Most African countries depend heavily on international donor funding to support healthcare, of which only 3% is geared towards non-communicable diseases, even though they constitute 29.3% of the total healthcare burden in disability-adjusted life years.
The burden of non-communicable diseases (NCDs) in African countries is a ticking time bomb expected to blow up in our faces over the coming decades unless we urgently do something about it.
African governments are not doing a great job at investing in tackling NCDs because despite having committed to spending a minimum of 15% of GDP on healthcare in the 2001 Abuja Declaration, only a few of them are actually doing so today.
A major part of the reason is that most African countries depend heavily on international donor funding to support the healthcare of national populations, of which only 3% is geared towards NCDs, even though they constitute 29.3% of the total healthcare burden in disability-adjusted life years (DALYs) in low-income countries and 44.5% in low- to middle-income countries.
The lion’s share of international support goes towards the high-profile infectious diseases HIV, malaria, and TB, which constitute a threat to donor countries, while the non-contagious NCDs take a backseat in the funding agenda.
Thanks to this structuring of international support, we now excel at saving people from dying of HIV-Aids only to lose them to undiagnosed cancer, uncontrolled blood glucose or untreated high blood pressure.
When the NCD time bomb explodes, it will not only leave egg on the faces of African governments and international donors, but also millions of lives and economies shattered beyond measure. In this article, I explore some solutions that could begin to defuse that time bomb.
A matter of self-interest
Finance is, of course, fundamental. Unless there is money to fund disease prevention, management and treatment programmes for NCDs, nothing is going to get done. However, significant money is unlikely to come from international sources to fund the NCD agenda until the donors can see the angle of “what’s in it for them”.
For HIV, TB and malaria that angle was obvious: squash them at source or you’ll soon find them on your own doorstep. This thinking does not apply to NCDs which by definition are non-transmissible. Hence, for anything to change donors would either have to start to genuinely care about the health of African nations or see how not addressing the burgeoning NCD burden in African countries now might result in an economic blowback in their own countries in the future.
The latter is a more likely scenario because donors’ actions are primarily driven by self-interest rather than anything else. For African countries themselves the reasons to tackle NCDs should be clear since their toll is already large and predicted to get even larger.
Time and time again, events have categorically shown us that no African nation can protect its economy without protecting health. Still, not enough money is being allocated towards NCDs or to creating balanced health systems capable of addressing all population health needs.
Most African governments are funding less than 50% of their health budgets. Given the current structuring of international support and the consequent calibration of the national systems in African countries, it will take some time before a greater proportion of GDP can be allocated towards managing health, let alone NCDs, to achieve integrated disease management.
This does not mean that we should sit idle while waiting for things to change. There is much scope to reimagine and shape the future of healthcare in Africa right now regardless of the existing structural and resource constraints.
The solution I propose is twofold. One: African countries should leverage innovative sources of affordable NCD medicines and impact funding coming from outside the usual international support. Two: African countries should increase health spending and ramp up their participation in clinical studies and collection of healthcare data to ensure that NCD-treatment guidelines are relevant to African patients.
Pharma initiatives such as Sanofi’s Impact Brand and Impact Fund and Pfizer’s “Healthier World” offer impact funding and NCD medicines at a lower cost. They have the potential to significantly reduce gaps caused by the long-standing neglect of NCD management by African health systems, provided that African governments seize the many opportunities that these initiatives offer.
These initiatives can, for example, help catalyse greater integration of NCD management and care into national health systems, especially at the primary care level. They can help secure access to the required medicines at affordable cost, catalyse training of health workforce in NCD management, and promote approaches to NCD diagnostics that enable patients to be diagnosed and receive treatment even in the remotest locations.
Workforce training and diagnostic approaches are important since, as I have written elsewhere, they constitute some of the most consequential bottlenecks that need to be addressed before increased availability of affordable medicines can translate into a positive impact on patient health.
The Sanofi impact brand includes the $25-million Impact Fund for supporting local healthcare start-ups and for strengthening health systems. Supporting local entrepreneurs is a great way to catalyse an ecosystem of new solutions that are embedded within local communities and are sustainable over the long term.
If African governments add their own resources, they could leverage impact initiatives to significantly expedite the integration of NCDs into routine primary care and to amplify the impact on a population level with measurable improvements in patient outcomes. This way we could stop saving people from dying of HIV/Aids only to lose them to NCDs soon after.
This kind of intelligent cooperation with pharma initiatives is attractive because the angle for pharma companies is clear – they want to do business. It is much better than charity support which is invariably underpinned by complex political and economic interests that have proved harmful to African health systems by driving their relentless verticalisation and consequently weakening them for decades.
Pharma companies just want to sell more medicines. If they support countries such that they are set up to diagnose and treat more patients at a cost affordable to patients, they will sell even more medicines. They will also look good in the eyes of investors who are increasingly interested in impact, and those who monitor corporate social responsibility.
We should accept this calculus because, in the end, everybody wins – African countries, the companies and, most importantly, African patients.
Understanding the diseases
To truly improve NCD management and care in African countries, we have to improve our understanding of NCDs in the African context. Effective NCD treatment guidelines need to take into consideration patients’ comorbidities and their use of medications to manage other conditions they may have.
Ideally, they should also consider patients’ biomarkers and possibly genetic profiles to determine what treatment suits them best. This is important because NCD patients in African countries often have many other comorbidities.
For instance, patients with HIV or multidrug-resistant TB (MDR TB) are increasingly affected by other chronic diseases such as diabetes. With this comes the use of multiple medicines, all of which have a potential impact on NCD management.
Today, however, most clinical trials – including real-world evidence trials – that shape NCD treatment guidelines are done outside the African continent, with African trials accounting for fewer than 3% of all clinical trials done globally.
If we want to create NCD treatment guidelines relevant to African patients, we must start to do more clinical trials in African countries. Doing more trials locally could also improve trust in African communities that historically have been excluded from data collection efforts and mistreated in trials.
In addition to randomised controlled trials, African countries should get better at collecting real-world evidence to better understand the complex needs of individual patients and the best way to use specific medicines to treat those with multiple chronic morbidities such as HIV, diabetes and obesity.
Gathering real-world evidence can be achieved with longitudinal tracking of medical records, which is easier to do with electronic health records (EHR). The use of EHR in African countries remains limited, however, and is primarily driven by the need to respond to infectious diseases, especially HIV and MDR-TB.
Beyond its impact on real-world evidence gathering, the limited use of EHR constrains the ability of health systems to provide integrated care at a single point of contact. The result is poor quality of care when managing chronic diseases such as NCDs.
Unless urgent action is taken to address the many complex bottlenecks to NCD management, African countries are on an inexorable march towards a health catastrophe that will affect generations to come.
It will take resolute action, taken systematically and consistently, and leveraging the power of people and organisations to recalibrate primary care so that it delivers value for the African patient.
Countries can achieve this and more if they are willing to learn the multitude of lessons from the past while being pragmatic about the path forward. Where there is a will, there is a way.
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