The health and health care systems in sub-Saharan Africa have faced many challenges that dragged them to such a catastrophically poor state. The challenges range from conflicts, poverty to inequality and industrialisation. One wonders how people survive such preponderant calamities – yet here we are – some alive, some disabled, and others dead. It isn’t by coincidence that the continent with one of the highest fertility rates has the youngest population. Maybe, in Africa, we deliver many children as insurance for those we shall lose during our stay in this calamity-stricken continent. In today’s article, we dissect the state of the health care systems in sub-Saharan Africa. We gain insight into the reasons why they are so poor.
Without indulging in the geopolitics of what we mean by sub-Saharan Africa, let’s agree that it entails all countries south of the Sahara Desert. As of 2019, the region is a cradle to 1.1 billion people, which is about 14.3% of the world’s population 1. Africa has 25% of the global disease burden. Astonishingly, the continent does not only inhabit 3% of the world’s health workers but also has less than 1% of the world health expenditure 2.
In the beginning, infectious diseases like malaria, tuberculosis (TB), diarrhoea, and measles contributed to the disease burden. However, chronic illnesses like HIV/AIDS, heart disease, diabetes, and stroke have constrained the continent further in recent years 3. Conflicts, gender inequality, poverty, risky pregnancy and childbirth, have worsened the whole scenario. Ebola, global warming, refugees, and now, Covid-19 have sunk the continent to the lowest of the low.
Various governments here do not prioritise health care because they comprise either flawed democracies or authoritarian regimes 4. The Abuja declaration of 2001 postulated that for any country’s health care system to provide substantial-quality health care, the government must spend at least 15% of its expenditure on health care – yet few countries in sub-Saharan Africa have achieved this 5. In the Americas, this expenditure is more than 15% 6.
The low expenditure means few resources are available for the population to utilise. At worst, the few resources congregate in referral centres within the cities 7. Most countries in sub-Saharan Africa meet the World Health Organisation (WHO) criteria for health workers critical shortage – defined as any country that has 2.28 doctors and midwives per 1000 population. In this region, nations rely on mission hospitals, non-government organisations (NGOs), and external Aid to fund and provide health care services 8.
Foreign Aid isn’t inferior; however, in many instances, it drives vertical disease-oriented programmes. It skews central planning and priorities. Importantly, it offers higher salaries to health care workers – creating an internal brain-drain – where workers move out of the public sector 9.
Human rights violation is a day-to-day affair in many sub-Saharan African countries – yet health governance borders human rights.
The disease inequity and fragmentation of the health system in sub-Saharan Africa leads to patients wishing they had HIV instead of diabetes 10. Many countries lack a national insurance scheme. It implies that most families spend on health care out-of-pocket. If they don’t have the money, they don’t get the care they require 10. Those that have the funds pay exorbitantly. The national insurance scheme of Uganda is still in its infancy. That of Ghana focuses on universal health coverage and community-oriented primary care 11. Through the ‘mutuelles de sante’, Rwanda provides universal health care. It also has the highest enrolment in health insurance in sub-Saharan Africa 12. In most areas, health care workers who form the skeleton of the primary care workforce have limited training. They lack skills, resources, support supervision, and managerial leadership. The situation is dire in that doctors are rarely seen in public hospitals; they are there in well-established private settings 10.
For robust primary health care, a country should have enough family physicians – yet many countries in sub-Saharan Africa lack or have very few of such. Family physicians improve the quality of care, patient satisfaction and continuity of care and participate in transforming the health system, among other roles 10.
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Human rights violation is a day-to-day affair in many sub-Saharan African countries – yet health governance borders human rights. Good health governance promotes effective health service delivery. But sub-Saharan Africa does not have it. To further note, sub-Saharan Africa has poor service delivery, below par procurement system, resource mismanagement and corruption, poor health infrastructure, and brain-drain to wealthy nations. There’s a poor allocation of resources. Buying military ammunitions to fight internal conflicts takes up a considerable percentage of the national budgets 13.
The region’s health care systems face several challenges. They include conflicts, poverty, unemployment, food insecurity, climate change, inequality, and industrialisation. Because of competing demands, prioritising health is onerous. We noted earlier that sub-Saharan Africa heavily relies on Foreign Aid – it hasn’t helped entirely. It is astounding that the African Union established the African Centre for Disease Control after the US CDC committed to providing Aid; however, this only substantiated when EBOLA hit West Africa in 2013 13.
Of the 2.4 million infant deaths that occur in the first 28 days of a child’s life, sub-Saharan Africa carries a big chunk of them. When compared to the higher-income nations, infants are ten times more likely to die. Pregnant women are fifty times more likely to succumb. In 2018, sub-Saharan Africa had the highest neonatal mortality globally, at 27 for every 1000 live births. The risk that a child will die before their first birthday is highest in this region at 52 for every 1000 live births – yet that of Europe is 7 for every 1000 live births. Preterm births, birth asphyxia, infections, and congenital anomalies top the causes of neonatal deaths 6.
Last but not least, on average, you are likely to die 18.1 years earlier when living in a low-income country than in a high-income country. In the high-income countries, most people dying are old, whereas the reverse is true for low-income countries – 1 in 3 deaths occurs in children under the age of 5. People in low-income countries have reduced life expectancy due to communicable diseases, injuries and maternal conditions 6.
In a nutshell, we should deliberately improve the health and health care systems of sub-Saharan Africa. We should encounter and solve the calamities of poor resource allocation, poor service delivery, resource mismanagement and corruption, poor health infrastructure and brain-drain -both internal and external. We must implement the 2001 Abuja declaration at the bare minimum. For years, we have relied on the Global Vaccine Alliance for expended immunisation programmes. When will we start manufacturing them ourselves? We cannot rely on Foreign Aid forever. We must arise and awaken or, else we shall still dwell in the global income inequality that prevails to-date.