Emergency versus Disaster Medicine
Health professionals must recognise that disasters are qualitatively different (rather than merely quantitatively different) from smaller events such as encountered in daily emergency medicine practice. In contrast with these lesser events, disasters place community systems under extreme stress and responders face new and different demands. Thus, disasters may generate a whole host of problems for which routine emergency procedures are not well adapted. The management of the health effects of a disaster is one of the most difficult tasks that must be performed by health professionals by doing ‘the best for the most’ versus ‘the best for everyone’. It requires special knowledge and professional skill to provide healthcare of quality in a primitive or hostile environment (e.g. terror attacks) and an ability to innovate and organise a disaster medical response system.

Are we handling disasters as effectively as we think we should be?
Several studies on medical disaster preparedness and lessons learned from recent disasters indicate a lack of education and training of the different parties involved in the medical management of disasters. Furthermore, health professionals and researchers from a broad spectrum of disciplines and specialties contribute to the knowledge base of disaster medicine science. Although multidisciplinarity can be a strength, it can also be a hindrance due to the lack of mutual understanding between people from different backgrounds. Moreover, there is large variation in the organisation of the disaster medical response in different countries and even within countries. Without a standardised framework for describing and reporting the features that impact on disaster medical response, it is very difficult to compare results of disaster medical response evaluations and even more difficult to identify best practice. This lack of a common language also hinders intra- and interdisciplinary collaborations, appropriate training and the relationship between researcher and practitioner.

Looking for evidence: Standardised data collection by Emergency Medical Teams
Disaster medical planning and response are only as good as the assumptions on which they are based. Many of these assumptions are incorrect and not based on systematically collected evidence. Our current knowledge of disaster medical management relies on expert opinions and individual descriptive reports, which often lack scientific rigour. Databases available for disaster medical research are underdeveloped, incomplete and inaccurate. Disaster medical response principles, concepts, structures and processes are not evidence-based. Moreover, research that analyses the effectiveness and efficiency of disaster interventions on the health outcomes of disaster survivors is very scarce. One of the reasons is the fact that randomised clinical trials have been described as unable to accommodate the complexity that characterises disaster medical response, and are impossible or ethically unacceptable – or both – to be carried out in disaster situations. Nevertheless, there is an increasing awareness among the disaster medicine community of the need to collect empirical data derived from formal research or systematic investigations, to allow researchers to determine the effectiveness of disaster medical response interventions and the impact of the response on patient outcomes. This collection of consistent data should lead, over time, to the development of a consensus on, and validation of evidence-based processes and outcome indicators. In a field of research where data will always be difficult to obtain – as most healthcare providers prioritise the provision of care to a large number of victims over the documentation of medical and operational management – the lack of universally accepted standards for collecting and reporting data will hinder or make it impossible to compare research findings in different types of disasters or across different types of interventions.

Based on the empirical data collected by (enhanced) type 1 emergency medical teams (EMT) in five different humanitarian emergencies, our research group was able to define pathology patterns this type of EMT will face, and propose recommendations with respect to the staff composition and medical logistics of these EMTs over time.

Injury patterns may change according to the type of disaster or humanitarian emergency, but patterns of communicable and non-communicable diseases do not differ strongly across different types of disasters.

Communicable diseases are proportionally more prevalent among children (65-95%) than among adults (30-55%). Most infectious diseases are of respiratory, digestive or skin origin, and are mainly indirect consequences of the disaster, when affected populations become homeless and are relocated to IDP or refugee camps. Lack of shelter, sanitation, safe water and food creates the very conditions of infectious diseases. Additional communicable diseases are the result of endemic agents in the affected area. Non-communicable diseases are mainly caused or exacerbated by worsening of the health conditions, by a direct impact of the disaster or by lacking routine therapy for chronic disorders.

Differences in pathology patterns can further be determined by a number of other factors such as time of EMT deployment after the occurrence of the event, the type of EMT deployed and the environmental context of the affected area. Injuries will be most prominent during the first two weeks after a sudden onset disaster. Different types of EMTs will attract different types of pathology: major trauma will be directed to type 2 and 3 field hospitals and undamaged hospitals which will be transformed into trauma centres, with the result that more non-injured patients are referred to type 1 EMTs.  Last categories of patients who will present to EMTs are pregnant women, women in labour, new-borns, and those with health problems for which an appropriate treatment is locally unavailable or too costly.

The results of these studies indicate that the staff and resource composition of EMTs should be flexible and dynamic in time, in order to meet the changing needs of disaster victims in the subsequent phases of the humanitarian response. There is an early role for emergency surgeons, anaesthesiologists, intensivists, emergency nurses and their ancillary staff to be deployed in type 2 and 3 field hospitals, but patients needing urgent surgery or follow-up will present to type 1 field hospitals as well. There is an early role in all types of EMTs for emergency physicians, paediatricians, gynaecologists, midwives, psychologists, pharmacists, and interpreters. Public health specialists have an important role in preventing the emergence of infectious diseases. EMTs deploying after the first week of the onset of the emergency should operate as a “subsidiary” emergency department and be prepared to treat mostly infectious diseases, non-communicable disorders and minor surgery. EMTs can scale-up in the second week with internists, reconstruction surgery and rehabilitation teams, maternal health specialists, and psychologists. As many patients will require long-term follow-up, it is essential to include local staff in the EMTs as soon as possible. The actual Interagency Emergency Health Kits should be adapted to the specific needs of disaster victims in the different phases of the response, by adding medications and supplies for respiratory, digestive, ophthalmic and non-communicable diseases, as well as rehabilitation materials, and paediatric formulas of essential medicines.

The template for uniform recording and reporting medical data developed in the five humanitarian emergencies, based on empirical data collected during the response to different disasters, should be the start to initiate an Utstein-style consensus process including all stakeholders, in order to define a final set of medical data to be recorded and reported in disaster situations. The use of such a template will make a substantial contribution to better establish the effectiveness of medical interventions on the outcome of disasters patients. Implementing Utstein-style templates is always challenging. Whether the template will have the desired impact of improving the science of disaster medicine can only be answered by the future use and justification of the template.

Simulation and modelling in disaster medicine research
Uniform medical data gathering and the identification of the key elements of the response will facilitate the development of conceptual models. These models are describing a comprehensive approach to managing the medical assets during an acute response and to coordinating across the various response tiers. Models and simulation, if used correctly, can support experimental research on disaster response management. Simulations using disaster medical response models can provide evidence-based data for an optimal use of resources when applying specific response interventions or procedures and allow comparisons of the efficiency of response interventions or procedures in order to define best practice, taking into account the contextual factors of the affected area and the specific disaster scenario.

Conclusion
Education and training in disaster medicine and management can only be done when a solid and standardised scientific basis is present. The cornerstone for a solid scientific basis is the collection of reliable experimental (medical) data.  A lot of work has been done already but there are still challenges for the future. Our ultimate goal will be doing ‘the best for the most’.

References available on request.

Assessing and managing risks is the best weapon that can be used to avert catastrophes. By evaluating the action plan for potential problems and developing strategies to address them, one can improve one’s chances of a successful, if not perfect, execution and implementation of services. Even the most carefully planned activities can run into trouble. No matter how well a plan is orchestrated, there is always a chance to encounter unexpected problems. Team members get sick or quit, resources that you were depending on turn out to be unavailable, even the weather can throw you for a loop (e.g., a hurricane).

To understand risk in the Emergency Department (ED), it is important to examine the workflow of the patient journey in an ED. The Emergency Department is a dynamic and often unpredictable place, which makes it a high-risk inducing environment. The staff of an ED may see anything in the course of a shift, ranging from a common cold or upset stomach that are treated with a simple medication to a trauma or cardiac arrest that requires full resuscitation efforts. Speed, efficiency, and accuracy of assessing, diagnosing, and treating patients are essential, due to the unpredictable and often heavy flow of patients through an ED. A visit to an ED involves a complex series of decisions, interactions, and activities, which will make it vital for risk planning and assessing to be accurate. A systematic approach that facilitates fast, efficient and accurate patient documentation and treatment within defined processes is required to minimise unexpected failures or human errors.

