Dr Mamy Andrianirina Rakotondratsara (centre) distributing antimalarials in rural Madagascar.

Malaria has long been at the heart of public health efforts in Africa. As a preventable but potentially fatal disease, it is caused by a parasite transmitted by mosquitoes. In 2022, the WHO African Region accounted for about 94% of cases globally. WHO says 78% of deaths in the region are among children under 5 years of age.

That’s why Dr Mamy Andrianirina Rakotondratsara, a medical doctor and research technician for Madagascar’s National Institute of Public and Community Health (INSPC), wanted to dedicate his TDR-supported studies for a Masters in Public Health to malaria research.

Originally from an endemic region in eastern Madagascar, Rakotondratsara has been personally affected by malaria as he lost his older brother to the disease. 

“I lost someone close and beloved to me from this disease,” he told Health Policy Watch in an interview. That reinforced his determination to address the disease in the course of his studies. 

Dr Mamy Andrianirina Rakotondratsara lost his brother to malaria and is passionate about addressing the disease.

In 2021, during the course of his Masters studies at the Cheikh Anta Diop University of Dakar (UCAD), Rakotondratsara  also completed TDR’s Massive Open Online Course (MOOC) on implementation research. 

As part of this course, he designed a study around the relationship between the frequency of malaria episodes and mosquito bed net coverage, working with other researchers and doctors that specialize in malaria. This research is still ongoing and specifically targets the rural population of Madagascar’s Anosibe An’Ala district. 

Although results are still pending, designing such a study has laid the foundations for Rakotondratsara to put the research findings into practice in his home region and disease context, complementing his prior work on malnutrition. 

Sub-regional training centre for Francophone Africa

Students engaged in a field training in participatory epidemiology organised by the  National Institute of Public and Community Health Madagascar.

Rakotondratsara was able to undertake this research thanks to TDR’s global postgraduate training scheme – which focuses on building students’ skills to do interdisciplinary forms of research that look at barriers and opportunities for better uptake of available preventative and treatment methods.

For physicians, researchers and other professionals interested in local public health, the fellowships supported by TDR – the global research programme on diseases of poverty co-sponsored by UNICEF, UNDP, WHO and the World Bank – provides essential skills for health programme management and implementation. It is particularly important for addressing infectious diseases affecting vulnerable and underserved populations and promoting engagement in research from the local to global levels.

UCAD is one of the two universities in French-speaking West Africa to collaborate with TDR in the programme. It has been hosting students since 2021, to conduct research into how to control infectious diseases found across the region. In 2022, University of Sciences, Techniques and Technologies in Bamako, Mali, joined the programme with the support of Germany’s Deutsche Gesellschaft für Technische Zusammenarbeit.

“The TDR training allowed us to have a new vision of the health system,” Rakotondratsara  observes.  It changed my way of asking questions when faced with poor health indicators. Regarding my Master’s thesis, it gave me an idea of issues to be explored in the mosquito net distribution process, starting with the quantification of needs to end point use.”

He strives to integrate such lessons learnt into his current role with the INSPC. And he is also planning to pursue a PhD with a specialization in implementation research.  

“The INSPC is a public health training and research institution attached to the Ministry of Public Health,” he explains. “Given that it is a research institution, in collaboration with funding bodies, we are often called upon to carry out expert appraisals on their behalf. As a research technician, I accompany this research and bring my contributions to it,” he says.

“Based on my experience, it’s my intention to ensure that implementation research finds an important place both in the research and the teaching context.” 

Towards better management of Schistosomiasis

Although less well known, schistosomiasis, also known as bilharzia, is the second most prevalent disease after malaria both in Senegal and much of the rest of sub-Saharan Africa.

Its most common form – urogenital schistosomiasis – can result in damage to the bladder, urethra, and kidneys. It is a parasitic disease that occurs in tropical and subtropical regions where there is limited access to clean water, particularly in the Senegal River Basin, a hyper-endemic region for several species of the parasite that causes the disease. 

The different variants of the disease are classified by WHO according to the NTD principles for which a greater global response is needed, making it an important research target in the TDR program.

Oumy Kaltome Boh, a physician originally from Dakar, has been interested in the burden of NTDs in Senegal since her formative years, and hopes to see their eradication by 2030.

Dr Oumy Kaltome Boh

“Faced with the impact of these diseases on the health of the population,” she says, her main objective is to contribute to their management “through the implementation of innovative interventions.” 

This is what led Boh to undertake a Masters degree in management of health programmes at UCAD, as well as an International Inter-University Diploma in emerging infections.  

Benefiting from a TDR grant in December 2020, Boh was able to conduct a study examining the day-to-day lifestyle practices and environmental factors that make schistosomiasis transmission more likely in endemic areas of her home country.

As part of this study, done in collaboration with Senegal’s national bilharziasis programme, she also aimed to verify the effectiveness of schistosomiasis treatment with praziquantel, the only available treatment option currently. A total of 287 children were followed over the course of three weeks, with ‘Day Zero’ representing the date of administration of a single praziquantel dose. Between days 14 and 21, both the effects of the drug on disease progression were assessed and a favourable efficacy profile was found, with a 98% reduction in parasite eggs by day 21.

Today, Boh holds the position of deputy chief medical officer in the health district of Saint-Louis, Senegal, and is mainly involved in care and prevention activities for people living with HIV or tuberculosis.

Recruited into this position by the Ministry of Health, she stresses that it was through the support of the TDR postgraduate training scheme that she acquired the skills she needed to manage the public health challenges in this district. In particular, learning about community-based approaches allowed her to better “understand the specific needs and problems” of the districts. 

New research and management approaches

As a key aspect of disease control, students supported by TDR can learn to apply new health research and management approaches previously unknown in Senegal, Boh says.

Among these is the One Health approach, which aims to assess how diseases emerge from a holistic and ecosystem-oriented perspective, taking into account the reciprocal role of humans, animals, plants, and microorganisms such as the aforementioned pests.

By combining scientific, strategic, and rigorous implementation training, the TDR grants offered through UCAD enable their recipients to evaluate and propose improvements to health interventions against poverty-related infectious diseases. 

