HUMANITARIAN CRISIS IN SOUTHERN AFRICA: An …



HUMANITARIAN CRISIS IN SOUTHERN AFRICA: a wake up call

Draft Report, focussing on health issues

Prepared by: DR. DAVID O. OKELLO, WR/Swaziland

Introduction:

Southern African countries are prone to erratic rainfall and drought, and this worsened since the late 2001. In March 2002, an Inter-agency Standing Committee (ASC) which has been monitoring the vulnerability of the region to adverse weather effects found that Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe were at risk of severe food shortages. The assessment initially found that 12.8 million people were at risk of a serous food crisis and in need of food and other assistance by March 2003. Subsequent assessments done in August and September 2002 indicated increasing vulnerability, and 14.4 million people in the affected countries were at risk.

While erratic weather changes were considered to be the main triggers of the vulnerability, in many cases the crisis was being exacerbated by a complex mix of factors, including serious problems of governance, the impact of HIV/AIDS, weakened social sectors, poorly functioning or constrained private sectors, and poor macro-economic performance in a number of these countries.

Following a review of the vulnerability assessment in June 2002, the UN launched a Consolidated Appeal to help avert the crisis. As part of this appeal, the UN-Secretary General named Mr. James Morris, Executive Director of the World Food Programme as his Special Envoy for the Humanitarian Needs in Southern Africa. The Special Envoy was asked to visit the region in order to meet with key stakeholders and review the humanitarian situation and ongoing relief efforts, as well as raise international support and awareness, and to provide recommendations on how to strengthen the humanitarian response and mobilize donor support.

To help him undertake the assignment, the Special Envoy assembled an inter-agency team of 13 people, comprised of representatives of WHO, UNICEF, FAO, WFP and SADC, as well as the UN Deputy Emergency Relief Coordinator.

The specific tasks of the Envoy were:

• Visit the countries in the region affected by drought;

• Meet with the Government, the Southern African Development Community, and representatives of the donor community in the countries visited;

• Discuss with the UN Country Teams in the region;

• Review the humanitarian situation, current relief efforts, and contingency planning in order to ensure a coherent and complete response is occurring, including the special needs of people living with HIV/AIDS and AIDS orphans;

• Provide recommendations on strengthening humanitarian operations and address any relevant operational or policy impediments to the effective delivery of humanitarian assistance;

• Look for gaps in donor support and seek to find ways to address them through dialogue between donors, Government and agencies;

• Mobilize media support and interest in investigating and reporting on the humanitarian crisis; and

• Provide recommendations on the efforts needed to create sustained capacity at the national and regional levels to address longer-term food security issues and non-food assistance.

Method of Work

The team visited the six affected countries in the period 3-15 September 2002. In each of these countries, the team held meetings with top government officials (usually ministers and their relevant technical staff, and in some cases heads of states or their deputies), UN-country teams, donor agencies and NGOs. In all cases, the UN Country teams prepared elaborate briefs and supporting background documents on the humanitarian situation in the country. The team reviewed these documents and other relevant publications (e.g. press coverage of the crisis) to identify the outstanding issues in the country. Field visits were organised to communities most affected by the food crisis, where the mission witnessed relief efforts and interacted with people directly affected by the crisis. The team visited health clinics, HIV/AIDS orphanages, families and institutions known to offer home-based care for vulnerable groups.

The main findings

A special report on the findings of the Envoy was submitted to the UN-Secretary General. The vulnerability assessments and the subsequent responses to date have focussed mainly on the food crisis. However, the mission findings indicate several major health-related problems that require urgent attention. The aim of this overview is to try and highlight the health related aspects of the humanitarian crisis and provides some suggestions on how to address them.

It is important to point out that the mission of the Special Envoy took place just about one week after a meeting of SADC Health Ministers organised by the Director General of WHO in Harare. This meeting sought to address the health aspects of the humanitarian crisis in the region.

Furthermore, it should also be noted that the major factors responsible for the current crisis in the region – environmental factors, agricultural failures, and macro-economic policies – are all major health determinants.

The key health issues identified during the tour of the six countries include:

Health Sector Response

In many countries the response to the health needs created by the crisis has been slow and limited by ailing capacity. The health system is suffering from chronic problems such as low budget, weak human resources capacity, low staff morale, inadequate supplies and lack of resources for essential drugs. Faced with the now emerging severe malnutrition problems, the system will certainly be unable to cope unless additional capacity and essential drugs are mobilised.

Crucially, surveillance systems in some countries are weak or have failed to detect critical health problems. Government systems have begun to break down in some of these countries, due to HIV/AIDS as well as a general macro-economic decline (notably the retrenchment of mine workers from South Africa). As an example, though child growth monitoring is still being done in some centres, outreach programmes have largely stopped. Nurses are being “poached” from many of the countries, travelling to South Africa or the UK to take up better positions. Donors, UNICEF and WHO must support and work closely with Governments to strengthen these systems.

The mission raised several health concerns with the Governments in the region. The ability of Government in the six countries to address health aspects of the crisis, however, is clearly in question. It is obvious that national systems are limited and support is urgently needed to reinforce health systems. The availability of essential drugs throughout the region is extremely limited. Additional donor resources are urgently needed for the purchase of basic supplies and drugs for epidemic prone diseases such as measles, meningitis, cholera, malaria and other opportunistic diseases in HIV/AIDS.

Malaria continues to take a heavy toll of lives and livelihood in all the six countries, with the number of cases increasing in recent years. EPI coverage is hampered by both limited capacity, and poor access. The prevalence of diarrhoeal diseases has increased markedly in communities hard hit by drought; and some communities have reported outbreaks of scabies and eye diseases, mainly related to water and hygiene problems.

