24

900 DAYS TO MAKE A DIFFERENCE

MALARIA CONTROL:

DAYS TO MAKE A DIFFERENCE

estimates that 219 million cases and 660,000 deaths occur each year, inflicting a heavy economic and social burden on families, communities and nations;90% of all malaria-related deaths occur in subSaharan Africa, mainly among children under five years of age. The 17 most affected countries account for over 80% of malaria cases. The highest malaria mor tality rates are being seen in countries that have the highest rates of extreme poverty. At present, 25 countries Malaria-endemic countries in Africa are are en route to eliminating malaria and highly committed to reducing the disease many more have declared elimination as burden and have been working together a national goal. through platforms offered by the African U n i o n ( A U ) , t h e W o r l d H e a l t h PROGRESS IN REDUCING MALARIA Organization, the Roll Back Malaria (RBM) D E AT H S A N D CA S E S H A S B E E N Partnership and the African Leaders SUBSTANTIAL Malaria Alliance (ALMA). The AU has framed a compelling vision for the future In the course of the last decade, the global of the continent and has developed effort to control and eliminate malaria powerful health policy frameworks that expanded significantly. As a result of a have resulted in a substantial reduction of scale-up of control interventions including an expansion of access to longthe malaria burden. lasting insecticidal nets, indoor residual spraying programmes, diagnostic testing MALARIA FACTS and quality-assured treatment more Malaria is an entirely preventable and t h a n a m i l l i o n l i v e s h a v e b e e n treatable vector-borne disease. Disease saved.Malaria mortality rates decreased transmission affects 99 countries around by an estimated 26%globally and by 33% the world, with an estimated 3.3 billion i n A f r i c a b e t w e e n 2 0 0 0 a n d p e o p l e a t r i s k . Wo r l d w i d e , W H O 2010.Worldwide, 50 countries (of which 9
Roll Back Malaria Progress & Impact Series: A Decade of Partnership and Results, 2011 World Malaria Report 2012, World Health Organization, 2012 Assessment published in the World Malaria Report 2012, World Health Organization, 2012

With just 900 days left to achieve the Millennium Development Goals (MDGs), strategic decisions need to be made about investing in initiatives that yield high economic, social and health benefits. Malaria control has proven to be a highly cost-effective public health strategy to save lives, improve maternal and child health and lift obstacles to economic development and children's education.

900 DAYS TO MAKE A DIFFERENCE

are in Africa) are now on track to reduce their malaria case incidence rates by 75%, in line with World Health Assembly and RBM Global Malaria Action Plan targets for 2015.However, these 50 countries make up only 3% of estimated global cases of malaria. S H O RT FA L L I N F I NA N C I N G THREATENS FURTHER PROGRESS

malaria deaths, but without it, gains could be quickly reversed, putting millions of lives at risk.

MALARIA CONTROL:

In order to move closer to 2015 targets, and to achieve wider economic and social b e n e f i t s a c ro s s A f r i c a , m a l a r i a investments need to be expanded WHAT CAN BE DONE? markedly between 2013 and 2015. Recent years have witnessed a gradual levelling off of international funding, staying well Maintain high-levels of coverage with below the US$ 5.1 billion that would be malaria interventions needed each year to achieve universal access to life-saving prevention and It is cr itical that malar ia-endemic control measures. In 2013, the funding c o u n t r i e s c o n t i n u e s c a l i n g u p gap for malaria control in Africa stood at inter ventions to achieve universal US$ 3.6 billion for the period 2013-2015. coverage of all prevention, diagnostic and Should efforts to maintain high levels of treatment interventions, in line with WHO coverage fail, malaria will resurge in policy recommendations. Together with areas where commodities cannot be the UN Special Envoy for Financing the provided to at-risk populations in time. Health MDGs and for Malaria, the RBM 2013 is therefore a critical year for Partnership is rolling out a strategy to malaria financing.With sustained funding mobilize financial resources to help and commitment, endemic countries can endemic countries meet the 2015 targets. continue to progress towards ending This includes supporting the

DAYS TO MAKE A DIFFERENCE

900 DAYS TO MAKE A DIFFERENCE

partners are also working closely with national malaria control programmes to resolve key logistics and technical challenges at regional and country level. I n c re a s e d d o m e s t i c f i n a n c i n g f o r Strengthen malaria surveillance and malariaand the development of innovative response systems financing mechanisms are also key elements of this strategy. Possible Currently, only around one-tenth of the innovative financing tools include airline estimated global case count is detected ticket levies and financial transaction by surveillance systems. Without taxes; private sector financing through effective surveillance systems, it is bonds; pooled or bulk procurement; and i m p o s s i bl e t o re l i a bly m e a s u re improved local manufacturing -- as called progress towards malaria targets. for previously by RBM and ALMA.RBM Strengthened surveillance would

replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which currently provides approximately 60% of all international financing for malaria.

