Ebola: A Unique Opportunity To Rebuild And Strengthen Health Systems In Africa


A Presentation to the House Committee on Foreign Affairs

By Dr. Chinua Akukwe

September 17, 2014

The Perspective
Atlanta, Georgia
September 25, 2014


President Obama and Mrs. & Dr. Brantly
Health workers remove the body of a young man suspected to have died of Ebola.
Courtesy of (Reuters/James Giahyue)

I thank Chairman Christopher Smith and Ranking Member Karen Bass and other members of the Subcommittee on Africa, Global Health, Global Human Rights and International Organizations for the unique, privileged opportunity to participate in this very timely hearing on global efforts to fight Ebola. I also express my gratitude to the Foreign Affairs Committee Chairman, Edward Royce for the formal invitation to this hearing.

I am particularly honored to share this podium with Dr. Kent Brantly, perhaps the best known face in ongoing global efforts to fight Ebola for his inspiring, heroic and graceful personal fight against Ebola. Seeing Dr. Kent Brantly walk out of the ambulance on his own after his evacuation from Liberia to Emory Hospital in Atlanta will forever remain one of the brightest days in the global fight against Ebola. By making those fateful, short steps into the hospital, Dr. Kent sent an incalculable message to the world: Ebola is not a universally, fatal disease. You can win the fight against Ebola. Dr. Kent’s discharge home weeks later from the hospital also represented another powerful milestone: survival is possible.

Eminent clinicians and scientists, Dr. Anthony Fauci and Dr. Lucinna Borio should have addressed key clinical, epidemiology and security implications of an unchecked Ebola global epidemic in their prior presentation. The focus of my intervention is on how the preventable spread of Ebola presents a unique opportunity to rebuild and strengthen health systems in Africa to minimize future occurrences.

What Do We Know About Ebola in Africa?

According to the World Health Organization (WHO), as of Sunday, September 14, 2014, at least 4366 cases of Ebola have been identified, with 2218 deaths (www.who.int/csr/disease/ebola/en/). Three countries in Africa: Guinea, Liberia and Sierra Leone remain the epicenter of Ebola. These countries have “widespread and intense transmission” according to the WHO. Nigeria and Senegal have “cases” or “localized transmission.” Neighboring countries such as Benin, Burkina Faso, Cote d’Ivoire, Guinea-Bissau and Mali are at risk of cross border transmission. The WHO also reports that the Democratic Republic of Congo is recording an upswing in confirmed Ebola cases, with 31 more cases since early September. Ebola as noted by the WHO is endemic in poor, remote villages at the edge of rainforests in Central and West Africa. The current 47% fatality rate with the 2014 Ebola outbreak is significantly lower than previous rates of more than 90 percent.

The overwhelming mode of transmission in the 2014 Ebola outbreak is human-to-human. Between 2 and 21 days, suspected cases must only be quarantined but should be monitored closely until the end of the incubation period. As of today, the WHO is reportedly not aware of any “licensed, specific treatment or vaccine” to manage serious cases of Ebola.

Each serious case requires intensive, supportive care by doctors, nurses, laboratory scientists and other paramedical staff. In Ebola outbreaks, strict protocols must be observed in regards to direct contact between an infected person and other individuals. This protocol extends to exchange of bodily fluids and interaction with environments contaminated with bodily fluids, including blood.


Challenges of Health Systems in Africa

Any individual that has spent time in a typical public hospital or health center in Sub-Sahara Africa can immediately grasp the fundamental challenge of stopping human-to-human spread of Ebola in Africa. Sub-Sahara hospitals and health centers are typically overcrowded, with overwhelmed health workers trying their best to cope with huge demand. As we noted in my edited book on Healthcare Services in Africa: Overcoming Challenges, Improving Outcomes, a typical hospital or health center faces difficulties of operating in dilapidated infrastructure, working under the constant threat of poor funding, navigating inadequate supplies and malfunctioning equipment, dealing with poorly motivated co-workers and facing dissatisfied clients on a daily basis.

In every index of health by multilateral agencies, including the WHO, African countries dominate the laggards. The WHO estimates that although Africa accounts for 24% of the global burden of diseases, it is home to only 3% of the global health workforce. Life expectancy in Africa has now “improved” to 58 years according to the WHO (www.who.int/healthinfo/global_burden_diseases/en/) compared to 76 years in the Americas;
67 and 76 in South East Asia and Europe, respectively. At least 63 out of every 1000 newborn in Africa will die before their first birthday compared to 13 in the Americas, 39 in South East Asia and 10 in Europe. Adult deaths in Africa are nearly three times higher than comparable rates in the Americas and Europe.

In regards to coverage of preventive and treatment services, Africa is the only region to show on the average just 50% of its population covered by both modalities of care. Latin America and the Caribbean have more than 70% coverage. In nearly every healthcare indicator, the Africa region overall ranking is much lower than other regions.

