WHO Africa Region Research Articles

Research Priorities for Addressing Gender Based Violence in the WHO Africa Region

Background: There is an increasing emphasis on conducting research to identify gender based violence issues to enable development of appropriate programs and interventions. However, these efforts are mixed in quality and often raise ethical questions. The increased pressure on policy makers to move to a more evidence-based approach in addressing gender based issues creates the need for this research prioritization activity. Inadequate evaluative evidence in this area poses a challenge in the planning for responsive interventions especially in resource limited settings. The purpose of this paper is to present gender based violence research priority areas for the WHO Africa Region. Methods: We utilized a modified version of the Child Health and Nutrition Research Initiative approach to reach consensus on research priorities on the thematic area of gender based violence. In three phases, we first conducted an online survey with sexual and reproductive health and rights experts in academia, ministries of health, non-governmental organizations and other health actors with a wide range of experiences. These questions were consolidated by three experts from World Health Organization headquarters into themes. Secondly, experts were invited in a meeting in Cape Town South Africa to analyze and generate relevant areas of research based on the themes. Finally, a smaller group of experts prioritized research areas based on agreed criteria. Results: A list of 10 priority research questions for addressing gender based violence were scored and ranked. Four priority research questions scored 30 points out of the possible 30 points and were thus ranked as the highest priority. These included questions that “engage young adolescents in behavioral interventions to influence gender roles”, “determinants of gender based violence analysis”, “both long and short term complications of gender based violence on survivors” and “assessment of men’s involvement in addressing gender-based violence against women”. The second most highly ranked question was on the assessment of the extent and strategies to prevent gender-based violence in the context of humanitarian crises. Conclusions: Priority research questions for addressing gender based violence were identified. This exercise provides a three year investment case for research with high potential of effectively identifying interventions with high impact on addressing gender based violence.

Research Priorities for Preventing Unsafe Abortions in the WHO Africa Region

Background: Unsafe abortion is a commonly neglected sexual and reproductive health and rights issue despite the serious health problems it causes to women and girls in their reproductive ages. It is classified as a main cause of maternal mortality and morbidity. This paper has considered questions that have the greatest potential to successfully reduce unsafe abortions in the resource poor settings. Methods: We adapted the Child Health and Nutrition Research Initiative (CHNRI) to identify and prioritize many competing sexual and reproductive health and rights research ideas that impact the health of the populations. The implementation was done in three phases which included generation and collection of research ideas from various experts virtually in August 2019 consolidation of the potential questions through thematic analysis conducted in September 2019. Finally, scoring and ranking of the research questions was done in a workshop of experts. Results: Out of a list of 45 priority research questions, two questions were ranked the highest scoring 28 out of the possible 30. The research priorities include: “The effectiveness of interventions (e.g. counseling or incentives or home visits) to increase post abortion uptake and continuance”, “Reducing repeat abortion on improving maternal health outcomes” and “Evaluation of community-based awareness programs to reduce unwanted pregnancies and encourage women to seek help early”. Conclusions: Ten key research priorities in preventing unsafe abortion were identified. The priority list covers areas of focus that could effectively impact preventing unsafe abortions while also acting as a knowledge base for researchers, policy makers and other interested stakeholders who would want to invest in this area.

Research Priorities for mHealth and Innovative Strategies in Sexual and Reproductive Health and Rights in the WHO Africa Region

Background: The use of mobile phones continues to rise rapidly in the provision of health related services. Many countries have adopted the use of mobiles to provide sexual and reproductive health and rights and especially among the adolescents where specific messages are tailored for various audiences with specific messages. The purpose of this paper is to present the results of a research priority setting exercise on mHealth and innovative strategies. Methods: We adapted Child Health and Nutrition Research Initiative methodology to identify and set research priorities on mHealth and innovative strategies that respond to sexual and reproductive health and rights services. General potential research questions were gathered online from multiple stakeholders in the region and sent for consolidation consolidated to technical experts in World Health Organization headquarters. The second phase involved a meeting with experts to review and thematically analyze the questions list of 33 questions producing a list of 22 research questions. The questions were scored against a six point criteria and ranked accordingly. Ten top priority research questions were identified. Results: Lists of 33 priority research questions for mHealth and innovative strategies were proposed for discussions by 67 stakeholders. The questions were reviewed, scored and ranked in a technical meeting by experts. The highest ranking questions at 87% include evaluation of mHealth for data management and sexual and reproductive health and rights decision making, assessment of innovative local financing techniques to support community based sexual reproductive health and rights and evaluation of the role of mobile technologies in referral and counter referral. Conclusions: Information and communication technology is developing drastically and has a great potential in improving health especially in sexual and reproductive health and rights service delivery. This potential must be demonstrated with more relevant and quality research on mHealth and innovative strategies priorities identified.