ED’s can have multiple areas within the department, such as Minors, Majors, Resus, Observation and Treatment. Emergency Departments can be split into two types: Minor Injury Unit (MIU), Acute ED, etc.
Minor Injury Units, as the name suggests, tend to deal with patients with minor injuries. These units often only consist of 2-3 treatment areas and a waiting room. Most are also nurse-led units staffed by Emergency Nurse Practitioners who will see, treat, and discharge patients. Following clinical protocols and care pathways will enable a more controlled and safe environment for patient treatment. The workflows in these units can differ greatly depending on its size, hours of opening, and number of patients seen.

Typically, patients self-present and are fully registered. In smaller units, the nurse will complete this registration. Patients will then wait to be seen in a queue based on length of stay. Young children and those clearly requiring more attention that is urgent will be fast-tracked.

Acute Emergency departments are larger units that require a more robust workflow. Patients can enter the ED either by ambulance or on their own. Whilst the initial workflow between these patients may differ slightly, the same systematic approach is taken with both.

The vast majority of patients will self-present to the ED receptionist. Once they are fully registered they will be seen by a nurse to triage or stream them. A front sheet will be printed on completion of registration. This will include demographic information and the reason for visit. This sheet can then be combined with an investigation sheet.

Triage involves a brief assessment where the patient will be assigned a priority which will dictate the order in which they are seen. Clearly patients who require immediate investigation and intervention will be moved straight into a room. Those with lower priority will be asked to wait in the waiting room until called by the doctor or primary nurse. The Triage Nurse will decide which area the patient is more suitably seen (Majors or Minors). They will assign the patient to that particular queue. The nurse in charge of the assigned area will look through the patients in their queue, ordering the patients on a combination of their triage category and length of stay.
Patients arriving by ambulance will be brought to a specific area where they can be streamed. This is often to the nurse in charge of majors. The nurse will complete a brief assessment to ascertain where they are best treated. The patient may immediately be assigned a bed in Majors, moved to Minors or Resus, or moved into the waiting room to be formally triaged from there.

Patients assigned to a bed will be seen by their primary nurse. The nurse will complete the formal triage and complete their initial assessment. This will include vital signs. Hence, it is important to ensure the comprehensiveness of data entry at the triage stage.

Although doctors will move around the different areas of the department depending on the demand, they tend to concentrate on the area they have been assigned for their shift. After assessment, the doctor will document their findings and plan of action. If the patient has been in the hospital before, the doctor may ask reception to request any previous notes from medical records. They may also request investigations such as blood and X-rays, and treatments such as initiation of intravenous fluids and drugs. The primary nurse will be informed of these requests verbally and/or sometimes using a whiteboard. Care for the patient is a continual process carried out at any point as needed prior to, during, and after diagnostic tests are complete, in collaboration with the ED doctor. Interventions and course of care are based on the patient’s needs.

Patients that are to be discharged home from the ED will be given prescriptions (these will have to be collected from the hospital pharmacy), and/or any patient education documentation they require. A discharge summary also will be completed by the ED doctor and sent to their family physician or general practitioner (GP).

Should the ED doctor decide that the patient might need admission, they will contact the appropriate on call team (e.g. Surgery, Medicine, etc). If the team accepts the patient, the process of arranging a ward bed is initiated. Hospitals with admissions units, such as Medical Admissions Unit (MAU) may now transfer the patient to the MAU to await assessment by the on-call team. After this assessment is complete, the patient may be moved to the ward, or discharged home.

With hospitals that do not have an MAU, or when the MAU is full, the admission to ward process is initiated. Large hospitals have teams of Bed/Site managers responsible for assessing the current bed state and assigning new admissions to suitable beds. Once the decision to admit (DTA) has been made, the bed manager will be contacted either by the nurse in charge or the patient’s primary nurse. Once an available bed has been found, the bed manager will ring back to the ED to let them know where the patient will be going. In the meantime, the primary nurse will be completing the documentation necessary for the admission. The receptionist will make up the hospital notes. The primary nurse generally contacts the ward to verbally handover the patient. When the patient is unstable they will accompany the patient to the ward and handover in person.
Not all patients can be fully registered on admission to the ED. The patient may arrive unconscious. In this situation, the patient will be given an emergency code so that they can be entered onto the system and investigations and treatments can be initiated immediately. If the patient is identified during the admission, the receptionist may combine the patient notes, or this process will be managed by medical records.

Within the ED environment, managing operational risk is vital in the following dimensions:

• People and skills
• Processes and procedures
• Systems and technology

Emergency clinicians (physicians and nurses) face the challenge of treating patients in short encounters with the possibility of not seeing the same patient again. These short spells of interaction and the rapid pace of the workflow in the ED represents fertile ground for unexpected circumstances to take place any time. Challenges occur under circumstances that could range from minor injuries to life-threatening cases. The rapid decision-making process characterises the nature of a high-risk environment which requires managing risk through well-established controls and procedures.
There are many factors that contribute to increased risk in an emergency department:

• Lack of knowledge or experience
• Incomplete demographic information collected at the ED registration
• Inadequate clinical history documented by the triage or assessment nurse
• Failure to perform adequate examination or investigation
• Mis-diagnosing the patient due to lack of evidence-based assessment
• Inability to interpret lab or radiology investigations
• Mis-treating the patient based on incorrect documentation or human-induced errors
• Lack of communication is a significant threat that might result in severe consequences
• Incorrect decision not to admit a patient and instead opt to discharge the patient

These are examples that show how a sense of constant analysis and use of data will enable better risk planning and more effective mitigation of threats. The automation of the ED is a solution to build robust risk management process by utilising and analysing the all the data collected. Digital innovation will enable the ED staff to produce effective tools and policies to mitigate risk and predict threats.
In conclusion, the working environment of the ED is a unique, complex, and dynamic environment. This is reflected in the varying, often overwhelming volume of patients seen in busy EDs, as well as in the range of acuity of clinical encounters. With decisions being made under time constraints, often with incomplete information, emergency physicians are highly vulnerable to error and claims of malpractice. Thorough clinical documentation is critical not only for protecting emergency clinicians but also for ensuring the continuity and quality of care for patients.

In 2017, it was reported that Gauteng Health Department alone had paid out at least R1 billion in lawsuits since January 2015 while the Eastern Cape is facing pay outs of R14 billion.

The Medical Protection Society SA (MPS), in 2015 settled a claim of almost R24 million on behalf of a member and has reported a 35% increase in the number of claims made against healthcare professionals between 2011 and 2016, with larger claims, in particular, on the rise. MPS further reports that claims over R1 million have increased nearly 550% compared to those of 10 years ago and claims of more than R5 million increased by 900% from 2008 to 2013.

What, therefore, are the reasons for the rise in medical claims? According to Justin Malherbe, Senior Associate at international law firm Norton Rose Fulbright, one among the several reasons include an increase in public awareness of patient rights coupled with incessant and deliberate marketing by personal injury lawyers eager to capitalise on this awareness.

“Amendments to South African legislation, such as the Road Accident Fund (RAF) legislation is also to blame,” he adds, explaining that with damages claims during motor vehicle accidents becoming less profitable for lawyers, they are turning to other forms of personal injury litigation like medical malpractice.

Professor Sylvester Chima, Associate Professor and Head at the Programme of Bio and Research Ethics and Medical Law at the University of KwaZulu-Natal, believes that the high levels of lawsuits in South Africa are in part due to the legal framework which both governs and protects patients and healthcare providers.

“A good example of this is the law around Termination of Pregnancy (TOP) which provides for termination up to 40 weeks of pregnancy for severe congenital abnormalities. This means that if a doctor fails to diagnose a severe abnormality, the parents may sue the doctor for maintenance costs for the child,” says Prof Chima, who will be presenting his findings at the 2018 Africa Health Congress.

Another example is the law which obligates health professionals to obtain signed consent from patients before providing their services, but which many doctors do not adhere to, leaving them vulnerable to malpractice claims.

In South Africa, it is not only the number of claims which continue to rise but also the size of the claims and pay outs. Malherbe explains that the costs of ‘catastrophic claims’, such as those for birth defects and brain injuries, have risen drastically as the cost of caring for patients has increased due to technological advancements which improve life expectancy and quality of life.

Both experts agree, however, that progressive interventions need to be found to stem the litigation tide.

Professor Chima suggests that the current system relies on ‘righting a wrong’ through the courts, which by its nature is expensive and adversarial. “A compensation fund, similar to the UK’s Clinical Negligence Scheme Trust, where cases are mediated and settled would save on expensive legal fees but still compensate those who have been affected by medical negligence,” he says.

Malherbe comments that stakeholders in both the private and public health sectors are committed to changing the claims situation by implementing better risk management strategies and renewed interventions, such as defined standards of care; managing patient expectations versus outcomes and improving patient experience through timeous communication and education.

“The shared hope of all stakeholders is that the current effects of the rise in medical malpractice claims can be off-set by timeous intervention and a co-ordinated approach to preserve the stability and ensure the sustainability of healthcare in the future,” concludes Malherbe.

Both Professor Chima and Justin Malherbe will be speaking at the Ethics, Human Rights & Medical Law Conference at Africa Health Exhibition & Congress 2018 to be held at Johannesburg, South Africa, from 29 – 31 May.

Shortage of healthworkers is one challenge among others: according to the World Bank, there is only 1.2 doctor in LMICs (versus 2.9 in high income countries) and 2.1 nurses or midwives per 1,000 people (versus 8.7 in high income countries). At the same time, 90% of smartphones users will be located in LMICs in 2020. The promise of digital health to address some of the underlying health systems challenges is undeniable. Digital health can significantly support the achievement of Universal Health Coverage (UHC), one of the targets of the third Sustainable Development Goal (SDG). A recent report estimated for example that 1.6 billion people could benefit from quality medical services through digital health solutions. Beyond access, digital health can also play an important role in terms of cost reduction and health systems efficiency and quality. Although not many countries have yet analysed the impact of digital health on their systems, it is notable that Canada estimated that their investments in digital health (implementation of electronic medical records (EMR), telehealth and district information systems) generated savings of CAN$16 billion since 2007.

Many challenges remain to fully leverage the tool of digital health. Fragmentation, data interoperability and lack of appropriate legislation and laws are still prevalent. The Ebola crisis was one of the wake-up calls to the growing realisation that data fragmentation needs to be addressed if ICT tools are to be used for effective data collection and analytics. Data needs to be integrated to make it useful in real-time to healthcare professionals or public health authorities.

A striking example of what we mean by fragmentation is Mali where there are 11 different mobile health initiatives for maternal and child health funded by different institutions. Moreover, most of these institutions use their own tools and systems which are not interoperable with systems used by the national eHealth agency. In LMICs, the number of digital health projects had increased by more than 30% between 2005 and 2011 but two thirds were still in pilot or informal stages. Although this statistic is a bit dated, “pilotitis” has been a common word used in the field of digital health for many years and is still prevalent.
Many countries still do not have the appropriate data security and data privacy regulations in place and this is a current hot topic that hinders the trust of any user. A lack of proper legislation to govern mHealth Apps or connected devices and sensors can also undermine investments in countries.

Beyond these obstacles, other barriers still need to be tackled: insufficient human and technical capacity to analyse health data and meet patients’ needs, resistance to technology, unsustainable financing, lack of coordination between national ICT plans and national digital health strategies, connectivity gaps, quality and performance issues of networks, and lack of reimbursement schemes.

As the cycle of digital health evolves, there is a growing realisation on the fundamental role governments have to play in advancing the use of technology for health by developing the right policies and infrastructure as well as building capacity for digital health. In February 2017, the Broadband Commission Digital Health Working Group  (co-chaired by Novartis Foundation and Nokia) published a report called: “Digital Health: A Call for Government Leadership and Cooperation between ICT and Health”. It advocates for governments to take action on national digital health strategies to solve the fragmentation dilemma and help tackle the challenges mentioned above. 

As of 2016, 58% of WHO’s member states had developed national digital health strategies. This does not  translate in the fact that countries have implemented these and there is therefore still a lot of work ahead. Implementing a strategy is no minor task and represents a significant investment: the Government of Rwanda committed US$32 million for its first 5-year eHealth plan for example. Tanzania’s more recent digital health road map calls for overall investment of approximately $74 million. The above-mentioned report looked into 8 countries that managed to advance effectively the digital health agenda (Canada, Estonia, Malaysia, Mali, Nigeria, Norway, the Philippines and Rwanda) and provides key insights and lessons which other countries can leverage from.

A key finding was that countries achieving success in implementing strategies shared responsibility and investment between the Health and the ICT authorities (typically between Ministry of Health, Ministry of Communication and the eGovernment agency).

Perhaps the most important learning from the global scan that was done, is the utmost importance of having the appropriate leadership and governance in place to enable the effective implementation of a national digital health strategy. Many stakeholders saw this as the most challenging first brick to attain in order to robustly build around the other essential components of a strategy: Strategy & Investment, Standards and Interoperability, Infrastructure, Legislation & Policy & Workforce.  Government leadership is vital in fostering an enabling environment for digital health policies and an effective cross-sectorial governance mechanism, the basis for facilitating alignment and cooperation between health and ICT sectors.

In terms of governance and government leadership, some LMICs are true models. In the Philippines, close cooperation between health and ICT ministries has been materialised in a joint MoU and governance mechanisms with clear role and responsibilities, and Rwanda’s very strong high-level commitment of broadband policies and extraordinary intersectoral governance makes it a real example for many countries around the world. It embodies the promise for these countries to leapfrog and avoid the difficulties today faced by high-income countries, often linked to legacy infrastructure and systems. 

The digital health eco-system in LMICs is entering a new phase where the focus is starting to shift to investing in “the roads” for digital applications and services to scale. In other words, a shift to a “system” thinking vs. solutions. This evolution will accelerate the scaling and development of digital health and help in achieving Universal Health Coverage.

References available on request.
Florence Gaudry-Perkins is a Speaker at the Healthcare Management Conference at Africa Health Exhibition & Congress scheduled to be held from 29th to 31st May in Johannesburg, South Africa. 

As Head of Solutions at Med-e-Mass & MediSwitch, businesses that focus specifically on healthcare IT and e-commerce, I believe that the market for e-health services in Africa has been growing steadily for the past five years, with some parts of the continent having adopted SMS as a means to roll out public health initiatives early on.

The growth in such services is visible in both the private and public sectors, and is driven by the increase in broadband access and the concomitant decrease in price. The increasing availability of applications and smartphones is also playing a part in driving further e-health growth.

This, in turn, leads to increasing benefits to both patients and healthcare organisations. For the providers, technology enables effective e-records, including patient information, lab results and care plans for patients with chronic conditions. This means that a doctor checking such records is made fully aware of previous and current ailments and treatments.

As far as individuals go, patient-based applications allow people to become more involved in looking after their personal health. Access to relevant information empowers patients to take ownership of their conditions, such as in diabetes cases, where patients can now monitor blood glucose levels, weight and calorie intake. There is also a move towards social media, with individuals engaging with other patients who have the same conditions.

