Testing a patient for hypertension. Two-thirds of Africans with high blood pressure are unaware of this.

Africa’s limited pharmaceutical industry, high costs of raw materials, and dependence on imported medicines have long hampered citizens’ access to the medicines they need. 

The challenges the continent faces are daunting. They include poor supply chain systems, lack of government investment in the pharmaceutical sector, unfavourable manufacturing conditions, limited health workforce, lack of sustainable health financing mechanisms or infrastructure and technical know-how, low investment in research and development, and circulation of fake medicines. 

Rectifying these problems is where the African Medicines Regulatory Harmonization (AMRH) programme comes in. Five years after the inaugural AMRH Week in Kigali, Rwanda in 2018, experts gathered in Ghana last week to discuss the AMRH’s potential to address these gaps, drive change for the African continent, achieve Universal Health Coverage, and galvanize resources to meet the continent’s health needs.

The week brought together African leaders and policymakers, members of the AMRH steering committee and technical committees,  regional economic communities, the AMRH Partnership Platform and other partners and stakeholders.

Safe medicine

“At its core, the mission of the AMRH is to facilitate the harmonization of medicine regulation and to create the desired outcome of access to quality, safe, efficacious and affordable medicine for the African continent,” said Mimi Darko, CEO of Ghana’s Food and Drugs Authority. “There are many reasons this is critical but in recent times nothing has brought this home but the ravages of the COVID-19 pandemic.”

COVID-19, she said, helped to shift the attention of many African countries from the short-term, urgent needs of their populations to building long-term resilience for the continent.

“It is no surprise that vaccine production is at the centre of initiatives culminating in the partnership for the African Vaccine Manufacturing, the first ever kind of collaboration for Africa,” added Darko.

This year’s focus was on regulatory processes, harmonization and strengthening National Regulatory Authorities (NRAs) across Africa and other low- and middle-income countries facing challenges in ensuring access to quality-assured medical devices, in-vitro diagnostics, personal protective equipment (PPEs) and other health products.

European Medicines Agency offers support

Dr Matshidiso Moeti, WHO Regional Director for Africa.

Emer Cooke, executive director of the European Medicines Agency (EMA), said it was critical for Africa to develop its medicines agency to gain control over regulatory and price mechanisms for the continent.

“The EMA’s support for the region during the pandemic was enormous through the EU-AU partnerships and the Africa CDC. But what is critical now is the efforts to establish the African medicine agency initiative,” Cooke said. “This will help coordinate, facilitate and harmonize access to medicine for disease cohorts in the region.”

The EMA pledged to give the AMRH steering committee technical support to address some of the challenges highlighted.

Slow pace of ratifying AMA

Dr David Mukanga, deputy director of African regulatory systems at the Gates Foundation and chairperson of the AMRH Partnership Platform, said member states’ delays in ratifying the AMA treaty was the main challenge so far.

“The rate at which we’re moving as a continent in signing and ratifying the AMA treaty is of great concern. This is because ensuring that medicine and medical products are available for everyone is a huge task and we need to move faster in professing solutions by turning our ideas into products for our people and the delays are not helping” he stressed.

In the long term, Mukanga said leveraging the scarce resources of the continent to create the AMA would help to  will deliver universal health coverage.

Dr Matshidiso Moeti, the World Health Organizations’ (WHO) Africa regional director, said in a statement to the meeting that substantive strides have been made by the AMRH to develop the regulatory framework to oversee pharmaceutical products, capacity building and technical support for member countries.

The AMRH strategy, which is operating in five regional and economic committees, has been able to deliver positive results by helping countries to access a robust legal framework and to harmonize regulatory requirements, standards, processes and capacity building.  

However, she urged the extension of regulation from generic medicine to cover new chemical-entity vaccines, medical devices and in-vitro diagnosis, hinting that $1 million has been allocated for the AU-WHO joint work plan to  establish and operationalise the AMA.

Pledging the WHO’s support for the AMA, she called for local investments in the regulatory systems and its processes to safeguard it.

Image Credits: Hush Naidoo Jade Photography/ Unsplash.

COVID-19, conflicts and climate change are posing additional challenges to efforts to achieve universal health coverage (UHC) in the Eastern Mediterranean region (EMRO), the World Health Organization (WHO) acknowledged on the eve of Universal Health Coverage (UHC) Day on Monday.

“The COVID-19 pandemic demonstrated the vulnerability of our health, social protection and economic systems,”  Dr Ahmed Al-Mandhari, WHO EMRO regional director told a media briefing on Sunday at the start of a three-day regional UHC meeting.

“Half of all countries in our region are experiencing protracted conflicts and humanitarian crises. Eight of them have reported outbreaks of cholera and acute watery diarrhoea. Extreme climate events, like the floods in Pakistan and drought in the Horn of Africa, are leading to acute hunger and health crisis.”

Dr Ahmed Al-Mandhari, WHO EMRO regional director

Cholera outbreaks signal weak systems

Lebanon had been cholera-free for the past 30 years until a few months back when it reported an outbreak, indicative of challenges to its water supply amid the country’s weakening economic crisis, according to Dr Rana Hajjeh, WHO EMRO director of programme management.

“Cholera is not only a repercussion of climate change,” said Hajjeh. “It is evidence of weak and fragile health systems. We have two countries in the eastern Mediterranean region suffering from cholera at the moment in addition to the six countries where it is endemic. 

“Cholera in Syria and Lebanon is a very grave sign as it is linked to the collapse of the infrastructure, not only the health of infrastructure but also all that is relevant for the cleanliness of water and securing of clean water and services for citizens.”

However, climate change was having a huge impact on the region, Hajjeh acknowledged. The floods in Pakistan, one of the biggest EMRO member states, had disrupted the country’s health systems, while Somalia was in the midst of a very severe drought, and was in a grave food crisis in Somalia “and may be encountering starvation”.

The WHO had developed guidelines for member states on climate change and would assist them to address its impact.

Dr Suraya Dalil (left) and Dr Rana Hajjeh, WHO EMRO director of programme management.

Primary Health Care

“Primary health care is the most cost-effective way to bring services or health and wellbeing closer to individuals and communities. Reorienting our health systems towards the primary health care approach means engaging in multisectoral action, ensuring community engagement, increasing equitable access to quality health services and strengthening public health functions, added Al-Mandhari.

