A Mexican study has found that younger people are more vulnerable to heat, possibly because they spend more time working outside.

Some 75% of heat-related deaths occurred amongst people under the age of 35 , and one-third of such deaths were young adults between the ages of 18 to 35, according to a new study on heat mortality in Mexico.

This contradicts previous assumptions that the elderly are the most vulnerable to heat.

“We project, as the climate warms, heat-related deaths are going to go up, and the young will suffer the most,” said R. Daniel Bressler, a PhD candidate in Columbia’s Sustainable Development program and co-lead author of the study, published in Science Advances.

“It’s a surprise. These are physiologically the most robust people in the population,” said the study’s co-author Jeffrey Shrader  from the Center for Environmental Economics and Policy, an affiliate of Columbia University’s Climate School in New York City. “I would love to know why this is so.”

The researchers speculate that several factors may be at work. Young adults are more likely to be engaged in outdoor labour including farming and construction, and thus more exposed to dehydration and heat stroke. Young adults are also more likely to participate in strenuous outdoor sports, the researchers pointed out.

Infants and children under the age of five are also particularly vulnerable to heat as their bodies are not yet efficient in regulating temperature. Deaths of infants and young children, together with those aged 18-35, made for 75% of all heat-related deaths.

Meanwhile, people in the 50 to 70 age bracket suffered the least amount of heat-related mortality to the surprise of researchers.

Using the same daily temperature and mortality data, the researchers found that elderly people were at a higher risk of dying from modest cold, as compared to heat, at least in the Mexican context. Mexico is mainly tropical and subtropical country, but it has many climate zones including high-elevation areas that can get relatively chilly.

Younger people do most manual, outdoor labour

The new study has global implications, said the team of researchers, who along with Shrader, are mostly affiliated with Columbia, as well as Boston University, Stanford and the University of California. Many poor, hot countries, mainly in Africa and Asia, have young populations, with a large proportion working in manual and outdoor labour.

The retrospective analysis assessed heat-related deaths over a twenty-year period, from 1998 to 2019. For individuals under 35, heat causes 2.6 times more deaths than cold whereas for individuals 35 and older, cold causes 56 times more deaths than heat.

Children under five, especially infants, also had a disproportionate number of heat-related deaths, although not as large. Overall, people under 35 years accounted for 75% of historical, heat-related deaths, the researchers found.

Historical and projected annual deaths due to heat and cold exposure by age group in Mexico. Among adults, people aged 18-35 had by far the highest risk of death from heat exposure (top), with infants and children under 5 close behind.

A previous separate analysis by primarily Mexican researchers showed that death certificates of working-age men were also more likely to list extreme weather as a cause than those of other groups.

“These are the more junior people, low on the totem pole, who probably do the lion’s share of hard work, with inflexible work arrangements,” said Shrader.

The vulnerability of infants and small children came as somewhat less of a surprise. It is already known that their bodies absorb heat quickly, and their ability to sweat, and therefore cool off, is not fully developed. So exposure to temperatures that exceed their body temperature can be rapidly fatal.

Their immune systems are also still developing, which put them at higher risk of ailments that become more common with humid heat, including vector-borne and diarrhoeal diseases.

The researchers reached their conclusions by correlating excess mortality or the number of deaths above or below the average, with average temperatures in the same period, on the “wet-bulb scale” that reflects he magnified effects of heat when combined with high levels of humidity.

Despite being based mostly in the USA, the researchers y chose Mexico for the study because it collects highly granular geographical data on both mortality and daily temperatures.

Older people more likely to die of cold

Older people tend to have lower core temperatures, making them more sensitive to cold. In response, they may be prone to staying indoors, where infectious diseases spread more easily.

Despite all the attention given to the dangers of global warming, other extensive research has generally suggested that to date, excessive cold exposures, not heat, are currently the world’s number one cause of temperature-related mortality, including in Mexico. However, the proportion of heat-related deaths has been climbing since at least 2000, and this trend is expected to continue.

Around 4.1 billion people or roughly half the world’s population has experienced unusually hot temperatures between June and August this year, according to a report from US-based non-profit Climate Central.

Deaths occurred at lower-than-expected heat levels

There is a widespread recognition that temperatures alone are not a good measure of the impact of heat but “wet bulb temperatures” that also factors in humidity, are. Essentially, the same temperature level in conditions of high humidity is more dangerous than at low-humidity because humid conditions reduce the absorption of sweat, which cools off the body.

Wet bulb temperatures are often referred to as the “real-feel” heat indexes where numbers can vary depending on the exact combination of heat and humidity.

Previous research has suggested that workers begin to struggle when wet-bulb temperatures reach about 27°C, which would equate to 86 to 105°F, depending on humidity. However, the new study found that the largest number of deaths occurred at wet-bulb temperatures of just 23 or 24°C, in part because those temperatures occurred far more frequently than higher ones, and thus cumulatively exposed more people to dangerous conditions.

A study published last year showed that farm workers in many poor countries are already planting and harvesting amid increasingly oppressive heat and humidity.

Bressler, the report’s lead author, said the team is now looking to firm up its conclusions by expanding its research into other countries, including the United States and Brazil.

Image Credits: Unsplash, Study: Heat disproportionately kills young people: Evidence from wet-bulb temperature in Mexico.

The International Court of Justice in the Hague heard arguments from the WHO Director-General on Friday in a landmark case on climate justice.

Climate change poses an immediate and catastrophic threat to human health worldwide, the World Health Organization (WHO) chief warned the UN’s highest court on Friday as it considers a landmark case that could establish fresh legal obligations for nations to cut emissions and pay for climate damages.

WHO director-general Dr Tedros Adhanom Ghebreyesus testified to the International Court of Justice (ICJ) that climate change is “fundamentally a health crisis” that is already “wreaking havoc” on human health, societies, economies, and overwhelming healthcare systems worldwide.

The case, brought by the Pacific island nation of Vanuatu, represents the largest in ICJ history, with nearly 100 countries and organizations participating. While the court’s advisory opinion, expected next year, will not be binding, legal experts say the ruling could strengthen climate litigation worldwide. For small island nations, the stakes are existential – climate models predict many will disappear beneath Pacific waters without dramatic cuts to global emissions.

“The climate crisis is among the most significant health challenges facing humanity today,” Tedros told the court. “It is not a hypothetical crisis in the future. It is here and now. Without immediate action, climate-related increases in disease prevalence, destruction of health infrastructure, and growing societal burdens could overwhelm already over-burdened health systems around the world.”

The UN health chief highlighted how climate change is already altering disease transmission patterns for infections like malaria, dengue and cholera, while extreme weather events are destroying health infrastructure and claiming thousands of lives. Tedros also emphasized that noncommunicable diseases, including cancers and cardiovascular conditions, are linked to climate change and air pollution.

An estimated 920 million children currently face water scarcity, a situation he warned would worsen as climate change intensifies droughts and contaminates water supplies. Rising temperatures are also increasing heat-related deaths and illnesses. Tedros further articulated fears of massive population displacement and projected that over 130 million people could be pushed into extreme poverty by 2030, with devastating impacts on health.

“Millions are expected to be pushed into poverty. This will dramatically increase health burdens and disparities,” he said. “Not enough is being done…to avoid the most catastrophic impacts related to climate change.”

‘Health at the centre’

Iririki Island, Vanuatu.

The WHO chief criticised “massive fossil fuel subsidies,” citing International Monetary Fund projections that appropriate fossil fuel pricing that includes health and environmental costs could prevent 1.2 million air pollution deaths annually. The UN health agency estimated last month ahead of COP29 in Baku meeting climate targets could save two million lives a year.

“The value of health improvements from mitigation significantly outweighs the costs,” Tedros said. “The failure to respond to climate change is undoubtedly the most costly approach.”

WHO’s chief legal counsel Derek Walton urged the court to place health considerations at the center of its advisory opinion, emphasizing that “science and technical evidence should be at the heart of the court’s consideration.”

“WHO respectfully requests the court to place health at the center of its advisory opinion, and in this regard, to give full effect to the fundamental right of every human being to the highest attainable standard of health,” Walton said.

Walton further cited precedents in ICJ rulings that consider health as a human right, pointing to the court’s 1996 ruling on nuclear weapons.

