

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Universities should: o

o o

develop a student body with advocacy skills and engage students in advocating for improved health and security in Africa (e.g., students should learn how to develop an advocacy strategy, acquire skills in various advocacy tools, and determine which avenues and vehicles for advocacy are most effective in a given sphere of policymaking); train leaders and managers at all levels of the health system (6); and Play a key role in building coalitions by linking organizations.

In 2005, the GW Africa Center signed a memorandum of understanding with the Constituency for Africa, an advocacy organization that builds support for Africa in the United States. The partnership between the Africa Center and the Constituency for Africa is a first step towards linking the educational and advocacy communities and integrating the research and policy agendas in Africa. Enhancing Human Security in Africa As human security is still an evolving concept, it is not fully understood. Historically, security has been defined largely in state and military terms. Human security is not intended to replace the traditional concept of security, but rather complement it, by looking at security from a more holistic perspective. US universities can play an important role in coordinating efforts in this area, as well as providing Africans with the building blocks to improve human security. US universities can play this role in a number of ways. 1. Raise the profile of human security to promote understanding and acceptance Although human security has rapidly taken center stage in international discussions, including those held by the Group of Eight (G8) nations and the United Nations, much work remains to be done. By collaborating with African institutions, US universities can play an important role in promoting understanding and acceptance of human security by helping to define its research and policy agenda, and by

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identifying its drivers. The human security agendas noted by King and Murray (7) could be based on its key characteristics: it is universal, its components are interdependent, it is best ensured through prevention, and it is people-centered. 2. Develop indicators for measuring human security and improve data collection The success of enhancing human security depends on our ability to measure it. Therefore, US universities and African institutions should evaluate and develop indicators for the many vectors through which challenges, such as the spread of HIV/AIDS, can generate a host of social and economic problems (e.g., demographic collapse, loss of human capital, massive urbanization, overburdening and collapse of health systems, spiraling healthcare budgets, poverty, and institutional collapse). Once indicators have been identified and developed, US universities can assist African institutions in collecting and using data to monitor and evaluate a range of human security concerns including population issues, health, and nutrition. Specific needs include data archiving, documentation, and dissemination, as well as data disclosure and accessibility. Geographic data from satellites (e.g., climate, elevation, soil, vegetation, population, land use, and economic activity) can provide reliable information to support decision-making in Africa. Therefore, maximizing the use of African data for academic and policy oriented research will benefit both African governments and individuals interested in African research.

3. Develop strategies for increasing human security Africa faces complex and interconnected challenges that will be easier to understand once indicators are established and data are collected. Once the baseline data is established and trends are analyzed, US universities and African institutions can identify strategies for increasing human security, such as developing a comprehensive health system to re-establish trust in African governments and reduce the chances of conflict. 4. Promote the Rule of Law and an independent judicial system It is important for universities to support rule of law and independent judiciary initiatives. These initiatives represent the

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foundation of social and economic development in any country. According to the African Judicial Network (8): “Rule of law issues have posed an impediment to development on a number of levels in African countries. In some countries, the executive branch of government has dominated the judicial system. In others, access to justice has impeded the uniform application of law. In still others, the judiciary struggles to operate effectively in their resourcestarved environments. All of these situations create environments where business contracts are not enforced, breeches of civil rights sometimes go unaddressed, and legal decisions become unpredictable and untimely” (http://ajn.rti.org/index.cfm?fuseaction=About&l=eng).

Although states across the African continent are working to construct liberal societies and effective governments, much remains to be done to promote the Rule of Law, multiparty systems and elections, anticorruption initiatives, and free media. US universities can partner with African institutions to support an African-led process to reform the judicial system and the legal profession. Activities can include: ⇒ ⇒

⇒ ⇒ ⇒

building capacity through long-term programs that support law societies; providing technical assistance in areas of the Rule of Law, legislative reform, human rights, and public interest and constitutional issues; providing media advisors; increasing knowledge and support of the international legal community through educational programs; and Training law enforcement and security personnel.

5. Attract and train Africans for senior scientific leadership positions In Africa, there is a general scarcity of qualified candidates to hold scientific leadership positions. Despite increases in the number of postdoctoral candidates, there is a failure to attract and develop a new generation of researchers. Scientific research professionals competing for senior positions often have experience in macro-management, fundraising, and policy formulation but need experience in such areas as quantitative and qualitative methodologies, research implementation, and scientific writing and publishing. U.S. universities can prepare professional development modules for the candidates

