Health in Africa

This essay was written by Sam Kinyanjui and Francis Ndungu and was first published in the 2005 Mill Hill Essays.

It is difficult to write about health in Africa without reiterating the grim picture invariably encountered in many reports on the continent. Morbidity and mortality statistics always run to six or seven digit numbers. Every year millions of people in Africa are infected with malaria, HIV, tuberculosis (TB) and other debilitating infectious diseases. Several millions of these, particularly children, eventually succumb and die. In addition to this huge amount of human suffering and loss of life, infectious diseases impose a heavy economic burden on the already impoverished continent. Despite these bleak statistics, it should be pointed out that for about 25 years, after gaining independence in the early 1960s, many African countries made remarkable progress in many aspects of health. Infant mortality was on the decline, life expectancy was on the rise and many of the measures that experts call ‘health indicators’ were improving. Unfortunately, since the advent of the HIV pandemic in the late 1980s, the last fifteen years have seen a major reversal in all these gains. With up to one third of the population in some countries infected with HIV, many health systems in Africa are now teetering on the edge of collapse under the tremendous weight of demand placed on them by AIDS-associated infections. A recently developed method of calculating life expectancy that takes into account not only the number of lives lost from birth but also the number of productive years lost to disease among survivors, shows that life expectancy in Africa has dropped precipitously in the last ten years and this is almost solely due to the HIV pandemic.

Clearly, there are natural factors that help fan disease transmission in Africa. The hot and humid regions of equatorial Africa are a haven for vectors of malaria, sleeping sickness, filariasis, bilharzias, and many other diseases. On the other hand, the droughts that frequently ravage many of the non-equatorial regions leave children malnourished and highly susceptible to diseases. Controlling disease within such an environment can be a very demanding exercise, even for well-resourced countries. Take the case of malaria control. After the successful elimination of malaria from Mediterranean-Europe, the US, and parts of India through large-scale spraying of insecticides to kill the malaria-vector, optimism was high that malaria could be eradicated globally. Why did it not happen in Africa? Unfortunately, Africa’s climate supports species of mosquitoes that are extremely efficient at transmitting malaria. Furthermore, while malaria was only transmitted during summer in Europe and America, high-level transmission occurs all year round in many parts of Africa. Only very intensive and sustained spraying could keep malaria at bay. Such intensive control exercises were simply too expensive for many African governments to sustain, and were always interrupted by dramatic resurgence of malaria transmission. Furthermore, mosquitoes eventually developed resistance to insecticides. Thus the dream of eradicating malaria in Africa by eliminating mosquitoes gradually faded, leaving drug treatment as the only means of controlling the disease. However, the effectiveness of drug therapy is also repeatedly undermined by the ability of malaria parasites to develop resistance to drugs. The last few years have been a hectic race against time as scientists struggle to find new drugs that are not only effective against malaria parasites but also affordable to the public in Africa. Whereas vaccines have proved to be highly successful in controlling several diseases that previously wreaked havoc on humans, a vaccine against malaria has remained elusive, as have vaccines against HIV and other tropical diseases.

