Health systems in sub-Saharan Africa: What is their status and role in meeting the health Millennium Development Goals?
This paper reports on an assessment conducted in 2007 of the global progress towards achieving the health Millennium Development Goals (MDGs) which showed disparities, with sub-Saharan Africa trailing the rest of the developing world. This situation exists despite the existence of cost-effective interventions for addressing the targeted health problems. It is increasingly assumed that the missing link has been ineffective use of the interventions and the weakness of health systems that are unable to scale up implementation of the interventions. Consequently, a health systems review was conducted in five countries of sub- Saharan Africa, namely Kenya, Malawi, Namibia, Uganda and Zambia. The countries were purposefully selected on the basis of the availability of country reports. A literature review was carried out, focusing primarily on country health sector reports and United Nations data on MDG indicators complemented by on-line literature. The status of health systems was assessed using WHO’s six health system building blocks, covering the period up to 2007. Whereas Malawi, Namibia and Zambia are likely to achieve the measles immunization targets, only Malawi and Zambia are likely to meet the under-five mortality targets. However, in considering the maternal mortality rate (MMR), where approximately 5.5% annual average reduction is required in order to meet the MDG target, all countries are not on track, although Namibia has made progress in the provision of skilled birth attendance. In all the countries reviewed, there is a weakness in health policies and guidelines, and a shortage of human resources and medicines, while public expenditure on health has not risen as expected towards the 15% Abuja target. Health information systems are fragmented and not fully utilized and health service coverage is not adequate. Overall, there is inadequate progress towards achieving the selected MDG impact indicators in the five reviewed countries, against a background of non-conducive health sector policy environment and inadequate resources and service coverage. Achieving the MDGs will require timely national refocusing of health sector policies and commitment to health systems strengthening.
En 2007, l’évaluation des progrès réalisés vers l’atteinte des objectifs du Millénaire pour le développement (OMD) dans le monde a révélé bien des disparités, et montré que les pays d’Afrique subsaharienne demeurent à la traîne par rapport aux autres pays en développement, en dépit de l’existence d’interventions d’un bon rapport coût-efficacité qui permettent de résoudre les problèmes de santé ciblés. L’on est porté à croire que le «chaînon manquant» demeure l’utilisation inefficace des interventions proposées et la faiblesse des systèmes de santé, qui ne parviennent pas à passer les actions à l’échelle. En conséquence, un examen des systèmes de santé a eu lieu au Kenya, au Malawi, en Namibie, en Ouganda et en Zambie, 5 pays d’Afrique subsaharienne sélectionnés à dessein sur la base de la disponibilité de rapports pays. Une revue de la littérature a été effectuée, avec un accent marqué sur les rapports sectoriels de la santé produits par les pays et sur les données des Nations Unies relatives aux indicateurs des OMD, complétée par la documentation en ligne. En utilisant les six blocs constitutifs du système de santé de l’OMS, l’état des systèmes de santé a été évalué jusqu’en 2007. Il en ressort que si le Malawi, la Namibie et la Zambie réussiront probablement à réaliser les objectifs de vaccination antirougeoleuse, seuls le Malawi et la Zambie pourront atteindre les cibles relatives à la mortalité des moins de cinq ans. D’autre part, s’agissant de la mortalité maternelle, dont le taux doit baisser annuellement de 5,5 % environ pour atteindre la cible de l’OMD, il convient de relever qu’aucun des cinq pays n’est en bonne voie sur cet indicateur, même si la Namibie a fait des progrès sur le plan de la disponibilité d’accoucheuses qualifiées pendant l’accouchement. Tous les pays évalués se caractérisent par une absence de nombre de politiques et lignes directrices sanitaires et par une pénurie de ressources humaines et de médicaments. En outre, la dépense publique de santé n’a pas augmenté comme prévu pour atteindre l’objectif d’Abuja, qui est de 15 % du budget national. Les systèmes d’information sanitaires sont fragmentés et ne sont pas utilisés comme il convient, et la couverture des services sanitaires demeure insuffisante. En général, les progrès vers l’atteinte des indicateurs d’impact des OMD demeurent lents dans les cinq pays examinés, qui évoluent au demeurant dans un contexte de politiques sectorielles de la santé peu propices, de ressources insuffisantes et de couverture sous-optimale des services. Pour atteindre les OMD, il faudra recentrer comme il convient les politiques sectorielles de la santé et renouveler l’engagement en faveur du renforcement des systèmes de santé.
