The end of the emergency phase of the COVID-19 pandemic was announced by WHO on May
5, 2023. Reflecting on the legacy of the pandemic in low-income and middle-income
countries (LMICs) where most excess deaths occurred, it will be remembered for the
pervasive inequities that plagued every crucial aspect of the global response, from
access to vaccines and therapeutics to gaps in health-care infrastructure.
1
Despite the many failures of global solidarity, the pandemic also showcased the resilience
and innovative capacity of LMICs, providing some positive aspects and a roadmap for
continued improvement in infectious disease and health system strengthening.
Three pieces in this Series explicitly amplify the voices of experts in LMICs on how
to leverage the potential opportunities for sustainable vaccine capabilities in Africa,
2
combating the increasing threat of antimicrobial resistance (AMR),
3
and establishing more equitable structures to ensure effective and fair collaboration
among stakeholders and nations during future pandemics.
4
During the COVID-19 pandemic, vaccine nationalism caused substantial delays in vaccine
access, particularly in the region of Africa that had the lowest coverage in the world.
As a result, nations without local manufacturing capabilities suffered avoidable deaths
from COVID-19.
5
Moreover, the absence of vaccines created a void that allowed misinformation and vaccine
hesitancy to spread, which also affected the uptake of other vaccines.
6
The pressing need to establish sustainable vaccine development and manufacturing capacity
in the continent with the fastest-growing population is undeniable. Africa has a population
of 1·2 billion, yet less than 1% of the vaccines used in Africa are manufactured on
the continent.
7
Unless this crucial gap is addressed, Africa will be left behind again and have to
wait for trickle-down charity from high-income countries (HICs).
Bavesh Kana and colleagues examine the landscape of vaccine capability in Africa and
propose a comprehensive continuum for vaccine manufacturing, which spans from fundamental
discovery to production and distribution.
2
Building on initiatives that emerged during the pandemic, such as the WHO-sponsored
mRNA hub, the authors emphasise strategies that can foster sustained growth in this
field while establishing what will serve as key indicators for success: equitable
access, quality, and affordability.
To ensure the affordability of vaccines in Africa, it will be necessary to establish
risk-sharing mechanisms among local vaccine manufacturers, governments, and societies.
Additionally, the creation of multi-country platforms for vaccine manufacturing and
resource pooling could facilitate trade and enhance the availability of vaccines across
the continent. African countries can contribute to affordability by making advanced
market commitments to purchase locally manufactured vaccines, even at higher prices,
thereby increasing demand. Maintaining high manufacturing standards will necessitate
a skilled workforce, incentives for quality improvements, and the implementation of
robust regulatory and legal frameworks to ensure safety and efficacy. Embracing a
broad portfolio of vaccines is especially relevant and essential to promote innovation
and develop vaccines, which might not be prioritised by the pharmaceutical industry
or HICs.
The success of these initiatives will depend on building demand for locally manufactured
vaccines, obtaining political buy-in from African governments to invest in vaccine
manufacturing for the long term, ensuring geopolitical stability, and navigating existing
trade and intellectual property restrictions that are designed to profit pharmaceutical
companies and HICs. These challenges can be proactively addressed by treaties and
bold trade and intellectual property regulatory frameworks, instead of a reactionary
approach in times of crisis. It is crucial to ensure that the mRNA vaccine platform
does not remain a monopoly of big pharma and HICs. This novel and highly adaptable
platform should be equally available and accessible to LMICs and repurposed for developing
new vaccines against other diseases (eg, HIV, malaria, tuberculosis, and influenza).
COVID-19 exacerbated the considerable threat of AMR, which ranks among the top ten
public health challenges worldwide. Overuse of antimicrobials spiked during the pandemic,
8
and irrational use of ineffective therapies (eg, hydroxychloroquine and ivermectin)
was rampant.
9
In 2019, sub-Saharan Africa and south Asia reported the mortality rates attributed
to AMR, totalling 4·95 million lives lost and 1·27 million deaths directly caused
by resistance.
