Health is a fundamental human right and a cornerstone for social and economic development.
Despite its importance to individual wellbeing as well as the growth and prosperity of families, communities, and entire nations health has historically been de-prioritized by many African governments in favour of physical infrastructure. Globally, 400 million people are still waiting for essential health services. In Africa alone, millions of people do not have access to the quality health care that they need or are pushed into poverty from spending on health care.
Thankfully, recognition of the importance of health to all aspects of sustainable development is growing, and we are currently witnessing a positive shift. In recent years, the concept of Universal Health Coverage (UHC) has gained momentum among governments, civil society, the private sector and donors, across Africa and around the world. more and more countries are recognizing the importance of “health for all,” – both as a means of achieving their development targets, and because it is the right thing to do. As a medical doctor and as someone who has worked in the health industry for many years, I believe that this renewed focus on health particularly primary health care and the growing momentum around UHC– is a first and critical step along the path to achieving better health for all people.
I was born in Kenya in 1970, the eighth-born in a family of nine children, at a time when access to quality health care was limited. I count myself lucky, as I was among the five of my siblings that were delivered by a midwife at a nearby health center (the rest of my siblings were delivered at home). the first time I visited a ‘bigger hospital,’ I was six years old and had broken my arm – the health center we visited referred us to Kenyatta National Hospital in Nairobi. before that, I had never gone beyond our local dispensary. All our needs, including vaccinations, were met there.
Growing up, we ate food from my mother’s farm. she was and still is a subsistence farmer. she lives on the same farm I grew up on. On that small piece of land, the maize, beans and vegetables that she grew were our food. We also picked coffee because that was the main cash crop to take to the factory. Once a year, when the coffee payments would come in, we would get a serv- ing of meat – that was like a celebration to us. At heart, I am and always will be a village boy.
When I was six years old, my mother became pregnant with my sister. I remember walking with my mother to the dispensary and sometimes to the health center where she was going for antenatal care. We were lucky that there was a health center 5km away from where we lived. Not all my mother’s friends were as lucky to have uncomplicated pregnancies and several of them lost children during pregnancy or childbirth. every life lost to preventable causes is a tragedy, but unfortunately, this story is not unique to my mother’s friends. Despite the global progress in reducing child mortality over the past few decades, an estimated 5.4 million children under age 5 died in 2017—roughly half of those deaths occurred in sub-saharan Africa.
Looking back at these mem- ories, I see how they shaped my path to leading the largest NGO in Africa – Amref Health Africa, which reaches more than 10 million people each year through 150 health-fo- cused projects across 35 countries. seeing the limited access to health care in my own community, the loss of friends and neighbors from preventable causes, and the way my own mother struggled to provide the necessary health services for her children, it was a no-brainer that when I turned 19, I chose to study medicine.
As a medical student, most of the text books I used for Community Health modules were written by Amref Health Africa. many of the doctors, nurses and midwives across the east African region have been to medical schools in which Amref Health Africa’s learning tools or platforms were and continue to be used. even as I was beginning my career in health, I was aware of the impact of Amref, and inspired by its work on community health – with a focus on bringing the necessary services and quality care to as many people as possible, including the most marginalized, vulnerable and hard to reach.
Basic primary healthcare
In the years since – working as a medical doctor, as well as in the media industry, the private sector and civil society – one of the most critical lessons I have learned is that we cannot achieve health for all without basic primary health care services at the community level. the founders of Amref Health Africa strongly believed that health should start at home, and much of our work today is still guided by this princi- ple. After all, about 80 percent of a person’s health care needs across his or her lifetime can be covered by primary health care, which is much more cost-effective and accessible than hospital-based services.
In this regard, as we look with a critical eye at the number of hos- pitals in our communities, let us also look at the number of toilets and access to clean water, to pro- mote proper sanitation and hygiene practices. As we look at access to essential medicines, let us also look at the immunization coverage across our counties and districts, to prevent infections from occurring in the first place, and protect children and their families from life-threatening diseas- es. As we look at the number of doc- tors, let us also look at the number of community health workers – who must be appropriately trained and compensated for their vital work – who are taking health services to the communities that have no hospital, or to the families that cannot afford transport to the closest health center. strengthening health systems from the community level is essential if we want to make health for all a reality. In the African context, community health workers (CHWs), are a critical cadre in achieving UHC. CHWs bridge the gap between their communities and the formal health system, bringing health care as close as possible to where people live and work. Yet they are often treated as volunteers. their role needs be integrated into health systems if those are to successfully respond to the disease burden that exists in African countries. Ethiopia and rwanda, for example, have recruited tens of thousands of community health workers – who are chosen by their neighbors and trained by the government to take care of people’s health. CHWs take health care to the people, instead of the other way around. Despite the vital role that CHWs play in promoting health and delivering essential services – especially in Africa – many African countries have yet to make this necessary investment. my own country, Kenya, has a higher GDP per capita than Ethiopia and Rwanda, but the primary care system is weaker.