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competing for senior positions based on their individual competency, experience, and specific development needs. Additionally, faculty members from U.S. universities can mentor African colleagues by providing instruction in research implementation, design, and management in areas of health and human security. 6. Create opportunities for African Diaspora, faculty, and students to serve internationally US immigrant communities can identify and influence their homelands in many important ways. U.S. universities can support efforts within Diaspora communities to address self-identified concerns, particularly in such areas as healthcare delivery, post-conflict reconstruction, and development in Africa. U.S. universities can also create an environment for encouraging faculty and students to conduct their research projects in international settings. Similarly, faculty and student exchange programs can promote exposure to health and human security issues (e.g., infectious diseases, maternal and child health, malnutrition, and domestic abuse). Funding mechanisms, such as travel stipends and fellowships, can be established to bring students from Africa to the US and vice versa. Conclusion Although enormous developmental challenges remain in Africa, including healthcare woes, US universities can play constructive roles in international and national efforts to improve living conditions in the continent and create enabling environments for Africans to reach their full potential. United States and other Western-based institutions and organizations need to think outside the box and embrace constructive partnership with their African counterparts where mutual respect is paramount. As noted in the recent Institute of Medicine report on workforce issues in developing countries, the solution to this complex problem lies in creative policy and program initiatives (2). Since Africa’s development must be led by Africans, US and Western universities should work closely with African partners in accordance with priorities identified by Africans. With deeper partnership and understanding, US universities and their counterparts in other Western countries can play catalytic roles in strengthening capacity in health and education to achieve human security in Africa. By partnering in 243

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education, training, research, and policy development and implementation efforts, African constituencies and US universities can advance critical health and human security initiatives. References 1. The United Nations Commission on Human Security (2006). Available at http://ochaonline.un.org/webpage.asp?MenuID=10473&Page=1494. 2. National Academies (2005). Healer’s Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. National Academies Press, Washington, DC. 3. AfricaRecruit on Africa Health Diaspora Issues (2006). Available at http://www.africarecruit.com. . 4. Sachs, Jeffrey D. and Peter J. Hotez (2006). Fighting Tropical Diseases. Science, Volume 311, Number 5767, page 1521. 5. Katz, Ruth (2006). Remarks made at the Constituency for Africa/George Washington University African Health Policy Town Hall Meeting: The Role of US Universities in Health Advocacy for Africa. September 6, 2006, Washington, DC. 6. Oluwole, Doyin (2006). Remarks made at the Constituency for Africa/George Washington University African Health Policy Town Hall Meeting: The Role of US Universities in Health Advocacy for Africa. September 6, 2006, Washington, DC. 7. King, Gary, and Christopher J. L. Murray (2001). Rethinking Human Security. Political Science Quarterly, Volume 116, Number 4, pages 585-610. 8. African Judicial Network. Available at: http://ajn.rti.org/index.cfm?fuseaction=About&l=eng. Accessed on April 10, 2006.

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Chapter 21

THE FUTURE OF HEALTH CARE SERVICES DEPENDS ON LESSONS LEARNED FROM SUCCESSFUL PROGRAMS AND SHARING IDEAS ON BEST PRACTICES MOHAMMED AKHTER Introduction In the preceding chapters of this book, you read about significant challenges that impede the provision of health services in Africa. These challenges include inadequate national policies to address emerging health issues and concerns, lack of fully functional health facilities, shortages of health workforce, overwhelmed health systems that are incapable of meeting the needs of target populations, the limited role of public/private/civil society partnerships in healthcare delivery, and, the inability of target populations to demand better health services. I know that these challenges are not limited to Africa. These challenges face policy makers in rich countries and emerging economies around the world. Global health experts now know that healthcare problems do not respect national boundaries. With the advent of modern transportation networks, the trading of goods across continents and oceans, and the mobility of skilled workforce, a health issue in one part of the world can quickly find its way to destinations thousands of miles away. Today, an individual can leave Lagos, Nigeria and within 15 hours may stop in London and disembark in New York. Another person may board a plane in New York and within a 24 hour period, can spend time in London, Kenya, Dakar and Paris. Goods and services traverse the globe. This effortless movement across the world challenges our concept of disease prevention, control and management. It also challenges how we plan to respond to international emergency situations such as tsunamis, hurricanes, and a possible bird flu pandemic.

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In this chapter, I discuss a future of health services where both rich and poor nations and regions share ideas, scale up successful programs and share best practices. This partnership will be made possible by shared global commitment to improve access to health services for all individuals and families. A recent demonstration of this shared responsibility is the global concern to avoid a bird flu pandemic. A single incident of bird-to-human transmission of the avian influenza can trigger a global emergency with significant mortality and morbidity. In discussing the shared vision of global health, I briefly review my long journey as a health policy maker and health administrator starting from my earliest years in my native Pakistan. I then briefly review the healthcare challenges in the richest nation on earth, the United States, and discuss how these challenges are being addressed. Then, I end with an overview of how policy makers anywhere in the world can learn from each other on how best to meet the healthcare needs of target populations. A Long Way from a Poor Village in Pakistan Like most Africans of the 1940s and early 1950s, I grew up in Pakistan walking barefoot to my primary school. When I completed my secondary school education, I enrolled in a Medical School in Pakistan. I graduated 40 years ago as a medical doctor with every intention of being a neurosurgeon. However, the overwhelming lack of access to health services and the significant proportion of families living in poverty made me decide on a public health career. I received my public health and preventive medicine training in the United States. During my training, I was surprised to notice that in poor neighborhoods of urban cities of the United States, the kinds of challenges I had noticed in Pakistan were also applicable. I also noted that access to health services were patchy in poor rural communities. The poor in the United States faced serious obstacles to better health. The poor in the United States are sicker than the rich, and also die earlier. Poor mothers had higher rates of low birth babies and higher rates of infant deaths. Poor mothers were also more likely to die during child birth (despite the rarity of such deaths) compared to rich mothers. The poor were more likely to be sicker when presenting for medical care compared with the rich. Blacks were more likely to be sick and die