Setting Regional Research Priorities for Sexual and Reproductive Health and Rights Services in Humanitarian Settings

Background: Despite increased recognition of the need for sexual and reproductive health and rights in humanitarian settings, evidence focusing on mainstreaming reproductive health services such as maternal, neonatal mortality, human immunodeficiency virus transmission and unsafe abortion still remains inadequate. The ability to understand the magnitude of the needs and highlight existing gaps is supported by improved data which is critical to informing effective policies, programming and funding decisions. The purpose of this report is to present the results of a research prioritization exercise on sexual and reproductive health and rights services in humanitarian settings for the WHO Africa region for the next three years. Methods: We adapted the Child Health and Nutrition Research Initiative method in three phases. Experts from the region participated in an online survey to identify key areas for research in sexual and reproductive health and rights. To identify potential areas for research, the experts ensured answerability, effectiveness, deliverability, equity and potential impact of the questions. The research areas they identified were reviewed by World Health Organization technical team from headquarters. In a meeting of 67 participants, the questions were subjected to further review and analysis. Using a modified for scoring criteria, the questions were scored and ranked to provide the top ten priority questions to address sexual and reproductive health and rights services in humanitarian settings. Results: A list of 21 priority research questions on sexual and reproductive health and rights services in humanitarian settings were scored and ranked. Top ten priorities research questions were identified. Those that scored highly by scoring 30 points out of the possible maximum of 30 include: “determining the prevalence and associated factors of unwanted pregnancies and abortions performed in emergency and humanitarian settings”, “evidence on gender-based violence in humanitarian situations and its associated factors” and “defining an optimal model for coordinating sexual and reproductive health and rights interventions and responses in crisis situations”. Conclusions: Top ten research priorities in sexual and reproductive health and rights services in humanitarian settings were identified. The priority research areas have the potential to identify the best areas for programming of services in humanitarian settings. It is our hope that the identified research areas will be prioritized to support programming of services in humanitarian settings based on scientific evidence.

Converging pandemics: implications of COVID-19 for the viral hepatitis response in sub-Saharan Africa

Sub-Saharan Africa is currently bracing itself as the next front in the fight against the coronavirus disease 2019 (COVID-19) pandemic. Despite low testing capacity, 61 991 cases and 1778 deaths had been reported in the WHO Africa Region as of May 18, 2020, with a recent increase in reported daily cases and deaths. Despite younger age demographics and less travel than in other regions, and strong efforts for early containment, the potential for widespread community-based transmission in sub-Saharan Africa is high, but current modelled estimates vary widely.

The IUPHAR/BPS Guide to PHARMACOLOGY in 2020: extending immunopharmacology content and introducing the IUPHAR/MMV Guide to MALARIA PHARMACOLOGY.

The IUPHAR/BPS Guide to PHARMACOLOGY (www.guidetopharmacology.org) is an open-access, expert-curated database of molecular interactions between ligands and their targets. We describe significant updates made over the seven releases during the last two years. The database is notably enhanced through the continued linking of relevant pharmacology with key immunological data types as part of the IUPHAR Guide to IMMUNOPHARMACOLOGY (www.guidetoimmunopharmacology.org) and by a major new extension, the IUPHAR/MMV Guide to Malaria PHARMACOLOGY (www.guidetomalariapharmacology.org). The latter has been constructed in partnership with the Medicines for Malaria Venture, an organization dedicated to identifying, developing and delivering new antimalarial therapies that are both effective and affordable. This is in response to the global challenge of over 200 million cases of malaria and 400 000 deaths worldwide, with the majority in the WHO Africa Region. It provides new pharmacological content, including molecular targets in the malaria parasite, interaction data for ligands with antimalarial activity, and establishes curation of data from screening assays, used routinely in antimalarial drug discovery, against the whole organism. A dedicated portal has been developed to provide quick and focused access to these new data.

