Primary and secondary healthcare in Africa
… continued from Mortality in Africa …
Efforts to control the three pandemics (HIV/AIDS, tuberculosis and malaria) have made real differences to longevity in Africa and should be applauded. But there are reasons to think that there is too much focus on these three pandemics. In healthcare this kind of focus on a specific health issue is called a ‘vertical’ focus, and many critics think that it too often prevails in preference to a ‘horizontal’ focus that aims to strengthen health systems in a more general way.
Pulmonary infections kill nearly as many Africans as AIDS, and almost as many as tuberculosis and malaria combined. But, perhaps because the most effective way of responding is through relatively unglamorous promotion of basic medicines and clinics, combating pulmonary infections has been left to African governments. And African governments’ healthcare efforts have not been universally impressive.
Primary healthcare, as per the WHO statement adopted in Alma-Ata in Kazakhstan in 1978, includes:
- health education
- promotion of proper nutrition, safe water and basic sanitation
- maternal and child health care (including family planning)
- immunisation against major infectious diseases
- appropriate treatment of common diseases and injuries
- provision of essential drugs.
With the exception of the high-profile pandemic diseases, governments, multinational organisations and NGOs currently prefer to focus on primary healthcare simply because it is the most cost effective way of improving the health of a population and to deliver high impact interventions at low cost.
In order for primary healthcare to receive the necessary attention, some important actors in the sector, especially the NGOs who do so much high-profile work, will have to change their focus from a ‘vertical’ one on high-profile epidemics, to a ‘horizontal’ focus on more humdrum but potentially more effective actions like improving water supplies or supporting vaccination drives.
Administrative projects are often overlooked as potentially transformative healthcare initiatives, but a health ministry which is in control of roll-outs of medicine, aware of the priority areas in which the most urgent action is required, and in contact with external and private-sector partners, can rapidly make a difference to its population’s health. The best recent example of this is Ethiopia, where the success in improving healthcare by all available metrics is to a large extent due to the government’s willingness to recognise the importance of the role that the healthcare bureaucracy plays.
So the Health Minister Tedros Ghebreyesus, who believed that management was “the oil on which the complex organizational machinery of hospitals runs”, reorganised the entire bureaucracy of his ministry, drew up new and simpler standard operating procedures, decentralised to delegate as much authority as possible to teams working within each health facility, and improved communication structures in order to minimise the delays that emerged in instances where it became necessary to obtain instructions from the next level.
In the two decades since 1990, Ethiopians’ life expectancy has gone up by 10 years, and infant mortality has dropped by more than half.
The biggest potential gains in healthcare in Africa are to be made in primary healthcare and in improving the healthcare bureaucracies of government health departments. The former is the most cost effective way of improving the health of a population, delivering high impact interventions at low cost, and the latter (when properly implemented) can ensure that medical programmes are suited to a particular country.
While private hospitals and similar advances in medicine will become increasingly important to Africans in cities and in wealthier countries, the most lives can be saved and improved by focusing on the basics. In Africa, these basics are showing real improvement… but, as in the health metrics examined in The state of healthcare in Africa, absolute levels are still much lower than in the rest of the world.
The percentage of Africans with access to improved water sources went from 49% to 61% from 1990 to 2010, but that is still far below the global figure of 89%. Measles immunisation coverage for one-year-olds has gone up spectacularly in 30 years, from 6% in 1980 to 76% in 2010, but the global figure is 85%, and in the Western Pacific region, which was behind Africa in 1980, the percentage is 97%.
The challenge for most of Africa’s population is still to implement basic sanitation and medical techniques to address diseases that have been eradicated or brought under control in most of the world. But development, economic growth, and urbanisation is driving rapid growth in the number of Africans who live in cities, have high levels of disposable income, and expect good standards of medical care.
It is especially this market which has been driving the founding and expansion of private hospitals. The major private healthcare companies in Africa are three big South African operators, all listed on the Johannesburg Stock Exchange: Mediclinic, Netcare and the somewhat smaller Life Healthcare.
It is understandable that private healthcare grew fastest in the most prosperous African country, but other cities in Africa are now also viable markets for private hospitals. African Medical Investments operates private hospitals in Maputo, Dar es Salaam and Harare, and plans to expand into other East African countries and Nigeria. In the latter country Lagos state, home to just under 10 million people, boasts more than 80 private hospitals. Not all private facilities are massive hospitals like the Mediclinics in South Africa’s cities: Carego Livewell, for instance, is a Kenyan company which provides fairly basic services through five community-based clinics in the Nairobi region.
The development of private healthcare will continue over the next few years and represents an attractive investment opportunity. The World Bank’s International Finance Corporation (IFC) estimates that $25bn to $30bn will be invested in Africa’s healthcare infrastructure between now and end-2016, and that up to $20bn of that will come from the private sector.
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