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early compared to the White population. Blacks in America were more likely than Whites to be poor and lack access to health services. They were also less likely to benefit from preventive health programs. Eventually as I continued my public health career, I became the Director of Health Services of the State of Missouri in the United States. I also served as the Commissioner of Health of Washington, DC, the nation’s capital. Next, I served as a senior advisor to the US Department of Health and Human Services. From there I became the Executive Director of the American Public Health Association and a board member of the World Federation of Public Health Associations. In 2005, I was appointed the President of the American Council for International Voluntary Action (INTERACTION) the largest coordinating organization of all American –based organizations engaged in health and development activities abroad. I have also served as the Senior Associate Dean for International and Public Health at the Howard University, Washington, DC and helped establish a new Masters in Public Health degree program in the institution. Currently, I am the executive director of National Medical Association, the national organization for African American and other minority physicians in the United States. In all these positions and with extensive travels around the world, I gradually came to realize that five issues are critical in the provision of health services worldwide: A) The provision of health services is a political process that must command the attention of politicians and national policy makers in every country. Health experts often make the mistake of ignoring the political process in their country. In almost all countries, final decisions regarding the funding of health services are made by individuals who did not attend medical schools or have formal health professional training; B) The mangers and staff of health services must bend over backwards to accommodate the needs of the poor, the weak and the marginalized. No health system can be efficient and effective if the poor are excluded. When the poor are excluded from health services, the country invariably pays down the road from high cost of emergency services, morbidities and mortalities; C) The provision of health services requires a decision on a minimum set of health services that should be available to all citizens. 247

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It is always a difficult process to set these minimum set of health services due to a combination of differing political ideologies and limits on resources; D) The provision of quality health services is not entirely dependent on the availability of money. No amount of money will substitute for each nation’s ultimate responsibility to develop national health policies, national health plans, national health systems and national health services. Each country must decide what is best for its citizens through a transparent stakeholder process linking the public and private sectors as well as the civil society; E) No foreign country or organization can develop or manage the delivery of health services in a host country. Each country no matter its limitations in financial, technical and financial resources should develop and implement health services that respond to the expressed needs of its target population. Challenges to the Provision of Health Services in the United States Challenges to the provision of health services in the United States, in my view, presents important insights on the dynamics of healthcare delivery. I discuss these challenges. First, money is not the answer to every problem regarding delivery of health services. The United States spends more money per capita on health than any other country in world (1). In 2004, the US spent more than US$1.9 trillion dollars on health. Yet, more than 40 million Americans either did not have health insurance or had only partial health insurance for the entire year. Second, poverty is a formidable foe of access and utilization of health services. Adults living in poverty in the United States are more likely to have poor or fair health status, and, more likely to have chronic health conditions and disabilities compared to their economically better off peers. The poor in the US are also less likely to have access to available health services. They are also less likely to utilize available health services. Third, the national government continues to shoulder a significant burden of healthcare cost. In 2004, the federal government financed 34 percent of the US$1.9 trillion health cost compared to private health insurance (36 percent), state and local government (11 percent), and

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out-of-pocket payments (15 percent). Collectively, governments at all levels financed 45 percent of all healthcare services. Fourth, the US continues to experience ethnic disparities in health. The disparities exist in regards to risk factors for ill health, access to available health services, and morbidities (1). The infant mortality rate of Black infants was 13.6 per 1,000 live births compared to 5.6 for White infants in 2004 (1). Blacks had a life expectancy rate of 73.1 years compared to 78.3 years for the White population in 2004. Black women 20 years and above were more likely to be obese (51 percent) compared to 31 percent of White peers. Experts in the US (1, 2) believe that these ethnic disparities in health persist because of differences in socioeconomic status, psychosocial stress and coping mechanisms, access to community-based resources, racial discrimination, access to available health services, and, state of personal health throughout life. Fifth, an aging population is fueling an upsurge on the utilization of health services. Nearly one-third of Americans age 75 years and above reported fair or poor health compared to individuals ages 25 through 44 years (1). More than one fifth of individuals 60 years and above are living with diabetes. Sixth, the healthcare system in the United States is in urgent need of reforms (3, 4). The healthcare system is largely based on two formats: (A) Employment based and (B) Income-tested programs such as Medicaid and Medicare. Preventive strategies and programs are weak. Mental health coverage is patchy at best. Doctors spend considerable time filling paperwork, a critical task if they wish to be paid. The health system is not cost effective. The growing clout of forprofit organizations creates disincentives for population-based health care. The 46 million uninsured Americans remains a sore point as most of them use expensive emergency services or forego care altogether. The health care system loses money on administrative overheads, inadequate management information systems, unnecessary medical tests and defensive medicine. Despite these problems and inefficiencies, the health system in the US is highly rated and prized by Americans. Citizens of other countries clamor to receive healthcare in the United States. Life expectancy rates are increasing and more Americans live into the seventh, eight and ninth decades.

