Local Solutions to Build Stronger, Resilient Health Systems
The concept of localization in global health or humanitarian aid is not new. It has been a topic of discussion for decades, but global health emergencies of recent years have given new life to these conversations. COVID-19 and other large outbreaks such as Ebola, Marburg and H5N1, Mpox have turbo-charged conversations around localization and the failure of responses that do not meaningfully embody it.
First, what does this term ‘localization’ really mean?
Well, there is no one agreed upon definition of localization. The Inter-Agency Standing Committee’s Health Cluster, led by the World Health Organisation (WHO) defines it as a process by which to achieve meaningful and equitable engagement of local and national actors to achieve a locally led health response in line with humanitarian principles.
USAID defines localization more operationally, characterizing it as the set changes required of stakeholders across the global health ecosystem to ensure local actors lead efforts to strengthen local health systems and ensure they response to community needs. These changes include internal and external reforms, actions, system shifts and behaviour changes.
So, why is localization in global health needed?
Time and again, different health and humanitarian crises – especially in Africa and the Middle East – demonstrate that an effective and timely response depends upon the degree of involvement of local health actors at all levels. Adequately resourcing and financing those nearest to the crisis-affected populations to enable them to lead the response is crucial, as they are best placed to respond quickly and appropriately. Too often, however, in practice we see the Global North dominating resourcing, financing and decision-making, with catastrophic consequences for the Global South.
Prioritization is a process that heavily depends on context. If those determining the urgency of need are not where the emergency is, there is often a mismatch in the speed, magnitude and efficiency of the response. Recently the World Health Organisation (WHO) has faced criticism for being slow to declare mpox a Public Health Emergency of International Concern (PHEIC), despite West African countries warning of the scale of outbreak for some time. Designating an outbreak a PHEIC should mobilise funding and political will to address the crisis which is crucially needed in the case of mpox. Countries across Africa that are facing the worst outbreaks remain desperately short of vaccines, diagnostics and therapeutics, as they rely on donations from the EU, Japan and the US. This situation mimics the stark vaccine inequity of Covid-19.
Localization cannot happen by chance – it is intentional by nature. Directed and systemic investments are needed and must be delivered in a well-coordinated manner. This often requires market incentives and guarantees of some kind to facilitate bringing this capacity ‘closer’ to home. While localization is high up on the agenda of the Global South, it is very much still driven from the Global North as most of the related funding and technology is coming from there.
Looking forward, will promises made to empower the Global South post COVID-19 be fulfilled?
Sounding the loudest alarm bell in global health, the WHO declared COVID-19 a PHEIC on the 30th of January, 2020. The outbreak caused more than 680 million cases worldwide, claiming over 6.8 million lives. While a tremendous amount of effort was put in by governments, collaborative partners, the private sector and communities, we fell short of an adequate coordinated response. Many lives were lost as a result.
COVID-19 was characterised by major equity and access challenges, with hoarding by the Global North of medical countermeasures such as vaccines, diagnostics tools and treatments. Further, complex issues with some vaccines being ruled out by counties in the Global North and failures of under-resourced local health systems to address complex geographical or social needs caused hesitancy among some patients. This added another layer of complexity once vaccines eventually became available.
These geopolitical and economic dynamics are not new. Taking a step back to look at the HIV/AIDs journey, we can see remarkable progress in the development of new lifesaving medicines to tackle the disease. These developments are marred, however, by the continued lack of accessibility and affordability to countries in the Global South.
The first anti-retroviral drug AZT (zidovudine) was approved by the US Food and Drug Administration (FDA) in 1987. Today in 2024 there are more than 30 approved antiretroviral medications in six drug classes, with each class attacking different stages of the life cycle. The HIV drugs market size is estimated to grow from USD 33.32 billion in 2023 to surpass around USD 49.68 billion by 2032.
Issues of access persist, however, as many of the newer and better medicines are still manufactured overseas at prices far too high for Global South countries to afford. For example, in December 2022 Cabotegravir (CAB-LA) – a novel pre-exposure prophylaxis - was priced at $22 000 per year, more than 185 times higher than the $60-119 estimated cost-effectiveness threshold for middle-income countries.
