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Strengthening health systems

Strengthening health systems to make them more resilient to major external events
--Richard Smith?
RICHARD SMITH: How soon it will take health systems to get back to normal will of course depend on the scale and length of the outbreak. But I think perhaps more important is thinking about whether we want them to get back to normal. Actually we’d rather these health systems became considerably better and improved through this dark time they’re going through. If not, it’s just a matter of time until we’re here again. But what’s important is we utilise what’s happening here and now to leverage continued investment in health systems so that this doesn’t happen again.
So rather than health systems return to normal, we should make sure that they actually move on to become better and stronger than they were before the outbreak. A good example where health systems became stronger through initiatives around a global disease burden would be polio. Polio eradication– the initiative, the launch and expenditure of time and effort and resources and emotions that went into that was very significant because it impacted on health systems in a very positive way, which left them stronger and more able to deal with other forms of infectious disease than just polio. So it was looking at improving the skills of the health workers, the infrastructure of the health systems themselves.
We would hope that the Ebola outbreak does something similar, that the immense resources from the national governments and the international community– international aid agencies– is not simply going to be left to rust and wither– as often has been the case in the past– or was removed and reallocated somewhere else, but actually is integrated much more into the health system that it’s currently in and leaves it in a much stronger position to prevent, really, these sorts of outbreaks occurring– or occurring to the same magnitude– through very early identification and preventive measures. Creating strong health systems requires access to adequate numbers of health workers, well-skilled health workers, access to essential medicines– all those sorts of aspects, of course.
But strong health systems can only be founded on strong economies. Somehow the health workers, the pharmaceuticals, the hospital beds, and all the rest of it will need to be paid for. And that can be paid for from development aid– and that creates dependency of countries on the international community– or it can be paid for from economic growth. And that’s why it’s very important that we think of health systems not just in an isolated sense and the aspects related to them being improved, but also that at its most basic there needs to be resources to pay for strong health systems. Where do those resources come from? So a critical element of a strong health system is a strong economy.
When it comes to Ebola, what’s important is continuing to strengthen the health system aspects around health workers, infrastructure, and the things that we see and then use every day that the international community is investing in, but also that they continue to invest in those areas to support development of the countries’ economies. Perhaps the most important role that donors and the international community can play as we go forward to strengthening health systems is actually to keep Ebola on the agenda for much longer than it would naturally be. Clearly outbreaks come and then eventually, hopefully they go quickly, but they do go. And as usual, agendas move on to something else.
What’s important is why we’ve had such a large outbreak of Ebola this time, and we didn’t in previous occasions. A lot of that is around prevention and the importance of health systems as a preventive measure rather than a treatment vehicle. It’s very important that we use Ebola, and the international community continue to use it and to refer back to it to make it clear why prevention is important, why investing in a health system for prevention is important. The amount of resources that have currently and in the future will be spent on trying to deal with this outbreak probably outstrips the sum that would have been required in previous years to allocate to strengthening these health systems.
The laboratory services, the surveillance, the health workers, the primary care– strengthening those elements to prevent an outbreak like this. And that’s the typical dilemma we have, or the paradox we have around prevention and treatment, of course. From a national level through to the international level it’s much harder to gain traction to prevent something happening than it is to deal with something that has happened. Internationally, if infections are controlled, those countries which don’t invest in them can benefit as well. The problem, of course, is that no one has an incentive to invest in them when they don’t happen. It’s important that we therefore have international cooperation and agreement to fund things which are going to benefit everybody.
And infection control surveillance are absolutely the most critical global public goods for health which should be invested in by national governments as part of their own national health systems and in terms of their own national health security– not as part of aid or development, but in addition to aid and development.
Looking ahead, it is essential to ensure that health systems are strengthened to prevent similar crises from happening again and to support broader aspects of health for the people of West Africa. Building strong health systems requires a range of actions, including economic and social development.
In this video, Professor Richard Smith emphasises the importance of using what is happening in the outbreak to leverage investment in health systems in the future. As Sierra Leonean lawyer Yasmin Jusu-Sheriff puts it1: ‘I don’t think we want things to return to normal at all in terms of the health system in Sierra Leone; I think that would be the worst outcome. After the outbreak we have to have a new health system.’

What’s needed to strengthen a health system?

There is a good understanding of what is required to strengthen health systems. The World Health Organisation (WHO) summarises the five key elements required2: leadership, information systems, health workforce, financing, supplies and service delivery. Planning for the strengthening of health systems is already underway. There is a focus on ensuring coordination across the different countries, reflecting how disease threats, like Ebola, are a threat to the entire region.
Strengthening a health system requires many things, including health workers, surveillance and supplies. A strong economy is also necessary for the system to be properly funded. Global institutions, such as the World Bank, the International Monetary Fund (IMF), and key international donors, were central to policies that led to weak economies in West Africa and elsewhere3. Recognising the role of global health architecture in creating vulnerability to Ebola means we must ensure that actions within countries to strengthen health systems and economies are linked with global reforms. Key institutions, such as the WHO, World Bank, and IMF, can then play a supporting role in these processes.
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Ebola in Context: Understanding Transmission, Response and Control

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