REDEFINING THE PATH TO HEALTHCARE DEVELOPMENT IN AFRICA

Innocent Chinedu Udemezue

2013

Redefining the Path to Healthcare Development in Africa: Lessons from Cuba

In a speech to the United States Council on Foreign Relations in 1999, Gro Harlem Boundland, the Director of the World Health Organization (WHO), argued that With globalization on which the American prosperity so much depends all of humankind today paddles in a single microbial sea and we have to conclude: there are no health sanctuaries. The levels of ill-health in countries constituting a majority of the worlds population pose a direct threat to their own national, economic and political viability, and therefore to the global economic and political interests of the United States and all other countries. Territorial disputes are no longer the prime source of conflict. It is increasingly rooted in human misery, aftermaths of humanitarian crises, shortage of food and water and the spreading of poverty and ill-health. So investing in global health is investing in national security. The Washingtons based Center for Strategic and International Studies (CSIS) also asserts that the resulting US global health policy has been predicated on a consensus that substantial U.S. investments in health in Africa have indeed advanced U.S. interests. They are fulfilling American humanitarian values by saving and enhancing lives; strengthening health security against common and emerging threats; and are promoting the stability and long-term development of vulnerable communities in low-income countries. This treatise therefore highlights the importance of tailoring healthcare development financing and management strategies to align with the structural, economic and socio-political peculiarities of the countries they are targeted at. It advocates for a strategic international alliances between African countries and countries leading in the fight against diseases. It promotes development of innovative indigenous solutions for Africas challenges. As we approach the 2015 deadline for meeting the UN Millennium Development Goals (MDGs), In the 2013 World Health Report, Dr. Margaret Chan, the Director General of the World Health Organization maintains that there was a need to take stock of the progress that has been made since 2000, suggesting "it was time to reflect on how we made progress, and on how we could do better". Dissatisfied with the results so far, Dr. Chan regrets that despite the 'great' strides that have been taken since the turn of the millennium, especially in reducing deaths after the neonatal period, the best measurement indicate that nearly 7 million children under 5 years died in 2011 (2013 WHO Report). "From experience in high income countries, we know that most of these deaths are preventable. But how can that be implemented everywhere?" One idea, Dr Chan suggests is to make greater use of community based interventions. Consequently, the need for developing and harnessing the potentials of community based capabilities underscores the essence and motivation for this article. In another report by the Center for Strategic & International Studies (CSIS) Global Health Policy Center authored by Stephen Morrison, he reiterates claims that despite the funding from rich nations and multilateral organizations, progress has remained fragile and in the meantime, several challenges are outstanding. Morrison further highlights that for malaria control and elimination to succeed, bed nets must be replaced every three years once insecticide loses potency and nets become worn, ripped, or torn. Inexpensive, rapid diagnostic procedures to confirm cases and prevent overuse of antimalarial drugs are needed. Drugs and insecticide resistance need to be addressed. And there is need to better clarify the division of responsibility between the Presidents Malaria Initiative (PMI) and the Global Fund. Stephen Morrison suggests that consolidating on the gains of decades of funding, management initiatives require meantime strategies that have indeed been focused on insecticide treated nets, diagnostics and management of drug resistance. But after over a decade of the existence of the Global Fund and USAID humanitarian activities in Africa, analysts have opined that results have been a reflection of the fact that efforts have continued to be targeted more at control. It is therefore suggestive that frameworks should be expanded to facilitate the translation of existing strategies for a sustained engagement in Africa to one that is exclusively predicated on the

