The future of healthcare in Africa

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Healthcare demands in Africa are changing. Ensuring access to clean water and sanitation, battling ongoing communicable diseases and stemming the tide of preventable deaths still dominate the healthcare agenda in many countries. However, the incidence of chronic disease is rising fast, creating a new matrix of challenges for Africa’s healthcare workers, policy makers and donors.

Africa’s healthcare systems are at a turning point. The reforms that governments undertake over the next decade will be crucial to cutting mortality rates and improving health outcomes in the continent. The Economist Intelligence Unit has undertaken this research to focus on how African healthcare systems might develop between now and 2022. It looks at both current challenges and promising reforms. The five scenarios that have emerged from this research reflect these trends, and are intended to show the possible consequences of decisions being taken by healthcare’s stakeholders today.

To research this report, the Economist Intelligence Unit surveyed the literature and data available on Africa’s current healthcare systems. We also conducted 34 in-depth interviews with leading experts in the different professional roles that make up the healthcare sector: academics, clinicians, healthcare providers, policymakers, medical suppliers, and think tanks. The interviews were carried out by Andrea Chipman and Richard Nield. Andrea Chipman was the author of the report and Stephanie Studer and Aviva Freudmann were the editors.

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The future of healthcare in Africa

  1. 1. The future of healthcare in AfricaA report from the Economist Intelligence Unitsponsored by Janssen
  2. 2. The future of healthcare in Africa Contents Foreword 2 About the research 3 Executive summary 4 Part I - Drivers of the current crisis 6 Box – Ghana: Tackling maternal mortality10 Box – Tunisia: Starting ahead of the game16 Part II - Future trends17 Box – Ethiopia: Creating a primary-care system from scratch19 Box – South Africa: Developing a national health insurance plan 24 Part III - Five scenarios for 2022 25 Conclusion 30 Appendices 31 © The Economist Intelligence Unit Limited 2012
  3. 3. The future of healthcare in Africa Foreword Healthcare demands in Africa are changing. Ensuring access to clean water and sanitation, battling ongoing communicable diseases and stemming the tide of preventable deaths still dominate the healthcare agenda in many countries. However, the incidence of chronic disease is rising fast, creating a new matrix of challenges for Africa’s healthcare workers, policy makers and donors. A growing urban middle class is willing to pay for better treatment. This has opened the door to the private sector, which is starting to play a new role, often working in partnership with donors and governments to provide better healthcare facilities and increased access to medicine at an affordable price. For the vast majority of Africans still unable to pay for health provision, new models of care are being designed, as governments begin to acknowledge the importance of preventive methods over curative action. This, in turn, is empowering communities to make their own healthcare decisions. At the same time, some countries are experimenting with different forms of universal health provision. Africa’s healthcare systems are at a turning point. The reforms that governments undertake over the next decade will be crucial to cutting mortality rates and improving health outcomes in the continent. The Economist Intelligence Unit has undertaken this research to focus on how African healthcare systems might develop between now and 2022. It looks at both current challenges and promising reforms. The five scenarios that have emerged from this research reflect these trends, and are intended to show the possible consequences of decisions being taken by healthcare’s stakeholders today. © The Economist Intelligence Unit Limited 2012
  4. 4. The future of healthcare in Africa About the research To research this report, the Economist Intelligence Unit surveyed the literature and data available on Africa’s current healthcare systems. We also conducted 34 in-depth interviews with leading experts in the different professional roles that make up the healthcare sector: academics, clinicians, healthcare providers, policymakers, medical suppliers, and think tanks. The data and interview comments were then analysed to define trends likely to have an impact on the direction of healthcare over the next decade. Finally, bearing in mind these trends, we developed five extreme scenarios, each a distillation of a possible outcome of the trends identified. The intention is to use these scenarios as a policy-neutral set of platforms upon which some degree of agreement can be reached about the future direction of African healthcare. A list of data sources consulted for this research is in Appendix I. A list of participants in the in-depth interview programme is in Appendix II. The Economist Intelligence Unit bears sole responsibility for the content of this report. The findings and views do not necessarily reflect the views of the sponsor. The interviews were carried out by Andrea Chipman and Richard Nield. Andrea Chipman was the author of the report and Stephanie Studer and Aviva Freudmann were the editors. © The Economist Intelligence Unit Limited 2012
  5. 5. The future of healthcare in Africa Executive summary Like many other regions, Africa must reassess The financing system is as deficient as the its healthcare systems to ensure that they are healthcare-delivery system that it supports. viable over the next decade. Unlike other regions, Public spending on health is insufficient, and however, Africa must carry out this restructuring international donor funding is looking shakier while grappling with a uniquely broad range of in the current global economic climate. In the healthcare, political and economic challenges. absence of public health coverage, the poorest Africans have little or no access to care. What The continent, already home to some of the is more, they frequently also lack access to the world’s most impoverished populations, is fundamental prerequisites of health: clean water, confronting multiple epidemiological crises sanitation and adequate nutrition. simultaneously. High levels of communicable and parasitic disease are being matched by Despite these major challenges, reforms of the growing rates of chronic conditions. Although the continent’s healthcare systems are possible. communicable diseases—malaria, tuberculosis, Indeed, some