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Africa: Health for All?

AfricaFocus Bulletin
Jan 6, 2004 (040106)
(Reposted from sources cited below)

Editor's Note

In mid-December, the World Health Organization (WHO) released its annual World Health Report, the first under the leadership of Director-General Jong-wook Lee. Building on its earlier announcement of a plan to bring AIDS treatment to 3 million people by the end of 2005, the WHO called for a return to the goal of "Health for All" adopted twenty-five years ago. The report calls for strengthening health systems across the board to address the widening gap between rich and poor countries, and it stresses that AIDS treatment will not be sustainable unless it is linked to the strengthening of primary health systems.

The report thus presents a sharp contrast to the U.S. model of commercialized health care and the bilateral approach stressed by President Bush's new AIDS initiative. U.S. officials have used the weaknesses of national health care systems in African and other developing countries as an argument for a slower pace in funding for AIDS programs. The WHO reverses that argument, stressing the need for immediate steps to build additional health care capacity.

This will be a critical test year for both multilateral institutions and the Bush administration, as well as national governments, to deliver on their promises to rapidly scale up treatment for almost 6 million people in need of immediate antiretroviral treatment.

This issue of AfricaFocus Bulletin contains excerpts from the WHO's World Health Report, as well as links to additional recent reports from late 2003. Another issue of the Bulletin today contains excerpts from a paper by Brook Baker of Health Gap defending the WHO's accelerated treatment plan against doubts reportedly raised by U.S. and pharmaceutical company representatives.

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

World Health Organization

The World Health Report 2003: Shaping the Future

Brief Excerpts

(1) From WHO Press Release 18 December, 2003

Health for all remains the goal

"These global health gaps are unacceptable," said Dr LEE Jong-wook, Director-General of WHO. "Twenty-five years ago, the Declaration of Alma-Ata on Primary Health Care challenged the world to embrace the principles of health for all as the way to overcome gross health inequalities between and within countries," said Dr Lee.

"The principles defined at that time remain indispensable for a coherent vision of global health. Turning that vision into reality calls for clarity both on the possibilities and on the obstacles that have slowed and in some cases reversed progress towards meeting the health needs of all people. This means working with countries especially those most in need not only to confront health crises, but to construct sustainable and equitable health systems." ...

The report confirms that HIV/AIDS has cut life expectancy by as much as 20 years for many millions of people in sub-Saharan Africa. Every day in the poorest African countries, 5,000 men and women and 1,000 children die from HIV/AIDS.

Today only 5% of all those people living in the developing world who require antiretroviral treatment for HIV/AIDS actually receive it: a treatment gap which WHO declared a global health emergency in September 2003.

"The WHO goal of universal access to HIV/AIDS treatment, with the concrete target of providing treatment to three million people in the poorest countries by the year 2005 is a clear demonstration of how the principle of equitable access can be put into practice," said Dr Lee. "Working with our partners, we will show that investments we make in treating people with AIDS can help to build up health systems for the benefit of all." ...

The report suggests ways in which international support can counter some of the main health care systems weaknesses, including critical shortages of health workers, inadequate health information, a lack of financial resources and the need for more government leadership aimed at improving the health of the poorest members of society. The report calls for rapid increases in training and employment of health care workforces, and stronger government-community relationships. ...

From the Message from Director-General Jong-wook Lee

Today's global health situation raises urgent questions about justice. In some parts of the world there is a continued expectation of longer and more comfortable life, while in many others there is despair over the failure to control disease although the means to do so exist. ...

Major disparities also exist in areas such as child mortality. Of the more than 10 million children under 5 years old who die every year, almost all are in developing countries. A world marked by such inequities is in very serious trouble. We have to find ways to unite our strengths as a global community to shape a healthier future. This report on the world's health, my first since taking office, gives some initial indications of how to do it.

A message that runs throughout these pages is that progress in health, including rapid and sustainable expansion of emergency treatments, depends on viable national and local health systems. Scaling up ARV therapy in resource-poor settings has to be done in such a way as to strengthen health systems based on primary health care. In most countries, there will be only small and short-lived advances towards acceptable standards of health without the development of health care systems which are strong enough to respond to current challenges. ...