These opportunities are game-changers for both UCAD students and the future of implementation research in French-speaking Africa. With the help of TDR grants, Boh emphasises, students can gain exposure to critical health programmes and “pool their skills in order to end the neglect of poverty-related diseases and to achieve the Sustainable Development Goals.”

This is the second article in a series on TDR’s research capacity strengthening programme – building skills of public health researchers, implementers, health practitioners and policy-makers in the fast-developing field of implementation research for improving uptake of effective health interventions.

None of the over 2,000 young women and girls injected twice a year with a new drug, lenacapavir, contracted HIV in one of the most important advances in HIV prevention.

Gilead Sciences announced these results last Friday, reporting that its Phase 3 PURPOSE 1 trial, conducted in South Africa and Uganda involving 2,134 women and girls aged 16-25, had been so successful that it was terminating early.

Its announcement has been widely hailed as a huge breakthrough in the HIV sector where a vaccine has been elusive, and a range of groups urged Gilead to priorise early access to lenacapavir.

The injectable was compared with Truvada and Descovy, two pills taken daily that have proven successful as pre-exposure HIV prophylaxis (PrEP). 

Sixteen of the 1,068 women in the Truvada group and 39 of the 2,136 women in the Descovy group contracted HIV during the trial. 

During a scheduled review of results, the trial’s independent data and safety monitoring board (DSMB) found the lenacapavir regimen was safe and highly effective. The trial, expected to run until September, was terminated early based on its success. Results of the trial have not been peer-reviewed yet.

The age group targeted by the trial is the worst affected by HIV in southern Africa. In 2022, over three-quarters of infections in 15 to 24-year-olds in the region were girls and women, according to UNAIDS.

“Every week, 4,000 adolescent girls and young women aged 15–24 years became infected with HIV globally in 2022, and 3,100 of these infections occurred in sub-Saharan Africa,” added UNAIDS.

One of the ‘most important results’

“This is one of the most important results we’ve seen to date in an HIV prevention study,” said Mitchell Warren, executive director of AVAC, a non-profit HIV prevention advocacy organisation.

“Adding additional HIV prevention options means more people may find an option that is right for them. Beyond expanded choice, a twice-yearly injection has the potential to transform the way we deliver HIV prevention to people who need and want it most – from an easier-to-follow regimen for individuals to a decreased burden on healthcare systems that are stretched to the limit.” 

Professor Linda-Gail Bekker, director of the Desmond Tutu HIV Centre in South Africa, said that the twice-a-year injectable could provide a “critical new choice” to prevent HIV.

“While we know traditional HIV prevention options are highly effective when taken as prescribed, twice-yearly lenacapavir for PrEP could help address the stigma and discrimination some people may face when taking or storing oral PrEP pills, as well as potentially help increase PrEP adherence and persistence given its twice-yearly dosing schedule,” added Bekker.

Gilead expects results by early 2025 from the programme’s other trial, PURPOSE 2, which is assessing twice-yearly lenacapavir for PrEP in men who have sex with men, transgender and non-binary people, currently underway in Argentina, Brazil, Mexico, Peru, South Africa, Thailand and the US. 

Access to lenacapavir, marketed as Sunlenca in the US, still needs to be worked out once it is approved by regulatory authorities.

Cost of access?

Lenacapavir (marketed as Sunlenca) was approved in the US in 2022  for “heavily treatment-experienced adults with multi-drug resistant  HIV-1 infection and for treatment of people living with HIV who have been on other HIV treatment regimes which are currently failing”.

However, Gilead charges $40,000 per patient per year in the US, reports aidsmap. 

When announcing the PURPOSE 2 results, Gilead acknowledged  the “importance of helping to enable access in order for twice-yearly lenacapavir for PrEP, if approved by regulatory authorities, to achieve the broadest impact”. 

“In light of today’s milestone and the company’s ongoing commitment to communities affected by HIV, Gilead intends to brief community partners and provide a public statement regarding its planned access approach for high-incidence, resource-limited countries, which are primarily low- and lower-middle-income countries,” said the company.

Gilead’s statement was welcomed by African HIV medicines access group AfroCAB in an open letter to its CEO, Daniel O’Day.

“Replacing 365 pills of oral PrEP with just two injections is a life-changing transition and urgently needed option, as millions of our brothers and sisters, friends, and neighbours face challenges of stigma, pill burden, and adherence, leaving them unprotected against HIV acquisition,” said AfroCAB.

“To forge a new pathway forward for [lenacapavir], we call on stakeholders to act now. After thousands of our community members have taken part in clinical trials for LEN and other injectable PrEP products, it is time that pharmaceutical companies, governments, and donors play their part in driving access among the communities that supported the science.”

“We expect to see a timeline that takes into account a full analysis of PURPOSE 1 data and the coming data from PURPOSE 2 from Gilead as soon as possible, and we urge regulatory agencies to prepare to fast track regulatory review,” Warren added.

“We also call on [the World Health Organization] to be prepared to quickly include lenacapavir, if approved by regulatory agencies, in HIV prevention guidelines. There is no time to waste if we are to translate these exciting clinical trial results into actual public health impact and expand the toolbox of HIV prevention choices.”

Meanwhile, Unitaid urged Gilead to make access to lenacapavir a priority, calling for “the terms of their access strategies – including any voluntary licensing agreements – [to be] transparent, global health-oriented, and equitable”.

“Lack of prompt and broad action would jeopardise translating the clinical trial results into real-life impact,” said Unitaid, which offered to work with Gilead to enable access, including “quality-assured, low-cost generics”.

“Unitaid is dedicated to leveraging its recent investment through the Wits Reproductive Health and HIV Institute to facilitate market shaping interventions on long-acting PrEP options (in partnership with the Clinton Health Access Initiative), as well as its continued support to enabling elements such as the key work of WHO and the WHO Prequalification program, the Medicines Patent Pool and other intellectual property grants, to ensure access to this life-saving product is as broad as possible,” the organisation said in a statement last week.

Image Credits: Gilead, Diana Polekhina/ Unsplash.

A member of the ring vaccination team vaccinates a man in Bosolo village. Vaccines offered as part of Gavi’s portfolio now also include preventive Ebola vaccines for care workers.

