Bolder action for health in Africa: From building health systems to building systems for health for NCD prevention

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African countries are not on track to achieve the targets for NCD prevention and management.

Key Messages


  1. African countries are not on track to achieve their targets for non-communicable diseases (NCDs) prevention and management. These targets are – reducing the prevalence of NCDs by 25% by 2025 and by 30% by 2030.
  2. The risk factors for NCDs are driven by complex ecological drivers including poor urban development, poverty, socio-cultural factors, and the unbridled proliferation of the commercial determinants of health including unhealthy food environments, tobacco, and alcohol.
  3. The prevailing focus of Universal Health Coverage (UHC) on healthcare service provision is insufficient in itself to achieve health and wellbeing in Africa. This is because the risk factors for NCDs are shaped outside the healthcare sector.
  4. To turn the tide of this emerging NCD epidemic in Africa, a re-think of universal health coverage towards a systems-for-health approach is required, from reactive provision of health services to proactive health creation and prevention
  5. This approach incorporates health determinant sectors that produce health outcomes – housing, planning, waste management, education, governance, finance, amongst others; in strategies to improve health.
  6. For long-term cost-saving, in addition to financing healthcare, investments in universal health coverage in Africa should invest in strengthening the systems that can be harnessed to produce health, aligning governance mechanisms and strategic objectives of all health determinant sectors for health creation.

African countries are not on track to achieve the targets for NCD prevention and management. These targets are – reducing the prevalence of NCDs by 25% by 2025 and by 30% by 2030. Instead, NCDs continue to rise in prevalence and are overshadowing the gains recorded in communicable disease prevention. In the period between 1980 and 2014, the prevalence of diabetes in the WHO African region rose from 3.1% to 7.1%. NCDs strike people during their economically productive years, with significant implications on the earning ability of individuals, and by extension their families, compounded by out of pocket healthcare expenditure.

The 1st World Health Organization Africa Health Forum in 2017 identified NCDs as an emerging threat in Africa and highlighted the need for intersectoral action to address the social determinants of these diseases. The 2nd forum in March 2019 provides an opportunity to build on the initial call to action, engage constraints, and plan to achieve the 3rd Sustainable Development Goal (SDG) – Health for All – on the African continent. This SDG is often linked to the concept of Universal Health Coverage (UHC), with its underlying principles of equity, quality, and financial protection. However, the disease- fighting, health-system centric vision of UHC constrains the achievement of WHO’s definition of health as the attainment of complete physical, mental and social wellbeing, especially for people with NCDs. A major reason for this is that NCDs are shaped by multi-tiered and multi-faceted factors that do not stem solely from the healthcare sector.

The behavioral risk factors for NCDs are shaped by complex ecological drivers intersecting in local social, cultural, environmental, policy and economic contexts. They are further impacted by global dynamics, such as the globalization of unhealthy diets and lifestyles, and short-term donor-driven governance priorities. The influence of commercial determinants of health especially tobacco, alcohol, sugar-sweetened beverages, and fast food continue to interfere with NCD prevention and control strategies.

But policy responses to NCDs in the African region are mostly fragmented and vertical. Existing public awareness programs are not effective because they lack integration with multi-sector stakeholders. Most do not have fully implemented regulations on commercial determinants of NCDs such as alcohol and tobacco, sugar-sweetened beverages. This results in environments that increase the burden of disease, driven by urban development initiatives unconducive for equitable access to active living and healthy eating.

Systems to prevent, detect, and manage NCD risk factors are therefore warranted from a health economics perspective. Sub Saharan Africa has the largest cohort of young people in history – 405 million people aged 0–14 in 2014. This young population has the potential for economic productivity and development. However, if current patterns persist, a majority of these population will have an NCD in their middle age. The cost implications of treating and managing them will be crippling.

It is imperative to expand the focus of UHC from one of reactive provision of health services to one of proactive health creation and prevention for long term cost-saving. Sectoral silos need to be broken down to achieve this. We present a sustainable approach to tackle the problem of NCDs from the root cause.

a) Systems and service delivery for health


The first part of this approach is to act with an understanding that factors outside of the health sector drive NCDs. For example, whether or not people engage in physical activity is heavily dependent on access to infrastructure that encourages an active lifestyle – transit systems, built environment features that promote walking, cycling and green spaces. This infrastructure needs to be safe, clean, functional and of reasonable quality. This falls within the remit of urban planning, waste management, and local governments, but not necessarily the healthcare sector.

Therefore, rather than work for improved health through the healthcare systems alone, we must have integrated systems including but not limited to the health sector.

This should be reflected in policy making, accountability mechanisms, government departments and ministries, financing structures which encourage multi-sectoral action, an integrated approach to producing health, and the leveraging of co-benefits across sectors. Figure 1 illustrates this point by showing the connections between sectors such as food, transport and planning and how they directly influence human health, as well as the intricate links between human health and planetary outcomes.

