Lenias Hwenda of Medicines for Africa examines the true impact of access to medicine initiatives in Africa, noting that many of the measures takes are often cosmetic and leave a swathe of “impact bottlenecks” unaddressed. Hwenda calls for a more holistic approach, moving beyond simply bringing medicines to African countries at a price that patients can afford to also including screening, diagnosis, and treatment initiation measures, concluding that treatment is not just medicine, but the total management of an illness.
More than a decade of working on access to treatment and care issues have taught me that it is nearly impossible to improve healthcare without addressing the challenges affecting the availability of healthcare services, the ability of patients to afford those services, and the quality of care. These challenges are greatest for African patients the majority of whom pay for healthcare out of pocket amidst widespread income disparities. Medicines needed to treat a large proportion of societal burden of disease in most African countries are often not available or accessible to patients consistently. When they are available, they are often too costly to be accessible at the point of care and their quality is often questionable. Such absence of quality affordable medical products undermines the performance and quality of national disease responses, interventions, and programmes.
The aid industry and pharma initiatives, like the recently launched Sanofi impact brand which aims to bring 30 high-impact medicines including insulin to 40 low-income countries on a non-profit basis, have long sought to address access to medicines issues. Impact initiatives invest millions of dollars to make affordable treatments available to patients. They are an important additional resource towards tackling access to medicines in African countries, but their impact is typically not lasting, partly because the measures taken are often cosmetic that leave numerous, what I term “impact bottlenecks”, unaddressed.
The only purpose vanity metrics serve is to perpetuate a status quo beneficial for a few elite players in the system whilst little lasting effect is being made on the intended beneficiaries of impact initiatives, the African patients
Impact bottlenecks are factors that, if left unaddressed, reduce the true positive impact of healthcare initiatives. Impact as reported in press releases and brochures often focus on vanity metrics such as companies having an access to medicines policy regardless of whether it is implemented or the number of medicines packs shipped regardless of whether they actually reached the patient at a cost they could afford. The only purpose vanity metrics serve is to perpetuate a status quo beneficial for a few elite players in the system whilst little lasting effect is being made on the intended beneficiaries of impact initiatives, the African patients.
The severe shortage of health workforce in African countries is probably the most important impact bottleneck for access to medicines initiatives. After all, prevention, the appropriate initiation of treatment, and management of disease is only possible if you have adequately-trained health care professionals and appropriate diagnosis services. Only then can patients receive medication that is appropriate to their clinical needs in doses that meet their individual requirements for an adequate length of time. Without proper diagnosis, effective treatment is impossible. Availability of diagnostic equipment can also be a bottleneck, but it is of secondary importance to the availability of healthcare professionals needed to operate the equipment. The treatment also needs to happen at a cost accessible to patients, otherwise, again there is no impact. Let’s also remember that the cost to patient is not only the out-of-pocket diagnostic and treatment cost, but those costs plus the cost of transport to healthcare facilities, cost of time taken off work, and the cost of possibly having to tour multiple pharmacies in search of the medicine that is out of stock in most places. Hence, bringing medicines and diagnostic services close to the patient addresses another major impact bottleneck.
With few African governments meeting their commitment made in the Abuja Declaration in 2001 to spend a minimum of 15 percent of GDP on health, the impact bottlenecks are not going away. The African continent is expected to have a deficit of 6.1 million health workers by 2030. To put this in perspective, Africa´s most populous country, Nigeria, has only one doctor for every 5´000 people to deliver basic essential health services to its 200 million population, significantly below what the WHO recommends as the minimum threshold of health worker to population ratio of 4.45 doctors per 1000 people. Granted, African countries also leak a big proportion of healthcare workforce they spent money on training into Western countries, but that leak too could be addressed with increased domestic healthcare investment.
But what about the all the support given to African countries by all the international organizations, wealthy foundations, and innumerable NGOs? Aren’t they solving the issue of impact bottlenecks? For a few specific infectious diseases, the answer is yes, but for Africa’s double burden of communicable and non-communicable diseases (NCDs), the answer is no. The problem is that support to countries is often given in ways that have adverse effects on the broader health goals of nations. For instance, the relentless verticalization or siloing of African healthcare systems by partner initiatives that operate by creating multiple parallel systems have the effect of incrementally and perpetually weakening healthcare service delivery over time. Furthermore, when health priorities are being set by African countries, the supremacy of donor interests, which is to curtail diseases considered security threats to the international community like HIV, malaria, and TB, has compelled African health systems to overlook the growing burden of chronic non-transmissible diseases like cancer, diabetes and cardiovascular problems. Consequently, the design of most African health systems is significantly biased towards a limited number of infectious diseases leaving them unequipped to meet the entire scope of existing population health needs.
Decades of government underinvestment in NCDs management have resulted in their near universal omission from national health strategies in African countries. The case in point is South Africa, which is one of four countries on the continent that actually exceeds the WHO threshold ratio of health worker to population. Despite this seemingly favourable ratio, South Africa has limited state-funded NCD specialist posts like endocrinologists or diabetic nurses for managing diabetes with no professional pathways for career progression. This creates an impact bottleneck that manifests itself as follows. The South Africa government provides glycaemic control agents for free to its estimated 4.6 million adults with type 2 diabetes (T2D). Some of these patients, around 10 percent, have low insulin secretion and require insulin to maintain glycaemic control.[1] Under South Africa´s guidelines for managing diabetes, only doctors are permitted to initiate treatment like insulin. Some of the doctors and healthcare providers and people with T2D, however, resist the initiation of insulin.[2] The result is that even though insulin and other glycaemic control agents are provided for free, only half of the people with diabetes are diagnosed and only one in ten of those are receiving treatment. Such are the deleterious effects of impact bottlenecks like workforce availability and specialist training on access to treatment.
The above example is not unique to South Africa. In most African countries, the guidelines for NCD care generally recommend that treatment initiation be done by doctors. Considering that most primary healthcare clinics on the continent lack specialist NCD doctors and nurses, and the few that are there carry a heavy workload and limited time,[3] this is not a feasible approach. Many African countries also have no national strategy for managing NCDs. Few, like South Africa[4],[5],[6],[7] and Kenya, have recently begun to create them and others like Zimbabwe are still working on creating one. Many have not started at all. The result is that most African countries are poorly equipped to deal with a growing double burden of disease affecting a significant proportion of national populations whilst facing an increasing frequency of health emergencies, which according to the World Health Organisation (WHO) increased by 63 percent between 2012-2022 compared to 2001-2011[8]. Throwing more low-cost treatments at systems riddled with significant impact bottlenecks is not going to achieve the results desired unless the bottlenecks are addressed in parallel with increasing treatment availability.
In conclusion, whilst the success of any healthcare system depends on the availability of quality essential medical products – diagnostics, therapeutics, equipment, and technology, it is not enough to just have the medicines at a price that patients can afford. You also must be able to screen, diagnose and initiate treatment correctly. Only then can they truly improve treatment outcomes for patients. Treatment is not just medicine, but the total management of an illness. This requires knowledge which, in turn, requires adequately trained healthcare professionals. Without an adequate well-trained workforce providing basic essential services, impact initiatives will always have a narrow and limited effect. Beyond making sure that the right medicines reach patients, most of whom live in rural areas with little infrastructure for diagnosis and dispensing of medicines, there are strong compelling reasons why access initiatives need to identify and address critical impact bottlenecks that affect medicines use. Neglecting to address impact bottlenecks results in missed opportunities to screen, diagnose and treat patients and result in preventable errors during disease management even when treatment is provided for free.
References
[1] Hayes RP, Fitzgerald JT and Jacober SJ. Primary care physician beliefs about insulin initiation in patients with type 2 diabetes. Int J Clin Pract 2008; 62: 860–868.
[2] Iotie PM, Wood P, Webb EM, Hugo JFM, Rheeder P Designing an integrated, nurse-driven and home-based digital intervention to improve insulin management in under-resourced settings. Therapeutic Advances in Endocrinology and Metabolis.
[3] Webb EM, Rheeder P and Wolvaardt JE. The ability of primary healthcare clinics to provide quality diabetes care: an audit. Afr J Prim Health Care Fam Med 2019; 11: e1–e6.
[4] Essential Drugs Programme. Primary healthcare standard treatment guidelines and essential medicines list. 6th ed. Pretoria, South Africa: National Department of Health, 2018..
[5] Ngassa Piotie P, Wood P and Webb EM, et al. Willingness of people with Type 2 diabetes to start insulin therapy: evidence from the South African Tshwane Insulin Project (TIP). Diabetes Res Clin Pract 2020; 168: 108366.
[6] Nadasen DM and Naidoo M. Patients with type 2 diabetes and difficulties associated with initiation of insulin therapy in a public health clinic in Durban. S Afr Fam Pract 2012; 54: 436–440.
[7] Mayet L and Naidoo SS. An evaluation of insulin therapy initiation among patients with type 2 diabetes attending a public health facility in South Africa. S Afr Fam Pract 2012; 54: 525– 530.
[8] WHO Africa. In Africa, 63 percent jump in diseases spread from animals to people seen in last decade (14 July 2022) https://www.afro.who.int/news/africa-63-jump-diseases-spread-animals-people-seen-last-decade
