Re-engineering Resilient Systems for Health to Manage Current and Emerging Health Challenges

Introduction:

The recent COVID-19 pandemic once again demonstrated to the world why investing in health makes economic sense. Earlier on the Ebola Virus Disease outbreak in West Africa between 2014 and 2016 showed how investing in vertical health programs without strengthening systems for health was counterproductive. By the time the epidemic was ending, most of the gains in maternal and child health, malaria, Tuberculosis and HIV had been wiped out.

The world is now grappling with unprecedented health challenges and their risk factors abound. While infectious diseases- new and old, cause a high burden of morbidity and mortality, the emergency of non-communicable diseases as leading causes of poor health has caught most of the developing world by surprise. The causal inter-relationships between communicable and non-communicable diseases is becoming significant and clearer. The major risk factors including nutrition, lifestyle changes, environmental changes, climate change, human activities, and weak systems for health are all working in concert to expose millions of people in Africa to higher levels of illness, disability and premature mortality.

Health Systems are a cornerstone in the prevention, detection, and management of the current and emerging health challenges. However, the current state of health systems does not match the level of investment, technical support, technological sophistication, and accountability needed to address the challenges we face. We have identified a limited number of health systems entry points which if well addressed might have great impact in terms of building, improving and mainstreaming accountable systems for health.

• Addressing the challenge of emerging and re-emerging infectious diseases

Emerging and re-emerging infectious diseases have a lot to do with the changes in environment as well as human activities including irrational use of antimicrobials.  Even where cost-effective interventions for prevention are known, their use is suboptimal. Detection of outbreaks is weak because surveillance systems are weak and quickly get overwhelmed when epidemics occur.  The One Health Approach envisages acting on a triad of human health, animal health and the environment. Antimicrobial resistance is currently considered a global public health issue as many antimicrobials are no longer effective and yet fewer new drug classes are becoming available. In this work program we want to address the following questions:

1. a) Why is prevention of major diseases not working?

Vaccines have been at the center of prevention of major diseases some of which have been eradicated like smallpox or nearing eradication like polio. Over the years, the technology in vaccine development and manufacturing have improved, meaning that vaccines can be made available quicker as was the case for COVID-19. However, major challenges remain and these form part of the areas we need to support. We will investigate the following issues: vaccine hesitancy; vaccine nationalism; weak vaccine delivery systems and lack of vaccine research platforms.

1. b) Why are surveillance systems not working?

Surveillance is at the center of early disease detection and response. The Global Health Security undertaking places disease surveillance at the center of global and national plans to detect, respond and manage potential health threats. When COVID-19 broke out, few countries in the global south had capacity to carry out diagnostic tests, and reporting and sharing knowledge was haphazard. Majority of the countries in Africa do not have functioning civil and vital registration systems. Alternative sources of mortality through use of verbal autopsies can be leveraged. We plan to support improvements in disease surveillance by working with governments and partners such as the USA government to strengthen diseases detection and reporting on the continent through:

1. i) Advocating for building capacity at national level in terms of human and laboratory capacity,
2. ii) Streamlining reporting systems and information sharing

iii)  Conduct special prevalence and incidence studies on key diseases such as HIV, TB, Malaria, COVID-19 and neglected tropical diseases.

1. iv) Use data from health and demographic sites in study and track mortality trends and ascertain causes of death using verbal autopsies.
2. c) Antimicrobial stewardship:

Antimicrobial resistance is growing and unchecked with several classes of antimicrobials becoming ineffective.  Several drugs against tuberculosis, HIV and other bacterial infections are currently ineffective. The global community developed the Global Action Plan on Antimicrobial Resistance and most countries have developed National Action Plans. The implementation of this remains a mirage. Irrational drug use in human and animal health is unchecked as well as the discharge of antimicrobials in the environment. We plan to support governments to actualize their action plans through strengthening the antimicrobial stewardship through three entry points:

1. i) Support Policy implementation
2. ii) Assess and make recommendations on Antimicrobial use in humans

iii)   Assess and make recommendations on Antimicrobial use in the food systems and the environment.

