The Ebola outbreak has shocked the entire world of global health. Even while Ebola lingers in West Africa the future of health security and the organisation of health systems are being debated.
There have been many conferences held and reports published to provide “lessons learned from the Ebola crisis. A thread running through all of these events has been an agreement on the need to build resilient health systems. Yet building such a system requires planning, investment and serious long term commitment. Short term investment does not produce the necessary workforce needed for a functioning health system. Dhillon and Yates identified 5 key areas that require immediate attention in order to rebuild health systems: community based systems; access to generic medicines; restoring preventive measures; integrating surveillance into health systems and strengthening management.
An Oxfam paper identifies six critical foundations for resilient health systems. I can visualise these foundations as a chair with 4 legs. If you keep one leg short and invest in another leg, the balance is tipped and the chair falls. Meantime if you ignore the base or the back of the chair, it moves from the seating area to the recycling bin!
An adequate number of trained health workers, including non-clinical staff and Community Health Workers (CHWs)
The urgency of allocating resources over a ten year period cannot be better expressed than by Bernadette Samura, a health worker from Pamaronkoh, Sierra Leone:
“Because many nurses have died, it is time for the government now to train more nurses’.
Based on the WHO’s minimum standards of 2.3 doctors, nurses and midwives /10,000 people, Oxfam calculated the gap in these workers and the cost of training and paying them. Liberia, Sierra Leone, Guinea and Guinea-Bissau require $420m to train 9,020 medical doctors and 37,059 nurses and midwives. Once they were trained, a total of $297m annually would be needed to pay their salaries for 10 years. It is worth remembering that at the height of the outbreak, all humanitarian agencies were desperately seeking program managers, logisticians, financial officers, epidemiologists, community mobilizers, and others in addition to clinical staff. Yet these cadres hardly feature in global talks or statistics about the necessary composition of an adequate health workforce.
The lack of vaccines and medicines for Ebola shone a spotlight on the failure of the global research and development (R&D) system. The current system relies on monopoly created by intellectual property rules which leads to pharmaceutical companies conducting R&D in diseases that are expected to produce high profits. In order to get the balance in favour of public health, the public sector has to have a hold over sitting the health priorities and financing of R&D.
The Ebola outbreak highlighted the critical role of HIS in disease control. However, surveillance, which is now being highlighted as critical to disease control, needs to be an integral (not parallel) part of HIS and the overall health system. Epidemiologists alone will not be able to produce useful and reliable data. Effective surveillance requires doctors and nurses to diagnose the diseases, and community workers who gain community trust to report cases. All these workers are needed to act appropriately in their respective roles to prevent the spread of and treat those affected by these diseases.
There are 0.8 hospital beds per 10,000 people in Liberia and 0.3 in Guinea compared to an average of 50 beds in OECD Countries. Scaling up the number of well-equipped health posts and district hospitals, especially in underserved areas, is critical not only to address health needs but also to build community trust in health systems.
Countries’ experience clearly indicates that long term sustainable, reliable and equitable financing has to be based on public financing. The annual funding gap that must be covered in order to achieve universal primary health care is approximately $419m for Sierra Leone, $279m for Liberia, $882m for Guinea and $132m for Guinea-Bissau. Although the sums specified are large it is possible to raise the necessary resources by relying on various forms of tax funding, innovative financing and donors’ support. For example, in 2012, tax incentives awarded to six foreign companies in Sierra Leone were estimated to be worth eight times the national health budget.
Evidence shows that countries that achieved or made progress to achieve UHC relied on a strong public sector. Relying on private provision risks creating a two tier system, whereby poor people pay for a dubious quality of service from drug peddlers and others, while wealthy people enjoy the services of 5-star hospitals.
Building resilient systems that protect people’s health and deal with outbreaks has to address all the six elements of the system simultaneously and systematically. Achieving better health outcomes for all and protecting the world from emerging diseases requires a long term global commitment for building health systems. This must start now.
Organisation for Economic Co-operation and Development
Calculated from the estimated figure to reach UHC (the agreed $86/person per year multiplied by the population number) and the current public spending on health
This Saturday is world Universal Health Coverage (UHC) Day. The UHC day comes after a year of the international community being busy in producing numerous reports on learning from the Ebola crisis. Most of the learning from these documents has focused on mechanisms for effective global response to outbreaks.
However, more attention should be directed to learning from the role of local institutions in tackling the Ebola outbreak including how critically needed advances towards UHC can be achieved. Two key ingredients for effective epidemic prevention and response require particular focus: community engagement and health systems strengthening.
