Africa: Decade-Long Study Reveals Key Drivers of Global Health Success

The most effective public health outcomes are often driven by shared factors across countries

Dr. Nadia Akseer, an epidemiologist and biostatistician at Johns Hopkins Bloomberg School of Public Health collaborates with colleagues in the Exemplars in Global Health (EGH) program. Her research focuses on international health, including child and maternal health, survival, and nutrition, particularly in humanitarian settings and low- and middle-income countries. Her analysis of Exemplar studies, Drivers of Success in Global Health Outcomes: A Content Analysis, was published in PLOS Global Public Health.

Akseer said the EGH program was inspired to undertake this study due to the impressive health gains observed in several African countries.

“While the EGH program studies positive outlier countries globally, those within Africa have been making impressive health gains,” she said. “However, when the data is examined, it’s clear that there are some countries that stand out for how quickly they are making progress. EGH’s global coalition of partners, including researchers, academics, experts, funders, and country stakeholders, seek to learn from these positive outliers and share lessons so they can be adapted in comparable contexts.”

Akseer said that this “cross-topic analysis is notable because it found that the highest performing countries across public health outcomes generally prioritize the same eight factors. The hope is that by synthesizing this data and identifying the key drivers of success, funders, policymakers, leaders, and stakeholders can make more informed decisions about what to prioritize to help shape effective health policies and optimize public health impact”.

A Decade of Global Health Research

The extensive research produced by the EGH program since its inception notes that over 30 country narratives covering topics such as vaccine delivery, under-five mortality, and women’s health, among others, she said.

“Since the program’s inception, EGH has produced a thorough body of research that includes over 30 country narratives and counting. The topics we study include Vaccine Delivery, Under-five Mortality, Neonatal and Maternal Mortality, Stunting, Anemia Among Women of Reproductive Age, COVID-19 Response, Advance Warning and Response, Primary Health Care, Community Health Workers, Family Planning, Adolescent Sexual and Reproductive Health and Rights, and Women’s Health and Wellbeing, among others,” Akseer said.

The research published in PLOS Global Public Health offers a cross-topic analysis of 31 EGH studies, spanning six topics and including data from 19 countries in Africa, Latin America, Asia, and the Caribbean. The study, which was limited to six topics with completed results available at the time, identified eight key drivers of success through a conceptual content analysis approach that maps and quantifies patterns across studies. This process involved close collaboration with a technical advisory group to review and validate the research methodology and findings.

“As part of this process, we worked closely with a technical advisory group that reviewed our content analysis approach, shared feedback and suggestions, and worked to ensure alignment across our research methodology to validate these findings.

“Robust political commitment and governmental leadership were one of the strongest common drivers we identified – 90% of the 31 studies we looked at showed that these elements were critical for achieving health progress.”

Dr. Akseer said, as with all EGH findings, “contextual factors are especially important to consider”. For instance, Akseer said that countries took “specific actions unique to their local context to establish strong commitment,” such as Senegal’s establishment of the Coordination Unit for the Fight Against Malnutrition, Liberia’s contingency plans after the Ebola epidemic, and the Dominican Republic’s mobilization for mass vaccination under a new administration during the COVID-19 pandemic.

EGH-Senegal Partnership Boosts Vaccine Delivery

In collaboration with the Exemplars in Global Health program, Dr. Moussa Sarr, a physician and epidemiologist, was instrumental in improving Senegal’s routine immunization success, advancing global health metrics such as the WHO MoNITOR program’s Skilled Birth Attendance Index, and consolidating health facility data in Senegal.

Over the past two decades, Sarr led health research and public health initiatives in the United States, Senegal, and Africa, and is a consultant at the Institut de Recherche en Santé, de Surveillance Épidémiologique et de Formations (IRESSEF) in Dakar, Senegal.

Dr. Sarr said that the Exemplars in Global Health (EGH) conducted a study on vaccine delivery ‘exemplar’ countries, in which Senegal was one of the countries studied. The study in Senegal was a partnership with IRESSEF, the Ministry of Health and Social Action (MSAS), EGH, and international partners like the World Health Organization. The research yielded valuable insights into drivers of successful vaccine delivery, enhancing both implementation and effectiveness of programs in Senegal.

