At the Crossroads of Social Justice and Medicine - Dr Githinji Gitahi, Group CEO of Amref Health Africa

Shiv Gaglani: Hi, I'm Shiv Gaglani and today on Raise the Line, I'm delighted to welcome Dr. Githinji Gitahi, the Group CEO of Amref Health Africa, the leading Africa-based health development international NGO whose vision is to achieve lasting health change in Africa. To achieve its mandate, Amref influences health programs in over thirty-five countries and maintains fundraising offices in Europe and North America. It further owns and operates three enterprise units, namely, Amref Flying Doctors, Amref International University and Amref Health Innovations. 

Dr. Gitahi joined Amref Health Africa in 2015, after working in various positions in the health, media and private sectors. Prior to joining Amref, he was the vide president and regional director for Africa with Smile Train International. He is renowned as a leader on the global and regional front with notable achievements, including co-chairing the global UHC 2030 movement, serving on the Commission on Africa's COVID-19 response, serving as a member of the governing board of Africa's CDC, and he was recently appointed to the board of the Coalition for Epidemic Preparedness Innovations. He also serves on the board of the Standard Group in Kenya and the Board of Trustees of Safaricom foundation. Dr. Gitahi is a vocal advocate for universal health coverage and leads the largest thought leadership convening on the Africa health agenda. So, Dr. Gitahi, thanks for taking the time to be with us today.

Dr. Githinji Gitahi: Thank you very much for having me.

Shiv Gaglani: We always like to ask our guests to say in their own words what got them interested in a career in medicine in the first place?

Dr. Githinji Gitahi: Well, I must say, actually, that my starting was not actually to get into the career of medicine. I went through school, and what I find when I look back is that I ended up in medicine because I have always had a very nagging need for social justice and I think I ended up in medicine, because that was a place that I found where social justice is needed, and is probably the foundation for healthy population. So, I didn't look out for medicine as a technical area. I was looking to enter into an area of social justice and that is why, even after doing a bit of clinical work in the hospital, I found myself gravitating more and more towards public health because I was more concerned about why people were getting sick, why are they coming in, where are they coming from, what was the relevance of their family situation and their work situation in their health? So, it was more a platform of social justice and that's what has kept me going on it.

Shiv Gaglani: That's wonderful, and actually echoes what some of our Raise the Line guests have said about medicine being a great place where you can affect large social change as you're doing at Amref Health Africa. We gave some description in the introduction around what you all do at Amref Health Africa. Can you give us a better sense about your priorities and what you're focused on? I'm sure things have changed since you joined in 2015, especially given the COVID experience, which we'll get into. But, what's top of mind for you and what would you add to my description?

Dr. Githinji Gitahi: I think what I’d add to your description is our approach as an organization. Whereas we work in all these countries and whereas if you look at our documents, you'll see a lot of work on HIV, malaria, tuberculosis, water and sanitation, you will actually find that the most unique thing about our work is the approach. It is not the actual vertical or theme that we are working on. Our approach has always been to build sustainable health for all, from the community up. So, most of our work will be based at a community level, at a household level, and utilizing a really critical asset of the community, which is a community health worker -- people who identify by communities -- and those becomes our agents of change. They will become an agent of change for COVID vaccination, they will be agents of change for TB tracing, they’ll be agents of change for encouraging women to go find prenatal care, they'll be agents of change in encouraging adolescents to seek family planning, they’ll be agents of change in carrying water and sanitation and hygiene. So, our approach is what is unique. It is actually using communities as agents of change, and everything else we do -- whether we are training or delivering medicine -- the basis of the foundation is actually community health systems strengthening, which are built bottom up.

Shiv Gaglani: That's fantastic and obviously, you know, community health workers and social determinants of health are key things that were always important, but because of COVID have become even more important. Can you talk to us a bit about the experience you and your team have had during COVID? Plus, it's very hard to paint broad brushstrokes about the African experience, but for our audience who've mostly heard from guests from North America and Europe, what's the situation been like over the past several years and how is it now in Kenya or beyond in Africa?

Dr. Githinji Gitahi: When you think about COVID and how African people experience COVID the context is extremely different from the rest of the world, and I'll talk about that. The first thing being that the responses to COVID that we found initially were not responses that were wholesomely bought by the people. For example, some of the original regional policies of the WHO -- such as telling people that you cannot be allowed to bury your dead if they died of COVID -- are extremely anti the cultural values of the African people. We found that people really struggle with not be able to bury their dead. Whereas in the developed world burial is a more of a very technical issue, here is a cultural issue so we found people fighting with the police. They wanted to bury their own people and there were running battles on that. So, that's one. 

