Ernest Darkoh

I have always loved the title of Dugmore Boetie's book, 'Familiarity of the Kingdom of the Lost'. Each decade of my global health career has revealed the increasing poignancy of these words. Despite the large number of public health initiatives, the last four decades have seen Africa become the top ranking abode of some of the world's nastiest pathogens and diseases. So why are these inherently addressable problems so resistant to solutions?

I believe that the 'familiarity trap' plays a pivotal role in constraining us from meeting the complex evolving needs. The fundamental healthcare delivery model is deeply flawed for what we expect it to do, yet it still represents the cornerstone through which all programmes are delivered to the public. This is a model whereby healthcare is delivered to the population from advanced hospitals and satellite clinics which are supposed to be staffed with highly trained professionals and be well equipped with technologies and medicines. It is reactive in nature -- something generally has to go wrong before one accesses this system.

The model fails at delivering 'service' at the points that really matter -- homes and communities, the very setting in which things actually go wrong (non- adherence to medications, unhealthily eating, participation in risky behaviours). So why is it failing?

The model was designed to address low prevalence conditions affecting less than 1 percent of populations. Applying it as our sole health delivery approach against gargantuan epidemics in Africa like HIV, hypertension and diabetes is akin to a person trying to kill a charging tyrannosaurus rex with a pen knife.

The incongruence of the specialized medical model was starkly framed by the late WHO Director Lee Jong Wook in a Canadian press communiqué of 2005: "with a population of 682 million, sub-Saharan Africa has just 600,000 health-care workers. Canada, with a population totaling less than 5 percent of sub-Saharan Africa, has 500,000 healthcare workers." Africa is still trying to build this model despite the fact that Canada, as we speak, is not exactly having an easy time delivering healthcare to its population.

Familiarity, in the form of continuing with outmoded policies and approaches, has constrained those responsible for implementation and prevented rapid innovation which is necessary for health systems to change. Healthcare programming occurs largely in vertical silos (driven by vertical funding approaches).

Outmoded policies still have nurses making beds. Nurses are still largely forbidden from prescribing but are the key roleplayers in most health systems, particularly in rural clinics. Battles are being fought over whether those outside of the laboratory -- doctors, nurses, trained counsellors -- can perform simple diagnostic procedures like HIV rapid tests.

Many countries still insist that hospital management posts be filled by doctors or nurses (usually specialists) despite the fact that their skill set may have nothing to do with management, logistics and finance. Few countries have developed policy frameworks for engaging private and traditional health practitioners in national health responses despite the fact that they often are the de facto primary care system and first point of call. Even when the problem is acknowledged, changing policy is near impossible because everything has equilibrated around these flawed points.

A preventive wellness based model is the only feasible way forward. Africa simply cannot afford to deal with the consequences of any more uncontained epidemics. But what do we do about current endemic disease burdens? I do feel cautiously optimistic. Although still at seedling stage, there are initiatives out there which represent the fundamental thinking and approaches that hold high promise.

The Partners in Health 'accompagnateur' model of deploying trained lay people in the communities of Haiti to support treatment of conditions such as TB and HIV points towards the ways in which the potential of the 'lay person' workforce could be unlocked in other environments. Botswana's HIV programme, which has managed to treat over 90 percent of those in need of treatment in under five years, gives a glimpse of what is possible when public-private partnerships are put into play.

Ethiopia's large scale community health worker programme, which trains thousands of lay people to ensure service delivery is taken to every village, is a good example of 'at scale thinking'. Senegal's approach of involving communities and traditional and religious structures from the outset to tackle HIV demonstrated the power of inclusive approaches that generate large scale and effective messaging. The disease management and low-tech telemedicine systems used by some private health management firms in South Africa are demonstrating how the skills of a small group of specialists can be channelled through technology to a wider group of doctors and nurses, and in this way reach millions of patients who would not have had access to specialized support

Rwanda has used cellphone technology to revolutionize health systems reporting and logistics management. Most of these initiatives are funded by new sources such as PEPFAR and the Global Fund, which in themselves represent a new focus on making available financing that is commensurate with need.

Although these are but a few examples, they demonstrate key features of what should be hallmarks of any new models we create, namely out of the box thinking which is 'at scale' from the start. Breaking out of the familiarity traps will require concerted commitment and courageous action.

*Ernest Darkoh is chairman of Broad Reach Healthcare, a consultancy which specialises in antiretroviral treatment and offers expertise to countries around the world. He is former operations manager of Botswana's treatment programme for HIV/Aids and is one of the US public broadcast service (PBS) 'global health champions'.