Systemwide barriers impede health care delivery in the region. A comprehensive approach that strengthens key elements of national health systems is required to save lives.

In recent decades, global attention to the harrowing state of health in sub-Saharan Africa has increased dramatically. Funding to combat the major health problems there has reached unprecedented levels, and marked improvements have been made. In Zanzibar (Tanzania), for example, malaria deaths have been cut substantially. And in Uganda, maternal mortality has dropped by more than half.

Despite these improvements, the health of the vast majority of people in sub-Saharan Africa remains in jeopardy. From 1990 to 2005, life expectancy slid by more than 2 years, to 47.1 years. What’s more, millions of Africans still suffer from diseases that are relatively simple to prevent or treat.

As the region’s health systems struggle to meet basic standards of care, many experts have come to believe that systemwide barriers to its delivery are preventing greater progress. A comprehensive approach is required to overcome these barriers. But how can systemwide changes occur in countries that struggle to provide even basic care? To address this issue, the Touch Foundation, a nonprofit organization active in Tanzania, and McKinsey recently conducted an intensive investigation of the health system in the Lake Zone, in the northwest part of the country. This area was chosen because it is small enough to be studied in detail but large enough to serve as a suitable geographic proxy for Tanzania as a whole and, potentially, for the entire sub-Saharan region.

These initiatives will require new investments, and we do not underestimate the difficulty in finding the necessary funds. But because the initiatives are targeted, their impact would be disproportionate to their cost. The diagnostic approach we used in the Lake Zone provides a way to move past the debate about whether countries in sub-Saharan Africa should pursue “vertical” programs targeted to specific disease outcomes or “horizontal” efforts to strengthen health systems. Any health system, in sub-Saharan Africa or elsewhere, could adapt this approach.

The challenges

The poor health of so many people in sub-Saharan Africa has been widely known for years. Over the past decade, however, Africa’s health care crisis has received renewed attention because of factors such as the spread of HIV/AIDS and a greater understanding of the link between health and economic development.

These efforts have produced important results. In a growing number of African nations, the catastrophic rate of new adult HIV infections appears to be falling: according to the UNAIDS (the Joint United Nations Programme on HIV/AIDS), the number of new infections in sub-Saharan Africa declined by approximately 25 percent in 2008. Similarly, tuberculosis rates are slowly decreasing across the region. Malaria incidence and mortality are declining not only in Zanzibar but also in several other parts of Africa.

Nevertheless, the region continues to face profound health challenges. Tanzania, for example, has made progress against childhood mortality, yet one in every nine Tanzanian children still dies before age five. And the country’s maternal mortality rate remains stubbornly high, despite almost three-quarters of these deaths being preventable.

Diagnostic approach

Our investigation aimed to identify the primary barriers thwarting the delivery of preventive health services, diagnostic services, and effective treatments in the Lake Zone. To define the effort, we constructed four different clinical pathways that describe the journey patients take through the health system. Because each pathway focused on a specific health problem—malaria, child health, maternal health, and trauma care—together they provided insights into how the system functions as a whole (see sidebar, “Using clinical pathways to understand care delivery”).

This innovative approach provides several benefits. It offers a window into how patients actually experience the health system as well as a comprehensive view of how care is delivered on the ground. In addition, by enabling comparisons between actual care delivery and best-practice international guidelines, it illuminates gaps between them. More important, it exposes the barriers that allow these gaps to persist.

The primary barriers to effective care

Three mutually reinforcing problems make up the most important barriers in all four pathways: access to primary care is at most only one-third of what the Lake Zone requires, the workforce is only a fraction of the size needed, and several operational weaknesses prevent the system from functioning well.

Insufficient access

In the Lake Zone, the greatest gaps in delivery occur in primary care. About two-thirds of it is provided by the public-health system, the remainder by nonprofit organizations, private enterprises, or the informal sector (traditional healers or moonlighting health workers, for example). Primary care delivered in the public sector is mostly free, but private and nonprofit organizations often charge user fees. In addition, patients often opt to pay out of pocket for services delivered in the informal sector. Despite the services all these groups provide, primary care in the Lake Zone remains woefully insufficient.

Two types of facilities deliver primary-care services there: dispensaries and health centers. Dispensaries are small clinics that provide basic consultations, diagnostic services, treatment for routine conditions, and referrals for more advanced treatments. Health centers provide these services as well as certain more advanced ones. The shortage of both types of facilities makes it difficult for people, especially mothers and children, to gain access to primary care conveniently. Further, the facilities’ effectiveness is compromised by significant shortages of medical supplies and skilled staff and by the frequent absence of electricity and clean water. Within all four clinical pathways we studied, we found that the greatest gaps in care delivery occur at the dispensaries, with the health centers faring little better.

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