Opinion: A new model of NCD care to achieve UHC in sub-Saharan Africa

Noncommunicable diseases kill more than 36 million people globally each year. Eighty percent of these deaths occur in low- and middle-income countries, where health systems are largely ill-equipped to deal with the double burden of disease posed by communicable and non-communicable diseases.

The Global Health Observatory data from the World Health Organization shows that the African region suffers more than 24 percent of the global burden of disease, yet has access to only 3 percent of health workers and less than 1 percent of the world’s financial resources.

There has been renewed focus on the impact and threat of NCDs since their inclusion in the Sustainable Development Goals. The effort to reduce premature mortality from NCDs by one-third by 2030 is being highlighted in major fora, such as the U.N. High-level Meeting on NCDs.

Achieving universal health coverage by 2030 is a further SDG commitment that is inextricably linked to achieving success in controlling the NCD epidemic in sub-Saharan Africa.

To achieve both SDG targets, we must focus on how to strengthen health systems and develop new models of NCD care in developing countries. Sub-Saharan Africa’s health systems, in particular, have been crippled by a cycle of low investment and an inability of the state to efficiently collect taxes from citizens who work in the informal sector.

According to 2018 data, employment in the informal sector accounted for 83.4 percent of total employment in Kenya. A recent study has outlined that health insurance coverage in Kenya is low, at 19 percent, with the National Hospital Insurance Fund, the main health insurer, covering 16 percent. The remainder is made up of coverage through private insurers. The fund provides mandatory health insurance to formal sector employees through income-assessed monthly contributions. It remains voluntary for informal sector workers who pay a flat rate of 500 shillings ($5) per month directly to the fund.

In their current state, the health budgets of sub-Saharan African countries do not allow the region to adequately cover NCD care for the population. To achieve UHC in these countries we must reduce the cost of care of NCDs.

In a recent study into the costs of NCD care in Kenya, there was found to be wide variability in cost depending on the type of facility attended. NCD screening ranged from $4-35 and annual hypertension medication costs ranged from $26-234 in public facilities, and $418-987 in the private facilities.

Given the average household expenditure per adult is $413 per annum, the high cost of services relative to income not only creates a significant barrier to seeking treatment but also exposes patients to potentially catastrophic financial expenses.

A new model of care adopting the following three principles is essential to reducing the cost of NCD care and achieving UHC:

1. Remote monitoring, chatbots, and telemedicine can improve efficiency and reduce costs

According to WHO, there are 2 physicians per 10,000 population in Kenya and 4 physicians per 10,000 population in Nigeria. This compares to 32 physicians per 10,000 population in the United Kingdom — the minimum WHO recommendation if 10 physicians per 10,000 population.

The scarcity of health professionals alone means that the traditional models of care in established health systems are not applicable to developing countries. Moreover, developing countries cannot currently train enough health professionals to meet the demand for medical care.

There are several ways in which technology can be of benefit in overcoming the low physician-patient ratio as well as improving overall clinic efficiency. Remote monitoring of blood pressure and blood sugar levels, with results being electronically transmitted to a clinic doctor for assessment could reduce clinic visits for routine consultations. Telemedicine and, increasingly, chatbot services are convenient for both patient and doctor and could be utilized on a standard follow-up schedule or on a schedule co-developed between the two.

Telemedicine and chatbots as a model of care are now possible given the high degree of reliable telecommunication services and advanced mobile phone usage in Kenya. Alternatively, for those without access to a mobile phone, kiosks at local pharmacies or community centers could serve as points of access.

Beside increased patient satisfaction, telemedicine can address the acute shortage of doctors in sub-Saharan Africa by reducing routine clinic appointments and allowing the doctor to identify and see patients who are at high risk of deterioration or hospitalization based on objective results from remote monitoring.

2. Generic drugs must become the default prescription dispensed by pharmacies

Much of the out-of-pocket costs borne by patients are for pharmaceuticals. For common chronic diseases such as diabetes and hypertension, generic drugs are equally effective and widely available. They should also be the default choice in all pharmacies in sub-Saharan Africa.

Trust must be regained by the local pharmaceutical industry, which has been afflicted by the counterfeit drug market. Large international pharmaceutical companies have capitalized on this lack of trust to sell their branded drugs at a premium to patients. By increasing the availability of generic drugs and improving the transparency of the supply chain, the uptake of generic drugs as the standard of care will result in significant cost savings to patients and the health system.

3. Prevention must form the cornerstone of all treatment

Leading a healthy lifestyle by addressing the modifiable risk factors of NCDs, namely tobacco smoking, alcohol consumption, poor diet, and lack of exercise has significant long-term health benefits.

Prevention forms the cornerstone of treatment for all diseases. While this is widely known, it is not commonly practiced, indicating that behavioral change, and maintenance of that change, is a complex interaction of biological, social and psychological issues that have no easy fix.

The emergence of wearable movement monitors and mobile phone applications that incentivize healthy living has the potential to have an impact. However, this technology is at an early-adopter phase for much of the population in sub-Saharan Africa. Therefore it is too early to determine whether it will have a meaningful impact.

By 2050, Nigeria is expected to become the third most populous country in the world. Additionally, half of the world’s population growth will be concentrated in nine countries, of which four are in Africa. These include Nigeria, the Democratic Republic of the Congo, Tanzania, and Uganda.

As population and economic growth expand rapidly, governments must avoid the tendency for urban sprawl and build cities that make the healthy choice the easy choice. This may include higher density urban design with access to parks and bicycle paths, limiting marketing and advertising of unhealthy food products to children, and using taxes and subsidies to encourage healthy eating.

Established UHC systems are already struggling with increasing health care costs for chronic diseases.

There are several factors that make the achievement of UHC in sub-Saharan Africa especially difficult: The health workforce shortage, the inability of the government to efficiently collect taxes to invest in the national health system, the resulting high out-of-pocket expenditure for patients, and the inability of the government to pay for the true cost of NCD care in its current form. An alternative model is required.

The high mobile phone penetration, technology-savvy population, and booming social entrepreneurship scene make the environment in sub-Saharan Africa ripe for innovation. The ability to use technology to significantly reduce the cost of care for NCD care will be a critical step for sub-Saharan Africa achieving UHC and is an opportunity for the region to lead the rest of the world and demonstrate what is possible in terms of NCD prevention and care.

For more coverage of NCDs, visit the Taking the Pulse series here.