World Health Organization African Region. Int Arch Med. 2017;10(34)

WHE Programme demonstrates gains in health security Investments made in WHO’s Health Emergencies Programme (WHE) in the African Region are beginning to yield dividends, following the reform of WHO’s work in emergencies. The capacity of the WHO Secretariat to support Member States to detect and rapidly respond to epidemics and ensure health security in the Region is improving.

During the reporting period, the Programme detected 331 signals of potential health threats in 29 countries. Following investigation, risk assessments were conducted and 110 were classified as public health emergencies consisting of outbreaks, natural disasters and ongoing humanitarian crises. An elevated response was required for 20 events in 13 countries, leading to activation of WHO’s emergency procedures to provide increased support to Member States in line with the new WHO Emergency Response Framework.

This showed a marked change from the Programme’s past performance. WHO has established an Incident Management System (IMS) which is activated for all graded public health events (outbreaks, natural disasters and ongoing humanitarian crises) within 24-48 hours.

IMS support teams established at Regional Office and Headquarters ensure coordinated backup to country level operations. WHO deployed over 1100 experts to support response operations, and WHO country offices repurposed staff to accelerate Photo (C) WHO response efforts. Contributing to this increased capacity to deploy was the establishment of two operational hubs in Dakar (for Central and West Africa) and Nairobi (for Eastern and Southern Africa), and one liaison office in Addis Ababa (for the Africa Centres for Disease Control and Prevention). The purpose of these hubs, established during the second half of 2017, is to build the capacity of Member States, leverage existing collaboration with regional and subregional partners, and strengthen communication and partnerships. The status of preparedness of Member States to detect and rapidly respond to epidemics is also improving. Through the collaborative efforts of WHO and the African Union Commission, African Heads of State at their Summit in July 2017 adopted a declaration to accelerate implementation of the International Health Regulations (IHR 2005). In compliance with the IHR, Joint External Evaluations (JEEs) to assess the capacity of countries to detect and respond to public health threats were carried out in 18 Member States during the reporting period. In total, 36 countries have detailed information on their gaps, and WHO is supporting them to prepare plans and mobilize resources to address them. For the first time since the adoption of the IHR 2005, all 47 Member States submitted IHR annual reports in December 2017. viWHO’s Health Emergencies Programme was put to the test following a reported outbreak of Ebola virus disease (EVD) in the Democratic Republic of the Congo in May 2018. The outbreak was reported in three health zones of Equateur Province, including Mbandaka town. The country’s rapid, decisive declaration enabled WHO to coordinate an immediate response with Government, partners and donors. The initial focus was on enhanced capacity for case f inding, contact tracing, and community engagement before moving to the strategy of breaking each chain of transmission. By the end of June 2018, the outbreak had been largely contained. For the first time, with the support of Gavi, health workers and people at risk in affected health zones were offered a safe, effective vaccine developed during the West African EVD epidemic in 2015. WHO worked with at-risk neighbouring countries and multiple partners to improve surveillance, detection and case management, including advocating for resources for priority activities, community engagement and risk communication. The epidemic was declared over on 24 July 2018, and the Director-General and the Regional Director joined the Government in Kinshasa to celebrate the event. WHO is working with the country to intensify surveillance and strengthen capacity for early case-detection and response in the future. The yellow fever outbreak in Angola and the DRC highlighted the need for more focused attention to effective prevention in the Region. In April 2018 in Nigeria, WHO launched the “Regional Framework for implementing the Global Strategy to Eliminate Yellow Fever Epidemics” adopted by the Sixty-seventh session of the Regional Committee. The Framework aims to increase the coverage of immunization through routine programmes and with catchup campaigns. Since then, WHO and partners have supported the 11 highest-risk countries to develop three-year workplans for implementing the framework. Preventive campaigns have resulted in more than 3.2 million people in Angola and 8.8 million in Nigeria being vaccinated, representing 60% of the total population targeted for coverage in the Region by the end of 2018. The Region will have to address gaps in coverage and reduce inequities in order to maximize the required population levels of immunity to prevent large outbreaks. Advancing towards universal health coverage (UHC) WHO’s work to support countries build responsive, resilient health systems is currently focusing on implementing the “Framework for health systems development towards universal health coverage in the context of the Sustainable Development Goals in the African Region”, adopted by Ministers of Health at the Sixty-seventh session of the Regional Committee in August 2017. The Framework guides Member States’ efforts towards realigning their health systems to accelerate progress towards UHC and attainment of their sustainable development aspirations. It suggests actions to assist countries in determining and phasing priorities when planning, implementing and monitoring their national strategies towards UHC. The AFRO UHC Flagship Programme will provide focused support to selected countries, while guidelines and tools will enable all Member States to apply the strategies proposed in the Framework. Scoping