The recent emergence of zoonotic diseases such as Highly Pathogenic Avian Influenza (HPAI) and Severe Acute Respiratory Syndrome (SARS) have contributed to dominant Global Health narratives around health securitisation and pandemic preparedness, calling for greater co-operation between the health, veterinary and environmental sectors in the ever-evolving One Health movement. A decade later, One Health advocates face increasing pressure to translate the approach from theory into action. A qualitative case study methodology was used to examine the emerging relationships between international One Health dialogue and its practical implementation in the African health policy context. A series of Key Informant Interviews (n = 32) with policy makers, government officials and academics in Nigeria, Tanzania and Uganda are presented as three separate case studies. Each case examines a significant aspect of One Health operationalisation, framed around the control of both emerging and Neglected Zoonotic Diseases including HPAI, Human African Trypanosomiasis and rabies. The research found that while there is general enthusiasm and a strong affirmative argument for adoption of One Health approaches in Africa, identifying alternative contexts away from a narrow focus on pandemics will help broaden its appeal, particularly for national or regionally significant endemic and neglected diseases not usually addressed under a “global” remit. There is no ‘one size fits all’ approach to achieving the intersectoral collaboration, significant resource mobilisation and political co-operation required to realise a One Health approach. Individual country requirements cannot be underestimated, dismissed or prescribed in a top down manner. This article contributes to the growing discussion regarding not whether One Health should be operationalised, but how this may be achieved.
One Health acknowledges the close relationships between humans, animals and ecosystems, promoting the potential added benefits to each sector or species that emerge as a result of its operationalisation (Figure 1). Whilst attempts to categorically define One Health are many and varied, the general consensus that it promotes a transdisciplinary, collaborative “whole of society” approach towards global health in the 21st century remains key [1]–[4]. The unprecedented financial and political response to H5N1 avian influenza at the turn of the 21st century facilitated the development of global intersectoral alliances, creating a unique policy space for agencies, governments and institutes to collaborate under a large scale One Health banner for the first time [3], [4]. There is currently a strong drive to maintain the momentum and alliances established during the Global Response to Avian Influenza (GRAI), with advocates promoting One Health as an approach towards various other aspects of international and regional health governance. However in the absence of a specific disease threat, examples of national commitment to One Health are increasingly difficult to find, particularly in developing countries. The argument for inter-ministerial platforms to co-ordinate policy and action for zoonoses control is well founded. However whilst One Health is theoretically - and arguably economically - attractive, significant political will and state capacity is required to overcome existing institutional and financial barriers to its implementation; particularly in developing countries where numerous health and development priorities compete for attention and programmatic funding. Identification and critical analysis of current examples is required if One Health is to be perceived as anything other than an “attempt to grab funds on the tail-end of the avian influenza bonanza” [4]. Africa is a relevant continent for the examination of One Health policy, particularly for the control of endemic and “neglected” zoonotic diseases [5]. Although Asia has been the recent focus regarding high profile emerging zoonotic disease outbreaks, Africa has historically been home to some of the most striking examples of disease spill over from animals including HIV, Rift Valley Fever and Ebola. Additionally, it is estimated one third of Africa' s agricultural Gross Domestic Profit is obtained through livestock production [6]. Whilst significant economic gains could be realised on the continent through control of production-limiting zoonoses including the trypanosomiases, brucellosis, cysticercosis and anthrax, the existing socioeconomic evidence available to promote concrete policy shifts towards multisectoral approaches is currently lacking. In addition to the socioeconomic evidence, documenting the successes and challenges of existing One Health platforms, as experienced by those driving disease control policies on the continent, is also urgently required. Through interviewing a selection of respondents currently at the forefront of policy development for zoonoses control in Uganda, Nigeria and Tanzania, attempts have been made to address this latter issue.
A preliminary review identified that despite the ubiquitous international promotion of One Health through various meetings, agreements, frameworks and pledges, relatively few examples of successful long term adoption of the approach existed, particularly in sub-Saharan Africa [7]. A qualitative case study methodology [8] was applied in three African contexts in order to understand how – or where – a One Health policy approach may be appropriate to the control of diseases of regional or national importance. A total of 32 Key Informant Interviews were held with key policy actors in Uganda, Nigeria and Tanzania, including officials from the Ministries of Health and Agriculture, academia and international research institutes (Table 1). These countries were chosen given they have reported higher than average burdens of endemic zoonotic disease [5], and were key International Cooperation Partner Countries (ICPCs) of the European Commission' s Integrated Control of Neglected Zoonoses (ICONZ) project through which the research was undertaken [9]. Individual interview respondents were selected using a snowball sampling technique; a type of purposive sampling whereby existing local networks direct the researcher to further potential participants [8]. Given the relatively “closed” doors and time constraints common to government officials across many African ministries, snowball sampling was deemed the most sensible - and in many cases the only available - technique to ensure that interviews were secured from a wide variety of sectors and ministerial levels. With the exception of one international researcher, interview respondents were all nationals of the three focus countries, representing several sectors and governance levels as outlined in Table 1. Whilst the semi-structured interview approach allowed for a certain degree of flexibility to reflect respondents' areas of expertise and experience, several key themes exploring intersectoral collaboration in the context of disease control were used as a general interview guide (Figure 2). Verbal consent was obtained prior to the commencement of all interviews, which were then documented via handwritten notes and voice recordings if the respondent agreed. Resulting transcripts were then manually coded according to the various emerging themes and topics, from which several context-specific narratives were then developed. The resulting observations and recommendations, discussed in the remainder of this article, outlines the various personal experiences of those in the “driving seat” of disease control in the three countries, potentially increasing the understanding of how One Health' s application can extend to a wider variety of diseases and national contexts outside the GRAI.
Human African Trypanosomiasis (HAT), or “Sleeping Sickness”, is a Neglected Tropical Disease of significant public health importance across much of Africa, with Nagana the corresponding disease in livestock. Transmitted by the Glossina species of tsetse fly, trypanosomiasis manifests in humans as either an acute or chronic form caused by T. br. rhodesiense and T. br. gambiense respectively. Presently the only country with foci of both forms of this fatal human disease, Uganda has suffered from devastating epidemics and outbreaks since the beginning of the 20th Century. To date the two forms have been confined to separate geographical foci in Uganda, facilitating surveillance and treatment. More recently however, country-wide movements of infected cattle - an essential reservoir of the T. b. rhodesiense parasites responsible for acute human disease in Uganda - have fuelled fears of disease convergence [10], [11]. The intersectoral approach required for HAT control “lies at the heart of African rural development” [12], providing a relevant case study through which to examine One Health. On the 6th of February 2006, Nigeria reported Africa' s first case of H5N1 Highly Pathogenic Avian Influenza in a commercial poultry farm in Kaduna state. The political and financial backing for control was unprecedented - “the government was giving money before they were even asked to” (Key Informant 1, Nigeria) - with an alleged USD $50 million credit received from the World Bank to commence activities [14], [Key Informant 1 Nigeria]. Pressure from external agencies resulted in the “Nigeria Avian Influenza Emergency Control Preparedness and Response Project”; a three year action plan that promoted the added benefits of a One Health approach through its objective to minimise the threat of HPAI to humans whilst simultaneously promoting poultry production in the country [15]. Through evaluating the extent to which intersectoral partnerships have been maintained since completion of the project in 2009, this case study examines where One Health may be headed now that the H5N1crisis is over. Rabies is widespread in Africa, contributing to an estimated 23 000 deaths per year despite the existence of an effective toolbox for control [18], [19]. Many officials do not prioritise rabies, doubting the feasibility of its elimination through mass dog vaccination [19]. A major question in the recent flurry of One Health activity is how localised academic and scientific projects funded by international donors can move into wider policy spheres in the African context; the ongoing experience of rabies research in Tanzania is illustrative of this process. The critical message emerging from all three case studies is that One Health will not “just happen”. Broad institutional changes - and ownership of these changes across the various ministries, departments and interest groups with a stake in disease control – are required for One Health to become a widespread approach to health policy. Moreover, institutional change and ownership will not drive One Health forwards in the absence of sufficient funding. Where external donors are to be the main source of financial support for One Health operationalisation, the need to balance global health agendas with national ownership of change will become even more crucial. There is no “blanket approach” to One Health; individual country requirements cannot be underestimated, dismissed or prescribed in a top down manner by the international community. Although One Health promotes intersectoral collaboration through flexibility and “small ‘g’ governance” [22], evidence from these three case studies suggest that achieving this in the absence of a global health emergency, political endorsement and nationally-owned financial commitment is at once both challenging, yet urgently required.
The One Health movement requires more robust evidence around its practical implementation if it is to truly become a way forwards for addressing health issues at the human, animal and ecosystem interface. The research in this paper discusses some of the recent successes and challenges with both Emerging and Neglected zoonoses in the sub-Saharan Africa context. Through speaking to various human and animal health practitioners and policy makers in Uganda, Nigeria and Tanzania, the authors have created three case studies highlighting the various successes of the approach to date, but also clarifying areas where the approach will take longer to implement, often as a result of the wide institutional and policy changes required in many countries. The authors conclude that whilst the “goodwill” is certainly there, the reality of planning, executing and budgeting for joint interventions – particularly at the national or regional level – proves in many cases more difficult than first thought. It is hoped however that through gaining better insight from those charged with the decision-making in these countries, One Health practitioners will be encouraged to build on the momentum through addressing some of the issues that arise with its implementation.
public and occupational health
political science
infectious diseases
veterinary diseases
medicine and health sciences
global health
biology and life sciences
social sciences
veterinary science
One Health: Past Successes and Future Challenges in Three African Contexts