The similarities are striking— much like India, Africa's death rate due to COVID-19 has been lower than in the developed world, antibody surveys have detected large number of infections, and governments in the region are concerned over the threat of second wave of infections, even as economic compulsions have made lockdown and tight restrictions nearly impossible now, despite the upcoming threat.
Dr Githinji Gitahi, group CEO of Amref Health Africa, the largest African-led international organisation on the continent, feels that though Africa had the experience of Ebola when dealing with COVID-19, the way forward for resource-constrained countries such as India and Africa is investing in primary health care. Focusing on health information systems with adequate data protection safeguards, too, will be crucial, as will enhanced health budgets, if countries want to successfully prepare and manage health crises in the future.
Gitahi, a doctor of medicine and a management professional, whose organisation reaches more than 11 million people each year through 150 health-focused projects across 35 countries, spoke to THE WEEK on the sidelines of Grand Challenges, the recent virtual health summit led by the department of biotechnology, ministry of science and technology, Bill and Melinda Gates Foundation, ICMR and Niti Aayog.
Excerpts from the interview:
What are some of the key lessons from the African region that could help other countries such as India in dealing with a health crisis such as Covid? Conversely, what key measures from India’s response could be applied in African countries in a health crisis such as this?
Months before COVID-19 was officially declared a pandemic, its impact was already being felt across Africa’s economies. In responding to the impending health, economic and social crisis, African governments recognized the critical need for a rapid and multi-sectoral collaboration for an effective response to the pandemic. Governments had to take bold steps to adopt socio-economic measures to help mitigate the human and socio-economic toll, measures to reduce infection spread, and increase the capacity of the health system. Some of the successes in controlling COVID-19 can be attributed to lessons learned from previous health emergencies such as Ebola.
As has been the case in certain parts of India, African countries, too, have relied on the experience with patient tracking/contact tracing, and engagement of community leaders. Here are the key points that I would like to highlight. First, African heads of state quickly rallied under the leadership of the African Union to support the Africa Joint Continental Strategy for COVID-19 Outbreak. Through this, platforms were created for pooled procurement mechanisms and for establishing relevant policies such as testing protocols, use of face masks and more recently, the creation of the vaccine trials consortium.
In April, the Africa Centres for Disease Control and Prevention (Africa CDC) launched a new initiative, the Partnership to Accelerate COVID-19 Testing (PACT). As an Africa-led and Africa-owned response endorsed by African Ministers of Health, PACT aims to facilitate implementation of the Africa Joint Continental Strategy for COVID-19. The strategy aims (within 10 months) to conduct 10 million COVID-19 tests (14 million tests have been conducted so far), deploy 1 million community health workers and train 100,000 healthcare workers to support COVID-19 response in Africa.
Before the first case of COVID-19 was reported on the African continent, screening procedures were already in place at several entry points. Airports across the continent deployed staff dedicated to checking temperatures and travel documents, as well as recording information that would be useful in the event that contact tracing was required. In Ghana, for example, extensive testing allowed the country to track individual outbreaks. The country’s corps of community health workers helped it respond effectively. WHO is studying some of Ghana’s techniques, including the potentially time saving practice of “pool testing,” in which multiple blood samples are tested together and processed separately only if a positive result is found.
Movements were restricted, too. Rwanda was the first country to suspend all international travel, other African countries followed suit. Whether through lockdowns or curfews, most African countries directed citizens to stay indoors in order to minimize disease spread and buy time to build health system capacity. Schools closed as soon as the first few cases were reported and physical gatherings were restricted (in some cases banned).
Recognising that these restrictions would do more harm than good on the economy and general livelihoods, countries have since eased restrictions, but still enforce public health measures such as social distancing, use of face masks and handwashing.
How can South-South collaboration support countries in maintaining essential health services throughout the COVID-19 response? Immunisation, for instance, has been badly hit in several countries.
COVID-19 has also provided a space for collective action. With the pandemic affecting nations across the globe, south-south collaboration can support knowledge exchange on maintaining essential health services. It promotes sharing of best practices, collaborative and coordinated interventions, and could even inspire partnerships to pool resources, leverage platforms and explore opportunities for sustainable solutions to improve health outcomes. We can learn practical tips on how to scale up high-impact interventions, conduct immunisation, and ensure routine health services are still delivered.
Further South-South collaboration can strengthen the advocacy voice in global health on public goods like the COVID19 vaccine and call for equitable access.
What models of healthcare financing can help India, Africa, cater to the needs of their population?
Africa and India have highly informal economies as well as large portions of the populations living below the poverty line. This presents a fiscal space challenge because of low tax efficiency and a large dependency ratio. The high informality and low tax efficiency makes it difficult to implement a ‘single payer’ system as is in the United Kingdom because this assumes adequate taxes though a high tax efficiency.
At the same time, mandatory health insurance like those employed in some countries with mandatory deductions from the employed would leave a big number of unemployed people without cover denying them of their right to access health services.