Ultimately, technology is helping to close the loop between the patient, the healthcare provider and the medical aid funder. This is being driven by increasing volumes of data, coupled to advanced analytic techniques. Healthcare professionals can now extrapolate more knowledge from this information, thereby making better decisions, managing costs more effectively and being able to treat patients earlier and more effectively – thus reducing the number of expensive hospitalisations.

The biggest challenge facing large-scale implementation of e-health services, however, lies in interoperability. Different players in the field have different systems, and these do not always talk to one another.

Fortunately, the South African National Department of Health has set up the Health Normative Standards Framework (HNSF) in conjunction with the Council for Scientific and Industrial Research (CSIR), which lays out the ground rules for interoperability and should help to integrate health enterprise standards.

With these clearly defined rules, we will be in a position where any application related to e-health in South Africa will need to be compliant with the HNSF. Once true interoperability is achieved, an increasing number of disparate e-health systems will be able to securely share healthcare information more effectively.

As for Med-e-Mass& MediSwitch, our companies have recognised e-health as a huge growth area and as such, has made significant investments in respect of both applications and resources. We expect to see a huge upward trajectory in terms of the usage of e-health systems, encompassing applications, security and analytics, to name a few. Each of these areas offers opportunities and our company is putting a lot of effort and resources into developing solutions for the future.
This is a really exciting time for e-health care in South Africa and across the continent. We believe we will have a key role to play in this space as things move forward.

Dilip Naran is a Speaker at the Healthcare Management Conference at the 2018 Africa Health Exhibition & Congress scheduled to be held from 29th to 31st May in Johannesburg, South Africa. 

“The healthcare industry is shifting to a patient-centred model that harnesses technology to both open communication channels and create a platform for patient engagement,” said Doris Savron, executive dean for the College of Health Professions at University of Phoenix, in a statement. “Given this shift, it is crucial that patients not only have access to these technologies, but also view them as important resources for improving their health and overall care experience.”

Digital revolution is in its early days but it is expected to have a profound effect on
healthcare delivery.

By digital health is meant all “disruptive technologies that democratise the access to data, information, devices and procedures in healthcare”. It also extends to “tearing down the Ivory Tower of medicine and empowering patients at the same time”.

A look at the sectors around us that have been affected by digital disruption escalates the need for healthcare to promote digital transformation as a strategic priority.

• Uber is upending the taxi Industry
• Airbnb is threatening hotel revenues
• Netflix, Hulu and similar services have radically changed the TV industry dynamics.

McKinsey’s recent Digital Enablement Survey, shows that healthcare organisations are devoting an increasing proportion of the IT budget to build digital capabilities rather than supporting core IT infrastructure (e.g. claims processing systems). This is expected to account for more than 50% of their strategic IT budgets within the next 3 to 5 years.
Digitisation can help payors and healthcare delivery. It will have a significant positive impact on payer economics, primarily through four levers.

Lever 1: Stronger connectivity

This will enhance a greater consumer experience. It will also enable payors to engage more effectively with providers.
It will provide more sophisticated, digitally enabled tools to manage population health and also provides a clearer method for gauging the quality of care delivery.
In addition, it will provide for better collaboration and data sharing with providers which will support more effective care coordination.

Lever 2: Greater efficiency and automation

Automation is defined as the use of control systems and information technology to reduce the need for human work. It also increases efficiency. As healthcare transitions to population health, automation goes from “nice to have” to a “must-have”.
As automation is not subject to human error or fatigue, they can provide consistent basis for care activities and improved quality. It also improves predictability of outcomes and provides for a higher throughput.
Efficiency is further aided by “data driven” insights.

Lever 3: Better decision-making

Digitisation allows for advanced analytics and big data insights and will make it possible to implement value-based reimbursement which, through advanced analytics, can be extended to population health. It will have a direct effect on the economy as a whole.

Lever 4: More advanced innovations

Digital support allows payors and governments to think more broadly about their business models and care delivery innovations.

New approaches to care delivery have the potential to hold down costs. These include wearables that monitor the health status of patients with chronic conditions, telemedicine, and “virtual visits” that reduce the need for in-person physician consultations. This, however, must be qualified to be extended to the doctor’s patients, and within the specified period of last face to face consultation. There will also be a need to qualify extent of treatment and medications prescribed.

Digitisation can also make healthcare more accessible by giving patients easy access to their medical history, and help them locate nearby clinicians, specialists and facilities.

By a combination of these four levers, payors can achieve a significant impact on the way healthcare is delivered and managed.

Financial Benefits of Digital Transformation

• The average savings are predicted to be about 10% to 15%, i.e. $15bn to $25bn.
• Over a long term, there is bound to be a significant decreased spending on medical services. Most of the savings will come from substitution of lower cost efficient services for more expensive alternatives.
• Most of the primary care services are likely to increase as would spending for those services. It is estimated that the increase in costs will be affected by lower utilisation of more expensive services.
• Consumers will be the primary beneficiaries of the lower spending, but some of the savings will accrue to the payors and providers.

To get the buy-in by healthcare professionals, one has to advance rational reasoning and incentives.
The present healthcare delivery is focused on cost savings far more than quality. Often corporate involvement assesses the benefits solely based on return on investment or impact on the bottom line of “balance sheets”.
The advancement of digitisation must benefit the patients. There must be quality outcomes, wellness enhancement and cost savings. To achieve this, one must factor in the cost of digitalisation to the providers of care and also extra skills and responsibilities on the providers. It will not work if the providers are not reimbursed appropriately against the savings realised. This has to be a transparent and responsible participation of all the stakeholders.
At present digitalisation is financially more beneficial to payors whilst providers are not incentivised adequately to participate in this digital transformation.

Digitisation and Chronic Healthcare

Digitisation has been described as a most innovative programme for the future of healthcare. By 2025 it is estimated that the spend on chronic healthcare will be as much as 67% of the total healthcare spend. This will impact the way patients receive healthcare and the manner in which providers are reimbursed.

The digital revolution will help to manage chronic care, allow for early diagnosis, avoid increase in co-morbidities, decrease hospitalisation, promote healthier populations and manage the rising healthcare costs.

This is a major concern as we prepare for the future and navigate a challenging healthcare journey towards 2025. Many healthcare programmes are setting a target of total digitisation by 2020.

Digitisation is the Future of Healthcare

We need to embrace this debate and switch to a digitalised healthcare platform. There will be different channels available to stakeholders depending on how competent they are. But the change has to start now. Healthcare must embrace the digital revolution to stay relevant. Providers must embrace this change as the evidence is clear that competent digitalisation is the destination for the future of global healthcare.
To support the impact that this programme will have on healthcare, venture capital investment into digital health more than quadrupled between 2011 and 2015 (from $1.1billion annually to $4.5 billion).
We must not lose sight of the people driving the demand for this technology and their needs – the patients, citizens and communities for whom it will be put to work.

References available on request.

Prof Morgan Chetty is the Chair of the Healthcare Management Conference at the Africa Health Exhibition scheduled to be held from 29th to 31st May in Johannesburg, South Africa. 

For a continent that accounts for 25% of the world disease burden, the healthcare space in Sub-Saharan Africa requires holistic approaches across several verticals to attract the required investment to tackle the growing challenges across the region. According to a report by the IFC, the private-sector arm of the World Bank, it is estimated that by 2022, Africa will need US$25 billion - US$30 billion in investment in physical healthcare assets alone, including hospitals and clinics.

Analysis by Frost & Sullivan suggest that, generally, the growth of the Sub-Saharan Africa healthcare market for 2018-2019 will be hampered by the slow down in economic growth across the continent (an average of between 4% and 6%). While this has an effect in multiple areas, this has seen smartphone sales growth reduce from double to single digits since 2016 and will have a direct effect on mHealth, for example.