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A very important issue is why the US recorded significant gains in health since the turn of the 20th Century. The reasons for these significant gains are surprising. Why United States Made Significant Gains in Health in the last 100 Years Experts believe the following issues are responsible (1): ⇒

⇒

⇒ ⇒

⇒

⇒

The control of infectious diseases through decontamination of water. This effort practically wiped out new cases of typhoid and cholera; The comprehensive implementation of age-appropriate immunization programs against polio, diphtheria, pertussis and measles; The fluoridation of water supply to significantly reduce the occurrence of dental caries; The national focus on motor vehicle safety through increased use of seatbelts, helmets for motorcycle and bicycle rides, and, the introduction of safety equipments in redesigned cars; The significant impact of aggressive preventive health initiatives such as smoke cessation, healthy lifestyle choices, and taking charge of personal health status; and The steady advances in technology, medical knowledge, diagnostic services and medical procedures.

It is surprising that all but one of the aforementioned issues is within the capabilities of most national governments anywhere to significantly reduce morbidities and mortalities. The only strategy that resource challenged governments may find difficult to implement is the introduction of advanced technologies. The process of designing and deploying the low cost, low tech strategies for better health were often controversial and required political leadership to ensure general acceptance in the United States. Scaling Up Successful Programs and Sharing Best Practices As the Executive Director of the then more than 50,000 member American Public Health Association (APHA), I had the privilege of working with my colleagues to recognize global health as one of the

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major concerns of the association. Thousands of members work in global health. As the largest association of public health professionals in the world, the APHA members understood that we live in an interconnected world where the impact of globalization is far reaching, the middle class struggle to maintain access to health services, and the poor are often excluded from health services. In addition, the leadership of APHA sought to create opportunities for the membership to learn from successful programs and best practices from their peers in similar organizations worldwide. Policy makers in Africa can learn how the US recorded advances in health status through low tech, low cost strategies; American policy makers can learn from successful strategies for community mobilization for health in Africa. Both African and Western policy makers, including American health leaders and stakeholders can share best practices from primary health care programs in Africa and the delivery of primary care services in the West. Both sides can learn from efforts to reduce untimely deaths and severe injuries from road traffic accidents. Both sides can learn from what works and what does not work in information, education and communication campaigns for better health. In particular, both sides have a lot to share in preventive health programs targeted to the poor, the disenfranchised, the always-on-the move population groups, and, the provision of health services to poor mothers and their small children. African countries move to introduce or consolidate insurance programs; there is much to learn from the ongoing struggles for timely and affordable access to quality health services in the United States. The role of the private sector in the delivery of health services is another area that can benefit from shared best practices. The participation of the civil society as important watchdogs of national health dialogue, policies and programs will benefit from exchange of ideas, experiences and best practices. Health experts and policy makers in Africa and the West will have to work together to ameliorate the ongoing health workforce crisis in various African countries. Every year, Africa loses thousands of health professionals trained with scarce national resources. The predominant destination is Western countries, including the United States. Some of the African health professionals move to more affluent African countries. It can be argued that Africa is training its health workforce to meet the needs of Western countries. The solution to the problem is 251

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complex as these health professionals are leaving for multiple reasons, including political instability, economic recessions, poor pay and conditions of service, lack of personal safety, lack of professional satisfaction, and the desire to create a better economic future for their families. The future of healthcare delivery in an increasingly global community will likely depend on shared commitments. It will also depend on a shared approach to the design and implementation of proven strategies, with all of us learning from successful strategies and best practices. One of the most important areas where health policy makers in Africa and the United States can share ideas and collaborate is in the development and implementation of a minimum set of health services in each community. In the US, national and local health stakeholders in a voluntary, collaborative effort developed the essential public health services that should be provided in local and communitybased health systems. The core functions of Essential Public Health Services at local and community levels include: a. b. c. d. e. f. g. h. i. j.

MONITOR health status in order to identify and solve community health problems; DIAGNOSE and INVESTIGATE health problems and health hazards in the community; INFORM, EDUCATE, and EMPOWER people about health issues; MOBILIZE community partnerships and action to identify and solve health problems; DEVELOP POLICIES and PLANS that support individual and community health efforts; ENFORCE laws and regulations that protect health and ensure safety; LINK people to needed personal health services and ensure the provision of health care when otherwise unavailable; ASSURE competent public and personal health care workforce; EVALUATE effectiveness, accessibility, and quality of personal and population-based health services; and, RESEARCH for new insights and innovative solutions to health problems.

Finally some closing thoughts to consider for the future. Based on the historic relationship between the United States and Africa, and in a