Gavi, the Vaccine Alliance, announced last week that it will offer high risk countries the option of obtaining preventative Ebola vaccines, particularly for health workers, as part of the rollout of new vaccine offerings, which also include  meningitis, rabies and hepatitis B vaccines.

Plans to add the vaccines to the basket of available products were initially drawn up before the  COVID-19 pandemic, but put on hold due to lack of appropriate supply or regulations, with applications opening only now to eligible countries.

“Gavi’s ability as an alliance to protect health and save lives hinges on its ability to ensure vaccines are accessible, as quickly as possible, to those who need them the most,” said Gavi CEO Dr Sania Nishtar. “The new programmes launching today demonstrate the impact of this work.” 

Ebola is a rare but dangerous viral disease, with a 50-60% mortality rate. Infections may be transmitted through close contact with infected animals – for instance, fruit bats – but also through human-to-human contact. 

Gavi first offered Ebola vaccine candidates to health workers and suspected Ebola contacts during the 2014-2016 West Africa outbreak as an outbreak response. 

Two vaccines subsequently received regulatory approval and in May 2024 WHO’s Strategic Advisory Group of Experts on Immunisation (SAGE) decided to recommend the vaccines for preventive use, as well, in high-risk groups, such as health care providers in areas of endemic transmission.

Meningitis vaccine rollout aims for elimination

Gavi will also roll out a newly-approved vaccine for five strains of meningitis: meningococcal serogroups A, C, W, Y, and X. 

Central and Western African countries most prone to meningitis infections in the so-called “meningitis belt”

The vaccine is a likely game-changer in the fight against the disease, experts say, noting that in the so-called “meningitis belt” of sub-Saharan African countries, the bacterial form of the diseases, regarded as the most dangerous, could potentially be eliminated. 

The product, MenFive, received WHO pre-qualification in July 2023 and has already been implemented in standard childhood immunisation programmes in Nigeria and Niger.

In 2019, there were about 236,000 meningitis deaths, with the greatest burden in children younger than five years, with 112,000 deaths.

Hepatitis B and rabies post-exposure jabs

Other new vaccines include hepatitis B vaccines for newborns, granting infants critical additional protection in their first months of life, when they are at high risk of infection: including from maternal transmission.

According to Gavi, nine out of ten infants infected with hepatitis B will develop chronic forms of the disease, while a quarter develop severe liver disease, which currently kills 884,000 people a year.

Human rabies post exposure prophylaxis (PEP) vaccines are the last of the new package. 

The initiative aims to build more stockpiles of the rabies vaccine, which are often scarce and inaccessible, especially in remote areas, for post-exposure use. 

Rabies, which has an almost 100% mortality rate, remains a serious health problem in some 150 countries, where it is transmitted by infected dogs.

But vaccines alone are not enough to stop the disease, experts underlined. 

“To stop human rabies deaths completely, we urgently need better data and surveillance, dog populations must be vaccinated, and people must be educated about what to do if bitten, and how to avoid being bitten in the first place,” said Professor Lucille Blumberg, Chair of United Against Rabies, pointing out to several blind spots of the human immunisation programme.

Image Credits: WHO/L. Mackenzie , CDC.

The latest episode of the Global Health Matters podcast, hosted by Dr Garry Aslanyan, delves into the extraordinary careers of two global health leaders and the crucial role that capacity development has played in their journeys.

This episode, produced to celebrate the 50th anniversary of TDR, the Special Programme for Research and Training in Tropical Diseases, features insights from Dr Wilfried Mutombo, Head of Clinical Operations at the Drugs for Neglected Diseases Initiative (DNDi) in the Democratic Republic of the Congo, and Dr Yasmine Belkaid, President of the Institut Pasteur in France. Both leaders share their experiences and the impact of TDR’s support on their professional growth.

Dr John Reeder, the Director of TDR, reflects on the importance of capacity development in fostering the potential of researchers in low- and middle-income countries. Reeder highlights his transition from hands-on research to global leadership, emphasising the value of putting research into action and nurturing talent at the grassroots level.

He underscores that effective capacity development goes beyond providing resources; it involves empowering individuals to fulfil their potential and significantly contribute to their fields.

“When you’re looking at science and laboratory science particularly, people get fixated on the expensive equipment and the fancy technology that surrounds this,” Reeder says. “But the most important investment in a laboratory is the scientist who is in that laboratory because, all other things aside, the ability to see the problem, think of innovative solutions to test them critically and to have the open mind to be able to see the discovery coming through that, you invest in that, and you’ve got great science.”

From left: Dr John Reeder, the Director of TDR; Dr Yasmine Belkaid, President of the Institut Pasteur in France; and Dr Wilfried Mutombo, Head of Clinical Operations at the Drugs for Neglected Diseases Initiative (DNDi) in the Democratic Republic of the Congo
From left: Dr John Reeder, the Director of TDR; Dr Yasmine Belkaid, President of the Institut Pasteur in France; and Dr Wilfried Mutombo, Head of Clinical Operations at the Drugs for Neglected Diseases Initiative (DNDi) in the Democratic Republic of the Congo

Clinical Trials in Remote Areas: Three Challenges

Mutombo’s story is a testament to the transformative power of research capacity development. Starting as a medical doctor in a small village in the DRC, Mutombo faced the challenge of treating sleeping sickness with toxic drugs. His clinical research fellowship from TDR enabled him to lead the first clinical trial in the DRC for fexinidazole, a safer oral drug for sleeping sickness. He discusses the immense challenges of conducting high-quality clinical trials in remote areas with inadequate infrastructure and highlights the importance of sustained support and training for local health workers.

“The first challenge is to reach those areas because to perform a clinical trial, you need to go there in those areas, in those remote areas, and as you may know, we have bad roads, and sometimes this is not very safe,” Mutombo says. “The second challenge is, when you are in those areas, you can imagine in what state those health facilities are… So we had to improve these health facilities.”

Another challenge, he says, is the health workers.

“Health workers are there, but they are not aware of what a clinical trial is,” according to Mutombo. “To have a high-quality clinical trial, they needed to train them and have a very, very close supervision of their activities. So we organised all this.”

Finally, “We need our governments … to give more support and more money to maintain those facilities. This is very important for the government because the first and very important step has been done, but now we need to maintain them at that level.”