Twenty-five years ago, the Declaration of Alma-Ata challenged the world to embrace the principles of primary health care as the way to overcome gross health inequalities between and within countries. "Health for all" became the slogan for a movement. It was not just an ideal but an organizing principle: everybody needs and is entitled to the highest possible standard of health. The principles defined at that time remain indispensable for a coherent vision of global health. Turning that vision into reality calls for clarity both on the possibilities and on the obstacles that have slowed and in some cases reversed progress towards meeting the health needs of all people. This entails working with countries especially those most in need not only to confront health crises, but to construct sustainable and equitable health systems.

I urge the global health community to set its sights on bold objectives. All countries of the world have pledged to reach the Millennium Development Goals set at the United Nations Summit in 2000. These include ambitious targets for nutrition, maternal and child health, infectious disease control, and access to essential medicines. With this support we have a real opportunity now to make progress that will mean longer, healthier lives for millions of people, turn despair into realistic hope, and lay the foundations for improved health for generations to come. ...

From Overview chapter

Global health is a study in contrasts. While a baby girl born in Japan today can expect to live for about 85 years, a girl born at the same moment in Sierra Leone has a life expectancy of 36 years. The Japanese child will receive vaccinations, adequate nutrition and good schooling. If she becomes a mother she will benefit from high-quality maternity care. Growing older, she may eventually develop chronic diseases, but excellent treatment and rehabilitation services will be available; she can expect to receive, on average, medications worth about US$ 550 per year and much more if needed.

Meanwhile, the girl in Sierra Leone has little chance of receiving immunizations and a high probability of being underweight throughout childhood. She will probably marry in adolescence and go on to give birth to six or more children without the assistance of a trained birth attendant. One or more of her babies will die in infancy, and she herself will be at high risk of death in childbirth. If she falls ill, she can expect, on average, medicines worth about US$ 3 per year. If she survives middle age she, too, will develop chronic diseases but, without access to adequate treatment, she will die prematurely.

These contrasting stories reveal much about what medicine and public health can achieve, and about unmet needs in a world of vast and growing health inequalities. The World Health Report 2003 affirms that the key task of the global health community is to close the gap between such contrasting lives. ...

A key message of this report is that real progress in health depends vitally on stronger health systems based on primary health care. In most countries, there will be only limited advances towards the United Nations Millennium Development Goals and other national health priorities without the development of health care systems that respond to the complexity of current health challenges. Systems should integrate health promotion and disease prevention on the one hand and treatment for acute illness and chronic care on the other. This should be done across all levels of the health care system, with the aim of delivering quality services equitably and efficiently to the whole population. The lessons from SARS and poliomyelitis eradication programmes shape strategies for an urgent health system response to HIV/AIDS; in turn, scaling up the attack on HIV/AIDS will do much to strengthen health care systems. ...

This report argues that the key to success is health systems strengthening, centred on the strategies and principles of primary health care, constructing responses that support integrated, long-term health systems development on behalf of the entire population. This requires both effective use of existing knowledge and technologies and innovation to create new health tools, along with appropriate structures and strategies to apply them. Success will demand new forms of cooperation between international health agencies, national health leaders, health workers and communities, and other relevant sectors.

From Chapter 1: Global Health: today's challenges

Reviewing the latest global health trends, this chapter finds disturbing evidence of widening gaps in health worldwide. In 2002, while life expectancy at birth reached 78 years for women in developed countries, it fell back to less than 46 years for men in sub-Saharan Africa, largely because of the HIV/AIDS epidemic. For millions of children today, particularly in Africa, the biggest health challenge is to survive until their fifth birthday, and their chances of doing so are less than they were a decade ago. This is a result of the continuing impact of communicable diseases. However, a global increase in noncommunicable diseases is simultaneously occurring, adding to the daunting challenges already facing many developing countries.

Although this report is global in scope, the findings irresistibly draw the main focus to the increasingly fragile health of sub-Saharan Africa. It is here, where scores of millions of people scrape a living from the dust of poverty, that the price of being poor can be most starkly seen. Almost an entire continent is being left behind.

Overall, 35% of Africa's children are at higher risk of death than they were 10 years ago. Every hour, more than 500 African mothers lose a small child. In 2002, more than four million African children died. Those who do make it past childhood are confronted with adult death rates that exceed those of 30 years ago. Life expectancy, always shorter here than almost anywhere else, is shrinking. In some African countries, it has been cut by 20 years and life expectancy for men is less than 46 years.