“As the court stated nearly three decades ago in its advisory opinion on nuclear weapons, the environment is not an abstraction, but represents the living space, the quality of life and the very health of Human beings, including generations unborn,” Walton said. “We respectfully ask you to allow the science and the technical evidence to guide your analysis.”

Out of the COPs and to the courts

COP 29 in Baku, Azerbaijan

The proceedings come just weeks after December’s UN climate summit in Baku ended without meaningful commitments on emissions cuts or climate finance, even as global carbon dioxide emissions hit record highs and 2024 is confirmed as the hottest year on record.

Throughout the two-week proceedings in the Hague, which concluded on Friday, major emitters pushed back against the ICJ’s jurisdiction in the case. China urged the court to defer to existing UN climate mechanisms as “the primary channel for global climate governance,” while Saudi Arabia insisted national climate pledges represent only “an obligation of best efforts, not of results.” The United States and several EU members similarly argued existing treaties should be sufficient.

Low-lying islands, several of which called the outcome at COP29 a death sentence, argued the failure of current UN climate instruments is precisely why this case is before the court.

“We’ve heard much about the Paris Agreement as being the solution, but the reason why the climate-vulnerable states have come before the court is that the Paris Agreement has failed,” said Payam Akhavan, counsel for small island states, pointing to projections of 3.1C warming by century’s end.

Small islands represent just 1% of the global population, economy and emissions, but face existential threats from rising seas. In his remarks, Tedros recounted meeting a boy, Falou, on the island of Tuvalu five years ago who shared discussions with friends about what they would do if their island disappeared.

“They worry about the survival of their island homes due to the emissions produced by distant nations,” he said. “This reality weighs heavily on their young shoulders.”

Falou’s island home is projected to be the first nation to disappear beneath the waves. “Tuvalu will not go quietly into the rising sea,” its representative Philippa Webb told the court on Friday.

The court’s opinion, which small island states and developing countries hope to leverage in climate lawsuits worldwide, is expected in 2025. Though not legally binding, the ruling will carry significant moral and legal weight, legal experts say.

“States’ long-standing duties to prevent transboundary environmental harm and human rights violations, including from climate change, did not begin with the UNFCCC or the Paris Agreement, and they do not end with any COP deal,” said Nikki Reisch, director of the Climate and Energy Program at the Center for International Environmental Law (CIEL).

“The ICJ can and must make clear that when States breach their climate obligations, and harm ensues — as it so evidently has — they must right the wrongs,” Reisch said.

Kathmandu has introduced air sensors to monitor pollution.

More than one-third of countries worldwide lack government-level air quality monitoring, leaving nearly one billion people in the dark about one of the greatest risks to their health, a new report showed on Friday.

The assessment by non-profit OpenAQ, which maintains the largest open-source database of air quality measurements, found significant gaps in government tracking and sharing of air quality data, particularly in low and middle-income countries. The biennial report is the only global assessment of whether and how national governments are producing and sharing air quality data with the public.

Thirty-six per cent of countries provide no government monitoring of air quality, with 90% of people in nations without monitoring programs living in low and lower-middle-income countries, where the World Health Organization (WHO) says higher pollution levels and disease rates make populations especially vulnerable. A further 9% of countries do collect government air quality data but do not share it publicly, widening the gap of public access to this critical health threat even further.

Air pollution ranks as a leading cause of death and disability in all the most populated countries without monitoring, including the Democratic Republic of Congo, Tanzania, Afghanistan and Iran. Progress in expanding monitoring remains slow, with only a 3% increase in countries conducting national or subnational air quality monitoring since 2022.

“In order to deliver clean air for all, governments need to not only track air quality, but also offer an accessible, quality data set,” said Dr Colleen Rosales, OpenAQ’s Strategic Partnership Director. “Billions of people do not know what they are breathing and could benefit from greater data transparency.”

Air pollution, mainly from fossil fuel emissions, kills more than eight million people annually and costs over $8 trillion worldwide, making it the largest environmental health risk. Its impact on life expectancy matches that of smoking and exceeds that of alcohol use, transport injuries and HIV/AIDS.

Exposure to pollutants in the air affects health from birth, causing respiratory diseases, cardiovascular problems and developmental issues, with babies, young children and low-income communities facing the greatest risks. WHO data shows 99% of people worldwide breathe unhealthy air every day.

Transparent data would benefit billions 

While NGOs, academic institutions and private companies monitor air quality, government data provides unique value through continuous, comprehensive measurements. Unlike time-limited studies, government monitoring tracks a wider range of pollutants, supporting regulatory compliance, legal proceedings, health research, pollution tracking and air quality forecasting.

Only 55% of governments share their air quality data publicly, with just 27% providing it in a fully transparent and accessible format, the report found. Countries facing major air pollution crises that continue to lack transparency include China, Russia, India, Pakistan, and seven other major nations with populations of at least 70 million people.

“While many populous countries have partially shared their air quality data, an increase in transparency could benefit over 4.5 billion people,” the report said. “Barely over one-quarter of countries provide full and easy public access to data detailed enough to inform scientific inquiry and pollution reduction policies.”

Air Quality Indexes (AQI) vary widely between countries, leading to inconsistent messaging to the public about the risks of pollution levels.

Countries lacking transparent reporting frequently rely on Air Quality Index (AQI) systems that vary widely between nations, often triggering different health warnings for the same pollution levels and confusing communication with the public. While these help with daily decision-making, they lack the detailed measurements scientists and policymakers need for research and regulation.

India and Pakistan illustrate the data transparency challenges, even as their cities rank among the world’s most polluted. Both countries share air quality data only in “static, non-machine-readable formats” like PDFs and graphics rather than analysable datasets, the report said. Last month, Delhi suspended schools and construction as pollution reached twenty times WHO’s safe limit, while Lahore recorded its highest-ever levels. The severity of the crisis has forced long-time rivals toward cooperation, with Pakistan’s Punjab province seeking unprecedented talks with India.

“Although sharing data as a PDF or graphic is a good first step, when data are provided in a machine-readable, analysis-ready and standardized form, many more use cases—and ultimately, impact—can be derived from the data,” the report found. “In the quest for clean air for all, we appeal to all governments to offer data-transparent air quality monitoring versus only the 27% that do so today.”

Some nations have made progress, with 30 countries improving their monitoring or transparency since 2022. Eleven countries, including Japan, Italy and Kenya, achieved full transparency in that period.

Barriers to monitoring

Three-wheelers trapped in smog in Lahore, Pakistan in late November, 2024

Nearly one billion people live in countries without air quality monitoring, but government inaction isn’t always the cause. Many nations, particularly low- and middle-income countries, lack the financing and technical expertise to implement monitoring systems. A 2022 Clean Air Fund survey found one-third of 119 countries could not establish monitoring networks due to these constraints.

The report suggests increased investment could quickly expand monitoring, but funding remains scarce. Only 0.5% of development aid and 0.1% of philanthropic funding targets clean air initiatives. Health programs linked to climate change – a key driver of mounting air pollution deaths – receive just 2% of adaptation funds and 0.5% of multilateral climate funding.

War and civil conflict have also disrupted monitoring efforts. Air quality monitoring systems have collapsed amid wars in Ukraine and Palestine, while ongoing civil conflict in Sudan has prevented any progress on building air surveillance infrastructure.

Beyond disrupting measurement systems, warfare itself creates severe pollution. Millions of bullets, grenades, bombs and missiles detonated in Ukraine during Russia’s ongoing assault led to an abrupt spike in air pollution across Europe, with around a 10% increase in harmful pollutants such as PM2.5 and NO2 in cities near the fighting.

The health impacts of air pollution in war zones are also likely underestimated, according to research from the International Union Against Tuberculosis and Lung Disease. Even small increases in pollutants significantly raise hospitalization risks for cardiovascular and respiratory conditions, while war zones face multiple simultaneous pollution sources and populations under extreme stress, weakening their response to environmental hazards.

“In a war zone, air pollution is likely to result in more deaths than bombs,” the Union found.

Image Credits: Partnership for Health Cities.

Members of the trade union, PSLink, protesting outside the Philippines Supreme Court. The union petitoned the court to win increases for nurses.

Countries are most likely to have laws about health workers’ pay and least likely to provide them with mental health services and protection against discrimination.

There is also little correlation between a country’s wealth and the protection it offers its health workers.

