If you were at the Fourth Global Symposium on Health Systems Research (HSR2016) held in Vancouver, Canada, you would know that “Resilience and Responsiveness of Heath Systems” was the (timely) theme of the symposium. I had the honor and privilege of speaking and participating in the closing plenary of HSR2016, as a representative of the Emerging Voices for Global Health program. In many ways, this was a defining moment for me, to share the platform with six stellar thinkers in the health policy and systems research (HPSR) community, and another EV alumnus, Kopano Mabaso, who expertly moderated the panel.

With the closing plenary in mind, I kept an eye out for sessions which addressed the theme of resilience and responsiveness. My aim was to gather thoughts from leading thinkers in the field, and where fitting, to include those final reflections in my closing speech. Like many attendees, I heard several definitions being attributed to “resilience”, without any consensus; on the other hand, responsiveness seemed to be much easier to define. Gathering all these diverse perspectives at once, felt a bit like ‘let a thousand flowers bloom’!

Could “resilience” really mean many different things to many different people all at the same time? This would be fine, if we only gathered in Vancouver to celebrate our diversity. But, I presume our investment in knowledge exchange platforms of such magnitude goes beyond celebrating our diversity, to promoting engagement around common and shared ideas. Yet, as the symposium progressed, I became increasingly uneasy about the lack of consensus around what resilience in health systems is – and I have a hunch I wasn’t the only one.

The eye opener for me was the moment I heard Agnes Soucat (moderator of the opening plenary) state with refreshing honesty that she wasn’t quite sure yet what the term resilience meant. This, along with reflections from other talks at the symposium, was reflected in my closing plenary speech. The many-sided perspectives on resilience were also reflected in the closing Vancouver statement – which highlighted that “resilience” means different things to different people and needed some “revisiting” or redefinition. I wondered how, with all the expert knowledge present at the symposium, we as a community didn’t reach a consensus on defining resilience within the context of health systems research.

Weren’t these themes supposed to anchor our research to be relevant to policy? I left my thoughts on that hanging, to revisit at a later time. But “later” came sooner than I thought as I prepared to pack up from Vancouver to head back to Ottawa where I am based. I stared at the messy pile of clothing on my hotel room bed that I had “unpacked” from my suitcase the night before. I was reminded of my friend’s unfavorable reaction on the use of the term “unpack” in health policy and systems discourse. Is it because “unpack” suggests a messy endeavor? Could “unpacking” resilience be a downright messy job, that HSR2016 didn’t do enough justice? At some point, someone  (any takers? health systems researchers?) – has to do the dirty job.

HSR2016 is over and we’re already looking forward to HSR2018 in Liverpool. I still feel uneasy each time I see a tweet canvassing for potential themes for HSR2018. What did we do with resilience? The closing statement in Vancouver certainly suggested it was unfinished business. So why are we happy to move on to the next catchy term? Maybe we should do some soul searching here. What drives our desire in generating themes for symposia? Should we re-examine our euphoria at having a theme that’s only good for a symposium, and lacks the consensus for continuity beyond? How will all the research projects framed to align with the theme of resilience continue if we’re already on to the next theme? Whatever happened to unpacking resilience in health systems research and practice?

Looking back

In hindsight, our responsiveness as a community towards evidence, though not always timely, has gained traction since the advent of major health policy reform that occurred in the 70s. Building on the work of British historian Thomas McKeown, Canada’s 1974 Lalonde Report, was the first government document to argue the importance of social over biomedical determinants of health. Granted, the report lacked objective targets and timelines (MacDougall, 2007). Yet, five years later, the US Surgeon General’s 1979 Healthy People Report concluded that capital-intensive investments in ‘medicalized’ healthcare did not yield parallel improvements in health (Irvine, 2006). The report also set national targets for radical reform of health policy and systems in the United States. That critical paradigm shift remains a pillar of public health policy and promotion today; supported by extensive work, such as “Closing the Gap in a Generation” – the report of the WHO Commission on Social Determinants of Health (WHO, 2008).