A avaliação dos progressos em relação à consecução mundial dos Objectivos de Desenvolvimento do Milénio (ODM) em 2007 revelou disparidades, com a África Subsariana a ficar atrás do resto dos países em desenvolvimento. Esta situação verifica-se apesar da presença de intervenções custo-eficazes para os problemas de saúde visados. Assume-se cada vez mais que o elo em falta tem sido a utilização ineficaz dessas intervenções e a fragilidade dos sistemas de saúde, que se mostram incapazes de as implementar adequadamente. Consequentemente, foi feita uma análise dos sistemas de saúde em cinco países da África Subsariana, nomeadamente no Quénia, no Malawi, na Namíbia, no Uganda e na Zâmbia. Os países foram deliberadamente selecionados com base na disponibilidade de relatórios nacionais. Foi feita uma análise da literatura incidindo sobretudo nos relatórios nacionais do sector da saúde e nos dados das Nações Unidas sobre os indicadores dos ODM, complementada por literatura online. O estado dos sistemas de saúde foi avaliado utilizando as seis componentes essenciais do sistema de saúde da OMS, abrangendo o período até 2007. Embora o Malawi, a Namíbia e a Zâmbia consigam provavelmente atingir as metas de imunização do sarampo, apenas o Malawi e a Zâmbia conseguirão provavelmente alcançar os objetivos em termos da taxa de mortalidade em menores de cinco anos. Por outro lado, a redução da taxa de mortalidade materna (TMM), que requer uma redução anual de cerca de 5,5% para alcançar a meta dos ODM não está no bom caminho em todos os países, embora a Namíbia tenha registado progressos na prestação de assistência especializada durante o parto. Em todos os países analisados, faltam algumas políticas e linhas de orientação sanitárias, recursos humanos e medicamentos, não tendo as despesas públicas na saúde aumentado como previsto no sentido do objectivo de Abuja de 15%. Os sistemas de informação sanitária estão fragmentados e não são totalmente utilizados, e a cobertura do serviço de saúde não é adequada. Em termos gerais, o progresso registado foi inadequado para a consecução dos indicadores de impacto dos ODM selecionados nos cinco países analisados num contexto de uma política do sector da saúde desfavorável, assim como de recursos e cobertura de serviço inadequados. A consecução dos ODM requer um reenquadramento nacional oportuno das políticas do sector da saúde e um compromisso no sentido de reforçar os sistemas de saúde.
Eight MDGs were adopted by 189 countries following the signing of the United Nations Millennium Declaration in 2000(1,2) MDGs 4, 5 and 6 directly relate to health namely; reducing under five child mortality by two thirds, reducing maternal mortality by three quarters and to halt and begin reversing the spread of HIV/AIDS, malaria and other major diseases, using 1990 as the baseline and 2015 as the target year for achievement.(3,4) However, assessment of progress in 2007 showed uneven results globally with sub-Saharan Africa trailing behind the rest of the developing world not withstanding that proven and cost-effective interventions to implement against the targeted health problems are known and well understood.(3,5) The interventions are not effectively used and health systems are not always capable of implementing them to scale.(3) It was with this background that a literature review was conducted to gain an insight into the current status and role of health systems in meeting the health MDGs in sub-Saharan Africa.
A desk review of the literature on health systems and MDGs was performed between the months of July and September 2009 for five countries from Eastern and Southern Africa, namely Kenya, Malawi, Namibia, Uganda and Zambia. The countries were selected purposefully based on the availability of national health sector reports. The review primarily focused on country health sector reports that are in the public domain and data from the United Nations on MDG indicators.(6,7) These sources were complemented by literature search in the following electronic databases: national ministry of health websites, WHO's Global Information Full Text, Pub Med and Google Scholar. The status of country health systems was assessed using the WHO's six health system building blocks' selected desirable attributes as outlined in the Framework for Action for Strengthening Health Systems to Improve Health Outcomes.(8) See Table 1.
