Challenging the Europe-Africa Partnership on Healthcare: Redressing the Balance

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Ben Lowings
POLITICAL ANALYST

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Discussion paper following the 13 April 2022 webinar event, “Healthcare and Politics in the Europe-Africa Partnership: Improving Policy and Discourse”.

1.   Introduction

On 13 April 2022, the Brussels International Center organized a webinar event “Healthcare and Politics in the Europe-Africa Partnership: Improving Policy and Discourse” that brought together policy makers, practitioners, advisors, and NGOs together to discuss some of the key obstacles facing better Europe-Africa trans-continental policy and practice while implementing healthcare strategies in African countries. This level of engagement, mainly at the level of the EU and AU, or more directly between the EU and African states, has seen a much greater focus on healthcare considering the COVID-19 pandemic which culminated in health being cited as one of the key priorities in the Sixth EU-AU Summit in February 2022.

 

In many respects the inclusion of health as a key priority was a big achievement, insofar as this was the first time that this theme has ever been included as a central theme in any prior EU-AU Summit. On the other hand, the fact that it took such a global pandemic, one which specifically affected European countries in such a disruptive way, for health to become a theme when there have been plenty of prior health emergencies affecting Africa, is also indicative of doubt towards European engagement, a doubt that emerged throughout our panel discussion. For yes, while the language of policymakers on healthcare has been better at this Summit, the proof is in the practical implementation.

The key question then becomes: how do we move from good rhetoric to effective policy? The panel articulated several issues across the multiple layers of healthcare implementation from supply chains, financing, distribution by national governments, medication, and vaccine licensing as well as actual on ground administration by local doctors, which can roughly be categorized into three interlinked challenges.

2.   Communication Challenges

2.1 Knowledge-Production for On-Ground African Doctors and Practitioners

 

The barrier I found the most surprising, actually came from doctors and those in the medical profession… While at the policymaking level at the Ministry of Health, we were pushing for these [COVID-19 vaccines] to be made available, it’s really the doctor that carries the risk [to address the concerns of patients about COVID-19 and the vaccines] … So the second barrier was really around knowledge production and ensuring that doctors were equipped sufficiently with information regarding the… safety of the vaccines.

                                                                                                            Asil Sidahmed, BIC Strategic Advisor and Analyst for Africa

 

Firstly, there is still obviously a lack of understanding of the differing contexts in the many different countries and regions of Africa. While there are several chronic impediments to effective understanding, such as the reality of continued militarization and ongoing armed conflict in certain contexts, a key issue especially relevant to European policymakers is communication.

 

For example, the supply chain for vaccine production, distribution and administration of COVID-19 vaccines has been established extremely quickly across the world but has seen a rise in disinformation and misinformation about the safety and effectiveness of the vaccines. But this has also been the case in African contexts, where doctors have been given vaccines from other parts of the world, like Europe, without sufficient information about that medicine. In Sudan, for example this led to several doctors themselves expressing scepticism about the vaccine. This would appear to indicate that some information about the vaccine was lost at some stage of the supply chain.

 

2.2 Increasing Feedback from African Contexts to the EU

 

At the same time, communication is a two-way process. European policymakers continue to ask and encourage for more contextual information from their African counterparts on how to improve this engagement. And this acknowledgement that African states know what’s best for their own context when receiving medical supplies, emerged during the panel discussion.

 

There is no model for delivery, it has to be tailored, it has to be country-specific … We know there are multiple bottlenecks right, whether it be logistics, infrastructure, cold-chain, human resources, personnel, but indeed countries know the best what are the bottlenecks which need to be addressed and which additional funding can be mobilized.”.

              Gabriella Fesus, Head of Unit Social Inclusion, Protection, Health and Democracy at the European Commission

 

But this engagement is still limited to the national, governmental level and focussed on vaccine delivery, of which there are several mechanisms in place through COVAX and UNICEF. Regarding more general implementation of healthcare delivery however, the picture is less obvious. It is unclear what the status of the various national mechanisms for on-ground doctors to report about the effectiveness of healthcare implementation strategies is. There could be political space here for a new encouragement for better feedback from on-ground doctors to their respective Health Ministries so that these concerns can be better transmitted. 

