FORESIGHT Global Health - Spring Issue by FORESIGHT Media Group

FORESIGHT — 02 Global Health

On the steps of recovery IN SEARCH OF A NEW DIRECTION FOR BETTER HEALTH CARE

GLOBAL HEALTH POLICY

SPECIAL REPORT

HEALTH FINANCE

TECH & INNOVATION

Integrated health care must happen

Medicines that changed the world

Make the link between NCDs and growth

Treatment by video is here to stay

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REBUILDING FOR A HEALTHY WORLD

Recovery builds momentum for change

FORESIGHT Global Health SPRING / SUMMER 2021

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EDITOR Andrea Chipman andrea@foresightglobalhealth.com

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More than a year after covid-19’s arrival, the disparities in global health appear to be wider than ever. While a small group of welloff countries with high rates of vaccination are slowly returning to some semblance of normal life, the majority are still struggling to tamp down outbreaks and in some cases provide basic care for those seriously ill with the virus. Covid-19’s transformational impact on the health sector has laid bare the need for more equitable access to care and sparked strong momentum for change. The time is ripe to set a new direction for a health sector that is more financially stable and serves all the world’s population. A reworked sector must provide treatment for non-communicable diseases (NCDs) that too often receive scant attention, a neglect that has dire human and financial consequences, as the pandemic has made clear. Rectifying health inequalities will require countries to overcome political intransigence as well as structural barriers—technological, financial and workforce related. “Building back better” has become a common refrain and better access to health care is a key step on the ladder to recovery, especially with regard to NCDs. No longer should NCDs fall victim to other pressing health demands. A less fragmented and more integrated approach to care will be a crucial part of rebuilding health systems that are more efficient and responsive and better value for money. Frequently overlooked NCDs must be included, notably mental illness, which is expected to peak after the isolation and upheaval of a year of lockdown. Policymakers also have to take stock of the way virtual patient care has expanded during the pandemic and determine which areas can be integrated on a permanent basis to make health care provision more effective and accessible. For global health, 2021 is a significant year. It marks 100 years of medical development since the discovery of insulin and is the year in which the roll-out of covid-19 vaccines started, at least for some countries. In our special report, we ask what we can learn from the past 100 years of extraordinary progress in medical treatment, how we can spread innovation more equitably and what the future of medicine looks like. The development and launch in less than a year of several novel vaccines is an inspiring example of the global ability to tackle health challenges, given the will to do so. Around the world leaders need to summon a matching level of imagination and resolve to tackle the pressing need for a global health infrastructure that is fit for purpose.

Andrea Chipman EDITOR-IN-CHIEF

CONTENT

GLOBAL HEALTH POLICY

SPECIAL REPORT

HEALTH FINANCE

TECH & INNOVATION

INTEGRATED CARE HAS TO HAPPEN

MEDICINES THAT CHANGED THE WORLD

LINKING CHRONIC DISEASE AND ECONOMIC OUTPUT

VIRTUAL TREATMENT IS HERE TO STAY, THANKS TO THE PANDEMIC

Medical discoveries have made NCDs more manageable

Regions with pandemic-ranged economies will struggle to finance the expected surge in cases of chronic ill-health

Telemedicine start-ups are growing and many are targeted at disadvantaged communities

The pandemic has shown that NCDs and infectious diseases are closely linked and health systems must be reformed accordingly PAGE 4

KENYA SHINES A LIGHT ON AFRICA’S MENTAL HEALTH CRISIS

African policymakers are increasingly committed to combatting poor mental health but many obstacles remain PAGE 10

INSIGHTS

A small group of professionals is helping put mental illness on the African health agenda PAGE 14

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LANDMARK DISCOVERIES WITH STAGGERING IMPACT

New treatments have helped people with NCDs live normal life spans PAGE 18

FAKE DRUGS AND PROTECTING THE VULNERABLE

NCD medicines offer huge promise but are out of reach to many PAGE 24

MEDICAL ADVANCES HOLD PROMISE FOR A BETTER WORLD

Five global experts offer a glimpse of the kind of innovations we may see in the future

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INCREASING RISK FACTORS HURT ECONOMIC GROWTH

OPINION: TO MANAGE SYNDEMICS THINK LIKE AN OCTOPUS

Better prevention of NCDs could avert millions of years of lost productivity

Reimagining health care will require both efficiency and exploration

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OPINION: COMMUNITY HEALTH WORKERS KEY TO AFFORDABLE NCD PREVENTION

Local health care workers will play a critical role in providing affordable preventive care PAGE 46

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FORESIGHT

PATIENT NEEDS ARE HOLISTIC ACROSS NCDs AND INFECTIOUS DISEASES The covid-19 pandemic has illustrated how chances of recovery from a severe infectious disease are strongly influenced by the presence, or not, of a non infectious disease. People without underlying health issues are far less likely to succumb to covid-19. As societies age, health care must better integrate the care of NCDs with that of other diseases. It will save both lives and money

he coronavirus pandemic has left little untouched, health services and systems included. Non-communicable diseases (NCDs) have heavily contributed to severe disease and death from covid-19, emphasising the close relationship between NCDs and infectious disease (ID), and reinvigorating the need for policies and plans for improved integration of health care. Covid-19 has hit high, middle-and-low-income economies alike, and become a huge stress test for different countries. “One would never think that high-income countries with advanced healthcare systems would be put in serious difficulties by an infectious disease, but they were,” says Cherian Varghese, cross-cutting lead for NCD and special initiatives at the World Health Organization (WHO). “This brought in a new realisation about the need for preparedness for IDs and better control of NCDs and we need to build back better and be better prepared.” The pandemic has provided a tiny glimpse of a 4

growing, global problem. People living with more than one disease (NCD or ID), so-called multi-morbidity, usually die younger and experience greater physical and social impairment, and poorer quality of life. Estimates of the proportion of people living with multi-morbidity range between 14% and 68% in low-and-middle-income countries. The data reinforce the need to avoid treating NCDs in isolation and present a clear opportunity to further integrate the care strategies for people with multiple illnesses. Richard Sullivan, professor of cancer and global health at King’s College London, worked during past peaks of the pandemic in clinical care of covid-19 patients and on international biosecurity aspects. He highlights the impact of obesity/overweight on disease severity. “We had wards full of people who had serious weight issues,” he says. Covid-19 has exposed public health weaknesses, Sullivan points out. “Covid-19 has shown us the vulnerability of ageing societies and poor public health. FORESIGHT

One health Covid-19 has reinforced integrated care of infectious and non-communicable diseases as core to better healthcare

TEXT Becky McCall ILLUSTRATION Trine Natskår

Integrated health care has to happen

GLOBAL HEALTH POLICY

FORESIGHT

GLOBAL HEALTH POLICY

As our societies become older and sicker, there is little sign of compression of morbidity and as such we are losing our intrinsic resilience. The covid-19 pandemic has ruthlessly highlighted unhealthy lifestyle and obesity.”

DUAL DISEASE BURDEN NCDs are often referred to as chronic diseases and are categorised into five main groups: cardiovascular diseases (CVD), cancers, chronic respiratory diseases, diabetes, and mental disorders. Together, they account for 63% of all deaths (36 million out of 57 million global deaths) and 80% in low-and-middle-income countries. Over the next decade, the prevalence of NCDs will increase by 17% globally and in Africa by 27%, stressing the acute need to find a workable way to manage the burden, especially in lower income countries. The problem is compounded by the added burden of infectious diseases. Novel data from a study tracking the development of NCDs in people diagnosed with HIV between 1985 and 2017 shows that, on the one hand, there has been an encouraging decline in death rates over the course of the HIV epidemic, but on the other, this success has been somewhat marred by the persistent higher burden of NCDs in the HIV-positive population. At the ten year follow up, the study found that the proportion of HIV-positive individuals with at least one NCD increased to 42% from 24% a decade earlier. In particular, the ten-year cumulative incidence of liver disease was nine times that of the control group without HIV; and kidney disease was found in 4.1% of people with HIV, compared to 1.2% of those without HIV.

LOW-AND-MIDDLE-INCOME COUNTRIES STILL LAGGING BEHIND NCD management has a mixed history. Prior to World War II, North America and Europe improved their health primarily due to advances in hygiene and sanitation. As living standards improved, life expectancy increased and NCDs became more common. LMICs lagged behind and around the mid-20th century, infectious diseases, combined with malnutrition and poor maternal and child health plagued these regions. In 1978, the Alma-Ata declaration articulated the need for comprehensive primary healthcare for all countries. Many of these best intentions later got waylaid when the Millennium Development Goals siphoned much of available funding into disease specific initiatives, typically HIV/AIDS, malaria, and tuberculosis. Universal healthcare programmes that addressed the burden of NCDs took a backseat, says WHO’s Varghese, co-author of a 2019 report, Better Health and Wellbeing for Billion More People: In6

tegrating Non-Communicable Diseases in Primary Health Care. In lower-income countries in Africa and Asia, the effort to control infectious diseases has paid off, with people living longer over the past 25 years. But at the same time, as life expectancy increased, people started to shift from typically active, rural lifestyles to more sedentary and urban living. The change was reflected in a rise in NCDs. Likewise, NCD risk factors also rose, notably obesity, poor diet, tobacco and alcohol misuse.

“In India, for example, health services are dealing with outbreaks of malaria and dengue at the same time as managing cancer services”

Despite significant improvements, infectious diseases persist in low-and-middle-income countries. Moreover, as seen with covid-19, not even high-income countries are immune to the devastating effects of such diseases. Sullivan, in his global health role, has worked across Afghanistan, South Sudan, India and Pakistan. “There is a paradox between the healthcare available for NCDs and that for infectious diseases in many low-and-middle-income countries,” he notes. “In India, for example, health services are dealing with outbreaks of malaria and dengue at the same time as managing cancer services. The Tata Memorial Centre in Mumbai delivers cancer care equivalent to a comprehensive cancer centre in the US, while in the same city people are succumbing to infectious diseases and malnutrition.”

OPPORTUNITY KNOCKS Varghese compares managing infectious diseases to a 100-metre sprint, while NCDs are a marathon. “The health system is not prepared to look after this person who is running a very long distance. This is currently a fundamental weakness, but we can start to tackle it by some of the new approaches that came out of the pandemic and through universal health coverage,” he says. By way of example, he mentions the rapid approval of some medicines for the treatment of covid-19: the generation of evidence was fast tracked to show that systemic corticosteroids rather than no corticoFORESIGHT

GLOBAL HEALTH POLICY

Multi-morbidity is a growing problem globally

SOURCE UNAIDS, 2011; WHO, 2011; WHO Europe, 2017

Many people live with non-communicable and infectious diseases simultaneously

Of all cigarettes smoked globally one-third are smoked by people with a mental disorder, increasing their risk for lung diseases and cancer

For people with diabetes the risk of tuberculosis is 2-3 times higher than for people without diabetes

People living with HIV are at increased risk of developing a range of NCDs, including cardiovascular disease, diabetes, chronic lung disease and cancer

About 25% of people living with cancer have a mental disorder such as anxiety or depression

steroids helped improve the outcome for patients with severe and critical covid-19. Other examples from the pandemic include decentralised care, where local providers were given greater control of patient management, including routine care, without having to interact with higher levels of the health system. Further innovations included prescribing for longer durations to limit the number of clinic visits patients need to make, as well as the expansive adoption of telemedicine and self-care. “Covid-19 propelled a lot of things that were waiting at the threshold, over it. But we need to clarify the cross-over between NCDs and infectious diseases because otherwise, without a healthier population, both infectious diseases and NCDs will come and hit us again,” says Varghese. FORESIGHT

RETHINK INFRASTRUCTURE Medical advances account for many improved outcomes in health, but not all. Sometimes a rethink of the healthcare infrastructure alone will deliver substantial patient benefit. In a low-income setting, travel to a healthcare facility can take a whole day and sacrifice a day’s wages. “In Afghanistan, people move to Pakistan to access cancer care,” Sullivan says. Practical changes to health care delivery alone can reap significant reward. A project in Ethiopia has investigated the feasibility of conducting health checks when people are already at the clinic because it might be a long time before they return. Dr Netsanet Fetene Wendimagegn is a clinician and public health specialist at the Yale Glob7

