World Health Day: Sub-Saharan Africa treads a checkered path

The world commemorated “World Health Day” yesterday (Friday, April 07) under the theme Health For All,  a goal proposed four decades ago by the World Health Assembly, the World Health Organization's highest decision-making body.

The day also marked the World Health Organization's 75th anniversary, an occasion used to ostensibly reflect on public health successes that have improved people's quality of life over the last seven decades, while also motivating action to address today's and tomorrow's health challenges.

"Health For All" as a goal emphasises, among other things, achieving the highest level of health possible for all societies.

Dr. Peter Wambi, a research scientist and systems strengthening specialist, giving a presentation on COVID-19 and its effects on human rights at the Uganda Human Rights Commission's 24th Annual Report Consultative Meeting at the Commission's headquarters in 2022. (Credit: Twitter/Uganda Human Rights Commission)

In Sub-Saharan Africa, a region that faces more than 100 health emergencies per year, as well as other challenges such as humanitarian crises, climate shocks, and the rising burden of chronic illnesses such as diabetes and cancer, the road to achieving health for all or universal health coverage has been anything but smooth, yet it is the bedrock of health-related SDGs, that will ensure equitable and sustainable health outcomes while also contributing to other SDGs to ensure an effective health system.

As of 2020, only 20 of 54 (37%) African countries (Uganda inclusive) had a formal political commitment, beyond the health sector, by the president or cabinet to prioritise universal health coverage as part of their development agenda.

Uganda’s goal for universal Health Coverage is to provide at least 65% of its population quality healthcare and financial protection by 2030.

Karim Bendhaou, chairman of the Africa Engagement Committee of the International Federation of Pharmaceutical Manufacturers and Associations.(Credit: Facebook/Karim Bendhaou)

The country’s health experts recognise that reaching Universal Health Coverage is an important goal in Uganda’s path to get Middle-income country status.

In a 2021 study published in the South Eastern European Journal of Public Health, Nigerian researchers Mobolaji Modinat Salawu, Obinna Emmanuel Onwujekwee and Olufunmilayo Obitola Fawola noted that African nations had failed to achieve the mandate of “Health For All” forty years after the Alma Ata declaration of 1978.

The Alma Ata declaration, which was later reaffirmed by the 2018 Astana declaration emphasised the need for all governments, health and development workers, and the global community to build strong primary healthcare systems and take immediate action to protect and promote the health of all people.

Thumbi Ndung'u speaks at the World Economic Forum on Africa in 2019. (Credit: World Economic Forum)

The WHO endorsed the Astana Declaration to renew the commitment to strengthen primary health care and achieve universal health coverage.

In 2021, as well, the State of Universal Health Coverage in Africa Report indicated that only 48% of people in Africa received the healthcare services they needed, implying that approximately 615 people in Africa do not receive the healthcare services that they require.

The positive trends 

“Achieving the highest possible level of health for all people in the region remains a distant reality, but there have been positive developments over the last two decades. If you refer to  the 2022 WHO Africa region "tracking Universal Health Coverage in the WHO Africa region" report, for instance, you can see that there have been positive trends,” explained research scientist Catherine Onyait.

The report indicated that substantial progress had been made in the region in the universal health coverage service coverage index. The region’s population-weighted universal health coverage service coverage index rose to 46 in 2019, up from 24 in 2000. 

By 2019, 35 countries in the region had a universal health coverage service coverage index above 40 and none was below 20. 

Uganda’s score at 50 had moderately improved but was insufficient to attain SDG3.
Six countries also had their universal health coverage service coverage index exceeding 60 compared to 1 in 2000.

For good measure, the "Tracking Universal Health Coverage: 2021 Global Monitoring" report found that between 2000 and 2019, Africa had the fastest growth in both the universal health coverage service coverage index and life expectancy, with an increase of 22 index points in the universal health coverage service coverage index and a gain of 11.7 years in life expectancy.

Furthermore, while most governments in the region continue to fund health below their agreed targets of investing (15%) of their budget into health, there has been an increase in capital health spending in recent years. 

Botswana, for example, has increased its health expenditure in recent years, reaching 14% in 2019 according to data from the WHO Global Health Financing database.

By all accounts, the COVID-19 pandemic and other diseases like Ebola and Marburg were partially responsible for the increased health expenditure (improvements in labs, research facilities, intensive care units, etc.).
 
 Improved research funding led to the development of African COVID-19 therapeutics in several countries like Uganda, Ghana, South Africa and Egypt.

In recent years, as well, the infant and under five mortality rates in the region have decreased by more than a half.

Over the last few decades, there has also been considerable progress in combating the HIV/AIDS pandemic. 

The WHO reported a 42% decrease in AIDS-related deaths in the WHO Africa region between 2010 and 2017.
 
 More work to be done

“There is no doubt that strides have been made but significant reallocations of public and non-government funds are still required if the region is to achieve better health outcomes, particularly away from expensive health services that only benefit a small number of people and towards more affordable interventions in a comprehensive package of services that are made available to everyone,” said Tanzanian public health researcher, Emmanuel Mwamba.

The WHO estimates that an additional US$ 41 per person per year in health spending is required in low and middle-income countries to make progress towards the health targets of SDG 3 by 2030.

In the region, public health funding has not kept pace with government commitments to universal health coverage, despite some health experts putting forth that additional healthcare investments (an average of $21 to $31 million per capita, per year) could save 3.1 million lives and generate more than $100 billion in economic gains over that time.

