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Ebola’s lessons for Universal Health Coverage  by Mohga Kamal-Yanni, Senior health policy advisor, Oxfam

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”.

Community engagement.

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:

  • Enable CHWs to continue their role as the trusted front line workers for individuals and communities. CHWs must be an integral part of building resilient health systems;
  • Include other influential community actors – such as religious leaders, women’s groups, youth leaders and traditional healers – in outbreak control and response;
  • Make government and donor resources available to strengthen community linkages to district and national planning and implementation;
  • Implement accountability mechanisms to empower communities and civil society organisations to monitor funding for public health.

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:

  1. Adequate numbers of trained health workers, including CHWs. Oxfam calculated that training the missing 9,020 doctors and 37,059 nurses and midwives in Sierra Leone, Liberia, Guinea and neighbouring Guinea Bissau would costs $420m. Once they were trained, a total of $297m annually would be needed to pay their salaries for 10 years
  2. Low cost medical supplies (medicines, diagnostics and vaccines)
  3. Robust health information systems (HIS), including surveillance
  4. Adequate infrastructure of well-equipped health facilities, laboratories, and clean water and sanitation
  5. Adequate public financing. No country has achieved UHC without public funding. Governments should act immediately to increase their budget allocations to health. However, their ability to spend sufficient resources is blocked by an unfair global tax system that must be reformed. Donor countries must also increase their aid targeted to building country capacity in health and education
  6. A strong public sector to deliver equitable, quality service during both normal and outbreak times

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.

 

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