Building Research Capacity: Support is Crucial

In many ways, Belkaid’s journey from Algeria to leading the Institut Pasteur in France exemplifies the global impact of TDR’s fellowships. She speaks about the crucial support she received, which allowed her to pursue her PhD and establish a notable research career.

Belkaid emphasises creating environments that nurture talent and passion, enabling researchers to address pressing global health issues. Her vision as President of Institut Pasteur includes fostering international collaboration and continuing to build research capacities that can address future health challenges.

Belkaid says if there is anything she can do over the next few years, it will hopefully be helping in any way she can to grow and nurture the leaders of tomorrow internationally.

The episode underscores the ongoing need for international organisations like TDR and WHO to prioritise capacity building in low- and middle-income countries.

Reeder points out the shift towards in-country training and the importance of sustainable research systems driven by local needs and priorities. He says this approach helps ensure research capacity development and is not just about immediate results but about long-term, sustainable growth that empowers countries to tackle their health challenges effectively.

Read related Inside View by Dr John Reeder.

Listen to the Global Health Matters podcast on Health Policy Watch.

Visit the podcast website.

Image Credits: TDR.

Ted Herbosa, Health Secretary for the Philippines

A tax on tobacco and alcohol in the Philippines resulted in a sixfold increase in the country’s health budget as well as a drop in consumption of the harmful products, Ted Herbosa, the country’s health secretary, told a meeting on non-communicable diseases (NCD) and financing on Thursday.

“It increased the health budget by six times from 1.8% to 5.8% of GDP, so we were able to infuse money into the healthcare system to be able to care for the poorest populations,” Herbosa told an international financing dialogue for NCDs and mental health, hosted by the World Health Organization (WHO) and the World Bank in Washington DC. 

The two-day meeting aims to generate consensus about how best to finance effective strategies to tackle NCDs and mental health. It is part of the build-up to the United Nations High-level Meeting on these issues in 2025.

Excise taxes on harmful products is one of the WHO’s package of 88 “best buys” to tackle NCDs – but countries should prioritise which of these will work best for the NCDs they face, said Bente Mikkelsen, WHO director for NCDs.

However, Mikkelsen appealed to countries to focus on diagnosing hypertension, a major cause of cardiovascular disease (CVD), which causes around a third of global deaths. Less than half of those living with hypertension have been diagnosed, yet testing is cheap and easy to do, she added.

Despite three prior high-level meetings on NCDs, only a handful of countries are on track to meet global targets to reduce these. A mere six countries are on track to reduce NCD mortality, for example.

In some countries, death rates due to NCDs have increased and millions of people, especially in lower-income settings, lack access to interventions that could prevent or delay NCDs, mental health conditions, and their consequences. 

Phased approach

Countries at the meeting shared some of their insights and experiences, stressing political will, multi-sectoral collaboration and the importance of sustainable domestic financing for NCD prevention and care services. 

In 2018, Egypt started to phase in universal health care (UHC) starting with a pilot of one million people in a single city with all citizens contributing to a special health insurance fund based on their income.

Some six million Egyptians are covered out of the total population of 100 million, and the country expects to cover all citizens by 2030.

“My advice is not approaching everything at once,” said Radwa Iman from Egypt’s health promotion department.

Egypt’s Radwa Iman

“Actually 85% of our mortality rate was due to NCDs in 2018. Now all our chronically ill patients [covered by UHC] get monthly medications from the primary healthcare facilities. They have medical files. They have regular checkups, and we have annual checkups for the citizens to screen earlier for any medical problems so we can find them in the early stage instead of getting complications.”

Ala Nemerenco, Moldova’s health minister, said that her ministry was largely funded by health insurance contributions, which enabled flexibility as money could be redirected fairly easily.

“Moldova was coming from a post-Soviet system, where for mental health, everything was about hospitalisation,” said Nemerenco. Over several years, the country has  integrated mental health care into primary health care, where family doctors work with nurses and social workers to address mental health.

However, Moldova’s health facilities are being strained by Ukrainian refugees who are in need of mental health support as they flee Russian aggression.

“One year ago, we approved one year ago a national programme on mental health care services. We approved by the government programme on NCDs, including cardiovascular, cancer and diabetes. We now are working on a cancer registry and early detection, screenings and programmes,” she added.

Fiji, with a high burden of NCDs in its population of about one million scattered over 300 islands, has invested in health promotion in schools to prevent NCDs.

Mental health out in the cold

Devora Kestel, WHO Director of Mental Health and Substance Use, appealed for the mental health focus to cover the full spectrum of life – from child and adolescent mental health to dementia in old age.

Devora Kestel, WHO director of mental health.

Kestel described investment in mental health as “totally inadequate”, usually comprising 1-2% of the health budgets in low and middle-income countries, with “70% of that budget in many countries going to old fashioned [mental] institutions”. 

“Even in high-income countries, 50% of the people affected by depression will not have access to care. In low-income countries this is 90%,” she said.

“We need health system financing reforms that are part of a universal health coverage approach and that need to be adequately targeted to answer to the mental health and NCD agenda. 

“We have evidence, we have good ideas, we know what works and what doesn’t. We need to make sure that they become a common practice everywhere.”

The meeting continues on Friday.

Sania Nishtar, Gavi’s CEO, during the Global Forum for Vaccine Sovereignty and Innovation in Paris

Gavi has already raised $ 2.4 billion of the $9 billion it needs to finance its operations between 2026 and 2030, the global vaccine alliance announced at Global Forum for Vaccine Sovereignty and Innovation in Paris on Thursday.

The Forum, co-hosted by France and the Africa Centres for Disease Control and Prevention (Africa CDC), also marks the launch of the African Vaccine Manufacturing Accelerator (AVMA) to promote regional vaccine production.

AVMA already has financing pledges of “at least $1.2 billion”, already exceeding the initial benchmark of $1 billion, said Gavi CEO Sania Nishtar.

 

When talking about AVMA, “we are not just talking about money. We are talking about people, who […] start to dream, to see Africa manufacturing our own vaccines,” highlighted Africa CDC Director General Dr Jean Kaseya.

Reaching zero-dose children and expanding vaccine portfolio

In the coming strategic period, Gavi plans to add new vaccines to its portfolio, prioritise “zero-dose” children who have not received any vaccines and speed up its operations to double the recent achievement of a billion vaccinated children from 2000 to 2020 in half the time.

