1 Introduction
This chapter examines major activities of the African Union (AU) in health governance, particularly during 2021. Declared by the World Health Organisation (WHO) in January 2020 as a public health emergency of international concern, the Covid-19 pandemic continued to be considered as such throughout 2021.
Given the AU’s recognition of health as an important sector for the development of African states and peoples, several initiatives have been introduced to improve health conditions across the continent. The response to the Covid-19 pandemic has taken place within the existing framework for health intervention provided by the AU (see Boateng and Iroulo 2021; Engel and Herpolsheimer 2021; Patterson and Balogun 2021; Tieku 2021). Additionally, health forms an important part of the Union’s Agenda 2063: The Africa We Want (AU Assembly 2013; see AU Commission 2015), as well as several decisions and declarations made by African leaders over the years.
The African Union has displayed a commitment to recognising and promoting the importance of health to a comprehensive development agenda that takes into consideration the livelihood and capacity of people as well as to economic growth. The Health and Humanitarian Affairs Division and the Health Systems, Disease and Nutrition Division, both within the Department of Social Affairs of the AU Commission (AUC), contribute to a holistic regional health agenda that builds on policy and implementation concerning health-related matters. The Africa Centres for Disease Control and Prevention (Africa CDC) is a specialised technical institution of the AU responsible for promoting effective disease prevention, detection, and control as well as effective responses to outbreaks. Additionally, the African Medicines Agency (AMA) is a newly established regional agency responsible for promoting the beneficial and sustainable production and supply of medicines across the continent (AU Assembly 2019a; see Yearbook on the African Union 2020, 108).
The above-mentioned institutional framework provides a broad overview of the regional health agenda devised and implemented under the auspices of the AU to cover various aspects of health, including, inter alia, strengthening
2 2021 Africa Health Facts and Figures
In 2019, the Africa region had the lowest life expectancy among WHO regions, at 64.5 years, and communicable diseases accounted for 52 per cent of all deaths in the region (WHO 2019, 19). Of the adult population in Africa, 7.5 per cent were recorded as being infected with hepatitis B. The Report on the Performance of Health Systems (2020) in the WHO Africa Region states that health systems in the region perform at a rate of 52.9 per cent, meaning that ‘the health systems in the WHO African Region are performing at an average of 52.9% of what they can feasibly do’ (WHO Africa 2020, 2). In 2019, the under-five mortality rate in Africa was 74 out of 1,000 births, the highest in the world, and almost twice the global average of 38; and neo-natal mortality rate in the region was also the highest in the world, 27 out of 1,000 (ibid.).
The Africa region ranks poorly in relation to the performance of other regions and the global average in malaria, tuberculosis, and HIV/Aids incidence and mortality rates. Between 2019 and 2020, there was more than an increase of 5 per cent in global malaria incidence, and most of that increase was centred in the Africa region, which accounted for about 25 per cent of malaria cases that year. The increase in cases has been attributed to disruptions in service delivery and health infrastructure during the Covid-19 pandemic (WHO 2021a, xv). Malaria deaths also increased from 534,000 in 2019 to 602,000 in 2020. On the bright side, of the 1.7 billion malaria cases and 10.6 million malaria deaths averted globally, 82 per cent and 95 per cent respectively were from the Africa region, and of the $3.3 billion invested in malaria in 2020, 79 per cent went to the WHO Africa Region (ibid., XVII, XIX). Additionally, of the 191 million Artemisinin-based combination therapies (ACT s) distributed to the public sector by national malaria programmes in 2020, 95 per cent were distributed to the public sector in sub-Saharan Africa (ibid.).
In 2020, there was a flat trend in tuberculosis deaths in Africa, compared to 2019 when the region accounted for 25 per cent of recorded cases (WHO 2019, 23), despite an increase in most other WHO regions as well as a record of faster decline in incidence of tuberculosis in the region. Also in 2020, the Africa region was declared polio-free (ibid., 27). However, the highest proportion in the world of coinfections of HIV and tuberculosis were recorded in countries in the Africa region (WHO 2021b, 9). According to the 2021 UNAIDS Global AIDS Update, in 2020, 67 per cent of the global population living with
African states have adopted a health systems approach to addressing health challenges in the region, noting the importance of resilient health systems to achieving universal health care, developing the capacity to provide essential services, and fostering health security across populations (WHO Africa 2020, 1). While there has been some progress towards achieving the United Nation’s Sustainable Development Goals (SDG s) and other milestones over the past several years, the Covid-19 pandemic placed a considerable strain on health systems globally, particularly in the already challenged health systems in the Africa region. Given these acknowledged obstacles, the AU has prioritised health as an important development area and a key aspect of the regional development agenda.