UHC Day is an official United Nations designated day that marks the anniversary of a unanimous decision seven years ago to endorse UHC as an essential component of international development, and work towards achieving this globally by 2030.

“UHC means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential quality health services across the life course from health promotion to prevention, treatment, rehabilitation and palliative care,” added Al-Mandhari.

Meanwhile, the WHO plans to mark UHC Day with an event at the FIFA Fan Festival in Doha, Qatar, on the eve of the World Cup semi-finals on Tuesday. 

The WHO also issued its UHC service Package Delivery and Implementation Tool aimed at supporting countries to design and implement comprehensive health service packages to meet the needs of their populations on Monday.

It also launched a digital knowledge hub for the public called, ‘Your life, your health: Tips and information for health and wellbeing,’ to provide people with trustworthy health information.

Image Credits: UN-Water/Twitter .

Babies under 28 days are particularly vulnerable to AMR-resistant infections.

Leading public health experts are calling for urgent action to develop antibiotics for newborn babies, a population that is particularly vulnerable to antibiotic resistance. 

Each year, there are an estimated three million cases of neonatal sepsis causing up to 570,000 deaths, many due to a current lack of effective antibiotics, according to a paper published by international experts in the field of antimicrobial resistance (AMR).

Last Friday, the World Health Organization (WHO) released a report that shows a high level of antibiotic resistance from a number of bacteria that cause life-threatening bloodstream infections, and increasing resistance from bacteria that cause common infections. 

The Global Antimicrobial Resistance and Use Surveillance System (GLASS) report shows high levels (above 50%) of resistance in the largely hospital-acquired bacteria, Klebsiella pneumoniae and Acinetobacter spp. These require treatment with last-resort antibiotics such as carbapenems, but 8% of bloodstream infections caused by Klebsiella pneumoniae were even resistant to carbapenems.

Meanwhile, over 60% of Neisseria gonorrhoea isolates showed resistance to a common oral antibacterial ciprofloxacin. Over 20% of E.coli isolates – the most common cause of urinary tract infections – were resistant to both first-line drugs (ampicillin and co-trimoxazole) and second-line treatments (fluoroquinolones). 

Few drug trials for newborn antibiotics

Despite the rising number of newborn deaths caused by AMR, very few effective antibiotics have been studied to treat serious bacterial infections such as neonatal sepsis. 

Of the 40 antibiotics approved for use in adults since 2000, only four have included dosing information for newborns in their labels, according to the AMR experts.

In addition, far fewer trials investigating new antibiotics are currently being conducted in neonates than in adults: six neonatal trials compared with 43 adult trials.

“On any given day, up to 40% of infants admitted to a neonatal intensive care unit are prescribed antibiotics, with an estimated 90% exposed to antibiotic medications over the duration of their stay in the intensive care unit,” according to the paper.

“Many of these antibiotics are prescribed off-label because of the perceived or documented need for empiric or targeted therapy of MDR pathogens. Such prescribing risks reducing efficacy or increasing toxicity be – cause of under- or over-dosing; it also increases the potential for antimicrobial resistance selection pressure because of suboptimal dosing.”

Inter-disciplinary network

The experts, including researchers from the Global Antibiotic Research & Development Partnership (GARDP) and Penta Child Health Research, propose an international, inter-disciplinary network to accelerate the development of antibiotics for newborn babies.

“There is an urgent need to identify high-priority antibiotics to understand which ones work best and safely in children, and then make them available where they are needed,” said Mike Sharland from St George’s, University of London, and a member of the Antimicrobial Resistance Programme at Penta.  

According to recent estimates, about 2.3 million newborns die of severe bacterial infections each year.  An increasing number of babies under 28 days’ old are becoming resistant to currently used antibiotics.  Over the last decade, AMR has worsened to the point that around 50-70% of common pathogens exhibit a high degree of resistance to available first- and second-line antibiotics.  

Working together collaboratively could speed up both development and access to urgently needed antibiotics for newborns. 

“By bringing together academic clinical trial networks, international research networks, regulators, donors, government and industry sponsors, these public-private partnerships can leverage their multi-disciplinary expertise and funding to speed up access to antibiotics and facilitate the update and routine implementation of global treatment guidelines,” said Carlo Giaquinto, President of the Penta Foundation.    

The paper outlines how a stakeholder group could work together to define a Neonatal Priority Antibacterial List, and to standardise regulatory criteria.     

“We need to move fast to develop guidelines and protocols on the use of antibiotics, as well as develop new antibiotics,” said Professor Sithembiso Velaphi, Head of Paediatrics at the Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. 

“We have the opportunity to prevent more unnecessary deaths of babies from these severe and preventable infections by intervening, quickly, equitably, and safely.  It is also critical that all efforts must be made to prevent these infections by ensuring that all healthcare facilities and providers adhere to infection prevention and control protocols.” 

GARDP, Penta, St George’s, University of London (SGUL) and other key partners are partnering on an upcoming clinical trial starting in South Africa in the next few months before being expanded to other countries to evaluate more effective neonatal treatment regimens to overcome resistance to current treatments, especially in low- and middle-income countries. 

Image Credits: 20 May 2021South AfricaKL Schermbrucker/GARDP.

chronic disease
Two women walk through the streets of Aleppo, an ancient Syrian city reduced to rubble by war.

On the occasion of Universal Health Coverage Day, thought leaders on the front lines outline the challenges and opportunities of health systems in conflicts.

The last decade of 12-year-old Zaynab’s life has been spent in an informal settlement in Lebanon, after her family fled from the Syrian conflict. She shares a three-room tent with her parents, grandparents and six siblings. 

Since leaving Syria, Zaynab has been diagnosed with type 1 diabetes and controlling her blood sugar level requires taking insulin several times a day. Zaynab is not the only one in her family with a long-term health condition – her father and grandmother are living with type 2 diabetes.

Managing an NCD like diabetes is tough for any child – but for Zaynab and her family, buying insulin and blood sugar testing strips has been an ongoing challenge.

She and her family members have often delayed, reduced, or completely missed out on treatment because of the cost. For people living with type 1 diabetes, their life depends on sustained access to insulin – a century old drug that remains costly and hard to access in many settings like Zaynab’s refugee camp.