The bulk of its pledges – $1.58 billion – have been promised by the US. However, Gavi has about 18 months to finalise its current financing period and fine-tune the details of its plan for the years ahead. 

In the 20 years of its existence, Gavi has saved 17 million lives, said Nishtar, all while maintaining a $54 return on every dollar invested. 

Panelists during Gavi’s replenishment launch: Sania Nishtar, Gavi’s CEO, Christophe Guihou, representing the French government, Jean Kaseya, Director General of Africa CDC

The organisation asserts that it is on track with its 2025 targets despite the pandemic disruptions.  

Its aims for the next period are more ambitious, such as extending the availability of  new Ebola, meningitis, rabies and hepatitis B vaccines, put on hold because of the COVID-19 pandemic, regulation, or supply issues.

Decentralising vaccine production

With AVMA, Gavi is turning to regional vaccine manufacturing instead of working with the biggest producers to get low prices per dose.

This will initially cost more, but the imperative for regional production to safeguard all parts of the world became evident during COVID-19, as vaccine-producing countries prioritised jabs for their own populations, leaving Africa behind.

Many European countries, for instance, accumulated more vaccines than they would use – on average, 0.7 dose wasted per resident – at the time when some regions in Africa did not have enough jabs for health workers, Health Policy Watch reported.

Per capita COVID-19 vaccine doses wasted by European countries: 0.7 on average

In response, the African Union announced a target of producing and supplying more than 60% of the continent’s vaccine requirements by 2040.

Africa is home to 20% of the world’s population and yet, it constitutes only 0.1% of the global vaccine production. Though vaccine hoarding was not addressed openly during the launch, the pandemic has shown that local vaccine manufacturing is key for obtaining the doses in time.

AVMA is meant as a catalyser for more investments in vaccines and drugs in the region. “I saw in so many people announcing now additional support around AVMA,” highlighted Kaseya. “For me, is a success story.”

AVMA is an innovative investment tool that will offer incentive payments to offset some of the initial high costs of production, with specific caps and categories designed to ensure priority vaccines receive adequate funding and that no vaccine type or manufacturer is overrepresented. 

The minimum goal is to support at least four African vaccine manufacturers and produce over 800 million vaccine doses over 10 years.

“The launch of the AVMA represents a groundbreaking financing instrument, to help both catalyze vaccine production within Africa and bolster global health resilience and equitable access to vaccines,” said Greg Perry, Assistant Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA).

“The pharmaceutical industry is committed to playing our part in the collective efforts to […] equitable access to innovative vaccines.”

Image Credits: Politico.

Long queues for passports make it more difficult for healthcare workers to emigrate.

HARARE, Zimbabwe – After a decade of service as a nurse in the public sector and very little to show for her years of toil, Letina Chiwongotore has thrown in the towel.

The 35-year-old is packing her bags for the UK, no longer able to bear mounting economic hardships.

Nurses, doctors, pharmacists and other healthcare staff have been fleeing for several years to escape low salaries and poor working conditions in a country that seems unable to overcome its economic problems. 

Earlier this year, the Zimbabwean government converted the $300 COVID allowance it had been paying to nurses to a permanent salary. Nurses now take home an average of $255 every month after tax. 

The payment in US dollars, although small, has been welcomed by the Zimbabwe Nurses Association (ZINA) as nurses had previously been paid in local currency. With hyperinflation, the local currency had almost completely lost its value, rendering the nurses’ salaries and pensions of retired nurses virtually worthless.

People queue to draw money as the cash crisis in Zimbabwe shows no signs of improving.

However, this salary is substantially lower than that paid back in 2018 when nurses received $540. Meanwhile, civil servants’ organisations estimate that the minimum wage should be $840.

Years of brain drain

Zimbabwe’s health care system has been crumbling under the strain of decades of brain drain, fuelled by economic and political instability since the late 1990s, which has caused high inflation and the collapse of the local currency.

Health workers’ salaries have not been spared the inflation amid currency woes, forcing many professionals to migrate in search of better opportunities abroad.

By 2000, 51% of Zimbabwe’s doctors and 25% of its nurses were already practising abroad. By 2019, the UK’s National Health Service employed 4,049 Zimbabwean healthcare professionals including doctors, nurses and clinical support staff.

As if that was not enough, more than 4,000 health workers, including more than 2,600 nurses, left Zimbabwe in 2021 and 2022 alone, according to official statistics. 

Aside from the UK, health workers have sought employment in Canada and Australia.

Between September 2022 and September 2023, some 21,130 Zimbabweans were given visas to work in the UK, many of those being nurses and care workers, according to that country’s Home Office data.

Late last year, the World Health Organization (WHO) went on record, saying that 4,600 Zimbabwean health workers had left the country since 2019.

Crippling effect on health

The brain drain of health professionals from Zimbabwe has had a crippling effect on the country’s public health system and on health outcomes.

For example, in 2021 life expectancy was 58.5 years, a two-year drop from the already low 60.7 years in 2019, according to WHO figures. This is also lower than the average life expectancy for Africa, which was 63.6 years in 2021.

WHO data (2021)

The growing shortage of healthcare workers is endangering the lives of patients in hospitals that are already poorly equipped.

HIV, respiratory tract infections and neonatal conditions –  mostly preventable and treatable – are the three biggest killers. Tuberculosis infection has worsened since 2021. Infectious diseases, maternal, perinatal and “nutritional conditions” including malnutrition are responsible for 47% of deaths. However, non-communicable diseases are on the rise, accounting for almost 40% of deaths.

The few Zimbabwean nurses that remain in the country’s crumbling healthcare facilities are having to attend to ballooning numbers of patients. 

This has caused a domino effect, accelerating the exodus of health workers who cannot manage the work load and face daily demoralisation in under-resourced facilities.

Melina Chiwara, a 28-year-old nurse, says that she is struggling to cope with the growing workload and deteriorating working conditions.

Chiwara, like thousands of others who have left the southern African nation, says that she too will soon join the quest for a better life abroad as she can no longer manage.

