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CAPACITY ASSESSEMENT OF THE MINISTRY OF HEALTH OF THE REPUBLIC OF ANGOLA

June 2006

João Carlos Blasques de Oliveira M.D.

CONTENTS

Acronyms / 2
Executive Summary / 4
Introduction / 7
Methodology / 7
General Country Profile / 7
Health Status and Vital Statistics / 8
Epidemiological Situation / 9
The AIDS Epidemic / 10
Analytical Work by Other Partners / 11
Organization of the Health System / 12
Health Information System / 17
Development of Policies, Strategies and Action Plans / 18
Government Financing and Budgeting / 18
Funding from International Donors / 20
User Fees / 21
Coordination with Donors, NGOs and the Private Sector / 21
Provincial Capacity and Decentralization / 21
Human Resources Development and Management / 22
Health Professional training / 24
The Role of the Private Sector in Human Resources Training / 25
Drugs and Logistics / 26
Conclusions and Recommendations / 27
Conclusions / 27
Recommended Next Steps / 29
Bibliography / 32
Annex 1 / 33

ABBREVIATIONS AND ACRONYMS

AIDS / Acquired Immune Deficiency Syndrome
ASDI / Agencia Sueca para o Desenvolvimento Internacional (Swedish Internacional Development Agency)
CFR / Case Fatality Ratio
DNRH / Direccão Nacional de Recursos Humanos (National Directorate of Human Resources)
DNSP / Direccão Nacional de Salde Publica (National Directorate of Public Health)
DNME / Direccão Nacional de Medicamentos e Equipamentos (National Directorate of Drugs and Equipment)
DPS / Directo Provincial de Saúde (Provincial Health Directorate)
DFID / Department for International Development ( U.K.)
EU / European Union
ETPS / Escola Tecnico Profissional de Saúde (Mid-level Nurse and Para-medical School)
ETS / Escola Técnica de Salde (only trains basic nurses)
GOA / Government of Angola
GEPE / Gabinete de Estudos Plano e Estatistica (MOH Cabinet of Planning Studies and Statistics)
GEPE/SC / Gabinete do Plano/Sector de Construção ( MOH Infrastruture Sector)
HIV / Human Immunodeficiency Virus
HMIS/HIS / Health Management Information system or health information System
IMS / Instituto Medio de Saúde ( Nurse Schools for registered nurses)
IDP / Internallly Displaced People
IUD / Intra Uterine Device
ISE / Instituto Superior de Enfermagem
MICS / Multiple Indicator Cluster Survey
MINARS / Ministry of Social Action and Reintegration
MOH / Ministry of Health
MOF / Ministry of Finance
NGO / Non-governmental Organization
OCHA / Organization for Coordination of Humanitarian Aide
ORS / Oral Rehydration Salt
PASS / Projecto de Apoio ao Sector da Saúde (Health Sector Support Project – European Union
PNLS / Programa Nacional de Luta contra o Sida (National AIDS Control Program)
PNME / Programa Nacional de Medicamentos Esenciáis (Essential Drug Program)
PCRRP / Post Conflict Rehabilitation and Reconstruction Program
PHC / Primary Health Care
PHCT / Primary Health Care Team
PHR / Partners for Health Reform
SMS / Secção Municipal de Saúde ( Municipal Health Section)
STI / Sexually-transmitted Infection
TB / Tuberculosis
UNDP / United Nations Development Program
UNICEF / United Nations Children Fund
UNFPA / United Nations Family Planning Agency
USAID / United States Agency for International Development
VCT / Voluntary Counseling and Testing
WHO / World Health Organization

Executive Summary

The following table summarizes the strengths and weaknesses in the capacity of the health sector in Angola. A more detailed assessment is presented afterwards.

Strength and Weakness of the Health Sector in Angola and Opportunities.

Health Functions / Strengths / Weakness / Opportunities
Service provision / The MOH objective is to develop primary health care approaches and programs that provide preventive services to the population – such as EPI and maternal health services.
The sector has the capacity to develop technical norms and guidelines for health programs and standard case management procedures for disease control programs.
There are sound strategic plans for the major diseases and vulnerable groups / Excessive verticalization of disease control programs.
Difficulty to implement and supervise the implementation of the strategic plan.
Weakness of the health information system, including the disease surveillance system, which is not used for management purposes at all levels. The municipal level receives little feedback from information they produce.
Health system and health facility management and planning is of limited quality due to lack of norms and trained personnel / Ensuring that at provincial and municipal level integration of programs is a reality, and creating integration mechanisms at the national level.
HMIS including epidemiological surveillance is receiving support from partners.
There is a need to train and develop human resources capacity in health statistics and in health system management and planning
Health system financing / Recent increase in the level of financing of the sector as % of GDP
Decentralization of budget funds to the provinces and certain hospitals.
Analysis of user fees.
Capacity to mobilize funds from donors / Despite the increasing funding, the MOH does not attend to the needs of the majority of population.
Too much funds go to hospitals compared to PHC services,
Limited capacity in terms of management and budgeting. / The MOH with support of international partners is improving the participation of provinces in definition of budget and its link to the health plan.
Revision of user fees.
Resource generation / Existence of Human resources development plan.
There is a process to improve the quality of training schools in the country through an accreditation process.
There is a new National Drug Policy in process to be approved,
Basic procurement procedures and tender documents exist.
There is a huge effort on health facilities rehabilitation and equipment all over the country with support of international donors mainly China / Quality of training is uneven across the country and curricula for training of some category of nurses need further revision.
The number of nurses (for example midwifes and pediatric nurses) and doctors are not enough for country needs.
The acquisition of drugs and medical equipment as well as the overall logistical system including the procurement process is inefficient and prone to leakages. Stock-outs of drugs are frequent.
There is no clear process to coordinate the rehabilitation of infrastructure financed from different sources. There is a risk of duplication and to respond to the regulation of the ministry.
It is not clear how all new and rehabilitated health facilities will be staffed and maintained. / Need to define a human resources policy to improve supply of services. This may include the need for new health staff categories. Training of health promotersshould be resumed, under a new framework to be defined.
The Ministry of Education is prepared to open new medical schools.
New types of incentives to be developed to encourage health professional to move to the provinces and municipalities.
New drug policy needs rapid approval and regulation.
Support to the MOH to improve its forecasting, and procurement process through training and technical assistance.
Support to help provinces and the MOH improve the coordinating capacity in planning the health infrastructure.
Stewardship / There is a political commitment to ensure health services for all.
Thereis an ongoing effort to develop a National Health Planthrough a participatory approach. / For years the sector was neglected in terms of political and financial support.
Lack of a comprehensive and detailed health policy document.
Laws can stay without regulation for years. The capacity to implement and enforce regulations is often limited.
Low efficacy of the sector in consistently setting the rules of the game and monitoring service delivery / There is room to improve stewardship, the one function providing the guidance and the normative and governance principles underpinning all other functions.
Support to the design and implementation of a National Health Plan and involvement of provinces in the planning exercise.
Environment / The end of the war creates the possibility to expand heath care.
The country has a huge economical potential in the future.
There is a decentralization process at administrative and budget levels / The increased mobility of the population may cause imbalances between supply and demand for health services. It may require innovative approaches to service provision.
The lack of coordination in the decentralization process has weakened the role of the MOH in managing the system.
Decision making in the current coalition government requires more consultation for the reconciliation of different points of view, which may result in delays in the implementation processes. / Mobile service provision could complement the expanding health facility network.
The decentralization process needs to be closely supervised and nurtured. The capacity of the structures to be decentralized needs to be strengthened.
After the next elections, the government will have an opportunity to improve health policy and develop new strategies.

