Category Archives: Health Care

Globalist or Statist, Ebola is a Health Systems Issue

As the world holds its breath on how the latest Ebola outbreak in West Africa might evolve, a clash of statist and globalist approaches has been evident all through; from media analysts, to International NGO’s to governments. Statist approaches have their reference point as the state/country and tend to view health risks as security concerns while globalist approaches have the individual as the reference point and tend to consider health risks as human rights issues that know no borders.

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A map of West Africa detailing the most affected areas by the EVD.

In classical statist responses, the government of Zambia has banned entry from or travel to any of the four most affected countries; Nigeria, Liberia, Sierra Leone and Guinea. Neighboring Ghana and Ivory Coast have suspended flights within the region while Guinea, itself the epicenter of the outbreak, has closed borders with her neighbors Sierra Leone and Liberia and even declared a state of emergency! The latter three countries have deployed troops at their borders to help enforce movement restrictions. Similarly, many Americans, in the wake of Dr Kent Brantly’s airlifting, voiced reservations at their government’s decision to import the virus onto US soil. In fact, retired famous Neurosurgeon Dr Ben Carson is on record recommending that the two infected Americans should have been at best treated abroad. Back home, many Kenyans are apprehensive and concerned that the virus might make its way into the country aboard the national carrier Kenya Airways, a major carrier connecting West African countries to Kenya. A suspected case late last week (Aug 9th) threw panic across the city. Thankfully, he tested negative. These measures are reminiscent of the early days of HIV/AIDS when fear and panic rather than sound medical principles informed most reactions.

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An electron micrograph of the Ebola virus

The common theme through statist approaches is the definition of disease as a security threat to the nation akin to an invasion. As a result, nations tend to go onto the defense and shut borders, ban flights, expel victims, declare states of emergency and at the bottom of the list, even deploy propaganda. Granted, the socio-economic disruption across West Africa as a result of this outbreak is indeed a threat to the stability of the most affected nations. While in certain instances some or all of these interventions might be helpful, they are seldom successful of their own. Purely statist approaches, beyond securitizing the health threat and evoking a pervasive sense of fear, often overlook the actual necessary interventions.

“The bottom line with Ebola is we know how to stop it: traditional public health,” US CDC Director, Dr Tom Frieden.

In the case of Ebola, a viral infectious hemorrhagic fever of which there is fair medical knowledge, proper hygiene and isolation of symptomatic victims seem to help forestall further spread even as a cure remains elusive. At best, only about a third of infected patients may be nursed back to health. That said, Ebola outbreaks remain either an indictment or appraisal of a health system’s infection prevention and control mechanisms, sensu lato.  This outbreak has therefore merely put to the fore an underlying and long prevalent rot: health systems that are weak from the foundation up.

In as many Sub-Saharan hospitals as homes, clean running water remains a luxury rather than the basic commodity it ought to be. Further, basic and cheap protective gear like gloves and facemasks are frequently out of supply. It is no guess whether these institutions would have enough of costly supplies like intravenous fluids and colloids for the medical support of potential Ebola survivors or management of other conditions. The last nail on the coffin that such a health system represents is surprisingly not the prevalent biting shortage of qualified personnel nor the mismanagement of the few available skilled hands, it’s the population!

“Ignorance and poverty, as well as entrenched religious and cultural practices, continue to exacerbate the spread of the disease,” President Ellen Sirleaf, Liberia.

Many Africans are yet to adopt the germ theory of infectious disease. Developed in the mid 1800’s, this theory remains the most plausible explanation for infections: that tiny living matter (bacteria, viruses, fungi, etc) must physically enter a susceptible host through a particular mode (air, food, blood, etc) in sufficient numbers to cause a disease. With this knowledge, people are forewarned and therefore forearmed on ways to avoid known infections. For Ebola, this means limiting if not avoiding all unprotected contact with infected individuals and bodies of victims and washing up adequately when such contact occurs. Sadly, many individuals still believe diseases like Ebola are curses that need exorcism or just prayers. The sick and bodies of the dead are handled casually every day; Ebola or other disease.

