As with the educational sector, so with the health sector. Cost recovery programmes as well as pay disputes have interrupted the
B. The Demographic Situation
216. The African population, estimated at 744 million in 1995, will double in 23 years at the current growth rate of about 3 per cent per annum. The rapid rate of growth has made rational management of resources difficult, as population pressures contribute to unsustainable use of natural resources and environmental degradation - both of which in turn accentuate poverty. In 1985-1990, all the major regions of the world except Africa had population growth rates lower than those in 1950-1955. Africa's current rate of population growth is ftP0ve that experienced in any other region during the last 40 years. On the whole, the African demographic profile is characterized by high fertility levels, and current estimates indicate that the average number of children per woman was 6 in
17
United Nations, World population Prospects: the 1992
Revision, 1993, p.12. Sales No. E.93XIII.7.
Africa, compared to 3.21 in Asia and 3.05 in Latin America and the Caribbean. A survey carried out in 1992 by the UNFPA in 41 selected African countries reve~led an average number of children per woman ranging from 6 to 8.5 . The high fertility levels are associated with high infant mortality rates (IMR) of 103 deaths under the age of 1 year per thousand live births. Maternal mortality rates per 100,000 births and under-five mortality rates (U5MR) per 1,000 live births, at 650 and 165, respectively, are among the highest in the world. These figures, as shown in table IV.1 below, mask significant differences among countries.
Table IV.1
Some basic demographic indicators in selected African countries 217. Developing Africa is experiencing an unusual high rate of urban population growth, at around 5 per cent per annum during 1970-1990, compared with 3.43 per cent for Latin America and 3.97 per cent for South Asia, the other two regions with high population growth.
The current level of urbanization in Africa, at 35 per cent, is comparable only to that of East and South Asia, which have been estimated at 29.4 per cent and 29 per cent, respectively. The rapid urbanization in Africa has been particularly acute in the last decade in Addis Ababa, Cairo, Dar es salaam, Lagos and Kinshasa, shown in Table IV.2 below. The African urban population is poised still for a higher growth with its built-in momentum of high fertility rates and declining mortality rates. This implies an urban population which, rising from an estimated 217 million in 1990, is expected to reach 544 million by 2010 and 783 million by 2020 - an almost four-fold increase. By the latter ye9~ some 54 per cent of the population would be living in urban areas.
218. This rate of urban population growth will have profound consequences for the economies of African countries and the lives of their city dwellers. They will culminate in: intolerable pressure on the already over-stretched social infrastructure, especially housing, water and sanitation, health and educational facilities; growing unemployment and underemployment; the misery of urban slums, shanty towns and peri-urban areas; rapid environmental degradation; and anti-social behaviour.
219. In Africa's exploding cities, intense congestion and increased pollution (with its hazardous effects on the health of the population) pose immense health problems for a population already over-burdened by pr Ima ry poverty and the pressures of economic adjustment and reform.
18 UNFPA, Population Issues : Briefing Kit, 1994, p. 11.
19 Estimates prepared by the Population and the and Human Settlement Divisions of the Commission for Africa (ECA), 1994, p.58.
Industry Economic
Table IV.2
Trends in population of selected African cities, 1970-1990 and projections for 1995 and 2000
(Thousands)
220. since 1980, African total fertility rates (TFR) have been on the decline, albeit very gradually. Kenya, for instance, which had one of the highest rates in the world almost 8 births per woman -is experiencing a decline, thereby reducing the average for the East Africa sUbregion 20. Use of contraceptives, education (particularly at the second and third levels), increased labour force participation by women and the impact of population policies - are among the most important instruments in the campaign to reduce fertility rates in the region. The percentage of the population using contraceptives, however, is among the lowest in the world: i t ranges from 9 per cent
in sUb-Saharan Africa to 36 per cent in North Africa.
221. Despite the emphasis in many of the seminal documents and plans of action emanating from Africa on the importance of population factors in development planning, concrete progress to date has, with some exceptions, been limited, and most Governments are yet to formulate concrete policies geared to lowering the high population growth rates, let alone implementing such policies. By 1992, only 15-20 African countries had explicit population policies geared to reduction or stabilization of the growth rate through changes in some aspects of national demographic behaviour, and the redress of the negative effects of rapid population growth on development efforts.
The lack of effective policy in this regard can be attributed in part to the lack of political commitment, inadequate resources, ineffective co-ordination of activities and insufficient data.
222. Important as they are in the harmonizing of the demographic trend with the objectives of development, population policies may not by themselves suffice to halt population expansion, let alone bring about the desired transition. poverty, the slow pace of economic growth and the extreme neglect of critical issues relating to social development are at the heart of the population problem. Indeed, rapid economic development is an essential condition for the slowing down of population growth. As reiterated at the united Nations International Conference on Population and Development, held at Cairo, Egypt, 5-15 September, 1994, the inexorable link between eradicating poverty and sustaining development is such that the former must be viewed as central to the policy to slow population growth and achieve population stabilization by an early date.