GLOBAL HEALTH POLICY

“In comparison, managing infectious diseases is a 100-metre sprint, while NCDs are a marathon. The health system is not prepared to look after this person who is running a very long distance. This is currently a fundamental weakness, but we can start to tackle it by some of the new approaches that came out of the pandemic”

al Health Leadership Institute in Addis Ababa, Ethiopia. Drawing on his experience within the Ethiopian healthcare system, he has developed an Integrated Healthcare Services (IHS) framework for an holistic approach to patient care. It draws on the continuity of care needed between chronic NCDs and their risk factors on one side of the balance and infectious and nutrition-related diseases on the other. “It aims to address the relationships among predisposing factors to NCDs along with the type of interventions needed at every step,” Wendimagegn explains. He determined the four most common risk behaviours as tobacco use, misuse of alcohol, unhealthy diets, and a lack of physical activity. They lead to four key metabolic changes: raised blood pressure, overweight/obesity, hyperglycaemia (high blood sugar) and hyperlipidaemia (high blood lipids), all of which are intermediate risk factors for chronic NCDs. “A relatively small number of risk factors account for a large share of the disease burden. We need to identify and act upon these early,” he says. Two approaches have emerged as being potentially suitable for implementation: case finding and preventative examinations. The first involves following up on undiagnosed symptoms or diseases during patients’ routine hospital visits, which meets the aim of viewing patients’ health needs beyond their presenting illness. The second is conducting periodic health examinations for disease prevention and health promotion during clinic visits. For case finding, hypertension, cervical cancer, diabetes, breast cancer, HIV and tuberculosis were all determined as plausible targets by Wendimagegn and clinicians. “The IHS framework focuses on the holistic needs of the 8

patient. The health promotion and prevention needs of both symptomatic and asymptomatic patients is addressed along with the curative services,” states Wendimagegn. Another structure for integrated healthcare has been developed in a cross-Atlantic co-operation between North America and England and dubbed the “flex-competence©” approach. Behind it is Dr Norman Coleman, senior scientific advisor to the International Cancer Expert Corps, an international organisation that aims to transform global cancer care, working with colleagues from the University of Pennsylvania Perelman School of Medicine, the United States Embassy in Mexico and England’s Oxford university. The concept supports an integrated approach to routine care for NCDs, including cancer, while being able to rapidly adapt to changing needs as presented by infectious diseases and other catastrophic incidents; a prime example is the surge capacity required for the recent covid-19 pandemic. The cross-over between cancer and infectious disease via disease-causing mechanisms is clear. Human papilloma virus (HPV), which causes cervical cancer, is a case in point, while hepatitis C can lead to liver cancer.

ESSENTIAL NCD INTERVENTIONS WHO has developed and launched a Package of Essential Non-communicable Disease Interventions (WHO PEN) for use in primary care in low-resource settings. “This package of NCD interventions covers CVD, diabetes, chronic lung diseases, pain management and palliative care, and created a set of protocols that we felt all facilities could manage to prevent life-threatFORESIGHT

Risky business Relatively few health risk factors account for a large share of the disease burden

GLOBAL HEALTH POLICY

ening complications such as heart attacks, stroke, kidney failure, amputations, and blindness,” says Varghese. Underpinning the WHO-PEN cross-cutting approach is management of multi-morbidity. “It’s important to see the person as one entity. Take an average middle-aged person from an average income country, it is very unlikely that person has only one adverse health condition,” he says. “They’ll usually have high blood pressure, possibly some cholesterol abnormality, or high blood sugar. They might also have issues with smoking or alcohol.” A project in Bhutan illustrates what can be achieved with a structured approach like that of WHO-PEN. Here, interventions were implemented in two primary healthcare settings where patients were assessed over three months for the effect of the interventions on their cardiovascular outcomes. Among the 444 patients who completed three follow-up visits, the proportion with high ten-year cardiovascular disease risk declined from 13% to 7.3% and among those with hypertension, use of medication increased and high blood pressure declined from 42.3% to 21.5%. Among 115 persons with diabetes, use of anti-diabetes medication increased and high blood sugar declined from 68/100 to 51/100.

SOCIAL AND COMMERCIAL INFLUENCE Underpinning models of integrated care and novel point-of-care services lie the social and commercial determinants of health that the pandemic has highlighted and that serve as both barriers and enablers to prevention, diagnosis and treatment, says Victoria Haldane, health services researcher at University of FORESIGHT

Toronto in Canada. “We saw the disproportionate impact of Covid on different communities globally. It’s looking beyond hospital beds to income, employment, education and other wider determinants,” she points out. “When I think of health care and health systems since the pandemic, my lens has spread wider. Healthcare can be an anchor institution in society. We can’t just take a piecemeal approach and take point-of-care without looking broader.” Haldane also stresses the importance of focusing care on people and nurturing trust to optimise integrated care interventions. “In low-income countries, we see effective community models of care that have played a huge role during the pandemic,” she says, highlighting the example of how community health workers in Thailand leveraged their long-established networks built on trust among local residents to effectively mobilise surveillance and prevention activities. “Thailand had a lot of experience with avian influenza previous to the pandemic, so when Covid hit, systems were already in place that they could add to or pivot to respond,” Haldane says. “We need to draw on these examples as ways to integrate care of NCDs and IDs and consider this in our preparedness arsenal in low, as well as high-income countries.” Integrating care across NCDs and combinations of NCDs and infectious diseases, is a huge and unwieldy challenge. Best-laid plans, programmes and packages have met with success, but NCDs continue to gather momentum and escape many of these efforts. If there is a silver lining to the covid-19 pandemic, it has given global health a booster shot, awakening the sleeping giant that is integrated NCD care. • 9

FORESIGHT

TEXT Verah Okeyo PHOTO Steve Wafula, Robin Hammond and Rainer Kwiotek

URGENT NEED FOR MORE PSYCHIATRIC SPECIALISTS

Kenya shines light on mental health crisis sweeping Africa A new commitment by Kenya’s leaders helped move mental illness onto the health agenda, yet political will was only the beginning of the journey. The country’s first steps towards meeting the mental health needs of its population illustrate the broader obstacles to extending psychological care throughout the African continent

FORESIGHT

GLOBAL HEALTH POLICY

60 50.0

50 40 30 20 10.0

10.9

Americas

2.5

AN AFRICA WIDE CRISIS The picture painted by the numbers of widespread and untreated mental illness in Kenya is replicated across many African countries, where psychological well-being is under pressure. The rapid modernisaFORESIGHT

Europe

dations and given Mathari National Teaching and Referral Hospital autonomy to run its budget free from political interference. It took media reports to jolt Kenyatta into action and Kagwe’s personal experience to achieve at least some results. The crisis, however, had been years in the making, as evident from a mental health policy blueprint for 2015-2030. It contained sobering statistics: one in every four people visiting outpatient health facilities in Kenya and two in every five in inpatient care have mental conditions, including depression, attempted suicides, substance use disorder, bipolar disorder, and schizophrenia. Access to treatment is woefully inadequate. Even today Kenya does not have a mental health budget and few of the policy recommendations, such as training and hiring of more psychiatric specialists, have been acted upon.

SOURCE WHO, 2017

0.9

9.0

Western Pacific

7.7

Global

Eastern Mediterranean

Number of mental health workers per 100,000 citizens

SouthEast Asia

FOR EVERY DOLLAR SAVED FIVE ARE LOST And act they did. By November 2019 the government had formed a task force to investigate the state of mental health in the country. That investigation, chaired by Njenga, reported back after three months of intelligence-gathering and visits to the few existing mental health facilities in the country. “We told them that for every single dollar they did not invest in mental health, they were losing another five,” Njenga said. Appalled by the group’s findings—including stories of children as young as eight years old taking their lives—Kenyatta appointed Njenga as his adviser on mental health. Two months later the government had implemented one of the task force’s recommen-

Shocking contrast across regions

Africa

or ten long years, Mutahi Kagwe visited Nairobi’s Mathari Mental Hospital where his close friend, a once brilliant scientist, was confined. Kagwe saw at first hand the conditions at the century-old psychiatric treatment centre, the largest in Kenya, as his friend lost a long battle with mental illness. “It broke my heart when he died,” recalled Kagwe in 2019. At the time Kagwe had just been appointed Kenya’s Minister of Health. Kagwe did not let his personal knowledge of the tragedy that is severe mental illness go to waste. The experience, he said, changed his perception about mental health in Kenya. He became aware of the scarcity of hospitals dedicated to mental health and the ill-equipped state of those that existed. As Kagwe mourned the loss of his friend, events on the streets were bringing the topic of mental health to the notice of Kenya’s President, Uhuru Kenyatta. A spate of suicides and people annihilating their families in murderous rages had attracted media attention, spooking Kenyatta into speaking out about a growing national health crisis. Kenyatta used the platform of his Madaraka Day speech in 2019 to call attention to the country’s rising tide of mental illness. The speech, made every June 1, marks the day Kenya assumed self-determination after throwing off the chains of British colonial rule in 1963. Kenyatta recognised in his speech that Kenya needed to also break free of the chains of mental illness. He ordered his health minister to implement programmes and policies to achieve that end. Kagwe was more than ready to rise to the occasion. As two of Kenya’s most powerful politicians experienced a reckoning with mental health, the psychiatrists, nurses and psychologists who had waited for such a political commitment for decades saw their opportunity. “This was the time to act and we were ready to offer the technical know-how to sort this issue once and for all,” says Frank Njenga, one of Kenya’s most prominent psychiatrists.

GLOBAL HEALTH POLICY

you test and say, ah, you tested positive, mental illnesses rely on questionnaires, interviews and a physician’s appreciation of what is serious,” says Solomon Teferra, a psychiatry professor and head of psychiatry at the School of Medicine in Ethiopia’s Addis Ababa University. It is common for patients to be shuttled from one hospital department to another and treated for a physical disease because no health worker or clinician suspects a mental illness, he says.

As two of Kenya’s most powerful politicians experienced a reckoning with mental health, the psychiatrists, nurses and psychologists saw their opportunity

Specialist Saguedin Kpiémam, community mental health worker, Togo PHOTO: Robin Hammond

tion of society brings people into direct conflict with age-old cultures, yet lack of understanding of the nature of mental illness, cultural taboos and the stigma attached to the disease in many African societies means it goes unrecognised and untreated. Visits to mental health outpatient facilities in Africa are estimated to be at a rate of 508 for every 100,000 citizens, less than a third of the global rate of 1601 per 100,000, reports the World Health Organization (WHO) in its Mental Health Atlas 2017. Kenya’s health ministry estimates that 75% of people in need of medical services for mental health challenges cannot get it. The numbers are as high as 99% in war-torn countries such as Sierra Leone. Ethiopia, a country with a 117 million people, has fewer than 100 psychiatrists, according to WHO. Africa as a whole has one mental health worker for every 100,000 citizens, compared with 50 in Europe; the number of psychiatric nurses in Africa is 0.5 per 100,000, the lowest of WHO’s seven global regions. Poor diagnosis of mental illnesses is the inevitable result of the lack of investment in psychiatry professionals. “Unlike Malaria, with biomarkers like blood where FORESIGHT

Globally, mental illness on average attracts just 2% of government spending on health, according to WHO. An indication of how little of that is spent on mental health in Africa shows up in a comparison with Europe. Of the just 2% of funds that go to mental health, Europe spends 20 times more per head of population than Africa, according to the WHO atlas. Without money to develop and implement policies, even African countries that do have clear mental health polices are stymied. “The money is not just for the clinical work, but for research, hiring qualified health workers, community engagement to teach the public about mental health,” says Lukoye Atwoli, a psychiatry professor and dean of East Africa’s Aga Khan Medical College.