As more of Africa opens up to itself and the world, future outbreaks might be more complex and widespread in the absence of significant systemic changes on the public health platform. However, this threat also presents hope. The growth that is opening up and connecting Africa might come with more medical workers in the unreached areas, greater economic strength for adequate stocking of facilities with essential supplies and greater population knowledge and practise of basic hygiene and sanitation. Additionally, improved communication networks mean future outbreaks maybe detected earlier and aid to stricken populations availed sooner.

Globalist approaches to public health crises know no borders. They view health risks anywhere as a health risk everywhere in cognition of the inherent value of human life, right to a dignified pain-free existence and the interconnectedness of humans. These approaches therefore focus on open borders for collaborations, funds, skills and supplies to affected areas, advocacy for action and open reporting of events. An Africa seeking greater ties within itself and with the rest of the world will have to adopt more globalist approaches to our numerous public health perils.

“African states must do more to promote conditions for a dignified human existence within their borders.”

Finally, even though investment in proper health systems is one sure way to healthy populations, these efforts must not stop at the hospital level. The bulk of health dividends will be reaped from investment in other sectors. It is ignominious that 50 years post-independence, many African countries have yet to supply their people with adequate clean water, clean energy, safe public transport, adequate food and enough relevant knowledge. Globalists and other non-state actors will continue to play  a role in this respect but the long end of the buck lies in the hands of our respective states to do that they were set up to do: promote conditions for a dignified human existence within their borders.

Learn about Ebola

The Kenya Medical Practitioners and Dentists Board, What is It?

The Kenya Medical Practitioners and Dentists Board is a statutory body established by Chapter 253 of the Laws of Kenya in 1978. As the name suggests, the primary role of the Board is the determination, licensure and maintenance of an annual register of duly qualified doctors and dentists.

To achieve this, the Board regulates and supervises the general practice of medicine and dentistry, conduct of internship and the academic programs of medical school programs. Contrary to public opinion, the Board is neither a welfare society for doctors nor a tribunal for medico-legal cases. In fact, the Board’s mandate in medico-legal disputes is only indirectly implied in the Act that establishes it! However, its operations and decisions might make it appear as either: depending on one’s perspective.

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By composition, the Board is a ‘special-interests’ body drawing appointees from government, medical schools and doctors. The Cabinet Secretary for Health appoints the Chairman and nominates at least four other doctors. Additionally, the Director of Medical Services and his deputy are automatic nominees to the Board. In fact, the DMS is the Board’s registrar. After government, the next most represented interest group are the medical schools; each sending nominees to the Board.  Finally, duly registered doctors have seven slots to the Board filled through an election. Tenure for all members is a renewable term of five years.

The bare minimum qualification for Board membership is a due registration as a doctor/dentist. In principle and letter of the law, a newly qualified Medical Officer is as eligible to the Board as is a Paediatric Neurosurgeon of 20 years. Traditionally though, members to the Board have been highly qualified and extensively experienced senior doctors. To its credit or disdain, the Board has been an unofficial holding ground for appointment to senior government positions or conversely, a halfway house from top echelons in government.

For more details, follow these links to Chapter 253 of the Laws of Kenya (the primary reference source for this article) and the Board.

Dealing with Free Maternal Care; Financing

It has been with great joy to observe scores of pregnant women flock public hospitals for their deliveries in the wake of the government’s directive abolishing user fees for this category of patients. Indeed, this is an important move that teaches us several important lessons. Top of the list is the fact that most women would rather deliver in hospital than elsewhere. Several studies have attributed various reasons to why nearly half our women deliver outside the formal health system. This recent phenomenon at least vindicates researchers who for long have advocated against a fee for care system in the health sector. Second, it teaches us that the fees charged at our facilities are actually a barrier to access to services. Most will recall that user fees were introduced as a revenue stream that would in addition, instill a sense of ownership on the users. On those two counts, user fees have not only failed to raise any meaningful revenue for most hospitals but have in effect disenfranchised a large swathe of the populace from quality care. As noble a cause as this new directive by the government is, its success will largely be dependent on its implementation. Many commentators and observers have already noted: nothing is ever free; user fee waivers must be accompanied by an alternative revenue stream. Herein lies the opportunity to transform healthcare in Kenya or, if not well implemented, a compounding of the problems bedeviling the sector.

