The MAP has the following characteristics:
- It comes with streamlined procedures to permit faster preparation. Funds
will be available for all prevention, care, and treatment activities and to
build capacity;
- The central goal of the program is to help achieve truly national coverage.
One of the key tools would be a mechanism to ensure that a large share of the
money flows directly to communities to support their own local responses.
When we took the MAP to the Board in September 2000, we took two fully
negotiated country projects as examples. These countries are Ethiopia and Kenya.
The two countries fulfilled the eligibility criteria of the MAP and both country
projects became effective in January 2001. At this point, $ 60 million dollars
were committed to helping Ethiopia fight the AIDS epidemic under the MAP
program.
As I mentioned earlier, the MAP has a unique funding scheme where two
separate accounts are set up to funnel money into the country's HIV program. A
fund called the Emergency Fund goes directly to communities, NGOs, the private
sector bypassing the different layers of bureaucracy. In addition, communities
can be funded from the other account. All governments have to agree to provide
40-60% of the loan directly to the community. This is very unusual.
Under the Ethiopian MAP with 60 million dollars in funding, Ethiopia is
already making tactical changes in building up capacity in its health systems.
For example, the number of Woredas reached through the MAP fund has reached 240
(6709 Kebeles) well beyond the initial target of 165 wards. The number of
woredas are expected to increase over the next year.
In terms of the facilities and technology, it already established 170
functional VCT centers and it plans to add 20 more in rural areas. Twelve
machines to test CD4 count and 12 more to test viral load are being installed in
Addis Ababa and surrounding regions. The number of PMTCT centers is also growing
with an additional 47 sites on top of the already established 47 centers.
Millions of the MAP fund have already been used for equipments and drugs.
In addition thousands of communities have received direct funding from the
MAP. However, I believe that there is a lot more that can be done.
The World Bank, however, is not alone in this challenging road towards
AIDS-free Africa. In Ethiopia, GFATM has committed $137 million for the first
five years of which $ 55.3 million is allocated for the first two years, while
PEPFAR plans to allocate $ 40 million for the first year.
Now, I would like to return your attention to the issue of the challenges
posed by HIV/AIDS to the capacity and the development of the African health
systems. As I discussed in the first half of the presentation, the World Bank as
well as other major donors have been fully committed to fund Africa for its
fight against HIV/AIDS.
However, money is not the only solution. Now we have the strong international
commitment and financial resources, we must move forward in order to utilize
this financial support wisely and meaningfully.
One of the major challenges in Ethiopia and in Africa in general that I see
in order for them to fully take advantage of these financial resources is the
limited capacity of the health systems.
It is clear that the dilapidated health systems of the continent are the
weakest link in the progress towards AIDS-free Africa. The recent trend in
international and bilateral treatment initiatives is going to serve as a reality
check for the countries to realize the undeniable truth that adequate health
systems are indispensable part of reaching objectives such as the "3 by 5
initiative": (treating 3 million infected persons by 2005) recently launched by
WHO. One of the assumptions of the "3 by 5 initiative" is that "sufficient
numbers of qualified staff are trained, recruited or return to the health
sector..." which is expected to arise from "National plans for human resources
development and Measurable progress in their implementation". The fact is that
such an assumption is indeed needed to achieve and sustain this objective of 3
by 5 . However, in order for this to become a reality, in addition to an
increased need for skilled workers, more specific and massive investment is
required to improve the health services as a whole.
As health professionals, we are well aware of the consequence of commencing
ART treatment to the AIDS patients - that the ART treatment is for a life time.
And this requires sustained availability of trained health care workers and
adequate health systems that could sustain such services to millions of infected
people for a life time.
The question now is "is Africa ready for this?" As I mentioned before, Africa
cannot afford to wait for the ideal infrastructure and the capacity to be in
place. So, what must we do?
Let us first take a closer look at the current situation of the African
health systems.
First of all, one of the crucial aspects in delivering quality health
services is the facilities. A survey from 1998 by the World Bank funded
Ethiopia-Health Sector Development Program found that many existing facilities
in SS Africa are in an advanced state of disrepair; 47% of hospitals, 33 % of
health centers, and 47 % of health stations, require major repair or complete
replacement.
Only 65 % of surveyed hospitals, 28% of health centers and 57% of health
stations had at least 75% of the recommended supplies of basic drugs on-hand.
These results demonstrate that the capacity of the health systems in terms of
the physical buildings and commodities necessary to provide adequate and quality
services is being severely compromised.
The capacity of the health system in the physical sense of facilities and
commodities is important as HIV/AIDS represents an increased need for
specialized testing and treatment facilities with relatively sophisticated
laboratory support. For example, proper testing facilities are needed for VCT
programs.
Secondly, improving facilities and having the right (and enough) products
would be meaningless if people cannot access them. Although access to basic and
adequate health care should be an equity issue not a health problem, it is still
one of the more serious and fundamental problems in improving the health of
Africans.
