Placing people at the heart of African health systemsBMJ 2023 ; 381 doi: https://doi.org/10.1136/bmj.p734 (Published 13 April 2023) Cite this as: BMJ 2023;381:p734
- Githinji Gitahi , group chief executive officer ,
- Ndirangu Wanjuki , country director
Evidence shows that primary healthcare improves health outcomes, equity, and health system efficiency, and that it is the operational strategy for achieving universal health coverage. 1 An average 48% of the population in Africa have access to primary healthcare, which means that the healthcare needs of around 615 million Africans are not being met. 2 As a result, sub-Saharan Africa has a high maternal mortality rate—545 deaths per 100 000 live births. 3 This is a red flag, signalling that the health system needs an overhaul.
For universal health coverage to be universal, a shift is urgently needed from health systems designed around diseases and institutions to those designed around prioritisation of people. Without this shift, health systems will become increasingly inefficient and unsustainable; unable to cope with climate change, epidemics, and non-communicable diseases.
Africa’s response to the covid-19 pandemic highlighted the need for the continent to rethink its health systems, supported by authentic and bold leadership and robust health institutions such as the Africa Centres for Disease Control and Prevention.
How can Africa’s health systems improve? Firstly, African leaders and institutions must do more to empower communities and foster trust in health systems. This change would involve more co-designing and co-leading health initiatives with affected communities, drawing on lived experiences and adopting approaches such as including young people and women on community advisory boards. Empowering communities also requires a shift in the training of the health workforce to embrace promotive and preventive health and move away from prioritising curative medicine over integrated care.
A vital part of empowering communities is enabling citizens to exercise their right to hold governments and donors accountable through civil society-led accountability mechanisms. These mechanisms hold duty bearers accountable to develop and implement policies that fulfil the social justice principles of universal health coverage. They track the extent to which governments fulfil health commitments. Take the case of the Global Alliance for Vaccines and Immunization (GAVI). The alliance is backed by the Gavi CSO (civil society organisations) Constituency of more than 4000 organisations. Among other roles, this constituency engages government leaders, multilateral agencies, the private sector, and communities to strengthen political commitment, enhance accountability, build trust in vaccines, and support the delivery of immunisation services so that no one is left behind.
Countries in sub-Saharan Africa that have invested in health systems that are both accessible and trusted by communities are reaping the rewards. In 2020, the unweighted average maternal mortality rate in five countries in the region that ranked highly on the universal health service coverage index (South Africa, Namibia, Eswatini, Kenya, and Zambia) was 249 deaths per 100 000 live births. In stark contrast, the average maternal mortality rate among those countries that ranked the lowest on the index (Madagascar, Central African Republic, South Sudan, Chad, and Somalia) was 827 deaths per 100 000 live births. 3 4
Secondly, governments of African countries must embrace a whole-of-society approach, welcoming partnerships between sectors. Many African governments managed the covid-19 pandemic by working with the private sector, civil society, research institutions, media, and political leaders to save lives and strengthen the resilience of communities by tackling socioeconomic effects such as livelihoods and food security. This move to whole-of-society approaches can enable the continent to improve social determinants of health, such as education and income. Similarly, civil society organisations and the private sector have unique ability and confidence of communities to deliver last-mile services to people living in remote areas. For example, across multiple African countries, the Global Fund has financed civil society organisations to facilitate community health volunteers to diagnose and treat people with malaria at home using rapid diagnostic and treatment kits, greatly increasing access and saving lives.
Thirdly, health financing must be reformed to support people-centred healthcare. Between 2000 and 2019, one in six households in sub-Saharan Africa experienced a catastrophic expenditure when seeking healthcare. 5 Reforms can include improving tax efficiency and increasing the percentage of gross domestic product allocated to healthcare—although more is needed. Take Lesotho as an example—by 2020, this country had the highest health expenditure (11.8% of its gross domestic product) in sub-Saharan Africa, up from 5.6% in 2000. 6 Despite this high expenditure, the maternal mortality rate remained high: 545 and 566 deaths per 100 000 live births in 2000 and 2020, respectively. 3 This dissonance suggests that the increased financing did not lead to a robust people-centred health system.
Fourthly , Africa’s governments and development agencies urgently need to invest in data science to extract meaningful information from existing demographic and health surveys. For example, Kenya’s 2021 demographic and health survey showed that although skilled birth attendance was close to 90%, maternal mortality remained high, emphasising the need to tackle systemic gaps in health systems that impede access to quality and affordable healthcare throughout sub-Saharan Africa. 3 But data science without learning within the health ecosystem is like pouring water on sand. Africa-led learning platforms such as the Africa Health Agenda International Conference (AHAIC), held in Kigali, Rwanda in March 2023, must be a core part of a reform agenda. Key insights from this conference include the urgent need to protect health workers, build partnerships that care about Africa, prioritise public health security and mitigation of the effects of the climate crisis in health systems strengthening, and make diversity and inclusivity a core principle in health investments.
Finally, the definition of health systems must be reformed. The World Health Organization health systems framework focuses on leadership and governance; service delivery; financing; health workforce; medical products, vaccines, and technologies; and health information systems as the six building blocks of a health system. This framework must be revised to include people as the seventh foundational building block. Tools and guidelines must accompany this shift to enable practitioners to make health systems more people centred.
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.