“A Stitch in Time Saves Nine” — Why Africa’s “next M-Pesa” must be in the field of chronic disease management

A stitch in time saves nine. Never has that saying been more apt than in the non-communicable disease epidemic, particularly chronic kidney disease, that is silently ravaging the African continent. Non-communicable diseases — also known in the medical community as silent killers” — are a group of diseases whereby affected people suffer minimal or no symptoms (asymptomatic) in the early stages, then begin to experience severe, life-threatening symptoms in the advanced/late stages. An important feature of most non-communicable diseases is that they are not curable; rather, they need to be managed for the rest of the sufferer’s life. A typical example of a silent killer is  Chronic Kidney Disease (CKD) — the focus of this article — a condition in which the regular functioning of the kidneys is compromised due to a variety of factors. The chronic nature of the illness means that it progresses over 10 – 30 years in five stages. [Read more about CKD here]

Why Africa is on the ledge: A look at the numbers

Chronic Kidney Disease affects over 700 million people in the world today – an average of 1 in 10 people. In Sub-Saharan Africa, there are over 70 million people living with the disease. In Nigeria alone, there are over 25 million people with Chronic Kidney Disease — 15% of the adult population. What makes for worse reading is that Africa as a continent suffers the highest burden of the disease, as measured by Disability-Adjusted Life Years (DALYs). That means the average African with CKD suffers greater disability and earlier death as a result of the illness than her peer with CKD in other parts of the world.

Based on these facts, CKD has already achieved epidemic status in Africa. And it is expected to get significantly worse in the coming decades. One estimate predicts that there will be 240 million Africans living with CKD by 2050. The main reasons for this concerning rise in CKD prevalence in Africa are three-fold:

1.) Genetics

It has been long-known that people of African descent are at significantly higher risk of developing kidney disease than other races. For example, in the United States, African-Americans are three times more likely to have kidney failure than their Caucasian counterparts.

Scientists are beginning to find a clearer explanation (other than lifestyle) for this discrepancy. A major culprit gene has been identified as APOL-1 — “a gene with variants that is related to an increased risk of early onset kidney disease and rapid progression. People of West-African ancestry are at increased risk of developing end stage renal disease, and common APOL-1 polymorphisms may account for this risk.” 

It was previously thought that the young age of the African population would be a protective factor for CKD and other chronic diseases. However, this is clearly not the case with CKD because of the genetic factors at play. Consider that the average dialysis patient in Europe & North America is in their late 70s, whereas the average dialysis patient in Nigeria is in their 40s.

2.) Population explosion

Today, there are about 1.2 billion people in Africa. By 2050, there will be about 2.4 billion people on the Continent— a doubling of the population in just three decades. This population explosion, coupled with advances in treatment of infectious diseases on the Continent (meaning people will live longer), naturally means that there will be more people with chronic diseases living on the Continent.

3.) Rampant urbanization

Urbanization — defined by Brittanica as, “the process by which large numbers of people permanently become concentrated in relatively small areas, forming cities” — has been identified as the major driver for the rising prevalence rates of CKD in Africa and Asia over the past 30 years. Urbanization causes a large number of people to undergo a drastic change in lifestyle — from rural life to city life. This often translates to significantly less physical activity, consumption of high-caloric, fatty foods, increased levels of stress and of course, exposure to more pollution. These factors together can triple an individual’s risk of developing diabetes and hypertension — the two main causes of Chronic Kidney Disease.

It is estimated that by 2050, an additional 950 million people in Africa will live in cities like Cairo and Lagos — a 90% increase from today. Hence, the prevalence rate of CKD in Africa is expected to increase rapidly over the next 30 years – even more than the 20% increase it has experienced since 1990.

What needs to be done?

Fortunately or unfortunately, CKD is not a uniquely African problem; it is a global problem. For instance, the United States government spends $40 billion annually on dialysis treatments — 7% of Medicare’s annual budget, although only 0.03% of Medicare-covered patients have end-stage kidney disease. However, CKD has also been mostly neglected in all parts of the world. After almost 50 years with minimal innovation in the treatment of kidney failure, governments, investors and entrepreneurs in technologically-advanced countries have finally begun to put significant efforts into developing alternatives to centre-based hemodialysis, which in its current form is an ineffective and costly form of treatment. “Last year, US President Donald Trump issued an executive order on kidney health, including strategies to reduce the shortage of kidneys available for transplantation, encourage more dialysis at home and incentivize research into artificial kidneys through a partnership called KidneyX. The partnership is led by the US government and the American Society of Nephrology and plans to raise US$250 million over the next five years.” Similar investments are being made by governments and investors in Europe, Japan and Australia.

Which then begs the question, what about Africa? An appreciable trend in the aforementioned investments and innovations being made in other parts of the world is the focus on improving Stage 5 CKD treatment options (cost, efficacy and safety). This makes sense for those countries — given that in Europe & North America, >90% of people who need dialysis are currently receiving it. In Africa, on the other hand, <10% of people who need dialysis are able to receive it. Therefore, the focus of Africa’s innovation efforts must, by default, be on the prevention of end-stage kidney disease. The good news is: this is not rocket science nor is it expensive. The progression of Chronic Kidney Disease can be effectively controlled by early diagnosis, followed by holistic life-long management of diabetes and hypertension. For instance, researchers observed that good hypertension control slows the progression of CKD from Stage 3 to Stage 5 by 3.5 times — from 7 years with untreated hypertension to 24 years with well-treated hypertension. The bad news is: this requires a robust primary healthcare system, which Africa — with its decaying healthcare infrastructure, serious shortage of healthcare workers and ongoing brain drain — is severely lacking. In the midst of these challenges is exactly where the opportunity for a revolutionary healthcare delivery technology, i.e. Africa’s next M-Pesa, lies.