These and other developments culminated internationally in the WHO Declaration of Alma Ata in 1978  – a milestone with an enduring legacy of primary health care. The Alma-Ata agenda of “Health for All by the Year 2000” redesigned public health systems around the concept of primary health care, and pushed the boundaries from disease-oriented to appropriate technology; from medical elitism to involving lay and traditional providers from a community-engagement stand point; and, from dependent, consumer-driven health services, towards health as an enabler for socio-economic development. Alma-Ata was a game changer. It made a strong case for comprehensive primary health care, by linking health to development, with obvious political implications (Ceuto, 2004). It stressed the need for action against persistent social and economic inequalities that impact health. It emphasized equity, community empowerment, and participatory planning – principles which still guide our work as a global community. On the downside,  comprehensive primary healthcare was difficult to implement, criticized as unwieldy, and replaced within a year by a selective, disease-specific approach to promising cost-effectiveness through measurable and attainable goals. This appealed to our community of scholars, experts, donors and policy makers (Evans et al. 1981), leading to wide proliferation of programs, projects, and organizations focused on developing countries. The impact is undeniable – 20 million lives saved from HIV/AIDS, Tuberculosis, and Malaria – the Big Three. Yet, parallel programs siphon human resources from overburdened national health systems, leaving them worse off than before. (Scott, 2016, Cueto, 2004). Their legacy also includes a growing conundrum of neglected and re-emerging diseases.  Case in point – guinea worm eradicated from 186 countries as of 2013, re-surfaced in 2016, long after many donor-supported programs became defunct. Clearly, the difficulty of implementing Alma-Ata principles tested our collective resilience to evidence-based health systems reform. And? We gave way. We chose economic expediency over systemic viability. While the cost implications of such choices are often delayed, they are also often compounded until disaster strikes.

Disaster certainly struck the international community in 2014 during the West African Ebola Virus Disease outbreak in Guinea, Liberia, and Sierra Leone. Despite well-funded parallel programs on HIV/AIDS, Tuberculosis, malaria, and maternal and child health, health systems in these three countries came to a grinding halt. Limited capacity to isolate and contain the epidemic, dismal outcomes for hordes of infected people, and fear mongering aggravated the costs of this deadly hemorrhagic fever beyond direct counts of 28,000 cases, and 11,600 deaths. Guinea, Liberia and Sierra Leone together lost 240 doctors, nurses and midwives combined, creating bottlenecks to essential services delivery, and maternal mortality, increased by 30% over the period to more than 111% across the three countries. Failure to comply with the International Health Regulations, which would have ensured better preparedness and responsiveness, came at a dear price, especially for frontline health workers in the eye of the storm. Not unexpectedly, these poorly resourced health systems caved, making recovery and reorganization more challenging and capital intensive. Along with trying to make sense of the rubble that remained of a society brought to its knees, survivors must live with the painful final memories of loved ones – mothers, children, family, and front line health workers carried in body bags to a makeshift gravesite as a final resting place. The lessons are well rehearsed among many experts. In times of calm, resilience building is vital; in moments of crisis, reaction time is priceless.

The world was outraged to learn about the ill-timed and uncoordinated response to early evidence of the outbreak from the WHO and its AFRO region office. Yet historical examples suggest an unfortunate precedent of professional and political inertia to evidence that challenges the status quo. In 1980, the Black Report released in the UK, identified poverty as a major determinant of ill health and death, and yet was sidelined for purely socio-political reasons. In 1997, the WHO Jakarta Declaration identified poverty as the greatest threat to health (WHO, 1997). We as a solution-oriented community could have been two decades ahead in the fight against global poverty, if our response to evidence was resilient to political shocks. Like society, shocks to health systems have morphed into complex factors. Today’s political shocks include migration, displacement and human mobility, or an influx of refugees. Economic stress comes in funding cutbacks, and donor driven-agendas giving rise to buzz words that distract from the core value of health systems strengthening, and push us further apart into artificial disciplinary silos. Long-term strains include the burden of non-communicable diseases, emerging and re-emerging infections, global health security, and climate change. In the face of these challenges, governments, civil society, local communities, frontline health workers and managers, and the international community rely on us for insight into current challenges.

So how can the HPSR community avoid being crippled by our own expert criticisms, and overridden by political agendas, in order to contribute to health systems resilience? We must continue to draw on our collective expertise to build a unified resilience in the system as a whole.

We must be strategic to ensure routine healthcare delivery is effective, and health systems responses and recovery during global health emergencies are timely. We must recognize that the mainstay of resilience lies in the dynamic strength of its stakeholders, and in how effectively we communicate, to ensure convergence across our diverse contexts. This “C3” approach  – communication, convergence, and context – must be core to activities health systems strengthening to build resilience over the long-term.

Communication requires the HPSR community be on the cutting edge of information technology (IT), to enable real-time innovation for care delivery and decision-making. We should support routine monitoring, evaluation, and surveillance to boost health workforce capacity and function. And we must be clear with our communication – yes, including what we mean by resilience and responsiveness.