CULTURAL CHALLENGES Traditional culture and religious beliefs have a strong bearing on perceptions of mental health. Most people in Ethiopia, medical professionals no exception, view mental illness as a supernatural affliction or punishment from the gods, rather than as a medical condition, Teferra says. Victims and their families turn for help to religious leaders and traditional healers in far greater numbers than to psychiatry professionals, he adds. Teferra’s observations are backed by studies by Oluyomi Esan of the psychiatry department at Nigeria’s University of Ibadan. He found that traditional and religious healers could accommodate a far great13

GLOBAL HEALTH POLICY

INSIGHTS

THE POWER OF MOTIVATED PROFESSIONALS

thiopian psychiatrist Solomon Teferra appreciates just how daunting a task it will be to get mental illness accepted as a disease and included into national health policies across Africa. But as part of a disparate network of motivated mental health professionals he is determined to do what he can to stem the rising tide of an illness that is barely recognised as such by many Africans despite the risk it poses to economic prosperity for entire countries, from Kenya, to Nigeria to South Africa. Teferra and his colleagues laboured to pull provincial ministries of health across Ethiopia to meetings and workshops to write the country’s first 2013-2016 National Mental Health Strategy, a document that in the end was never ratified. That failure was a lesson for other mental health advocates, such as Bonfoh Bassirou, the director of research consortium Afrique One, based in Cote D’Ivoire. It strives to involve regional pan-African bodies in work to improve the continent’s mental health. Bassirou’s primary focus is zoonoses, diseases that afflict human beings but come from animals. As his interest broadened beyond pure veterinary medicine, he rubbed shoulders with people from a broad range of medical disciplines. Mental health was something he read about in passing when studying the suicides of livestock herders whose animals died from drought and disease in the 1980s and 1990s in the Sahel Belt in West Africa. One of his Ph.D. students was studying a neglected tropical disease, Buruli ulcers, that forced patients to stay in hospital for more than four months until the wound healed. Bassirou found himself wondering how such an isolating experience might affect a person’s mental health. The more he read about the prevalence of mental health disease and the lack of funding, the more motivated he became to approach his own academic networks to find out if there was anything they could do to provide more resources for mental health. Bassirou approached 14

Friendship bench Pictured Dixon Chibanda, famous for his Friendship Bench project. To help fill a yawning gap in mental health treatment, grandmothers are trained to administer talk-therapy in the community PHOTO: Rainer Kwiotek

the management of the African Academy of Sciences (AAS), one of the continent’s most prominent research funders, of which he is a fellow. The African Union-backed AAS formed a task force on mental health in Africa that Bassirou volunteered to chair. Throughout 2020 he worked with other scientists to draft a document that would determine what aspects of this complex public health issue governments should prioritise. FORESIGHT

Another member of the task force was Dixon Chibanda, an associate professor of psychiatry at the University of Zimbabwe and the London School of Hygiene and Tropical Medicine. One of just 12 psychiatrists practising in Zimbabwe, Chibanda is famous for his Friendship Bench in Zimbabwe, a project in which he trained thousands of grandmothers in talk-therapy, giving them the skills needed to sit on a bench and successfully communicate with depressed people, deterring many from suicide. Bassirou tried a form of the Friendship Bench on the Buruli ulcer patients, arranging for them to cook and share meals in the hospital. Ultimately, the members of the AAS task force hope to explore ways of using bench therapy and other successful and cheap treatments for rallying Africa’s regional bodies around the idea of including mental health in national care plans. •

GLOBAL HEALTH POLICY

Chronic failure in resource distribution Mental health spending per capita (US$)

25 21.7 20

15 11.8 10

SOURCE WHO, 2017

Europe

2.5

Americas

SouthEast Asia

2.0

Global

0.1

Western Pacific

0.1 Africa

1.1

Eastern Mediterranean

er number of patient admissions than conventional mental health providers in Ghana, Kenya and Nigeria. But the quality of treatment from traditional healers was variable, especially compared with more standard psychiatric practice, and included physical restraint. Semantics plays its part in maintaining the stigma attached to mental illness, which prevents people from seeking qualified help. Many people in Africa attribute the cause of depression to excessive thinking, reveals work by Emma Louise Backe, a medical anthropologist at George Washington University. In Zimbabwe’s Shona tribe, depression is called kufungisisa, which means “thinking too much”. The cure prescribed by families and at least some health workers is to stop thinking.

SOLUTIONS GOOD AND BAD One approach to solving the shortage of mental health specialists has been to provide additional training to primary care and traditional health workers, a process referred to as “task shifting” and already used in FORESIGHT

HIV and tuberculosis programmes. The treatment of mental illnesses, however, is not an easy task to shift to the shoulders of non-specialists. In Kenya, a mental health amendment bill in 2019 sought to include mental illness in primary health services, but a red flag was raised by psychiatrist Susan Hinga at Kenyatta University’s school of medicine. She warned that delegating management of mentally ill people in hospitals to psychologists, including admission and discharge, could have potentially lethal results. “Some people may present signs of depression, but perhaps they have deficiencies in the thyroid hormones that makes them lethargic, and not depression,” Hinga said, adding that only a physician would have the training to make such a complex diagnosis. The bill was opposed by Kenya’s doctors, who may have been sensitive to tragedies caused by mental health legislation in other countries. In 2016, more than 140 psychiatric patients died when South Africa’s Gauteng provincial government transferred 1711 state-funded psychiatric patients from Life Esidimeni, a private health care provider, to other facilities that were not properly licensed. A government investigation revealed patients had been tortured, starved and suffered head injuries. Subsequent to that scandal, Human Rights Watch, an organisation based in New York, published its Living in Chains global report in 2020, documenting how care homes, state-run and private institutions, and traditional and religious healing centres detained mentally ill people against their will.

Semantics plays its part in maintaining the stigma attached to mental illness

Rather than be led by national governments, improvements in care and treatment of the mentally ill in Africa may be more likely to arise from grassroots initiatives developed by well-informed, motivated and highly concerned medical professionals with detailed understanding of the issues and local needs (page 15). Cross border collaboration through professional networks is already happening to spread best practice. Mental health reforms across the continent will in no small part depend on sharing and learning across borders from local successes and on pan-African collaboration between organisations and countries. • 15

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s the world continues to undergo one of the biggest healthcare upheavals in a generation, it seems to be an appropriate time to look back on an era of exponential growth in scientific knowledge that began with the last major pandemic—and forward to the era of increasingly individualised treatment that lies ahead. This special report casts a retrospective eye over a century of transformative medical discoveries that have revolutionised the treatment of the most prevalent non-communicable diseases (NCDs). In the process of this evolution, diseases that were once life-threatening have become largely manageable. Diabetes, cardiovascular disease, respiratory illnesses and cancer together account for the lion’s share of NCD prevalence globally. Developing treatments for all four of these conditions has not only improved life-expectancy and quality of life for people with the diseases, but also gradually built our knowledge about the human body and basic cell biology. Yet, while treatments have been increasingly effective, they also have become more costly. This, in turn, has made them harder to access for many of those living with NCDs, and especially those in lowand-middle-income countries (LMICs). The pandemic has shone a spotlight on global

health inequalities, including the extent to which those with NCDs and those from disadvantaged groups are more likely to contract the Covid-19 virus and are at greater risk of dying from it. Competition between countries for Covid vaccines has revealed how difficult it can be for many to access essential medicines, an inequality of opportunity that is a major obstacle to bringing the epidemic of NCDs around the world to a halt and stopping premature deaths. Once the Covid-19 pandemic recedes, recovering healthcare systems will face new challenges: development of treatments for those suffering the after-effects of long Covid and other consequences of the virus; and an expected growth in cases of NCDs, just when the health infrastructure is at its least resilient. Simultaneously, the development of new medicines are on a transformative journey, as the current acceleration in development and use of RNA technology demonstrates. NCD treatments will not be left behind. The launch of new classes of medicines for treating NCDs, especially for cancer, offers hope to those with chronic conditions. But it will also put pressure on national health budgets. Only by tackling the problems headon, with comprehensive, joined up strategies, will the most innovative new treatments be able to fulfil their promise. FORESIGHT

TEXT Andrea Chipman

Medicines that changed the world

Timeline Selection of medical discoveries that transformed the lives of people living with NCDs

Insulin (1921)

DIABETES Medicine (injection) to normalise blood glucose levels

Metformin (1922)

DIABETES Oral medicine for the treatment of type 2 diabetes

Sulfonylureas (1942)

DIABETES Oral medicine for the treatment of type 2 diabetes

Oral steroids (1950s)

RESPIRATORY DISEASES Oral medicine that controls respiratory diseases indirectly, via the bloodstream

Metered-dose inhalers (1955)

RESPIRATORY DISEASES Localised treatment that delivers (combined) medication directly to the lung

Beta-blockers (1965)

CARDIOVASCULAR DISEASE Medicine that decreases blood pressure and heart workload

Salbutamol (1966)

RESPIRATORY DISEASES Widely prescribed metered-dose inhaler for COPD and asthma

ACE-inhibitors (1975)

CARDIOVASCULAR DISEASE Widely prescribed for blood pressure control and lowering the risk of heart attack and stroke

Chemotherapy (1940s-1980s) CANCER Cancer treatment that uses one or more anti-cancer drugs to eliminate cancer cells

FORESIGHT

A CENTURY OF TRANSFORMATIVE MEDICAL SCIENCE As long ago as 550 BC, Chinese philosopher Confucius told us to “study the past if you would define the future.” In that spirit FORESIGHT Global Health takes a look at how specific medicines for treating non-communicable diseases (NCDs) have revolutionised the prospects and care of people diagnosed with an NCD. Understanding this evolution in medical knowledge shows what research can achieve—and what it can aspire to next

n the annals of medical history, 2021 will go down as the year in which a rapidly developed series of vaccines prevented the loss of millions of lives at the hands of Covid-19. The year also marks the centenary of the discovery of insulin. Just as covid-19 vaccines were the result of revolutionary recent developments in mRNA technology, insulin was also borne out of advanced technical expertise, the isolation of insulin-producing islet cells, an achievement that since 1921 has made diabetes a disease to be managed, not a death sentence for millions. The impact of landmark discoveries in medical science can be staggering. Insulin has extended the lifespan of people diagnosed with type 1 diabetes from a typical one to two years before its discovery to around 80 years today, while covid-19 vaccines are preventing serious disease and death in millions by protecting them from the virus. The development of insulin became a model for the treatment of other non-communicable diseases (NCDs), showing the way to self-management for peo-

ple living with chronic conditions, observes Carsten Timmermann who lectures in the history of science, technology, medicine and medical humanities at the University of Manchester in England. In much the same way, angiotensin-converting enzyme (ACE) inhibitors and inhalers have made it easier for those with hypertension and respiratory conditions such as asthma to live more comfortably with their conditions. Now, the newest generation of cancer medicines are aiming at the previously elusive goal of making cancer a chronic condition rather than a killer. It is this level of progress that has made the past century so remarkable, Timmermann says. “You turn something acute and life-threatening into something chronic that you manage.”

LIFE CHANGING DRUGS The World Health Organization (WHO) singles out four of the most prevalent NCDs worldwide for particular focus—cardiovascular disease, diabetes, respiratory diseases, and cancer. Alone, these four kill FORESIGHT

A new lease on life NCDs that were once life-threatening have become manageable thanks to medical advances

TEXT Bob Kirsch and Becky McCall MAIN ILLUSTRATION Luke Best INFOGRAPHIC Trine Natskår

Landmark discoveries with staggering impact

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FORESIGHT

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High blood pressure affects 1.13 BILLION people worldwide

around 41 million people every year, according to WHO. Without the medicines developed to prevent and treat them, however, the number of dead would be significantly higher. Four classes of medicine epitomise the advances in NCD treatment: heart drugs such as ACE-inhibitors, diabetes therapies like insulin, respiratory drugs like salbutamol, and anti-cancer drugs such as methotrexate. All four of the NCDs for which these drugs were developed were life-limiting a century ago. Now, with proper treatment, many of those with these conditions can hope for a normal life span. Specific medicines have been transformative for those living with the most common NCDs and development and application of them has led to better understanding of disease aetiology and risk factors. It has also contributed to the continued improvement of global health infrastructure and served to light the way for better global management of NCDs. The steady progress has rested on a series of building blocks, from the comparatively rudimentary ability to use an organ extract to manufacture insulin to the more advanced understanding of cell biology and reproduction that ultimately led to the development of cancer treatments.