Guinea, Liberia and Sierra Leone face enormous, daunting healthcare challenges. According to the WHO, the proportion of physicians per 1000 population in the three countries are among the lowest in the world at rates of 0.1 for Guinea, 0.014 for Liberia and 0.022 for Sierra Leone. Compare these rates to 2.79 in the United Kingdom and 2.453 in the United States. In every healthcare indicator with country specific data, Guinea, Liberia and Sierra Leone consistently rank poorly.

Concurrent Human Development Challenges

One of the most worrying trend is that Africa and African countries dealing with serious health challenges also lag behind in human development indicators. The widely respected United Nations Development Program (UNDP) Human Development Index (HDI) consistently show Africa and African countries lagging behind other regions and countries. The 2014 HDI reaffirms Sub-Sahara’s highest rates of income inequalities compared to other regions (www.undp.org/en/2014-report; hdr14-report-en-1.pdf) with up to 72% of Africans living with “multidimensional” poverty related issues such as poor living standards and limited access to quality education and healthcare services. Of the 187 ranked countries in the 2014 HDI, with number one, Norway adjudged the best, Guinea is ranked 179, Liberia 175 and Sierra Leone,

Progress towards attaining the Millennium Development Goals (MDGs) by 2015 also show the Africa region and African countries struggling to meet the eight MDG goals.  The United Nations 2013 MDGs report (www.un.org/millenniumgoals/pdf/report-2013/mdg-report-2013- english.pdf) and the accompanying Africa regional report (www.uneca.org/publications/mdg- report-2013) show that Sub-Sahara Africa lags behind other regions in meeting each goal on or before 2015. Guinea and Sierra Leone will likely achieve only one of the eight goals by 2015. Liberia, optimistically, may meet the target of two goals. A critical challenge for Africa post 2015 is how to deal with the dual challenge of ensuring timely access to services and at the same
time improving quality of services.

Governance remains a fundamental challenge in Africa despite progress made in organizing elections, the peaceful transfer of power in some countries and reduction in intractable conflicts. Africa retains poor ranking in various accountability and transparency indices. The Transparency International 2014 Corruption Perception Index ranks Guinea at 150th out of 170 countries and Sierra Leone at 119th. Liberia is ranked better at 83rd. The Heritage Foundation 2014 Index of Economic Freedom lists Guinea, Liberia and Sierra Leone as “mostly unfree” with poor ranking among 165 nations.


Taking Advantage of Global Anti-Ebola Efforts to Rebuild and Strengthen Africa’s Health System

The Global fight against Ebola has firmly reestablished the concept of the global village. An outbreak that reportedly started with a traditional healer in a remote part of Guinea without extensive, expensive countermeasures could have reached major capitals of the world by now. Although it is possible for Ebola to be transmitted in Western countries, including the United States, the existing healthcare infrastructure can adequately handle emerging cases. Years of steady advancements in all facets of healthcare delivery ensures a robust response to any emerging health threat in the U.S. and other industrialized countries. This is far from the situation in Africa, including West Africa with three hardest hit countries.

I have shown earlier the poor health and human development indicators in Guinea, Liberia and Sierra Leone, current epicenters of the 2014 Ebola outbreak. This scenario is applicable to many African countries. Simply put, only a handful of African countries can mount a robust firstresponse to a potential Ebola outbreak. Nigeria is one of such countries as evident from its so far, successful containment efforts.

However, I am not aware of any African country that can mount a sustained, multi-sectoral, multidimensional response to Ebola or any fast spreading infectious disease.

We have learnt from the HIV/AIDS global epidemic that robust health systems are critical in mounting and sustaining a vigorous response to an emerging disease threat. A successful response against a multi-country disease threat requires rapid national and coordinated regional responses. It also requires sharing resources, expertise and experiences. Mainstreaming human development strategies in highly optimized, functional healthcare delivery system is equally important.

Unlike mistakes made with the largely vertical response to HIV/AIDS in Africa until recently, the 2014 Ebola outbreak provides a unique opportunity to rebuild and strengthen health systems in
Africa. This rebuilding and strengthening effort unlike the primary healthcare days of the late 1970s and 1980s when many health facilities were constructed should focus on dedicated, long term, public/private international partnerships to tackle specific deficiencies in healthcare delivery systems in Africa. This long term approach will end the current episodic, disease specific response that I have witnessed in Africa in nearly three decades of active engagement
in the healthcare industry. A deliberate, systematic process for tackling specific deficiencies in Africa’s current chaotic healthcare system will be the best guarantee that Africa will not only protect its people in the event of an emerging health threat but will also be part of a resilient global health architecture capable of safeguarding individuals and families around the world.

I briefly review the proposed international public/private partnership should.

International Public/Private Partnerships on Transforming Africa’s Health System

United States and other industrialized nations should go into a mutually beneficial, long term partnership with African countries to transform healthcare delivery systems in the continent.