However, environment and nasty bugs are only part of the story. The sorry state of health in Africa is the result of multiple factors; environmental, social, political, and economic. While debates may go on about the relative importance of each of these factors, there is no question that they are all intertwined and not easy to disentangle. Many regions of the continent have been repeatedly plagued by political upheavals and civil wars resulting in mass dislocation of large populations. Such dislocations create prime conditions for the spread of disease within and between populations and frustrate any attempts to put in place any meaningful disease intervention structures. In addition, social instability curtails economic growth and impoverishes communities that were previously self-sufficient, and worsens conditions for those who were already poor. Many people have argued that in fact poverty is what ails Africa and that most of the health problems seen there simply reflect the abject lack of basic needs. This notion presumes that health is necessarily preceded by wealth and that as people become wealthier they will become healthier. This is only partly true. Ill health and poverty are locked together in a vicious cycle and each drives the other. Disease imposes tremendous economic cost on a country through the costs of treatment and patient care and through loss of manpower. Malaria fevers, for example, are most frequent during the rainy season just when maximum manpower is required for the preparation of land and planting of food crops. Thus, malaria impacts heavily on food production and consequently contributes to the malnutrition seen in many malaria endemic areas. Even when not directly afflicting the working population, malaria affects economic activities by drawing adults away from work in order to care for sick children. However, the economic costs of malaria are not restricted only to the cost of treatment and loss of physical manpower. Studies of children in Kenya show that not only do malaria fevers deny children a large proportion of schooling hours but also, in its severest form, malaria can interfere with the development of children’s mental ability and hence their future productivity. The link between HIV and loss of economic productivity is also very clear. HIV afflicts the most economically productive age groups and many African countries are therefore set to have unusual population structures dominated by two groups that are relatively unproductive in economic terms, the very young and the elderly. In view of this association between ill health and economic depression, any poverty eradication strategy for Africa must seek not only to make people wealthier but also healthier in order to facilitate sustainable economic growth.

However, making people healthier is easier said than done especially when it comes to Africa. It goes beyond a simple matter of giving drugs to treat sickness. A war paradigm is often used when discussing health interventions and it is common to hear commentators on scientific documentaries ask questions such as “Are scientists winning the war against malaria or HIV?” However, this is like asking if armaments manufacturers are winning a war. The war against these diseases is not fought in a laboratory, that is where the weapons are forged, but the battlefronts are in those regions of Africa where the diseases are rampant. Granted, having the right weapons i.e. effective preventative measures such as insecticide–treated bed nets, vaccines and effective drugs, is necessary to win the war, but it is certainly not sufficient. These weapons need to be made accessible in areas where they are most needed, deployed at the right time and in a sustainable manner. Provision of health services in Africa is severely hampered by poor physical infrastructure and logistical problems. Transporting drugs and vaccines to where they are needed is often very difficult. The lack of proper storage facilities is associated with substantial wastage of temperature-sensitive drugs and vaccines. Though often overlooked, the lack of information concerning the geographic spread and seasonality of different diseases is a major handicap in planning health intervention programmes and in prioritising allocation of health resources.

Even where the drugs and other intervention tools are accessible, their costs are prohibitive for the majority of people. To put this in perspective, a full course of anti-TB drugs costs about fifteen US dollars, even after the recent reduction in cost; anti-retroviral drugs (ARV) still cost over twenty dollars a month; a course of malaria treatment costs more than a dollar. Many African families survive on less than one dollar a day and these costs are well beyond reach unless other domestic needs such as food are neglected. Despite proving to be effective in reducing malaria-related mortality among children, insecticide treated bed nets are yet to see widespread usage in Africa – they are simply too expensive for most people. So why not develop cheaper drugs that are affordable in Africa? Drug development is expensive and pharmaceutical companies are generally driven by commercial consideration rather than philanthropy. As such, they tend to engage themselves in the development of drugs for rich markets such as those presented by Europe and America where they are assured of good returns. The market for anti-malaria drugs and drugs for other tropical diseases is simply too impoverished to be worth investing in. Compared to the amount of money invested in developing drugs for cancer, diabetes, cardiovascular and other diseases that afflict developed countries, the amount committed to development of drugs against tropical diseases is measly to say the least.

