By Dr. Olajide Ademola (UNFPA) and Dr. Benjamin Djoudalbaye (Africa CDC)
The COVID -19 pandemic has drastically challenged and strained health systems worldwide. All components of the health delivery architecture – from human resources to physical infrastructure – have been severely tested as morbidity and mortality caseloads, unfortunately, gallop. Globally, over four million people have been infected, with about 282 244 lives lost and over one million recoveries between December 2019 and May 2020. As the pandemic continues to evolve and the numbers trickle in, we are not just learning about the fatalities and survival, but also about redefining our healthcare systems.
Western societies are experiencing the heaviest of the unprecedented effects yet they host advanced health care amenities and have established economies. A report released early March called on leaders in Africa to prepare for worse but on the contrary, the continent appears to be gradually reaping benefits of policy decisions taken some years back. For instance, the Abuja 2001 Declaration urges African governments to step up the allocation of at least 15 percent of the national budget to the improvement of the health sector. Countries that have achieved this target are also among those with the lowest COVID-19 confirmed cases: Rwanda, 280; Liberia, 199; Madagascar, 193; Togo, 153; Zambia, 252; and Malawi, 56. Moreover, there was dire concern about conflict and post-conflict countries like Somalia, the Central Africa Republic, the Democratic Republic of Congo, and South Sudan with limited capacity for large scale public health service provision. Fortunately, even such countries have shown impressive resilience against the pandemic. These outcomes go a long way in showing that when it comes to investing in health systems, it is not just about the proportion allocated, but rather the efficient use of the dedicated amount.
An additional policy decision is the establishment of the Africa Centre for Disease Control (Africa CDC). Since inception, Africa CDC has played a vital role in global health, responding to the world’s most deadly disease outbreaks and advancing critical research that promotes the health and security of communities in Africa. The institution is leading the fight against coronavirus in Africa based on the systems established and lessons garnered during the Ebola epidemic in West and Central Africa. This has enhanced the capacity of the continent to benefit from coordinated technical guidance adaptable to the socio-economic and political realities of the AU Member States. Evolution of Africa CDC led to the establishment of Regional Collaborative Centres through which Africa CDC and strengthens the capacity and capability of Africa’s public health institutions to detect and respond quickly and effectively to disease threats and outbreaks, based on data-driven interventions and programmes.
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African Union (AU) Agenda 2063 is yet another policy-related milestone contributing to the Goal 3 under Aspiration 1 of AU Agenda 2063 identifies heath as a key pillar of continental development priority. The adoption of this priority has taken place at the regional level, and continues to be embraced by AU Member States at the national level. Countries like Kenya have identified health as a key pillar in national development priorities dubbed the “Big Four Agenda”. Other components of the agenda include manufacturing, housing and food security which favorably correspond with achievement of health outcomes. Mainstreaming healthcare into national development blueprints is a discernible contributing factor to the transformation in the disease vulnerability narrative in Africa.
The pandemic is still evolving, making response challenging and largely experimental as no health system was established to anticipate the experience of responding to a highly contagious pathogen with extremely slowed down supply chain pathways and reduced contact-based service provision. In addition, the restrictions of travel within the continent have severely hampered the ability of countries to balance demand and supply of healthcare services and the Africa CDC to provide onsite, hands-on technical assistance. All the same, we must continue to reflect on what is working in different African countries, and how this can be leveraged on to improve the outcome in Africa.
Egypt, South Africa, Algeria, Morocco and Nigeria are among the top five countries having a higher infection rate in Africa, with a combined total of 24,583 cases as of 10 May 2020, which is still comparatively lower than the trends documented in a number of countries in the West. However, it is important to note that testing capacities and regimen have been varied across the continent, while being significantly much lower than those of the West. In order to catch up, the African Union Commission and the Africa Centres for Disease Control and Prevention (Africa CDC) have launched a new initiative, the Partnership to Accelerate COVID-19 Testing (PACT): Trace, Test & Track (CDC-T3). The partnership is to facilitate implementation of the Africa Joint Continental Strategy for COVID-19, endorsed by African Ministers of Health on 22 February 2020 in Addis Ababa, Ethiopia, and approved by the Bureau of the Assembly of the African Union Heads of State and Government on 26 March 2020.