These are some of the findings of a study of over 1,200 laws relating to health and care workers from 182 countries led by the O’Neill Institute for National and International Health Law and the World Health Organization (WHO).

Researchers examined the countries’ laws to see how well they aligned with the Global Health and Care Worker Compact adopted by the World Health Assembly in 2021.

The Compact was introduced to provide countries with guidelines to protect their health and care workers – a response both to the huge price health workers paid during COVID-19 and the growing shortages of health workers.

Over 115,000 health workers were estimated to have died from the virus by the time the Compact was adopted, while there is a global shortage of over 10 million health workers.

Significant gaps

The research identifies key areas where governments can use law and policy to safeguard health workers’ rights, promote and ensure decent work free from discrimination, and a safe and enabling working environment.

Around 62% of the laws were aligned with the Compact, according to Matt Kavanagh, Director of the Center for Global Health Policy and Politics at the O’Neill Institute.

“Our analysis shows significant gaps. Nearly every country has multiple areas where national laws are not yet aligned with the Care Compact, although alignment is feasible,” Kavanagh told a media briefing on Tuesday. 

The findings were published in Plos Global Health on Monday and details about the countries’ laws are available on a dedicated website that will serve as a baseline 

“While 69% of countries have some form of health services guaranteed for health workers, only 20% of those ensure that mental health and well-being are covered,” Kavanagh noted.  Twelve percent of countries had zero provision for health for healthcare workers.

“This analysis highlights the need for, and opportunity of, law reform in countries throughout the world to elevate and protect the rights and well-being of health and care workers and, in doing so, improve health systems,” noted Kavanagh.

With 105 countries aligned to half of more of the Compact’s recommendations, Kavanagh  described the report as “half-full”.

“Law reform is a key piece of what might drive us toward better retention and better effectiveness of our health and care workforces.”

One of th biggest gaps is that community health workers are usually not protected and often do not earn even the minimum wage.

Speakers at the launch of research on the protection of healthworkers (L to R): Atul Gawande, Matt Kavanagh, Catherine Kane (moderator), Laetitia Rispel, Jillian Roque and Jim Campbell

Health workers ‘are the health system’

Dr Atul Gawande, Assistant Administrator for Global Health at USAID, described the research as “transformative” as it provides both a baseline for countries to assess themselves against the Compact as well as the capacity to track progress.

“When we are talking about plans for strengthening systems, what we’re really talking about are plans for strengthening health workers. ‘Systems’ is abstract. Health workers are the system,” said Gawande. USAID assisted in funding the research.

Jim Campbell, Director of the WHO’s Health Workforce department, said the research marked a move “beyond political will into evidence-based policy”.

“Health systems are under huge challenges – population, ageing, conflict, humanitarian disasters, climate disasters. These are being transferred to the health and care workers worldwide,” he added.

With an estimated shortage of around 11 million health workers, “health systems will not have the capacity to respond to the demand, transferring a burden onto the workers that we seek to protect,” said Campbell.

“The first action has to be to invest in today’s workforce to seek those protections.”

Sub-optimal working conditions

Professor Laetitia Rispel from the School of Public Health at the University of the Witwatersrand in South Africa noted that slightly more than half of African countries had laws aligned with the Compact.

Yet Africa is going to be one of the worst affected by health worker shortages, Rispel noted.

“Sub-optimal working conditions, which are often most acute in the region, often serve as a push factor for health workers to migrate,” she warned.

Trade unionist Jillian Roque, Chief of Staff at the Public Services Labor Independent Confederation (PSLink) in the Philippines, also decried the “persistent gaps” in the protection of healthcare workers’ rights.

“In many areas, public health care workers are denied their fundamental rights to freedom of association and collective bargaining,” Roque said.

PSLink is part of the global federation of public sector workers, Public Services International (PS), which is fighting for “fair pay, decent work, equality and non-discrimination” through organising unions, said Roque. 

In the Philippines, unionists have been killed, harassed and “red-tagged” [labelled as communists], making it one of the 10 worst countries for workers in the world, she added.

Despite this, PSLink has successfully ensured the ratification of important conventions on occupational health and safety, the elimination of violence and harassment in the workplace and compelled the government to raise the salaries of nurses after filing a petition at the Supreme Court. 

Campbell noted that two-thirds of the global health workforce (67%) is women and this is often linked to the lack of protections.

Image Credits: Sophie Mautle/HeDPAC , PSLink.

Purchasing drugs at a pharmacy in Johannesburg, South Africa, in May 2020; out of pocket health expenses have soared in many low- and middle-income countries.

After an early surge of spending during the COVID pandemic, public health layouts by countries at all income levels declined in 2022, on average, as compared to 2021.

Meanwhile, there was a 60% increase overall in per-capita health expenditures between 2000 and 2022 – but in low income countries this was largely driven by a sharp rise in out-of-pocket spending (OOP), according to WHO’s 2024 report on global health expenditures, released on the eve of Universal Health Coverage Day, 12 December.  

In low income countries, public spending on health has in fact stagnated since the turn of the millennium, with governments de-prioritizing health spending in national budgets while international donor aid made up for an increasing share of the shortfall. 

40 x 40: Only 40% of spending covered with just $40 per person by public health authorities

By the end of 2022, as countries emerged from the COVID pandemic, out-of-pocket spending, per capita, in low-income countries stood at slightly more than 40% of health expenditures. And  overall spending averaged $40 per person annually – less than half of the minimal baseline WHO estimates is needed to run a health care system. 

Per capita health spending all sources – grew but not always for the right reasons.

The report emphasizes the urgent need for increased domestic health spending to meet  2030 Universal Health Coverage goals, said WHO’s Director General Dr Tedros Adhanom Ghebreyesus in a launch of the report this week at WHO’s Geneva Headquarters. 

“Between 2000 and 2022 global spending per capita grew by more than 60% outpacing GDP,” Tedros said. 

On the plus side, that increase is critically correlated with significant improvements in life expectancy, including lower maternal and child mortality. But there is a big minus as well: 

 “Over the same period, governments in low income countries consistently deprioritized health in national budgets,” Tedros observed. “So while the increase in health spending is welcome, the trends in the sources of that spending are concerning…. Out of pocket health spending is the most inequitable type of spending, while aid is volatile and dependency is a major issue for low income countries. 

“Increasing domestic health spending must therefore be a policy priority for all countries to reduce financial hardship caused by out of pocket spending and aid reliance.”

Report accompanied by launch of the world’s largest global health spending database 

Dr Tedros Adhanom Ghebreyesus – spending trends pose obstacle to UHC.

The report’s publication coincided with the launch of a new WHO global health expenditure  database – also marking 25 years since WHO began tracking health finance systematically.  

Billed as “the world’s largest global health spending database,” it covers spending by more than 190 countries since the year 2000, covering health expenditures by governments, donors and households. 

“These products are not just numbers,” Tedros stressed.  “They are used widely by governments, development partners, international organizations, academia and civil society to monitor financial trends, to assess equity and efficiency in health spending and to guide evidence based health financing decisions nationally and globally. 

“This is especially important in a time of increasingly tight budgets with many competing demands.”

Insights into how countries responded to the COVID pandemic – and afterwards

Post-pandemic decline in spending seen in countries of all income levels.

While most countries increased public health spending for a while during the pandemic, the across-the-board decline seen as countries emerged from COVID, reflects a worrisome trend, he added. This is particularly in light of the big gap between present day spending and the aims of the 2030 Sustainable Development goal for UHC. 

“In 2022, domestic public health spending per capita actually decreased for the first time since 2010,” Tedros observed, “Although it did increase significantly during the COVID 19 pandemic, it’s too soon to tell which direction spending on health will go. It could return to pre pandemic levels, or it could continue on a declining trend, putting us even further off track. 

“We therefore are at a time of uncertainty as countries emerge from the pandemic. Enormous challenges remain.” 

Among those, about one half of the world’s population still lacks access to one or more essential UHC services, such as primary health care. And over two billion people face financial hardship due to out-of pocket spending strains. 

In many low-income countries, public health spending is a fraction of minimum health system needs

Kalipso Chalkidou, WHO

In 42 low-income countries, mainly in Africa and South Asia, domestic public spending, per capita, on health remains below $30 per person per year, pointed out Kalipso Chalkidou, Director of WHO’s Department on Health Financing and Economics. 