He said that one of the key outcomes was the impact of integrating immunization within the broader health agenda of Senegal. This strengthened the accountability for vaccine delivery and the allocation of resources. In addition, he said that the research showed the importance of Senegal’s evidence-based decision-making and aligning national priorities with global health standards. Senegal, for example, implemented District Health Information Software in health posts in 2014 to facilitate the collection of reliable and timely information at the district level. The system is monitored weekly to tailor strategies to improve immunization coverage.

Sarr believes that community engagement is another contributing factor to Senegal’s high vaccination rate. The research describes how the Ministry actively engaged communities in addressing issues such as vaccine hesitancy and promoting community ownership of health outcomes. The Ministry also prioritized tailoring strategies to address local geographical and social barriers.

“One example of a successful community engagement program in Senegal is the unique cadre of community health workers, such as the bajenu gox (or “godmothers”) and the Relais,” said Sarr. “These community health worker programs build trust in communities, engage families, support immunization initiatives, and link existing health care services to those who need it the most. The community health worker partnership has also helped tackle challenges in remote regions, such as near the Guinea and Mali borders, where mobility issues between Senegal and neighboring countries are significantly affecting vaccination coverage rates.”

The research also demonstrated the importance of public-private cooperation, he said, particularly in the integration of data from the private sector to monitor vaccination progress. Joint efforts like this continue to generate important recommendations that will help shape future policies, for example in regions like Dakar where a large proportion of the population receives health care through private providers.

“We are now initiating a research sprint to better understand midwifery and midwife-led care models in Senegal and Kenya, collaborating with Ministries of Health, Gates Ventures, and the Bill and Melinda Gates Foundation,” Sarr said.

The Exemplars in Global Health research intentionally included a diverse range of countries to identify common success factors across different contexts. While regional and contextual differences did influence the relative importance of factors and timelines for improvement, the analysis focused on synthesizing overarching findings rather than detailing country-specific challenges. For in-depth examinations of how individual countries navigated implementation challenges, Dr. Akseer encouraged reviewing EGH’s country-level research findings available online.

Akseer said: “The EGH research intentionally included countries with diverse geographic, political, and other differences to identify commonalities across various environments.” These contextual differences often influenced “the relative ranking of the eight factors and the time required to achieve positive changes.” While the cross-topic analysis aimed to synthesize broad findings, it did not delve deeply into how individual countries navigated specific challenges. However, she said that “EGH’s country-level research findings, available online, offer a comprehensive look at the specific challenges countries have faced and continue to face in the implementation process.”

Convergence or Conflict?

Dr. Sarr said that the findings from the PLOS study align closely with observations and data collected from our vaccine delivery research in Senegal.

In both studies, effective data collection plays a critical role in improving surveillance, monitoring, evaluation, and decision-making processes. The PLOS study highlights high-level organizations like Senegal’s Cellule de Lutte Contre la Malnutrition, which coordinates multi-sectoral efforts to improve nutrition, he said, drawing parallels with Senegal’s government’s commitment to immunization as an integral part of its health strategy.

Sarr also said the importance of stakeholder coordination, noting that both studies affirm the need for effective collaboration between the Ministry of Health and external partners to enhance decision-making, funding allocation, and policy implementation. In addition, he said the importance of community-based health workforces in achieving health outcomes. As a result of both studies, robust national policy frameworks are essential, resulting from a combination of top-down and bottom-up approaches.

“The PLOS study confirms observations from our work, but also expands on several factors not highlighted as separate factors in our Senegal vaccine delivery study,” he said.

Dr. Sarr said that both studies emphasize the role of efficient data collection in improving surveillance, monitoring, evaluation, and decision-making processes. “While the PLOS study highlights women’s empowerment and engagement as a distinct factor, our research focused on this factor in the context of the community-based health workforce,” he said.

“The bajenu gox, in particular, exemplifies this, as they are respected women who provide vital support from prenatal care through to vaccination. This empowerment element is confirmed by mothers who praise the bajenu gox for their role in community health.”

