Before the covid-19 pandemic, Modupe Abayomi, a primary care nursing officer in southwest Nigeria, worked passionately to help her overweight patients to better health. Patient waiting time for doctor appointments was used for counselling and awareness sessions, with lessons given in how to monitor and control body mass index (BMI); obesity sufferers were taught how a better lifestyle would lower their risk of diabetes, cardiovascular disease and other chronic conditions, collectively known as non-communicable diseases (NCDs).
As covid-19 took hold, however, frontline health workers had less time to spend with each patient. Ancillary services such as Abayomi’s were among the first to be hit. So too were medical outreach sessions held by the Nigeria-based African Development and Empowerment Foundation, where volunteers provided blood sugar, blood pressure and BMI tests free of charge. Supplies for the tests came from local health authorities and charitable donations, but that support pivoted to focus on Covid-19 interventions, says the foundation’s Victoria Feyikemi.
“Our ability to help patients with previously undiagnosed diabetes, obesity, hypertension and other NCDs has been greatly hampered and we don’t know when, or if, things will go back to normal,” she says.
The change in priorities has occurred despite evidence that those with NCDs are more likely to die from covid-19 than others, an argument for increased spending on treatment and prevention of chronic conditions rather than diverting money away from them. As it is, the neglect of NCDs is expected to see them surge, with pandemic-pressured health centres unable to cope with the rising caseload.
Even so, Johanna Ralston, who heads the World Obesity Federation, believes the evidence that obesity is the second greatest predictor of death and morbidity from covid-19, after age, will make health policymakers take a closer look at NCDs.
“The countries that are doing worst on obesity have the highest number of covid deaths,” she points out. The ability of countries to successfully manage an NCD surge will largely depend on their economic strength. Developed countries with deep pockets and extensive health systems are better positioned to rise to the challenge than low-and-middle-income countries (LMICs). The economic impacts of the pandemic on LMICs could further reduce financial allocations for health, with the risk that NCDs will be ignored, despite the long-term damage to economies that endemic ill-health results in.
DECADES OLD DEFICIT
Lack of spending on NCDs is not a new problem. Twenty years ago, in April 2001, a gathering of heads of state of African Union countries in Abuja, Nigeria’s capital city, agreed on the Abuja Declaration, pledging to allocate at least 15% of their annual budget to the health sector. Ten years later, the World Health Organization (WHO) noted that only three countries out of 55 were on track to meet the target. Covid-19 has only made matters worse.
Typically, countries struggling with inadequate funding for health services are those with economies already ravaged by terrorism, environmental degradation and inflation. Education, social welfare, agriculture, unemployment, and other needs compete with healthcare for scarce budgetary resources
Health spending in poorer countries tends to be reactionary rather than proactive, with urgent demands attracting investment away from NCDs
WHERE IS THE MONEY TO COME FROM
NCDs were not a top priority for many LMICs prior to covid-19. Health spending in poorer countries tends to be reactionary rather than proactive, with urgent and pressing health demands attracting funds away from much-needed investment in NCDs. A common perception is that chronic conditions do not kill people quickly, though statistics on unmanaged NCDs suggest otherwise.
Prior to the pandemic, the primary health issues that required urgent attention were malaria, HIV/AIDS and tuberculosis. But these suffered a similar fate to NCDs when covid-19 quickly spread across the world.
WHO has called for more money to be spent on healthcare. It proposes increasing government healthcare budgets, the introduction of compulsory or voluntary prepaid insurance policies, direct out-of-pocket payments by users, and provision of external aid to LMICs. By pooling the various money streams into pre-paid funds on behalf of some or all of the population, adds WHO, the funds can be used to buy health services or to allocate resources to health service providers.
WHO’s regional office for the eastern Mediterranean stresses primary health care as the principal avenue for managing. “People with non-communicable diseases, or at risk of developing one, require long-term care that is proactive, patient-centred, community-based and sustainable,” it says. “Such care can be delivered equitably only through health systems based on primary health care.”
PRIMARY CARE AND INSURANCE
People most frequently enter the health system at the primary care gateway, where the chances of detecting individuals at high-risk of an NCD are good, even though their initial contact can be for other health reasons. As such, the primary care route is a highly affordable and equitable option for reaching and treating those with NCDs, says the WHO regional office. The theory is being practised by a number of LMICs, including El Salvador.
Since 2009, the Latin American country has scaled up its national public health system based on a broad primary care system. A key component of the strategy is a comprehensive and inter-disciplinary approach to NCDs.
Despite the potential financial savings from taking a primary health care-driven approach to preventing and managing NCDs, some countries are reluctant to make an investment of scarce resources for what are mainly long-term returns. Health insurance, however, can close the gap between immediate need and long-term benefit. Properly structured, a national insurance system for health care provides the means for better preventative capacity while meeting the short, medium and long-term needs of individuals and families living with NCDs.
For all its faults, the British National Health Service (NHS) is an insurance system that works. When Gladys [not her real name] decided to emigrate from Africa to Europe, she chose the United Kingdom because its NHS guaranteed her entire family access to health services without having to prioritise a specific health issue.
“Breast cancer, hypertension and diabetes run in my family. This is why I need a reliable health system that allows me to access early prevention and management services before the prognosis becomes poor,” Gladys says. Living in London means regular health screenings and medical examinations, including mammography and screening for cervical cancer, all of which are covered by the NHS rather than directly charged to the recipient. In LMICs, such national health insurance services are struggling to take off.