Not only are these barriers to access for lower-income countries a moral failure, they are poor global health policy. Time and again we have seen how pandemics do not respect borders. The West-Africa Ebola outbreak of 2014-2016 spreading from Guinea to Liberia, Sierra Leonne, Mali, Senegal and Nigeria is a stark example. This outbreak lasted 28 months and resulted in 28, 652 cases and 11, 325 deaths. There was slow national, regional and global level response, with a reactive and inappropriately designed strategy in the three most affected countries. Notably, this included large-scale deployments of individuals with no previous experience in Ebola outbreak response and - despite multiple Ebola outbreaks occurring previously in Central and West Africa - the response relied heavily on medical countermeasures coming from the Global North.
These global health crises exacerbate the already existing global power dynamics, sensitive geopolitics and the uneven distribution of resources, financing, technology and people-power when it comes to health emergency response.
Is local manufacturing the solution?
While localization in global health goes beyond the manufacturing of drugs, vaccines and therapeutics, the research and development (R&D) pipeline is a critical indicator of what new products may come to the market in the near future. The forced reliance of Global South countries on the Global North for medical countermeasures to tackle domestic outbreaks is a model that intrenched by current global health architecture and the distribution of resources and financing.
Take - for example - vaccines. Low and middle-income countries (LMICs) are largely still dependent on Gavi, the Vaccine Alliance for their routine vaccines for children. Through this model, the number of manufacturers supplying prequalified Gavi-supported vaccines grew from 5 in 2001 to 19 in 2022 (with more than half of these based in LMICs, mostly in Asia). This growth is impressive and was made possible through systematic market shaping efforts by Gavi and its partners.
But there is an incoherency in this model that leaves countries at the behest of western counterparts or global health institutions. For example, Africa is currently reliant on technology transfers from non-African vaccine manufacturers and capacity to produce antigens locally is very limited and well below the capacity that would be needed to meet regional production targets.
African vaccine manufacturing capacity is currently heavily concentrated on form/fill/finish, with planned capacity to more than double the projected African vaccine demand by 2030. At that level, there is a risk that not every vaccine manufacturing project would be sustainable and commercially viable, leaving countries still dependent on non-African manufactures and vulnerable to the inequalities that plague historic and current examples.
Further, there is a significant issue with lack of funding for the development of new medicines in the Global South, by domestic governments and by international funders. The G-Finder report published by Policy Cures Research in January this year details that global funding for neglected disease basic research and product development totalled $3.931m in 2022, a 10% drop from the previous year.
As in all previous years, the top three funders of global neglected disease R&D in 2022 were the US NIH, industry and the Gates Foundation. Their combined funding in 2022 was $3,010m, a record 77% of the global total. In contrast, funding from LMIC governments declined in 2022 to $91m (2% of the global total). Also worthy to note that the philanthropic sector (mostly from the Global North) invested $767m in neglected disease R&D in 2022, contributing 20% of the global total.
What changes to the global health architecture are needed?
To achieve meaningful and sustainable localization in global health, there are major ecosystem shifts that are required. For products already being manufactured globally, we need to bring them closer to home by investing in local capacity to develop these products as well as creating a market for these products produced locally to be purchased.
For new products being developed, firstly we need greater and better coordinated investment from LMICs governments and funders for products needed by their populations. National budgets must include financing for local R&D and manufacturing, human capital and overall health systems strengthening. Secondly, we need investment by global north governments and funders to intentionally address the access needs in the global south by ensuring the products are developed with the aim to be produced at scale and affordable in LMICs.
Private sector and industry are also critical players in this ecosystem, with the potential to better help bridge the gap in both funding and R&D. In our increasingly global and interconnected world, it is an imperative to ensure that the Global South is not only adequately prepared to manage their increasing demands on their health systems, but also equipped to efficiency and adequately respond to disease outbreaks and health emergencies, such as the ongoing Mpox outbreak.
In conclusion…
Localization in global health must bring solutions to where the problems are. It requires true empowerment, structured and measurable commitments and accountability from governments, sustainable investments by funders (both public and private) and - mostly importantly - leadership from the Global South.
The facilitation and financing of local leadership of local health systems to meet the needs of local communities.
Mobilizing Municipalities Against Mpox in East Africa Hubs
Context
The spread of mpox - recently designated as both a Public Health Emergency of Continental Security and a Public Health Emergency of International Concern - demands urgent and coordinated action.
Key transit hubs and port cities within the East African Community (EAC) 1 are on the front lines of this growing threat. Municipalities and cities across Kenya, Burundi, DRC, Rwanda, Uganda and Tanzania are currently at acute risk of mpox transmission.