PORTRAIT OF A PATHFINDER The one-hundred-year anniversary of the discovery of insulin marks a story of what was, what is, and what may be possible for people with diabetes. It is a seri20

MORE THAN 40% of the 262 million people living with asthma worldwide is under the age of 24

The innovations of the past century in NCD treatments have made it possible to live with rather than die from chronic diseases

ous illness with several co-morbidities such as heart disease, stroke, and kidney disease; it can damages sight and nerves. In 2016, an estimated 1.6 million deaths globally were directly caused by diabetes. The disease lies behind almost half of all deaths before the age of 70 attributable to high blood glucose levels. Diabetes medication is based on two fundamental players: insulin and metformin. Metformin reduces the body’s own production of glucose and makes its use of insulin more efficient. Widespread use of metformin started in the late-1950s, half a century after the discovery of insulin. By around 1980, animal insulin was being replaced with human insulin and since the beginning of the current century an array of insulin analogues have appeared. “There are efforts to increase production, demand, and quality assurance of generic biosimilars,” says Gene Bukhman, a medical anthropologist and cardiologist at Brigham and Women’s Hospital in Boston in the US, who heads the global programme in non-communicable disease and social change at Harvard Medical School. FORESIGHT

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SOURCE IHME, Global Burden of Disease Study, 2019; WHO 2017; WHO 2021

34 Cancer causes more than 10 MILLION deaths a year

Main killers Four groups of diseases accounts for 41 million deaths annually

A relatively recent and significant development for those with diabetes includes wearable continuous glucose monitors as an option to finger-prick tests multiple times a day. Even more recent and exciting are closed-loop systems, which are the nearest thing to an artificial pancreas in that glucose is monitored automatically and an insulin pump is worn on the body to administer medication to meet real-time demand. Diabetes technology has come a long way in a century. At the same time, affordability of insulin as well as the availability of equipment used to test glucose levels or administer insulin remain key issues for those living with the disease, also in a country as developed as the US.

A SILENT KILLER FOR CENTURIES Hypertension is particularly challenging because it is an asymptomatic, silent killer and often remains hidden until caught during monitoring or evidenced in a hypertension-associated disease such as heart failure or stroke. Undiscovered and untreated, hypertension significantly increases the risk of developing cardiovascular, brain, and kidney diseases. High blood pressure is a worldwide problem, but the greatest increases in the absolute burden of hypertension are currently being seen in East Asia and the Pacific, Latin America and the Caribbean, South Asia, and Sub-Saharan Africa. The Global Burden of Disease Study for 2019 estimates that about ten million deaths were attributable that year to high blood FORESIGHT

In 2019, 34 MILLION life years were lost due to diabetes

pressure, mostly in low-and-middle-income countries (LMICs). “Only about a third of people with hypertension are receiving pharmacological treatment and only one in ten have their blood pressure appropriately controlled, in LMICs,” points out Pablo Perel at the World Heart Federation. Elevated blood pressure has been a major public health challenge and cause of premature death for thousands of years. The Chinese referred to it as “hard pulse” disease in 2600 BC and the Ebers Papyrus from 1550 BC testifies to the ancient Egyptians describing the relationship between palpated pulse and the development of heart and brain afflictions. Even so, outside the medical profession high blood pressure was not widely recognised until 1945 when US President Franklin D. Roosevelt reported a severe occipital headache and died with a recorded blood pressure of 300/190 (normal is considered to be less than 120/80 mmHg). Perel observes that progress in hypertension medication in the past five decades has been remarkable and that there is now a wide portfolio of cost-effective and safe pharmacological options with which to treat people. “The evidence is supported by a large number of outcome-based randomised clinical trials. There is strong evidence that a 10 mmHg reduction in systolic blood pressure, which measures the pressure in arteries when the heart beats, or a 5 mmHg reduction in diastolic blood pressure, which measures arterial pressure when the heart is resting 21

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between beats, is associated with substantial reductions in all major cardiovascular events and mortality,” he states.

A DISEASE WITH STRONG ENVIRONMENTAL LINKS An upside of covid-19 lockdowns in cities has been the reduction in outdoor air pollution, largely due to less human activity on the roads and in the air. The link between air pollution and lung diseases is well established, with more evidence of it provided in a 2020 survey by the British Lung Foundation. Over the spring lockdown, the charity found that one in six people in the UK with lung conditions had experienced better health, with the number increasing to one in five for children. Asthma sufferers reported most benefit, with one in four showing improvement in their condition. In 2017, close to 545 million people in the world were classified with a chronic respiratory disease, representing a near 40% increase since 1990 and accounting for 3.9 million deaths according to the Global Burden of Diseases. A wide range of conditions fall into this category, including chronic obstructive pulmonary disease, asthma, bronchiectasis, tuberculosis, pneumonias, and undefined interstitial lung diseases. Environmental and social determinants like clean air and poverty reduction are fundamental to improving chronic respiratory diseases, but medicines, including inhalers and nebulisers, can ease suffering once the damage is done. Of all the NCDs, chronic respiratory diseases illustrate most clearly the direct interaction between the human body, the environment, and the economic interests bound up in polluting the air, from the money made from fossil fuel exploitation and toxic chemical processes to savings made on worker protection. While the air is free, what is circulated within it from human activity may prove to be extremely costly for the planet.

ADVANCES IN CANCER CURES AND CARE Cancer is the second leading cause of death globally, after cardiovascular conditions, with tobacco use responsible for approximately 25% of cancer deaths, according to WHO. Comprehensive cancer treatment is available in more than 90% of high-income countries, but in fewer than 15% of low-income countries. Even in high-income countries, many knowledgeable physicians as recently as the 1950s doubted that medicines could be used to cure cancer. Back then the mainstays of cancer treatment were surgery and radiation. During the 1960s and early 1970s, after chemotherapy successes had been achieved with 22

cancers of the blood and the lymph system, questions remained about its potential to contribute to the cure of advanced solid tumour cancers. But new findings steadily emerged, sometimes along unexpected paths. During the World War II an accidental spill of sulphur mustards on troops in Bari Harbour, Italy, led to findings that nitrogen mustard could achieve cancer regression. The realisation spawned the discovery of cyclophosphamide, a medicine still used in the treatment of cancers of the blood, lymph, breast, and nerves. Another advance propelled by the WWII came from investigations into antibiotics used to treat wound infections, which led to the development of anti-tumour antibiotics, types of medicine still used for breast, lung, gastric, ovarian, thyroid, lymphomas, multiple myeloma, sarcoma, and paediatric cancers.

“Development of the right kind of health system is at least as important as development of the right drugs”

Nutritional research started prior to WWII found that a substance present in green leafy vegetables folate affected bone marrow. Subsequent research on folate antagonists resulted in development of the chemotherapy and immunosuppressant, methotrexate. The substance is still used in the treatment of leukaemia, lymphoma, breast cancer, lung cancer, head and neck cancer, and bone cancer. In the mid-1950s, research on the cells of cancer of the liver in rats led to the synthesis of fluoropyrimidine 5-fluorouracil, known as 5-FU, currently used in the treatment of cancers of the breast, colon, rectum, stomach, and pancreas. Recent advances now allow cancer treatment to include both chemotherapy and personalised medicine (also called precision medicine). Today’s innovative treatments are designed according to the specific genetic make-up of the individual’s tumour and evidence suggests these more targeted treatments are less likely to produce severe side-effects. While chemotherapy agents may be given to large numbers of patients with a certain type of cancer, in personalised medicine the drug selection is tailored to the patient; not all patients with any one type of cancer, such as lung cancer or breast cancer, are given all of the same medicines. FORESIGHT

Ensuring access The complexity of modern treatments threatens to make them less affordable

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4/5 2 BILLION people worldwide lack access to basic medicines

ACCESSIBILITY AND AFFORDABILITY A new medical revolution is required to build equal access to treatment and a healthcare infrastructure that is all-inclusive. While medical innovation has progressed apace, healthcare systems have often failed to reflect and respond to the distribution of the burden of disease, or societal and environmental factors, that would allow for revolutionary medicines to be accessible to all, including vaccines. The innovations of the past century in NCD treatments have made it possible to live with rather than die from chronic diseases. These lifesaving advances, however, have introduced two challenges that policymakers must resolve. First, the escalating cost of medicines makes them unaffordable or unavailable to many citizens of low-and-middle-income countries. Second, the current health infrastructure is not yet designed to support people with NCDs in management of their conditions over many years. Most of the main innovative medicines developed for NCDs have generic equivalents, but with limited dissemination. “Massive populations are suffering and dying because they are not properly diagnosed and treated and are not able to afford these same medications,” says Harvard Medical School’s Bukhman. “It’s a great injustice that, as a world, we should really remedy as quickly as possible.” With medical solutions becoming more complex, the associated risks of failure are higher, resulting in skyrocketing demand for investment in medicine FORESIGHT

FOUR OUT OF FIVE People living with NCDs reside in low-andmiddle-income countries

development. The introduction of blockbuster treatments that could serve huge populations during the second half of the last century, from antibiotics to the growing field of oncology medicine, caused the transition of the pharmaceutical industry from smaller companies to big pharmaceutical giants, Timmermann notes. The technology involved to develop the newest generation of medicines has made research and development of them increasingly expensive, contributing to the consolidation within the industry. An era of more individualised medical treatment, dominated increasingly by biotechnology, is likely to accelerate the rate of advance, but the difficulty of producing generic biotech drugs is making it harder for health systems to hold down costs, he adds. One of the key lessons of the past century’s medical discoveries is that those living with chronic conditions cannot benefit from new treatments in isolation. A robust system is needed for supervision of people under treatment for NCDs and to help them to manage their own conditions. Development of the right kind of health system is at least as important as development of the right drugs. “A pill is easy to administer, but for chronic conditions, it is not just a question of a pill, but of referral networks, monitoring and a whole infrastructure of care,” Timmermann says. The infrastructure needed to diagnose and apply the right interventions at the right time seems to be missing, he says. • 23

FAIR AND EQUITABLE ACCESS TO AFFORDABLE MEDICINES With non-communicable diseases increasingly becoming a major health issue for poorer and wealthier countries alike, securing access to the medicines used to control them is a key concern. Cost, supply and licensing are all challenges. Solutions to a number of the problems encountered are being tested in low-and-middle-income countries in an effort to improve availability

Fake drugs and how to protect the vulnerable

ting access to the medicine she needed. Her death led to the Tobeka Daki Campaign, supported by more than 31 organisations by February 2017. By July that year, the South African Department of Health had included the drug in its essential medicines list which meant patients in the public health system could access it. Daki’s story is just one example of the struggle faced by many patients living with non-communicable diseases (NCDs) when seeking life-saving treatments. Two billion people do not have access to basic medicines, according to a WHO estimate. A former director of the organisation, Margret Chan, notes in a 2007-2017 ten-year review that along with poor health systems and infrastructure, affordability is the biggest factor that prevents people from accessing medicines, especially in low-and-middle-income countries (LMICs) where cost of medicines is borne out of pocket. Lack of access to medicines is an acute problem for people living with NCDs and LMICs bear twothirds of the burden. It is in LMICs that low funding, scarce resources and the challenge of adapting to the dual burden of infectious diseases and NCDs causes FORESIGHT

Hurdles to treatment Many people in low-and-middleincome countries find essential medicines costly and unaffordable TEXT Swagata Yadavar ILLUSTRATION Luke Best

n 2013 in South Africa, Tobeka Daki, a single mother of two, was diagnosed with stage three HER2 positive breast cancer, an especially aggressive and deadly form of the disease. Her oncologist told her she needed a life-saving drug for her type of cancer—one the World Health Organization (WHO) recommends as essential treatment, along with chemotherapy—to have a fighting chance. Despite being a good candidate for the drug and having health insurance through her employer, Daki was unable to access the drug because of its high cost. For a year’s treatment the price was $38,375, about three times the per capita income at that time. The high cost made the drug unavailable in the South African public health system, where 84% of the population seeks care. Access to the drug was prevented by a structural barrier: South Africa’s patent laws allowed the drug’s manufacturer to hold multiple secondary patents that blocked biosimilars from entering the market until 2033, long after its patent should have expired. Daki died at home in November 2016 without get-

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Imposter syndrome

Africa 42% Americas 21% Europe 21%

WHO REGIONS

Western Pacific 8% Eastern Mediterranean 6% Southeast Asia 2%

acute suffering. Poor supply chain management exacerbates the issue, according to a 2015 review by nonprofit organisation, PATH on access to diabetes drugs in low resource settings. Affordability is just one factor. In LMICs, people living with NCDs must also contend with the risk of counterfeit products, lack of supply and patent and licensing barriers, which are also linked to affordability. Efforts to overcome the obstacles are showing promise, however, through cross-border partnerships, technology start-ups, strategies to nudge change through ranking systems and the implementation of policy measures, such as compulsory licensing.

