tag:theconversation.com,2011:/us/topics/african-health-systems-32519/articlesAfrican health systems – The Conversation2023-06-25T11:09:53Ztag:theconversation.com,2011:article/2067832023-06-25T11:09:53Z2023-06-25T11:09:53ZFive questions for African countries that want to build climate-resilient health systems<figure><img src="https://images.theconversation.com/files/531313/original/file-20230612-23-rcpr42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Sudan has been beset by floods for the past four years. Its health system, like those in other African countries, will have to adapt to climate change.</span> <span class="attribution"><span class="source">SIMON MAINA/AFP via Getty Images</span></span></figcaption></figure><p>Every day seems to bring a new headline about a devastating climate event. African countries aren’t spared. A “<a href="https://mg.co.za/thoughtleader/opinion/2022-04-19-flood-prone-durban-ill-equipped-to-weather-the-climate-crisis/">rain bomb</a>” in South Africa. <a href="https://www.scientificamerican.com/article/warming-worsened-west-africa-floods-that-killed-800-people/#">Flooding</a> in Nigeria. <a href="https://theconversation.com/cyclones-in-southern-africa-five-essential-reads-200371">Cyclones</a> battering Mozambique, Malawi, Zimbabwe and Madagascar. <a href="https://theconversation.com/kenyas-seasonal-rains-keep-failing-what-needs-to-be-done-115635">Drought</a> in Kenya.</p>
<p>These events have enormous <a href="https://www.amazon.com/Planetary-Health-Protecting-Protect-Ourselves/dp/1610919661">health and social effects</a>, among them death, injuries, malnutrition and diseases (infectious and non-communicable). This all puts tremendous pressure on countries’ health systems, both in terms of caring for those affected and because facilities like hospitals and clinics are vulnerable to damage and destruction.</p>
<p>Extreme weather events, for example in South Africa’s <a href="https://doi.org/10.4102/phcfm.v14i1.3778">KwaZulu-Natal</a> and <a href="https://www.medicalbrief.co.za/floods-destroy-generators-at-two-eastern-cape-hospitals/">Eastern Cape</a> provinces, also disrupt energy supplies, communications, supply chains, the workforce and provision of essential services such as maternity and chronic care. </p>
<p>How, then, can African countries build more resilient primary healthcare systems as the effects of climate change worsen? We recently conducted a <a href="https://www.sciencedirect.com/science/article/pii/S2667278223000299?via%3Dihub">scoping review</a> on primary healthcare and climate change in Africa and found very little evidence to guide health systems in answering this question. </p>
<p>We looked for any studies in the African context that investigated primary healthcare and climate change. The review mapped the available evidence onto the World Health Organisation’s (WHO’s) <a href="https://www.who.int/publications-detail-redirect/9789241565073">health system building blocks</a>: leadership and governance; the health workforce; the health information system; infrastructure and technology; service delivery; and health financing. </p>
<p>We identified five key questions that health systems must answer to build more resilient primary healthcare.</p>
<h2>1. What training do medical professionals need?</h2>
<p>Health professionals in most African countries receive barely any training related to the health and social effects of dramatic changes in weather patterns.</p>
<p>There are some moves to change this. The Southern African Association of Health Educationalists recently published a <a href="https://doi.org/10.4102/phcfm.v15i1.3925">position paper</a> calling for the integration of planetary health and environmental sustainability into health professions curricula in Africa. The World Organisation of Family Doctors has also launched a <a href="https://www.globalfamilydoctor.com/News/WONCAEnvironmentlaunchesplanetaryhealthcourse.aspx">global online training programme</a> on planetary health. </p>
<p>This kind of training should focus on how different health services – for instance nutrition, HIV, TB, malaria, immunisations, maternity – should adapt to the effects of climate change. It should also offer insights into how facilities can be better prepared for emergencies and extreme events.</p>
<p>But training new health professionals isn’t enough. Continuing professional development and in-service training is key too.</p>
<h2>2. What are the community’s key vulnerabilities?</h2>
<p>The primary healthcare system in Africa should be <a href="https://gh.bmj.com/content/4/Suppl_8/e001489">community-orientated</a>, focusing on the health needs of the whole community, not just those who use a particular facility. This kind of primary care has become policy in some health systems, <a href="https://doi.org/10.4102/phcfm.v12i1.2632">for instance</a> in South Africa’s Western Cape province. </p>
<p>The community-orientated approach has usually focused on addressing the <a href="https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1">social determinants</a> of ill health such as early childhood development or education. Now, environmental determinants of health and key climate-related vulnerabilities must also be considered.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/africas-first-heat-officer-is-based-in-freetown-5-things-that-should-be-on-her-agenda-199274">Africa's first heat officer is based in Freetown – 5 things that should be on her agenda</a>
</strong>
</em>
</p>
<hr>
<p>For example, <a href="https://cer.org.za/wp-content/uploads/2023/02/Health-impacts-of-Eskoms-non-compliance-with-minimum-emissions-standards-Google-Docs.pdf">air pollution from coal-fired power stations</a> is a major cause of non-communicable diseases such as ischaemic heart disease, stroke, asthma, chronic obstructive pulmonary disease and lung cancer. </p>
<p>Building informal settlements in flood plains or having no trees in urban slums can increase vulnerability to floods and high temperatures. Floods can displace people and cause injuries as well as water-borne diseases such as <a href="https://health-e.org.za/2023/02/08/cholera-third-case-confirmed-in-gauteng/">cholera</a>. High temperatures can lead to dehydration, heat exhaustion and even <a href="https://www.medicalbrief.co.za/change-in-work-hours-suggested-after-heat-stroke-deaths/">death from heat stroke</a>.</p>
<h2>3. How can the health system track environmental changes?</h2>
<p>Health information systems traditionally collect data on health services and a population’s health needs. For instance, such systems can identify outbreaks of notifiable infectious conditions to support rapid responses.</p>
<p>But they rarely include indicators that warn of environmental challenges. </p>
<p>Primary health care facilities and services need to identify the particular climatic events that they are likely to face. For some this may be extreme temperatures or drought. For others it may be severe storms or cyclones, or sea level rise and storm surges. </p>
<p>They should also identify the most likely changes in the burden of disease linked to such events. For example, will they face an increase in climate migrants, heat-related conditions, water or vector borne infectious diseases, mental health problems or malnutrition? </p>
<p>Our <a href="https://doi.org/10.1016/j.joclim.2023.100229">scoping review</a> did not find any African examples of health information systems tracking the changes or providing early warning of climate-related events.</p>
<h2>4. How can health systems build climate resilience?</h2>
<p>Primary healthcare facilities and services need to continue functioning in the face of environmental challenges, such as cyclones, and provide safe healthcare, for example with extreme heat. Facilities need robust infrastructure, lighting, water, heating and cooling, and energy supply. Services need healthcare workers, equipment, medication and supplies, and communications. </p>
<p>For example, a <a href="https://doi.org/10.1016/j.seta.2017.02.022">hybrid energy system</a> may improve resilience and mitigate the health system’s carbon footprint. Such systems may also provide resilience against power cuts. Health systems need to consider how they can design facilities and systems to withstand environmental challenges, respond to emergencies and continue offering essential services.</p>
<h2>5. What are the next steps?</h2>
<p>The scoping review reveals a widespread absence of evidence on how to address the issue of climate change in African primary healthcare. There’s a need for more research. </p>
<p>South Africa’s Stellenbosch University and the primary care and family medicine (<a href="https://primafamed.sun.ac.za/">PRIMAFAMED</a>) network in sub-Saharan Africa are studying the impact of climate change on primary healthcare, developing tools for facilities to identify their risks and vulnerabilities, and identifying the learning needs of primary care providers. </p>
<p>Health systems also need to explicitly address the risks of climate change. There are examples that others can learn from: for instance, the Department of Health and Wellness in South Africa’s Western Cape province has established a Climate Change Forum to develop policy on both mitigation (becoming carbon neutral by 2030) and adaptation (preparing for climate related events and challenges).</p><img src="https://counter.theconversation.com/content/206783/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bob Mash receives funding from the Flemish Interuniversity Council (VLIR), the SA Medical Research Council, the National Research Foundation, and World Diabetes Foundation. He is the President of the SA Academy of Family Physicians and coordinates the Primary Care and Family Medicine (PRIMAFAMED) network in Sub-Saharan Africa.</span></em></p><p class="fine-print"><em><span>Christian Lueme Lokotola receives funding from the Flemish Interuniversity Council (VLIR). He is coordinating the African Hub of climate change, migration and health network research (under the Flemish Interuniversity Council grant). He is an active associate member of Wonca Environment Group, Global Family Doctors Association, Primafamed (Primary Health Care and Family Medicine Association in Africa), Southern African Association of Health Educationalist (SAAHE) and Public Health Association of South Africa (PHASA).