The cultural value and paying attention to people's lives and what they value most was not considered when the policies were being set up. This also includes the measures for lockdowns. We found very early on they were not going to be effective in the continent and the reason for this is if you look at a country like France or Britain or the US, say 80-90% of people are formally employed, meaning that they will receive their salary anyway, even if they took a day off. In Africa, 80% of all people across the continent are informally employed. So, if a mother has to sell vegetables on the street to make a living for her children, she cannot do that virtually. She has to show up at work to sell the vegetables. If I am a plumber, I have to go and do the plumbing work. If I work on a construction site, I have to show up myself. 

The moment you say, "People stay at home," then you have to find a way of feeding them and because of course the economies are small, the social protection mechanisms in Africa are not robust like they are in other areas. We found that policies like lockdown could not work and I think that because some governments tried to follow the guidelines to the letter, this resulted in a significant level of unrest in the content. 

So, we ended up just saying, "Well, why don't we build the trust of the people and actually understand what they want and explain to them what is that the lock downs are for -- not so that they do them -- but so they actually exhibit behavior that can keep them safe while they still go to work.” We started talking more about social distancing than lockdowns...allowing people to go to work, but telling them to wear their masks, to wash their hands, to avoid close contact and to avoid going into closed spaces. We started to define what the risks looked like, and why these policies were in place, and that's tended to work a little more. 

The final point that I would like to say is, we noticed that trust was really critical. We found that the measures were more effective in countries where the communities had trust with their government, and where there was no trust, we found that the measures were not respected at all. That brought us to the conclusion that community trust should be built before it's needed. It is a continuous asset for the government and for public health measures. 

Shiv Gaglani: That's really helpful and insightful. Diving into that, what are some examples of countries that maybe have done extremely well in terms of the response, versus countries that still need a lot of help to get to those other levels?  

Dr. Githinji Gitahi: When we talk about trust for government, remember that government is a complex construct. If people don't trust the police, that is government. If people don't trust the judges, that is government. So, it's not purely just the president or the ministers. It's how people trust their institutions of government and that trust comes from those institutions being transparent to them, and those intentions serving their needs. 

We found that where that was happening -- like Rwanda, Ethiopia, Kenya to a certain extent, Senegal -- we found that the responses were near adequate or were good, because people trusted what the government was saying. In countries like DR Congo -- where the trust with government has been broken because of an extended civil war and because of the previous outbreaks of Ebola -- that resulted in people fighting with government because they wondered why Ebola was more important than the diarrhea that was killing their people. They wondered why Ebola was more important than malaria and cholera and therefore, they thought that government was simply doing these things to attract money from WHO and the World Bank. Therefore, they didn't trust whatever the government said during COVID. So, this trust element was critical in the response and was also even more critical in the vaccination drive. And we found the countries that are actually low trust have also very low vaccine penetration.

Shiv Gaglani: That's extremely insightful and a big issue we're facing now with trust and misinformation. Obviously, in the U.S., different states have different responses and outcomes based on things like trust and compliance with different measures. You mentioned Rwanda. I wanted to actually touch base on that because in September, I was at the Clinton Global Initiative summit. Melinda Gates was on the stage with the Dean of the University of Global Health Equity from Partners in Health and Dr. Sheila Davis, who was a previous guest on the podcast. They announced a wonderful scholarship to fund the free training of Rwandan medical students to become physicians and hopefully stay in Rwanda. 

We've had the opportunity to work with UGHE for several years since we began providing free content to them for their training. I'm curious...Rwanda seems like a great example of a country that obviously went through a lot of strife, and now has a lot of trust in government, and a lot of great development and outcomes from it. What are some of the things that different countries in Africa are doing to train more healthcare workers -- whether community healthcare workers or physicians, and not just train them, but keep them in practice and/or keep them in the country? I know brain drain has been such an issue across the world, but certainly in certain regions in Africa?

