I was recently asked to give a talk on public health in Africa. I didn’t know where to start or what to say. I think of myself as an infectious disease physician and a viral immunologist who has over the years dabbled in work that has public health implications. But I don’t really know what exactly is “public health” particularly in Africa. I decided to search for a definition, hoping for something more concrete than my vague notions of public health as the implementation of health care measures for the benefit of the public/community. I couldn’t find one but instead found many. The definitions touched on the art and science of the field, on prevention, treatment, the community, environment, history, disparities, access, epidemiology, and research.
The CDC foundation defines public health as ‘the science of protecting and improving the health of people and their communities.’ My gut reaction was ‘this seems incomplete’. ‘The science of …’ seems more connected to the field research that my research teams have done in the past, and less connected to the day to day of treating patients and running a public HIV clinic. Were either of those activities public health? So, I began to ask if public health is about ‘improving the health of people and their communities’, then who decides what the health of the people and their communities should be, how it should be implemented and who pays for it?
In 2001 as part of the Abuja Declaration, African Union governments set a goal of dedicating 15% of their annual budgets to health. According to WHO Afro in 2021, the average expenditure on health was only 9.8%, and a few years prior in 2018 only two countries met the 15% target. A large component of socio-economic development is driven by the health of the population and yet the relative allocation to health remains small compared to other competing priorities. If countries are not meeting these goals, who fills in the gap?
Total spending on health in sub-Saharan Africa in 2020 was US$91 billion, 38% was government spending (US$35 billion), development assistance for health (DAH) accounted for 17% (US$15 billion), prepaid private spending 15% (US$14 billion), and out of pocket spending 30% (US$27 billion). Governments provide a large proportion of healthcare expenditure but it is clearly not enough. Governments in Sub-Saharan Africa spend on average US$73 per capita; this is less than 2% of the per capita spending by high income governments and well below national needs. DAH has likely served as an important lifeline for millions, particularly the poor. However, reliance on DAH to help close the financing gap especially for the poor has its share of problems and may be detrimental to Africa’s social and economic development by driving the public health agenda.
The measure disability adjusted life years (DALYs) for a disease is the sum of the years of life lost due to premature mortality and years lived with a disability due to the disease in a population. According to the data from the Institute of Health Metrics and Evaluation DALYs for non-communicable diseases such as cardiovascular diseases, neoplasms, diabetes etc. accounted for 31% of total DALYs in Africa in 2019. DALYs for HIV/AIDS, TB and Malaria were 7%, 3.4% and 8.5% respectively. These diseases are important but in 2020 (excluding COVID-19 funding) accounted for 31% of DAH spending. I was always struck as a clinician on the medicine wards in a government hospital that it was easier for a 37-year-old with HIV and TB to access treatment at little or no cost while a 57-year-old grandmother taking care of her HIV orphaned children could not get free treatment for her hypertension and diabetes complications. This imbalance means that public health for the poor is not driven by community needs but the priorities of the payer.
Private health expenditures are playing an increasingly important role in financing health in Africa. In 2000, pre-paid private expenditures in Sub-Saharan Africa were US$8.5 billion and out of pocket expenditure was US$13 billion; by 2020 prepaid private expenditure had risen to US$14 billion, while out of pocket expenditure had more than doubled to US$27 billion. Out-of-pocket payments for healthcare are necessary for many who don’t have diseases that are readily funded through DAH or government health expenditure. However, these costs can have devastating implications for individuals and their families. According to a 2019 report from the Brookings Institute, healthcare costs led to catastrophic financial crisis for 11% of Africans while 38% delay healthcare due to costs. This lack of resources to invest in preventative care worsens chronic medical conditions and fuels catastrophic spending to cover health emergencies.
But does lack of good ‘public health’ to meet the needs of the people, drive revolutions the same way that inflation and rising food prices has triggered revolutions throughout history? Would lack of access to antiretroviral therapy have led to sufficient fear of political instability that politicians would have invested in health systems strengthening? Would that have led to a focus on developing the local pharmaceutical industry or spurred long term investments in science and technology such that 40 years later African scientists would have developed their own vaccines, therapeutics, and diagnostics.