“Despite this, healthcare spending is expected to continue increasing in both public and private sectors, assisted by global aid organisations,” says Takudzwa Musiyarira, who is a healthcare research analyst for Middle East and Africa at Frost & Sullivan. “Over the next year, the market for chronic disease pharmaceuticals will see double digit growth through an increase in government funded diagnostic and prevention initiatives (mainly diseases such as diabetes, hypertension and cancers). Disease prevalence has grown due to an increase in unhealthy lifestyles, and limited treatment.”

As such, there are several areas of the healthcare market in Sub-Saharan Africa that will remain the focus for investment, both from the public and private sectors. Localised solutions, coupled with foreign expertise, will offer much needed answers to the ongoing issues in the regional healthcare space.

Sustainable development goals and universal health coverage

The Sustainable Development Goals (SDG) adopted by the United Nations General Assembly in September 2015 have targets that relate to health. In particular, Goal No. 3 focuses specifically on ensuring healthy lives and promoting well-being for all at all ages. Target 3.8 of SDG No. 3 - which addresses achieving universal health coverage (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all – is the key to attaining the entire goal as well as the health-related targets of other SDGs.

As Musiyarira explains, while the SDGs were established in 2015, in Sub-Saharan Africa, significant but slow progress has been made in meeting them over the past 15 years, particularly poverty reduction.

“Food insecurity is on the increase due to high population growth rates, and low agricultural output. This has a negative impact on the battle to reduce undernourishment. On the positive side, access to and use of contraceptives in Sub-Saharan Africa have increased,” Musiyarira says. “Maternal and child mortality have reduced drastically in the last 15 years, by over 30%, although the continent is still the highest in the world.”

Limited healthcare infrastructure has also negatively affected the ability to meet the health SDGs, particularly in rural Sub-Saharan Africa, adds Musiyarira. As such, he says it is still a long road ahead in the journey to meet SDGs by 2030. Emerging African economies will likely meet some of the SDGs quicker due to targeted initiatives by governments and faster economic growth. 

Universal health coverage has had slow but positive growth. To date only Rwanda has managed to achieve UHC of over 90% in Sub-Saharan Africa. According to Musiyarira, this has been due to its community-based insurance programme targeting the lower income bracket of the population which has had a direct effect in decreasing mother and child mortality, and a rise in the number of skilled birth attendants.

“Financing of UHC has been the major drawback in implementing and increasing coverage in most nations. This has resulted in countries such as South Africa experiencing delays in rolling out UHC. However, it is expected that there will be significant progress made over the next year in establishing relevant regulations in Sub-Saharan Africa, which is the first step in UHC rollout,” adds Musiyarira.

Russo G et el. (2017) echo this sentiment in their article titled ‘Universal health coverage, economic slowdown and system resilience: Africa’s policy dilemma’ published in BMJ Global Health. They say that there a need to consider how the health system can withstand and be resilient in the face of an economic slowdown or contraction while still striving to expand access and services. Russo G et al. also highlight that policies are needed to bring the different ways health services are provided in resource-scarce settings under the broad vision of UHC.

mHealth: Driving investment

mHealth presents a significant opportunity in Sub-Saharan Africa where basic access to healthcare is a challenge. Not only can mHealth improve the current healthcare system, but it can provide healthcare to those populations living in remote areas across the region. Increasing mobile access, coupled with better quality networks and the introduction of healthcare apps and other mobile healthcare services are set to make remarkable improvements on the road to achieving the SDGs.

“While Sub-Saharan Africa has a high mobile penetration rate (80%), smartphone usage has been relatively low due to the traditionally high preference for cheaper feature phones. However, smartphone and Internet (particularly mobile) penetration are slowly growing due to cheaper Chinese models entering the market and more affordable connectivity options. This will have a positive impact on the growth of mHealth which had been focused less on the Internet and more on using SMS and USSD methods via feature phones,” says Musiyarira.

Meanwhile, consumer application usage, through fitness and health trackers, is only popular in urban areas and will continue to rise as the middle class in Sub-Saharan Africa grows. However, according to Musiyarira, medical grade apps and wearables are becoming more preferred globally as they offer real benefits and mHealth will play a tremendous role in achieving SDGs through the proliferation of mobile services in various economic sectors.

One such platform is TalktomeDoc, a telehealth platform from Nigeria. Driven by the desire to ensure healthcare is cost effective, affordable, easy to reach and convenient to use while ensuring that healthcare spending by health facilities is reduced while maximising profit, their platform makes it possible for several medical service providers to converge and give comprehensive healthcare to everyone. The platform makes consultation and diagnosis easily accessible to patients who are normally beyond the reach of medical specialists due to location.

Similarly, MedAfrica app, a product of Nairobi-based Shimba Technologies, offers direct access to health information and services. With this app you can search, filter and view health information and services near you even when offline as well as connect with doctors on the go. Other services include hospitals, diagnosis, symptoms, nutrition, drugs, first aid, insurance and fitness. Med Africa personalises your health services by frequency of use.

Riding the wave of Public-Private Partnerships

A May 2017 report from the India-Africa Partnership, between the African Development Bank (ADB), the Health Systems Research India Initiative (HSRII) and the University of the Witwatersrand (Wits) based in Johannesburg, South Africa, found that Public-private partnerships (PPPs) in healthcare financing and delivery offer significant opportunities for accelerated improvements in health service access in fast-developing economies such as those found in Africa.

While the overall idea of the report was always to explore the potential for health-related PPPs in Africa, the central question examined in the report was how to achieve this. It said: “Having governments partner with the private parties in the achievement of public goals is an important means to leverage public interventions to achieve results that would otherwise not be possible if pursued exclusively by public sector actors – at least in the medium to long term. While PPPs remain only one strategic option amongst many in the achievement of UHC, they are likely to become a permanent feature of any modern growing and accountable health system.”

Musiyarira agrees: “PPPs will continue to be the main business model for delivery of healthcare due to the mostly public nature of healthcare initiatives. PPPs will be particularly effective in the establishment or upgrading of healthcare infrastructure. On average, only 5% to 20% of healthcare in SSA is in the private sector. It is expected that by 2030, as Sub-Saharan African markets become more mature and after the roll out of UHC, other funding models will emerge enabling greater commercialisation, thus putting innovation into overdrive. Africa has suffered from 'pilotisis' due to lack of funding, thus hindering credible innovations from commercialising, particularly in mHealth.” 

A hub for innovation for medical diagnostics

Sub-Saharan Africa requires cost-effective, easy-to-manufacture healthcare solutions to address the unique challenges on the continent. Traditionally, innovative medical devices have been developed abroad and imported into the region. However, with investment in localised Research& Development (R&D), local companies are now beginning to develop ground-breaking ideas in response to the medical needs of the continent. 

As Musiyarira explains, over 80% of Sub-Saharan Africa’s medical device market is serviced by imports from mainly North America, Europe, China and Japan. Thus, he says, there is a huge opportunity for import substitution through increasing local manufacturing capacity. “Investing in the production of high value medical devices such as imaging equipment will be beneficial to the continent and will add export opportunities, reducing the trade deficit and be able to compete on the global stage. However, investment in Research & Development will be key in realising this goal.”

Exchange rate volatility has negatively impacted imports, thus making devices more expensive locally, due to weakening currencies against the US dollar over the past decade. “Local manufacturing will minimise this risk and will be supported by intra-Africa trade agreements. There will continue to be a high preference for low tech products and consumables for local manufacturers in the next few years, and portable devices to service inaccessible communities,” says Musiyarira.

Today, we are seeing great examples of local companies bucking the trend by using innovative technology to manufacture solutions across the medical device spectrum.