Government withholds proof of qualification 

Desperate to stem the brain drain, the government has resorted to withholding the verification letters that thousands of nurses and doctors need to secure jobs abroad. These letters confirm health workers’ qualifications.

In addition, it is time-consuming and costly to get a passport.

Incensed by the ongoing recruitment of health workers by wealthy countries, Vice President Constantino Chiwenga threatened legal action last year against the recruiting countries.

“If one deliberately recruits and makes the country suffer, that’s a crime against humanity. People are dying in hospitals because there are no nurses and doctors. That must be taken seriously,” said Chiwenga.

However, despite the challenges, many qualified health workers are still opting to leave, taking lower-paying jobs as care workers in the UK in particular, as these jobs will enable them to support families back home.

“I will be going to the UK because I can’t keep on offering my nursing services for peanuts. I am tired. If I don’t get all my relocation papers in order, I will settle for any dirty job in the UK and at least earn something [more] meaningful than remaining in this jungle,” Chiwongotore told Health Policy Watch.

‘The heart belongs at home’

Nurse Setfree Mafukidze relocated to the UK three years ago with his wife and four children. For years, Mafukidze had toiled at a clinic in Chivhu, a town located approximately 140 kilometres south of the Zimbabwean capital, Harare.

Now living in Somerset in the UK, Mafukidze asserts that “most nurses are better off outside Zimbabwe than they were in Zimbabwe.” The starting salary is around $34,000 per month.

“Nurses earn enough to survive within the UK because most of the nurses are not required to pay school fees for their children if they have any,” said Mafukidze.

“They don’t need to pay for healthcare services either unless one chooses to go private.  The normal healthcare services here are always free for nurses, while in Zimbabwe if a nurse falls sick, you need to do crowdfunding to help them – yet they are the people that sustain the healthcare,” said Mafukidze.

Since Zimbabwe was placed on the WHO ‘red list’ of countries with critical health worker shortages, the UK has stopped recruiting its health workers.

News of not-so-rosy conditions have also started to filter back to remaining health workers.

“It’s unfortunate that, with the UK now being flooded by migrant healthcare workers, shifts for care workers are now scarce. I have heard of inflation and increased cost of living there as well. I no longer see myself leaving any time soon,” said Warren George, a 30-year-old nurse who has opted to stay in the country.

For those nurses already abroad, even as they pride themselves after fleeing from Zimbabwe, they remain attached to their country despite the odds.

“The heart belongs home. Most nurses and doctors want to be home, but home doesn’t provide the tools for the trade. Home doesn’t provide good mental care to its workers,” said Mafukidze.

Image Credits: WHO.

WHO Regional Director for Africa Dr Matshidiso Moeti.

Five male candidates are contesting to be the next regional director for the World Health Organization’s (WHO) African Region.

One of them will replace Botswana’s Dr Matshidiso Moeti, who has served two terms in the position and is not eligible for re-election. Moeti, who was appointed in 2015, has overseen WHO’s operations through trying circumstances, including Ebola outbreaks and the COVID-19 pandemic.

Two of the candidates are currently employed at WHO headquarters, while a third is also based in Geneva.

Senegalese Dr Ibrahima Socé Fall, who has been proposed by his home country, is currently the WHO director of Global Neglected Tropical Diseases (NTD). Prior to this, he was WHO Assistant Director General for Emergency Response, appointed a year before the COVID-19 pandemic (in March 2019), where he led WHO’s global response to all emergencies, heading the incidence teams.

Dr N’da Konan Michel Yao, proposed by his home country Côte d’Ivoire, has been WHO Director of Strategic Health Operations since August 2020, where he coordinates the body’s response to health, natural and humanitarian disasters.

Dr Richard Mihigo, proposed by Rwanda, is also based in Geneva where he has worked for Gavi, the vaccine alliance, since 2022. He is currently senior director of programmatic and strategic engagement with the African Union and Africa CDC. Prior to this, he was Gavi’s  global lead and senior director for COVID-19 Vaccine Delivery, Coordination and Integration.

Dr Boureima Hama Sambo, proposed by Niger, is WHO’s Representative to the Democratic Republic of the Congo as Head of Mission. He has previously worked at the WHO headquarters on climate change.

Dr Faustine Engelbert Ndugulile, proposed by Tanzania, was that country’s Minister for Communication and Information Technology between December 2020 and September 2021 and has also served as a deputy minister of health.

The Regional Committee of WHO African Region will vote for the next regional director in a closed meeting from 26 – 30 August in Brazzaville in the Republic of Congo.

Their nomination will be submitted to the WHO Executive Board meeting in January 2025. The newly appointed director will take office in February 2025 for a five-year term and be eligible for reappointment once.

Image Credits: WHO.

Air pollution in Shanghai, China

The fifth State of Global Air report shows air pollution is now the second-leading risk factor for death globally, after high blood pressure. Most of the deaths are from non-communicable diseases (NCD). The report has a silver lining about lives saved which shows how there’s been a large drop in the death rate of children

Almost 2,000 children under the age of five die every day because of air pollution, according to the latest State of Global Air (SoGA). Yet, the annual total of 700,000 deaths is a fraction of the 8.1 million lives lost because of air pollution. While there is a silver lining that some progress has been made, SoGA has several messages of concern for governments and citizens, especially parents. 

The report looks at deaths and health impacts caused by three pollutants: fine particulate matter (PM 2.5), household air pollution, and ozone (O3). It also looks at nitrogen dioxide (NO2), which causes childhood asthma, particularly for infants and toddlers. The study underscores how traffic exhaust, a major source of NO2, can make children acutely ill with long-term consequences. 

“Children are particularly susceptible to the health effects of air pollution, especially since their organ systems, including lungs, are still developing. To the extent possible, efforts should focus on reducing children’s exposure to air pollution.

A recent systematic review reported that exposure to traffic-related air pollution could result in asthma onset as well as acute lower-respiratory-tract infections in children,” Dr Pallavi Pant, head of Global Health at Boston’s Health Effects Institute (HEI), told Health Policy Watch. 

The SoGA report is a joint effort by HEI and UNICEF. It is a detailed analysis of recently released data from the Global Burden of Disease study from 2021.