Dr. Githinji Gitahi: The training of the health workforce has evolved from where it was in the early 70s and 80s from being a publicly-driven agenda, meaning the government was training people. When I went to medical school, only the government was training people. But then the private sector has now come in to play a major role and the reason for this is because of demand. We have a huge and growing youth population who need jobs. We have education access as a major drive and desire for everybody, but also a growing middle class that has resulted in parents being able to pay school fees for their children, and therefore seeking institutions that could provide that for them. So, in countries in Africa, especially in countries where the middle class is rising quickly, the education sector has expanded even for health courses, health sciences, nursing and public health. All these people are paying for themselves and that's why scholarships are important, because then you also have to close the gap of equity by ensuring access to those who can't afford it. 

What we are seeing is a rapidly increasing number of people trained in health sciences, people trained to be health workers. But we are also seeing a big challenge, an increasing gap between those who are then trained and employed and those who are unemployed. At the same time, because populations are growing, the need and the demand for health workforce in both the private and public sector is rising significantly, but can it absorb the number of people who are being trained? And the answer is no. We have trained nurses and doctors who are jobless and this is what is driving what we're now calling health labor migration, which people refer to as brain drain -- people moving out of Africa to seek for jobs. That is something of concern to us and I think the solution is that if the demand continues to be addressed with more and more training, then we should be open to free labor migration, because it's also an individual right for people to seek work where they think it's best for them. 

Remember, number two is that we have a challenge of retention, which is also driven by under investment in the health sector. So, if you're trained as a nurse but you don't have the necessary health products and technologies to deliver your work; if you're trained as a psychologist or lab technologist, but you don't have the right health product and technology to deliver your work; then you will seek work elsewhere. Part of this challenge has to do with investment capacity, or what we call the fiscal space. 

Today, I was talking about the population of France, which is five million people, and the population of Africa, which is 1.3 billion people but the two geographies have exactly the same GDP. So, you can actually see that is a stark explanation of what the challenges are. It's not purely refusal to absorb, it is that the fiscal space is very low and the competing priorities for the available tax is actually very high. But the tax also is low, because as I say, most of the people are informally employed and it's very difficult to tax the informal sector. The tax efficiency is low, the GDP is low, the population is growing and therefore that puts tension in terms of being able to invest in all the areas that are needed or demanded by a growing population or their needs on healthcare.

Shiv Gaglani: That's a really clear breakdown of some of the challenges and opportunities ahead of us. And is that one of the main reasons why there's such an investment in community healthcare worker training and expanding scope of practice? Because ultimately, it’s much cheaper and much easier to train a community healthcare worker -- and they're the ones who can develop a lot of trust -- than it is to train a neurosurgeon in a specific city in Africa, or anywhere? Is that the big focus of Amref or of African governments as a whole?

Dr. Githinji Gitahi: We need to look at these cadres as complementary to each other, and we look at them as complementary, meaning that we don't train one to replace the other. We train one to complement the other. Amref Health Africa trains thousands and thousands of community health workers in multiple countries and they are trained to ensure that the communities understand health promotion, health prevention, and improve their health-seeking behavior. That is absolutely important in ensuring that we have a healthy community. 

At the same time, Amref has a university that is actually training nurses, training physiotherapists, training people in reproductive health, diploma and master's degrees in public health, so that people understand how to run the health system. So, we train all of them, all the cadres in a complementary manner. Now, of course, as the public health develops, the concept of task sharing is also improving and increasing, and the policy framework for it.

I'll give you an example. Right now, and for a long time, community health workers were only allowed to just go and talk to people and if somebody has pain, they could give painkillers and give advice and refer. But now we are seeing policy changing in many countries where they're being allowed to carry anti-malarial tablets. We are seeing that task sharing because instead of somebody going to the facility, they can actually give them a tablet and get diagnosed in the community. We are seeing a shift where community health workers were only allowed to carry condoms for family planning or reproductive health. But now we are seeing countries changing policy to allow them to carry oral contraceptives. Community health workers for a long time could not carry antibiotics, but now we know that pneumonia in children is heavily impacted positively by community health workers being able to provide, treatment with amoxicillin at home. Of course, there are many challenges to ensuring that they don't create antimicrobial resistance and microbial resistance, all these things, but that just come from training, monitoring and good compliance. 

So, the cadres are complementary, but we're also seeing the tasks being shared. Originally, only ophthalmologists or ophthalmology physicians could carry out a cataract surgery. But now we know that ophthalmology technicians who are trained at diploma level are now carrying the bulk of cataract surgeries. This task sharing must be seen to be just part of complementarity, not as basically shifting tasks from one country to another. So, we train all the cadres to support the health system as needed.