One example is Cape Town-based BioTech Africa who are specialists in recombinant protein production and bioprocessing services driven by the global requirement for improved in vitro diagnostics. Their current range of highly purified recombinant proteins are used in the manufacture of diagnostic test kits for point of care rapid diagnostics, and research institutions. They offer a variety of protein expression platforms along with a host of other protein services, including protein refolding and structural biology analysis. With their proprietary technology, they are able to deliver highly stable and functionally active recombinant proteins.

Excerpts from the interview:

1. What are the top healthcare market predictions for Africa in 2018-19?

One of the main predictions for the African healthcare market in the year ahead is that the market will embrace technologies and innovations that can improve efficiency and access to healthcare like, for example, e-health.

We will also see the region give greater focus on affordable national health insurance to reduce out-of-pocket expenditure. One outcome of this is that most economies will embrace Public Private Partnerships to achieve universal health coverage, leading, in turn, to increased affordability of specialised care.

The year ahead will also see greater priority given to manufacture of pharmaceutical production.

Although majority of countries will continue to focus on communicable diseases such as HIV/AIDS, Malaria and TB in 2018-2019, major financing disparities will continue in comparison to disease burden as Africa accounts for over 11% of the global population; almost 25% of the global disease burden; just 1% of the global healthcare resources and only 3% of the global health workforce.

2. What are the key trends and growth opportunities affecting the African healthcare market? What are the major challenges as well as growth opportunities that you foresee in the immediate future?

Throughout Africa, we are currently witnessing an epidemiological shift with increased non-communicable diseases and life expectancy. As the purchasing power of the population is improving, countries are focusing on Public Private Partnership models in healthcare. Development partners are now moving towards impact financing from mainstream aid and the region is also investing in large health infrastructure developments.

Africa is characterised by an unmet need for specialised services and diagnostics. However, the growing availability of a skilled workforce to deliver quality healthcare across the region is a promising trend.

In addition, healthcare innovations are emerging as a key enabler of care delivery, and opportunities exist in digital health systems by using mobile phones as drivers for better healthcare outcomes.

Growth opportunities abound in several sectors in the healthcare industry. Chief amongst these are: health infrastructure, pharmaceutical production, laboratory and diagnostics, support sectors including water and energy, e-Health, healthcare insurance, specialised healthcare, and financial services such as private equity.

However, the expansion of these market segments is not without its challenges. Africa, as a whole, has its unique set of challenges as systemwide barriers impede healthcare delivery in the region. Some of the chief obstacles that prevent African countries from achieving better results include the lack of large capital investments, unaffordable healthcare, unpredictable political environment in the region, and the gradual transition from donor aid.

3. What, according to you, are some of the practical steps African countries can take to improve their national health systems?   

There is no denying that fundamental changes must occur within the African health system to bring about improved care in a real and substantial way. First and foremost, we need to strengthen national systems in terms of public expenditure management, governance, leadership and accountability. Sustainable financing of health can be ensured by making more deliberate and innovative ways in increasing domestic sources.

Embracing affordable healthcare insurance is another key element to improve the health system. While building partnerships with civil society and other partners will help expand access to medical care, there is also a vital need to invest in district and community health systems to fulfil our vision for a health-creating society.

The success of several Public Private Partnership models in transforming health services across Africa proves beyond doubt that this model of collaboration is key to improving healthcare provision. However, for it to continue to foster development, we need to scale up capacity in the health work force by providing opportunities for professional development and skills enhancement. There is also an increased need to encourage the vital build-up of strategic health infrastructure to meet the increased demand for services.

The adoption of new technologies across the continent to improve efficiency is offering unprecedented opportunities for improving health. Digital solutions, for instance, can bolster healthcare access and services across Africa at a fraction of the cost.

As we rethink Africa’s approach to health, we also need to align external funding to national priorities, programmes and systems. Finally, there is an urgent need to provide ample and affordable speciality care service to curb and reverse the current trend of medical tourism.

4. Could you highlight the main technologies to watch out for in Africa in the coming year/s?

In terms of technology, we have seen how mobile technologies and digital solutions can penetrate through the problems of geographical barriers and low resources. Digital health is therefore definitely changing healthcare delivery and access in Africa. The availability and penetration of Electronic Medical Records is also expected to increase in the coming years.

Gene therapy is also slowly emerging as a strategy to treat diseases caused by genetic abnormalities. Genome-editing technology has immense therapeutic potential in treating diseases by the repair of gene defects.

The growing incidence of non-communicable diseases will also require large-scale investments in diagnostic and imaging equipment for in-patient monitoring. In addition, provision of specialised care services will contribute to a stronger healthcare delivery system. 

Africa is also gearing towards achieving affordable medical insurance to provide everyone with access to quality health services at a reasonable cost. Greater coverage will certainly transform healthcare in Africa.

5. With respect to the private healthcare sector, what are the main emerging trends in Uganda?

In Uganda, the role of the private sector is significant in achieving healthcare coverage. There is increased private sector involvement in the implementation of healthcare facilities, greater investment in pharmaceutical production and the supply chain, and on new technology and innovation.

The private sector is also involved in infrastructure and other support sectors like water and energy. The implementation of public–private partnership policies and provision of incentives for investments has further promoted the private sector.

6. In which areas do you see scope for partnerships with private investors? How can the government encourage the private sector to increase investment into the healthcare system in Africa?

The chief areas for partnerships include contracting in service delivery and supply chain, pharmaceutical production, IT systems, health insurance, and infrastructure development.
Governments can support the private sector by providing investment of incentives and subsidies, fostering Public Private Partnerships, inclusion of the private sector in policy and planning, stabilisation of the political and economic environment for business, and promoting foreign direct investment.

7. What would you like investors and visitors around the world to know about the health sector in Uganda? What are the real benefits and opportunities that an event like Africa Health can provide to healthcare and trade professionals?

The health sector in Uganda is ready for large capital investment. The Government of Uganda has provided a conducive environment for foreign direct investment in the form of subsidies and market incentives, as well as a stable political and macroeconomic environment. Market players enjoy economies of scale from the regional market and the market has huge potential of expansion.

An event like Africa Health will provide an opportunity to showcase real investment opportunities in Uganda to potential investors and help to attract foreign direct investment in the sector. The event will also offer opportunities for shared learning on promoting the role of the private sector in achieving health-related Sustainable Development Goals.

The health sector has been contributing more significantly to the economy through creation of new jobs, expansion of manufacturing, medical tourism, innovation and technology. The sector should therefore be seen as a profitable area of social enterprise and a foreign exchange earner to the region.

“This is a beautiful platform where we meet and network with people who provide tech solutions for health, academics and healthcare managers.”

• Hon Minister Dr Bernard Hauku, Minister of Health, Windhoek, Namibia

“All the key international industry players are at Africa Health… It is important for industry professionals to attend Africa Health to stay up to date with technology, as it is a great platform to view innovation in the healthcare field.”
- Douglas Austen, Business Unit Manager, Obsidian Health

Expected to attract more than 10,100 healthcare professionals and over 553 leading international and regional healthcare and pharmaceutical suppliers, manufacturers and service providers, the 8th annual Africa Health Exhibition & Congress will be held at the Gallagher Convention Centre, Johannesburg, from 29 – 31 May 2018.

Africa Health is the largest platform on the continent for international and local companies to meet, network and do business with the ever-growing African healthcare market.  

Having experienced stellar growth over the last decade and showing no sign of slowing down in the near future, the African region is seen to be one of the most sought-after markets globally for healthcare investments. According to a report by the IFC, the private-sector arm of the World Bank, titled ‘Health Care in Africa: IFC Report Sees Demand for Investment’, it is estimated that by 2022, Africa will need $25bn-$30bn in investment in physical healthcare assets alone, including hospitals and clinics. The report also states that as Africa's economies improve, the demand for good quality healthcare will only increase further.