Conflict, health emergencies and the climate crisis continue to impact lives across the world, with an estimated 103 million displaced persons in 2022. The conflict in Ukraine has driven one of the largest exodus of people since World War II and it remains, alongside Syria, one of the largest refugee and displacement crises of our time.  However, those crises are only the tip of the iceberg. 

Eight out of every ten displaced persons live in low- and middle-income countries, where people are also  disproportionately at risk of premature death from chronic, or noncommunicable, diseases (NCDs).  

When a humanitarian emergency strikes, many people affected or forced to flee live with pre-existing chronic health conditions that are exacerbated by the accompanying stress and difficulties in accessing scarce or disrupted medical care. Persons living with a chronic disease, including those with hypertension and type 2 diabetes – the most common among Syrian refugees – are more vulnerable in humanitarian emergencies, as they need continuous access to essential health services, including affordable and available medicines and testing equipment adapted to crisis settings and climate extremes. 

Care that leaves no one behind

Zaynab’s father doesn’t have regular work, and her mother earns less than the cost of feeding the family a simple diet of potatoes and pulses. As one of several humanitarian agencies operating in Lebanon, the International Committee of the Red Cross (ICRC) has stepped in to guarantee the family’s medicines and supplies, including Zaynab’s life-saving insulin treatments. However, the family still faces the expense of buying healthy food and challenges in applying other medical recommendations, such as regular physical activity.

If the world is to achieve universal health coverage (UHC) – in which no one is left behind – finding solutions to challenges faced by individuals like Zaynab and her family must form part of the discussion. Recent years have seen increased attention to address the specific challenges of people living with NCDs in humanitarian settings. World Health Organization (WHO) Member States, for example, have adopted the NCD Compact to protect the lives of 1.7 billion people living with NCDs the world over by 2030, including during humanitarian emergencies. For that to happen will require strong leadership, reliable data and an efficient multi-disciplinary and multi-stakeholder approach.

While operational considerations proposed by a set of humanitarian agencies around NCD prevention and care in humanitarian settings are yet to be widely implemented in the way HIV/AIDS guidelines for humanitarian settings have been, encouraging progress is being made.. A new set of recommendations on the issue was  approved by WHO Member States at the World Health Assembly earlier this year and it is hoped there will also be progress made on the issue through a series of WHO meetings on the topic in 2023 as well as through next year´s UN High-Level Meeting on UHC.

The path towards universal health coverage

An ‘informal tented settlement’ in Lebanon’s Bekaa valley. The mountains in the background form the border with Syria, just a few miles away.

Fundamentally, all countries need to be working towards achieving UHC, including countries impacted by humanitarian crises. Lebanon for example is a country of fewer than seven million inhabitants and is hosting nearly one million registered Syrian refugees. This has increased the country’s population by 15%, placing enormous pressure on its infrastructure, including the health system.

All efforts towards achieving UHC must include the integration of NCD services into community services and primary health care (PHC) facilities to ensure people living with NCDs have access to quality services across the continuum of care, and avoid the need for costly and time-consuming travel to distant hospitals and overburdening secondary and tertiary care. Local nurses and community health workers are indispensable: with appropriate training, they can manage many conditions in collaboration with primary care doctors, facilitate referrals, and support continuum of care and adherence to treatment.

Increasingly, people live with more than one health condition: for instance, hypertension, diabetes and mental health conditions are often interlinked. Person-centred care building care around the person and their family, their needs and perspectives can be achieved through an integrated service approach. People living with NCDs usually require care throughout their lives, including regular follow-up to prevent long-term complications, such as diabetic foot ulcers or terminal kidney failure. Therefore, they need to be empowered to manage their health, to engage proactively with and help shape health services, and incorporate treatment into daily life and make the healthiest possible choices.  

Person-centred care in humanitarian crises

The smoke of the Beirut harbour explosion spreads over the skies of Lebanon. In their journey to seek safe new homes, many displaced persons find themselves in countries with their own set of problems and challenges.

To ensure person-centred care during situations of displacement, the continuum of care must be protected. Authorities could explore the option of providing information about possible access points to be consulted during a person’s onward journey.

Alternatively, individuals could be offered larger quantities of medication and care supplies to cover periods where it will be difficult to access a health facility, as well as information on self-management of their conditions, including clear guidance on any red flags that signal the need to seek in-person medical care.

Building a bank of evidence-based research would help us understand how to best improve care for people living with NCDs under very challenging circumstances. Also, the private sector could and should play a larger role when it comes to identifying solutions that meet the needs of people with NCDs affected by humanitarian crises.

Finally, the importance of community support for displaced people and those living in humanitarian crises – both practically and emotionally – cannot be overemphasized. 

In Zaynab’s family for example, there are in fact now three people living with diabetes; they support one another in adhering to treatment plans, and in self-care. Supporting families and peers to manage healthcare in their own communities may improve  more self-reliance, while also giving them a greater sense of stability, empowerment and purpose.

Overcoming the challenges faced by people living with NCDs under very difficult conditions extends far beyond access to medication. It is about how health systems under serious stress can be strengthened to provide continued, affordable access to NCD prevention and treatment. Until this is achieved for the most vulnerable groups of people, including those living in humanitarian settings, there can be no Universal Health Coverage. 

About the authors

Éimhín Ansbro is the Deputy Director of Centre for Global Chronic Conditions and NCD in Humanitarian Settings Special Interest Group Lead at the London School of Health and Tropical Medicine.

Micaela Serafini is the Head of Health Unit at the International Committee of the Red Cross.

Nicolai Haugaard is the Vice President and Global Head of Access to Care at Novo Nordisk.

Peter Klansø is the Director of International Department at the Danish Red Cross.

Grace Dubois is the Policy & Research Manager for the NCD Alliance.

Image Credits: UK DFID.

Margaret Gyapong, director of the Institute for Health Research at the University of Health and Allied Sciences in Ghana, with her research team.
Margaret Gyapong, director of the Institute for Health Research at the University of Health and Allied Sciences in Ghana, with her research team.

Whether researchers provide good quality data or not, healthcare systems will continue to function. In this episode of the “Global Health Matters” podcast, Margaret Gyapong, director of the Institute for Health Research at the University of Health and Allied Sciences in Ghana, tells host Garry Aslanyan that this has been a hard lesson that has shaped her career.

Joining the podcast is also Lee Hampton, vaccine preventable disease surveillance and vaccine safety focal point at Gavi, the Vaccine Alliance based in Switzerland.