These municipalities are crucial in the region’s trade and transportation networks, as high-traffic intersections through which goods and people flow. They are host to high-risk populations, including long-haul truck drivers, farm workers and sex workers.
The extensive mobility and close contact inherent in these professions puts workers and surrounding communities at significant risk. The disease is spread through close contact with an infected person and is known for causing painful, pus-filled lesions, severe illness or, in some cases, death.
The Africa CDC and WHO launched a joint continental response plan for Africa. Given the strategic importance of these municipalities in EAC, their proactive participation is critical to operationalizing and supporting this strategy.
Crucially, with 367 confirmed mpox cases, including 3 deaths, reported across Southern and Eastern Africa 2 in September, the time for action is now.
At-Risk Communities
The EAC has an estimated 500,000 long-haul truck drivers who regularly travel between key transit hubs across the region, with many spending over 14 days on the road from Kinshasa to Dar es Salaam.
The municipalities through which these workers travel are also home to large numbers of farm workers and sex workers, who are at higher risk of transmission due to the close contact inherent in their work. Truck stops, farms and urban centers where sex work is prevalent pose opportunities for mpox to spread, whilst contaminated objects like towels, clothing and personal hygiene items can also carry the virus. Aside from vaccines and other medical countermeasures, this underscores the importance of safe WASH practices.
Call To Action
As the threat of mpox grows, key transit municipalities do not have the luxury of waiting for the full implementation of the strategies being developed by Africa CDC and WHO. These workers and surrounding communities are facing a perfect storm, with high-mobility and close contact professions putting them at increased risk. Immediate, proactive action is needed to protect communities and the region at large.
We are calling on municipal leaders -- particularly those of key transit cities and towns 3 -- to convene joint emergency meetings with key stakeholders to mobilize funding and resources to begin rolling out critical interventions. Stakeholders include relevant private sector actors and trade unions and East African philanthropy, as well as regional organizations.
By pooling resources, sharing costs and engaging the private sector, municipalities can ensure that the necessary medical countermeasures and community-based interventions are in place to combat mpox effectively. This coordinated approach not only mitigates the immediate threat and helps prevent the uncontrolled spread of mpox, it also strengthens the overall resilience of the region’s public health infrastructure, safeguarding both the health and economic stability of the East African Community.
Immediate Steps
Municipalities must ensure availability and deployment of effective medical countermeasures to tackle transmission and spread, including:
PPE and WASH supplies
Personal protective equipment (PPE) includes gloves, masks and face shields which could cost approximately $0.60 per mask and $1 per pair of gloves when procured in bulk. Distribution must prioritize frontline health workers and high-risk groups.
WASH supplies must include hand sanitizers, soap and water purification tablets. Mpox can also be spread through shared personal items such as towels, clothing and toothbrushes, so care packages should include these items. Setting up a mobile handwashing station costs around $500 per unit and individual hygiene kits could cost $10 to $15 per kit.
Condoms
Building on successful HIV prevention strategies, municipalities should ensure the widespread availability of condoms, which are vital in reducing the risk of mpox transmission. Condoms also limit the spread of other STIs whose interaction with mpox could aggravate complexity in treating the disease. The cost of condoms, when procured in bulk, can be as low as $0.03 per unit.
Care Packages
Care packages should contain PPE, WASH supplies and condoms, as well as educational materials about mpox. Care package costs an estimated $20.
Municipalities must strengthen community health worker (CHW) networks by:
Immediate Training and Deployment of CHWs
CHWs are essential in reaching high-risk populations. Investment in training them on mpox prevention, symptom recognition and case reporting is crucial. Training costs can be estimated at $100 per CHW.
The deployment of CHWs, including their transport and daily allowances, might require an estimated $20 per day per worker.
CHW-Led Community Engagement
Regular visits to truck stops, farms and areas where sex workers operate should be conducted by CHWs. These visits are essential for distributing care packages and providing education. A small-scale engagement initiative could start with $5,000 per municipality.
Municipalities must enhance community-based surveillance and reporting through:
Digital Surveillance Tools
Investments is needed in digital tools that enable CHWs to report suspected mpox cases in real-time. These tools can be integrated with national health databases to ensure timely responses to outbreaks. Tools ready to be deployed for truckers include the RECDTS App. Others may exist for CHWs.
CHWs must be trained on using digital tools to collect data on symptoms, report cases and monitor the health status of individuals in high-risk groups.
