Ebola has been prominently featured in the news for the past several months. The outbreak continues to grow in number and geographic scope of cases, and many people are wondering how it got so out of control in the first place. The hardest-hit countries are Liberia, Guinea, and Sierra Leone, with a total of 8376 confirmed, probable, or suspected cases reported up to October 10 (World Health Organization, 2014).
The current epidemic began in Guinea, a developing country in West Africa. Poor public health infrastructure made this an ideal location for the outbreak to spread. There are only 0.1 doctors per 1000 people in Guinea, compared to 2.07/1000 people in Canada (CIA World Factbook, 2014). Approximately $67 per person is spent each year on health in Guinea; in Canada, this number is $4676 per person per year (World Health Organization, 2014). It is clear that poverty is a factor here. Guinea’s health system was simply not able to contain the initial Ebola outbreak – but let’s scratch beneath the surface to find a more nuanced explanation.
“A health system is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health” (WHO, 2014). In order to function effectively, health systems need human, financial, and physical resources, as well as information technology infrastructure. Health systems strengthening is a very important part of global health and development, however, investment in this area has historically been lacking. Instead, for many years, disease-specific or vertical health programming was favoured, especially by non-profit organizations. Disease-specific programs are often run in parallel to a country’s existing health system. They can draw human and financial resources away from a country’s health system. Furthermore, the efforts of the many health-related non-profits are uncoordinated, which often results in duplicate programming and inefficient use of financial resources.
Neglect of health systems strengthening in favor of disease-specific programming has had serious consequences for public health in developing countries. Ebola has emerged from the perfect storm. Two of the countries hardest-hit by the current epidemic – Liberia and Sierra Leone – globally spend the highest percentage of GDP on health, about 18%. However, approximately 80% of healthcare services in Liberia are financed by non-profit organizations (Health Systems 2020, 2014). Aside from the problems with this outlined above, we know that health systems must provide more than healthcare in order to effectively promote and protect the health of populations.
Figure 1: The 10 essential public health services (CDC, 2014)
Several key activities of a functioning health system are missing, and are hampering the response to Ebola. The first puzzle piece in controlling an outbreak is to know when and where cases emerge. Disease surveillance is carried out by the CDC in the United States, but the countries currently struggling with Ebola do not have the capacity for rapid and thorough case detection through surveillance. The ability to accurately diagnose Ebola is another problem. Public health laboratories are needed in order to confirm a diagnosis. Finally, public fear is affecting another key function of a health system – to inform and educate people about health issues. People are afraid, and many are mistrustful of the government’s advice. The reason that Ebola will not spread beyond a few dozen cases in North America and Europe is because the health systems of the countries therein are equipped to identify cases, and have protocols for risk reduction to the rest of the population – i.e. contact tracing, and isolation and treatment of the patient.
In August, the World Health Organization declared an international public health emergency over the Ebola outbreak. Efforts to halt the spread of the infection have thus far been unsuccessful. More resources are needed to target the many avenues that will be required to get this outbreak under control. The United Nations recently set up a mission specifically to combat the outbreak. UN Secretary-General Ban-Ki Moon said the mission will have five priorities: “stopping the outbreak, treating the infected, ensuring essential services, preserving stability, and preventing further outbreaks” (UN News Centre, September 18, 2014) In order to prevent similar situations from occurring in the future, health systems strengthening should be emphasized and invested in to strengthen national capacity to deal with emerging health threats.
Central Intelligence Agency (2014). The World Factbook. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/
Centres for Disease Control and Prevention (2014). The public health system and the 10 essential public health services. Retrieved from http://www.cdc.gov/nphpsp/essentialservices.html
Health Systems 20/20 (2014). Liberia: Post-conflict health sector reform. Retrieved from http://www.healthsystems2020.org/section/where_we_work/liberia
World Health Organization (October 10, 2014). WHO: Ebola response roadmap update. Retrieved from http://apps.who.int/iris/bitstream/10665/136161/1/roadmapupdate10Oct14_eng.pdf?ua=1
World Health Organization (2014). Global Health Expenditure Database. Retrieved from http://apps.who.int/nha/database
World Health Organization (2005). What is a health system? Retrieved from http://www.who.int/features/qa/28/en/
United Nations News Centre (September 18, 2014). UN announces mission to combat Ebola, declares outbreak ‘threat to peace and security.’ Retrieved from http://www.un.org/apps/news/story.asp?NewsID=48746#.VDnRMymwLZQ
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