Where does Africa's New Public Health Order stand?

The COVID-19 pandemic laid glaringly bare the fractures in the public health systems on the African continent — prompting a chorus of calls to shake up the status quo.

In the first year of the pandemic, Dr. John Nkengasong, then director of the Africa Centers for Disease Control and Prevention, laid out a path for Africa to establish a new way of delivering public health which he dubbed a “New Public Health Order.” At its core is continental ownership over health responses that will lessen dependence on an international system that leaves African countries in the lurch when crisis hits.

The African Union Commission and Africa CDC have since adopted this vision as a formal road map to ensure health security on the continent.

Work toward revamping the health systems is well underway. Last week, over 2,500 public health practitioners gathered in Kigali for the second annual International Conference on Public Health in Africa. The conference itself is part of the road map.

At the conference, participants took stock of progress toward achieving the New Public Health Order and outlined work ahead.

“Allow me to also persuade you that it is time for a new way of doing things on the continent to achieve our health security. ... A vision that takes Africa from always following others to a continent that is confident in its own skin,” Africa CDC's Acting Director Dr. Ahmed Ogwell Ouma said during the conference. “A continent that sets its own agenda, develops its own internal capacity, establishes its own priorities, seeks indigenous solutions, and uses domestic resources to initiate action.”

The AU’s road map centers around five goals: strong African public health institutions, expanding manufacturing of vaccines, diagnostics and therapeutics, investment in the health workforce, increased domestic health spending, and respectful partnerships.

Though it’s still early days, an assortment of initiatives has launched on the continent in line with the road map, such as increased vaccine manufacturing capacity, new health institutions, and the creation of new task forces. But the efforts are not without resistance from those benefiting from the systems currently in place, health experts told Devex.

Strengthening African institutions

The AU’s road map leans on a foundation of strong African public health institutions. At the helm is Africa CDC, which recently underwent a year of transitions aimed at building its resilience. In February, the African Union assembly voted to give it greater autonomy, which will allow it to become more agile in health emergencies. The implementation is ongoing, with key frameworks up for approval at the next AU assembly in February.

Africa CDC also has regional collaborating centers, and there are existing regional structures, such as the West African Health Organisation. As part of the road map, the AU is also urging each country to establish its own national public health institute or strengthen existing ones.

These institutes serve as a single point of entry and coordinating mechanism into a country’s public health systems, Dr. Ebere Okereke, honorary senior public health advisor at Africa CDC and senior technical advisor at the Tony Blair Institute for Global Change, told Devex. Nigeria’s Centre for Disease Control is an example of a successful one, she said.

The continent is also working to operationalize the new African Medicines Agency, a body aimed at harmonizing regulation and standardization of medicines, health products, and technologies. Rwanda was chosen to host it in July, but it is not yet functional.

And the African Development Bank announced the creation of the new African Pharmaceutical Technology Foundation in June aimed at "enhancing technology access and transfer for domestic manufacturing in Africa." Rwanda will also host it. It's expected to launch in the first half of next year.

Self-sufficient manufacturing

African nations were left scrambling during the COVID-19 pandemic to access vaccines, diagnostics, and therapeutics. To rectify this, the AU launched the Partnerships for Africa Vaccine Manufacturing in 2021 that aims to ensure 60% of vaccines administered on the continent are locally manufactured by 2040. It’s ambitious, as the continent currently imports about 99% of its vaccines.

The AU’s road map reinforces this goal as a way to “democratize access to life-saving medicines and equipment.” In the wake of the pandemic, new initiatives have emerged such as the World Health Organization’s mRNA vaccine technology transfer hub in South Africa, Senegal’s establishment of the MADIBA vaccine facility, the expansion of vaccine manufacturing production at South Africa’s Aspen, and the building of BioNTech’s vaccine manufacturing plant in Rwanda.

But a perennial concern with vaccine manufacturing on the continent is whether those who purchase vaccines in bulk for Africa will buy local. As many African nations receive vaccines from Gavi, the Vaccine Alliance, and UNICEF, the AU created a working team with key partnersto develop a market-driven approach to include commitments from these global entities to purchase from African manufacturers, Dr. Githinji Gitahi, group CEO of Amref Health Africa, told Devex. There are also efforts to decide the priority molecules African manufacturers will produce and ensure they are produced in a coordinated way across the continent.