“And that’s way lower than the $80 to $90 that we estimate is needed to support necessary workforce and essential commodities in low income countries,” she said. 

In some 35 low- and lower-middle income countries government health spending, or the share of government budget allocated to health, actually declined during the COVID-19 pandemic response and recovery of 2019-2023, the report also points out.

“Gandhi said that it’s not just words, but actions that express priorities,” Chalkidou said. “These are not just numbers, and the time for action is now.” 

Gap between low income countries and everyone else is growing larger 

WHO’s Xu Ke: Public health expenditure (blue line)  stagnated, while donor aid (green) rose and out of pocket spending (red line) grew fastest in the poorest countries.

“Government spending from domestic sources is absolutely essential for moving towards UHC,” added Ke Xu, senior health finance analyst, who led the work on the 2024 report, “Out of pocket payments are the most inequitable way to finance health services.”

And the gap between overall spending in low income countries and all other nations is only growing. 

Between 2000 and 2022, overall spending on health in low-income countries – from out of pocket, public and donor sources, grew from about $25 to about $30 on average.

“But even that is lower than what lower-middle income countries spent on health 20 years ago,” she pointed out. “So you can see the magnitude of the differences across income level. 

Out of pocket spending increased less, in upper and high income countries, as compared to middle and low-income ones.

“And in upper middle income countries, we’re now around $600 per capita, while in high income countries spending is about $3000 per person. So it’s not difficult to imagine the differences in the countries across income levels, in terms of the availability of the services, the quality of the services, and also the financial accessibility of the services.”  

While in lower income countries, out-of-pocket spending represents the biggest part of national health expenditures, in all other income groups, public spending by the government plays the leading role.

Out of pocket spending also increased significantly in lower-middle income countries, while more gradually in upper middle-income ones. It is in the high income countries, therefore, where financing trends are healthiest, with out of pocket spending almost flat over the past 20 years.

“In the high income countries, it is very clearly, is the domestic government spending that has driven all the [spending], while the out of pocket (OOP) is very stable and at the lower level,” Ke said. 

Interest in tracking health spending grew over time 

Health finance reporting developed over past several decades.

While tracking patterns of health spending is a critical core task at WHO today, it wasn’t always that way. 

It was only in the 1980s that the Organization of Economic Cooperation and Development (OECD) first began to consolidate and report on member states’ health spending at annual meetings. 

In 1993, the World Bank’s publication of the a milestone World Development Report ‘Investing in Health’, sharpened interest in the issue, underlining the importance of public health expenditure  to development overall. 

In 1999, WHO established its health finance program. But it wasn’t until 2011 that WHO’s first global health expenditure database was published, with the inaugural health expenditure report published in 2017.  Overtime, the scope and scale of the data has been expanded in collaboration with countries and other partners, Ke said, with primary health care indicators first added in 2018. In 2022, data on vaccine spending was added, reflecting the concerns raised by the pandemic with access. 

“Data matters, because data drives transparency. “It’s important for equity purposes, because that’s the only way we can see who’s left behind – who is benefiting and who is not from the investments, and also we can understand who’s bearing the growing burden of out-of-pocket expenses,” Chalkidou said.

In 2022 and 2023, the issue was also the focus of a series of Future of Global Health Initiatives consultations, led by Kenya and Norway. The consultations, involving several dozen countries, bilateral and international partner agencies, culminated in a meeting in Zambia in November 2023, with a “Lusaka Agenda” etching a way forward to strengthen domestic public health spending in low-income countries.

Adding spending data on emergency preparedness, pharma spending and more 

Pharmaceutical spending can drive out-of-pocket health costs for households which lack insurance, or have plans that fail to cover drug costs.

The WHO data repository is expected to continue growing, Chalkidou said, citing national budget data as one planned feature: “to see how countries do or do not execute this budget [in their spending].” 

Spending on emergency preparedness and response, is another expanding point of interest, Chalkidou noted, to help track how countries are planning for possible future pandemics. 

“We’re also working to improve the tracking of primary health care spending,” she added. “The latest data from OECD shows a reduction in spending on WASH and on primary health care – whilst at the same time, ODA (overseas development aid) has been growing towards pandemic preparedness and response. But these are really unacceptable trade-offs.” 

“Finally, we’re keen to do more and better tracking of pharmaceutical spending, because we know that spending on drugs is driving out of pocket spending and poverty in many places.”

Ensuring countries routinely capture spending data efficiently

More systematic data collection on health spending by countries is critical to tracking gaps and challenges.

The WHO thrust also aims to push countries to routinely collect, and efficiently report on their own health expenditure data – rather than relying upon donors or multilateral agencies to perform that task on their behalf. 

“We want to move away from expensive, manual, retrospective and consultant-led, data extraction exercises, more to routine, prospective and automated solutions,” Chaldikou said.

“Where we can, we want to work with countries to integrate financial information with health data and link to financial management information systems.

“These systems are used by the Ministries of Finance to routinely capture budgets and expenditures in the standard format, typically aligned to countries on accounting standards,” she pointed out – although the same processes and standards are not always are not always used in health ministries’ own accountancy. 

“We need sustainable investments by WHO, by partners and by member states themselves to institutionalize these processes.”

Forthcoming WHA resolution by Nigeria on health finance aims to raise ambition

Victor Nwaoba Itumo: Nigeria’s WHA resolution aims to raise ambition on health spending.

While the threat to low-income families from out-of-pocket spending is obvious, the gap between insurance coverage and healthcare costs can be a threat to financial stability even in higher income countries and households, observed Victor Nwaoba Itumo, Minister at Nigeria’s UN Mission in Geneva. 

“Countries need to do more when it has to do with health financing,” he said. “In the most advanced global economies, the cost of health [services] for households is on the high side.  Even the middle class in most societies find there’s a threat to their finances due to health challenges.”

With that in mind, Nigeria is leading the development of a new World Health Assembly resolution on health finance, due to be presented at the May 2025 meeting, which will appeal to countries and international partners to increase health spending.

It remains to be seen exactly what targets WHA member states might agree to support on domestic outlays, if any. A 2019 report by WHO recommended that at least 1% of GDP should be spent on primary health care, a target recalled in the September 2023 UN High Level Declaration on UHC. Other WHO and expert assessments have cited a figure of 5% of GDP as a better goal for overall public health expenditures. Internally, some professionals question the extent to which one-size-fits-all targets negotiated at WHA can in fact usefully motivate action – or not. 

“There are three major areas, relating to solutions being tabled by Nigeria,” Itumo said of the draft resolution. Those include provisions for: “strengthening and providing some support for health financing of households within countries; for what countries can do at international level together to make sure they create support for health financing; and what multilateral institutions, including financial institutions, can do to support health finance.”  

Building up other parts of the health ecosystems, such as domestic R&D and medicines manufacture, can also make healthcare more affordable while supporting development, he added.  

Can’t achieve UHC by 2030 without addressing these trends

Bruce Aylward, Assistant Director General for UHC.

“We’ve said public health spending is a priority, but government spend isn’t showing that,” said Bruce Aylward, Assistant Director General for WHO’s UHC Division, of the report’s findings.

“Domestic spending in low income countries is flat and stagnant – that’s hugely alarming in the current environment. And …out-of-pocket spending is going the wrong direction.

Health- it’s on the government – is the theme of this year’s UHC day.

“We cannot achieve UHC by 2030 without addressing these things. And as we look forward, we also face three big challenges: economic headwinds are going to be worse for countries for this next period. The debt burden – debt servicing burden – is huge. Some 3 billion people live in countries where they’re spending more on debt than they are on these kind of [health] services, which are crucial.

“And of course, there are other priorities emerging post pandemic for countries. So what are we going to do with this report? Well, the very first thing who is going to do is act on it, and we’re hoping all member states, all partners, will do the same thing. On UHC day [Thursday], the theme this year is ‘Health- it’s on the government’ and that’s a wonderful theme.”

–Updated 25.12.2024 

Image Credits: WHO Global Health Expenditure Database0, Health Policy Watch , WHO Global Health Expenditure Repository, WHO GLobal Health Expenditure Data Repository, HP Watch, Flickr: SteFou!, HP Watch , WHO.