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rapidly changing globalized world, health is now a shared concern. Politicians, scientists, public health professionals and other intellectuals on both sides of the Atlantic must learn from each other and work together to protect the health of all no matter where we live. It is much better to act collectively to control the spread of disease at the source rather then wait until the disease hits the shores of America. This will require enforcement of global standards and additional investment in disease control and prevention programs. Global warming is now a reality and environmental concerns affect the health of the people. Planet Earth is getting warmer and we must find ways to preserve the environment so that life on Earth continues to flourish. This requires thoughtful collective action including international treaties to repair the damage to the environment. Poverty is the leading cause of poor health, both in Africa and the United States. Wherever there is poverty, it provides the opportunity for disease to gain foothold in the community. Scientists, politicians and policymakers around the world must work together with the business community to find ways to deal with absolute poverty. The aging of the population has resulted in increased rates of chronic diseases such as diabetes, cancer and heart disease. This has created an enormous need for health care services. Providing these services is a major challenge for all nations. Even the most powerful and the richest country in the world the United States of America is having difficulty delivering these services to its rapidly aging population. Cost of health care is a serious concern among policymakers, politicians and the public. We must work together to find new ways to deliver health services. This requires rethinking of ways we provide services in our communities and thoughtful consideration of collaboration between Western medical care and traditional healing practices. Almost all the decisions that affect the health of our people are made by politicians through a political process. In order to be effective, health professionals must learn to deal with the political process in their countries. It is only through political will and action that improvement in the delivery of health services will result. This means that future health professionals and public health students must educate themselves about the political process as part of their professional training programs. It is through political activism and

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collaborative effort that we can hope to achieve better health for our people. References 1. National Center for Health Statistics (2006). Health, United States, 2006. With Chartbook on Trends in the Health of Americans. Washington, DC: Centers for Disease Control and Prevention, United States Department of Health and Human Services. 2. Jane Otado, Chinua Akukwe, James Collins (2004). Disparate African American and White Infant Mortality Rates in the United States, pages 355-368. In Praeger Handbook of Black American Health. Policies and Issues Behind Disparities in Health. Second Edition. Ivor Lensworth Livingston (Editor). Praeger Publishers, Westport, Connecticut, USA. 3. Jonathan Cohn (2007). Sick: The Untold Story of America’s Health Care Crisis – And the People Who Pay the Price. HarperCollins Publishers, New York, USA. 4. Ezekiel Emanuel, Victor Fuchs (2007). Beyond Health-Care BandAids. Washington Post Newspaper, Wednesday, February 7. 5. Centers for Disease Control and Prevention (2007). The Essential Public Health Services. Available at http://www.cdc.gov/od/ocphp/nphpsp/EssentialsPHServices.htm

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About the Chapter Authors Chinua Akukwe Dr. Chinua Akukwe , editor of this book., is the Chairman of the Technical Advisory Board of the Africa Center for Health and Human Security, George Washington University Medical Center, Washington, DC. He is an adjunct professor of global health and also an adjunct professor of preventive and community health at the school of public health, George Washington University. Dr. Akukwe is the Chairman of the Board of Directors of the new Africa Center for Epidemiology and Diseases Economics Research, Abuja, Nigeria. Dr. Akukwe has written extensively on HIV/AIDS, health and development issues in Africa. He is the author of two recent books on Africa (1) HIV/AIDS, TB, Malaria and other Health Crisis (2) Development Challenges. He is the coauthor of the new book on AIDS Orphans in Africa and their Grandparents. He developed the communicable diseases guidelines for the African Development Bank. He also developed the strategic framework and plan of action for achieving universal access to HIV/AIDS, TB and Malaria for the Africa Union (AU) Commission. African Heads of State during the Abuja 2006 Special Summit on HIV/AIDS, TB and Malaria for the African Union (AU) Commission had directed the AU Commission to develop the Strategic Framework for Action. The African Council of Health Ministers approved the Strategic Framework for Action document at its April 2007 continental summit in Johannesburg, South Africa. Dr. Akukwe is a Fellow of the Royal Society of Medicine, London and a Fellow of the American College of Epidemiology. Anthony Ajemba Colonel Anthony A. Ajemba is a member of the Nigeria Medical Army Corps. Colonel (Dr.) Ajemba joined the Nigerian Army as an infantry officer. He received his medical degree from the University of Nigeria Teaching Hospital. He trained in cardiology at the University of Ibadan Medical School, Nigeria. He then attended further training in cardiology in Denmark and the United Kingdom.

About the Chapter Authors

Colonel Ajemba is a Consultant Physician and Cardiologist Coordinator, Clinical and Emergency Services, 68 Nigerian Army Reference Hospital, Yaba, Lagos, Nigeria Mohammad Akhter Mohammad Akhter is the Executive Director of the National Medical Association, Washington, DC. He is a former Executive Director of the American Public Health Association. He served as the President/Chief Executive Officer of the American Council for Voluntary Action (InterAction), Washington, DC, the largest group of American-based organizations working in the development field abroad. Dr. Akhter is a former Commissioner of Health, Washington, DC and a former Director of Health of the State of Missouri in the United States. He served as professor and Senior Associate Dean of the Howard University College of Medicine. He is a former dean of a school of public health in Pakistan. Dr. Akhter is widely recognized as one of the preeminent public health experts in the world. Amina Salum Ali Honorable Amina Salum Ali is the first Permanent Representative of the African Union to the United States. Ambassador Ali had served as the finance minister of the government of Zanzibar. She became the first woman to contest for nomination as the president of Zanzibar in 2000. She had also served as Minister of State for International Cooperation in the Ministry of Foreign Affairs of Tanzania. An accomplished technocrat and grassroots politician, Ambassador Ali had served in various high level positions in the ruling party and government. She holds a Masters Degree in Business Administration Florence Baingana Dr Florence Baingana is a psychiatrist, presently working as Research Fellow with Makerere University Institute of Public Health, Uganda.

