Africa’s health systems are deeply influenced by the structures of the global political economy. From international financial institutions (IFIs) to private health initiatives, the governance of health in Africa reflects stark inequalities. In this piece, Vivek N.D. explores how systemic issues within global health governance influence Africa’s health landscape, examine the environmental and economic factors worsening health crises and discuss the challenges faced by regional initiatives like the Africa Centres for Disease Control and Prevention (Africa CDC). The piece provides a critical analysis of the interaction between global and local factors, highlighting systemic flaws in Africa’s health governance.
By Vivek N.D.
Africa’s health crises cannot be disentangled from global health governance systems. The World Health Organisation reports a 34% global decline in maternal mortality from 2000 to 2020, yet Southern Africa still accounts for nearly 70% of maternal deaths. Persistent high rates in the region stem from challenges like limited access to quality care, inadequate infrastructure, poor socioeconomic conditions and low awareness of maternal health. These challenges are in turn closely linked to the structural adjustments imposed in the late 1980s and early 1990s by two of the most ruthless institutions at the heart of the Western neoliberal ensemble, the International Monetary Fund (IMF) and World Bank. Historically, structural adjustment programmes (SAPs) mandated reductions in public spending, crippling health infrastructure across the continent.
Since the 2000s, the influence of private foundations and public private partnerships (PPPs) also underscores the asymmetric power dynamics in global health governance. Initiatives like the Bill and Melinda Gates Foundation (BMGF) and the GAVI Alliance may have achieved measurable successes, such as increasing vaccination rates, but these achievements often come at the expense of systemic health improvements. Their initiatives prioritise disease-specific vertical programme-interventions (focusing on, for instance, TB or malaria), side-lining the broader social and political determinants of health including poverty, lack of healthy food options and poor environmental conditions.
Moreover, pharmaceutical companies play a pivotal role in perpetuating inequalities. Pharmaceutical companies, through WTO patent restrictions and profit-driven policies, have perpetuated health inequities especially for African people living with HIV and AIDS. Over the past decade, tens of millions of lives have been saved in Africa through the widespread use of antiretroviral therapy (ART), with 20.8 million of the 25.6 million people living with HIV in the region on ART by the end of 2022. However, rising HIV drug resistance, driven by genetic changes in the virus, threatens the effectiveness of all current medications, including newer antiretrovirals. As of 2023, the global cases of HIV and AIDS related deaths stood at 630,000. The figure for East and Southern Africa was 260,000, accounting for 42% of global deaths.
Africa’s health challenges are further compounded by the climate crisis, which is disproportionately driven by industrialised nations. Rising temperatures, erratic rainfall, and extreme weather events are worsening health outcomes across the continent. For instance, the incidence of malaria has risen sharply in the past 20 years, and is projected to further increase in East Africa as rising temperatures expand the habitats of disease-carrying mosquitoes.
The links between global neoliberal economic models and Africa’s environmental health crises are stark. For example, Kabwe in Zambia is one of Africa’s worst pollution hotspots due to toxic waste from a former lead and zinc mine, once owned by Anglo-American and other colonial companies, later nationalised and closed in 1994, but never cleaned up. Despite local protests and media coverage, efforts to hold these corporations accountable remain limited. Similarly, deforestation in the Congo Basin, driven by global demand for palm oil and timber, has disrupted ecosystems and heightened the risk of zoonotic diseases.
Industrialised nations bear significant responsibility for these crises, yet their commitments to funding climate adaptation in Africa fall short. As of 2022, developed countries provided USD 115.9 billion in climate finance to developing nations. At COP29 in Baku, Azerbaijan developed nations pledged to lead in raising USD 300 billion annually for developing countries by 2035. However, actual disbursements remain far below this target, leaving African countries to shoulder the dual burden of health crises and environmental degradation.
Global health institutions and partnerships, while instrumental in tackling specific diseases, often perpetuate dependency. Programmes like the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) have undoubtedly saved millions of lives. However, their disease-centric approach undermines the development of comprehensive health systems.
The African CDC, established to coordinate the continent’s public health response, faces significant challenges. It remains heavily reliant on external funding, limiting its ability to assert autonomy in health governance. Furthermore, the fragmentation of health priorities among African nations hampers the CDC’s ability to implement continent-wide strategies effectively. This reflects the broader marginalisation of African voices in global health decision-making.
The influence of multinational corporations further complicates the situation. Companies involved in global health initiatives (GHIs) often prioritise profit over equity. For instance, the Roll Back Malaria Partnership, while celebrated for its successes, has faced criticism for being highly dependent on donor contributions. In addition, its efforts are hampered as a result of initiatives being designed to privilege donor interests over local needs. As Seye Abimbola, et al. state, “Much too often, international donors and funding organisations who come as ‘saviours,’ prefer to fund projects that address their own interests, on their own terms. This, in turn, leads to a waste of resources, loss of local research interest, and lack of trust between grantees and donors.” Such dynamics expose the systemic inequalities embedded in global health governance.
The COVID-19 pandemic laid bare the inadequacies of global health governance. Initiatives like COVAX, which was said to have been designed to ensure equitable vaccine distribution, failed to meet their objectives. High-income countries hoarded vaccine supplies, leaving low-income nations with limited access. The COVID-19 pandemic starkly illustrated the ill-effects of vaccine nationalism: while wealthier nations secured over 70% of vaccine doses by 2021, Africa faced a severe shortage, with vaccination rates lagging behind the global average. As of 14 August 2024, 13.6 billion vaccine doses were administered globally, with African countries accounting for 863 million doses, fully vaccinating only 32.4% of the continent’s population.
This inequity reflects broader structural flaws. Intellectual property rights, enforced by the WTO, prevent the local production of vaccines in Africa. Further, in the context of Africa, persistent colonial extractive institutions have contributed to the technological and industrial underdevelopment of Africa’s pharmaceutical sector, resulting in a lock-in effect that hampers progress. Efforts by South Africa and India to secure a waiver on COVID vaccine patents faced strong opposition from pharmaceutical companies and wealthier nations, illustrating how global systems prioritise profit over public health.
Moreover, the pandemic highlighted the limited capacity of African health systems to manage large-scale crises. The reliance on external funding and expertise underscores the need for self-sufficiency. However, achieving this requires dismantling the systemic barriers imposed by global institutions and rethinking the political economy of health.
Global health governance must confront its structural inequalities. This requires dismantling the power asymmetries that prioritise the interests of wealthier nations and multinational corporations over the needs of vulnerable populations. Without addressing these systemic flaws, the goal of equitable global health systems will remain elusive. It is important to note the Africa CDC’s New Public Health Order launched in 2023 which aims to enhance health security in Africa through stronger institutions, workforce development, local manufacturing, increased investment and equitable partnerships. Reimagining health governance requires a fundamental shift in priorities. This includes holding multinational corporations accountable for their role in health crises, ensuring equitable funding for climate adaptation and empowering African institutions to lead the continent’s health agenda. Most importantly, it demands a departure from the disease-specific, donor-driven models that have dominated global health governance. The lessons of COVID-19 and ongoing health crises underscore the urgency of this transformation. Africa’s health systems must be strengthened not through external dependency but through investments in local capacities and structural reforms. Only then can the continent navigate the complex challenges of the 21st century and achieve health equity for its people.
Vivek N.D. is a writer based in Bangalore and founder of the Nenmi9 Fellowship. He specialises in global health governance, development issues, and non-traditional areas of international relations in relation to Asia and Africa. He has a PhD in Political Science from the University of Hyderabad. He has published extensively in academic journals and media outlets like Development in Practice, Geneva Health Files, and Geopolitical Monitor.
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