The WHO interim panel’s report on Ebola recognised that “Risk assessment was complicated by factors such as weak health systems, poor surveillance, little early awareness of population mobility, spread of the virus in urban areas, poor public messaging, lack of community engagement, hiding of cases, and continuing unsafe (e.g. burial) practices”.
As late as October 2014, 2 months after the WHO announced the Ebola outbreak as a “Public Health Emergency of International Concern”, donors were unwilling to fund large-scale social mobilization activities designed to facilitate community prevention work and treatment-seeking behaviour. There was little real understanding of community realities, beliefs and practices, or the different roles of community women and men.
Things only changed when it became clear that community engagement through trained local community health workers (CHWs) was critical for the success of the work of the treatment centres. Such work was essential for contact tracing and for encouraging people to report fevers. It also helped to change decades of unsafe burial customs that were critical for halting the spread of Ebola.
As Ebola is becoming under control it is essential that the work of building trust between communities and the authorities continues. Therefore, global and national strategies to deal with health crises must:
Resilient Health Systems
My biggest fear is that the health sector is not improved.
George Caulae, New Kru Town, Liberia, February 2015
Resilient health systems are a global public good that requires long-term commitment from national governments and international donors in order to provide universal health coverage that is free at the point of use and to respond to disease outbreaks.
The Ebola outbreak was a magnifying glass that revealed chronic under-investment in public health services. Health systems collapsed under the pressure of Ebola. Many health centres closed and people had nowhere safe to seek medical care. Maternal services came to a standstill. As a result there has been more maternal and child deaths than before Ebola.
Since then there has been a strong emphasis on developing disease surveillance and laboratory capacity. Yet for these functions to work all elements of health systems need to be built simultaneously. Resilient systems require six essential elements:
For the countries that suffered from Ebola, external funding is urgently needed. Last July (2015), donors’ pledges to the recovery efforts of the three affected countries reached US $ 5 billion. However, it is not clear what funds have been disbursed to date and what programmes will be financed. Therefore, it is critical that governments, with donors’ support, implement mechanisms for clear accountability and transparency including community and civil society participation in monitoring programme funding.
Even before the devastating Ebola epidemic in West Africa, development agencies were highlighting that health indicators in this region were lagging the rest of the continent. In a 2013 report UNICEF noted:
“West and Central Africa in particular requires a special focus for child survival, as it is lagging behind all other regions, including Eastern and Southern Africa, and has seen virtually no reduction in its annual number of child deaths since 1990.”
But as Ebola has overwhelmed some countries and threatened many others, questions are being asked about the role of international agencies in undermining health systems in West Africa. Specifically, fingers have been pointed at the 1980s structural adjustment policies of the World Bank and IMF for forcing poor African countries to cut public spending on health. These policies also shifted the financing burden of health services onto poor populations by charging them user fees. Interestingly at the time one of the leading critics of this policy was none other than the current President of the World Bank.
Other health policies promoted at the same time were also damaging to poor people’s access to health care. The Bamako Initiative (BI) launched in 1987, was prompted by UNICEF and WHO as community management of “revolving drug funds”. However, BI institutionalized user fees for essential medicines in some of the poorest countries in the world. Not surprisingly, with most households unable to pay these fees, utilization of health services in the countries concerned slumped, with the poor most likely not to seek care. In West Africa where the BI became established, typical utilization of curative services at the start of the millennium was around one visit per person every three years!
Thankfully a huge volume of research evidence over the last 20 years has conclusively proved the folly of this approach. User fees have been shown to be ineffective in raising health revenues, inefficient in incurring high administration costs and inequitable in excluding the poor. They have also resulted in outrageous human rights abuses where poor people (often women and babies) have been detained in hospitals because they can’t pay their bills. Sadly this practice continues to this day.
As a result of these findings many prominent aid agencies have radically changed their health financing policies, including the World Bank whose President has referred to user fees as “unnecessary and unjust”. Even one of the architects of the World Bank’s previous pro-user fees policy has publicly stated his change of position on user fees although he did not admit that it was a mistake then.
However, not all agencies have been so clear in making a break with the past. As recently as 2008 in its State of the World’s Children Report, UNICEF was still championing the Bamako Initiative and openly criticizing NGOs that were advocating the removal of user fees Indeed one of the countries singled out for praise in implementing the BI was Guinea, from where the current Ebola epidemic has spread
It is true that the international agencies involved in promoting the BI have gradually shifted their positions on health financing and are now rallying behind the goal of universal health coverage. However, the agencies that promoted the BI need to acknowledge their past mistakes rather than assuming that the Bamako Initiative never happened.