For decades, the AU – and its precursor, the Organisation of African Unity (OAU, 1963–2002) – has introduced health policies and programmes to tackle general and specific health challenges. These have formed part of the comprehensive development agenda of the organisation through its various policies, programmes, and projects. The AU is committed to supporting member states in developing constructive health systems that will enhance the health and living standards of citizens and promote economic development across the region (see Yearbook on the African Union 2020, 108).
In addition to the institutional and regulatory challenges and critical capacity deficits that impact health indices and the livelihood of citizens in the Africa region, the Covid-19 pandemic has impacted the performance of health agencies and institutions in achieving the SDGs and other health-related goals. Nevertheless, as indicated in the existing data, there have been some wins, for example the recorded eradication of polio in the region and improvement in access to sexual and reproductive health services (see, for instance, AUDA–NEPAD 2022). In its continued response to the Covid-19 pandemic and its commitment to pursuing the attainment of the highest standard of health for the region’s population, the African Union continues to engage with its members and partners to develop robust programs and interventions.
3 Health Sector Developments and Interventions
As noted above, the AU has, since its inception, prioritised health as an important aspect of development, as was done by the OAU before it. Consequently,
3.1 Agenda 2063: The Africa We Want
In 2021, the African Union continued its efforts to contain the spread of the Covid-19 virus through comprehensive campaigns, an impressive vaccine rollout, and a detailed data collection and sharing mechanism, among other things. Nevertheless, the pandemic had severe effects on health infrastructure and services and on social and economic conditions in the region (AUDA–NEPAD 2022, 64). In the 2022 assessment of the implementation of Agenda 2063, comprising a data review of the 7 aspirations and 20 goals that make up the regional development agenda, the regional performance was recorded for the various health-related points as follows.
Goal 1: A High Standard of Living, Quality of Life and Well-Being. The regional performance on this goal was recorded as 31 per cent, down from 56 per cent in 2019. For that period, prevalence of undernourishment was at 24 per cent, way below the anticipated target of 9 per cent; population with access to clean drinking water was 64 per cent, below the anticipated target of 97 per cent. The regional performance in several priority areas, including hunger, was poor, owing largely to the Covid-19 pandemic (ibid., 15).
Goal 3: Healthy and Well-Nourished Citizens. The regional performance on the achievement of this goal was recorded as 77 per cent, revealing significant progress towards protecting the health and nutrition of African citizens. Despite an increase in malaria incidence and neo-natal mortality rate of 24.4, compared to the target of 15.5 out of 1,000 deaths, increased investment in health saw improved performance in overall health services and infrastructure (ibid., 20).
Goal 17: Full Gender Equality in all Spheres of Life. As part of its efforts to ensure that women and girls, in particular, are not discriminated against on the basis of their gender and to ensure that their health needs are not undermined, this goal seeks, inter alia, to tackle sexual and physical violence against women and girls – an important health issue. The report recorded a decline in the occurrence of physical violence from 41.6 per cent in 2013 to 21.2 per cent
In addition to the above health-related goals and performances, the African Union also supported several initiatives impacting health in 2021. The Partnerships for African Vaccine Manufacturing (PAVM) was introduced in April 2021 to accelerate Covid-19 vaccine production in Africa while strengthening the ongoing work of the Pharmaceutical Manufacturing Plan for Africa (PMPA) and supporting the goals of the AMA (ibid., 65). The African Union Smart Safety Surveillance (AU–3S) programme, initiated in 2020, was one of several surveillance and testing mechanisms introduced to aid monitoring and observation of Covid-19 trends and general disease surveillance in the region. The AU also continued to work with Regional Economic Communities (REC s) like the East African Community (EAC), the Economic Community of West African States (ECOWAS), and the Southern African Development Community (SADC) to strengthen their coordinated responses, in addition to guiding pilot programmes for vaccination production and distribution as well as testing and surveillance in member states (ibid., 66).
3.2 Health Financing
Resource allocation is an important aspect of achieving health goals, hence the continued commitment to meeting the endeavours of African governments in the 2000 Abuja Declaration to allocate up to 15 per cent of their national budgets to health expenditures. In 2019, the African Leaders Meeting (ALM)–Investing in Health Declaration was endorsed by the AU Assembly (see Yearbook of the African Union 2020, 108), following the recommendations of the ALM-Investing in Health event that brought together African leaders, private sector actors, and global development institutions to work alongside the AU Assembly, to discuss the critical issue of health financing (AU Assembly 2019b). Rwandan president Paul Kagame was appointed as the ‘Leader of Domestic Health Financing’, to work closely with the AUC Health and Humanitarian Affairs Division to improve domestic health financing in Africa (AU Assembly 2020).
In its pursuit of improving domestic health financing, the technical working group set up under the implementation of the ALM-Investing in Health Declaration proposed the establishment of several tools and programmes, such as regional health financing hubs, to be set up within the REC s; the ALM tracker, to track domestic health financing trends; private engagement in the health sector; and the ALM Accountability Framework to present ‘the roles and responsibilities of different ALM Declaration stakeholders’ (ibid., 5). These
The ALM-Investing in Health initiative is expected to support existing programmes, such as the African Scorecard on Domestic Financing for Health, a tool that combines indicators linked to various databases with relevant datasets to help AU member states plan and track their health expenditures.1 Concerns about health financing lie at the core of Africa’s health systems challenges, with limited capacity to drive the infrastructure and services needed to effectively improve healthcare and access in member states and across the region. Therefore, health financing remained a core focus in 2021 for the AU and its partners, for instance the African Development Bank (AfDB), which introduced schemes such as the $10-billion Covid-19 Response Facility, announced in April 2020.2 The comprehensive facility was established to provide funding to governments and the private sector ‘to maintain vital health services, expand social protection, and protect jobs and businesses’ (AUDA–NEPAD 2022, 65).
3.3 Research and Innovation
The Africa Health Strategy (2016–2030) provides a broad strategic and programmatic framework for the regional health agenda. It covers a broad range of issues, including leadership and good governance, multi-country collaboration, disease surveillance, and health research and innovation, among others (see Yearbook of the African Union 2020, 108). To facilitate the implementation of the strategy and to promote scientific development, innovation, and research for health objectives, the AU Specialised Technical Committee on Health, Population and Drug Control (STC–HPDC) mandated the African Union Development Agency (AUDA)–New Partnership for Africa’s Development (NEPAD) to develop, in collaboration with partners and stakeholders, a research and innovation strategy to facilitate the implementation of the overall strategy. This was a response to calls from the AU Assembly for the AU to address the science, research, and innovation needs of the continent, in collaboration with member states and the REC s (AU Assembly 2015a, 2015b).
In May 2019, the Health Research and Innovation Strategy for Africa (HRISA) was adopted in collaboration with the AUC and other stakeholders, including AU member states and the REC s. In the strategy, several gaps were identified as impeding the growth of research and innovation in the region’s health sector,
To strengthen capacity for sustained, integrated, coordinated and collaborative research, innovation and translation [sic!] for health
To develop and implement sustainable mechanisms for investment and financing in research and innovation for health
To generate new knowledge aligned to health goals and targets and advocate for its translation into products, services, policies and practices to improve health
To strengthen data-sharing platforms and systems to optimise health delivery
To advocate for the adoption of emerging technologies and supporting platforms to improve health
To strengthen and harmonise regulatory, ethics and intellectual property systems in order to maximise the benefits from African-led research and innovation for Africa and the global community (ibid., 16).
Certain fundamental principles underpin the strategy, including health as a human right, sound decision-making in public health policy, country ownership, the need for multi-sectoral approaches, and research and innovation as critical components for building resilient health systems, among others (ibid., 16). The following priority interventions were specified:
Developing human capacity for sustained health research and innovation
Developing a conducive environment for research and innovation
Promoting sustained investments and financing mechanisms in research, development and innovation for health
Supporting the generation of new knowledge and its translation into products, services, policies and practice to improve health
Generating, warehousing, sharing, and utilising data to inform and guide decision making in terms of health delivery
Support the development and adoption of emerging and existing technologies to improve health
Developing and strengthening regulatory systems, intellectual property and ethics that leverage the benefits of health research (ibid., 6–7).
Following the onset of the Covid-19 pandemic and the ensuing vaccine race,3 the AU has ensured that the continent has not been left behind (see Yearbook on the African Union 2000, 120–122). In addition to efforts to improve vaccine access and awareness,4 regional programmes have also been introduced to pursue and promote vaccine availability and production on the continent, including the African Medical Supplies Platform (AMSP), African Vaccines Acquisition Trust (AVAT), introduced by the African Vaccine Acquisition Task Team (AVATT), and African No Fault Compensation Scheme Trust (ANFCST). The Africa CDC has also been at the fore of implementing important projects, such as the African Medicines Supply Platform (AMSP). These represent the large-scale regional endeavours to transform the narrative and experience of vaccine access, depicted by the poor vaccination rate in Africa of 5 per cent, compared to the global rate of 50 per cent.
