In December 2006, Gorik Ooms and colleagues argued that humanity may need some kind of “world health insurance” to realize the right to health. Concurring, Wim Van Damme added that it should take the form of a world social health insurance which strengthens health systems in low-income countries. In a nutshell, we argued for a Global Fund for Health Systems that would allow even the poorest countries’ governments to spend US$35 per person per year on building and maintaining basic but robust health systems. On top of increased domestic efforts, this required at the time 0.1% of the GDP of high-income countries, or just 10 cents out of every $100 produced. (Today, a similar effort would allow the poorest countries’ governments to spend US$80 per person per year on health systems.)
Our essential argument was and remains the realization of the right to health for everyone. But it is not the only argument. The 2007 World Health Report added ‘global public health security’ to the equation and warned that at least “57 countries, most of them in sub-Saharan Africa and South-East Asia, are struggling to provide even basic health security to their populations”. The authors of the report asked rhetorically: “How, then, can they be expected to become a part of an unbroken line of defense, employing the most up-to-date technologies, upon which global public health security depends?”
According to our estimates, high-income countries should have contributed around $7 billion in total to these countries (to allow the $80 expenditure level) to build health systems strong enough to prevent the present Ebola disaster. As you probably read in a recent WB study, the two-year regional financial impact of Ebola could already reach US$32.6 billion by the end of 2015. A rather unwise underinvestment, it seems.
However, the real cost, in our opinion, is not the economic loss, but the enormous human cost of – what economists like to call – the “externalities” of an economic and political world order that seems unable to get a grip on rising income inequality or to show even the petty solidarity required – 10 cents out of every $100 – to maintain a minimum of dignity for humanity. On top of that, it would be silly to think that this Ebola outbreak is and will be the only global public health disaster that could have been prevented, or that could be prevented in the future. It is merely the tip of an iceberg of (re)-emerging infectious diseases. While the world rightly focuses on the containment of Ebola, these already fragile ‘post-recovery’ (in the case of Sierra Leone and Liberia) health systems in the affected countries are further collapsing. Many health centers have closed as people avoid these centers out of fear of becoming infected with the virus. Last week UNFPA warned that “120.000 women could die in childbirth within the next year in Sierra Leone, Liberia and Guinea”. The three countries rank at the bottom of the Human Development Index and their maternal mortality and infant mortality rates remain amongst the highest in the world, and recent progress will be reversed.
The engagement of the global health community in developing and advocating for a long term response matters not just for preventing future similar disasters, but, unlike most would think, also determines how we can deal (more) effectively with the one raging in front of our eyes. Government health expenditure stands at $7 per person per year in Guinea, at $18 per person per year in Liberia, and at $13 per person per year in Sierra Leone, according to the 2014 World Health Statistics report (estimates for 2011). Are we really going to build a ‘state of the art’ emergency response assuming that government health expenditure (including international assistance) will return to these (low) levels after the crisis? Or will the international community make sure that these levels increase to $50 or even $80 per person per year, and never again decrease to unacceptable levels?
The answer to this question – and everyone involved will have to answer this question, one way or another – will be decisive for the design of the ongoing emergency response and its aftermath. It is hard to imagine an effective response with 2.7 nurses (Liberia) or 1.7 nurses (Sierra Leone) per 10,000 people. It is striking that the 57 countries which lack basic health security are the same 57 countries lacking minimum access to a skilled health workforce (see World Health report 2006).
Additional caregivers will have to be trained on the spot. But how to find volunteers for this task, if short-term prospects are hazardous, and unemployment might ensue in the longer term? Over the last decade many health workers have migrated from countries in West-Africa, now affected by Ebola, fleeing the war, looking for employment elsewhere. They are direly missed now.
After the crisis, lessons will be learned, or not. For this Ebola outbreak, we cannot wait until the crisis will be over. The international community has to decide now whether it will provide the caregivers of Guinea, Liberia, and Sierra Leone the bare minimum to protect themselves while risking their lives to save others – decent training and quality protective wear for a start – and the perspective of a job in a functioning health system after the crisis. Someday, this Ebola outbreak will be over, and the international health community, together with the governments of the affected countries, will have to face up to the arduous and long overdue task of restoring people’s trust in the health system.
Other viral outbreaks, such as SARS, have taught us that we are dealing with “post-Westphalian” pathogens, i.e. “transcending the idea of independent nation-states established by the Peace of Westphalia in 1648”. As Richard Horton noted last week, Ebola shows that the WHO and its member states-funders seem to have forgotten some of the lessons of the SARS crisis: “In its pursuit of “reform”, precipitated by member-state reluctance to invest in WHO’s core activities, the agency implemented cuts that fatally weakened its ability to respond to a global health crisis.” Admittedly, WHO has been chronically underfunded the last decade, with tied funding to programs that restricted the organization in its efforts to build an autonomous response program to a global health crisis, so the blame is to be shared. Member States should seriously consider to re-invest in the WHO and/ or consider the development of a separate global (“health systems” see infra) contingency fund and mechanism to address future outbreaks of (re)emerging infectious diseases in an equitable and accountable manner.
The global health community, and decision makers, could continue neglecting transnational epidemics such as Ebola, and fail to adjust to “post-Westphalian public health” . It appears ever more likely though that sooner or later, the world will be forced to deal with “the Great Stink of the 21st Century’” in a more serious way.