Africa CDC: Its Evolution and Key Issues for its Future

Introduction

The Africa Centers for Disease Control and Prevention (Africa CDC) works to build the capacity of public health institutions across Africa to strengthen the timeliness and effectiveness of public health responses. First envisioned a decade ago, the 2014 West African Ebola outbreak accelerated its creation and it was formally approved as a specialized technical entity of the African Union (AU) in 2016. While it originally operated as an arm of the AU, with the aim of establishing a new regionally owned and managed “public health order for Africa” it has grown in prominence and role including being recognized as helping to lead the African continent’s response to COVID-19. In 2022, the AU revised the foundational statute for Africa CDC to transform the institution from a specialized technical agency of the AU to an autonomous public health body. As the global community increasingly focuses on strengthening global health security in advance of future pandemics and health emergencies, there is growing recognition that Africa CDC occupies an especially strategic position with respect to pandemic preparedness and response.

This brief reviews the history of Africa CDC, describing its structure, funding and operations to date, including U.S. government engagement, as well as challenges and opportunities for the institution moving forward. It is based on analysis of the literature and interviews with experts.

Creation and Evolution of Africa CDC

While African leaders officially recognized the need for the creation of an Africa-wide public health agency in 2013, it was the 2014 West African Ebola outbreak that drove home this need and accelerated the process. After formal approval by the AU in 2016, Africa CDC was officially launched in January 2017. The Africa CDC’s founding statute declared that the agency would function as an organ of the African Union and like the AU, it is based in Addis Ababa. In early 2017, Cameroon-born Dr. John Nkengasong, a longtime public health official at the U.S. Centers for Disease Control and Prevention (CDC), was named the first head of Africa CDC. Nkengasong is cited by key informants as a driving force in Africa CDC’s launch and maturation.

AU member states have primary responsibility for public health activities within their borders. Much like the U.S. Centers for Disease Control and Prevention, Africa CDC plays a normative, coordinating and capacity-building role. This encompasses work in a number of areas, as directed by its founding statute, including early warning and response, pandemic preparedness and response, mapping hazards and risks, supporting emergency responses, promoting partnership and collaboration on health, harmonizing disease control and prevention policies, and building public health capacity (including field epidemiology and laboratory capacity). The founding statute directs Africa CDC to establish and work through regional collaborating centers representing the five major sub-regions on the continent: Central Africa, Eastern Africa, Northern Africa, Southern Africa, and Western Africa.

Africa CDC was minimally staffed at its outset, with U.S. CDC seconding two technical experts to work alongside Nkengasong to get the agency up and running. Its initial focus was in supporting the development of regional capacity for syndromic surveillance (i.e., monitoring of illnesses to provide early warning of disease spread). In recent years, as external funding has increased (see below) and the agency’s remit has expanded, staffing has substantially grown, with one key informant referring to the increase on staffing as “exponential.” With financing from China, Africa CDC now has a new headquarters in Addis Ababa which will include an emergency operations center, a data center, a laboratory, and other facilities.

The founding statute also directs Africa CDC to collaborate with the World Health Organization and other partners to enhance coordination and avoid overlap. Prior to the formal launch of Africa CDC, the African Union Commission and WHO executed a framework of collaboration to guide and inform the working relationship between Africa CDC and WHO, as the respective constituencies of the two organizations differ in some respects. Africa CDC’s geographic remit is more extensive than WHO’s, as several AU member states (including Djibouti, Somalia, Libya, Morocco, Sahwari Republic, and Tunisia) are not members of WHO’s AFRO region. Another difference is that while WHO’s African regional office works primarily through Ministers of Health, Africa CDC, as a body of the AU, has a direct line to, and ability to convene, African Heads of State.

Although created by the African Union, it was initially expected that the agency would operate somewhat independently of the AU bureaucracy. In practice, however, the AU often exercised close oversight and control over such functions as hiring, approval of travel and agency communications, which proved challenging to Africa CDC’s need for flexibility and rapid response to emerging health issues.  External support assisted the agency in gaining agility and capacity in the early years, including funding from the Bill & Melinda Gates Foundation to accelerate the hiring of key personnel and to support strategic planning. Africa CDC (with support from the U.S. CDC) also leveraged the hiring capacity of the African Field Epidemiology Network (AFENET), a non-profit network that works to build capacity for public health functions, to strengthen epidemiological capacity across the region. After COVID-19, there was a broad recognition of the need for greater autonomy at the agency, which led to the AU’s decision in 2022 to clarify and institutionalize the independent nature of Africa CDC.