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To be certain, the Ministry of Health has promised to reimburse health facilities various flat rates for clients attended under this program. This means in the short term, facilities will be expected to file claims at the end of the month with the ministry for processing and reimbursement. This arrangement dives headlong into a financing pitfall that has been the bane of many a health sector; timing of fee collection. In insurance systems, most fees are prepaid; that is before they are actually needed by the insured. This is also true for social schemes in which fees (taxes) are collected well in advance of the need. User fees on the other hand are postpaid; services are delivered at the time of or soon after payment. Some systems obviously combine both pre and post pay elements to enjoy the benefits of both worlds.

Irrespective of what payment system is in play in any given health system, financing health care will always involve three critical functions; fee collection, pooling of the funds and purchasing/paying for services and supplies. The best systems are those that collect the fees ahead of the need, pool these into a large fund and plan and pay for the services and supplies before they are needed. When fees are collected ahead of services, it gives the system a window of time to plan more comprehensively for service delivery and be prepared for their clients when the time comes. Collection of fees in advance also allows for the funds to be consolidated into a large account. This has obvious economy-of-scale benefits; from reduced administrative costs to the possibility of introducing efficient information technology systems to manage the system, to bulk purchasing for services and supplies or even investment of the funds to generate more. (The Ghanaian Health Insurance Authority for instance generated 22% more funds through the investment of the levies they collected as premium in 2009.)

In our system, the ministry of health is not collecting any fees directly from anyone but taxes from the consolidated fund are used to bankroll the free maternity project. The tax collector therefore does the collection and pooling functions leaving the ministry with the purchasing end of the stick. The ministry for now has settled on a post pay system; no different from a user fee system. Hospitals therefore have to do with whatever funds and supplies they have to deliver services and only collect payment from the ministry later. This arrangement only worsens the dynamics of a user fee system; rather than wait for the patient to pay the fees soon after services were offered, hospitals will now have to wait up to 30 days. This may be untenable for facilities that do not have other revenue streams to plug the gap or in the absence of supplies of consumables by the government.

While more women coming to hospital for delivery is a desirable achievement, we must not lose sight of the fact that what really matters is a safe delivery. Mere delivery in hospital is not synonymous with a safe delivery. The picture is only complete when the hospitals have enough qualified personnel, the right tools of the right quantity and enough consumables of an acceptable quality. It is therefore in the patients’, government’s and hospitals’ best interests that a substantial amount of the projected funds for the free maternal care program be advanced to the hospitals for consumption on a reducing balance. This would give individual hospitals the time and funds to budget and procure necessary inputs in advance to ensure quality service provision. With proper record keeping and auditing, unit costs for every hospital in providing this service can be determined over time and improvements be made on efficiency.

The ray of hope is that if well piloted, this project could be a first step into providing universal health care for all Kenyans. As the American literature professor George Woodberry said in his time, ‘Defeat is not the worst of failures. Not to have tried is the true failure.’ Shall we try?

Quality Medical Care Begins with You: The Patient

In recent days, there has been much talk in the public space concerning the general subject of quality of healthcare in Kenya. The discussion, unregulated and undirected, has generally pitted health workers on one side against the public on the opposite side. The media and a motley other organizations including the KMA (Kenya Medical Association), KMPDB (Kenya Medical Practitioners and Dentists Board) have found themselves somewhere in the middle-ground and often drifting to one of either sides to advance their points. Pointedly, there is absolutely nothing wrong in the various interest groups drumming up to their tunes; it is their duty to inform either side of why things are as they are. As long as a modicum of objectivity is maintained, this kind of engagement is as healthy as it is necessary.

Curiously, not the entire public is involved in this discourse. It is the ‘aggrieved’ public whose voice is loudest. These are relatives of people who died or suffered injury in circumstances that were less than satisfactory in their eyes. While I empathize with this group as an individual who has also lost a parent in similar circumstances, I am alive to the fact that such loss and the attendant emotion often do not make for an objective background upon which a critical evaluation of a system can be carried out. Nevertheless, that does not negate the import of such claims. On the other hand, those silent cannot expressly be presumed to be at peace with the quality of care in our hospitals, neither can we assume they share the sentiments of the aggrieved public. Their silence in a matter of life and death is to say the least disturbing. Archbishop Desmond Tutu once said, “If you are neutral in situations of injustice, you have chosen the side of the oppressor. If an elephant has its foot on the tail of a mouse, and you say that you are neutral, the mouse will not appreciate your neutrality.” It is this silence from the rest of the public that is my concern.

