2.3. Challenges and Gaps 3. NORTH AFRICA ...................................................................................................................................................................................... 165

Much of the progress reported on the region’s health outcomes can be seen in relation to HIV. In Rwanda, the percentage of people with HIV has decreased, though HIV is more prevalent in women than men in the same age group.1147 In Seychelles, a commitment to dealing with HIV is demonstrated through the country’s third and latest National Strategic Plan for HIV, AIDS and Viral Hepatitis 2019–2023.1148 This aims to reduce the number of HIV cases and infections in the country through increased testing and by protecting the rights of those who already have HIV.1149 Meanwhile, Somalia remains committed to fighting HIV through its National Strategic Plan for HIV and AIDS 2015–2019.1150 HIV prevalence in Tanzania is again higher among women than men, at 7% compared with 4%;1151 this can be understood as being a result of gender inequality and partly of women getting married earlier to older partners.1152 Although Ugandan women are also more affected by HIV than men, they have higher rates of receiving treatment, with 79% of women compared with 63% of men.1153

2.3. Challenges and Gaps

The SDG health targets include reducing the maternal mortality rate, especially in high-risk regions like sub-Saharan Africa, which accounts for an estimated two-thirds of global maternal deaths.1154 As a result, countries in the East African region are actively coordinating both internal and external efforts to reduce their unacceptably high rates of maternal mortality. However, despite record improvements, the region has a long way to go in this regard.

Levels of awareness regarding HIV transmission and prevention are low in Eritrea and Ethiopia. In Eritrea, only 24.7% of women have reliable knowledge,1155 and in Ethiopia only 20% understand HIV transmission and prevention.1156 Lack of comprehensive knowledge about the modes of transmission of HIV as well as other sexually transmitted diseases, as well as the low use of contraceptives, is evident in both countries. In order to assist with HIV testing, Tanzania has amended legislation to lower the age of consent for testing from 19 to 15.1157 As part of the 2017–2022 HIV Prevention Strategy, the government aims to promote the usage of condoms. However, lack of funding and weak supply chains for the massive number of condoms needed make this a difficult goal.1158 Despite progress made in lowering infection rates, women in Rwanda, Tanzania and Uganda continue to have a higher infection rate of HIV in comparison with men.

In Madagascar, the country’s government is actively working to overcome gaps through the provision of free access to contraceptives and family planning information and services at public clinics. However, lack of resources mean these services are not always available,1159 resulting in low levels of modern contraception use among women, at 36.4%.1160

The Kenyan Demographic Health Survey found maternal mortality to be at 360 per 100,000 women in 2010. To lower the statistics further, the government ensured that skilled physicians attended births, to reach attendance of 44% of deliveries in 2014.1161 Measures to deploy more skilled medical personnel to attend births have also been put in place in Ethiopia and Madagascar, with 62% of births in Ethiopia provided by skilled obstetric staff in 20161162 and 46% in Madagascar in 2018.1163 Despite these improvements, the East African region maternal mortality figures are still the highest in the world.1164 Djibouti’s maternal mortality rate is among the lowest in the region, at 229 per 100,000 live births in 2015. This has been achieved through the provision of pre-natal and post-partum care.1165 Madagascar is another lowranking country, recording 353 maternal deaths per 100,000 live births.1166

With ongoing conflicts in the region resulting in a flow of refugees and internally displaced persons, there remain difficulties with access to quality, available and affordable health. Along with poor access to health services, there is a shortage of skilled health workers. A focus on raising the number of health staff, especially midwives, would address many of the key issues leading to high rates of maternal mortality.1167 Improvements were made during the Decade but challenges persist. In South Sudan, the health sector is not well funded, receiving only 2% of the national budget.1168 Low levels of government funding lead to limited health care infrastructure, sparse supplies and few trained professionals. This lack of prioritisation of health in the country has impeded efforts to improve on maternal mortality rates, even though many needed elements are being funded through the support of other nations and organisations.1169 According to an estimate by the UN, there is one doctor for every 65,000 patients,1170 and only 19% of births are assisted by medical professionals, indicating a direct correlation between rising maternal mortality and lack of medical professionals.1171