Author: Fred Hersch

Addressing NCDs in Ghana – viewed through a camera lens

This week on PLOS TGH, we hear from Dr Fred Hersch – research fellow with The George Institute for Global Health at the UK’s Oxford University. As part of the crowd-funded NCDFREE Campaign, he and his team have just returned from Wa in the Upper West Region of Ghana, making a short advocacy film on the innovative, community-led, NCD prevention and control activities taking place there – and in particular, the inspiring work of young NCD activist, Emmanuel Sanwuok.

 

NCDFREE Ghana Film

When we think about diabetes, high blood pressure and heart disease, we don’t generally think about Sub-Saharan Africa. And yet it is in the countries of this region, that they sit side by side with persistently high rates of maternal and child health and infectious diseases we traditionally associate with poverty and Africa – HIV, malaria and tuberculosis.

The fact of the matter is that in Sub-Saharan Africa, things are changing. Fast. Just like every other region of the world, the burden of non-communicable diseases (NCDs) is rapidly rising. According to the WHO the burden of deaths from NCDs will climb from 28% in 2008 to 46% by 2030.

Ghana Sunset

The impact of this is dramatic.

NCDs place a huge strain on already under-resourced health systems. In low- and middle- income countries alone, annually, NCDs are responsible for 8 million deaths under 60 years of age. For a family, a society and an economy, this is a huge loss.

Ghana, the Star of Africa, has long been a success story of Sub-Saharan Africa. The first country in the region to gain independence in 1957, it has been relatively stable ever since. Since 2001, Ghana has experienced rapid economic growth and rising human development.

ghana_star_web

Ghana has made some impressive achievements in terms of healthcare. There is a universal health care system and a national health insurance scheme that provides access to health services and prescription medications. Life expectancy at birth is 66 years (2010). For decades Ghana has trained a cadre of physician assistants to make up for the lack of Doctors (15/100,000) – especially in rural areas.

Despite this, resources for health are still relatively scarce. Ghana spends only 5% of GDP on healthcare; a long way short of the 15% agreed to in the Abuja Declaration (2000). At this level, health systems are at risk of being overwhelmed by the emerging epidemic of NCDs.

Wa, the regional capital of the Upper West Region and some 12 hours North of Accra, is like any rural-urban centre in Sub-Saharan Africa. It is a dusty, bustling commercial hub struggling under the weight of a rapidly changing society with ever increasing demands on its meagre resources. Visiting this part of the world it is instantly evident that globalisation and its effects on society are felt everywhere.

Conventional wisdom holds that NCDs should not be a problem here. And yet since 2011, under the direction of the Regional Director for health, the Ghana Health Service has been setting up NCD prevention and control strategies. This is no small task.

Traditionally health systems in such places have been oriented towards addressing maternal and child health or dealing with common infectious diseases. NCDs are different. Prevention strategies that lead to early identification of high-risk individuals are key to curbing the impact. The goal is to prevent as many ‘events’ e.g. a stroke or heart attack, for which there is no treatment. This requires a different approach.

33 year old Emmanuel Sanwuok, the Regional Co-ordinator for NCDs is on a mission. He is driven by a passion to address the neglect for NCDs that he sees. His dream for Ghana is for a country where people are able to lead healthy lives, and for those who need it, access quality health care.

Emmanuel with his wife and 2 young daughters.

Emmanuel with his wife and 2 young daughters.

Central to their efforts has been the formation of a multi-disciplinary team of health workers, the NCD Task Force. The NCD Task Force undertakes workplace and community based screening services where adults are invited to participate in a health assessment. The aim is to identify those at highest risk of common conditions and to intervene early with either lifestyle advice or where required medication.

Sanwuok and his team believe that key to addressing the rising burden of NCDs is to raise awareness amongst the community about the risk factors and the steps that people can take to lead healthier lives – eating more fruit and vegetables, avoiding foods high in salt, and engaging in regular physical activity. They take to the air-waves on a weekly basis and run various activities to spread their positive message about leading healthier lives.

NCDFREE Task force - Multi-disciplinary team of health workers

NCDFREE Task force – Multi-disciplinary team of health workers

The cost of inaction is too high to ignore. In Wa, NCDs cost lives and livelihoods. For a family and society, the loss of a breadwinner is devastating. For a person with diabetes, the costs of seeking care can consume an entire households income (despite health insurance).

Seeing the work of Sanwuok and his team in this corner of the globe is truly inspiring and acts as a solemn reminder that NCDs affect everyone, everywhere. What is needed is more support to build the capacity of health workers and the health system to be able to provide comprehensive care that includes addressing NCDs.

Sanwuok and those around the world like him are in a David and Goliath struggle. Unlike malaria, TB and HIV, there is no global fund to fight NCDs. If countries like Ghana are to meet the ambitious targets that have now been set, more support for programs like these are needed. After all, in slaying Goliath, even David had a sling-shot.