Politicians, loud and macabre as ever, have shouted themselves hoarse at us with Bishop Tutu’s timeless quote when galvanizing support for their causes; noble or otherwise. There has never been a shortage of takers to this call; young men, women and people of all walks of life have taken part in political discourses of one type or another as a way of dispelling even the mere thought of their neutrality. The commendable pinnacle of this national duty has been the electoral process; a period during which the country literally grinds to a halt as people queue up for hours to vote and diligently keep tabs on the counting and tallying process for days on end. Indeed, until the winners are declared (or even sworn into office), it is not over. I am least suited to explain the reason for this kind of enthusiasm.

The average voter has little grasp of the technical details of democracy and governance; not unlike the average patient’s grasp of the technical details of medicine and health. In both cases however, these two individuals clearly understand what they want of the process. The voter may have no more a reason to vote than to put their tribesman in office in the same way the patient may have no more a reason to visit the hospital than to have a safe delivery, surgery or relief from a nagging headache. It is for the professionals to sift through the tomes of theory and practice in order to meet the client/patient at their point of need. This interaction between technical expertise and client demands is the basis of quality. For historical perspective, I will quote a 1988 article published in the Journal of American Medical Association (JAMA) by Dr Steffen Grant that defines quality of medical care as “the capacity of the elements of that care to achieve legitimate medical and nonmedical goals.” It is instructive to note the word ‘elements’; as this signifies a system of multiple components. The healthcare system brings together health workers, medical infrastructure and clients: management and finance play overarching roles to enable the first three components achieve legitimate medical and nonmedical goals. It is therefore preposterous and sensationalist, nay defeatist, to blame lapses in quality of care on any one of the components without giving the rest a fair share of scrutiny.

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While it is obvious health workers need proper training and skills with appropriate medical tools and equipment as well as a well-financed and managed system to be most effective in their trade, the role of the patient is seldom emphasized. Without the patient, there would be no need of a health care system in the first place. Patients have the pride of place as consumers in the health system. It is for them that everything else in the system works. It is therefore incumbent upon patients and their carers to not just be passive goods on the health conveyor belt but active participants in every stage of the decision process. The best time for any patient to make a contribution to the health system is not when they lay prostrate on their hospital bed; it is when they are healthy, strong and able. That is to say, we all have a duty to improve the quality of care in our hospitals. We must demand to have our hospitals staffed with enough qualified personnel. We must demand that these hospitals have running water and electricity as well as the appropriate equipment. We must demand that the system is well financed to handle emergencies without asking for money beforehand. We must demand to have a working health facility within no more than half an hour’s walk. If we leave these demands to only doctors and other health professionals to make, we shall continue making unfounded and salacious claims (of 30% of patients dying of poor care and 10% of all patients being misdiagnosed) as have been carried in the print and electronic media recently.

It does not make sense that a poor Kenyan will prepare a makeshift bed in his living room for an overnight visiting friend but accept to share a bed with a sick stranger in hospital! Why should anyone have to sit in a queue at the hospital for 30 minutes? Or have to walk in labour in the rain, in the dead of the night for 2 hours to reach a hospital? The same energy we exhibit in showing our love for politicians, music, dance and enterprise must be directed at advocating for quality of care in our health system. The doctors have done their part in exposing the problems; you must do your part in demanding for better from your leaders at the grassroots to the President. And in the inevitable event that you fall ill, be forthright and candid with your health provider: amicably share with them your pain and agony and help them meet your needs; medical or otherwise.  They will be in a better position to prioritize your legitimate needs and make a sound plan of action. Even then, ask questions and get answers; every doctor is trained to listen to and act on their patients’ concerns with humility and empathy. Should this not happen, speak out about it even if you suffered no obvious loss. This is the only way to better healthcare; all players of the system pulling in the same direction openly, frankly and with unity of purpose.