Despite not explicitly separating equitable access to vaccination as a separate factor in their study, it is evident from the community’s strong emphasis on vaccines as a fundamental right for each child, Sarr said. Strategies such as Reaching Every District and Reaching Every Child are systematically designed to improve coverage for underserved populations. In addition to funding available through international partners like GAVI or UNICEF, he said, community health development committees play a critical role in sustainable financing, health fund management, maintaining cold chains, and improving infrastructure.

Key Factors and Challenges

Dr. Akseer said that “countries across Africa and around the world all have access to the same information, health tools, and global recommendations, yet some exceed expectations even when accounting for economic growth”. She said, “there’s a growing understanding that success in health outcomes is as much about how a country achieves it as it is about what it does”. This cross-topic analysis validated this idea by highlighting “the importance of implementation – the how – across the outlier countries”.

The analysis identified three core factors for successful implementation: “The establishment of a national commission to address key priorities; the development of effective plans and actions for multisectoral stakeholders at all levels; and crafting policies that focus on priorities for marginalized communities or household decision-makers.”

These factors showed that both top-down and bottom-up approaches are vital for the widespread adoption of health policies.

Akseer said that while “a focus on community-level engagement emerged as a common driver of progress,” it remains a significant challenge due to variables like geography, dialect, culture, and others, reaching communities – especially in rural areas – can be a significant hurdle to establishing widespread adoption of high-level, national policies”.

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“The estimates for full coverage of vaccines, such as BCG (for tuberculosis), Diphtheria, Tetanus, Pertussis, polio, and measles vaccines, have steadily increased in Senegal from 2002 to 2007 and remained relatively constant from 2007 to 2019. For example, the third dose of Diphtheria, Tetanus, and Pertussis vaccine has increased from 52% to 93%, outperforming most other low-income and lower-middle-income countries,” said Dr. Sarr.

He said that this high and sustained routine immunization coverage was driven by the prioritization of vaccination programs, improved surveillance systems, a mature and reliable community health worker program, and tailored strategies for addressing geographical, social, and cultural barriers, leading to reduced rates of preventable diseases across the country.

“Another significant improvement is the introduction of new vaccines to reinforce the Reaching Every District/Reaching Every Child strategy. Between 2004 and 2018, Senegal introduced vaccines against hepatitis B, Haemophilus influenzae type b, pneumococcus, polio (inactivated vaccine), rotavirus, rubella, and yellow fever. Immunization was expanded beyond infancy with an additional dose of measles-rubella vaccine in the second year of life and human papillomavirus vaccination for young adolescents,” he said.

Next Steps

“We will continue collaborating with the Ministry of Health to align data-driven insights with programmatic priorities to achieve high vaccination coverage. Our focus will be on addressing challenges by reducing access-related barriers, enhancing facility readiness, and addressing mobility issues to ensure vaccines reach all communities,” said Dr. Sarr. “For instance, regions like Kedougou face vaccination coverage challenges, possibly linked to mobility issues and proximity to neighboring countries such as Guinea, where coverage rates appear lower.”

He said that addressing cross-border health dynamics and fostering collaboration with Ministries of Health in neighboring countries could be crucial to improving coverage in these areas.

“We aim to strengthen data-driven decision-making by improving collaboration between the public and private sectors. The private sector plays a vital role in Senegal’s Expanded Program on Immunization and overall vaccination efforts, but its contributions are not always fully reflected in vaccination coverage data,” he said. “In the Dakar region, for example, approximately 75% of health structures are private, providing vaccination and healthcare services to a significant portion of the population. To ensure more accurate coverage assessments, it’s critical to better integrate private sector data into national reporting systems.”

“The main takeaway is that we can see what works well in public health: strong political commitment, efficient data use, sustainable financing, effective stakeholder coordination, local and connected workforces, women and girls’ empowerment, widespread adoption of national policies, and equitable outreach,” said Dr. Akseer.

Studying Exemplar countries and identifying these common lessons means “stakeholders and leaders can learn about what approaches are having the biggest impact and adapt those approaches to their own settings”.

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