Community Reporting Networks
Network of CHWs must be leveraged to establish community reporting networks where individuals can report symptoms or concerns anonymously. This approach has been effective in previous health crises, allowing for early detection and containment of outbreaks.
Cross-municipality cooperation is needed to implement pooled procurement and cost-sharing. Municipalities must collectively establish:
Pooled Procurement Mechanism for Medical Countermeasures
Measures must include PPE, WASH supplies and condoms, allowing municipalities to benefit from economies of scale to reduce costs overall.
Municipalities across the EAC should contribute to a central procurement fund managed by the EAC Secretariat. This fund would handle the bulk purchasing of supplies, ensuring that all participating municipalities receive a fair allocation based on their population size and risk level.
Cost-Sharing Arrangements
Cost-sharing arrangements must be predicated on wealthier municipalities or those with more robust budgets contributing more to the procurement fund, subsidizing the costs for smaller or less financially capable municipalities. This ensures equitable access to essential supplies across the region.
Municipalities can also explore public-private partnerships (PPPs) to fund the procurement and distribution of supplies, involving local businesses and multinational corporations operating in the region.
The private sector can play a role in financing municipality led prevention and protection strategies. Municipalities should make use of:
Private Sector Partnerships:
Invitations to private sector organizations should include prominent businesses like the Mo Dewji Foundation and MeTL Group.
Organizations can provide financial support, donate supplies or offer logistical assistance for distributing medical countermeasures.
Companies involved in logistics and transport, such as those managing truck fleets, can play a critical role by ensuring that their drivers are educated on mpox prevention and are equipped with care packages.
Corporate Social Responsibility (CSR) Initiatives:
Encourage businesses operating in key transit municipalities to integrate mpox prevention into their CSR initiatives. This could involve sponsoring public health campaigns, funding CHW training or providing mobile health clinics at truck stops and farms.
Involve the private sector in the pooled procurement process by offering them opportunities to supply goods and services. This will boost local economies while addressing public health needs.
Committees and Policy Instruments Available
The EAC has established several policy instruments and committees that provide a framework for coordinated action among municipalities. These include:
The Urban Development and Human Settlements Sectoral Committee:
This committee focuses on urban development, housing and municipal management. It is well-positioned to support municipalities in implementing health-related urban planning and infrastructure projects, especially those aimed at preventing and controlling disease outbreaks like mpox.
The East African Local Governments Association (EALGA):
EALGA serves as a coordinating body for local governments within the EAC, facilitating cooperation and capacity building. Municipalities can leverage EALGA to share best practices, pool resources and ensure a unified approach to public health emergencies.
Cross-Border Health Collaboration Protocols
These protocols are designed to facilitate seamless cooperation between municipalities and national governments, particularly in managing cross-border health risks. Municipalities can activate these protocols to enhance their surveillance and response efforts against mpox.
These policy instruments may prove useful for the design of coherent response efforts, ensuring that they are aligned with regional strategies and best practices.
Conclusion
Key transit municipalities in EAC are home to workers and communities facing an acute risk of mpox transmission. There is an immediate and critical need to protect these people from the risk mpox poses as well as safeguarding the region as a whole. Mpox has already shown its capacity to spread across borders and continents, making it a significant threat to public health and economic stability in the EAC region and beyond.
In order to prevent the uncontrolled spread of mpox and safeguard the health and stability of the region, key transit municipalities must take immediate, proactive steps to protect their communities and the region at large.
The time for action is now.
References
- The East African Community – is a regional intergovernmental organization comprising of eight partners States, including the Republic of Burundi, Democratic Republic of Congo, Republic of Kenya, Republic of Rwanda, Federal Republic of Somalia, Republic of South Sudan, Republic of Uganda and United Republic of Tanzania.
- In Southern and Eastern Africa, about 367 confirmed mpox cases, including 3 deaths, have been reported in 5 countries, including Burundi (328), South Africa (24), Uganda (7), Rwanda (4) and Kenya (4) as of 2 September. Experts estimate the actual numbers could be higher. Source: https://reliefweb.int/report/burundi/southern-and-eastern-africa-mpox-situation-snapshot-3-september-2024
- Municipalities include Lubumbashi, Bukavu and Goma (DRC), Bujumbura (Burundi), Kigali (Rwanda), Kampala and Jinja (Uganda), Malaba/Busia Town (Kenya-Uganda border) and Arusha, Tabora and Dodoma (Tanzania). Port cities include Mombasa (Kenya) and Dar es Salaam (Tanzania).