Empowerment is Key to Improving Health Infrastructure in Developing Countries

Miracles have happened in global health over the last fifteen years. Deaths from malaria and tuberculosis have each fallen by a quarter or more globally. Twelve million people in sub-Saharan Africa with HIV/AIDS were put on lifesaving treatment.

The great killers of children – pneumonia, diarrhoeal diseases, measles, whooping cough, and diphtheria—are receding. The once fearsome scourges of polio and Guinea worm are on the verge of extinction.  

While the war against microbes is hardly over, the need for continued vigilance should not blind us to the great progress that has occurred. For the first time in recorded history, plagues, parasites, and other infectious diseases are no longer the leading causes of years of life lost to death and disability in any region of the world.

In 1950, one out of five children perished before their fifth birthday in nearly one hundred countries, including almost every nation in sub-Saharan Africa, South Asia, and Southeast Asia. Today, the number of countries where one out of five children die under the age of five is zero. The average baby born in a developing country is now expected to live to 70. 

But the sustainability of this era of miracles in global health is uncertain. The recent gains in longevity and child survival in many countries have not been accompanied by the same economic growth, job opportunities, and infrastructure improvements that occurred with those changes in today’s wealthy nations. 

While extreme poverty has declined everywhere, the middle class has hardly expanded at all in South Asia and Africa. When higher-income countries took on the scourge of infectious diseases, advanced medicines played less of a role than today.

Only half of the declines in death rates in developing nations between World War II and 1970 were due to vaccines and antibiotics. Instead, the drivers of public health progress were government measures like quarantines and housing reform, investments in effective water and sewage systems, and improvements in girls’ education and child care. 

China was poorer than Chad, Benin, or Niger when it began a dramatic campaign against plagues and parasites after World War II that helped it later emerge as one of the great global economic powers. 

In contrast, medical innovations and global health aid initiatives are driving more of the recent progress against infectious diseases.

Beginning in 2002, global health aid to reduce child deaths, maternal mortality, and the infectious diseases in poor countries rose more than 10 percent annually over a decade, expanding from £8.25 billion to £21.6 billion.

From shantytown slums in sub-Saharan Africa to the rural highlands of Peru, aid-funded programs brought medicines, vaccines, and insecticide bed-nets to world’s poorest people.  

The returns on those investments are spectacular and measured in longer lives and the reduced suffering of children, but broader economic and social benefits of improved health have remained elusive. While extreme poverty has declined everywhere, the middle class, individuals living on $10 to $20 per day, has hardly expanded at all in South Asia and Africa, the places that have recently seen the greatest health improvements.

With limited access to health care and many people still too poor to purchase it out of pocket, cases of cancers, diabetes, and heart diseases are surging in many lower-income countries.

When low-income nations finally achieved an average life expectancy of 60 in 2011, their median GDP per capita (£815) was a quarter of the wealth that the residents of high-income countries possessed when they reached that same average life expectancy in 1947 (£3371).  

In too many countries, too little is being done to ensure that the children and infants surviving to adulthood find adequate health systems and employment opportunities to accommodate their needs as adults. The governments of all 48 countries of sub-Saharan Africa spend less on health care than the government of Australia.

With limited access to health care and many people still too poor to purchase it out of pocket, cases of cancers, diabetes, and heart diseases are surging in many lower-income countries. Foreign aid to address these non-communicable diseases has been lacking. The disparity in adult health –life expectancy at age 15 – between wealthy and poor nations is growing, even when one ignores the effects of HIV/AIDS.  

More people surviving childhood and adolescence used to mean more workers for factories and mills. But manufacturing only employs 7 percent of the workforce in sub-Saharan Africa, and manufacturing represents the same share of overall economic output in that region as it has since the 1960s.

The World Bank estimates that the working-age population (more than 15 years old) in developing countries will increase by 2.1 billion by 2050. Unless current national employment rates improve, that will mean nearly 900 million more young adults without work.

The recent declines in infectious diseases present an historic but time-limited opportunity. With steeply rising rates of child survival, more sub-Saharan Africans will reach the ages of prime employment (ages 15 to 64) by 2035 than will be added by the rest of the world combined.

While sub-Saharan Africa has greatly increased school attendance, up to 40 percent of children in the region still do not meet basic learning outcomes in numeracy, and half fall short in literacy. Without more investment in quality education, capable health care systems, and workforce development, large numbers of underemployed and under-productive young adults can be a recipe for instability and higher rates of migration.  