Finally, the mass media has the unique role of arbiter and educator. As the late Paulo Freire, an internationally acclaimed 20th century thinker and educator, once said, “The educator has a duty of not being neutral.” The media must highlight failings of each of the components of the system with equal zeal. Without trying to appear irrationally optimistic and escapist, I know for certain there are positive stories of doctors, managers and other players in the system who are selfless and going beyond the extra mile to make healthcare in Kenya of better quality. It is not a waste of space to mention these in the media.

Preventing HIV Using ARV’s; The Feasibility.

In theory, behavior change that leads to total non-exposure to HIV would halt the further spread of the virus. This would entail complete abstinence from all sex or remaining totally faithful to a mutually faithful partner and at the very least, always correctly using condoms in all other sexual encounters. The reality however, is much different; behavior change responses need to be sustained and widespread to have any impact. In any case, behavior change strategies (the oldest tool in the prevention of HIV transmission) cannot stand alone in the control of HIV; they work best in complement to other strategies. Similarly, it is my opinion that Treatment as Prevention (TasP) is not the silver bullet in the control of transmission of HIV and will only have relevance in some limited contexts and not others.

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It needs no emphasis that HIV as a global epidemic has exacted an unwarranted toll on humanity since it was described slightly over thirty years ago; the statistics speak for themselves. Every viable effort against the epidemic will remain welcome and worth consideration. To date in addition to Anti-Retroviral Therapy (ART); male circumcision, condoms, microbicides, donor-blood screening, voluntary testing and behavior change strategies are all interventions in use against the spread of HIV/AIDS across the world. Variable successes have been noted with each or combinations of these strategies in different contexts. To this arsenal, the World Health Organisation (WHO) has since late 2010 recommended universal treatment as a preventive measure. By WHO’s definition, TasP is the prescription of antiretroviral (ARV) drugs to all persons infected with HIV as early as possible and irrespective of their CD4 cell counts for the rest of their lives. This definition excludes ARV microbicides and pre-exposure ARV prophylaxis. It is noteworthy that only the United States of America (USA) offers TasP as defined above in its national program so far.

Worldwide, majority of the HIV infections are acquired by heterosexual contact. These infections occur predominantly in low-income countries of sub-Saharan Africa and parts of Asia. Other modes include use of contaminated blood products and needles, mother-to-child and homosexual sex between men. The epidemic has a different face in different regions: generalized in Africa, concentrated among homosexual men in the USA, female sex workers in Thailand and injection drug users (IDU’s) in Russia. With these epidemiological differences, successful control strategies thus need to be context-specific and locally-adapted for most impact. The principle of TasP is based on knowledge from the experience with anti-retroviral drugs (ARV’s) in the management of HIV; particular for prevention of mother-to-child transmissions (PMTCT) and between sero-discordant couples. Properly administered, ARV’s progressively lower viral load in blood to near non-detectable levels; concomitantly lowering the risk of virus transmission. It is this benefit that on a population-level scale is postulated to slow if not halt the further spread of HIV.

The Proximate-determinants Conceptual Framework of infectious disease transmission requires the interaction of 3 key biological determinants; i) exposure, ii) duration of infectiousness and iii) efficiency of transmission of the infectious agent to propagate, halt or reverse the disease transmission process. An intervention on any one of these biological factors is important in any preventive strategy.

Multiple studies have demonstrated that viral load is a principle factor in the efficiency of transmission of HIV; the higher the load, the higher the likelihood of transmission between sexual partners. It is also known that viral loads are highest in the acute phase of infection; TasP therefore aims to start treatment as soon as possible after infection unlike regular ART. However, the efficiency of transmission is also influenced adversely by other factors like the presence of other sexually transmitted infections, sores, nature of sexual acts, circumcision and condom use. In addition to lowering the transmission efficiency, TasP also has an effect on the other two biological determinants of transmission; duration of infectivity and exposure to infectious material. By lowering viral load, ART greatly improves patients’ quality of life and as a result, they generally live much longer than they otherwise would. When the use of ART begins early in the course of the infection as in TasP, the additional length of healthy life provides a longer period upon which infection of others could potentially occur. On to the third determinant, certain studies have noted increased risk behavior in persons infected with HIV once treatment was widely available and quality of life greatly improved; the phenomenon of risk compensation. This has an influence on exposure; with more risky sexual encounters, there is a greater risk of (re)infection of oneself and partners.

