The consequences of unequal access to health care have proven deadly as Ebola continues to ravage already weakened health systems across West Africa. The Ebola crisis has highlighted the devastating impact of inequities in the treatment of disease, underscores the importance of universal health coverage as a key component in the post-2015 agenda, and provides a crucial opportunity to “cement” health as a human right.
Primarily seen as an African disease, the global response was woeful until Ebola began to threaten Western economies. As former United Nations Secretary-General Kofi Annan aptly said recently: “When you look at the evolution of the crisis, the international community really woke up when the disease got to America and Europe.”
It has taken an epidemic like Ebola to expose the gaps in health priorities and stigma. While people in Liberia were being left to fend for themselves on the street, Western aid workers and doctors were sent home for special treatment. Essentially, the poor were left to die.
Sufficient and qualified health workers, service provision and delivery, accountability, infrastructure and equal access to medicines are all building blocks to achieve UHC. But for it to be truly universal, it must also serve the needs of the poorest and most marginalized. What it really boils down to is financial protection.
Health inequities are widening and the cost of health care pushes millions into poverty each year. Only 11 percent of global health spending ($ 2.8 trillion) is in low- and middle-income countries. High out-of-pocket spending means that nearly a third of households in Africa and Southeast Asia are forced to borrow money or sell assets to pay for health care, often falling into financial ruin. It is therefore vital that the costs of health care are shared throughout a population, through pooled funding, so that everyone has access to health services without fear of financial hardship.
Human resources for health
Achieving UHC requires access to health workers, but there are not enough health workers to meet the needs of populations. Indeed, there is a direct correlation between the decline in health workers and the increase in maternal and child deaths. It is therefore hardly surprising that up to 99 percent of all maternal deaths occur in developing countries.
Although the amount of aid to global health has increased over the past decade, the percentage allocated to human resources for health has been miniscule. Last year, the World Health Organization estimated that the global health workforce shortage could reach 12.9 million in the coming decades.
Investments in health care are shaped by inequity, governed more by the market than by the burden of disease. Simply put, it is easier to build a clinic than to pay health workers over an extended period of time. Building a hospital fits donor and project funding priorities better, even though increasing the number of health workers is more sustainable.
As a result, donors have been reluctant to pay health care workers’ salaries directly, given the long-term commitment. For too long, governments and the international community have overlooked the basic fact that health systems cannot function without qualified health workers.
This has had tragic consequences as we have seen in Liberia, Guinea and Sierra Leone, which were ill-equipped to withstand the onslaught of Ebola. In October, Liberia had approximately one doctor per 100,000 people, while Spain had 370. Liberia was already buckling under the strain of an increasingly weak health system, and struggling to contain preventable diseases like malaria and typhoid. Hospitals across these three countries were chronically understaffed and lacked the most basic of medical equipment — including protective clothing. The spread of mistrust was almost as virulent as the disease itself, prompting health workers to abandon hospitals.
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Working to tackle the ongoing Ebola crisis, Prince Kreplah of the Liberian civil society organization WASH Network asserts that health systems strengthening is crucial: “The Ebola crisis has been compounded by poor health facilities, a distrust of public health care systems, and a lack of adequate health workers trained in disaster response. Communities are critical to bridging these gaps.”
Community-driven health systems
Strong community-led campaigns played a significant role in the swift emergency response in Nigeria, the most populous African nation, which was declared Ebola-free after just 19 cases.
As seen in Nigeria, community-driven health systems step in where government health systems fail by reaching marginalized, underserved and rural populations. Communities hold governments and donors accountable by ensuring that resources are spent effectively. Integrating community-driven health systems into public health systems is key to ensuring the roll out of UHC to everyone, everywhere.
Most of the care at community levels focuses on prevention. However, when faced with serious medical illnesses, there need to be connections between the community health worker, the general practitioner, the hospital and the entire health system. Donor assistance must support the building blocks of a country’s health system — and this includes community health systems.
Critically, as Joan Awunyo-Akaba, executive director at Future Generations International Ghana points out: “Health starts at the community level. We need to look at the social determinants of health: basic hygiene, access to clean water, sanitation, nutrition. If there is no running water, and children are defecating on rubbish dumps, what good is a hospital?”
Since 2005, G-8 governments have made successive commitments to address the critical shortage of health workers in developing countries. Yet, evidence of this has been sparse, at best.
Ebola has killed 5,000 people in Guinea, Sierra Leone and Liberia. Scaling up services to confront major infectious diseases is crucial, but the global community also needs to focus on strengthening health systems. Aid to HIV and AIDS, tuberculosis and malaria has taken precedence over building resilient health care systems and striking a balance between the two priorities will be imperative — as well as galvanizing donors to take action.
The EU should ensure that 50 percent of all new funding for health is directed towards health systems strengthening. Since health systems cannot properly function without health workers, 25 percent of all health spending should be allocated directly to human resources for health, according to the WHO. Partnerships must be established between governments, global institutions and communities to implement fully funded health systems, accountable and responsive to the needs of vulnerable and impoverished populations.
UHC ensures strong health systems, which are essential to poverty eradication. Healthy populations make for prosperous nations. Until everyone, everywhere has access to even the most basic of health care, we are at risk of further health crises like Ebola.
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