Shiv Gaglani: That's awesome. I'm glad to hear that and it's definitely patient-centric. It's trying to figure out how do you coordinate care across these different cadres, as you're mentioning. It speaks to some personal experience I've had. Before we started recording the podcast, I mentioned to you that I was born in Namibia. The reason was my dad trained as a physician in India and my mom is a physical therapist and similar to what you were describing in Africa, there actually weren't enough good paying jobs in India to support the healthcare workforce. So, my parents immigrated to Namibia and then we grew up in South Africa near Durban for five years where my dad ran a hospital. But as a general practitioner, he was doing very complicated cesarean sections, OB-GYN procedures and he was doing ophthalmologic surgery just because the need was so high that they had to expand the scope of practice to be able to do those things. So, even my story comes from a similar kind of migration and then they eventually migrated to the U.S. where I mostly grew up. So yeah, that's fascinating.

Dr. Githinji Gitahi: That's fantastic, and maybe a rejoinder to that is imagine if your parents were stopped from moving from India to seek opportunity because they were described maybe as brain drain. Their trajectory may have been completely different and yours as well. So, even as we talk about health worker migration as a negative force, we must remember that individuals have the human right to seek opportunity.  The most important thing is that any government that wants to employ them must provide the right working environment for them, and pay them well so that they are retained. Rather than to focus on forcing the health workforce to stay where they're trained, we should focus on improving the environment of work so that they're also seeking for great opportunities, like the example you've given of your parents and yourself, as well. It may have been what fed your trajectory.

Shiv Gaglani: It obviously helped with the focus on tech in the U.S., which got me into Osmosis. The nice thing is the circularity of this where now Osmosis has a new project to train to 250,000 ASHA community health care workers in India for 90 million patients. I'll be coming back to Africa in a couple of months for rare disease work and a Kilimanjaro trek that we're doing. And we provide free access from Osmosis to many universities across Sub-Saharan Africa, including University of Namibia, UGHE and University of Malawi as a couple of examples. 

So, I think the circularity of it is because my parents were allowed to migrate as freely as they were, but my parents never forgot their Indian and African roots. It's kind of part of my DNA as well, to come back and work and hopefully that helps train more healthcare workers in Africa, too.

Dr. Githinji Gitahi: Exactly and you're welcome to partner with us at Amref University as well for those great things that you're doing with UGHE.

Shiv Gaglani: We'd love that. I know the reason I even got in touch with you is Ylann Schemm and Domiziana Francescon at the Elsevier Foundation spoke highly of the work that you all do at Amref and I know about the big conference coming up in a couple of months that you are hosting for Africa's vision. 

You've now been leading Amref for several years. What are you most proud of as far as accomplishments, and then what are you hoping Amref will achieve in the next decade for the continent?

Dr. Githinji Gitahi: Well, our time for that has been slightly above seven years. I think what I am most proud of is our continued engagement and support of the public sector. Because Amref's model has never tried to replicate or do things in parallel to government. We have always supported the government and what that has done is build significant trust with the people, with the communities, because they don't see as competing or purely charity-driven and just saying, “We are just coming to give you money to do the following.” We actually use our efforts to complement government. So, that has been significant. 

The second thing that I do appreciate is our rising voice and influence on the health agenda in the continent. Originally, it was difficult to tell whether there was a common voice across the continent. But now we can say that -- when we're thinking about civil society, or an NGO and their voice on the continent -- we give our voice on the community health workforce, we've given our voice on universal coverage and primary health care, we've given our voice on vaccine inequity during COVID, we've given a voice now on visa discrimination for people from Africa who are trying to travel to conferences globally that are discussing their needs. These have actually positioned Amref to be a really trusted organization within the continent itself, and outside the continent. 

Looking into the future, we're asking ourselves, “What is really going to be transformational for achieving lasting health change?” As you say, that's our vision, and I asked myself, “What is really going to be transformational?” We are now remodeling our strategy and we are starting a new strategy which is going to be launched at a big conference in Kigali in March. We are now focusing on accurate social determinants of health. We are starting to say that if indeed a woman who can read gives her child a 50% chance of survival to five years, we cannot say that survival to five years is purely a health sector issue. We also have to worry about women's education. If we know that nutrition improves when a woman is educated, then you cannot ignore the education of women. So, we have to play a role in ensuring that the policies are shaped and the advocacy is shaped to also bring in those areas that influence health, either positively or negatively, and to influence them for better outcomes, not only to focus on the health system as a singular issue. 