Disease surveillance for malaria control. Operational manual, and Disease surveillance for malaria elimination. Operational manual, World Health Organization, 2012 http://www.who.int/malaria/areas/test_treat_track/en/index.htmlRoll Back Malaria Progress & Impact Series: A Decade of Partnership and Results, 2011 World Malaria Report 2012, World Health Organization, 2012 Assessment published in the World Malaria Report 2012, World Health Organization, 2012

900 DAYS TO MAKE A DIFFERENCE

enable Ministries of Health to direct financial resources to populations most in need, to respond effectively to disease outbreaks, and to assess the impact of control measures. RBM partners therefore urge and support endemic countries to strengthen their malaria surveillance and response systems in line with WHO and RBM guidance released in the 2012. Malaria surveillance is a critical foundation of WHO'sT3: Test.Treat.Track.approach. PREVENT DRUG AND INSECTICIDE RESISTANCE The double threat of emerging drug and insecticide resistance poses an urgent challenge that should be addressed at the national level, with support f ro m t h e g l o b a l m a l a r i a community. Parasite resistance to ar temisinin thekey component of recommended combination treatments for malaria has already emerged i n t h e G re a t e r M e ko n g subregion of South-East Asia. A fur ther spreadof resistant strains, or the independent emergence of artemisinin resistance in otherregions, could threaten the success ofmalaria control efforts in Afr ica and around the globe.Resistance to at least one insecticide has been reported from 64 endemic countries globally, with the majority of these countries being in Africa. It is cr itical that national malaria control programmes i m p l e m e n t t h e recommendations contained in the Global plan for artemisinin

resistance containment and the Global plan for insecticide resistance management. ENGAGE SECTORS OUTSIDE OF HEALTH In order to be effective, cost-efficient and sustainable, malaria control efforts should be better integrated in the work of key non-health sectors, and be considered in the context of the broader economic, environmental and social challenges faced by endemic countries. Factors such as climate change, urbanization, industrial and infrastructural investments, and natural resources management can substantially influence patter ns of malar ia transmission.Changes in demographic and population dynamics and ecosystems alsohave an impact on the epidemiology of malaria and the required package of control measures that need to be rolled out. With all these elements considered, malaria control should become an integral part of national development strategies. Completing the unfinished business In the remaining two and half years, the international community and malaria-endemic countries should intensify malaria control and elimination efforts and scale up cross-border activities to prevent reintroduction of the disease into areas that have become malaria-free. Malaria should remain a high priority in the post-2015 agenda, together with efforts to strengthen maternal and child health services and expandcommunity health worker programmes. A strong focus on health system strengthening is also key to making visible progress against this disease. To sustain the gains made to date, national malaria control programmes need predictable international donor funding, increased domestic investment and innovative financing mechanisms that can tap into new resources.Coordinated action through regional intergovernmental mechanisms, such as the African Union, will be critical for fostering national support for strong multisectoral collaboration, improving surveillance and fighting drug and insecticide resistance. Finally, sustained political commitmentand an effective global partnership under the umbrella of Roll Back Malaria will be fundamental to future progress.

http://www.who.int/malaria/publications/en/

900 DAYS TO MAKE A DIFFERENCE

sustainable for the treatment of the pandemics in the post MDG era, and given the impossible task facing our regulators to quality assure a vast supply base, contributes to the scourge of counterf eit and sub-standard medicines. We need to reorganize and strengthen our pharmaceutical industry so that it

POLICY BRIEF

LOCAL PRODUCTION OF PHARMACEUTICALS IN AFRICA

Introduction In Africa we bear a disproportionate burden of disease with for example, 75% of the world's HIV/AIDS cases and 90% of deaths due to malaria. 50% of global deaths under five occur on our continent largely due to neonatal causes, pneumonia, diarrhea, measles, HIV, TB and malaria. As well as communicable diseases, the incidence of noncommunicable diseases such as cardiovascular disorders, cancer and diabetes are on the rise and are already very significant public health issues especially in the North of our continent. It is estimated that by 2020 Africa will have 6 0 m i l l i o n p e o p l e s u f f e r i n g f ro m hypertension and nearly 19million people living with diabetes. To date we have been overly reliant on imports for our essential medicines needs. It is often estimated that 70% of essential medicines used in Africa are imported from other continents. This situation leaves us vulnerable in terms of security of supply, is not long term
5