For example, in Ethiopia, a large country with population of 71 million, only
about 45 % of the population have access to a health facility (access defined as
having a health facility at most 10 km away). Coverage of basic health services
and infrastructure in the country is very low. Child immunization rates are 28 %
each for DPT and polio and 22% for measles. Only 10 % of all births in Ethiopia
are attended by trained health personnel, compared to approximately 60% in
Tanzania and 34% in Sub-Saharan Africa overall. Furthermore, only 10 % of
Ethiopians have access to proper sanitation facilities and 18 to 24 % to safe
water, the availability being highly skewed in urban areas. As if this is not
enough, Africa has a raging HIV/AIDS epidemic. Therefore, improving access to
available health care seems to be one of the top priority in strengthening the
African health systems.
Access to care holds the key to success in many aspects of the existing and
future HIV programs. For example, for a VCT program to be successful, a person
using the service must make at least three trips to the facility; for initial
counseling, testing and to find out the result. If accessing the facility is a
problem, that could be a huge factor for the person to not come back and find
out the result of the test.
Another example is providing people with ART. It is crucial for people to
take the medication consistently everyday. For that, there needs to be a proper
infrastructure for procurement of the drugs and consistent and reliable
mechanism of their delivery.
Thirdly, human resource is at the core of health systems and is crucial in
realizing the health and development goals in Africa. However, the current
situation in Africa is quite distressing. SS Africa has the lowest ratio of
health workers to population anywhere in the world, and Ethiopia the lowest.
According to the most recent WHO estimates of health personnel (2003), the
situation in Ethiopia sends some alarming messages. Compared to its neighboring
countries, Ethiopia's health worker to population ratio is extremely low. It is
estimated that there is only 3 physicians and 6 nurses per 100,000 Ethiopians.
The capacity of training schools and the trend of migration and brain drain
of health professionals also contribute to the problem of serious shortage of
health professionals in SS Africa. For example, Kenya has only retained 600 of
6000 physicians trained in public hospitals according to its Health Minister. In
Zimbabwe, only 360 of 12,000 physicians trained during the 1990s were practicing
in their country in 2000; half of those trained in Ethiopia and Zambia have also
emigrated (Frommel, 2002).
In short, Ethiopia has one of the lowest health worker to population ratio,
the worst health indices with 1/3 - 1/2 of its locally trained doctors abroad
and the fastest population growth.
Overall, the HIV/AIDS epidemic has devastated every aspect of the health
services in SS Africa. It is clear that a decline in health status in SS Africa
in the past two decades, is largely due to the epidemic. Indeed, life expectancy
is estimated to have dropped for 17 of the 48 countries between 1970 and
1999(1).
The Ethiopian health care system is no exception. It is stretched beyond its
limit as it not only deals with a growing number of AIDS patients and the loss
of health personnel due to death and illness, but also copes with rising cases
of tuberculosis and other opportunistic infections. In Ethiopia, the current
life expectancy at birth of 42 years is expected to decline to 39 years by 2010,
paralleling trends in neighboring countries.
There are also some disturbing figures. Kinoti (2003) reviewed UNAIDS and
World Bank data indicating that mortality in HIV negative patients was rising in
Kenya (14 to 23%) at the same time as admission of people not infected by HIV in
a Nairobi hospital decreased by 18%. This is partly because such patients were
being admitted at late stages of disease due to the tremendous burden of the
AIDS epidemic on the health services.
What are the lessons and where do we go from here?
I deliberately chose to use HIV/AIDS as an example not only because it is my
specialty but also as a very good example to show the miserable state of health
services on which the epidemic capitalized on. I would like us to focus on two
issues here; the first one is resources and the second capacity.
Let us look at resources first, if you look at the two health and HIV/AIDS
Bank funded projects, the health project of 100 million USD which was meant to
be a three year project took seven years to complete. The HIV/AIDS project was
for US 60 million for a period of three years. By the end of the three years
only half of the money was used. The project has now been extended. In the mean
time the Global fund has provided 137 million for five years and the President's
emergency Plan another 40 million. Although I will be the last person to even
assume that these resources are enough given the magnitude of the problem, the
question we need to ask is why are resources not being used?
Let us go back and see what some of the problems were in starting up the Bank
financed AIDS program in Ethiopia. Ideally a team should have been in place
before project negotiation so that activities could start immediately. It took a
year to get the teams in place and some of the issues identified during
negotiation. One important issue was to agree to exceptional implementation
mechanisms.
If you remember, the two countries we took to the Board were Ethiopia and
Kenya. Both countries refused to contract out the financial system to a private
firm. Why did the Bank insist on a private firm? For the simple reason that in
both countries the public sector had no experience to channel money to
communities, NGOs and the private sector. In Kenya it took a year and half of
negotiation, no resources flowed the first year. After one and half years a
private agency was contracted to channel the resources with the responsibility
to ensure that all the checks and balances were in place. In less than a year
the Kenyans reached 1,500 communities, NGOs and the private sector. The firm has
been audited and so far we have not seen any problem.