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She served for six years as a Mental Health Specialist with the World Bank, Washington, DC. Dr. Baingana was the first National Mental Health Coordinator in the Ministry of Health of Uganda. Her present work interests include research and training in mental health policy, planning, and economics in the developing world, particularly in SubSaharan Africa. Titilola Banjoko Dr. Titilola Banjoko is the founder and Chief Executive Officer of AfricaRecruit and one of the preeminent global experts on Africa Diaspora healthcare professional community. Dr. Banjoko pioneered the formation of AfricaRecruit designed to build capacity in Africa using human capital as a driver. AfricaRecruit quickly became successful and subsequently became a key component of the New Partnership for Africa’s Development (NEPAD). Dr. Banjoko, a dentist by profession, serves on the board of numerous organizations. She has received numerous awards and commendations such as the 2006 Ethnic – Corporate European Federation of Black Women Business Owners award; Black Business Awards 2005, and, Best of Nigeria 2004. She was named by the United Kingdom Independence Newspaper (September 2006) as one of the 19 Pride of a Continent: Africaʹs gifts to the world. Dr. Banjoko lectures frequently on African Health Diaspora issues and has written numerous technical reports on capacity building in Africa. Today, AfricaRecruit is a mobilization program of NEPAD, the Commonwealth Secretariat and the Commonwealth Business Council. Kristen K. Campbell Kristen K. Campbell, MS, is the Program Director for the Africa Center for Health and Human Security, the George Washington University, Washington, DC. Kristen Campbell provides program and coordination leadership to the Africa Center. Her professional interests include African issues, global health, sustainability science, global change and nature-society relations. She is a former Program Officer at the prestigious National Academies of Science in Washington, DC. Ms. Campbell is a former director of programs at the Renewal Natural Resources Foundation. 257

About the Chapter Authors

She received her Masters degree in Environmental Sciences from the University of Virginia. Ann L. Carter-Obayuwana Dr. Ann L. Carter-Obayuwana is Director for the Graduate Counseling Programs and an Associate Professor in Counseling Psychology at Howard University in Washington, DC. A licensed psychologist and counselor, her research and practice focus on the ways that hope, coping, and resilience can empower individuals, families, and communities. Dr. Carter-Obayuwana serves on the Board of Directors of the Association of Scientists and Physicians of African Descent (ASPAD International) and is a member of the Public Policy & Legislative National Committee of the American Counseling Association. Currently, she is a consultant working on the development of a HIV/AIDS Code of Practice for mental health professionals, physicians, and other psychosocial practitioners in the Caribbean. (E-mail: [email protected]). Leroy R. Charles Leroy R. Charles, MBA, is the Assistant Vice President for Development and Government Relations, Medical Center, the George Washington University, Washington, DC. As a member of the senior management executive team of the GWU Medical Center, Leroy Charles utilizes his extensive experience in administration, clinical operations, planning, marketing, public affairs and government relations in his work as chief community and corporate liaison. Leroy Charles is a member of the American Planning Association, American Public Health Association and American Association of Health Service Executives. Cecilia Chukwu Dr. Cecilia Chukwu is an Assistant Professor of Geriatrics Medicine, George Washington University Medical Center, Washington, DC. Dr. Chukwu, a native of Nigeria received her MD degree from the University of Nigeria Teaching Hospital, Enugu, Nigeria. She began

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her residency training in Enugu before moving to the United States where she completed her residency in internal medicine and did her fellowship in geriatrics medicine. Dr. Chukwu has nearly 30 years experience with teaching hospitals in Nigeria and the United States, dating back to her days as a medical student in Enugu. Frank J. Cilluffo Frank J. Cilluffo is the Associate Vice President for Homeland Security and Director of the Homeland Security Policy Institute, the George Washington University, Washington, DC. Frank Cillufo is widely acknowledged as a leading expert on homeland security issues in the United States. He served as the Special Assistant to the President of the United States on Homeland Security. He also served as a principal advisor to the first Homeland Security Secretary of the United States. He has published extensively on homeland security issues, antiterrorism, transactional crimes and homeland defense. He is frequently in demand as a high profile speaker and moderator on homeland security issues. Kate Douglass Dr. Kate Douglass is an emergency medicine physician currently completing her fellowship in International Emergency Medicine at the George Washington University, which includes an MPH degree. At the conclusion of fellowship, she will continue at GWU as an academic faculty with the Department of Emergency Medicine. Dr. Douglass has extensive experience in international health projects, and has been actively working in Ethiopia during her fellowship on emergency systems development. Bience Gawanas Honorable Bience Gawanas is the Commissioner of Social Affairs of the Africa Union Commission, Addis Ababa, Ethiopia. Commissioner Gawanas is responsible for all health policies and programs of the Africa Union in addition to her major responsibility on labor, social issues, youth and culture. Prior to her current position, Advocate Gawanas served as the National Ombudsman of the 259