According to Gyapong, the drive to better serve healthcare providers has pushed her to ensure that she works on projects that are relevant and to consider them as true partners.

This approach has been crucial in the development and deployment of the new malaria vaccine.


“Just recently, the World Health Organization made their official recommendation to widely use the long-anticipated malaria vaccine,” Aslanyan notes. “This recommendation was based on research evidence from a pilot programme in Ghana, Kenya, and Malawi that reached more than 800 000 children since 2019. This is an excellent example of how evidence, based on implementation research, tells us whether the health interventions, such as vaccines, will be effective in real life beyond the laboratory.”

Focusing on health workers

Gyapong, who has been involved in the process, shares some of her experience.

“Many times when we are delivering a new intervention, we think that we should focus all our attention on community members because they have low levels of literacy,” she says. “But then one of the things I have realized from the introduction of the new malaria vaccine is that we need to have a better understanding of our health care providers and the way they think.”

“We found out that the health workers at the lower level who were going to be the frontline workers to deliver the vaccinations had a shorter period of training than those at the higher level, and the health workers complained bitterly,” Gyapong adds, pointing out that the need for better training is relevant also for COVID-19 vaccine’s deployment.

Asked about what researchers working in different settings and areas should do, the scientist encourages them to understand “the situation on the ground” and “the needs of your stakeholders.”

Different communities have different needs

One of the challenges in deploying new vaccines is the expectation that strategies that are developed and tested in a specific society, often a high-income one, can be applied to other places, Hampton tells Aslanyan.

“We have a strong tendency to try to apply the game plans and the experience that worked in those countries that had the resources to first do the development everywhere,” he points out. “But then we run into trouble.”

Understanding the needs and characteristics of each community is crucial for a successful vaccination campaign. Hampton offers the example of the newly developed typhoid conjugate vaccine, which they expect will help prevent tens of thousands of cases and potential deaths.

Image Credits: Courtesy of TDR.

Vaccines
A United States delivery of 655,200 COVID-19 vaccine doses through COVAX to Ethiopia on September 23, 2021.

Gavi, the Vaccine Alliance, has pushed back on media reports that its board has decided to end COVID vaccine support for 37 middle-income countries next year – and end altogether the dedicated COVAX vaccine facility, supplying free vaccines to some 92 low- and middle-income countries, in 2024.

A high-ranking official at Gavi told Health Policy Watch that its Board’s approval Thursday in principle of a plan to end the free provision of vaccines to the 37 countries – including Egypt, Indonesia and Argentina – is neither final nor definitive, and would not in any case affect vaccine deliveries in 2023. 

Other officials, meanwhile, said that if funding cuts for middle income countries are made in 2024, the money saved would be shifted to a pandemic pool to confront new, and more dangerous SARS-CoV2 surges or similar future threats. 

Even so, no changes to Gavi’s support of some 92 middle and low income countries for COVID vaccines through the COVAX facility’s Advance Market Commitment (AMC) will be made in 2023, said Dr Derrick Sim.  A final decision on the shape the COVAX facility takes in 2024 will not be voted on until June of 2023, he added, following consultations with countries themselves. 

“We are not changing the approach for 2023, all AMC countries including AMC-supported middle-income countries will be supported to get fully-funded doses and delivery support,” said Sim, who is the Acting Managing Director of the Gavi-led COVAX facility, which has rolled out some 1.8 billion COVID vaccines to 146 low and middle income countries over the past two years.  

“Looking forward to 2024, every scenario we are considering involves some support for middle-income countries, and no decision will be taken until at least next year after countries have been fully consulted – and it will be based on the state of the pandemic at that time,” he added. 

New pandemic pool aims to correct problems in COVID vaccine rollout 

A lack on on-hand funding at the onset of the COVID pandemic hamstrung Gavi’s ability to respond in the early stages of the outbreak.

Under the proposal approved by the board on Thursday, any money saved on procuring vaccines for the 37 middle-income AMC countries would instead go to funding a new pandemic finance pool, which could be rapidly and flexibly deployed to confront surges of new SARS-CoV2 variants, or similar threats, added Olly Cann, Gavi’s director of communications.

“The idea behind it is, can we learn the lessons from 2020?,” said Olly Cann, Gavi’s director of communications.

During the early stages of the COVID vaccine rollout, Gavi and COVAX were heavily criticized for over reliance on just one vaccine supplier, the Serum Institute of India, which then froze its shipments when India faced a major COVID surge. 

The problem, widely acknowledged later, was that Gavi had no cash in hand at that time  to seal deals with some of the other large vaccine manufacturers, like  Pfizer, Moderna and Johnson & Johnson, for advance vaccine purchases. So it was forced to the back of the vaccine procurement line. 

New strategy part of scenario planning 

The new strategy approved by the Gavi Board Thursday is anchored in alternative scenarios for COVID’s evolution, developed by the World Health Organization, which leads the policy side of COVAX. 

WHO has defined three scenarios for the evolution of the SARS-CoV2 virus and pandemic: a worst case surge of new or existing variants; a medium case; and a best case, in which mortality from SARCoV2 continues to decline as virus mutations become less deadly. 

Only in the ‘best-case’ scenario would the COVAX programme of free vaccines and vaccine distribution support to the 37 middle income countries be replaced with a more step-wise approach, officials said. 

Under the new approach, the countries would be able to receive a “catalytic grant” – a one-time payment covering 50-60% of the estimated cost of the jabs needed to immunize health workers, older people and other vulnerable groups. 

In a medium or worst-case scenario, assistance to these middle-income nations would be increased accordingly.

Integration of COVID vaccines into routine countries may be preferred  

COVAX deliveries arrive in Sudan, August 5, 2021.

In best-case scenarios, the COVAX facility might foreseeably dissolve its emergency operations and integrate COVID vaccine distribution – into routine national vaccination programmes, officials also admitted.  

However, regardless of whether COVAX is dissolved entirely, or not, the progressive main-streaming of Covid vaccinations into national vaccine delivery programmes is in line with good practice – and what countries want.  

“Countries are finding it administratively burdensome to administer COVID vaccines as an entirely separate emergency programme,” one Gavi official said, speaking on condition of anonymity. “They would rather see vaccine distribution integrated into ongoing routine vaccination programmes.”

