Ebola's footprint on health system strengthening

The Sustainable Development Goals have donors, implementers and civil society organizations looking to the future and asking: what’s possible, what’s measurable and what’s next?

But in the run-up to the 2015 Paris Climate Conference, also known as COP21, and the release of the SDG indicators in March 2016, fewer stakeholders are using the SDGs as an opportunity to look back.

The U.S. Centers for Disease Control and Prevention announced Monday Sierra Leone will be declared Ebola-free if no new cases are discovered by Nov. 7. The West African country had more than 14,000 diagnosed Ebola cases, the largest number of confirmed cases in the outbreak that has killed more than 11,000 people since Jan. 2014.

“Lessons learned” have so far focused on operational reasons why health systems faltered and why the humanitarian response came late, often taking donors and international aid agencies like the World Health Organization to task for mishandling the crisis.

But a recent report released by the Overseas Development Institute offers a look at the systemic causes behind one of the deadliest disease outbreaks of the century, and why Ebola will be a wake-up call for the global health community.

Marc DuBois, former executive director of Médecins Sans Frontières, now an independent consultant and a co-author of the report, spoke with Devex about its findings and how the crisis should shape the world’s approach to disaster risk reduction and building health systems.

The report claims the Millennium Development Goals may have displaced other strides to improve health systems in the most-affected countries. What lessons should we learn from this for the SDGs?

There seems to be widespread agreement that as a matter of first priority, people in countries like Guinea, Sierra Leone and Liberia required and still require functioning health care systems.  The degree to which the very complex, setback-ridden, long-term goal of building a health care system does not mesh well with an aid system increasingly focused on quantifiable, short-term, “sexy” targets.

[Individual] projects and [silos of success] do not [add up to] a [health] system, and development work often seems to avoid complexity. The question is how to ensure that the SDGs will not reinforce piecemeal, project-based action that fits more easily into our highly modulated and segmented aid architecture.

The lesson from the MDGs would be the need for a much deeper understanding of the interrelationship between an MDG/SDG approach and an approach focused less on components and projects and more on overarching systems. That is not to imply that the two are mutually exclusive.

Can you explain the criteria for labeling a health crisis, as opposed to an humanitarian crisis? Are these hard-and-fast distinctions and if not, should they be? How does this play into criticisms of the World Health Organization and how it handled the response?

There is no criteria that would set such definitions, and there is both overlap and a circularity in terms of causation. Humanitarian catastrophe often provokes a health crisis, [for example] cholera or measles outbreak in an [internally displaced persons] camp, while the reverse is also true, [like with] Ebola in West Africa.

A major health crisis may not entail much of a humanitarian crisis if it can be managed, such as with severe acute respiratory syndrome, also known as SARS, or it may constitute a humanitarian crisis in and of itself, such as the meningitis outbreak across parts of West Africa a few years ago.

I don’t think [the distinction] is particularly accurate — too subjective — or helpful. It is probably more useful to think in terms of the needs of the people.  

In the early stages of the Ebola crisis, the people needed a response focused on health, and hence the logic of a WHO or local ministry of health taking the lead. But once Ebola had spread, it triggered a multisectoral crisis, with devastating effects on education, agriculture, livelihoods, security, protection, water and sanitation and non-Ebola health. At that stage, it should be evident that the mechanism for coordinating the response requires a more diverse set of skills and expertise, much more similar to the [United Nations Office for the Coordination of Humanitarian Affairs]-led cluster system found in many complex emergencies.

In terms of coming up with SDG indicators in March, and metrics for measuring the growth of health systems, what's the challenge? What's the most difficult to measure? And what's been discovered in the Ebola recovery effort about how to facilitate a better response — both from the get-go and after the fact?

The problem starts with the idea that you can measure the growth of health systems. Of course, one can measure many components of a health system, such as numbers of clinics, or staff, or the availability of key drugs. This is known as hard capacity, and it has become the bread and butter of the aid business.  

But this focus on hard capacity can lead to two key concerns raised in our report: First, a system is larger than the sum of its parts — all of this tangible stuff that is delivered through aid projects does not necessarily aggregate upwards into a system. Second, certain “vital” system components defy measurement, such as the degree to which a health system depends on legitimacy of government and on relationships between people.  

There is nothing wrong with building clinics or training staff per se, but there is a risk if those activities are expected to add up — presto! — to a health system, or if they become the sole focus of development efforts.

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