PHM-Exch> Africa: Query re: 15% commitment for health

[Claudio Schuftan]

>From <tschrecker at sympatico.ca>

>
>
> How does this announcement from the Heads of State Summit fit with the AU
> finance ministers’ decision in March to repudiate the Abuja 15% commitment?
> Could anyone provide some clarification?
>
>
>
> Ted Schrecker
>
> University of Ottawa
>
>
>  *From:* ausummit2010 at africa15percent-plus.net
>

*Subject:* Summit Review:15% Campaign Welcomes Restatement of Financing
> Commitment-Identifies 6 Key Policy & Budget Priorities
>
>
>
> *Public Statement - Issue Date August 19, 2010.*
>
>
>
> The Africa Public Health Alliance & 15% Plus Campaign has welcomed the
> laudable decisions by the recent July 2010 AU Heads of State Summit - on
> various health policies, and budget commitments especially the restatement
> of the 2001 Abuja commitment to allocate at least 15% of annual budgets to
> health.
>
>
>
> In the recently released official certified copy of the July Summit
> Decisions, African Heads of State at the end of July committed amongst
> others to:
>
>
>
>    - *“Provide sustainable financing by enhancing domestic resources
>    mobilization, including meeting the 15% Abuja target, as well as mobilizing
>    resources through public-private partnerships and by reducing out of pocket
>    payments through initiatives such as waiving of user fees for pregnant women
>    and children under five and by instituting national health insurance;*
>
>
>
>    - *Strengthen the health systems to provide comprehensive, integrated,
>    maternal, newborn and child health care services, in particular through
>    primary health care, repositioning of family planning including reproductive
>    health commodities security, infrastructure development and skilled human
>    resources for health in particular to train Community Health Workers to
>    mitigate the human resource crisis in the Health sector”;*
>
>
>
>    - *REAFFIRM the commitments undertaken at the Special Summits on
>    HIV/AIDS, TB and Malaria in 200, 2001, and 2006… Extend the Abuja Call for
>    Accelerated Action Towards Universal Access to HIV/AIDS, Tuberculosis and
>    Malaria Services in Africa (the Abuja Call) to 2015 t0 coincide with the
>    MDGs;*
>
>
>
>    - *UNDERSCORE the need to promote throughout the continent, programs
>    for the total eradication of mother to child transmission so that no child
>    is born with HIV/AIDS.”*
>
>
>
> **(Attached At End of Review - Full Texts of Certified Official Final
> Decisions on Theme of Maternal, Newborn, Child Health; & MDG 6)*
>
>
>
>
>
> *However, the Africa Public Health Alliance & 15% Plus Campaign has
> identified 6 key areas requiring improved elaboration in countries
> implementation of Summit Decisions on Maternal, Newborn and Child Health;
> Financing; Universal Access & PMTCT. These factors constituting pillars of
> the improved 15% Plus formula are:*
>
>
>
>
>
> *1. Social Determinants; Vaccinations; Integrated Health, Population and
> Social Development Investment, Crucial to Reducing Child Mortality – and
> Improving Overall Healthy Life Expectancy.*
>
>
>
> Non-health sector social determinants affecting Child Mortality, and
> overall health outcomes were not directly addressed by the Summit decisions.
>
>
>
> The main causes of an estimated 4.1 to 4.5 million deaths annually of
> African children under 5 years are: malnutrition including deficiencies in
> essential vitamins and minerals;  diarrhoea; pneumonia / respiratory
> infection; malaria; measles; tetanus - alongside prenatal conditions; and
> increasingly Mother to Child Transmission of HIV.
>
>
>
> *In other words, about half of annual under 5 deaths (over two million
> deaths) linked with malnutrition, unclean water, poor sanitation and
> environmental policies can be prevented by providing key social determinants
> not included in health sector budgets: i.e. improved nutrition and food
> security; clean water; improved sanitation, and environmental measures –
> alongside other key preventive public health actions such as improved
> vaccination coverage.*
>
>
>
> Although identified in other AU policy documents, and underlined in work of
> the AUC Department of Social Affairs, the high impact of social determinants
> requires they be visibly emphasised in high level decisions (as key social
> development factors) affecting Child Mortality and general health outcomes.
> This will help ensure comprehensive frameworks for integrated social
> development investment at national level – and improve Healthy Life
> Expectancy, currently at a low Africa regional average of 45 years.
>
>
>
>
>
> *2. Per Capita Investment in Health, as Important as Percentage
> Allocation.*
>
>
>
> African Heads of State have responded positively to the calls of citizens
> not to abandon health commitments, by upholding the 2001 Abuja commitment to
> allocate at least 15% of budgets to health.
>
>
>
> *However, four years of global and African budget analysis and tracking
> has demonstrated that only 15% to health does not have the desired impact if
> inadequate in terms of actual investment per person.* Percentage
> allocation alone provides mainly a broad picture of government priorities,
> whereas efficient budgeting requires needs based analysis built on unit, or
> per person estimates.