3.   Resource Challenges

3.1 Increasing Local Manufacturing in Africa

 

The second challenge is the continued resource gap in terms of finance, access to medicines, and expertise in African contexts. The status quo approach to this has generally been a simple provision of aid. However, as accountability issues such as corruption, and the understanding of structural challenges have become increasingly visible, policymakers have begun to move away from this approach, the EU included. For instance, there has been a greater emphasis on investment in local manufacturing of medicines through new initiatives, such as the Global Gateway Initiative.

 

Looking ahead, I think what is certainly very positive is that there is now really a genuine commitment from our side… to indeed to support African efforts. If we start with the whole question of manufacturing capacity, … the EU is already a strong supporter of building manufacturing capacity. … So far over 800 million euros have been mobilized by the three key member states are very much engaged, Germany, France, Belgium but also the European Commission, to support capacities in South Africa, Senegal, Rwanda, and Ghana but also at the continental level, precisely to build the local production capacity.      

              Gabriella Fesus, Head of Unit Social Inclusion, Protection, Health and Democracy at the European Commission

 

These manufacturing initiatives are a welcome first step, however it remains to be seen whether the participating Western manufacturers, such as BioNTech, will be willing to fully transfer key technology to African partners, and under what terms and conditions. BioNTech’s current plan to set up “mobile-manufacturing” units conveniently avoids this requirement. While the WHO led mRNA tech-transfer hub is making impressive progress in its goal to reverse-engineer COVID-19 vaccines (and potentially other mRNA vaccines in the future), it has notably not received any support or technology from Moderna or Pfizer- BioNTech.

 

3.2 The Issue of the TRIPS Intellectual Property Waiver

 

Conversely, this approach towards local manufacturing within Africa seems to be undermined by the recent controversy regarding intellectual property rights (TRIPS) on COVID-19 vaccines and the TRIPS compromise text recently proposed to the WTO membership. Some of the core objections to the “compromise” TRIPS waiver are that it only covers vaccines and not diagnostics nor treatments, and that the actual intellectual property waiver only includes patents, and not intellectual property rights in broader terms, such as trade secrets. The lack of this broader coverage could then block key information needed for medicinal manufacturing. This was a point of discussion during the panel, on what the ramifications of the text would be, as well as the role of the EU in this.

 

The blockage to the TRIPS waiver in which Europe is a heavyweight… it is a real failure. … We have looked at the leaked EU proposal (already telling in terms of transparency). According to what we have seen, this proposal will be a step backwards to the past. … Some of the problematic aspects are: It only covers vaccines; it doesn’t cover therapeutics and diagnostics. It is based on compulsory licensing and based only on patents and not on broader intellectual property and it arbitrarily excludes some countries.”

                                                                  Inma Vasquez, Representative for the EU and NATO at Médecins sans Frontières (MSF)

 

As it stands, the “compromise” text has been presented to all 164 World Trade Organisation members with the only official endorsement of the text coming from the EU.

 

3.3 Inequity of the COVAX Mechanism for Global Vaccine Distribution

 

Similarly to the issue of rights to production, are the available mechanisms for vaccine distribution that have been criticised for undermining African autonomy and healthcare implementation as a response to COVID-19. The COVAX mechanism implemented by Gavi, and supported by the WHO, to enable distribution of COVID-19 vaccines around the world has been the most significant provider of COVID-19 vaccines to Africa so far. However, it has been criticized for allocating global resources unfairly, and failing to challenge pharmaceutical monopolies over production and distribution.

 

“Initial discussions were focused on a global decision-making mechanism to ensure that resource allocation is based on needs, but this failed. The creation of COVAX was positive, the EU has put a lot of resources, but the problem is that COVAX was undermined from the beginning since it was created as a parallel system. The EU and other high-income countries pre-booked the doses for their own population in quantities completely out of proportion and COVAX was left as a parallel system for those that can afford less.”