Progress on selected health MDG impact indicators
Health impact indicators monitored through the United Nations include MMR and under five mortality rate.(6) Among the reviewed countries, the MMR in 2005 was 210 maternal deaths per 100 000 live births for Namibia representing 6.7% reduction from the 1992 level translating into 0.5% average annual decrease; in the same year Uganda was at 435/100 000 with a 13.9% reduction from 2000 level, a 2.8% average annual decrease; so too was Kenya at 560/100 000, a 16.4% decrease from 1990 making 1% average annual decrease; 449/100 000 for Zambia in 2007 representing a 30.8% decrease 1996 and 2.8% average annual decrease; and 807/100 000 for Malawi in 2006, a 30.2% increase from the 1992 level.(6,9,10,11,12,13)
The trend of under five mortality rate from 1990 to 2007 among the countries is shown in Figure 1. Malawi and Uganda show a declining trend in under five mortality while the other three countries seem to have a generally stable trend.(6)
Leadership and governance
All reviewed countries have incorporated the MDGs in national policies and plans as follows: through the national MDG based planning process in Kenya; the Growth and Development Strategy in Malawi; Vision 2030 in Namibia; the Poverty Eradication Action Plan in Uganda; and the Fifth National Development Plan in Zambia.(9,10,11,12,13) They also generate periodic reports on national progress of achievement of the MDGs.(9,10,11,12,13)
By the time of this review, all countries except Malawi had National Health Policies and all of them except Namibia had National Health Sector Strategic Plans or Programmes of Work.(14,15,16,17,18) By the year 2008 some national policies and guidelines relating to the three MDGs were either in draft form or needed updating: in Namibia on the minimum essential package, health promotion, patient referral, Expanded Programme on Immunization (EPI) and essential medicines list; in Uganda on EPI, national health laboratory and public private partnership; in Kenya the reproductive health strategy, child health, communication strategy and the immunization policy; in Malawi the national health policy; and the health facility policy for Zambia in 2007.(14,15,16,17,18)
With the exception of Namibia, all the reviewed countries have a formal collaborating arrangement with development partners through the sector-wide approach (SWAp) whose objective is to have all significant health sector funding supporting a single policy and expenditure programme.(14,15,16,18,19,20) Since inception of SWAp in these countries, they hold annual joint review meetings with stakeholders as one form of accountability; Namibia held its first health and social services system review in 2008.(14,15,16,18,20)
General government expenditure on health as a percentage of total government expenditure in 2006 compared with 2002 has generally been stable in all reviewed countries except Zambia where it has increased(21) (see Table 2). Notable also is that only Malawi and Zambia are above the 15% target of the Abuja Declaration 2001.(22)
Comparing the years 2006 and 2002 the per capita total health expenditure (THE) has increased in all countries varying from a 31% increase in Malawi to over 100% for Namibia and Zambia(21) (see Table 2). While external resources for health as a percentage of THE slightly decreased between the years 2002 and 2006 in Kenya, it increased for the rest of the countries with Namibia experiencing over 100% increase.(21) Out of pocket (OOP) expenditure as a percentage of private expenditure on health, varied from 5.7% in Namibia to 80% in Kenya in the year 2006(21). See Table 2.