can explicitly help us in meeting our medicine needs medicines that live up to the acceptable international standards of quality, safety and efficacy and that are affordable. The African Union Commission (AUC) with support from the United Nations Industrial Development Organization (UNIDO) has developed a Business Plan for the accelerated implementation of the Pharmaceutical Manufacturing Plan for Africa (PMPA). The plan recognizes the different contexts that our countries and regions face as well as the complexity of the pharmaceutical industry. It sets out a practical approach to developing the industry on our continent so that, first and foremost, it can serve to improve access to quality medicines to our people.Through implementation of this plan we will become less dependent on importsand improveour self-reliance. A s t ro n ge r a n d re l i a bl e l o c a l pharmaceutical industry would also contribute to the economic development, job creation, human resource development and associated industrial development.

900 DAYS TO MAKE A DIFFERENCE

Fig 1. Illustration of the foundations required, key interventions and ultimate ambition for developing the pharmaceutical industry in Africa {Greek temple diagram} The PMPA Business Plan key Pillars In order for our pharmaceutical industry to develop there is a need to create a conducive environment which can be achieved through: enhancing the talent pool for the pharmaceutical industry facilitating access to investment capital and providing well-tailored b u t t i m e l i m i t e d i n c e n t i ve s strengthening the regulator y control of our pharmaceutical markets and industry facilitating our companies to access know how and technoloy facilitating market a c c e s s a n d i m p rov i n g t h e availability of market data. Human Resource Development The pharmaceutical industry is knowledge intensive and requires a workforce of highly skilled professionals. We have the skills on our continent but we need to expand this talent pool and equip our pharmaceutical industry with the practical knowledge of how to produce medicines of inter national standard at competitive cost. Investment Capital and Time limited Incentives Pharmaceutical companies need to make significant investments and require access to capital with long term maturity and at affordable rates. Demonstrable commitment

from African leaders will increase the appetite for the sector amongst the investment community but there is a need to facilitate and support investment through initiatives such as context specific and time limited incentives. For example India supported the development of its industry over decades through incentives such as interest subsidies, working capital credits and export incentives. Many of the products that we import still benefit from export incentives and there is a need to level the playing field if our manufacturers are to be competitive and be able to invest. Increased Regulatory Control For our companies to be able to invest they need to be protected from the unfair competition of, sometimessub-standard and even counterfeit products requiring greater oversight of the market place. To assist our companies to develop and to mitigate risk to public health it is necessary to implement a roadmap towards international quality standards that they will be supported to and required to follow, and this should be enforced by our vigilant and strengthened regulatory authorities. Access to Know How and Technology In the short term it will be necessary to enable companies to access the requisite skills and know how to develop and implement upgrading plans in accordance with the road map to international quality standards. We also need to expand the range of products manufactured in Africa and to realize the opportunity for improving access to for example second line ARVs that could be achieved through the TRIPS flexibilities. Facilitating Market Access and Improving the Availability of Market Data The Business Plan is closely aligned with the African Medicines Regulatory Harmonisation (AMRH) initiative. Through defragmenting our regional markets the business environment f or our manufacturers will improve as they will be able to serve a larger market with the efficiencies in production that can then materialize. There is limited market data available such that it is difficult for companies to make informed decisions
6

900 DAYS TO MAKE A DIFFERENCE

and for investors to properly assess the risk and opportunity that the industry presents. The PMPA Business Plan Implementation The development of the industry requires coordination and collaboration of a number of different players at national and regional levels. Therefore political will is essential as is establishing policy coherence across ministries to support our companies and establishing a sound multi stakeholder strategy. The Business Plan recommends that a consortium of development partners must work together to provide technical assistance and capacity building across the different dimensions of pharmaceutical sector development. The nucleus of the consortium which is being convened under the authority of the African Union will be made up of the African Development Bank, UNAIDS, UNIDO and the World Health Organization (WHO). Other partners such as the New Partnership for Africa's Development (NEPAD), the Federation of African Pharmaceutical Manufacturers Associations (FAPMA), the African Network for Drug and Diagnostic Innovation (ANDI) and the United States Pharmacopeial Convention (USP), amongst others, also have an important role to play.Subject to invitation from the AUC, the consortium of partners is open to contributions from yet other agencies who are interested in supporting local production in Africa. Conclusion Developing the pharmaceutical industry on our continent can contribute to improved access to essential medicines, sustainability of treatment programmes and to economic development. The PMPA Business Plan sets out a practical approach that recognizes the complexity of the pharmaceutical industry and the different situations that our countries face. A consortium of African and International Partners is being convened to provide coordinated technical assistance and capacity building so that we reduce our reliance on imports, are able to provide high quality affordable products for our people, can sustain treatment programmes in the post MDG era and contribute to economic development through import substitution and exports to international markets.

