BY: DR GITHINJI GITAHI
As the world meets in New York 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 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. The MDGs have 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 the majority of the MDG targets were significantly below at the start of the campaign. Further, inequalities and disparities still muddy the successes observed.
Sub-Saharan Africa has 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 sub-Saharan Africa 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 was 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 and in absolute numbers has grown because of rapid population growth as discussed above. This has largely been contributed to by rapid population growth putting a strain on resources, environmental fragility as well as political and economic upheaval.
Maternal nutrition before, during and after pregnancy as well as exclusive breastfeeding and availability of nutritious weaning foods have remained a problem. As a result of the chronic malnutrition, an average of 26 per cent of Kenyan children are stunted and this seriously reduces their future economic productivity.
Child mortality too has remained a problem in Africa. The infant mortality and the under five mortality rates in Kenya have dropped to 39 and 52 per 1,000 live births, but they are still above the world average. This reduction is not enough to meet the goals set in the MDGs and will be further compounded by a rapidly expanding number of live births in Kenya and the rest of Africa.
Can the reduction in under-five mortality outpace population growth?
Africa will record the largest amount 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. In addition to high birth rates, the region’s population is also quite young, with 43 per cent of the population below age 15 and, therefore, these estimates might be conservative.
Even though the MDGs have resulted in dramatic reductions in child mortality rate, 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. Maternal mortality still remains the highest in the world at 510 maternal deaths, which is more than double the world’s 210 per 100,000 live births.
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 one other every two minutes dying on pregnancy and childbirth-related causes.
With only one in two accessing skilled assistance (doctor, nurse or midwife) during delivery, it’s clear to see that the biggest problem lies in access to care and 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 three per cent of the world’s health workers struggling to cope with the health needs of Africans. This is compounded by an inadequate mix of health workers.
However, Human Resources for Health will have to be 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 rural populations in sub-Saharan Africa access skilled birth assistance, only 38 per cent of rural populations do while in Kenya, an average of 62 per cent of births were skilled. This may look profound but still masks widespread inequalities between regions.
A key contributor to slow progress in maternal mortality is adolescent pregnancy. However, 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 is 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 early sexual encounter. Increasing school enrolment is helping but the rapidly growing under 18 years population is eating away 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 and still less than 40 per cent of youth in sexually active age brackets of 15-24 years have comprehensive correct knowledge on HIV.
Still, Aids-related deaths have not decreased among adolescents aged 10-19 and remain the number one killer of adolescents 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 and 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 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.
In conclusion, health is a precondition, a practical indicator as well as an outcome of sustainable development. As part of the post-2015development agenda, efforts are needed tosustain 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 SDG Three 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 sustainable 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 into their training curricula to expand training and save cost.
They must also recognise that Community Health Volunteers are not a stop gap in achieving universal healthcare but are an integral part of the strategy and should be integrated into the 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 health care 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.