This chapter presents a range of suggestions made by participants in the workshop with respect to the fundamental principles and approaches underpinning the practical systems-strengthening strategies presented in subsequent chapters. Many participants throughout the workshop also highlighted the importance of effective leadership and management, and the need for more concerted efforts to foster better engagement among all sectors and stakeholders.
“Leadership and decisions should be directed in the context of existing structures and take into account where we need to strengthen those structures to produce effective outcomes.”
—Daniel López-Acuña, Former Director for Recovery
and Transition, Cluster of Health Action in Crisis,
World Health Organization
Several participants returned frequently to the need for strong and effective leadership in order to steward efforts to strengthen health systems, and to manage emergency responses, by working within existing structures at all levels. Dan Hanfling, Contributing Scholar, UPMC Center for Health Security, reported that top areas of discussion to emerge included
- Principles of leadership in response to public health emergencies;
- Accountability, including International Health Regulations (IHR) compliance;
- Donor management; and
- Communicating and disseminating information.
Regarding leadership and management, some participants noted that sometimes leadership is defined by what you bring to the table, and
the absence of leadership—or bad leadership—can make things worse. Ann Marie Kimball, Associate Fellow, Royal Institute of Foreign Affairs, Chatham House, cautioned that different cultures have different definitions of leadership, so it is important to be mindful of cultural assumptions when assessing leadership styles.
Principles of Leadership in Response to Public Health Emergencies
Delanyo Dovlo, Director, Health Systems and Services Cluster, World Health Organization (WHO) Africa Regional Office, cautioned that leadership during an emergency response cannot occur in a vacuum and must take into account the existing health system; he noted that when external groups converge on a country during a crisis, it can destroy that country’s leadership structure. Multiple participants noted that leadership should be involved in all aspects of the emergency management cycle and that predictable national structures and systems should be established for response to public health emergencies, with the caveat that each infectious disease has unique characteristics that may evolve over time. Trish M. Perl, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, suggested incorporating a bilateral decision structure to build trust, augment response activities, and ensure accountability; a further investigative component would inform an emergency response that is situated appropriately within its particular political and social context.
Hanfling noted that the availability of resources can influence the ability to lead—the response to an event needs to be constructed by local emergency management authorities, with the affected country setting the requirements for what is needed. López-Acuña warned about the tendency to fall into a one-size-fits-all response, which could be mediated by building the necessary relationship between outbreak response and the national response plan. Acknowledging that every response is unique, both Perl and Rob Fowler, Physician, University of Toronto, Canada, advised country leadership to leverage relevant experiences from countries around the world that have gone through similar outbreaks.
Training Leaders to Lead
Hanfling reminded participants that they have some responsibility for identifying and training leaders about how to lead, how to support adaptability, and how to ensure accountability. Irene Akua Agyepong, University of Ghana, called for more investment in capacity building with respect to the “soft skills” of leadership, particularly for leadership in cross-sectoral work, which should encompass skills in listening, negotiation, conflict reso-
lution, engagement, observation, and taking the time to understand people’s interests and cultures within countries and organizations.
Various participants discussed the need for leadership to work within and support existing functional structures at the global, national, regional, and district and local levels to strengthen systems and create strong models of emergency preparedness that maintain the integrity of the local context. While the ultimate goal would be the alignment of all of the partners in achieving capable systems that can deal with emergencies, Hanfling suggested that other beneficial outcomes could include
- Building and strengthening capacity
- Promoting emergency management systems and implementing a national emergency management plan (focus on process)
- Building a systems approach to managing emergencies
- Optimizing interemergency periods to build capacities and capabilities
- Instilling leadership with the attitude and accountability to make good decisions and fulfill expectations, and
- Strengthening of civil societies
Joan Awunyo-Akaba, Future Generations International, Ghana, strenuously urged the African Academy of Sciences to take a much stronger leadership role in bringing together the top professionals and scientists in the continent to create roadmaps, set clear agendas, and seek out people and organizations with available resources to solicit support. Many participants discussed how achieving the aforementioned desired outcomes would require intergovernmental ministries and partners across all sectors to be willing to work together and recognize the benefits of coordination. Incentives to motivate leaders to act in the way the people want and need them to would also need to be identified in order to realize progress.
“How we can engender better stewardship and governance of health systems, both nationally but also at a local level, in a way that builds stronger accountability for results, holding the people responsible for our health to account for the results that they bring?”