The impact of HIV/AIDS

The relationship between the HIV/AIDS pandemic and the reduced capacity of people and Government in Southern Africa to cope with the current crisis is striking. In every country of the region, HIV/AIDS is causing agricultural productivity to decline, forcing children to drop out of school, and placing an extraordinary burden on families and health systems.

The pandemic has created a crisis of care and support particularly for children, elderly and the terminally sick. The number of orphans in the region has risen dramatically and their needs are acute. UNICEF estimates that there are now over 4 million orphans in the six countries. Additional support is necessary to current efforts, although programmes need to be coordinated carefully with other forms of assistance in order to ensure that their objectives are complementary. To this end, efforts should be made in the short term to bring together stakeholders in the development process and to map out a concerted strategy for the region that considers food security and HIV/AIDS.

Limited capacity (exacerbated by HIV/AIDS and economic emigration) within key sectors is a major constraint for Government ability to mount effective responses. WHO/UNDP support to help target national capacity building initiatives is vital so that Governments are able to take greater responsibility for addressing the needs of their people.

Nutritional problems

The team encountered several forms of extreme malnutrition in health clinics, ranging from overt kwashiorkor and marasmus, as well as various grades of stunting and extreme wasting in communities affected by food shortages.

Perhaps the most outstanding nutritional problem was the lack of a sustainable mechanism for feeding the very sick, lactating mothers, and orphans, both at home and in health clinics. Support for nutritional interventions has been inadequate throughout the region. Nutritional surveillance capacities need to be reinforced (WHO, UNICEF), diet diversification (FAO, UNICEF) and fortification (WFP, UNICEF) should be promoted.

Improved dietary quality is urgently required to provide to those affected by HIV/AIDS and other debilitating illnesses. Equally, there is an urgent need for supplementary feeding for other target groups such as lactating mothers, orphans and those affected by debilitating disease. Health clinics and schools should be considered as key entry points for supplementary and therapeutic feeding programmes.

Recommendations

It is not an easy task to convey on paper the range of impressions, thoughts and emotions that individuals or a team experiences when coming face to face with the realities of what is likely the most serious humanitarian crisis facing the world today. Many people are suffering now, and they have genuine humanitarian needs that must be addressed now or they will likely die.

It is clear that the health sector in all the six countries has not treated the crisis with the urgency it deserves. Moreover, more than in many other emergencies, there is a need to link closely humanitarian programming with longer-term efforts to meet development objectives. Emergency relief may in some cases provide an impetus to quicken the pace of development programming.

To address the health issues identified above, it is recommended as follows:

1. The need to address the health impact of the crisis must be highlighted as a key area of concern. Reference must be made at the commitment made in the recent meeting of Health Ministers convened in Harare by WHO. In view of the limited capacity of the Health Ministries to fight HIV/AIDS pandemic, every effort must be made to advocate for the early disbursement of the Global Fund for Health to fight HIV/AIDS, TB, and Malaria.

2. Support should be provided to the Ministries of Health to strengthen health and nutritional surveillance as a matter of priority. This will allow for a determination of the real needs that exist in the countries, and should help WHO and the Ministry of Health enter into a process of contingency planning.

3. There is an urgent need for supplementary feeding for certain target groups such as lactating mothers, orphans, and people living with HIV/AIDS and TB. Health clinics and schools should be considered as important entry points for supplementary feeding programmes.

4. Additional resources are required for the purchase of basic supplies and drugs for epidemic-prone diseases such as measles, meningitis, cholera, skin conditions, malaria and acute respiratory diseases.

5. Water and sanitation initiatives should be supported in order to improve hygiene conditions and reduce the likelihood of opportunistic infections in people living with HIV/AIDS.

6. The HIV/AIDS situation in southern Africa is challenging the paradigm of humanitarian assistance. In almost every sector – food, health, education, agriculture, water and sanitation – the crisis response needs to be re-orientated in order to convince donors, governments and the international community to take urgent action. Although the condition might be considered to be a longer-term problem, it does need to be addressed in the context of the vulnerability that the current humanitarian crisis has generated. The main line of response in all these countries is currently limited to prevention and awareness, as well as some limited home care initiative. Truly fighting a war against the disease would require not only stopping all new infections, but also treating those who are sick with anti-retroviral drugs and other care measures.

7. Surveillance and absorptive capacity in the health system remains a key concern. Additional support for the health ministries is crucial for it to respond effectively to the increasing demand for life saving services. Surveillance must also be maintained so that vulnerability continues to be the main criteria for targeting assistance. To provide for the increasing number of HIV/AIDS patients, home based care needs to be expanded. The mission recommends the provision of care and comfort kits at the community level to help provide for terminally ill patients, including targeted feeding.

8. Food is considered the best ‘first defence’ against the impacts of HIV/AIDS, but clearly will not be sufficient; more concerted efforts and measures must be taken to highlight the severity of the socio-economic impacts of the condition on the region.

Conclusion

With a crisis often comes an opportunity. The humanitarian crisis experienced in southern Africa should be no exception. The Governments of the affected countries and the international community must take the crisis as a wake up call. As plans are put in place to tackle the crisis, there is need to launch a renewed effort to strengthen the Government’s capacity to respond. At the same time, it must be emphasize that the crisis at hand is not just about food, but rather it is a multi-sectoral problem with a paramount health and health-related aspects. Four critical elements require immediate attention: (i) water and sanitation; (ii) supplementary and therapeutic feeding for the target groups identified; (iii) retention and attracting skilled staff back to service in their respective countries; and health and nutritional surveillance to keep tract of the evolution of the crisis. However, the evidence highlighted in this report indicates inadequate government capacity to deal with these problems fully. The intervention of the international community is critical.

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