missions have been carried out in four countries – Nigeria, Eritrea, Kenya and Mozambique – to build consensus with governments and partners on the roadmaps and investments required for UHC. Underlying UHC is the need to ensure that all people and communities receive the quality health services they need without incurring financial hardship. Institutionalizing National Health Accounts (NHAs) in countries is important for monitoring resources allocated for health, for making fairer financing decisions and monitoring progress on financial health protection. Towards this end, WHO supported 25 countries to produce NHAs. Countries are increasingly using the data to develop appropriate health f inancing strategies and mobilize additional domestic funding for the health sector. To improve the availability and equitable distribution of quality human resources for health for UHC, the Sixty-seventh session of the Regional Committee adopted the “African Regional Framework for the implementation of the Global Strategy on Human Resources for Health: Workforce 2030”. WHO worked with the West African Economic and Monetary Union (WAEMU) and the Southern African Development Community (SADC) countries to develop subregional five-year action plans and road maps for addressing the human resources for health crises most countries are facing. Namibia, Mozambique, Nigeria and Tanzania have moved ahead in establishing National Health Workforce Accounts which generate information for planning, implementing and monitoring workforce policies, while Algeria has established a National Health Workforce Observatory. Access to affordable and quality medicines is also essential for UHC. WHO is providing technical support to SIDS countries in the Region – Cabo Verde, Comoros, Mauritius, Sao Tome and Principe, and Seychelles – to develop a pooled procurement strategy to achieve economies of scale and improve affordability and availability of medicines for noncommunicable diseases. Benin, Cabo Verde and South Sudan were also supported to develop national essential medicines lists to guide procurement and use. In addition, Cameroon, Central African Republic, Congo, Equatorial Guinea and Gabon were supported to implement their action plans on substandard and falsified medical products in line with the “Regional Strategy on Regulation of Medical Products in the African Region, 2016-2025” adopted by the Regional Committee during its Sixty-sixth session. viiEXECUTIVE SUMMARY Addressing the burden of Communicable Diseases The Region continued to make progress in addressing communicable diseases such as HIV/AIDS, viral hepatitis, tuberculosis and malaria. Nearly two thirds of Member States have adopted and are implementing WHO’s “Treat All” policy for people living with HIV to start antiretroviral therapy regardless of their CD4 count. Steady scale-up of HIV testing and antiretroviral therapy continues. Botswana, Eswatini and Namibia have nearly achieved “90-90-90” testing and treatment targets. Treatment coverage in West and Central Africa has improved significantly since WHO, UNAIDS and other partners developed catch-up plans in 2016 to accelerate the HIV response, with more than 40% coverage of HIV treatment compared to 28% in 2015. However, the latest global report indicates that if current trends continue, the HIV prevention target of a 75% reduction by 2020 (against a 2010 baseline) will not be reached. With the support of WHO and partners, the coverage of prevention of mother-to-child transmission (PMTCT) services in the African Region increased from 67% in 2015 to 79% by the end of 2017. WHO and partners have developed a stepwise “Path to Elimination” approach to advance the elimination of mother-to-child transmission (eMTCT) of HIV and syphilis infections in infants by 2020. Countries will be supported to adopt this approach in order to meet the 2020 target. Momentum is building on action to address viral hepatitis, a long-neglected public health problem of global importance in the Region. Following the adoption of the Regional Framework “Prevention, Care and Treatment of Viral Hepatitis in the African Region: Framework for Action, 2016-2020” by the Sixty-sixth session of the Regional Committee, Member States are taking concrete steps to address this disease. Nearly half have developed national action plans, and 16 countries now have national technical working groups and ministry of health focal points to oversee and coordinate the national response. Eleven countries have introduced the hepatitis B birth dose vaccine to reduce new cases of hepatitis B in children. While TB remains a major public health problem, the fight against the disease continues to make progress. Countries were supported to implement strategic initiatives to find missing TB cases and adopt and scale up the more accurate molecular tests recommended by WHO as the first line of diagnosis to increase capacity to detect active TB cases. WHO supported five countries to initiate or prepare for national TB prevalence surveys to measure the true burden of disease, and a further five countries to determine the levels of resistance to anti-TB medicines. Twenty-one countries introduced the recommended shorter nine-month treatment regimens for multidrug-resistant TB as opposed to the 24-month long regimen. Laboratory capacity for detecting TB cases was strengthened in 21 countries, with the Benin National TB Reference Laboratory accredited as the fourth Supranational TB Reference Laboratory in the Region. The World Malaria Report 2017 shows that progress in the global response to malaria has stalled and many countries in the African Region are not on track to achieve the targets of the Global Technical Strategy for Malaria, 2016-2030. About 70% of the estimated case burden and 71% of the estimated deaths occurred in 10 African countries. To reverse these trends, WHO and partners are spearheading a new “10+1” initiative to intensify support to these Member States and India to avert deaths from this preventable, curable disease. Following extensive consultations with the