Nine out of 10 deaths are caused by the tiny PM 2.5 particles. These enter the lungs and then the bloodstream, increasing the risks of NCDs in adults like heart disease, stroke, diabetes, lung cancer, and chronic obstructive pulmonary disease (COPD). 

The report exposes climate inequities as developing and low-income nations have the highest number of deaths. It also underscores how PM 2.5, the most-tracked air pollutant, is linked to greenhouse gases which are warming the world. The sources of both are largely the same – burning fossil fuels and biomass, particularly coal-fired power plants and transportation, and wild and farm fires. The most vulnerable populations are disproportionately affected by both climate hazards and polluted air.

India, Nigeria, and Pakistan top list of child air pollution deaths

Of the 700,000 child deaths are due to air pollution, and almost half a million are due to household pollution. The air pollution-linked death rate in children under the age of five in East, West, Central and southern Africa is over 100 times higher than their counterparts in high-income countries. There are two deaths per 100,000 of the population in rich countries, but the death rate in Africa’s children is 210/100,000. 

The highest number of children dying of air pollution is in India, Nigeria and Pakistan. The reason is largely pollution within households burning polluting fuels such as coal/charcoal, wood, animal dung, agricultural residue etc. 

In India over 169,000 children are estimated to have died in 2021 because of air pollution, that is more than one death every four minutes. Nigeria’s toll is over 114,00, and Pakistan’s over 68,000. 

“Despite progress in maternal and child health, every day almost 2,000 children under five years die because of health impacts linked to air pollution,” said UNICEF Deputy Executive Director Kitty van der Heijden.

“Our inaction is having profound effects on the next generation, with lifelong health and well-being impacts. The global urgency is undeniable. It is imperative governments and businesses consider these estimates and locally available data and use it to inform meaningful, child-focused action to reduce air pollution and protect children’s health.”

Globally, air pollution is only second to malnutrition in terms of risk factors for child deaths. The report points out that children are uniquely vulnerable to air pollution. The damage from air pollution can start in the womb with health effects that can last a lifetime. Children inhale more air per kilogramm of body weight and absorb more pollutants relative to adults while their lungs, bodies, and brains are still developing.

Countries with the highest air pollution deaths 

The total number of deaths linked to air pollution was 8.1 million in 2021, which is one out of every eight deaths globally. This is more than any previous year, which indicates that the disease burden of air pollution continues to rise.

The top 10 countries account for about 70% of all global deaths which includes two hundred countries and territories. 

The two countries with the most such deaths by far are China (2,349,332) and India (2,087,016), which is about 4 deaths a minute due to air pollution.

Air pollution is second only to high blood pressure as a global risk factor for death, except in South Asia where air pollution is the biggest cause of death. 

Most of the global deaths – 7.8 million, or nine out of every 10 – are because of PM 2.5 or ambient air pollution. As the report points out, nearly all of the world’s population lives in areas with unhealthy air. Among the key air pollutants that are currently measured, long-term exposure to PM 2.5 is the most consistent and accurate predictor of poor health outcomes across populations. 

Ozone and NO2: Traffic exhaust a threat to humans 

Apart from PM 2.5 and household pollution, the third cause of death the report examines is ozone (O3). Ground-level ozone is not emitted but it is a product of traffic exhaust, in particular nitrogen dioxide, and warmer temperatures in the presence of sunlight. That’s why, for example, during heatwaves, there is a higher level of ozone in place with heavy traffic from where it can travel long distances. It is also a greenhouse gas. 

For humans, O3 increases the risk of both acute and chronic respiratory illnesses such as COPD. The chances of fatalities are higher among those vulnerable, the sick, and the elderly. The report estimates that in 2021, long-term exposure to ozone contributed to an estimated 489,518 deaths globally, including 14,000 ozone-related COPD deaths in the United States, higher than in other high-income countries. 

However, now ozone is also a rising threat in developing nations as well. SoGA notes that countries including India, Nigeria, Pakistan, and Brazil have experienced increases of more than 10% in ambient ozone exposures in the last decade. 

As the table below shows, while the overall number of air pollution deaths has increased since 1990, this has mainly happened because of a rise in PM 2.5 and ozone (which in turn is produced by, among other factors, nitrogen dioxide from burning fossil fuels in vehicles, etc.) Deaths due to household air pollution declined largely thanks to the use of cleaner cooking fuels. 

Traffic triggers childhood asthma

While the current SoGA report has not looked at deaths attributable to nitrogen dioxide (NO2), exposure has been linked to a variety of health effects, including asthma and other respiratory diseases. As with ozone, the highest exposure to NO2 is in countries with high socio-development index, for example, Canada, Japan, and Singapore. But the exposures are declining because of policy actions like switching to more public transport and electric vehicles. 

Traffic is a major source of NO2 and its concentration is typically highest in urban areas, even though there are other sources of the gas such as power plants, industrial units, and agriculture. Pinpointing the traffic patterns and other factors that lead to spikes in NO2 pollution can help cities identify effective ways to control NO2 and reduce exposure.

Some ‘good news’

SoGA has emphasised that there is some “good news.” Since 2000, the death rate linked to children under five has dropped by 53%, due largely to efforts aimed at expanding access to clean energy for cooking, as well as improvements in access to healthcare, nutrition, and better awareness about the harms associated

with exposure to household air pollution. Although the report has not gone into the effects of specific schemes, India, which has the largest number of child deaths, launched the Ujjwala programme to provide cleaner cooking gas to low-income families. 

The reports authors are clear that air quality actions help. In under-served regions like Africa, Latin America, and Asia, steps can include installing air pollution monitoring networks or low-cost sensors, implementing stricter air quality policies, or switching to hybrid or electric vehicles. 

Arsenal of data 

Scientific studies over several decades have established that air pollution is associated with impacts on every major organ system in humans. While earlier ones looked at the more obvious connections with heart and respiratory issues, more recent ones are exploring the link with diseases such as Alzheimer’s and other neurodegenerative diseases. 

Breathing polluted air for months or years can lead to illness and early death from heart and lung diseases and diabetes, and increase the likelihood of adverse birth outcomes including preterm births, stillbirths and miscarriage. SoGA is the latest of several scientific studies that have conclusively demonstrated the vast health and economic benefits of slashing emissions from burning fossil fuels and biomass.