The envisaged partnership should include:

1)   African governments, continental and regional institutions;
2)   Bilateral agencies;
3)   Multilateral agencies;
4)   Global Foundations;
5)   The Academia;
6)   The Organized Private Sector;
7)   The Civil Society; and,
8)   Africans in the Diaspora.

The International Partnership should target the following overarching issues that bedevil seamless operation of healthcare delivery systems in Africa:

A)  Intractable Governance, Accountability and Regulatory deficiencies; B)  Lack Luster Continental and Regional Technical Response;
C)  Silo-based Human Development and Healthcare Strategies and Programs;
D)  Ineffective Health Financing Mechanisms; E)   Dilapidated Infrastructure;
F)   Erratic Logistics support;
G)  Poor Operational Management and Service Delivery;
H)  Limited Monitoring and Evaluation protocols and utilization processes; and, I)      Inadequate Stakeholder Engagement and Participation.

The foundation of the proposed International Partnership is that both African and international partners must commit to transparency and accountability in the health sector, to timely access to care for at-risk populations and to the highest quality of care at all times.

The International Partnership should holistically address the following technical challenges in
Africa’s healthcare systems:

i)          Establishing strong technical capability at continental and regional economic levels in Africa. Africa needs strong continental and regional leadership on technical assistance, research, regulatory frameworks, public/private partnerships and rapid response mechanisms. Very few African countries at present can mount a credible, sustained response to disease outbreaks and emergencies. The African Union Commission and the WHO Africa region can develop strong technical capacities to provide assistance to African countries. The regional economic communities can also provide critical early response support on emerging and known health threats;

ii)         Rebuilding and Strengthening National Health System Architecture. Virtually every country in Africa will benefit from this effort. Key national rebuilding efforts include transparent policy frameworks, accountable operational mechanisms, infrastructure development, surveillance systems/situation assessment/response mechanisms, health workforce development/retention, essential drug regimen, health financing mechanisms, management of primary healthcare systems, and management of secondary and tertiary healthcare systems;

iii)        Supporting Viable Public and Private Health Systems. I am not aware of any African country where public sector health systems are meeting needs of target population, especially the poor. I am also not aware of any African country where private sector healthy systems are perceived as comprehensively attuned to health priorities of target populations as well as an ethical, affordable alternative. The key is to encourage viable, ethical, affordable and accessible public and private health systems throughout Africa.

iv)        Implementing Successful Preventive Health Programs. A worldwide problem particularly acute in African due to cultural taboos and practices, mistrust of governments and its foreign partners as well as  limited access to health services.

Designing credible, effective information, education and communication (IEC) campaigns will be crucial to any successful transformation of Africa’s health system. The early effort against Ebola in Guinea and Liberia suffered from poorly managed and poorly received IEC campaigns, with disastrous consequences. It took several weeks for some target population in these two countries to believe that an Ebola outbreak was afoot and several more weeks to alter risky practices such as elaborate burial rites that facilitate human-to-human transmission.

v)         Science, Research and Technology should be key. The envisaged international partnership can play accelerated, catalytic role in jumpstarting the role of science, research and technology in successful healthcare transformation efforts in Africa. Twinning arrangements between Africa and academic institutions around the world will be crucial in assuring a steady pipeline of world class scientists and translation of findings from innovative scientific/research projects to guide transformation efforts.

vi)        Engaging Africans in the Diaspora. This will be a very tough nut to crack since it is difficult to organize Africans in the Diaspora for specific, large scale efforts in Africa. However, the upside is incredible. The National Medical Association, the National Dental Association, the National Black Nurses Association and other similar organizations have thousands of members that could be incentivized to work and live in Africa. Africa Diaspora entrepreneurs and investors, scientists, lawyers, administrators and other professionals can play critical roles in reshaping healthcare delivery systems in the continent.

Africa healthcare system is currently at crossroads. The 2014 Ebola outbreak is exposing well known fault lines in Africa’s healthcare system that could have grave repercussions worldwide. Africa is not prepared to deal with Ebola or any future health threat on its own without external assistance. I am calling for a long term, mutually beneficial international partnership to SPECIFICALLY ADDRESS known deficiencies in Africa’s health systems and transform the continent into a reliable component of a global healthcare architecture capable of preventing and warding off known and emerging health threats.  More 14 years ago, the 106th Congress passed the historic, novel Public Law 106-264, The Global AIDS and Tuberculosis Relief Act of 2000 (www.gpo.gov/fdsys/pkg/STATUTE-114/pdf/STATUTE-114-Pg748.pdf) to jumpstart the global response against HIV/AIDS.  Today, the 2014 Ebola Outbreak in Africa provides another opportunity for the U.S. Congress to lead the way, one more time.

Thank you so much for your time and attention.

Dr. Chinua Akukwe
National Academy Fellow and Chair, Africa Working Group, National Academy of Public Administration, Washington, DC.

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