This is problematic because whereas other development agencies are aware of the changing consensus on health financing, this may not be the case in many countries. Some governments are still laboring under the illusion that the BI is working and thus user fees policies are still implemented. Thankfully, some countries in the region are now replacing user fees with public financing, for at least some of the population, most notably in Liberia, Ghana, Senegal, Niger and Sierra Leone. The latter’s free health services initiative for pregnant women and children under 5 has been a particularly good example of the impact of removing user fees.
However in West and Central Africa, out-of-pocket payments including user fees remain by far the biggest health financing mechanism. With the Ebola virus not beaten yet in the region, the lack of effective healthcare coverage doesn’t only threaten the health of the population in the region but also poses a threat to global health too.
Therefore, as the international community begins to support countries in West Africa to develop more resilient health systems, there is one immediate action they should take as a top priority. This action would cost practically nothing but its impact could be profound in helping put countries on a path towards equitable universal health coverage. After a twenty-eight year failed experiment, it’s time that agencies including UNICEF and WHO formally and publicly end the Bamako Initiative.
 UNICEF 2013 Committing to Child Survival, a Promise Renewed, Progress Report 2013 Available at: http://www.unicef.org/publications/files/APR_Progress_Report_2013_9_Sept_2013.pdf
 IDS Practice Paper in Brief 2015 Ebola and Lessons for Development Available at: http://opendocs.ids.ac.uk/opendocs/bitstream/handle/123456789/5849/ID557%20Online.pdf
 Kim JY et al editors 2000 Dying for Growth Global Inequality and the Health of the Poor. Common Courage Pres
 UNICEF 2009 Maternal and Child Health the Social Protection Dividend: West and Central Africa
 Yates R 2009 Universal Health Care and the Removal of User Fees The Lancet 373: 2078–81 Available at http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)60258-0.pdf
 Kippenberg J Burundi A High Price to Pay Detention of Poor Patients in Hospitals 2006 Human Rights Watch Volume 18 No 8(A) New York, USA
 See https://www.youtube.com/watch?v=RNfzXh4I-Pw
 Kim JK Poverty Health and the Human Future [Speech] World Health Assembly, Geneva, Switzerland 21 May 2013 Available from: http://www.worldbank.org/en/news/speech/2013/05/21/world-bank-group-president-jim-yong-kim-speech-at-world-health-assembly
 Boseley S (2012) From user fees to universal healthcare – a 30-year journey. The Guardian
 UNICEF 2008 State of the World’s Children: Child Survival available at: http://www.unicef.org/sowc08/docs/sowc08.pdf
When the Ebola crisis eventually begins to diminish, and the journalists and camera crews withdraw, public interest fades and political pressure on leaders subsides, the people of Sierra Leone, Liberia and Guinea will be left to rebuild their lives, their communities and their countries. Understanding the problems that led to the escalation of the Ebola crisis is essential in order for these countries to emerge safely from it and to prevent another crisis in the future.
The ability of a country to contain an outbreak of an infectious disease like Ebola is largely dependent on the strength of its healthcare system and on having enough staff working within it to cope with the crisis. Clearly the healthcare systems in the affected countries were too weak to control the outbreak. For example, Sierra Leone had 119 doctors serving a population of nearly six million people. This meant that for every 50,000 people in Sierra Leone, there was one doctor compared to a 100 in the UK. That ratio in Sierra Leone falls well below the WHO’s recommended minimum of at least 23 doctors, nurses and midwives per 10,000 of the population.
In Liberia and Guinea, the shortage of healthcare workers is even worse. In these countries, there is only one doctor for every 100,000 people. In addition to the severe shortage of health workers, there are also problems in terms of the number of health facilities accessible to citizens and insufficient medical supplies. For example, in Liberia, there are only 3,352 hospital beds for a population of nearly 4.5 million. Guinea has a similar number of beds (3,435) for a population of nearly 11.5 million. It is hardly surprising then that these countries have struggled to contain the Ebola virus.
Inequality and the rich country drain on health workers
The health worker shortage in Africa is a stark example of global inequality. According to WHO research, Africa has the highest burden of disease of any continent, but has only 3% of the world’s health workers, and less than 1% of the world’s financial resources. While the continent continues to grapple with infectious diseases, such as HIV, malaria, cholera, tuberculosis and child pneumonia, as well as problems with maternal health, there has also been a rise in noncommunicable diseases. But the number of health workers to respond to these challenges remains remarkably few.
In order to address the unequal distribution of healthcare workers, we need to understand the labour market dynamics that affect the training, recruitment, deployment and performance of global and local health workforces. There is a global shortage of healthcare workers, affecting high-, middle-, and low-income countries, from the USA and Germany to India and Uganda. The difference between high-income countries and low- and middle-income countries lies in their ability to address these health workforce shortages, and to invest in the recruitment and training of medical staff and managers. Too often, richer countries simply recruit staff from poorer ones. It is estimated that 10% of Sierra Leone’s trained nurses are working in the UK health system.
