Ebola makes the definitive case for health workers and strong health systems

This blog was originally published by Global Health TV on Nov. 25, 2014.

Since I first wrote about Ebola here at Global Health TV two months ago, the number of Ebola deaths has more than doubled, to 5,459, and the number infected has reached 15,351, according to the World Health Organization. Ebola has caused countless angst and affliction, mostly in West Africa but also in Spain and the U.S.

But there is one good thing that Ebola has done: It has made the case for strengthening health systems and frontline health workers more effectively than we in global health have been able to do. It has shown that weaknesses in health systems in poorer countries can affect people in richer countries. It has made that case not only to the global health community, but to the entire world.

“Weaknesses in West Africa’s health systems do not affect just West Africa – they affect us all,” said Pape Gaye, president and CEO of IntraHealth International, in testimony to the U.S. Senate Appropriations Committee on Nov. 12. “Ebola, HIV and other viruses and infectious diseases do not respect borders. Globally, our countries’ health systems are interconnected, creating one global interdependent health system. Today, that system is woefully precarious.”

In his keynote address to the annual conference of the American Society for Tropical Medicine and Hygiene on Nov. 2, Bill Gates presented lessons we have learned about Ebola. In his opinion, the first and most basic lesson is: “We really should be investing in the primary health care systems of all countries, and in Africa in particular. When those systems are weak, it means our ability to understand what is happening and our capacity to respond is likewise weak.“

In the last five years, I’ve seen an increasing number of organizations — like IntraHealth International, AMREF USA, PSI and the Frontline Health Workers Coalition — do a great job of making this case. But little progress has been made in the places that need it most, like the countries most afflicted with Ebola, and it has not had much of an impact outside of the global health community. Ebola has changed that.

Blame is often leveled at donors who have tended to focus their health assistance on specific diseases like HIV, malaria and tuberculosis. Countries with high levels of these diseases, especially HIV, tended to attract greater support for their health systems, and this benefit often went beyond HIV/AIDS.

But countries with low rates of HIV, like most of West Africa, missed out on this health investment bonanza over the last decade, reported Guardian Health Editor Sarah Boseley. No such investment took place in Guinea, Liberia and Sierra Leone.

One hopes that this thinking is now starting to change as the Ebola crisis has exposed the fragility of health systems in developing countries and how this can threaten developed countries’ health.

The Frontline Health Workers Coalition is exploiting this new opportunity by presenting its recommendations to the U.S. Senate Appropriations Committee. “The Ebola virus disease epidemic in West Africa has highlighted the urgent need for increased support for frontline health workers and the systems that support them in the region and around the world,” begins the written testimony submitted on Nov. 12.

The Coalition believes it is no coincidence that the three countries primarily affected by Ebola have some of the lowest numbers of health workers per capita in the world – “less than three doctors, nurses or midwives per every 10,000 people before the Ebola epidemic even took hold, far less than the 22.8 per 10,000 ratio recommended by the World Health Organization to deliver basis health services.”

Others are also saying that more can be done.

“The United States can and should do more,” writes global health writer Nellie Bristol in the blog of the Center for Strategic and International Studies Global Health Policy Center. “These are not glamorous activities, and they have long been a difficult sell to Congress. They are hard to explain and quantify and lawmakers are under constant pressure to justify foreign aid to a deeply skeptical public. But the Ebola outbreak provides a glaring example of the need … Congress can act to send a strong message that health aid can be used more broadly and with a focus on long term results.”

Pape Gaye of IntraHealth has pointed out that the U.S. Agency for International Development already funds several projects to strengthen health systems but could do more, such as stipulate that a small portion of all its projects be invested in health systems strengthening.

Ethiopian Foreign Minister (and former Health Minister) Tedros Adhanom Ghebreyesus sees Ebola as an opportunity to build the primary health care systems. “Ebola could be prevented through simple disease prevention activities,” he told Devex in this interview. “Strong primary health systems are long overdue … If you have that kind of system, any outbreak can be detected easily and contained and information can flow through the system.”

Richard G. Marlink, a professor at the Harvard School of Public Health and head of Harvard’s AIDS Initiative, writes in the Global Post that we need to take an approach similar to the President’s Emergency Plan for AIDS Relief (PEPFAR) to build strong health care systems in the poorest countries of Africa.

“What’s needed now is a PEPFAR for African health at large, moving beyond the single-disease focus that is a hallmark of crisis management,” he wrote.

Ebola is a tragedy but it could be transformed into a strategy for building strong health systems and health workers that will be essential for dealing effectively with the next global health crisis that will surely come.