</span></em></p>Primary health care systems must become more resilient as the effects of climate change worsen.Bob Mash, Distinguished Professor, Division of Family Medicine and Primary Care, Stellenbosch UniversityChristian Lueme Lokotola, Lecturer in Planetary Health, Division of Family Medicine and Primary Care, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/808982017-07-16T10:20:56Z2017-07-16T10:20:56ZAfrican academics set out what Dr Tedros needs in his toolbox to tackle health ills<figure><img src="https://images.theconversation.com/files/178244/original/file-20170714-3488-1i1rcen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New World Health Organisation Director-General De Tedros Adhanom Ghebreyesus. </span> <span class="attribution"><span class="source">Reuters/Denis Balibouse</span></span></figcaption></figure><p>Africa has the highest burden of HIV/Aids and malaria with escalating rates of non-communicable diseases. How will the World Health Organisation’s Director-General Dr Tedros Ghebreyesus deal with the mounting challenges? The Conversation Africa asked academics across the continent what impact his appointment will have, and for advice on what he needs to do, to manage the challenges.</p>
<hr>
<p><strong>What is the significance of his appointment?</strong></p>
<p><em><strong>Dr Thumbi Mwangi, Washington State University, Kenya Medical Research Institute:</strong></em> It’s two fold. As an African he has been closely involved in the battle against <a href="https://parasitesandvectors.biomedcentral.com/articles/10.1186/1756-3305-5-240">neglected tropical diseases</a> like rabies, trachoma, guinea worm and others which affect <a href="http://www.who.int/mediacentre/news/releases/2017/ntd-report/en/">1 billion</a> people. He was <a href="http://www.reuters.com/article/us-health-who-idUSKBN18J278">health minister</a> in Ethiopia where neglected tropical diseases are common. He needs no lectures on why the WHO must remain at the forefront of fighting them.</p>
<p>Secondly, his ownership of the agenda as set out in his campaign <a href="http://www.drtedros.com/">manifesto</a> – to work towards “a world where everyone can lead healthy and productive lives, regardless of where they are or where they live” – should be seen and felt.</p>
<p><em><strong>Dr Andrew Githeko, Kenya Medical Research Institute:</strong></em> Dr Tedros
brings a <a href="http://www.who.int/dg/tedros/en/">wealth of experience</a> and skills in governance, diplomacy, advocacy and resource mobilisation.</p>
<p>His efforts as <a href="https://www.usaid.gov/news-information/frontlines/child-survival-ethiopia-edition/interview-dr-tedros-adhanom-ghebreyesus">health minister</a> in Ethiopia produced measurable and significant outcomes. He’s familiar with addressing infectious diseases like malaria as well as non infectious diseases.</p>
<p>He also led <a href="http://www.drtedros.com/publications/">research</a> into effective ways of controlling malaria and greatly improved the ways in which it’s prevented and controlled.</p>
<p>On top of this, he played a momentous role in bilateral and multilateral malaria initiatives including those supported by <a href="http://www.rollbackmalaria.org/">The Roll Back Malaria Partnership</a> and the <a href="https://www.theglobalfund.org/en/">Global Fund</a>. </p>
<p>As a researcher he will be sympathetic to the plight of researchers from developing countries.</p>
<p><em><strong>Dr Karen Daniels, South African Medical Research Council:</strong></em> Dr Tedros comes from The Horn of Africa which remains a politically fragile setting, vulnerable to the impact of conflict and natural disasters. What this means is that he’s been in the health care trenches, like many of us who live and work in health settings across the continent. This is precisely where it’s been shown that Africa can find African solutions to African problems. </p>
<p>A leader like this is needed at the helm of the WHO. Dr Tedros will understand that Africans can be included in partnerships rather than dominated in the quest to find solutions to the unique challenges that the continent faces. </p>
<p>From an African health policy and systems research perspective, there are many reasons to laud his appointment. He brings the combined perspective of having been a researcher, a health systems manager, minister of health for Ethiopia, and a policymaker. </p>
<p><em><strong>Professor Bob Mash, Stellenbosch University:</strong></em> Dr Tedros is the first WHO director-general to have firsthand knowledge of the challenges facing African countries and health systems. One of his priority areas is “health for all” and providing universal health coverage. This implies a commitment to the strengthening of health systems, particularly primary health care. </p>
<p>This should stimulate research on disease orientated programmes as well as cross cutting systematic issues like the primary care workforce, access to care, patient-centredness, community orientated primary care as well as continuity, coordination and comprehensiveness of care. </p>
<p>But his experience in Ethiopia may not have sensitised him as much to the global problem of non-communicable diseases that’s also becoming a problem on the African continent. One of my concerns is whether he will give sufficient attention to the epidemic of diseases such as hypertension and diabetes.</p>
<p><strong>What are three biggest challenges facing him? What should he tackle first?</strong></p>
<p><em><strong>Dr Mwangi, Washington State University, Kenya Medical Research Institute :</strong></em> The WHO has faced <a href="http://www.who.int/topics/financial_crisis/financialcrisis_report_200902.pdf">financial constraints</a> addressing global health challenges including outbreaks of emerging infections.</p>
<p>Countries that are adversely affected by <a href="http://www.who.int/neglected_diseases/diseases/en/">neglected tropical diseases</a> need his voice and the diplomacy of his organisation to keep these diseases high on the global agenda, as well as top priority in affected countries.</p>
<p>Dr Tedros needs to make three focused commitments while he’s at the helm. </p>
<p>The first is domestic financing: for a long time countries affected by neglected tropical diseases have relied mainly on external funds. He needs to urge them to commit their own budgets to these diseases. Domestic budgets can help significantly. We need relatively low cost solutions such as drug tablets that are out of patent, improved hygiene for the affected populations and existence of effective vaccines.</p>
<p>Dr Tedros should also encourage partners to keep their commitments.</p>
