By Dr Githinji Gitahi, CEO, Amref Health Africa
As the world meets in New York in September 2015 to close the door on the Millennium Development Goals and open another on Sustainable Development Goals, Africa also needs to examine herself and her role as the main beneficiary of this global concert of goals and targets.
In the year 2000, world leaders committed to “spare no effort to free our fellow men, women and children from the abject and dehumanising conditions of extreme poverty”. Fifteen years later, millions of lives have been saved and living conditions for many more improved across the world and more specifically in Africa.
This globalised campaign on Millennium Development Goals has demonstrated that global campaigns can work to pull the world together for a common objective in the effort to ensure widespread gains against poverty and disease.
However, gains have been sketchy especially in the developing world, where health indicators in particular were significantly below the MDG targets at the start of the campaign in 2000. Further, inequalities and disparities still muddy the successes observed.
With sub-Saharan Africa having the least progress in poverty reduction at 28 per cent – while the world average was at 68 per cent – more than 40 per cent of the people in the region still live in extreme poverty, with more women affected than men. Putting population growth in perspective, we can see that despite the gains, more people in Africa in absolute numbers are living in extreme poverty!
Even if the 50 per cent reduction in proportion of people living in extreme poverty were to have been achieved in Africa by 2015, going by the current population explosion (630 million in 1990 and 1.16 billion in 2015) the absolute numbers of people living in extreme poverty would at worst be the same and at best reduce by a mere 30 million people.
The rate of undernourishment in sub-Saharan Africa still remains at 23 per cent of the population but has grown in absolute numbers as discussed above. This has largely been contributed to by rapid population growth, putting a strain on resources and precipitating environmental fragility as well as political and economic upheaval.
Maternal nutrition before, during and after pregnancy as well as exclusive breast-feeding and availability of nutritious weaning foods has remained a problem. As a result of the chronic malnutrition, more than a third of African children are stunted and this seriously reduces their future economic productivity.
Child mortality too has remained a problem in Africa. While the rates have dropped by 52 per cent in sub-Saharan Africa, they are still double the world’s average at 86 for every 1,000 live births compared to a world average of 43. Despite this reduction, over 10,000 children continue to die every day from preventable diseases. This reduction is not enough to meet the targets set in the Millennium Development Goals and the situation will be further compounded by a rapidly expanding number of live births in Africa.
Can the reduction in under-five mortality outpace population growth?
Africa will record the largest rate of population growth of any world region between now and 2050. Her population is expected to more than double, rising from 1.1 billion today to at least 2.4 billion by 2050. These estimates might be conservative because in addition to high birth rates, the region’s population is also quite young, with 43 per cent of the population aged below 15 years and therefore not yet in the reproductive age.
Therefore, even though the MDGs have resulted in dramatic reductions in child mortality rates, Africa’s population growth is likely to reverse the gains as scarce resources are stretched thinner and thinner in a rapidly growing population. Percentage indicators will become irrelevant as absolute numbers of children dying will be increasing.
More work is needed to improve child survival rates but this has to be addressed hand in hand with population control initiatives in the post-MDG sustainable development agenda.
As children continue to face this daunting challenge, maternal mortality in sub-Saharan Africa still remains the highest in the world at 510 per 100,000 live births, which is more than double the world’s average of 210.
Despite significant reduction in maternal mortality, Africa still accounts for 200,000 of the 289,000 mothers who die every year from pregnancy or childbirth-related complications. This is a chilling reality – one mother dying every two minutes.
With only one in two mothers accessing skilled assistance (from a doctor, nurse or midwife) during delivery, it is clear that the biggest problem lies in access to care, and that human resources for health must remain a key focus in the post-MDG agenda. Africa has 11 per cent of the world’s population, accounts for 24 per cent of the global disease burden, but has only 3 per cent of the world’s health workers struggling to cope with the health needs of Africans, and this is compounded by an inadequate mix of health workers.
