Challenges in African Healthcare Delivery Part 2 – An Overview
Last week, we began a discourse on challenges in African Healthcare delivery by focusing on the six pillars as described by the WHO which are service delivery, healthcare workforce, health information systems, medicines & technologies, finances, & leadership/government. These are the foundation for any system of healthcare delivery. We have identified that there are structural issues with all these pillars in our various healthcare systems in Sub-Saharan Africa.
This week, we will attempt to give an overview of the current landscape and the multi-factorial challenges that we face in healthcare delivery in Africa. This article is primarily based on a conversation, I had on my podcast, DrShoCares with Dr Mary Balogun, Senior Lecturer and Consultant in Community Medicine and Occupational Health at University College Hospital, Ibadan, Nigeria. You can find the link here.
To assess where we currently are in healthcare delivery across the continent, it is helpful to consider a few health indices. In particular, the maternity mortality ratio, under-5 mortality rate, infant mortality rate and life expectancy. Across the continent there is some disparity in these indices but on the whole, we can see a much poorer outcome in comparison to most countries in Europe, Asia and the Americas. For example, for life-expectancy, we observe the following: in Nigeria 54.3, Cameroon 58.9, Ivory Coast 57.4, Kenya 63.3 , Ghana 63.8, South Africa 63.9, & Rwanda 68.7 with an average of 61.2 across Sub-Saharan Africa. This is in comparison to Europe & Central Asia 74.2, East Asia, South-East Asia & Oceania 75.3 and Latin America & the Caribbean 75.4. To understand why this is we have to consider multiple perspectives.
One of the perspectives that is of particular interest as a family physician are the responsibilities that lie with the individual, the community and the government for accessing and delivering healthcare services appropriately. For the individual, education and literacy is key. If people don’t know about services or how to access services, even if the service delivery is excellent, it would not be serving the needs of the individuals that require it. For example, in parts of Nigeria where the female literacy rate is low, we see high maternal mortality ratios compared to other parts of the country.
Considering the community role, it is important that community leaders such as Kings, Chiefs, religious leaders, and market-women leaders are promoters of good healthcare practices as this has a strong influence on the health-seeking behaviours of individuals. For example, there was a mass refusal within some communities in certain parts of Nigeria to allow their children to have the polio vaccine which caused a surge in infection rates and put back the worldwide timeline to eliminate polio. There was an emphasis made to improve community buy-in by engaging religious leaders and this strategy appears to be working.
The role of government is crucial. Adequate budgetary allocation to healthcare is vital to the quality and availability of services. It is important that the focus is not just on the urban centres as a large proportion of the population still reside in rural areas. Furthermore, the government, at all levels, local, regional and federal, is responsible for ensuring that there is appropriate regulation of healthcare providers. In addition, the government has an important role in looking at the OTHER factors that impact healthcare and creating an environment that makes good health a priority.
At this point, it would be useful to consider another perspective. The issues with African Healthcare delivery run even deeper than we have so far discussed. Prevalent inattentiveness to health and safety rules have resulted in many preventable deaths across the continent. For example, road traffic accident are still a major cause of death. Many non-roadworthy vehicle remain on our roads. Many of our roads are unsafe. Furthermore, many of our motorcyclists do not wear helmets whilst on the road. In addition, widespread poverty across the continent is a major factor as this results in poor sanitation, poor nutrition, environmental pollution and poor access to basic healthcare services and this means that many easily preventable diseases are rife within our communities.
For another subclass of the population, increased wealth and exposure has resulted in adoption of lifestyles such as smoking, being sedentary and unhealthy eating that are underlying a rising surge in hypertension, diabetes, strokes, heart disease and cancers. Risk factors for these diseases are also modifiable and many of the complications are preventable with good primary health care service interventions. However, we also need excellent secondary and tertiary hospitals with up-to-date equipment, technology and expert staff to manage the complications of these diseases.
This brings me to the fundamental structure of how functional healthcare services should be delivered. It is useful to consider the image of the pyramid. At the bottom with widest access and reach is primary healthcare. This is delivered by trained primary healthcare doctors and nurses in the community via clinics and practice. Most things can and should be managed here. It is the more complicated problems that require referral to the secondary care services and more complicated still that are referred to the top of pyramid which we call tertiary care services. However, in many countries in Africa, we have an hourglass shape. Patients often turn up to secondary or tertiary institutions inappropriately or late in the disease progression when had they been seen earlier in a good primary care service they would have had less costly, more efficient and more convenient healthcare.
The last perspective that we need to consider for this discourse is public (government funded) healthcare providers versus private healthcare providers. The demand is very high for quality healthcare so there is more than enough space for these two models to co-exist. However, there needs to be more regulation of private healthcare providers to fit in properly within the overarching pyramid structure to ensure qualitative care. Furthermore there needs to be more reliability in the services provided by public healthcare service to ensure patient trust and community engagement.
As we are currently, in the midst of the COVID-19 pandemic, many of these issues have been brought to the forefront of all of us. And there is currently the political will and appetite to make changes in African healthcare landscape. We need to capitalise on this but in a systematic way that will ensure that the improvements catalyse a structured transformation in African healthcare delivery as opposed to just sticking a metaphorical plaster over the gaping wounds.
From all these perspectives, we can see multi-factorial challenges that would require changes from all facets of our African societies. The individual needs to learn about managing their own health risks, they also need to know about how to appropriately access healthcare services in a timely manner. There needs to be community support for the individuals to access preventative healthcare services such as immunisations, family-planning and medical checkups. There also needs to be community support for government regulations that would reduce avoidable disease and deaths such as road safety rules, sanitation standards, and pollution reduction.
Therefore, our governments across the continent need to increase budgetary allocations to healthcare service delivery so we can develop a more reliable primary healthcare service and have world-class secondary and tertiary care hospitals with the technology and personnel that is necessary to support this infrastructure. The government also needs to ensure that the benefits of education, literacy and appropriate use of healthcare services is appreciated by the populace. They also need to implement policies that would encourage our African people, families and communities to make better health choices.
Ultimately our goal should not just be to improve the indices of maternal mortality ratio, infant mortality rate, under-5 mortality rate and life-expectancy but to improve the quantity and quality of life for all our people. I believe in a future where there is Affordable, Accessible and Quality Healthcare delivered to every African man, woman and child. This is the start of a revolution in African Healthcare Delivery. Join us. Join the conversation.