• Making Universal Health Coverage work in sub-Saharan Africa

Inequity in access to health services is part of the reason some health challenges with known cost-effective interventions still persist. Inequitable access to services is brought about by many factors including lack of appropriate information, distance to service points, cost barriers, stigma and discrimination, quality of service and other contextual factors. Universal Health Coverage has been fronted as an important solution under Sustainable Development Goal 3. The intention is to have individuals access quality services from wherever they are, and when they need them without facing financial barriers at point of service. Here we plan to:

1. Design and test innovations to improve prevention and health promotion interventions for selected health challenges: chronic diseases (HIV, tuberculosis, malaria, diabetes and hypertension) and vaccine preventable diseases. The risk factors for these are known and yet utilization of prevention interventions is limited. We will explore the impact of using community health workers in improving health behaviours for disease prevention and management.
2. Test Digital Health Financing to Address Financial Risk Protection: Most people in the region have no access to medical insurance and pay out of pocket to purchase health services. We aim to harness the power of digital health to test innovations that will improve financial resource mobilization, pooling and purchase of health services. 

• Multimorbidity

In the era of double burden of infectious and non-communicable diseases (NCDs), simultaneous occurrence of two or more diseases (multimorbidity) is bound to happen in an individual. This is especially true in low and middle-income countries (LMICs), which still bear the bulk of the burden for infectious disease while also battling a new threat from the rapid emergence of non-communicable diseases and malnutrition. Multimorbidity increases costs in the healthcare systems and to patients alongside gaps in quality of healthcare since it typically challenges the single-disease framework, which most healthcare delivery systems adopt, and how health research and interventions are accustomed to. It is also associated with increased risk of mortality, disability, poor functional status, poor quality of life, and adverse drug events often occasioned by polypharmacy.

Multimorbidity research has received increasing attention in recent years but more so in the developed country settings and among older adults aged 60 years and above. With the increasing prevalence of chronic conditions occurring among younger age groups (40–60 years), especially in LMICs, the occurrence of multimorbidity is expected to rise. Multimorbidity is a public health concern due to its association with high costs to healthcare systems and individuals, strain on quality of healthcare and increased risk of mortality, disability, or poor quality of life. Multimorbidity therefore requires prioritization by states and other key actors, considering the broader implications of multimorbidity, such that resources and the public health system are well placed to adequately address this issue. The proposed research program aims to contribute evidence and knowledge to support the delivery of appropriate, responsive and integrated health services to patients with multimorbidities in sub-Saharan Africa. We aim to do through:

1. Designing Task-sharing models including use of Community Health Workers
2. Developing and test self-care models
3. Healthcare financing and financial risk protection
4. Health services delivery integration.

Why should this proposed work be funded?

All the ideas proposed in this concept align with APHRC’s 2022-2026 Strategic Plan, specifically for the scope of work envisaged in the Health and Wellbeing research Theme. The five units within the HaW Theme will work together in developing and implementing the proposed actions. We also intend to work with the Policy Engagement and Communication unit as well as Population Dynamics and Urbanisation on defining scope of work in the environment and food systems. Over the next 9-12 months, the team leading the work from APHRC will engage with ministries of health in the six countries (Kenya, DRC, Senegal, Ghana, Burkina Faso and Malawi) and at least one research institution in those countries to co-create and concretize the proposed and or add new ideas. The proposed work will involve capacity building in research, action and policy engagement for lasting impact. The proposed work will involve a wide range of stakeholders because we are cognizant of the fact that none of the actors on their own will bring about lasting impact. For that reason we will deliberately involve research institutions, ministries of health, environment, agriculture and food systems (standards and quality control). In the co-creation workshops, we intend to invite at least two funders (Bill and Melinda Gates Foundation and USAID/NIH). With the seed funding from APHRC, we are confident that we will collaboratively develop a multi-year, multi-country research program on improving systems to deliver better health.

Our Approach (Activities)

1. i) Analysis of our own existing data and other data
2. ii) Desk reviews

iii) Co-creation with Ministries of health for six countries (Kenya, DRC, Senegal, Ghana, Burkina Faso and Malawi).

Budget considerations:

The total budget for this activity is approximately 55,000 USD. See the budget below

Activity timelines