West Africa is now home to the largest ever epidemic of Ebola virus disease. The first cases were reported in March 2014, and it has now become the disease’s largest and most complex outbreak, with over 10,000 people infected and nearly 6,113 deaths. The great majority of these cases have occurred in Liberia, Sierra Leone, and Guinea, with Liberia hardest hit.
One may wonder how this happened, all of a sudden, in a matter of a few months. For starters, the virus did not replicate, spread and infect thousands overnight. The virus grew and multiplied over time, and had a strong health system been in place, could have been limited to a few rural cases. However, Liberia, still recovering from two prolonged civil wars, has a compromised health system. The limits of the health system enabled the virus to transform itself into a disaster.
Why is the health system capacity of Liberia so limited? A country’s financial capability is a primary predictor of health system success. The government’s budgetary allocation to the Liberian Ministry of Health and Welfare (MoHSW) has incrementally increased from US $ 10 million in 2006 to US $ 48 million in 2012. The health system is heavily reliant on external donor support; donors are responsible for implementing over majority of health services in the country. Despite notable efforts by the MoHSW, Liberia continues to battle serious capacity issues, with chronic human resource, equipment, and drug shortages, stemming from health system degradation during the civil wars. Liberia has only 50 practicing doctors for its 4 million population. More than 75 percent of the population has limited access to basic care, compounded by ongoing economic challenges. While life expectancy was 56 years in 2010, up from 53 years when the war ended in 2003, these gains were largely negated since the Ebola outbreak, setting the health system in some ways back to where it started post-war.
These health systems limitations, coupled with delayed reactions and limited human resources in government as well, could be at the root of the outbreak in Liberia. In the absence of very basic resources in rural and urban areas, the ability to contain the virus is an ongoing challenge. The inability to contain Ebola brings to light longstanding health system limitations, highlighting an urgent need for system-wide change and strengthened local capacity.
Uncoordinated allocation of resources, primary focus on donor priorities as opposed to recipient needs, and lack of communication and understanding between government and private funding organizations are crucial health system management challenges, prevalent in many developing and post-conflict nations, that must be resolved to tackle the Ebola outbreak sustainably. Resolving these issues would enable the country to tackle core issues in human resources and basic health infrastructure, particularly in rural, hard-to-reach areas. Liberia must face the challenge of resolving with its existing basic health system development priorities, coupled with the Ebola outbreak.
A solution to this conundrum will need to target several fronts at the same time. On the donor side, the United States must integrate its activities more fully with other international partners and with the MoHSW. A step in this direction has been taken with the approval of President Obama’s funding request being approved by lawmakers, to spend $5.4 billion on Ebola treatment and prevention measures in the U.S. and West Africa. The United States Agency for International Development (USAID) committed to invest in health priorities agreed upon with the government of Liberia, a good start. The Liberian health system is in urgent need of critical changes on several fronts to be able to survive this epidemic, and the MOHSW should target their weakened health system as a whole while responding to Ebola.
The overall response will have to stem from the MoHSW, prioritizing targeted Ebola response, without pausing health systems strengthening, through the initiation of a new healthcare framework with proper protocols and legislations in place. A community health worker initiative led by the MoHSW in partnership with international organizations, such as Partners in Health and Last Mile Health, in which lay community members are being trained as an Ebola response workforce that can be converted into a sustainable community health workforce, is a step in the right direction. Other initiatives should be started to meet the dire need for human resources and increase training programs for healthcare professionals. Large-scale basic health infrastructure development must also be prioritized in an integrated response, such as through plans to convert Ebola response units into sustainable health clinics and appropriate placement for such units. This is the only path to address the current epidemic, to stunt epidemics like this in the future, to value each human life, and to bring about revolutionary changes to provide for every human’s basic right to good healthcare, even in those areas hardest hit by the Ebola outbreak and by weak health systems overall.
Priyanka is a dental surgeon with four years of work experience in general dentistry, currently pursuing her Masters in Public Health at NYU’s Global Institute of Public Health. The lack of oral health awareness and a dire need for community level interventions inspired her to study public health. She aims to work in the field of health policy at a global level especially to improve facilities in resource-limited settings. Her areas of passion include tobacco cessation, tobacco related disorders and prevention programs.