Preoccupied with managing day-to-day crises, healthcare-related and otherwise, African countries struggle to plan for tomorrow, let alone the next pandemic lurking around the corner. Better preparedness depends on developing flexible funding models and self-reliance.
There is little doubt the world was largely unprepared for the disruption and devastation of the covid-19 pandemic. While much of Africa appears to have escaped the severest effects of the pandemic—likely due to younger populations, warmer climes, and familiarity with public health crises—what it has not evaded is the exposure of its weak health systems.
Many countries on the continent simply could not deal with the increased number of people needing medical help and intensive care. Amid a surge of covid-19 cases, a 2020 Reuters survey found that African nations had less than one intensive care bed and one ventilator per 100,000 people. At the very least, the continent needed at least 10 times the number as the outbreak peaked.
The fallout from the pandemic has been especially stark in areas outside acute covid-19 care. In particular, funds for other high-priority health initiatives were quickly diverted towards covid-19 response. Services to prevent and treat malaria, tuberculosis, and HIV, still the leading causes of death in Africa, were disrupted.
The economic impacts have also been severe. The Africa Development Bank (AFDB) says the effects of lockdowns shrank the continent’s overall GDP by 2.1%. An estimated 55 million people were pushed below the poverty line.
As the continent attempts to overhaul its health systems to be better prepared for future pandemics, a greater focus on self-reliance, targeted resourcing, and longer-term planning will be key to improving health outcomes.
Tracking the pandemic’s impact
Across the African continent, the pandemic not only impacted healthcare delivery but also standards of living, including in two of its biggest economies.
Professor Walter Jaoko, director of the KAVI Institute of Clinical Research at the University of Nairobi, says in countries like Kenya the effects of the pandemic were a “mixed bag”. Because the country’s counties govern independent of the central government, some areas fared better than others, depending on leadership priorities. “For example, when the central government releases funds, some counties focus on laboratory supplies, others on testing diagnostics,” Jaoko says.
In rural areas, especially, the pandemic undid years of progress in healthcare, with clinics and health facilities perceived as covid-19 hotspots and the government diverting resources for critical health services to fight the pandemic. In Nairobi, the pandemic’s epicentre in the country, overcrowded conditions and underfunded development projects allowed the virus to flourish.
Nigeria was basically scrambling to contain the disease; fortunately, we did not have the severity of Europe or other places.
In Nigeria, the primary effects of the pandemic have been economic in nature more than health-related. The early months ushered in Nigeria’s deepest recession since the 1980s, with services and industry hit especially hard. This can be largely attributed to lockdown measures. Even after economic activity began to recover, inflation accelerated, especially for food items.
Prominent Nigerian virologist, Professor Oyewale Tomori, who has served as vice-chancellor of the Redeemer’s University and president of the Nigerian Academy of Science, says his country is “lucky” that the pandemic was not as severe as it was in Europe because that would have “shattered” the health system.
“Nigeria was basically scrambling to contain the disease; fortunately, we did not have the severity of Europe or other places,” he says. “Apart from South Africa, I don’t know of any other country in Africa that can contain a pandemic."
Towards self-reliant health security
There are ample warnings that another pandemic as deadly as covid-19 could occur in a matter of decades, leading to questions over introspection how African countries can shore up their health systems to cope adequately. There is no question that the continent needs to better prepare—indeed, ‘pandemic preparedness’ has become a popular phrase—but what such preparedness entails is subject to varied interpretations.
The global Epidemic Preparedness Index (EPI) assesses the national-level preparedness of 188 countries under five sub-indices—economic resources, public health communication, infrastructure, public health systems, and institutional capacity. Developed in 2018, it found West and Central Africa, along with South-East Asia, had the weakest capacity to detect and respond to epidemics and pandemics.
Given the scale of the threat, it is a worrying finding. Africa Centres for Disease Control and Prevention (Africa CDC) regional coordinator, Dr Lul Riek, says before the emergence of covid-19 the top four epidemics were cholera, measles, yellow fever, and influenza. Over the last two decades, there have been six global health security threats: SARS in 2003, H1N1 (swine flu) in 2009, MERS in 2012, Ebola in 2014, covid-19 in 2019, and polio and monkeypox in 2022.
There is no question that the continent needs to better prepare—indeed, ‘pandemic preparedness’ has become a popular phrase—but what such preparedness entails is subject to varied interpretations.
At a gathering of journalists from Uganda, Zimbabwe, Kenya and Zambia in September 2022, Riek stressed that now was the time for African countries to shore up their health systems. Africa CDC is leading the charge, calling for the implementation of a new public health order—a roadmap towards self-reliance, sustainable health outcomes and health security.
Given the recent experience of Africa being left behind in access to lifesaving covid-19 vaccines and therapeutics, Riek says self-reliance is a critical focus area. A similar problem emerged after the monkeypox outbreak, he says, as the continent was left waiting for assistance since it was unable to deal with it on its own.