THE WAR ON FAKE DRUGS One in every ten medicines in LMICs are falsified, according to WHO. The counterfeit drug industry is worth up to $200 billion a year. Fake malaria drugs led to more than 122,350 deaths in sub-Saharan Africa in 2013, according to the 2019 article, “Falsified and Substandard Drugs: Stopping the Pandemic.” African countries bear the brunt of the problem, 26

accounting for 42% of fake drug complaints between 2013 and 2017, says WHO. Countries with poor monitoring arrangements and weak health systems suffer most from counterfeit drugs. A few innovative start-ups, however, are working to resolve the problem and spoil the market for counterfeits by empowering consumers with information. Founded in 2007 in Ghana, mPedigree uses text messages to help consumers find out if the drugs they are buying are fake. The process is simple—consumers can scan the barcode or scratch the medication package to reveal a code which they send to a toll-free number to determine its authenticity. Since its foundation, the company has worked with non-profits, governmental agencies and drug regulators covering Nigeria, East Africa and India reaching 100 million users. Another such company is Medsaf, a Nigerian startup, that connects manufacturers of authentic drugs directly to hospitals and pharmacies, with the added benefit that a more direct supply chain increases cost efficiency of delivery. FORESIGHT

SOURCE WHO Global Surveillance and Monitoring System, 2017

Substandard and falsified medical products reported, by WHO region

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Ghana-based mPedigree uses text messages to help consumers find out if the drugs they are buying are fake

A cross-border partnership that has the potential to make a significant dent in the supply of counterfeit medicines is the 2019 treaty to establish an African Medicines Agency, which will come into effect once it is ratified by 15 African Union states. The agency aims to enhance the capacity of the countries to regulate medical products and ensure access to safe drugs.

BETTER LOGISTICS FOR HEALTHY STOCKPILES NCDs, such as diabetes, hypertension, and cardiovascular disease, require long-term consumption of medicines. Their consistent supply to pharmacies is essential, but often difficult in LMICs. FORESIGHT

Running out of stock, or “stockouts”, in public facilities represents a major barrier to drug access, according to a 2020 study on the accessibility of medicine in Uganda. Among the many factors affecting availability, the study found, are inaccurate forecasting of demand by facility staff, inefficient procurement or distribution mechanisms in the supply chain and inadequate budget allocation from the Ministry of Health to the facilities. Distribution cycles as long as four to eight weeks are another factor leading to wide fluctuations in availability of the drugs. The challenges are not unique to Uganda. The Coalition for Access to NCD Medicines and Products, a multi-sectoral group of government agencies, private-sector entities, NGOs, philanthropic foundations, and academic institutions, has convened a technical working group and collaborated with government health ministries in Kenya and Uganda, to create an advanced forecasting tool specific to NCDs. “Without this methodology, health systems often forecast their commodity needs based on available funds and inaccurate past consumption patterns with 27

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insufficient service delivery data leading to stockouts or expired products,” says Marilyn Noguera, senior supply chain officer for NCDs at charity PATH: a member organization for the Coalition for Access to NCD Medicines and Products. In addition to the ongoing work in Kenya and Uganda, the coalition aims to scale up its tool for use in other countries in 2021, she adds.

other countries to adopt their country’s patent policies have been deliberating on how to lower drug prices for their citizens. “Sadly, the situation has not improved. In the past five years, 13% of Americans have lost a loved one due to the unaffordable cost of prescription drugs. That figure is twice as high for people of colour,” says Priti Krishtel, co-founder of I-MAK.

RANKING EFFORTS TO IMPROVE ACCESS Since 2011, the Access to Medicine Index has ranked 20 of the largest research-based pharmaceutical companies on their efforts to improve access to medicines across LMICs. A change can already be seen in the 2021 index that could shorten the time people in lower income countries wait for new vaccines and medicines. “Eight leading pharmaceutical companies are moving to systematically pair candidates in their R&D pipelines with plans for making them accessible in low-and-middle-income countries soon after the products are launched onto markets,” says the index’s Claudia Martinez, head of research. The shift in working practice by so many companies is an improvement over 2018, when only one had adopted the approach, she adds. Access plans can cover activities such as pricing to ensure affordability, registering products for sale in countries facing high disease burdens and advance licensing agreements that allow manufacturers to start making generic versions.

THE PROBLEM WITH PATENTS Despite the Tobeka Daki campaign and inclusion of the HER2 breast cancer drug on essential lists, the drug is still unavailable across all provinces of South Africa, says Soleme Meyer, advocacy manager for Cancer Alliance, a coalition based in the country. “Even now the drug is still priced high and a few provinces have refused to make the drug available in the public health system.” South African laws do not allow for patent examination, which has led to disproportionately higher numbers of patents being granted there, compared to other countries. By filing multiple patents to prevent competition, a process known as “evergreening”, manufacturers help to support high drug prices. Evergreening also enables pharmaceutical companies to hold a monopoly on a drug beyond the mandated 20 years. The approach is common practice in the US, which has the highest per capita spending on health care in the world. Among the 12 top selling drugs in the country, 125 patents have been filed and 71 patents have been granted per drug, according to analysis by I-MAK, an advocacy organisation that works on drug policy reform in the US. The costs of the drugs have increased 68% since 2012; only one has decreased. Even politicians in the US who have encouraged 28

“Health systems often forecast their commodity needs based on available funds and inaccurate past consumption”

The first step in ensuring affordability of a drug is to ensure it undergoes the test of novelty when manufacturers seek secondary patents. In 2013, India’s supreme court delivered a landmark judgement that rejected a pharmaceutical company’s appeal for patenting a widely used cancer drug. The court’s ruling in the seven-year legal battle upheld section 3(d) of the Indian Patent Act that restricts granting of a patent for “incremental innovations” in many drugs unless they provide significant therapeutic advantages to existing molecules. The court’s verdict had far reaching effects. “It alerted other pharmaceutical companies to be cautious and reduce the number of frivolous patents,” says Y K Sapru, founder of Cancer Patients Aid Association, a non-profit, that took action to make the drug affordable. Sapru cites World Intellectual Property Organisation data that shows that up to September 2018, 45,379 patent applications were filed in India. Of these, 27% were granted, 65% were withdrawn or abandoned by the applicants and 7% were rejected. Since 2013, the Indian government has pursued compulsory licenses that allow local manufacturers to produce the generic version of a medicine by paying royalties for three cancer drugs—two for breast cancer and one for leukemia. The application of section 3(d) in India has inspired activists in South Africa and Thailand to push for stricter patent criteria and patent opposition.

COMPULSORY LICENSES Compulsory licensing, which helped bring down the cost of antiretrovirals by up to 90% in the global South, is now a tool used by even high-income countries to manage drug prices. Recently, the NetherFORESIGHT

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Not all breast cancers are alike Cancers that test positive for particular proteins (like this HER2 positive breast cancer image) often are more responsive from targeted treatment

lands has been considering using compulsory licenses to bring down the costs of health care, a policy that has attracted US censure. Pharmaceutical companies are also involved in making drugs accessible in low-and-middle-income countries. Recognising that developing countries face significant resource constraints and access barriers, German pharmaceutical company Merck has adopted a policy of not filing or enforcing patent application in a large majority of developing countries, says Isabel Klinnert, Director Global Government Affairs, Merck KGaA. In countries where Merck files patents, they commit to enhancing data sharing with researchers and improving public access to clinical trial information. For NCDs in developing countries, it supports voluntary licensing agreements to improve access. “Our R&D partnerships are designed to address diseases impacting developing countries and to help advance our partners’ R&D and manufacturing capacity,” says Klinnert. Countries can negotiate with companies directly to bring down prices of drugs by ensuring bulk orders. The approach especially makes sense for countries like Nigeria, which are seen as less attractive markets for pharmaceutical companies due FORESIGHT

to their LMIC status. “One way to mitigate this challenge is through volume guarantee for production of NCD drugs, which would make Nigeria attractive for Big Pharma and NCD drugs affordable for sufferers,” says Ifeanyi M Nsofor, CEO of EpiAFRIC and policy director at Nigeria Health Watch.

GLOBAL ILLS NEED GLOBAL TREATMENT The covid-19 pandemic has demonstrated why efforts to improve access to drugs and vaccines need to move beyond national borders. As vaccines bring the promise of an end to national lockdowns, existing global inequalities are evident for all to see, with developed nations often buying far more vaccines than their populations require, while many LMIC countries have yet to begin vaccination programmes. “It is clear that the covid-19 pandemic has destabilised the great advances made in global health in the past decades, while showing how deeply the structural issues preventing access to medicine really run,” says Martinez of the Access to Medicine Index. “Our hope is that the global community—including the public and private sector—will see this as a wake-up call for bringing fair and equitable access to medicine to everyone.” • 29

INNOVATIONS IN MEDICINE—Q&A WITH FIVE EXPERTS

AMAZING ADVANCES IN MEDICINES HOLD HUGE PROMISE FOR A BETTER WORLD The pace of scientific research holds the promise of dramatically improving the lives of people living with non-communicable diseases (NCDs). Finding ways of extending the benefits of the most innovative treatments to all who need them will be the biggest challenge facing global health policymakers. FORESIGHT Global Health asked five global health experts what the future of medicines for NCDs looks like and what innovations we can expect to see.

FORESIGHT

TEXT Jo Waters MAIN ILLUSTRATION Luke Best INFOGRAPHIC Trine Natskår

The past century has been one of enormous progress in the understanding of human pathology and treatment of diseases. We are now looking at a future in which technology and state-of-the-art treatments offer previously unimaginable potential for health care that is specifically targeted to individual patient requirements

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THE RESEARCH VOICE

“What’s happening now is amazing—it’s almost science fiction in some ways” Mike Fraser, general manager at Novartis Gene Therapies for Europe, Middle East and Africa

Q: HOW WILL GENE THERAPIES TRANSFORM NCD MEDICINES? A: We all know that NCDs are the cause of 70% of all deaths and even with the current chronic [illness] treatment options there is still an urgent need to develop breakthrough technologies as we do need to treat them more effectively, not only to save resources spent on them by healthcare providers but to improve healthcare for society. What’s interesting now is that we have discovered that some people with NCDs have a genetic make-up that predisposes them to these conditions; we’re seeing this with diabetes for instance. There is a lot of work going on in this space now in industry. I think gene therapies (or rather a collection of different gene therapies including gene editing, gene addition and some types of cell therapy) can target the underlying causes of diseases and this is going to change health care and society.

lymphoma with CAR-T drugs [drugs genetically engineered to produce an artificial T-cell receptor for use in immunotherapy] and that knowledge will now be applied to solid organ cancer tumours. I can envisage a time when people won’t have to take daily pills over a long period as we will be able to treat the root cause of the problem. I also believe it is very important to identify those who are predisposed to certain conditions as early as possible—as we are doing with newborn screening to look for babies with the genes for Spinal Muscular Atrophy (SMA), a muscle wasting condition. Once identified we can then correct the gene defect as we are doing currently in SMA babies with a one-off treatment that targets the underlying gene dysfunction by introducing a fully functioning gene to replace it. This is done by using a virus vector which has been ”de-diseased”, so it is not harmful to humans.

Q: CAN YOU FORESEE A TIME WHEN PEOPLE WITH TYPE 1 DIABETES WILL NO LONGER NEED INSULIN SUPPLIED? A: Yes, with type 1 diabetes at least, I could imagine a point where we will be able to get the pancreas functioning again so people would not need insulin shots. But I’m talking hypothetically at the moment. What we have done with our product for SMA and another gene therapy for retinal dystrophy, is showing that you can address the underlying root cause and treat it. What we are seeing today with these treatments and what we hope will be their long-lasting effects is amazing—it’s almost science fiction in some ways. I spoke to a parent of a SMA child recently and she said to me: “Imagine a time when you won’t be able to tell which child in the playground has SMA because they’ve had gene therapy and they’re completely normal.” When you think about all diseases, including rare ones, but also NCDs such as cancer and diabetes, can you imagine the time when they are just gone? That’s what drives me and my team to work every single day.