evidence of reform is already and above all HIV/AIDS—are the best known, it is present. A number of countries are trying to the chronic conditions such as obesity and heart establish or widen social insurance programmes disease that are looming as the greater threat. to give medical cover to more of their citizens. These are expected to overtake communicable Ethiopia, for one, has demonstrated the power diseases as Africa’s biggest health challenge of strong political will to create a primary-care by 2030. service virtually from scratch. Yet the sheer diversity of the continent means that overall Additionally, continued high rates of maternal progress has been patchy at best. and child mortality and rising rates of injuries linked to violence, particularly in urban Considering the massive challenges facing areas, are weighing down a system that is Africa’s healthcare systems, several major already inadequate to the challenges facing it. reforms will be needed continent-wide to ensure Healthcare delivery infrastructure is insufficient; their viability in the long term: skilled healthcare workers and crucial medicines are in short supply; and poor procurement and l shifting the focus of healthcare delivery distribution systems are leading to unequal from curing to preventive care and keeping access to treatment. people healthy; © The Economist Intelligence Unit Limited 2012
  6. 6. The future of healthcare in Africa l giving local communities more control over healthcare resources; l improving access to healthcare via mobile technologies; l tightening controls over medicines, medical devices, and improving their distribution; l reducing reliance on international aid organisations to foster development of more dependable local supplies; and l extending universal health insurance coverage to the poorest Africans. Implementation of these reforms could strongly influence the future shape of healthcare in Africa. The Economist Intelligence Unit has identified the following five extreme scenarios to show how the system might develop over the next decade: l health systems shift to focus on preventive rather than curative care; l governments transfer healthcare decision- making to the local level; l telemedicine and related mobile-phone technology becomes the dominant means of delivering healthcare advice and treatment; l universal coverage becomes a reality, giving all Africans access to a basic package of benefits; l continued global instability forces many international donors to pull out of Africa or drastically cut support levels, leaving governments to fill the gaps. © The Economist Intelligence Unit Limited 2012
  7. 7. The future of healthcare in Africa 1 Drivers of the current crisis For decades, Africa has seen the life expectancy Many African countries, however, are still of its populations stunted by communicable unable to provide basic sanitation, clean and parasitical diseases that have mostly been water and adequate nutrition to all of their stamped out in the developed world. Now, the citizens, let alone deal with the onset of continent also faces increasing rates of the non- these latest killers. These countries, beset communicable lifestyle diseases that have become by poor infrastructure, a shortage of skilled the biggest killers in industrialised countries. professionals and geographic and socio- Leading causes of burden of diseases in the African Region, 2004 (% of total DALYs*) 14 14 12 12 12.4 10 11.2 10 8 8 8.6 8.2 6 6 4 4 3.6 3.6 2 3.0 2.9 2 1.9 1.9 0 0 HIV/AIDS Lower Diarrhoeal Malaria Neonatal Birth Prematurity Tuberculosis Road Protein- respiratory diseases infections asphyxia and low traffic energy infections and other and birth birth rate accidents malnutrition trauma * The disability-adjusted life-year (DALY) provides a consistent and comparative description of the burden of diseases and injuries needed to assess the comparative importance of diseases and injuries in causing premature death, loss of health and disability in different populations. The DALY extends the concept of potential years of life lost due to premature death to include equivalent years of ‘healthy’ life lost by virtue of being in states of poor health or disability. One DALY can be thought of as one lost year of ‘healthy’ life, and the burden of disease can be thought of as a measurement of the gap between current health status and an ideal situation where everyone lives into old age, free of disease and disability. Source: Health Situation Analysis in the African Region, Atlas of Health Statistics 2011, World Health Organization. © The Economist Intelligence Unit Limited 2012
  8. 8. The future of healthcare in Africa economic inequalities, face an uphill struggle Treatable diseases continue to blight in delivering adequate healthcare. With outlays the future on treatment for the major communicable The continent’s continuing struggle with diseases likely to occupy a significant chunk communicable diseases such as HIV/AIDS and of national health budgets for the foreseeable tuberculosis (TB), parasitic diseases and poor future, better preventive care will be crucial to primary and obstetric care has been a major keep spending in check—and to improve health factor in stalling the development and the outcomes in the next decade. extension of healthcare services in African countries at even the most basic level. Africa’s healthcare challenges are heightened by the sheer diversity of the continent. Undoubtedly, a unified global effort by Countries range from the resource-rich to governments and multilateral organisations has the impoverished, from those with dynamic been hugely successful in recent years at bringing economies to those where conflict zones still down mortality rates linked to these biggest simmer; they encompass large cities, remote killers. Deaths linked to malaria have fallen by villages and nomadic lands. Sharp discrepancies 33% since 2000.1 The adoption of antiretroviral in the prevalence of illness and access to medication as the main treatment protocol for treatment exist, as well as differences in data HIV/AIDS has transformed HIV from a terminal collection, which complicates comparisons for illness into a manageable chronic condition in policy-making purposes. For example, “In some a number of African countries. Child mortality states, midwives’ salaries might be included in on the continent has dropped by 30% since the healthcare budget, while in others it might 1990, largely thanks to routine immunisation not,” says Anshu Banerjee, the World Health programmes.2 Organization (WHO) representative in Sudan. The results of these policies remain, however, Moreover, a