<p>Secondly, there should be a deliberate effort to integrate the detection, surveillance and treatment of these diseases into the health system. Countries stand a much better chance of reducing and finally eliminating neglected tropical diseases if the interventions are embedded in primary health care systems.</p>
<p>The <a href="http://apps.who.int/iris/bitstream/10665/43485/1/9789241594301_eng.pdf">One Health</a> concept that brings together the human and animal health perspectives should also be practised. Dr Tedros supports this <a href="http://www.sciencedirect.com/science/article/pii/S0140673610614651">concept</a>. His challenge will be how to break the current silos in individual sectors. </p>
<p>Innovations offer important toolkits to consider. This includes <a href="http://www.sciencedirect.com/science/article/pii/S0277953613006485">mobile phones</a> to diagnose and report diseases as well as attempts such as use of <a href="http://www.gavi.org/library/news/gavi-features/2016/rwanda-launches-world-s-first-national-drone-delivery-service-powered-by-zipline/">drones</a> to supply emergency medical care and use of <a href="https://news.wsu.edu/2016/10/24/rabies-vaccine-effective-warm/">rabies vaccine</a> that needs little refrigeration that can be delivered by community health workers.</p>
<p><em><strong>Dr Githeko, Kenya Medical Research Institute:</strong></em> When it comes to malaria his greatest challenge will be to sustain – and increase – resources to the various control programmes, particularly in sub Saharan Africa.</p>
<p><a href="http://www.who.int/malaria/areas/drug_resistance/overview/en/">Resistance</a> to malaria medicines is a global health threat. Dr Tedros should support malaria endemic countries to expand and accelerate national efforts to control and eliminate malaria.</p>
<p>The WHO should urge member states to improve the training of health workers so that they closely follow the protocols in the treatment and management of malaria. This will save more lives.</p>
<p>The infrastructure in health facilities should also be improved to test for malaria, and to treat it more efficiently. This can only be achieved through concerted efforts and commitments by WHO member states.</p>
<p>The research wings in various countries need to be supported to encourage novel research of drug and insecticide resistance. Support for research will be critical to address scientific, behavioural, and socioeconomic factors that affect malaria control.</p>
<p><em><strong>Dr Karen Daniels, South African Medical Research Council:</strong></em> There is a vicious cycle in which the burden of increased communicable and non-communicable diseases weaken health systems. Dr Tedros has the challenge of strengthening these systems, something he’s already committed to. </p>
<p>This has to be supported by sound health policy and systems research, to help find solutions to the continent’s health challenges. But better home grown solutions need more investment in national and Pan African centres of excellence. Dr Tedros could help by enabling greater WHO investment in health policy and systems research. These centres of excellence should be founded on close collaboration between researchers, health systems managers, health systems policymakers, as well as communities and civil society organisations. </p>
<p>Centres of excellence could facilitate closer collaboration between health policy, the research community and the WHO. This could help ensure that research is more closely aligned to the real challenges faced in our own countries. We will hopefully begin to reduce the “know-do gap” where research evidence exists, but isn’t taken up in implementation.</p>
<p><em><strong>Professor Mash, Stellenbosch University:</strong></em> One of his greatest challenges will be strengthening health systems at primary health care level. Governments need to be convinced to invest in primary health care as the hub and not the marginalised periphery where poorly trained and low level health care workers offer fragmented and poor quality care. Strong multidisciplinary teams should include a family physician.</p>
<p>Strong primary health care is a prerequisite for providing universal health coverage. Ideally this should be through a national health insurance or systems that – at the very least – don’t impoverish people or increase inequality.</p><img src="https://counter.theconversation.com/content/80898/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bob Mash receives funding from European Union to strengthen primary health care through primary care doctors and family physicians in South Africa.</span></em></p><p class="fine-print"><em><span>Karen Daniels is a Specialist Scientist for the Health Systems Research Unit of the South African Medical Research Council, and a member of the Health Systems Global Board. The opinions expressed here are based on her own independent thoughts and views.</span></em></p><p class="fine-print"><em><span>Thumbi Mwangi receives funding from Wellcome Trust, GAVI and World Health Organisation.</span></em></p><p class="fine-print"><em><span>Andrew Githeko does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>How will the World Health Organisation’s Director-General Dr Tedros Ghebreyesus deal with the mounting challenges? Africa’s academics have some tips.Andrew Githeko, Chief Research Officer, Kenya Medical Research InstituteBob Mash, Division of Family Medicine and Primary Care, Stellenbosch UniversityKaren Daniels, Specialist Scientist, Health Systems Research Unit, South African Medical Research CouncilThumbi Mwangi, Clinical assistant professor, Washington State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/802152017-07-06T13:07:39Z2017-07-06T13:07:39ZMost people in Africa don’t have access to palliative care. This needs to change<figure><img src="https://images.theconversation.com/files/176805/original/file-20170704-31139-fjax6q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are very few palliative care facilities in Africa. </span> <span class="attribution"><span class="source">EPA/Nic Bothma</span></span></figcaption></figure><p><a href="http://www.who.int/cancer/palliative/definition/en/">Palliative care</a> aims to improve the quality of life for individuals – as well as their families – with life limiting illnesses. Access to palliative care should be viewed as a <a href="http://www.who.int/medicines/areas/policy/access_noncommunicable/AccesstopaintreatmentasahumanrightBMCMed_Lohman_2010.pdf">fundamental right</a> but in <a href="http://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.0010005&type=printable">Africa</a> it’s been largely ignored as part of health care. It’s been given less priority than preventive and curative services.</p>