In November 2020, the AU Assembly established AVATT to lead the regional vaccine acquisition strategy. AVAT was set up by AVATT as a special purpose vehicle to facilitate the implementation of Africa’s Covid-19 vaccination strategy, based on a whole-of-Africa approach that aims to leverage economies of scale for the procurement of vaccines and achieve vaccination status for at least 70 per cent of the African population. The whole-of-Africa approach is meant to consolidate vaccine acquisition and ensure that all African countries have access to a collective pool rather than piecemeal vaccine acquisition by member states. While this coordinated approach has been in operation, there have also been bilateral vaccine donations and acquisitions outside AVAT. Consequently, AVAT, together with the Africa CDC and the Covid-19 Global Vaccine Access (COVAX) initiative, issued a Joint Statement on Dose Donations of Covid-19 Vaccines to African Countries on 29 November 2021, acknowledging that AVAT and COVAX had facilitated the donation of more than 90 million vaccine doses to Africa. This amount did not include the millions of more of dose donations that were made through
Another key continental initiative with respect to vaccine access and production is the Partnership for African Vaccine Manufacturing (PAVM), launched in April 2021 during a virtual summit on ‘Expanding Africa’s Vaccine Manufacturing for Health Security’.6 The PAVM was adopted by the AU Executive Council as the main partnership mechanism for fostering regional vaccine manufacturing, under a coordinated strategy and framework of action that would provide the required support to all stakeholders, including AU member states, financiers, and manufacturers, with a goal to increase the continent’s manufacturing proportion from 1 to 40 per cent by 2040 (AU Council 2021a). To this end, the mandates of the PAVM are
Steward a continental strategy that maintains scale and cost-competitiveness of local manufacturing and promotes equity and security for all
Support partnerships to create a conducive business environment that will encourage the emergence of a thriving manufacturing base
Play intermediation and partner role between Member States and the global community of supporters on an as-needed basis
Communicate updates and serve as the central source of information for Africa vaccine manufacturing (ibid.).
3.5 Coordination and Partnerships
Given the multi-sectoral approach to development and integration that is embodied by the African Union, health as an important theme is not undertaken in a vacuum but involves coordination among units and institutions of the AU and partnerships with external organisations whose plans fit the interest areas of the AU. In 2021, the AU continued to pursue the most effective coordination mechanisms and partnerships to coalesce the work of stakeholders in their commitment to tackle the health needs of the region.
Within the AU institutional framework, there are several divisions, agencies, and programmes with health-related objectives and concerns, thereby causing overlapping interests and activities. Consequently, there have been efforts to ensure that the various endeavours are coordinated to form a comprehensive regional health plan for the benefit of all member states and their citizens. Within the AU, the department responsible for health-related matters is the AUC Department of Health, Humanitarian Affairs and Social Development, which houses the Health and Humanitarian Affairs Division and the Health Systems, Disease and Nutrition Division. In addition to the department, the Africa CDC is a specialised technical institution of the AU responsible for disease control and surveillance, and several other AU programmes and agencies have been established to address health matters or health-related matters across the region. Consequently, there are common areas of interest and intervention, requiring coordination – and sometimes cooperation – among institutions, agencies, and programmes with common interests.
In addition to matters of internal coordination, there are also important partnerships that have been introduced with external collaborators to foster health-related interventions. The AfDB’s 2020 Covid-19 response investment for the AU, member states, and businesses impacted by the pandemic is also a health-related partnership.10 And the AfCFTA has been a partner in several aspects of regional health response and planning. For example, during a meeting of stakeholders of the African vaccine manufacturing initiative, the role was acknowledged of the Agreement Establishing the AfCFTA, and in particular the Intellectual Property Rights Protocol of the AfCFTA, in the market taking shape ‘for Covid-19 vaccines, development of value chains in pharmaceutical products, private sector engagement and removing trade policy-related barriers with measures, including harmonizing standards’.11 Consequently, it was agreed that collaboration with the AfCFTA was necessary to facilitate Covid-19 vaccine and other pharmaceuticals manufacturing and intra-African trade for such products.
support Africa with over €1 billion and expertise to help develop its own pharmaceutical, biotech and medtech industries, and ease equitable access to quality and safe products and technologies. The Initiative will also help develop a number of regional manufacturing hubs across the continent, so that the whole of Africa can benefit.13
These regional manufacturing hubs are meant to be developed in collaboration with the AU and Africa CDC through technology transfer and support for the AMA from the European Medicines Agency.14
AVATT partnered with the World Bank to secure the delivery of 400 million vaccines to African countries, to enable the purchasing and distribution of vaccines by governments across the region. The principal partners of AVATT, in seeking to acquire Covid-19 vaccines for Africa, are the AU, the Africa Export–Import Bank (Afreximbank), Africa CDC, and the UN Economic Commission for Africa (UNECA).
