Public health in Africa: Challenges and solutions

 

Overview: What is Public health?

The Center for Disease Control and Prevention (CDC) – the agency charged by the US government to protect the health of Americans, defines public health as “the science of protecting and improving the health of people and their communities".¹ Those served by public health can be as small as a local neighborhood, or as big as an entire country or region of the world.

Services included in public health are, the promotion of healthy lifestyles, researching disease and injury prevention, and detecting, preventing and responding to infectious diseases.¹

Overall, the administration of public health commonly falls under the directive and control of governments worldwide.

Whereas in high income countries generally, public health standards and practices are high and well entrenched, many low income countries especially in Africa still have numerous challenges that plague their public health system. Indeed, “The African Regional Health Report –The health of the people. What works” published in 2014 by the WHO, identifies the existing state of health affairs in the African continent as a ‘public health crisis’.²

The health crisis gets compounded by other major factors which include:

• Leadership and governance issues;
• High disease threats (communicable and non-communicable);
• Inadequate heath work force with ongoing brain drain that continuously weakens capacity for health services delivery;
• Shortage of medicines, vaccines and technologies;
• Poor health information dissemination;
• Low funding.  

Other additional factors inhibiting the development of public health in many African countries include, underdevelopment, intra-national and cross border conflicts, poor infrastructure, unmitigated population explosion and weak or ill-managed government institutions.

 

Challenges and Solutions

Disease threats

According to the World Health Organisation (WHO), communicable diseases account for two thirds of the total disease burden, the rest being due to non-communicable diseases (NCDs) and injuries.

The highest communicable disease threats of Africa include:

    . HIV/AIDS

    . Tuberculosis

    . Malaria

 

HIV: HIV stands for Human Immunodeficiency Virus, The virus attacks and breaks down certain cells that help defend the body against illnesses. HIV is spread when blood, semen, or vaginal fluids from an infected person enter another person's body, usually through sexual contact, or from sharing needles when injecting drugs, or from mother to baby during birth.

Fever, tiredness, headache, nausea, vomiting and diarrhea, achy joints and muscles, swollen lymph glands, sore throat and dry cough, night sweats are some of the early signs and symptoms of the disease.

What works: The incidence of HIV in many African countries has witnessed sharp reduction where HIV prevention strategies have been scaled up to change behaviours. Improvements in access to antiretroviral medicines, enhanced by the use of standardized and simplified treatment protocols in decentralized service delivery models, contributed in no small ways to the downward trend in this HIV incidence. However relatively high HIV burden remains a public health challenge in few African countries like South Africa. In addition, lack of local ownership of antiretroviral medicines production remains a challenge.

 

Tuberculosis: Although tuberculosis (Tb) still remains a significant public health challenge in many countries of Africa, its incidence is also on the downward trend due to successful control measures and intervention strategies implemented in the continent.

What works: A key intervention strategy in Tb prevention, treatment  and control is the Directly Observed Treatment, Short Course (DOTS) that encompasses a basic package of improved diagnosis and detection, better access to relatively cheap first line drugs taken under direct supervision as well as better access to HIV testing and treatment for Tb patient. Challenges still remain for the complete eradication of tuberculosis in Africa.

 

Malaria: Malaria remains a life-threatening disease. It is caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes. It is preventable and curable.

African countries bear the highest burden of malaria globally. According to the WHO, in 2015, 88% of global cases and 90% of global deaths from malaria occurred in Africa. Between 2000 and 2015, reported malaria cases declined by 42% while the malaria death rate declined by 66% in the African Region.³ 

What works: This reduction has been facilitated by such public health measures like the wide availability and promotion of the use of insecticide-treated nets, diagnosis-based treatment with better anti-malaria artemisinin-based combination therapy, engagement of communities in malaria control, and strengthening capacity in vector control for malaria. Vaccine for malaria is being trialed as an additional tool for malaria control in Africa.³ 

Despite these laudable efforts, malaria remains a major cause of deaths and disability within Africa especially in children under five years old, and more remains to be done towards the elimination and or the eradication malaria in the continent.

The rate of malaria eradication progress in any one country within Africa will depend on the strength of the country’s national health system, the level of funding support for malaria control, and such other factors, including: biological, environmental, and the social, demographic, political, and economic realities of the country.