<p><a href="https://www.health-e.org.za/2013/09/19/need-rethink-palliative-care-south-africa/">South Africa</a> is one of the leading countries in Africa that has realised the social economic benefits of this speciality of medicine. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345706/">Malawi</a> and<a href="http://uganda.hospiceafrica.or.ug/"> Uganda</a> have also integrated palliative care into their mainstream health care systems. </p>
<p>One of the challenges is that <a href="https://bmcpalliatcare.biomedcentral.com/articles/10.1186/1472-684X-10-6">stigma</a> has affected the acceptability of palliative care. Very often people believe that palliative care is only suitable for people who are dying. This isn’t entirely true. Palliative care is also about helping people deal with the effects of having an incurable disease.</p>
<p>I witnessed this myth a few years ago when dealing with a patient diagnosed with stage four cancer who needed medicine to control pain. But he declined pain medication because he associated palliative care with death. </p>
<p>The use of the commonly used phrase “there is nothing more we can do for you” negates the critical role of controlling advance symptoms of a disease as well as providing quality health care and support for families.</p>
<p>A number of developed countries have shown that these myths can be overcome. But most countries in Africa have no palliative care facilities available as part of the <a href="https://www.africanpalliativecare.org/integration/introduction/">health system</a>. </p>
<p>This needs to change because palliative care is recognised as a health right by the World Health Organisation. The <a href="http://apps.who.int/medicinedocs/en/d/Js21454zh/">WHO resolution 67</a> of 2014 requests governments to integrate palliative care in the mainstream health care system. Countries such as Malaysia, Costa Rica and South Africa have done well in integrating palliative care.</p>
<h2>Countries at the forefront</h2>
<p>Countries can learn the integration models from the US and European countries where integration is advanced and the field has grown exponentially. But it has to be tailor made to their setting and context.</p>
<p>Uganda became the <a href="http://www.who.int/medicines/areas/policy/access_noncommunicable/AccesstopaintreatmentasahumanrightBMCMed_Lohman_2010.pdf">first</a> country in Africa to recognise liquid morphine as an essential drug for treating pain. It also set a precedent in Africa by allowing palliative care nurses to prescribe it.</p>
<p>In <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970621/">Kenya</a>, palliative care has grown from one hospice in 1991 to 70.</p>
<p>Three models of palliative care are found in Kenya. There are stand alone hospices. They are independent facilities with autonomous administrative and decision making arms. Most of them are found in the headquarters of former provinces.</p>
<p>There are also hospital based palliative care units. They are part of the public, private or mission run health facilities. They provide their services to patients that seek treatment in the hospitals.</p>
<p>And there are palliative care consultation teams. They are found at the in patient and out patient departments in a hospital.</p>
<h2>What needs to be done</h2>
<p>Building <a href="http://www.who.int/cancer/media/FINAL-PalliativeCareModule.pdf">integrated</a> palliative care services begins by ensuring policies are in place, essential medicines are available and checking that comprehensive education on palliative care is delivered. </p>
<p>All this is necessary to guarantee the availability of specialist services to the sickest patients in the health care systems.</p>
<p>The integration of palliative care can be done in three ways; </p>
<ul>
<li>policy formulation</li>
</ul>
<p>Palliative care is an <a href="http://apps.who.int/iris/bitstream/10665/250584/1/9789241565417-eng.pdf">integral</a> component of quality health care. Governments should recognise it as an essential factor in health care provision and this establish clear policies, guidelines, pathways and protocols for proper access.</p>
<p>This should be done by creating awareness at the primary health care level and refer appropriately based on the patient needs.</p>
<ul>
<li>public awareness </li>
</ul>
<p>The importance of timely access of palliative care should be taught to all cadres of health workers and the general public.</p>
<p>Improving doctor’s skills and knowledge significantly improves access to palliative care. </p>
<ul>
<li>Avail drugs and other treatment forms</li>
</ul>
<p>Medicines used by patients in palliative care programmes should be appropriately prescribed and availed. The use of strong medicines to control severe pain is highly recommended.</p>
<p>There is a need to have sustained public awareness for patients and their families on the benefits of timely palliative care.</p>
<p>Governments need to develop, strengthen and implement appropriate palliative care policies and integrate palliative care services at all levels of health care provision. They should update essential drug lists to include those used in palliative care.</p>
<p>Domestic funding and training of staff in palliative care should also be prioritised.</p>
<p>Partnerships with non-governmental organisations, civil society, governments and patients organisations should also be strengthened to support the provision of palliative care.</p><img src="https://counter.theconversation.com/content/80215/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Weru does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Palliative care improves the quality of life for patients and families facing problems associated with life threatening illnesses.John Weru, Assistant Professor of Palliative Medicine, Aga Khan University Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/689882016-11-23T21:03:02Z2016-11-23T21:03:02ZAfrica’s health won’t improve without reliable data and collaboration<figure><img src="https://images.theconversation.com/files/146367/original/image-20161117-18123-mud2pw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children play alongside stagnant water and rubbish in Lagos, Nigeria.</span> <span class="attribution"><span class="source">George Esiri/Reuters</span></span></figcaption></figure><p>The Universal Declaration of Human Rights <a href="http://www.un.org/en/universal-declaration-human-rights/">asserts</a> that “all people are born equal in dignity and rights”. Sadly, this statement doesn’t reflect billions of people’s daily lives. Health is one of the areas in which many – if not most – people have no real rights.</p>
