Health in Africa: the tree that hides the forest – by Pierre M’Pelé

In August, WHO’s Monitoring Report on Universal Health Coverage in Africa revealed a 10-year rise in life expectancy between 2000 and 2019. This drastic increase is a consequence of the 37% drop in mortality between 2000 and 2015 following the implementation of the 2000-2015 Millennium Development Goals.

Indeed, over the past two decades, Africa has made enormous progress in healthcare and these two essential indicators, markers of the health of a population, attest to this. While it is certainly legitimate to rejoice in this increase for a continent plagued by so many ills, we must be cautious and avoid complacency because this positive news is a tree that hides the forest. It is therefore wise to remain vigilant and to pursue tirelessly the efforts to improve the level of health of African populations.  

The Tree…The baobab that hides the forest

Numerous reports, studies, and evaluations, including those published by the WHO, show that this progress stems from advances in the prevention and treatment of infectious diseases (HIV, tuberculosis, and malaria), reproductive, maternal, neonatal and child health, particularly with the improvement in the coverage of essential health services, which reached 46% in 2019, compared to 24% in 2000.

While this progress is notable, it is unevenly distributed across Africa, between regions, between countries, and even within countries, and the slow reduction in infectious diseases indicates an epidemiological transition that deserves special attention because noncommunicable diseases are a silent and deadly epidemic now and in the future.

This progress is also the result of the commitments made successively in the framework of the Millennium Development Goals 2000-2015 followed by the Sustainable Development Goals (SDGs) 2015-2030. They have led national leadership to serve the greatest number of people to ensure lasting change. At the national and international levels, these commitments have enabled a people-centered vision and planning for greater investment in health as part of national development programs. Good democratic governance, stability, and economic growth in African countries over the past two decades, as well as support for numerous initiatives, have also positively influenced health indicators.

To achieve Universal Health Coverage in line with the SDGs by the year 2030, it is essential to build effective, inclusive partnerships between governments, the private sector, civil society and communities. They must be built on common principles and values of solidarity and brotherhood that place all people at the heart of the process.  In this context, Mercy Ships has been working with the people of Africa since 1990 to, in the words of French medical professor Marc Gentilini, “temper the pain of the world” through free access to high quality, very complex surgical care to those who would not otherwise be able to access it.

The Forest…Disorganized, fragile, and unbalanced health systems

Home to 17% of the world’s population, Africa has only 2% of the world’s total number of physicians and less than 1 surgical specialists per 100,000 inhabitants. The continent alone accounts for 25% of global morbidity and one-third of clinical conditions requiring surgical, obstetric, and anesthetic care.

Today, the African health systems bring to light significant weaknesses, such as:

• Insufficient funding and public health budget, and far too high “remaining costs” for the patients
• Limited access of the population to quality, affordable healthcare and services, available at all times and in all places
• Inadequate data collection and statistical systems that prevent the monitoring and evaluation of interventions, which is so useful for guiding public health action
• An oversized centralization of the systems affecting the peripheral levels
• Poor health infrastructures
• Persistent inequalities in access to proven health interventions, especially in the coverage of key and vulnerable populations such as children, adolescents, women, and the elderly
• Insufficient and inadequate health human resources
• Inadequate surveillance and response systems for epidemics and pandemics
• Poor access to essential medicines, vaccines, and technologies
• Lack of transparency and leadership in governance, which does not always consider health as a fundamental human right.

At the same time, the Covid-19 pandemic has recently revealed the fragility of health systems in many African countries. Public health management must therefore be rigorous and efficient, transparent, and supportive, based on scientific evidence and respect for human rights. At the center of the action, women and men of excellence, competent, of integrity, and responsible will make it possible to achieve the SDG: “To live in good health and promote the well-being of all people at all ages, which are essential conditions for sustainable development”.

Left-behind outskirts…Surgery, a neglected component of health systems in Africa

Over the past two decades, public health efforts in Africa have not been accompanied by similar progress in health systems, service integration, or hospital care, nor have they been equitably distributed among individuals of all socioeconomic statuses. Surgical and anesthesia care has been largely neglected in most African countries.

According to the Lancet Commission on Global Surgery, 93% of the population of sub-Saharan Africa do not have access to safe surgery and more than 25 million additional surgeries are needed each year to save lives and prevent disability. The challenge of equity and the integration of surgical and anesthesia care into national health systems are prerequisites for achieving Universal Health Coverage in Africa.

