Ambitious Targets For Global Health
If these targets are to be achieved by 2030 worldwide, the global community must focus on achieving them in Africa.
On 23 September 2019 heads of state, health leaders and policymakers gathered in New York for a meeting of the United Nations General Assembly. The meeting resulted in what UN Secretary-General Antonio Guterres described as “the most comprehensive agreement ever reached on global health”.
It was considered a watershed moment in achieving the key Sustainable Development Goal (SDG) of ensuring all people receive the quality health services they need by 2030. At the heart of the agreement was a pledge to implement high-impact health interventions to combat communicable and non-communicable diseases, and strengthen the health workforce, infrastructures and governance. It was also agreed that no one requiring healthcare should suffer financial hardship by paying for health out of their own pocket.
Innovation is a byword when it comes to future healthcare delivery, empowering us to prevent disease, treat clinical conditions with precision, empower patient participation and predict the behavioral and environmental causes of illness.
If these commitments are to be achieved by 2030 worldwide, the global community must focus on achieving them in Africa. With 16 percent of the global population, the continent accounts for 26 percent of the global disease burden yet receives less than 2 percent of total global healthcare funding. If we can make significant progress here, it will be a major step forward, which is why Africa is a focus of this section.
We will look at solutions being explored to address these new commitments set by the UN when it comes to healthcare in Africa, and in developing countries elsewhere. Achieving “high-impact health interventions” while ensuring access to affordable healthcare is going to require a new generation of digital innovations along with R&D in the field of vaccine and drug delivery. Vaccines have extraordinary knock-on effects, reducing healthcare costs, wages lost as the result of illness, and infections that impair cognitive and physical development. They also lead to lower birth rates as mothers no longer fear infant mortality. According to the International Vaccine Institute, every $1 invested in vaccine technology saves $44 to society.
One of the key findings of the FII Institute healthcare study is the need for future initiatives to be heavily focused on ill-health prevention measures. So we explore how it is possible to reach low-income communities that are reliant on a few staple crops and are most at risk of nutrition loss. The UN Food and Agriculture Organization estimates that around one-quarter of the world’s population is deficient in minerals and vitamins, increasing the risk of lifelong deficits in physical and cognitive development. We look at how the new science of biofortification is helping alleviate the problem.
HEALTH IN THE BALANCE
The good news is that since 2000 life expectancy in Africa has been increasing on average at a rate of five years per decade. With economic growth at over 5 percent between 2000 and 2010, improvements in health structures have been paying dividends. Other key metrics include the infant mortality rate, which since 1990 has more than halved, and maternal mortality, which fell by just under 1 percent a year between 1990 and 2015.
I have seen firsthand how lack of access to affordable healthcare can blight the lives of ordinary people.
There have also been some momentous achievements. On August 25 this year, the World Health Organization (WHO) celebrated ridding the Africa region of wild polio, an event described by WHO Director-General Dr. Tedros Adhanom Ghebreyesus as “one of the greatest public health achievements of our time”. Wild polio was a source of the polio virus, responsible for paralyzing more than 75,000 children a year in the mid-1990s. Its eradication is thanks to a 30-year campaign to vaccinate over 95 percent of Africa’s population.
But Africa still has a long way to go to meet the UN’s health-related SDGs by 2030. Covid-19 has thrown into sharp relief the strengths and weaknesses of Africa’s health structures. On the plus side, African states have had extraordinary success in marshaling armies of community workers to get to hard-to-reach communities to stem the spread of the virus. “Local, well-trained community workers who have a lot of past experience in dealing with contagious diseases have been key to our strategy,” says Dr. Ahmed Ogwell, Deputy Director of the Africa Centers for Disease Control. “The reason we have been so aggressive with prevention measures is that if people start requiring critical care, countries will get overwhelmed very quickly.” It is at the acute end of health delivery that the African health systems are at their weakest.
LOSS OF SKILLS
According to research published in December 2019 by the UN Economic Commission for Africa, skill shortages are one of the biggest obstacles to strengthening healthcare structures. The WHO recommends a minimum of 23 skilled health workers per 10,000 population. In 11 African states that ratio is below five, while in Niger and Somalia it is less than two. The problem is more acute in rural areas where it is difficult to attract qualified workers. The report reveals that skill shortages are being compounded by a recent 60 percent increase in qualified health workers migrating to OECD countries.