>
>
>
> *32 African countries currently invest less than $20 per capita, including
> four of the six countries that have achieved the 15% target. This is less
> than half the World Health Organisation recommended minimum package of at
> least $40 per capita (which also assumes that crucial none health sector
> social determinants or social development issues, such as clean water,
> improved sanitation and nutrition have been addressed). * Some countries
> currently invest as little as between $2 and $10 per capita in health which
> barely provides some plaster and aspirins, and inadequate to tackle a
> combination of health challenges such as Maternal and Child Mortality; HIV,
> TB and Malaria.
>
>
>
> *Research by the Africa Public Health Alliance and 15% Plus Campaign has
> also demonstrated improvement in life expectancy and other indicators in
> some African countries allocating less than 15% of budgets to health, but
> which have higher per capita investment in health of between $38 and $424
> per capita *- alongside significant percentage allocation; required
> investment in social determinants; as well as pillars of health such as
> vaccinations, and health workforce. These include countries such as Egypt,
> Tunisia, Mauritius and Seychelles.
>
>
>
> Global comparison also demonstrate that countries broadly similar to some
> African countries such as Costa Rica and Cuba have achieved the health MDGs
> based on (1) Improved health per capita investment, which enabled targeted
> investment in key areas such as vaccinations, health workforce, gender
> equity in health, and primary health care; (2) Improved investment in social
> determinants of health including safe water, improved sanitation, food and
> nutrition.
>
>
>
> For instance Costa Rica currently invests $356 per capita in health, or
> 25.8% of national budget; and Cuba invests $558 per capita, or 14.5% of
> budgets to health. In addition and as recommended by the WHO, they also
> implement excellent preventive health and social determinants programs by
> ensuring 98% (Costa Rica) and 91% (Cuba) of their population has access to
> improved water sources respectively; 96% and 98% access to improved
> sanitation; and 90% and 99% vaccination coverage. Also combining this with
> amongst the best global ratio of health workforce to the population.
>
>
>
> Consequently both countries have achieved life expectancy of well over 70
> years, similar with G8 countries such as the United States which invests US
> $3,317 per capita or 19.5% of its budget to health; or Japan which invests
> $2,237 per capita, or 17.9% of budget to health.
>
>
>
> *The 15% Plus formula - which emphasises dual improvement of per capita
> investment with percentage allocation; alongside improved investment in
> social determinants - is increasingly acknowledged and supported by senior
> policy makers.* The 10th anniversary of the 2001 commitments in 2011 is an
> excellent opportunity to formally improve and upgrade the old Abuja
> commitments based narrowly on only percentage allocations.
>
>
>
>
>
> *3. Integrated Health, Education and Labour Policy are Crucial to
> Resolving Health Workforce Shortages – and Meeting All Health MDGs.*
>
>
>
> Commendably, the Summit decisions explicitly recognises the importance of
> resolving health workforce shortages, primary health care and stronger
> health systems. *The main causes of Maternal Mortality: Haemorrhage;
> Sepsis, infections; Hypertensive disorders; Anaemia; Obstructed labour;
> Complications of abortion; & increasingly HIV/AIDS related complications in
> expectant mothers - all require highly skilled personnel, well equipped and
> stocked clinics and hospitals to resolve them sustainably.*
>
>
>
> It is crucial however to underline that resolving health workforce
> shortages at country level requires - comprehensive strategies involving -
> long term collaboration of health, education, labour and human resource
> sectors.
>
>
>
> *Presently, most African countries have only between 10% to 40% of actual
> numbers of doctors, nurses and midwives, and other health workforce required
> to provide quality health care at primary level.* Doubling, tripling or
> quadrupling staff to make up for shortages will require providing more
> training institutions and facilities, and teaching staff, as well as
> deployment and retention strategies for rural and urban areas that will
> include improved working conditions and remuneration.
>
>
>
> None of the health MDGs 4; 5/5b; and 6 will be met without full resolution
> of the health workforce shortages, and certainly not Reproductive, Maternal,
> Newborn and Child Health, which are human resource intensive. The laudable
> progress of African countries like Egypt in producing record numbers of
> diverse health workers, and Ethiopia which has started making important
> progress is based on integrated health, education, labour and human resource
> policies.
>
>
>
> Without integrated planning by the health, education, labour and human
> resource sectors, removal of user fees for pregnant women and children will
> in most cases mean more people will turn up to access non existent services.
>
>
>
>
>
> *4. Ensuring Gender Equity in Health Budgeting; Adolescent & Youth Health.
> *
>
>
>
> Budget allocation is arguably the most crucial policy instrument of
> governments. Successful implementation of Reproductive, Maternal, Newborn
> and Child Health policies at country level requires a high degree of gender
> based assessment of budgets, equity in budgeting, as well frameworks to
> ensure women’s rights and gender equality.
