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No health security without health systems by Mohga Kamal-Yanni, Senior Health Advisor, Oxfam GB

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!

A Graph showing the trend of healthcare utilisation in Province Orientale (Source: IRC position paper. www.rescue.org) image001

 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.

  1. Available medical supplies, including medicines, diagnostics and vaccines

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.

  1. Robust health information systems (HIS), including surveillance

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.

  1. An adequate number of well-equipped health facilities (infrastructure), including access to clean water and sanitation

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[1] 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.

  1. Adequate financing

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[2]. 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.

  1. A strong public sector to deliver equitable, quality service

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.

Footnotes

[1]Organisation for Economic Co-operation and Development

[2]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

 

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The race has begun to select the new WHO Director General By Mohga Kamal-Yanni

The WHO has announced that the election process for the new Director General (DG) is now open. The election comes at a critical time in the organisation’s history. WHO was criticised by many for failing to respond to Ebola sufficiently quickly, while the fact that Member States had de-prioritised WHO’s emergency work and cut WHO funding was not widely acknowledged.

WHO has been facing serious financial difficulties for more than 6 years. The crisis prompted Margaret Chan to launch a reform process in 2010.  Implied in the reform plan was a correction of the imbalance in the WHO budget whereby ear-marked project funds outweighed flexible core funding in a ratio of 80/20. Six years later and the financial imbalance has not improved. It is also not clear what different member states require from the reform. WHO is in danger of becoming a ‘pay-as-you-go’ service organisation, far from its constitutional mandate.

The results of underfunding its core budget are not only limited to decreased WHO ability to perform its functions, but it also threatens its independence. Countries rely on WHO’ guidance on the assumption that advice is independent from commercial and political interests and is based on science and evidence.

Previous elections lacked transparency and failed to allow public scrutiny of the process. The global health community did not know the “manifestos” of the candidates or how they would prioritise and deal with global health problems.

The prestigious medical journal The Lancet has attempted to fill the manifesto gap by inviting candidates to share their visions. The journal also did its own ranking of the candidates according to the key competences needed for the job.

In the new recruitment processes, the WHO has announced some changes aimed at enhancing transparency. These include a forum for Member States to interact with the candidates, and allowing the WHA to choose from three candidates – instead of simply approving one.

The new DG will have to face huge challenges in terms of the impact of years of financial stringency on core functions and on moral and mandate as well the difficulties facing the role of the WHO in the complex global health field. Given the critical importance of the DG role and the challenges he/she will face, we recommend that mechanisms be put in place to enable public scrutiny of the candidate’s vision for the WHO. In order to enable this public engagement we propose:

  1. Each candidate publicly presents his/her manifesto including:
  • Their vision for what WHO would look like at the end of his/her term
  • Their key priority reform issues
  • How they will secure WHO’s independence while enhancing its financing
  • How to prioritise work areas across the complexity of global health issues and the various requirements of member states
  • Their aspiring legacy
  1. Open public debates with stakeholders to discuss the candidates’ manifestos. This can be done as a webcast to allow participants from all countries with a moderator to organise the debate

As countries begin to nominate their candidates, the global health community is entitled to know where candidates stand on key health questions as well as on the fundamental challenges and issues facing the WHO.

 

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Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni