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The State of Global Health: Key Trends, Challenges and Opportunities

In advance of the many health-related discussions to take place in September at the Clinton Global Initiative, the Social Good Summit, UN week and other such events, the Skoll World Forum asked some of the world's leading voices in global health to paint a comprehensive picture of key trends, challenges and opportunities to realizing healthcare access and treatment around the world. *In partnership with Forbes, a new post will be published everyday through Friday, August 9th. Check back for more!*


The Top 3 Public Health Trends Across Africa

The Top 3 Public Health Trends Across Africa

August 7, 2013

Rahim Kanani: As the Executive Director of the African Population & Health Research Center in Nairobi, Kenya, what are the top 3 trends you’re seeing from a public health perspective across Africa?

Alex Ezeh: The top three health trends that I see are: growing inequities in access to health services and health outcomes, the shifting burden of disease from infectious to noncommunicable diseases (NCDs), and a greater push for country ownership of health programming and funding.

There are many dimensions to the health inequities across African countries, cities, and regions, but the most pervasive are typically among groups defined by their economic status, geography, age, and gender. People living in remote and marginalized rural areas and urban slums, older individuals, and young children often bear a disproportionate share of the disease burden while simultaneously having limited access to care. Apart from sexual and reproductive health services, there are few interventions aimed at improving adolescent health, which is a precursor to adult health. Addressing the social and structural determinants of these inequities remains a challenge for global health programming.

Unfortunately, with growing urbanization, changing lifestyles, and poor governance, the incidence of NCDs is increasing rapidly in sub-Saharan Africa even while the region still bears a huge burden from infectious diseases like HIV, tuberculosis, malaria, diarrhea, and other neglected tropical diseases. Injuries, especially among young adult males, are also on the rise. These trends will further stretch already weak health systems and could result in a reversal of recent improvements in health.

Lastly, as rich countries struggle with the current economic crisis and as poorer countries achieve higher levels of economic growth, the push for country ownership of strategies and funding for health and other development programs will continue to grow. The rate of this transition in funding arrangements and the positioning of health among other development priorities within countries will have huge implications for health programming in Africa. These factors also will have implications for the mix of country-level expertise to support health programs.

Rahim Kanani: Within these trends, what are the critical challenges or dilemmas that need “solving”?

Alex Ezeh: For inequity in access to health care and in health outcomes, the critical dilemmas that need to be solved include: How do we improve access to health care among marginalized groups? Bearing in mind human resources, funding, and other constraints, how do we achieve universal access to health care at the country level?

The critical challenge to addressing the increasing burden of NCDs and injuries is how to reorient health systems, which have traditionally focused on a cure-centric approach to health care, to respond to the new reality by emphasizing prevention. This demands multisectoral approaches to prevention, tackling the social determinants of disease and injury from all dimensions. There is currently very limited evidence for how these approaches can be operationalized in countries with weak accountability mechanisms, weak governance structures, and weak health systems.

With respect to country ownership, one challenge is ensuring that health remains at the top of national priorities once external funding for health programs is curtailed. Another is managing the transition from external to internal funding in a manner that does not reverse the gains already made in improving access to care and in health outcomes.

Rahim Kanani: In helping to address these issues, how can philanthropy in particular be a more effective partner to the people of Africa?

Alex Ezeh: Reaching marginalized groups with effective services may require changing or adapting current strategies. This will require more research and more context-specific programming, which, by nature, are often more expensive. Philanthropy has a role in supporting the development of these new strategies, for instance, by helping to identify the groups that need to be targeted by health programs.

Philanthropy can recognize the shifting disease burden and reorient health programming in Africa to raise awareness and promote efforts to change behavior. Current evidence suggests that most of the behavioral factors that affect NCDs risk originate in the early adolescent years. Therefore, addressing such factors will be important for sustained improvement in health in sub-Saharan Africa. Earlier diagnosis is also critical. Up to 80 percent of Africans with diabetes don’t know they have the disease—as a result, they suffer complications sooner and die earlier in life. Some philanthropic and independent research institutions are in fact already working to raise that awareness and identify solutions. For example, the African Population and Health Research Center (APHRC), where I serve as executive director, is working to develop, implement, and evaluate a cost-effective model for primary prevention of cardiovascular disease in slum settings in Africa that is sustainable and scalable.  Also, PATH is currently studying a number of promising diagnostic technologies as well as innovative approaches to integrating NCDs screening and care into existing health systems. But right now, there is very limited funding for NCDs work in Africa.

With respect to country ownership, philanthropy can invest now in building local and national capacity in health programming. Externally funded programs often run parallel to government programs and often through international nongovernmental organizations (INGOs). Building local and national capacity to design and implement health programs will be essential to effectively manage the transition to country ownership. The tendency of some funding agencies to work together to come up with common goals and funding priorities to create more synergy and impact is commendable in terms of increased harmonization, but these agencies should ensure their goals are consistent with national priorities by engaging governments and civil society organizations in setting such priorities.

Rahim Kanani: Technology, and in particular mobile phones, seems to be playing a very important role in Africa’s progress, but are we overestimating its promise and potential?

Alex Ezeh: I would have included technology as the fourth major health trend in Africa. I do not think we are overestimating the promise and potential of technology, particularly mobile phones, for the future of health in sub-Saharan Africa. Indeed, we are seeing innovative applications of mobile technology in the finance sector, agriculture, and increasingly in the health sector. It is already being used to manage distribution of health commodities to avoid stockouts, to address fake products, and improve evidence generation.

I believe mobile phones will be one of the inputs that help us achieve significant improvements in health outcomes over the next decade. For example, mobile phones are playing a part in addressing one effect of South Africa’s HIV epidemic—the orphaned and preterm and low birthweight babies who don’t have access to the protection and nutrition of their mothers’ milk. To ensure that donated breast milk is safe for these babies, PATH, the University of Washington, and the Human Milk Banking Association of South Africa developed an inexpensive system to manage the heat pasteurization of donated breast milk that can be used in homes and resource-limited health care facilities. The system uses mobile phones to precisely monitor the pasteurization process.

Rahim Kanani: Finally, if you were to give a keynote address to the major multilateral institutions of the world such as the World Bank, the United Nations, and others, on how best to advance the African continent, what would be your opening paragraph?

Alex Ezeh: My title for my keynote would be: “Africa: Now or never” and would begin like this: I believe Africa is standing on the precipice where the actions we take today will determine whether Africa will join the rest of the world in achieving significant improvements in human well-being or be perpetually left behind by the rest of humanity. There are huge opportunities today: increasing economic growth in a number of African countries, expanding advancements in knowledge and technology, the increasing voice of civil society organizations willing to hold governments more accountable, and current goodwill from many development partners. Africa can marshal these opportunities to achieve significant improvement in the education, health, and overall quality of life of its citizenry, which will in turn drive further opportunities for the continent. At the same time, the region faces major threats—rapid population growth, civil conflict, potential negative impacts from climate change, over-reliance on staple products, and poor governance and corruption, among others. In the absence of improved human capacity, these factors will likely drive Africa far behind other world regions. We must work today to implement programs that develop the necessary capabilities Africans need to move the continent forward.


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