“COVAX’s planning is driven by countries’ needs and what we are hearing,” Sim added.  “They want to find ways to integrate COVID-19 into existing programmes in a way that benefits both, and reduces the administrative burdens of running a separate emergency programme in a time of other competing priorities, from routine immunization to outbreak response.” 

The Pandemic Vaccine Pool is the long-term strategy 

Under one of the scenarios included in the proposal approved by the Board on Thursday, any savings in supplying free vaccines to the 37 middle-income AMC countries, that would be channelled into Gavi’s new Pandemic Vaccine Pool – so as to have cash in hand for any new SARS-2 surge, or other future pandemic threat. 

The Pandemic Vaccine Pool created by the Gavi Board in April is a critical, new part of Gavi’s long-term pandemic preparedness strategy, Sim said. The aim is to ensure ready funding that would allow the Alliance to be on proactive footing should another deadly variant or virus emerge. 

“The Pandemic Vaccine Pool helps us have funding on hand to act immediately if there is a need, for example, for new vaccines,” he explained. “Gavi put in place this contingency measure based on COVAX learnings from the beginning of the pandemic that the course of the pandemic can change suddenly and delays can occur due to lack of available financing.” 

Middle-income countries normally do not qualify for Gavi support

Arrival of the first COVAX package to Argentina, comprised of Oxford/AstraZeneca vaccines.

Gavi officials also stressed that prior to the COVID pandemic, Gavi’s remit was limited to assisting the world’s 54 lowest-income countries, as defined by World Bank economic data. Middle income countries were eligible only for targeted funding, upon request, and not free vaccines as such. 

But the historic nature of the Covid emergency led to an expansion of eligibility for countries that qualified for free vaccines and support. And thus for COVID vaccine rollout purposes, some 37 middle income countries, as well as India, were included to the Gavi “Advanced Market Commitment (AMC)” scheme – making for 92 countries eligible for free COVID vaccines as well as distribution support.  

“These middle-income countries normally run their own routine vaccination programs, without Gavi support except for one-off targeted interventions,” Sim said. “When COVAX was set up, it exceptionally included a larger group of countries given the unique challenges of equitable access in a supply-constrained pandemic environment.”

In effect, then, any policy change in 2024 would revert Gavi’s scope to what it was pre-pandemic: a system of free vaccines and distribution support for 54 of the world’s lowest-income countries – and targeted support to middle income countries in need, he said. 

Proposal not related to vaccine contracts

Gavi also pushed back on reports by the New York Times that the draft proposal, approved by the Board, is reflective of financial pressures resulting from Gavi being overcommitted to vaccine purchases for which there is now no demand. 

In fact, Gavi’s fixed purchase commitments for 2023 amount to only 150 million vaccine doses, one Gavi official told Health Policy Watch – while the rest are simply “options to buy”.

At the same time the existing list of AMC countries have already expressed interest in twice as many doses – 300 million in total for 2023 – and that is only after a polling of half of the eligible countries.    

 Global demand for vaccines has indeed fallen significantly as the world’s population already builds immunity, the Gavi official added.  For instance, some 52% of people in low income countries have at least had a primary vaccine dose – a far higher proportion than six months or a year ago. And countries have some 400 million doses in stock, as well. 

As a result of declining demand trends, Gavi had earlier renegotiated a number of fixed-order commitments in its portfolio to become options – orders they can fulfill if demand jumps.

But these negotiations had already happened before this week’s board meeting. 

And between a replenishment for the 2021-2025 period that exceeded Gavi’s request for $7.4 billion, reaching $10.5 billion, and the $4.8 billion committed by world leaders at the COVAX AMC summit in April, the alliance’s financials are in order.

“The focus is on increasing coverage rates, protecting high-risk groups including with boosters, and laying the foundation for integration into existing programs,” said Sim.

 “Budget isn’t a problem, and supply isn’t a problem,” Cann said. “The biggest problem is we have no idea what 2024 will look like.”

 

Image Credits: US State Department, Nana Kofi Acquah, Argentina Health Ministry.

As we observe Universal Health Coverage day, it’s time to look again at gender barriers to health care, and particularly health care for chronic diseases. 

Monowara lives in the Khulna Division of Bangladesh. A mother of four, she is from a rural community experiencing significant levels of poverty. Now in her sixties, she spent 13 years with cataracts and deteriorating vision, unable to fully participate in community life and see members of her family clearly. Eye disease has been found to be almost 35% higher among women than men in Bangladesh, yet the surgical coverage rate for cataracts is more than 12% lower in women .

Observations of Universal Health Coverage (UHC) Day on 12 December will surely focus on how far we remain from attainment of the SDG goal 3.8 of UHC for all by 2030. 

Coverage by essential UHC services, by country, according to the  WHO UHC Service Coverage Index.

In that context, it’s important to examine how gender inequality continues to pose a barrier to UHC for women and girls – particularly for prevention and treatment of non-communicable diseases which have not traditionally been part of the standard package of womens’ and girls’ health services. 

Many aspects of gender inequity are easy to see. Women and girls globally are more likely to be living in poverty, working low-skilled jobs for inferior rates of pay, providing unpaid care for their families, facing barriers to education and proper nutrition, or withdrawn from education should there need to be a choice between siblings of different genders. They are much more likely than men to face gender-based violence.

Beyond ‘bikini’ medicine

Other aspects of gender inequity are ‘invisible’. The term ‘bikini medicine’ describes the mistaken belief that women’s health only differs from men’s in the parts of the body that a bikini would cover. 

Our focus on reproductive health blinds us to broader gender differences – in risk factors, in access to care and health promotion, and in health outcomes. Around the world, girls and women living with NCDs experience specific challenges in accessing prevention, early diagnosis, treatment and care, particularly in low-resource contexts; for example, low prioritization of female health within families, women’s limited access to financial resources to cover the costs, their caring responsibilities, and restrictions on their ability to travel freely, to name a few.

India’s example: more insurance payouts to men than women

In Bangladesh, is it estimated that women are up to twice as likely to experience blindness as compared to men.

This can lead to stark gender differences. For example, an analysis of national data collected by India’s Insurance Information Bureau found that while more women were covered by government-funded health insurance schemes than are men, a staggering 70% of insurance pay-outs went to males. Barriers to accessing care are compounded by health systems that may fail to respond to the specific needs of girls and women with NCDs; either because they are not considered ‘women’s diseases’, or because gender differences in the way they are experienced are not understood.