<p><a href="http://www.who.int/social_determinants/en/">Social determinants of health</a>, as defined by the World Health Organisation, are “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life”. These systems and forces include economic policies and systems, development agendas, social norms and policies, and political systems.</p>
<p>It’s clear, then, that social determinants can negatively affect health. The poor are denied basic needs that would keep them healthy: access to good quality food, shelter, clean water, sanitation and proper clothing. They have limited access to medical care, education and finance. </p>
<p>All of these drive health inequity – systematic disparities in health between social groups who have different levels of underlying social advantage or disadvantage. </p>
<p>Africa’s young scientists know that health inequity poses a major obstacle to improving population health and well-being. That’s why representatives from some of the continent’s Young Academies of Science met in Johannesburg in early November 2016 to discuss the issue. The young academies represented at the meeting were from Nigeria, Uganda, Ethiopia, South Africa, Kenya, Senegal and Zimbabwe.</p>
<p>We discussed a number of problems that cause health inequity in Africa. Then we collectively drew up some solutions. The <a href="http://www.sayas.org.za/">full statement</a> has been made available online, but here we’d like to focus on two issues: data limitations and an inability to scale up health innovations.</p>
<p>If these can be systematically addressed, we believe that the continent will take great strides towards keeping its populations healthy.</p>
<h2>Data limitations</h2>
<p>Africa has <a href="https://theconversation.com/poor-data-affects-africas-ability-to-make-the-right-policy-decisions-64064">a data problem</a>. This is true in many sectors. When it comes <a href="https://theconversation.com/without-good-data-africa-will-find-it-hard-to-fight-non-infectious-diseases-31543">to health</a> there’s both a lack of basic population data about disease and an absence of information about what impact, if any, interventions involving social determinants of health – housing, nutrition and the like – are having.</p>
<p>Simply put, researchers often don’t know who is sick or what people are being exposed to that, if addressed, could prevent disease and improve health. They cannot say if poor sanitation is the biggest culprit, or if substandard housing in a particular region is to blame. They don’t have the data that explains which populations are most vulnerable. </p>
<p>These data are required to inform development of innovative interventions that apply a “Health in All Policies” approach to address social determinants of health and improve health equity.</p>
<p>To address this, health data need to be integrated with social determinant data about areas like food, housing, and physical activity or mobility. Even where population data are available, they are not always reliable. There’s often an issue of compatability: different sectors collect different kinds of information using varying methodologies. </p>
<p>Different sectors also use different indicators to collect information on the same social determinant of health. This makes data integration challenging.</p>
<p>Without clear, focused, reliable data it’s difficult to understand what a society’s problems are and what specific solutions – which may lie outside the health sector – might be suitable for that unique context.</p>
<h2>Scaling up innovations</h2>
<p>Some remarkable work is being done to tackle Africa’s health problems. This ranges from <a href="https://theconversation.com/how-drones-can-improve-healthcare-delivery-in-developing-countries-49917">technological innovations</a> to harnessing <a href="http://www.universityworldnews.com/article.php?story=2013030712115748">indigenous knowledge</a> for change. Both approaches are vital. But it’s hard for these to be scaled up either in terms of numbers or reach. </p>
<p>This boils down to a lack of funding or a lack of access to funding. Too many potentially excellent projects remain stuck at the pilot phase, which has limited value for ordinary people.</p>
<h2>Young scientists’ recommendations</h2>
<p>We emerged from our meeting with a number of recommendations. Governments, researchers, universities and research institutions and science academies will need to work together to implement these.</p>
<p>Governments need to develop health equity surveillance systems to overcome the current lack of data. It’s also crucial that governments integrate and monitor health and social determinants of health indicators in one central system. This would provide a better understanding of health inequity in a given context. </p>
<p>For this to happen, governments must work with public and private sector stakeholders and nongovernmental organisations – not just in health, but beyond it so that social determinants of health can be better measured and captured.</p>
<p>The data that already exists at sub-national, national, regional and continental level mustn’t just be brushed aside. It should be archived and digitised so that it isn’t lost.</p>
<p>Researchers have a role to play here. They have to harmonise and be innovative in the methodologies they use for data collection. If researchers can work together across the breadth of sectors and disciplines that influence health, important information won’t slip through the cracks.</p>
<p>When it comes to scaling up innovation, governments need to step up to the plate. It’s crucial that they support successful health innovations, whether these are rooted in indigenous knowledge or are new technologies. And since – as we’ve already shown – health issues aren’t the exclusive preserve of the health sector, governments should look to different sectors and innovative partnerships to generate support and funding. </p>
<p>A single thread runs through these recommendations: the notion of shared learning across Africa. As young researchers from a range of disciplines and countries, we have learned first hand through our own work and our academies that collaboration is crucial.</p>
<p>That’s why another of our recommendations is that research institutions in Africa should produce and share documents that outline their best practices and their mistakes. Others can then learn from the good and avoid the bad. In this way, experts on the continent can learn from each other – and find common approaches to improving millions of people’s daily lives and health.</p><img src="https://counter.theconversation.com/content/68988/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tolullah Oni receives funding from the South African National Research Foundation. </span></em></p><p class="fine-print"><em><span>Fadzai Mukora Mutseyekwa works on a USAID funded project.