900 DAYS TO MAKE A DIFFERENCE

BACKGROUND
1. Fighting TB is a prerequisite for fostering economic growth, ending poverty and improving livelihoods - addressing TB must therefore be prioritized in national government programs At a macro-economic level, TB significantly hampers the economic development of middle- and lowincome countries. According to the recent report of the High-Level Eminent Panel on the post-2015 development agenda, investment in TB will yield a 30fold return. T B i s a d i s e a s e t h a t wo r s e n s p ove r t y a n d disproportionately affects poor communities. Studies suggest that TB patients are out of work for an average of 3 4 months; that household incomes decrease by up to 80% as a result of a family member contracting TB; and that each TB death deprives a family of 15 years of income. TB creates a vicious cycle, with TBpatients remaining poor because of the devastating impact it has on their families' life. The 2012 SADC Heads of State Declaration on TB in the Mining Sectoris a response to the economic impact of TB on a prominent African industrial sector. The recent Swaziland Statement highlights solutions for a multisectoral, regional and international response to the problem of TB in Africa.

Studies in Bangalore showed a decrease of household income due to TB diagnosis costs of 80%. In Malawi, studies indicate that the income of a family decreased by 49%, in Yangon/Myanmar by 68% due to a TB infection of a family member. Stop TB Partnership. (2000). Tuberculosis and Sustainable Development. Geneva: Stop TB Partnership.

900 DAYS TO MAKE A DIFFERENCE

1. Accelerated action to integrate TB and HIV services in A f r i c a n c o u n t r i e s wh e re c o infection rates are highest will lead to substantial cost-savings and improved health and economic outcomes A key stumbling block to progress in the fight against TB in the region is the extremely high co-infection rate of TB-HIV. In 2011, 80% of all new TB-HIV cases in the world were in Africa. 75% of all 435,000 people w i t h H I V wh o d i e d o f T B i n 2011worldwide were from Africa. The impact of what can be achieved through integrated TB and HIV services is remarkable: between 2005 and 2011, 1.5 million lives were saved due to TB and HIV integration. While this is notable progress, much remains to be done.Enhanced collaboration between HIV- and TB-services is required, too often patients are still going to different sites, but patients who have both diseases should be seen and treated by one health worker. The objective must be that every HIV patient is tested for TB and every TB patient is tested for HIV, and that treatment is easily provided. Conclusions We are the closest we have ever been to defeating TB forever. Impressive progress over the last five decades shows that TB can be stoppedwith strong political will and adequate financial resources. New tools are now available with which to accelerate progress. We must set ambitious targets against TB if we are to overcome poverty, foster economic growth and save millions of lives. Health Financing in Africa

11

900 DAYS TO MAKE A DIFFERENCE

HEALTH

FINANCING IN AFRICA
The Heads of States' commitment toincrease government funding for health has been emphasizedin the Abuja Declaration of 2001.The same commitment by Heads of state has been reiterated inthe Africa Health Strategy: 2007-2015; the 2008 Ouagadougou Declaration on Primary Health Care and health systems strengthening; the World Health Assembly resolution 68.5 on sustainable health financing structures and universal coverageand the 2012 Tunis Declarationof the Ministers of Health and Finance on value for money, sustainability and accountability in the health sector. There is broad agreement that sustainable,adequate and fair financing for health is one of the prerequisite to achieving country and international health goals and MDGs. Keys messages: Member states of the African Union are onaverage still far from meeting key health financing targets of the Abuja Declaration. In 2010, only 5 countries reached the target of allocating at least 15% of their annual budget to health. Twenty eight countries out of fifty spent the minimum of US$ 44 per capita as estimated by the High Level Task Force on Innovative Financing for Health Systems (HLTF). Only three countries in Africa reached the targets set in both the Abuja Declaration and the HLTF report; Out-of-pocket payments (OOP) still represent more than 20% of total health expenditure (THE) in 40 countriesin Africa.. Only one country has managed to spend more than 15% of their annual budget, the minimal level of US$ 44 per capita expenditure and OOP less than 20% of THE as shown in figure 1. A key challenge for member states and their partners is to ensure effective and efficient use of availableinter national and domestic resources, improved predictability,alignment to national priorities and use of government mechanisms; The reinforced dialogue between Ministers of Health and Finance, as spelt out in the Tunis forum organized by HHA in 2012, has shown increased engagement towards financing for health and improving the effectiveness of available resources. Member States are often challenged by conflicts, natural and man-made disasters with significant public health consequences calling for provision of funds to address these threats; in this regard financing of the African Public Health Emergency Fund (APHEF) by member states should be prioritized.