Figure 1: Multisectoral upstream approach to Universal Health Coverage

Through this lens, healthcare services would be seen as just one part of services that are needed to create health. The conceptualization of health services must be expanded to incorporate the sectors that produce health outcomes such as housing, planning, waste management, education, governance, finance, amongst others. These sectors must have the capacity to collaborate in a multi- sectoral manner and must be financed in ways that allow collective impact, the flow of knowledge and shared vision between and within sectors.

A more ecological paradigm of population health is urgently needed where public health and healthcare professionals, as well as professionals in health determinant sectors are trained and supported to move upstream – out of disease and sector silos into whole ecosystems thinking.

b) Harnessing global policy opportunities


While addressing the existing need, it is critical that global health policy plans are in place to reduce future need. It is often the case that the existing need is framed as a case to not invest in future need. However, without attending to future need, there will simply not be resources to manage NCDs in the future. Investments in universal health coverage in Africa should, therefore, invest in strengthening the systems that can be harnessed to produce health as well as in financing healthcare delivery in order to meet demand for equitable health in the long term.

There are promising developments and policy opportunities, such as the Inter-ministerial Taskforce on Health and the Environment in Africa that must be leveraged to ensure that development produces health as an outcome in Africa. Similarly, there has been a history of, and ongoing research on healthy city initiatives in Africa. These existing political commitments, the lessons learned, and knowledge generated should be leveraged to revive home-grown approaches to fostering intersectoral action and accountability for improving health through action across all sectors.

Conclusion


There is an urgent task at hand – to plan for health in the long term. This is a mammoth task, the benefits of which may not be visible at scale in the short term requiring genuine innovation and the boldness to take urgent action to prevent disease and associated costs for skyrocketing in perpetuity. In Panel 1, we share action recommendations for Africa’s policymakers and research community, working together to inform the re-thinking of UHC, towards holistic systems for health needed to turn the tide on this emerging epidemic of NCDs in Africa.

Recommendations for action


Policymakers


  1. Systems for health must work alongside health systems: Re-thinking systems for health is needed, integrating healthcare with sectors that determine health, which should be aligned for health creation, with innovative intersectoral accountability processes for health across the public and private sector.
  2. Health financing should be focused on producing health rather than managing disease: This should include long term budgeting structures to support intersectoral accountability mechanisms for co-benefits.
  3. Health creation should be central to development: Africa has the opportunity to re-define what the measures of its development success will be, grounded in its people to address structural inequities within societies. This requires a re-imagination of what a thriving city or country in Africa could look like; adjusting measures of development to align with this re-imagination.
  4. All policies should be aligned to create health as an outcome: This means proactively identifying incoherence between policies. For example, it makes little economic sense for policies that allow the proliferation of fast and processed foods, and policies that increase access to diabetes treatment to co-exist, especially in poorer communities. One policy (or absence thereof) simply increases the need and demand for healthcare by increasing risk and prevalence of disease.

Research community


  1. Conduct research in partnership with policymakers: This will facilitate the transdisciplinary integration of evidence to drive health creation. This will also flatten the slope of increasing healthcare need and enable innovation on intersectoral financing for health creation.
  2. Invest in platforms for knowledge sharing: While different countries have their own path to achieving health for all, it is critical that platforms exist for African countries to learn from each other through sharing knowledge and evidence generated.
  3. Support frugal innovation for health (beyond healthcare): We simply cannot afford to treat ourselves out of serial epidemics that are preventable. Long term frugal innovation is needed to make our growing cities and societies spaces that promote health and equitable thriving.

Authors


Tolu Oni is a Public Health Physician and Clinical Senior Research Associate at the Medical Research Council Epidemiology Unit, University of Cambridge, UK; an Honorary Associate Professor, School of Public Health and Family Medicine, University of Cape Town, South Africa; a Fellow of the Stellenbosch Institute for Advanced Study, South Africa; and a Next Einstein Forum Fellow.

Ebele Mogo is a Postdoctoral Fellow at McGill University, Canada.

Aliko Ahmed is a Senior Fellow and Executive at the Cambridge Institute of Public Health, University of Cambridge, UK, and Senior Associate fellow and Convener, Public Health Africa Policy Forum, Chatham House, UK.

Charles Ebikeme is a Science Officer of the Urban Health and Wellbeing Programme, International Science Council, France.

Yonette Thomas is Executive Director of the International Society for Urban Health.

Amy Weimann is a PhD candidate at the School of Public Health and Family Medicine, University of Cape Town, South Africa.

Justine Davies is a Professor of Global Health, University of Birmingham, UK, and affiliated to the MRC/Wits Rural Public Health and Health Transitions Research Unit, University of the Witwatersrand, South Africa.

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