THE EBOLA OUTBREAK AND ITS AFTERMATHThe outbreak of the Ebola virus in West Africa has taken a heavy toll on people’s lives and the economies of the affected countries. Dr Matshidiso Moeti, WHO Regional Director for Africa, explains what international health organisations can do to improve health infrastructure in the affected countries and the way forward for Africa.
Health workers carry load the body of a woman that they suspect died from the Ebola virus, onto a truck in front of a makeshift shop in an area known as Clara Town in Monrovia, Liberia, Wednesday, Sept. 10, 2014. A surge in Ebola infections in Liberia is driving a spiraling outbreak in West Africa that is increasingly putting health workers at risk as they struggle to treat an overwhelming number of patients. A higher proportion of health workers has been infected in this outbreak than in any previous one. (AP Photo/Abbas Dulleh)
IntroductionSince the first cases of the Ebola Virus Disease (EVD) were reported from the town of Gueckedou in the Nzerekore Region of Guinea in March 2014, a cumulative total of over 23,250 EVD cases and 9,300 deaths have been reported as of 16 February 2015. The chronology of events is highlighted in the figure below.
In addition to Guinea, five other countries in West Africa namely – Liberia, Mali, Nigeria, Senegal and Sierra Leone — have been affected by the EVD epidemic. Unlike in previous EVD epidemics which affected mostly the rural areas of Central and East Africa, the current epidemic has spread to the densely populated urban areas of Guinea, Liberia and Sierra Leone resulting in rapid spread of the virus and disruption of normal urban life.
Furthermore, this epidemic, the largest of its kind, has escalated to unprecedented levels, affecting countries beyond the African continent namely, USA, Spain and the United Kingdom. The epidemic has caused disruptions in agriculture, education, trade and international travel mostly in Sierra Leone, Guinea and Liberia. Analyses by the World Bank Group, estimate that the economies of the three most affected countries namely Guinea, Liberia, and Sierra Leone, will lose at least US$1.6 billion in economic growth in 2015 as a result of the epidemic[i].
Impact of Ebola on health infrastructure and resourcesThe EVD outbreak in West Africa has worsened the already weak health systems and services that existed in these countries before the onset of the epidemic. For instance, the availability of human resource for health (HRH) in the three most-affected countries was below the African Region average. The EVD epidemic has worsened this situation as Health Care Workers have been disproportionately infected by the disease accounting for nearly 10 per cent of the total reported cases and deaths. This has also been compounded by the inequitable distribution of the available HRH, poor working conditions and low staff morale.
The availability and functionality of health infrastructure in the most affected countries was limited and inequitably distributed. Furthermore, the EVD diagnostic capacity, information and surveillance systems and community participation were suboptimal.
At the peak of the Ebola outbreak, a significant number of health workers were infected and this in turn resulted in most non-Ebola health facilities closing. This has led to disuse and lack of periodic maintenance of the health infrastructure. Significant funds will be required to re-establish the routine health services in the three most affected countries.
Potential Role of an African Centre for Disease ControlAt the African Union Special Summit on HIV and AIDS, TB and Malaria (ATM) in Abuja in July 2013, the Heads of State and Government took cognizance of the need for an African Centres for Disease Control and Prevention (African CDC) to serve as a strong platform for technical coordination. The role of the African CDC would be to conduct life-saving research on priority health problems in Africa and to serve as a platform to share knowledge and build capacity in responding to outbreaks, man-made and natural disasters and public health events of regional and international concern. Consequently the Assembly mandated the AU Commission to work out the modalities of establishing an African Centres for Disease Control and Prevention.
It is envisaged that had the African CDC been in place and the proposed coordination and implementation roles operational, it would have contributed to attainment of the necessary human resource surge capacity needed to effectively respond to the outbreak; provide diagnostic support to the affected countries; ensure timely sharing of information and data within the sub region and beyond as well as participating in the on-going trials on Ebola vaccines. Through its Collaborating Regional Centres Network, the African CDC would have also focused on other non-Ebola problems that hitherto have been forgotten as partners focus on responding to the Ebola outbreak.
How International Health Organisations can support in improving health systemsThe three most affected countries and indeed the entire West African sub-region will need substantial investment to rebuild agriculture, education, and trade alongside establishing resilient health systems given that catastrophic public health events may have effects far beyond the health sector.