 

The highest non-communicable disease threats of Africa include:

• Cardiovascular diseases (like heart attacks and stroke)
• Cancers
• Diabetes, and
• Chronic respiratory diseases like asthma
• Motor vehicular related trauma

Non-communicable diseases are chronic, of long duration and slowly progressive. According to the WHO, non-communicable diseases (NCDs) represent the leading cause of death globally. NCDs were responsible for 40 million (70%) of the world's 56 million deaths, with 27% (15 million) dying prematurely (between the ages of 30 and 70). Over 80% of these premature deaths occurred in low- and middle-income.⁴ 

In some African countries, NCDs cause over 50% of all reported adult deaths. The implication of this is that NCDs will become a leading cause of ill health, disability and premature death throughout Africa with consequent impact on socioeconomic development in the region.

The risk factors for major NCDs are:

• Tobacco use
• Sedentary lifestyle
• Alcohol abuse
• Unhealthy diet
• Poor road infrastructure and road safety enforcement

These risk factors are driven by social and economic determinants like poverty, globalization, trade, education, urbanization, climate change, employment conditions and gender disparities among others. These determinants exist outside the domain of the health sector and pose tremendous challenges for intervention activities directed at addressing these NCDs.

 

Cardiovascular diseases: The burden of cardiovascular disease (CVD) is reported to be increasing rapidly in Africa, and has become a public health problem throughout the continent.⁵ 

The most important CVDs are:

• Hypertension.
• Stroke.
• Cardiomyopathies (or heart muscle and valvular diseases).
• Coronary heart disease (otherwise referred to as “heart attack”) and
• Rheumatic heart disease

Some contributory factors to the increased cardiovascular diseases (‎CVDs)‎ profile in Africa include:

• Rising life expectancy and increase in the aged populations.
• Rising urbanization and exposure to various modifiable risk factors that are responsible for at least 75% of all the CVDs.
• Low public policy attention to non-communicable diseases including CVDs. This in turn means that most countries lack national programmes to address CVDs.

What works: Public health interventions activities that needs to be directed at reducing the burden of CVDs in Africa must include:

• Setting up national non-communicable diseases programmes including CVD;
• Setting up surveillance systems to address risk factors;
• Training and retention of health personnel to address the problem;
• Ensuring availability and access to cost effective medicines;
• Regulating tobacco advertising and marketing activities for purposes of reducing tobacco use;
• Public education regarding healthy diet, physical activities and reduced alcohol usage;
• Implementing prevention of rheumatic heart disease.

 

Cancers: The WHO reports that the burden of cancer in Africa has been increasing over the past few decades. In 2012 alone, more than two thirds of the 8 million yearly cancer related deaths worldwide occurred in low- and middle- income countries like in Africa.⁶

Common cancers in the Africa include:

• Cancers of the cervix and breast in women.
• Cancer of the prostate in men.
• Cancer of the liver in both men and women.
• Colorectal cancer in both men and women
•  Kaposi's sarcoma and non-Hodgkin's lymphoma, also in both men and women.

The rise in the number of cases of cancer is due to

• Ageing populations;
• The increasing adoption of risk behavior such as:
  • consumption of unhealthy diets,
  • lack of physical exercise,
  • harmful use of alcohol and tobacco use.
• Infections due to human papillomavirus (HPV) and hepatitis B and C viruses. These infections significantly contribute to the burden of cervical and liver cancer respectively.

What works: Many lives will be saved if efforts are made to raise public awareness on the early signs and symptoms of common cancers in Africa. In addition people should be motivated to adopt healthy lifestyles that reduce the risk of cancers.

 

Diabetes: This is a disorder that causes unregulated increase in blood sugar level. It occurs when an organ in the abdomen, called the pancreas, does not produce enough insulin – a hormone that regulates blood sugar level, or when the body cannot effectively use the insulin it produces.

Recent studies from Africa indicate that up to 15% of adults aged 25 to 64 have diabetes.⁷ Since diabetes is often a silent condition, a significant number of people are unaware that they have the disease and therefore go undiagnosed.

Diabetes in Africa is a serious, chronic and costly disease that is estimated to rise to 23.9 million cases by 2030 when it will be the 7^th leading cause of death . Diabetes risk factors include physical inactivity, overweight and obesity, tobacco use and consuming foodstuffs that are high in bad fats and calories.⁷ 

The main symptoms of diabetes include increased thirst, needing to urinate more often than usual, and increased hunger. There are three different types of diabetes called type 1, type 2 and gestational diabetes.

For various reasons, including cost, diabetic patients in Africa often lack access to proper treatment and diabetic medications, especially insulin, resulting in avoidable complications. Complications include neurological, vascular or visual disorders, heart disease, stroke, lower limb amputation, kidney failure and many other chronic conditions.