After Nkengasong left in 2022, following his U.S. Senate confirmation as U.S. Ambassador-at-Large and global HIV/AIDS coordinator, Dr. Ahmed Ogwell Ouma, a Kenyan epidemiologist, served as acting director. In February 2023, African heads of state approved Dr. Jean Kaseya, a Congolese public health expert, to serve as the first Director General of the newly autonomous Africa CDC.

Africa CDC Operations

Africa CDC is governed by a 15-person board, consisting of 10 health ministers (two per each of the five regions), two representatives of the African Union Commission, two nominees of the Commission chair, and one regional health organization. The Board directs and approves the agency’s strategy, operations, budget, and other key governance activities. There is also a 25-person advisory council, which reports to/informs the Board and provides technical guidance to Africa CDC.

The agency uses a decentralized model that relies on the work and cooperation of national health institutions, which are incorporated in each AU member state. As noted above, Africa CDC has established five regional collaborating centers in Central Africa, Eastern Africa, Northern Africa, Southern Africa, and Western Africa, which it funds, intended to serve as hubs for the strengthening and coordination of Africa CDC’s surveillance, preparedness and emergency response activities and to enable sub-regional approaches to disease outbreaks and other public health priorities. The regional collaborating centers are in various stages of development, with some becoming fully operational only in 2021.

Building robust laboratory capacity across the region – a pillar of pandemic preparedness – has been a major area of work for Africa CDC. Informed by an early mapping exercise of laboratory capacity gaps in Africa, Africa CDC provided laboratory workforce training and capacity-building support focused on preventing and addressing antimicrobial resistance. Through its Regional Integrated Surveillance and Laboratory Network (RISLNET), Africa CDC is working to establish harmonized standards to improve quality control and facilitate the sharing and timely, strategic use of public health data. These efforts have helped close gaps in disease detection in the region and accelerated the steady strengthening of laboratory systems in Africa. While these lab-focused efforts ultimately rely on the laboratory systems and professionals in AU member states, Africa CDC has helped to train laboratory workers and create a coordinated, linked regional laboratory network.

The agency also works to establish public health norms, partnerships and coordination mechanisms. For example, in July 2022, Africa CDC called on all African countries centers to respond to future health emergencies. It also provides a platform for the development of regional public health policies, such as the Africa Medical Supplies Platform, created in 2020 which pools and shares health resources and commodities. Africa CDC also enters into strategic partnerships to benefit the region, such as its Memorandum of Understanding with FIND to increase access to diagnostic tools as well as its close working relationship with the African Society for Laboratory Medicine (ASLM).

U.S. Government Collaboration with Africa CDC

The U.S. Government played a foundational role in the early days of Africa CDC, facilitated by having Dr. Nkengasong as its first director, and continues to serve as a central technical partner for the organization. U.S. CDC entered a Memorandum of Understanding with Africa CDC in 2015 and the following year placed two senior staff at Africa CDC. Alongside Nkengasong, these staff served as the organization’s early nucleus. Expertise from the U.S. CDC helped shape and direct the creation of syndromic surveillance systems across the region. U.S. CDC also supported Africa CDC’s early efforts to develop a strategic public health plan for the region. While the U.S. CDC has provided much of the U.S. Government’s support for Africa CDC, other arms of the U.S. government, such as the Department of Defense (primarily via the Defense Threat Reduction Agency, DTRA), have also provided technical and financial support (more information below in the Funding section).

With its long history of delivering technical support to health systems in Africa, U.S. CDC has supported Africa CDC in strengthening the public health workforce, with a particular focus on creating a network of trained epidemiologists capable of addressing outbreaks that cross national borders. This close working relationship has enabled Africa CDC to leverage U.S. CDC’s existing investments in the region’s laboratory capacity, disease surveillance, and response preparedness. Using a cooperative agreement with the African Field Epidemiology Network, U.S. CDC hired 10 graduates of the epidemiology program to work at Africa CDC in its early years.