Increased investment is imperative in fields where i t plays an important role in the eradication of poverty - for example, in basic education, reproductive health, sanitation and the provision of drinking water, housing, adequate food and nutrition, gender equity, equality and empowerment of women. In short, the objectives and
20 United Nations, World Population Prospects: the 1992 Revision, op. cit., pp.23-24.
goals of the Programme are consistent with population, family and
of Action endorsed at the above conference21 those of the Dakar/Ngor declaration on sustainable development.
223. Rapid population increases are antithetical to environmental stability and sustainable development. The symbiotic relationship between poverty and environmental degradation has long been known;
it was pithily brought to the fore at the united Nations Conference on Environment and Development, held at Rio de Janeiro, Brazil, in 1992 and was strongly emphasized in its Agenda 21. Unfavourable spatial distribution of the population, large-scale displacement, and damaged ecosystems are all symptomatic of environmental degradation.
The imbalance between resources and rapid population growth rates is reflected in the poor water filtration, faster soil erosion and depletion of soil nutrients, food insecurity, famine, droughts, desertification and deforestation. Deforestation has culminated in the loss of 80 per cent of Africa's pasture and range areas.
C. Health
1. How achievable is "Health for all" by the year 2000?
224. The International Conference on Primary Health Care, sponsored by WHO and UNICEF at Alma Ata, USSR, 6-12 September 1978, declared Primary Health Care (PHC) the cornerstone of health development globally. Within that framework, health and socio-economic development w~re to be treated henceforth as closely interconnected. Subsequently, with the Declaration of Health for All by the Year 2000 (HFA/2000), PHC became the main vehicle for achieving that target. Following the global initiatives, the African Ministers of Health adopted the African Health Development Framework in 1985 , followed by the Bamako Initiative. Both documents are grounded in the principles laid down at Alma Ata, and both called for people-centred health care ser~ice and community-oriented health policies. The Bamako Ini tiati ve emphasized, in particular, the adoption of low-cost approaches, the decentralization of services, and the important community participation.
225. However, as the health indicators in table IV.3 below show, the declarations have had little impact on the African health landscape so far. The decay which has taken place in the health infrastructure and the failure to implement programmes of PHC in full have had catastrophic consequences on the health status of most
21
22
23
Programme of Action of the united Nations International Conference on population and Developmen~Cairo, Egypt, 1994
WHO/UNICEF, Primary Health Care: Reoort of the International Conference on Primary H.ealth Care, Alma Ata, USSR, 6-12 September, 1978.
WHO/UNICEF, Toward Maternal and Child Health Care for All: A Bamako Initiative, Mali, 9 September 1978.
people in the region, especially women, children and the poor. As the Regional Director of WHO in Africa once pointed out:
" ... most health ministers are obliged to spend their health budgets on curative care. They are caught in a vicious circle -more money is spent on curative medical and surgical care, so
less is available for health promotion and disease prevention.
consequently there is an increase in the burden of disease and injuries, whicH necessitates even more money for hospitals and specialists ".
Table IV. 3
Selected health indicators in African countries
226. The combination of severe socio-economic crisis and the lack of serious orientation and implementation of PHC have regrettably culminated in the erosion of past achievements in the health sector and the recrudescence of previously controlled diseases. The importance of PHC re-emerged on the agenda of the above mentioned Cairo Conference, which called for measures to achieve a life expectancy at birth in Africa at 65 years by 2005 and 70 years by 2015. The Conference also urged member States to make strenuous efforts to reduce morbidity and mortality differentials between males and females, as well as between g~~graphicalregions, social classes and indigenous and ethnic groups .
227. Immunization coverage is tending to decline in a growing number of developing countries. In Africa, except in the case of BCG, coverage of children i~ still generally below what pertains in other regions of the world 6. Major outbreaks of diphtheria and measles continue to affect children who could be protected if
imm~ization programmes were given a high priority. As WHO points out , declining or static levels of immunization coverage and continued high fatality rates in many areas are clear indications of the need to step up efforts. The benefits of immunization are cut across many areas of child health. Immunization against measles and pertussis, for example, contributes significantly towards the containment of acute respiratory infections, especially pneumonia, which is the biggest single killer of children. For that matter, the
Meeting the Challenge of Health for All Mission of WHO in Africa from 1995 to of Significant Achievements 1985-1994, WHO Regional Director", WHO/AFRO, Congo, p.3.
G.L. Monekosso, Africans, liThe 1999, A Decade Profile of a Brazzaville, the
24
25 UN, Programme of Action of the United Nations International Conference on Population and Development, Ibid, p.45.
26 WHO, The Work of WHO: 1992-1993 Biennial Report of the Director-General, p. 85.
27 1.!2.j.g , p • 87.
provision of sanitation and safe drinking water dramatically reduces mortality and morbidity from such endemic diseases as cholera, dysentery and diarrhoea, while widespread use of oral rehydration therapy (ORT) -which is extremely cheap and easy to administer - can save millions of lives of children.