Kenya and Namibia's public health services have a policy of applying user fees at the hospital level with the former exempting under five children.(14,23) Uganda abolished the user fees in public facilities in 2001 while Zambia removed them in 54 selected rural districts in 2004; Malawi does not have a user fee policy for public health facilities.(16,24,25)
Malawi, Namibia, Uganda and Zambia have national human resources for health (HRH) strategic plans focusing on training, recruitment, retention and management; however, in all cases implementation was slow.(14,15,16,18) Training institutions have inadequate human and infrastructural capacity; by 2008 Malawi and Zambia's comprehensive human resources information systems were still under development and Namibia's was paper based.(14,15,16,18) Namibia and Uganda were experiencing lengthy recruitment processes and implementation of HRH rural retention schemes were making slow progress because of inadequate funding, while Namibia abolished its rural retention schemes in 1995.(14,15,16,18)
The density of public sector medical doctors, nurses and midwives combined per 1000 population was 0.18/1000 in Malawi in 2006; 0.98/1000 for Zambia in 2007; 1.4/1000 in Kenya in 2004; and 2.0/1000 for Namibia in 2008.(14,16,23,25) Overall, public sector vacancy rates were at 27% for Namibia and 49% for Uganda in 2008; while Zambia and Malawi reached 50% and 77% for laboratory personnel and nurses respectively in 2006 and 2008.(14,15,16,18,25) See Table 3. The vacancy rates were worsened by recruitment freezes in Kenya and Uganda in 2005 and 2007 respectively.(11,12)
By 2008, the majority of doctors, dentists and pharmacists and close to half of registered nurses in Namibia were working in the private sector, serving an estimated 15% of mostly urban populations.(14) The distribution of HRH in favour of urban areas was also experienced in Zambia and Uganda.(15,16)
Medicines and vaccines
A health system review in Namibia in 2008, reported medical stock outs in a number of regions of the country with 50% of health facilities in one region having had a stock out of oral rehydration salts (ORS) and 35% for Coartem in a three-month period.(14) In 2008 a Uganda national facility survey, established that 72% of surveyed health facilities had stock outs of one or more of the six tracer medical products that included Coartem, Cotrimoxazole, ORS and measles vaccine in the 2007/08 fiscal year; while in Kenya 33% of health facilities were without national tracer drugs for a period of more than two weeks in the same fiscal year.(15,17) A national survey in Kenya in 2004 established that first line medicines that included anti-malarial drugs and antibiotics for the treatment of children's conditions were available in 83% of facilities and pre-referral medicines were available in 25% of the facilities; it further reported that 40% of the facilities had all components for providing quality child immunization.(27)
In Malawi a national review in 14 purposefully selected district hospitals and 11 health centres reported consistently higher average stock out rates at health centre level than district hospitals with Amoxicillin capsules having an average of 134 stock out days as compared with 70 days for hospitals in 2008.(26) Stock outs were also reported in Zambia on some vaccines, anti-malarial drugs and family planning commodities in purposefully selected facilities in the same year.(16)
All reviewed countries have established health information systems (HIS) as the main source of routine health data.(14,15,18,23,27) It was noted in 2008 that Namibia has multiple stand alone information systems managed by different divisions of the central Ministry of Health and Social Services and running on different software in addition to the HIS.(14) A similar situation was reported in Malawi where there are separate, individual reporting systems particularly for national disease control programmes operating both at national and district levels.(18) The private health sector in Namibia and Malawi does not participate in the routine HIS reporting.(14,18)
In 2005–06 Namibia achieved 80% of timeliness and completeness of national reporting of disease surveillance data from districts while in Zambia it was 99% in 2007.(27,28) Uganda reports that while 83% of districts submitted the disease surveillance weekly reports to the national level, only 56% submitted them on time.(15) Local utilization of the data through trend analysis was reported at 66% of health facilities in Uganda while in Zambia it was at 100% in 2007.(15,27)
All the reviewed countries except Namibia are implementing health services based on an integrated essential health package by level of health services; Namibia's policy towards developing this package was in draft form in 2008.(14,15,16,18,23) In 2008 40% of Namibia's population lived within 5 kilometres of a health facility; 46% for Malawi in 2004; 50% for Zambia in 2008 and 75% for Uganda in 2008.(14,15,27) Health service provision coverage, as exemplified by measles immunization, antenatal care (ANC) and the provision of skilled attendance during delivery, is shown in figures 2 and 3. The immunization trends show stagnation or little increase in coverage. However, Malawi, Namibia and Zambia are reported potentially likely and Uganda unlikely to achieve the measles immunization target by 2015.(9,10,12,13)
From demographic and health surveys, skilled attendance during delivery varies from 81% in Namibia to 42% for Uganda in 2006.(6,14) See Figure 3. Namibia reported good progress towards attaining the MDG goal of providing skilled attendance at births while the rest of the reviewed countries reported inadequate progress.(9,10,11,12,13) The percentage of under five children sleeping under insecticide treated bed nets was at 4.6% in Kenya in 2003, and 9.7%, 22.8%, and 23% for Uganda, Zambia and Malawi respectively in 2006.(6)
This review has shown that the progress in meeting the health MDG goals among the selected countries is quite varied with inadequate progress overall. The reduction of MMR which requires a 5.5% annual reduction to meet the MDG target is not on track in all countries.(7) Only Malawi seems likely to meet the under five mortality targets; the rest of the countries are performing below the required 4.3% average annual reduction to meet the target.(29) Only Namibia made progress in the provision of skilled attendance at birth; while Malawi, Namibia and Zambia were likely to achieve the measles immunization targets. This inadequate progress is against a background of weak health systems unable to effectively deliver health services required to reach the MDGs.