Understanding financing of health helps to clarify how health priorities are defined in Africa for the public. Improving the health of the public is driven by funding agendas that may not reflect the needs of the public. But if public health is also defined as the science of improving the health of people and the communities then who is currently driving the science agenda in public health Africa? Most countries in Africa spend <1% of GDP on research and development (R&D) with very little funding for R&D from the local private sector. Governments often will fund the overall infrastructure and base salaries in academic research institutions but funding for technology upgrades and discovery research work is limited. Most funded research in Africa is by foreign institutions giving rise to neocolonial global health economy in academia in which African science is led by western institutions.
In thinking about my discussion on public health I was troubled by the prospect of painting a gloomy picture of my continent. Could I put a positive spin on public health in Africa by addressing the potential of the continent to leapfrog and adopt new technologies more rapidly than parts of the world with legacy technology and infrastructure? Is there a healthcare version of MPesa (the fintech solution that revolutionized financial transactions and banking in Africa) lurking in the shadows? I am bullish about Africa but biotech to address public health problems has its unique challenges. Although a nucleic acid revolution is taking place with the cost of science and technology decreasing, revolutions in biology are often slow, build upon decades of basic science research, don’t take place in garages and are typically not led by college dropouts but are nurtured in enabling environments. The decades of future forward investments in education, science and technology in post-war United States helped to build the country into the medical research and innovation superpower it is today. These investments developed the necessary infrastructure and institutions to take on challenges in science and attract talent from all over the world to work on pressing problems. These investments allowed for basic scientists to discover, collaborate, and build a bioeconomy that has been critical for advancing human health. Is this possible in Africa? How can a public-driven public health agenda built on a strong foundation of science and discovery be established in Africa?
The first thing is to redefine public health in Africa on the continent’s terms. Increasing health expenditures by governments will be critical. However, this should not focus on simply increasing expenditure to 15% of the budget but focusing on having data driven tangible impact on people’s lives. This requires establishing an ecosystem to support public health that extends beyond the traditional remit of the Ministry of Health. An all of government approach is required. Investments in education develop the future pipeline of doctors, nurses, community health workers, scientists, engineers, problem solvers. Investments in general infrastructure such as safer and better road networks, housing, water, and sanitation significantly improve the quality of life and health outcomes. Investments in addressing energy poverty by building sustainable energy infrastructure that is not only good for the planet but immediately transform lives is critical. An all of government approach to public health in Africa could be transformative and is not too different from the paths to development that have taken millions out of poverty in Asia. Public health cannot rely on supplementing health expenditure by foreign assistance or sending families further into poverty by out of pocket costs; it needs to be locally driven by the public with visionary national and continental leadership.
Public Health in Africa to me means an all of government, people centered approach to health that combines pragmatism with vision. How do we get from where we are today to where we want to be in 50 years? As we set audacious goals such as manufacturing 60% of Africa’s vaccines by 2040 we will need to map out the investments that will bear fruit tomorrow and those that will bear fruit 20-50 years from now. Rapid adoption of technologies such as ‘vaccine manufacturing plant in a container’ may only be a stop gap measure. Investments into science, technology, engineering, mathematics from kindergarten through to tertiary education is critical to build the human resource base that is needed to innovate and develop novel healthcare solutions. Investments in building a middle class that pays taxes and enables government revenue to build and strengthen health systems and has the voice to make government accountable in its spending, supports public health initiatives and research into local diseases, will be critical. A stable middle class will also fuel industries, economic growth and create a market for new innovations.
It seems to me that public health in Africa is not global health, or tropical medicine, or donor funded development assistance for health but perhaps can be defined as research and implementation of healthcare for the people, by the people to improve the health of individuals and their communities. Africa’s public health must be led by its political leadership with an all of government approach that works towards a bold vision to improve the lives of Africans.