A new public health order for Africa's health security
Authors: John Nkengasong, Benjamin Djoudalbaye, Olawale Maiyegun
Journal: The Lancet Global Health (2017)

On July 3, 2017, African heads of state and government issued a declaration and committed to accelerating implementation of the 2005 International Health Regulations (IHR)1The African UnionAfrican Union heads of state and government commit to accelerate the implementation of international health regulations.https://www.au.int/web/en/pressreleases/20170707/african-union-heads-state-and-government-commit-accelerate-implementationDate: July 7, 2017Google Scholar and tasked the Africa Centres for Disease Control and Prevention (Africa CDC), the African Union Commission (AUC), and WHO with supporting the venture.1The African UnionAfrican Union heads of state and government commit to accelerate the implementation of international health regulations.https://www.au.int/web/en/pressreleases/20170707/african-union-heads-state-and-government-commit-accelerate-implementationDate: July 7, 2017Google Scholar The IHR is a global legal agreement that aims to prevent and respond to the spread of diseases to avoid their becoming international crises.2WHOStatement of the 14th IHR Emergency Committee regarding the international spread of poliovirus. World Health Organization, GenevaAug 3, 2017http://www.who.int/mediacentre/news/statements/2017/14th-ihr-polio/en/Google Scholar The Ebola virus disease outbreak that started in March 2014, resulted in an estimated 11 000 deaths3Centers for Disease Control and Prevention2014–2016 Ebola outbreak in west Africa.https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.htmlDate: 2016Google Scholar and US$3 billion in economic losses in west Africa.4The World Bank2014–2015 west Africa Ebola crisis: impact update.www.worldbank.org/en/topic/macroeconomics/publication/2014-2015-west-africa-ebola-crisis-impact-updateGoogle Scholar The declaration is not only a reaffirmation of Africa's determination to scrupulously implement the IHR but should also serve as a new African public health order in addressing health security and inequities on the continent. Here we argue that a new public health order should address two broad categories of barrier that have challenged the implementation of IHR (2005) in Africa: health systems and systems for health. Five key improvements to the health system are necessary. First, public health capabilities should be strengthened, with national public health institutes as the drivers of IHR implementation. There should be improved infrastructure and enhanced capacities for integrated national and regional networks for disease surveillance, including laboratories, emergency operation centres, and innovative information systems. Second, a reward and penalty system should be implemented along with financial incentives to acknowledge whether progress has been made in implementing the core capacities of IHR through rigorous objective external stepwise assessments, such as the joint external evaluation (JEE), creating an IHR aggregate score for each country. Only 64 of 196 signatories to the IHR had developed the necessary core capacities as of 2015.5Kamradt-Scott A Strategic security analysis. Achieving global health security: the implementation of international health regulations. Center for Global Policy, GenevaJanuary, 2016www.gcsp.ch/download/5089/123206Google Scholar Third, implementation of the IHR should be decentralised to the subnational levels of the health service, with a strong community engagement. Fourth, the African public health workforce should be enabled to meet the IHR needs and other commitments at a national level, including by adapting and recognising community health-care worker programmes, field epidemiology training programmes with subspecialties to meet IHR requirements, field laboratory leadership programmes, public health informatics training programmes, and through public health management of hazards and pandemics. Fifth, governance procedures for the management of public health data sharing should be established. The continent's ability to generate, warehouse, and use quality public health data in real time is a challenge. As such, a culture of data sharing must be promoted in the new public health order. Data sharing is not a zero-sum game, so must be seen as a collective public health improvement to stimulate appropriate confidence among member states. Sharing disease data in a timely fashion through recently established public health constructs such as the Africa CDC's Regional Integrated Surveillance and Laboratory Networks will be critical to advance the implementation of IHR and enhance African health security. Not sharing disease data for public health is costly to countries as it can lead to duplicate research efforts to generate data that might already exist and might have enabled a neighbouring country to be better alerted, prepared, and able to respond to a disease threat. To accompany the health system strengthening agenda, a strong commitment to enhancing systems for health must be made. First, political commitment must be translated into action by making available the necessary domestic financing for strengthening health systems. Second, legal instruments to facilitate implementation of the IHR in member states should be issued—all member states should commit to establishing national public health institutes as the driving body for implementing the IHR. Third, country leadership and ownership needs to be encouraged. Partners and donors should commit to cooperating and coordinating their efforts within national plans for the IHR, with a clear and unified matrix for measuring progress—one country, one plan. The JEE tool developed by WHO in partnership with other organisations provides a unique opportunity for partner coordination, information sharing, and avoidance of fragmented efforts that often undercut national health systems. Fourth, there should be a private sector engagement strategy in which commitments to developing financial analogues to support health systems are treated as an investment and not a cost—outbreaks and pandemics constitute serious threats to businesses in Africa, including airlines, the hotel and leisure industry, banking, the food industry, and mining. Fifth, an AUC health diplomacy strategy must be developed to enable and supplement efforts for enhanced health systems and systems for health. The provision of the legal capacity by the appointed oversight institutions to implement corrective action on non-compliant member states will be key to the success of the IHR framework. In summary, the declaration of African heads of state and government offers a momentous opportunity for renewed engagement for strengthening health systems to accelerate implementation of the IHR and other commitments using a broader multisector approach including public–private philanthropic partnerships. We declare no competing interests.