Context questions our intrinsic values as a research and practice community. Do the social determinants of health undergird preemptive research to demystify the underlying drivers of health inequities? Have we championed transparent governance to improve fiscal responsibility of low-income governments, for instance, on compliance with international health regulations? Do we demand accountability of multinational corporations, international trade and development agreements? How has our work supported fair-trade negotiations, that enable residual capacity building across multiple sectors? Have we truly acknowledged that these issues are fundamental to boost economic development particularly in low-income settings, thus making universal health coverage (UHC) feasible, and equitable health services delivery attainable?

Convergence highlights the rich diversity within the HSRP community. We can efficiently broker research uptake in practice and policy decision-making, to expand health system capacity, and to support primary healthcare delivery, which in some regard is an informal indicator of the general health of the population. Beyond identifying what works and how in various contexts, we should strategically engage and re-align key players and motives, to level the field, making universal health coverage attainable and broad-based services accessible to all, including poor families. Hiding behind knowledge brokers and power brokers to interpret our pet jargon to decision makers, only widens the divide between evidence generation and decision-making.

Looking forward

Building resilient health systems requires research policy, and practice that acknowledges and values local champions – those with invested, long-term relationships of mutual trust with communities we seek to improve. We must identify whose input these communities consider critical to their welfare, which champions they trust to represent their best interest and not just ours, and therefore whose voices should be represented at brainstorming and decision-making tables. And we must endeavor to work collaboratively towards solutions.

We, as the HSRP community, must now go ‘long and deep’ – the era of enabling ‘elite experts’ (or with our best efforts ‘expats’), who ‘parachute’ into crisis situations, provide their expert opinion and leave, is outdated. Much too often, this strategy does not build residual (localized) capacity that is essential for resilience. A beautiful example is how BBC Media Action, had worked in Sierra Leone for ten years before the 2014 Ebola outbreak. They brokered innovation with their long acquired ‘social capital’ to promote socio-culturally informed communication strategies, which helped to reduce misinformation, and was vital to save lives.

Investing in local capacity also allows us to apply lessons learned from one end of our increasingly smaller global village to the other. What works in urban planning to mitigate poverty and improve livelihoods in Khayelitsha, a largely impoverished urban sprawl in Western Cape, South Africa, may be applied to reduce unsafe gas emissions, and possibly, to improve containment of a potential disease outbreak in the slums of Dharavi in Mumbai, India.

As we consider a post 2015 sustainable development agenda, with our goal to build resilient health systems, let’s rethink our response strategies to evidence, events, and emergencies. Our emergency paratroopers (the experts) are critical to analyzing a crisis. However, their expertise may be better translated to effect desired change by the ground troops who are invested in raising, and in leveling the field to provide equitable health care. This involves long-term resilience building  – the kind that is needed to overcome latent stresses.  Like resilience, trust is built over time, and is tested in difficult circumstances. Crises create time windows of opportunity for establishing trust between affected populations and those in a position to help.

We have made much progress in strengthening our responses towards systemic and external shocks. We continue to invest in systems that enable timely and coordinated responses to evidence, events, and emergencies. Arguably, containment of the Zika virus outbreak in multiple countries earlier this year attests to this. To sustain this momentum in building stronger and resilient health systems, we must amplify stakeholder engagement, maximize the opportunities presented in and out of crises, pursue integration along health and all other sectors, and remain flexible to adapt our strategies as needed.

The next two years will be critical to what becomes of ‘resilient and responsive health systems’. Let’s do the due diligence to streamline central tenets that promote synergy within our interdisciplinary community. Let’s have the audacity to bridge the divide across professional silos. We are one community and we represent more than policies and programs, budgets and building blocks – there is no identity crisis here. We are the critical link between health systems strengthening, resilience, and achieving the 2030 Sustainable Development Goals. Resilience will require much more than each of us striving to do better; it will take us striving to do better together.

References

1. Hancock T. Lalonde and beyond: looking back at ‘A New Perspective on the Health of Canadians’. Health Promot 1986;1(1):93–100
2. World Health Organization, Committee on Social determinants for Health, 2008
3. Cueto, M. (2004). The Origins of Primary Health Care and Selective Primary Health Care. American Journal of Public Health, 94(11), 1864–1874.
4. Evans JR, Hall KL, Warford J. N Engl J Med. 1981 Nov 5; 305(19):1117-27. Shattuck Lecture–health care in the developing world: problems of scarcity and choice.