number of social and demographic uneven. In 2000, world leaders drafting the UN transitions taking place simultaneously on the Millennium Declaration adopted three health continent are exacerbating the problem. Unni goals, which signatory countries were expected Karunakara, international president of Médecins to reach by 2015. These included reducing child Sans Frontières, notes that epidemiological mortality, improving maternal health, and and demographic shifts are coinciding with combating HIV/AIDS, tuberculosis, malaria and economic and migratory transitions, which other diseases. make tracking and treating diseases more difficult. “Countries are no longer a useful unit Some African countries have made remarkable to define the population from a health point of strides in these areas, including Ghana, which view,” he adds. “In India, there are populations is on track to halve maternal mortality rates in 1 World Malaria Report 2011, World Health Organization, with health profiles similar to those in Europe or just a decade (See box Ghana: Tackling maternal Geneva. the US, and others whose health is the same or mortality). Yet, in a 2010 report, the WHO noted worse than populations in the poorest parts of that overall progress towards meeting these 2 “Levels and Trends in Child Mortality”, Report 2011, UN Africa. We’re now seeing that in Africa too.” Millennium Development Goals (MDGs) had been Inter-agency Group for Child less than impressive. Just six countries were Mortality Estimation. Factor in the perilous state of the global deemed on track to reduce under-five mortality economy and, in particular, the foreign aid by two-thirds during the time specified, with 16 3 Towards Reaching the and multilateral budgets on which African having made no progress; only 13 countries had Health-Related Millennium Development Goals, World healthcare systems are heavily dependent, and maternal mortality rates of fewer than 550 deaths Health Organization, 2010, the magnitude of the challenge becomes all the per 100,000 live births, while 31 countries had pp 19-20. more apparent. rates of 550 deaths or higher. 3 © The Economist Intelligence Unit Limited 2012
  9. 9. The future of healthcare in Africa Trend in maternal mortality ratio in the WHO African Region, 1990-2008 (per 100,000 live births) 1,000 1,000 900 900 850 830 800 780 800 700 690 700 620 600 600 500 500 400 400 300 300 200 213 200 100 2015 100 MDG target 0 0 1990 1995 2000 2005 2008 2010 2015 Source: Health Situation Analysis in the African Region, Atlas of Health Statistics 2011, World Health Organization. Although Africa bears 66% of the global burden of needing active antiretroviral therapy is likely to HIV/AIDS, according to the WHO,4 just one-third soar to 30m by the middle of the next decade, up of the population with advanced HIV infection from less than 7.5m today. in Africa had access to antiretroviral medicines in 2007.5 “It’s pretty unlikely that an effective Improvements in access to safe drinking water and HIV vaccine will be in place [within the decade]” sanitation have also stalled in Africa, making it says Sneh Khemka, medical director for BUPA difficult to combat stubbornly high levels of water- International, adding that the number of people borne illnesses.6 As a result, parasitic diseases HIV/AIDS mortality rate in WHO Regions, 2007 (deaths per 100,000 population) 4 Strategic Orientations for 180 180 WHO Action in the African 160 174 160 Region 2005-2009, World 140 140 Health Organization, Africa. 120 120 5 “Towards Reaching the Health-Related Millennium 100 100 Development Goals: 80 80 Progress Report and the Way 60 60 Forward”, Report of the Regional Director for Africa, 40 40 World Health Organization, 20 20 2010, p 23. 13 12 11 5 5 0 0 6 Towards Reaching the African South-East Americas European Eastern Western Pacific Health-Related Millennium Region Asia Region Region Region Mediterranean Region Development Goals, charts Region pp 26-27. Source: Health Situation Analysis in the African Region, Atlas of Health Statistics 2011, World Health Organization. © The Economist Intelligence Unit Limited 2012
  10. 10. The future of healthcare in Africa such as guinea worm and schistosomiasis continue healthcare has traditionally been more extensive to wreak havoc in many areas of Sub-Saharan than elsewhere on the continent. Yet Morocco Africa. The continent also bears 60% of the global continues to struggle with high rates of TB, with burden of malaria, for which insecticide-treated 25,000 new cases a year despite a vaccination net use is about 3.5% for adults and 1.8% for rate of 95% at birth. under-fives.7 While the announcement in October of promising results in clinical trials of a new These conditions are both a result of, and a malaria vaccine rekindles hope for a new weapon contributor to, weak and fragmented health against the disease as early as 2015, questions systems throughout Africa. The WHO notes that remain over the vaccine’s affordability. the combined impact of these factors put the continent’s average life expectancy at birth North Africa, which is much less affected by at 53 years in 2008, up only slightly from 51 communicable diseases, has generally been years in 1990.8 the bright spot in the picture. Because of both cultural and historical reasons, access to basic Life expectancy at birth in WHO Regions, 2008 and 1990 (years) 2008 1990 African 53 Region 51 South-East 65 Asia Region 58 Eastern 65 Mediterranean 61 Region European 75 Region 72 Western 75 Pacific Region 69 Americas 76 Region 71 68 Global 64 Source: Health Situation Analysis in the African Region, Atlas of Health Statistics 2011, World Health Organization. 7 Ibid. 8 Health Situation Analysis in the African Region, Atlas of Health Statistics, 2011, World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo. © The Economist Intelligence Unit Limited 2012