Introduction. The World Bank commissioned a capacity assessment study of the Ministry of Health (MOH) that was undertaken in March 2006.The terms of reference covered the following areas:

  1. Identify the existing analytical work being done by other donors in the health field and summarize their terms of reference and main conclusions;
  2. Assess the MOH capacity to implement health policies and strategies adopted by the government;
  3. Assess the MOH capacity to implement projects financed by the Bank, the Global fund, EU and others focusing the analysis on the MOH capacity for policy formulation, mobilization of funds, and program implementation;
  4. Assess the capacity at central, provincial and municipal level in (i) program management, (ii) service delivery, including the number and distribution of staff;
  5. Analyze the decision making process and the incentives for decision making including how much the system is centralized or decentralized;
  6. Analyze the existing stock of health professionals including the MOH and military, identifying key constraints and gaps in capacity, government plans to increase capacity; existing training institutions and their capacity to produce new professionals and follow-up training;
  7. Propose options for short term and long-term interventions including training managers, training of doctors and nurses, recruitment, on-job-training, review of curricula and other;
  8. Make cost estimates of short term capacity building interventions that could be financed by the Bank and other donors; and
  9. Identify future work that may be needed to undertake deeper or follow-up analysis.

Methodology. The information was gathered through interviews with key staff in the MOH, Ministry of Defense, the University, and with the main stakeholders namely WHO, UNICEF, UNFPA, UNDP, the Global FUND, and USAID.

A review of the existing documents and reports on the health sector in Angola, as well as the most recent health sector appraisals and financing studies, helped in the analysis.These include the recent studies on capacity assessment of the health sector done by USAID, Global Fund/UNDP, and the EU–PASS project. The results of the work are also based on the previous experience of the consultant with the country and the MOH.

As work was carried out during only 10 days and by one consultant only, it was not possible to undertake an in-depth analysis or to visit locations outside the capital and the MOH.

General Country Profile. Angola,with more then 13 million inhabitants and an area of more the 1.2 million km²,is a sparsely populated country. Ithas a young population, with about 50 percentunder 15 years old, and 93 percent under the age of 50. Its total fertility remains high (7 in 2001). According to the Human Development Index, the country is in the162nd place among 173 countries.

The prolonged armed conflict has prompted massive movements of population and produced about 4 million internally displaced people (IDPs), most of whom have found refuge in the costal provinces. Despite almost four years of peace there are still refugees and IDPs whoare very poor, and it is still difficulty to reach some areas of the country.

Living conditions are still inadequate for the majority of the population. One third of the population is concentratedin three big cities. Poor water and sanitation increases the risk of ill health as demonstrated by the on-going cholera outbreak that resulted in more than 3000 cases by March 2006, with a case fatality rate of 4 percent.

Selected Health Indicators
Indicator / Angola / Sub-Saharan Average / Source
Total Population (2003) / 13.5 million / 15.0 million / WDI
Population Growth Rate (2003) / 3.0% / 2.1% / WDI
Rural Population (2003) / 63.8% / 61.8% / WDI
Life expectancy at birth (2003) / 40 years / 49 years / WDI
Fertility Rate (2002) / 7.0 / 5.0 / WDI
Infant Mortality Rate (per 1000 live births - 2000) / 154 / 92 / WDI
Maternal Mortality Ratio (per 100,000 live births) / 1,700 / 914 / WDI
Contraceptive Prevalence/100,000 (2003) / 6.0 / 22.9 / WDI
GDP/Capita US$D / 975 / 1,073 / WDI

Health Status and Vital Statistics. The health status of the Angolan population is one of the worst in the world. The 2003 maternal mortality ratio is reported by WHO at 1,700, compared to 600 in 1992. The under-five mortality rate is estimated at 250 per 1000 live births, and the infant mortality rate at 150 per 1,000 live births (UNICEF MICS II). For infants, the main causes of death are malaria, diarrhea, respiratory infections, anemia, measles, and in certain areas, malnutrition

Like a number of Sub-Saharan countries, Angola has not gone through the demographic transition. The MICS points to a total fertility rate of 7.0, with no significant difference between rural and urban populations. More worrisome is the fact that 27percent of adolescents (aged 15-19) were mothers already and, in the sub-group of 18-19 years old it was as much as 33 percent.Women with secondary level of instruction tend to have lower fertility rates, around 5.2.