Despite widespread global awareness of the ongoing Ebola crisis in West Africa, humanitarian and relief organizations on the ground say the current response is inadequate to effectively contain the epidemic, even if some progress is noticeable. The debate on the international response has been fierce in recent months. But has Africa, at the epicenter of this crisis, demonstrated the necessary leadership in the ongoing fight against Ebola? This first part of a two-part communication spotlights African responders and responses to the Ebola epidemic. A second piece will then weigh the pros and cons of Africa’s response so far, with a focus on whether things are headed in the right direction to stem this crisis where it began. (We are well aware we are chasing a moving target here.)

Africa is facing its most horrific Ebola outbreak to date. Till now more than 18,000 cases and over 6500 deaths have resulted from this Ebola epidemic, which began in Guinea and spread rapidly to Liberia and Sierra Leone. In spite of a heightened sense of urgency, the human and medical resources needed to address the epidemic still far outweigh the capacity of humanitarian and relief organizations offering critical support through health personnel, medical supplies, food, quarantine services, and community education. The number of cases being reported daily has fallen, at least in Liberia, but transmission continues in the three hardest hit countries, with Sierra Leone currently as the biggest worry. Aid and healthcare workers are constantly at risk of infection, with several such cases garnering international media attention. The UN Mission for Ebola Emergency Response (UNMEER)’s 70-70-60 goals – to get 70% of the cases isolated and treated, and 70% of the deceased safely buried within 60 days starting from 01 October to 01 December turned out to be too ambitious. Nevertheless, the hope is that in 2015, African and the world will manage to get this Ebola outbreak under control.

Expert opinions differ about who should bear primary responsibility for the crisis in West Africa. Lately the mantra has been that we should ‘stop the blame game’, at least until the crisis is over (Margaret Chan did so, but see for example also here). That seems to make sense. Anyhow – just as some background for this communication then – some observers attribute challenges with containing the infection to delayed  international awareness and hence a belated response to the crisis. Others blame the rapid spread of the epidemic on fragile health systems in West African states; depending on the perspective of analysts, they refer to civil war & post-conflict reconstruction difficulties or, instead, to neoliberal policies, structural violence and/or a GHI “vertical” focus on diseases to explain these weak health systems (and the weak governance situation in general). No doubt last week’s WHO High level meeting in Geneva on building resilient systems for health in Ebola-affected countries also offered some explanations for poor health systems – the background document gives some more detail on the pre-Ebola health systems (as well as on the current health system situation).

As is well known by now, the WHO and especially its regional office for Africa (WHO AFRO) and some country offices have been harshly criticized for their response, as demonstrating poor and incapacitated leadership (see for example an editorial in the Lancet). According to last week’s Economist issue, WHO top staff in the three main affected countries have even been removed by Margaret Chan, presumably not because she was extremely happy about their performance. Prominent African voices have also critiqued government and regional responses across Africa as being marginal, and shamelessly dependent on Western aid to handle the crisis – not the least because of the seemingly colonial carving up of the response (with UK assisting in Sierra Leone, the US in Liberia and France in Guinea). Conversely, though, other documented responses portray a resurgent Africa fighting Ebola with grassroots initiatives that make apt use of social capital and media. Like SARS and the HIV/AIDS pandemic before it, Ebola has entered the niche of truly global threats to health that defy confinement to their place of origin – what David Fidler calls ‘post-Westphalian’ public health. With incapacitated health systems, West Africa is unlikely to effectively contain the epidemic without international support. They’re working on it, including on “post-Ebola” health systems, together with the international community – see last week’s ‘building resilient health systems’ meeting in Geneva. But the question we’re interested in here, is: despite limited capacity, has Africa somehow demonstrated the resolve to take leadership in stemming this horrific global crisis? Let’s try to map the responses, without aiming to be exhaustive as the situation still changes fast.

African governments, regional institutions and other stakeholders

The Economic Community of West African States (ECOWAS), WHO Afro and other West African stakeholders including ministers of health, donors, and industry representatives already obtained member state consensus at an emergency meeting in Accra, Ghana in early July, convened by WHO Afro, on how best to interrupt ebola transmission and limit the human, economic and social impact of the epidemic and any future outbreaks (WHO & governments of Guinea, Liberia & Sierra Leone Ebola response plan W/A). The two main goals agreed upon then were to stop transmission in affected areas by scaling up proven interventions, and to limit spread through better preparedness and response. This led to the adoption of a strategy for an accelerated response to Ebola which ECOWAS is implementing. National governments in Guinea, Liberia, and Sierra Leone pledged $0.7 million, $6.2 million and $17 million USD respectively to support national responses from July to December 2014. This left an overwhelming shortfall of over $71 million to implement the response plan.  In September this year, the WHO launched a global appeal for more than $1 billion USD to confront Ebola. By the end of October 2014, no African countries were on the UN list of international donors to fight Ebola. Pledges of support from African countries in terms of personnel and resources were also yet to be fulfilled at the time.

