A lot has been written about the Ebola crisis in West Africa in the last few weeks. Many excellent articles have highlighted the plight of those suffering with Ebola (Newsweek), and the people on the frontline trying to tackle the virus (Time) and the consequences on the affected countries as a whole (How we made it in Africa). However, the real tragedy is how an inherently preventable virus was able to spread like wildfire throughout West Africa and why public health facilities failed on such an enormous scale.
I first heard about Ebola in March 2013, four months after the first patient died of the virus in a small village in south-eastern Guinea, the first ever in West Africa.
With the death toll rising across the border in Guinea, discussions in Monrovia turned to the threat of it reaching the capital: “no previous outbreak has killed more than 300 people”, “it is easy to avoid just don’t go near sick people and you are safe”, and “the disease kills people so quickly it will die out before it reaches Monrovia”. The general message was “it is scary, but we can control it with basic public health.”
Despite these reassurances, everyday you check the news: how many infected? How many died? How many health clinics were beginning to shut due to healthcare workers leaving their posts? Despite the growing chaos, we in Monrovia continued to rationalize the situation. We knew things were getting worse but we didn’t act in time.
So when did it get “out of control”? Was it when MSF declared it to be so in June? Was it when the virus hit Conakry, Freetown and Monrovia, making control of the disease in crowded urban environment increasingly hard? Perhaps it was when the Liberian-American Ministry of Finance consultant died after flying to Lagos, inadvertently putting a planeload of passengers and Africa’s most populous country at risk.
Whenever it was, there is no question that we are now in the middle of an unprecedented crisis. Every day, I dread reading the news. The front page of every newspaper is full of articles discussing the bleak picture of Liberia’s largest slum quarantined like something out of a science fiction novel. I read about the almost complete collapse of the government’s health care facilities and the justifiable fear of the healthcare workers too scared to go to work. We hear terrifying stories of suspected cases being turned away from treatment centres because there is no space to treat them, and bodies left on the street for days without someone coming to pick them up. Most of all, I fear for the secondary threats should countries follow through on plans to impose economic embargoes on the country.
Already five airlines have stopped flying to Liberia through fear of the disease. Earlier reports that West African ports have refused entry to vessels which have docked in Liberia appear false, but raise an alarming prospect of the country cut off from essential imports. This is dangerous given that Liberia is completely dependent on imports with an import bill equal to 60 percent of GDP including two of the most important commodities, fuel and rice. Even without an economic blockade importers are worried.
Early reports suggest for the last four weeks the number of import certificates are down 30 percent from the previous year. Not to mention, the travel restrictions inside the country making movement of agricultural goods from farm to market next to impossible. These developments will raise the price of essential goods necessary for the Liberian economy to function and will harm the very poorest. They also raise the possibility of riots on the street and a return to the days of anarchy last seen during Liberia’s bloody civil war.
So how did this happen? The underlying causes of this outbreak are many and difficult and will be discussed for years to come. Fundamentally, they focus on the fragility of West African states and the failure of emergency planning to tackle the crisis when it was at a manageable level.
What can we do about it? Despite the fear, there are many brave West Africans and foreigners continuing to fight this disease. The Ministry of Health is working to open new treatment centres, MSF continues to fight the battle on the front line and are managing patient care alongside national governments. The World Bank has promised USD200million to fight the disease in West Africa. The African Development Bank has promised USD210million to build West African public health facilities. The World Food Program has begun the process of bringing in food to tackle the secondary crisis. NGOs on the ground, including Oxfam, have begun gearing up awareness campaigns to get the message out that Ebola is preventable. These things are vital to the immediate fight and the world needs to react, and react fast.
Once the immediate crisis is brought under control, we must consider measures to strengthen the state institutions especially the health service in order to effectively deal with health threats in the region.
In a new report published today, Oxfam is warning that health insurance schemes introduced in the name of universal health coverage (UHC) are excluding the majority of people and leaving the poor behind.
While the new growing momentum for UHC is welcome there is a concern that the mistakes of history could be repeated. The optimism in 1978 following the Alma Ata ‘Health for All’ declaration was quickly replaced by disillusionment as influential donors failed to act on the shared vision of comprehensive universal primary health care. They financed low cost selective interventions instead. Today, a similar danger exists as we witness a wide range of ‘business as usual’ interventions being rebranded as ‘UHC’ despite them bearing little resemblance to the World Health Organisation’s UHC principles.
This is certainly the case for health financing. Our new report takes a critical look at the almost exclusive focus of some donors and low and middle income countries on contributory insurance schemes as the way to achieve UHC. Such schemes fail to provide coverage for the majority of citizens and serve to divert attention away from needed reforms to national and international tax systems that could raise significant additional revenues for health.