he problems of decrepit health infrastructures and inability to buy drugs are compounded by a severe shortage of trained personnel. The ratio of patients to doctors, nurses, midwives and other health personnel in many African countries falls far short of that recommended by the World Health Organisation. In the western world, one physician serves about 400 people; in contrast a physician in Africa serves over 3000 people. African nations ranking toward the bottom of the year 2000 UN Human Development index have one physician per 50,000 people. It is estimated that African countries will have to at least double the number of health professionals over the next five years if they are to cope with the demands of HIV and other diseases. This is an almost impossible call for most of the countries. To begin with, the rate of training of health personnel in most sub-Saharan African countries is way below what is required to meet demand. The few that make it through the training are faced with poor salaries, lack of facilities, and such demoralising working conditions that many eventually opt to emigrate to developed countries where there are better career prospects. So severe is this loss of personnel to developed countries that many health systems in Africa are slowly grinding to a halt. For example, it is estimated that Ghana has lost more than 12,000 health professionals to developed countries in the last decade while over 5000 Kenyan nurses have emigrated to Europe in the last five years alone. While some of the developed countries are only inadvertently the destination for the emigrating health professionals, other countries are guilty of actively seeking to recruit professionals from developing countries. Either way, many feel that it is time developed countries acknowledged their complicity in this problem and began compensating the source countries and helping them address the personnel shortages, perhaps by funding training and helping governments commit more money to health workers’ salaries.

It is clear from the discussion in the preceding paragraphs that addressing health issues in Africa requires a multi-pronged approach. On the one hand, more research into the biology of the various pathogens that cause diseases in Africa is required in order to develop cheap and effective tools for fighting the diseases. One approach to try to overcome the reluctance of commercial pharmaceutical companies to invest in the development of drugs and vaccines for tropical diseases has been the initiation of public-private partnerships. Here, public health funding agencies work together with commercial pharmaceutical companies to develop drugs or vaccines for diseases affecting poor populations. The funding agency may help finance part of the research and insure the commercial company against possible losses arising from trying to sell the drugs to an impoverished market. In addition to basic pathogen biology research, detailed epidemiological studies are required to provide the vital information required for planning of health programmes. An example of these is the ongoing project to map the risk of contracting malaria in various regions of Africa depending on the vegetation and climatic conditions. So far, data from the project suggest that the number of people at risk of malaria infection is much larger than was previously thought. Thus, they outline a need for even more funding for malaria control programmes than has hitherto been forthcoming. However, even with the right drugs and other interventions tools available, formulation of health policies in Africa needs to take into account the social, political and economic state of the region if they are to be appropriate and sustainable. The HIV control program in Uganda, often hailed as an example of successful health intervention activity in Africa, illustrates this well. As Ugandans were emerging from a period of prolonged civil turmoil in the early 1980s, they found themselves faced with a new enemy that was more deadly than the bullets they had survived – the Human Immuno-deficiency Virus. A devastating HIV epidemic was sweeping across the country leaving a trail of decimated villages in its wake. By the early 1990s, nearly 30% of Uganda’s population was infected with HIV. Fortunately, the government realised the direness of the situation and was quick to initiate measures to contain the escalating situation. By the year 2000, HIV prevalence in Uganda had fallen to below 8%.

Uganda’s success in reducing high HIV infection rates is the result of a broad-based national effort backed by high-level political commitment to HIV prevention and care, and the involvement of a wide range of partners and sectors of society. From the outset, the country’s president provided strong backing for the campaign and personally traversed the country advocating a change in sexual behaviour. The government also engaged religious and traditional leaders, community groups, non governmental organisations, and all sectors of society to help design culturally–appropriate strategies for educating Ugandans about HIV/AIDS. This, coupled with sex education programmes in schools and on the radio, helped to bring about behavioural change and to destigmatise HIV. Condom usage was encouraged and access to condoms made easy through a social marketing scheme that involved sales of condoms at subsidized prices or free distribution by both the government and the private sector. As sexually transmitted infections (STI) are a particularly high risk factor for HIV infection, the social marketing approach, which depended on ordinary retail shops, was used to dispense kits for self-administered treatment of STI. Finally, the same-day voluntary counselling and testing services launched in Uganda in 1997 proved to be an effective innovation in the fight against HIV spread. Before then, clients had to wait two weeks for their HIV test results and up to 30% of them failed to return. Thousands of people who have taken advantage of same-day testing have since been recruited and trained as peer educators and counsellors. By combining all these strategies Uganda was able to achieve an impressive reduction in the prevalence of HIV infections even before the advent of cheap anti-retroviral drugs or any HIV vaccine. Worryingly this achievement is now under threat following the call by religious groups and the Bush administration in the USA to withdraw support for the promotion of condoms as an HIV prevention tool and to concentrate on preaching abstinence as the only effective way of controlling HIV, despite clear evidence to the contrary.

While political goodwill and innovative approaches are necessary for successful health intervention, the urgent need for funding to sustain health programmes in Africa cannot be overstated. For a continent severely constrained by poor economic development and an incapacitating burden of foreign debt, this funding will inevitably have to come from outside, at least for now. Fortunately, developed countries are gradually waking up to this realization which has resulted in the establishment of several initiatives to fund health intervention programmes in poor countries. These initiatives include the International Finance Facility for Immunisation to which the UK has pledged the equivalent of £70m each year in hope of reducing disability and deaths caused by preventable diseases like measles, polio, hepatitis B, tetanus, and diphtheria. However, the most ambitious initiative is the Global Fund, founded in 2000 with an aim of raising ten billion dollars every year to provide funding for countries worst affected by HIV/AIDS, malaria and TB. Though spearheaded by the G8 group of industrialized countries, the Fund has so far received pledges and donations from nearly fifty countries and other institutions such as the Bill and Melinda Gates Foundation. Since 2001, the Global Fund has attracted nearly five billion dollars in financing. In its first two rounds of grant-making, it committed one and a half billion US dollars in funding to support 154 programs in 93 countries worldwide. Nearly one billion dollars has gone to over 100 projects in thirty eight African countries.

The Global Fund takes a comprehensive approach to AIDS, TB and malaria control, funding prevention and treatment projects based on locally initiated strategies and does not impose health policies on the recipient countries. Most of the funding for HIV projects is expected to go towards the provision of antiretroviral treatment while the rest will be used in prevention activities. Grants for malaria will both expand access to insecticide-treated bed nets and give tools and training for health officials to diagnose and treat the disease. In the case of TB, the aim is to provide effective treatment and ensure patients’ compliance so as to increase cure rates and prevent spread of resistance to the drugs. However, not only is the amount of money pledged by donors to the Global Fund still short of what is required to bring about a significant change in global health in the near future, but also many donors are yet to fulfill their pledges. The USA is the leading culprit in this. Initially they pledged to contribute up to one third of the Global Fund, but have yet to do so. During the Fund replenishment meeting in September 2005, the USA pledged only six hundred million dollars, against three billion dollars pledged by the other donors, thus falling nearly one billion dollars short on its initial pledge. From the renewed commitment, there will be sufficient money for renewals of existing grants during the years 2006 and 2007, but not for any new grants. It is doubtful that the Fund can achieve its goals without the willingness of rich countries to dig deeper into their pockets. Furthermore, the Global Fund and most of the other initiatives for improving health in Africa are almost solely focused on infectious diseases, not chronic ones such as smoking-associated cancers and diabetes which, contrary to common belief, are a significant cause of morbidity and mortality in the developing world.

In conclusion, the health problems facing Africa appear to be almost insoluble and even the most stoical optimists are often hard pressed to justify hope. Yet examples such as that of HIV control in Uganda and other success stories not discussed here, few though they may be, offer hope that in fact the problems are not insurmountable. However, very strong commitment from Africa and the rest of the world is required if the current state of affairs is to be overturned. Both sides must recognize the multiple factors that contribute to the pitiable state of health services in Africa. On their part, African countries need to put in place governance and management systems that enhance the transparent utilization of tax revenues and donor funds. Without such systems, a substantial proportion of funding will be lost through corruption and inept bureaucracy. The developed world in turn should be ready to recognize two things. First, a massive increase in financial commitment for tackling health problems in Africa and other developing regions is required for any noteworthy change to be effected. Second, health and poverty are intertwined. As such, any attempts to help Africa tackle its health problems must be made in concert with poverty reduction initiatives such as debt cancellation and fair trade. Only through such an approach can Africa eventually become self-reliant and achieve domestically-funded sustainable health programmes.

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