While working in Liberia during the Ebola outbreak in 2014, I witnessed firsthand how public-health events can highlight gaps in our existing public-health systems. But these events (be it Ebola in a predominately West African context then, or Covid-19 across Africa now) also present opportunities to learn crucial lessons that can help to strengthen public-health preparedness and response going forward. In not learning these important lessons, we risk exacerbating the challenge at hand and also exposing ourselves to future risks.
Regional public-health systems in Africa play a key role, as they are able to provide leadership and optimise efficiencies across multiple national-level systems. Regional public-health systems also occupy an important middle space between the global multilateral agencies and national agencies. When each of these systems is functioning well, the ecosystem works together in a way that's complementary and responsive, providing what governments across the continent truly need to successfully keep millions of people healthy.
Two of Africa’s supra-national public-health systems – the West African Health Organization and the Africa Centres for Disease Control and Prevention – help to illustrate the challenges and opportunities faced by these important players and how they have fared during the Covid-19 crisis.
The West African Health Organization (WAHO) was founded in 1987 by the 15 member countries of the Economic Community of West African States (ECOWAS) as a specialist health agency to harmonise policies, pool knowledge and resources, and foster cooperation for a collective, strategic fight against the health problems of the sub-region. Though it has more than three decades of experience, and had demonstrated value during the West Africa Ebola outbreak; during the Covid-19 pandemic WAHO lacked the necessary attention and critical resources, with a staff of under 100 people to serve the populations of 15 countries with a population of over 400 million.
The Africa Centers for Disease Control and Prevention (Africa CDC) was launched much more recently, in 2017, and while it has done well in coordinating emergency preparedness and response across the continent during Covid-19, it has experienced its own challenges. It is a young organisation thrust into limelight during a period of extreme trials, without the benefit of long-running established systems and structures. Although, it has done well, and has been recognised globally for the value of its contribution, it has a small staff base, and operational challenges such as recruitment, finance, procurement and other systems and procedures not attuned to its growth needs.
It became clear over the past year that limited resources and underdeveloped systems had a negative impact on how quickly these supra-national public-health organisations could adapt and respond amid the crisis, making the need to ensure their strengthened position especially urgent. Just five years ago, the Nigeria Centre for Disease Control (NCDC) was struggling with these similar challenges, when it began a process of organisational transformation. Together with the Bill & Melinda Gates Foundation, we at the Tony Blair Institute for Global Change (TBI) partnered with the NCDC on this journey and provided embedded support on institutional strengthening and capacity building. As a result of this journey and with the support of other partners, the NCDC was able to put in place functioning systems and a high-performing workforce prior to the Covid-19 pandemic, and the agency was much better equipped to handle the crisis than it had previous disease outbreaks.
Through TBI’s experience supporting the NCDC, we have learned key lessons and identified steps that regional public health organisations and their partners can take to transform and strengthen their operations.
Lesson 1: Take time to understand the organisation. As part of our embedded support, TBI allowed for a six-month scoping period to learn about the NCDC as it was, to listen to current employees, and to build trust and buy-in. Rather than applying a one-size-fits-all strategy, build in this time so that you can fully understand possible solutions. During this period, we understood the organisation and the ecosystem within which it needs to operate, so we could match the leader’s vision to the reality on ground and help him set and calibrate his vision.
Lesson 2: Build a flexible, individualised strategy. Yes, a regional public health agency must have global standards, but it needs to still be attuned to its environment. A good strategy is a way to anchor the journey so that you can then build structures around the strategy to turn vision into reality. The strategy also needs to be flexible and responsive so, when working with the NCDC, we revisited the plan at the end of every year to evaluate and revise. The NCDC never strayed from its original vision, but the team could refocus on priority projects, identify bottlenecks and challenges and build new ways around them.
Lesson 3: Invest in people. In 2016, the NCDC staff was far too small for the workload (around 70 people in total) but eventually scaled up to 300 employees. The NCDC and its partners also invested in human resources to create a robust and consistent onboarding process; this ensured new staffers had a full understanding of the wider strategic goals of the NCDC and how their work would fit within it. We also set regular meetings for directors from each of the technical workflows, who had been siloed, to collaborate. What resulted was the transformation of the original top-down strategy into a bottom-up strategy, informed by the employees across all departments who are doing the work.
Lesson 4: Invest in support functions. Improvements to HR, IT and communications departments will never be as flashy as last-mile deliverables, but these create an environment where people can do their best work and are the “silent” pieces of success. A few years ago, the NCDC website was unusable and staff even lacked official email addresses. Investing in the IT team meant addressing those issues plus rolling out new digital disease surveillance software to 17 states in the Nigerian federal system, making it much easier to expand to all of Nigeria’s 36 states and the Federal Capital Territory once Covid-19 arrived. Taking the time to build systems today means that when a crisis hits, organisations can scale up existing systems rather than trying to create new ones from scratch in the midst of an emergency.
Lesson 5: Recognise the importance of a transformational leader with vision. Chikwe Ihekweazu, the Director General of the NCDC, came in with big ideas and a mission to identify issues and then make meaningful change. He tapped his network of health researchers and leaders around the world to bring in best practices, met with every staffer, and led by example. His motto is “we keep pushing, till we deliver” – and you need a leader who will continue to move an organisation forward in bold new ways.
The journey of transformation has taken about five years of hard work so far for the NCDC, but it emerged a stronger organisation that was able to deal with the challenges of the pandemic in a much more productive and efficient way – saving countless lives. When development partners invest in these kinds of institution-strengthening projects, it ensures regional public health agencies have the resources and systems they will need to carry out their core functions, now and for years to come. Through investing in strengthening the systems and staff of regional public-health agencies, we can build high-functioning and resilient organisations, which can then work in unison as well as collaborate with both global and national public health bodies. By starting this work today, we can set the groundwork for a faster, stronger, better response to tomorrow’s health crises.
You can read Chikwe Ihekweazu's thoughts on the Nigeria Centre for Disease Control's progress here, and more information on its transformative journey here.
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