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Government of Namibia focusing on governance and accountability issues. Honorable Gawanas is a lawyer by training with more than two decades experience in the legal profession. Tenagne Haile-Mariam Dr. Tenagne Haile-Mariam is a physician and an Assistant Professor of Emergency Medicine at The George Washington University Medical Center. She is also the Student Clerkship Director and Medical Director of the University’s Wound Care Center. Dr. Haile-Mariam is the Assistant Director of International Programs at the G.W.U. Ronald Reagan Institute of Emergency Medicine and a member of the Ethiopian North American Health Professionals Association Ndunge Kiiti Dr. Ndunge Kiiti is an Associate Professor of Intercultural Studies at Houghton College, New York State, United States. Dr. Kiiti served for 15 years in various capacities with the Medical Assistance Programs (MAP) International, Atlanta, USA, including serving as the senior director of partnerships. A noted expert on health communications in Africa and International Health Policy, Dr. Kiiti received her PhD from the Cornell University. She had her undergraduate degree from Haughton College where she was also a standout athlete in hockey and basketball. Dr. Kiiti was inducted into the Houghton College Hall of Fame in 2003 for her athletic accomplishments. She is an adjunct professor at the Emory University Department of Global Health and had served as a member of the Board of Directors of the international ecumenical organization, the Christian Connections for International Health (CCIH), Mclean, Virginia, USA. Dr. Kiiti has worked extensively on health communication issues in Africa, especially in the areas of HIV/AIDS, gender equity issues, health policy communications and the management of information, education and communication campaigns.

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About the Authors

Angela Lee Dr. Angela Lee is an emergency medicine physician and MPH candidate at George Washington University School of Public Health. She has over 8 years of experience working in a broad range of international health projects. Most recently, she has been engaged in developing emergency medicine in Turkey, China, Thailand and Ethiopia. Her interests are in the promotion of health security through sustainable, rational health systems development. Henry Mbah Dr. Henry Mbah has over 16 years of a diverse scientific career. He began as a veterinary surgeon in Cameroon and moved into fulltime research. As a postdoctoral fellow, in the New York University Medical Center and the Institute of Tropical Medicine, Antwerp Belgium, Dr. Mbah has extensive research experience in the immunopathogenesis of HIV/AIDS and African sleeping sickness. His current work is focused on implementing laboratory quality management systems, capacity building and infrastructure development in resource limited settings, especially in Africa. Dr. Mbah holds a Doctorate in Veterinary Medicine from the University of Ibadan, Nigeria and an MSc in Molecular Biology from Vrije University Brussels, Belgium. Pascoal Mocumbi Honorable Pascoal Mocumbi wrote the foreword for this book. He is the High Representative for the European and Developing Countries Partnership (EDCTP), Hague, Netherlands. Dr. Mocoumbi has a distinguished public service career. He served as the Prime Minister of Mozambique for ten years (1994-2004). He also served as the Foreign Minister and the Health Minister of his country. After training in Switzerland as an obstetrician and gynecologist, Dr. Mocumbi started his medical career in Mozambique in a rural part of the country.

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About the Chapter Authors

Alphonsus O. Obayuwana Dr. Alphonsus O. Obayuwana is the Director of Graduate Medical Education in Obstetrics and Gynecology at the Maryview Medical Center, Portsmouth, Virginia, and is Clinical Assistant Professor of Family Medicine and Obstetrics-Gynecology at Eastern Virginia Medical School, Norfolk, Virginia. He is also the current secretary of the Association of Scientists and Physicians of African Descent (ASPAD International), Washington, DC. He is a Past President of the Association of Nigerian Physicians in the Americans (ANPA). Dr. Obayuwana has extensive experience with medical missions of the Diaspora to Africa. Dr. Obayuwana is a Fellow of the American College of Obstetrics and Gynecology with research interest in Psychosomatic Ob/Gyn, particularly stress and pregnancy outcome. (E-mail: [email protected]). John F. Williams John. F Williams, MD, EdD, MPH, is the Provost and Vice President for Health Affairs, and Bloedorn Professor of Administrative Medicine, the George Washington University, Washington, DC. Provost John Williams is the founder of the University’s Africa Center for Health and Human Security. Provost Williams is a professor of Anesthesiology. He is also a professor of health services management as well as a professor of health policy. He served previously as the Dean of the GW Medical School. Provost Williams is also an economist and political scientist having received a Master of Science degree from the London School of Economics. Dr. Williams has received numerous domestic and international awards for his leadership of major medical initiatives. He is currently leading the GW Africa Center partnership efforts with the Government of Rwanda.