For example, women are less likely than men to receive recommended medication after experiencing a heart attack. Women having a stroke are more likely than men to be wrongly diagnosed, and despite widely reported sex- and gender-based differences in asthma and asthma management, these issues frequently are not considered by health care professionals.

All this points to a need to address barriers to accessing health services for women in particular. We need to recognise gender as a determinant of health; for example, through the obstacles women face to adopting healthy lifestyles, such as unsafe environments that restrict their opportunities to be physically active. We need women-centred policies and programs focusing on prevention and care across the life course, prioritised to address the inadequacy of current systems. As the eyes of the global health sector turn to the High-Level Meeting on Universal Health Coverage in 2023, we must look anew at what’s needed to deliver effective, targeted services for both women and men.

Prioritize better data collection, service integration and women’s leadership

We suggest three key priorities:

  1. Disaggregated data and analyses – The gender inequities highlighted here are just the visible tip of a likely enormous iceberg, which remains hidden because we lack the data needed to identify these and other, intersecting inequities related to age, race, ethnicity, sexuality and so on. We urgently need data disaggregated and analysed by gender and other characteristics in order to effectively identify and break down barriers to health services access.
  2. Integration of services – Leveraging health infrastructure built for maternal and reproductive health can be an effective way to reach women with other services; for example, by incorporating screening and treatment for diabetes and high blood pressure into routine pregnancy checks.
  3. Women’s leadership in health – Despite making up close to 70% of the health workforce globally, women are underrepresented in health sector leadership, with only 25% of women in decision-making positions. Adequate representation of women at the top would ensure policies, programs and laws more fully consider the experiences and perspectives of half the population.

Monowara’s untreated cataracts were spotted when she accompanied her daughter Munni to a maternal and child health clinic which has integrated eye care into the services it offers, training MCH workers to detect basic eye conditions. Monowara’s eyes were checked while Munni was nursing her newborn baby, and her cloudy lenses were subsequently replaced with new ones in a relatively simple, 20-minute procedure, which was provided to her for free.

Both are simple examples of service integration that can be transformative for the individuals involved. 

The impact on Monowara’s life of being able to see clearly again after 13 years is immeasurable; not just for her, but for her entire family. Only by lifting our sights to the full picture of women’s health – including gender differences beyond the ‘bikini’ and across the life course – and by investing in women’s leadership and a whole-of-government approach to tackle deep-seated gender inequities across the board , can we hope to achieve the vision of universal health coverage for all.

About the authors

Jane Madden is the chair of The Fred Hollows Foundation.

Dr Monika Arora is the vice president of the Public Health Foundation of India and President-Elect of the NCD Alliance.

Emma Feeny is the global director of impact & engagement at Australia-based George Institute for Global Health.

UNITE
UNITAID Panel discussion at the UNITE Global Summit 2022.

The world can achieve the global health goals of the Sustainable Development Agenda 2030 only if it makes focussed investments into health innovation in the coming years. 

This was a key message from parliamentarians and representatives of the global health agency, UNITAID, at a panel on “Achieving the Global Health Targets Through Equitable Access to Health Innovation”, at the UNITE Global Summit 2022, which took place in Lisbon, Portugal this week. 

Dr Tenu Avafia, the deputy executive director of UNITAID, highlighted that the agency has an annual funding target of about $1.5 billion, which is funnelled into projects in low-income countries that help ensure equitable access to health tools – from prevention to diagnostics and treaments.  But the Geneva-based agency, which works in partnership with WHO and other global health partners, also has a strong innovation focus. It’s recent projects range from support for community trials testing shorter and less toxic formers of MDR-TB treatment in high-burden countries, to the testing and scale up of mass media campaigns for HIV self-testing amongst youth in Africa.  

UNITAID
Dr Tenu Avafia at the UNITE Global Summit 2022

“2023 is going to be a massive year for global health,” he said. Avafia added that Japan and India’s leadership at G-7 and G-20 respectfully will put universal health coverage and equitable access top priorities in the coming year. “We cannot keep the model where we concentrate, manufacture and distribute technologies in a handful of countries.”

Apart from Avafia, Maureen Murenga, a UNITAID board member, and Dr Ricardo Baptista Leite, UNITE head and a member of parliament from Portugal, were part of the panel discussion. 

Advancement in diagnostics, prevention and treatment has come a long way since HIV was discovered in the 1980s. Narrating the story of her own HIV diagnosis in those early years, Murenga related how she was initially tested five times, each test cycle returning the results after two weeks.  Now, health technology innovations has made possible immediate results, which opens up the door for more robust self-testing as well as other measures to prevent HIV infection from becoming full-blown AIDS.  

UNITAID
Maureen Murenga at the UNITE Global Summit 2022.

Murenga said that the invention of antiretroviral (ARVs) drugs was a game-changer for people living with HIV since it increased their lifespan and also decreased the chances of transmitting the virus to another person.

“So we are actually working towards the end of these epidemics…And if we don’t defeat them, they will come back and it’ll be too expensive for us to respond.” 

Attributing the progress in TB regimens and malaria vaccine to focussed efforts in innovation, Murenga stressed on the need to invest in solutions that will yield longer term benefits to the population. 

While investing in developing newer health solutions is important, it is equally important to ensure that the money goes into “innovation” and not “simple novelty”, Leite added. 

UNITE
Dr Ricardo B Leite, a Portuguese parliamentarian and head of UNITE, at the UNITE Global Summit 2022.

“I believe that the role of UNITAID is very important to also distinguish what is innovation from simple novelty. And there is a lot of industry interest, sometimes, trying to push certain technologies as being true innovation, but at the end of the day, are not adding value to health systems,” he said. 

Dr Leite added that investing wisely is the need of the hour and parliamentarians must do whatever it takes to ensure the well being of the people they represent. “We all know what it means to go against our own party, but that’s part of the job. Our first responsibility is not to our party, it’s to the people that we serve, and making sure that we use science to base all our positions and decisions so that it is very clear where we’re coming from.”  

Dr Avafia reiterated that collaboration is key in achieving goals of health equity and innovation. UNITAID’s goals over the next five years include accelerating the introduction and adoption to new health products and to address systemic conditions that affect equitable access and to encourage inclusive partnerships to set the health agenda, he explained. 