10
LMICs face unique challenges in fighting AMR due to factors such as inadequate hygiene
practices, fragile health-care infrastructure, a lack of essential diagnostics, weak
regulatory systems, and suboptimal implementation of infection control strategies.
The urgency with which countries addressed the COVID-19 pandemic should be matched
when confronting the AMR crisis.
Kamini Walia and colleagues highlight the need for LMIC governments to prioritise
AMR as a major public health crisis and allocate sufficient funding to mitigate its
effects.
3
Additionally, leveraging technology platforms (eg, molecular diagnostics and gene
sequencing), which were scaled up during COVID-19, can be extended to enhance AMR
diagnosis, surveillance, and reporting. Because of the pandemic, incredible improvements
were made in scaling up molecular diagnostics and self-testing technologies. These
investments should now be repurposed for other infectious diseases.
11
Telehealthcare, which saw tremendous expansion during the pandemic, also offers opportunities
to extend clinical care, education, and antimicrobial stewardship practices.
Effective risk communication is a crucial aspect in crafting an effective response
to AMR, which can benefit from adopting a consistent and message-centred approach
similar to that used during the COVID-19 pandemic. Many individuals within communities
perceive AMR as an abstract concept lacking the immediate threat of a newly emerging
virus. By improving risk communication on AMR, behavioural modifications can be achieved
among both the general population and health-care practitioners, leading to potential
long-term benefits.
Countries have shown regulatory flexibility during the COVID-19 pandemic to swiftly
provide vaccines to their populations. However, vaccination, which has the potential
to reduce the need for frequent antibiotic prescriptions and contain AMR, remains
underutilised. Expanding the scope of routine vaccination programs to include influenza,
pneumococcus, typhoid, and Haemophilus influenzae type B vaccines is another strategy
for reducing AMR. Generating evidence to support the economic effect of vaccination
on AMR and its long-term effects on morbidity and mortality will inform decision making
in this area.
The urgent need for genuine solidarity within the global health system cannot be overstated.
Insufficiently acting upon the idea resulted in the failure to deliver equity during
the pandemic. Ayoade Alakija draws from the lessons of the COVID-19 pandemic and highlights
the importance of tailoring interventions in response to pandemics to the unique circumstances
of different regions.
4
For example, it is crucial to implement context-specific and evidence-based non-pharmaceutical
interventions, which might have a differential effect on the economy and on the lives
of individuals depending on the setting and available resources. Successfully instilling
public trust and fostering adherence to these interventions cannot be reduced to a
single, universal solution. The notion that what worked in affluent HICs will seamlessly
translate to other contexts has proven to be misguided. Addressing these challenges
will require deft advocacy, effective risk communication, and meaningful community
engagement.
As we emerge from the COVID-19 emergency, forging a new global health order mandates
transparency, deep-rooted trust, global coordination, and substantial investments
that can be sustained over time. Realising this vision will necessitate robust regional
collaborations, facilitating platforms for cooperation among LMICs, and leadership
of countries with limited resources in decision-making processes. Most importantly,
it is time to shift from the charity and saviourism model of global health to a model
that is rooted in equity, justice, and allyship.
12
HICs should act on solidarity and support the vision of LMICs for self-determination,
self-reliance, and self-sustenance.
1
If all HICs supported the equity provisions in the pandemic accord that is under negotiation,
that would demonstrate a concrete act of allyship. A pandemic accord that does not
include equity, transparency, and accountability is destined to fail.
Even as we reflect upon the failures during the COVID-19 crisis, we should capitalise
on opportunities for growth and improvement. Amidst the devastation, some positives
abound, particularly for LMICs. Seizing these opportunities in the present moment
presents a chance to prevent the repetition of past mistakes and ensure better preparedness
and a more equitable health future for all.
© 2023 Flickr - GovernmentZA
2023
MP serves as an advisor to non-profits organisations namely WHO, Stop TB Partnership,
Bill & Melinda Gates Foundation, and Foundation for Innovative New Diagnostics. None
of these organisations were involved in this Comment. We declare no competing interests.