Published byAnnette Gerritsen
Published on22 January 2018
The final results of a 4-year project to analyse the challenges and opportunities for health in sub-Saharan Africa are now published as a Lancet Commission—The Path to Longer and Healthier Lives for All Africans by 2030—led by African physicians, health scientists, and policy makers. Their conclusion is one of qualified optimism, grounded in a rigorous appraisal of new evidence and past experience. The vision of the Commission is that Africans should expect the same opportunities for health by 2030 as all other peoples.
Sub-Saharan Africa’s health challenges are numerous and wide-ranging. Most sub-Saharan countries face a double burden of traditional, persisting health challenges, such as infectious diseases, malnutrition, and child and maternal mortality, and emerging challenges from an increasing prevalence of chronic conditions, mental health disorders, injuries, and health problems related to climate change and environmental degradation. Although there has been real progress on many health indicators, life expectancy and most population health indicators remain behind most low-income and middle-income countries in other parts of the world.
Our Commission was prompted by sub-Saharan Africa’s potential to improve health on its own terms, and largely with its own resources. The spirit of this Commission is one of evidence-based optimism, with caution. We recognise that major health inequities exist and that health outcomes are worst in fragile countries, rural areas, urban slums, and conflict zones, and among the poor, disabled, and marginalised. Moreover, sub-Saharan Africa is facing the challenges and opportunities of the largest cohort of young people in history, with the youth population aged under 25 years predicted to almost double from 230 million to 450 million by 2050. The future of health in Africa is bright, but only if no one is left behind.
Sub-Saharan countries face difficult development agendas in the decades to come, but also immense opportunities to be acted upon without delay. A key message of this Commission is that the opportunities ahead cannot be unlocked with more of the same approaches and by keeping to the current pace. Continuation at the current pace of progress, using models of service delivery and population health that are struggling with results, equity, and sustainability across the world, including in high-income countries, is a recipe for failure. Therefore, we advocate an approach based on people-centred health systems and inspired by progress, which can be adapted in line with each country’s specific needs. Moreover, we believe firmly that better health will not only benefit countries’ populations directly-it will also act as a catalyst, enabling successful pursuit of other development agendas summarised in the Sustainable Development Goals (SDGs).
Leadership on Africa’s health, scientific, and development challenges should come from Africans in close collaboration with the global community, including non-traditional development partners. In addition to alignment with the host country’s priorities, harmonisation of the different global and domestic health mechanisms is important to reduce transaction costs of service delivery and reporting.
A comprehensive approach and system-wide changes are required. A fragmented health agenda will deliver some results but will not succeed in strengthening health service delivery and public health systems, and will not address the determinants of health. Broad partnerships beyond the medical and health community are essential to move the health agenda forward. Without a serious shift in mindsets across all levels of society, all sectors of government, and all institutions it will be difficult to have meaningful and sustainable change. Young people in Africa will be key to bringing about the transformative changes needed to rapidly accelerate efforts to improve health and health equity across sub-Saharan Africa.
- Africa’s health indicators remain behind those of other continents and major health inequities exist. Health outcomes are worst in fragile countries, rural areas, urban slums, and conflict zones, and among poor, disabled, and marginalised people.
- Most sub-Saharan countries face a double burden of infectious diseases, malnutrition, and child and maternal mortality, in addition to emerging challenges of chronic conditions, such as hypertension, mental health disorders, and health problems related to climate change and environmental degradation.
- Substantial progress in many health indicators has been made in the Millennium Development Goal era but progress at the present pace is a recipe for failure.
- The vision of this Commission is that by 2030 Africans should have the same opportunities for long and healthy lives that new technologies, well-functioning health systems, and good governance offer people living on other continents.
- The main opportunities ahead cannot be unlocked by keeping to the same pace and using more of the same approaches to health systems, as even high-income countries are struggling with the rapidly growing burden of chronic conditions.
- Africa-based and home-grown solutions-with the realities of each country and each community embedded at their cores-are required, and each country needs to chart its own sustainable path to improve health outcomes.
- A framework shift is needed to deliver better health outcomes through people-centred health systems, with focuses on prevention, primary care, and public health.
- There are historic, not to be missed opportunities to improve several health outcomes within the next decade, seizing the momentum generated by the Millennium Development Goals by bringing traditional challenges under control and preventing others from taking hold.
- Achievement of good health for all citizens should be a political and investment priority for every country, which will also contribute to economic growth and sustainable development.
- Countries can and should invest more in health and do more to address inefficiencies by identification of new funding sources and movement towards prioritisation of health in domestic budgets.
- Local generation and use of innovation will accelerate better health outcomes, reduce inequities, and have huge scope for prevention and care by harnessing the rapid growth in information and mobile technology in the African continent.
- Investment in higher education and research are essential for better health and sustainable development by enhancing research capacity for identification of challenges and devising local solutions.
This Commission highlights 12 strategic options that all sub-Saharan countries should consider in their policies and plans. These options are connected to the health-related SDGs and integrate commitments made by regional African bodies. The strategic options are as much about promotion of health and prevention of disease as they are about expansion of access to treatment.