In order to cater for the needs of their populations which are highly informal, high unemployment and significant number of households below poverty line, a blend of both where taxes provide financial protection for the poor through health insurance or otherwise and a pooling mechanism for the employed would best serve the unique needs of both Africa and India. For this to work adequate allocation of government taxes, specifically towards 5 per cent of GDP or 15 per cent of total government general spending must be set as a goal if health is going to be a foundation for their socio-economic growth.
In the end, the goal is to minimise or eliminate out-of-pocket expenditure from individuals, reduce health related poverty and build human capital.
What sort of funding or financial mechanisms are needed to minimise the economic impact of the pandemic across the continent?
This pandemic has underscored the importance of the health sector, as one that contributes significantly to human capital and safeguards the population. Low government spending results in high out-of-pocket spending which further widens the gap between those who can afford and access quality health services. New or revised finance models should focus on increasing health spending to adequately resource the health sector in order to achieve health equity and eventual universal health coverage. These models should reduce inefficiencies in health spending so as to make better use of existing resources. There are a few examples from Africa - Algeria, Botswana, Lesotho, Kenya, Morocco, Senegal and South Africa increased fiscal space by improving tax collection capacity. Gabon, Ghana and Nigeria earmarked allocations to the health sector from government revenue. Tanzania and Uganda implemented reforms to improve resource flows to health facilities and improved resource use. Ethiopia and Rwanda achieved high levels of population coverage through social protection systems that guarantee access to healthcare services.
How are African countries preparing to provide the COVID-19 vaccine for their people?
All 54 African countries have expressed interest in accessing the COVAX facility in the hopes that they will be able to secure adequate co-financing for the COVID-19 vaccine once one becomes available. Countries have just started discussions on country readiness, and in some countries such as Uganda, a national taskforce on the COVID-19 vaccine has been established. Most discussions will centre on (i) community sensitization and engagement in order to increase acceptance and uptake of the vaccine; (ii) eligibility criteria (who will be prioritized?); (iii) strengthening procurement and supply chain management especially the vaccine distribution strategy including adequate cold chain storage; (iv) sustainability plans to ensure continued availability and access to the COVID-19 vaccine; (v) available and trained human resources for health etc. South Africa is entering into a deal to be involved in the manufacturing and distribution of the COVID -19 vaccine locally so that the country can play a key role in the effort to expand access to vaccines. Under the African Union, the Africa CDC Consortium for COVID-19 Vaccine Clinical Trials (CONCVACT) was established to expand the number of clinical trials on the African continent thereby increasing the availability and access to COVID-19 vaccines.
What kinds of long-term effects on economies and health systems are being anticipated due to COVID-19?
As the global economy sinks into a deep recession due to the pandemic, Africa has not been spared. The African Development Bank estimates that Africa will lose between $35 and $100 billion due to the fall in raw material prices. This poses a real risk that Africa’s inequality gap will worsen in the coming years. Several sectors have suffered – agriculture, tourism and travel, oil and gas, etc. An extreme poverty rate is predicted especially among vulnerable households and in countries with high informal sectors. African governments such as Kenya and Rwanda are establishing and promoting local industries which will create employment and hopefully make products modestly more affordable. With healthcare resources being diverted to the COVID-19 response, progress has slowed in building the capacity of our health systems. Due to severe disruption of routine healthcare services, many countries will not meet their health targets in addressing maternal and child health for example. WHO already warned that children around the world are at great risk of missing their vaccine schedules due to a pause in mass immunisation programs.
At the same time as we witness the devastating toll on economies and health systems, there are opportunities in technology, including the acceleration in science. Digital technologies are providing us with new tools to manage the economic and social disruption that have become part of our daily lives. From telemedicine platforms to fever-detecting robots to contactless financial tools, technology is stepping in to play a crucial role in keeping societies functional. Some examples:
· Rwandan medical workers deployed robots to minimise coronavirus risk. The robots, used in Rwanda's treatment centres, can screen people for COVID-19 and deliver food and medication, among other tasks.
· Ghanaian start-up Farmerline is sharing vital COVID-19 updates with at-risk farming communities through its voice message service. Their field agents are also delivering essential inputs farmers need to cultivate their farms while observing all safety protocols.
· The Senegalese government launched a country-wide e-commerce platform for Small and Medium Enterprises (SMEs). The platform facilitates the distribution of food, hygiene and health products, federates the SMEs and encourages more traditional businesses to go online.
· Kenya is helping to set up 1 million kitchen gardens to improve food security for households
Preparing for pandemics is particularly challenging for resource poor countries. Going forward, how can health systems be better prepared to deal with such a crisis?
· Governments must invest in strong primary health care systems which can not only respond to health emergencies but also have the capacity to ensure minimal disruption to delivery of quality health services.
· Engage the community as co-creators of solutions. Community engagement remains central to defining the needs of the community, therefore health services must be people-centred.
· Invest in robust and agile health information systems that produce reliable data in a timely fashion. We must also strengthen the use of these data to inform decisions, drive policy and investments in service delivery.
Universal health coverage and health security are often defined as two sides of the same coin!