</span></em></p><p class="fine-print"><em><span>Mariamawit Yonathan Yeshak works for Addis Ababa University. She receives funding from International Science Program, Uppsala University, Sweden. She is affiliated with Ethiopian Young Academy of Sciences.
</span></em></p>Africa battles with a dearth of data and seems unable to scale up health innovations. If these can be systematically addressed, the continent can take great strides towards better health for all.Tolullah Oni, Senior Lecturer at the School of Public Health and Family Medicine, University of Cape TownFadzai Mukora Mutseyekwa, Research fellow in Public Health, Africa UniversityMariamawit Yonathan Yeshak, Assistant Professor of Pharmacognosy, Addis Ababa UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/673252016-10-27T17:44:14Z2016-10-27T17:44:14ZFamily doctors are the key to improving primary health care in communities<figure><img src="https://images.theconversation.com/files/143281/original/image-20161026-11239-1p8688a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A doctor immunises a baby at the Shire Clinic in Ethiopia. Most health systems in Africa are fully developed. </span> <span class="attribution"><span class="source">UNICEF Ethiopia/2009/Tuschman</span></span></figcaption></figure><p>Countries that have well developed primary health care systems are known to have <a href="http://www.globalfamilydoctor.com/InternationalIssues/WONCAGuidebook.aspx">better health outcomes</a>, fewer people in hospital, increased patient satisfaction and lower costs.</p>
<p>Primary health care is where people engage with the health system for the first time. In high income countries this is often with a general practitioner who has postgraduate training in family medicine. But in low and middle income African countries this is most often with a community health worker or nurse.</p>
<p>The challenge with this is few countries in Africa have <a href="http://www.who.int/whr/2008/en/">well developed primary health care systems</a>.</p>
<p>In addition, these African communities carry a heavier <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31012-1/fulltext">burden of disease</a>. Communicable diseases such as HIV, tuberculosis, and malaria live side by side with interpersonal violence and trauma, maternal and childhood deaths and a growing number of noncommunicable diseases such as hypertension and diabetes.</p>
<p>So while these <a href="http://content.healthaffairs.org/content/early/2009/08/06/hlthaff.28.5.w849.citation">African health systems</a> try to tackle this burden of disease, they are constrained by a scarcity of health workers and poorly developed <a href="http://www.who.int/whr/2008/en/">primary health care</a> services.</p>
<p>To improve primary health care, services must be built around the <a href="http://www.who.int/whr/2008/en/">needs of people rather than diseases</a>. This person-centred care is a <a href="http://www.safpj.co.za/index.php/safpj/article/view/1045">core principle of family medicine</a>. </p>
<p>But family medicine is rarely encountered in African health systems. The continent is the last to embrace the <a href="http://www.aafp.org/news/education-professional-development/20150331worldhlthmapper.html">need to train family physicians</a> as a key component of the primary health care team and district hospitals.</p>
<p>Unless family physicians are trained along with the primary care providers such as nurses, doctors and mid-level healthcare workers, Africa will not be able to reform its health services.</p>
<h2>Primary health care is important</h2>
<p>In Africa health systems are often <a href="http://www.globalfamilydoctor.com/InternationalIssues/WONCAGuidebook.aspx">more developed in the capital cities</a>. These systems focus on prestigious referral hospitals and specialist care as well as private health care for a small group of people with health insurance.</p>
<p>Primary health care is often seen as cheap health care by low level health workers in distant outposts of the health care system with <a href="http://www.globalfamilydoctor.com/InternationalIssues/WONCAGuidebook.aspx">few resources</a> to make a difference. Sometimes programmes for priority diseases such as HIV replace comprehensive primary health care and <a href="http://www.globalfamilydoctor.com/InternationalIssues/WONCAGuidebook.aspx">create inequity by disease</a>.</p>
<p>Primary health care is often the responsibility of community health workers or nurses with <a href="http://www.who.int/whr/2008/en/">limited training</a>. These health workers may lack the capability to offer a comprehensive service by themselves. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/143282/original/image-20161026-11265-1xe4h0c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/143282/original/image-20161026-11265-1xe4h0c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143282/original/image-20161026-11265-1xe4h0c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143282/original/image-20161026-11265-1xe4h0c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143282/original/image-20161026-11265-1xe4h0c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143282/original/image-20161026-11265-1xe4h0c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143282/original/image-20161026-11265-1xe4h0c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A nurse at Merawi health centre in northern Ethiopia prepares a measles vaccine for delivery.</span>
<span class="attribution"><span class="source">Pete Lewis / DFID</span></span>
</figcaption>
</figure>
<p>In South Africa, for example, mental problems such as depression and anxiety are common but rarely recognised in primary care. Children still die from dehydration and pneumonia after receiving care and patients with chronic diseases such as diabetes remain uncontrolled. South Africa has recently decided that <a href="http://www.hst.org.za/publications/ideal-clinic-programme-201516">every clinic should have access to a doctor</a>.</p>
<p>But doctors are few and far between in public sector primary care services. When they are available they are often junior, transient, or lack the skills needed to provide effective general practice. At district hospitals there are also problems. This results in mothers, for example, dying due to “a low skill set among <a href="http://www.scielo.org.za/pdf/samj/v106n6/06.pdf">junior and inexperienced doctors</a>”. </p>
<p>To change this a <a href="http://www.safpj.co.za/index.php/safpj/article/view/1045">family medicine</a> approach is needed. </p>
<h2>An emerging discipline</h2>
<p>Family medicine is an emerging discipline in sub-Saharan Africa.
