Opinion, South Africa

Dr Ann Aerts: An Innovative Model to Meet Urban Health Challenges

The Head of the Novartis Foundation, Dr Ann Aerts, sat down to talk about the impact of rapid urbanisation on health, such as non-communicable diseases.

Anne Aerts - EHN

The Novartis Foundation – a philanthropic organisation pioneering innovative healthcare models that have a transformational impact on the health of the populations in low-middle income countries hosted the first Urban Health in Africa Dialogue event in Africa in February this year, bringing together key stakeholders to discuss emerging urban health challenges. The Foundation seeks to lead the way in finding solutions to meet these challenges, advocating a multidisciplinary approach to find holistic solutions for healthy cities and communities.

The Head of the Novartis Foundation, Dr Ann Aerts, sat down to talk about the impact of rapid urbanisation on health, such as non-communicable diseases, and the Foundation’s work to improve access to hypertension screening and management. 

Why did the Novartis Foundation choose to focus on hypertension?

Hypertension is the number one killer in the world. It’s responsible for 10 million deaths every year around the world – the total number of deaths by all infectious diseases combined. But it’s also important to note that 80% of these deaths are in low-middle income countries. It’s not a lifestyle disease anymore as much as a disease of poverty.

Secondly, hypertension is also relatively straightforward to diagnose and treat; there’s a whole arsenal of evidence-based treatment guidelines and medicines that have proven effective in minimising the effects of hypertension on the heart, brain and kidneys.

And lastly, hypertension is also a disease that you can reverse as long as adequate screening and health services can reach citizens and provide appropriate treatment and follow up. That in itself is a challenge, again for developing economies but at the same time, highlights numerous opportunities to combat the disease.

Let’s talk about hypertension in the context of urban health.

The disease encompasses many factors related to lifestyle such as physical activity, salt and fat intake, weight, smoking and excessive use of alcohol and last but not least, air pollution. Air pollution has the same effect on your arteries as a diet high in fat and refined sugar. The underlying determinants like pollution, sedentary lifestyles and unhealthy processed foods can’t be ‘treated’ by the health sector and therefore it’s necessary to take a multidisciplinary, holistic approach to reducing the prevalence of hypertension.

What we’re seeing is a clear link between rapid urbanisation and incidences of hypertension, particularly in Africa. Not only is obesity on the rise in developing economies but we’re seeing a younger generation of patients with high blood pressure. Africans are being treated for high blood pressure in their 30s and for strokes in their 40s. You don’t see that in developed countries. We don’t know why this is happening, one reason may be genetics which is an easy explanation but it’s not enough. We need to devote dedicated research to understand hypertension in the African context.

A question posed by one of the expert panel during the conference was whether the health sector should redirect some of its budget to the transport sector, for example, to work together to reduce air pollution and its associated health issues. I think it stayed with me because initially it sounded like a ludicrous idea but on the other hand, it gave me another perspective to think about preventing over curing growing health challenges. Can you add anything to that?

If you relook at health as urban health, the same way we identify rural health as having its own unique challenges and opportunities, it becomes inclusive of a number of vital role players. This is one of the reasons why we like to convene dialogues with different sectors and different disciplines – we want to bring all these minds together to learn from each other, challenge each other and catalyse new thinking that will get us all closer to our objectives.

In our case as the Novartis Foundation, it’s ambitious to take on the challenge of combatting hypertension and we don’t want to operate in an exclusive bubble. That’s why these dialogues are so necessary. But at the same time, our experience has shown that it’s not enough to get all the stakeholders around the same table. We’ve seen progress when efforts are rooted in very strong political will to address the issues.

What is the Foundation’s position on digital health tools and innovation?

We are passionate about digital health because we truly believe that digital is transforming the way that health services are delivered.  We actively use digital health tools to carry out our work on the ground; whether it’s related to quality assurance and support for our team or to empower patients to take responsibility for their health. One example that we’re actively working on is around telemedicine services that aren’t only centralised hubs of clinical expertise for patients, but guidance centres for healthcare workers.

It’s a simple model that has been very efficient in Ghana. So much so that the government chose it over seven other telemedicine models that was being piloted in Ghana to be scaled up nationally. We are currently supporting them with that and along with other examples of how we use digital, we also work at a policy level on digital health in low and middle income countries.

I was nominated to be a Broadband Commissioner for the Broadband Commission for Sustainable Development, which is chaired by ITU and UNESCO, and I chaired a working group on digital health. The group comprised of 20-25 experts in digital health and together we produced a report with recommendations for governments on how they can realise the full potential of digital health in the sense that digital health responds to the priority needs of the country. What we have all witnessed is well-intentioned ideas as solutions to a problem that rarely get scaled up and we’re left with a very fragmented landscape of digital health tools. Our report offers guidance on how to leverage digital to deliver on a country’s health strategy.

You mentioned earlier that political will is essential to the success of digital tools. Do you want to add to that?

Yes definitely, I think anyone in this space for any length of time knows that every tool has to be developed both with the end-user in mind and on the patient-centred model for it to work. But that in isolation doesn’t guarantee its success. We have case studies from Canada, Estonia, the Philippines, Mali, Rwanda, Nigeria and many others, and what we have distilled out of all the studies is that first and foremost, you need very strong leadership from government; someone or a team that is visionary enough to have made the decision that digital is really our future and how can we harness it to achieve universal health coverage or the Sustainable Development Goals (SDGs).

After strong leadership in government, you need a national framework for ICTs that entrenches interoperability and standards that every solution has to comply with.

The third key factor is logical thinking. It’s important to have a good idea of who all your stakeholders are, especially within government and different departments. The Ministry of Health, Ministry of Communication Treasury and Home Affairs have to collaborate and work together to solve national problems. We place a lot of importance on collaboration between the public and private sectors but intergovernmental collaboration is even more key to progress. Once that is established, the practical act of mapping your overall stakeholders outlining very clear roles and responsibilities for each, including the private sector. It seems obvious but everything needs to be clearly agreed upon. Together, those are what we have found to be the three keys for governments to really transform health services with the power of digital health.

Does the telemedicine project in Ghana have those three traits?

Absolutely! I have to give all the credit the Ghanaian Ministry of Health and health services for pioneering an innovative model of delivering health services to patients and their drive to scale up to reach every citizen and support every health worker in delivering patient care. Second to that, the message is really that it’s a simple concept that hinges on a simple phone call, but the impact is powerful. 70% of cases that are called in are problems that can be solved over the phone so it means an enormous cost saving for the health service because of the reduction in referrals.

But to get back to your question, the Ghanaian government owned this project and that’s why it’s working. Our contribution as the Novartis Foundation was largely directed towards training, skills and infrastructure for the first call centre, but even this was small in comparison to the investment by the government to staff the teleconsultation centres that operate 24/7.

In the Ghana programme for hypertension, we had to find a simple but innovative solution to screening. The answer was to contract with spaza shops to offer free blood pressure tests to the public. It’s another way of looking at healthcare or urban health as an inclusive ecosystem of stakeholders and role players. The model works because citizens have direct access to a health service they can make use of as part of their daily lives, they don’t need to take a day off work to wait in a queue at the clinic for blood pressure screening. On the other hand, the local businesses attract more customers, so it makes the model sustainable. I think there’s a lot of work being done and yet to be done to bring in some of the private sector mind-set into the discussion about healthcare and urban health because sustainability is not only about measurement and data-based decision making but also about finding those models that can become business cases for sustainability.

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