12

900 DAYS TO MAKE A DIFFERENCE

Financial risks and barriers to access to health not. In general however, raising more public revenues should indirectly benefit the services health sectorwhose share, even it is not As shown in Figure 1, although 29 countries increased, will be from a larger resource have reached the level of US$ 44 THE per envelope. capita, 22 of these haveOOP payments exceeding 20%of THE. This level is higher than External funds for health the ceiling at which financial risk protection Although external sources play a significant can be ensured. Countries that have reached role in financing health services in low the US$ 44 per capita but have a high level of income countries, the current level of OOP payments still need to f ocus on funding still falls below commitments. It developing and strengthening pooled would be possible to achieve a significant prepayment mechanisms. The potential to increase in international resources for identify new sources of tax revenue such as health, if donor countries would fulfill their sales taxes and currency transaction fees can promise to allocate 0.7% of their gross also be further explored. Ghana, for example, n a t i o n a l i n c o m e ( G N I ) t o o f f i c i a l has funded its national health insurance development assistance (ODA). In 2009 scheme (NHIS) partly by increasing the value- only 5 out of the 22 donors met this added tax (VAT) by 2.5%. requirement. Domestic funds for health Key recommendations Many African countries have limited capacity Reinforce financing for to raise public revenue mainly because of the h e a l t h t h r o u g h n a t i o n a l s t r a t e g y informal nature of their economies. This emphasizing appropriate policies for makes tax collection difficult including payroll revenue collection; using sound methods tax collection for social health insurance.The and approaches such as sharing financial p e r f o r m a n c e , a c c o u n t a b i l i t y a n d risks and ensuring equitable and efficient administration of the tax system are often an use of resources. . additional problem for many countries. Concretize engagement The extent to which countries will mobilize toimplement Universal health coverage public financial resources for health will through strong and sustainable health depend on the level of economic development systems based on PHC. in that, countries with a high GDP percapita will do better. This explains to a large extent why Increase funding for health from countr ies, with comparable GGE as a innovative financing, prepaid mechanisms percentage of GDP will have significantly and pooled sources for health. different levels of THE per capita. Gabon is an example here with a government expenditure S u s t a i n t h e c u r re n t p ro c e s s o f of US$ 2410 per capita while others, with a dialogue between ministries of health and similar share of GGE over GDP (28%) for f i n a n c e t h r o u g h i n t e r - m i n i s t e r i a l example Malawi, spend only US$ 110 per committees, strategic alliances, and the capita on health. presence of senior health officials in bilateral and multilateral discussions The capacity of countries to generate public between government and development financial resources lies outside of the health partners. sector to a large extent. Health advocates wishadditional revenue streams to be Prioritize fundingof the African earmarked for health but very often they are Public Health Emergency Fund, which was

14

900 DAYS TO MAKE A DIFFERENCE

established by Ministers of Health and endorsed by the AU head of state of the AFRO region. Improve effectiveness of external funding through addressing identified challenges among such as unpredictability and fragmentation of health systems..
AU: Abuja declaration on HIV/ADS, Tuberculosis and other related infectious diseases. Abuja, Nigeria, April 2001. CAMH/MIN: Africa Health Strategy (2007-2015). Addis Ababa, Ethiopia, November 2007. WHO/AFRO: Ouagadougou declaration on Primary Health Care and health systems strengthening: Achieving Better Health for Africa in the New Millennium. Ouagadougou, Burkina Faso, April 2008. WHO: The Sixty-fourth World Health Assembly on Sustainable health nancing structures and universal coverage. Geneva, Switzerland. May 2011. HHA: Tunis declaration on value for money, sustainability and accountability in the health sector. A joint Declaration by the Ministers of Finance and Ministers of Health of Africa. Tunis, Tunisia. July 2012. AU: Decision on the Establishment of the African Public Health Emergency Fund (APHEF) Doc. Assembly/AU/18(XIX) Add.4. Dec.436(XIX). The indicator %GGHE/GGE does not necessarily mean domestically generated resources only. If external resources are owing through the government, these will be captured as well. Governance, taxation and accountability: issues and practices. Organization for Economic Co-operation and Development. Paris. 2008. WHO/AFRO: State of health nancing in the African Region. Brazzaville. January, 2013.