In South Africa it has recently been recognised as a speciality and all nine medical schools have functioning departments of Family Medicine with both undergraduate and postgraduate training programmes. </p>
<p>Family physicians are doctors with postgraduate training to work as <a href="http://www.safpj.co.za/index.php/safpj/article/view/1045">expert generalists in primary care</a> and the district hospital.</p>
<p>But in other African countries, family medicine departments have been struggling for recognition. The health systems are still dominated by a reliance on centralised specialist services. Many of these countries are emerging from conflict and need to rebuild infrastructure. Others, like Swaziland, do not have medical schools, or like Namibia and Botswana, have only recently created them. </p>
<p>There is no requirement for doctors to be trained as general practitioners with the necessary competencies after they leave medical school. Career pathways are also poorly developed in district health services.</p>
<p>Nevertheless many countries in Africa have started to offer training for their doctors after graduation to provide them with the skills to work in primary care and district hospitals through <a href="http://www.phcfm.org/index.php/phcfm/article/view/151/53">Departments of Family Medicine</a>. These are based at local medical schools. Countries such as Ghana, Nigeria, Uganda, Kenya, Malawi, Botswana and South Africa have established training programmes. But numbers remain small.</p>
<p>South Africa, for example, started full-time training for family physicians in 2008 and now has around 0.1 family physicians for every 10,000 people. This compares to <a href="http://dx.doi.org/10.1186/s12960-015-0090-7">1.2 in China</a> and up to 11.4 in <a href="http://dx.doi.org/10.1186/s12960-015-0090-7">Canada</a>. Many other countries are <a href="https://www.ncbi.nlm.nih.gov/pubmed/25072584">ambivalent or uncertain</a> such as Zambia, Zimbabwe, Rwanda and Tanzania.</p>
<p>The African context is completely different from high income settings. One key difference is that doctors must also be equipped to work in district hospitals, often in rural and remote areas, where there are no specialists. </p>
<p>The model of primary health care that is emerging is that of a <a href="http://dx.doi.org/10.1186/s12960-015-0090-7">multidisciplinary team</a> that works in both the community setting and primary care facilities. This model has been very successful in countries like Brazil.</p>
<h2>The road to better health care</h2>
<p>The World Health Organisation says primary health care is needed <a href="http://www.who.int/whr/2008/en/">“now more than ever”</a> to successfully tackle the burden of disease on the continent. </p>
<p>The World Health<a href="http://www.who.int/hrh/resources/A62_12_EN.pdf">Assembly</a> has reiterated the need</p>
<blockquote>
<p>to train and retain adequate numbers of health workers, with appropriate skill-mix. This includes primary health care nurses, midwives, allied health professionals and family physicians, who are able to work in a multidisciplinary context in cooperation with non-professional community health workers to respond effectively to people’s health needs.</p>
</blockquote>
<p>But primary health care is not just about tackling disease and caring for sick people. Ideally it should also focus on promoting health and wellness, preventing disease and addressing the underlying social determinants of ill health. </p>
<p>It is meant to be accessible and to offer a <a href="http://dx.doi.org/10.1186/1472-6963-10-65">comprehensive range of services</a> across the burden of disease. It should enable continuity with a team of health care workers that you trust and to be the hub from which your care is co-ordinated.</p>
<p>African countries with a strong commitment to developing effective primary health care must include a family physician in their primary health care team. Africa needs family medicine and needs to commit to training its doctors to provide it in a model appropriate to the African context.</p><img src="https://counter.theconversation.com/content/67325/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bob Mash receives funding from European Union to strengthen primary health care through primary care doctors and family physicians in South Africa.</span></em></p>Africa is the last continent to embrace the need to train family physicians as a key component of the primary health care team and district hospitals.Bob Mash, Division of Family Medicine and Primary Care, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.