This analysis demonstrates that the entire WHO African region continues to be at risk of health security threats—a blunt reminder of the need for robust public health emergency preparedness and response systems everywhere. Further, our analysis suggests that there is an increase in the frequency of infectious disease epidemics, disasters and other potential public health emergencies in the WHO African region. This observation is similar to what was reported in a 2016 WHO African region review of the occurrence of epidemics for the period 1970–2016 . There were fewer epidemics of Measles and Viral Haemorrhagic Diseases in the 2016 review compared to this review. However, Cholera was common in the 2016 review and is still very common in this review, while Polio and Malaria are less common in this review.
A caveat to this observation is that there has been improvement in public health surveillance, reporting and data collation practices on epidemics and better diagnostics to identify the disease-causing organisms, hence, these trends could be confounded by this bias. Nonetheless, the number of epidemics remains high—more than 100 epidemics were recorded in both 2017 and 2018, compared to 58 epidemics recorded in 2016. The increase in the frequency of epidemics and other public health emergencies is probably due to the combined impacts of rapid population growth resulting in increased population density and unplanned urbanization creating conditions that are conducive for the spread of diseases and leading to a greater scale of epidemics. Some of the changes in the infectious disease transmission patterns are likely a consequence of climate change, but the underlying causal relationships are also complex . We know that vectors and disease-causing pathogens and hosts require optimal climatic conditions to survive and produce; chief among them are temperature and precipitation, which obviously are changing. Additionally, complicit are health system weaknesses which hamper early detection and prompt effective response.
Reforms in the WHO health emergency programme post the 2013–2016 West Africa Ebola are beginning to bear results. For example, the time taken to control outbreaks in the WHO African Region, has reduced from an average of 418 days (well over a year) in 2016 to 51 days (under two months) in 2018. Further, epidemics are being detected and responded to faster . Moreover, African countries are commended for their willingness to assess and subsequently strengthen their IHR capacities to prepare for and respond to emergencies . To date, forty-six countries in the WHO African region have had their IHR capacities assessed through joint external evaluation (JEE) [11, 18]. This is the highest number of JEEs among the WHO regions. Importantly, 30 of the countries that have conducted a JEE have subsequently developed their national action plans for health security (NAPHS) to address the identified gaps . Nigeria and Uganda are two practical examples of countries showing the benefits of investing in building IHR capacities. Both countries have been able to detect and respond much faster to outbreaks. In Uganda, improvements in public health surveillance have been shown to substantially improve the response time for Viral Haemorrhagic Disease epidemics, thus reducing the scale and length of epidemics . Similarly, Nigeria is strengthening implementation of the IHR. In 2016, the Nigeria Centre for Disease Control (NCDC) was established and has been instrumental in improving coordination of public health emergency preparedness and response. This was demonstrated during the 2017 Monkey pox outbreak. Previously, Monkey pox surveillance was hindered by inadequate actionable data as Monkey pox was not a notifiable disease. A more sensitive surveillance system led to the detection of the index case in 2017 after 39 years of the last recorded case . Surveillance for the early detection of viral spillovers and advanced genetic characterization for determination of the origin of the outbreak was improved through collaboration with partners [23,24,25]. The response of the NCDC in creating awareness and providing tools for surveillance led to the detection of more suspected monkey pox cases in 21 states. In addition, increased coordination and partnerships from the Federal Government, the States and other collaborating partners, led to its containment, largely credited to strengthened surveillance and laboratory diagnosis support.
There are several worrying trends. First, there is evidence that Viral Haemorrhagic Disease epidemics that were previously rare have recently caused devastating epidemics in the region [26, 27]. For instance, Ebola and Marburg Virus Diseases (MVD), previously known to be rare, have recently caused major epidemics in Liberia, Guinea and Sierra Leone (2013–2016) [28,29,30,31], in Uganda (2017 and 2018) [32, 33], and in the Democratic Republic of the Congo (2018 and 2019) [34,35,36,37]. A 2016 comprehensive regional risk assessment and mapping for all epidemics reported in Africa between 1970 and 2016 revealed that the epicentres for the Ebola virus disease and Marburg virus disease epidemics were mainly in East and Central Africa, except for the West Africa Ebola virus disease epidemic ). Second, several epidemics of meningococcal meningitis recently occurred outside the meningitis belt, showing a high likelihood that the areas at risk are expanding . Third, Cholera is transitioning from an epidemic to an endemic disease. In 2017, over 150,000 Cholera cases, including over 3000 deaths were reported from 17 countries in the African region and countries, such as Chad and Zambia, where Cholera epidemics were rare prior to 2016, reported epidemics . Fourth, many of the countries at risk of epidemics also continue to suffer from disasters and humanitarian crises that disrupt livelihoods and the economy of the affected countries, thus constituting a dual threat.