—Delanyo Dovlo, Director,
Health Systems and Services Cluster
World Health Organization Regional Office for Africa
Throughout the workshop, the importance of building in measures of accountability was reiterated not only for leadership but also for many other components of the health system, including health care providers, disease surveillance and reporting, private-sector actors, nongovernmental organizations (NGOs), and donors. Much of the discussion concerning accountability centered on the issue of IHR compliance, but some participants also considered the use of peer-reviewed publications that describe emergency management capabilities as an independent measure of accountability. Such publications could include scientific analysis, descriptive reports, and lessons learned. Increased access to published data, experience, and response lessons learned could contribute to both accountability and performance improvement, though resources would be needed to fund, conduct, and disseminate the reports.
Ensuring Accountability and Commitment to IHR Compliance
López-Acuña characterized lack of accountability to IHR compliance as a “global failure” of member states, WHO, investment banks, and bilateral cooperation that should be a priority to rectify. Oyewale Tomori, President, Nigerian Academy of Science described it as a “toothless” document that gives assessed targets to countries but does not take any action if they are not achieved.1 Stella Anyangwe, Honorary Professor in Epidemiology at the School of Health Systems and Public Health at the University of Pretoria, South Africa, noted similarly that WHO does not currently “name and shame” countries for not signing or ratifying IHR, or take any real action against countries that fail to comply with the regulations, which needs to change.
Kimball of Chatham House remarked that countries are not given adequate operational guidance about how to achieve IHR core capacities. Myers of Rockefeller noted that the modalities for achieving compliance should be contextual to each country, taking into consideration the resources available to support the member state’s compliance. While there are minimal requirements to implement IHR, country specificity in capabilities can create different variations, meaning that the baseline systems for laboratory capacity, risk community, surveillance, and emergency operations centers can be responsible for country-specific differences in timing and accurate response. Gabriel Leung, Dean, Li Ka Shing Faculty of Medicine, The University of Hong Kong, suggested implementing a program of peer assessment by a national, unaffiliated team of technical experts invited in to provide an assessment using a continuous quality improvement approach. He further proposed making Official Development Aid (ODA)
1 He noted that WHO has set up a new committee to look into making IHR more effective.
contingent on certified IHR adherence. He noted that “certified” is key in this context, because there are some countries whose self-certified compliance does not actually adhere to the established standards.
A Roadmap for IHR Compliance?
During one of the panel discussions, David Fitter, Epidemiologist, Emergency Response and Recovery Branch, U.S. Centers for Disease Control and Prevention, raised the possibility of a “roadmap” to achieve IHR core capacities, which might include a country-specific assessment of the feasibility and requirements for compliance. He explained that one component of IHR is that its goals are accomplished in day-to-day systems, so funding opportunities need to come with the guidance and further support. Kimball replied that the capacities are basic-level and were heavily negotiated after the severe acute respiratory syndrome (SARS) outbreak before IHR ratification in 2005, but WHO operational research tools have not been tested fully and financial research still needs to be conducted on a country-to-country basis. She remarked that efforts to ensure and facilitate IHR adherence have thus far primarily been driven by global leadership, and she encouraged local leadership to take a more active role in advocating for compliance. Because of the importance of implementing IHR capacities as currently established (and any further stipulations that are agreed to), she suggested devising a financial roadmap for IHR and encouraging countries to maintain the safety they provide for the benefit of their own populations. Adinoyi, of the International Federation of Red Cross and Red Crescent Societies (IFRC), concurred that drawing a roadmap is a very important first step. From the Red Cross perspective, after Ebola virus disease (EVD), there was agreement to support disaster response and IHR compliance in the African region. Aba Bentil Andam, Ghana Academy of Arts and Sciences, contended that IHR involves policy makers: whatever the extent of the resources that providers and researchers try to invest, policy makers must work harder to ensure compliance. She suggested campaigning to engage politicians and the media for support.
The need for leadership to more effectively steward and manage donor funding was highlighted throughout discussions. Many participants explained how establishing long-term, sustainable financing solutions is a key part of alleviating long-term dependence on donor funding and moving away from the donor-directed allocation of resources. They suggested that ultimately, countries should be able to self-regulate and audit their systems, and to maintain accountability to themselves, the people, and
invested stakeholders. López-Acuña argued that health financing should be “home grown,” and that the quantum of health expenditure matters, noting that there is a current overreliance on out-of-pocket expenditures. He also noted that there is very little accountability and external scrutiny of good donor practices in terms of effective systems strengthening. Some of the platforms that have been created in recent years are still operating at a very conceptual level, without getting down into the necessary granularity to take action.
Kimball described how donor funding can fall into a trap of accidentally forcing country dependency; to address this, there needs to be a turnover of skills and resources to in-country investors and participants. Fitter suggested that donors should try to avoid initiating programs; rather, they should work to strengthen and improve on existing resources. Ring-fencing2 of donor funding was another concern raised by some participants. For instance, Tomori remarked that in some cases, the giver actually benefits more than the receiver in donor relationships and the biggest benefactor in system building is often the donor. Anyangwe attributed the lack of essential infrastructure-building in some countries to donors providing money that could not be used for infrastructure or any purpose other than the donor’s chosen one: “beggars cannot be choosers, and so those begging for funds flex and bend to the whims of those giving the funds.” This results in fragmentation that undercuts horizontal system-strengthening efforts. Kimball noted that the concept of a “code of ethics” for donors had emerged during several conversations. The opportunity would allow the donor community to become part of the process of sustaining health systems in the intercrisis period rather than contributing to fragmentation, and the self-interest needs of businesses can be brought to light ahead of a disaster.
A few participants called for leadership to provide better guidance to donors to channel funds to where they are most needed; funding should focus primarily on public health priorities and infrastructure, not the “emergency disease of the day.” As an example, Greenough of Harvard School of Public Health noted that while people are dying of EVD in Sierra Leone, children under 5 years of age are also dying of diarrheal illnesses, which will continue after the EVD outbreak is over. He encouraged government and leadership to educate donors about funding allocation priorities while also striving for transparency and openness. Koku Awoonor-Williams, Regional Director of Health Service for the Upper East Region of Ghana, highlighted the need for a paradigm shift in the sense that donors should provide fund-
2 A ring fence is a protection-based transfer of funds from one account to another; it is often used to separate assets from an account and protect them against certain restrictions, or to lower tax consequences on the assets. See more at http://lexicon.ft.com/Term?term=ring-fence (accessed October 20, 2015).
ing to developing countries even during inter-crisis periods, to help those countries improve their health systems even when there is no imminent outbreak present. Peter Lamptey, Distinguished Scientist and President Emeritus, FHI 360, pushed for considering an additional health services tax, or VAT, in addition to every funded vertical program (e.g., immunization) or any money devoted to improving just one part of the infrastructure. Such a tax would ensure that the rest of the system is maintained as well.
Communicating and Disseminating Information
One of the primary responsibilities of leadership and management identified by several participants is the facilitation of clear and open communication among all partners, providers, and the community—a trustworthy health system is not possible without sharing information. Communication gaps between care providers, patients, their families, government officials, public health officials, and the community are common. Creating informed and sensitive communication channels to country leaders and politicians can be just as important as communicating information to the public. Anyangwe noted that all stakeholders should receive the information they need in a timely and transparent way. Greenough remarked that system breakdown at the local level occurs when there is a lack of two-way communication, for instance, when local officials do not receive the information they need from higher levels of government. He suggested that relationships, relationship building, and other forms of communication between different agencies and levels of response are crucial because they can provide short-term solutions to health systems concerns before considering long-term change.
One of the topics explored was the development of short-, medium-, and long-term communication plans to address the need for sustained, coordinated, and continuous communication between health care providers and the population at the national, regional, and local levels that is maintained during and between emergencies. Lamptey specifically called for the use of social media for effective outreach. Multiple participants throughout the workshop echoed this strategy, in addition to recommending the use of short message service (SMS) alerts to deliver a range of health-related messages, especially in developing countries where SMS alerts can be a primary method for message dissemination. Andam and other participants also noted that governments often fail to adequately employ the media as a communication tool. Suggestions for engaging the media include having frequent meetings and training about how to report on outbreaks, and a general strategy of forming close ties with the media to “bring them on board” and help to reduce the amount of false information spreading.
“If we talk about resilience, it isn’t something that can exist in a silo in a single system in the health system. If you really want to talk about resilience it requires efforts of all the society. So that’s not just the state sector; it also very much needs the contribution of the private sector and civil society, but it also needs us to think beyond the health sector to the contribution of other sectors than health. And often in the health sector perhaps we underplay that contribution. For too many people health just equals health care. Health care is very important, but health care itself can’t be delivered without the contribution of other sectors.”
—Kumanan Rasanathan, Senior Health Specialist, UNICEF
During discussions on cross-sector engagement in building systems to support health, participants were asked to identify and engage the broad array of stakeholders spanning multiple sectors: public health; health care; mental health; NGOs and civil societies; the business and private sectors; and communities. Discussion centered on finding ways to effectively integrate all sectors in health care delivery and response to crises. Francis Omaswa, Executive Director of the African Centre for Global Health and Social Transformation (ACHEST), commented that bringing people together between outbreaks is difficult but should remain a priority until the various players can be united as a cohesive whole. Referencing Canada as an example, Fowler of the University of Toronto highlighted the creation of the Public Health Agency of Canada following the SARS outbreak in 2003. Looking even further, Rasanathan urged participants to think beyond the health sector and recognize how other areas contribute to overall health. He drew a distinction between two understandings of cross-sectoral engagement. One is how different sectors such as government, civil society, and the private sector engage with each other; the other is how the different thematic sectors work together, such as water and sanitation, nutrition, education, energy, transport, and finance. As an example of poor cooperation between the health sector and other sectors, he cited the fact that 38 percent of health care facilities in low- and middle-income countries (LMICs) have no water, 19 percent do not have improved sanitation, and 35 percent lack water and soap for hand washing (WHO, 2015b). He questioned how settings that lack basic sanitation could realistically have the capacity to build health systems. Demonstrating this even further, Accra was facing an ongoing cholera epidemic at the time of the workshop, affect-
ing more than 20,000 people and compounding already existing health care workers’ fears surrounding the lack of personal protective equipment (PPE) available for infection control and a looming Ebola epidemic very closeby (Nyarko et al., 2015).
While other sectors provide opportunities for direct health care delivery and provision of services, Rasanathan cautioned against instrumentalizing other sectors for health, because the core business of other sectors is not defined by health outcomes. Other sectors bring different core values and interests to the table that need to be respected in a collaborative effort, rather than one sector imposing its own values on the others. But he remarked that because outbreaks create fear, they do create a fruitful opportunities for cross-sectional collaboration. However, he noted that for such collaboration to lead to joint action it will require new competencies from the health sector in terms of understanding the interests of other sectors,3 paired with joint accountability for indicators and targets that is government-enforced. He concluded by remarking that while command-and-control efforts are needed in certain outbreak situations, they are not always conducive to cross-sector collaboration. He called for national leadership to think about ways to bring all of society’s players to the table “to build resilience in health systems and to build resilience in societies, because without that collaboration we’re certainly not going to achieve this important task.” Participants discussed the need for clear communication and coordination among stakeholders across sectors at the national, regional, and district levels. As Hanfling declared, there is a moral imperative and social responsibility of all partners to ensure the health of a population.
Lessons from Past Outbreaks
Because EVD and other recent emerging threats are not the first time many countries have experienced these types of challenges, the discussion also included references to lessons learned from other past disease outbreaks in these countries, such as HIV/AIDS. Having spent much of his career focused on HIV, Lamptey offered some parallels between the response to the emergence of HIV 30 years ago and the disease groups that are the focus of this workshop (see Box 2-1). Both are emerging infectious diseases with high morbidity and mortality rates that engender stigma and fear, he said, and they are both perceived threats to high-income countries that generate irrational political and emotional responses. Both have also had a devastating impact on health services in affected countries, especially at
3 He made particular reference to the need to engage members of the private sector with their own core interests explicitly expressed, as well as appreciating the range of contributions that civil societies make as advocates of and agents for their communities.
the outset as global health professionals struggle to understand the disease with only trial and error methods available for treatment options. Finally, the responses to both types of outbreaks have primarily been vertical, and without the horizontal aspect including the various sectors described in this report (community, civil society, and the private sector, among others), it becomes difficult to mount a successful, comprehensive response to a threat as pervasive and complex as HIV or EVD.
Integration of Public Health and Health Care
Many participants called for better integration of the public health and health care delivery divisions. Greenough highlighted the false dichotomy between the sector that provides health care and the public health infrastructure that should drive population-level health improvements. Resolving this fragmentation, not only between these two sectors but also among governments and donors as well, will require reciprocal efforts from both sectors. A key concern echoed by multiple participants is that health care professionals, as well as leadership, generally lack sufficient grounding in
the basic tenets of public and population health. As López-Acuña noted, effective treatment is often the most important step toward the prevention of a disease or outbreak. Poor infection control and prevention practices are also widespread in both high- and low-resource settings, leading to amplified nosocomial transmission. Education and training in basic public health principles within and beyond the health care delivery sector was a key highlight.
Improved, early-stage education and training for health care workers and clinicians could also serve to help them understand the importance of tasks they may be less willing to devote time to, such as surveillance and reporting, as well as the serious public health consequences of failing to carry them out diligently. Convincing health care providers, including community health workers and traditional healers, of their important role in the greater public health infrastructure is critical, according to Greenough. Perl suggested that risk assessment could be bolstered by integrating the distinct types of knowledge and experience that clinicians “on the ground” in health care facilities have with that of public health academics and experts. Public health experts could also further benefit from epidemiologic field experience, according to Anyangwe.4
Greenough emphasized the need to put resources toward the integration of public health and health services delivery, to build a system that can respond to crises without diverting resources away from routine care geared toward preventing the most prevalent causes of mortality in the community. In Guinea, health care workers do not have access to sufficient PPE and have limited isolation rooms and other methods of infection control, making even day-to-day diseases difficult to address. Perl noted that hospitals and health care facilities are in fact part of the public health infrastructure—despite not often being recognized as such—due to silos in the system. Hanfling called for recasting public health at the governmental level—currently hampered by fragmentation and system failures—to be inclusive of emergency preparedness and response; however, recognizing the prerequisite of solidifying fundamentals of care, such as care for noncommunicable diseases prior to achieving emergency preparedness capabilities.
Educating the population and community health workers to dispel myths and misconceptions about emerging infectious diseases is another component of this process. However, as Anyangwe remarked, every outbreak is unique; different myths are pervasive for different diseases, so it is important to engage with communities at the outset of an outbreak and in the interepidemic period to learn about the specific beliefs they may hold about the disease and its causes. Given that public health often measures
success or failure in terms of the number of fatalities, Lewis Rubinson, Director, Critical Care Resuscitation Unit, University of Maryland, recommended using different types of metrics to determine the number of preventable deaths, thus exposing the opportunities available for improvement. This plan would facilitate a crossover between public health and clinical approaches, because clinical approaches with this mindset should look toward improvement in care across time. Greenough added that the bulk of this work will need to be done during interoutbreak periods, but that the system’s ability to cope with a crisis is not the only metric for the success of the integration efforts—measuring success in delivering care to the population is also valuable. Public health outcomes and their benefits should also generate data to inform and test potential frameworks for future integration efforts.
“Community engagement is crucial and it must lead to mutual respect and a sense of trust between two parties; experts must realize that they are sometimes wrong and that local approaches are correct.”
—Fred Martineau, London School of Hygiene & Tropical Medicine/Ebola Response Anthropology Platform
A prevalent topic throughout the workshop was the concept of effective engagement with local communities. Several participants proposed that sustainable health systems could be aimed toward reducing poverty and improving the livelihoods of the people in the communities they serve. This involves a wide range of partners, including regional and national governments, NGOs, civil societies, private businesses, and local leaders. Some participants explored strategies for integrating and coordinating with community partners to improve public health and health care delivery both during and between disease outbreaks. Two potential strategies for community engagement emerged: one designed to foster community engagement over the longer term between outbreaks, and the other to guide immediate short-term response to outbreaks.
At the most fundamental level, the first strategy (pre-outbreak identification and engagement) seeks to establish trust and equity within the community. To do so requires a keen understanding of the community’s particular structure and leadership—for example, who the formal and informal leaders are. Mosoka Fallah, Co–Principal Investigator: Ebola Natural History Study, and U.S.–Liberian Research Partnership/National
Institute of Allergy and Infectious Diseases, Liberia, emphasized that communities need to be clearly informed, by sources they know and trust, of the potential disease threats that they face. Janet Nakuti, Senior Program Officer, Monitoring and Documentation, Raising Voices, Kampala, Uganda, suggested that health education and training should be provided at all community levels, with tools and resources for taking action tailored to the specific community in terms of language, literacy (or lack thereof), cultural practices, and customs. Partners involved in this effort would be wide ranging and ideally “close to the ground”: youth, colleges of medicine and public health, local NGOs, faith-based organizations, professional associations, health facilities, philanthropic organizations, and the media. Central bodies such as Ministries of Health would assist in coordination and governance, as well as facilitating channels of communication, financing, and training. Financial, logistical, human, and motivational resources would be required for implementing and maintaining the program. The second strategy, offered by Paul Biondich, Research Scientist at Regenstrief Institute, Inc., encompassed establishing evidence-based “archetypes” of successful community engagement, providing communities with templates to guide their responses to outbreaks that are designed especially for settings that lack established resource centers. A few participants suggested that key components of the frameworks might include prevention/continual behavior change, rapid communication and information dissemination, and collective or group action.
The discussion was informed by two presentations describing effective community-based initiatives in Liberia and Uganda, and offering lessons learned. Nakuti related her experience in Uganda with SASA! (start/awareness/support/action), an activist kit for mobilizing communities to prevent HIV and violence against women. She described how working within communities intensely over the long term is more effective than sporadic initiatives. Working with a cross-section of the community (e.g., men and women, leaders and nonleaders) through a combination of communication channels is important. For instance, the program adopts an approach of critical consciousness raising and questioning to stimulate discussions with community members, rather than preaching or teaching, coupled with benefits-based inspirational framing to avoid negative critiquing of existing behaviors. The aim is to guide communities through a change process that transitions to support and action. She stated that by investing in social norm change interventions at the community level, prevention is possible.
Fallah described how a community-based initiative was able to eradicate EVD from the West Point Slum in Liberia, which comprises 70,000 residents in 5,000 houses with just 7 public toilets and 1 health center. These conditions led to very high rates of EVD transmission and death: 92 cases with a 90 percent case fatality rate in a 4-month period. He explained how
the behavior of the community—covert burials, hiding the sick, incomplete contact tracing, mistrust of outsiders—drove the high transmission rate of EVD. By engaging community leaders and developing a community-based lead council to drive the initiative, the West Point Slum was the first community to be declared free of EVD in Liberia. In the absence of experienced community leaders and workers, cultural anthropologists often play a leading role in understanding and altering community behavior to ensure that medical professionals and communities understand each other and can work together to end outbreaks of disease. During the 2014 Ebola epidemic in West Africa, the American Anthropological Association and other societies urged governments and aid organizations to bring anthropologists to affected areas for support (Lydersen, 2014). Sharon Abramowitz writes that anthropologists are able to “make sense of local ideas, beliefs, and behaviors in ways that are actionable.” Cultural anthropologists are able to interpret local ideas and ensure that outside medical professionals become sensitive to them (Abramowitz, 2014).
Community-Based Initiative Philosophy
Fallah emphasized that adequately empowered communities can engage in a surprisingly effective fight against EVD or any other public health emergency. He outlined one such strategy for empowerment, the Community-Based Initiative (CBI) philosophy: engaging communities in mass meetings, planning community mapping, conducting training in simple messages, active case finding, providing logistics, and setting up a case-reporting structure. He outlined what he terms the “five strategic pillars of CBI”:
- Door-to-door awareness,
- Daily search for the sick,
- Daily search for the dead,
- Daily search for potential contacts coming in as visitors, and
- Social support and counseling for affected homes and for those returning from the Ebola treatment unit (ETU).
Engaging NGOs and Civil Society
Small NGOs are uniquely situated to strengthen health systems and respond to infectious disease outbreaks in rural and remote areas, according to Saran Kaba Jones, Founder and Executive Director, FACEAfrica, Liberia. FACEAfrica works to provide safe water, sanitation, and hygiene (WASH) facilities in Liberia. Jones explained that despite the vital role that WASH serves in preventing the spread of disease (e.g., EVD, diarrhea, cholera,
typhoid, etc.), WASH remains a low priority for the Liberian government.5 Even though every dollar invested in WASH represents a $4 return on investment in terms of reduced health care costs, it accounted for only 0.4 percent of the Liberian budget for the 2013-2014 fiscal year.
“International partners, whether private-sector or large donor agencies, need to understand the importance of engaging with communities and local groups in a meaningful, respectful, and equitable way, as well as the importance of empowering and supporting these groups so that they have the tools and resources to sustain their work. Local groups need to have their voices heard, they need to have their approaches evaluated and their structures and capacities improved and enhanced to scale their impact . . . they must be offered a seat at the table.”
—Saran Kaba Jones,
Founder and Executive Director, FACEAfrica, Liberia
FACEAfrica’s efforts are concentrated primarily in rural Rivercess County where 80 percent of households lack access to safe water.6 Due to its remote location, lack of road access, and limited communication networks, this area is not attractive to larger international NGOs who tend to focus more on intervening where accessibility is better, such as in urban centers. Jones argued that small NGOs can have a powerful effect in these types of marginalized communities, which are often the last to receive external assistance. Particularly in such circumstances, groups that have a long-term and consistent presence in affected areas have the advantage of being able to:
- Employ existing on-ground resources
- Foster trust within underserved communities
- React quickly and flexibly during crisis situations
For instance, Jones contended that FACEAfrica’s work with WASH-related community engagement in Rivercess allowed the launch of an EVD awareness campaign more quickly and effectively than an international organization with no community ties. Similarly, during the EVD outbreak, the local groups were the ones that were eventually able to slow trans-
5 Ghana has also suffered a high incidence of cholera in recent years, see more at http://reliefweb.int/sites/reliefweb.int/files/resources/Cholera%20regional%20update_W52_2014%20West%20and%20Central%20Africa.pdf (accessed November 4, 2015).
6 FACEAfrica has implemented more than 50 projects since 2009, with all projects still functional to date due to aggressive follow-up mechanisms.
mission by developing their own autonomous protection and quarantine measures.7
To work toward improved partnerships with civil society, she called for empowering local organizations and groups on the ground by involving them in coordination and outreach in a more meaningful and equitable way. She characterized the undermining of local nonprofit and civil society groups by governments and funding partners as a form of institutional racism, which parlays into systematic challenges in funding and resource allocation that are not faced by their international counterparts. She concluded by calling for all sectors to recognize, respect, and support organizations working within communities; these groups promote the long-term health and strength of the communities they serve and will continue to do so when international players have left.
Integrating Mental Health Care
While mental health is in fact part of the health sector, it is a crucial component of a resilient and sustainable health system that often lacks sufficient resources and emphasis—particularly during infectious disease outbreaks. Inge Petersen, Professor of Psychology, University of KwaZulu-Natal, South Africa, explained how living through an outbreak can increase a person’s risk of developing mental disorders. Experiences such as witnessing and caring for severely ill, death and bereavement, perceived life threat, food and resource insecurity, and discrimination directed toward the affected and infected can all have a negative impact on a person’s mental health (Shultz et al., 2015). Compounding this is the effect that mental disorders can have on multiple dimensions of disease management, remarked Petersen (Prince et al., 2007). People with mental health issues—such as depression—are generally less likely to seek help and more likely to engage in unsafe behaviors, which can compromise prevention and propel transmission. Poor adherence to treatment and immune suppression can compromise treatment and propel disease progression. The mental health of care providers themselves is also an issue of concern; outbreaks are also associated with increased incidence of psychiatric morbidity among care providers, which of course impedes their ability to provide care for others. Thus, “caring for the caregivers” needs to be a priority, according to Petersen.
Petersen cited WHO projections that in the 12-month period after an emergency event, there will be a 50 percent to 100 percent increase in the number of severe (e.g., psychosis, severe depression, and anxiety) as
7 During the discussion, Awunyo-Akaba suggested finding ways to measure the input of civil society, such as indicators or technology to measure involvement.
well as mild or moderate (e.g., mild to moderate depression, and mild to moderate posttraumatic stress disorder) mental disorders among affected adults (WHO, 2013). Further evidence that mental health is a neglected sector is that more than 75 percent of people with severe mental disorders in LMICs do not receive treatment (Demyttenaere et al., 2004). Mental health care needs to be strengthened generally during interoutbreak periods, she emphasized, in order to foster the resilience health systems need during crisis periods. However, she noted that health emergencies can also serve as opportunities to strengthen mental health care in fragile states through approaches such as WHO’s Building Back Better framework (WHO, 2013), particularly when coupled with leveraging interventions from donor agencies.
Petersen recommended the use of a platform approach to decentralize and integrate mental health care into the health care system, as well as other service delivery platforms, to strengthen mental health overall and improve emergency response. She also noted that this type of approach allows for the identification of both of the roles played by different sectors and of areas where resources are needed. Specific interventions suggested for each platform and subplatform are provided in Table 2-1.
Peterson concluded by urging countries to leverage leapfrogging opportunities to accelerate the development of mental health services by adopting innovations and technological advances, as well as incorporating the evidence-based experiences of other countries to advance mental health practice.
Business and Private-Sector Engagement
“The business sector exists to support in building resilient systems, but the content and the leadership and the ideas and the strategies must be something which are led by the health sector . . . we are not the experts, we are only available to facilitate the process.”
—Nana Yaa Afriyie Ofori-Koree, Foundation and Sustainability
Manager, Vodafone Ghana Foundation
Graham Davidson, Managing Director, Simandou Project, Guinea, RioTinto, and Ofori-Koree both related experiences from the perspectives of private-sector organizations situated on the ground in areas affected by infectious disease outbreaks. In considering ways to engage the private sector effectively in cross-sector efforts to strengthen health systems, both presenters underlined the importance of effective leadership, seeking oppor-
TABLE 2-1 Interventions to Strengthen Mental Health by Platform
|HEALTH CARE PLATFORM|
|Primary health care||
|Neighborhood and community groups||
|Policy, legislation, and regulation||
|Information and awareness||
NOTE: Interventions drawn from lessons learned from the Emerging Mental Health Systems in LMICs and the Programme for Improving Mental Health Care research consortia.
SOURCE: Petersen presentation, August 6, 2015.
tunities to leverage nonfinancial private-sector resources, and enhanced clarity with regard to government strategies and how the private sector can help to facilitate their implementation. Rio Tinto is a British-Australian multinational metals and mining corporation that operates in 40 countries; Davidson is the managing director of Simandou, Rio Tinto’s iron ore min-
ing and infrastructure project based in southeast Guinea, which employs thousands of local people and contractors. The organization is currently building and facilitating the country’s transportation infrastructure through railways, tunnels, ports, and trucking routes. He projected that the project’s impact will double Guinea’s gross domestic product each year for a number of years, in addition to employing up to 5,000 local people overall.
Davidson described the emphasis that Rio Tinto places on the health and safety of its employees, as evidenced by the fact that none of its 3,000 employees in Guinea at the time contracted EVD during the 2014 outbreak in West Africa.8 To illustrate the impact that private-sector companies can potentially have in safeguarding the health of their local employees and contractors, he outlined the four main principles that they implemented in response to the epidemic to keep their employees safe (see Box 2-2).
Davidson explained that Rio Tinto strives for a holistic, joint, and open approach to contribute in building resilient health systems, stressing that its role—and that of others in the private sector—is not just that of “financier.” For instance, the majority of financial support they provided during the EVD outbreak was in kind. He stressed that the company is in a strong position to help to build on, facilitate, and manage existing capacities and health strategies set forth by countries, but that it is not their role to create those strategies or systems. But in order to add value to a government’s strategic plan, the design of the plan must be adequately transparent.
In that vein, Ofori-Koree described the Vodafone Foundation’s work in the health sector in Ghana to enact social change through partnerships and technology. She concurred that support from the private sector should not always be about funding; there are many other resources one can leverage as another form of financial capital, such as human resources and technology. For instance, she described a Foundation medical call center in Ghana staffed by physicians that is available to everyone in the country, 24 hours per day. The center partnered with WHO during the EVD outbreak to train staff health workers and to engage the community at large with social mobilization activities related to the disease. They also partnered with the Ghana Medical Association to deliver relevant content and important updates to Vodafone subscribers. She pointed to the key issue of scale, noting that many piloted projects are never scaled up: a project’s ability to deliver the right impact is predicated on its being at the right scale.
Ofori-Koree also highlighted the central role of effective leadership in driving cross-sector collaboration in general and engaging the private sector specifically: “the private sector will be coming with its own culture, its goals, its vision; but I think in order for it to be successful, there has to be
8 He estimated that the Ebola outbreak cost the project more than $100 million in direct costs.
a shared vision developed by all across the table.” She explained that the private sector can bring its own tools, resources, and potential solutions to bear on collaborative efforts to improve health systems. As an example, she described Vodafone’s emergency instant network box, a tool that can provide 3G services even when all cellular systems are down.
Cross-Sectoral Communication Gap
Addressing the participants representing the private sector and NGOs, Aceng, of the Ugandan Ministry of Health, contended that private sector actors often do not make it adequately clear to governments as to how they can offer support. She remarked that when governments do try to reach out, private industry often becomes uncertain with what they can and cannot offer; she challenged the private sector to more closely align their work with government plans and strategies by communicating in a more clear, explicit manner.
Ofori-Koree replied that it is not the private sector’s core responsibility to develop health systems—“We are solutions, not strategy”—thus, until they know what the plans are, they cannot support them. During the EVD
crisis in Ghana, her company reached out to organizations to see what was needed and how they could help, but it was difficult to get answers, and no one could clearly tell them what sort of help was required. She pointed to a lack of engagement prior to emergency situations, contending that it is only when disaster strikes that people think about calling the private sector. She stressed the importance of bringing the private sector to the table during the preparedness stage.
Jones highlighted the issue of leadership as critical. Small NGOs such as her own work independently of government in the sense that they cannot take the lead on a country’s national health or WASH plan, but they can plug into it once it is established. Davidson said that his organization goes to extra lengths to say they are transparent, though that message may not be reaching the population effectively enough. They need the support of the governments in Africa and they need them to be transparent about what is needed: “We don’t know what to do if a clear strategy is not articulated.”