KENYA SHOWS THE WAY
Even in many LMIC with health insurance systems, NCDs tend not to be included, deterring people from buying into a policy. Kenya, where NCDs are integrated into health insurance, is an exception. Here the pandemic has helped drum up support for NCD care and could potentially result in an increase in the number of subscribers signing up for health cover.
Kenya is one of the few African countries where cancer treatment is available under a national health insurance system. In Nigeria, up to 89% of breast cancer patients pay out-of-pocket, compared with a high of 20% in Kenya, according to a 2019 study in the Journal of Clinical Oncology.
Kenya’s National Hospital Insurance Fund (NHIF), established in 1967 as a department within the health ministry, is the country’s largest health insurance provider. It aims to grow its membership from seven million in 2018 to 19 million by 2022 under the national and universally available SUPA Cover policy. Members receive health insurance coverage for hospital visits at more than 8000 NHIF-contracted hospitals (private and public) across the country. Monthly rates for those in the informal economy are a fixed 500 Kenyan shillings (KES) and for those informal employment they range from KES 150 to KES 1700. The service also provides coverage for those it describes as “disadvantaged” through government-sponsored programmes.
As well as providing coverage for a range of services from outpatient consultation and procedures to health education and vaccine immunisation, NHIF’s benefit package also covers NCDs, including diagnosis and management of diabetes, renal dialysis, radiology and chemotherapy for cancer treatment.
HEALTH TAXES AND POLITICAL WILL
For citizens to gain sufficient trust in a health insurance service to contribute to it can take a while, especially in countries where most employment is in the informal sector. The World Bank has advocated introducing taxes to fund universal healthcare in the wake of covid-19. In a March 2021 report, From Double Shock to Double Recovery—Implications and Options for Health Financing in the Time of Covid-19, the bank points out that in LMICs, the healthcare sector is in a position to drive tax reforms and mobilise and absorb external financing.
The report also recommends introducing or increasing taxes on health damaging products like tobacco and alcohol. As a way of raising money for healthcare in LMICs, the idea is supported by the World Obesity Federation’s Ralston. She notes, too, that making toxic substances less available could help prevent some NCDs.
“We can restrict access to unhealthy foods and sugary beverages by putting taxes on them. The evidence for putting taxes on sugary drinks shows it definitely works. So, in addition to other measures, we are strongly encouraging countries in Africa to have sugar sweetened beverage tax,” she says.
We need healthy populations, we need healthy institutions to be able to do whatever else we need to do
The risk of a post-pandemic surge in NCDs in Africa has not gone unnoticed in political circles. Rwandan President Paul Kagame stressed the urgency of increasing health sector financing to bolster pandemic-weakened systems at a virtual conference on vaccine manufacturing in Africa in April 2021.
“I think every one of us should be considering health spending from our resources as probably the number one priority, because if we get that right, then it enables us to deal with other priorities… We need healthy populations, we need healthy institutions to be able to do whatever else we need to do that is a priority,” Kagame said.
Africa’s most populous country, Nigeria, has also pledged to improve its health financing.
“We will always prioritise the health sector’s funding,” said Zainab Shamsuna Ahmed, finance minister, in March 2021. “Despite the failure to meet the 15% commitment [of the Abuja Declaration], Nigeria has progressively funded the health sector with incremental funding,” he added.
NEW IDEAS FOR FINANCING
Despite such commitments from LMICs, plans for how to increase health sector funding are few and far between. Some options are emerging, however.
Abdul-Rahman Lediju, director of innovative finance at the Health Finance Institute (HFI), based in Washington DC, argues that access to health services can prevent chronic diseases by early screening and diagnosis of NCDs. The institute’s approach to establishing such basic care services in LMICs is to design and implement financing solutions through public-private partnerships, he says.
HFI is working to design a financial structure to stimulate research and development in mass production of new diagnostic devices that can be used to better monitor the progression of chronic diseases, such as diabetes, in LMICs and remote communities located at the “last mile” of medicine and health care delivery. Under this instrument, manufacturers would be asked to mass-produce the instruments, backed by a guarantee from a mixed pool of government, philanthropic, and corporate funding. This would give manufacturers the incentive to develop and produce the devices needed, since they would have a guaranteed market.
One HFI project is focused on stimulating development of glucose-monitoring devices for type 1 diabetes targeted at “last mile” patients by securing advanced market commitments for their purchase. The specialised monitors would allow patients at the far end of the health supply line to better control and manage their disease. Another project assists financing of early-stage companies that marry digital solutions with physical infrastructure solutions to improve “last mile” healthcare delivery. Ultimately, he adds, this sort of financial mechanism can help release bottle-necks at the R&D and manufacturing stages of the device supply chain.
Convincing LMICs to make the long-term financial commitments needed to support initiatives like those of the HFI is a daunting task, particularly when they are struggling with weak economies under pandemic pressure. But Lediju says it can be done. The economic case for such investments is sufficiently compelling, he argues.
“I think that the health systems that invest in the right prevention and the right care infrastructure can then be in a position to help [people living with NCDs] maximise their economic output for the good of their community and for the good of society. What we need here is to make that case consistently to local health systems, local ministries of health, to appreciate that link between chronic disease and economic output,” he says. “If that’s done, then there’s a clear path for that buy-in.” •
TEXT Paul Adepoju – PHOTO Lars Just and Unsplash