In March 2022, the U.S. Government renewed its partnership with Africa CDC by entering into a new Memorandum of Understanding. The MOU outlines several priority areas for engagement, including building the capacity of national health institutes and regional collaborating centers, especially with regard to surveillance, public health information exchange, early outbreak warning systems, and development of testing and diagnostics capacity. Strengthening the public health workforce is also prioritized as an area of collaboration under the new MOU. The U.S. Government has also pledged to support the purchase and distribution of key health commodities, to advance next-generation molecular sequencing capacity, and to aid in expanding vaccine manufacturing capacity in Africa.

Funding of Africa CDC

Although Africa CDC was initially created as an arm of the AU, informants indicate that the AU has provided only minimal direct funding to the agency, although it has covered the salary costs for certain personnel. This has meant that external donors have, to date, been the primary source of funding for Africa CDC, with contributions to the organization surging during the COVID-19 pandemic.

The U.S. government has provided in-kind support to Africa CDC since 2015, with annual support ranging from approximately $1 million to about $3 million. Financial support from the U.S. government has come from the U.S. CDC, with some additional funding from DTRA. Early funding from the U.S. CDC helped in organizational strategic planning, the hiring of field epidemiologists, and the hiring of technical and administrative staff. In 2018, the U.S. Government announced an initial $150 million in support to national health institutes in Africa. In 2020, the U.S. CDC joined together with the Bill & Melinda Gates Foundation, Microsoft, Illumina, and Oxford Nanopore Technologies to launch a $100 million Africa Pathogen Genomics Initiative to improve disease surveillance and emergency response.

China is another key government donor to the Africa CDC (specific funding amounts are not publicly available), including support for the construction of the new Africa CDC headquarters building in Addis Ababa. China, sometimes in concert with the U.S. CDC, has also provided in-kind health workforce training, national regulatory capacity-building, and support for laboratory systems across the region. The U.S. and China have in the past formally collaborated in supporting Africa CDC, reflected in a Memorandum of Understanding signed in 2016.

While a detailed budget is not available, a number of donors have provided funding to African CDC since the start of the pandemic to help with various aspects of COVID-19 response activities such as vaccine purchases and distribution, investments in public health workforce, laboratory strengthening, and a number of other areas (see Table 1). Major donors over this time period have included the MasterCard Foundation ($1.5 billion), the World Bank ($100 million), the Gates Foundation along with the US CDC and other partners ($100 million), the African Development Bank ($27.3 million), and the European Union (€10 million). Africa CDC has also leveraged other financial sources to advance its mission, such as using a financing facility established by the African Export-Import Bank to procure COVID-19 vaccines. Moving forward, Africa CDC is also a potential recipient of donor funds directed from the new Pandemic Fund housed at the World Bank, although it had as of February 2023, not been approved as one of the Fund’s “Implementing Entities” to which funds can be provided.

Africa CDC and its role in disease outbreaks, including COVID-19

Africa CDC plays prominent leadership and operational roles during outbreak response efforts on the African continent. For example, during the Ebola outbreak in the Democratic Republic of Congo (DRC) in 2018-2020, Africa CDC collaborated with the DRC government and WHO on contact tracing initiatives, laboratory services, and the training of thousands of healthcare workers and traditional healers – all in the context of a fragile security situation and under exacting political scrutiny.

The COVID-19 emergency accelerated the work of Africa CDC and raised its profile as a public health leader – regionally but also globally. With Africa CDC in place when COVID-19 emerged, the region was spared the need to invent mechanisms for collaboration and information-sharing in response to the pandemic.

Africa CDC helped catalyze an early, coordinated response to COVID-19. By February 2020, at a time when the U.S. Government was assuring Americans that COVID-19 posed little danger, Africa CDC spearheaded the creation of a joint continental strategy to respond to the pandemic, with 55 countries agreeing to harmonize their COVID-19 approaches and strategies. An Africa Task Force for Coronavirus (AFTCOR) was established in February 2020, meeting bi-weekly thereafter.

Africa CDC also served as a regional source of public health information on COVID-19, providing a central data hub for member-state reported data on cases, deaths, recoveries, tests and vaccination uptake, developing and disseminating issue briefs on important aspects of the COVID-19 pandemic and serving as a media information hub. It also tracked news and social media channels to identify and address vaccine-related disinformation and misinformation.