eradication of diseases despite the associated hindrances and political hurdles arising from the target societies.
The Cuban success story is briefly highlighted below as an illustration of how a seemingly poor country can transform its healthcare systems and improve the lives of its citizens. The Cuban model attracted my keen interest following my participation at the LABIOFAM 2012 International Congress and the 2nd International Symposium on Natural Products in the therapy against Cancer held in Havana, Cuba in September, 2011. Having been acquainted with the reformist product and service delivery outcomes, the experience left me with the question, what lessons can the African continent learn from the Cuban success story? How can we integrate these into Multilateral, USAID, Global Fund and UKAID health systems frameworks that have continued to guide healthcare development in the continent? The Cuban government operates a National Health System that assumes fiscal and administrative responsibility for the health care of all its citizens. The state guarantees these rights by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, hospitals, preventative and specialized treatment centers; by promoting regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease". Today, over 100 countries are taking cue from the Cuban approach, which has the same 78-year life expectancy of the U.S despite spending 4% per person annually of what the US does (with an annual total health spend per head of $300 which is about one twentieth of the United States $7,000). Despite a 50 year trade embargo by the United States and a postSoviet Collapse in international support, Cuba has achieved unquestionable success in creating one of the worlds most successful primary care network and an unequalled public health system, freely educating a skilled work force, sustaining a thriving biomedical research infrastructure, and even meeting the emergency health needs of less developed countries. But sadly enough, analysts have insisted that much of the major public health advances in Cuba, and the underlying strategy that has steered its health gains, have been systematically ignored without due regard to the tremendous benefit it would bring to humanity. The silence is said to stand in stark contradiction to the passionate rhetoric emanating from the many multilateral conferences, declarations, and gatherings of world leaders directed at alleviating worlds health challenges. According to the World Health Organization, Cuba provides a doctor for every 170 inhabitants, and currently has the highest doctor-to-patient ratio in the entire world. In comparison, official statistics show that there is one doctor for every 6,400 patients or inhabitant in Nigeria which falls short of the W.H.O recommended one doctor for every 600 persons. The fact that out of the 65,000 registered medical doctors in Nigeria, only about 25,000 are currently practicing in the country contributes in worsening the situation. To meet the WHO benchmark, Nigeria needs over 283,333 doctors (which is far from the estimated 25,000 currently practicing in Nigeria) in order to meet the requirements of a country with a population approaching 170 million. Cuba remains an enigma to the whole world. In 2000, the then Secretary General of the United Nations, Kofi Annan stated that "Cuba should be the envy of many other nations" adding that achievements in social development are impressive given the size of its GDP per capita. "Cuba demonstrates how much nations can do with the resources they have if they focus on the right priorities - health, education, and literacy." The Kaiser Family Foundation, a non-governmental organization that evaluated Cubas healthcare system in 2000 described Cuba as "a shining example of the power of public health to transform the health of an entire country by a commitment to prevention and by careful management of its medical resources. President of the World Bank James Wolfensohn also praised Cuba's healthcare system in 2001, saying that "Cuba has done a great job on education and health", at the annual meeting of the Bank and the International Monetary Fund. Wayne Smith, former head of the US Interests Section in Havana identified "the incredible dedication" of Cubans to healthcare. Dr. Robert N. Butler, president of the International Longevity Center in New York and a Pulitzer Prize-winning author on aging, has traveled to Cuba to see firsthand how doctors are trained. He said a principal reason that some health standards in Cuba are what they are today is that the Cuban system emphasizes early intervention. Clinic visits are free, and the focus is on disease prevention rather than

on treatment which is said to be in contrast to U.S emphasis on treatment.

