Investing in Women and the People of Africa
Upon taking office as Director-General of the World Health Organization (WHO) in 2007, I said that I wanted to be judged by the WHO’s impact on the health of two populations: women and the people of Africa. We, the WHO, are of course concerned with everyone’s health, but within the broad compass of global health these two large groups of people have been at a particular disadvantage. For reasons of history, geography, climate, and ecology, the people of sub-Saharan Africa (“Africa” from here on) bear the greatest burden of ill health and disease. In many societies around the world, women are still denied the same opportunities as men to participate in decisions that affect their health and the health of their families. For many African women, the two kinds of disadvantages coincide. I therefore concluded in 2007 that supporting women and the people of Africa would be two powerful ways of working towards greater health equality worldwide.
Seven years later, it is clear that there have been substantial improvements in the health of these overlapping populations, but the gains that have been made are nowhere near enough. In Africa, maternal and infant mortality were cut by more than 40 percent between 1990 and 2012, falling, respectively, to 480 per 100,000 live births and 63 per 1,000 live births. However, the rates of decline in these key indicators have been slower than in other WHO regions of the world; consequently, the levels observed in 2012 were still higher than for any other region.
Over the same period in Africa, the drop in neonatal mortality, which is closely linked to the health of mothers and young children, was even smaller (just 29 percent). Therefore, while these indicators of maternal and child mortality are moving in the right direction—downwards—they show that the health of African women and infants is falling behind that of individuals in other regions.
An important underlying reason for these persistently high death rates is that mothers and children in Africa still have relatively poor access to essential health services. Considering some of the services that are important for families, WHO statistics show that Africa has, by standard measures, the greatest unmet need for family planning, the lowest use of contraceptives, and the lowest percentage of births attended by skilled health workers. Falling ill is costly. To pick just one example, only one in five people in the world enjoy a form of social security that covers for wages lost due to illness; but in Africa the proportion is less than 1 in 10 according to the World Health Report 2010. The challenge for most national governments, but especially those in Africa, is to raise enough funds for social protection, to reduce the reliance on direct, private payments to finance services, and to improve the efficiency and equity of public spending.
High death rates among children are accompanied by high birth rates—a characteristic of countries in the earlier stages of demographic and epidemiologic transition. The typical woman in Africa still gives birth to 5 children, twice the global average. Even with relatively high mortality rates, the difference between births and deaths means that Africa’s population continues to grow faster than any other region. Consequently, Africa is likely to have more than 2 billion inhabitants by 2050, more than double the number in 2010, mostly living in densely crowded cities.
With health problems dominated by infectious diseases, and by maternal and childhood illnesses, Africa’s health agenda has been guided over the past decade by the Millennium Development Goals (MDGs). MDG numbers 4 (children), 5 (women), and 6 (communicable diseases) are unfinished business, but Africa’s young populations are getting older as well as larger, so that chronic, non-communicable diseases are adding to the burden of ill health. With limited resources, African nations must make some careful choices to get the best returns on health spending.
But the story of health must be told not only in terms of demographics, epidemiology, and financing, but also from a cultural perspective. Here too, the people of Africa, especially women, are at a disadvantage. Compared with other regions of the world, Africa has the highest reported prevalence of sexual violence, mostly directed against women. As a 2014 study by Abrahams et al. points out, the full extent of the problem, and its consequences, are not yet understood. However, it is clear that violence has a wide range of serious health consequences—along with the physical injuries there are unwanted pregnancies, sexually transmitted infections, and mental illness.
... it is clear that there have been substantial improvements in the health of these overlapping populations, but the gains that have been made are nowhere near enough.
Violence lies at one end of a pernicious spectrum, and the health of many more women is compromised in less severe ways. For example, although early marriage is on the decline, tens of millions of girls still marry in their teenage years. Once in the home as housewives, the domestic chores come with occupational hazards. When cooking over open fires or on traditional stoves, women are exposed to an assortment of pollutants every day. WHO data shows that, in 2012, household air pollution was responsible for an estimated 1.8 million deaths among women worldwide. During pregnancy, exposure to harmful pollutants raises the risks of low birth weight and stillbirth.
With so many different kinds of health risks, on so many different levels, the challenges facing women and the people of Africa are daunting. The possible solutions are as numerous as the challenges, but I want to emphasize two in particular. Neither is new but both are vital: investing in women, and investing to achieve universal health coverage.
Women: from Vulnerability to Empowerment
Although women are vulnerable in many ways, they can also be powerful agents for change, not only for their own benefit, but for their families’ benefit as well. A large body of evidence shows that support for women often generates greater income and better health in households and communities. For instance, Khandker and Samad’s recent review of 20 years of microfinance in Bangladesh found that borrowing by women raised household spending by one and a half times as much as borrowing by men, increased the female labor supply by nearly three times as much, and boosted school enrollment. A key point about microfinance is that even small loans can give women the freedom to work—escaping from household chores—and the power to create more educational opportunities for their children. When women have more money, wherever they are in the world, they commonly spend it on ways to improve family health.