national authorities, regulatory approval has been obtained to initiate pilot implementation programmes for the RTS,S malaria vaccine in Ghana, Kenya and Malawi during the second half of 2018. The results of these pilots are expected to be a potential game-changer for malaria control in the Region. Continued progress towards the elimination and eradication of targeted diseases Work to eliminate and eradicate certain targeted diseases, such as poliomyelitis and neglected tropical diseases (NTDs) like onchocerciasis and Guineaworm disease in the Region continued. The final push towards Polio eradication in the African Region continues to be a priority. Tremendous progress has been made since the last wild poliovirus transmission in Nigeria in 2016. By 30 June 2018, it had been 22 months since the last case of wild poliovirus was reported in the African Region. The localized inaccessibility of children to be immunized due to insecurity as well as surveillance gaps remain the last “frontiers” for certification of polio eradication for the Region, and we are constantly working with Member States to surmount these challenges. Due to concerted efforts, 40 countries in the African Region have had their polio-free documentation accepted by the African Regional Certification Commission for Polio Eradication. If this progress is sustained, the African Region could be certified to have eradicated polio by the end of 2019. Outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2) were confirmed in the Democratic Republic of the Congo, Kenya and Nigeria. To stop these outbreaks quickly, AFRO deployed 21 international WHO polio experts and 200 local public health personnel. viiiDuring the Seventy-first session of the World Health Assembly in May 2018, the Regional Director convened with her counterpart, the WHO Regional Director for the Eastern Mediterranean, a polio side-meeting with Ministers of Health of Ethiopia, Kenya and Somalia to declare the cVDPV2 outbreak in Kenya and Somalia as a Horn of Africa subregional public health emergency. Since then, WHO and partners have supported several synchronized cross-border vaccination campaigns. To ensure surveillance systems of adequate sensitivity for polio certification, Member States were urged during the Sixtyseventh session of the Regional Committee to adopt the AFRO Geographical Information Systems (GIS) tool for enhanced surveillance and to have “real-time” data for action. By the end of the reporting period, 42 out of 47 Member States were using the system, resulting in improved performance of surveillance systems. With regard to the polio end-game, Member States have f inalized the budgeted transition plans with support from WHO and partners, and are encouraged to mobilize domestic resources and continue engagement with their international development partners to implement them. Photo (C) WHO WHO and its partners, through the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN), are working with Member States to mobilize political commitment and resources to control and eliminate the five most prevalent NTDs amenable to preventive chemotherapy (PC-NTDs) in Africa: lymphatic filariasis, onchocerciasis, soil-transmitted helminthiasis, schistosomiasis and trachoma. ESPEN is proving to be an effective mechanism for combining the efforts of governments, partners, nongovernmental organizations and the private sector, particularly pharmaceutical companies in coordinating the supply and distribution of donated medicines. With funding support from partners, at least 30 million people in 13 countries have benefitted from mass drug administration. ESPEN has set up a fully-fledged laboratory in Ouagadougou, Burkina Faso to support regional efforts for scaling down treatment for onchocerciasis where appropriate impact has been achieved. Guinea-worm disease is on the verge of eradication, and Kenya became the 41st country to be certified free of local transmission. Human African Trypanosomiasis, a disease prevalent only in the African Region, is moving towards elimination, while cases of Buruli ulcer halved between 2014 and 2017 through the use of WHO-recommended oral antibiotics and the integrated case management strategy for NTDs. Tackling Noncommunicable Diseases (NCDs) Deaths from NCDs in the Region are rising, along with the costs of treating these diseases and the related risk factors and ill health. High-level advocacy urging Member States to adequately resource and prioritize NCDs in national health plans is beginning to bear fruit. WHO provided technical support to seven Member States to develop/finalize national multisectoral NCD Strategic/Action Plans in line with the UN Declaration on NCDs and the WHO Global NCD Action Plan 2013-2020. By 31 March 2018, thirty-one Member States had NCD Strategic/Action plans and in 17, significant action was ongoing. Following the adoption of the “Regional Framework for Integrating Essential NCD Services in Primary Health Care” at the Sixty-seventh session of the Regional Committee, WHO collaborated with the West African Health Organisation (WAHO) to train NCD programme managers on the WHO Package of Essential NCD Interventions (WHO PEN). The package comprises costeffective NCD actions which can be integrated into primary health care settings to assist countries scale up early detection and treatment of NCDs. By June 2018, ten countries were implementing the WHO PEN. Synergy between WHO PEN and the UHC Flagship Programme is expected to rapidly increase the coverage of an integrated package for the treatment and prevention of NCDs. WHO continued to support Member States to develop and enforce legislation and regulations on tobacco control. Laws to address tobacco use in line with the WHO Framework Convention on Tobacco Control (WHO FCTC) were adopted in eight Member States. In addition, 17 Member States and three subregional blocs – the East African Community, the Economic Community of West African States and the West African Economic and Monetary Union – were supported to implement changes in their policies on tobacco taxation. i