Q: WHAT DISEASES ARE BEING INVESTIGATED NOW FOR TREATMENT WITH GENE THERAPIES? A: Cancer and diabetes are two that come to the fore. If we can understand the genes that are predisposing people to these diseases it will accelerate the development of products. We have already come a long way in treating blood cancers such as leukaemia and 32

FORESIGHT

SPECIAL REPORT

to go in treating pancreatic cancer; immunotherapy doesn’t appear to be working as there is a stroma around it which prevents drugs getting to the tumour.

Q: WHY IS GENOMIC TESTING OF TUMOURS SO KEY?

THE VOICE OF LIVED EXPERIENCE

“Genomic testing of cancer tumours will be a game changer” Pancreatic cancer survivor Ali Stunt is CEO and founder of Pancreatic Cancer Action in the UK and a past president of Pancreatic Cancer Europe

Q: WHAT CAN YOU SEE ON THE HORIZON IN TERMS OF NEW TREATMENTS FOR CANCER PATIENTS? A: Things haven’t advanced much in pancreatic cancer treatments in the past 50 years, but we’re beginning to see some chinks of light, mainly along the lines of more personalised medicine for all cancer patients—and a lot of this is being patient-driven. Biomarker tests, genomic testing and targeted treatments are nudging up survival rates. But there is huge geographical variation. Australia has a five-year survival rate of 15%, compared to only 6.9% in the UK. The UK had only a 24% one-year survival rate but the figure is 50% in Austria and Belgium. The Know Your Tumour Registry study of 1000 cancer patients with biopsy-confirmed metastatic pancreatic cancer, carried out by the US Pancreatic Cancer Network, found that 26% had genomic alterations that were actionable with currently available drugs. This could be potentially game changing if health systems routinely tested the genome of each tumour. The same study found that those given genetically targeted treatments rather than standard care had a year’s improvement in survival. When you consider at the moment that average life expectancy is four to six months with metastatic pancreatic cancer, an extra year of life is a phenomenal gain. Genetically targeted treatment is definitely the way we want FORESIGHT

A: To take an example of how genome testing can expand treatment options, around 4% to 7% of pancreatic cancer patients have the BRCA1 and BRCA2 gene mutations found in breast, ovarian and other cancers. We know from research done into other BRCA cancers that these patients respond better to platinum chemotherapy as a first line treatment. Last year, the POLO trial in the US showed that a PARP inhibitor drug, which helps to repair damage inside cells, doubled progression free survival for patients with metastatic cancer who had been first treated with platinum chemotherapy. Understandably, there is a lot of buzz about genomic testing of cancer tumours—I’d like to see it offered routinely by health care systems as this will determine if patients could be offered targeted treatments that could extend their survival time. Information is key. We have patients walking around today with cancer gene mutations which could benefit from therapy, but they don’t know about it and will probably die without knowing.

Q: ANY NEW BREAKTHROUGHS IN IDENTIFYING BIOMARKER TESTS? A: Yes, there have been some exciting results in April [2021] from a study that used a blood test together with a biomarker for pancreatic cancer. The study was designed to detect early-stage cancer in patients in high-risk groups with symptoms that are concerning but not specific. The test detected cancer with 92% specificity and 81% sensitivity. This could mean that we have a non-invasive test that we could use to screen relatives of patients who have had pancreatic cancer. Non-invasive biomarker tests for cancer have been the Holy Grail, and it looks like we could have this potentially by the middle of 2021.

SPECIAL REPORT

THE LAWMAKER

“If we don’t find a new financing model for NCD medicines in the next decade we will be creating a two-tier system—one for the rich and one for the poor” Ricardo Bapatista Leite, physician, Portuguese member of parliament and head of public health at the Catholic University of Portugal in Lisbon

Q: WHAT ARE THE TRENDS IN NCD MEDICINE DEVELOPMENT? A: Medical technology is going after retail medicine, developing products for conditions that affect millions of people (such as diabetes) for the mass market. What we are seeing in the pharma industry is a trend to invest in fields of medicine where there are currently no solutions (conditions such as pancreatic cancer). What I can foresee—especially when you add in all that is currently happening in the genomic and precision-medicine fields—is that in the next decade, if we do not find a new financing model, we’ll basically be creating a two-tier system, one for the rich and one for the poor. Those that have the resources will get access [to the newest medicines] and those without, will just have access to whatever is currently available. This is exactly the opposite of what universal health coverage is aiming to achieve.

Q: WHAT ARE THE COST IMPLICATIONS OF SOME OF THE NEW NCD MEDICINES SUCH AS GENOMIC DRUGS FOR CANCER AND ”CURE” DRUGS? A: The issue from the pharmaceutical company’s point of view is the discussion around value and what the 34

cost of that value should be based on—including not only what they have invested, but also the drugs that have failed during that process and other pipelines they are building. Many of the technologies are life changing and some of them are real cures. The issue from policymaker perspectives and for those having to manage the finances, either private insurers or those controlling public spending, is that it’s not an issue about cost but affordability. Nobody can dispute a technology that saves lives or cures disease. The issue is about how you get that value embedded within your system in a sustainable manner that doesn’t undermine the other efforts of a health delivery system—and that’s where I think we need to discuss how payers and pharmaceutical companies can work together to find these solutions.

Q: DO YOU THINK WE NEED NEW PAYMENT MODELS FOR FINANCING MORE EXPENSIVE TYPES OF NCD TREATMENTS? A: Following the introduction of new drugs for hepatitis C, a new kind of payment model has come into being, the so-called “Netflixing” of medicines, with the idea that you pay a rent or fee for medicines and use as much as you need. This type of approach is aimed at curative drugs for diseases affecting a big population, where there is need and you can see the value and true benefit that technology brings to the health system. Wider use of this model could keep costs within budget and create a true incentive to treat as many people as possible. If you think about hepatitis C, your incentive is to cure all people as soon as possible. The more effective you are in diagnosing and treating those people, the more you free yourself from the expense moving forward. I think we need to incorporate different ideas and find solutions that work. I also think that pharmaceutical companies need to rethink the way they brand and commercially present themselves to the payers— be they states, ministries or insurance companies. The “one-size-fits-all” approach many pharmaceutical companies use when addressing different countries doesn’t look at the specifics of that health system. They need to provide solutions to overcoming barriers that exist in that health system to make sure the technology is made accessible. At the end of the day, instead of selling a pill, companies will be selling a solution that adds value that can be measured at the end. There is also this idea that countries, governments, and insurers can pay after the benefits have been proven in the real world with real world data. These are all different models which I think could be considered to make sure everyone gets a fair deal. FORESIGHT

SPECIAL REPORT

Q: SHOULD COUNTRIES BE WORKING TOGETHER ON INNOVATION AND PROCUREMENT OF NEW TECHNOLOGIES? A: For rare diseases and some cancers, it may be that we need a joint procurement approach between countries. This would create a critical mass to allow us to negotiate in a way to make a win-win solution for those investing and for those buying. On the other hand, it may be necessary for countries to allocate specific funds for innovation. At the moment, it’s becoming impossible for health systems to manage their budgets as innovation comes in and disrupts everything. To have central funds dedicated to innovation would enable access and ensure that innovation doesn’t disrupt the normal functioning of the health system. Those that own the patents, who are also investing in R&D, would also know the limits of the system, so it becomes more transparent; this would make negotiations more realistic so everybody knows what there is to gain and how far each party can go.

THE INDUSTRY VIEW

“Medical innovation is meaningless unless it reaches those in need” Vanessa Peberdy, Associate Director, NCD Policy & Advocacy & WHO Engagement, International Federation of Pharmaceutical Manufacturers and Associations

Q: WHAT IN YOUR VIEW ARE SOME OF THE MOST EXCITING BREAKTHROUGHS IN THE PHARMACEUTICAL PIPELINE FOR NCDS? A: Some of the most exciting developments in treating NCDs have been in relation to treating cancer and cardiovascular disease (CVD). Innovative regimens based FORESIGHT

on progenitor cells [powerful cells with the ability to form new blood vessels] are also emerging as promising approaches for the treatment of a variety of CVDs as this technique could play a key role in repairing damaged heart tissues. Investments in R&D are providing tools and techniques to exponentially decrease the costs of genetic sequencing and allow clinicians to increasingly treat each cancer patient with a personalised combination of drugs.

The field of immunotherapy holds much promise, as evidence has shown that increasing the strength of the patient’s immune system to attack tumour cells can lead to a cancer-free diagnosis. Another immunotherapy approach called adoptive cell transfer (ACT) collects and uses a patient’s own immune cells to treat their cancer and one of the most advanced forms of ACT is CAR-T cell therapy. CAR-T cell therapy uses T-cells, which play a critical role in orchestrating the immune response and killing cells infected by pathogens. Decades of cancer R&D have also benefited the development of the latest covid-19 vaccines. The most talked about are mRNA vaccines, which carry instructions to tell the body to make proteins that attack viruses. This breakthrough was built on the back of more than a decade of research into mRNA in the field of oncology.

Q: WHAT ARE SOME OF THE MAJOR CHALLENGES IN DELIVERING THESE NEW NCD TREATMENTS TO THOSE WHO NEED THEM? A: Biopharmaceutical innovation is behind some of the greatest achievements in modern medicine. Unfortunately, not all communities have fully benefited yet from these medical advances. Addressing the reasons for this is a complex challenge that requires long-term commitment from governments, society, 35

SPECIAL REPORT

and the private sector. Medical innovation is meaningless unless it reaches those in need; it is also a critical element for achieving universal healthcare. (UHC) Our industry understands the responsibility it has to people living with NCDs and has a strong track record of sustaining programmes to improve the health of patients in low-and-middle-income countries. These initiatives strengthen local healthcare capacity, educate patients and populations at risk, and conduct R&D in diseases of the developing world. A resilient health system with well trained and well equipped health professionals is foundational to achieving UHC. Innovative medicines have a major role to play in this regard, as they can put healthcare systems on a more sustainable path by reducing costs in other parts of the system such as hospitalisations and healthcare practitioners’ time. For example, per capita expenditure on cardiovascular hospitalisations would have been 70% higher in 2004 had new cardiovascular medicines not been introduced between 1995 and 2004. Having said this, medicines are still only one part of the overall access-to-healthcare equation. As we see in diabetes, strong primary healthcare systems, secure supply chains, health literacy, good public health and prevention policies, access to diagnostics and devices—all need to be in place to achieve good health outcomes. The work of Access Accelerated, our industry-wide initiative to tackle NCDs, is exemplary in showing how even when treatments for chronic diseases are widely available and affordable, the barriers to access to early diagnosis and ongoing treatment can only be addressed holistically, involving governments, society, as well as biopharmaceutical companies.

Q: WHAT HAS THE COVID-19 VACCINE DEVELOPMENT PROGRAMME TAUGHT US? A: Covid-19 has genuinely taught us that we need to ensure all players that can contribute to positive change have a seat at the table. In this light, there are many positives to take away from the covid-19 experience in terms of collaboration and solidarity that will be useful for “building back better” as a society; we have also learned the hard way that the linkages between NCDs and covid-19 cannot be ignored. Seeing people living with NCDs at greater risk of complications from covid-19, greater risk of hospitalisation and higher risk of death just re-emphasises the need to ensure we invest more in NCD prevention and control as a means of building back a global population that will be more resilient to the next pandemic. 36

THE ACADEMIC

“We must not let opioidphobia deter countries from ensuring access to opioids for palliative care” Dr Afsan Bhadelia, research associate, Department of Global Health and Population at Harvard T. H. Chan School of Public Health, United States

Q: HOW IMPORTANT IS PALLIATIVE CARE IN TREATING NCDS? A: In much of the world, palliative care falls at the bottom of the priority-setting list, if it makes it on there at all. It is one of the most neglected areas in global health. Policies and resources to strengthen health systems and improve health outcomes tend to focus on prevention and treatment, as well as on prolonging life and increasing productivity. This focus has also resulted in the overall neglect of quality of life and of reducing suffering. Palliative care is a core part of the care continuum and is important to ensuring dignity in life and death. Health systems need to be designed to ensure care throughout the care continuum, prioritising suffering alleviation, which is of immense value to patients and families who don’t want to see their relatives in pain or experiencing other forms of distress. I was one of the lead authors of the 2017 Lancet Commission on Global Access to Palliative Care and Pain Relief report, which introduced the concept of serious health-related suffering (SHS). The report quantified the burden of SHS that can be addressed with adequate access to palliative care. We found that over 25.5 million people of the 56.2 million who died in 2015 and more than 35.5 million people who did FORESIGHT

SPECIAL REPORT

not die in 2015 experienced SHS, a large proportion of which is associated with non-communicable diseases. More than 80% of people with SHS lived in low-andmiddle-income countries with severely limited access to any palliative care, even oral morphine for pain relief, demonstrating a major health inequity. Misconceptions around palliative [care] include that it is only relevant at the end of life—during the last months and even hours—when it is actually essential from the point of diagnosis through to death. Another is that palliative care is only required for cancer patients, while in fact it is essential to alleviating suffering associated with other conditions such as HIV, TB, dementia, cerebrovascular disease, and lung disease. Suffering can also include other physical symptoms such as shortness of breath and psychological symptoms, including depression. The burden of NCDs is projected to rise and this will also increase demand for palliative care.

