A systemic approach to care for non-communicable diseases like hypertension and diabetes is Africa is in its early stages, with the biggest challenge for patients being the price of medications, says Anne Stake, Chief Strategy and Product Officer at Medtronic Labs.

Medtronic Labs is a nonprofit organization that works with governments and local communities in across Africa to create local ecosystems for the management of hypertension and diabetes.

This is an excerpt from the discussion with Anne Stake:

If we try to outline the work that you are doing, everything started off in Kenya. According to the world-held data from 2018 Kenya currently spends around 4.6% of its GDP on healthcare. According to various sources, basic government-funded public healthcare is provided at primary healthcare centers and dispensaries. And the interesting part here is that these are usually run by nurses. One of the challenges that many countries in Africa, Kenya included, are plagued with is the issue of low-quality and counterfeit medications. What's your experience so far? What have you learned through the work that you've been doing there about the healthcare system as such, and what then led to the design of the program that you're leading there?

Kenya, Ghana, Rwanda, all of the health systems where you work in Africa, one thing I wanna highlight for the audience is that many people maybe living in the US or Europe imagine that there are all of these challenges that the health systems aren't as robust as they are in the “developed countries”. One of the key learnings for us is that there is a really robust community health infrastructure that exists. There's a history of the community health workers and community health volunteers that are really the underpinning of the health system in these countries. And because there is such a strong public sector approach in many of these countries, it enables us to do more innovative and scalable programs that would not be possible in the United States, for instance, because of the fragmentation that exists here. That's one thing to mention this kind of robustness of the community. The system, of course, there are lots of issues as well with goals to professionalize the community health workforce and make sure that they're paid and compensated for the work that they do but they do exist and it's something that is key to the models that we design and implement. We work with the community health infrastructure and link the community, healthcare delivery through community health workers and volunteers to health systems and then up into like national level reporting so that all of the data flows and is directing patient care.

Of course, there are so many challenges with the supply chain, as you mentioned counterfeit medication. Still, in terms of the positives and what the health systems enable, I think this kind of single-payer health system with a robust community healthcare delivery sets many of the countries that we're working in apart. It gives an advantage perhaps in terms of what could be possible in the long run. 

One of the things that Medtronic Labs prides itself in is the engagement of the local community. How do you gain their trust, and how do you form the partnerships you have in Kenya or working with the Ministry of Health and local governments for the hypertension and diabetes program?  

At Medtronic labs, it's really important to us, to partner at every single level all the way from the village and the community up to the county level governments and then up to the national level governments as well and surrounding that with all of the existing partners in the global health ecosystem. So the way the partnership in Kenya and for the audience - we have a large public-private partnership between Medtronic labs and the Ministry of Health with funding from many different partners. But essentially, to scale our digital health-enabled program for hypertension and diabetes across the entire country. And the way that came about was really just with a small program in one county. So we got funding from Novartis a few years ago and had good relationships with the county government. We had good relationships that we formed with the facilities and all of the doctors at the various facilities that we were working in - the hospitals and the health centers. And it really started from this kind of grassroots approach where we started screening patients for hypertension and diabetes, referring them into the health center. And then, we slowly iterated upon that model to become what we are today as we grew but making sure that all of the stakeholders at every level are aligned takes a lot of work and community engagement. Most of the staff at Medtronic labs are from the counties where we work and also work in those counties. And all of the community health workers that are part of the government system are directly from the villages where they work. So there's this inherent trust built. And then, as we start engaging at the community level, we work with trusted community-based organizations, whether that's a church or a village leader or whatever current infrastructure or the ecosystem already exists. So we plug into.

Could you compare what chronic care management looked like before? Or what does it still look like in the counties that you're not present in, and what are the clinical outcomes of the programs that you provide? 