A Ghanaian child receives a  malaria vaccine, which has been credited with reducing deaths in children since its introduction.

New WHO Global Malaria Report points to funding shortfalls, climate change, and antimicrobial resistance as key challenges to control.

Last year saw 263 million new malaria cases and 597,000 deaths in 83 countries worldwide, an increase of almost 11 million cases from the prior year, according to the World Health Organization’s (WHO) newly-released Global Malaria Report. The vast majority of cases occurred in the African continent, with children under five bearing the greatest burden of malaria mortality. 

Targeted interventions like insecticide-treated bed nets and integrated vector management, alongside factors such as improved nutrition, housing, and urbanization, have all reduced malaria transmission and disease in the past decades. More than 177 million cases and 1 million deaths were averted globally in 2023, and Egypt was declared malaria free, a significant milestone for Africa’s third-most populous country, according to the WHO.

Yet despite progress made in reducing the spread of the ancient disease, challenges like climate change, humanitarian crises, drug resistance, and persistent disparities all threaten global malaria progress. 

“Instead of dying, mosquitoes are dancing on the treated bed nets,” said Dr Michael Charles, CEO of RBM Partnership to End Malaria, referring to the growing number of mosquitoes resistant to commonly-used insecticides. 

Malaria burden per country in 2023

The number of new malaria cases actually increased in the past years, the report notes. Malaria case incidence – the number of new cases while accounting for population growth – grew from 58 to 60.4 cases per 1000 between 2015 and 2023. Five countries accounted for the majority of this increase in cases: Ethiopia (+4.5M), Madagascar (+2.7M), Pakistan (+1.6M), Nigeria (+1.4M) and Democratic Republic of Congo (600K). 

The WHO presented its newly-released report on the global state of malaria as a combination of both hard-fought victories, and obstinate and emerging challenges ahead of key replenishment rounds next year.

“No one should die of malaria; yet the disease continues to disproportionately harm people living in the African region, especially young children and pregnant women,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

“An expanded package of lifesaving tools now offers better protection against the disease, but stepped-up investments and action in high-burden African countries are needed to curb the threat.”

 

Africa ‘not on pace’ to meet WHO target

The Africa region bears the brunt of the global malaria burden – both in the number of cases and deaths – with 11 countries accounting for two-thirds of cases worldwide. Nearly half of these deaths occurred in just four countries: Nigeria (30.9%), Democratic Republic of the Congo (11.3%), Niger (5.9%), and United Republic of Tanzania (4.3%). 

Over 75% of deaths in the African region were among children under the age of five. Progress to reduce malaria mortality has barely budged in the past decade. The 2023 malaria mortality rate of 13.7 deaths per 100,000 people at risk was more than twice the WHO global strategy target of 5.5. 

While these rates remain high, many African countries have either stabilized or reduced their mortality rates. Dr Mary Hamel, WHO Team Lead for Malaria Vaccines, credits this to vaccinations for children in conjunction with bed nets and other interventions. 

“The vaccine is recommended by the WHO from five months of age, and during the pilot implementations where the governments of Ghana, Kenya, and Malawi introduced the vaccine …we saw high impact from these young age periods, with reduction in all cause mortality in these young children by 13% in all cause mortality.”

Seventeen countries have since introduced the malaria vaccine alongside childhood immunizations, with supply so far sufficient to meet demand.

WHO goals for malaria mortality rates (green) and projected rates under the status quo (blue).

Climate change, conflict, biological threats undermine progress

The many climate change-related disruptions in rising temperatures and changing weather patterns favor the quick-adapting and anthropophilic mosquito species that transmit malaria. The report warns that these changes are impacting the “health, security, and livelihoods of people around the world,” particularly in the hardest hit African region. 

But climate change is threatening malaria control in other parts of the world, like Pakistan. The devastating floods that submerged a third of the country in 2022 also left pools of standing water – “ideal breeding grounds for mosquitoes” and leading to an 8-fold increase in malaria cases between 2021 and 2023, the report notes.

Cases rose from about half a million to more than four million. The increasing frequency of extreme weather events is expected to increase the burden of malaria in the long term, especially because the mosquitoes that transmit malaria are “highly sensitive” to environmental changes, noted Dr Arnaud Le Menach, Unit Head, Strategic Information for Response, WHO Global Malaria Progamme. 

Conflict and ensuing humanitarian crises are impeding efforts to curb malaria. “In some countries, their conflict is also stopping people from getting the needed health access and the needed commodities,” said Charles. Internally displaced peoples often lack access to malaria prevention and treatment, leaving them “highly vulnerable to the disease,” said Le Menach. The report highlights these additional drivers of malaria transmission, noting that more than 80 million people in malaria-affected countries are internally displaced or refugees in 2023.

Biological threats in the form of resistant mosquitoes and antimicrobial resistance make it increasingly difficult to control vectors and treat patients. Resistance to pyrethroids, a common insecticide, was reported in nearly every country it was monitored, while resistance to artemisinin, the most effective malaria treatment, was reported in four African countries. 

Better global, regional, and country coordination is a key solution, according to Charles, to bring together stakeholders. This includes involving civil society organizations and resource optimization to overcome the above challenges. 

Reaching vulnerable populations

The global report features for the first time highlights the significant disparities in malaria burden, with a particular emphasis on gender equality.

“[W]e need to keep in mind the issue of poverty, poverty being a significant risk factor,” said Alia El-Yassir, director of the WHO Department for Gender Equality. “Malaria takes the heaviest toll on those who are poorest and are the most disenfranchised segments of a society. The data shows that children under the age of five who are living in low income households have the highest prevalence of malaria, and as their socioeconomic status improves, the risk of malaria and the prevalence will decrease.”

A host of biological, environmental, social, structural, and economic factors converge to increase a person’s vulnerability to malaria, “disproportionately” impacting those living in poverty, refugees, migrants, and indigenous peoples, notes the report.

“Poverty is very much gendered…gender norms become so deeply entrenched and institutionalized that they will place many women and girls at a disadvantage, and that affects their risk of malaria and also their access to treatment,” said El-Yassir. To address these challenges, the report urges health system strengthening to collect disaggregated data because current averages “are not giving us the true picture in terms of who is being affected.”

Calls for funding ahead of replenishment rounds

Several panelists made calls for funding at a recent WHO press conference in Geneva given the current “shortfalls” in funding. In 2023, less than half of the target $8.3 billion was invested in malaria response. This gap has widened in the past several years from $2.6 billion in 2019 to $4.3 billion in 2023. The vast majority of these funds come from international sources, with endemic countries contributing 33% in the past decade.

“Next year is a very, very big year for all of us in the malaria world,” noted Dr Charles. “We have two replenishments. We have the GAVI replenishment, and we also have the Global Fund replenishment…The mosquito is so unrelentless and so smart that the longer we wait, the harder it is.”

Even with malaria vaccines available, GAVI, the Global Fund, and the President’s Malaria Initiative all need replenishment “to realize the promise of the vaccine and other interventions,” argued Dr Hamel.

The Global Fund also released a statement urging funding to meet targets, making the argument that “investing more in the fight to end malaria not only has the potential to save millions of lives, but it can also help rebalance global economic power and stimulate trade.

“This, in turn, can unlock additional funding to strengthen health systems and enhance health security both in Africa and around the world. Malaria investment is not just a health imperative—it is a strategic driver of broader, far-reaching economic and social benefits,” said Peter Sands, Global Fund executive director, in a press release.

Image Credits: Fanjan Combrink / WHO.

WHO Director General Dr Tedros Adhanom Ghebreyesus (center) at year-in-review press briefing.

WHO Director General Dr Tedros Adhanom Ghebryesus urged a ‘wait and see’ attitude Tuesday in his first public comments on US President-elect Donald Trump’s nomination of Robert F Kennedy Jr as Secretary of Health and Human Services – despite a flurry of fresh criticism by 77 Nobel Laureates over the controversial appointment.

“It’s a transition time for the new US government, give them some space so that they can prepare for the transition. and I hope and believe that they will do their best,” said Tedros, at an end-year briefing with the Geneva UN Press Association (ACANU), that also reflected on the successes and setbacks seen by WHO over the past year – as well as the challenges ahead. 

