The recent Ebola crisis in West Africa made me think deeply on how to make health systems work in poor countries.
It reminded me of a trip to rural Nepal in 2009 for the U.N. Population Fund. Driving along meandering mountain tracks, with steep ravines below, I held my hand over my heart as we gave way to oncoming vehicles, fearing that we could roll down into the valley below. Yet transporters used this route daily to deliver essential medicines to remote health centers in the Hetauda region. At the centers, health personnel spoke of the lack of adequate storage facilities, lack of vehicles and poor road conditions reducing the availability of medicines.
The World Health Organization observes that while governments and development partners spend billions of pounds each year procuring health products for low-income countries, these often fail to reach the people who need them.
Unreliable access to medicines and other health supplies remains one of the leading causes of preventable deaths and poor health outcomes in developing countries like Nepal. One-third of lives are at risk because of irregular access to medicines.
While many factors affect the availability of medicines, the capacity of a country’s supply chain to ensure access to health supplies can be a major constraint. Crucially, successful health care programs depend on a reliable supply of essential products to support the services they provide.
Ebola is a wake-up call
The recent Ebola outbreak in West Africa demonstrated that the health supply chain is the first component of the health system infrastructure to be aggressively challenged at the outbreak of an epidemic.
Recently, I attended the recording of Al-Jazeera’s “Head to Head” program with Obiageli Ezekwesili, the former World Bank vice president for Africa. In relation to Ebola, I asked: What can the World Bank and other donors do to ensure their investments lead to sustainable improvements that reduce dependency on external assistance? Ezekwesili answered that the question should not be about what donors can do, but about what government leaders are doing to get into the driver’s seat and drive their development agenda — rather than waiting for this to be imposed by an outsider.
If the supply chain is inefficient, as in all the countries affected by Ebola, essential and lifesaving supplies are not available where needed. This results in unnecessary illness and death. In addition, people lose confidence in the health system at a critical time. Communities resort to coping strategies that complicate the epidemic control efforts of governments. In desperation, concerned development partners turn to the parallel supply systems that increase cost and inefficiency, creating a vicious cycle.
Indeed, Ebola should be seen as a wake-up call for governments and partners. They need to realize that investing in robust supply chains not only improves routine health service delivery but also ensures that when an unforeseen emergency strikes, these supply chains will respond appropriately. This will help prevent the emergency control measures from being undermined.
Health systems need to be integrated
One cause of the poor state of national supply chains is the multiplicity of parallel programs combating specific diseases. These programs procure their own supplies, which then burden the national health supply chain systems with storage and distribution costs, without making an adequate financial contribution. The overall effect is a weakening of the national system. Donor support for selective interventions often results in wasteful parallel programs, lacking public accountability.
Donors and health agencies should support an integrated health supply chain, by taking a whole-system perspective. This would be more effective than looking at separate organizations, functions and processes with competing priorities that confuse and burden the national health workforce.
Increased donations are also putting an additional strain on public health system supply chains. Since the adoption of the Millennium Development Goals in 2000 and the advent of the Global Fund to Fight AIDS, Tuberculosis and Malaria, there has been a marked increase in development aid and caused exponential growth in the procurement of medical products.
Health systems strengthening is crucial for scaling up medical aid. However, the multitude of international actors endowing resources has largely exempted national governments from their duty to provide essential public health services to their people.
Frequently, low- and middle-income countries are requesting support to strengthen health supply chain systems to promote self-sufficiency and reduce reliance on external expertise. But strengthening health supply chains is a complex and costly undertaking. It requires the rare skills of planning, execution and monitoring as well as mastering supply operations. But most of all, it’s about excelling in the art of advocacy and building coalitions with stakeholders far beyond the supply chain context.
Money and good intentions are not enough. Programs seeking to strengthen health supply chain systems can become a hindrance without the right mindset, capacities and collaboration model.
While supply chains in developing countries like Nepal will continue to struggle with poor infrastructure for years to come, it is possible to strengthen the national health supply chain to provide a reliable supply of medicines and ensure patients can access it when they need it.
And there is good news: A few countries that have transitioned to middle-income country status, such as Botswana, Namibia and Morocco, are graduating from dependency on foreign aid for their health systems. But even more good news comes from Rwanda, where political leadership is producing very good results in health care. Strong political leadership at the highest level is essential for change.
Governments need to be more accountable and willing to address health systems challenges. They need to get into the driver’s seat and they need to take a systematic approach to addressing health system strengthening and coordination of partners as a foundation for improving health care. Certainly this will be needed to achieve sustainable development goals on health and for universal health coverage to become a reality.