  11. 11. The future of healthcare in Africa Ghana: Tackling maternal mortality Most countries in Africa have long struggled dropped between 2005 and 2007—from 54% 9 Global Health Observator with high rates of maternal mortality. In recent to 35%—following a steady improvement in Data Repository, World years the issue has taken on international the figure during the decade between 1993 Health Organization, www. prominence, attracting a number of high- and 2003. Some experts speculate that this who.int profile celebrity campaigners. Ghana, which decline could be related to underfunding of the had an estimated maternal mortality rate exemption policy and a strike by health workers 10 S. Witter, Sam Adjei, of over 500 deaths per 100,000 live births a in 2007.12 Margaret Armar-Klemesu decade ago,9 has been at the forefront of this and Wendy Graham, battle on a national level. Still, an evaluation of the delivery-fee “Providing free maternal exemption by the Initiative for Maternal health care: ten lessons from In 2004 Ghana introduced a national policy to Mortality Programme Assessment (IMMPACT) an evaluation of the national exempt women from paying for delivery care found that the policy had increased the use delivery exemption policy in public, mission and private health facilities, of obstetric facilities and achieved some in Ghana,” Global Health with payments initially delivered through local reductions in inequality of access to care Action, Vol. 2, 2009. governments and later through the health between different income groups. system. The exemption was funded from a debt Figures from the World 11 relief fund under the Highly Indebted Poor Ghana’s experiment with the delivery-fee Health Organization, 2008. Countries (HIPC) initiative. This was phased exemption provides a number of lessons out gradually and ultimately taken over by the to countries looking to improve maternity 12 “Providing free maternal national health insurance scheme in 2008.10 care, including the importance of strong health care: ten lessons from policy management or “ownership” within an evaluation of the national The exemption from delivery-care fees the relevant ministry (which was lacking in delivery exemption policy contributed to a drop in the maternal mortality Ghana); tailoring exemptions to address the in Ghana”, Global Health rate from an estimated 500 deaths per main household cost barriers, such as travel Action, p 3. 100,000 live births in 2000 to an estimated to hospital facilities; and reimbursing medical 350 per 100,000 in 2008. Despite this clear facilities for their costs.13 13 Ibid. achievement, however, it remains doubtful whether Ghana will meet its Millennium A number of African countries are already 14 “Mixed Blessings: Development Goal of 185 maternal deaths per following suit. Burundi introduced free services Burundi’s free birth 100,000 live births by 2015.11 for pregnant women in 2006, although health delivery and medical care facilities have often struggled to cope with the for under-five children”, One factor limiting the impact of the delivery- influx of patients amid insufficient funding.14 Unicef Humanitarian Action fee exemption may be the stubbornly high In the same year, Burkina Faso introduced an Report, 2007. number of Ghanaian women who continue to 80% subsidy policy for deliveries;15 and Kenya give birth without a trained birth attendant already provides free antenatal care.16 present. Indeed, the proportion of deliveries Providing free maternal 15 attended by skilled health personnel actually health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana. Lifestyle diseases threaten to double mortality rates in 2006.17 Tuberculosis mortality the burden rates on the continent have fallen by more than 16 R Ochako, J-C. Fotso, L one-third since 1990.18 Although many hope that The work of donor groups, including the Global Ikamari and A Khasakhala, Fund to Fight AIDS, Tuberculosis and Malaria this will help to shift the focus to chronic disease “Utilization of maternal health services among young and the Gates Foundation, on the major management, others are less optimistic. For women in Kenya: Insights communicable diseases has been crucial in them, the concentration of substantial amounts from the Kenya Demographic cutting mortality rates for specific illnesses. In of donor funding on individual diseases has made and Health Survey, 2003”, Sub-Saharan Africa, AIDS-related deaths fell by it more difficult to address broader health needs BMC Pregnancy and and set appropriate strategies for the future. 30% between 2004 and 2010, despite a peak in Childbirth, January 10th 2011.10 © The Economist Intelligence Unit Limited 2012
  12. 12. The future of healthcare in Africa Indeed, increased urbanisation in many African that is focused on promoting healthy lifestyles countries, along with growing incomes and and changing behaviour,” says Stefano changing lifestyles, have led to a rise in the Lazzari, Tunisia’s World Health Organization rate of chronic conditions such as diabetes, representative. Kara Hanson, a health economist hypertension, obesity, cancer and respiratory at the London School of Hygiene and Tropical diseases. These threaten to put considerable Medicine, explains that “the interventions to further strain on already overstretched reduce non-communicable diseases are very healthcare systems. The WHO estimates that different,” adding that primary care will need chronic diseases will overtake communicable to widen its traditional focus on women and diseases as the most common cause of death children to meet the needs of men as well. in Africa by 2030.19 The organisation has also 17 “Global HIV/AIDS predicted that a major increase in the number of One major problem is that much of the existing Response: Epidemic Update deaths in Africa will come from cardiovascular chronic disease burden has not yet been and Health Sector Progress Toward Universal Access; and respiratory diseases, such as asthma and identified. Dr Khemka notes that probably 85% Progress Report 2011”, chronic obstructive pulmonary disease (COPD), of diabetes cases in Sub-Saharan Africa go UNAIDS/UNICEF/World both of which are related to fuel-burning for undiagnosed. Currently, just 12.1m diabetes Health Organization, patients have been recorded, a number that is cooking and smoking.20 December 2011, pp 5-26, expected almost to double to 23.9m adult cases and Progress on Global In North Africa, lifestyle diseases are already by 2030. “In real terms, that represents a greater Access to HIV Antiretroviral Therapy, World Health more prominent given comparably wealthier number of people having diabetes than currently Organization/UNAIDS, populations and the eradication of many have HIV,” he says. March 2006. communicable diseases. With affordable tobacco, higher rates of smoking and urban This lack of preparedness is compounded by 18 WHO Report 2010: Global pollution are leading to an increase in lung a lack of data. The Harvard School of Public Tuberculosis Control, World cancer, according to Sherif Omar, professor Health’s Partnership for Cohort Research and Health Organization, of surgical oncology and former head of the Training (PaCT) programme, which was launched Geneva, Switzerland, 2010, in 2008, aims to conduct a cohort study in p 34. National Cancer Institute at Cairo University. four African countries—Uganda, Nigeria, Most worryingly, the interplay of these new Tanzania and South