The African Union (AU), criticized for not responding until 4 to 6 months after the crisis began, released $1 million USD for medical supplies from its emergency fund for drought and famine in August 2014. In September, staff and members donated an additional $100,000. The AU also formed the African Union Support to the Ebola Outbreak in West Africa (ASEOWA) (humanitarian) mission, finalized a concept of operations, and deployed the first set of paid volunteers to Liberia in September. The task force comprises epidemiologists, clinicians and communications personnel, and facilitates existing field response operations by means of “technical expertise, resources, political and financial support”. The mission also includes expertise from WHO, UNOCHA, IFRC, US Mission to AU, CDC and others. Plans are underway to deploy volunteers to Sierra Leone and Guinea.

The (response) track record of the African Development Bank (AfDB) looks a bit better. It contributed over $3 million USD in May and approved a further $60 million in grants to support the emergency response, as part of an overall $210 million investment to strengthen health systems in West Africa. The investments will focus on boosting human resource capacity, epidemic preparedness and response, mobile technology (m-health), governance and regional institutions. AfDB has also signed a $300,000 grant protocol together with ECOWAS, to support affected countries, ECOWAS and the Mano River Union to deal with Ebola. (figures from a while ago)

Colonial lines were drawn again for (international) Ebola aid  (in line with institutional aid relationships between the United States and Liberia, the U.K. and Sierra Leone, and France and Guinea ), but the three national governments of affected countries also took action, even if perhaps belated. Like their population, they had to go through a ‘learning curve’ (see for instance the involvement of the military) in dealing with Ebola, and cope with low levels of trust and limited governance capacity in general. Liberia re-institutionalized its Ebola response unit within the Ministry of Health and Social Welfare, and employed the CDC’s incident management system to increase national autonomy over managing the Ebola response in the country. The Liberia Institute for Biomedical Research is also receiving training from WHO on safe collection of oral swabs and identification of cause of death. After initial skepticism to play down the severity of the epidemic, the President of Guinea is now very directly involved in stemming Ebola infections and transmission in the country – and you can take that quite literally. The grim situation in Sierra Leone (the most worrying setting for the moment) raises awkward questions among the population and abroad – see  Laurie Garrett for example in Foreign Policy, on the question why the situation in Liberia seems to improve steadily while the Ebola outbreak in Sierra Leone is still spiraling out of control. WHO’s Bruce Aylward even thinks that part of the reason is that the people in Sierra Leone didn’t go through the same behavioural learning curve yet (as in Liberia & Guinea).

Nevertheless, Sierra Leone also demonstrates the selflessness of health workers fighting Ebola on the frontlines, with no guarantee of recovery if infected in the line of duty, and with often shaky payment modalities. These African health workers and their heroic response stand in stark contrast with the rather marginal contributions from most African leaders and institutions. Foreign aid and health workers suspected of contracting the infection are typically flown outside to Western countries for treatment, where they stand an arguably better chance of recovery. On the contrary, local health workers are treated in-country, with few survival stories. Worse, The Lancet just reported that local doctors went on strike in Sierra Leone after it emerged that they would not be able to access a specialised British-run Ebola treatment unit for health-care workers. We hope this can be solved soon. Anyhow, no matter whether they’re local or foreign, health workers engaged in the fight against Ebola are all heroes, as Time Magazine acknowledged last week. The same goes for the burial workers, a very unthankful but vital job.

Nigeria, Senegal, DRC, and some communities within Guinea, have successfully contained the spread of the disease (and Mali seems to be heading in the same direction, touch wood). These and other countries in the region are – to some extent at least – sharing their resources and expertise to limit the spread of infection (even if neighbouring countries also sealed off borders, regrettably). WHO helps (is helping?) countries in the region prepare for the event of an Ebola outbreak. Among others, The Gambia and Botswana also gave a monetary contribution. Nigeria pledged $3.5 million to the three affected countries, to the West African Health Organization (WAHO) and to the ECOWAS Pool Fund. In Senegal, public awareness through an existing SMS  platform proved successful in combating the epidemic. The DRC promised to send 1000 volunteers to the affected regions. The Telimele district in Guinea set an example by becoming Ebola-free by supporting healthcare interventions with a crisis committee involving religious, community and political leaders to promote awareness and aid case containment.