So, we are now bringing social determinants of health, education of women and young people into our primary health care approach for UHC. As I mentioned, the number of young people in Africa is rising rapidly. That was not a big concern for people ten years ago, but now we realize young people need to take the lead and not only be at the table but actually owning the table and adapting the system to their takeover. So, bringing women and young people to the center, education, climate change, water sanitation, housing...bringing all of that to the conversation around health is going to be our next strategy which is going to be eight years anyway because we'll be a mapping it to the UHC2030 agenda as well.

Shiv Gaglani: That's fantastic. There's obviously a lot of deep challenges --you mentioned climate change and just education as a whole – but that means a lot of opportunities for innovations. I've been enthused by seeing a lot of the companies and organizations that have started on the continent. There are huge numbers of software engineers now across Africa with Nigeria and I think South Africa and Kenya leading the way, among others. So, I'm sure the same will happen for healthcare as well, especially with Amref pushing that agenda. 

I'm aware of your time so I only had two other questions for you. The first is, many of our listeners may want to follow in the footsteps of leaders like yourself. What would your advice be to them about meeting the challenges of this moment and beyond? Many of them, as you know, are in healthcare too, so if you can comment on anything they could be doing to approach their clinical and leadership careers, I know they'd I appreciate that.

Dr. Githinji Gitahi: I think that, for me, everyone has their own pathway and their own trajectory. But there are certain foundational issues that we always need to pay attention to because we are in service. We are all in service. We are serving the communities that are busy living their lives, with dignity, but we're just trying to serve their needs, as identified by them. 

So, the first thing I would say is being authentic to the issue and reflecting on the issue as it is without trying to change the issue. The issue is the issue. So, focus and be authentic. That's number one. And number two is to wear the lens of social justice. I think that in my life, just wanting to see a better life for people, guides the way I talk to people, the way I manage, the way I relate, the way I design my responses, the way I understand my insight. That is a really critical issue. 

But then those two things I've said -- authenticity and social justice -- cannot be truly realized if we are not aware of our privileges...that actually the most important point about many of us are our privileges and we are not conscious of it. You have to deliberately and actively be aware of it, and privileges are layered. Many of us think privileges are race and color...just that one dimension of privilege. But income is a major dimension of privilege and gender is a major dimension of privilege. If we are aware of our privileges, and we actually recognize them, then the next thing to do is to hand over our power -- which is derived to us by our privileges -- to those that we want to serve. Once you do that, then authenticity and social justice is going to be achieved.

Shiv Gaglani: I love how you laid all that out and I agree. There are so many layers to privilege. I'm obviously the product of some highly privileged, motivated, disciplined people and definitely would not be where I am without them. I think many of us can say the same. So, that's great, great advice. 

Is there anything else about you, about Amref about healthcare in general or universal health coverage that you want to leave our audience with before we let you go for the day?

Dr. Githinji Gitahi: Well, I think that what I would like to say about us, about myself, is that there is no path to success. The path is co-created. We as an organization, and myself, are always open to listening to people. We don't have boundaries like, "We do this and this we don't do." We listen to people and we say, "That sounds like a good idea. But this is what the community needs. This is the objective. These are the interests of the community. Let us co-create." 

So, we are always open to discussing with people when they have great ideas. Some may result in something, some may not, but we always have a listening ear because we always go back to the community and check to see what are their insights? What's driving their behavior? Therefore, we don't know what we need to know for tomorrow, we will discover what we need to know for tomorrow together.

Shiv Gaglani: I love that. I think there's a famous African proverb too, which is, "If you want to go fast, go alone. If you want to go far, go together." What you just said reminded me of that. I'd love to continue the discussions and hopefully see you in Africa in a couple of months.

Dr. Githinji Gitahi: Thank you very much for having me, and thanks for this conversation.

Shiv Gaglani: Of course. Thank you again, Dr. Gitahi, for not just for your time, but the work you do to raise the line in Africa and beyond and strengthen our healthcare system. I'll leave our audience with that. Thank you for listening to today's show and remember to do your part to raise the line and strengthen our collective healthcare system. We're all in this together. Take care.