Dr Gijs Walraven joined the Aga Khan Development Network in 2003, where he is now the Aga Khan Development Network Director for Health and General Manager of the Aga Khan Health Services (AKHS). He is also Honorary Professor in Community Health Sciences at the Aga Khan University. For 15 years, he worked in Africa in healthcare provision, management and research, with a major emphasis on district health systems. Dr Walraven has published widely in international peer-reviewed journals. He is also the author of Health and Poverty: Global health problems and solutions (Routledge, London), which received first prize in the category “health and social care” in the 2011 British Medical Association Annual Book Awards.
Dr Walraven has been on several occasions technical advisor to the World Health Organization, and he co-chaired the global expert committee on recommendations for optimising health workers’ roles to improve access to key maternal and new-born health through task shifting. He is the co-chair of the AKDN COVID-19 Global Task Force (GTF), and a member of its governance Steering Committee.
Non-communicable diseases were ascendant in Central and South Asia, the Middle East and East Africa, where AKHS works. Then COVID-19 happened. How has the pandemic changed perceptions of the health burden in developing countries?
Because COVID-19 is an infectious disease, people often think that our focus on non-communicable diseases (NCDs) has become less intense. But the contrary is true. In fact, underlying conditions brought on by NCDs have led to a rise in the death toll from COVID-19. The majority of those who have died from COVID-19 had an underlying NCD, such as obesity, cardiovascular disease, diabetes, chronic lung disease or cancer. Nearly three-quarters of all deaths around the world are caused by NCDs, so the urgency of the problem was only further highlighted by COVID-19.
In fact, at the World Health Organization (WHO), Dr Tedros Adhanom Ghebreyesus, the WHO Director-General, has said that “the COVID-19 pandemic has highlighted the full danger of noncommunicable diseases – and signalled the urgent need for stronger public health policies and investment to prevent them”. In the work of AKHS, and as part of the COVID-19 response, we have increased our health promotion and disease prevention activities to address risk factors for NCDs, as well as augmented our efforts to diagnose and treat disease early.
How has AKDN responded during the pandemic? Can you speak about the Global Task Force and your role?
We began by tracking the pandemic in early 2020. The Aga Khan Health Services (AKHS), the Aga Khan University (AKU) and the Aga Khan Foundation (AKF) engaged with Ministries of Health to develop country- as well as area-specific COVID-19 preparedness plans. The priority was to bolster government and AKDN’s diagnostic and care capacities and secure much needed supplies and test kits.
By mid-March of 2020, an AKDN COVID-19 Global Task Force (GTF) was set up to mount a robust response to the pandemic across all agencies and the Imamat, and to make use of global learning.
The AKDN response ranged from frontline health workers testing suspected cases and treating mild and moderately ill patients, construction of additional temporary health facilities and increasing the capacity to treat severe and critical cases, to advising national authorities on their country’s response and preparedness.
The AKDN COVID-19 GTF adopted three pillars for its work: slow and stop transmission, prevent outbreaks, delay and suppress the spread (or “flatten the curve”); provide optimised care for all patients, especially for the severely and critically ill; and minimise impact on communities, the vulnerable, social services and economic activity.
In Pillar 1, the immediate work included increasing public awareness of COVID-19 and taking key actions to prevent its spread, such as deploying government messaging through all available platforms, identifying and filling gaps in messaging and materials, and launching campaigns to improve awareness about physical distancing. Guiding community actions to protect those most at risk of severe illness, such as the elderly and people with underlying conditions, was particularly important. Given the geographies where AKDN works, much of the focus of the campaigns was reaching communities and individuals who were offline or lived in hard-to-reach places.
When it became clear that the uncertainty, fear and stress of a pandemic required scaling up psychosocial support and mental health awareness, AKDN agencies also responded with several initiatives. They encompassed campaigns to improve individual and community knowledge of danger signs, referral systems and healthcare providers.