Building health systems commensurate to the challenges of 21st century Africa requires action in the critical areas of:
- people-centred health systems, universal health coverage (UHC), the social determinants of health, and health outcomes.
- leadership, stewardship, civil society engagement, and accountability at all levels.
- financing for health.
- commodity security (eg, medicines, technologies, essential equipment, tools, and supplies).
- public health systems.
- health workforce development.
- research and higher education.
- innovation in products, service delivery, and governance.
These eight interconnected areas are covered in separate sections of this Commission. We describe the different areas where changes are needed and make recommendations for the way forward, recognising the great diversity within the region.
This Commission’s vision and aspiration is that by 2030 Africans should have the same opportunities for long and healthy lives that new technologies, well-functioning health systems, and good governance offer people living on other continents. The Commission concludes with an agenda for action based on the following key messages.
A framework shift is needed to deliver better health outcomes through people-centred health systems and UHC:
Frameworks that rely on hospitals and individual care are unlikely to lead to achievement of greatly improved health for all Africans. A rapid expansion of new, African-bred approaches to people-centred health systems, focused on prevention, primary care, and public health, and supported by clinical referral systems and quality tertiary care is required to move to the next stage of better health. UHC should be designed with local values, sustainability, and equity in mind from the onset.
There are historic, not to be missed opportunities to improve health within the next decade:
Given the African region’s economic growth and societal changes, and building on the momentum from the beginning of the SDG era, most sub-Saharan countries have an opportunity to bring some traditional health challenges under control and prevent others from taking hold and having the same devastating effect seen in other regions of the world. Examples include elimination of polio and guinea worm, meeting demand for modern contraceptives, reduction of maternal mortality and water-borne diseases, greatly reducing the mortality and incidence associated with HIV infection, making substantial progress on sanitation, and prevention of an epidemic of tobacco-related diseases, among others.
Achievement of good health for all citizens should be a political and investment priority for every sub-Saharan African country:
In addition to a better life for people, more investment in health will contribute to economic growth and sustainable development. Good health for all citizens is a central responsibility of the state and its elected bodies, which requires considerable investment of public funds, a legislative framework, and a whole-of-society response. Accountability requires mechanisms to hold duty-bearers to account, and people need to have the capacity to demand their rights.
Each country needs to chart its own sustainable path to improve health outcomes:
Each country needs home-bred solutions to build the required systems based on its own culture, while making maximal use of international experiences and evidence, strengthened stewardship of health, and commitment to accountability. All domestic and external resources for health should be aligned to a country’s national health strategy, with actions evaluated by specific health outcomes.
All countries can and should invest more in health and do more to address inefficiencies:
Governments need to identify new funding sources and maintain steady progress over time towards increasing the share of prepaid contributions in total health expenditure and towards prioritising health in domestic budgets. Although there is no single benchmark to determine funding needs, targets to aim for include 5% of gross domestic product (GDP), 15% of government expenditure, and US$86 per capita. Improvements to access and outcomes for poorer individuals should remain a priority and requires more effort to identify and reach these groups. Improvement to public financial management is the foundation of better health spending and should be complemented by taking a systemic approach to implementation of reforms, with a view to reducing fragmentation and inefficiencies across health system functions, public sector portfolios, and stakeholders.
Closing health equity gaps should be a core concern for policy and action:
Poor people in Africa still have disproportionately less access to health services and are more exposed to impoverishing expenditure compared to non-poor people. All efforts to improve health should explicitly address the serious inequities within countries. Health inequities are greatest among very poor people, rural populations, those who are marginalised or excluded from society, and those who live in humanitarian settings and conflict zones. A key priority is the reduction of out-of-pocket payments: despite overall progress during the past decade, some countries have had little reduction in their share of total health expenditure. In more than a third of sub-Saharan countries, such payments make up more than 40% of total health expenditure, and in only five countries (Botswana, Mozambique, Namibia, Seychelles, and South Africa) these payments represent less than 10%. Further progress is needed to remove user fees and ensure poorer people benefit the most from health insurance schemes.
Investments in higher education and research are essential for better health and sustainable development:
Higher education is crucial for development of an adequate and skilled health workforce and increasing health research capacity, and should receive a higher priority in national and regional agendas. Because of the importance of context in improvement of health and delivery of health services, local research is necessary to identify challenges, set priorities, devise original solutions, and make the best use of scarce resources.
Generation and use of innovation will accelerate better health outcomes and reduce inequities:
Capitalising on innovation is key to the future of health in sub-Saharan Africa and can support leapfrogging health improvements, by adopting more advanced technologies rather than following slow, classic paths. Innovative, low-cost vaccines, diagnostics, therapies, and information technology applications have huge scope for prevention and care. Innovations in health professional education, health service delivery, and governance are also urgently needed, particularly those using information and communication technologies.
Stronger regional cooperation will add value to national health efforts:
Pooling resources among sub-Saharan countries and collaboration on issues related to commodity security, surveillance, emergency response, governance, the health workforce, and research and development would benefit population health and quality of care in countries and the African region as a whole, and would facilitate more proactive sharing of data, innovations, and technical expertise.
In summary, through sustained commitment towards good governance and health investment, cross-sectoral action, and leadership geared towards innovation, closing the health gap in a generation is within reach.