The AU wants to invest in a diverse manufacturing ecosystem beyond fill-and-finish to include production throughout the value chain, Okereke said, but that relies on sharing of intellectual property and technology transfer, “which currently we're getting very little traction on,” she said, although this is improving. For example, the Coalition for Epidemic Preparedness Innovations is beginning to engage directly with African research institutes and laboratories on development of candidate vaccines, she said.

“Until we have that dispersed manufacturing ecosystem … The next pandemic will knock us out, just as this one did,” she said.  

Ramping up domestic spending and battling brain drain

In 2001, heads of African nations pledged to allocate at least 15% of their budgets to health, but most have failed to do so. The road map works to reinvigorate energy behind that target.

Breaking international dependence requires countries to increase health spending, experts in Kigali said. During a panel discussion at the Kigali conference, Dr. Soji Adeyi, president of Resilient Health Systems who serves on the faculty at Johns Hopkins Bloomberg School of Public Health, called COVAX a form of “narcissistic charity,” and encouraged African nations to end “dependency on the global north" and avoid a COVAX repeat by ramping up spending on pandemic preparedness and response.

Dr. Claude Muvunyi, director general of the Rwanda Biomedical Center, also said in Kigali that most African nations spend a piddly 0.5% on research and development as a percentage of gross domestic product. These investments are key because they can lead to the creation of new vaccines, diagnostics, and therapeutics where the intellectual property ownership rests on the continent, he said.  

And part of that domestic spending includes salaries for health workers adequate enough to keep them from leaving Africa. There is an “active pull” by some higher-income countries that recruit health workers from abroad to fill their own workforce gaps, including African nations, Okereke said. Many African governments fund or subsidize medical training, only to see talent wooed away to higher-income countries.  

"We need to create an environment that those people want to stay in,” she said.

To try to stem these trends, in February, the AU Assembly approved the development of the Africa Health Workforce Task Team that will assess country-by-country workforce needs to develop a blueprint for moving forward, Gitahi said. The AU has requested this task team be established by June.

‘A fair playing field’

Too often the African continent is not at the table when global health decisions are made — not given the opportunity to inform, influence, and steer partnerships, Okereke said.

“We're not looking for begging — we're looking for a fair playing field,” she said.

For example, she said, while there has been a push for the World Bank to designate Africa CDC as an implementer of its new pandemic fund, the bank has not accepted this. She said the denial hampers Africa CDC’s ability to serve as a voice of influence on behalf of the continent around funding for pandemic response and preparedness.

She added that the AU should have a permanent seat at the U.N. Security Council, which has been a platform where health decisions are made, such as action on the West Africa Ebola outbreak.

 The AU’s road map calls for mutually beneficial partnerships where agendas generated by  the continent are respected, Gitahi said. For example, if the AU decides it wants Ebola or cholera vaccines as a preventative measure as opposed to a responsive measure, its partners should respect that, he said. But legacy plays a role in stunting respectful partnerships.

 "We know that our partners are also working from existing policy and governance frameworks that are defining how they operate with us,” he said. Organizations have existing boards, as well as measurement and evaluation frameworks within which they operate.

“We have to go all the way up and work together with their governance to actually reform and make sure their agenda is inclusive of our desires,” he added.  

Clinging to the status quo

Although the continent has made gains toward achieving the goals in the road map — Africa does not exist in isolation but within “a global ecosystem that is actually skewed to our disadvantage,” Okereke said.

“The challenges in the global system haven't been resolved — we still have a pharmaceutical industry that is not built on equitable principles,” she said.

Conversations at the World Trade Organization have not resulted in an outcome on intellectual property that many have pushed for, there are no global commitments preventing travel bans and export restrictions on medical products, and much of the increased manufacturing capacity is for COVID-19 vaccines.

“There is still a concern that if something else happens today, we in Africa, particularly, will be at a disadvantage and at the end of the queue, again, because the rules are still the same,” she said. “Somebody is benefiting from the status quo … We've seen companies that were doing all right, really expand their resources. Why would they want to change the status quo?”