We explored the dual occurrence of infectious disease epidemics, disasters and humanitarian crises. A comparison of data on infectious disease epidemics, disasters and other potential public health emergencies suggest that certain countries have a high frequency of infectious disease epidemics, as well as, a high frequency of other public health emergencies including: drought, flooding, cyclones and humanitarian crisis due to conflict. From the data assembled it is evident that several countries in tier 1 such as the Democratic Republic of the Congo (DRC), Kenya, Uganda, South Sudan also witnessed more humanitarian crisis events than other countries during the period 2016–2018. There are several factors that could explain these observations. Firstly, most of these epicentres are in the tropical savannah or tropical rain forests, which are ecologically prone to numerous infectious diseases. Secondly, most of these countries have had recurrent civil, social and political strife, which has often resulted into refugee and internally displaced populations, living in overcrowded settings with poor living conditions, inadequate access to clean water, food, shelter, health and other social services. Thirdly, most of them have inadequate health systems with poor access to quality health services. Fourthly, several of them have had challenges with governance and leadership and consequently limited political and financial commitment for building resilient health systems. The latter, together with lessons from recent disasters in southern Africa highlight the negative compounding effects of humanitarian crisis and infectious disease epidemics, suggesting obvious benefits of cross linkages and the potential value of leveraging financing for humanitarian crises to build IHR capacity .
It is increasingly apparent that emergency preparedness and response is best achieved within strong health systems for universal health coverage(UHC) . In countries with weak health systems, response to health emergencies is slow or inadequate, and outcomes are poorer. Indeed, the JEE index scores correlate with various health metrics, including: life expectancy, under-five year old mortality, disability-adjusted life years, and other measures of social and economic development . Consequently, efforts to strengthen health security should be integrated within health system strengthening. This would prevent duplication of efforts and wastage. However, how best to achieve or measure this integration is not clearly defined [40, 42]. The ability of deadly pathogens to exploit weak health systems was clearly demonstrated in the Ebola outbreak of 2013–2016 . However, there is paucity of data on the benefits of integrating health security with health system strengthening. Several components are cross cutting and improvements or deficiencies in one, often impact the other. Nevertheless, evidence on the public health, economic, social and political dividends to support the integration of these two approaches is urgently needed and would be insightful to policy makers and funders. We are investigating the potential dividends of investing in an integrated approach to UHC and health security.
All countries in the WHO African region have embraced the revised IHR monitoring and evaluation framework , including: mandatory annual reporting, JEEs, after action reviews (AARs) and simulations and exercises (SIMEX). Most of the countries have subsequently developed and costed their NAPHS. However, the same cannot be said about mobilizing the financing for preparedness. Based on the 30 costed NAPHS, the financial needs for health security over next 3–5 years vary from approximately USD 7 million in Eswatini to USD 700 million in the Democratic Republic of the Congo (DRC). The region-wide estimate is approximately USD 7–8 billion or approximately USD 2.5–3 billion annually, which translates to USD 2.5–3 per capita per annum [11, 18]. Most of the countries with the lowest JEE scores are either low or middle-income countries and will require substantial development assistance to fill the gaps identified in the JEEs. A September 2019 report commissioned and prepared by the World Bank Group for the Global Preparedness Monitoring Board on pandemic preparedness financing has suggested six broad areas namely: Mobilizing domestic resources; Mobilizing development assistance; Incentivizing countries to prioritize allocation of funds for preparedness; Leveraging the insurance model, accessing existing loans, grants and new funding; Mobilizing funding for research and development (R and D) and strengthening clinical research capacities; and finally sustainable financing to strengthen WHO’s capacity . WHO needs to be better resourced to galvanize intergovernmental and non-state actors to finance health security preparedness. More importantly, there is a need for a global financing mechanism to support countries that are not likely to have the required resources to implement the IHRs fully. In the early 2000s, HIV/AIDS, Tuberculosis and Malaria were affecting millions of vulnerable populations. In 2002, the Global Fund was established as a partnership to accelerate the end of the “epidemics” of AIDS, Tuberculosis and Malaria. The Global Fund mobilizes and invests more than US$4 billion a year to support programs in more than 100 countries . Public health emergency preparedness financing in the low and middle-income countries, requires similar bold partnerships with governments, civil society, technical agencies, bilateral and multilateral funding agencies, the private sector and the communities to surmount the challenging barriers, while embracing innovation. Importantly, there is an urgent need to conduct a landscape analysis of existing funding to leverage on the opportunities provided by funding for vertical disease programmes, climate change, the Global Fund, and private sector contributions. Further, there is a need for further reprioritization of the country plans. Moreover, countries need to explore opportunities for: sharing capacities through regional centres of excellence that are serviced by several member states; and setting up regional public health emergency response workforces. Finally, there is a need to explore additionality and counterpart financing mechanisms to incentivise countries that increase their domestic financing for preparedness.
Several of the major events reported here were cross border events or crossed from one country to another, which necessitated cross border collaboration to contain them. Over the last two decades WHO has supported several high level ministerial meetings on cross-border health issues. These ministerial level meetings led to the signing of protocols of cooperation and memoranda of understanding to facilitate containment of cross border public health challenges and to harmonize strategies and policies across countries. This led to improved operational coordination, improved epidemic response and synchronization of public health interventions for health systems strengthening, implementation of integrated disease surveillance and response (IDSR) and IHR. However, the institutionalisation of mechanisms and processes for cross-border information sharing and collaboration to effectively address epidemic preparedness remain challenging. For example, few countries have established mechanisms and systems for joint planning, joint implementation and joint monitoring and evaluation of strategies for prevention, preparedness, early detection and response to cross-borders events. Moving forward, countries need to identify the major challenges to cross border coordination, collaboration and operations for preparedness and response activities. This should be followed by identification of opportunities for strengthening cross border collaboration to address the identified issues and challenges, using the existing protocols, strategies and frameworks or formulating new ones. Finally, countries should establish effective and sustainable cross border collaboration mechanisms and formulate strategic actions, including inter country agreements for cross border health service delivery.