A Wake-Up Call: Lessons from Ebola for the world’s health systems


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We all know the dreadful toll that Ebola has taken in Guinea, Sierra Leone and Liberia. It is not over. A conference today in Brussels is trying to maintain international support for the job of reaching zero cases and helping these countries to recover. Save the Children has seen this first hand, helping to fight Ebola in all three countries. As these efforts continue, we must also learn some lessons which apply to all countries. The reasons for Ebola spreading are complex but a new report we launch today – A Wake-Up Call - focuses on the way that the inadequate health services in the countries ensured that Ebola could not be quickly contained, reversed or mitigated. Their dangerously under-funded, under-staffed, poorly-equipped and fragmented health services were quickly overwhelmed and needed massive international help to start to fight back. Donors have had to play a vital role, especially the UK in Sierra Leone, the USA in Liberia and France in Guinea.

However, the poor state of the health systems in Liberia, Sierra Leone and Guinea was never a secret, nor were the extremely low amounts they were able to spend on health. Although they had made important progress in recent years, Sierra Leone’s government was still spending just $16 per capita in 2012 instead of the $86 recommended - and the lack of health workers – and Liberia had only 51 doctors in the whole country. In our report, we have created a new Health Access Index which shows that the three countries are far from alone in having weak health systems. We have ranked the countries with the highest levels of child mortality according to spending on health, number of health workers, coverage of key health services and mortality rates. It shows that many countries have health services equally bad or worse than those in the three countries. In fact, 28 countries come below Liberia in the Index.

The Ebola crisis must be a wake-up call to all of us to take serious action to transform the health services of all developing countries. Not doing so is causing unnecessary deaths and suffering every day, but also risking future infectious disease outbreaks that, in our interconnected world, have the potential to lead to pandemics. Researchers at the University of Washington have calculated that a new influenza outbreak on the scale of the 1918 Spanish Flu crisis could kill up to 81 million people worldwide.

2015 is an important opportunity to try to change this, through the push for universal health coverage. While some say that ensuring universal access to essential health services is unaffordable, our evidence paints a different picture. While reforms of health services and addressing inefficiencies and corruption are badly needed, a large part of the $101 billion annual gap in health spending could be filled if governments raise greater domestic resources by improving their tax systems, allocate more of their available funds to health and reduce illicit financial flows and tax avoidance. The international community, including the International Monetary Fund, needs to enable these governments to increase spending but must also continue to provide aid to help fill gaps, making sure this helps to build comprehensive health services.

The gap in funding for comprehensive health services reveals that prevention is better than cure. For the three Ebola-affected countries, the gap in 2012 was $1.58 billion, only a third of the $4.3 billion that international help to fight Ebola has pledged so far.

As well as preventing infectious disease outbreaks, lack of access to essential health services causes a daily burden of death and disease including high rates of maternal, newborn and child mortality. While we have had great success in halving the number of under-five deaths since 1990, further progress is not assured. Rates of newborn mortality are not falling fast enough and the fall in child mortality has been far from equal with children from the poorest households and regions being left behind. Only 16 of the 75 priority countries have demonstrated sufficient progress among their poorest and most marginalised populations.

The Ebola crisis is an opportunity to see that we cannot leave the world’s poorest countries with dangerously inadequate health services. The Sustainable Development Goals can commit to an historic shift to end all preventable child deaths, reduce inequalities and ensure universal health coverage for the poorest people in the world.

Justin Forsyth is the Chief Executive of Save the Children. Follow him on Twitter: @justinforsyth


Join the Conversation

Marjan Kruijzen
March 03, 2015

Dear Justine, thanks for summarising the challenges faced by the ebola affected countries and many more fragile states on building resilient health systems. The possible global effects and threats of the current situation are indeed worrisome. I do hope the Brussel conference will indentify and agree on the best strategies forward for quality impact on fragile health systems. Based on the best practices in over 14 fragile countries, evidence is all over that a shift is needed from input-based towards output funding; PBF or RBF (Performance/Result Based Financing). The ebola crisis made clear once more that the levels of international and local funds/support is not the real issue; its the ineffectiveness and inefficiency of the support which should worry us together with the lack of a joint global vision and understanding on how to build smart and resilient health systems. May I invite everyone during the next months to follow the PBF-Plus pilot which Cordaid is about to start in one frontrunner District in Sierra Leone, of course with the leadership of MoHS and in close collaboration with the World Bank. For more info on PBF/RBF see https://www.cordaid.org/en/topics/healthcare/result-based-financing/
Marjan Kruijzen
Healthcare coordinator Sierra Leone

Simon Wright
March 04, 2015

This is a really interesting debate to have. The issue with PBF is that it can only be as good as the planning of the results wanted and the consideration of unintended consequences to be avoided. If PBF has narrow outcomes, no-one would have designed PBF projects with Ebola in mind in West Africa. The outcomes need to be comnsprehensive health systems rather than spoecific disease outcomes. So PBF could have helped if the outcomes tied to aid were carefully designed to build a stronger universal helath system. Often however they are more aligned with donor specific priorities. I would be interested in discussing this more.