However, human resources for health will have to be addressed in the context of poverty and lack of adequate infrastructure because they are also key contributors to access of care. This can only be seen when numbers are disaggregated between rural and urban populations. While 71 per cent of urban populations in sub-Saharan Africa access skilled birth assistance, only 38 per cent of rural populations do. This may look profound but still masks widespread inequalities between regions.
A key contributor to slow progress in maternal mortality is adolescent pregnancy. Adolescent childbearing remains high in sub-Saharan Africa, at 116 births per 1,000 adolescent girls in 2015, which is more than double the world’s average. As Africa’s population grows and considering that already nearly half of Africa’s population has yet to enter the reproductive age, this problem is only going to get worse.
Adolescent pregnancy is wrought with complications and must remain an area of focus. Sex education and family planning interventions must be stepped up as evidence continues to show an increase in early sexual encounters. Increasing school enrolment is helping but the rapidly growing under-18 population is eating away at the gains.
On infectious disease, significant and laudable reduction in new HIV infections has been achieved during the MDG era. However, sub-Saharan Africa still accounts for more than 70 per cent of all new HIV infections, yet less than 40 per cent of youth in the sexually active age bracket of 15-24 years have correct and comprehensive knowledge on HIV.
In fact, AIDS-related deaths remain the number one killer of adolescents aged 10 to 19 years in sub-Saharan Africa. Access to knowledge, testing and medicines should be a key focus in the post-MDG era. The role of substance abuse in this adolescent epidemic cannot be over emphasised; HIV health promotion should go hand in hand with efforts to reduce irresponsible drinking and substance abuse in adolescents.
Serious challenges in health persist in relation to the health of women and children, communicable diseases and infectious diseases that have long been eliminated or mitigated in other continents.
Africa additionally faces an emerging and rapidly growing health burden from non-communicable diseases. Whereas communicable diseases are currently on the top of the list as leading causes of death, it is estimated that this trend will change in the next decade with hypertension, diabetes, chronic pulmonary disease and cancers leading the way.
Africa’s health systems remain weak and fragmented due to decades of under-investment, weak leadership and poor management that do not respond adequately to the health needs of Africans in the era of universal health coverage. In some countries, up to 40 per cent of healthcare expenditure is out of pocket as the majority of African countries have not honoured their commitment to allocate 15 per cent of their recurrent budget to health as per the Abuja Declaration of 2001.
The massive gains over the past 15 years have been due largely to an increase in international financing along with strengthened political commitment and an expanding global economy especially in Africa and Asia. Sustained political commitment, predictable financing and strategic investments in health systems, disease surveillance and new tools are necessary to maintain and improve on these gains.
In conclusion, health is a precondition, a practical indicator as well as an outcome of sustainable development. As part of the post-2015 development agenda, efforts are needed to sustain gains made to-date and integrate additional health-related issues into the sustainable development agenda.
Family planning cannot be left as an ‘implied target’ under Sustainable Development Goal 3 as it is a key determinant to the absolute and effective achievement of tangible gains by the citizens of Africa. Universal access to sexual and reproductive health in Africa is the cross-cutting factor if the Sustainable Development Goals have to be achieved.
In the absence of adequate resources, the use of innovation in training of human resources for health as well as in health promotion will be a key tool in achieving the Sustainable Development Goals.
African governments should be ready to adopt mobile technology innovation similar to Amref Health Africa’s Health Enablement and Learning Platform (HELP) to expand training and save costs.
They must also recognise that Community Health Volunteers are not a stopgap in achieving universal healthcare but are an integral part of the strategy and should be integrated into health plans and budgets. They must also enact polices that adopt task shifting to address the shortage of human resources for health.
Further, accountability, efficiency, value for money, and transparent tracking of health expenditure must become standard principles in utilisation of healthcare resources by both state and non-state health stakeholders.
Non-governmental organisations like Amref Health Africa must advocate with the key stakeholders to focus attention continuously on translation of evidence to investment decisions for sustainable health systems in Africa.
All of these are needed to ensure healthy lives and promote well-being for all people of all ages in the post-MDG sustainable development era.