15

900 DAYS TO MAKE A DIFFERENCE

Burden of disease The African Region has a high disease burden, with only 10% of the world population, the Region's contribution to the global burden of HIV/AIDS, TB and malaria is 66%, 26% and 80% respectively. In general it contributes24% of global DALYS. It accounted for 46% of Under-five deaths in 2011; 55% of the maternal deaths; 22% of AIDS-related and 90% of the malaria deaths. Thirteen countries are on track to meet MDG 4, while 24 are making progress, though insufficient. Only two countries (Eritrea and Equatorial Guinea) are on track to meet the MDG 5 target. Issues and challenges related to health systems The goal of a health system is to improve the health of people in a manner which is equitable, efficient, responsive and financially fair. A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction to function. Strengthening health systems thus, means addressing key constraints in each of these areas. Some of the weaknesses and challenges identifiedinclude weak policies and guidelines; low public expenditure on health with only five countries reaching the Abuja 15% target; shortage of adequately trained and motivated health workers; inadequate supply and regulation of essential medicines, medical products, and technologies; fragmentation of the health information system which is not fully utilized and, low coverage of health services. In addition, health systems are sensitive to weak governance, accountability, political instability, natural disasters, underdeveloped infrastructure, and economic and financial instability. Opportunities for Health Systems Strengthening There is a strong and growing political willingness at various levels to strengthen health systems. Governments have increased the proportion of their national budget allocated to health. Regional initiativesundertaken include the Abuja Declaration to increase government funding for health, the Ouagadougou Declaration on Primary health care and health systems in Africa, the Africa Health Strategy 2007-2015 of the AU and, the Tunis Declaration on value for money, sustainability and accountability in the health sector. The region has shown innovation through increased and structured participation of communities to improve the coverage of essential services through Community Extension Workers as seen in Ethiopia, Rwanda and Mali. The amount of Overseas Development Aid to the health sector has increased. Some global health initiatives such as the Global Fund and the GAVI Alliancehave opened financial windows for health system strengthening. Global and regional partnerships such as the International Health Partnership (IHP+) and the Harmonization for Health in Africa(HHA) have the objective to move towards better coordination and alignment of donor funds to country priorities. These are all important conditions for effectively strengthening health systems to meet the MDGs and move towards universal health coverage.

17

900 DAYS TO MAKE A DIFFERENCE

Recommendations Governments should provide political leadership with effective regulation, oversight and governance for health through formulation of national policies, strategies and plans. Governments' investment plans should focus on building institutional capacity, promoting equity in access to services by decentralizing health systems and, enhancing community empowerment to participate in the management of health services through a high commitment to PHC approaches. Increase investment in health by allocating more funds to health from national budgets whilst ensuring efficient utilization of all available funding. In addition, there is need to reinforce advocacy for sustainable financing of health systems. Countries should seize the opportunity of resources provided by global health initiatives to strengthen the health system in a comprehensive manner. Through independent bodies, countries should develop a scorecard on health system performance and regularly high authorities on the progress made in health system strengthening. Strengthen all the building blocks of the health system; increase the quantity and quality of the health workforce, ensure availability and rational use of essential medicines and other health commodities, improve and expand available infrastructure, improvehealth information management systems and IT innovation. Conclusion Effective public health interventions are available to curb the heavy disease burden in Africa. Unfortunately, health systems are often too weak to efficiently and equitably deliver those interventions to people who need them, when and where needed. Strong health systems are an effective means of improving the health of the people of Africa.In addition to health being a human right, the dividend of a healthier population in Africa is very high given the fact that healthy individuals are more productive, and have a positive impact on the gross domestic product (GDP) of a Nation. Therefore, investing in African health systems is an opportunity to accelerate economic development, contribute to saving millions of lives, prevent life-long disabilities, and move countries closer to achieving objectives of national poverty reduction strategies, the Millennium Development Goals (MDGs) and prepare them to move towards meeting the challenges of the post 2015 development agenda