In Africa, receiving appropriate care for hemorrhage from childbirth or burns, for example, is a challenge for the individual, his or her family, healthcare personnel, and the community. A dystocia (birth injury) leads to the death of the mother and the newborn, a cleft lip and palate becomes an obstacle to the normal growth and development of a child, a broken bone leads to permanent disability for a young man who works to support his family. Access to quality, safe and affordable surgical, obstetric, and anesthesia care is a luxury in most African countries and especially for the poorest populations.

Africa, Mercy Ships and partners take up the challenge…

In commemoration of its 30 years of service on the African continent and to strengthen its advocacy for safe, quality surgery in Africa, Mercy Ships has engaged African governments, national and international partners, and health experts in a continent-wide, strategic and political action: from action research to political commitment. It aims to increase investment in upgrading surgical, obstetric, and anesthesia care systems by 2030 to achieve Universal Health Coverage.

The Research

The research consisted of an assessment of the inadequacies of surgical care systems in Africa. It led to the development of a priority action plan for scaling up and investing in strengthening healthcare in Africa, and a strategy for implementation, monitoring, and evaluation. This unique study was conducted in 602 district hospitals in 32 sub-Saharan African countries. Preliminary results show an alarming situation that requires urgent action in all countries. For example, one in four district hospitals has no water or electricity, and only one in twenty-five has an Internet connection in this century of computerization.

The strategic discussion

From May 4 to 6, 2022 in Dakar, experts from 28 African countries in the fields of surgery, obstetrics and anesthesia were brought together. The Ministers of Health, who pledged to improve the situation over the next ten years, proposed a commitment called

Access to Equitable, Affordable and Quality Surgical, Obstetric and Anaesthetic Care in Africa, as well as a Regional Action Plan 2022-2030. They submitted them to African Heads of State, including HE President Macky Sall, of the Republic of Senegal and Chairperson of the African Union.

Political commitment

On May 30 in Dakar, six African states (Cameroon, Comoros, Congo, Gambia, Guinea Bissau, and Senegal) adopted the Dakar Declaration. This Declaration announces nine strong commitments, and a Regional Action Plan 2022-2030 which includes 12 urgent and necessary actions, 6 strategic priorities, 16 key indicators and an annual monitoring scorecard.

This Declaration is ambitious and brings hope for filling the healthcare gap for most Africa’s populations. This hope is that all African leaders, governments, and partners, will commit to the financial investment necessary to develop concrete actions for better health for the populations, especially the poorest.

But a political declaration is only the starting point for action. To make it a reality, there must be real political will and strong leadership for health. In Africa, so many declarations have remained in the starting blocks… The 2001 Abuja Declaration (allocation of 15% of the annual national budget to health), for example, is still being implemented, resulting in inconsistent health systems and the fact that surgery remains a neglected component.

The forest ranger… The solution

Just as a person drives the car, pilots the plane or the drone, designs and guides the artificial intelligence, people must be at the heart of the change. It is more useful today to have qualified, specialized, and dedicated doctors and nurses even without sophisticated equipment, than hospitals with expensive equipment without high-level health human resources to operate them.

Therefore, training programs are essential; one of the great challenges for health professionals on the African continent is to access advanced training, continuous capacity building programs and research to avoid costly medical evacuations to developed countries. We need health professionals in Africa who can heal and restore dignity to patients.

In the march towards Universal Health Coverage, African governments must take a rigorous strategic and scientific approach: plan a program adapted to the local situation supported by sufficient political commitment to be sustainable, make better use of available resources, remove financial barriers for access to care while reducing the financial risks associated with disease, implement, and respect the Abuja 2001 commitment, and finally invest in building resilient health systems.

The relative wealth of a country is not the only factor at play. Although the priority given to health in national budgets generally increases with national income, it is important to note that some governments choose to devote a high proportion of their budgets to health spending despite a relatively low level of national income. Others, on the other hand, who are relatively wealthier, allocate a smaller proportion.

The Dakar Declaration on Access to Equitable, Affordable and Quality Surgical, Obstetric and Anaesthetic Care and its 2022-2030 Action Plan submitted to African Heads of State in May 2022 is a powerful policy lever. This roadmap will accelerate Universal Health Coverage by the year 2030 in Africa.

This is a real universal challenge to be met because we have less than 10 years left to succeed. African governments and their populations therefore have a key role to play in these efforts, especially those aimed at improving access to quality surgical care which leaves no one behind. It is clear that “political action will make the difference because it must be like the surgeon’s scalpel: leave no room for uncertainty.”