Revitalization of integrated disease surveillance and response in Sierra Leone post Ebola virus disease outbreak

BackgroundThe Ministry of Health and Sanitation (MOHS) in Sierra Leone partially rolled out the implementation of Integrated Disease Surveillance and Response (IDSR) in 2003. After the Ebola virus disease outbreak in 2014–2015, there was need to strengthen IDSR to ensure prompt detection and response to epidemic-prone diseases. We describe the processes, successes and challenges of revitalizing public health surveillance in a country recovering from a protracted Ebola virus disease outbreak.MethodsThe revitalization process began with adaptation of the revised IDSR guidelines and development of customized guidelines to suit the health care systems in Sierra Leone. Public health experts defined data flow, system operations, case definitions, frequency and channels of reporting and dissemination. Next, phased training of IDSR focal persons in each health facility and the distribution of data collection and reporting tools was done. Monitoring activities included periodic supportive supervision and data quality assessments. Rapid response teams were formed to investigate and respond to disease outbreak alerts in all districts.ResultsSubmission of reports through the IDSR system began in mid-2015 and by the 35th epidemiologic week, all district health teams were submitting reports. The key performance indicators measuring the functionality of the IDSR system in 2016 and 2017 were achieved (WHO Africa Region target ≥80%); the annual average proportion of timely weekly health facility reports submitted to the next level was 93% in 2016 and 97% in 2017; the proportion of suspected outbreaks and public health events detected through the IDSR system was 96% (n = 87) in 2016 and 100% (n = 85) in 2017.ConclusionWith proper planning, phased implementation and adequate investment of resources, it is possible to establish a functional IDSR system in a country recovering from a public health crisis. A functional IDSR system requires well trained workforce, provision of the necessary tools and guidelines, information, communication and technology infrastructure to support data transmission, provision of timely feedback as well as logistical support.

Introduction of The Second Dose of Measles Containing Vaccine in The Childhood Vaccination Programs Within The WHO Africa Region -Lessons Learnt

WHO recommends all countries to include a second routine dose of measles containing vaccine (MCV2) in their national routine vaccination schedules regardless of the level of coverage with the first routine dose of measles containing vaccine (MCV1). As of Dec 2016, 26 countries in the African Region have introduced MCV2. We reviewed the WHO UNICEF coverage estimates for MCV1 and MCV2 in these countries, and the reports of the post introduction evaluation of MCV2 from 11 countries. Twenty three countries have WHO/UNICEF estimates of MCV2 coverage available in 2015. Of these, 2 countries have coverage of ≥ 95% for both MCV1 and MCV2 while 5 countries have coverage of > 80% for both doses. Dropout rates of >20% MCV1 - MCV2 exist in 12 countries. Post-MCV2 introduction evaluations done in 11 countries from 2012 to 2015 showed that inadequate health worker training, insufficient sensitization and awareness generation among parents and suboptimal dose recording practices were common programmatic weaknesses that contributed to the low MCV2 coverage in these countries. MCV2 coverage remains low as reflected in large drop-out rates in most countries. Higher MCV2 coverage is necessary to sustainably achieve the regional measles elimination goal. National immunization programs must improve implementation of MCV2 using the standard introduction and evaluation guidelines available for EPI program planning.

A Pipeline Program to Address the South African Crisis in Human Resources for Health.

Background:The WHO Africa Region faces a shortage of health workers due to inadequate production of health workers and emigration of physicians and nurses to wealthier countries. South Africa and the United States share a history of discriminatory policies and practices resulting in groups that are under-represented amongst health professionals. One US response is the Area Health Education Centers Program (AHEC), a pipeline program to recruit members of under-represented groups into the health professions.Objectives:(1) Compare and contrast the United States’ AHEC model with that developed in South Africa by Stellenbosch University Faculty of Medicine and Health Sciences SA AHEC in partnership with Morehouse School of Medicine in the United States. (2) Describe a formative evaluation of the Stellenbosch AHEC Program.Methods:Four hundred students (grades 7–12) and 150 teachers participated in SA AHEC with the goal of preparing the students to better compete for university admission. Students received after-school tutoring, holiday schools, and counselling on study skills, health careers, and university entry. Educators received continuing professional education, classroom observation, and feedback. The program was evaluated through a series of interviews and focus groups involving AHEC staff, educators, and parents and caregivers.Results:Program strengths included educator training, collaboration, and increased student maturity, motivation, and academic success. Challenges included limited time with students, the location of some sites, and the educators’ need for more engagement with AHEC staff and schools. Quarterly workshops were conducted to address challenges. Over 50% of program alumni are currently enrolled in institutions of higher education. Students will be tracked to determine whether they are able to complete their health professions studies and return to the communities where they grew up, or to similar communities.Conclusions:With appropriate adaptation and attention to context, it might be possible to implement similar programmes in other African countries. The comparison of the United States and South African models suggested that more parent and teacher participation in an advisory capacity might help to avoid some challenges.