The current World Health Organizations Country Cooperation Strategy (CCS) in Nigeria focuses on a set of strategic agenda that includes strengthening health systems within the context of Primary Health Care. Under this framework, the strategies for improving access to essential medicines and health technologies is being developed and implemented. Strengthening health information and research systems and supporting the implementation of national health financing policy are some of the positive approaches of this strategy. Nevertheless, these strategies should also place even more greater priority to supporting the financing of an integrated scheme for building and expanding capacity for local production of essential medicines. Local 'primary' pharmaceutical production is a key strategy required to guarantee sustainable, predictable and equitable access to medicines in Nigeria and Africa as a whole. Countries that are succeeding or ahead of the race of reaching the core MDG goals are principally those that have a well-developed local primary production capacity. In acknowledgement of this reality, the African Union (AU) Assembly in 2005 mandated the AU Commission to institute the Pharmaceutical Manufacturing Plan for Africa (PMPA). Unfortunately, Africa with the greatest burden of disease still has the lowest capacity for local drug production and pharmaceutical research & development in the entire world. In Africa, only about 37 countries are known to have some pharmaceutical production capacity, and only South Africa has limited primary production capacity for active pharmaceutical ingredient (API) and intermediates. Currently, local production in Africa is heavily dependent on imported active ingredients. As a result, the continents pharmaceutical supply remains highly contingent on foreign imports, foreign funding and manufacturing. This is further complicated by the fact that stimulating interest in research and development directed at improving African disease burden have received poor attention in a largely market driven pharmaceutical industry. This negates assertions that medical research should be targeted in the direction of greatest need. From 1975 till 2004, only 1.3% of the 1,556 new chemical entities registered were meant for use in tropical diseases even though these diseases have been known to account for 12% of global disease burden. Bearing these limitations in mind, Africa can learn from the Cuban experience at medical research, local pharmaceutical production and the integration of traditional medicine into Medicare. The country presents empirical evidence of the fact that lives have been saved through preventive medicine tools like nutrition and hygiene and an acknowledgement of the fact that traditional cultures have their own healing wisdom. It is also heartwarming to know that there is currently in motion a framework, established by the WHO for the promotion of local manufacturing capacity in countries like Nigeria. The document recommends inter alia that governments can negotiate support for local production by inviting international organizations such as UNCTAD, UNIDO, WHO, and bilateral donors, to support special projects for building local production capacity for medical products. It also recommends that care needs to be taken to ensure that donor initiatives are not working at cross-purposes with private local production initiatives in ensuring greater access to medicine and medical products. A policy framework for local production and access to essential medical products needs to be advocated in countries that are interested in establishing or strengthening local production so that the public health perspective in local production is promoted. Following this recommendation, only six pharmaceutical manufacturing companies in Nigeria comprising firms such as Evans, SWIPHA, CHI Pharmaceuticals, May and Baker, and Fidson Healthcare PLC are said to be in the process of upgrading their facilities with the goal of complying with WHO prequalification requirements. The maiden African Pharmaceutical Summit (APS) held in September, 2013 in Tunisia with over 125 delegates from 29 countries participating in the event, in addition to all other related regional activities shows that African thought leaders are taking the subject of access to medicine by all very seriously. The APS 2013 conference is known to have brought together key stakeholders from across the globe to explore investment opportunities in Africa pharmaceutical sector and deliberate on issues such as the designing of government pharmaceutical policy, drug pricing, sustainable investment mechanisms, regional regulatory harmonization,

and African based research and development. It is hoped that humanitarian concerns took precedence over economic interest during the dialogues that ensued. African governments must take responsibility and leadership in advancing the public health needs of its populace. In recent times, the Economic Community of West African States (ECOWAS) publicly announced intentions to implement Cubas LABIOFAM vector control program which was responsible for the complete eradication of malaria in Cuba in 1967. A country with a record that is second to none in dealing with chronic and infectious diseases with amazingly limited resources.
There is therefore, a need to prioritize public health spending in established priority areas that include sanitizing weak health systems, qualitatively and quantitatively increasing public health workforce, and more directly addressing the needs of marginalized populations in a world where more than one billion people live on less than one dollar a day. The World Bank presents a grimmer future when it forecasts that some one billion people will still live in extreme poverty by 2015. African governments must ensure that amidst the contemptuous atmosphere of international politics, health policy makers must always act in furtherance of their national interest. Irrespective of perceived international politics of pharmaceutical power monopoly by any region or nation, African countries ought to exploit existing apparatuses and competitive advantages to ensure that as a matter of national, regional and continental security, the capacity for sustainable production of required medicines must be established. Africas policy makers must therefore strongly advocate for a new development strategy that builds African capacity to eliminate the burden of diseases. Strategic International Healthcare alliances with nations like Cuba, the U.S and China become inevitable if the continent is to fast-track its success rate in the fight against diseases. Support is needed for an aggressive continental purging of disease promoting organisms through measures that include but are not limited to vector control programs; funding for local primary production capacity; increased funding for research activities into the local development of drugs needed to treat tropical diseases; the stimulation of innovative research on disease, and the implementation of an aggressive disease prevention plan. END NOTES/REFERENCES