A similar program we have started in Ghana a year after Ethiopia and Kenya
has utilized the resources ahead of time and we are preparing for a second
round. What have we learned from this, in countries where there is un enabling
environment and supportive policies things can work and resources can reach
populations. In countries where AIDS is treated as business as usual very little
happens.
Apart from bureaucracies, the real issue in developing countries is lack of
capacity. Ethiopia is not an exception, if you take Botswana, a country which is
well off by African standards and had a well established health system, it took
two years to get the Merck and Gates funded program off the ground. The singular
reason for this 2-year delay was lack of capacity.
The problem with capacity we face today does not pertain to the health sector
alone. It is the lack of skilled work force in every sector. The reality is that
many of the same people who have been assigned by the government to coordinate
the World Bank projects are the same people to work on the Global Fund and the
presidents initiative. Apart from being over worked, there is very little
incentive to take such additional responsibilities. These are some of the real
and current issues we need to focus on and find ways of improving and solving
them.
Where does ENHAPA come in?
Currently at the international level, there is a lot of effort to better
harmonize and coordinate our efforts so that we do not (a) pull the limited
country capacity apart and (b) find ways of enhancing existing capacity while
making sure that each external assistance should have a clear plan to build
capacity. I am coming from such a meeting today at the Bank and tomorrow we will
discuss how these major agencies could work together. Peter Piot refers to them
as the "three ones"? one national strategy, one national program and one
Monitoring and Evaluation System.
What can you do?
Before I tell you what to do, I would like to commend you on the wonderful
contribution you are making already. All I am trying to do now is to ask you to
push the envelop a bit further and be more systematic. Following are some of the
important pointers:
There is no such thing as Bank money or Global fund money. Once the
agreements are signed the money belongs to the country. If indeed the donor
agencies and governments agree on the three ones, then the countries will be the
ones calling the shots, but they will only able to do so if they have the
capacity. Therefore the first thing to do will be to focus on enhancing/building
the capacity of the countries. Here is where ENAHAPA comes in from at least two
directions:
- Find a way of working with the local authorities on how to strengthen there
capacity so that the resources are utilized appropriately and on time. This
needs a lot of patience and humility on your side. The MOU signed between
ENAHAPA and the Ministry of Health should be used as an entry point.
- You can also be directly in touch with the donor agencies and governments
and ask about these funds, what they are used for, how sustainable capacity can
be built and how you can help. You can help in educating them on the reality of
the country. You need to be part of the lobby group which should insist that AID
without a capacity building component creates dependency. On our part those of
us working for international organizations and donor governments can facilitate
the dialogue.
- You can also intervene and bring some sense into how Ethiopians abroad can
help in a systematic manner. Why is it so difficult to send drugs or books or
computers etc. Is it because we here are so out of touch and we do not know what
is needed or are the current policies prohibitive?
- You can also be much more systematic, I remember I was the one who advised
you to start small three years ago, now that you have moved ahead of mine and
your own expectations, I challenge you to become more focused and systematic.
You can focus your support be more systematic and invest on institutions, and
building capacity in hospitals, or regional medical schools to build the country
level capacity in health. Take it upon your self to train support and encourage
your colleagues at home who you meet when you go to do the kinds of things you
did last summer. Remember they are in the front lines and they need for you to
be humble and supportive. What ever you chose to provide, you can do with the
kind of support that will sustain it and also make it an example to show that it
can be done.
- Take a hard look and determine how best to utilize your time and resources,
ask the question what does Ethiopia need from health professionals today? That
is what the next agenda of ENHAPA should be. When you do this be well informed
and critically analyze what is there, what is needed and where you come in.
Closing Remarks:
In closing, the data and the problems I presented are not news to you, and
are also not meant to make your task more daunting. On the contrary it is meant
to emphasize where the real problem lies and to find a common solution for
it.
Two years ago, I, along with other Bank staff, was at Harvard Business School
for a six weeks executive program. After we put our stuff in the rooms and were
having coffee, a Ghanaian colleague of mine asked me, have you seen the rooms? I
said, Yes. For me it was just a room which looked like a nice hotel room, but
was a student dormitory room at a university. He was going at length describing
how space efficient it was, how good and conducive for studying for students it
was, etc. etc. When the discussion went for what I thought was a long time, I
asked him why he was so interested in a dormitory and whether he had his own
children going to college. The answer he gave me was both a shock and an
inspiration to me. He said "we Ghanaians working abroad are rebuilding the
university where we were taught in Ghana."
You have to realize how little I felt. Here I am complaining what is and is
not happening. But what we must realize is that you and I can do much more and
at a very large scale. ENHAPA is beginning to do these significant things, but
my job is to push all of us even further and do much more, for a very simple
reason:
