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.