John E Ataguba
The need to ensure health systems resilience globally has never been tested significantly in the past century until the coronavirus 2019 (COVID-19) took centre stage. The outbreak of the coronavirus in Wuhan, China in December 2019 has changed many things globally, including how persons interact with each other. The full ramification of the pandemic is yet unknown, but its effects will last for an extended period. An important effect of the COVID-pandemic that is of significant importance to this piece is the possibility of crowding out of primary health care spending as countries in Africa respond to the COVID-19 crisis.
The old saying goes that “prevention is cheaper than cure.” Unfortunately, many health systems in Africa, even before the onset of the COVID-19 pandemic, are hospi-centric. They pay limited attention to primary health care, including disease prevention and health promotion that produces a higher return on investment compared to curative/hospital care. The hospi-centric approach adopted across Africa also applies to how funds for health services are allocated to different activities. Hospitals and curative services, compared to primary health care activities, continue to receive a larger share of public health spending. Typically, hospitals absorb about 70% of public spending on health. Research across Africa indicates that more poor and vulnerable groups are lost along the cascade of care from primary to tertiary or quaternary levels. Poorer individuals, with a higher share of health service needs, are predominantly the users of lower-level public health services such as community health clinics and centres, and health posts while the wealthier individuals with a relatively smaller need for health services, benefit substantially from higher-level facilities, including specialised inpatient care. This means that the bulk of government spending on health services already benefits the wealthier population groups while poorer groups continue to suffer increased disease burden and limited access to needed higher levels of care.
It is important to note that many countries in Africa have responded differently to the COVID-19 pandemic, initially with policies originating from developed countries. Some critics argue that some of these policies may not be suited for the continent and that for political reasons and other considerations, many governments feel that any action, no matter the consequences, is better than inaction. Many countries in Africa have started adapting to understand the local context in implementing policies to address the COVID-19 crisis. Undoubtedly, COVID-19 pandemic has increased and will continue to increase public spending in many African countries. From the perspective of Africa, the COVID-19-related public spending should essentially, at least at the current levels of infection, be on activities that are about disease prevention (e.g. contact tracing, screening, testing, quarantining, public campaigns, etc.) compared to curative services. The need for an increased focus on preventive services is imperative as many health systems in Africa are weak and cannot withstand the pressure that comes with the need to use intensive care at hospitals when a significant proportion of the population is infected, and complications increase. In fact, adequately equipped health facilities are simply not available even in many cities in many African countries not to mention the rural areas. So, Africa cannot afford to manage many COVID-19 cases but can do better to prevent the cases, the remit of primary health care.
So, has the COVID-19 pandemic crowded out primary health spending in Africa? Because many health systems in Africa are already hospi-centric, perhaps the appropriate question to ask is: has the COVID-19 pandemic compounded the hospi-centric nature of health systems in Africa? The answer is not straightforward. In fact, it depends, among other things, on the level of infections in countries and the level of efforts that countries have exerted to prevent or reduce infection rates. It is crucial to understand what constitutes primary health care. The World Health Organization (WHO) explains primary health care to be a whole-of-society approach to health and wellbeing centred on the needs and preferences of individuals, families and communities. It is not about a specific set of diseases but a range of activities that include promotion and prevention, treatment, rehabilitation and palliative care. Alternatively, rather than asking whether the COVID-19 pandemic has affected primary health spending in Africa, the relevant question may be: has the COVID-19 pandemic crowded out spending on other issues of public health concerns in Africa such as communicable, nutritional, non-communicable and other infectious diseases? In many parts of the world, especially in developed countries with a significant number of confirmed COVID-19 cases, we see that health care professionals spend a significant proportion of their time attending to COVID-19-related cases. In some instances, coronavirus infected health workers have to stop working, reducing human resource capacities. These are resources, beyond the direct financial outlays, which have been directly impacted by the fight against the COVID-19 pandemic. This occurs at the expense of other pressing issues of public health importance. The focus on COVID-19 cases has substantially reduced access to some health services such as elective surgery and routine check-ups, with many health facilities recording “unexpected” reductions in facility attendance rates.
In Africa, a concern for primary health care services is not just about a reduction in resource allocation, at least in the short-term, but a decline in health facility attendance in some countries due to country lockdown measures and people’s fear of contracting the virus when visiting a health facility. People are not comfortable visiting a health facility now. The reduced facility attendance could increase the burden of diseases that are manageable but remain undetected and untreated. The magnitude of the problem will depend on how the COVID-19 infection rates increase and the accompanying complications. That said, it is crucial for countries in Africa to continually track and monitor spending on COVID-19-related activities to ensure that it does not crowd-out primary health care spending or spending on other public health issues facing countries. Countries in Africa must ensure to build a resilient health system, recognising that all parts of the system are relevant. A resilient health system is prepared to handle shocks and evolvingly adapt to changes by ensuring that people receive the needed quality health services timeously without suffering financial hardship.