The fact that Africa has less doctors than the rest of the world has frequently been identified as one of the root causes of the continent’s health challenges. In Kenya, for instance, the doctor to patient ratio is 1 to 17,000 against the World Health Organisation’s recommended ratio of 1 to 1,000.
However, increasing the number of doctors in service is not the silver bullet to Africa’s health challenges, says Dr Githinji Gitahi, Group CEO of Amref Health Africa.
In an address at the just concluded Africa Health Africa International Conference, Dr Gitahi noted that: “a survey by a local research firm found out that only 30 per cent of Kenyans knew of the doctors’ strike two months into the strike.”
These findings draw attention to the fact that most health needs are not met by doctors, but by middle-level heath workers and community health workers.
Ironically, investment in middle-level health workers in Africa are sporadic, while investments in community health workers are virtually non-existent. Community health workers are not paid in many African countries, including Kenya, despite calls by the World Health Organisation for a more sustainable community health strategy.
Africa needs to explore strategies of empowering community health workers, including pushing for legislation to get them paid and integrated into the formal health system.
Besides increasing the number of doctors, drug affordability has also been touted by a section of health experts as a remedy to Africa’s health system challenges.
Affordability is affected by drug and vaccine development, an expensive and uncertain process, typically taking a decade or more and demanding sustained sales to recoup investments. Pharmaceutical companies, therefore, have little incentive to invest in Africa since African countries lack resources to pay for research and treatment. A compelling indicator is health spending as a proportion of GDP, which is 30 per cent lower than the global average.
However, in the past decade, interventions to improve drug affordability have been largely successful. Product development partnerships—where the risk of funding drug development is shared between private sector, public sector and NGOs—have increased availability and affordability of medicine.
Granting of licenses to generic manufacturers has also helped. Tellingly, global consultancy McKinsey says that Africa’s pharmaceutical industry, which was valued at $20.8 billion in 2013, is expected to double in a decade.
But with access to drugs improving, why aren’t health indicators in Africa also improving?
Though it is still necessary to focus on addressing inadequacies in the health workforce and improving drug affordability, these shouldn’t be the key focus areas.
The social determinants of health, it emerged at the just concluded conference, are equally important.
“In fact, the founder of social medicine Thomas McKeown, wrote in 1976 that medicine was not very useful and that the roots of health improvement lay in economic and social progress particularly in better nutrition and living conditions, literacy and access to healthcare workers,” said Dr Gitahi.
The need to focus on social determinants, including poverty eradication, underscores the fact that government economic policy is critical in addressing health challenges.
An example is the slum problem in Nairobi, underscored by the fact that 60 per cent of Nairobi’s 3.5 million citizens live in informal settlements. If the government doesn’t invest in housing and jobs, especially for the youth, this problem will only grow worse. Consequently, health indicators in the city will also get worse, as overpopulation and poor sanitation in informal sectors are directly linked to high incidence of communicable diseases like HIV and tuberculosis.
HIV prevalence in Nairobi slums stands at 12 per cent, compared with five per cent among non-slum urban residents, and six per cent in rural areas, according to the 2008/2009 Kenya Demographic and Health Survey.
Focus on the social determinants by, for instance, improving housing, environmental conservation and meaningful jobs will have a stronger impact on health in Africa. This should be the top priority.
Sixty per cent of Nairobi’s 3.5 million residents live in informal settlements and, without government investment in jobs and housing, overpopulation and poor sanitation in these settlements will lead to high incidence of communicable diseases such as HIV and tuberculosis.