It's how you spend the money that saves lives

Members of the African Union (AU) reaffirmed at the end of their meeting on 27 July in Kampala, Uganda, that they would strive to spend 15 percent of their national budgets on health, but at the end of the day it is about how "effectively and efficiently" you spend the money, not about how much.

The promise to spend 15 percent on health was made in Abuja, Nigeria, in 2001, but health experts like Chikezie Anyanwu, Africa Advocacy Advisor to Save the Children, which works to promote children's rights, were left wondering whether the percentages actually made a difference.

Countries could spend more than 15 percent and still show no real reduction in the deaths of children younger than five, or among women during or after childbirth, as specified in the Millennium Development Goals (MDGs) set by the UN.

Rwanda, Liberia and Tanzania are the only three African countries devoting more than 15 percent of their national spending on health, said Anyanwu, citing a 2010 World Health Organization (WHO) report, based on data from 2007. "But they have made insufficient progress in meeting MDGs [Millennium Development Goals] four and five [reducing maternal and child mortality]."

In South Africa, one of the most developed and richest countries in the continent, the infant mortality rate has escalated and the country will probably not achieve the MDG target by the deadline of 2015.

An under-five mortality rate of 67 per 1,000 live births put South Africa at 141 out of 193 countries; in 1990 the rate was 56 deaths per 1,000 live births, according to the UN Children's Fund (UNICEF). HIV/AIDS is cited as the leading cause of death among children in South Africa.

Rwanda, Liberia and Tanzania are the only three African countries devoting more than 15 percent of their national spending on health...But they have made insufficient progress in meeting MDGs

Mortality audits by the government's Child Healthcare Problem Identification Programme indicated that more than 60 percent of children who died in hospital between 2005 and 2007 were underweight, and according to the most recent national food consumption survey in 2005 nearly one in five children was stunted or chronically malnourished.

Yet Malawi, poorly resourced and with a high HIV prevalence rate, is on track for achieving its MDG targets, but since 2007 it has pushed its spending on health beyond 15 percent, said Health Minister Prof Moses Chirambo.

Malawi is now one of only 10 African nations that could meet MDG 4 – reducing child deaths by two-thirds of the 1990 levels by 2015 - according to an African Scorecard prepared by Save the Children, using WHO and UN Children's Fund (UNICEF) data.

The case of South Africa

"In 2006, the South African government spent seven times more money on health than Malawi, and 17 times more than Madagascar – two countries that have reduced child mortality by more than one-third between 1990 and 2008," said an article written jointly by Prof David Sanders of the University of the Western Cape, Debbie Bradshaw of the South African Medical Research Council, and Ngashi Ngongo of UNICEF.

"South Africa is one of 12 countries going backwards on reducing infant mortality," said Sanders. The other 12 countries include Zimbabwe Botswana, Kenya and Sierra Leone.

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The article was among several in the latest edition of South African Child Gauge 2009/10, an annual snapshot of the status of South Africa's children published by the University of Cape Town (UCT), which took critical stock of spending on child health.

Malawi and Madagascar started with a mortality baseline even more abysmal than South Africa's. Eight percent of South Africa's gross domestic product is spent on health, but about five percent of that is spent by the private sector; 60 percent of the remaining roughly three percent that goes to the public sector is spent on personnel, Sanders told IRIN.

HIV was a major cause of death in South Africa, accounting for between 35 and 40 percent children younger than five, but other diseases such as diarrhoea also chalked up heavy casualties.

Sanders and his co-authors cited recent analyses implicating South Africa's high HIV prevalence of about 18 percent in its poor health performance, and mother-to-child transmission in high morbidity and mortality among infants and young children.

There are lessons that Malawi, with an HIV prevalence of 14 percent, extreme shortages of paediatricians, doctors and midwives, can offer South Africa and other countries, said Sanders.

It has focused on improving community-based health services and recruiting health surveillance assistants to administer antiretroviral drugs, supervise the directly observed treatment short course (DOTS) for TB, and contribute to maternal, newborn and child healthcare, which includes paying postnatal visits, an often critical service.

Malawi has also prioritized spending on nutrition - a sector run by the Malawian president himself - as a key preventive action to ensure that children's and women's immune systems are not compromised.

The South African government should ensure that quality foods like vegetables, fruits and good animal protein sources were cheaper than foods with poor nutritional value, said Sanders.

In another article Michael Hendricks of UCT and Lesley Bourne of the Medical Research Council said 80 percent of households could not afford an average nutritionally adequate food basket.

"But this calls for addressing broader issues, such alleviating poverty and ensuring people have access to good living environments, with water and well ventilated homes," said Sanders.

In 2008, 64 percent of children lived in poor households, said Hendricks and Bourne, who called for a multi-sectoral approach to tackling malnutrition by using several ministries, such as health, education, agriculture and social development.

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