Other African countries also committed money, staff and/or medical supplies, whereas Ghana serves as a base for UNMEER. Kenya, Namibia, and Cote d’Ivoire have each pledged $1 million USD; Ethiopia $500,000 and 200 volunteers, and South Africa approximately $4.5 million and diagnostic laboratory support. Uganda has deployed health workers to support the ongoing response in affected countries. South Africa has been instrumental in some more ways. A South African diagnostic center in Sierra Leone is training local personnel to assist with diagnosing Ebola. The UNDP is deploying South African-produced sterilizing units suited to low resource environments, to limit infection spread through medical waste. South Africa’s National Institute of Communicable Diseases is set to host a regional center of excellence to diagnose Ebola. Private and public sector donations of approximately R50-million have also been mobilized for the international Health and Humanitarian Response in Guinea, Liberia and Sierra Leone. Additional financial pledges have been made by leading businesses in Africa ($28 million – probably far more by now).

So it’s not like nothing has been done by African government actors, regional institutions and other stakeholders. Nevertheless, the overall feeling was one of ‘relatively little, and rather late’.

Grassroots initiatives

The grassroots picture has been more uplifting. Local non-governmental organizations and Africans in the diaspora are using social mobilization and public awareness campaigns to inform affected communities, reduce fear and resistance to health personnel. Below you find some of the key examples.

Africacare has raised over $70,000 USD to support medical supplies for health workers and behavior change messages to help contain ebola. More than 200 primary healthcare workers and 350 community health volunteers in Liberia have been trained and given necessary supplies. Over 100,000 community residents have received behavior change communication to limit infection spread. ActionAid (Liberia), Africa 2.0, and Restless Development (Sierra Leone) support social mobilization, provide a stable supply of personal protective equipment to frontline responders and train a local WASH Committee for monitoring active cases using the Ministry of Heath guidelines. LunchBox Gift provides food to victims and affected families in hospitals, orphanages and quarantine zones in Sierra Leone. HOPE provides Sierra Leonean families with food and sanitation kits, and trains community leaders to provide awareness, education, and psychosocial support. THINK helps to connect affected children and youth to transit quarantine centers to facilitate treatment and integration into foster families, with regular monitoring visits. More Than Me (Liberia) has launched a mobile application to track the infected cases and families, assist ambulance teams to capture vital information, and track movements of health workers. A Liberian student at Ashesi supports real-time tracking of new cases, and potential contacts to limit the spread of the disease. Africans in the Diaspora (Liberia) supports grassroots organizations through the Africa Responds platform – to pool their resources and networks to increase solidarity. African celebrities including Tiken Jah Fakoly, Amadou & Mariam, Salif Keita, Oumou Snagare, have collaborated to promote awareness through a song whose lyrics explain how to stop the spread of Ebola. The song went viral. Several African football stars have collaborated with Hollywood actor Idris Elba (of African descent) to  launch a campaign to support health workers on the frontlines with the necessary supplies to protect themselves from infection. This campaign recognizes the health workers, the burial teams, and all stakeholders on the ground for the heroic act of working to save lives, while putting themselves in harm’s way.

As for religious stakeholders, it is clear that especially at the beginning, traditional healers, pastors and other religious groups didn’t always play a positive role – from a public health point of view – but recently there has been progress, and religious leaders have played a more constructive role, for example in raising awareness. The picture for the (mass) and social media was equally ambiguous, not unlike in the West (see the US). Fearmongering and sound information redressing misconceptions – with Ebola deeply, founded by Isha Sesay from Sierra Leone, as a key example of the latter, were both present.

Previous discussions on an African-based Center for Disease Prevention and Control (ACDCP), an African equivalent for the CDC and a long awaited centre to help in addressing emergencies on the continent, have been revived in the wake of the crisis and are now being fast tracked by the AU. This might be one of the key tools necessary to ensure implementation of the International Health Regulations across Africa (together with the WHO health system resilience actions considered at last week’s meeting in Geneva). Forty-three of 46 African countries reported assessments of the core capacities for these regulations, yet none have begun implementation, according to a Lancet Letter from a few weeks ago.

Let’s hope that will change soon. For a preliminary analysis of the African response till now, check out the second part of this two-part communication!

Let’s now try to come up with an early analysis of the overall African response till now, after our – admittedly – ‘quick & dirty’ mapping effort (see the first part of this communication). A very preliminary analysis, obviously, as the Ebola outbreak is far from over, and also based on incomplete information. We are sure that in the future, scholars will ponder the same question, based on better and more comprehensive (including also more inside information) sources. But this is the blogosphere, so let’s try to kick off the debate already, in spite of all these caveats. We invite you to comment below this blog.

To begin, we might as well start with the obvious truth that there is no one, single coordinated “African” response to ebola. “The” African response does not exist. It’s a very diverse picture instead.