“The United States has been a good model of partnership, and has been partnering for many years,” Tedros said – shrugging off the bitter criticism levelled by Trump at WHO during the COVID pandemic, when he also tried to pull the US out of the global health agency. 

The WHO Director General also expressed hopes that the new US administration would still back a WHO pandemic accord, which he said could be completed by member states in their next session in February 2025 and approved at the next World Health Assembly, in May.

This despite sharp criticism by conservative pundits in the US and elsewhere about how an accord might impinge on US ‘sovereignty’ – something Tedros and other senior WHO legal officials have rejected over and again. 

More immediately, there are mounting concerns that WHO member states negotiating a deal won’t manage to agree on the last thorny issues that have eluded consensus so far – notably a  formula for more equitable distribution of vaccines and medicines between richer and poorer nations. See related story:

No Pandemic Agreement This Year – And Doubt About Feasibility of May 2025 Deadline

“I still believe that there is very broad support for the pandemic agreement.  I hope that they [WHO member states] will finalize it by the set date,” Tedros told reporters, referring to the May 2025 target date set by the World Health Assembly for approval of a draft agreement.  “I hope they will honour that commitment they already have. And as I said earlier, we are still vulnerable. 

“I believe that the US leaders understand that the US cannot be safe unless the rest of the world is safe,” he added, with regards to the global threat that local outbreaks of deadly pathogens can pose. 

He cited repeated outbreaks of Ebola, and more recently mpox, in the Democratic Republic of Congo, as contemporary examples of remote settings where WHO and its partners have acted to head off the spread of deadly disease threats with a combination of new diagnostics, surveillance and vaccination of at-risk groups. 

Vaccine skepticism causes uproar over Kennedy’s nomination

Anti-vaxxers demonstrating against COVID-19 measures in London in 2022; Kennedy made whirlwind trips around Europe to encourage protests.

Tedros spoke on the same day that the 9 December letter by 77 Nobel Laureates in medicine, chemistry, physics and economics was first published by the New York Times, calling on US Senators to reject Kennedy’s nomination as HHS Secretary.  

“In addition to his lack of credentials or relevant experience in medicine, science , public health, or administration, Mr. Kennedy has been an opponent of many health – protecting and life-saving vaccines, such as those that prevent measles and polio; a critic of the well-established positive effects of fluoridation of drinking water; a promoter of conspiracy theories about remarkably successful treatments for AIDS and other diseases; and a belligerent critic of respected agencies (especially the Food and Drug Administration, the Centers for Disease Control, and the National Institutes of Health),” the scientists wrote. 

“In view of his record, placing Mr. Kennedy in charge of DHHS would put the public’s health in jeopardy and undermine America’s global leadership in the health sciences, in both the public and commercial sectors,” the Nobel laureates concluded. The US Senate, which has a narrow Republic majority, must confirm Trump’s nomination of Kennedy following the president-elect’s inauguration on 20 January 2025.

Trump team rejects Laureate’s appeal as ‘elites telling them what to do’ 

Donald Trump with NBC’s Kristin Welker on Meet the Press: suggests Kennedy might re-open investigations into long debunked claims of vaccine-autism linkage.

In response to the Laureates’ appeal, a spokeswoman for the Trump transition team said: “Americans are sick and tired of the elites telling them what to do and how to do it. Our healthcare system in this country is broken, Mr. Kennedy will enact President Trump’s agenda to restore the integrity of our healthcare and Make America Healthy Again.”

Meanwhile, in a wide-ranging interview with NBC TV, Trump suggested that his pick for HHS Secretary might indeed re-open investigations into a long-debunked theory about a linkage between vaccines and autism,  which Kennedy has at times championed. 

“I think somebody has to find out,” Trump said in an interview with NBC’s Kristen Welker in “Meet the Press”, adding that “if you go back 25 years ago, you had very little autism. Now you have it.”

Childhood vaccines prevent about 4 million deaths a year 

Infant in Rwanda receives a combined measles and rubella vaccine, recommended by WHO.

Welker challenged Trump with data showing that childhood vaccines save several million lives worldwide every year, while increases in autism diagnoses are attributable to increased screening and awareness – not vaccines.

According to the Centers for Disease Control and Prevention (CDC), one out of every 36 children in the US was diagnosed with autism in 2020, compared with one in 150 in 2000.

During the COVID pandemic, Kennedy led a worldwide anti-vaxer movement against SARS-CoV2 vaccines. Along with his organization, Children’s Health Defense, Kennedy has also advocated in the past against other routine childhood vaccines, saying in a 2023 Fox News interview: “I do believe that autism does come from vaccines.” 

“We should have the same kind of testing place or control trials that we have for every other medication,” Kennedy said at the time, claiming that “vaccines are exempt from pre-licensing control trials, so that there’s no way that anybody can tell the risk profile of those products, or even the relative benefits of those products before they’re mandated. We should have that kind of testing.”

In fact, all major childhood vaccines undergo extensive pre- and post-licensing trials for safety as well as for efficacy, prior to regulatory licensing. 

In 1998, a British doctor first claimed a link between autism and childhood vaccines, particularly the measles, mumps and rubella vaccine (MMR). His research was subsequently retracted, and he was later banned from practicing medicine in the United Kingdom. 

Finding common ground 

Dr Mike Ryan, WHO executive director of Health Emergencies: “We need to look for what we have in common.”

Despite the obvious concerns over Kennedy’s position on the vital role vaccines play in  preventing infectious diseases, WHO officials are also clearly looking for entry points where they might be able to build bridges with the new HHS Secretary, should his appointment be confirmed. 

And they don’t have to look very far.

Kennedy Jr. also has been outspoken about the epidemic of non-communicable (aka chronic) diseases faced by Americans – and the need for more emphasis on prevention with healthier diets, environments and active lifestyles – capped by social media posts of the 69-year old showing off his muscles in a workout.

But in fact, these are also increasingly high priorities in WHO’s strategic work  – particularly in a year when the United Nations High Level Meeting on Noncommunicable Diseases will be a featured event at the UN General Assemblies September 2025 meeting.  

Over the past two decades, the agency has also locked horns with increasing frequency with powerful food industry interests on WHO guidance about reducing sugar intake, sugary drinks, transfats, processed meats, and other unhealthy foods – not to mention contaminants in food, air and water supplies.  

“We need to always look for what we have in common. What can we do together? Where do we agree?” said Mike Ryan, executive director of WHO Health Emergencies, at the briefing. 

“And if you’re looking at things like healthier lifestyles, health promotion, the reduction of toxins in food or in the environment, that’s common ground. There’s no question that that’s common ground. And there’s a huge agenda there to be worked on.

“I think we can choose to differ on many things, and sometimes we do have ideological differences. But Tedros often uses the example that we managed globally to eradicate smallpox at the height of the Cold War. 

“So if there ever is a reason to find common ground, [it is] now …when over half the world’s population lacks access to proper healthcare. We have a mental health crisis. We have a nutritional crisis. We have non-communicable disease crisis. 

“We have hundreds of millions of people slipping into fragility and conflict. If there ever was a reason to pull together to find common ground rather than the grounds for conflict, we have those problems now.”

‘No one has the right to take a life’

Saving both individual’s and societies high healthcare costs is yet another reason why national health systems need to “move towards prevention,” Ryan suggested. 

 “No one has a right to take a life,” he observed, commenting on the 4 December murder of a senior health insurance executive in New York City, in an apparent rage attack against the US health insurance industry. 

“But right now, becoming unwell can be both catastrophic to your health, catastrophic to your future, your children’s future.” Ryan added.  “There is a lot more financial hardship associated with people having to directly pay for healthcare when they’re not insured or they’re not part of a national insurance programme, … and that’s happening in many, many countries.

“We need to move towards …a health system that is more focused on keeping people healthy, and less focused on treating disease, reducing what we’re exposed to, in terms of protecting the health of our people, protecting them from what’s out there in the environment, protecting them from anything that was unsafe within our food or farms,” Ryan stressed. 

“Each sovereign country decides how it designed its health system. WHO’s concern is to ensure that every person has a right and access to health. WHO’s concern is that every individual has access to the same level of health care, and that we don’t see inequities in that health care is distributed within the society.”

Image Credits: Sarah le Guen/ Unsplash, NBC, WHO.

Kelly Chibale at his research organisation, the Holistic Drug Discovery and Development Centre (H3D) at the University of Cape Town.