These small-scale finance schemes—where they work—should be seen as contributions to a bigger plan. There is a strong argument for directing government and donor funding towards the health of women and children at a national level. In our own recent analysis of maternal and child health investments in 74 countries, the WHO concluded that an increase in expenditure of just US$5 per person per year up to 2035 could yield far greater value in health and social benefits. By acting on this Global Investment Framework we could prevent an estimated 32 million stillbirths, and the deaths of 147 million children and 5 million women, with substantial benefits for economic productivity.
Although these investments focus on women and children, they stand to benefit everyone. This is because interventions to support family planning and immunization, child nutrition, and the control of malaria and HIV/AIDS, among others, are all steps towards universal health coverage.
Africa: Towards Universal Health Coverage
The cost of the Global Investment Framework is an extra US$30 billion annually. In terms of global health spending, this is a small amount of money, but the sources do have to be identified. Who will provide such a large amount of money? For the poorest countries, support from foreign donors is still vital, but as development assistance for health flattens, African nations will need to raise more of the money themselves. As described in the WHO report “The Abuja Declaration: Ten Years On,” of September 2000, 189 heads of state adopted the Millennium Declaration designed to improve social and economic conditions in the world’s poorest countries by 2015. Subsequently, a set of eight goals was devised, drawing on the Millennium Declaration, as a way of tracking progress. Three of these relate specifically to health; two more have health components. In April 2001, heads of state of African Union countries met and pledged to set a target of allocating at least 15 percent of their annual budget to improve the health sector. At the same time, they urged donor countries to ‘fulfill the unmet target of 0.7 percent of their GNP as Official Development Assistance to developing countries.’ This drew attention to the shortage of resources necessary to improve health in low-income settings. At that time, the median level of general government health expenditure from domestic resources in African Union Countries was approximately US$100 with a thousand-fold difference between the minimum (US$0.38) and maximum (US$380). The World Health Report 2010 indicates that if African governments spent 15 percent of their budgets on health, as promised in the Abuja Declaration in 2001, they could together raise around US$30 billion per year, for Africa alone.
... besides direct spending in service delivery, investment is needed in public health infrastructure, in methods of minimizing waste and in promoting efficiency in national health services.
The good news is that according to the International Centre for Tax and Development, the governments of African countries are, in general, increasing their tax revenues. However, the poorest countries still face a huge task in trying to increase domestic health spending—especially those with low GDP per capita, with large informal sectors that are difficult to tax (agriculture and others), and with small volumes of taxable goods.
In spite of these challenges, researchers from the WHO and other organizations note that more than 20 African countries have made specific plans to reach the Abuja target, and each country is finding its own best mix of financing methods. The aim is not just to raise funds but also to ensure protection against the financial risks of paying for health services through forms of prepayment and pooling. As outlined in the World Health Report 2010, Ghana uses a tax-based system to fund national health insurance, especially through a 2.5 percent national health insurance levy on value-added tax, which is applied to goods including alcohol and tobacco. Rwanda uses community-based health insurance, with contributions from households, government, employers, and donors, and has demonstrated how maternal and child health services can be scaled up in just a few years. With the help of external donors, Tanzania doubled public health expenditure during the early 2000s, channelling funds into the integrated management of childhood illness, insecticide-treated nets, vitamin A supplements, immunization, and breastfeeding.
A 2012 article by Mills et al. indicates that the reward for improving the coverage of these services was an accelerated reduction in child mortality. As Dr. L.G. Sambo described in his keynote address at the 2012 Conference of Ministers of Finance and Health in Tunis, it is widely recognized that besides direct spending on service delivery, investment is needed in public health infrastructure, in methods of minimizing waste and in promoting efficiency in national health services.
There must also be more investment in research, because as the World Health Report 2013 points out, we do not know how to achieve universal health coverage everywhere. Tanzania, for example, has been progressive in many ways, but a better understanding is needed to fill remaining gaps in health services: as various studies on the nation’s health care system reveal, children are not fully vaccinated throughout the country, primary care for non-communicable diseases like hypertension and diabetes remains weak, and the need for mental health services has not been properly assessed.
Besides identifying specific research questions, African countries also need ways to capitalize on discovery, for the benefit of private business as well as the general public. In this context, the African Union Commission’s proposal for implementing the Pharmaceutical Manufacturing Plan for Africa (PMPA) is a welcome initiative, as described by a 2014 article in the Bulletin of the World Health Organization. The goal is to scale up investment in Africa’s pharmaceutical manufacturing capacity, especially for generic essential medicines, while aligning objectives for industrial development and public health.
The health of people in Africa, and the health of women everywhere, present big tests for universal health coverage, and big tests for the WHO. But we have built momentum around initiatives to support both populations: the WHO has affirmed in “Women and Health: Today’s Evidence, Tomorrow’s Agenda” that the value of investing in women is beyond dispute, and as Dr. L.G. Sambo has pointed out, nearly all the countries in the world have made a commitment to achieving universal health coverage. The World Health Organization shall use its energies to add to this momentum. As Africa’s health ministers affirmed in Luanda this April, to achieve universal coverage is critical, not only for health, but as an integral part of social and economic development across the continent.