Money, Food And Survival: What Drives Paid Sex Among Young Mums In 3 African Countries

Transactional sex is a coping strategy for some adolescents. Stephane de Sakutin/AFP via Getty Images

ANTHONY IDOWU AJAYI, BERYL NYATUGA MACHOKA AND CAROLINE W. KABIRU

Transactional sex, defined as the exchange of sex for money, food, or favours, is common among young people in Africa. Studies have reported that about 10% of those aged 15-24 have engaged in this exchange in South Africa, 23% in Nigeria and 25% in Uganda. The behaviour has been linked to negative consequences such as unintended pregnancy, sexual violence and HIV infections.

Transactional sex refers to sexual relationships outside marriage that are not classified as commercial sex work, but where there is an expectation that material, financial or other benefits will be exchanged for intimacy or companionship.

We are sexual and reproductive health researchers focused on the intersection of evidence, policy, and lived realities of adolescents in Africa. We recently examined the extent and drivers of transactional sex among pregnant and parenting adolescents in three African countries: Burkina Faso, Kenya and Malawi.

In our earlier qualitative research work with pregnant and parenting girls in Nairobi’s informal settlements, we found that pregnancy intensified economic insecurity. The focus of government and most NGOs, however is mainly on preventing adolescent pregnancy. Little attention is paid to the plight and realities of pregnant and parenting girls.

Our research set out to bring attention to these girls. We did this by examining the prevalence and correlates of transactional sex among adolescents in Burkina Faso, Kenya and Malawi. We surveyed 2,243 girls: 980 in Ouagadogou, Burkina Faso; 594 in Korogocho, Nairobi, Kenya; and 669 in Blantyre, Malawi. They were all either pregnant or already parenting. The youngest participants were 12 years old in Burkina Faso and 13 years old in Kenya and Malawi. The oldest girls in all three countries were 19.

Our findings indicated that transactional sex prevalence varied by context. Living in urban informal settlement environments was a risk. The results were a reminder of the need for stronger support systems for adolescents engaged in transactional sex across the three countries, including those who are pregnant or parenting.

Our findings

Our study found that 44.3% of the girls we surveyed in Kenya, 25.4% in Burkina Faso, and 13.0% in Malawi had engaged in transactional sex at some time. The particularly high prevalence in Kenya reflects the study setting in one of Nairobi’s densely populated informal settlements. There, adolescent girls face poverty, unstable support systems, unsafe living conditions, and limited opportunities for self-development. Other studies have also shown that prevalence is lower in other settings outside informal settlements.

The most common reason girls gave for engaging in transactional sex was money. Money was a reason reported by 31.3% of participants in Kenya, 20.5% in Burkina Faso, and 7.8% in Malawi. But girls also reported exchanging sex for food, rent, shelter, clothing, school fees and sanitary pads.

In Kenya, 13.5% specifically cited sanitary pads, compared to 1.0% in Burkina Faso and 1.8% in Malawi. Smaller percentages engaged in transactional sex for school fees, phones or airtime, or other needs such as baby supplies (milk, diapers, clothes).

Individual-level factors

At the individual level, being single increased the likelihood of transactional sex across all three countries. In Burkina Faso, 20% of married and 46% of single girls had transactional sex. In Kenya it was 28% of married girls and 50% of single girls. In Malawi it was 10% of married girls and 16% of single girls.

This suggests that having a partner may provide some degree of financial, material and childcare support. Without support, single adolescent mothers may face pregnancy and early motherhood with very limited resources, increasing their vulnerability to transactional relationships.

One of the surprising findings emerged from Ouagadougou, Burkina Faso. There, 31% of adolescents with a secondary education had engaged in transactional sex, against 21% of those with only a primary education. This challenges the common assumption that education is an immediate shield against exploitation. It suggests that remaining in school may itself become financially difficult for adolescent girls living under poverty and weak support systems. For girls who are in school from a poor background, the need for money, food and school fees may make them engage in transactional sex.

Substance use also more than doubled the risk in Burkina Faso, among girls who reported using alcohol or drugs compared to those who did not. This association was not significant in Kenya or Malawi.

Interpersonal-level factors

At the interpersonal level, orphanhood mattered, though differently across countries.

In Malawi, girls who had lost both parents faced nearly double the risk of engaging in transactional sex, compared with non-orphans. In Kenya, girls who had lost one parent were 43% more likely to engage in transactional sex. Even more significant at the interpersonal level was the impact of low parental support in Malawi, where girls who felt unsupported by their parents were three times more likely to engage in transactional sex.

Community-level factors

We asked participants questions to assess how safe they felt in their neighbourhoods. In Kenya and Burkina Faso, a higher score for perceived neighbourhood safety was associated with a lower likelihood of transactional sex. Girls said they engaged in sex in exchange for security and protection. In Malawi, feeling safe didn’t make a difference.

What needs to change

The study demonstrates that transactional sex among pregnant and parenting adolescents is less a choice than a strategy to cope with severe socioeconomic hardship. It is shaped by distinct individual risks, fracturing family support and community insecurity.

What drives transactional sex changes from country to country. Because of this, programmes to address it need to be customised for each specific place.

Interventions should address structural vulnerabilities and strengthen family and community support systems. They must also improve neighbourhood safety to reduce adolescent mothers’ reliance on transactional sex and the harms associated with it.

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One Health In A Fractured World: Why Global Health Governance Must Adapt To Geopolitical Fragmentation

BY CLAIRE J. STANDLEY AND ERIN M. SORRELL

The COVID-19 pandemic exposed weaknesses in global health systems and underscored how interconnected drivers such as changes in land usage, urbanization, and climate amplify zoonotic disease threats. One Health, an integrated approach linking human, animal, and ecosystem health, has gained institutional traction via global governance approaches, yet faces persistent structural challenges, including siloed mandates, funding misalignment, and limited enforcement. We argue for pragmatic, polycentric governance—local leadership supported by regional mini-lateral coalitions and existing bi- and multilateral regimes—to operationalize One Health sustainably and equitably.

Introduction

In early 2020, the COVID-19 pandemic revealed the weaknesses of global health systems to infectious diseases. However, less recognized was how the emergence of this novel virus highlighted the global changes converging to heighten outbreak risks: increased human-animal contact and agricultural intensification, accelerated population growth and urbanization, and changing weather and climatic patterns. These dynamics are playing out repeatedly, from the devastation to the poultry industry—where migratory birds and marine mammals suffer from rampant H5N1 influenza—to surges in mosquito-borne virus infections like chikungunya and Oropouche across the Americas. While these examples demonstrate that health threats are increasingly transboundary, global governance mechanisms are at risk of fragmentation amid political instability and declining trust in multilateral institutions. This article argues that given current geopolitical fragmentation, One Health governance must evolve from idealistic coordination, toward pragmatic, resilient, and multi-level cooperation.

 
What is One Health?

The term “One Health” first emerged in the early 21st century due to growing scientific recognition that infectious diseases of wildlife and livestock could negatively impact humans, and vice versa. Since then, the most widely adopted definition is that of the One Health High Level Expert Panel:

“One Health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems.”

Early origins of One Health focused on operational collaboration to contain specific infectious disease outbreaks. Yet, the field has grown considerably, benefitting from formalized, interdisciplinary frameworks and governance systems. The most prominent of these is the Quadripartite, established in 2010 between the World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), and the World Organization for Animal Health (WOAH; formerly OIE), and subsequently joined by the United Nations Environment Programme (UNEP) in 2022. The Quadripartite led the development of the One Health Joint Plan of Action (2022-2026) (OHJPA), providing a blueprint for how these organizations would coordinate to sustainably advance One Health collaboration and implementation, prevent pandemics, and contribute to enhancing resilient health systems.

Since its inception, the Quadripartite has successfully raised the profile of One Health, earning commitments from the G7, G20 and numerous individual countries to adopt the approach in addressing global health threats, particularly for pandemic preparedness and response. The establishment of the One Health High-Level Expert Panel brought geographically and culturally diverse interdisciplinary expertise to the Quadripartite, facilitating better navigation of policy processes and anticipation of implementation barriers. Workshops in different WHO regions further advocated for adoption of One Health strategies, enhanced regional and national coordination, and resulted in the creation of country roadmaps. Yet ultimately, such efforts are limited by the resources of the Quadripartite and critically rely on national ownership, financing mechanisms, and momentum to move from strategy to operationalization.

 
Intrinsic Challenges with One Health Governance

The effort to coordinate sectors with responsibilities in One Health policy and implementation may appear straightforward in theory, but faces persistent structural problems as well as legal and normative weaknesses in practice.

While broad support for One Health exists across the various sectors involved, they often operate with different mandates, budgets, and data systems, making coordination difficult or ad hoc rather than automatic. Though these operational difficulties are being addressed in some settings through multisectoral national and regional strategies, integration is unlikely to ever be fully equitable. One Health has traditionally been promoted with a human health focus by the Global North, marginalizing local and Indigenous knowledge of the cultural and environmental drivers of emergence. This imbalance is mirrored in funding: expecting the environment, veterinary, and agriculture sectors to contribute personnel, knowledge, and consumables to a human health-centric preparedness and response cycle—without acknowledging fundamental discrepancies in resources and mandates—will not resolve the problem.

Government funding is also often reactive—focused on crisis response—whereas One Health approaches to epidemic preparedness depend on sustained investment in prevention. It promotes monitoring ecosystems, conducting surveillance across animal reservoirs, and detecting early spillover. While One Health encompasses far more than just infectious diseases, this remains its most widely applied use case and the one that has gained the most political traction to date. As such, it has become difficult to advocate for One Health multisectoral funding without a looming global health security threat, resulting in trade-offs between sectors.

Finally, One Health as a global initiative lacks a central governing body with real power. While WHO, WOAH, UNEP, and FAO collaborate via the Quadripartite, no one organization can enforce policy across sectors or countries. Similarly, although OHJPA provides a comprehensive framework for advancing One Health and offers technical assistance to support national implementation targets, its initiatives are non-binding and completely voluntary.

The Added Negative Impact of Global Fragmentation

Global fragmentation is increasingly undermining One Health governance. The shift away from Pax Americana and a US-led world order towards a multipolar system has eroded trust in multilateral institutions, including those of the Quadripartite. The WHO has been most dramatically affected, with the US withdrawal prompting a comprehensive review of its core functions and strategic streamlining in response to new fiscal constraints. There have been knock-on effects across other global bodies: the US presidency of the Group of Twenty (G20) in 2026 has refocused its efforts towards economic growth and prosperity, moving away from prior high-level priorities—such as the Sustainable Development Goals (South Africa) and renewable energy (Brazil)—that were more closely aligned with One Health objectives.

This geopolitical fragmentation has been shaped by the prioritization of national interests, the politicization of global health, and international conflicts. Vaccine nationalism during COVID-19, whereby high-income countries disproportionately over-purchased limited supplies of life-saving vaccines, hampered efforts of multilateral initiatives to provide vaccines to countries unable to afford them directly from pharmaceutical companies, further demonstrating the limitations of global cooperation when it is most needed. The politicization of the origins of the pandemic not only directly influenced the US decision to withdraw from the WHO, but also cast a pall over scientific efforts related to zoonotic diseases. Global health and foreign assistance budgets are easy targets in this period of fragmentation when defense budgets are on the rise, as was the case when NATO members agreed to increase their defense spending to support Ukraine. While defense stakeholders increasingly recognize the value of a One Health approach, their integration into One Health governance needs careful consideration.

 
Rethinking One Health Governance: From Idealism to Pragmatism

Moving from idealism to pragmatism requires confronting structural, political, and operational realities. One Health, at its core, is aspirational, requiring efficient collaboration, shared priorities, and sustained funding across a variety of sectors. The stark reality is that international governance systems are, as aforementioned, fragmented and unlikely to be sufficient; a polycentric model provides an alternative approach. Referred to as polycentric governance, this model involves systems in which authority is distributed across levels rather than centralized. Each center operates semi-independently, interacting through cooperation, competition, and coordination, while adapting to local contexts and contributing to broader system goals.

For One Health, centers of authority span communities, governments, and international organizations. The approach emphasizes local actors taking the lead, with higher levels providing support and coordination, leveraging existing and functional structures rather than creating new ones. Local communities are on the front lines of spillover—they are often the first to observe emerging risks but may lack the necessary resources to report these events or respond effectively. Governments are the seat of policy and regulation, housing national surveillance systems and allocating budgets for preparedness and response, but, as noted earlier, lack of coordination and siloed reporting systems prevent effective response. Thus, intergovernmental organizations such as the African Union or the Association of Southeast Asian Nations (ASEAN) can come into play and facilitate coordination between borders. For example, the African Union has a One Health Data Alliance Africa Project, which seeks to “enhance digitalized One Health governance” across the continent. As such, polycentric governance does not replace centralized authority, rather it complements it through a “system of systems.”

One Health events often require decisive action at local or regional levels without waiting for global alignment. Mini-lateral cooperation—small coalitions of middle-powered willing states—help narrow the focus on polycentric governance. It can translate One Health from broad visions into tangible outcomes. Cooperation like this can prove to be quite effective, as One Health challenges are typically geographically and ecologically focused, making global agreements inefficient. Mini-lateral groups are politically aligned sufficiently to cooperate effectively and capable of acting quickly on a shared problem, focusing on specific outcomes rather than broad mandates. One Health mini-lateralism can therefore leverage a variety of platforms including regional networks that share cross-border surveillance data, functional coalitions established for specific technical issues like vaccine research and development, antimicrobial resistance monitoring or climate-health data sharing, or public-private partnerships linking policy to operational action. One example is the newly launched WOAH-PREZODE Working Group, which is convening experts across diverse One Health fields to bridge gaps between scientific evidence and policy formulation. While not automatically resolving the structural challenges highlighted above, such efforts provide stronger opportunities to set shared objectives that rebalance sectoral inequities and prioritize local knowledge while supporting regional priorities.

When pursuing intergovernmental cooperation on One Health—be it at the mini-lateral or multilateral level) —rather than creating new frameworks or initiating new agreements, a more effective strategy may be to mainstream One Health into existing regimes that have authority, financing, and compliance mechanisms, notably climate, trade, and pandemic governance. The goal, then, is to incorporate human–animal–ecosystems linkages where decisions are already being made. Climate agreements and trade frameworks provide clear future opportunities to integrate One Health principles. However, lessons from the 2025 Pandemic Treaty should be taken to heart: while One Health was formally recognized in the Treaty as central to pandemic preparedness, important points related to implementation and funding, especially for lower- and middle-income countries, were pushed to subsequent deliberations and left unanswered.

Finally, these examples underscore the importance of aligning incentives for One Health, both between participating sectors and across levels of polycentric governance. As major powers pivot to bilateral approaches to foreign assistance and health funding, countries must react by identifying areas of convergence with One Health structures and programs. Mini-lateral coalitions can expand through inclusion of emerging economies—providing opportunities to center new voices and advance equity—as well as through the engagement of non-governmental actors: philanthropic entities, industry, and civil society organizations can all play important roles and, in turn, benefit from greater One Health integration.

 
Conclusion

Experts suggest that there is approximately a 50/50 chance of another deadly pandemic before 2050, and the likelihood is that it will be zoonotic in origin. While the benefits of One Health encompass far more than infectious diseases, the reality is that pandemic preparedness offers a critical incentive for the levels of political and operational commitment needed for establishing sustainable and effective One Health governance. Though some may argue that geopolitical fragmentation makes cooperation needed for a global One Health approach unrealistic, we suggest that flexible, networked governance can replace, and even outperform, simplistic visions of top-down oversight. Global change is accelerating biological and environmental risks faster than our current systems can respond: One Health is the only framework designed to manage these interconnected threats. With appropriate and effective governance to guide implementation, it can provide practical, risk-reducing strategies to strengthen ecosystem health, support productive economies, and bolster national and regional security.

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Ebola Outbreak In The DRC: Four Reasons It Will Be Hard To Contain

A road leading into Goma, the capital of the province of North Kivu in DR Congo. Picture by guenterguni/Getty Images

BY JIA B. KANGBAI

SENIOR LECTURER, 

NJALA UNIVERSITY

By the second week of the latest Ebola outbreak in the Democratic Republic of Congo it was already clear that containing the spread of the haemorrhagic disease was proving to be difficult.

On 17 May 2026, the World Health Organization declared the outbreak a public health emergency of international concern. This is its highest level of global health alert. It is mostly reserved for an extraordinary disease outbreak or event that is a public health risk to many countries through international spread and hence requires global coordinated efforts.

According to the WHO, as of 19 May 2026 the DRC had recorded more than 500 cases and 130 deaths, while its neighbour (Uganda) had recorded two cases and one death.

These statistics are huge considering that the current outbreak was only declared on 15 May. The largest Ebola outbreak was in west Africa from December 2013 to March 2016. It caused 28,652 infections resulting in 11,325 deaths in 10 countries; 99% of the fatalities were in Guinea, Sierra Leone and Liberia.

Infectious disease outbreaks are nothing new for the DRC, a central African country. Last year, while other parts of the world were shaking off the global mpox outbreak, the DRC was still struggling with it.

But the current Ebola outbreak in the DRC has potential to become huge and of long duration.

I am an infectious disease epidemiologist with experience of dealing with the Ebola outbreak in 2013-2016 in Sierra Leone.

In my view there are four reasons while this outbreak will be hard to contain:

late detection and insecurity

misdiagnosis

cultural factors

shortage of global health funds.

Late detection

One of the challenges is the time between a person being infected and being diagnosed (identifying the disease in a laboratory). This detection lag is a major problem because to control the spread of the disease, infected individuals need to be isolated. Ebola is highly contagious.

Late detection was responsible for the early deaths and increased number of Ebola cases in Sierra Leone during the 2013-2016 outbreak. Early cases went unnoticed there because Ebola was new in the country. Clinicians and laboratory scientists were totally unfamiliar with it.

The DRC is familiar with Ebola outbreaks and has witnessed more than any other country.

But in the DRC, late detection is fuelling the rapid spread of the disease and is primarily due to insecurity in the region.

The time it takes to identify an infectious pathogen in the laboratory depends on how long it takes for the pathogen to replicate to detectable level, the type of laboratory tests used, and (for some diseases) the development of antibodies. Ideally, for Ebola virus it varies between one and 32 days.

The first confirmed case was a resident of Goma, a town which lies on the border with Rwanda and is highly unstable. Fighting between DRC government forces and rebels (believed to be backed by Rwanda) has been going on around Goma for a long time.

The instability and volatility of the epicentre of the outbreak is having a major impact. Under those conditions, an infectious disease thrives and outbreaks mostly go unnoticed.

The number of Ebola cases and deaths that have been registered in the current Ebola outbreak in the DRC is difficult to place within the susceptible-infected-recovered (SIR) model, a tool used in epidemiology. Ebola’s R0 (basic reproduction number, a measure of disease transmission) ranges between 1.5 and 2.5, which means within a susceptible Goma population, a single infected person can spread the virus to an average of 1.5-2.5 Goma residents.

However, the current Ebola incidence and deaths in the DRC exceed the expected number of secondary infections based on Ebola’s basic reproduction number. As of 21 May there were over 136 suspected deaths, 35 confirmed cases, and more than 600 suspected cases caused by the Bundibugyo strain in the ongoing outbreak in the DRC.

Misdiagnosis

The delay in diagnosis may also have been due to subtle early Ebola symptoms that can be misdiagnosed. Both malaria and typhoid have identical fever symptoms.

During the early days of the Ebola outbreak in Sierra Leone, many nurses working at the Kenema Government Hospital and the Lassa Fever Hospital lost their lives because they misdiagnosed the disease as Lassa fever. Ebola and Lassa fever belong to the same class of viral haemorrhagic fever diseases since patients present with similar symptoms and pathophysiologies (what the disease does to the body).

The other challenge with diagnosis in this outbreak is that it is a different virus to the one treated in the most recent Ebola outbreaks. Bundibugyo virus was first identified in Uganda in 2007. Unlike Zaire Ebola virus disease, which was discovered decades ago, the relative newness of Bundibugyo Ebola virus disease means it’s less researched, especially in terms of vaccine and medicine development.

Cultural factors

Other factors affecting the spread are cultural practices such as ritual burials. Ritual burials are common in many African countries, like Sierra Leone and the DRC. These are ceremonies born out of the belief that death is a sacred passage to another world or ancestral realm. Mostly it starts with communal grieving and wake keeping, followed by the ceremonial preparation of the body.

In Sierra Leone a ritual burial of a high priest who died of Ebola in the southern town of Moyamba during the 2013-2016 Ebola outbreaks led to the death of scores of people who took part in ceremonial preparation of his body. It is not surprising to learn of relatives setting Ebola hospital tents on fire simply because they were prevented from handling the corpse of their loved one.

Shortage of global health funds

The cuts in global health funds and the ending of many projects through the dissolution of the United States Agency for International Development (USAID) is greatly affecting the operations and effectiveness of public health activities around the world.

Most global health security projects aimed to prepare for and mitigate any future disease outbreak.

Sierra Leone and other countries affected by the 2014-2016 Ebola outbreaks benefited immensely from international donor (including USAID) support during that outbreak.

Unfortunately, the DRC will have less international support to help fight this outbreak. The country has long experience in tackling disease outbreaks (especially Ebola) but the lack of experts and logistics on site implies an extended delay in managing this situation. The DRC has the people and the necessary labs and facilities. The major challenge with the current outbreak is that it started in an insecure environment where access to testing facilities are scarce, hence the late detection.

Additionally, the country is about the size of western Europe (including France, Germany, Spain, the UK and Italy). This vast size, coupled with insecurity, will make it difficult to channel logistics across the affected regions.

What’s needed

Tackling the current Ebola outbreak in the DRC requires a rapid, multi-tiered response. It should focus on rapid case detection, multinational support, swift collaborative surveillance and community engagement.

Over the past years the DRC has served as a scientific base for major international research institutions that work on infectious diseases and medical microbiology.

In the absence of a vaccine or medication, the health authorities should embark on community engagement to raise awareness and sensitisation. They must also enforce public health laws, especially those targeting cultures that promote unsafe burials and elevate the risk of Ebola infection. This is to prevent human transmission as many people might still be out there undetected.

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Agriculture In Africa: Science And Research Can’t Make An Impact Without Investment And Good Policies

Women rice farmers in Senegal. Photo by Alvo Pavan, via Getty Images

BY PAPE ABDOULAYE SECK

CHERCHEUR ACADEMIE NATIONALE,

DES SCIENCE ET TECHNIQUES 

DU SENEGAL (ANSTS)

Agriculture is the lifeblood of Africa. More than 60% of African households depend directly or indirectly on the land for their livelihoods. And the continent has nearly 60% of the world’s uncultivated arable land.

Farming is a fragile sector, however. It has to deal with climate change, market volatility, weak infrastructure and demographic pressure. Addressing these challenges requires political commitment and investment. It also requires science, innovation and high-quality research.

I have been involved in scientific research, particularly agricultural research, for more than four decades. My roles have included researcher, member of multiple science academies, director general of the Africa Rice Center/CGIAR, and Senegal’s minister in charge of agricultural research.

Throughout these years, one criticism has repeatedly surfaced: agricultural research is often perceived as expensive while delivering little for people. This perception is widely shared and frequently echoed in political and media debates.

Based on my experience, I believe the criticism rests on a questionable assumption: that the impact of science depends exclusively on those who produce it. When innovations fail to change the world, scientists themselves are often presented as the culprits.

The reality is far more complex. The history of agricultural transformation across the world shows that research alone never changes societies. Impact follows when an agricultural ecosystem effectively connects science to producers, markets, finance, institutions and public policy.

International institutions have highlighted the difficulties many developing countries face in turning scientific knowledge into development. The reasons include weak innovation ecosystems, too little infrastructure and limited institutional coordination.

An example of what success looks like is the Green Revolution in Asia. Scientific breakthroughs improved wheat and rice varieties which transformed agriculture. It was not simply because the science was strong. There were other factors too. They included governments investing in irrigation, extension services, rural infrastructure, credit systems and market organisation.

In India and Vietnam, for example, science operated within a coherent system linking researchers, farmers, institutions and markets.

Science generates knowledge, informs policies, stimulates innovation and opens new possibilities. But it does not change societies on its own.

The missing parts

Recent decades have brought advances on a number of fronts. In seeds, irrigation, soil fertility management, climate adaptation, biotechnology, digital agriculture, agroecology and sustainable food systems.

African researchers, universities and international agricultural research centres have contributed enormously to this progress.

Rwanda and Ethiopia provide useful examples of how coordinated ecosystems can speed up change. In both, stronger links between research, extension systems, public investment and farmer support mechanisms have made a difference. They have contributed to faster uptake of new technologies. And they have led to productivity gains in several strategic crops such as maize, rice, cassava, beans and soybeans.

Another example is rice. During my years at AfricaRice, I saw major scientific advances in rice research. This included the development of New Rice for Africa varieties. ⁠ These resulted from years of scientific work combining the high productivity potential of Asian rice with the resilience of African rice, particularly its tolerance to drought, poor soils and local climatic stresses. It wasn’t easy, because the two rice species are genetically distant.

Farmers quickly took up the new varieties. Farmer incomes and food production improved in countries where governments, seed systems, extension services and development partners worked together. In Uganda, Guinea and several west African countries, coordinated programmes helped accelerate adoption among smallholder farmers.

These examples show that effective agricultural innovation will only be adopted and scaled if several conditions are met together. These include:

access to inputs and technologies

accessible financing

efficient extension services

functioning infrastructure

organised markets

coherent, predictable public policies.

Without these conditions, innovations often remain confined to research stations, pilot projects or scientific publications. Where seed systems, rural financing or market organisation are weak, good science makes little difference.

In several African countries, farmers aren’t using improved seed varieties because they can’t get certified seeds at scale. Likewise, promising innovations in irrigation, post-harvest technologies or digital agriculture have struggled because of weaknesses in infrastructure, rural credit or institutional coordination.

What’s needed

Debates on agricultural research in Africa must go beyond simplistic criticism. Agricultural research should not be viewed as a cost. Rather it is a strategic investment in food security, economic sovereignty, environmental sustainability, public health, social stability and human dignity.

Blaming science for lacking impact masks the weaknesses of broader development systems.

As Africa faces the defining challenge of the 21st century – feeding its population without destroying the planet – it would be a mistake to weaken scientific research. The continent must instead strengthen alliances between science, policy, finance, private sector actors, farmers, universities and civil society.

Across Africa, emerging innovation platforms show that when these actors work together, scientific advances can create tangible economic and social change. The challenge now is to broaden this beyond isolated successes.

In the end, the impact of science is a collective responsibility.

And science can only change the world when societies decide to give it the means to do so.

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Africa Has The World’s Greatest Genetic Diversity, Yet It’s Missing From Research: We’re Filling The Gap

Africa has the richest genetic diversity, making it crucial that its people feature in genetic databases. Jacob Wackerhausen / IStock Getty Images

BY MICHELE RAMSAY AND ANANYO CHOUDHURY

Throughout history, most of the world’s genomic research has relied on DNA data from people of European ancestry.

A genome is the full DNA code of about three billion (a thousand million) bases, including all the chromosomes. Each person has two genomes: one from their mother and the other from their father.

Well resourced environments favour European-based research generating hundreds of thousands of whole human genomes with associated health data. Yet modern humans, our species, evolved on the African continent. African populations therefore contain the deepest branches of human genetic history and the greatest genetic diversity on the planet. Yet the continent remains strikingly underrepresented in global genomic databases.

The African continent is populated by people from over 2,000 ethnolinguistic groups, yet genetic data exist for fewer than a hundred groups. This is akin to having a GPS map of a city with only 5% of the streets marked and the rest left blank.

This bias has profoundly shaped modern medicine, from disease prediction tools to ancestry testing. And it’s why researchers increasingly recognise that studying African genomes has the potential to reveal insights and health-related biological pathways never observed before.

As a team of researchers we were involved in identifying under-represented groups in nine African countries for human whole-genome sequencing. Our multidisciplinary team involved in the Assessing Genetic Diversity in Africa project (AGenDA) has worked out ethical ways to obtain, record and share genetic material and to add to global databases.

The AGenDA dataset alone is expected to uncover millions of previously unknown genetic variants and analyses are underway. These discoveries will inform research into diseases that affect populations in African and worldwide. They include diabetes, heart disease, cancer and neurological or mental health conditions.

This is only a first step. Capturing the full scope of African genomic diversity will require hundreds of thousands of genomes. The project aims to bridge some of the most obvious gaps rather than fully map the continent’s diversity.

But expanding African genomic data is not only important for Africa. It will strengthen global biomedical science.

What it takes

Modern genomic science relies on large databases of DNA sequences to understand disease risk, ancestry and human evolution. These databases underpin a wide range of scientific and medical tools. They are used in medical research, disease prediction, drug development, ancestry testing and increasingly in artificial intelligence models that analyse health data.

When a population is absent from a reference database, a library of whole genome sequences, science simply cannot detect it. Genetic algorithms work by comparing individuals to reference populations. In the absence of a specific reference population, the algorithms will assign the closest available match.

This problem becomes particularly visible in ancestry testing. This is a form of genetic testing often used to learn more about biological heritage. Because African reference data remain incomplete, people with African ancestry may receive vague or misleading results about their origins.

Without more African genomic data the assignment of specific ancestry may be incorrect. In addition, disease risk predictions would be misleading. For example it has been shown that standard doses for medications like warfarin (a blood thinner) or efavirenz (an HIV medication) could be ineffective or toxic for people who harbour specific variants that are more common in African populations.

Prior knowledge of the distribution of such variants in a population could be key to deciding the suitability of a drug for patients from that population.

Filling some of the gaps

The AGenDA project was designed to begin addressing some of the gaps in genome data and African representation. This project involved large multi-country scientific collaborations across the continent. It also required co-ordinating research across multiple ethics committees, regulatory frameworks and institutions. Scientists collaborated with research partners in Angola, the Democratic Republic of Congo, Kenya, Libya, Mauritius, Rwanda, Tunisia and Zimbabwe.

The aim was not simply to increase the number of African genomes in global databases. Instead, the team carefully selected populations to address major geographic and ethnolinguistic gaps in genomic data.

But generating large genomic databases requires careful community engagement and consent from participants to share their data. Biological samples for DNA extraction must be collected and the sequencing performed one base at a time.

We therefore built community engagement and culturally appropriate consent processes into the project from the beginning.

More than 1,000 whole genomes were sequenced from communities that had rarely been included in previous genetic studies. These included:

hunter-gatherer populations

Nilo-Saharan-speaking communities

Afro-Asiatic speakers

understudied Bantu-speaking populations

communities from north Africa and the Indian Ocean islands.

Selecting samples required careful consideration of what African diversity actually represents.

Genetic diversity does not map neatly onto modern national borders. Instead, researchers considered a range of additional factors. These included:

poorly represented geographic regions in genomic databases

major ancestral population histories

languages spoken and self-identified ethnic groups

recent patterns of migration.

In some cases, neighbouring communities may appear close due to geographic proximity but have distinct genetic histories that reflect population separations thousands of years ago.

Why studying African genomes benefits science everywhere

African genomes contain more genetic variation than populations on any other continent. This diversity provides a powerful resource for scientific discovery. When researchers study more diverse populations they are better able to achieve a number of things.

Firstly, they can identify new genetic variants.

Secondl,y they can investigate evolutionary forces, like natural selection, that have shaped the genomes of people in different parts of the world.

And thirdly, they can pinpoint variants that influence health and disease.

More inclusive genomic datasets are also essential as genomics becomes integrated with artificial intelligence systems that analyse medical data and predict health outcomes. Future medical technologies could be biased to work best for whoever is represented in the data.

Ultimately, expanding African genomic representation will help ensure that the benefits of genomic medicine are shared more equitably. At the same time, it will improve the accuracy and depth of understanding in global genetic science.

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Africa Is Losing Health Workers When It Can Least Afford To – A Pattern Rooted In Colonial History

Healthcare workers demanding improved living conditions and higher wages in Nairobi, Kenya, 2024. Anadolu/Getty Images

BY DANICA SIMS

SENIOR LECTURER IN MEDICAL

EDUCATION, UNIVERSITY OF OXFORD

Africa has a challenge to retain the health workers it needs.

The World Health Organization estimates a global shortfall of 11 million health workers by 2030, with Africa predicted to face shortages ranging from five million to six million workers. The shortfall is calculated according to disease burden and health population needs. This is the population’s size and demography together with the prevalence of diseases and risk factors, and type and frequency of health interventions planned or necessary to address the identified diseases, conditions and risk factors.

This shortage is deeply unequal. Many of the 83 countries already below the recommended minimum workforce threshold are in Africa, where in 2022 only four countries (Seychelles, Namibia, Mauritius and South Africa) had more than the recommended ratio of 4.45 doctors, nurses and midwives per 1,000 people. Madagascar, Malawi, Togo, Benin, South Sudan, Chad, Central African Republic and Niger reported less than 0.5 doctors, nurses and midwives per 1,000 people in 2018. In many African countries, it’s difficult to deliver basic services, reduce preventable deaths and achieve universal health coverage.

In contrast, Europe reports a range of 5.43 to 20.0 doctors, nurses and midwives per 1,000 people.

At the same time, wealthier countries such as the UK, US, Canada and Australia are increasingly reliant on internationally trained staff. In 2023 nearly half of new doctors joining the UK workforce were trained abroad.

This pattern is often described as “brain drain”, explained by “push” factors (low pay, poor working conditions) and “pull” factors (better salaries and opportunities abroad).

I am interested in this topic as an international worker: a South African health education researcher working in the UK, where I train healthcare workers and research workforce issues.

In a recent paper I argue that this explanation is incomplete. The “push-pull” framing misses a crucial point: the flow of health workers is not random. It consistently moves from poorer countries to richer ones – a pattern that tracks closely along lines drawn by colonial history.

The term “brain drain” suggests a natural, almost inevitable flow of talent. But health worker migration is not neutral or equal; it is shaped by history, economics and power.

I argue that the pattern isn’t just “brain drain” driven by individual choice. Rather, it’s part of a deeper, unequal global system shaped by colonial legacies – with major implications for health, education and workforce policy.

This shifts the conversation away from blaming individual doctors and nurses for leaving, and towards the systems that shape those choices in the first place.

The three factors at play

My research draws on a decolonial perspective to rethink healthcare worker migration. Rather than treating migration as a series of individual decisions, it examines the global systems that structure those decisions.

Decoloniality argues that European colonialism created a matrix of power that still organises:

power – who controls resources and labour

knowledge – whose expertise is valued

being – who is valued.

Through this lens, I argue that health worker migration looks less like a neutral labour market or unfortunate by-product of globalisation, and more like a continuation of historical extraction. In other words, the same global hierarchies shaped during colonialism still influence who controls and benefits from African resources and labour, whose expertise is recognised, and how international workers are viewed and treated.

Power: First, wealthier countries often underinvest in training their own workforce, then recruit from countries with far fewer resources. This transfers human capital from the global south to the global north. The financial losses are significant: one study estimated that sub-Saharan African countries lost millions to billions of dollars through the emigration of doctors, while receiving countries saved on training costs.

Knowledge: Second, global hierarchies of knowledge shape professional mobility. Medical education in Europe and North America is often treated as the gold standard, while qualifications from African institutions may be questioned or require additional validation. This reinforces the perception that moving northwards is necessary for career advancement and legitimacy.

Being: Third, many internationally trained health workers face discrimination that negatively impacts on their well being and career progression. They further risk deskilling. As international healthcare workers can be employed at lower levels of employment than they are qualified for, this can result in them losing skills. This reflects colonial dehumanisation and exploitation.

In short, global systems are structured in ways that make leaving more likely and more beneficial to receiving countries than sending ones.

Developing a fairer system

If health worker migration is shaped by structural inequalities, then solutions must also operate at that level.

1. Invest in and retain health workers locally

African governments should address “push” factors by expanding training and employment opportunities, improving working conditions, and ensuring fair pay and career progression, making staying a viable and attractive option. Health professional education should be aligned with local health needs, equipping healthcare workers to first and foremost meet the population healthcare needs of their home contexts.

2. Reform global recruitment and redistribute resources

High-income countries must reduce their reliance on international recruitment by investing more in domestic training. Ethical recruitment codes exist but are inconsistently enforced. There is also a strong case for reparative measures – including financial compensation or investment – to offset the losses borne by countries that train health workers who then emigrate.

More balanced partnerships, such as circular migration schemes (where health workers return home after training internationally) or bilateral training agreements (where the expertise of both countries is recognised, and both contexts benefit), could support skills exchange without permanently draining capacity. But these must include clear pathways for return and meaningful investment in health systems in countries of origin.

3. Recognise and value global south knowledge and professionals

Addressing the “coloniality of knowledge” means recognising the legitimacy of training and expertise developed in African contexts. At the same time, tackling the “coloniality of being” requires confronting racism, bias and discrimination in healthcare workplaces globally.
Moving forward

When African health systems struggle to retain staff, it is not only because of poor national planning. Many of these systems operate in the long shadow of colonial extraction and ongoing global economic inequality.

Recognising this deeper reality opens up new possibilities. A fairer global health system is possible – but only if it no longer depends on Africa’s loss for others’ gain.

The Bias In Medical Research: Africa Carries A Huge Disease Burden But Is Missing From Clinical Trials

Researchers at the Institute of Medical Research and Medicinal Plant Studies in Yaounde, Cameroon. Daniel Beloumou Olomo / AFP via Getty Images

BY BAMBA GAYE

ADJUNCT PROFESSOR, UNIVERSITE

CHEIKH ANTA DIOP DE DAKAR

Modern medicine prides itself on being a universal science, built on evidence from clinical trials.

But there’s a bias in medical research. While Africa accounts for roughly 25% of the global disease burden and 19% of the global population, the continent’s people are largely invisible in some clinical trials.

The scale of the erasure is revealed in a landmark study of 2,472 randomised controlled trials globally published between 2019 and 2024.

I led this team of researchers, who scrutinised the world’s most influential medical publications to quantify African representation. They included the New England Journal of Medicine, The Lancet, the Journal of the American Medical Association, Nature Medicine, and the British Medical Journal. There were also three leading cardiovascular journals in the study: Circulation, the European Heart Journal and the Journal of the American College of Cardiology.

I am a physician-scientist working at the intersection of cardiometabolic epidemiology and biomedical data science. I also focus on large-scale population studies in Africa and data-driven cardiovascular prevention.

Randomised controlled trials are a cornerstone of evidence-based medicine. Introduced in the mid-20th century, they rigorously evaluate the safety and effectiveness of treatments by randomly assigning participants to different groups. This is done to minimise bias. Trials like these have been central to major medical breakthroughs, from cardiovascular therapies to vaccines. They continue to guide clinical decisions and the development of new treatments worldwide.

What we discovered

Our findings show a profound imbalance in the global clinical research landscape. Across the five most prestigious general medical journals, only 3.9% of trials were conducted exclusively in Africa. In cardiovascular health, the numbers drop to a statistical whisper. Of the major trials published in leading cardiology journals, just two studies (0.6%) were conducted solely on African soil.

This is a crisis of scientific accuracy. When clinical trials exclude African populations, they produce evidence that lacks “external validity”. This refers to how well the results of a study can be generalised beyond the participants. It asks whether findings from a clinical trial will still hold true when applied to different populations, settings, or real-world conditions.

Without that validity, doctors are essentially conducting unmonitored experiments on millions of patients every day.

Modern medicine cannot claim to be universal if entire populations remain invisible in the evidence base. Biology, health systems and disease patterns are not identical across the world.

The gap and why it matters

Many treatments used across the continent are based on evidence generated in non-African populations, raising concerns about their applicability.

Moreover, most Africa-based trials still focus on infectious diseases, despite the rising burden of non-communicable diseases such as cardiovascular disease.

Emerging evidence shows that genetics, environment and diet can radically alter how a body responds to a drug. It therefore makes no medical sense that an entire continent is left out of the trial net.

There’s also evidence showing that certain treatments have different safety profiles in Black patients. Diabetes and gout are just two examples. So are certain common blood pressure medications, such as angiotensin-converting enzyme (ACE) inhibitors. Research shows that they carry a three- to four-fold higher risk of severe, life-threatening side effects in people of African descent compared to other populations.

When clinical trials exclude populations, doctors are forced to extrapolate findings from one population and apply them to another.

The study also highlights a dangerous lag between global research funding and the evolving reality of African health. The new data show that nearly 76% of trials conducted exclusively in Africa focused on infectious diseases. But the continent is undergoing a massive epidemiological shift. Non-communicable diseases – heart disease, stroke, and diabetes – now account for about 38% of all deaths in many African nations.

The middle class in Africa has tripled to 300 million people from roughly 100 million people in the early 2000s. More people are now living long enough with lifestyles that increase the risk of chronic conditions such as heart disease, diabetes, and hypertension. Consequently, there is a growing need and market for long-term treatments that manage these diseases, rather than short-term therapies for infections. Yet cardiovascular trials continue to be discouraged.

Even within the continent, the data show deep “black holes” of information. South Africa accounted for over 62% of all trials conducted on the continent. Central Africa, a region that’s home to more than 180 million people, was virtually non-existent in the global research record. It contributed less than 3% of the continent’s limited trial output. Possible reasons include South Africa’s decades of cumulative investment, seen in stronger academic hubs, research governance, experienced trial units, and more established sponsor relationships. Other regions face barriers like fewer resourced research institutions, less access to trial platforms, and sometimes language and publication issues that can reduce visibility in top-tier journals.

The inequity extends into the hierarchy of science itself. Even when African sites are included in large, multicontinental trials, they are often relegated to the role of “recruitment hubs” rather than scientific partners. Our study found that African scientists led only 3.6% of multicontinental trials that included an African site.

Towards a new era of African science

Africa should not simply be a location where studies are conducted.

It must be a place where research is conceived, led and interpreted. The current model creates a cycle of external dependence where international institutions manage the funding and the data. This leaves local research systems fragile and unable to translate evidence into national policy.

There is need for “ring-fenced” funding for African-led research, the development of regional trial networks, and a mandate for medical journals to report on the diversity of trial populations.

There are signs of a rising momentum. Organisations like Alliance for Medical Research in Africa are working to equip a new generation of African investigators. Africa must create a research ecosystem that is too important for the global community to ignore.

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Ending Malaria In Africa: 5 Essential Reads On Gains And Challenges

A nurse prepares a dose of vaccine against malaria at a district hospital in Cameroon. Xinhua News Agency/Getty Images

BY WALE FATADE

Malaria, a life-threatening disease spread to humans by some types of mosquitoes, is preventable and curable. The World Malaria Report 2025 shows that in 2024, there were an estimated 282 million malaria cases and 610,000 malaria deaths in 80 countries. Africa carries a disproportionately high share of the global malaria burden.

In 2024, Africa accounted for 95% of malaria cases (265 million) and 95% (579,000) of malaria deaths. Children under five accounted for about 75% of all malaria deaths in the region. Over half of all deaths in Africa occurred in three countries: Nigeria (31.9%), the Democratic Republic of Congo (11.7%) and Niger (6.1%).

But there have been some positive developments. One is the first malaria treatment for babies and very young children of two months up to five years. This was approved for use by a Swiss agency for therapeutic products, Swissmedic, in July 2025. Another is the rollout of malaria vaccines in 17 endemic countries in 2024. These countries, with roughly 70% of the global malaria burden, now offer malaria vaccines through their routine childhood immunisation.

To mark World Malaria Day 2026, whose theme is “Driven to End Malaria: Now We Can. Now We Must”, we’re sharing some of the articles our authors have contributed in the past.

Floods increase the risk of malaria

When flood occurs, the most visible damage is immediate: homes washed away, crops destroyed, clinics disrupted, families displaced. These images dominate headlines and humanitarian appeals. As communities clear debris and try to rebuild livelihoods, they are also entering the most dangerous window for malaria transmission.

Tiaan de Jager and Taneshka Kruger show that frequent climate-driven floods not only wash away infrastructure, they are reshaping malaria risk in ways that entrench poverty and threaten fragile progress towards malaria elimination. Floods leave behind an increased risk of malaria transmission, as standing water and disrupted control programmes create ideal conditions for the disease to spread.

Gut bacteria to fight malaria

Researchers in Africa are not left out in the battle to eliminate malaria; they are busy in their laboratories. One of these efforts is research to find the right bacteria that can be used to help stop the spread of malaria.

Chia-Yu Chen and Shüné Oliver have found that different types of mosquitoes carry different sets of bacteria. They have also found that there are several anti-parasitic bacteria in mosquitoes that do not spread malaria well. Since these bacteria can boost the immune system of the mosquito, they could help to prevent the insects from transmitting the malaria parasite.

The thinking is that if we understand exactly which bacteria are involved, they can be used as biocontrol. These candidates could be given to a malaria-transmitting mosquito through a blood-meal (that contains the bacteria) or through genetic modification.

Shrinking funds and rising threats

In 2021, nearly half of the sub-Saharan African countries relied on external financing for more than a third of their health expenditure. But donor fatigue and competing global priorities, such as climate change and geopolitical instability, have placed malaria control programmes under immense pressure. These funding gaps now threaten hard-won progress and ultimately malaria eradication.

Taneshka Kruger and Tiaan de Jager argue that there’s a need to think smarter about funding. This is because it’s far cheaper to prevent malaria than to treat it. The total cost of procuring and delivering long-lasting insecticidal nets typically ranges between US$4 and US$7 each and the nets protect families for years. In contrast, treating a single case of severe malaria may cost hundreds of dollars and involve hospitalisation.

Two new malaria vaccines

Since 2019 more than 2 million children in Ghana, Kenya and Malawi have been vaccinated with the RTS,S malaria vaccine.

The world’s first routine vaccine programme using the RTS,S started in Cameroon in January 2024. The country is offering the vaccine free of charge to all infants up to the age of six months. It could change Africa’s public health history. Two vaccines are currently available for prevention of malaria. The second is R21/Matrix. It is a second-generation RTS,S vaccine, developed by Oxford University’s Jenner Institute and approved by the WHO in October 2023.

Jaishree Raman says the vaccines are a welcome addition to the malaria elimination toolbox. They should ideally be used together with other control strategies like long-lasting insecticide-treated bed nets, rapid diagnosis, and treatment with an effective antimalarial.

First malaria treatment for babies

The absence of effective malaria treatment options specifically tailored for newborn babies left a significant gap in care for the most vulnerable children. Children’s bodies and physiological needs differ greatly from those of adults.

But in July 2025, the first malaria treatment for babies and very young children of two months up to five years was approved for use. Fortunate Mokoena says “this approval is profoundly important” and will help in achieving the WHO’s ambitious and visionary goal to end malaria by 2030.

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Nigeria Imports 70% Of Its Medicines – Why Local Manufacturing Doesn’t Meet Demand

BY EFEFIOM KOFON

SOAS, UNIVERSITY OF LONDON

Nigeria imports at least 70% of its medicines. This is striking for a country of over 230 million people and at least 120 active pharmaceutical manufacturers.

Domestic manufacturing is largely concentrated in lower-end medicines that require relatively simple production processes. The more complex and higher-value pharmaceutical products continue to be imported.

This pattern has persisted for decades. It reflects two things. First is the limited impact of policies aimed at reducing import dependence. The other is the entrenched interests across pharmaceutical companies. An incentive structure that favours imports over local production.

I recently completed my doctorate studies focusing on the political economy of pharmaceutical manufacturing in Nigeria, with comparisons to Uganda, Bangladesh and India. My research looked at how the industry had evolved and analysed how the distribution of organisational power and manufacturing capabilities has made it difficult for reforms to work.

I found that policy interventions have largely failed because weak institutions cannot influence manufacturers to expand their production capabilties.

The biggest obstacles stem from how power and benefits are distributed across political, bureaucratic and pharmaceutical actors.

Any policy that does not fully take this into account will likely be resisted.

Factors militating against Nigerian manufacturers

Nigerian manufacturers face:

a lack of protection and incentives to produce certain medicines

high levels of imports of finished medicines

pressure to import as well as manufacture

low manufacturing capabilities.

Weak incentive structure:

The first policy to specifically support domestic manufacturers of medicines was introduced in 2005, when the Nigerian government restricted the importation of 17 lower-end medicines. The prohibited medicines included paracetamol, aspirin and metronidazole (antibiotic) tablets.

The protectionist policy has not been expanded since then. So manufacturers have no incentive to invest in technological upgrading to make more complex medicines.

Importation of finished medicines:

At least 100 manufacturers also import medicines – including some that are produced locally. In some cases, manufacturers both produce and import the same medicine, marketing them under different brand names.

Two medicines illustrate this. The antibiotic ciprofloxacin (tablet form) is currently imported by at least 93 registered pharmaceutical companies, even though 21 domestic producers make it too.

A similar pattern is evident for artemether-lumefantrine, a widely used antimalarial medicine. Fewer than 30 pharmaceutical companies produce it locally. More than 200 import it – including some established manufacturers.

Manufacturers as producers and importers:

Many companies combine local manufacturing with importing finished medicines as a way of managing risk.

This creates commercially attractive, lower-risk revenue streams for manufacturers. They are likely to resist policy or reforms that would limit imports in favour of expanded local production.

Low manufacturing capacities:

Nigerian pharmaceutical companies have low manufacturing capacities. And the learning process involved in complex manufacturing is time consuming, costly and risky.

It is also difficult to compel a company to do something where governance is weak.

In the absence of adequate and sustained policy support, many manufacturers rely on political networks to protect their interests or challenge policies that threaten them.

An example is the modification of a regional tariff in 2016 because it threatened locally manufactured medicines. The regional trade policy had imposed zero duty on essential finished medicines and up to 20% on the raw materials used in medicine manufacturing. This was to increase the availability and affordability of essential medicines across the region. Nigerian manufacturers exerted pressure on government to reject it.

In the absence of credible policy support for upgrading into technologically sophisticated medicines, manufacturers continue to rely on imports. Similarly, they continue to influence policy decisions that could disrupt existing revenue streams.

Why the problem persists

When some pharmaceutical companies manufacture medicines locally while others import the same products, it weakens collective action. It’s harder to mobilise around shared policy demands.

The Pharmaceutical Manufacturers Group of Manufacturers Association of Nigeria, an influential trade association, illustrates this challenge. One of its objectives is to lobby for increased market protection for locally produced medicines. But member firms have differing commercial interests in locally manufactured and imported medicines. This often works against policy objectives.

It impedes how member firms form alliances to support or oppose policies. It also affects influence over them.

Nigeria’s reliance on imported medicines has less to do with the commonly cited capability constraints. It is the outcome of a policy vacuum that has made it more attractive to import products.

This dynamic is also evident in some other African countries, such as Ghana, Kenya, and Uganda. Manufacturers similarly import more complex medicines and produce simple medicines locally. There is limited support for domestic manufacturing of more complex medicines.

Moving forward

High levels of imports limit the rewards for expanding manufacturing capabilities and any credible path to competitiveness. The significant revenues generated from imports also weaken incentives to invest in learning how to produce more complex medicines.

Recognising this matters for policymakers and international development organisations.

The challenge is not simply increasing financial support or political commitment. It is designing policies that reconfigure current benefits. They need to make it worthwhile to invest in more complex pharmaceutical manufacturing.

THE CON

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Maternity Health Services In Nigeria Are Failing Women: 4 Steps To Better Care

The paediatric ward, Jos University Teaching Hospital, Plateau State in Nigeria. Photo by Stefan Heunis/AFP via Getty Images

BY OBASANJO BOLARINWA SND REBECCA TADOKERA

Nigeria faces one of the world’s highest maternal mortality rates. Around 1,047 women die for every 100,000 live births, far above the African regional average of about 531 deaths per 100,000. This highlights the fact that not all women are getting maternal healthcare.

Reasons include:

differences in access to healthcare between geographical regions

socio-demographic factors such as education, poverty, age and limited decision-making power within households

religious affiliation, which in some communities shapes health-seeking behaviour

limited exposure to health information

poverty and unemployment

a lack of health insurance.

Nigeria has implemented several maternal health programmes over the past two decades. The National Integrated Maternal, Newborn and Child Strategy, Midwives Service Scheme and Free Maternal and Child Health Programmes were designed to increase skilled birth attendance, improve access to antenatal and postnatal care, and reduce financial barriers to maternal health services.

But progress in reducing maternal deaths has been uneven across Nigeria. Maternal mortality in the north-east and north-west exceeds 1,000 deaths per 100,000 live births, far higher than rates in southern regions of the country. Many women still do not receive essential maternal health services. For example, only 47.8% of women reported delivering with a skilled birth attendant, and millions of women have limited access to regular antenatal care.

The challenge is no longer about identifying the problem. It is about removing the real barriers Nigerian women face.

We are global public health researchers with a focus on maternal health systems in low- and middle-income countries.

Our recent published policy brief highlighted why many women in Nigeria aren’t using maternity services. Our findings suggest that there are four practical shifts that the Nigerian government could make to improve the use of maternity services across Nigeria. These are:

region-specific interventions

increasing the coverage of services so that they’re closer to where women live

removing financial barriers to care

using digital capabilities to overcome gaps in services.

Four interventions that can make a difference

1. Target regions differently

Maternal health policies often take a national approach, but Nigeria is not uniform. Northern and some southern regions face different cultural, religious and geographic barriers. Government policies therefore need to target specific barriers in different regions. For example, improving transport and health facility access in rural areas, expanding community-based maternal services, and strengthening culturally appropriate health education programmes.

Such policies would typically be developed by Nigeria’s Federal Ministry of Health in collaboration with state governments, local health authorities and community organisations. Regional inequalities in maternal death have shown why a uniform policy approach is ineffective. For example, skilled birth attendance is far lower in the north-west than in southern regions.

The Federal Ministry of Health should empower the state governments to:

work with the religious and traditional leaders to promote skilled birth attendance

engage community influencers to counter harmful norms

train health workers in culturally sensitive care

strengthen primary healthcare services in underserved districts.

When communities trust the system, they use it.

2. Take services closer to women

Distance remains a barrier, especially in rural areas. Many women cannot travel long distances while pregnant. In many parts of Nigeria, a health facility may be more than 5-10 kilometres away, and poor roads, limited transport and travel costs make it difficult to reach care.

Mobile health clinics can bridge this gap. They bring antenatal care, family planning and basic obstetric services directly to remote communities. These clinics can be established and operated by state ministries of health and local government health authorities. Though there are mobile clinics in Nigeria currently, there ought to be more.

Outreach teams dedicated to maternal health specifically and including trained midwives, nurses, community health extension workers, volunteer community health workers, supported by local primary healthcare staff should:

provide health education in local languages

offer on-the-spot referrals

use community health workers to track pregnancies early.

Care that comes closer to women increases uptake, as seen in western Kenya.

3. Remove financial barriers

Out-of-pocket payments still prevent many Nigerian women from seeking care. Health insurance coverage remains low. Fewer than 10% of Nigerians are currently covered by any form of health insurance, leaving the majority of households to pay directly for services. This is despite the fact that it was made mandatory for all Nigerians and legal residents in 2022.

Maternal health is meant to be free. But the policy isn’t implemented consistently.

Three reforms are critical:

expand health insurance coverage for maternity service

enforce policies that prevent informal or hidden charges

introduce targeted financial incentives such as vouchers or conditional cash transfers for poor women.

These reforms would require coordinated action across Nigeria’s federal, state and local health systems, which jointly oversee healthcare financing and service delivery.

Evidence from other low- and middle-income countries shows that financial incentives increase service use. When cost is removed, utilisation rises.

Long-term economic empowerment of women is equally important. Women with stable incomes are more likely to seek care.

4. Use digital health to widen access

Nigeria’s digital penetration is growing rapidly. More than 100 million Nigerians use the internet, representing about 45% of the population. Mobile phone penetration exceeds 80% of the population. This creates an opportunity to create digital platforms that:

send appointment reminders

provide pregnancy education

support teleconsultations

use artificial intelligence tools to improve risk screening.

Digital health will not replace physical services. But it can reduce delays, improve awareness and connect women to care earlier.

Rwanda has integrated AI into healthcare through digital platforms that support remote consultations and clinical triage. Tools such as the Babyl telemedicine platform use AI-assisted systems to help nurses assess symptoms, guide treatment decisions and connect patients to doctors through mobile phones, expanding access to care in rural areas. This shows what is possible when technology is used strategically. Nigeria can adapt similar models for maternal health.

Way forward

Nigeria does not need more policy documents. It needs targeted implementation.

First, federal and state governments must align efforts. Nigeria already has national institutions coordinating maternal health policy, including the Federal Ministry of Health and Social Welfare and the National Primary Health Care Development Agency. But because health services are delivered largely by state and local governments, implementation varies widely. Maternal health policies should be state-specific but nationally coordinated and adapted to state-specific realities.

Second, funding must prioritise primary healthcare and community engagement. Investments should focus on where utilisation is lowest.

Third, monitoring systems must improve. Data should guide decisions at local levels. Programmes that work should be scaled. Those that fail should be redesigned.

Finally, women themselves must be part of policy design. Solutions imposed from above rarely succeed. Improving maternity service use is not only a health goal. It strengthens families, communities and the economy.

The next step is clear: implement smarter, targeted policies that remove barriers and bring care closer to every woman.

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