Africa—following 500,000 19 WHO African Region “lifestyle conditions” with Africa’s most participants over a ten-year period. According Ministerial Consultation on Noncommunicable Diseases, debilitating communicable conditions has to Shona Dalal, an investigator with the Brazzaville, Republic of created an entirely new double-disease programme, one of the main goals is to quantify Congo, April 4th-6th 2011, burden, which most healthcare workers have better, and to understand the causes of, the p 6. current chronic disease burden on the continent not seen before, and which current healthcare infrastructure is ill-prepared to manage. with the ultimate goal of informing disease 20 WHO African Region prevention. Ministerial Consultation on Moreover, there is growing evidence that Noncommunicable Diseases, communicable diseases and chronic conditions p 10. often exacerbate each other. For example, Resources under strain patients with diabetes are three times as likely African countries have traditionally had fewer 21 “Growing Pains”, The to contract tuberculosis; Burkitt’s lymphoma healthcare workers per head than anywhere else Economist, September 24th is linked to malaria; and HIV patients on in the world.22 Low pay and poor living conditions 2011. antiretroviral treatment are at a higher risk of contribute to a continuous brain-drain of health developing diabetes and cancer.21 professionals to the developed world and make 22 Health Situation Analysis in the African Region, Atlas it difficult to recruit and retain skilled staff, of Health Statistics, 2011, “It’s very difficult to go from a health service particularly in more remote regions where the World Health Organization, focused on treating diarrheal disease, TB and need is often greatest. This exacerbates health pp 38-40. providing vaccinations for children to one inequalities within nations and makes it more11 © The Economist Intelligence Unit Limited 2012
  13. 13. The future of healthcare in Africa Nursing and midwifery personnel-to-population in WHO Regions, 2000-09 (per 10,000 population) 80 80 70 70 60 68 60 50 55 50 40 40 30 30 20 28 20 21 10 10 14 11 11 0 0 European Americas Global Western Pacific Eastern South-East African Region Region Region Mediterranean Asia Region Region Region Source: Health Situation Analysis in the African Region, Atlas of Health Statistics 2011, World Health Organization. difficult to develop comprehensive primary a convergence of patients from neighbouring care systems. Chad, where there is no such scheme. In Algeria, the human-resource challenge comes Additionally, distribution channels for medical from deteriorating professional qualifications, equipment and pharmaceutical products remain according to an Algerian analyst who claims fragmented, and shortages of medicines and standards have slipped over the past 20 years. supplies are common in many countries. One “You hear increasingly of doctors making important consequence of these logistical issues mistakes because they are badly qualified,” is the growing problem of counterfeit medicines he says. and medical devices. Jacqueline Chimhanzi, the Africa lead for Deloitte Consulting South Africa, It is not surprising, therefore, that many notes that in parts of Sub-Saharan Africa, sub- African countries suffer from the poaching of standard medicines can range from an estimated their specialists by neighbours, as they rely 20% in Ghana to 45% in Nigeria, and up to a high on a dwindling pool of experienced workers. of 66% in Guinea.23 Medical tourism, aided by porous borders, is also putting strains on overburdened healthcare Yet continued affordability of life-saving systems. In Tunisia, Libyans seeking treatment medicines is the dominant concern for most. in private clinics make up nearly 70% of patients With a few notable exceptions, such as South in some hospitals. Countries bordering with Africa’s Aspen, a manufacturer and supplier of conflict regions also suffer from transient and branded and generic medicines, there is little acute influxes of patients. During the fighting domestic pharmaceutical production on the in Libya last year, more than 300,000 medical continent, leaving many countries dependent 23 Deloitte estimates on refugees crossed the border into Tunisia for on imports from Indian and Chinese generics the basis of surveys that safety, doubling the number of daily patients companies. “The challenging thing is that measure deviation from in some medical centres. Similarly, vaccination the drugs that are available locally are the quality standards. programmes in the Darfur region of Sudan report simple drugs, such as painkillers. The active12 © The Economist Intelligence Unit Limited 2012
  14. 14. The future of healthcare in Africa pharmaceutical ingredients (APIs) [for newer, Given shortages of vital medicines such as insulin more specialist drugs] aren’t available,” in some parts of Africa, most agree that the observes Emmanuel Mujuru, acting chairman continent will almost certainly need to develop of the Southern African Generic Medicines its own manufacturing capability for essential Association. drugs and vaccines. One interviewee, however, raised the question of financial viability given Meanwhile, pressure from the EU and world the huge production plants in the high-growth trade bodies for the generics industry to adhere economies of Brazil, India and China. Other to stricter intellectual property rights are obstacles include a lack of pharmacy degree contributing to a more immediate potential programmes in many countries and a critical crisis. African countries are due to implement shortage of product development capabilities. the Trade Related Aspects of Intellectual Property Rights (TRIPS)—an agreement Equally problematic is the lack of a stable establishing minimum standards for intellectual pharmaceutical market, for which Africa’s property and administered by the World Trade reliance on donor funding could be partly Organization—by 2016. Some non-governmental responsible, Mr Mujuru says. “Donations in some organisations assert that this would make African countries have had a negative effect, Africa less attractive to generics companies shutting out the local industry,” he explains, by strengthening the intellectual property noting protections afforded to patent holders. that his home country of Zimbabwe had experienced this difficulty first-hand. He cited Dr Karunakara of Médecins Sans Frontières, one example in which a local manufacturing for example, says that the continent’s company for mosquito nets treated with anti- pharmaceutical sector is likely to remain malarial solutions was pushed out of business underdeveloped for many years as it continues because of large donations of nets from a to depend on imports of generic drugs. Local multilateral agency that sourced its products generics manufacturers agree: if the 2016 TRIPS outside the country. deadline is not extended, says Mr Mujuru of the Southern African Generic Medicines Association, The Business of Health in 24 “we will lose that cheaper access to APIs.” Gaps in financing Africa; Partnering with the The improvement and extension of healthcare Private Sector to Improve delivery in Africa is also being constrained by However, African pharmaceutical manufacturers People’s Lives, International could ultimately benefit from the TRIPS regime. gaps in financing. Sub-Saharan Africa makes up Finance Corporation, vii By harmonising product standards, TRIPS could 11% of the world’s population but accounts for also smooth the way for patent holders to issue 24% of the global disease burden, according to 25 Health Situation Analysis licences to local companies to produce generic the International Finance Corporation.24 More in the African Region, Fig. 38, p 34. There is some versions of patented products. worrisome still, the region commands less than discrepancy between 1% of global health expenditure. reports on which countries North African countries have a key advantage are meeting the target. over their southern neighbours because they Public-sector funding for healthcare remains The latest figures on public already have a developed local manufacturing uneven across the continent. While 53 African healthcare spending are sector for generic drugs, often involving joint countries signed the Abuja Declaration pledging due to be released by the World Health Organization ventures between local firms and Indian or to devote 15% of their national budgets to in February 2011. Chinese companies. Yet a general preference for health, most remain far from that target and, branded drugs also indicates that the population according to some estimates, seven countries 26 Ibid, Fig. 41, pp 35 and needs to be educated in parallel to ensure take- have actually cut their spending on health over 36. up of out-of-patent medicine, for example. the past decade.25 More than half of healthcare13 © The Economist Intelligence Unit Limited 2012
  15. 15. The future of healthcare in Africa General government health expenditure in sub-Saharan Africa, 2009 and 2001 (as a % of general government expenditure) Representative sample of countries 2009 2001 20 20 18 18 16 16 Target set in the Abuja Declaration, 2001 14 14 12 12 10 10 8 8 6 6 4 4 2 2 0 0 Angola Botswana Burkina Côte DRC Ethiopia Ghana Kenya Malawi Nigeria Rwanda Senegal South Togo Tanzania Faso dIvoire Africa Source: Global Health Expenditure Database, World Health Organization. costs on the continent are currently met by out- the problem in North Africa; he notes that many of-pocket spending, a ratio that rises to as much observers believe this was one of the major as 90% in some countries.26 With many of the catalysts for the uprisings of the Arab Spring poorest unable to afford treatment, costs are kept in 2011, along with lack of access to healthcare down artificially by people’s ability to pay, further for the poorest citizens. “[The North African exacerbating the problem. countries] have to reduce reliance on user fees as a mechanism of finance,” he says. “It is not A small handful of countries, including Ghana, sustainable”. Rwanda and South Africa, have taken steps towards universal healthcare coverage. However Across Africa, the result of fragmented coverage even in countries or communities that currently has been a growth in private financing and offer a form of insurance scheme, many drugs and private provision of health care—a category that services are not included and must be covered encompasses the for-profit sector and non- by out-of-pocket payments.27 The legacy of the profit providers such as aid organisations and French colonial period left Morocco, Algeria and missionary hospitals. A McKinsey study from 2008 Tunisia with varying levels of national health reported that in Ethiopia, Nigeria, Kenya and insurance coverage. Yet, by some estimates, as Uganda more than 40% of people in the bottom much as 50% of health expenditure is currently 20% income bracket received their healthcare out-of-pocket in Tunisia, although it boasts some from private, for-profit providers.28 Private The World Health Report 27 of the highest health indicators in the region (See insurance schemes have also been growing 2010. box Tunisia: Starting ahead of the game). in countries with larger affluent populations or industries capable of funding large worker 28 Arnab Ghatak, Judith For Belgacim Sabri, a Tunisia-based independent plans. However, the existence of these plans Hazlewood and Tony M Lee, health consultant, reduced public budgets and has contributed to concerns about two-tiered “How private health care can help Africa,” McKinsey the introduction of user fees have exacerbated provision of care. Quarterly, March 2008.14 © The Economist Intelligence Unit Limited 2012
  16. 16. The future of healthcare in Africa General goverment expenditure on health in the African Region, 2007 (% of total health expenditure) Western Sahara Algeria (no data) The Gambia Mauritania Senegal Mali Cape Niger Eritrea Verde Burkina Guinea Faso Guinea- Benin Bissau Côte Ghana Nigeria Ethiopia dIvoire Togo Liberia CAR Cameroon Sierra Equatorial Guinea Leone Uganda Kenya São Tomé Príncipe Democratic Gabon Congo Rwanda Republic of (Brazzaville) Burundi Congo Seychelles Tanzania % of total health expenditure 11.00% - 31.30% Comoros Angola Malawi 31.31% - 42.10% 42.11% - 52.80% Zambia 52.81% - 66.20% 66.21% - 81.60% Zimbabwe Madagascar Mozambique Namibia Botswana Mauritius Swaziland South Africa Lesotho Source: Health Situation Analysis in the African Region, Atlas of Health Statistics 2011, World Health Organization. In the meantime, donor funding for charity about its sustainability as a major source of hospitals and clinics, and for targeted medicines, financing for healthcare in Africa. is often the only way of filling the gaps, particularly in undertaking mammoth tasks “The opposite of sustainability is dependence such as the scaling up of antiretroviral protocols and what we’ve done in most cases is create across Africa. However, while some analysts dependence,” says Keith McAdam, a member of have criticised donor financing as an insufficient the board of directors of the African Medical and solution even during better periods, the global Research Foundation (AMREF). economic crisis has in turn raised new questions15 © The Economist Intelligence Unit Limited 2012
