This article analyses global health developments over the past half century, current challenges and future trends. It is largely inspired by the African Development Bank’s March 2013 publication of the same name. A summary will be offered below, along with some additional examples and indications, but the overall contribution is to highlight five key considerations which modern global health strategists will have to account for:
- i) Demographic shifts; ii) Equitable access and resource allocation focussed on the poorest are ever more important following evidence that economic growth does not necessarily lead to improved health; iii) the ICT revolution which must be capitalised upon; iv) Climate change and new environmental challenges; and v) decline in aid flows to African countries.
Progress over the last 50 years
The authors applaud progress made in recent decades, for example in maternal and infant mortality rate, while acknowledging that Africa remains the continent with the world’s lowest life expectancy. Provision of healthcare has improved in some areas, notably child immunisation, but is lacking in family planning, for example. Funding issues tend to belie the access problems, but the private sector has an increasingly important role to play.
Challenges Confronting the Health Sector
Progress towards health-related MDGs are falling below expectations. Greater efforts are needed to improve preventative healthcare in fighting main diseases such as pneumonia, diarrhoea and HIV/AIDS. Similarly the MDG on maternal health is way off target, with some countries having made no progress at all. Key to this is stepping up family planning measures and the development of cultural attitudes. The fight against HIV/AIDS, malaria and other diseases (MDG6) is winning, but modern-day challenges pertain to sustaining access to medicines in the longer term (it should be added that the funding environment is very uncertain) and the need to remain alert to co-infections and drug-resistant strains.
The key to improving equity in access to and use of quality health services is in focussing attention on the poor, rural and women as they are the most disproportionately affected. Issues, which will be elaborated below, concern shortages of crucial medicines and skilled workers (brought into sharp relief with the ongoing Ebola crisis), brain drain and the connected issue of increasing incentives.
The challenge ‘Strengthening health systems/sustainable and equitable financing’ calls for, on the one hand, the need to shift from reliance on foreign assistance which is declining and, on the other, an acknowledgement that weak systems stymy rapid response to crisis. A pertinent example here is that such systems rapidly turnover senior officials, are inefficient and bad value for money. Paul Collier cites a survey tracking money released by the Chad Ministry of Finance to help rural health clinics; less than 1 per cent reached the clinics.[i]
This is linked to the final challenged identified: tackling health as a cross-cutting issue. Indeed, a heightened awareness of the health impacts of gender inequality, climate change and urbanisation. There is an inevitable interplay, for instance, between a nation’s health and how it manages urban growth (including slum sizes); a proportionate response must manage the effects.
The Way Forward: The Next 50 Years
The next half-century portends a double-burden of communicable and non-communicable diseases, with the latter strongly predicted to overtake the former as the biggest health challenge. Likewise, a ‘nutrition transition’ is forcing health systems to combat rising rates of obesity when sectors of the population are still under-nourished.
Gradual aid withdrawal on hitherto laudable efforts in tackling HIV/AIDS is also a worrisome issue; indeed, as much as $12 billion is needed annually just to contain the epidemic. The post-2015 goals are to be geared more towards equity and universal health coverage. African countries must become more self-reliant. Sustainable and efficient health systems will therefore be crucial, while they focus on private sector investments and rebalancing government expenditure. Reforms aimed at reducing out-of-pocket expenditure levels, which hit the poorest the hardest, need to be introduced as part of broader insurance systems. Finally, harnessing the role of technology and e-health will partly reduce the need for as much human resource, but will nonetheless require more investment i.e. medical equipment and training.
Additional analysis and comments
The authors pointed to the role of the private sector in improving healthcare access and efficiency. We must underline at least two key issues that, in reality, complicate this endeavour. The African healthcare market remains overwhelmingly constrained by a shortage in skills; Africa is believed to host a quarter of the world’s disease burden yet has just 3% of its medical workers.[ii] Secondly, few Africans are currently able to buy insurance policies or obtain workplace insurance. Kenya is an illuminating example, although not the worst, where so few citizens work in the formal sector: by 2013, just 600,000 out of a population of 43 million were estimated to have bought policies or been given workplace insurance.[iii] Moreover, given the dangerous tendency for out-of-pocket payments ($77 of every $100 spent on private health care in Kenya[iv]) to push Africans into poverty traps during a health crisis, something of a middle ground has been proposed by PharmAccess: pre-paid private health insurance[v]. This would involve the formalisation of the traditional pooling of risk; in many African societies, friends and relations informally agree to pool finances in times of need.[vi] In light of the World Bank’s assessment that a decent free health system demands at least $34-40 per head[vii], and even some wealthier countries in Africa are managing only around a third of that, it is clear that a free system is not yet affordable, which makes this new approach all the more interesting, especially insofar as it proposes to formalise current practices, rather than copy “unaffordable models from the West”.[viii]
Incorporating many of the lessons drawn from the article, Ethiopia is an encouraging example of a healthcare system that developed from ‘virtually nothing’ in the space of a decade.[ix] By 2013, 85% of the country had access to primary health care. This has been put down to strong leadership from the Ministry of Health, efforts to engage local communities, targeting young women with the aim of building ‘a women-centered’ health system and engaging local knowledge to counteract in some ways the brain drain discussed earlier.[x] The key strength here has also been to address what critics called the ‘fragmented approach’ to African healthcare. Awareness today of egregious governance failing health systems, that economic growth does not necessarily improve health and that donor aid is dwindling demands not only new approaches, like that of PharmAccess, but also more inclusive approaches, like that of Ethiopia. The growth of a middle class in Africa and heightened expectations will naturally spur this on, but the Ethiopia example shows that not only can governments kick-start this themselves, what’s more, they can actually do so from ‘virtually nothing’.
[i] The Bottom Billion, Paul Collier, New York: Oxford University Press, 2007
[ii] ‘Experts discuss improvement of medical education and training in Africa’, World Health Organization, http://www.afro.who.int/en/media-centre/pressreleases/item/6715-experts-discuss-improvement-of-medical-education-and-training-in-africa.html
[iii] World Bank Working Paper, Private Health Sector Assessment in Kenya, page 77, reference 1, http://books.google.co.uk/books?id=Xd3rQeEGytIC&pg=PA77&lpg=PA77&dq=health+policies+600,000++kenya&source=bl&ots=_4a7UXPuWA&sig=wZXpVtFntkrPxNcCNK1c2MbIQU4&hl=en&sa=X&ei=uqBwVIP9LdLgaP-0gbgB&ved=0CCgQ6AEwAQ#v=onepage&q=health%20policies%20600%2C000%20%20kenya&f=false
[iv] Out-of-pocket health expenditure (% of private expenditure on health), World Bank, http://data.worldbank.org/indicator/SH.XPD.OOPC.ZS
[v] PharmAccess Foundation, A New Paradigm, http://pharmaccess.org/RunScript.asp?Page=288&p=ASP%5CPg288.asp
[vi] Private healthcare in Africa: a middle way?, The Economist, 16-11-2013, http://www.economist.com/news/middle-east-and-africa/21589925-insurers-have-spotted-opening-no-frills-life-saving-health-care
[vii] Regional Office for Africa, World Health Organization, http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=2608&Itemid=2111
[viii] Private healthcare in Africa: a middle way?, The Economist, 16-11-2013, http://www.economist.com/news/middle-east-and-africa/21589925-insurers-have-spotted-opening-no-frills-life-saving-health-care
[ix] The future of healthcare in Africa, The Economist Intelligence Unit.
[x] ‘Developing primary care in Ethiopia to meet the Millennium Development Goals’, The British Journal of General Practice, Karen Ballard, 2012, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3459760/