There are many issues that lead health workers to seek employment outside their country of origin, including low salaries, inadequate health facilities and a lack of training and career development. Serious investment in these areas is needed in order to avoid the damage to local health services that is caused through the loss of healthcare workers. When significant numbers of doctors and nurses leave the countries that financed their education, there is a huge loss of public investment which makes it more difficult to deliver services and to offer education and training to people who wish to enter the health profession in the future. While workers should enjoy freedom of movement, mechanisms should be in place to support their retention, such as improving working conditions, and remuneration and career development. In Zambia, for example, healthcare workers receive an extra 25% recruitment and retention allowance on top of their basic salary, which has been effective in decreasing the migration of nurses.
Ensuring countries have the human resources tackle health crises
Wealthier nations are more able to make these kinds of investments, not only within their own borders, but internationally through providing aid and sharing expertise. A recent Global Forum on Human Resources for Health recommended that each country with severe healthcare personnel shortages should be supported to develop and implement a budgeted plan to strengthen its health workforce, as part of a broader national health strategy. This should include a special focus on the most poor and marginalised sections of society, as well as strategies to train skilled health workers and maximise their performance.
The Ebola crisis has undermined the economic progress that Sierra Leone, Liberia and Guinea were making, thereby limiting the ability of these governments to make much-needed investments in their public services. It has, however, also succeeded in focusing attention on the shockingly unequal distribution of healthcare workers, which stands in the way of achieving key public health priorities, such as reducing child mortality, improving maternal health, increasing vaccine coverage, and combating HIV/AIDS, malaria and other diseases.
The international community must invest in human resources for health for all. Health workers are the basis of a functioning healthcare system, which in turn helps to drive economic growth, save lives and improve the quality of life for millions of people around the world.
In 2001, I stood in the UN building in front of a huge picture of a woman dying with somebody next to her holding her hand. The writing under the poster read: “you mustn’t die alone”. I wanted to shout: “she mustn’t die full stop”. At that time the new antiretroviral medicines had started to work miracles, bringing people from their deathbeds back to life. Yet as a Ugandan doctor truly said: ‘the medicine is in the North but the disease is in the South’. The pharmaceutical industry was happy to sell the medicines at very high prices in rich countries while turning a blind eye to the rest of the world.
It was largely thanks to a huge global mobilisation of civil society led by people living with HIV that leaders and pharmaceutical companies started to feel embarrassed about denying access to life-saving medicines to millions of people. But it was only after generic competition kicked in that access to medicines became something policymakers talked about. An offer by an Indian company to sell a cocktail of the three basic medicines for one dollar a day slashed the prices of antiretrovirals, meaning that today over 9 million people are on treatment,, including over 7 million in Africa.
Generic competition was possible because India had not at that time implemented the Trade Related Aspects on Intellectual Property Rights (TRIPS) and thus was able to manufacture the medicines. Since adopting TRIPS, India’s ability to produce medicines has been limited. Yet the country has been under immense pressure from multinational pharmaceutical companies, the US and the EU to tighten its IP rules even further and thus to limit access to medicines to those who need them.
It seems that the world is obsessed by granting more and more monopoly power to pharmaceutical companies rather than by investment in research and development (R&D) for medicines and vaccines that are needed for public health.
For this reason Ebola is the other side of the coin to HIV as the intellectual property rights system allows the market to shape R&D priorities, rather than public health needs. That same system allows companies to charge high prices that are unaffordable in developing countries as the HIV crisis taught us.
The fear of Ebola crossing borders and affecting people in the US and Europe has changed the situation – clearly there is now a market for travelers, but more importantly the threat of a global epidemic means that donors may be willing to pay for products that contain the spread of Ebola and other hemorrhagic fevers.
The most promising vaccines that are now being rushed through clinical trials have been developed with public money, mainly from the governments of the US, Canada and the UK.
It is not ethical, sustainable nor safe to leave commercial interests decisions and financing for R&D for products, capable of modifying global health threats, to be dictated by the commercial interests of pharmaceutical companies.
Governments, under pressure from multinational companies, have agreed to a profit -based system (TRIPS) instead of looking for more innovative ways of financing R&D.
Throughout the history of medicine’s development, public funding has played an essential role in developing breakthrough medicines, including for the treatment of HIV and now prevention of Ebola. We need to change the present monopoly ownership system to allow public funds their proper place in stimulating accessible and affordable technologies that make our world a safer and more humane place.