Uganda’s Health financing currently accounts for only 7.8% of Uganda's annual budget and was reduced to 6% in fiscal year 2017/18.
 
 Last year, however, the health budget was projected to increase to sh3375 billion and sh3,722 billion, respectively, based on the approved allocations for 2021/22 and 2022/23.

In addition, the health ministry launched the sh5 billion National Community Health Strategy in February of this year, ostensibly to strengthen the country's community health services, which are primarily staffed by unpaid and overburdened volunteers.

The strategy, the Health Ministry website indicates  is an important tool in achieving Universal Health Coverage (UHC) including the targets made by the health sector under the Sustainable Development Goals.

Professor Thumbi Ndung’u, the director of basic and translational science at the Africa Health Research Institute  told the New Vision that the region’s approach to "Health for All" in the coming years, should be to invest more in health, address inefficiencies and corruption.
 
 “Governments in the region must increase spending allocation to healthcare. There is too little spending on healthcare and health care financing in the region needs reform. We also cannot get around the question of universal health coverage, considering the inequity that exists across many countries in Africa,” Ndung’u said.
 
 Ndung’u added that sub-Saharan Africa was currently off the mark with many countries not even having a legal framework for universal health coverage.

“Achieving universal access to sustainable health for all by 2030 is possible, however.  It will require that governments, civil society and other stakeholders work together. The other way, the region can enhance its underperforming health systems is through universal childhood immunization for vaccine preventable diseases and investment in training of healthcare workers.”

On the health workforce, that Ndung’u alludes to, the WHO this month urged nations to take urgent action to expand their health workforce as a strategic priority.
 
 Dr Tedros Adhanom Ghebreyesus, the WHO Director-General said investments in education, skills and decent jobs for health need to be prioritized to meet the rapidly growing demand for health and avert a projected shortage of 10 million health workers by 2030; primarily in low- and middle-income countries.

Dr. Peter Wambi, a senior health planner, researcher, and systems strengthening specialist at the Health Ministry told the New Vision that while overall progress towards achieving universal access to sustainable health for all has been made in the last two decades, recent stagnations across regional blocks suggested that only a small number of countries will achieve high health coverage by 2030, with the majority likely to score below an average of 50%. 

“If the region is to achieve universal access to health care, there must be a fundamental shift in the mindset of both her leaders first and the citizens. Leaders must appreciate that health care is a critical investment which accrues returns in the long run rather than perceiving it as a liability,” Wambi said.

“Only a healthy population can produce and contribute to the GDP. On average, sub-Saharan Africa spends USD 78 per capita per year, as low as 25% in Burundi, 36 % in Uganda, compared to developed countries which spend 150 times more on just one individual per year. Health care investments should therefore be prioritized and financed, and measures to efficiently use the meagre resources allocated must be strengthened.”

According to Wambi, citizens in the region also need to appreciate that to be healthy is their primary responsibility and take simple steps such as hygiene and sanitation, exercise, safe sexual and behavioral practices to ensure that they prevent both communicable and non-communicable diseases. 

“That way everyone cuts the burden of disease on themselves and their governments.”

Onyait said cost-effective basic health care service packages delivered through networks of local health centres and small referral hospitals in the region’s rural and peri urban areas can go a long way towards meeting the health needs of many households in the region.

“In order to meet the needs of their populations, reduce the burden of disease, and lower premature mortality rates, governments throughout the region must prioritise the provision of cost-effective health services, including family planning, immunisations, maternal and child health services, immunisations, regular school health information programmes, treatment of diseases, education, and health communication programmes. This will facilitate progress towards realising aspiration 1 of the African Union's Agenda 2063.”

In a recent article, Karim Bendhaou, Chairman of the International Federation of Pharmaceutical Manufacturers and Associations' Africa Engagement Committee argued that a thriving innovation ecosystem was essential to achieving universal health coverage in Africa. 

He noted that the private sector, as recommended by the World Health Organization, would be an invaluable co-investor and partner in finding solutions to increase access to healthcare goods and services and strengthen local capacities.

African researchers have also argued that genetic engineering has the potential to significantly reshape Sub-Saharan Africa's public health ecosystem and reduce disease burden.

Professor Landry Signe, a Cameroonian senior fellow in the Global Economy and Development Program and the Africa Growth Initiative at the Brookings Institution, wrote in his book "Africa’s Fourth Industrial Revolution" that biotechnology had implications beyond gene editing, including the development of new medicines.

He wrote that biotechnology played a particularly important role in driving malaria research. Signe cited Target Malaria's research alliance, which had encouraging results from the release of genetically modified mosquitos in Burkina Faso in 2019, propelling their goal of bioengineering to eradicate the disease, which causes $12 billion in lost economic activity each year.

He added that: Early in the Covid-19 pandemic, researchers at the Africa Higher Education Center of Excellence for Genomics of Infectious Diseases (ACEGID), in collaboration with the Nigerian Center for Disease Control, made significant contributions to our understanding of SARS-CoV-2 by identifying multiple viral lineages through genome sequencing.

He further wrote that: Early in the Covid-19 pandemic, scientists at the Africa Higher Education Center of Excellence for Genomics of Infectious Diseases (ACEGID), in partnership with the Nigerian Center for Disease Control, contributed to the understanding of SARS-CoV-2 by identifying multiple viral lineages through genome sequencing.