Q: IS ACCESS TO MEDICINES FOR PALLIATIVE CARE AN ISSUE GLOBALLY? A: We have the medicines we need to address SHS through palliative care and these are off-patent and cheap. While there is room for development of new formulations of opioids and of creating opioid alternatives, safe and effective options are currently available. The main issue is over access, particularly to both injectable and oral immediate-release morphine, in most of the world. The Lancet commission found that 95% of distributed opioid morphine-equivalent, an indicator used to examine the morphine available to prescribe to patients, is within the US, Canada, western and central Europe and Oceana, which together represent only 9% of the population globally. FORESIGHT

The Commission designed an essential package of palliative care services, including medicines, basic equipment and human resources that could alleviate much of the avoidable suffering, at a cost of only $2.16 per capita per year. Most of the medicines in the package make up only two to three per cent of the total cost of the essential universal health coverage package.

Q: WHAT ARE THE BARRIERS TO PALLIATIVE CARE BECOMING MORE WIDELY AVAILABLE? A: There are various barriers to addressing the huge inequities in access to palliative care. One is “opioid-phobia”, which stems mainly from misinformation on the medical use of opioids by policymakers and healthcare professionals alike. This is due to a focus on preventing non-medical use of opioids, particularly in response to the opioid epidemic in the US, instead of a balanced approach that simultaneously ensures access to the benefits of opioids while minimising risk of non-medical use. As such, regulatory barriers are a major hurdle. Issues of access for medical use exist even within the US, where impoverished and minority communities are less likely to have access to evidence-based palliative care and pain relief. However, we can take appropriate steps to ensure safe and evidence-based access. Greater awareness of policymakers on the issue is critical. Further, a lot of countries in the world don’t have palliative care experts, but specialised palliative care is not necessary in most contexts. Training of healthcare professionals such as primary care physicians and nurses on core palliative competencies, through integration in the medical and nursing curriculum, could vastly improve access to palliative care. • 37

HOW TO PAY FOR PRIMARY CARE OF NCDs

Make the link between chronic disease and economic output

TEXT Paul Adepoju PHOTO Lars Just and Unsplash

As covid-19 pandemic-priorities escalated, care of non-communicable diseases got pushed aside, particularly in less well off countries. Inevitably, a surge in cases of chronic ill-health is now expected. Regions with pandemic-ravaged economies will struggle to finance the increased healthcare burden. It will be up to politicians to stress the link between good health and economic prosperity and open the financial channels for new investment

FORESIGHT

It all has a price Bookkeeping of clinical treatment should include the economic cost of lost work-years PHOTO: Lars Just

FORESIGHT

HEALTH FINANCE

efore 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 40

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.

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.

Health spending in poorer countries tends to be reactionary rather than proactive, with urgent demands attracting investment away from NCDs

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 prepaid 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 region stresses primary health care as the principal avenue for managing NCDS. “People with non-communicable diseases, or at risk of developing one, require long-term care that is proactive, patient-centred, FORESIGHT

HEALTH FINANCE

Who carries the financial burden of disease? Financing schemes in % of total health expenditure

77%

15%

48%

WHO Global Health Expenditure Database, 2018

24%

NIGERIA

KENYA

28%

Government schemes and compulsory insurance

Household out-ofpocket payment

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 FORESIGHT

Voluntary insurance

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 41

HEALTH FINANCE

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 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 in formal 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 in42

creasing 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 pandemicweakened 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 FORESIGHT

HEALTH FINANCE

Health care avenue The road to improved NCD care starts at primary health care

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 earFORESIGHT

ly-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 bottlenecks 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.” • 43

HEALTH FINANCE

Increasing risk factors cause huge loss to the global economy NCDs cost millions of wasted work years that preventative care could have saved

NUMBER OF HEALTHY YEARS LOST (DALYS)* PER RISK FACTOR IDENTIFIED BELOW Global, both sexes, all ages (million)

HIGH SYSTOLIC BLOOD PRESSURE

220 200

AIR POLLUTION

180

HIGH FASTING BLOOD SUGAR LEVEL

160 140

HIGH BODY MASS INDEX

120 100

KIDNEY DYSFUNCTION

DRUG ABUSE

80 60 40 20 0

LOW PHYSICAL ACTIVITY

1990

1995

2000

2005

2010

* Disability life adjusted years are a measure of the total burden of disease, both years of life lost and years of illness. One DALY represents one lost year

FORESIGHT

2015

SOURCE IHME, Global burden of disease study, 2019

ALCOHOL ABUSE

HEALTH FINANCE

High yield on investment in NCD prevention and control Big economic gains to be had from WHO "Best buys" interventions

SOURCE WHO, 2018

FOR EVERY DOLLAR INVESTED IN NCD PREVENTION AND CONTROL AT LEAST SEVEN DOLLARS WILL BE RETURNED BY 2030

$350 billion THE 24 "BEST BUYS" INTERVENTIONS CAN GENERATE $350 BILLION (US) IN ECONOMIC GROWTH BETWEEN 2018 AND 2030

The WHO "Best buys" are cost-effective and feasible policy interventions for combating NCDs and reducing their risk factors

FORESIGHT

HEALTH FINANCE — OPINION

Community health workers key to cost effective prevention

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. 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. FORESIGHT

Prevention is a cost-effective policy. It needs to be prioritised

CHWs are largely underpaid, underutilised, 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

TEXT Devang Vussonji and Heri Marwa

revention 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 healthcare 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

Heri Marwa is the Tanzania Country Director for PharmAccess Foundation. Marwa is a qualified medical doctor and MA in health policy and financing

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

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-forservice 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.

SECRETS 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 FORESIGHT

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. • Other Contributors: Dalberg: Steve Kisakye, Grace Mallya, Maria Dorin Shayo, Divine Miho, Fitsum Gelaye. PharmAccess: Peter Risha 47

TEXT Marcella McCarthy PHOTO Lars Just

Connected care Increasingly widespread use of mobile phones is making health care available to many more people, using telemedicine as the delivery vehicle

FORESIGHT

THE PROMISES OF TELEMEDICINE

Treatment by video is here to stay thanks to the pandemic

FORESIGHT

TECHNOLOGY AND INNOVATION

It took a rampant, highly infectious and deadly virus to pluck delivery of medical treatment out of the past and into the modern world of advanced communications and over-the-screen access to doctor consultations. The market for telemedicine has exploded. Virtual care start-ups are innovating daily to meet demand. In this health care revolution, the biggest beneficiaries could be those who have been most disadvantaged to date

sing information technology to clinically treat patients at long distance has come into its own during the covid-19 pandemic. Known as telemedicine, demand for it grew as patients sought to avoid long periods in packed doctor waiting rooms for fear of contracting the virus. As the advantages of telemedicine became apparent, so too did the delivery and receipt of broader care services via information technology (IT). Virtual care companies pounced on the opportunity. The market for telemedicine and virtual care exploded. Investment amounting to $3.1 billion (€2.6 billion) poured into the telemedicine sector globally in 2020, more than in any other health tech category and about three times the funding seen in 2019, according to Start Up Health’s 2020 year-end Insights Report. Although telemedicine has existed since the 1960s its use has been patchy. The pandemic catalysed a digital movement across industries, with remote work and virtual healthcare leading the way. Telemedicine and virtual care have arrived to stay. How fast the huge change in health care will trickle down to reach those with sparse IT access remains to be seen. Healthcare in many parts of the world primarily remains a business with a strong focus on the bottom line and where demand outstrips supply. Making telemedicine more accessible may largely depend on the financial and organisational support garnered by marginalised populations. It is still unclear who will spearhead these efforts. In high-income countries—including the US, parts of Europe and Japan—a number of hurdles prevented the widespread uptake of telemedicine prior to the arrival of covid-19. The obstacles mainly involved insurance reimbursement and concerns about privacy, both of which were quickly resolved during the pandemic. “In this post-covid world, more and more telehealth solutions are being reimbursed,” says Unity Stoakes, co-founder and president of StartUp Health, a company that offers insights into the global health tech space with more than 300 health tech companies in its investment portfolio. But for people without insurance and living far 50

from medical services, these developments are irrelevant. More specifically, people living with a non-communicable disease in low-and-middle-income countries (LMICs) often need chronic disease management and without access to telemedicine, seeing an appropriate specialist may be nearly impossible.

ADAPTIVE SOLUTIONS CALLED FOR While much of the developed world has been able to embrace telemedicine, obstacles remain for senior citizens, people in LMICs, and for the disadvantaged in rural areas. Primarily, the barriers to adoption of telemedicine are an absence of technological knowledge, a lack of access to technology, and weak broadband infrastructure. Experts point out these are all barriers that can be dismantled, given the right investment. They also caution that communities regarded as marginalised may already be benefiting from remote care in ways not recognised by more developed countries. The key distinction is that the delivery model may look vastly different from the norm in more affluent populations. “The poor and rural get telephone calls and the rich get video calls—that doesn’t sound very good,” but the service provided may be the same, says Ateev Mehrotra, associate professor of healthcare policy at Harvard Medical School and a practising physician. Mehrotra’s research focuses on global medical delivery innovations such as retail clinics, e-visits, and telemedicine, including their impact on quality, costs, and access to health care. Underestimating the scope of telemedicine is common and agreeing on a definition is a key challenge. Telemedicine and virtual care are often used interchangeably and while video visits may be what comes to mind, text messaging and telephone calls are also included in the definition. “We can agree that texting is less effective than a video call, but if the alternative is nothing, then it’s certainly better than nothing,” adds Mehrotra. A primary and obvious barrier for telemedicine is lack of access, whether to a mobile phone, ideally a smartphone, or any internet enabled device. But by FORESIGHT

TECHNOLOGY AND INNOVATION

MODELS FOR REMOTE DELIVERY While not everyone has a smartphone, much of the world has access to the internet, including 89% of rural regions in South Africa, Mauritius, Kenya, and Malawi, according to a study published by Harvard Medical School in 2019. More developed regions will have at least the same level of access in most cases. The value, says Mehrotra, is that internet access enables the creation and use of community telehealth centres where even elderly people unfamiliar with IT can receive help to see a doctor virtually. All of a sudden, these services no longer depend on every individual having a smartphone or the know-how to use one.