“A fully-funded global health response requires a fully funded Global Fund, a fully funded WHO, fully funded UNITAID and Gavi as well. Members of Parliament, as you know much better than I do, are key interlocutors in both programme and donor countries to make sure that resource allocation for unmet health needs is prioritised.” 

Ukrainian MP Galyna Mykhailiuk at the UNITE Global Summit
Ukrainian MP Galyna Mykhailiuk at the UNITE Global Summit

A four-year-old asthmatic girl from Ukraine was forced to relocate to a gas station earlier this week where she could connect her ventilator, after a Russian missile attack cut off her city’s electricity supply, leaving her without any other means of receiving life-saving oxygen.

Pictures of her frightened, frozen eyes made social media. But according to a Ukrainian MP, this story is not unique – “there are so many dramatic stories.”

The child, explained Ukrainian MP Galyna Mykhailiuk in an interview with Health Policy Watch, “requires a ventilator to breathe normally. She needed electricity to supply her with oxygen. The only possible option for her parents was to leave their home and take her to the gas station. At the gas station there is a generator.

“You might not think about how energy is connected to health, but there is a direct connection.”

‘Different being an official during war time’

Mykhailiuk spoke to Health Policy Watch during a visit to Lisbon for the UNITE Global Summit, a conference that brought together parliamentarians from around the world on December 5 to 7 to discuss issues of global health.

To get to the conference, the MP had to travel more than 36 hours, taking a 17-hour train ride from Kiev to Warsaw and then two flights. There is no safe airspace over Ukraine, so anyone trying to leave the country has to leave by car, train or foot. The cold weather – some days it is negative 5 Celsius and the ground is covered in ice and snow – can make it dangerous to drive or walk too far.

Mykhailiuk chose to attend the event both, because of her friendship with UNITE President Ricardo Baptista Leite, who volunteered at a Ukrainian hospital in the summer, and so that she could share what is going on in her country with the MPs directly and not through media interpretation, she said.

“It is very different being an official during war time than during peaceful time,” she explained to Health Policy Watch. “I cannot give you details of my day-to-day for security reasons, of course. But it is much more challenging. We work 24/7.”

‘We know diseases are spreading’

Although Mykhailiuk lives in Ukraine, her mother and the rest of her family live in Odessa, where she is originally from. During the UNITE event on Monday, December 5, Russian troops launched a missile attack on two infrastructure facilities in the Odessa region, leaving the region without power. She received a phone call from her older mother on Tuesday complaining that there is no electricity or warm water, and afraid for her life.

The extreme weather conditions for people without heat, proper clothing, blankets or access to supplies leaves them at risk of getting ill or even dying. Mykhailiuk said that flu and COVID-19 are a huge concern for the country.

Moreover, infectious diseases, cholera and dysentery are becoming widespread in the occupied territories, where Russian soldiers have slaughtered civilians and left them on the streets for the animals.

“Twenty percent of our territory is occupied,” Mykhailiuk told Health Policy Watch, “that is like the size of the whole of Bulgaria. We do not have access to these territories, but we know from witnesses the implications and we are recording the evidence.”

She said that in the city of Mariupol, located on the north coast of the Sea of Azov, the Russians were “killing people just for fun” and leaving them all lying all over the streets. “The animals started to eat them – the dead bodies in the streets. We were told the animals have gotten used to human meat.”

Mykhailiuk said many bodies remain decaying, their remains polluting the environment. Residents – the few that remain – have no access to drinking water, since the majority of the water infrastructure was destroyed. The sewage system is also not functioning.

“We know diseases are spreading, and there is no one to help them,” she said.

The MP called on the health community to help with desperately needed medical and other life-saving equipment. She said the country continues to have a shortage of medical supplies for chronic diseases, such as diabetes and for non-communicable diseases like cancer.

“These diseases are not put on hold because of war,” Mykhailiuk said. “So, people are dying. The death rate in Ukraine is now seven times higher than during the COVID-19 pandemic, and it is just because of natural diseases and because of stress.”

She said “any kind of medicine would be helpful … we have a desperate need for any kind of help.”

‘A black period of Ukrainian history’

A recent health needs assessment conducted by the WHO Country Office in Ukraine found that “spiraling costs, logistical hurdles and damaged infrastructure are making access to essential services all the more challenging for growing numbers of civilians.”

The survey found that one in three people living in temporarily occupied territories and active combat areas – in comparison to one in five people nationwide – had reduced access to services and medicines.

Specifically, around 50% of respondents said it was difficult to obtain medication for high blood pressure and for heart conditions. Another 41% of respondents said it was hard to access pain medication, 33% said it was hard to obtain sedatives and 32% said it was difficult to get antibiotics.

Mykhailiuk noted that local hospitals are looking for partner hospitals abroad to provide them with supplies. She highlighted a recent incident where an individual died during surgery because the power went out and there were no generators. The doctors could not complete their work with solely their surgical headlights.

Additionally, analyses by the World Bank and the United Nations Development Programme (UNDP) showed that the war could push 60% or more of the Ukrainian population below the poverty line.

“This is a black period of Ukrainian history,” Mykhailiuk said. “Only with international partners can we survive.”

She added that “time is of the essence” as winter races across the country and the cold weather threatens to take more lives.

“We will continue our resistance until we are victorious,” Mykhailiuk stressed. “We will not stop until we win.

“In these dreadful times, just having our bravery will not be enough,” she continued. “We see ourselves as defending the whole democratic community… The Russians should be held accountable, and international justice should prevail.”

Image Credits: Maayan Hoffman.

Spending on Health
A new WHO report shows rising health expenditure in 2020, the first year of the COVID-19 pandemic.

Spending on health increased worldwide by 6% on average in real terms in the year 2020, according to the World Health Organization’s latest global review of health finance.

The analysis found that global spending on health reached US$ 9 trillion in 2020, or 10.8% of global gross domestic product (GDP), but remains highly unequal across income groups.

But the 6% global increase is skewered by huge outlays in the United States, which is by far the biggest global health spender, said WHO’s Joe Kutzin, the head of WHO’s health finance team that authored the report.

In real terms, average country growth was more like 4% he noted in a series of Tweets following the reports publication.

And in contrast to previous WHO studies on health spending trends, this latest report only captures more detailed and granular spending patterns for 4 low-income countries and 11 middle-income countries. The remaining 29 countries analyzed are all high-income nations.