Digital Transformation
According to Ryan Sanderson, Exhibition Director at Informa Life Sciences Group Africa – organisers of Africa’s largest healthcare conference, Africa Health - the pressure to identify real solutions for Africa’s healthcare challenges should be a critical consideration for any entity looking to invest in the region.

Sanderson says that with high levels of mobile penetration on the continent, coupled with advancing technologies and new approaches to healthcare management, digital transformation within the healthcare sector may be one of the solutions to addressing the challenges faced, particularly in rural parts of Africa. 

As the largest healthcare business platform in the MENA region, Africa Health is the perfect venue for exhibitors to showcase their latest products and services to an engaged audience that are looking for new business opportunities. It also serves as an excellent platform for both visitors and exhibitors to stay abreast of the industry's latest trends and advancements, meet new customers and develop relationships with existing clients.

CPD-accredited conferences
In addition, the event will run the Africa Health Congress which will feature a total of 16 conferences with the opportunity to gain CPD credits for selected tracks. These multidisciplinary conferences will offer education on the latest updates, trends and advancements on a range of clinical and non-clinical topics. The clinical conference listing will include surgery, nursing, medical obstetrics, emergency and trauma. Non-clinical conferences will consist of decontamination & sterilisation (CSSD), public health, healthcare management, procurement, etc. amongst others.

The exclusive Africa Health Leaders Forum will highlight the importance of Public-Private Partnerships (PPP) in enhancing the capabilities of healthcare systems in the region.

The Congress will host distinguished local and international experts and industry leaders speaking across the different conferences. Their presentations will touch upon key issues affecting the healthcare sector, including:

• Opportunities for investment in healthcare start-ups in Southern Africa
• Water saving and efficiency in health facilities
• Making nurses techno savvy
• Planning and managing healthcare technology across the lifecycle of healthcare facility
• Community-lived experiences of climate change in relation to energy sources
• The impact of political decisions on healthcare
• Telemedicine: Providing remote access to high quality care

Sanderson says that, year-on-year, Africa Health continues to cement its position as a leading platform for dialogue around the most pressing healthcare issues that the continent faces. “Finding solutions to these challenges will not only result in greater access to health services for those who need it the most, but it will, in turn, reduce the financial burden that all governments experience when trying to meet their nation’s healthcare needs.”

All proceeds from the conferences will be donated to local charity, RuDASA (The Rural Doctors Association of Southern Africa) and associations.

Africa Health Congress Overview

BIOMEDICAL ENGINEERING ^NEW (30th May)

In partnership with: IFBME, IBE and US

Theme: Past, Present and Future of BME in Africa

This session commences with a plenary address on ‘The West African Biomedical Engineering landscape - an update, review, lessons to be learnt and thoughts for the future’. Attendees at the event can explore initiatives that accelerate medical device innovation and manufacturing while also considering the role of biomedical engineering societies within Africa.

DECONTAMINATION & STERILISATION (CSSD) (29-31 May)
In association with: CSSD Forums of South Africa (CFSA) & Association for Peri‐operative Practitioners in South Africa (APPSA – Gauteng Chapter)
Theme: Best practice – best outcomes

This conference helps to gain more insight into CSSD in perioperative environments and advance knowledge in this niche area. It will examine new strategies to decrease risk of contamination, increase efficiency and reduce cost of handling instruments while also identifying sources of CSSD failures and develop risk management to control errors.

EMERGENCY MEDICINE ^NEW(31st May)
In partnership with: Emergency Medicine Society of South Africa (EMSSA)

Theme: Addressing and advancing emergency care in South Africa
Assessing the future of emergency care in South Africa’s healthcare system to help stay ahead of the curve, this conference session enables participants to determine the best course of action in advanced paediatric emergencies to improve patient outcomes. First-hand case examples are reviewed to tackle ways to improve response in tough situations in the ED.

ETHICS, HUMAN RIGHTS AND MEDICAL LAW (31st May)
Theme: Managing medical negligence and medical errors in South African hospitals & human rights issues surrounding human migration in Africa
This agenda will delve into the recurrent problems of medical negligence in clinical practice, as well as the ethics of human migration, in light of the impact of ‘brain drain’ and recent events surrounding the migration of African youth to Europe and elsewhere; and the duty and burden these two issues have placed on healthcare practitioners and other members of the civil society on the continent. 

HEALTHCARE MANAGEMENT (30-31 May)
Theme: Digital health revolution: Delivering high quality care to every patient in Africa in a sustainably affordable way 
Incorporating digital disruption into the healthcare market to deliver top-tier quality service at low cost is a key topic of discussion at this conference. The two-day session investigates the role of digital health in creating health equity and improving healthcare access to patients, and also compares the latest digital platforms to enable attendees to make the right investment decision.

HEALTHCARE TECHNOLOGY LIFECYCLE MANAGEMENT (31st May)
In association with: IFBME, SAHTAS & CEASA
Theme: Energising healthcare through practical solutions
This session offers an evaluation of the parameters of strategic medical equipment planning, management and maintenance to improve efficiency and productivity in any healthcare organisation. It looks at the role of state-of-the art medical technologies in enhancing the efficiency and management of a facility.

HOSPITAL BUILD (30-31 May)
Theme: Starting with the end in mind
Apart from discussing financing options and challenges in the healthcare build environment, this conference also explores contemporary design and fit-for-purpose healthcare facilities to maximise efficiency and patient experience. Participants can assess the latest resource management strategies in healthcare facilities and prioritise cost-cutting to improve efficiency.

IMAGING AND DIAGNOSTICS (29-30 May)
Theme: Techniques and technology towards imaging excellence
Chaired by Prof Sudhir Vinayak, President, African Society of Radiology, this session examines the impact of new initiatives that prevent occupational exposure in radiology. It also looks at new developments and the latest techniques for accurate diagnosis in various imaging specialities – cardiac, neuro, breast, abdominal, paediatric, and obstetrics & gynaecology.

NURSING (31st May)
In association with: Academy of Nursing in South Africa (ANSA)
Theme: Changing the game with technology
How does the application of modern technology affect the nursing profession? This conference helps you discover how technology can take nursing to the forefront of healthcare by improving care and patient outcomes, and how to include technology in nursing training and education to develop tomorrow’s nurses. Learn also about unified health systems used by nurses to improve patient flow and experience.

MEDICAL OBSTETRICS (29-30 May)
Knowledge Partner: Faculty of Health Sciences, University of the Witwatersrand
Theme: Best practice in medical obstetrics
Speakers at this conference discuss the best treatment strategy for common chronic diseases encountered during pregnancy that will help reduce negative outcomes. The agenda will familiarise obstetricians and healthcare providers with recent developments in obstetrics with the aim of enhancing scientific knowledge on current controversies and other clinically relevant topics. Speakers will also cover current issues in obstetrics such as obesity, hypertension, pulmonary complications, advanced maternal age, screening and more.

MEDICAL DEVICES PROCUREMENT (29th May)
In partnership with: Medical Devices Manufacturers Association of South Africa (MDMSA)
Theme: Procurement by Africa for Africa

This conference will help you discover quality and cost-effective procurement strategies to increase savings within any healthcare institution. It also explores new technology, initiatives and opportunities supporting the procurement of medical devices within Africa and, identifies and evaluates new medical device procurement regulations to ensure compliance.

PUBLIC HEALTH (29-30 May)
In partnership with: Public Health Association of South Africa 
Theme: Think Global, Act Local
From reviewing strategies to improve leadership and clinical governance to evaluating the impact of climate change on health, this conference is a must-attend event for anyone associated with the public health sector across Africa. The conference helps identify the prevalence of occupational disease and injuries, and also discusses the development of new vaccines for the treatment and prevention of infectious diseases.