“The M-Pesa Phenomenon”

In the expertly written book, “The Future Is Faster Than You Think: How Converging Technologies Are Transforming Business, Industries, and Our Lives”, futurists Dr. Peter Diamandis and Steven Kotler illustrate how exponential technology has been able to democratize, demonetize, digitize, disrupt and dematerialize various industries — from finance to insurance to healthcare — in various geographies. One of such innovations cited in the book was M-Pesa — the financial services and payments solution founded in Kenya in 2007. For the uninitiated, M-Pesa is the most commonly used form of payments in East Africa. Over 90% of the Kenya population use M-Pesa daily and it has been credited with lifting >2% of Kenya’s population out of extreme poverty. What is even more remarkable about the well-documented success story of M-Pesa is how it has spurred financial technology innovation in other parts of the world. “M-Pesa provides banking services to over 30 million people in ten different countries… In Afghanistan it’s how they pay the army. In India, it’s pensions.” Inspired by M-Pesa, services like bKash which serves over 23 million users in Bangladesh and Alipay which serves 1 billion in China, have been developed. The concept of a revolutionary innovation beginning in Africa to solve the Continent’s unique challenges and then spreading to the rest of the world is the M-Pesa phenomenon”.

As the economist, Tim Harford, narrates in 50 Things That Made the Modern Economy, M-Pesa was birthed after a presentation by Nick Hughes at a sustainable development conference in South Africa, where he urged large organizations to invest in the development of risky but innovative solutions with potential to scale across the Continent. Coincidentally, an official from the United Kingdom’s Department for International Development (DFID) was present in the audience and his organization had been looking to evaluate a growing trend they had observed in Kenya people without access to banking services using transfer of mobile phone airtime to re-pay loans. What followed was a $2 million investment by DFID, matched by Safaricom (partly owned by Vodafone), to develop M-Pesa as a mobile money service to offer micro-financing to the millions unbanked in Kenya. After a slow and unremarkable start, M-Pesa became much more than a micro-finance service for the unbanked. Leveraging on currently existing mobile airtime sellers, a wide network of M-Pesa kiosks were developed, with over 100 times more M-Pesa kiosks than ATMs in Kenya. However, the mainstream success of M-Pesa was derived through the various unintended ways its users found to utilize the service, making it an infrastructure which enabled other services and industries. City inhabitants found it to be a safer, faster and cheaper option to remit money to their relatives in the countryside than sending cash through bus drivers. Bus drivers themselves found it to be an ideal option to collect payments from their passengers, rather than cash which they often had to pay out as bribes to corrupt police officers at road checkpoints (police officers are reluctant to collect bribes in form of mobile payments because it can be tracked to them). Business owners found it safer to collect payments through mobile money, rather than hold and travel with cash and risk getting robbed. Even government officials discovered it was great solution to tracking and collecting taxes from previously un-taxed services, thus, extending the tax base.

In the words of Mr. Harford, “M-Pesa is a textbook leapfrog technology where an invention takes hold because the alternatives are poorly developed… M-Pesa exposed the banking systems — typically too inefficient to turn a profit from serving the low-income majority”. Therefore, the challenge for African healthcare entrepreneurs today is, how can similar concepts be applied to healthcare delivery, particularly in chronic disease management? 

Building Africa’s next M-Pesa for chronic disease management

The next M-Pesa will be in the delivery of healthcare for chronic disease management. It will do to healthcare delivery what M-Pesa did to financial inclusion on the Continent. And it will bring vastly higher financial returns to its protagonists than the significant returns on investment enjoyed by M-Pesa’s founders.

Admittedly, this is a bold prediction. However, looking closer at the dynamics of chronic disease management shows that this is not as far-fetched as one may initially suspect. Similar to financial services, chronic disease management is a service that almost every adult needs (or will need), yet only a small fraction of Africans are currently receiving quality care in this regard. Just like GSM technology and its widespread adoption was the catalyst for a financial services solution like M-Pesa, the remarkable adoption rates of mobile internet technology on the Continent offers an ideal environment for healthcare delivery innovation.

Having said that, taking on such a complex problem will be extremely difficult, and interested parties must possess three key qualities:

1.) Originality

Entrepreneurs will need to develop never-been-done-before solutions that are uniquely tailored to the African healthcare context. The “Amazon/Uber/Airbnb, but for Africa” model which is commonplace in many startups, will not achieve much success in this field.

2.) Collaboration

There must be interdisciplinary collaboration. While the clinical wisdom and experience of healthcare professionals will be important, talented individuals from various walks of life will be required to invent and execute wide-reaching solutions. In the same vein, there will need to be a convergence of technologies from various industries, which will then be applied in the unique contexts of healthcare in various African countries.

3.) Patience

While there is an urgency to act, investors  and entrepreneurs must have loads of patience and truly be in it for the long haul. They must have sufficient resilience to take the bruises that will come with tackling such an important and complicated challenge.

In conclusion, African governments, investors, innovators and entrepreneurs should rank healthcare delivery for chronic disease management as one of their priority areas as we move into the year 2021. The size and complexity of the challenge means there is significant potential to positively impact millions of lives across the Continent, create massive financial value for investors, and spread the innovations to other parts of the world (akin to M-Pesa). Crucially, all parties must remember that “a stitch in time saves nine”. Hence, we must act now, as the numbers suggest we are running out of time!