It is noteworthy that the evidence basis for TasP has mostly been collected from observations of cohorts of sero-discordant couples on ART and small populations of generally high HIV prevalence (concentrated epidemics) of male homosexuals and injection drug users. A population-based cohort in British Columbia, Canada was the first major large scale study of the effect of increased ART coverage on a population. The results of this study, later mathematically extrapolated on computer models, have been a strong evidence basis that widespread ART coverage could potentially lower both individual and communal viral loads and thus halt or even reverse the spread of HIV by making transmission less efficient.

Despite the impressive mathematical models demonstrating the turnaround effect TasP can have on HIV incidence, these projections are yet to be demonstrated in large population-level treatment programs in generalized epidemics. In the United States (US), high treatment coverage for heterosexual HIV infected individuals has not resulted into significant decline towards elimination as predicted on some of these mathematical projections. Even worse, certain models have shown a potential rise in incidence if TasP is not accompanied by appropriate behavioral change. Further, key assumptions made by these models (100% of the population is tested and there are no financial or other barriers to initiation and sustenance of treatment) cannot be wished away in real life. To be successful, a TasP program would need to maintain three conditions: ART coverage of the population needs to be significantly high (>75%) and sustained, patients’ ART adherence rate needs to be high (>80%) and sustained, and lastly, treatment must be initiated at the earliest time since infection (healthy individuals).

Besides biomedical interventions like TasP; improved quality of life, female education and empowerment as well as support for the vulnerable of society (orphans, the poor) have been shown to have greater impact on the long-term sustainable control of the spread of HIV. Such interventions, when complemented by programs that strengthen existing local health systems and infrastructure, create effective and long-term systems for HIV control. It thus appears that keeping HIV in control would involve the engagement of other sectors and other strategies that address the underlying determinants in an integrated system.

The efficacy of ART and its role in lowering the efficiency of transmission of HIV is not in doubt. This has been demonstrated in the PMTCT programs and among sero-discordant couples in studies referred to above.  If adopted universally, TasP carries the promise of eradicating HIV or at the least significantly slowing its rate of transmission. This promise is however bound by lack of experience with TasP on a large-scale in generalized epidemics and the fact that the benefits are largely the product of mathematical projections of current observations. These may not be guaranteed to replicate as projected. On another note, achieving ART coverage of above 75% (a requirement for TasP) would be a huge leap forward in meeting unmet treatment needs for those who currently need ART and lack it. Only 47% of those who need ART have access to it in the low and mid-income countries. However, achieving this high level of coverage may be a mirage considering the fact that in the over one decade of availability of ARV’s, only half of those who need them can access them in some regions. Scaling up coverage to include those who are healthy and not in immediate need of these drugs would thus be a formidable challenge.

As mentioned before, initiation of ART needs to begin at the earliest opportunity upon infection. This portends a double challenge; finding newly infected persons and keeping them adherent to treatment for life despite their being asymptomatic and relatively healthy at the beginning. HIV infected persons are most infectious in the acute phase of the infection (up to first 6 months) during which most are generally healthy and unaware of their status. On average, these persons are up to 10 times more infectious than they will ever be at any other time in the course of the infection and will often continue with risky sexual behavior. Current universal testing practices have failed and large groups remain out of reach of the health system. Ethical considerations have also meant that testing remains only voluntary. This presents a major challenge to TasP programs of diagnosing asymptomatic infected individuals who remain the most infectious. Further, providing ART to persons who are healthy for the communal good comes with the risk of poor adherence as well as raises ethical and equity concerns. Poor treatment adherence coupled with long periods of ART would lead to the widespread development of resistant strains; a catastrophic situation in the absence of new drugs. Equity demands that those most at need of treatment get it first hence raising programmatic concerns for resource limited countries. To further complicate the matter, some patients develop a false sense of security in ART and may actually practice riskier sexual behavior once on treatment.