  17. 17. The future of healthcare in Africa Tunisia: Starting ahead of the game As other African healthcare systems face a In common with most of its North African future characterised by multiple epidemiological neighbours, Tunisia’s health system has threats, fragmented health coverage, extreme benefitted from the French colonial legacy of poverty and disintegrating facilities, Tunisia robust infrastructure for primary healthcare and appears to have the edge in many respects. a strong medical education system. The country has built on these foundations over the past 30 Unlike many of its Sub-Saharan counterparts, years, making particular efforts in developing the country has no malaria and low rates of the health workforce and rehabilitating HIV/AIDS. It has a tuberculosis rate that is facilities.30 one-quarter that of Morocco, and a maternal mortality rate that is half that of Algeria.29 With Despite its clear advantages, though, Tunisia’s life expectancy of around 75 years for both current health challenge is similar to that faced men and women, the main burden of disease is by many of its African neighbours: an inefficient chronic conditions such as cardiovascular and distribution of services, which reflects and respiratory disease. contributes to social inequalities in the country. “In the rich coastal areas, the services are “Tunisia has the best health indicators across comparable to those in Europe, whereas in the the board of all the countries in North Africa”, interior of Tunisia the number of specialists says Stefano Lazzari, World Health Organization and doctors, the quality of equipment and the (WHO) representative for Tunisia. The country coverage of services are all much lower,” says Dr boasts a large number of qualified specialists, Lazzari. strong public and private hospitals, good equipment and a high level of services. Tunisia’s private sector currently serves only around 20% of the country’s population. Yet it Nearly 90% of Tunisia’s citizens have access gets the lion’s share of investment and attracts to health insurance that provides a relatively a disproportionate number of available medical high level of basic services—a higher coverage professionals. Bridging this gap in health rate than in Algeria and Morocco, according to provision will be a major challenge for Tunisia’s Belgacim Sabri, a Tunisia-based independent new leaders, healthcare experts say—but one health consultant and retired director of that the country is better positioned than most health systems for the WHO in the eastern of its neighbours to take on. Mediterranean. Coverage is funded through employee contributions and government- subsidised cover for those who are unemployed. 29 All figures from latest World Health Organization country health profiles, using 2009 data, www. whoint.org 30 Habiba Ben Romdhane and Francis R Grenier, “Social determinants of health in Tunisia: the case-analysis of Ariana”, International Journal for Equity in Health, April 3rd 200916 © The Economist Intelligence Unit Limited 2012
  18. 18. The future of healthcare in Africa 2 Future trends A wholesale restructuring of Africa’s healthcare Yet the growth of both chronic conditions and systems will be necessary over the next ten years, the increase in populations living for longer including strong measures to expand access to periods with diseases such as HIV/AIDS is healthcare, eradicate treatable illnesses and driving a new emphasis on preserving good manage chronic conditions. health and widening the current approach to primary healthcare. According to Ernest This would require a new approach to tackling Darkoh, founding partner of BroadReach disease. It would also involve an overhaul of Healthcare, an African healthcare services healthcare delivery, including greater use of company, the most successful outcome should technology, co-operation between the public be defined as never needing to see the inside and private sector and task-shifting to help of a hospital. The continuous need to build extend scarce human resources. The procurement more hospitals and clinics should be considered and supply of medicines and medical products a sign of failure. “We must make disease will need to be streamlined in order to reduce unacceptable instead of building ever larger shortages and logjams. Finally, governments infrastructure to accommodate it”, Dr and international organisations will be searching Darkoh adds. for funding solutions that can cover a larger percentage of the population and be sustainable Wellness campaigns will involve not only medical in the long run. staff, but also officials dealing with agriculture, transportation, law enforcement, water and From curing illness to preserving sanitation, food security and housing. Dr Darkoh health remarks that violence, road accidents and poor One of the biggest factors hampering Africa’s living conditions play as important a role in ability to confront its multiple health challenges, health outcomes as lifestyle does. Better and according to healthcare providers, aid focused education will be crucial to prevent organisations and entrepreneurs, is a structural African populations from developing chronic one. The continent’s healthcare systems remain diseases in the first place. Further down the focused on acute, short-term treatment, and on line, teaching those with chronic conditions fighting the traditional battles against infectious to manage their health will be key to avoiding and tropical diseases, diarrhea and maternal and overreliance on expensive and overstretched child mortality. health workers and facilities.17 © The Economist Intelligence Unit Limited 2012