18

900 DAYS TO MAKE A DIFFERENCE

Special Summit on HIV/AIDS, Tuberculosis and Malaria

POLICY BRIEF: ELIMINATION OF MATERNAL TO

CHILD TRANSMISSION
JULY 2013, ABUJA, NIGERIA

Scientific advances and their implementation have brought the world to a tipping point in the fight against AIDS. The science guiding interventions that address HIV risk reduction, prevent transmission, and reducemorbidity and mortality is now clear and established. Enhanced country and programme capacity, improved efficiencies, increased community engagement and participation, and innovative application of new technologies are helping scale up the accessibility and utilization of programme interventions, and achieving an 'AIDS-free generation' is now within reach. Eliminating new HIV infections in children and keeping mothers alive is critical to achieving this goal, and the Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, endorsed by Africa leaders, UN agencies, and development partners and launched in 2011, has set a goal of reducing new infections among children by 90% from baseline 2009 levels. Of the world's 34 million people living with HIV, 23.5 million are in Sub-Saharan Africa, and 21 of the Global Plan's 22 focus countries are in Africa. African women bear the majority of the world's epidemic. 92% of all pregnant women living with HIV are in Sub-Saharan Africa, and 60% of Africa's infections are among women. Without intervention, up to 40% of these women would pass infection on to their babies. Much progress has been made, particular in eliminating new infections among children, with a 24% reduction in new infections among children between 2009 and 2011, and a 40% reduction since 2003. In Africa, 7.1 million people are now receiving treatment, and 57 per cent of pregnant women l iv i n g w i t h H I V re c e ive d e f f i c a c i o u s antiretrovirals (ARVs) for prevention of mother to child transmission (PMTCT). Access to early infant diagnosis (EID) for HIV within the first few weeks of life by infants born to women with HIVinfection has increased to 35% in 2011, and while paediatric ART coverage has steadily increasedonly 28% of children needing treatment received it %in 2011. .

19

900 DAYS TO MAKE A DIFFERENCE

womenshould make concerted efforts to fully address other programme components needed to achieve elimination goals, including primary prevention among women of reproductive age,family planning and birth spacing and treatment for the health of the mother It remains essential to include women, their partners, PLHIV networks, communities, civil society, and the private sector in the design and implementation of programmes scaling up access to care, treatment, and support services. Efforts must be pursued to ensure that health service delivery mechanisms for both MNCH and care and treatment platforms are responsive to the needs of pregnant and postnatal women living with HIV, and to the ongoing needs of these mothers, their partners, and families. Universal access depends on communities supporting adolescent and family friendly HIV testing and counseling, without stigma and discrimination, and concerted national and subnational leadership is needed to make universal access a reality. 2) Leveraging synergies, linkages and integration for improved sustainability. Integrating HIV prevention and treatment for mothers and children into existing platforms for maternal, newborn, and child health, antenatal care, and family planning, will strengthen synergies, optimize outcomes for all women, and increase cost effectiveness and sustainability. Prevention and treatment should not be 'standalone', one time interventions, and more effective integration should not only increase access but also promote entry into a continuum of care across multiple health services, ensuring that HIV interventions contribute to global maternal and child health goals and strategies. This is particularly true in Africa, where the AIDS epidemic accounts for significant proportions of maternal and child mortality and morbidity. Integration is essential for improving loss to follow-up, strengthening referral linkages, effectively linking primary health care and treatment, increasing maternal and child access to longer term treatment, and promoting community mobilization and engagement. 3) Country ownership and accountability. Because countries have diverse epidemics and are at different stages of implementation in their efforts to eliminate new infections among children, it is essential that the leadership and development of context specific elimination plans rest at the country level. Strategic planning, priority setting, and performance monitoring must be led and coordinated at both national and decentralized levels, in collaboration with all critical stakeholders. Efforts to improve monitoring and progress reporting should also promote more active use of data for programme planning, priority setting, and decision making at decentralized levels. Country programs and their development partners must make adequate human and financial resources available and adopt evidence-informed policies. The sharing of best practices and lessons learned across countries needs to be improved, and additional support provided at regional levels to promote effective frameworks for cooperation and accountability. The roles, responsibilities, and contributions of all stakeholders need to be clear, specific, and transparent, and to ensure the efficient and effective use of resources, as well as address agreed upon gaps, bottlenecks, and capacity building needs, national leadership is needed to ensure the adoption and utilization of clear monitoring and evaluation frameworks and indicators to promote accountability and routinely assess programme progress.

21

900 DAYS TO MAKE A DIFFERENCE

AIDS, TB and Malaria have remained high on the African Union political agenda with several commitments to address the challenge since the 2000 and 2001 (Abuja Declaration). Over the past twelve years, AIDS Watch Africa has served as an African-led advocacy and accountability platform to press for the urgent acceleration of continental action to combat AIDS with a broadened mandate in 2012 to also address TB and Malaria. Timeline of the African Union and AIDS Watch Africa key commitments 2001: Abuja Summit on HIV/AIDS, TB and Other Related Infectious Diseases, eight Heads of State and Government; AIDS Watch Africa (AWA) created as an advocacy platform at Head of State level to monitor the African response and mobilize resources.

