The views expressed are those of the author and do not necessarily reflect the position of FORESIGHT Global Health.
Prevention is better than cure. Never has that age-old proverb been more applicable than to non-communicable diseases (NCDs). Control of NCDs has become a top-of-mind health care concern in countries with improving economies—and for good reason. In Sub-Saharan Africa (SSA), 34% of deaths are now attributed to NCDs, up from 23% in 2001, where they start to hit people a decade younger than is commonly seen in more developed regions. Indeed, without more preventative action, NCDs will become the leading cause of mortality and morbidity in SSA within 20 years, exceeding the toll from communicable diseases.
Already strained healthcare systems further burdened by the covid-19 pandemic are struggling to pay sufficient attention to NCDs, the presence of which are a known factor in serious illness and death in people who contract the novel coronavirus. Investment in NCD prevention would lighten the financial burden by reducing spending on treatment and care.
Prevention is a cost-effective policy. Money is saved on expensive training of physicians specialised in NCDs and on the purchase of costly diagnostic equipment and drugs. In a country like Tanzania, where in US dollars a typical monthly salary in rural areas lies between $100 and $255, the $26 average monthly cost of hypertension drugs can make up 26% of family income. The overall cost of diabetes in SSA is $20 billion, or 1.2% of gross domestic product, with 55% of that in direct medical costs. Preventative care helps avoid these costs. It needs to be prioritised.
Prevention is a cost-effective policy. It needs to be prioritised
A main way of doing so is through the use of Community Healthcare Workers (CHWs) outside the formal healthcare system. They can provide communities with affordable preventative care, which decreases the burden on formal healthcare. CHW is a catch all term for various types of community-located health aides, selected, trained, and working in the communities in which they live. Their low training and salary costs are critical to scaling the service and their strong local ties generate community trust.
Budgetary restrictions, however, driven by a lack of recognition of the role of CHWs as formal healthcare providers, are a major barrier to their widespread use. CHWs are largely underpaid, underutilized, and not fully recognised as healthcare providers as they are often recruited as non-salaried workers. An added problem is that the current system is not sustainable. Most CHWs are funded by donors and retaining their services is a challenge once donor programme funds run out.
BUSINESS MODEL SOLUTION
One solution for a sustainable CHW system is to base it on the business models of global brands like Avon, with CHWs operating as door-to-door sales representatives, selling a variety of services and products to patients at marginal cost and earning a living by doing so. Families would pay a modest subscription or service fee for a range of care offerings, from personalised NCD preventative advice to the promotion of healthy eating habits, physical fitness and mental health counselling.
A variation on the theme is a fee-for-service approach, with charges for specific services. The model has been a success in Uganda where it is operated by Living Goods, a non-profit organisation with headquarters in San Francisco and similar programmes elsewhere. Living Goods wields its purchasing power to make bulk acquisitions of health products at reduced prices, which are provided to patients by the programme’s “community health promoters”. CHWs supported by Living Goods have reduced mortality in the under-five age group by 27% and stunting by 7%, all for less than $2 a person a year.
Sales of products by CHWs yield small commissions to make it worth their while. Products can range from locally produced food to medication, mosquito nets, water purification tablets, and oral rehydration salts. CHWs could eventually also serve as sales agents for affordable micro-insurance policies, bridging a health insurance coverage gap across emerging economies.
SECRET TO SUCCESS
The Avon model is not without its challenges. Limited access to technical resources and the right drugs at the right time lead to low productivity and make the system inefficient. Communities can be sceptical of CHWs, limiting sales and fair compensation, which challenges the model’s financial sustainability. For the model to be successful, community trust in CHWs has to be created.
CHWs must be embedded in the communities they serve. They should be elected by community residents to encourage trust and transparency. Strong familiarity can help CHWs form lasting commercial relationships with communities and create more long-term business opportunities. CHW networks must reflect the composition and needs of the communities they serve, taking account of cultural and societal barriers. The nuanced understanding that comes from relating to patients can improve CHWs’ abilities to recommend and sell heath products, even those deemed controversial in certain communities.
A clear governance framework has to be in place, defining roles and responsibilities for actors in the ecosystem, including CHWs. The aim is to align community healthcare with local governance structures and initiatives. A common procedural approach helps ease access to essential resources needed by CHWs, including medical equipment, drugs and assistance for more complicated cases.
CHW networks should also leverage digital technologies to improve the effectiveness and efficiency of the services they provide. The existence of centralised digital platforms enables CHWs to upload and share patient data, facilitating referral of patients to primary healthcare providers and the collection of epidemiological data for initial mapping of disease outbreaks. Digital platforms also make it possible for CHWs to monitor how well patients are adhering to treatment and allowing them to share continuous reminders with their patients without the need for doorstep visits. Efficient processes allow CHWs to be more effective and productive and provide them with time to secure new clients.
With NCD treatment affordability and availability still a key issue across many countries, leaning towards preventative models is crucial for halting the NCD surge. CHWs are a significant part of healthcare ecosystems in developing countries and have been successfully implemented in some SSA countries, including Ethiopia, Rwanda, Zambia, Zimbabwe, and South Africa, where they have been instrumental in tackling tuberculosis, HIV/AIDS, and now covid-19. With that experience to lean on, CHWs can be leveraged to help promote and scale wellness initiatives in specific countries that prioritise preventative care. Nothing should hold us back from investing in this proven and cost-efficient preventative care model and lessening the burden on healthcare systems and citizens. •
TEXT – Devang Vussonji is the Tanzania Director for Dalberg Advisors. He advises public and private sector clients on health care, agriculture, rural development and youth unemployment.
Heri Marwa is the Tanzania Country Director for PharmAccess Foundation. He is a qualified Medical Doctor and holds a MA in health policy and financing.