The COVID-19 pandemic has reinforced several truths about the detrimental effects of Africa being over-reliant on western and international stakeholders to solve its health challenges and using western solutions to Africa’s health problems.
The continent has suffered heavily from the global COVID-19 supply chain crisis. Competitive procurement by governments with deeper pockets has hiked prices of vaccines while national export controls on essential commodities and raw materials have blocked access. These effects were recently highlighted by the African Union special envoy, Strive Masiyiwa.
This is a manifestation of a much larger systemic problem. African countries rely heavily on western funding, products and approaches within their health systems. This includes preventative and diagnostic measures developed for western societies and cultures as well as interventions developed and optimised in the west. One example is the international criteria for the autoimmune disease lupus. My colleagues and I recently showed that these were set using predominantly white patients and did not capture the unique characteristics of the disease in black Africans.
Another problem is that relying on donor funding means that the funder ultimately determines the health priorities. This is one reason why many programmes in Africa focus on a single disease such as HIV. This approach allows impact evaluation and accountability. But it leads to health workers and services specialised in managing a single disease.
Africa countries need integrated health systems in which priorities and services are decided on, led and owned locally. This is the approach being advocated for by the World Health Organisation for neglected tropical diseases.
Country leadership and ownership of health systems will only come if African governments step up to the plate. And if there’s private investment. Most African countries have pledged to set a target of allocating at least 15% of their annual budget to improve their health sector. None has achieved this.
With the additional COVID-19 damage to health services in 90% of African countries, the need to prioritise health in government budget allocations has never been more urgent.
Unique health needs
The COVID-19 pandemic has illustrated how African countries have unique health needs. The continent’s population is younger, it has more infectious diseases, a larger rural population, uses both western and traditional medicine, and has cultural practices that affect disease risk.
African countries need a systemic approach targeting training, research, infrastructure, implementation and awareness programmes through the following three ways.
First, countries need to invest in training and retaining health personnel and services appropriate for their needs. Europe has about 40 doctors and 75 nurses per 10,000 people. Africa has about five doctors and 10 nurses per 10,000 people. This has meant that countries can’t rely on clinical staff for universal health coverage such as COVID-19 testing and screening.
Community health workers have become a critical part of the African health system delivering universal health coverage. They have played an important role in the COVID-19 pandemic. For example, South Africa drew on its community-orientated primary care staffed by community health workers for disease surveillance and testing.
They should be trained and rewarded appropriately to deliver other forms of interventions such as treatments for neglected tropical diseases and maternal health services.
Second, invest in and promote world-class research on African health interventions including herbal medicines and traditional healers to solve African health problems. In Zimbabwe, a novel way of providing mental health therapy is a good case in point. The country only has 17 registered psychiatrists for a population of 15 million people. A team drew on the African tradition of talking therapy that can be delivered by community health workers as an intervention for mental illness. This therapy, formalised through the Friendship Bench, was used to deliver therapy to 30,000 people in 2017.
One reason the Friendship Bench has been successful is that its effectiveness has been evaluated in clinical trials.
A significant amount of research has been conducted on herbal medicines to identify active ingredients and mechanisms of action. But most have not undergone international standard clinical trials. As a result, they are treated with suspicion and inferiority. This is a gap that needs to be filled.
But these trials should be conducted in Africa. This is because genetic, comorbidity and cultural disease risk factors in Africans differ from elsewhere.
For example, Africans are more likely to carry concurrent infectious diseases such as parasitic worms and malaria, possibly with HIV as an underlying condition. An example of different practices is that many women still prefer to deliver their babies with the help of traditional birth attendants.
In addition, the African Union should insist that drug and vaccine trials carried out in Africa meet international standards to avoid repeating historical ethical concerns. This will build trust which underlies willingness to participate in trials.
The African Union should also ensure Africans receive the full benefit from clinical trials conducted on the continent by negotiating access to the interventions before granting trial permissions.
Third, countries must create a permissive environment to support research and innovation. This includes intellectual property and medicines controls policies and competitive markets. Researchers in Africa have indicated several barriers to running clinical trials including human capacity, delays in regulatory and ethical reviews, complex logistical and financial systems, bureaucracy and opaque procedures.
The continent already has frameworks for health innovations and most countries have medicines control authorities. These should now be harmonised at the continental level through the Africa Medicines Agency to facilitate sharing of best practices and transparency. The Pharmaceutical Manufacturing Plan for Africa provides a vehicle for local pharmaceutical production, while the African Continental Free Trade Area agreement aims to make African industries more competitive on the global stage. Their implementation needs to be accelerated.
It is clear that as long as African countries don’t produce the health personnel and products Africa’s health system needs, they will be at the back of the global queue for resources produced abroad.