MDGs are meant to influence re-alignment of national priorities towards human development; effective national leadership in this regard will ensure that strategic policies and plans are formulated or existing ones aligned to the MDGs and followed by effective oversight and coalition building.(8,30) The finding that all countries have adapted the MDGs to national policies and strategies is the right step in this direction; and this finding is in contrast to the global survey finding of 2005 in 118 countries where only one third of national strategies were amended to reflect the MDGs.(30,31)
At health sector level, the policy environment was not conducive to effectively guide the implementation of health services towards meeting the MDGs in the reviewed countries. The finding that some health policies and guidelines were in draft form or needed updating (and in some countries had been that way for a number of years), raises questions over the sector's stewardship in meeting the MDGs.(14,15,16,17,18) Some of the reasons advanced for this situation include inadequate institutional capacity for policy analysis and development in Namibia and the lengthy legislation process in Uganda.(14,15)
The introduction of SWAp in four of the reviewed countries has the potential of promoting collaboration in the formulation of national health strategies and plans, resources mobilization, monitoring and bolstering government leadership.(9,32,33) SWAp reduces the fragmentation and duplication of planning and programmes which is quite prevalent in Namibia where there were 36 parallel agreements with individual development partners by the year 2008.(14) Besides improving donor collaboration, stronger intersectoral collaboration would assist countries in effectively combatting other determinants of health crucial to meeting the MDG targets as indicated by Malawi and Namibia.(9,13)
A good health financing system raises adequate funds in ways that allow people to use needed services while being protected from financial catastrophe and impoverishment associated with having to pay.(8) For low-income countries, this requires an optimized combination of in-country equitable health financing and funding from donors.(3) Namibia and latterly Zambia have shown higher per capita expenditure, meeting the US$ 34 recommended by WHO's Commission on Macroeconomics and Health unlike the rest of the countries.(34) Indeed per capita expenditure on health in sub-Saharan Africa is lower than any other region, averaging US$ 23.35 Government expenditure on health as a percentage of total government expenditure has generally been stable between 2002 and 2006, whereas (except for Kenya) financing has increased. This raises questions on the fungibility of public funds in the face of favourable donor support – increases in external support do not seem to lead to increases in the allocations to health, but are absorbed elsewhere. In all countries except Namibia OOP expenditure, though seemingly decreasing or stable, was higher than the 15% threshold that would protect most households from catastrophic expenditure.(36) This situation is probably linked to the countries' user fees policies. Inadequate health financing has adverse implications for the other health systems such as health worker remuneration, the availability of medicines and supplies and health service coverage scale up.
A well performing health workforce is the one that has sufficient numbers and mix, is fairly distributed, competent and productive.(8) The density of public health sector medical doctors, nurses and midwives combined varied from 0.8/1000 population in Malawi to 2.0/1000 in Namibia. This is against a background of high vacancy rates and national maldistribution in favour of the private sector and urban areas. Even though there is no universal norm for minimum HRH density because it is context specific, it has been estimated that a density of less than 2.28/1000 generally fails to achieve 80% coverage for skilled birth attendance and child immunization.(37) The shortage of HRH has affected most sub-Saharan Africa countries; as of 2001, only 360 of the 1200 physicians trained in Zimbabwe in the 1990s were still practising in the country; while in Swaziland 44% of posts of physicians and 19% of posts of nurses were unfilled in the year 2004.(38,39) The maldistribution of HRH is also the case in Ghana where the Greater Accra Region has a doctor density 30 times that of the Northern Region.(38) The shortage of HRH will affect the quality and availability of services, in turn contributing to poor health outcomes.
A well functioning health system ensures adequate and equitable access to essential medical products, vaccines and technologies.(8) The findings have reported medicine and vaccine stock outs in all reviewed countries with respect to ORS, anti-malaria drugs, antibiotics, measles vaccines and family planning commodities, all of which are crucial to meeting MDG targeted services. Similar situations pertain elsewhere in Africa. For example, the unavailability of medicines reported in South Africa in 2003 was among the factors contributing to health service quality weaknesses in three provinces.(40) System issues of procurement, management and logistical challenges have been identified as the primary causes of the medicine and vaccine stock outs in Malawi and Zambia.(16,41) The shortage of medicines and vaccines makes services unavailable to the people that need them most, the poor, who may be pushed to make catastrophic expenditures as they resort to purchasing necessary products.