Specifically in order to improve health infrastructure in the most affected Ebola countries in West Africa, international partners will need to first take stock of what infrastructure capacities existed before the epidemic and what the likely impact of Ebola has been.
Therefore in order to improve the health infrastructure, international health partners should focus on the following:
1.Investing in the restoration of priority basic health infrastructureThe restoration of priority basic health infrastructure will be key in ensuring that services such as maternal and child health programs in the three most affected countries are reactivated and avoidable deaths are prevented. The infrastructure that will need to be restored should be determined through a national assessment of the existing capacities as well as the type of basic health package that will be delivered to the population.
Restoration of health services could involve, among other things, the rehabilitation and construction of new health facilities including laboratories at the district level, and provision of the basic medical equipment and essential commodities necessary to provide the identified health care services.
To complement the above, the capacity of health workers at district and community levels to deliver the basic health services will need to be built. The competencies of these staff could be enhanced through capacity building and regular on-site supportive supervision. This should be based on the real training needs identified by the initial rapid assessments.
2.Expand preparedness infrastructure and capacity in the African countriesWhile supporting the affected countries to restore health infrastructure, it is also important to ensure that those unaffected countries in the African Region have the necessary infrastructure and capacity to effectively and timely respond to any future outbreaks.
These could include setting up emergency operation centres to ensure coordinated response to future outbreaks; setting up and equipping diagnostic, isolation and treatment centres at strategic locations; reinforcing national epidemiological surveillance capacities through the creation of sub regional training facilities; and investing in communication infrastructure including health information systems that could support outbreak response and routine health services.
In addition there may be need to invest in building logistics infrastructure and capacities in order to ensure adequate storage for critical supplies, improved procurement of medicines to enable economies of scale.
There is also need to build the infrastructure to support surveillance; for example setting up of 24 hours functional hotlines for reporting public health events; information sharing systems across country borders and within individual countries; and data management infrastructure that will allow collating and analysis of data.
3.Building resilience in health systems and servicesGood health is essential to sustained economic and social development and poverty reduction. Access to needed health services is crucial for maintaining and improving health. At the same time, people need to be protected from being pushed into poverty because of the cost of health care.
Building resilience in health systems and services through the introduction of universal health coverage has become a major goal for health reform in many countries and a priority objective of WHO.
In building resilience in health systems and services, National Health Plans that existed before the Ebola epidemic will need to be revised based on the identified critical health system vulnerabilities that led to the unprecedented epidemic. The revised plans should address actions that take care of patient and health worker safety; improve surveillance and response; improve the interaction between health districts and their communities, and establish mechanisms that allow health services to respond effectively to unusual events that affect essential health services.
Countries should be supported to develop and implement evidence based robust national health strategies addressing priority areas in all the six building blocks of the health system namely: leadership and governance; health financing system; health information system; equitable access to essential medical products , vaccines and technologies; Health service delivery and Health workforce.
What is the way forward for AfricaAs a way forward in improving health services in general and health related infrastructure in particular international health partners should support countries to strengthen their health systems and services by:
- First interrupting the on-going Ebola epidemic, restoring basic health services and building more resilient and robust systems. This however will require major investment from all parties concerned including Governments.
- Putting in place health workforce strategies that ensure availability of competent, motivated and equitably distributed Health workers who will deliver good quality services that are responsive to peoples legitimated needs. This in itself will require the expansion of existing health worker training institution to ensure adequate numbers of graduates.
- Improving the availability and functionality of infrastructure through rehabilitation and equipping to enable delivery an integrated package of health services.
- Strengthening health information and surveillance systems to ensure timely production of good quality data on health determinants, health system performance and health status, which is analyzed and used in policy dialogue and decision making.
- Strengthening the capacity of the ministry of health, at both the national and decentralized levels, to ensure leadership and governance of health sector development. Countries will be supported to strengthen mechanisms and structures for donor coordination, governance and accountability.
- Putting in place sustainable health financing policies to guide resource mobilization and partner investments, whilst ensuring financial risk protection and value for money.
- Improving medicines availability through strengthening the procurement and distribution of medicines and medical commodities of assured quality, safety and efficacy; couple with strengthened monitoring to ensure cost effective use of medicines.
- Supporting countries to attain the core capacities of prescribed under the International Health Regulations (2005) and timely reporting of epidemic/unexpected occurrence of diseases.