Internet access enables the creation and use of community telehealth centres where even elderly people unfamiliar with IT can receive help to see a doctor virtually

Connecting the unconnected Low cost Wi-Fi is bringing remote health care to rural areas around the world, in this case facilitated by specialist supplier Bluetown

the end of 2018, 5.1 billion world citizens subscribed to mobile communication services, accounting for 67% of the global population, according to GSMA, a mobile network industry organisation. “People are surprised by how many people in low-income communities have smartphones,” says Mehrotra. “In rural areas, we’ve seen communities skip the landline altogether and go straight to a mobile or smartphone.” Startup Health’s Stoakes agrees. “The challenges of a decade ago are getting resolved. They may not even have running water, but they have a smartphone,” she says. Because smartphones have become so multi-functional, people have prioritised them over buying luxuries, adds Mehrotra. Smartphones are used for communication, but they are also used for banking, healthcare, news, research, and a number of other daily tasks. FORESIGHT

Parau, a rural village of about 3750 people in the northeast of Brazil, has no bank or high school and the largest city with substantial medical care is about four-and-a-half hours away by car, if one is available. While most in the community never had a landline, many have smartphones. A Catholic church in the village centre offers free Wi-Fi and at a basic medical centre a general practitioner is sometimes available, but no specialists. “People here still don’t have the custom of doing video visits, but you know, if we need to talk to a specialist in a different town, we can talk to them on the phone. I did that recently for my mom,” says Vera Amorim, a community leader and resident of Parau. It helps that Amorim is educated, well-travelled and in a better financial position than most in the village. She also has relationships with doctors in other cities. But without a system for a doctor to get reimbursed or compensated for such quick calls, formal access to telemedicine remains out of reach. To close the gap between demand and supply in parts of the world without organised health care, specialised health-tech start-ups are beginning to offer innovative approaches to virtual care that go beyond the video call between patient and doctor that has become familiar in some advanced economies during the pandemic. In Africa, telemedicine is seen 51

TECHNOLOGY AND INNOVATION

Remotely, a doctor can look down a patient's throat, in their ear, listen to their lungs, take their blood pressure and even listen to their heart

as a way of increasing access to care—an opportunity for innovators and local organisations to partner and provide essential healthcare services that are affordable, reliable, and tailored to local needs, according to The Africa Report, a leading news organisation on the continent in an article on e-health in Africa published in March 2020. For the chronically ill living with a non-communicable disease (NCD), care often involves symptom management as well as keeping the disease at bay. Frequent medical visits and medication adjustment are required. In remote rural areas, even something as non-threatening as recurring migraine headaches can leave a patient largely disabled if untreated. Companies like Vezeeta, based in Egypt, are working on ways to resolve the issue of getting health care to the remote patient.

SPECIALISED TELEMEDICINE PLATFORMS Vezeeta originated as a booking platform for in-person visits but has since pivoted into a telemedicine platform offering consultations with physicians in Egypt, Kenya, Nigeria, Lebanon, Saudi Arabia, and Jordan. Unlike most telemedicine platforms providing broad primary care, Vezeeta focuses on specialties such as psychiatry, nutrition, dermatology, gynaecology and infertility, diabetes and endocrinology, and oncology and oncological surgery. The price of each virtual appointment is listed in US dollars and an appointment with a 4.5 star-rated oncologist in Cairo starts at $20, which is about what it costs to refuel a car in Egypt. Investors are bullish on the African continent’s ability to churn out health tech companies that serve the needs of its population. African e-health start-ups operating across the continent raised over $90 million in 2020 alone. Indeed, more than half of healthtech investment made in Africa over the past five years happened in the first half of that year, according to Disrupt Africa, a source of investment news.

HANDS-OFF PHYSICAL EXAMINATION Elsewhere, an Israeli-founded company is working to resolve one of the major missing links in telemedicine: the inability to perform a physical exam. TytoCare 52

not only facilitates video visits but has also created a suite of tools that allow for a patient to be virtually examined by a doctor. The portfolio contains all the typical doctor’s tools, linked to a camera and Wi-Fi. Remotely, a doctor can look down a patient’s throat, in their ear, listen to their lungs, take their blood pressure and even listen to their heart. All these tools connect to an app and telemedicine portal. With the evolution of TytoClinic, the company has created the means to turn any location into a telehealth examination centre. It is focused on increasing access to care in rural and under-served communities in the US and around the world. “We have some people in remote villages in Latin America that are having their first primary care visit,” says Dedi Gilad, CEO and co-founder of TytoCare. As TytoCare bridges the gap between telemedicine and in-person care, attention is also turning to therapies and treatments for NCDs that have not only been difficult to address virtually, but for which in-person treatment aftercare has not been a great success either.

CARDIO REHAB REMOTE CARE SUCCESS Cardiovascular disease (CVD) is the number one cause of death globally and in 2016, an estimated 17.9 million people died from CVDs representing 31% of all global deaths, according to the World Health Organization. While surgeries and interventional therapies are available—including stents and bypasses— patients do not spring off the operating table and go back to their nine-to-five job the next day. Recovering from a CVD event requires follow-up therapy known as cardiac rehabilitation that has to take place in a hospital and usually involves three sessions a week for 12 weeks. The time and flexibility needed to accommodate the treatment schedule is a luxury many patients do not have. Only 20% of patients who need cardiac rehabilitation get it, according to Phas3, one of the companies in Startup Health’s portfolio. The biggest reason for the failure is that patients are getting back to full-time jobs, have families to care for and bills to pay, and little time or resources to make thrice-weekly trips to the hospital for several months. FORESIGHT

TECHNOLOGY AND INNOVATION

Age of health tech Entrepreneurs across African health tech start-ups have seized the moment created by the pandemic to introduce new ways of IT-delivered healthcare

Phas3, a Missouri-based start-up, focuses on providing virtual care for those who have suffered a cardiac event. It offers a telemedicine platform allowing cardiologists to conduct cardiac rehab remotely, plus connected devices such as a bluetooth heart rate monitor, a blood pressure cuff, and a weight scale. The platform allows clinicians to assign specific care plans that allow patients to work through guided exercises and activities daily.

MOUNTAINS HAVE MOVED Prior to the covid-19 pandemic, the inconvenience of missing half a day’s work and waiting what could be months to see a doctor for just 15 minutes had not been enough to push any significant adoption of telemedicine. Post-pandemic, however, it is a different FORESIGHT

story. Experience with IT-delivered health care that a rampant, deadly and highly infectious virus necessitated has created a new trust in its ability to deliver. Over the past year, start-ups in the virtual care space have pushed boundaries and innovated more quickly than ever. Patients, especially those who were less tech-savvy, found themselves learning to use healthcare IT, which steadily developed to become more user-friendly. Although the shift has been less dramatic in LMICs, many of the newest start-ups in the sector are dedicated to helping more remote areas leapfrog over some of the resource barriers that currently exist. The covid-19 pandemic roared into the world and turned the healthcare industry on its head; now there is no going back. • 53

TECHNOLOGY AND INNOVATION — OPINION

To manage syndemics think like an octopus

In the age of syndemics, it is time to think differently. We need more global health organisations to focus their energy outside the clean lines of health care to re-imagine what health means at a local level. To do this, healthcare practitioners need to spend time embedded in the social context to map problems and co-create solutions alongside individuals and communities. Another anthropologist, Clifford Geertz, called the nuanced and sometimes messy understanding of context, history, culture, and behaviours the “thick description.” Global health needs more thickness to be integrated in how we design systems, programmes, interventions and how the patient experiences care. It is not that global health organisations should abandon simple, life-saving protocols or expertise in delivering cost-effective interventions at scale. Rather, we must complement our efficiency in focused areas with exploration to find new solutions to the underlying thick problems.

THE EFFICIENCY-EXPLORATION TRADE-OFF It is hard to efficiently deliver proven interventions and innovate radically new approaches at scale, as the challenges of mass vaccination demonstrate. We know the capabilities required to rapidly deploy milFORESIGHT

lions of vaccine doses are different from those required to understand and resolve the root cause of vaccine hesitancy at community level. This tension between efficiency and exploration runs deep, not only in our organisations but in our own biology. Developmental psychologist Alison Gopnik describes this efficiency-exploration trade-off in her study of human consciousness. Children’s minds, she finds, are physically and chemically primed for open exploration while adult minds are built for efficient task execution; we often lose the former as we grow into the latter. There is, according to Gopnik, one creature that can do both simultaneously: the octopus. Octopi have a split consciousness, with their “head brains” executing efficiently on day-to-day tasks and their “tentacle brains” constantly taking in new information, synthesising and developing new solutions.

ORGANISATIONAL BIOMIMICRY To overcome the tension between exploration and execution, perhaps we should look to octopi to inspire our own organisational design. In its simplest form, this could mean carving out space for two distinct but connected approaches: one focused on executing the strategic priorities of an organisation—the “head-brain”—and

TEXT Anne Stake

or a year and counting, covid-19 outbreaks and deaths have continued to cluster in underserved and marginalised communities. Global health leaders watch as health disparities deepen against a backdrop of inequity in access to basic social needs: good food, clean air, green space, shelter, physical safety, education, employment. We’ve come up short. Despite decades of global health initiatives, we have clearly failed to adequately address health inequity and its root causes. The notion that so-called “social determinants of health” drive health outcomes is not new. Nor is the idea that these social determinants are key to understanding the patterning of epidemics in populations. In the 1990s, medical anthropologist Merrill Singer coined the term “syndemic” to describe the idea of two or more coinciding epidemics amplified by the interplay of biological and social factors. Much has been said about the syndemic of covid-19 and chronic disease, about the importance of social determinants, and about the reality of 80% of health outcomes being determined outside the bounds of the traditional health system. And yet, in terms of policies and actions, we are stuck firmly within the paradigm of traditional health care delivery.

one focused on driving fresh thinking and innovation—the “tentacle-brain.” If an organisation is “head-brain”-dominant (as most are), it is critical to make time and space for the “tentacle-brain” to flourish. At Medtronic LABS, the global health innovation arm of Medtronic, we purposefully built an organisational structure to insulate the “tentacles” from the day-to-day tactics and key performance indicators so critical to the operation of our social enterprises. We started with a two-person innovation team with expertise in human-centred design, ethnographic research, service design, and UX/ UI design. The team initially operated independently, exploring and developing and prototyping new concepts for health care delivery models. Over time, the innovation team has tripled in size, grown in influence, and strengthened its interface with the main organisation as its concepts become part of the wider operation. Today, design-based and exploratory methods are driven by the innovation team but practised by everyone at every level of Medtronic LABS, from field operations specialists to commercial leaders. Typically, team-members spend 15% of their time embedded with communities they are serving to explore new ideas and approaches. It all started with establishing the right octopus-like team structure to allow our “tentacle-brain” to start exploring, while remaining clearly connected to our “head-brain” over time.

PRACTISE EXPLORATION What does it mean to explore? And how does exploration translate into better approaches to syndemics and associated health disparities? In a sense, the lack of a simple answer to these questions is exactly the point: exploration is about understanding the “known unknowns,” discovering the “unknown unknowns” and ultimately arriving at the root of the problem to create novel solutions. We may not know where the journey ends, but we do know where to start. At Medtronic LABS, all of our exploration begins and ends with the people we are serving, upending old power dynamics by putting the patient and the community in the driver’s seat. Over the past year, our exploration

with communities has centred on two key themes: reimagining value and putting “health” back in health care. Health systems have been designed to optimise “value” for doctors, for governments, for payers, but rarely for patients. We have been working to reimagine what patient-centric value means in health care through a series of ethnographic and co-creation exercises with groups of men and women from the slums of Bangalore and Nairobi to villages in Ghana and The Philippines. While a “head-brain” approach may have focused on pushing blood pressure monitors or lab tests, our “tentacle-brain” exploration focused our attention on the things that actually matter for patients: the ability to take a walk in the park, to pay for a child’s education, to leave abusive home environments, to feel respected. We have built award-winning service models for diabetes and hypertension with this orientation at the core: the social support group curricula, virtual engagement modules, games, incentives, and measures of success are defined by the patients, not by us.

We need more global health organisations to focus their energy outside the clean lines of health care to re-imagine what health means at a local level In parallel, we are striving to put the “health” back in healthcare by thinking beyond the traditional walls of hospitals and pharmacies. In Kenya, we are exploring what it would mean to “prescribe” personalised diets and nutrition plans, working alongside patients to plant kitchen gardens and provide other sources of nutritional support. In India and The Philippines, members of our group-based FORESIGHT

Anne Stake is head of strategy, innovation and technology at Medtronic LABS, a social enterprise focused on expanding access to healthcare for underserved patients, families and communities across the world

service spend more time dancing, meditating, and engaging in talk therapy than they do learning about diabetic food or the risk of stroke. In all of our work we are partnering with local NGOs and governments who provide social services to ensure that patients receive refuge in the face of gender-based violence, food in the face of food insecurity, financial support for education and more. Health is a social subject and we have found success in approaching it in a social context.

THE TIME IS NOW We are proud of our initiatives and inspired by many others like them around the world, although we are also realistic: for now, at least, they remain exciting innovations on the periphery rather than the norm. As the world becomes more complex and interconnected, the “thickness” of the problems we face becomes ever more apparent and our natural “adult-brain” tendency towards simple and efficient solutions needs to expand. We are hopeful that the challenges of this syndemic age can spur new initiatives that may yet achieve a world not just free of human disease, but full of human health. • 55

FORESIGHT — Global Health

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