                                                         Inma Vasquez, Representative for the EU and NATO at Médecins sans Frontières (MSF)

 

3.4 Increasing African-Led and Owned Healthcare Solutions

COVAX is not the only mechanism for vaccine distribution, and the AU has developed its own mechanism, AVAT, to implement vaccine production within African countries themselves for African citizens. As our panel noted, building autonomy will be critical for long-terms sustainable solutions to African issues, including healthcare. AVAT is one of these autonomous solutions:

 

Africa has to deliver our own solutions… Whether mechanisms such as AVAT… Africa CDC’s models for genomic sequencing and other various initiatives, we have seen a tremendous drive for the Africa Continental Free Trade Agreement… we are seeing a momentum which is translating into potentially positive benefits.”

                                                                                                   Jens Pedersen, Independent Consultant at Africa First Advisory

 

3.5 Disparity in Available Financial Budgets

 

The issue of a continued resource gap is also incredibly stark when comparing the EU’s budget for healthcare in Africa, to the budget by a working NGO like MSF. Utilizing publicly available data from the EU’s multi-annual indicative plans on the countries that MSF works in Africa:

 

[Regarding the EU’s Multiannual Indicative Plans for the next 4 years], the budget allocated to human development [which includes the health and education sectors and assuming that 50% of this budget is allocated to health] for the Sub-Saharan African countries in which MSF works, making a quick calculation - which may not be entirely accurate - we get a total of €355 million per year MSF in those same countries, has a budget for 2022 of 600 million euros. When an organization like MSF, can not only compare but has more resources than the Commission, there may be something there that is not right … This is a point to say that the resources that the donors put on the table for health are insufficient.”

                                                         Inma Vasquez, Representative for the EU and NATO at Médecins sans Frontières (MSF)

 

Granted, when adding direct funding from Member States, the total budget for healthcare goes beyond this number.

 

If we look at the EU budget only, it is not an enormous amount. But, to that we need to add what EU Member States bring. … In addition, the EU continues to support global health initiatives.”

              Gabriella Fesus, Head of Unit Social Inclusion, Protection, Health and Democracy at the European Commission

 

However, the fact remains that much of the costs of implementation are being shouldered by partner NGOs.

 

3.6 Country-Specific Logistical and Technical Challenges

 

And there are also the contextual reality of practical difficulties affecting reception and distribution of vaccines in-country. In Sudan, a country currently going through a period of political transition these practical difficulties begin even at the point of reception of vaccines at the airport. One of the key logistical issues, for instance, is cold chain storage; the reality of transferring equipment and medicines that require storage at a controlled colder temperature between distributor and receiver. Cold chain implies that receiving countries need sufficient equipment readily available to at reception centres such as airports, so that supplies can be quickly transferred. It is not always clear in certain contexts within Africa if this equipment is readily available.

 

What ended up happening… given the… country that was at that time re-entering the global scene… there was a significant amount of pressure to respond and to say yes, even when we were receiving as little as 300,000 vaccines of AstraZeneca in one batch. When that batch arrives, you not only have the Ministries that you have to deal with, you also have to deal with airports, and the reality of cold-chain on the tarmac and demurrage.”

                                                                                                                 Asil Sidahmed, BIC Strategic Advisor and Analyst for Africa

 

There are also significant barriers derived from political instability. Fragile governments, often militarized such as the post-coup environment in Sudan, have weaker systems in place. This impacts not only the methods how to receive foreign supplies, but who is best qualified to receive those goods.

4.   The Structural Imbalance of Power

4.1 Whitewashing Europe-Africa Policy

 

The third and final challenge to be discussed here is strongly related to the other two challenges but is significant enough to warrant particular mention. A key underlying reality of Europe-Africa cooperation on any front, be it healthcare, education, migration, or any other theme, is that there is a significant imbalance of power between the richer and more powerful European countries and their institutions including the EU itself, and their African counterparts.

 

The value of acknowledging this power imbalance was a key subject of discussion in the panel in terms of its practical value to the policymaking at hand.