Finally, focus on TasP would take away much needed attention, focus and already-scarce resources from other interventions that would make a bigger impact on the incidence of HIV. Combination approaches to HIV prevention promise better and sustainable prospects at containing HIV. These programs are wholesome and encompass prevention, treatment and empowerment of the vulnerable members of the society. Termed as ‘Highly Active Prevention’ by Prof Holmes of the University of Washington School of Medicine, these strategies go beyond the medical realm into the underlying determinants of the HIV epidemic. This approach to HIV control takes advantage of strategies known to work directly in preventing the transmission of HIV (behavior change, treatment, circumcision) while addressing conditions that expose individuals to infection with HIV (poverty, poor education, gender disparity). It involves community participation in collaboration with their leadership to develop locally appropriate and sustainable solutions. This approach attempts to address health inequities, gender disparities and social injustices that make certain individuals vulnerable to exposure to HIV infection. I share the opinion that this approach is the surest way forward in the management of HIV particularly in the low-resource generalized-epidemic context. In concentrated epidemics, TasP may have a role particularly if those populations can be reached in totality and financial and other barriers to access to treatment be eliminated.

In summary, TasP is a novel concept with a noble cause whose prospects are yet to be agreed upon by various researchers as generally feasible. It presents challenging logistics in implementation as well as raises serious ethical and financial concerns. Curbing the spread of HIV will invariably involve concerted efforts that approach the problem from both the prevention and care perspectives. Even more importantly, improvement of the general quality of life for populations; including access to better quality education and employment will lay the foundation upon which health-sector interventions will make an impact. Health interventions (like TasP) on their own stand on shaky ground and may not hold long in the absence of programs that address the underlying determinants.

Is Universal Health a Public Burden in Africa?

The WHO has a long convoluted definition of health as is typical of most organizations of its stature and mandate. To the average person, African or not, health is subjectively defined in simpler terms; a state of wellness and ability to cope with the daily demands of life. The similarities end here. What counts for normalcy in Western Europe and North America is literally worlds apart from the same in Asia or Africa. While the per capita annual spend on health in the US is about $8000 and $3000 in Western Europe, every African individual spends only about $85 towards their health annually! This comparison, at face value, is damning. Indeed health care in the West is highly specialized and commensurately expensive; in great contrast to the African context where healthcare largely involves basic primary care. The expenditure gap is therefore a result of the size of the health ‘shopping cart’. This cart is significantly small for most of Africa with just a handful of goods while our American/European counterparts have a large cart bursting with goodies. Looked at differently, the African public sector is unable to push the ideal health cart and has chosen to keep only as few goods in it as it can push. This beggars the question; is health a public burden in Africa?

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In his book ‘Why Africa Is Poor; And What Africans Can Do About It’, prolific author, researcher and international expert Dr Greg Mills goes at great lengths to demonstrate the central role the health of any nation has on its ability to grow from poverty to prosperity. Health is the very foundation of productivity and growth. A population afflicted by disease and illness spends less time in the production of the goods and services it needs. Complementary to good health is education; the skills to produce, and leadership; the organization of priorities. All developed economies have had to make deliberate provisions for the health and skills of their people to be where they are today. Other factors are subsets of these three pillars. Is it thus plausible to argue that leadership is wanting in Africa for it not to have prioritized the health of her people? The statistics all point to a sector in wanton neglect and crying for attention; life expectancy at birth of 56 years (against 80 in developed countries) and unacceptably high all-cause mortality and disease rates. Viewed against investment in health and other social services, these grim figures are proportionate to the dismal investments in these sectors. However, Africa is a vast territory of 54 nations; each unique in its own right and internally very diverse. A sweeping statement like this may not fly but remains valid for the most part. Analyzing individual countries paints a more accurate if grimmer picture than these continental averages.