There’s enough in this arsenal of air pollution data for policymakers especially in the worst-hit countries to step up action quickly. Will they?

Image Credits: Unsplash.

Researcher explores evidence around the wildlife-trade- pandemic nexus

The world lacks the funds, political will and appropriate global platforms to tackle the next pandemic – and the World Health Organization (WHO) should possibly be split into two entities, with one focusing solely on health emergencies.

This is according to a new report by former New Zealand Prime Minister Helen Clark and former Liberian president Ellen Johnson Sirleaf, former co-chairs of the Independent Panel for Pandemic Preparedness and Response.

“If there were a new pandemic threat today, such as if H5N1 began to spread from person to person at scale, the world would likely be overwhelmed again. We just aren’t equipped enough to stop outbreaks before they spread further,” according to Clark speaking at an event to release the report hosted by Club de Madrid.

The report, No time to gamble: Leaders must unite to prevent pandemics, takes stock of progress made to implement recommendations made by the Independent Panel to the World Health Assembly in May 2021, following its eight-month review of the global response to COVID-19. 

“We were clear in 2021 at the height of COVID-19, that leaders needed to act urgently to make transformative changes to the international system so that there would be a new approach to funding, new ways of managing equitable access to products like vaccines, therapeutics and tests, and a new Framework Convention at WHO to complement the rules for outbreaks and pandemics,” said Clark 

“Instead of taking action to prepare for the next major outbreak, leaders have turned away from pandemic preparedness. This is a gamble with our futures,” write Clark and Sirleaf in the report. 

Clark decried the lack of funds to pandemic-proof the world, how “high-income countries are holding on too tightly to traditional charity-based approaches to equity”, and that there was still no pandemic agreement after two-and-a-half years of negotiations.

“A new agreement must be successfully concluded. But the world can’t wait for its adoption or for the ratification required from 60 countries – an effort that could take three or more years,” the report notes.

“There must be action now – to close the gaps that put eight billion people at risk of a new pandemic. The recent jump of the avian H5N1 virus to more mammals – including new human cases transmitted from cattle in the United States – portends an influenza pandemic the world is nowhere near ready to manage.”

However, Clark said there had been some “encouraging developments” such as the amendments to the International Health Regulations.

Sirleaf was not present as she was attending the funeral of her son, Charles.

Helen Clark. former co-chair of the Independent Panel.

Controversial proposal to split WHO

The report notes that 40% of the WHO’s operational spending goes on emergencies, including on the delivery of supplies, and this is “far outstripping” spending on important issues such as universal health coverage, non-communicable diseases and the social determinants of health. 

However, the WHO’s “focus should be on high-quality normative and technical work, not just during emergencies but also for preparedness purposes,” according to the report. 

“We pose an open question, and I stress it is an open question: Should WHO is split into two organisations, one that is focused on emergency operations, as that work has to be done, and one that’s focused on operational and technical excellence in health?” asked Clark.

WHO’s expenses in 2023, as captured by the report, “No time to gamble”.

She repeated the Independent Panel’s call for “a truly independent monitoring mechanism” to assess countries’ pandemic preparedness – such as a “Global Preparedness Monitoring Board which is completely independent of WHO” or “a new independent monitoring group”, perhaps along the lines of the Intergovernmental Panel on Climate Change (IPCC).

Inadequate financing

Around $10–15 billion is needed annually to fill the gaps in pandemic preparedness, particularly in low and middle-income countries.

“This does not include investments in One Health, which would require an added $10.3–11.5 billion annually to raise public veterinary standards, improve farm biosecurity and decrease deforestation in high-risk countries,” according to the report.

The Pandemic Fund, set up under the World Bank to assist, has raised almost $2 billion.

The report proposes that the fund be converted into a “preparedness and surge mechanism based on a global public investment model” rather than an ODA [overseas development aid] mechanism.

“All governments [should] contribute based on a formula according to their ability to pay, supporting both preparedness efforts and immediate response needs including to pay for the countermeasures countries will need to stop outbreaks and mitigate the impact of pandemics,” according to the report. It adds that countries should also have a say in the fund’s administration.

However, Mauricio Cardenas, former finance minister of Colombia, warned that public finances are “under a lot of stress in different countries, mainly because of the high levels of debt and very high interest rates”.

“Public finances play a very important role, because domestic resource mobilisation is crucial and should be the foundation of preparedness and response, but that’s not enough. We need international finance, but we don’t need charity,” he stressed.

Expanding access to medical countermeasures 

Budi Gunadi Sadikin, Indonesia’s health minister.

Indonesian Health Minister Budi Gunadi Sadikin called for different rules for the Pandemic Fund during a pandemic, which he compared to wartime, including “speedy decision-making and expedited fund disbursement”.

Sadikin, who addressed the launch, also called for all emergency medical countermeasures produced during pandemics to become “public”.

There needs to be an “upfront agreement” in the pandemic agreement that for-profit companies answering to shareholders will be reasonably compensated by a large public institution or country , for their products such as vaccines and therapeutics, added Sadikin.

The report describes medical countermeasures as a “global common good”, noting that inequities in access to these during COVID-19 “have left a lasting painful moral stain, and the resulting mistrust has affected negotiation of a pandemic agreement”.

Dr Petro Terblanche, CEO of Afrigen Biologics which hosts the WHO mRNA hub in South Africa, said that the world’s knowledge base around pandemic response had “tripled” in the past three years.

“Yet if we have a pandemic today, the Global North will move at speed and will be better prepared than three years ago because of the knowledge that we’ve been able to possess,” said Terblanche. But the position of the Global South would depend on “where these critical medical countermeasures are produced”.

The mRNA programme’s final outputs “are threatened now by lack of funding”, she said, urging investment in “end-to-end research and manufacturing capabilities in low and middle-income countries” to prepare for future pandemics.

“In 2023, the African continent had 155 outbreaks and for less than 10 of there, vaccines are available,” she noted.

“With Rift Valley Fever,  this is going to be an opportunity to develop a single vaccine using an antigen using mRNA to both for the vaccination of animals, livestock and humans,” said Terblanche, adding that such an approach should be prioritised  from a research and development and product development perspective.

 

Image Credits: Prachatai/Flickr, Wildlife Conservation Society .