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INDEX A Abuja Declaration, 10, 15 Addis Ababa Heath Bureau, 158 Adibe,Jideofor, viii Adult AIDS Clinical Trials Group, 103 Africa Center for Health and Human Security, George Washington University, Washington, DC,, ix African Council of Health Ministers, 32, 57, 255 African Development Bank, 7, 131, 204, 255 African Diaspora, 2, 6, 8, 9, 33, 47, 180, 209, 210, 211, 212, 213, 214, 215, 218, 219, 222, 234, 243 African Health Strategy, 57 African Judicial Network, 242, 244 African Union, v, ix, xi, 1, 3, 4, 7, 8, 10, 14, 15, 17, 18, 22, 28, 32, 34, 35, 38, 60, 64, 83, 127, 148, 185, 194, 197, 200, 204, 209, 255, 256 AIDS Vaccine Trials Network, 103 Ajemba, Col Anthony, 145 Akhter, Mohammed, 245 Akukwe, Chinua, 1, 25, 57, 67, 75, 119, 171, 185 Ali, Amina Salum, 197 Alma Ata declaration, 67, 69, 70, 174 Alma Ata Declaration, 68, 69, 70, 175 American Public Health Association, 182, 247, 250, 256, 258

Banjoko, Titilola, 207 Botswana, 22, 41, 43, 101, 107, 209, 232 Butabika National Referral Hospital, 130 Butabika National Referral Psychiatric Hospital., 133 C Cameroon, 101, 107, 261 Campbell, Kristen K, 257 Carter-Obayuwana, Ann L., 223 Chukwu, Cecilia, 85 Cilluffo, Frank J, 259 Community Oriented Primary Care, vi, 171, 181, 182 D Darfur, 146, 147 Declaration and Plan of Action, 15 Declaration of Health for All, 13 define community oriented primary care, 172 Democratic Republic of Congo, 146, 147 Department for International Development, 133, 209 Douglass, Kate, 157, 259 E Ego Strength, 226, 227, 228 Essential Health Care Package, 130, 134, 136, 138 European & Developing Countries Clinical Partnership, xii G

B Baingana, Florence, 129

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Gawanas, Bience, 13

Index

George Washington University Medical Center, Washington, DC, 89, 255, 258 Ghana, ix, 40, 42, 100, 101, 106, 147 Gleneagles G8 Summit in 2005, 209 Global Fund to Fight AIDS, 44, 103 Global Fund to Fight AIDS, Tuberculosis and Malaria, 44 Globalization, 53, 210 Guinea, 40, 147

Mbah, Henry, 99, 261 Mbarara University of Science and Technology, 130, 132 Mexico conference, 185 Millennium Development Goals, 4, 14, 44, 117, 186, 194, 197, 205, 209, 210, 230, 232 Mocumbi, Pascoal, xii, 70, 72, 261 Mozambique, x, xii, 70, 72, 261 N

H Haile-Mariam, Tenagne, 157 Harvard University School of Public Health, 151 HIV/AIDS Alliance, 110 Hope Therapy, vii, 223, 225, 226, 227, 228, 229 I in Malawi, 41, 46, 113 International Labor Organization, 50 International Maternal Pediatric Adolescent AIDS Clinical Trial Group, 103 International Monetary Fund, 50, 199, 207 International Office on Migration, 50 K Kiiti, Ndunge, 109 L Lee, Angela, 157 M Makerere University Medical School, 130 Malaria Program for Africa, 103

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National Army Medical Corps, vi, 145 National Dental Association, 180 National Medical Association, 180, 231, 247, 256 National Mental Health Coordinators. Meetings, 132 National Youth Service Corp, 52 New Economic Partnership for Africa’s Development, 209 Nigeria, 10, 17, 27, 34, 35, 41, 42, 45, 52, 85, 88, 91, 93, 94, 96, 136, 145, 146, 149, 150, 151, 152, 153, 154, 155, 209, 245, 255, 256, 257, 258, 261 Nigerian Army Eye Centre, 151 O Obayuwana, Alphonsus O., 223 Oslo HRH Global Consultation, 209 P Primary Health Care (PHC) principles, 13 R Ronald Reagan Institute of Emergency Medicine, 158, 160, 260

Index

Royal African Society, 209 S Senegal, 40, 147 slow to adopt a sector-wide approach (SWAP), 61 South Africa, ix, 8, 27, 28, 34, 41, 42, 54, 57, 64, 83, 110, 117, 127, 171, 175, 181, 194, 231, 232, 255 Students for International Medical Action, 160 T Traditional Birth Attendants, 132 U Uganda, 2, 40, 41, 47, 129, 130, 131, 132, 134, 135, 136, 137, 138, 139, 140, 142, 143, 230, 231, 256, 257 UN Economic Commission for Africa, xi, 10, 204, 230 UNAIDS, 2, 118, 224, 229 UNICEF-Uganda, 131 United Nations Commission for Trade and Development, 39 United Nations Development Program, 2, 10, 35

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United States President’s Emergency Plan for AIDS Relief, 44 W West African Army Medical Corps, 145 Western Sahara, 146 WHO Africa Region, 2, 62, 96, 188 Williams, John F, 174, 182, 234, 262 World Bank, 2, 4, 8, 10, 34, 35, 50, 52, 53, 54, 55, 96, 133, 134, 137, 138, 143, 169, 199, 205, 207, 220, 257 World Health Organization, xi, 2, 7, 10, 13, 22, 23, 34, 35, 37, 52, 53, 54, 55, 57, 62, 64, 65, 67, 70, 72, 81, 82, 83, 84, 86, 96, 97, 107, 119, 120, 127, 142, 143, 155, 157, 160, 169, 178, 183, 185, 187, 194, 195, 197, 198, 204, 205, 214, 223, 224, 229 Z Zambia, 19, 41, 42, 46, 47, 111, 211 Zimbabwe, 22, 42, 96, 135, 136, 143, 229

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