Developing Countries

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.

The United Nations has set ambitious targets to improve healthcare delivery in developing countries as part of the Sustainable Development Goals for 2030.Li Muzi/Xinhua/Eyevine/Laif

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.


THE FUTURE OF HEALTHCARE

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.

Precision: The Da Vinci XI surgical robot supports the surgeon when performing minimally invasive surgery. It enables the tiny wristed instrument to perform extremely precise movements while remaining under the control of the surgeon. Spencer Lowell/Trunkarchive.co
Prevention: Run by the non-profit organization Smile Foundation, Smile on Wheels is a healthcare van delivering essential medicines to an elderly woman on the streets of Mumbai, as well as offering mobile screening for Covid-19. Ashish Vaishnav/Sopa Images/Lightrocket Via Getty Images
Prediction: A genetic research scientist views DNA to confirm or rule out a suspected genetic condition or help determine a person’s chance of developing or passing on a genetic disorder. More than 1,000 genetic tests are currently in use. Andrew Brookes/Getty Images
Participation: In Rwanda, people who fail to take proper measures to stop the spread of Covid-19, such as wearing face masks correctly in public places, are required to listen to public health messages in Nyamirambo stadium in Kigali. STR/AFP Via Getty Images

 


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.


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The recent increase in skilled African healthcare workers migrating to OECD countries SOURCES: WHO

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.

Dr. Nadine Hachach-HaramDr. Nadine Hachach-Haram
Founder, Proximie

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.

An ophthalmologist at the Nampula hospital in Mozambique examines a patient after a cataract operation. The country has just 18 ophthalmologists for a population of 23 million.Tommy Trenchard/Panos Pictures/Visum

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.

A boy who lost his leg in a traffic accident watches as a 3D printer produces a prosthetic socket for him at CoRSU hospital in Kampala, Uganda.Jelca Kollatsch / Visum

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.

SURGICAL CARE

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.”

MEDICAL ADVANCES

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.”

At the national hospital in Cotonou, Benin, research is carried out into tuberculosis. Molecular testing is used to diagnose this highly infectious disease.Yannick Foly/Getty Image

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.

Proximie enables surgeons to collaborate remotely via audio, video and augmented reality. The software works at low bandwidth and latency.Proximie

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.


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of vaccines are spoiled due to incorrect storage temperatures SOURCES: VACCINE JOURNAL

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.”

CALL TO IMPACT
1 Technologies like sensors and cloud data storage must be made available along the vaccine supply chain to ensure that more vaccines are stored in the correct conditions. 2 Innovative solutions must be found to help address the challenges of delivering healthcare in regions where mobile phone coverage is weak. 3 Policies must be developed to sustain and scale up biofortification of crops as these help prevent disease by building immune systems.
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