Voluntary insurance – private and community-based – has never worked to achieve UHC yet is still being widely promoted. India’s voluntary RSBY insurance scheme for people below the poverty line is widely praised as a success but offers limited financial protection and has skewed public resources to curative rather than preventative care.
For those who recognise the pitfalls of voluntary schemes, social health insurance (SHI) has emerged as the model of choice. SHI has worked to achieve UHC in a number of high-income countries, but attempts to replicate in poorer countries have proved unsuccessful. In practice SHI schemes usually start with the small number of easy-to-reach formally employed and then struggle to scale up beyond. Premiums are too expensive for most and schemes become de facto voluntary, leading to large scale exclusion. Ten year old national insurance schemes in Tanzania and Ghana cover only 17% and 36% of citizens respectively. Kenya’s National Hospital Insurance Fund – established nearly 50 years ago – today insures just 18 per cent of Kenyans.
Hopes that insurance contributions from those outside of formal employment would raise significant additional revenue have also not been realised. In Ghana, premiums paid by the informal sector contribute just five per cent towards the cost of the national scheme. Governments also face huge bills to cover the SHI contributions of their workers. The Government of Tanzania spent $33m on employer contributions in 2009/10; this equated to $83 per employee – six times more than it spent per person, per year on health for the general population.
Instead of importing inappropriate health financing models from high-income countries, our paper recommends that developing country governments look to learn from the increasing number of home-grown UHC success stories in other, more comparable countries.
The countries making most progress towards UHC agree that entitlement to health care should be based on citizenship and/or residency (not employment status or financial contribution) and while specific journeys differ, these countries fall into two broad camps. First there are examples of countries at all income levels, including Sri Lanka, Malaysia, and Brazil, which use tax revenues to fund UHC. A second option increasingly being adopted by another set of successful UHC countries, including Thailand, Mexico, and Kyrgyzstan, is to collect insurance premiums only from those in formal salaried employment, and to pool these where possible with tax revenues to finance health coverage for the entire population. According to WHO, only eight of 49 low-income countries will be in a position to fully finance UHC from domestic resources in 2015 so international aid will continue to play a crucial role.
The focus on health insurance seems to have served as a distraction for the international health community from the key ingredient for all UHC success stories – public financing. Rather than focus efforts on collecting contributions from people who are too poor to pay, governments and donors should look to reform national and international tax systems in order to generate significant and urgently needed revenue for health. Oxfam estimates that strengthening tax administration alone could raise an additional 31 per cent of tax revenue across 52 developing countries, amounting to $269bn in increased domestic resources. Enough to double health budgets in these countries.
The growing momentum for UHC is welcome, exciting, and challenging. However, if we are to heed World Bank President Jim Kim’s warning that UHC could easily become a ‘toothless slogan’, then UHC advocates must stand true to the WHO UHC principles to reduce out of pocket payments, introduce mandatory pre-payment, create large risk pools and scale up public financing to cover those who cannot afford to contribute. To these we add that entitlement to health coverage should be based on citizenship and/or residence, and that progress can only be considered progress if women and men living in poverty benefit at least as much as the better off at every step of the way towards UHC.
Oxfam’s report ‘Universal health coverage: why health insurance schemes are leaving the poor behind’ is available to download from www.oxfam.org/uhc
Anna Marriott is a Health Policy Advisor for Oxfam and editor of Global Health Check
There have been some surprised emails going around amongst some of my colleagues in the NGO and academic community about a recent news item posted on the World Bank website. The title is ‘Lao PDR: How Free Births are Saving Women’s Lives’.
The surprise comes not from the Lao PDR government’s decision to pilot free care – more and more countries are trying this. It rather comes from the World Bank’s apparent public celebration of this approach. While it is not a first – we have seen the World Bank highlight the effectiveness of free care in countries like Sri Lanka and Malaysia before now – it is very rare. It is also very welcome and will hopefully send a message to other governments that they have the opportunity to consider submitting requests for similar support from the Bank, as well as other donor agencies, as part of their efforts to scale up access to health care.
In an effort to accelerate poor progress on saving women’s lives the Lao PDR government is piloting free facility-based maternal deliveries in two districts – Nong and Thapanthong – as part of the Health Sector Improvement Project. The World Bank says it is supporting the project – a $15 million grant was issued in 2005 and this was extended with an additional $12.4 million in May of this year.
Further details on the pilot are not easy to find. The World Bank reports that ‘the impact of the pilot is currently being studied but preliminary results suggest a significant increase in childbirths in health facilities since services being provided are for free. As such, the mothers who delivered at health facilities were at much lower risk of fatal complications.’
Any further information would be very welcome and let’s hope this is a sign of things to come from the Bank.