QUALITY MANAGEMENT (29th May)
In association with the Council for Health Service Accreditation of Southern Africa (COHSASA)
Theme: Ensuring a resilient approach to a high quality of care
What steps need to be taken to ensure high quality of care in health systems? This session outlines innovative approaches to improve quality, discusses tools and techniques for improvement and provides insight into standardising care by implementing improvement standards across the organisation. 

SURGERY (29th May)
Theme: Future of surgery in Africa
This session discusses the role of new technology and current treatment strategies to minimise human error in surgical care, compares treatment options and practice standards for benign and malignant breast disease, identifies how to manage complications in MIS and GI cases, and determines good practice in laparoscopic emergency procedures that reduce the risk of post-operative complications.

TRAUMA (29-30 May)
In partnership with: Trauma Society of South Africa
Theme: Advancing the expertise of the practicing trauma physician
Participants at this conference session can learn about best practices when dealing with advanced and severe trauma cases to enable faster recovery time, lower infection rate and overall better outcomes. This includes reviewing local multidisciplinary trends for trauma care and identifying how to efficiently manage trauma cases within the peripheral hospital.

AFRICA HEALTH LEADERS FORUM (31st May)
Theme: Harnessing PPPs in Healthcare - Imperatives for today’s leaders
This invitation-only event includes keynote addresses by prominent health ministers from across Africa and private health specialists in the field to discuss the rise and challenges associated with Public-Private Partnerships (PPPs) which governments are utilising as a means of gathering investment and expertise from the private sector to enhance the capabilities of healthcare systems.

Here, we would like to highlight the need to develop the following key areas of imaging to help achieve value-based, precision cancer care: molecular (primarily nuclear) imaging and therapy, interventional radiology, and radiology informatics.

The ability to image not just anatomy but actual molecular and cellular processes as they occur has long tantalised the medical community. Molecular imaging has existed for decades, but until recently, its growth has remained frustratingly slow. For many years after the advent of clinical positron emission tomography (PET), 18F-FDG remained the only PET tracer approved by the United States Food and Drug Administration (FDA) for clinical use.

For a number of reasons, however, progress in molecular imaging has recently begun to speed up, giving much cause for optimism that the field will fulfill its potential. A number of new tracers have recently received FDA approval, and dozens more are in clinical or pre-clinical trials. Unlike 18F-FDG—which is a marker for the elevated glycolysis that is a hallmark of cancer but not specific to it—many of the newer PET tracers are highly specific, targeting molecular entities such as prostate-specific membrane antigen (PSMA, which is overexpressed in prostate cancer) or estrogen receptors.

In addition, new probes and approaches for optical imaging, as well as the advent of combined PET/MRI and clinical hyperpolarized MRI (a technique that allows in-vivo assessment of chains of metabolic events), are adding still more dimensions to molecular imaging for pre-clinical research and clinical use. As a result, we are seeing more and more potential applications of molecular imaging in clinical decision-making for oncology, including selection of conventional as well as molecularly targeted treatments; dose-finding; and early assessment of treatment response.

With regard to the selection of treatments for precision cancer care, interventional radiology has a key role to play, particularly given its capacity to allow targeted biopsies. Acquisition of tissue samples adequate for complex molecular analyses is crucial for the appropriate selection of targeted therapies but is far from a given in many cases. For example, in the United States, analysis of the interim results of the National Cancer Institute Molecular Analysis for Therapy Choice (MATCH) trial of targeted therapies, in which patients were matched to treatments based on in-depth molecular analyses, found that around 13% of patients’ biopsies were inadequate for this purpose. This realisation has catalysed research efforts to improve the quality of biopsies, bringing together tools and expertise from interventional radiology and other disciplines, including computer science. By enabling consistent, high-quality biopsies, interventional radiologists will have an opportunity to make their work increasingly central to value-driven, precision cancer care, particularly as the number of molecularly targeted treatments available grows.

Advanced interventional radiology suites now feature not only fluoroscopy but also hybrid imaging equipment, including combinations of cross-sectional imaging modalities such as CT, MRI or in some cases even PET/CT with single- or bi-planar angiography. Expanding the ability to characterise tissue biology via these modalities should enhance the capacity of interventional radiologists not only to perform optimal, biologically targeted biopsies but also to provide effective treatments. The use of molecular imaging in the IR suite has already been shown to aid target localisation and facilitate immediate assessment of treatment, before the patient leaves the operating table. Because of its focus on minimal invasiveness, IR is ideally suited to address the goals of achieving precision and value/efficiency in cancer care. To ensure that IR contributes as much as possible to precision oncology, it is essential that we aim to integrate cross-sectional and molecular imaging modalities into IR suites whenever possible and that we develop IR physicians with the capacity to interpret these modalities.

Alongside the development of molecular imaging probes, the development of novel targeted radionuclide therapies and of theranostic agents that allow both targeted imaging and treatment has also been picking up speed. Examples include the development of lutetium-177 (177Lu)-DOTATATE, which has been found to lengthen progression-free survival in patients with advanced midgut neuroendocrine tumours; and the development of radiolabeled ligands of PSMA, which, in early clinical studies, have yielded highly promising results for the treatment of metastatic prostate cancer.

To fulfill the potential of radionuclide therapies and theranostics and maintain progress in these areas, it will be critical to dramatically increase the recruitment of physicians for training in molecular imaging and nuclear medicine and the availability of training programmes in these fields.  Furthermore, we must work to increase both the supply of radiochemists and other personnel and the maintenance and expansion of the complex infrastructure necessary for advancing these fields.

Last, but not least, we would like to highlight the growing importance of radiology informatics to the success and advancement of oncologic imaging as well as biomedical imaging as a whole. Rather than being a source of support in scattered areas, it is destined to become a pillar of radiology practice. We are now in the era of the “fourth industrial revolution,” in which the integration of disciplines and technologies, including machine learning and artificial intelligence, is leading to increasingly rapid innovation and the weaving of computer tools more and more deeply into the fabric of daily life.

Informatics tools for gathering and analysing data have the potential to monitor various aspects of daily radiological practice, facilitating efforts to improve both quality and efficiency. Furthermore, machine learning and artificial intelligence can be used to extract additional, clinically relevant data from images and enable faster identification and characterisation of abnormalities. Therefore, informatics tools will clearly be indispensible for helping radiology practices make the transition from volume-based healthcare to value-based healthcare that maximises both quality and efficiency.

Turning away from machine learning and AI out of fear that they will replace us is not an option. Rather, radiologists must embrace these new tools, remembering that our ultimate purpose is not to “decode” image patterns or analyse texture in images but to integrate all imaging findings with clinical and other findings and help solve clinical problems. We need to participate in developing machine learning and AI tools that will help us, and we need to become masters in their application to clinical care.

At present, the value that radiologists provide is, unfortunately, often overlooked. In the predominant value-based healthcare models, a correct diagnosis is taken for granted: Measurement of value begins only with the start of therapy, and the impact of radiology on value is calculated solely in negative terms (i.e., when radiology is a source of diagnostic error).

However, anyone who has been through residency training in radiology knows that being a good radiologist requires a great deal of learning and practice. Numerous studies have shown that sub-specialisation further improves radiologists’ interpretive abilities and that direct consultations between radiologists and referring physicians affect clinical decision-making. Moreover, radiologists carry out many other demanding responsibilities, from assessing the appropriateness of imaging requests, to adjusting imaging protocols, attending to radiation protection needs, communicating with patients, managing radiology personnel and performing research to move the field forward.

Thus, we already know that radiologists add value, but we need to make this clear to policymakers and the broader public. In addition to enabling us to contribute even more value to clinical care, informatics tools will be essential to develop metrics that demonstrate our work’s value. In short, if we embrace change, the future of radiology—and especially oncologic imaging—will shine more brightly than ever.