The global burden of tuberculosis mortality in children: a mathematical modelling study.

SummaryBackgroundTuberculosis in children is increasingly recognised as an important component of the global tuberculosis burden, with an estimated 1 million cases in 2015. Although younger children are vulnerable to severe forms of tuberculosis disease, no age-disaggregated estimates of paediatric tuberculosis mortality exist, and tuberculosis has never been included in official estimates of under-5 child mortality. We aimed to produce a global mortality burden estimate in children using a complementary approach not dependent on vital registration data.MethodsIn this mathematical modelling study, we estimated deaths in children younger than 5 years and those aged 5–14 years for 217 countries and territories using a case-fatality-based approach. We used paediatric tuberculosis notification data and HIV and antiretroviral treatment estimates to disaggregate the WHO paediatric tuberculosis incidence estimates by age, HIV, and treatment status. We then applied systematic review evidence on corresponding case-fatality ratios.FindingsWe estimated that 239 000 (95% uncertainty interval [UI] 194 000–298 000) children younger than 15 years died from tuberculosis worldwide in 2015; 80% (191 000, 95% UI 132 000–257 000) of these deaths were in children younger than 5 years. More than 70% (182 000, 140 000–239 000) of deaths occurred in the WHO southeast Asia and Africa regions. We estimated that 39 000 (17%, 23 000–73 000) paediatric tuberculosis deaths worldwide were in children with HIV infections, with 31 000 (36%, 19 000–59 000) in the WHO Africa region. More than 96% (230 000, 185 000–289 000) of all tuberculosis deaths occurred in children not receiving tuberculosis treatment.InterpretationTuberculosis is a top ten cause of death in children worldwide and a key omission from previous analyses of under-5 mortality. Almost all these deaths occur in children not on tuberculosis treatment, implying substantial scope to reduce this burden.FundingUNITAID, National Institutes of Health, and National Institute for Health Research.

Impossible to "wean" when more aid is needed

Kirigia and Diarra-Nama from the WHO Regional Office for Africa say that funding for health in the WHO Africa Region remains inadequate and that, in some countries, is significantly dependent on donor funding. They propose five strategies for these countries to “wean themselves off” donor funding. While each of the proposed strategies might have some value in itself, they will not succeed in the double objective the authors set: to wean countries from depending upon international health aid and to achieve the US$ 34 per person annual health expenditure target suggested by the Commission on Macroeconomics and Health1 – an amount that must now be adjusted to US$ 40 due to inflation.2 Of the five strategies proposed, only the second and third strategy – reprioritizing public expenditure and raising additional domestic revenue – would increase domestic financial resources for health. The other three strategies (reducing inefficiencies and corruption and increasing private sector involvement in health development) might improve efficiency but would not bring countries closer to the US$ 40 per person annual target. It could be argued that with increased efficiency, less money is required. However, the Commission’s target is based on need and does not factor in inefficiencies or corruption. Furthermore, even if countries were to reprioritize public expenditure and raise additional domestic revenue, this is unlikely to generate sufficient additional financial resources, particularly for those countries most dependent on international health aid. To test this, we estimated the impact of these two strategies for the 4 countries where – according to the WHO Statistical Information System – the external contribution to total health expenditure exceeded 40% in 2004 (Madagascar, Malawi, Mozambique and Sao Tome and Principe), plus four other countries where the external contribution to total health expenditure exceeded 40% in 2005 (Liberia, Rwanda, Sierra Leone and Zambia).3 Kirigia and Diarra-Nama propose reprioritizing public expenditure by adjusting military expenditure to the average of the countries of the WHO African Region. We estimated military expenditure per inhabitant by using data from the CIA of the United States of America4 – which are expressed as a percentage of GDP – and multiplied those with GDP per capita estimates of the International Monetary Fund.5 Using the average annual military expenditure of US$ 16 per person provided by Kirigia and Diarra-Nama, we find that the 8 countries of our selection already spend less than US$ 16 per person per year on the military. The proposed strategy would therefore not make a difference (Table 1). Table 1 Impact of strategies proposed to reduce dependency on aid The other strategy proposed to raise domestic financial resources for health is that all countries should aim for government revenue equivalent to 15% of GDP. Five out of the 8 countries of our selection already have higher government revenue. Three out of 8 countries would indeed increase financial resources if they followed the recommendation, but even if they spent 15% of these additional financial resources on health – in line with the Abuja Declaration6 – it would merely raise between US$ 0.8 per person per year (Rwanda) and US$ 1.5 per person per year (Madagascar). Furthermore, 6 out of these 8 countries still face a huge gap between current total health expenditure and the revised target made by the Commission on Macroeconomics and Health: in Liberia, Madagascar, Malawi, Mozambique, Rwanda and Sierra Leone, total health expenditure is still below US$ 20 per person per year, even with 40% coming from international health aid. Even if some countries of the African region might be able to wean themselves from international health aid, others obviously cannot: they need increased aid, urgently. This can be achieved through sustained international health aid, which should not be seen as an act of charity to be overcome as soon as possible, but as an act of global solidarity, with health recognized as a human right that entails both national and international duties. For these reasons we agree with the position of WHO’s Director-General who has called for much greater, and more predictable, international health aid for Africa.7 We hope that her voice will be heard and understood throughout WHO and the wider international community. ■