NCDFREE Team Ghana; Fred Hersch, Batsheva Lazarus, Emmanuel Sanwuok, Tom Eagar

NCDFREE Team Ghana; Fred Hersch, Batsheva Lazarus, Emmanuel Sanwuok, Tom Eagar

 

fred_circleFred Hersch is a medical doctor (MD/MPH) and technologist. He is passionate about global health and the role of technology in transforming health care delivery for the better. Prior to medicine and public health he worked in the web development space implementing medium to large scale web content management projects. He was an early pioneer in the tele-medicine space co-founding MedTech Outreach Australia and developing one of the first web based tele-medicine platforms. He is now a research fellow at The George Institute for Global Health where he is involved in research around the application of technology, particularly smart phones and clinical decision support tools and how these can be used to improve access to “essential healthcare” in resource poor settings. 

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Transforming health care: one SMS at a time?

I’m Fred Hersch, a medical doctor and techy with a passion for global health. I’m interested in the role of technology for improving access to essential healthcare. With years of experience developing web solutions (prior to studying medicine though I still do it), I bring a bit of pragmatic reality to the discussion about technology and healthcare. Don’t get me wrong, I’m a believer that technology has a huge role to play but it’s no silver bullet either. It’s what you do with it that counts. This article is the first that looks at what is going on in the health technology space and thoughts about how technology can be harnessed to improve the health of people everywhere.

mHealth is everywhere you turn these days. The mobile phone has become the new “must have” for any serious “innovative” global health project. Everyone’s doing it, hell, we’re even making jokes about it! Have you heard the one about how there are more pilots in mHealth than there are in the US Air Force? So, what is it about the mobile phone that has the global health community so excited, and what are the opportunities offered by technology and innovation?

The context

Health for all has been a long held goal.  The Alma Ata declaration of 1978 laid out the Primary Health Care (PHC) model which emphasised people centered care and advocated for equitable access to essential services. The Millennium Development Goals re-invigorated efforts at PHC in many countries, and as we attempt to deal with the growing threats of non communicable diseases, strong primary care systems are essential.

At the heart of this definition lies access and equity which in turn bring up two very important issues; that of an adequate health workforce to deliver the care, and who pays the bill.

On the first, according to the WHO, there is a global health work force shortage of 4 million health workers. In 57 countries, this shortage is at critical levels.

In terms of who pays the bills, it is not just the USA that lacks some form of universal health care. A quick look at the map, and it becomes apparent very quickly, that universal access (in green) is the exception not the rule.  In many poor countries (most of the gray), out of pocket health expenses can be so great that they lead to poverty.

Towards solutions

Mobile telecommunications have been a true revolution. Many countries have leap-frogged traditional “copper wire” landlines and gone straight to mobile. In 2012 there are approx 6 billion subscriptions. 4.5 billion in developing countries with approx. 1 billion in each of India and China. It is the ubiquity and the accessibility – in terms of both affordability and equity that make the mobile phone such an attractive platform for healthcare.

The global health community has been quick to see the potential opportunities across the health system spectrum. Over the past few years there has been a proliferation of activities, pilot projects and (mostly small scale) implementations. Examples include: (i) improving health care services at the community level e.g ChildCount or Project Mwana based on RapidSMS, (ii) real time public health promotion e.g.  Project Masiluleke – HIV/AIDS prevention via SMS in South Africa, (iii) clinical decision support and patient management e.g. via CommCare, (iv) real time data collection in the field e.g. EpiSurveyor.

The list goes on.

The mHealth arena whilst still in its infancy is maturing. Companies like DataDyne (makers of EpiSurveyor/Magpi) and CommCare provide supported hosted cloud-based solutions. The RapidSMS framework is open source and freely available for download. The mHealth alliance and TechChange have teamed up to run a course: “mHealth: mobile phones for public health“ (in which I recently participated). And smart phones and tablet computers are becoming more available in low and middle income countries, providing another avenue for supporting primary care workers e.g. for clinical decision support in rural India.

The transformation of health care

Disruptive innovation is a transformational process by which the existing “status quo” is challenged to such an extent that a new model takes over or “disrupts”. Often driven by technology, it is the process innovation that leads to new value networks or outcomes. In our case, “affordable healthcare” for example.

And this is where the exciting opportunities lie.

Solving the health care problem for the ‘bottom 3 billion’ will take new partnerships and new ways of working together. It will require smart use of technology (such as the humble mobile) and the development of affordable health care devices (such as diagnostics) that enable health workers to deliver more for less. And most importantly it will require new ways of thinking. How technology is used by innovative minds trying to solve this problem in the field will lead to the new approaches and models.

The final word?

For all of us interested in the health of populations, the mobile phone is an exciting tool for improving health service delivery. As global health professionals we need to understand this potential and how to harness it for driving innovation. Whether it be m-health or e-health, we are at an exciting time where if used properly, technology can move us towards reimagining health care in such a way that “health for all” is a bit closer.

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