228. There is another growing health hazard in Africa. It emanates from the devastation caused by the innumerable landmines in areas of past or present conflicts. According to the WHO Pan-African Centre for Emergency Preparedness and Response, landmines in Africa have:
"wide, and long lasting consequences for the population, the health services and the socio-economic fabric of the affected countries. Besides killing and disabling people, landmines preclude access to water, farming land, firewood, markets, schools and health facilities with a dramatic impact on the natural environment, the life of the communities, and the economy of a coun1:ry... And the fact that the civilian casualties of the la.ndmines are mainly women and children adds to the magnitude and gravity of the tragedy. One woman killed or mutilated represents higher risk of illness or malnutrition for the entire family, one disabled child represents a long-term burden to the health services of the society at large.
In war and in its aftermath, landmines, besides the workload represented by the wounded and disabled persons, pose a threat to Health mobile-teams, logistics, etc: the outcome will be reduced coverage and effectiveness for all PHC activities.
Heal th will lose personnel, equipment and supplies; funds will be diverted into tertiary care and long-term hospitalization, as well a~ towards staff insurance and disability allowances".
229. Though substantial efforts are being made by a number of African countries to improve the health status of their citizens, i t is clear from the foregoing discussion that the general health of the people can only be described as unsatisfactory, with vulnerable social groups such as ch.i.Ldren and women being the worst affected.
Unfortunately, with only five years to go and no significant positive changes in sight in social policy and planning, i t is doubtful that
"health for all" will be achieved in the region by the year 2000.
2. The HIV scourge and AID Pandemic in Africa
230. HIV!AIDS has enormously exacerbated the African health crisis.
Of course, other diseases, such as malaria, still claim many more lives. But the former affects the most productive segment of the labour force (15-49 years), has no cure and has more complex socio-political dimensions. In addition, HIV destroys the immune system, thereby making patients more susceptible to HIV-related infections
28 WHO, Pan-African Centre for Emergency
Preparedness and Response, Bulletin, Vol. 2, No.1, January 1995, pp. 1-2.
and complications. A case in point is the recent resurgence of tuberculosis (TB) , the incidence of which, in some cases, has doubled or even tripled since 1985. Recent data indicates that up to half the people newly piagnosed in Africa as having pulmonary TB are also HIV-Positive2 • Untreated sexually transmitted diseases (STDs) are also heavily implicated in the spread of HIV. WHO estimated in 1944 that there were over 10 million cases of HIV infection i~oAfrica
and projected a staggering 14 million cases by the year 2000 . The pandemic has been most severe in cities of East, Central and Southern Africa, where 25-30 per cent of all adults are infected and more thftn 20 per cent of all hospital beds are encumbered by AIDS patients . However, HIV is relentlessly spreading to other parts of the region.
For example, surveillance data from Nigeria in early 1992 indicated extensive spread of HIV in the country, with rates of 15-20 per cent in certain groups of female prostitutes. In Abidjan, COte d'Ivoire, where AIDS is already the leading cause of death among adults, HIV
prevalenc~ in the general population is currently thought to be 10-12 per cent" .
231. Findings from a number of studies indicate that in addition to the large number of orphans, HIVj AIDS is currently affecting disproportionately the groups with the highest levels of productive skills and human capital. The economic consequences of the epidemic are already to be seen in the declining levels of labour productivity and in a significant reduction of labour supply, especially in the most seriously infected areas of East and Central Africa.
232. To contain the HIVjAIDS pandemic a number of modalities have been adopted, especially in the countries most seriously affected.
They include media campaigns, community mobilization programmes, person-to-person education, promotion of condom use and control of STDs. To some extent these strategies have helped to change the sexual behaviour of some people, particularly in the severely affected areas. However, widespread dissemination of information, education and communication, on which so much hope of reducing the pandemic is contingent, have proved ineffective for the most part.
In addition, denial, complacency, poverty and stigmatization of infected people have combined to reduce the effects of those measures. Consequently, there is need for aggressive social mobilization, directed towards community participation, co-opting community opinion-leaders as the central pivot and agents of the campaign to bring HIVjAIDS under effective control. Success, however, will obviously depend on the political and financial support of African Governments, which is by no means assured at present.
29 30 31
32
WHO, AIDS: Images of the Epidemic. 1994, p. 7.
Ibid, p. 9.
WHO, "HIVjAIDS and Development in Africa", The HIV(AIDS Epidemic in Africa: an Overview, Conference at the African Development Bank Annual Symposium 1993, p.2.
WHO, AIDS. Images of the Epidemic, 1994, p.20.
3. Malnutrition
233. Food and nutrH:ion are major areas of concern in Africa.
continued food insecurity is evidenced by the fact that 33 per cent of the population is chronically undernourished. Drought, especially in Southern Africa, led to 18 million people being exposed to possible famine in 1991; and intractable civil wars and political instability, particularly in the Horn of Africa, created great ne~s
for food emergency action for over 15 million people in 1992 • Ethiopia continued to be at risk from famine, even in 1994: i t was then dependent on an estimated 1 million tons of food aid. In Somalia and the Sudan, a combination of drought and civil unrest has placed over half the population at risk from famine, while in Kenya, as a result of poor rains, 961,000 people were judged to be drought-affected in 1993, of whom 679,000 were in immediate need of relief assistance. The decline! in per capita food
33 World Food Programme, 1993 Food Aid Review, p.22.