Africa’s laboratory capacity – a major focus of Africa CDC’s work prior to COVID-19 – has been cited as a key part of the COVID-19 response not only on the continent, supporting training of laboratory personnel, but also for providing early COVID data to the global community before other labs. Nigeria sequenced and broadly disseminated the first African SARS-CoV-2 genome, the Network for Genomic Surveillance South Africa discovered the Beta variant, and genome-sequencing efforts in Botswana and South Africa led to identification of the Omicron variant.

In addition, Africa CDC spearheaded the procurement of essential COVID-19 commodities for the continent. In the very early stages of the pandemic, when countries across the world were competing for personal protective equipment and ventilators, Africa CDC negotiated with regional airlines, whose planes were grounded at the time, to deliver scarce commodities to the region. In August 2020, Africa CDC joined with partners to establish the African Vaccine Acquisition Team (AVAT) to serve as a centralized purchasing agent for COVID-19 vaccines for the region. Through AVAT, the African Union made multiple purchases of COVID-19 vaccines for use across the region, including 110 million doses of the Moderna mRNA vaccine in 2021.

As the COVID-19 Vaccines Global Access (COVAX) initiative began delivering vaccines to African countries in 2021, Africa CDC helped countries in ensuring fair, equitable and timely allocation of vaccines. More recently, in 2022, it brokered an agreement with Pfizer for the purchase of the COVID-19 therapeutic Paxlovid.

Africa CDC also supported innovative means to deliver COVID-19 interventions and to address vaccine hesitation or misinformation. For example, Africa CDC launched the Partnership to Accelerate COVID-19 Testing in Africa (PACT), recruiting and training thousands of community health workers to provide community education and link people to COVID-19 testing and vaccination services and fielded a vaccine perception survey in 2020 to inform and guide vaccination campaigns.

Future Challenges and Opportunities for Africa CDC

It is an important moment of transition for Africa CDC as a new Director General takes the helm and the agency undergoes the process of becoming a fully autonomous organization after years of working within AU systems and oversight. Africa CDC has recently released its new strategic plan (for 2022-2026), which outlines the agency’s strategic objectives and goals as it looks ahead after helping to mount a continent-wide response to a historic pandemic.

Expert informants uniformly expressed admiration for the rapid progress that Africa CDC has made in building its capacity, elevating its profile, and influencing regional public health policies and practice. In particular, the Africa CDC has played a key role in raising the visibility of pandemic preparedness across the region and in marshalling high-level political support for public health measures. However, as indicated in the agency’s new strategic plan document and information provided by expert informants, a number of questions remain regarding how robustly staffed and supported certain functions of the Africa CDC are and how it can best fulfill the vision outlined in its founding charter. These include:

• Mobilizing sufficient and sustainable financing: Donor funding has been central to establishing and growing the Africa CDC. However, Africa CDC’s reliance on external financing carries risks with respect to sustainability, and it could be facing more restricted funding in the coming years, as COVID-19 response activities wind down and societal and political attention on public health preparedness wanes. Some have called for increased contributions from AU member states – though it is unclear how willing and able governments across the region are to provide more for the agency over the coming years – as well other potential funding sources such as a continent-wide tax on airline tickets, an idea proposed by the incoming Africa CDC Director General.
• Building capacity of key national and regional actors: Africa CDC is most able to be successful and implement its vision and strategy when it has strong partners and robust institutions at the national and regional levels, including effective national health systems. However, given the economic, societal, and budgetary effects of the pandemic and resulting constraints on public spending in many African countries, the investments and support for national and regional health institutions is uncertain in the coming years. In particular, informants pointed to the importance of building up stronger regional collaborating centers in partnership with Africa CDC, given that at present, the quality and capacity of these regional bodies varies considerably across the continent and some are still relatively nascent.
• Maintaining hard-won goodwill and support: According to informants, Africa CDC has generated extraordinary goodwill across the region and in a relatively short time has become a remarkably influential public health institution. Many report that effective leadership helped build this reputation and expand influence, along with the impact of it work, it responsiveness, and success in communication. With a new leader taking the helm and the public health response in the region entering a new phase, informants advised that the agency will face challenges in building on its past successes and navigating the next phase. These include successfully leveraging the capacities and lessons derived from the COVID-19 response to continue to build robust regional pandemic preparedness, maintaining good relations with the AU and political leaders across the region, recruiting high-quality staff, implementing a code of conduct to govern its operations, and building the systems for follow through on Africa CDC’s autonomous status.
• Strengthening transparency and accountability: The transparency of transnational mechanisms for global health and development is recognized as a growing global priority. While Africa CDC’s web portal provides a wealth of information on organizational activities, relevant news items, and some epidemiological information, the site does not make readily available details about other important aspects of the organization such as governance and funding. In fact, there is no public source to turn to for key Africa CDC organizational characteristics such as staff size, organizational charts, governing board minutes, budgets, and other areas. Similarly, while Africa CDC has articulated a number of goals and targets (such as providing 10 million COVID-19 tests in four months or recruiting and deploying 1 million community health workers for contact tracing), target and goal information remains limited and it is not clear whether stated goals have been met. Publicly available annual reports (through 2019) provide extensive information on outputs (e.g. number of laboratory professionals trained, strategic frameworks developed, public health staff deployed to address outbreaks) but less information on outcomes and impact. As it transitions to greater organizational autonomy, providing more accessible information about key aspects of its work could help diverse stakeholders understand and engage with the organization.
• Navigating difficult political issues: In its early years, Africa CDC has understandably focused on core technical activities and fundamental public health capacity gaps, and its work on pandemic response has generally avoided being politicized or generated protests and pushback from member countries. However, this could change over time over time. For example, the U.S. CDC, a model for Africa CDC, has experienced numerous political controversies for its work on diverse public health matters such as adolescent health, gun violence, contraception, and COVID-19 measures, with U.S. states having varied rules and approaches to many of these issues. It is possible Africa CDC could similarly face complicated political issues linked to public health over which its member states have differing opinions and regulations. For example, as several African countries have taken steps to establish their own national vaccine manufacturing capacity, with the aim of avoiding a repeat of vaccine shortages that challenged the regional COVID-19 response, Africa CDC has cautioned countries to go more slowly, warning against the potential of a glut in vaccine capacity while other commodity priorities, such as diagnostics, are less prioritized. More broadly, Africa CDC’s commitment to support the establishment of robust vaccine manufacturing capacity and to ensure regional access to essential health commodities, for example, could touch on matters of considerable international political dispute. The recent appointment of the new Africa CDC Director General led to complaints about a lack of transparency and politicization from some African countries. Other public matters, such as the optimal strategy for preventing and controlling HIV and other sexually transmitted diseases, are often the source of political disagreements. Maintaining political support amid expanding ambitions could mean increasingly navigating politically difficult issues.
• Clarifying and strengthening the relationship with WHO: Key informants observed that Africa CDC’s relationship with WHO’s Africa regional office (WHO AFRO) can be complicated, as the mandates of the two organizations have sometimes overlapped and it has not always been clear which has primary responsibility for certain activities or how their separate efforts integrate together. Informants indicated that over time, Africa CDC and WHO AFRO have developed a mostly productive working relationship that was bolstered during the COVID-19 response, with regular information sharing and coordination meetings held between the leaders of the two organizations over the course of the pandemic. Even so, Africa CDC and WHO AFRO differ in important ways, which has implications for their relationship going forward. While WHO is a global entity with regional representation via AFRO, Africa CDC is an African institution. While WHO works primarily at the level of Ministries of Health, Africa CDC derives authority through the AU from Heads of State. According to informants there is an opportunity for these two important institutions to strengthen their partnership and joint work going forward, though doing so will likely require communication and diplomacy on the part of leadership and continued attention to defining respective roles in order to avoid duplication and unnecessary friction.
• Sustaining and further strengthening the partnership with the U.S. Government: The Biden Administration has indicated that it regards Africa CDC as a key partner, as reflected by the updated Memorandum of Understanding between the agency and the U.S. government. The U.S. has also made clear its commitment to building robust pandemic preparedness capacity in low- and middle-income countries, through advocacy for and early funding of the Pandemic Fund at the World Bank and by the establishment at the State Department of a Bureau of Global Health Security and Diplomacy, along with its ongoing financial and technical support to global health security programs including many efforts in the African region. This alignment of interests and priorities offers potential avenues for building on and further strengthening U.S. support for the work of Africa CDC.