Unprepared?

It’s already been said – Ebola hit a continent that had not even scratched the basics of implementing the international health regulations – essential requirements for national health systems to control outbreaks. But Ebola had hit Africa before, and previous outbreaks were contained relatively easily. The current crisis blindsided West Africa, hitting countries that were clearly unprepared for several reasons, including poor governance, low levels of public trust in the government, no previous experience dealing with ebola, and weak health systems (see the WHO high level meeting on building resilient health systems in ebola-affected countries for more details). We won’t belabor the point.

So it’s true – Africa (especially West Africa) was unprepared for this. But it is also fair to say that Africa did a rather poor job in terms of agenda setting – Ebola surfaced on the global health agenda months too late and African actors (like WHO Afro, and country offices in the affected zones) seem at least partly responsible for this delay, as were global health stakeholders (who were equally slow to respond to MSF warnings). Whether you can really “blame” African actors for this delay is less clear. Check out the media frenzy over foreign health workers who contracted the disease while volunteering in affected countries. If that is anything to go by, even if it seems unfortunately, news of Western casualties seems necessary before our global media ‘discover’ a story. In addition, many seasoned global health experts (including Peter Piot) didn’t think at the time that the Ebola outbreak would get so out of control, after a relative lull earlier this year, when it appeared that the outbreak was subsiding. In sum, there were some mitigating circumstances, but there was failure too.

As for the response, all in all, African governments and regional institutions reacted too slowly, and sometimes even wrongly at first. Again, there were mitigating circumstances. Governments in the three most affected countries had to go through a learning curve in dealing with a new disease like Ebola – not unlike the US government, but then several times worse. The needed response was also made difficult due to reasons spelled out earlier – weak governance, low levels of trust, collapsing health systems, … you name it. It was a perfect storm. Neighboring countries like Nigeria and Senegal did quite well in containing the response – they had some assets and did many things right, but perhaps they also had God or luck on their side? Neighboring countries were not always constructive, for example by simply sealing off their borders. But again, Canada and Australia were no different with policies going way beyond what is scientifically reasonable – perhaps, overreactions are to some extent unavoidable in a tragedy like this. Overall, it appears African countries in the broader region are getting their act together now, with some help from the international community. Touch wood.

Jockeying and geopolitics

As for African regional institutions and organizations, and some of the big countries, one has to wonder whether at least some saw this unfortunate situation as an opportunity to jockey for prominence and leadership in the response to the crisis (and in the African (health) governance architecture), not unlike at the global level (with WHO, CDC, World Bank and others all aligning themselves, strategically, if we may add). The African equivalent of this kind of institutional bickering obviously involves organizations like the African Union, ECOWAS, WHO Afro, …. By way of example, one has to wonder why Ethiopia with no prior experience in dealing with a disease like ebola  (and not present at the emergency meeting in Accra to launch the strategic ebola response earlier this year) seems determined to play a key role in a lot of these Ebola response efforts. African solidarity, yes,  but probably also something else.   Granted, timing was of course also an issue, in relative contributions of other African countries, with the DRC for example ready to give a hand at some point when it suddenly had to deal with its own Ebola outbreak.

Probably African geopolitics (including the threat of terrorism in Northern Nigeria and parts of North Africa, China’s involvement & respective allies in Africa, …) are also playing a role in the background. Like other regions in the world, parts of Africa are ‘catching fire’, sadly. We invite your comments and feedback on this factor. Already, there is an apparent lack of a coordinated ‘regional’ response, where country governments could complement each other’s efforts, with the overall shortfalls being met by bigger institutions that can better absorb the financial pressure involved in an immediate and effective response.

An interesting but somewhat downplayed aspect of the Ebola response till now has been the near-‘colonial’ carving up of the response in the main three affected countries. France is supporting response efforts in Guinea, the United States in Liberia, and the UK in Sierra Leone. Not very “21^st century-esque” and neither does it fit well with the ‘Africa rising’ narrative. Also, the fact that a lot of the funding from the international community seems to be channeled through US- and EU-based agencies and other international agencies (including the CDC, WHO, UNICEF, MSF, Partners in Health, …) isn’t very encouraging. The official story is that governments in the three countries are coordinating the response, together with their many international friends and partners (including under an UNMEER umbrella). But where are the equivalent African organizations that can accountably manage, disburse and allocate these funds to champion the fight against ebola? Whether there is really country ownership, is thus an open question.  It’s probably rather limited. But the hope is that, if for now ownership is too hard, in the future the governance and health systems in West-Africa will be boosted to make them more resilient.

