Universal health coverage and health technology assessment in Sub-Saharan Africa
" Africa's progress, if it is noticed at all, is seen as an improbable stroke of good fortune, a temporary break from its impoverished and war-torn destiny. … if you work for a company based in the old 'West' … you are probably missing opportunities in the largest expansion of the middle-income consumer market in history, which is taking place right now in Africa and Asia."
- Hans Rosling, Factfulness, 2018
In fact, Africa is making great progress in its health and healthcare.
I've just returned from a week in Accra, Ghana where I participated in a conference on decision making on sustainable healthcare in Sub-Saharan Africa.
The conference was called "Setting Health Priorities Fairly: Sustainable policies for effective resource allocation in Africa" and was jointly organised by the International Decision Support Initiative (iDSI) based at Imperial College, Health Technology Assessment International (HTAi) and the Ghanaian Ministry of Health.
As well as enjoying the warmth and hospitality of the Ghanaian people, the conference was a great opportunity to meet with government officials, private industry executives, academics and patient representatives from all over Africa to discuss how African countries can make decisions about allocating healthcare budgets as they transition away from donor aid.
What's often not recognised is that many African countries are rapidly developing into middle income countries with growing middle classes, growing economies and tech-savvy consumers who, like everyone else in the world, want excellent, affordable healthcare.
African economies have seen significant growth in per capita income since the turn of the century and, as a result, many of them will soon be 'graduating' out of assistance from international organisations.
Source: Shawview Consulting analysis from World Bank open data, https://data.worldbank.org/, accessed 30/9/2018.
As their economies grow and they step up to the challenge of domestically funding universal health coverage, African countries will have to prioritise their health spending. This comes at a time when many African countries are making substantial progress in treating and eliminating communicable diseases like HIV/AIDS, malaria and tuberculosis, but are now having to deal with increasing rates of non-communicable diseases like cancer, cardiovascular disease and diabetes that often come with growing incomes and development.
Top 10 causes of death, Africa and the World, 2000 and 2016
Source: World Health Organization, “Top 10 causes of death”, Global Health Observatory, http://www.who.int/gho/mortality_burden_disease/causes_death/top_10/en/, accessed 30/9/2018.
Decisions on which diseases to treat first, what treatments to adopt and the balance between prevention and treatment will all have to be made through some sort of prioritisation and decision-making framework.
Against this backdrop, at the conference there was much discussion in the conference of using health technology assessment (HTA), economic evaluation and budget impact analysis to make such decisions about allocating constrained healthcare budgets to the best health interventions.
There was recognition among the conference participants that there is a lot that needs to be done in African countries such as:
Allocating sufficient funding to invest in healthcare. The conference heard many examples where African countries haven't reached target spending levels in health and - believe it or not - not even being able to spend all of their existing budgeted funds already allocated to health
Investing in capacity to do HTA evaluations, such as in data systems, evaluation processes and the skills and capabilities of people
Building robust evaluation systems that incorporate the participation of stakeholders like the pharmaceutical and medical device industries, patient groups, private insurers and academics
Having better collaboration and constructive dialogue between governments, funders, patients, healthcare professionals and the private sector
Working out how to get understanding and buy-in from politicians to support HTA and the concept of using evidence-based decisions in health. There were stories of complex evaluations being done, only to be ignored or overturned by ministers for overtly political reasons, and
Ensuring the quality, safety and efficacy of both medicines and the supply chains that get medicines to patients, so as to combat things like fake medicines and inefficient distribution of medicines.
There was also discussion at the conference of how emerging, disruptive technologies like big data, mobile devices, apps and e-commerce can help African countries build their health systems in ways that deliver efficiencies and provide new opportunities whilst avoiding some of the infrastructural and 'legacy' problems experienced in more traditional established health systems in high income countries.
One example of this I heard is in Ghana itself where the National Health Insurance Agency developed a mobile app to allow patients to pay their health fee contributions through their phones using mobile money, as well as providing verification of patient identity during clinic visits through instant messaging. The app, developed after consulting patients on what they wanted, has been very popular especially in rural areas and has helped reduce fraudulent claims for clinic and medical services.
So Africa is making progress in healthcare. There's no doubt that major advances have been made in African health with countries recording substantial increases in life expectancy and overall deaths from infectious diseases are in serious decline.
The challenge now is to ensure that countries continue to prioritise investment in healthcare going forward and in the tools they need to deliver a good health system.
But with challenges also come opportunities for better healthcare in Sub-Saharan Africa. Investment in technologies and in greater efficiency will deliver better systems and value for money for payers, growing markets for the private sector and a package of essential healthcare and insurance for Africans.
These trends have implications for different stakeholders.
Private industry, such as insurers, pharmaceutical companies, medical device manufacturers and technology companies need to recognise that these fast-growing African markets now present real business growth opportunities. But these companies will need to ensure they provide services and products that meet the needs of these emerging health markets in terms of innovation, price and quality.
Governments and politicians in these countries should recognise the opportunities for their countries if they can sufficiently invest in health care in a sustainable and cost-effective way. Expanding investment in healthcare, spending the money that has already been budgeted, and driving efficiency reforms focussed on health will be critical here. All of this requires political will and leadership from the top.
Healthcare professionals will need to ensure their skills, training and professional standards are updated to manage the new, emerging health systems in these countries. With lots of scientific, technological and economic change going on in Africa, their role is going to be important in helping the community adapt and manage these changes.
And patient groups will need to skill themselves up to ensure the most important independent voice in the room – that of patients themselves – is actually heard in the debates, discussions and decision-making processes as African health systems are designed for the 21st century and beyond.