In Africa, when will there be health for all, everywhere?

In the Democratic Republic of Congo (DRC), the epicenter of the mpox epidemic, diagnosing a suspected patient can take up to three weeks. “It’s way too long, because all the while the virus continues to spreadregrets Cameroonian epidemiologist Yap Boum II, executive director of the Pasteur Institute in Bangui, in the Central African Republic. But you have to imagine how complicated it is when infected people are sometimes 200 kilometers from the nearest laboratory. »

According to the World Health Organization (WHO), from January to August, only 36% of suspected cases were tested in the DRC, a country where large swaths of territory are without passable roads. Decentralization of laboratories is now being implemented to improve the response and not start from scratch with the next epidemic. But the flaws highlighted by the mpox outbreak are a reminder of the extent to which health systems remain incomplete in the DRC, as in many African countries.

More than 50% of Africans still do not have access to essential health services, according to the WHO. The obstacles are multiple, from the lack of health structures, equipment and medicines to the shortage of qualified professionals: in 2021, sub-Saharan Africa had 2.3 doctors per 10,000 inhabitants, compared to 39.4 in Europe. “In the Central African Republic, there are no more than ten biologists for the entire countrytestified Yap Boum II. And in Cameroon, outside of Douala and Yaoundé, it is very difficult to find a gynecologist or cardiologist. »

Logistical difficulties heavily penalize rural communities, particularly in countries plagued by insecurity. Added to this are financial constraints for populations with limited income, while health insurance systems are still in their infancy across the continent. Thus, in Nigeria, the most populous country in Africa, health spending contributes to pushing more than 1 million people into poverty each year, according to a recent report from the World Bank.

“Great Killers”

According to a survey published in April by the pan-African polling institute Afrobarometer and carried out in 39 countries on the continent, two thirds of Africans say they have had to go without necessary medical care at least once – or even many more – during the year. previous. This is even the case for 83% of Zambians, 79% of Beninese and 77% of Ugandans. And the majority of those who attended a public health establishment mentioned absent staff, unavailable medicines and very long waiting times.

“Most African countries face galloping demographics and growing needs, but their economies are small. There are few resources to buy equipment, train agents, pay them”summarizes Doctor George Kimathi, director in charge of capacity development within the medical NGO Amref Health Africa. On average, African states devote a little more than 7% of their national budget to health, far from the target of 15% that they set in 2001 in the Abuja declaration formulated by the African Union. (UA). Only South Africa and Cape Verde have achieved this goal.

“What’s morecontinues Doctor Kimathi, investments made too rarely benefit primary care centers [vaccinations, protection maternelle et infantile…], where the majority of Africans go for treatment. »

Certain long-term trends are still encouraging. Between 2000 and 2019, Africans gained ten years of life expectancy and infant mortality fell. Progress credited to better prevention and, even more, to the fight against “big killers” such as malaria, AIDS or tuberculosis, thanks to funding from international donors.

But the onset of the Covid-19 pandemic in 2020 brought this to a halt. By seriously disrupting access to essential care (decrease in pre- and postnatal monitoring, breakdowns in the care of malnourished children, interruptions in vaccination programs, etc.), this crisis has highlighted the fragility of basic health infrastructures. .

Community workers

“What is needed today, rather than very vertical programs around a few major pathologies, which concentrate the bulk of funding and must demonstrate their results every three years, are lasting and in-depth reforms of health systemssays Elisabeth Paul, professor at the Free University of Brussels and specialist in public health policies in West Africa. Emphasis must be placed on human resources to have well-trained staff in multi-purpose health centers close to the populations. »

No one disputes the need to work towards a more robust health base. The objective is also recorded in the Lusaka agenda, adopted in December 2023 by African governments and major global health organizations. Donors are invited to delegate more responsibilities to beneficiary countries and regional bodies in the identification of intervention priorities and the use of funds.

“But there is not necessarily a contradiction between investment in health systems and the fight against diseases which remain extremely deadly to the point of overwhelming everything else”however, insists Françoise Vanni, director of external relations for the Global Fund to Fight AIDS, Tuberculosis and Malaria. Thus, in northern Nigeria, “80% of consultations in primary health centers are linked to malariashe illustrates. This burden prevents on-site staff from devoting themselves to other things”.

At the heart of the needs and attention: the strengthening of local systems, from dispensaries to mobile laboratories, including community workers. Neither doctors nor nurses, these agents nevertheless play a key role. Traveling through the most remote villages, they can spot a case of malaria, collect samples, carry out prevention and deliver essential medicines.

The Global Fund has announced that it will allocate 900 million dollars (around 850 million euros) between 2024 and 2026 to this workforce to improve its training, supervision and equipment. The Africa Center for Disease Control and Prevention (Africa CDC, the AU’s public health agency) is moving in the same direction, with the recruitment of 2 million community workers across the continent.

The last mile challenge

Support for actors in the field can be achieved through innovation and technology. “Some solutions are truly game-changing for isolated communities”enthuses George Kimathi. For example, Amref Health Africa offers community workers a learning module, accessible via a basic mobile phone, which delivers lessons and allows them to interact with peers.

Digital tools and artificial intelligence open up a wide range of possibilities in terms of remote diagnosis, prevention or inventory management for local pharmacies. Thus, in Mozambique, the government, in partnership with the Global Fund and private sector actors, is in the process of equipping all community agents with a mobile data digitization application called “UpScale”. In addition to securing patient information, previously recorded on paper registers, the challenge is to improve medical monitoring and better anticipate needs.

To solve the last mile challenge, more and more countries are also relying on drone delivery. Like Rwanda, Ghana or Nigeria, where the American company Zipline delivers blood bags, vaccines and other medical products to difficult-to-access areas using its unmanned mini-planes.

According to a study carried out in 2023 by the consulting firm McKinsey in Kenya, Nigeria and South Africa, increased use of digital health tools (teleconsultations, electronic medical records, etc.) would make it possible to achieve efficiency gains representing up to to 15% of health spending by 2030. Enough to generate substantial savings which, in a virtuous cycle, could be immediately reinvested in reforms and programs aimed at improving access to care.