Which takes us back to some of the criticisms from prominent African voices, of gross mismanagement of national assets being one of the fueling factors of collapsing health systems in Africa. On a side note, the Ibrahim Index of African Governance (though a debatable system of indicators) is as close to the ground as it gets with trends in governance, policy outputs and outcomes in Africa. Yet there are several years with no winner of the coveted Ibrahim Prize for (transformative and progressive) national governance.

In comparison to other stakeholders, perhaps the African business response has lagged a bit behind. As supporters keep emerging from the woodworks, the hope is that they will also find their wind and step in with timely support to maintain momentum and even boost morale for those battling the deadly disease on the ground.

Silver linings

It’s not all a doleful story, though. The grassroots and societal response in Africa has been strong. Actually, it’s been much more. It is innovative, makes apt use of social media, new media platforms (like Ebola Deeply), has tech entrepreneurs seizing opportunities to raise public awareness and Africans in the diaspora playing a positive role (see Africa Responds for example), engaging media, stars, communities and more. There are many silver linings here. Communities had (and sometimes still have) to go through a learning curve too, a painful one, as social relations had to change, but they got plenty of help from within their own communities to aid in this transition. Trust and community buy-in are key to overcome crises like these, and African grass roots initiatives have so far been very instrumental in this, although, more is certainly needed in Sierra Leone.

So even if the African response didn’t quite fit the ‘Africa rising’ narrative, if only because there is no such thing as an ‘African’ response – it’s a very nuanced picture – the general feeling is definitely not one of ‘powerless Africans’ either. This is also part of the reason why Band Aid 30 is now widely considered rather toxic and paternalistic, and an ill-fit for today’s society. Both the messenger and the message matter in the 21^st century (even if we still hear way too often the Peter Piots, Thomas Friedens and other famous Western global health voices in our global media, and not enough African global health voices on this crisis in West Africa). Africa is certainly not sitting on the fence as some may have believed. There is still some way to go here, but we’re getting there.

The true ‘African response’ if one exists is best displayed at the front line. The real heroes, when all is said and done, are African health workers and burial workers. Often with insufficient equipment, and sadly, also in many cases a lack of sufficient hazard pay, they have placed themselves in harms’ way, for months already, and still counting. Like most people, we are humbled when thinking of their bravery and heroism.

Moving forward

It’s clearly a very diverse story. The hope now is that Ebola will turn out to be a game changer for health systems & infectious disease control in Africa: (1) perhaps suffering from a bad conscience (?), the WHO seems eager to turn the crisis into an opportunity to strengthen health systems in the region (with follow-up ‘health systems resilience’ conferences in the respective countries planned in March next year for example) – ‘The health facilities and infrastructure put in place to help Sierra Leone, Liberia, and Guinea contain the Ebola virus disease epidemic should form the basis of a new health system’ the WHO urged last week at its event in Geneva;  (2) an ‘African CDC’ will now perhaps finally see the light; (3) maybe African countries can push more for international co-financing of UHC (implementing a future SDG health UHC goal/target), to help prop up weak health systems in poor countries in Africa. Weak health systems are obviously a problem for the whole world, as can been seen in this crisis, even if it shouldn’t be the key reason for global solidarity.

So it would be good if African countries & regional institutions could make use of the Ebola crisis to strategically place HSS in Africa much higher on the SDG agenda, having previously failed at least to some extent during the agenda setting stage of this global health crisis. It’s the least they can do to commemorate all (unnecessary?) Ebola victims so far and to honour the heroism of health workers engaged in the fight.

This won’t be easy, though. Little by little, Ebola already seems to be slipping off the global media radar, climate change (funding) will most likely take the spotlight in the coming year (with ODA health budgets being magically ‘reoriented’), and quite some powerful global health voices seem to be arguing for a global pandemic response fund (with the risk that HSS in Africa gets somewhat placed on the backburner?).

As for the massive economic impact of the Ebola crisis, let’s hope the international community will also lend a hand – and maybe here the African business community can also step up.  This crisis threatens to wipe away the health systems, economic, political, and social rubric of West Africa and to rob future generations of any gains made from international development initiatives to date. There is an urgent need for decisive leadership and wholehearted commitment to win the fight against Ebola, and the will to emerge strong when the storm blows over. Success however, is often worn on the shoulders of responsibility.

Africa’s future might be written – and its history rewritten – based on how the continent responds to the Ebola crisis today. Let’s follow the example of the real heroes in this story, health workers, burial workers, community advocates – selflessness in action. We owe it to them to overcome this crisis and re-build up the countries that many of them have died to save.