>
>
>
> *Without required gender budgeting to provide for the specific needs of
> women and men, and without legislative and social change to protect women’s
> rights to especially reproductive and sexual health, or family planning –
> Maternal Mortality will not be sustainably reduced.*
>
>
>
> Similar policy and budgeting is required for adolescent and youth health,
> including ensuring access to education and commodities.
>
>
>
> Importantly, reduction in Maternal Mortality will require the active
> participation of African Women, Gender and Youth policy makers – alongside
> health policy makers - in implementing key policy such as the AU Africa
> Health Strategy, Maputo Plan on Sexual and Reproductive Health, and the
> Campaign for Reduction of Maternal and Child Mortality (CARMMA).
>
>
>
>
>
> *5. Improving Capacity for Production, Purchase and Distribution of
> Pharmaceuticals, Essential Medicines and Commodities to Prevent Stock Outs.
> *
>
>
>
> The Summit decisions commendably underline the critical importance of
> commodities in Reproductive, Maternal and Newborn and Child Health (RMNCH);
> the urgency of meeting commitments on Universal Access to HIV and AIDS, TB
> and Malaria Services; and in particular to end Mother to Child Transmission
> of HIV - *but does not explicitly link this to urgent actualisation of the
> existing Pharmaceutical Plan for Africa.*
>
>
>
> Given the unmet need for RMNCH commodities for millions of citizens, and
> high burden of infectious diseases such as HIV, TB, Malaria and others -
> regional and country level capacity for production of diverse
> pharmaceuticals, essential medicines, and commodities – including storage
> and efficient distribution needs to be urgently improved.
>
>
>
> This is especially true for: specific aspects of MNCH such as Preventing
> Mother to Child Prevention of HIV, which potentially affects millions of
> women and children, and where timely and efficient treatment is the only
> form of prevention; TB which is easily curable but treatment intensive;
> distribution of mosquito nets, and malaria treatment.
>
>
>
> *It also needs to be explicitly underlined and elaborated that for
> regional and country level improvements in pharmaceutical and commodities
> capacity - most of the needed policy and investment falls outside the health
> sector.* The training of highly skilled scientists, engineers, and
> technicians requires targeted investment in the education sector; Primary
> level pharmaceutical and commodities production requires improved
> manufacturing and industrial investment; Necessary negotiations and
> legislation for Trade and Related Aspects of Intellectual Property Rights
> (TRIPS), require building the capacity of the trade sector.
>
>
>
>
>
> *6. At Least One Well Staffed and Equipped Primary Health Clinic Per
> Community.*
>
>
>
> *The great outrage of Africa’s health tragedy is that for millions of
> citizens, the nearest primary health clinic is beyond reasonable physical
> proximity – sometimes tens or hundreds of miles away* – especially for the
> great majority in rural areas.
>
>
>
> The poor demographic distribution of primary health clinics, is one of the
> greatest obstacles to access to quality healthcare – alongside poor
> investment in health workforce, poor pharmaceuticals and commodities
> capacity, poor provision of social determinants, lack of gender equity in
> budgeting, and overall poor per capita or per person investment in health.
>
>
>
> No country has been able to sustainably achieve desired health outcomes,
> without majority of its citizens being within at least half an hour away
> from the nearest well equipped and staffed primary health clinic – or at
> least without the ground and air ambulance facilities to bridge distances in
> emergencies - it cannot be different for AU member states.
>
>
>
> As an intergovernmental organisation, the AU can make broad statements of
> intention, and produce policy frameworks – but even when fully comprehensive
> and integrated - it is up to member states to implement these in detail –
> sometimes encouraged by citizens to do so in a timely manner.
>
>
>
> *For both federal and none federal countries, any health and social
> development policies and budgets that do not set out a transparent framework
> for a rolling plan to build, adequately equip and staff primary health
> clinics - on a basis of at least one for every community within a limited
> time - are deficient and need to be urgently improved.*
>
>
>
> But if they are not to be ghost facilities – they need to be backed up - by
> comprehensive plans: for integrated education and labour policy and
> budgeting for training and retaining health workers; improved capacity for
> production and distribution of essential medicines and commodities; gender
> equity in health policy and budgeting, including underlining the needs of
> children, youth and the elderly; overall improved per capita investment to
> ensure that key issues such as Maternal Newborn and Child Health; HIV and
> AIDS, TB, Malaria, and neglected diseases are all addressed.
>
>
>
> *ENDS*
>
>
>
> *List of Attached Documents Being Summit Decisions:*
>
>
>
> i. Decisions on AU July 2010 Summit Theme on Maternal, Newborn and Child
> Health
>
> ii. Summit Decisions on Eradication of Mother to Child Transmission of HIV
>
> iii. Summit Decisions on 5 Year review of Universal Access to HIV and AIDS,
> TB and Malaria.
>
> iv. PDF Copy of Summary Review
>
>
>
> *
> *
>
>
>
>
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