Africa’s age demographic is also a challenge. With its population expected to double between 2015 and 2050, one-third will be under 14 in 30 years. While this has the potential to create a “demographic dividend”, boosting economic growth and productivity, the flip side is that the 60 percent of Africa’s population currently under 20 will, by 2050, be starting to age. It means health systems will need to respond to heavy demands from both ends of the age spectrum. The sort of rapid urbanization Africa is experiencing is also set to pose problems. Urban migrants switch to less healthy diets, resulting in higher rates of costly chronic disease, while also living in overcrowded conditions, often with poor infrastructures.
COST OF CARE
According to the latest figures, the current healthcare funding gap for the continent is around $66 billion per annum. This is a serious obstacle to achieving affordable universal healthcare by 2030. On average, 36 percent of healthcare spending in Africa is paid for by those who require the medical treatment, compared to 25 percent in middle-income countries. This figure rises to 70 percent in countries like Cameroon, Comoros, Equatorial Guinea and Nigeria. The rest of the funding comes from domestic governments, external assistance or prepaid private spending in the form of some kind of health insurance. The inevitable consequence is that those who need treatment the most tend to be those who can afford it least.
LEAP INTO THE LIGHT
“Leapfrogging” is a term often used when discussing healthcare delivery in the developing world. It is shorthand for leveraging digital healthcare technology to compensate for severely stretched traditional primary care structures.
The term derives from the way cell phone technology has leapfrogged the development of fixed phone line infrastructures in Africa and Asia. It is an appealing idea, a sort of silver bullet that many believe will go some way to narrow the gap in global healthcare equity. The idea has attracted a huge number of tech companies to the healthcare field, many of which are having a positive impact on health delivery.
However, there are major obstacles to be overcome. Most recent World Bank figures show that in Sub-Saharan Africa about half the population lacks access to electricity. In rural communities, a solution is being found in the development of micro-grids connected to renewable energy sources. The African Development Bank is developing new finance structures to support companies providing off-grid, largely solar-powered electricity solutions rather than trying to extend existing grid networks. Ethiopia has ambitious plans using decentralized renewable energy grids in rural areas, while Kenya has embraced geothermal, wind and solar power to drive access to electricity up from 20 percent of the population in 2002 to 75 percent in 2018.
Another challenge in low-resource environments is that, when it comes to more advanced telehealth, poor connection speeds and “not spots” – areas with no cell coverage – are proving an obstacle. But there may be solutions in the pipeline here, too. In July 2020, Google and Telkom Kenya launched Project Loon: an initiative that enables high-speed Internet to be beamed from a fleet of high-altitude hot-air balloons over an 80,290 square-kilometer area of central and western Kenya, including the capital, Nairobi. The initiative is cheaper than laying cables or building cell towers and is being closely watched by other telecom providers.
But even with the existing patchwork of cell phone coverage, sophisticated telehealth solutions are still being developed. In 2016, plastic surgeon Nadine Hachach-Haram decided to combine her knowledge as a surgeon in the UK’s National Health Service with her charity work to help address a global shortage in surgical expertise. She founded Proximie, now operating in more than 35 countries, a platform that enables an expert surgeon to virtually transport themselves into any clinical setting simply by using a phone, tablet or computer to interact and support surgical procedures. “It allows two people in remote locations to interact virtually in a way which mimics what they would experience if they were collaborating in the same room,” explains HachachHaram. “I have seen first-hand how lack of access to affordable healthcare can blight the lives of ordinary people, technology is part of the solution.”
The ability of the technology to operate at low bandwidths means it can be used in low-resource settings as well as high-end hospitals. In a recent initiative, a leading Chicago-based ear, nose and throat (ENT) specialist was able to mentor surgeons in Ethiopia, increasing the skill pool so the number of surgeons now able to carry out ENT procedures has risen from one to six.