  19. 19. The future of healthcare in Africa Part of this evolution will also require new “We need to better leverage health workers,” healthcare strategies evaluated for the realities Dr Darkoh explains. “We don’t necessarily need of African life, says Dr Karunakara of MSF. “We doctors and nurses to provide basic things like need to develop new models of care to treat health education. We can use so many other people in rural remote areas,” he explains. “Even types of people with very little training and at if cheap insulin suddenly becomes available, if it little expense to build the model of individual, still needs to be refrigerated you can be sure that family and community ownership of health.” take-up will be low. Most of the tools developed today are being developed for wealthier Even non-professional people can be trained to societies, and that’s a big problem for Africa.” provide education, support treatment for HIV, Earlier diagnosis of diseases such as HIV/AIDS deliver prescribed medicines, and use a weighing will lead to earlier treatment and help prevent scale or glucose-testing device, say Dr Darkoh complications. Botswana is already a leader in and others, freeing up specialised medical this area; it was the first country to roll out opt- staff to perform more complicated procedures out testing for HIV in 2000, and has since raised and reducing the pressure on overstretched the percentage of those being tested to over 90% public-sector hospitals. One example of such from less than 10%. Increasing immunisation an initiative is Ethiopia’s health extension coverage rates for common childhood diseases programme (HEP), which trained extension such as diphtheria, polio, measles and hepatitis workers to provide basic health information and will also be a crucial part of this process. education in rural areas where none existed before (See box Ethiopia: Creating a primary-care system from scratch). Revamping healthcare delivery Reversing the focus from acute to preventive “We recognise that communities themselves care, and from treating single ailments to must own and lead the effort,” explains Tedros tackling multiple conditions, will require a Adhanom Ghebreyesus, minister of health for significant overhaul of Africa’s healthcare Ethiopia. Indeed, programmes such as Ethiopia’s systems, in terms of mindset, structure and are particularly good at creating a cadre of health human resources. According to some experts, workers who do not have advanced medical skills, a more proactive approach will be needed to but who, as local people already committed address current and future disease burdens, to their communities, are also less likely to be including the creation of systematic touch- poached by foreign healthcare systems. points throughout a citizen’s life to keep them healthy. “Hospital and clinic-based models of Other countries are looking at more regional care, where people must come to healthcare solutions. In South Sudan, where human- instead of healthcare coming to the people, are resource shortages are at crisis levels, support by definition reactive,” explains Dr Darkoh of from the Intergovernmental Authority for BroadReach Healthcare. Development (IGAD) allows neighbouring l Shifting tasks to lay healthcare workers in countries to provide specialist labour to the primary care country. The originating countries continue to pay the workers’ salaries, and the South Sudan Task-shifting, already important in a continent government provides an allowance, according to with severe shortages of trained medical Dia Timmermans, a senior health adviser with the personnel, is likely to be the only way to provide a Joint Donor Office of the World Bank, based in quality, basic level of care to entire populations. South Sudan.18 © The Economist Intelligence Unit Limited 2012
  20. 20. The future of healthcare in Africa Ethiopia: Creating a primary-care system from scratch Few countries in Africa can boast a healthcare initiative has already trained and deployed over system that has developed from virtually 38,000 health extension workers throughout nothing in the space of just a decade. As the the country—almost doubling Ethiopia’s health third most populous country in Africa, Ethiopia workforce in three years. These local health is also one of the poorest, emerging from nearly extension workers have been engaged as full- two decades of civil war and famine only 30 time salaried civil servants to ensure retention years ago. Missionary clinics and international and build a sustainable system, moving away donor-run hospitals then made up the from models based on volunteerism. fragile backbone of the country’s healthcare infrastructure, and a majority of the population The government has recently launched a relied on traditional and spiritual healers for mobilisation campaign targeted at young advice and care. women—who are often closest to the main beneficiaries of primary care—in the hope that Today, more than 85% of the population has more will train as health extension workers. access to primary healthcare. The percentage According to Dr Tedros, “We want to build a of births attended by a skilled worker doubled ‘women-centred’ health system. We are linking between 2004 and 2008; in the same period, leaders at all levels with women’s groups in the number of women receiving antenatal care every village across the country”. rose by more than 50%, as did the number of infants receiving full immunisation. Initial Although priority has been given to primary surveys indicate that under-five mortality was healthcare delivery, which usually involves high- down to 88 per 1,000 live births in 2010, which impact, low-cost interventions, the government corresponds to a 52% decline over the last is already close to its goal of building 15,000 decade. new health posts and 3,200 health centres across Ethiopia, thus complementing parallel Several factors have contributed to Ethiopia’s private-sector investments in new hospitals success. Strong leadership from the Ministry around the country. “This is helping to broaden of Health has driven healthcare policy. “The access to a continuum of care at secondary and approach they took was historical. They really tertiary levels,” says Dr Tedros. started from nothing,” says Dina Balabanova, senior lecturer in health systems at the London Dr Tedros admits that big challenges lie ahead, School of Hygiene and Tropical Medicine. The particularly in further scaling up towards government chose a top-down approach to a national health system and in sustaining kick-start the programme and to scale it up current efforts in the sector. Reaching the quickly across the country—a method that has maternal health targets set by the Millennium rankled a few stakeholders and prompted some Development Goals (MDGs) in Ethiopia will isolated criticism. Dr Balabanova concedes, also be challenging. For Dr Tedros, the two go “It was almost an emergency system; but the hand-in-hand: “We cannot hope to achieve the next stage will be getting people on board and health MDGs without ensuring universal access incorporating local knowledge.” to basic health service first”. Yet Ethiopia shows what it is possible to achieve in a limited time Indeed, the government claims it is now working frame, and may point towards a model for other to broaden and deepen the engagement of African countries with similar socio-economic local communities through its Health Extension and demographic conditions. Programme. According to Ethiopia’s minister of health, Tedros Adhanom Ghebreyesus, the19 © The Economist Intelligence Unit Limited 2012

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