Providing greater health access and more efficient health care delivery, especially for vulnerable populations, are priorities for anyone involved in public health. Poor health systems in developing countries mean a shortage of trained health care workers, inconsistent inventory of medical supplies, and inadequate surveillance systems. This list is not exhaustive, but we can start here. Building a better health infrastructure, like many public health priorities, requires multi-level coordination. Empowerment has to spread out from the government to the community and to the individual.

We can address the problem first by tackling the shortage of health care workers. Doctors in developing countries are in critically short supply. In 2006, the World Health Organization compiled data on the impact of HIV/AIDS on the health workforce in developing countries. Results showed that while European and North American countries have doctors at a ratio of 160 to 560 per 100,000 people, African countries only have two to sixty doctors for every 100,000. In Malawi, for example, there is one doctor for every 50,000 people.

The global shortage of trained hospital and health care staff currently exceeds four million. Training more staff and volunteers is one solution for improving health systems in developing countries. Training other previously unqualified individuals could ameliorate these shortages. Providing incentives for already trained workers to stay in a vulnerable state or country could help build a struggling health system. Having a foundation of trained workers and preventing them from migrating to wealthier countries is an important first step. Empowerment and opportunities to grow and help are at the heart of this strategy.

The second hurdle is maintaining a constant inventory of equipment, medicines, and other health supplies. War, along with political and social unrest, in certain regions further dampens the efforts to provide a steady supply chain. There has to be cooperation between donors and the government to work with the private sector to ensure receipt of necessary health supplies. Partnering with emerging pharmacy chains increases the availability of medicines and drives down the cost for the patients. In the Philippines, Generics Pharmacy has thousands of small storefronts that are widely used by both the rich and poor.

Convenience and ease of access are often of paramount interest to every person, regardless of income. The issue of payment is another facet of the supply and demand problem. Corruption that trickles to the local governments, and even the health care workers themselves, leads to some patients having to pay for medicine or services that should have been free. Reforming payment systems to ensure that patients have the medicines delivered before payment is processed directly to the provider will empower the patients and promote compliance. 

Compounding the shortage problems, both of trained workers and supplies, are the inadequate surveillance systems in place. This is the third issue that needs to be addressed, and it is arguably the most crucial. Surveillance is necessary to monitor not only the needs within health facilities, but also within the community and surrounding areas.

Without real-time tracking of disease and medical supplies, logisticians, doctors and community health workers are unable to properly estimate need and completely evaluate the effectiveness of their clinic’s efforts. This is where data comes into play. The Novartis Malaria Initiative, under the Roll Back Malaria Partnership, has led SMS for Life, which harnesses mobile phones, internet, and electronic mapping technology to track stock levels for health facilities. Sending SMS messages between health facilities and the district medical officers ensures treatment availability.

Stock-outs have been reduced in Tanzania during a six-month pilot program from 79% to 26% in three districts. Not only are these stock-outs reduced, but when they occur, they are also resolved much quicker due to the ease of communication. In areas where internet is unavailable or running inconsistently, Relief Watch has offered a similar solution. It also uses mobile technology, but the application allows workers to not only track supplies but also disease.

The easy and free setup is invaluable to developing countries that have previously relied on paper spreadsheets and forms. Giving workers data at their fingertips gives them more control over their health facility and their patients. These technological innovations are not only crucial for immediate supply tracking and disease surveillance, but they provide research institutions and governing bodies more accurate data. After all, it is data that public health professionals and policy-makers rely on to make decisions and plan strategies. 

The aforementioned plan to improve health systems is by no means novel. Public health practitioners have stressed the importance of training more workers, creating a steady supply chain of treatments, and addressing surveillance shortcomings for decades.

Solving Africa’s health and development problems takes more than statements of good intention, empty promises of aid — or movie stars’ adoption of African children. But definitely there are ways to solve them. In fact, many diseases affecting children and adults can be addressed with minimal resources — if they are used strategically.

Aid can strengthen civil society and community-based organizations — which are the basis of a democratic society. To bring hope to a continent ravaged by poverty and disease, effective action is required. It can be done.

Nevertheless, more support is needed, particularly from governments, donors and NGOs to encourage future entrepreneurs to seek to invent new solutions with the potential to create a lasting impact on the health of hard to reach communities.

Adhering to these solutions requires cooperation and active coordination that extend from the public to the private sector. This is something that cannot be over-emphasized. Empowerment—of individuals, community health workers, and governing bodies of fragile states—is an important foundation from which a better health infrastructure can grow.