Ebola crisis in West Africa: A wake-up call for donors?

The Ebola outbreak in West Africa has exposed the very poor health systems in the affected countries, and donors are starting to take notice: A number of them have announced assistance focused on strengthening the region's health infrastructure and human resource capacity. In August, the World Bank pledged as much as $200 million in emergency funding for the urgent purchase of medical supplies and provision of salaries for medical staff, and to build the region's disease surveillance and laboratory networks. It will also help provide social safety nets for communities affected by the epidemic. Also in August, the African Development Bank announced a three-year, $60 million multination response plan that aims to train skilled professionals and equip them with protective suits and items that are needed to respond to such epidemics. The plan also intends to put in place emergency alert and response systems, rehabilitate hospital facilities and help boost local capacity in the use of public resources and the development of communication campaigns. All these are in response to what has emerged following the outbreak: Insufficient isolation facilities for the infected, ineffective mass campaigns to educate people about Ebola and a stark shortage of professionals trained in handling infectious diseases. But is an epidemic, which in the span of six months killed more than 1,000 people, really needed before donors prioritize health systems strengthening? The HSS dilemma Devex research finds that while donors to Guinea, Liberia and Sierra Leone allocate funding to health, aid to the sector is much smaller compared with what is channeled to areas such as governance and infrastructure development. And even among donors that do invest in health, very few focus on strengthening health systems. Experts from the Kaiser Family Foundation, a U.S.-based global health policy research firm, explained this is due in part to the lack of data that monitor and show the impact of investing in health systems strengthening. “HSS is such an imprecise term and there is tension between donors wanting to focus on specific health issues rather than the ‘bricks and mortar’ of global health,” Jen Kates, vice president and director of global health and HIV policy, and Josh Michaud, associate director for global health policy, told Devex. “Donor governments respond well to evidence of their funding contributing directly to reducing disease and mortality; they respond less well to investments that seem to offer only diffused benefits that are hard to quantify.” But what does it really mean to invest in HSS? The experts pointed to the World Health Organization’s six “building blocks” of health systems: service delivery, health workforce, health information systems, essential medicines access, financing — which also helps allow individuals to access health care without the financial burden — and leadership and governance. Below, Devex takes a look at some of the top donors to the three countries hit hardest by the Ebola outbreak and what their health priorities are, if any. Guinea Health is a priority under the Guinean government’s third poverty reduction strategy, and the objective is to “make it possible” for all village and city communities to have access to basic social services, especially a well-equipped health care center. But many of the country’s top donors don't even have current projects on health. The World Bank’s International Development Association disbursed $32.45 million to Guinea in 2013, of which 14.8 percent was spent on health and other social sectors. But at present, none of the bank’s 16 ongoing projects in the country involve health and instead focus mostly on good governance, education and electrification. There are plans under its 2014-2017 country partnership strategy to set up skills development to “meet the demands in Guinea’s economy, as well as in basic and higher education and in health.” And the bank has a planned $10 million IDA project on health, but this is not expected until 2016. AfDB, which spent an average $170.79 million in Guinea in 2011-2012, does not have any health projects in the country either. Its 2012-2016 partnership strategy for Guinea focuses on addressing the country’s power generation gap, poor transport infrastructure, governance and public financial management. France meanwhile converted Guinea’s debt to grants, and signed an initial tranche of 75 million euros ($99.48 million) in 2013. Much of that funding is focused on education and agriculture, although France did contribute 9.5 million euros to an EU-led health project launched last year. The 29.5 million-euro project aims to build the capacity of the Ministry of Health and improve people's access to quality basic health services and essential medicines — with a focus on women and children — in the country's Forest Region, which is largely affected by the current epidemic. Interventions range from training health workers to the construction, expansion and rehabilitation of facilities and equipment. AfDB highlighted this low interest in health among Guinea’s donors in its strategy, noting that while a number of donors are interested in improving the country’s governance and infrastructure, they “appear to have little interest in the health sector.” Olivier Manlan, the bank’s principal economist in Guinea, told Devex that the strategy paper is due for a midterm review this year and will be an opportunity to discuss how it can take into account the bank’s $60 million support for West Africa. The EU meanwhile plans to spend 40 million euros on health, or 16.49 percent of its 244 million-euro allocation for Guinea for the period 2014-2020. “Donor governments respond well to evidence of their funding contributing directly to reducing disease and mortality; they respond less well to investments that seem to offer only diffused benefits that are hard to quantify.” --— Kaiser Family Foundation health experts Jen Kates and Josh Michaud Liberia In 2008, Liberia’s Ministry of Health and Social Welfare created the Liberia Health Sector Pooled Fund. It has four donors: the U.K. Department for International Development, Irish Aid, UNICEF and UNHCR. The fund has been lauded for helping boost the ministry’s capacity to deliver health services. But some of the fund’s donors seem to be nearing the end of their contributions. DfID, which appears to be its largest contributor, has so far spent 19.99 million pounds ($33.15 million) of its 20 million-pound contribution to the fund on a project that is scheduled to end Dec. 31, 2014. It’s unclear how these changes will affect