The first of a three-part series on a New Public Health Order for Africa, this introductory commentary examines the gaps, challenges and inequities of the current global health ecosystem.
The Covid-19 pandemic has highlighted weaknesses in the global health ecosystem – exposing underinvestment in the public-health infrastructure and suboptimal global coordination in response to public-health emergencies. At the same time, we have seen strides in scientific innovation, leading to rapid development of vaccines, therapeutics and diagnostics for Covid-19.
The response to Covid-19 also exposed the inherent power disparities in the global health ecosystem and the underrepresentation of African voices and institutions in positions of influence and decision-making. One of the clearest ways in which this has been demonstrated is in the unequal access to vaccines in African countries. While almost 58 per cent of the world has received at least two vaccine doses, as of March 2022 only 15 per cent of the African population had been double vaccinated. Africa relies on other regions for almost all its vaccine needs, with only 1 per cent of its entire vaccine needs manufactured locally. Currently, only seven African countries have companies operating across the vaccine-manufacturing chain (from drug-substance production to fill and finish). These persisting power asymmetries demonstrate the need to enhance the influence of African representation in the global health ecosystem, to ensure that African needs and priorities are better reflected in the response to and preparation for global health threats.
Africa’s Response to Covid-19: A Story of Collaboration and Coordination
Despite recent analysis and reports suggesting that the documented impact of Covid-19 in Africa is an underestimation of the actuality, the African response to the pandemic has, for the most part, exceeded the expectations of the global community. This response has been led at the continental level by the Africa Centres for Disease Control and Prevention (Africa CDC) and, at the regional and national levels, by organisations such as the West African Health Organization (WAHO), the Southern African Development Community (SADC) and the Nigeria Centre for Disease Control (NCDC). With visionary leaders at the helm of these institutions, the response has been fast and coordinated and has optimised the impact of limited resources. We have witnessed strong collaboration between public-health and political decision-makers, leveraging lessons from their experience of outbreaks in the past.
Days after the first case of Covid-19 was reported in Africa, African Union (AU) health ministers agreed to a joint continental strategy for Covid-19, committing to cooperate in their response to the pandemic. Since then, many initiatives have been implemented to address Africa’s priorities for the pandemic response and to prepare for future pandemics including the Partnership to Accelerate Testing (PACT), the African Vaccine Acquisition Task Team (AVATT), the AU Trusted Travel Portal, the AU Covid-19 Response Fund and the Partnership for African Vaccine Manufacture (PAVM). At the regional level, WAHO coordinated the response to Covid-19 in the Economic Community of West African States (ECOWAS), providing technical, material and financial support to member states including the provision of essential medical supplies, financial support, training and necessary technical assistance. WAHO also played a central coordinating function, facilitating early coordination, communication, and centralised logistics and procurement in the region. It was also able to activate response structures established during the Ebola epidemic to support member states.
Africa has been underserved by global coordination mechanisms in response to the pandemic with early export bans limiting importation of reagents for diagnostics, for example. In the initial stages of the pandemic, 70 countries imposed restrictions on exports of medical materials, including necessary reagents for Covid-19 testing, exacerbating limited diagnostic capacity in African countries. Stockpiling of vaccines by higher-income countries also led to limited access to direct vaccine purchasing through AVATT, as well as delayed access to vaccines promised through the COVAX initiative. As Dr John Nkengasong, director of the Africa CDC, has noted, “multilateralism will always be crucial to preventing and responding to epidemics and pandemics”, but Africa’s public-health approach has to be configured towards greater self-reliance.
More broadly, investment in health systems in African countries remains well below what is needed. A decade after the 2001 Abuja Declaration set a target of spending 15 per cent of government budgets on health, only two countries (Rwanda and South Africa) had achieved that target. More recently, three countries – Ethiopia, Malawi and Gambia – have met and surpassed the 15 per cent target. However, health investment has declined in recent years as economies have shrunk, worsened by the impact of Covid-19 on economic growth.
