Ebola has focused the world’s attention on the challenges of health care in Africa. The continent has 11% of the world’s population but 25% of the world’s disease burden. It also has just 1.3% of the global health workforce.
Yet African health leaders have shown enormous creativity, innovation and leadership in tackling global health challenges.
University of Melbourne Professor of Public Health Rob Moodie spoke with Lord Nigel Crisp about his new book – African Health Leaders: Making Change and Claiming the Future – and the lessons Australia and the world can learn from African health leaders.
Nigel Crisp is an independent crossbench member of the House of Lords, where he co-chairs the All Party Parliamentary Group on Global Health. Lord Crisp was chief executive of the National Health Service in England and permanent secretary of the UK Department of Health between 2000 and 2006.
Speaking with: Nigel Crisp.
Rob Moodie: If I could start out by setting the scene from your latest book, African Health Leaders: Making Change and Reclaiming the Future. In it, your co-editor, Ugandan doctor Francis Omaswa, writes that over the past 30 to 40 years, the relationship between donors and African countries has been pretty mixed. As he says, donors have helped improve things but it’s been done at a price.
He talks about a loss of core values, the loss of self-respect, self-confidence and self-determination. What do you think has gone wrong?
Nigel Crisp: Well, I think there was a certain inevitability about it. The quotation he uses is:
we went begging for help and we got it in return for some of our core values.
I suppose they were in the position of being weak in terms of their negotiating position, they were looking for help, and I suppose we came in from the west (and I associate the UK and the US and Australia and elsewhere) and tried to do our best.
You’ll know that very often you can come into a country and you can think you know the solutions because actually you’ve seen something similar in your own country. What, of course, you often forget and it takes you some time to remember and recognise, is that there are big cultural issues about how you do things and it’s not just as simple as applying our knowledge in another country.
Now, a lot of what was actually done by the west has been terrific, obviously things like the development of antiretovirals and so on. So there’s western science and all sorts of very good things.
But we’ve slightly steamrolled it, and there’s also been political issues. If I take the American example of PEPFAR, they had to report to [the US] Congress very clearly on results and what they were doing, and that political tie pulls them back into Americans doing things, rather than Americans supporting other people to do things.
Rob Moodie: The other argument that you spell out are the huge challenges for Africa. It has 11% of the world’s population, but 25% of the world’s disease burden, 65% of the HIV burden and a huge cut of the malaria burden, yet such a tiny proportion of the global health workforce.
You note that there have been some real successes out of this sort of adversity – task substitution is one. Your book is telling us what can we learn from African leaders in this regard.
Nigel Crisp: Yes, well I think there’s a lot of hidden stories, unsung heroes, because inevitably in the UK and America and around the world the stories you hear are the stories about your own people. We hear about the great successes of the Bob Geldolf sort of mission and we don’t hear these stories from people actually within the situation, the leaders who are there all the time.
Within the book you’ll have noticed they’re always very respectful of the help that others give them, they’re welcoming of the help that others give them. But they want more space for themselves. You do have these fantastic leaders.
Let me start with Miriam Were in Kenya, 1976. Top medical student of the year, she did her PhD then on patient participation. And she did it on patient participation in 1976 because she’d recognised that actually the biggest issues about health were about hygiene and how patients behaved and how villages behaved. She was going to have the biggest impact by doing that.
So she set up these programs, which are really the forerunners of many community health worker programs all across Africa. And it’s a really interesting set of issues about not just patient involvement, but community involvement – how you get people involved.
Some of that has now been taken and copied and is being used in New York, working with a different sort of community but using the same sort of principles. So here you have a really important point about how you use a community to help itself, or how you help a community to help itself.
Or the other one that was also in 1976 was a young doctor called Pascoal Moccumbi who, like a lot of these leaders, had been in exile fighting a revolution. The Portuguese left after independence in 1974. By 1976 he found himself the Minister of Health, and he found he had no doctors because the Portuguese had left and they were basically the doctors.
His biggest pressing problem was pregnant women and how to care for them. So he set up a program of training, essentially nurses, to be able to do obstetric surgery, including Cesarean sections. They did it so well that it was being done at the same complication rate as it would be with physicians, at about a third of the price. And, of course, the nurses stayed in the country.
Now, 37 or 38 years later, it’s still continuing as successfully as it was then, and it’s peer-reviewed and so on. It has been a really interesting success story and I think that whilst I’m not suggesting that here in Australia that cesareans should be done by nurses – others may wish to suggest that – it’s a point about the principles.
It’s about opening your mind so you don’t have to think in terms of the boundaries of doctors and nurses that have essentially been negotiated through trade agreements and that there are some principles which show how you can actually do that sort of task-shifting successfully.
Rob Moodie: In fact, in the UK, and certainly in Australia, we could learn from that in terms of practice nurses and nurse practitioners. It seems to be an ongoing demarcation dispute with the doctors, can’t we learn from that?
Nigel Crisp: Exactly, and I gather you have an issue about nurses and endoscopists at the moment in Sydney or somewhere, I was told.
Well we’ve gone past that in the UK; we’ve actually got nurses and endoscopists and they’re just normal; and we’ve got nurses prescribing and so on. But it’s the same set of principles.
There are basically five principles we pull out in the book, which are:
- Make sure you’ve got a plan.
- Make sure you’re recruiting the right people because it’s not just any nurse.
- Make sure they’re properly trained.
- Make sure they’ve got access to supervision and the ability to refer. Because quite a lot of these schemes – and there have been lots of them around the world as you’ll know – have failed because when people got out of their depth there wasn’t someone to refer on to.
- Then, finally, make sure that this is seen as part of a bigger plan of teamwork and teams.
By and large, when you see those five things applied, you see these things working successfully – whether they’re in the UK or Australia or indeed in Malawi or Mozambique.