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What I Learned in Africa

Read parts onetwothreefourfive, and six of Zeke Emanuel's Africa diaries.

We are having dinner at the residence of the U.S. Ambassador to Mozamique, overlooking the Indian Ocean. We are eating with the newly installed Minister of Health; the Executive Director of the Foundation for Community Development, Professor Narciso Mato; and other Mozambican and U.S. health leaders; discussing ways to improve the health system in Mozambique. 

The Mozambicans suggest that the country needs more doctors and discuss the opening of new medical schools in the country. No doubt many African developing countries have very few doctors. There are between 1000 and 1200 doctors in Mozambique for a population of 21 million. This is about one hundredth the number of doctors per capita that you find in the United States and other developed countries. Ethiopia has even fewer physicians per capita. But are doctors critical to addressing the major problems facing Mozambique, Ethiopia and other countries in Africa?

I doubt it. The first question is: What are the interventions that are critical to making dramatic improvements in health? My short list of interventions includes: combating malaria (as discussed in “How I Came to Own a Goat”), family planning, safer deliveries, deployment of the pneumococcal and rotavirus vaccines, treatment for pneumonia and diarrhea, nutrition and clean water. It also includes a series of steps to prevent the spread of HIV: male circumcision, preventing mother-to-child transmission, and antiretroviral treatment.

None of these interventions needs physicians to carry them out. The only intervention requiring highly skilled health workers is Cesarean sections for obstructed deliveries. And even this does not require a physician. At most it requires a trained nurse mid-wife.  Health workers, with training of a year or less, probably could do it. As I learned in Senegal, fighting malaria by distributing nets, using a rapid test to diagnose malaria, and giving 3 days of drugs for treatment can all be done by farmers with just a few days of training. Male circumcision can be done safely by someone with good dexterity and two weeks of training.

In the lingo of the field, this is called “task shifting.”   That amounts to having providers with the right training--that is, not too much training--provide the interventions.. These tasks require diagnostics that are easy to use and interpret, pre-packaged medications, simple treatment algorithms, good training, and, where possible, access to health facilities where more complex cases can be referred.

(We could use some “task shifting” in the US health care system too. There is no reason a pediatrician needs to diagnose and treat ear infections or give vaccines, or a hematologist must adjust blood thinning medications.)

What would life expectancy and quality of life be like if we effectively addressed the eight interventions I've identified here? It would dramatically reduce deaths for children under 5, maternal mortality, and HIV infections. As a rough guess, I suspect that effectively rolling out these interventions would increase life expectancy to 60 or even 65 in most African developing countries.

If this is true, it suggests that measuring the quality of a health system by the number of physicians per capita--a statistic many observers, the World Health Organization, and many governments use--is not particularly relevant. More important, it suggests that, over the next few years, African countries and donors should focus not on finding more of the highest skill medical workers but on increasing the number and training of lower level workers.


Traveling to see American health care aid in the distant villages of Africa was truly eye-opening, even for someone who has worked in the global health field for a long time. I took away four lessons. 

First, contrary to the prevailing cynicism, we are making great progress on everything from malaria and HIV prevention to vaccine coverage.  

Second, there is still plenty of “low hanging fruit”--that is, opportunities to make a lot of progress quickly at reasonable cost. Most require deploying not individual services, but integrated packages of interventions. 

Third, the real challenge now is scaling up interventions that have been proven to work--interventions like the comprehensive malaria package, male circumcision, safe deliveries, and long-lasting family planning. 

Finally, scaling up these interventions is a big management challenge that requires human resources. Really improving health is less about money and more about having management skills that can effectively deploy and integrate these effective interventions. 

Developing such skills requires sustained effort. But the US is helping, and we are making real progress in improving heath around the world.

Ezekiel J. Emanuel is special advisor for health policy to the Office of Management and Budget and the head of the bioethics department of the National Institutes of Health.