Nearly two decades ago, South African researcher Kelly Chibale recalls participating in a pioneering World Health Organization (WHO) meeting in Abuja, Nigeria, organized by TDR, the WHO-hosted Special Programme for Research and Training in Tropical Diseases, focusing on the concept of an African drug discovery network. 

For Chibale, the main outcome of that encounter was a bad case of food poisoning. But the researcher, who went on to found the University of Cape Town’s (UCT) Holistic Drug Discovery and Development Centre (H3D) a few years later, never forgot the idea.  

Twenty years later, in the wake of the COVID-19 pandemic fallout over the lack of research and development (R&D) and manufacturing on the continent, an African R&D network has finally come of age.

A network of African research institutions engaged in drug discovery research is taking full form. Earlier this year, some 21 research institutions spread across seven countries came together as the Grand Challenges African Drug Discovery Accelerator (GC-ADDA) co-sponsored by the Bill & Melinda Gates Foundation (BMGF) and LifeArc, a UK-based self-funded medical research charity.

The network was conceived in a 2017 conversation Chibale had with Peter Warner, BMGF Senior Program Officer, and Tim Wells, Chief Scientific Officer at Medicine for Malaria Venture (MMV), and the concept was championed by Warner within the foundation, Chibale recalls.

It was incubated between 2019 and 2023 against the backdrop of the COVID pandemic, with a series of Grand Challenges mini-grants disbursed to different African institutions that worked individually on key R&D challenges in malaria and TB drug discovery, among other issues.

Then, in January 2024, the GC-ADDA network came into its own with the $7.2 million grant from the BMGF and LifeArc.

Last month, LifeArc awarded another $6.3 million to H3D to establish a Center for Translational AMR Research (CTAR) at its UCT base.

The new CTAR project aims to identify and develop new precision antibiotics to combat several multidrug-resistant (MDR) Gram-negative bacteria, including Acinetobacter baumannii, which typically infects people with weakened immune systems, including in hospitals, and is a leading driver of antimicrobial resistance (AMR) on the continent.

Chibale, whose H3D Foundation will spearhead GC-ADDA, was in Geneva recently to discuss and promote the GC-ADDA network among African Ambassadors to the UN in Geneva Missions .

He sat down before that meeting to talk with Health Policy Watch about his vision and its development.

Flagship projects

“I can give credit to my colleague Solomon Nwaka of WHO/TDR for initiating the idea [of a network]. It was visionary. But the difference now is that this is a model that is based around specific, concrete innovation projects in research institutions on the continent,” said Chibale, whose H3D in Cape Town offers one such example.  

Based on lessons learnt in the two previous rounds of Grand Challenges Grants, the new GC-ADDA network will focus on four flagship projects. These will be led by research centers in Ghana, Cameroon, South Africa and Zimbabwe, but also involving the other African institutions, including those that were recipients of earlier grant rounds and will be integral parts of the developing network. 

“There was a closed call, to only those people who were already in the network and those strategically identified, to organize themselves, based on complementary expertise, and to propose a consortium project, which is on a much bigger scale than the individual projects,” Chibale said.

Out of seven applications received, two projects for R&D on new TB and malaria drugs were accepted. The malaria project, co-led by the University of Ghana and the University of Pretoria aims to deliver novel anti-malarial drug leads.

The TB project, led by researchers at South Africa’s Stellenbosch University with partners in Kenya and elsewhere, will take a new approach to TB by identifying new drugs that act by degrading essential proteins in Mycobacterium tuberculosis, the causative agent of TB. 

Complementary to that, two other novel projects have been funded as part of the $7.2 million grant from LifeArc and the Bill & Melinda Gates Foundation.

They include a project on African drug metabolism (DMPK) research, led by the Zimbabwe-based African Institute for Biomedical Science and Technology (AiBST)

Finally, there is an effort to build a library of African-derived natural products – so that the active pharmaceutical ingredients in traditional African medicines could be studied systematically.

R&D on drug metabolism in Africans

The drug metabolism project, headed by Collen Masimirembwa, who spent a decade in Sweden with AstraZeneca, has led to the creation of a dedicated laboratory, near Harare, to the all-important goal of studying how drugs are metabolized in livers obtained from African donors.

This, on a continent which boasts the greatest genetic diversity in the world.

“Why is this important for Africa? Is because the way Africans metabolize drugs is not well understood,” said Chibale, who co-authored an article last year in Nature Reviews Drug Discovery, describing the challenges.

The impact of Africa’s genetic variability on response to medicines is not well accounted for in African populations for two reasons, he explains: 

  •  Only about 3.7% of clinical trials are conducted on the continent “and for obvious reasons, medicines are only optimized for people who take part”;
  • Drug candidates are typically tested first in preclinical studies on cellular fractions containing drug metabolizing enzymes and liver cells from donated livers, the main organ in which food and drug chemicals are broken down in the body. In Africa, organ donation is uncommon.  

At the same time, genetic differences in the liver’s drug-metabolizing enzymes can mean that a drug may be processed more rapidly or slowly by the body. So, for instance, when the HIV drug Efavirenz was first introduced in Africa a while ago, a study in Zimbabwe found that the approved dose for Caucasians was toxic for some Africans who had a genetic mutation in the enzyme needed to process the drug, leading to a much slower metabolism.

“They observed people having adverse side reactions. Some would stop taking the medication, and some could even have died from the toxicity of the drug,” he relates. “Upon investigation, it turned out that people were actually being overdosed.”

“So this project aims to strengthen African drug metabolism research so that we can generate more data on how diverse populations in Africa break down drugs. And then we use that data to refine what we should be giving to people who carry particular genes, or genetic mutations in drug-metabolizing enzymes.”

Traditional drug library

Developing an African-based library of active ingredients derived from natural sources  another novel arm of the project, which will be led by the University of Buea in Cameroon.  

Like synthetics, medicinal plants also have active ingredients that bestow them with healing qualities, as part of natural (traditional or herbal) medicines, “these are molecules that come from plants, marine organisms or other natural sources,” he points out. 

“Africa has been endowed with a lot of these natural products. People use traditional medicines, right? But still, they have not been scientifically and clinically validated to the extent or point that they can receive approval from a stringent regulator.

“So the aim is to assemble a collection of well-characterized, purified natural products from Africa, and see how we can use them as a starting point for modern approaches to discovering a medicine – using them to test against causative agents of various diseases – communicable and non-communicable – whatever you want to do.

Concretely, this involves building a collection of such naturally derived “active ingredients”, which are already purified and characterized.

“They can be dispensed in what we call screening boxes – and made available to the African community to screen against any disease – in other words, providing starting points for drug discovery.”

Supporting local manufacturing of APIs

Complementary to the GC-ADDA R&D network is a parallel initiative in which H3D is engaged, which aims to support more local manufacturing of ‘active pharmaceutical ingredients’ (APIs) in Africa.

As was painfully evident during COVID, most of those APIs are currently produced in Asia and imported to Africa – and that hobbles the ability of African manufacturers to be competitive in the drug manufacturing space.

With the support of USAID, H3D, together with a private local pharma firm, Chemical Process Technologies (CPT) Pharma, is using and testing a “continuous flow reactor technology” that could make API production of antiretroviral drugs for HIV more economical, Chibale said.

“If and when we demonstrate the cost competitiveness of the process of making the three antiretroviral drugs we are working on as a pilot, we will license that technology to CPT Pharma, who can do the commercial manufacture.”

See related story: https://healthpolicy-watch.news/empowering-africas-pharmaceutical-future-the-critical-role-of-local-api-manufacturing/

Drumming up support for African R&D

The support of African governments, as well as the pharma industry, is critical to foster an ecosystem of R&D and manufacturing in Africa, says Chibale.

“And when I say support it is not always about giving money,” he stresses. “For African governments it can be as basic as supporting local researchers with the right policies that allow them, for example, to easily buy chemicals and reagents, which can be subject to high import fees or delays when donated equipment gets stuck in customs.”

In terms of the pharma industry, skills development and the exchange of scientists is a critical, practical pathway to fostering tech-transfer, said Chibale, whose own early formative experiences included a sabbatical as a visiting professor at Pfizer in 2008 at the company’s Sandwich R&D site in the United Kingdom.

