West Africa's Ebola epidemic has cruelly exposed the weaknesses of health systems in the countries where it struck. It was understandable that they were not prepared for Ebola, which has never been reported in the region before, but the director of the World Health Organization (WHO), Margaret Chan, says what they lacked was a robust public health infrastructure to deal with the unexpected.
“This requires good background data on the usual,” she says, “so that the unusual stands out. [It means] making good quality care accessible and affordable to everyone, and not just to wealthy people living in urban areas; having enough facilities available in the right places with enough well trained staff and uninterrupted supplies of essential medicines; diagnostic capacity that returns rapid and reliable results; and information systems that pinpoint gaps and direct strategies and resources towards unmet needs.”
Chan was speaking on what had been designated as the first Universal Health Coverage Day (on 12 December), setting out an ambitious check-list for health systems which can cope with whatever is thrown at them. This is clearly a challenge in any developing country, but much more of a challenge in fragile states like those currently affected by Ebola.
It could be SARS next time
Nick Hooton is a research, policy and practice adviser with the ReBuild Consortium which works on how to strengthen health systems in post-conflict states. He told IRIN that although research still had to be done, the post-conflict environment was almost certainly a reason why the disease spread so fast. “Undoubtedly the systems are very poor,” he says, “and the staffing levels are very low, but there are also subtler factors at work, issues about trust and things like that. This is a disease which has been well controlled in other places, and yet got massively out of control. If you look at the DRC [Democratic republic of Congo] and northern Uganda, there is no great supply of health professionals there either. So we are talking about things like a breakdown in the links between the communities and the public services which take a long time to build up again.”
Hooton stresses that addressing these underlying weaknesses is crucial: “It's Ebola this time, but it could be SARS next time, or some other disease. There is absolutely a need for a disease response - Ebola is a horrible disease and it is out of control - but to stamp out the disease and leave the systems as they were is not doing any favours to anyone.”
The Millennium Development Goals, now reaching their end date, set their health targets for particular sectors, maternal and child health, or for specific diseases - TB, malaria and HIV/AIDS. This approach had the advantage of providing measurable targets, and was able to attract donor funding, but didn't work on the kind of system-wide resilience that Margaret Chan is talking about. Now, with negotiations in full swing for the post-2015 goals, there is a chance to move from the single-sector, “vertical” strategy to a broader based, more “horizontal” approach.
David Heymann, the head of the Centre on Global Health Security at Chatham House, says we need to look at what has happened in the past. “In the past there has been an international treaty, the International Health Regulations, which clearly states that 194 countries have agreed to strengthen their core capacities in public health. Countries were left to evaluate themselves on whether or not they had attained these goals, and they were to have completed their core capacity strengthening by 2014.
“But what happened? I'll be a little tough here by saying that donor agencies didn't provide funding through the international health framework; they didn't bother to provide funding unilaterally to these countries, and international organizations didn't bother to try to enforce this treaty which 194 countries have signed. So we're back to zero. And now we have to start over again.”
Using the vertical to measure the horizontal
The demand for measurable outcomes is always going to favour single disease interventions over the less dramatic, more mundane strengthening of health systems, but Heymann says we just have to figure out how to incorporate one into the other. “We have to use some of those issues as indicators for universal health coverage. If you can accomplish community treatment for HIV or tuberculosis through a system, and you can hook other systems into that, that's universal health coverage. Let's use the vertical to measure the horizontal.”
Of course, it all takes money, and the discussion on universal health coverage on 12 December at the London School of Hygiene and Tropical Medicine produced vigorous debate on the merits of various types of financing.
Anne Mills, the deputy director of the London School, set out what she sees as the ground rules: “The core principle of universal health coverage is that people contribute according to their ability to pay, and benefit according to health need. A good financing system needs to be equitable - richer groups should contribute more than poorer groups. Secondly, it needs to put minimal reliance on payment at the point of use; payment needs to be collected in advance. And thirdly, financing should be pooled as much as possible and not segmented into many different pools for different population groups.”
Mills pointed out that a lot of health systems in Africa, for instance, are far from achieving this, with as much as 48 percent of health costs in Kenya, 66 percent in Nigeria and 76 percent in Sierra Leone being paid by the user at the point of use, which bears very heavily on the poor.
The UK's own health service is funded from general taxation and is free at the point of use, so it was perhaps not surprising that the dominant sentiment in the London debate was in favour of the public financing model.
Health economist Robert Yates has worked on these issues for the UK's development ministry, DFID, and for WHO. He told IRIN: “The key is compulsory and publicly governed financing, either through taxes, or through compulsory social insurance payments. You have to have richer people paying more and with voluntary insurance. If you leave it to the market, the market will always try to give lower premiums to healthier people, and charge higher premiums or exclude those who need it more. This is why voluntary systems always, always fail. Even community-based health insurance, which sounds great, has never worked anywhere.”
An intensely political process
Yates is scathing about past attempts by the likes of the World Bank to encouraged developing countries to switch to privately financed systems, with people taking out insurance or paying out of their pocket when they need care. This, he says was a terrible mistake, resulting in weakened health systems, especially in Africa. But he sees some positive changes happening, in Thailand, Latin America and most recently Indonesia.
“You find that when countries make the transition to middle-income status,” he says, “they have the resources to move towards a publicly funded system, but it doesn't happen naturally. To force the rich and the healthy to cross-subsidize the sick and the poor is an intensely political process. But then some smart politician recognizes that universal health coverage would be very popular with the masses, and it's wonderful when you see this starting to happen.”