UNINTENDED CONSEQUENCES OF GLOBAL AND NATIONAL HEALTH STRATEGIES
Public policy in the area of global health is a mess, and the desperate scramble by our leaders to limit the impact of Ebola and to reduce its transmission is evidence of long run failure to address a set of public policy issues. It is rather late in the day for President Obama to call for additional resources and finance ‘to bend the curve of the epidemic’ in West Africa although these are going to be essential to limit the global impact of Ebola and save potentially many thousands of lives.
But this state of affairs is scarcely accidental and the Ebola virus was identified many decades ago by Peter Piot and other scientists in the 1970s. Thereafter not a lot of resources were focused on finding a vaccine or the development of drugs since the problem seemed to be confined to Central Africa – a long way away from the centres of population in the rich developed countries. But with increasing population mobility – globally and in Africa- and growing urbanisation it was inevitable that Ebola would spread and that everyone would in time be threatened. Indeed this is precisely what has happened and as Professor Piot noted in a Guardian interview last week the real difference now is that Ebola is no longer confined to relatively sparsely rural populations in remote parts of Central Africa but has now spread to dense urban populations across West Africa – and beyond.
What is evident in Sierra Leone for example is not only the daily loss of life but that the epidemic is undermining the economic and social framework of the country – schools are closed and the public health system scarcely functioning. Economic activity has been brought more or less to a standstill and what is now needed is a massive injection of resources – not just public health [doctors and nurses and other technical staff] but logistical assistance on a massive scale together with increased access to food as local production is destroyed. What is evident is that local health capacity in Sierra Leone, Liberia and Guinea was always totally inadequate not just because of the ravages of war and the post war failures of reconstruction but were always in desperate need of resources. At the present time the health response has been almost entirely dependent on NGOs such as MSF and the Red Cross given the lack of local health capacity with WHO at best providing a purely coordinating role.
How did we come to this state of affairs?
Of course it is easy to blame the governments of the most affected countries and to argue that they should have put a lot more resources into developing health capacity. Resources that they generally did not have and that the international aid community was unwilling to provide. Indeed the more or less complete lack of doctors, nurses and medical technicians in these countries cannot wholly be due to failures of national planning for health needs but also has other contributing factors. Not least the rapacious demands for trained health personnel in rich countries such as UK, USA, Australia and Switzerland to name but a few.
In the case of the NHS some 30% of doctors and 40% of nurses were born outside the UK. Health workers have been a perennial problem for the UK and these shortages predated the foundation of the NHS with recruitment from the colonies going back to the inter-war period and especially from the Caribbean, It is worth noting that some health training facilities [medical schools and nursing colleges] particularly in South Asia [India and Pakistan] have aligned their training and degree programmes so as to meet the needs of the UK and that the NHS had direct recruitment systems in place which ensure special access to British citizenship. In 1997 some 44% of 7,229 registered doctors in the UK had received their initial education overseas. In 2013 no less than 6000 foreign nurse were recruited at the same time as the NHS cut the number of training places from 20,829 in 2010 to 17,219 in 2013 despite the fact that there were 226,400 applicants for these places [2013].
What is going on? What we have is an international market for scarce skills where the rich countries persistently raid over many years the health labour markets of the poorer countries of the world. So not only do these countries end up with few health staff as we observe in Sierra Leone and Liberia with enormous consequences of the health of their population [and a total incapacity to address the problems of Ebola and HIV/AIDS and drug resistant TB, and so on]. The poor countries pay for the education and training of nurses, doctors and other health technicians and they are then poached by rich countries who deliberately choose not to train and educate enough nationals in scarce health related skills. So there is an ongoing reverse transfer of resources – trained people from poor countries to rich ones. No wonder there is little or no health capacity in Ebola-affected countries.
The problem is not only the loss of scarce labour resources by poor countries but losses of experience management together with a distortion of local educational and training systems. To give an example when in Malawi relatively recently on a UN mission to address the problems of health care and treatment for people affected by HIV/AIDS and the strengthening of local capacity there were meetings with those responsible for nurses training. The Malawians were hoping to secure additional funds to expand teaching facilities and nurses accommodation. It was suggested by the UN team that what the country actually might find useful and less resource intensive would be to develop a 2 year in-service Diploma rather than expand the existing course. This was ruled out as a possibility precisely because the local nurse training was aligned with the needs of the international market for nursing recruitment, and thus provided an opportunity for recently trained nurses to be recruited internationally. Clearly what was actually needed in Malawi was an expansion of health staff to address a growing HIV epidemic but what the country were actually doing in large part was training people who then migrated. Indeed a member of the UN team [a Malawian] said that his wife had previously been head of nursing but was now working as a nurse in Manchester.
