Ebola: the case for health system strengthening

Health workers celebrate an Ebola free Sierra Leone

Last Saturday, thousands took to the streets as Sierra Leone, a country seen as the greatest affected by the crisis, was declared free from Ebola, after it went 42 consecutive days without any new confirmed cases.

Whilst there is just reason to celebrate, it would be unwise for both the international community and the governments of Sierra Leone, Liberia and Guinea, to rest on their laurels. A report by the Overseas Development Institute (ODI) looks back at some of the systemic weaknesses that caused the disease to spread so virulently. Much of the blame has focused on the technical aspects of the response to crisis, with the World Health Organisation (WHO) blamed for not responding to the crisis early enough so that it could coordinate donors, NGOs and governments. However, the international community must look beyond simply the technical aspects in order to avoid missing an important chance to consolidate lessons learned. This catchphrase, popular among donors, must do more than simply explore how aid organisations and health agencies such as WHO, Save the Children and MSF respond during the midst of a crisis, but call for a systemic approach to build health systems so that developing nations are better equipped to deal with outbreaks.

The ODI’s report highlights that, while there has been success in tackling HIV/Aids and maternal mortality across the three West African countries, health systems in three of these countries remain heavily dependent on external aid. Much of this, the report goes on to explain, has been driven by a donor agenda which focuses on “target-oriented approaches and tangible impacts at the expense of a holistic vision of health systems in the round”. This approach has been seen as symptomatic of the MDG approach, where piecemeal strategies were used that did not build sustainable health systems. In a Chatham House report, it was highlighted that:

“The Ebola crisis has shown that weak systems make individual countries more vulnerable and that strong, resilient and equitable systems at country level are needed to protect global health security. There is a pressing need for enhanced global disease surveillance and detection capacity, as well as improved international coordination in responding to emerging health threats.”

It is clear that health systems must be (re)built, from top-down as well as bottom-up. Where government policies should seek to build health systems, clinics and hospitals (with, of course, the assistance of foreign aid which seeks to build the capacity as well as finance structures), civil society be supported by national and international actors. As seen clearly in the case of the eradication of polio in Nigeria, surveillance networks and community health workers and vaccination distributors were vital in reaching even the most remote, rural villages.

community workers vaccinate a Nigerian child against Polio using OPV methods. Such concerted efforts have been paramount in ensuring Nigeria has become Polio free

Much of the criticism about the failure of the WHO, which should have been the cheerleader for the fight against Ebola from the start, was its inability to recognise the potential severity of the Ebola outbreak and for not organising a carefully collaborated response. Neither the first recorded death from Ebola, a Guinean boy named Emile (given the unfortunate name of “Patient Zero” by international media outlets), nor the fact that confirmed cases amounted to 112 by 30 March 2014, was enough for the WHO to declare the crisis as an emergency. By the 8 August 2014, the WHO only started to declare Ebola as “a public health emergency of international concern”. And even then it took until the middle of August for the United Nations to issue Council Resolution 2177, which launched a sudden call to action from global leaders and the international humanitarian community.

From the start, the humanitarian response was ordered from a top-down perspective and failed to truly mobilise a localised response. Community-based health workers can be the “messengers” and advocates for shaping public perception about aid intervention, and the first port-of-call in any crisis. The much needed armies of community health workers in every rural village, town and city were simply not at the level, in numbers or capacity, as those in Nigeria. This in turn shaped public opinion, creating a mistrust of aid workers and international interventions targeted at tackling Ebola.

The three countries, which neither had the infrastructure or community mobilisation as its regional neighbour, Nigeria, therefore found it difficult to contain the outbreak of the disease. Indeed, the WHO applauded former Nigerian President, Goodluck Jonathan, for his steadfast enthusiasm as a partner in implementing vital polio surveillance systems and community response mobilisation strategies that helped defeat Ebola so impresively:

“Nigeria has been running one of the world’s most innovative polio eradication campaigns, using the very latest satellite-based cutting-edge GPS technologies to ensure that no child misses out on polio vaccination.
When the first Ebola case was confirmed in July, health officials immediately repurposed polio technologies and infrastructures to conduct Ebola case-finding and contact-tracing. Nigeria has been running one of the world’s most innovative polio eradication campaigns, using the very latest satellite-based cutting-edge GPS technologies to ensure that no child misses out on polio vaccination.

By the 20th October, a mere three months into the crisis, Nigeria was declared Ebola free. The comparisons between the countries could not be more stark. Part of the issue is, of course, that a commonality between Sierra Leone, Guinea and Liberia, is that at the start of the MDGs, all three were emerging from brutal, internecine and interlinked civil wars, which further plunged the capacity of health systems to deal with crisis. What some may argue compounded this was the drive from international donors, led by the IMF, to focus on market-based solutions and painful structural adjustment loans to state building, rather than focusing on building the bureaucracies and systems needed to strengthen health systems. The infographics below go some way to illustrate how the preference for piecemeal, market-based solutions to tackling health crises, have failed the three affected countries miserably:

Source: ODI (2015)

Theoretically there is simply no incentive for the private sector to invest in comprehensive, systems-based healthcare that is available more widely. For-profit healthcare providers neither see the profit in upscaling healthcare coverage or form specialism rooted in components of overall healthcare coverage.

There is much hope that the SDGs will attempt at building health systems that benefit all, are resilient, universally accessible and of a decent quality to build some of the surveillance networks and implement some of the coordinated strategies as we have not only seen in Nigeria, but in other countries such as Nepal where children are vaccinated against 90% of diseases. There will be those who say it cannot be done in fragile states — Nepal has faced constitutional crisis and power struggles for over a decade without this being resolved, as well as the recent earthquake, while Nigeria has faced internal pressures, such as tackling Boko Haram or violence between Christians and Muslims. Questions of feasibility of course should be asked, but building health systems must be seen as a necessity for tackling the biggest health-related problems highlighted by the SDGs: the “silent crisis” of malnutrition, finally eradicating polio and tackling TB and HIV/AIDS, among others. For example, the dream of leaving no child behind, cannot be truly reached without sustainable health systems.

DfID’s current policy towards tendering to the private sector for healthcare provision certainly does not help to build these systems. Most noticeably, its £35 million investment into HANSHEP (Harnessing Non-State Actors for Better Health for the Poor), which champions private sector involvement in health in the Global South, supports this fact. Much of this is formed from some of the undeniable successes of the MDGs in reaching health-related indicators. Despite criticism of the piecemeal approaches of the MDGs, there have been notable successes in improving health indicators, such as the reduction of maternal mortality rates by 45% worldwide, the near eradication of polio (which, in truth goes back to the foundation of the Global Polio Eradication Initiative in 1988, but whose cause was furthered by global partnerships over the last 15 years) and the reduction of new HIV/AIDS cases by 40% since 2000.

These are among a few of the achievements which should be celebrated, but if the international community is to truly, sustainably improve health indicators it must prioritise the building of health systems to overcome such challenges.