Another striking example of investments in community health comes from Liberia, where bold reforms were made to the national CHW program following the ebola epidemic. many remote com- munities relied on community health volun- teers for essential health services, but because they were unpaid and under-supported, many dropped out of the program. In 2016, Liberia’s ministry of Health launched its revamped National Community Health Assistant (CHA) program. CHAs are now paid, and their work is overseen by nurses or other clin- ic-based health professionals. As of march 2018, Liberia had hired and trained almost 3,000 CHAs, and many counties are already reporting improvements from their services.
CHWs also play a vital role in empowering communities to take ownership over their own health. this approach of letting communi- ties drive their health agenda is how Amref Health Africa engages within the health ecosystem. It is through this community-led approach that Amref has grown to what it is today: Operating in over 35 countries and impacting 10 million people, working with more than 1,500 staff across Africa with a budget of about UsD 120 million a year, establishing offices in Africa as well as North America and europe for fundraising, and setting up subsidiaries which include Amref Flying Doctors, Amref International University and Amref social enterprises.
Amref Health Africa has always believed that everyone, everywhere, should have access to the health care they need to survive and thrive. As the idea of UHC – whereby all indi- viduals and communities receive the essential and quality health services they need without suffering financial hardship – is taking shape and gain- ing momentum across the African continent, we proudly lend our voice to the call for “health for all”.
The path to UHC will not be easy – particularly in Africa – but I firmly believe that we can reach our goal. Countries across Africa face unique challenges in implementing UHC – from limited resources to weak health systems and high disease burdens of both infectious and non-communicable diseases. because of this, we cannot model Africa’s health solutions through the same lens we might use for countries in the global north. there is no “one-size-fits all” approach to UHC, and African countries must design their own unique pathways toward health for all while at the same time learning from their success and failures from countries with similar challenges in the Global south as well as from their Global North counterparts.
While several African countries have taken bold steps along this ambitious path, other countries are struggling to put in place health systems that can deliver UHC to their people. Its realization will require political will, committed resources, and coordinated action among stakeholders. In this changing health landscape, private sector players, civil society organizations, and bilateral and donor agencies all have a role to play.
The idea that UHC is expensive is an assumption that needs to be adjusted. We need to view UHC not as a cost, but as an investment for the future. providing quality, affordable, health care for all is a triple win: it improves people’s health, reduces poverty and fuels economic growth. Aside from the obvious benefits of having a health- ier population, UHC improves how health care is delivered and financed, so that it is more accessible, more equitable and more effective. When health care becomes accessible and affordable, families will be able to educate their children, start a busi- ness and save for emergencies – con- tributing to both social and econom- ic growth within the nation.
the truth is that people are willing and are paying for health but they’re paying for it at the wrong time – when people are forced to pay exorbitant costs, or when they seek late stage treatment due to limited preventative care in their communities, the health system has failed them. As African countries reexamine their health systems to understand how we can make UHC possible, we must ask ourselves how we can spend better and smarter, improve quality of care, and reach all people with the resources we have available to us.
Pooling health funds
When people have to pay for their health services out of pocket, the poor are often unable to obtain essential health services and even the rich are exposed to financial hardship when faced with severe or long-term illness. pooling health funds through taxes, compulsory insurance contributions and voluntary health schemes helps to minimize the financial risk of illness across a population. In other words, pooling health resources creates a safety net to ensure everyone can access essential health services, regardless of their socioeconomic status. It is up to our governments to lead these conversations about strategic purchasing and pooling of health resources. For example, mandatory pooling of the money that people are already spending on health can help governments purchase better for their people. the focus should not be on whether the individual can pay, but on whether the government has put in place mechanisms to ensure that everyone is taken care of – those who can afford health care on their own, as well as those who can’t.
If we are to achieve UHC, African health systems must provide for all people, be equitable and affordable, and deliver on the promise of giving people the quality care that they desire and deserve. These health systems will look different in every country. they will not be judged on the number of hospitals or laboratories, but rather, on their ability to provide essential health services to all people in a timely manner and with desired outcomes.
The decisions we make today and the actions we take will determine whether we keep our promise to millions of people currently lacking healthcare across Africa. this month, we expect a historic UN General Assembly declaration in support of UHC.
In the face of this global milestone, we have a critical window of opportunity to accelerate our efforts and raise our voices to help make health for all a reality. The goal of achieving UHC in Africa is ambitious and it should be, because the stakes are high. Illness is a universal phenomenon – health care should be too