The immediate work in Pillar 2 included strengthening containment measures in areas with active cases and scaling up availability of testing. Supporting government initiatives around tracing as well as scaling up and ensuring access to testing locations evolved to include identifying more sustainable testing approaches, constructing rapid response centres, increasing intensive care capacity including through digital health, strengthening the capacity for safe medical waste management and disposal, and refining surveillance of transmission by leveraging data.
Related to this was the need to strengthen measures to prevent the spread of COVID-19 within health facilities while improving access to health services for those who needed medical attention. Working alongside government, AKDN facilities established joint prevention protocols and built healthcare worker access to personal protective equipment.
In anticipation of a large increase in caseloads, there was a need to support robust case isolation and case management protocols. This included preparing facilities and staff for large numbers of patients that would require acute and critical care. Standard operating procedures were continually assessed. Health facilities and operations were assured functional continuity through stockpiles and supply chains.
The immediate work in Pillar 3 included reducing risk, building resilience, ensuring social service continuity, supporting parents, and ensuring social protection and cohesion. At the forefront of this work was continuing to support families, educators and students to have access to relevant resources and tools to manage continued learning in the face of school closures.
It was also clear from the onset that there would be a major impact on livelihoods and food security. After conducting risk assessments and mapping vulnerable communities and households, food, seeds, stoves and toolkits were delivered to the most vulnerable, remote households. In particular, there was a focus on creating and enhancing women’s economic power. AKDN focused on encouraging enterprise creation, cash assistance and ensuring access to critical infrastructure, like telecommunications, that otherwise might be impacted by the pandemic.
COVID-19 has also had a great effect on mental health. It is normal to experience fear, worry or stress during the pandemic. First of all, we worry about contracting the virus and falling ill. But add to that the changes that have occurred as a result of the restriction of our movements, and many people having been confined to their small living spaces for weeks and months at a time. We do not have the ability to touch other family members or friends or shake hands with colleagues. Schooling has often been conducted at home. During the COVID-19 pandemic, we are particularly mindful of our health workers and managers of health facilities who have had to deal with more than a year of stress. They deserve our sincere thanks and appreciation for the tough job they have done and continue to do.
How is AKDN supporting COVID-19 vaccination?
For several months, AKDN agencies have been working closely with government authorities on COVID-19 Vaccination Implementation Plans (VIPs). Each VIP defines the concrete steps being taken to prepare for and implement the COVID-19 vaccination campaign, including the prioritisation of vulnerable populations. The plans also specify the measures implemented to mobilise the community to accept vaccination and to monitor the results of the programme. In several countries AKDN has been authorised to open COVID-19 vaccination centres where vaccinations with validated vaccines are being offered in first instance to frontline healthcare workers, the elderly and those with underlying conditions.
You subscribe to the Alma Ata principles of primary health. How does that affect the work of AKHS?
The specific actions needed to make “health for all” into reality are as absent today as they were in 1978 when the Alma Ata Declaration was first made. Unfortunately, in many countries the balance has tilted towards personal health care at the expense of the broader health of the population. The result is that a high proportion of patients treated in a hospital could have been treated in a primary healthcare centre. But the patient goes to the bigger hospital partly because he or she knows that the hospital has better facilities and has doctors with specialised skills.
At AKDN, we are trying to consider the influences and context of the community. The primary healthcare workers are oriented, as they should be, to the population’s overall health itself, next to ensuring access to quality personal health care when needed. This requires that healthcare workers understand the local health problems and their social and environmental determinants, plan the most effective preventative and therapeutic interventions for the community through co-creation, and advocate for improved living conditions and “quality of life”, while still providing individual health care. To use AKDN as an example, community health workers play a vital role in such a primary health care system, especially when they work in tandem with facility-based health staff.