This means that global spending trends for health care remain difficult to analyse more granularly, WHO officials speaking at Thursday’s report launch event cautioned. With just 4 low-income countries reporting data, spending patterns in this income group in particular cannot be generalized.

“While we can put this together globally, to look at these patterns and trends, it’s not a substitute for the country-level work and analysis that’s needed,” said Kutzin. “We need to be careful in drawing conclusions about “the average country” given this limitation.

In contrast, a WHO study of data from 2018 found global health expenditures rose by 6% annually but noted that government spending on health in some poor countries was stagnant or even declining, with some pulling back funding due to greater reliance on donors.   A study of data from 2019 also found that high-income countries accounted for approximately 80% of global spending on health. 

Those report had more representative sample of rich, middle income and poor countries. But for the report released on Thursday, the interruptions in routine health system operations caused by the COVID pandemic made it difficult for low-income countries to report their data this year, leading to a heavy bias in findings in favour or rich countries, Kutzin and other panelists at the WHO launch event said.

“What we have for only 50 countries in 2020 is a detailed decomposition of spending by “health care function” (inpatient, outpatient, medicines, etc), and indeed it is skewed towards higher income countries,” said Kutzin in a follow up tweet. This underlines the need to improve data availability as the pandemic’s impacts wane.

More public spending possibly driven by the COVID response

Spending on Health
Government spending was the main driver of the increase in total health spending from 2019 to 2020. Per capita government spending on health increased in all income groups and rose faster than in previous years, according to the report.

In the countries where data was available, the growth in spending was largely driven by increased public expenditure, the report found.

​​”The whole growth of health spending is really driven by government spending,” said Dr Ke Xu, the report’s lead author. “This year it has grown much faster than previous years.”

While vaccines were not yet widely available in 2020, it is likely some of the increase in government spending was driven by the early stages of the COVID response. Early waves led to sharp increases in hospitalizations, a competitive dash for procurement of items from oxygen to PPE, and bidding wars over vaccine contracts.

Spending on COVID accounted for an average of 8% of public spending on health in 2020, but the type of COVID spending varies vastly among country income groups. 

“In high-income and some upper-middle-income countries, you have significant spending on treatment,” Xu said. “In low-income countries spending is mostly on other preventative measures.” 

These discrepancies are related to the capacity of countries of differing income levels to set up testing, contact tracing, and provide access to facilities and equipment capable of treating COVID patients. The data may also be influenced by the different approaches taken by countries to control the outbreak at the early stages of the pandemic when the nature of the virus was still unclear. 

Conversely, out-of-pocket spending per capita fell during the first year of the pandemic, which may reflect reduced health service utilization of out-patient services. Fear of the virus may have encouraged many patients to stay away from hospitals or seek care for basic illnesses, while many health systems were overwhelmed by the weight of the pandemic, leading to reduced capacity to treat other patients.

There was also increased government support for items like free PCR diagnostics for people with suspected COVID, potentially lifting financial weight from individuals. The team in charge of the report stressed that further research is needed to understand the whats, whys and hows behind the datasets provided. 

“We raise issues, and there are clearly hypotheses or questions that might arise from the data,” Kutzin said. “It’s our job to help sharpen those questions, but not really answer policy questions. It is more to provide a foundation so that those questions can be answered.”

Low income countries increased health spending 

While the sample size of low-income countries’ spending was limited to just 4 nations, the report tracks other finance indicators across a larger share of developing countries. Among them, health spending as a share of total government expenditure increased from 2019 to 2020 in all income groups except high income countries. 

This presumably reflects the greater resources countries had to allocate to COVID response. The spending increase is a welcome development, but panelists warned it is not guaranteed to be a sustained one.  “In times of crisis, governments find the money,” Kutzin said. “The challenge is to sustain that over time.” 

And among the poorest countries, private, out-of-pocket spending increases comprised the largest share of the pie. 

Low income countries continue to rely heavily on external aid to finance health spending.

Little change was observed in external aid funding levels, but it continued to play a critical role in funding health systems in low-income countries. The report found external aid accounted for 29% of health spending on average in the low-income countries that provided data, the same as in 2020. 

Per capita health spending derived from external aid increased by US$0.70 to $10.80 on average, slightly higher than government spending in these low-income countries, which sits at $9.20 per capita. 

Health priority rose sharply in low, lower-middle and upper-middle income countries in 2020

The report also noted the continued gap in spending on primary health care versus outpatient care between country income groups. WHO’s 2021 report found primary health care spending for low-income countries sits around 70% of total health spending, while in middle and high income countries, this is reduced to around 50% and 40% respectively. 

“In low-income countries, most of the spending goes to prevention, while in upper-middle income countries outpatient services take a large share of total government and donor spending” Xu said.

Prevention services include population-based services such as information campaigns like brochures or public messaging campaigns, epidemiological surveillance and individual services like immunization, and condition monitoring. 

Study first to include social spending as part of health spending 

Health priority rose sharply in low, lower-
middle and upper-middle income countries in 2020, the report found.

What the WHO finance report lacks in representative data-sets it makes up for in innovation. The 2022 report is the first to consider government spending on social programmes as a factor contributing to overall health outcomes. 

“Government spending on health does not exist in a vacuum,” the report said. “Health outcomes are also shaped by other social spending, particularly on education and social protection.”

The panel defined social protections as in-kind benefits provided to in-need individuals and households. These include standard benefits such as disability, sickness, and child support payments, and transfers and services provided on a collective basis in the form of pension schemes, unemployment assistance or public housing. 

“We saw in previous years that even if the share of health and overall government spending fell, it didn’t necessarily mean that health was losing its priority because social spending is also good for health,” Kutzin said. “For WHO it’s a big challenge, and not typical for us to stop beyond our sectoral silo, but I think this is important.” 

While Kutzin stressed the WHO is not planning to become experts in social protections, the added scope of the report aims to acknowledge that medicines and hospitals are not the only contributing factors to health outcomes in a given country. 

“Health outcomes are also determined by other social and economic sectors,” Xu said. Sometimes, a roof over someone’s head or an accessible education in health literacy can be just as impactful to improving a life as providing disease screening services. 

–Updated 9 December 2022 with further clarifications from WHO about the features of the global dataset.