As of 2019, just ten African countries (Algeria, Botswana, Burkina Faso, Gabon, Mauritius, Namibia, Rwanda, the Seychelles, Tunisia and Zambia) provided free universal health coverage to their citizens.
The health workforce also remains limited. Between 2015 and 2030 out of the estimated global health-workforce shortage of 14.5 million required to achieve universal health coverage (UHC) and its Sustainable Development Goals (SDGs) Africa has the most severe shortage, estimated to reach 6.1 million workers by 2030. For example, in 2017 there were only 0.2 doctors for every 1,000 people in sub-Saharan Africa compared with 4.9 per 1,000 in Europe and only one nurse and midwife per 1,000 people compared with nine for every 1,000 in Europe. Brain drain also continues to be a challenge with wealthier nations continuing or increasing active recruitment of health professionals from the continent. It is estimated that one in ten UK doctors was trained in Africa.
Africa also remains underrepresented in global health discourse as the global health architecture is significantly skewed towards the Global North. For example, only 3 per cent of World Health Organization collaborating centres (WCCs), key resources which support public-health-system strengthening and which generate and synthesise the evidence necessary for health policy, are located in Africa. Nearly 80 per cent of all WCCs are based in just 22 countries, 13 of which are high-income countries.
These deficiencies have led to the call from African leaders for the establishment of a New Public Health Order for Africa to strengthen African public-health systems and give Africa a louder voice in the global health discourse.
What Is the New Public Health Order for Africa?
The New Public Health Order for Africa, as defined by Dr Nkengasong, focuses on four key elements: strengthening the continent’s public-health institutions and workforce, expanding local manufacturing of health products, increasing domestic investment in health and promoting action-orientated partnership.
Africa does not manufacture most of the medicines, vaccines and diagnostics it uses. Despite having the highest incidence of mortality caused by infectious diseases, less than 1 per cent of Africa’s vaccine needs are met by products manufactured on the continent. Additionally, between 70 and 90 per cent of medicines are imported and prior to Covid-19 no African countries were investing in local manufacture of diagnostics. To effectively address the continent’s global health challenges, Africa will need to increase the local manufacture and production of medicines, vaccines and diagnostics to meet its health priorities and ensure continental health security. It will also be important to strengthen vaccine and medicine supply-chain management to ensure that governments can distribute these products to the populations that need them.
Trusted partnerships between Africa’s public-health actors and the private sector as well as greater donor coordination aligned with African priorities will also be critical to addressing current and future public-health priorities on the continent. The Ebola vaccine deployed during the 2021 Ebola outbreak in the Democratic Republic of Congo, for example, was created through a public-private partnership between Gavi, the Vaccine Alliance and the pharmaceutical company MSD – illustrating the potential of such partnerships in tackling epidemics and pandemics. Engagement of African expertise and leadership in such partnerships will ensure the reflection of African priorities and utilisation of African skills for such initiatives in the future
A New Public Health Order for Africa will require significant investment in a strong public-health workforce with diverse skills and expertise to ensure health security on the continent. For example, the continent needs an estimated 25,000 frontline epidemiologists, but currently has trained only about 5,000. However, a skilled public-health workforce will need to be underpinned by strong institutions with the ability to attract and retain skilled workers.
Strong regional and continental global health institutions, equipped with effective systems, structures and skills to harmonise and coordinate public-health responses, will be pivotal to the New Public Health Order and will enable rapid response to – and preparation for – disease threats. This was recognised by the AU and the creation of an African public-health organisation was proposed in 2013, which was then established as the Africa CDC in 2017. ECOWAS established WAHO in 1987, focusing primarily on health-policy harmonisation but increasingly adopting a regional public-health-system coordination role. The value of these public-health institutions has been increasingly recognised in response to health-security threats that cross borders.
The change we see in the African public-health ecosystem and the relative success of Africa’s response to Covid-19 has in part been driven by this increase in functional public-health institutions that are able to effectively collate, coordinate and lead the public-health system at the national, regional and continental levels. This direction of travel is welcome and should be supported by all parties with a genuine commitment to strengthening public-health systems across the continent.
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