Public Health Solutions in the Post-Ebola World – the priorities

On the 12th July the London School of Hygiene and Tropical Medicine (LSHTM) and DAI with Health Partners International, and Chatham House brought together experts from around the world to ‘examine how health systems and services can better meet a dual purpose: improving the daily health of the public and leveraging the skills and protocols of public health providers to prepare for and respond quickly to the inevitable, but unpredictable outbreaks of the future’. This was as much about countries themselves making the necessary investments as but existing donors strategically investing in both preparedness and global health security and ensuring individual access to health services. The meeting highlighted the dichotomy between a top down approach to improving compliance with International Health Regulations (IHR) versus a bottom up approach to Health Systems Strengthening.

The meeting also drew attention to the mismatch between the pledges at international fora to reach and sustain IHR required competences; and domestic pledges to improve the quality and accessibility of healthcare for all; given the severe limitations in all the countries on the financial resources. This challenge is greatest in those countries most at risk, seeking to return to normality after outbreaks. The situation for fragile states without effective security, governance or a functioning health system is even worse.

As Dr Gork Ooms, of the LSHTM, pointed out different policy perspectives and commitments made without control over the resources to make things happen can lead to norm conflicts which can have a paralysing effect on effective action.

What is the way forward? The meeting also showed that framing public health policy development as ‘The International Health Regulations’ versus ‘The Health Systems Framework’ is a false dichotomy. Solutions being proposed from each side of the debate have much more in common, the more closely one looks at the challenge.

At the heart of this challenge is how to ensure people in the frontline of healthcare have the knowledge, confidence and competences to keep safe and keep serving their communities. They also need to be able to articulate their needs to their Governments and make their voices heard by the international community as well.

Finding the sweet spot in policy development where initiatives can serve both goals is important, but that alone will not be sufficient to ‘square the circle’. This was illustrated by the case study from Guinea where many of the capacities such as laboratory facilities, created during the crisis are simply not financially sustainable.

We need to find smarter ways of working. We also need to address the structural bias that constantly failed women in the past; WHO have played the most significant role as frontline carers, and have also paid the highest price in terms of those infected and the death toll.

Disastrous though the Ebola outbreak was, there were very significant successes, including the response in Nigeria. The outbreak in Lagos and Port Harcourt was quickly contained by having a workforce with the right mix of skills and capacity, and crucially the ability to quickly leverage systems developed to address other public health needs. The existing polio system was beneficial because it allowed for pathways to communities, a robust surveillance system, and a trained and experienced workforce. The importance of creating a regional ‘surge’ capacity was also highlighted by Dr Joshua Obasanya of Nigeria; and will be further supported by the creation of a regional CDC. The importance of building public health and research capacities incrementally over the long term was illustrated by case studies from Uganda and Malawi.

Dr Anne Philpott highlighted the importance and cost effectiveness of investing in prevention and preparedness. Dr Outi Kuivasniemi who led the Finnish Joint External Evaluation, a tool to assess countries progress in achieving IHR in an objective and transparent way, raised the need for ‘concrete solutions’ and the ability to properly evaluate IHR capacities.

Policy development will help to bring ensure a more coherent approach to promoting global health security and health equity under the one health banner, but we will still need to find smarter ways of implementing such approaches if we are going to address the norm conflicts on being asked to do more with inadequate funds. That can only be addressed if we recognise the role innovation and technology can play in providing better solutions.

One such example of smart innovation during the Ebola outbreak was the development of ebuddi by the Mentor Masanga Ebola Initiative (MMEI) in collaboration with MiiHealth Ltd. This initiative was an immersive simulation based training tool that modelled authentic health posts with avatars based on local health workers, and voice overs in local dialects. Being digital changes to protocols and equipment specifications could be updated in real time. Trainers and healthcare workers buddy’s appearing in the simulation could be female and speak in local dialects proactively addressing some of the structural challenges of giving women in the frontline the knowledge, confidence and competences to keep safe and keep serving their families and communities. The built-in monitoring and evaluation also enabled a shift from the idea of one off trainings and evaluations to a more continuous competency management.

Tools such as ebuddi may be key to demonstrating the false dichotomy sometimes perceived in the implementation of the IHR policies and Health Systems strengthening. They also may enable a greater return on the investment in workforce development, as well as addressing some of the gender and linguistic biases in this system. Most important of all, it is a tool that can make the knowledge and competences accessible to all, from doctors and nurses to the community health workers and volunteers who may be needed in the next crisis.

Top image: The consultation meeting was brought together by the Centre on Global Health Security, Chatham House; the London School of Hygiene and Tropical Medicine; and DAI together with Health Partners International