These coordinative frameworks and projects within the AU institutional structure as well as the partnerships with non-AU institutions have helped to harmonise related pursuits so as to properly manage resources and avoid duplicating efforts. As seen in the case of vaccine donations, poor coordination can hamper otherwise beneficial initiatives and create a burden for stakeholders.
3.6 2022: The Year of Nutrition
In October 2021, based on a proposal by the government of Côte d’Ivoire, the AU Executive Council adopted a concept note titled ‘Build Momentum for the African Union 2022 Theme: “Building Resilience in Nutrition and Food Security on the African Continent: Strengthen Agriculture, Accelerate the Human Capital, Social and Economic Development”’ (AU Council 2021b). Noting the deleterious effects of malnutrition and undernutrition on health morbidity and mortality in African countries and on socioeconomic development, the concept note acknowledges that given the multifaceted nature of nutrition, a multi-sectoral approach is necessary for truly understanding and tackling nutrition challenges. It also recognised the importance of nutrition as a critical issue area, in light of the growing global activities on nutrition and the need to take stock of related AU programmes and initiatives, such as the African Nutrition Strategy (2015–2025) and the Detailed Programme for the Development of African Agriculture (2015–2025). The AUC was requested to ‘(a) develop and implement an advocacy strategy in support of the activities of the AU theme of the year and
The following strategies underscore the nutrition focus of the AU, with the objective of improving human capital for comprehensive health and economic development:
- –building resilience
- –multisectoral and interdisciplinary approach
- –link between agriculture and nutrition
- –improving nutrition requires systemic change
- –investments in nutrition
- –commitments to action (African Union 2022).
The following priority areas were also designated as guiding elements for the 2022 theme:
- –data management and information systems, knowledge generation and dissemination, to inform decision making
- –advocacy for increased commitment and nutrition investment
- –partnerships and mutual accountability platforms for harmonised action and transparency
- –institutional capacity enhancement and enabling environment for intensified action and delivery of results and impact (ibid.).
The overall objective is to improve commitment and investment in nutrition at the national, subregional, regional, and continental levels and to foster implementation of nutrition-related programmes to help address the continent’s lingering nutrition challenges. This would involve tracking progress in nutrition-related initiatives, enhancing cooperation with partners, and facilitating dialogue and knowledge-sharing among stakeholders (ibid.).
The 2022 theme can be expected to contribute to the fulfilment of the region’s health agenda, address food security challenges by pursuing agricultural development and expansion, and promote economic development across the continent.
4 An Analysis of the AU’s Health Performance and Interventions
In 2021, the African Union’s health agenda was widespread and multifaceted, but the Covid-19 pandemic remained a priority issue. As the AUC and other regional institutions developed a coordinated response, regional plans remained anchored to the context and goals of broader global and regional agendas, such as the Sustainable Development Goals and Agenda 2063. The
While regional activities continued to focus on addressing critical endemic diseases, there was a key focus on research and innovation as well as developing regional capacities to devise scientific and technological solutions to health challenges, especially in pharmaceutical production. Vaccine acquisition was essential to improving access, but that demand also fuelled the emphasis on facilitating local (regional) manufacturing to meet the vaccine requirements of the region’s populations. Access to Covid-19 vaccines has been a major priority, but such innovations also entail developments that could be used in other target areas, including malaria.
Given the multifaceted nature of health interventions, the adoption of coordination among AU institutions and partnerships with non-AU institutions in various areas from vaccine distribution to vaccine manufacturing and the pandemic response, among others, depict a collaborative health agenda that encourages communication, cooperation, and coordination in addressing health challenges and promoting development. The AU incorporates a system that undertakes regional initiatives in a diffused way for the benefit of national and subregional stakeholders, whereby collaboration ensures that stakeholders are part of regional endeavours that will trickle down to the target beneficiaries.
Finally, the AU theme for 2022 was introduced in 2021 with the aim of prioritising nutrition interventions in member states, with the support of regional and global partners. The intrinsic connection between health and nutrition will allow the AUC to address nutrition-related health challenges in a multifaceted way that will bring diverse stakeholders to the table and contribute to the region’s broader development agenda.
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See footnote 4.
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See footnote 7.
See footnote 4.
See footnote 2.
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See footnote 12.
See footnote 12.