 

One of the phrases that I think is really important is a phrase that’s often referred to as ‘whitewashing’. Now whitewashing is often a phrase that is used in anti-racist literature that talks about how an avoidance of addressing the power imbalance and the reality of the power imbalance often leads to reproducing it. So, it can be quite easy to have a positive intention, to not further reproduce power imbalances, however I believe that avoiding those power imbalances inadvertently reproduces them further, and not being conscious of that, not being conscious of your own power, might have an impact on policy.”

                                                                                                            Asil Sidahmed, BIC Strategic Advisor and Analyst for Africa

 

Granted, there can be tendencies to overtheorize rather than establishing concrete policy, however on this issue structural imbalances have vast ramifications on the success of efficacy of policy implementation. The most concretely example of this during the pandemic was the realpolitik procurement of early vaccine doses, where the EU and wealthy countries snapped up over 5 times more vaccines than they even needed, pushing LICs to the back of the line. Appreciating these raw imbalances of power is essential to design contextually specific needs, safeguards, and countermeasures to ensure African interests receive equal consideration. This understanding is also essential to have a genuine and frank discussion between counterparts on how to make and implement policy.

 

4.2 Approaching a Mutually Beneficial Partnership

 

Beyond this, it is even a strategic objective of EU-AU cooperation to foster a ‘mutually beneficial partnership’.

At a more conceptual level, what was very clear was that the AU and African countries want… they want a mutual and equal partnership… The absence of that, there’s no need to beat around the bush and call it a partnership… The COVID-19 pandemic highlighted some of these perceptions around… double-standards for what can be done for Africa, what should be done, and what we want to do for Africa… The conversations were, and the language was, as always politically correct, it was around equity, it was around fair distribution, but as we know the reality was very different.”

                                                                                                   Jens Pedersen, Independent Consultant at Africa First Advisory

 

This will continue to be impossible without realizing the structural flaws within this partnership from the outset, which the EU still struggles to do. While both African and European leaders have agreed to dismiss the “donor-recipient relationship,” there is disagreement over what to replace it with. While African leaders aim to correct systemic inequalities, the EU maintains that ‘partnership’ is simply an equal balance of European and African interests, which can be achieved by simply increasing private sector collaboration.  

 

This means that in achieving a true “mutually beneficial partnership,” the real question lies in how much the stronger partner, the EU, will be willing to compromise in order to support the other, the AU, achieve its objectives for citizens. As it stands, there are several initiatives being implemented so far, but whether the level of such initiatives is sufficient to even come close to starting to redress this power imbalance is still doubtful.

 RECOMMENDATIONS

To the European Union:

  • Ensure the adoption of an intellectual property rights (TRIPS) waiver text to include, beyond patents, intellectual rights in broader terms such as trade secrets, and to include treatments and diagnostics at the World Trade Organization.
  • Increase consultations with civil society and NGOs, including networks and associations working on the matter, such as through the Global Health Policy Forum, and ensure recommendations for equitable solutions are taken forward.
  • Increase available resource capacity, including financial capital, to better support African healthcare response and preparedness. Increase the amount of ODA spent on health in the 2023 EU Budget, and adopt mid-term benchmarks for the 2030 Global Gateway targets.
  • Adopt better intersectional mainstreaming considerations, including anti-racist and post-colonial perspectives, when crafting and implementing policy that affects African citizens.

To the African Union:

  • Invest further in developing African-led and owned solutions to healthcare emergencies, such as the promotion of research and development at universities and private laboratories, medicines production, and incentivising local expertise to continue working in African contexts.

To African Member States, and their respective Ministries of Health:

  • Ensure greater knowledge transmission about the safety and efficacy of medicines, including vaccines, and treatments to medical staff to counter distrust and misperceptions among citizens. Consider more standardised information workshops.
  • Improve mechanisms for on-ground medical staff to provide feedback about the efficacy of healthcare programs such as standard evaluation procedures. Increase the share of national budgets allocated to healthcare.
  • Implement more streamlined, efficient procedures to receive and distribute medicine supplies for on-ground use. Utilise better solutions for cold chain logistics at airports and reception centres.

To the World Health Organisation:

  • Implement an independent evaluation of the COVAX mechanism regarding fair and equal distribution of medicines to ensure that the response to future global health emergencies will be shared equally.