Finally, he says H3D, as the GC ADDA network administrator through the H3D Foundation, can “bring excellence to this programme, because we’ve been through this ourselves.

“We can continue to provide access to infrastructure that we’ve developed, of course – with support from many partners, including pharmaceutical companies, including Medicines for Malaria Venture.

“And of course, the government of South Africa has been a major factor. It’s an important thing to highlight what a government can do, even when there are enormous social challenges.”

 

Image Credits: Je'nine May.

Africa CDC Director-General Dr Jean Kaseya (centre) during a visit to the DRC last week.

There is still no clarity about the cause of the mystery disease affecting people in the Panzi district of Kwango province in south-west Democratic Republic of Congo (DRC), despite hopes that it would be diagnosed by the past weekend.

Getting laboratory test results is proving more challenging than previously hoped as the district’s “limited laboratory capacity means that samples have to be transported to the national reference laboratory in [the capital of] Kinshasa”, according to the Africa Centres for Disease Control and Prevention (Africa CDC).

But the 700 km journey to Kinshasa currently takes about 48 hours due to poor roads and the rainy season, according to the World Health Organization (WHO).

The communication network is also limited in Panzi, a rural community of around 200,000 people spread over more than 7,000 square kilometres.

Suspected diseases

By last Thursday, 406 cases and 31 deaths of the undiagnosed disease had been recorded (case fatality ratio of 7.6%). However, the reported cases peaked in epidemiological week 45 (week ending 9 November 2024), according to the WHO. It took almost six weeks for Panzi health officials to notify national health officials about the unusual rise in cases.

All severe cases were malnourished, according to the WHO’s Disease Outbreak News (DON) from Sunday.

“The clinical presentation of patients includes symptoms such as fever (96.5%), cough (87.9%), fatigue (60.9%) and a running nose (57.8%),” according to the WHO.

Almost two-thirds of cases (64.3%) are children under the age of 15 , and over half of the children’s cases involve kids under the age of five. Some 71% of deaths occurred in children under 15.

“The area experienced deterioration in food insecurity in recent months, has low vaccination coverage and very limited access to diagnostics and quality case management,” according to the WHO.

In addition, the area is experiencing a shortage of supplies and health workers, with limited malaria control measures and access to transport.

Given the context of Panzi and patients’ symptoms, the WHO has listed the main diseases that are suspected. These include measles, influenza, acute pneumonia (respiratory tract infection), hemolytic uremic syndrome from E. coli, COVID-19 and malaria. 

Both the WHO and Africa CDC have sent health experts to assist the DRC’s team to assess the situation, accelerate diagnostic testing, and implement control measures.

The multidisciplinary team includes epidemiologists, laboratory scientists, infection prevention and control experts.

Since the mpox outbreak, the Africa CDC has been working closely with the DRC’s Ministry of Health (MoH), the National Institute of Biomedical Research (INRB), the National Public Health Institute (NPHI) to strengthen disease monitoring through genomic surveillance. 

“This collaboration focusses on creating a sustainable national pathogen genomics strategy and decentralising laboratory capacity to improve outbreak response and preparedness,” according to Africa CDC.

INB co-chair Precious Matsoso (centre) ends the 12th meeting, flanked by co-chair Anne-Claire Amprou and Dr Tedros.

There will be no pandemic agreement by year-end and, with only 10 days of formal talks set aside in 2025, some parties doubt whether an agreement can be reached by the May 2025 deadline.

The week-long extended 12th meeting of the Intergovernmental Negotiating Body (INB) made progress, particularly on research and development (Article 9) and financing (Article 20). 

While disagreement remains on a couple of key obstacles, informal talks will continue alongside the formal talks.

Dr Tedros Adhanom Ghebreyesus, the World Health Organization’s (WHO) Director General, suggested at the close of the meeting on Friday evening that delegates consider negotiating on “packages” rather than clause by clause to “break the stalemate”.

“When I see what’s left, I believe – and this is honest from my heart – it is not really difficult to conclude in a few days of negotiation, but between now and the next meeting it would be good to think about the issues left and find a middle ground,” said Tedros.

Earlier in the day, INB co-chair Anne-Claire Amprou took exception to criticism of the process and lack of progress from some NGO observers.

Noting that the nature of multilateral negotiations means finding a “landing zone” that is acceptable to everyone, France’s Amprou said sharply: “I don’t agree when you say that nobody gains anything. I invite everyone – delegations, stakeholders – to look at what we have already achieved. We have achieved a lot.”

She stressed that the INB would deliver on its mandate: “We need a pandemic agreement which is meaningful, and it will be.”

‘Not a colouring book’

Amprou’s response came after Medicines Law and Policy commented that while there is some new “green text”, indicating agreement on the draft agreement, “it’s important to remember that the pandemic agreement is not a colouring book”. 

The European think-tank continued: “Substantive provisions on very difficult issues such as equity and access, transfer of technology, intellectual property and [pathogen] access and benefit-sharing remain largely absent, or are, at best, weak.”

Third World Network (TWN) followed, saying: “Every time we hear a new text is green, we are looking to figure out what has been compromised, especially in terms of equity.

TWN added that the agreement lacks “a baseline of legal rights and obligations”, and  “protects the interest of business, not people’s rights”.

Oxfam presented a list of questions and objections on behalf of 26 stakeholders including that member states appeared to be under “extreme pressure” to defer agreement on a pathogen access and benefit-sharing (PABS) scheme to an annex, the contents of which would be decided on after the pandemic agreement had been signed.

The Pandemic Action Network (PAN) and the Panel for Global Health Convention both urged negotiators to keep the momentum going and asked for clarity on the way forward.

Rafael Gracia of Pandemic Action Network and Dame Barbara Stocking representing he Panel for Global Health Convention

Eloise Todd, PAN’s executive director, told Health Policy Watch after the meeting that while the INB has not reached a conclusion, “there is a more urgent sense of progress around the negotiations which we need to encourage”.

Todd called on “high-income countries in particular to dig deep and remember the reason why we need this agreement is because of the deep-seated inequality in the COVID response”. 

“⁠⁠It is crucial for negotiators to see the bigger picture with these negotiations. The pandemic agreement will serves as an important marker the world’s coordination and cooperation in times of pandemic threats – which we know will become more and more frequent. It’s time to deliver on this vital step forward that will benefit people in every country,” said Todd.

However, Spark Street Advisors’  CEO and long-time talks observer Nina Schwalbe was less positive: “They have missed a once-in-a-generation opportunity to make a difference because national interests prevailed over global solidarity.”

Crux of the stalement

The stalemate centres on differences between the European Union (EU) and the Africa Group. The EU wants an annex linked to Article 4 (pandemic prevention) that outlines countries’ responsibilities to prevent pandemics. The Africa Group is reluctant to agree to costly responsibilities and it wants an annex related to the operationalising of a system for pathogen access and benefit-sharing (PABS) in exchange.

What the Africa Group wants from PABS is preferential access to any pandemic-related products that are developed from them sharing information about pathogens that could cause pandemics. This is anathema to the pharmaceutical industry, largely represented by the EU and the US.

The Africa group is also concerned that a prevention annex could impose costly requirements that they are unable to finance. However, the first beneficiaries of prevention measures are individual countries’ citizens who would be protected by, for example, heightened surveillance of bats that harbour Ebola and Marburg.

“These two areas are the make-or-break articles of the negotiations. If we can reach agreement on these, we will make the deal,” co-chair Precious Matsoso noted in an address to scientists recently.

Health leaders wanted an early agreement

Tedros has long urged delegates to reach agreement sooner rather than later and Dr Jean Kaseya, head of Africa CDC, has also expressed hope for an early agreement.

On a recent visit to South Africa, Matsoso noted: “We don’t have six months left to finish negotiations. We only have a couple of days left, precisely because the geopolitical environment is so challenging. There is huge, huge pressure on the talks and we don’t know what the outcome will be.”

The elephant in the room is the Donald Trump presidency, largely expected to take an axe to what Team Trump terms “globalism” – virtually anything that puts global good before national interest.

Delegates paid tribute to US Ambassador Pamela Hamamoto for her positive contribution to the pandemic agreement, as that was her last INB meeting.

Further INB meetings are scheduled for February and April, with a completed agreement supposed to be ready to be voted on at the World Health Assembly in May.