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Africa: Time to heal

Africa Mercy at port in Liberia. Mobile units provide healthcare in a secure environment

An injection of design could be the stimulus Africa needs to improve its health condition, reports Emily Brooks.

Statistics concerning Africa's healthcare problems are breathtaking; eight million lives are lost a year through preventable disease; 18.8% of South Africans are HIV-positive; in order to beat TB, the funding gap is some $11bn. In 2001, African heads of state pledged to spend 15% of their national budget on healthcare, as a prerequisite to meeting the United Nations’ Millennium Development Goals by 2015. At this halfway point, just three countries out of 53 (Botswana, The Gambia and Seychelles) are at or near this figure.

Governments may be failing on the 15% pledge, but there has nonetheless been renewed political commitment to healthcare improvement in recent years, as well as vast increases in aid. Those countries with stable economies and steady growth are introducing measures, such as national insurance schemes, that will secure sustainable long-term funding and minimise economic risk. Furthermore, there is anticipation that public-private partnerships will bring huge opportunities for investors and a more collaborative approach to funding.

This is a swiftly developing market: a recent study by the World Bank estimates that the healthcare sector will more than double in size by 2016, rising to $35 billion¹.

One of AMREF's health projects. Major donors have to be safe in the knowledge that their money will get to the grassroots level

Critical issues
Africa’s health problems are critical and long-term, and a major barrier to social and economic development; principle causes of death are often from preventable or easily treated diseases, such as malaria. HIV/AIDS, malaria and tuberculosis account for more than half of the continent’s disease burden, and combating them is the cornerstone of the Millennium Development Goals. Reproductive health is a further priority.

Aside from these clinical issues, sub-Saharan Africa suffers from an acute shortage of healthcare workers, a problem that, according to the World Health Organisation, can be directly linked to higher mortality rates. An Oxfam report on the subject² estimates that 2.1 million healthcare workers are urgently needed to break Africa’s cycle of poverty.

Access to care and medicines is a further problem. In Mozambique, it is estimated that about 50% of the population have access to basic health services (meaning that they live within 10 km of a facility). The issue is more pressing in rural areas: in Zambia, 99% of urban households are within five kilometres of a health facility, compared to 50% in rural areas.

As countries such as Kenya, Botswana and South Africa prosper, typical diseases of the more developed world, including diabetes, heart disease and cancer, are becoming an issue. Positive moves towards long-term nationalised care can also create short-term problems – Ghana, for example, has found its public service overburdened with patients seeking treatment since it introduced its national health insurance scheme in 2004.

Who pays?
The WHO’s recommended minimum spend per capita on health is $34, but many low-income countries’ spend is less than $20 per capita, including sources from aid. Greater political stability in east and south African countries has tended to lead to higher Government spending on healthcare.

Arguably need is greater in the west, however, where civil war in countries such as Sierra Leone have destroyed healthcare systems and facilities, all medical care tends to be charged-for, and NGOs and aid tend to play a greater role. In the world’s poorest country by GDP, Burundi, Government spend per capita on health is just $0.70, making outside sources of help utterly vital.

Private healthcare plays a huge role in Africa. Government under-funding means that people often pay out-of pocket for even basic services – a challenge to the Western idea that private care is the preserve of the affluent. Furthermore, public sector spending tends to favour the rich over the poor because of where it is targeted – for example, at tertiary level in towns and cities, rather than for primary care in rural areas³.

Services provided by NGOs and other foreign aid may have no direct cost to the patient, but are still classed as private care; in Kenya, for example, the private sector delivers 49% of care, half of which comes from NGOs and religious organisations, the other half from small and medium-sized commercial operations⁴.

From a donor’s perspective, there is also the concern that aid will not reach its destination. “Corruption is a huge challenge that most governments in Africa are struggling with, this has made them extremely unreliable when it comes to managing donor funds,” says Susan Wandera, deputy country director of AMREF Uganda, a country in which the government last year began proceedings to prosecute two former health ministers accused of embezzling Global Fund money.

“With decentralisation some funds have managed to find their way to the districts, though they hardly reach the grassroots communities,” she adds.

Aid by design
Hospital design is beginning to address specific clinical and climatic requirements. Designed by Harvard graduate students in conjunction with Partners in Health, Rwanda’s Butaro Hospital features large windows on both sides of the building to improve air circulation, as well as outdoor waiting rooms, to minimise the spread of TB.

Just outside Kampala, Uganda, Symbion’s Mildmay Palliative Care and Training Center, which treats patients with AIDS and counsels them and their families, has addressed its users psychosocial needs with a single-storey complex of buildings linked with external walkways, intended to be friendly and welcoming.

Custom-designed mobile units can help to solve problems of accessibility to healthcare. Mercy Ships’ Africa Mercy, the world’s largest non-governmental hospital ship, has six operating theatres, a 78-bed patient ward and accommodation for more than 450 volunteer crew members.

