Justice Nonvignon: Head of Africa CDC’s Health Economics Unit speaks on ways forward for decolonizing global health
The Spotlight Series is an interview-based profile series by McGill Global Health Perspectives. The series focuses on researchers and practitioners in global health outside of high-income country settings (and) or representing marginalized groups. For our third Spotlight profile, we are featuring Head of the Health Economics Unit of Africa Centers for Disease Control and Prevention (CDC), Associate Professor Justice Nonvignon from the University of Ghana.
Dr. Justice Nonvignon, who grew up in Ghana, completed his studies in Ghana and Tanzania. He is a leading health economics researcher in Ghana focusing on economic and impact evaluation of health programs with experience of over 12 years in health economics. Justice recently took on the additional responsibility as the head of the Health Economics Unit at the Africa CDC.
Can you tell us about your journey in global health? How did you get involved, what was your path like?
My journey in global health or what eventually became the field of global health started as an undergraduate economics student and through my undergraduate project at the University of Cape Coast – Ghana. At the time, around 2003, Ghana introduced legislation for the health insurance scheme, and I became interested in this new national health insurance scheme. So, my undergraduate project used primary interviews to examine people’s willingness to join the health insurance scheme. Then, as a graduate student completing my master’s in economics at the University of Dar es Salaam in Tanzania, I wanted to do something related to health. So, I focused more on health economics coursework and completed my thesis within my master’s.
Health economics was interesting to me because I had an interest in applied economics. Fast forward a couple of years, my Ph.D. at the University of Ghana - Legon took me into public health. Since then, I've stuck with public health.
As we know your interdisciplinary approach has significant value. So how do you use your interdisciplinary training now?
I am an associate professor of health economics and policy at the School of Public Health at the University of Ghana in Accra. I've been in this teaching and research post for the last 12 years. However, I am taking on another role as the head of the health economics unit of the Africa Center for Disease Control (CDC). In academia, of course, there are so many commitments and demands, committees you chair or sit on, but these are the two main things for me currently, that take most of my focus.
That is exciting news about your new position as the head of health economics at the Africa CDC. Really well-deserved and Congratulations! Could you also speak more to your research focus?
My main focus is economic and impact evaluation of health programs. I started off assessing malaria interventions. One of the projects I'm currently working on is evaluating the cost-effectiveness of Seasonal Malaria Chemoprevention (SMC) in West Africa. Asking the question: “what are the true economic costs versus the health impacts of implementing this intervention?” I also apply economic evaluations to vaccines. I've done a lot of work around rotavirus vaccines, HPV, and now COVID-19 vaccines. Now I spend a lot of time looking at health technology assessments (HTA). Generally, how should countries be setting priorities to inform investment decisions, strengthening country level capacity for incorporating HTA into priority setting, to address efficiency issues.
If we are to expand a bit, can you say more about specifically how the field of public health research has progressed in Ghana?
A lot has changed, and I'm not too old. I joined not too long ago, but I see that a lot has changed. Particularly the number in grants, the funding amounts they get in public health, and the scope of public health research have increased. There is also the issue of global north and global south relationships. Things have changed on this front as well. I see more collaboration now, not only within the country but also between countries. There are some great Ghanaian researchers who are doing great inter-country collaborations.
Even the relationship between policymakers and public health researchers has really improved. A few years ago, I was mainly invited by a donor as a consultant to conduct an economic evaluation of a national program. There were very few requests from the ministry, or from partner agencies to do that. But this has changed. Now, people in the Ministry set up committees and recognize the need for health economists. They know they need health economists. That policy/research relationship is better now. My first grant was titled something like "Research Papers Gathering Dust," and it was meant to explore to what extent health research was used in the revision of the health insurance Act in Ghana. It turned out that most of the academic research that me and my colleagues were doing did not really end up anywhere. Now when I am setting research questions, I can call someone in policy and ask what areas I should look at. This enhances the research-policy link. It's not perfect, and we could improve it.
A lot has changed for the better, but there is also a lot more to do to make it better than it is now.
Maybe you can paint a picture for us of what it was like before in the field of public health research in Ghana - so that we can compare?
When I joined the university some 12 years ago, there were not many young people in public health research. That is because remuneration was low, which did not entice many young people to take positions. Older generations have their own ways of doing things. As time went on, there were more young people coming in, people who were completing PhDs elsewhere and wanting to take faculty positions here. This created much more collaboration among faculty members. The current generation is more collaborative, people see public health as a collaborative field.
Also, not many people would have welcomed interdisciplinary researchers like me, an economist. They would ask: “what are you doing in public health?” Public health was seen as a field for clinicians, epidemiologists, others, not for people with a social science or economics background, but this has changed for the better. Now you see physicians wanting to study health economics, because the need for a multidisciplinary approach to public health, beyond the clinical, beyond epidemiology, has become more apparent.
You mentioned that there is progress to made in public health in Ghana. What areas do you think could improve?
What we could also improve is strategic government funding of research in public and global health. Most governments do not put a lot of money into funding this research. We, as global health researchers, are exposed to all these problems which come with reliance on donor assistance. If we could make a conscious effort where the government (not donors) invest in research, we will be better off.
You mentioned you were working on Covid-19 vaccinations. What is the status of the COVID-19 vaccine landscape in Ghana?
As the head of the health economics unit of the Africa CDC, I've seen a lot of work around the COVID-19 vaccine, specifically around equity. In fact, the CDC has been leading work around policy regarding vaccine rollouts in multiple countries. There is still quite a bit we need to know, and this comes with funding for research. Specifically, we need to know about the delivery costs of this vaccine, and how information on the budget impact and cost-effectiveness informs government decision making around which vaccines to purchase, optimal delivery approaches, age groups to prioritize, and so on. Last December (2021), I was interviewed by CNN on mandatory vaccinations for travelers. This is related to Omicron and the countries that have taken extreme measures and imposed restrictions on specific countries. These are measures we need to assess; there is no better time than now. We knew this all along, but COVID-19 has really exposed that economics and health are inherently interlinked. You cannot tackle one without impacting the other. We need to put more effort into understanding what motivates policymakers to make the decisions that they make, and the implications of these on resource allocation for other diseases to ensure no one is left behind.
As it is a key challenge, can you say more about how is COVID-19 inequity is impacting the country and region?
In some WHO regions, vaccine uptake is around 30-40% or more. In the African region, as of December 2021, was less than 10%. Less than 10% of people are fully vaccinated. This clearly raises equity issues. Countries that are more readily able to get vaccines are more vaccinated. The world has pushed the COVAX mechanism, but there are issues. There are issues with financing COVAX, but there are also issues with the way the world is approaching this problem. Now, the world has called upon High Income Country (HIC) leaders to make a commitment, and now they are donating. My issue is that when a donation comes, even if through COVAX, you will have the flag of the donating country on the doses. Canada donates one million doses to Ghana; the donation comes draped in the flag of Canada. Also, the donation fulfillment remains slow and COVAX needs more support. I think the world can do better. I think that people should see this as a responsibility – not as advertising support. It's also not about people begging to receive donations, it’s about you wanting to help your own people, to ensure all of us, as a global community can heave a sigh of relief from this pandemic.
What are ways to improve equity, in relation to COVID-19 and within global health efforts?
There is so much we need to focus on. Research equity, for example. I've followed the movement to decolonize global health, but even within this movement, there are ways that people perpetuate colonization. How do we address this problem? I think we need to take it personally! I think there is too much talk and very little action. We need to see this as a moral duty, as a personal responsibility, and actually take action to ensure within our own collaborations with the so-called ' Global South' to not do things that create an impression of exercising power over others. I believe in movements, but I don't think movements alone bring solutions. Action does. We need to move beyond movements towards real action.
We need to increase transparency. Researchers in low-income countries might not have any idea how much a grant is awarded for, they will only know the amount earmarked for them. Authorship too, I was reviewing a paper about a low- and middle-income country (LMIC) and no authors were from that country or region. Now, HIC researchers are reaching out to people from LMICs to solve this problem, but often you don't get to contribute to the work. There are instances were researchers from LMICs are brought on board as an exercise to fulfil all righteousness. We want our intellectual contribution to be seen and acknowledged, not for our names to be put on papers for appearance’s sake. These are ways to back up the talk on decolonization and move the field of global health forward as a global collective.
Justice Nonvignon Tweets at @justice_nonvignon
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This is a collective effort of the McGill Global Health Perspectives Team. Madelyn Clark and Shashika Bandara led the interviewing and the writing for this conversation with Justice Nonvignon.