Digital solutions are also helping with health skill shortages at other points of health delivery. In Tanzania, where there is one doctor for every 25,000 people, a Swahili-speaking free-to-download app uses AI to enable a patient to input symptoms and pre-existing medical conditions. The Swahili-speaking chatbot app questions the patient, provides a diagnosis and recommends treatment. Swahili is spoken by 100 million people in East Africa, and the hope is to increase coverage across the region.
According to Dr Ahmed Ogwell, Deputy Director of the Africa CDC, cell phone technology has been empowering health delivery in Africa for many years. “An example is the way the African Medical Research Foundation has been using mobile technology for a long time to build the capacity of our health workers and for providing information for facility-based health workers,” he explains. “It really is a standard tool that is largely being used to provide SMS messages rather than the level they are being used elsewhere with GPS positioning.”
Technological advances are not confined to the digital. Jamie Bay Nishi is director of the Global Health Technologies Coalition (GHTC), which brings together 30 organizations working to accelerate development of drugs, vaccines and diagnostics for the developing world. “We look at where the biggest market failures happen, and that’s often around TB, malaria, HIV, neglected tropical disease and of course emerging infections,” explains Bay Nishi.
The GHTC acts as an advocate for public investment and policy solutions to advance global health research and development, such as improving delivery mechanisms for drug treatments in low-resource settings. “Some of our partners have worked on child-friendly formulations of tuberculosis and malaria medications,” says Bay Nishi. “Realizing that TB medications historically taste horrible and getting the right dosing amounts for pediatric populations was a really big problem. Reformulating an existing drug so that we can reduce its dosing and make it something that actually tastes good is a real game-changer for kids living with TB.” GHTC and its partners are currently advocating for solutions for nonintravenous delivery of Remdesivir, an Ebola drug being used for Covid-19 treatment. “An IV drip is just not going to work in a low-resource setting,” says Bay Nishi. “We need partners to think about how to have this in pill or inhalable form that is also heat-stable and does not require a cold chain.”
Safe delivery of vaccines and drugs has always been a challenge in developing countries. Most vaccines must be stored in temperatures between 2°C and 8°C, with too-cold storage temperatures often a bigger problem than spoilage from heat. A 2018 review by the journal Vaccine revealed that 37 percent of vaccines in low-income countries are exposed to temperatures below recommended ranges during storage. The advent of sensors capable of monitoring temperature as well as humidity, and storing the information in the cloud, is proving invaluable in optimizing supply chains to safeguard vaccine quality.
PREVENTION OVER CURE
Low immunity to disease as a consequence of malnutrition is also a major area of concern. A technological advance that many believe could have a dramatic impact on disease prevention is biofortification. Unheard of 20 years ago, it is the science of improving the nutritional quality of crops through conventional (non-GMO) plant breeding.
Jen Foley is a senior program manager for the HarvestPlus program, which leads a global effort to address malnutrition. “It is essentially the process of making micronutrients available to smallholder farmers and vulnerable populations through the crops and foods they are already eating every day. Year after year they can grow nutritionally enriched crops, without any extra cost to themselves,” explains Foley.
It is estimated that over 40 million people worldwide currently benefit from foods made from biofortified crops. In August this year, India’s third-most populated state, Bihar, announced plans to significantly scale up production of zinc-biofortified wheat. Zinc deficiency can be a major cause of stunted physical development and child mortality while also making people vulnerable to diarrhea, malaria and lower respiratory infection. It is estimated that the government-led initiative will increase availability to millions more nutritionally vulnerable families in a state with the lowest per capita income in the country. Other biofortification initiatives across Africa, India, Asia and Latin America provide micronutrients such as zinc, iron or vitamin A in maize, rice, sweet potato, wheat, beans, pearl millet and cassava, among other crops.
In 2019, the UN Food and Agriculture Organization published a joint report with HarvestPlus outlining this still relatively new strategy’s benefits. It concluded, “biofortification is a cost-effective, food-based, nutrition-sensitive agricultural approach for improving nutrition”. The World Food Programme includes biofortified crops in its guidance on food relief procurement.
Foley claims that while it has taken 15 years for the science to establish itself, it is now at a turning point. “There are now nearly a hundred global and regional strategies that include biofortification,” she says. “We believe we have reached a significant point where we can rapidly scale up.”