“It means we can introduce hi-tech equipment in a controlled environment,” says Jim Paterson, senior vice president of international operations. “On land, supplies could end up stolen and you would have to go and buy them back from the market, or the air conditioning wouldn’t work. On a ship, people can ‘plug in’ and immediately feel like they are in a familiar environment.”

Formerly a Danish rail ferry, it took two-and-a-half years to fit out the ship, guided by its medical staff’s past experience – for example, building higher ceilings in operating theatres to create enough clearance for lights and other overhead equipment. Many of its design considerations – patient flow, minimising infection – are identical to a non-mobile hospital.

Elsewhere, Italian architectural firm FAREstudio have put sustainability at the heart of its work on the Centre pour le Bien-e^tre des Femmes, Burkina Faso. The centre was built using sun-dried bricks made on-site, and is temperature-controlled by its favourable orientation, shaded areas and separation of enclosed areas by patios.

“Sustainability was not part of the initial agenda: we simply used common sense,” says FARE’s Riccardo Vanucci. “However, once there, the issue was raised dramatically particularly taking into account local conditions. In political terms sustainability is not an option, it is an obligation.”

FARE was conceived to work on humanitarian projects: Vannucci sees his ‘bread and butter’ commercial work as supporting these more radical activities. “Design excellence should be a right, and an investment, no matter where it takes place,” he says.

Concept design by Nightingale Associates for the Entabeni Hospital, Durban

In South Africa, Nightingale Associates has adopted a similar philanthropic attitude, but it is taking a more focused approach. “You have to balance being profitable with being socially responsible,” says managing director Matt Audinwood. “For our work with NGOs, we either do work speculatively or free of charge, to demonstrate our commitment to corporate social responsibility.”

The company has clear ideas about its future involvement in the development of South Africa’s infrastructure: “The government has all the right intent and the budget; the problem is often with delivery,” says Audinwood. “There is a great opportunity for a client-focused public service provision, to help fill that gap. We don’t want to sit around waiting for a commission to fall into our lap; we want to be approaching government with ideas for different procurement methods – in short, being proactive.”

The Ethekwini Hospital and Heart Centre in Durban, South Africa, designed by A3 Architects

Architectural practices in South Africa, the country with by far the most developed economy in the continent, are in a strong position to take advantage of widespread infrastructure investment elsewhere. “We’ve found ourselves investigating Africa generally and there are some huge development opportunities,” says Kevin Hinde, principal architect at a3 Architects.

Most up-and-coming markets have stable economies and plentiful natural resources, including Ghana, Angola, Kenya and Botswana. “Nigeria has a population of 140 million people, and all their infrastructure is depleted. It has vast mineral wealth, and a government that is willing to invest,” says Hinde.

There is no doubt that greater spending is needed if Africa is to offer even basic healthcare for all, but it is important that the money is well-targeted, too. All to often, funding is spent on high-profile prestigious projects such as hospitals, and not enough on primary care5. Hinde identifies “lack of foresight and capability, and lack of ability to deliver” as part of the problem.

Healthcare systems need to be overhauled. But investment also needs to be steady: the WHO states that “only an increased and predictable flow of donor funding will allow [countries] to meet basic health needs in the short to medium term.”

Public-Private Partnerships are a huge opportunity for solving Africa’s healthcare problems, both financially and as a way of harnessing foreign innovation and management expertise. South Africa’s government is actively encouraging PPP, and where it leads, the rest of the continent will follow. A World Bank report about the opportunities that PPP may offer Africa asserts that “The biggest individual investment opportunities will be in building and improving the sector’s physical assets... these opportunities can deliver compelling financial return and have an enormous potential development impact.”⁶

The report adds: “Ultimately, however, the vigour of the private health sector in sub-Saharan Africa will rely on the commitment, creativity and integrity of the people of Africa.”

Emily Brooks is an architectural writer

References
1. The Business of Health in Africa: Partnering with the Private Sector to Improve People’s lives. International Finance Corporation, World Bank Group.
2. Paying for People. Oxfam International briefing paper 98, February 2007
3. Peters, D H; Kandola, K; Elmendorf A; Chellaraj, G., Health Expenditures, Services and Outcomes in Africa: Basic Data and Cross-National Comparisons, 1990-1996 Health, Nutrition and Population Series. Human Development Network, World Bank.
4. Marke, T; Yamamoto, C; Zable, I. Trends and opportunities in public private partnerships to improve health service delivery in Africa. Africa Region Human Development, Working Paper Series Number 93, 2005
5. Castro-Leal, F; Dayton, J; Demery L; Mehra, K. Public spending on health care in Africa: do the poor benefit? Bulletin of the World Health Organization, 2000, 78 (1).
6. The Business of Health in Africa: Partnering with the Private Sector to Improve People’s lives. International Finance Corporation, World Bank Group.

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