Mostly, death comes in familiar garb. The main causes among children are depressingly recognizable: the perinatal conditions closely associated with poverty; diarrhoeal diseases; pneumonia and other lower respiratory tract conditions; and malaria. Becoming more familiar by the day, HIV/AIDS, now the world's leading cause of death in adults aged 15--59 years, is killing almost 5000 men and women in this age group, and almost 1000 of their children, every 24 hours in sub-Saharan Africa.

The main components of Africa's tragedy are shared by many of the poorest people everywhere and include the agonizingly slow progress towards the Millennium Development Goals of reduced maternal and child mortality; the HIV/AIDS pandemic; and the double burden of communicable diseases plus noncommunicable diseases, including the tobacco epidemic and the avoidable deaths from road traffic crashes.


Although approximately 10.5 million children under 5 years of age still die every year in the world, progress has been made since 1970, when the figure was more than 17 million. These reductions did not take place uniformly across time and regions, but the success stories in developing countries demonstrate clearly that low mortality levels are attainable in those settings. The effects of such achievements are not to be underestimated. If the whole world were able to share the current child mortality experience of Iceland (the lowest in the world in 2002), over 10 million child deaths could be prevented each year.

Today nearly all child deaths occur in developing countries, almost half of them in Africa. While some African countries have made considerable strides in reducing child mortality, the majority of African children live in countries where the survival gains of the past have been wiped out, largely as a result of the HIV/AIDS epidemic.

Across the world, children are at higher risk of dying if they are poor. The most impressive declines in child mortality have occurred in developed countries, and in low-mortality developing countries whose economic situation has improved. In contrast, the declines observed in countries with higher mortality have occurred at a slower rate, stagnated or even reversed. Owing to the overall gains in developing regions, the mortality gap between the developing and developed world has narrowed since 1970. However, because the better-off countries in developing regions are improving at a fast rate, and many of the poorer populations are losing ground, the disparity between the different developing regions is widening.


The African crisis of child mortality

There are 14 countries in WHO's African Region in which child mortality has risen since reaching its lowest level in 1990. About 34% of the population under five years of age in sub-Saharan Africa is now exposed to this disturbing trend. Only two countries outside Africa observed similar setbacks in the same period -- countries that experienced armed conflict or economic sanctions. Eight of the 14 countries are in southern Africa, which boasted some of the most notable gains in child survival during the 1970s and 1980s. Those promising gains have been wiped out in a mere decade.

The surge of HIV/AIDS is directly responsible for up to 60% of child deaths in Africa, ...

Other Recent Reports and Statements


Platform endorsed by 200 organizations for evaluating candidates in 2004 U.S. election.

Health Gap, 2003 AIDS Year in Review

14-page summary and analysis of U.S. policy developments in 2003, prepared by Health Gap for the November 24 March on White House Coalition

Journalists against AIDS (JAAIDS) Nigeria,
Special report: Saving the ARV programme

Reports on action by Nigerian AIDS activists to secure continued supplies of anti-retrovirals, after a threatened interruption due to funding gaps.

Global Health Council, Reducing Malaria's Burden: Evidence of Effectiveness for Decision Makers

New 54-page report by Global Health Council, in collaboration with other organizations, lays out the urgent need for increasing the global research budget on malaria, as well as for adequate funding for current treatments known to be effective. In the foreword to the report, Jeffrey Sachs of Columbia University notes that it is possible "to reduce the burden of malaria dramatically, through greatly scaled-up investment in both prevention and treatment."

Kaiser Family Foundation,
Global Funding for HIV/AIDS in Resource Poor Settings [no usable link to report; use search on site to locate document]

23-page detailed report on funding, including estimates of funds dispersed as well as budget commitments, from both multilateral and bilateral sources.

University of California, San Francisco,
Country AIDS Policy Analysis Project

Includes detailed country-level reports prepared in 2003 with most recent data available. The most recent is Uganda, released in November. Also includes Ethiopia, Malawi, South Africa, Zambia, and Zimbabwe, as well as Cambodia and India.

AfricaFocus Bulletin is a free independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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