Swift decisions by countries like South Africa, Rwanda and Uganda to institute stringent COVID-19 containment measures enhanced the capacity of health systems to cope. The focus in such countries has been on strengthening public health interventions, improving access to COVID-19 testing services, expansion in social protection and visible national leadership by the respective Heads of State. In the countries previously afflicted by experiences of epidemics like Ebola in West and Central Africa, already institutionalized responses to health emergencies, including at the community level. The established practices such as hand hygiene, respiratory etiquette and physical distancing as part of the public health system fairly normalized transitioning to COVID-19 measures.
Leadership by the African Union (AU) has been integral to the growing success story on a continent traditionally depicted as politically fragile, poverty stricken and disease burdened. The continental body has been emphatic on preparedness and prioritizing mechanisms to strengthen health systems for effective response to the pandemic. The AU Chairperson, President Matamela Cyril Ramaphosa, looking beyond the response into the prism of recovery and growth, appointed five Special Envoys to support the continent to stem COVID- 19. The five Special Envoys are: Ms. Ngozi Okonjo-Iweala from Nigeria, Donald Kaberuka from Rwanda, Mr. Tidjane Thiam from Cote d ́Ivoire, Mr. Trevor Manuel from South Africa and Mr. Abderrahmane Benkhalfa from Algeria. Understandably, an assertion that Africa is out of the woods with regard to the devastating effects of COVID-19 would be severely premature.
It was envisaged that countries in the low resource settings especially in Africa would be overwhelmed by the COVID-19 pandemic. For instance, a modelling concept projected that Kenya would be grappling with over 10, 000 COVID-19 positive cases and over 1,000 fatalities by end of April 2020. As of 10 May 2020, the country now has 649 COVID-19 positive cases and 30 deaths. The Chairperson of the African Union Commission (AUC), Moussa Faki Mahamat, has urged for more resource mobilization efforts, unity and responsibility. He cited the weak health infrastructure and underdeveloped technical capacities in most of the African countries as worrying.
Disparities are evident across regions and within countries. Therefore, the unique nature of social, economic and cultural experiences in Africa requires homegrown solutions to the pandemic. African governments have been cautioned against replication of COVID-19 response and mitigation models on the basis of their viability in developed countries. Falling back on south–south experiences in handling the pandemic could be more feasible. Fundamentally, though, no intervention can be copy-pasted between countries or regions.
Addressing the need for long-term sustainable and comprehensive strategies on the social determinants of health – education, housing, water, food, gender inequality, economic empowerment, is critical. That is why the African Union Member States adopted in 2016 the Africa Health Strategy (2016-2030), which provides them the strategic direction in their efforts in creating better performing health sectors, recognizes existing continental commitments and addresses key challenges facing efforts to reduce the continent’s burden of disease mainly by drawing on lessons learned and taking advantage of the existing opportunities. Its strategic directions require multi-sectoral collaboration, adequate resources along with leadership to champion its implementation and ensure effective accountability for its results.
African leadership must deliberately choose to rethink and strengthen health governance, promotion of regional integration, and broadening partnerships for health as important now more than ever before in the context of the Africa Health Strategy (2016-2030). The Africa Health Strategy (2016-2030) reinforces another continental policy framework on health such as the Sexual and Reproductive Health and Rights Continental Policy Framework and its revised Maputo Plan of Action 2016–2030. Given the demographic profile of the continent and its member states, guaranteeing sexual and reproductive health, and rights, must be an integral component of national and continental priorities. The implementation of the AU Maputo Plan of Action (MPOA 2016 – 2030) and ICPD-25 national commitments by AU States is germane.
In addition, the uncertainty about the critical need for a skilled and motivated human resource has been answered by the Covid-19 desperation. Africa must invest in growing a competent and inspired health workforce to acquire the capacity for resilience during unprecedented pandemics like COVID-19.
As Africa responds to and surmounts the COVID-19 pandemic, it must interrogate the conventional definitions and boundaries of the “health system” while taking into serious consideration what is working for the continent during this race to the eradication of the pandemic. The social fabric of societies that has served to reinforce the obvious weaknesses in health infrastructure, need to be strategically and deliberately strengthened.
A paradigm shift in health financing models in Africa is urgent – and attainable. There is need to pragmatically align the continent with the health priorities under Sustainable Development Goals and her own Agenda 2063. The continent should incline towards technological solutions that make healthcare available, accessible, affordable and inclusive while rewarding investors sustainably.
Dr. Ademola Olajide; Representative, United Nations Population Fund (UNFPA), Kenya.
Dr. Benjamin Djoudalbaye; Head, Division of Policy, Health Diplomacy and Communication, Africa CDC (and acting Head, Division of HIV, TB and Malaria, AUC).