There are many factors at work. One of these which is directly the result of actions by the international aid community. At the 2001 meeting of the G8 it was decided that a new institution was needed that would galvanise the international response to HIV/AIDS, Malaria and TB. As a result the Global Fund for HIV/AIDS, Malaria and TB was set up and began to function in 2002 – located in Geneva [where else would be suitable given that it was supposed to be addressing health problems concentrated in developing countries and especially in Sub Saharan Africa]. The GF was set up deliberately NOT to be part of the UN system because this represented the views of the Bush administration and people like Blair went along with this anti UN ideology. Initially the GF did have a working relationship with the WHO but this was severed in 2006. Supposedly the GF was to be a lean and non-bureaucratic organisation which did not have any country level capacity and which mobilised resources [financial and otherwise] from the private sector.
History has turned out rather differently from the expectations of our global policy makers back in 2001. Indeed the GF has not developed any direct health capacity in client countries [as we now witness in those countries affected by Ebola]. It has indeed done a great deal of excellent work in the specified areas but at the expense of distorting health capacity in many developing countries so that diseases such as Ebola have been neglected [more on this below]. It has failed to avoid becoming bureaucratic [a reason for its establishment in the first place] and now has almost 700 staff located in one of the most expensive cities in the world [Geneva]. Most obviously it has failed abysmally to tap into private sector and non-traditional sources of funding and of its current annual expenditure of approx $4billion no less than 94% comes from the usual DAC sources of funding [the USA, UK, France and so on, the usual official aid donors].
Why is this mini history of the GF relevant to the present Ebola epidemic? One impact of the setting up of the GF has already been noted – the distortion of health priorities in many recipient countries. This is not to say that there have not been great benefits and indeed there have been from the programmes set up by the GF and this has been especially true of the massive reductions in HIV/AIDS mortality due to the expansion of treatment funded by the GF and improved access to anti-malarial technologies. But this has turned out to be at the expense of the development and support for global health systems and most especially at the cost of destroying some of the capacity of WHO which is supposed to be the lead organisation for identifying and responding to global health threats.
The budget for WHO has been more or less flat in monetary terms since 2006/7and falling in real terms. With inevitable consequences: in the Budget for 2014/15 compared with the previous year there was a cutback in the programme for communicable diseases of 8% ,a cutback in allocations for emergencies and crisis response of 51% and cutback in research on tropical diseases of over 52%. These are precisely the areas directly relevant to the response to Ebola but there are also longer term impacts of the erosion of the capacity of WHO for the general response to global health threats.
WHO now has a budget which is about the same as the GF but has of course a massively broader remit in terms of global health needs – including of course new epidemic threats such as Ebola. That WHO resources have fallen away is directly the result of the neo-liberal anti-UN policies of Bush et al and the failure of current political leaders to perceive how important it is to sustain the capacity of WHO [and others such as NGOs like MSF] if we are to contain new epidemic threats. Remarkable as it may seem the largest financial contributor to the WHO is now the private Gates Foundation which provides more than the official contributions from the USA and the UK.
It is a bit late now in the day for our political leaders to have become so concerned about Ebola but one certainly hopes that resources will be mobilised to deal with the current threats to personal health not only in rich countries but especially in West and Central Africa. One would also like to think that once the present emergency is over our leaders would then seriously address what needs to be in place to prevent a recurrence of Ebola, and to ensure that there are resources and institutions tasked with sustaining and developing health capacity in the poorest countries.
What is not needed is yet another global fund to meet emergency health needs as is being proposed by the President of the World Bank. Strengthening health capacity and supporting research especially into areas neglected by big pharm requires long term programmes which is precisely why the WHO was set up by the international community. This is not to say that WHO is a perfect institution but it is the best that we have and could be even better once subjected to extensive reform processes. Afterall an organisation such as WHO that spends almost a third of its programme budget on its HQ has signally failed to get its priorities right.
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