The use of contraceptives is very low at 6 percent,and only 4.5 percent of women use modern methods. The highest use of contraceptives is in Luanda with 15 percent and the central provinces with 10 percent. The pill is the most used contraceptive (34%), followed byDepo-Provera injections (23%), abstinence (18%),and IUD (6%).This situation has negative implications in terms of reproductive health and maternal mortality.

The main causes of death for women are malaria, hemorrhage, eclampsia, abortion complications and prolonged labor. These causes are commonly associated to poverty and to the lack of access to adequate reproductive health services that are neither expensive, nor technically demanding. For example, in Malanjeprovince, increased access and limited training provided in the provincial capital, helped to reduce the MMR from 3007 /100,000 in 2000 to 1085/100,000 in 2003.[1]

The nutritional status of Angolans remains poor. The MICS II indicates that 45 percent of children suffer from chronic malnutrition, an improvement over 1996 when 53 percent of children were malnourished.Angolahas a high level of stunting and this will have enormous social and economic implications in the future. With 6 percent prevalence, the severity of wasting among Angolan children can be considered medium according to WHO threshold levels. More recent evidence shows that, from 2002 until the end of 2003, the health status has improved all over the country, and severe malnutrition is only expected in some areas.

Epidemiological Situation. Angola’s epidemiological profile is characterized by a high burden of disease related to nutritional deficiencies, and infectious and parasitic diseases, including malaria, tuberculosis, and HIV/AIDS.

The epidemiological surveillance system is poor. In recent years, with support from WHO and UNICEF a network of sentinel sites, based on a system of radio transmission, was established, and covers almost all the provinces. In 2001, the most common causes of visits to health facilities were malaria, acute respiratory infections, diarrhea, and typhoid fever. Among transmissible diseases, tuberculosis was the sixth cause for visits to health care facilities, and measles the tenth. Malaria and diarrhea were the most important causes of death, followed by tuberculosis and respiratory infections.

Malaria alone accounts for more than 60 percent of all outpatient visits and death by transmissible diseases reported in 2001. According to the National Malaria Control Program, every Angolan typically experiences 3-5 malaria episodes per year. The MICS II, using prevalence of fever as a proxy for malaria,reports that 25 percent of the children had fever in the previous two weeks. Only 10 percent of the population uses bed nets.

A small number of diseases, namely malaria, acute diarrhea, acute respiratory infections, measles and neonatal tetanus, are directly responsible for 60 percent of child deaths. Yetit is well known that it is easy to prevent or treat these problems at primary health care facilities, and through improved practices and care at the household level.

Diarrhea has a prevalence of 25 percent among the under-five year olds (MICS II), but only 7 percent of these cases were treated with rehydration fluids and continued feeding. The use of oral rehydration salt (ORS) was only 40 percent in these cases. Measles was the fifth cause of death by infectious diseases. A recent measles immunization campaign was conducted by the government with support from UNICEF. It was successfuland covered 93 percent of the 7.3 million target population of children between 6 month and 14 years old. During the last five years there have been outbreaks of meningitis and cholera in Luanda and some southern and central provinces that put an added burden on an already weakened health system.

One disease that is highly prevalent in the northern areas of the country is trypanosomiasis (sleeping sickness). There is a specialized autonomous institute set up to control the disease and actions related to this disease should be included in any basic health care intervention in the endemic areas.

Tuberculosis prevalence is increasing. Studies from 1990 estimated the annual infection risk to be 1.2-1.9 and the incidence to be of 120 cases per 100,000 inhabitants. Data from the TB program for 2001 (MOH TB Program Annual Report) shows more than 21,000 TB patients. Since 1996, the country has adopted the DOTS strategy for treatment. At the present time, it covers 44 of 163 municipalities in the country and about than 43 percent of the population.

The AIDS Epidemic. AIDS is a significant health problem in Angola. Surveys done by the National Institute of Health and the Italian Cooperation show a trend of increasing prevalence in pregnant women especially in Luanda and among sex workers. A recent survey, supported by CDC-Atlanta, covered more provinces that the 2001 survey. Itshoweda prevalenceof around 3.9 percent. There are disparities among prevalence rates in the provinces, and Cunene, Benguela, Cabinda and Luanda have already well established epidemics