the country’s health structure, but it should be noted that this is not the only avenue donors use to support health issues in the country. For instance, the Japan International Cooperation Agency helped fund the rehabilitation of a maternity hospital in the country in 2008, and provided capacity development to staff. The Japanese government also provided grants to UNICEF in 2009 and 2010 to help prevent infectious diseases among children. At present, JICA does not have any active health projects in the country. The World Bank has a $15 million health systems strengthening project covering five regional hospitals and supporting postgraduate medical residency programs in the country. But that is the bank’s only health project in Liberia. IDA disbursements to the country reached $36.91 million in 2013; only 5.5 percent of that was spent on health and social services. The United States does not contribute to the pooled fund but it does provide health assistance to Liberia through the U.S. Agency for International Development, including through an approach called the Fixed Amount Reimbursement Agreement that covers the period 2011-2015. USAID spent more than $53.6 million on health in Liberia in 2013, and is due to spend $54.5 million this year. The agency does not track its spending in a way that would allow it to break down its expenditure on health systems alone, but a spokeswoman told Devex USAID distinguishes between interventions aimed at supporting health systems and those focused on strengthening them. This is clear in the USAID Mission to Liberia’s objectives: improve service delivery of Liberia’s Essential Package of Health Services and strengthen health systems to increase institutional capacity and sustainability. For instance, USAID’s work in helping establish Liberia’s National Health Accounts can be distinguished as “strengthening,” while its projects that focus on building the capacity of country health and social welfare teams through joint supervisory visits to facilities and skills building in monitoring and evaluation can fall under “support.” USAID is currently actively engaged in the Ebola response in West Africa, and is “moving forward” to provide support to neighboring countries that are at risk. It is also preparing for “the looming challenge” of rebuilding the health systems of the already affected countries, the spokeswoman said. Sierra Leone Sierra Leone is the country hit hardest by the Ebola epidemic, registering the highest number of cases and deaths. As of Aug. 18, there had been 783 confirmed cases and 335 deaths — including two of the country’s top doctors. This is despite health being a top priority among donors in the country. The United Kingdom, for instance, is spending 29 percent of its 63.48 million-pound allocation for the country this fiscal year on health. Health was also an IDA priority in 2013, receiving the second-highest allocation that year. At 25.2 percent, it came second only to public administration and law, which received 39.2 percent of the bank’s $39.56 million IDA commitment in 2013. A look at donors’ health projects in the country reveals most, if not all, target maternal and child health. Of DfID’s 17 active health programs, six specifically tackle this problem. The only active World Bank health project also targets maternal and child health, although it is now being restructured to support the government’s Ebola response plan. JICA had a health project aimed at strengthening the country’s supervisory systems, which was set to run until 2017. The donor had also dispatched an expert to re-train health workers on better child health. Both of these projects are currently suspended because of the Ebola crisis. Health is not a focal sector for the EU under its 2014-2020 framework, but a representative told Devex the bloc is currently financing a maternal health program in Sierra Leone worth 24.2 million euros, which forms part of its 1 billion-euro MDG initiative. The project aims to deliver better health services especially for children and pregnant and lactating mothers by providing drugs and medical items like solar refrigerators, food and supplements like vitamins to treat malnutrition. The representative said the project also includes training for doctors and health care workers on maternal and child care issues, and provides for the rehabilitation of existing health facilities, ensuring the availability of clean water and sanitation facilities. The EU argues that focal sectors are decided together with partner countries, in line with their national development strategies and priorities. But “in case the situation deteriorates further, it would be possible to reopen discussion on the 11th [European Development Fund] in Sierra Leone,” the representative said. AfDB, meanwhile, does not have any active projects on health in Sierra Leone under its current portfolio, based on its project database. Its focus areas under the 2013-2017 country partnership strategy are public and private sector development, women and gender equality, economic inclusivity, green growth, climate change and regional integration. The big debate There are donors that channel their resources to some of the HSS “building blocks” as identified by WHO, but not all of these parameters are addressed sufficiently. In the Ebola-hit countries, there clearly aren’t enough trained health professionals. Kaiser’s Kates and Michaud said these countries had to resort to a “short-term fix,” which is to bring in workers from nongovernmental organizations like Medecins Sans Frontieres, or experts from the Centers for Disease Control and Prevention. “With limited exceptions, there has been no sufficient long-term, or even medium-term, strategy put in place for investing in the health care workforce more generally and proactively, before crises [like Ebola] erupt and as part of what donors do on an everyday basis,” they argued. Whether issue-based health spending is helping strengthen a country’s health system or further undermining fragile health systems remains a contentious topic. But the Ebola epidemic in West Africa clearly shows that much more needs to be done. And although there are donors that incorporate broader health system improvements in their programs “to a greater or lesser degree,” Kates and Michaud said “it is probably optimistic to think donors adhere to all or even most of these principles for contributing to HSS through their global health programs.” Check out more insights and analysis provided to hundreds of Executive Members worldwide, and subscribe to the Development Insider to receive the latest news, trends and policies that influence your organization.