In many countries where we work, the health systems, similar to everywhere in the world, have been set up for acute care. They are good at managing acute conditions when you go into the hospital in an emergency and get care. But these systems are not equipped or designed for longitudinal management of a condition. In Africa, in particular, there've been a lot of programs and a lot of funding dedicated to HIV, tuberculosis, and malaria. So you also have a strong. Infrastructure that's built up for those particular conditions, but not a lot of funding or focus has been on non-communicable diseases like hypertension and diabetes. But at the same time, all of these countries are going through an epidemiological transition to non-communicable diseases. So 70% of mortality in the countries where we work morbidity and mortality are due to non-communicable diseases, but only 1% of global health spending is focused on non-communicable diseases. So that's where we saw this opening to transform care delivery for chronic disease. Before we started, there wasn't any infrastructure. So a patient would have to go to a district hospital or a hospital that could be four or five hours away just to get a simple blood pressure check because there weren't even blood pressure monitors available at the healthcare centers. We had to make sure that equipment and training, and resources were moved from the district hospitals down to the community and health center level of the health system. And then we had to set up a way to make sure that patients, once they got screened and diagnosed with hypertension, and diabetes, were then followed up within the community so that we could actually manage those conditions because it's not a one-time intervention in these cases, it's a lifetime of monitoring and medication that's required to get patients controlled for hypertension and diabetes. And, of course, the value of all of this is that in the long term, you reduce complications and costs for the health system.

We're focused on hypertension and diabetes in all of the countries where we work. But we are expanding because we have been successful in managing and running programs for hypertension and diabetes. We've got a lot of interest in the model we're setting up, which is all kind of data-driven and focused on longitudinal management. We've gotten a lot of interest from other disease areas as well. So now we're looking at it as less of a hypertension diabetes program but as a comprehensive primary. Solution for any sort of disease area that requires follow-up. So we're, we've been looking at malaria, tuberculosis, HIV, we're launching mental health very soon.

We have that built into the application already - a suite of different areas that we're looking at. And right now, we have over a hundred thousand patients that we're managing. It's the largest. program for hypertension and diabetes focused on that longitudinal management on the continent.

What kind of differences do you see among the markets? Kenya attributes 4.6% of its GDP to healthcare Ghana attributes 1% less - 3.6% of its GDP to healthcare. Life expectancy in Kenya is 67 years, in Ghana 64 years at birth. And also looking at the partners that you're working with. They're different. So in Ghana, it's the Christian health association and Novartis global health; in Kenya it's the Ministry of Health. We too often look at Africa as one country and forget that it's a very diverse continent with many different countries and different situations and cultures and languages. 

Yeah, as you really said, it's a continent with many countries. For every single country, we have a lot of customization that we build into all of our programs. So we work with the partners on the ground to design the right intervention. We change all of the languages and all of the metrics in the applications. So that's all customized by region. And we also have different clinical algorithms by region. So we use one of the algorithms, for example, as the WHO hearts algorithm, and that's customized by region.

So Ghana has a different algorithm than Kenya. I think the other thing to mention since we are talking about digital health since our interventions are tech-enabled is that every country is on a different stage in its digital health ecosystem journey. To compare and contrast one example, Rwanda has decided that they want to use a set of global goods and standards set of tools. In Rwanda, we aren't even deploying our specific digital health solution but helping Rwanda build on the open-source tool that they've already chosen. But our team of developers is building directly into that system and scaling it across the entire country where in Kenya since we were there from the beginning and have been using our SPICE platform.

That's been the platform that's been chosen for the entire country. We're at different stages of development; Kenya, it's a little bit more advanced, so they're probably more ready for a more advanced tool. Other countries are just introducing their very first digital health product and perhaps are less advanced along that journey. We always have local teams that we hire in each country.

Are there any findings that you could highlight in terms of what you discovered are the biggest barriers to adherence to treatment, to managing diseases? 

The biggest barrier, not surprisingly, is cost and particularly the cost of the medications. At Medtronic labs, we provide the service delivery model, the tech platform, and the implementation alongside health systems. But we're not paying for the medicines. We're working and augmenting existing health systems. But of course, as we've been working with patients and with health systems, when we follow up with patients to understand, you had a prescription, why aren't you filling it? The biggest barrier is that medications aren't yet covered. Medications for hypertension and diabetes are quite expensive. And because there hasn't been a lot of focus or funding on non-communicable diseases right now, they're not included in the national health insurance funds. That's where our future vision on advocacy and a lot of health systems strengthening work that we've been focusing on lies really on how can we make sure that medications are actually affordable and getting to patients? It's not across the board because patients are, have been very creative in terms of pooling funding. And there are some funds out there to get medications to patients; it is still a big barrier and something that we've been working on with our pharma partners as well. So we are, we have partnerships with Sanofi. We used to work with Novartis, and we're also working with Novo Nordisk as well on some of their patient access work to try to get patients more affordable treatments.

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