A well functioning health information system will ensure the production, analysis, dissemination, and use of reliable and timely data.(8) All the reviewed countries have established HIS as a source of routine data; however, they face challenges of fragmentation, non-involvement of the private sector, untimeliness and incompleteness of data and inadequate analysis. The existence of parallel information systems has also been reported in Mozambique; and inadequate utilization and untimeliness in the United Republic of Tanzania.(15,42) "Projectization" of development assistance has been advanced as one of reasons for the fragmented HIS; and the private sector's non involvement and lack of legislative provision and noncompliance in Malawi and Namibia.(14,18) Untimeliness and incompleteness have been attributed to lack of feedback on the submitted data; and inadequate utilization to capacity and motivation constraints in Malawi, Uganda and the United Republic of Tanzania.(15,42) Health information that is of poor quality due to incompleteness and untimeliness negatively affects decision making at both policy and operational levels which then impacts the performance of the health systems.
Good health services are those that deliver health interventions to those who need them, when and where needed.(8) Malawi, Namibia and Zambia reported potentially likely and Uganda unlikely to achieve the measles immunization MDG target; while only Namibia reported good progress in providing skilled attendance at birth. See figures 2 and 3. Under five insecticide treated bed nets utilization varied from 4.6% in Kenya to 23% for Malawi; the reviewed countries have quite a long way to go in the fight against malaria. The delivery of an integrated essential package, a guaranteed minimum of interventions by level of health services in four of the five countries would focus resources to the most common local causes of disease burden and the integration would make services more accessible and convenient to users, increase service efficiency through sharing of resources, and reduce duplication in delivery and administration.(43) However, the challenge is inadequate funding of the packages as exemplified by Uganda's costing of the package at US$ 28 per capita but by the year 2008 the country was spending only US$ 8.2 per capita.(15) It is recommended that developing countries invest US$ 34 per capita per annum for delivering basic essential health care interventions.(34) The application of the user fees policies in three of the five countries and the low population density per health facility could prove to be barriers to accessing health services; the abolition of user fees in Uganda in 2001 saw a rapid increase in health service utilization especially for the poorest populations.(44)
It should be recognized that all the health system building blocks are interdependent on each other and therefore require an integrated approach to improvement.(8) For example while skilled attendance at birth is essential, maternal outcomes will still be affected by the systems in which they occur; in 2005, Uganda had over three times the skilled attendance rate (39%) than Bangladesh (12%) but still estimates of MMR were higher in Uganda at 505 compared with 322 for Bangladesh.(45) Explanations for this disparity were systemic such as the quality of hospital care; availability of medicine and doctors to handle complications and geographical barriers to accessing health service.(45)
Limitations of this review include the use of data from multiple sources that included routine data in some instances whose quality could not be ascertained; and the unavailability of data from some of the selected countries. The strength of the review includes the use of data from population based and other country surveys. There is need for further review to assess the quality of the adaptation of national health sector policies to the MDGs; to explore the operational bottlenecks faced by the health system building blocks; and to consider the private sector's role in contributing to achieving the MDGs in the face of public service health system challenges. In conclusion this paper has highlighted varied and inadequate progress towards achieving selected MDG indicators in the five reviewed countries against a background of non conducive health sector policy environment, underfunding, shortage of HRH, unavailability of medicines and vaccines and inadequate service coverage. Meeting the MDGs requires an urgent refocus of national sector policies and commitment to improving all health system building blocks holistically. National health sector leadership has to be displayed by timely formulation of relevant policies and guidelines and sufficient funding of the sector to sustainably complement the increased donor funding. In turn, health sector resources should be effectively funded to improve their availability. Health information systems should be strengthened so that they provide reliable data for resource planning, management and improvement of service coverage.
The recently adopted Ouagadougou Declaration on Primary Health Care and Health Systems seems to provide an opportune framework to sub-Sahara African countries to scale up health interventions and accelerate their progress towards meeting the MDGs in 2015.(46)
The authors would like to thank all those who made contributions during the draft and review stages of this article.
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