15% plus Campaign welcomes renewed African Union’s summit Public Health commitments

• Africa Public Health Alliance & 15% Plus Campaign Welcomes AU Heads of State Summit Laudable Commitments on: Financing; MNCH; Universal Access; & PMTCT.

• Identifies 6 Key Areas for Emphasis & Country Level Implementation: Social Determinants & Vaccinations; Improved Per Capita Investment; Integrating Health, Education & Labour Policy on Health Workforce; Gender Equity in Health; Pharmaceutical & Commodities Capacity; One Primary Health Clinic Per Community. 

• Calls for Timely Implementation of All Commitments by AU Member States. 

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.”

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.

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.

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.

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.

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.

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).

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.

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.

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. 

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