Improving the health workforce in Africa: the weak link

The article discusses the health workforce challenges in Africa focussing generally on the 46 countries of the WHO Africa region but within the context of the global shortages that has reached crisis levels. The momentum gained in advocating to reverse the crisis; the key issues and challenges being faced; the global, regional and sub-regional high level commitments on what needs to be done. Some of the reasons why these commitments are not yet bearing evident fruit in countries is also discussed. An argument is made that while recognizing that the issues are complex and require multiple actions, one of the major weak links identified in this chain is the weak human resources function in the ministries of health. The strengthened function should include coordinating and following up the pledges and commitments made for the health workforce in a sustained and strategic manner. The main outcome would be effective health services for the populations being served.

The burden of natural and technological disaster-related mortality on gross domestic product (GDP) in the WHO Africa Region

The WHO Africa region has the highest disaster mortality rate compared to the other five regions of the organization. Those deaths are hypothesized to have significantly negative effect on per capita gross domestic product (GDP). The objective of this study was to estimate the loss in GDP attributable to natural and technological disaster-related mortality in the WHO African Region. We estimated the impact of disaster-related mortality on GDP using double-log econometric model and cross-sectional data (from the UNDP and the World Bank publications) on 45 out of 46 countries in the WHO African Region. The coefficients for capital (K), educational enrolment (EN), life expectancy (LE) and exports (X) had a positive sign; while imports (M) and disaster mortality (DS) were found to impact negatively on GDP. The abovementioned explanatory variables were found to have statistically significant effect on GDP at 5% level in a t-distribution test. Disaster mortality of a single person was found to reduce GDP by US$0.018. We have demonstrated that disaster mortality has a significant negative effect on GDP. Thus, as policy-makers strive to increase GDP through capital investment, export promotion and increase in educational enrolment, they should always recall that investments in strengthening national capacity to mitigate the effects of national disasters expeditiously and effectively shall yield significant economic returns.

Impact of HIV/AIDS on Gross Domestic Product (GGP) in the WHO Africa Region

HIV/AIDS is hypothesized to have substantive negative impact on health status and economic development of individuals, households, communities and nations. The objective of this study was to estimate the burden of HIV/AIDS on GDP in the WHO African Region using a production function approach. The economic burden analysis was done using a double-log econometric model and a cross-sectional data on 45 to 46 countries in the WHO African Region. The data were obtained from WHO, UNAIDS, ECA, UNDP and the World Bank publications. The coefficient for Capital (K), Education (EN), Export (X) and Imports (M) were found to be statistically significant determinants of per capita Gross Domestic Product (GDP) at 5% level of significance (using a one-sided t-distribution test). Unfortunately, HIV/AIDS morbidity (V) and HIV/AIDS deaths (VD), at the same level of significance, were found to have statistically insignificant impact on GDP. However, the coefficients of these variables had negative signs as expected. In all African countries, there is need for more detailed research on the total economic cost of HIV/AIDS (probably estimated using micro-level costing and willingness-to-pay methods) and for economic evaluations of treatment, prevention and promotion programmes.