What works: Diabetes is a major cause of disability and life-threatening complications. Since it is a treatable disease, strong efforts should be put into raising public health awareness for screening for the disease towards the early identification and treatment of sufferers; promotion of a healthy diet, engagement in regular physical activity, maintenance of a normal body weight and avoiding tobacco use. In addition, early diagnosis and cost subsidy to increase access to diabetes medication will help lower the burden of diabetes within African societies.

 

Chronic Respiratory Diseases (CRDs): These affect the airways and other structures of the lungs altering ease of breathing. Preventable CRDs common in Africa include asthma and respiratory allergies, chronic obstructive pulmonary disease (COPD), occupational lung diseases, cancer, sleep apnoea and pulmonary hypertension.

The primary cause of COPD is tobacco smoke.

The symptoms of COPD include breathlessness, abnormal amounts of mucus in the airways, and a chronic cough. Daily activities such as walking or exercising can become very difficult as the condition gradually worsens.

With asthma, there is inflammation that narrows the airways that carry oxygen to the lungs. This results in such asthma symptoms as coughing, wheezing and chest tightness. Asthma is increasing throughout Africa, especially among children.

The major risk factors for chronic respiratory diseases include tobacco smoke and other forms of indoor air pollution such as silica dust, allergens, household chemicals and outdoor pollution especially from vehicular smoke and bush burning. There is strong evidence associating CRDs with living near roads with heavy traffic.⁸ 

What works: More needs to be done from a public health perspective to bring down the incidence of chronic respiratory disorders down in Africa. Needed efforts should include:

• Raising awareness about the disease within communities in Africa;
• Creating affordable housing in healthy environments, especially for poor and disadvantaged populations?
• Scaling up campaigns against tobacco smoking and exposure to second-hand smoke, indoor and outdoor air pollution, unhealthy diet and physical inactivity?
• Improving access to effective therapies for people with COPD.

All of these require high level political will and commitment from governments of individual countries for sustainable improvements in human health

 

Questions that need to be addressed

In light of the foregoing review of the challenges of public health in Africa and some solutions that work to reduce or address the challenges, few additional questions demand to be raised towards engaging public health leadership across African countries in needed dialogue for more sustainable public health improvements. These questions include the following:

1. What more needs to be done to improve access to public health care especially for marginalized populations in Africa?
2. How may existing public health systems be reformed to cost effectively achieve sustainable health improvements in the African population at large?
3. How can leadership be engaged and motivated to support broad public health system strengthening and make it more accountable in its service delivery process?

 

Ray of Hope

Amid the shocking public health statistics in Africa, there remains ample room for hope. While many communicable diseases have witnessed marked reduction in Africa, some are on the verge of eradication or elimination. For example,

• Due to local and international collaborative efforts, guinea worm disease is nearing eradication in most of Africa. There has been a prominent 97% reduction in guinea worm cases since 1986.¹
• Leprosy is almost on the verge of elimination with there being just 1 case per 10,000 people.¹
• Vaccination campaigns for measles have received a good response with as many as 75 million children receiving measles vaccines in the year 2005 alone. The deaths due to measles have declined by more than 50% since 1999.¹
• Efforts to eradicate polio have been relatively successful and it is close to extinction.
• The public health problem of river blindness (onchocerciasis) has been successfully eliminated.

 
Conclusion

Above mentioned success stories point towards the laudable progress that many Africa countries have made so far concerning their respective public health system. Whether African nations will be able to sustain these efforts and build on them will depend on:

• Country ownership of policies and programmes;
• Leadership engagement and support;
• Collaboration with international and bilateral actors for experience sharing, technology and capacity building

As regards country ownership, it is important to ensure that health remains at the top of national priorities.

As far as leadership engagement and support is concerned, leaders at all levels of governance must be enlightened to see and address public health matters as a national security issue and therefore commit utmost national resources and attention to resolving essential challenges.

If the wheel is not to be simply reinvented, public health managers in Africa must be open to collaborate with international and bilateral actors for purposes of experience sharing and knowledge and skills acquisition in what has worked in other domains to solve similar public health problems within the region.

 

References:

1. The Center for Disease Control and Prevention: What is Public health?

2. World Health Organisation (2014): The African Regional Health Report - The health of the people. What works.

3. World Health Organisation. World Malaria Report 2017.

4. World Health Organisation. Overview of Non-communicable diseases in Africa.

5. World Health Organisation (2005): Cardiovascular diseases in the African region: Current situations and prespectives.

6. World Health Organisation. Cancer in Africa - Overview and Factsheet.

7. World Health Organisation: Diabetes in Africa - Overview and Factsheet.

8. World Health Organisation: Chronic Respiratory Diseases in Africa - Overview and Factsheet.

 

 

 

Published: Dec 1, 2019

Updated: February 24, 2023

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