“At a time when the monkeypox virus was circulating in Africa, the world did not pay attention until the virus made a ‘mistake’ and spread northwards—then immediately it was declared an emergency,” Riek says. While there is a lot of “goodwill” from the global north to assist African countries, Riek says, it’s unlikely to suffice during a pandemic, present or future.
Strengthening national-level responses
Two key pillars of the new public health order are strengthening public health institutions and expanding local manufacturing of vaccines, diagnostics, and other medical supplies.
Riek says there is already progress on this front. At the Vaccine Manufacturing Summit in April 2021, the African Union set a goal to produce 60% of its vaccine requirement by 2040. “The good news is that work has already started, and we may even beat that target, because the commitment to do this came from the leaders themselves,” Riek says.
Riek is also optimistic about the ‘Lusaka Call to Action’, which aims to establish national public health emergency operations centers. The centres, which will be established by all African Union member states, will be critical for coordinating life-saving data, information, and resources to help countries prepare and respond effectively to public health emergencies.
In a recent report published by The Brookings Institution, John Nkengasong, director of Africa CDC, says the new public health order requires predictable, long-term funding, joint priority setting and stronger mechanisms to manage the allocation of funds in line with continent-wide aspirations.
He also emphasises that, “first and foremost,” political leaders are responsible for funding their public health systems. Since the 2001 Abuja Declaration, where African governments committed at least 15% of their annual budgets to health, “only a handful of countries have reached this goal, and overall funding has been inconsistent at best”.
This, Tomori says, is the main challenge. Billions of dollars will be needed to train healthcare workers and build and strengthen existing health systems. “If countries fail to honour their own commitments of 15%, where will they find money to pour into these new efforts?” he says.
Tomori says each county should be allowed to determine how much and what it needs to build a healthy population, rather than focus on a uniform percentage of annual budgets.
He says health should be viewed holistically, with all aspects of people’s lives considered. “If we strengthen water supply, it will get rid of waterborne diseases. If we provide good sanitation, we will get rid of flying toilets [open defecation]. If we provide affordable housing, people will live better. All this together will achieve healthier populations.”
The missing focus on a secure tomorrow
Tomori says self-sustainability, self-financing and equity are often discussed, yet there is little effort by African countries to own their epidemics and move away from external assistance. “[Political leaders and policymakers] do not store the lessons learnt from pandemics,” he says. “As soon as the problem goes away, they forget and wait for the next calamity to remember what must be done.”
Plus, much of African countries’ health funding is from the European Union, Tomori says. “African countries are totally dependent on PEPFAR [the US President’s Emergency Plan for AIDS Relief] to fight HIV and AIDS. So how can we demand equity when it comes to sharing resources?”
Governments have to deal with present day starvation with what funds they have. It is highly unlikely that they will plan for a situation that is not staring at them in the face right now
External influence also extends to decisions on issues like mitigation. Tomori says due to Africa’s overdependence on European data, often countries did not make the right calls when implementing covid-19 prevention measures. Guided by the severe situation in Europe, African countries went into national lockdowns instead of looking at their own epidemiology and targeting specific areas for lockdown. This approach could have spared citizens from the negative economic impact.
Jaoko, who is also a professor of medical microbiology and tropical medicine, agrees that the Abuja Declaration and other financing mechanisms touted by Africa CDC are “aspirational goals” unlikely to be achieved. He says allocations for healthcare should be increased gradually, commensurate with the spending capacity of individual countries.
Crucially, he says, given African countries are generally preoccupied with managing day-to-day health issues, they may struggle to plan for the long term, let alone set aside funds for it. “Governments have to deal with present-day starvation with what funds they have,” Jaoko says. “It is highly unlikely that they will plan for a situation that is not staring them in the face right now.”
Looking ahead to create change
Jaoko and Tomori recommend African countries look critically at their health allocations and, crucially, how it is utilised. “We are not poor because we lack resources—we are poor because we misuse those resources,” Jaoko says. To inspire confidence in the health systems, governments must close loopholes that allow corruption and theft, he explains.
Above all, explains Ethel Makila, director for communications advocacy and policy at non-profit scientific research organisation IAVI in Kenya, politicians and policymakers must plan beyond their term in office.
“There is this thing about leaving tangible evidence or return on investment, which must be realised in your tenure,” she says. “You cannot have it if you invest in, for example, research, which is a 10-15-year project and will probably be fully realised after your term in office has elapsed, denying you your accolades.”
Makila says health advocates must persuade politicians to make longer-term decisions to fund health systems and prepare better for pandemics.
“We call it ‘touch one to touch one’—we touch one person who influences another person,” she says. “That is what we did with Rwandan President Paul Kagame as a way of spreading the vision of better health systems one person at a time.
“Just like we have TB advocates, we want to create advocates who share the vision of funding better health systems for the long term in the public’s interest.”