Accountability
Introduction Accountability has been identified as a key factor in improving the response to AIDS, TB and Malaria and the broader health and development agenda in Afr ica and worldwide. Accountability and transparency plays a key role in promoting health policy development and health care service d e l i v e r y. A c c o u n t a b i l i t y i s ensured through information provision on set targets and commitments, ensuring feedback mechanisms, consultation and participation of key stakeholdersat all levels.

2003 Maseru Declaration on HIV and AIDS/ Maputo Declaration on Gender Mainstreaming/ Maputo Declaration on HIV/AIDS, TB, Malaria 2004: AWA Secretariat was relocated to the AU Commission 2003 The Protocol Relating to the Peace and Security Council (PSC) of the African Union (especially around violence) 2004-2005 Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa (Maputo Women Protocol) 2004 Solemn Declaration on Gender Equality in Africa (SDGEA) 2 0 0 5 : C o n t i n e n t a l H I V / A I D S S t ra t e g i c Framework and AWA Action Planapproved 2005: Maputo Plan of Action for implementing the Continental Policy Framework on Sexual Reproductive Health and Rights (SRHR)

22

900 DAYS TO MAKE A DIFFERENCE

2005 Continental Policy on Sexual and Reproductive Health and Rights, (Maputo Plan of Action related) 2006: Brazzaville Commitment on Scaling Up Towards Universal Access t o H I V a n d A I D S p re v e n t i o n , treatment, care and support in Africa by 2010 2006: R e a f f i r m a t i o n o f A b u j a Declaration Plan of Action Special Summit of the AU on HIV/AIDS, TB, and Malaria (ATM) adopted 2006 Maputo Plan of Action, Plan of Action on Sexual and Reproductive Health and Rights 2007-2010 (renewed till 2015) 2007: African Union Ministers of Health adopt Africa's Health Strategy; 2010: A U H e a d s o f S t a t e a n d Government approve A Partnership For The Elimination of Mother-Child Transmission of HIV in Africa 2010: African Union launches Campaign f or the Accelerated Reduction of Maternal Mortality in Africa (CARMMA) 2011: AU adopts Common Position on HIV/AIDS in activities pertinent to the prevention and resolution of conflict and post-conflict peacebuilding 2012: AU Heads of State and Government adopt the African Union Roadmap on AIDS, TB and Malaria (2012-2015) Translating political commitments into action

While political commitments play a vital role in delivering results, critically impor tant is the need to translate commitments into action. To ensure that that this is achieved accountability mechanisms need to be institutionalised to hold all stakeholders accountable to set targets. The revitalisation of AIDS Watch Africa in 2012 is a significant step in e n s u r i n g t h a t t h e re i s H i g h L eve l Accountability on the three diseases. The Alliance of African Leaders on Malaria in Africa has taken key steps in ensuring that governments remain on track on their Malaria commitments.Various civil society organisations have developed scorecards on AIDS, TB and malaria related to the African commitments and haveemployed various engagement strategies including lobbying and advocacy at various levels to ensure implementation of commitments. Accelerating the implementation of African Commitments on AIDS, TB and Malaria Over the years, quantitative and qualitative approaches to measure the performance of various stakeholders against their commitments have generated some re c o m m e n d a t i o n s t o i m p rove t h e implementation of these commitments. -Need to ensure that sets targets are measurable- there is need to ensure that commitments arequantifiedand costed to adequate monitoring and evaluation. -Commitments have no teeth without the money to back them up-Funding is required by governments in order to roll out commitmentsIf a commitment is left unfulfilled and unattained they become toothless, and this has a knock on effect for other commitments. Every commitment that is made and then ignored and not attained undermines the entire process of having commitments.

23

900 DAYS TO MAKE A DIFFERENCE

-Government needs to be involved more in the drawing up of the recommendations early in the process.In many countries government still sits with more knowledge of what is really happening on the ground and what can be realistically rolled out than any other group, including civil society and funding partners. They need to be consulted and their political buy-in secured from the early stages of the design of the commitments. -Tracking mechanisms for various commitments do not exist- There is need to ensure that the impact and roll out of commitments is monitoring and evaluation systems exist to track progress, outcome and impact. -The roles of implementing partners in the commitment should be clearly spelled out to ensure clear division of labour for greater accountability. -Civil society should not undermine thelong term accountability mechanisms or capacity of government and development partners- governments are ultimately accountable government to provide services.

24