Overall, what we are trying to do at AKDN is to create a well-functioning health system that includes health promotion and prevention activities at the community level and a primary healthcare centre when there is a more serious illness. This is our “hub and spokes” model. Only if that clinic lacks the skills and equipment to treat the patient will they go to a next level of health service delivery, and the same applies for further levels. The system is advantageous for both the patient and his or her relatives, as primary healthcare facilities can be small and therefore within reasonable travel distance.
If the Alma-Atta principles are to be realised, lower-income countries should not make the same mistake as the one made by many high-income countries. To move this forward requires strong commitment and leadership that places primary health care at the centre of efforts to attain universal health coverage. We need governance structures and policy frameworks in support of primary health care.
How can you collaborate with other AKDN and external agencies to deliver health care?
In all endeavours, AKHS tries to take a primary care approach with a traditional emphasis on maternal, neonatal and child health. This is complemented by community-based models which address the non-communicable disease burden, including mental health issues and palliative care. Digital health initiatives, including teleconsultations, are in place in many of our facilities and programmes.
We work with local communities, local and national governments, international donors and other AKDN institutions, to get the best health care result for that country or area that is possible. That means, concretely, supporting the health needs of local populations through our hub and spokes model and strengthening the care at all levels, including existing primary care facilities, secondary healthcare providers and tertiary hospitals.
In Tanzania, for example, we have joined forces with the Government of Tanzania, the Government of France, and other AKDN agencies to provide better and early diagnosis and treatment for cancer patients. In northern Pakistan, we work with local communities, governments and AKDN agencies to find sustainable ways of delivering primary health care in the high-mountain valleys. We also work with other AKDN agencies and units, such as the Aga Khan University, in training and operations research.
In Afghanistan, AKHS supports government efforts by implementing the country’s standard Basic Package of Health Services and Essential Package of Hospital Services in two provinces on behalf of government. This is done through an innovative public-private partnership (PPP) agreement that involves a pay-for-performance element and enables AKHS to manage two provincial hospitals, five district hospitals, 25 comprehensive health centres and 158 basic health centres covering a population of 1.5 million people.
Our overall goals are to support government health policies and plans, including expansion of PPPs in health care; introduce and scale up health insurance and social protection schemes; and implement and contribute to global standards in health and health care.
What can hospitals and clinics do to combat climate change?
You might not imagine that hospitals and clinics have a role to play in climate change, but they do. After His Highness the Aga Khan and Prince Rahim Aga Khan provided guidance to all AKDN agencies to reduce their carbon footprint, we redoubled our efforts in trying to reduce it. It is surprising how much carbon is produced by the healthcare delivery systems and how much can be reduced.
We’re building hospitals that reflect state-of-the-art “green” technologies. The provincial hospital in Bamyan, Afghanistan, is a good example. The Hospital’s special low-impact, rammed earth architecture is designed to be not only culturally sensitive to the surrounding area, but also climate-friendly, durable and seismic-resistant. A 400-KW solar plant provides for the majority of the electricity supply of the hospital. We are also looking at retrofitting older facilities with an emphasis on reducing carbon emissions, air pollution, energy and water consumption.
A large part of the agenda focuses on reducing greenhouse gas emissions through innovations in transport, water consumption (recycling and conservative use) and air pollution. We are also attacking the need to travel – and the pollution caused by it. Quicker detection and resolution of health problems is part of the solution, but we try to use technology that helps patients receive information and care close to home: digital health solutions, telephone consultations and telemedicine that supports remote diagnosis and consultations are all part of our “hub and spokes” model.
Another part of our efforts includes the procurement of pharmaceuticals, medical devices, food and other products. During surgeries, for example, we stopped using the most potent greenhouse gas, Desflurane, and made better substitutions wherever it was possible. Commonly used dose-metered inhalers that use liquefied compressed gases are another substantial producer of greenhouse gas emission. There are effective, much greener and cheaper alternatives with dry powder inhalers, and this is another important step towards creating zero-carbon health systems.
One of AKDN’s ethical principles is good stewardship. At AKHS, we take that principle seriously, and we try to reduce our carbon footprint where we can.