Take Kenya for instance, a country with a per capita GDP (PPP) of  just under $ 2000 spending a meager 4% of her GDP on healthcare. Two thirds the citizens live on less than $ 2 a day and predominantly rely on the state-run health system for their health needs. The health system is mainly funded by central government taxes (direct and indirect) in addition to co-payment into a largely voluntary national insurance scheme that covers nearly two million of the 40 million citizens. Those not covered, an overwhelming majority, are expected to share costs with the state in the form of user fees at points of care. These direct fees amount to 60% of all the national health spend. There is no explicit provision for the care of the worst-off in the society; the elderly and the extreme poor. Where provisions exist, like for children under five, free treatment is often negated by a lack of an assortment of supplies including drugs which patients routinely have to buy out of pocket. In addition to the direct costs of healthcare, majority of the population bear disproportionately high indirect costs in accessing health. Transport costs are highest in the rural areas where physical access is lowest and poverty highest. The opportunity cost of time in seeking care also tends to be higher for the worst-off of the society; they make no income when sick and have to pay to get back on their feet. As though not already overburdened, the poor further face a silent hidden cost: counterfeits and illegal practitioners. Illegal practitioners take advantage of the unmet health needs of those disenfranchised by the formal system. It is here where counterfeits are passed off for genuine drugs and overall quality of care much lower than anywhere else but at a fraction of the direct monetary cost. This situation is not unique to Kenya: across Africa, millions of poor peasants have to make the choice between their health and food or work. While it is obvious that productivity is lost with every episode of illness, most African governments have failed to embrace this rather simple fact that a good health status is the basic unit of productivity; even ahead of education/vocation.

A sad irony is that while majority wallow in poor health, a small middle class in Kenya (like in other African countries) has access to fairly comprehensive employer-financed health covers tenable at some of the best health facilities around the country. These people do not lose much income (if at all) for their sick-time and do not have to pay for their health costs at the point of care. This sad state of affairs ensures that only a small subset of the nation enjoys good health and subsequent productivity and therefore carries the resultant burden of the sick and less productive. This further widens inequalities and keeps entire nations stuck in poverty, disease and underdevelopment; a reality so prevalent across Africa and within nations.

On the contrary, Germany spends 12% of its GDP on healthcare with direct private fees amounting to only 25% of the total health spend. The health basket in Germany is certainly larger but it is important to note that the bulk of the financing for health is prepaid. Public funds shoulder nearly one quarter of the health budget with the rest covered by prepaid compulsory universal health insurance into which employees and employers contribute. Further, the government makes payments for those out of employment or otherwise unable to make an income. This single feature creates a system in which ability to pay is not a determinant of access to health services. Efficiency and collaboration between private and public players in financing, service delivery and research into healthcare is high and the overall result is a system that meets the health needs of all citizens including the less fortunate. Needless to add, the dividends of a healthy nation are self-evident; greater productivity, longer lives and greater quality of life.

However, a good national health service is not by itself a guarantee to improved national health status. The health service is only one of a retinue of factors that determine the health status of individuals. Commodities like food security, water and sanitation, education, clean energy and social cohesion achieve greater health benefits and savings than the health service itself. It takes leadership to define programs that integrate these individual components into a system that delivers health to the nation. This demands an awful amount of political capital and ownership for any meaningful success. Africa must begin making homegrown decisions for her people. The introduction of user fees in hospitals and state divestiture from several key public sectors (including water, electricity and transport) can be remembered by all to have been a top down condition by the Bretton Woods institutions in the infamous Structural Adjustments Program era of the 80’s. Today, fragmentation of healthcare in most African countries amongst disparate donors with as many interests has made sure that only modest gains have been made in the improvement of healthcare. The presence of these programs if for nothing else is testimony to the fact that our health systems are not functional as presently constituted. A conscious effort must be made to ensure the attainment of universal population coverage as the first step in achieving universal health care. To ensure a meaningful health package, the financing of health – as a necessity – needs to be prepaid rather than at the point of service. Mechanisms must also be placed to ensure the most disadvantaged of society are not disenfranchised from the health system by way of fees. And more importantly, there must be efficiency at every level; collection and pooling of funds, purchasing of health goods and services, management of the health workforce and research. This calls for closer mutual public-private partnership and for emphasis; leadership. Only then shall we begin to have a healthy enough population that can engage in production and economic and social development. Fortunately, these developments are already taking place in countries like Ghana, Rwanda and Burkina Faso with steady and remarkable results. It must remain alive to us that universal health is a public burden; not to be shunned, but one to be borne by everyone in a way that especially seeks out the most disadvantaged in the society.