In countries like Liberia and Nigeria, declining budgetary share in health services continues to undermine public well-being
Severe financial crunch continues to affect healthcare services in Western Africa, especially in Ebola-ravaged Liberia. Even after huge global investments to contain the 2014-2015 epidemic, public health pre-paredness has not improved in the country. Take the instance of Soniiwien Clinic, a public health facility in capital Monrovia, where an effective screening system was put in place after the Ebola breakout. Though at present, a nurse at the entry gate takes temperature readings of patients and visitors before allowing them inside, the readiness ends here. Patients running high temperature are subsequently referred to the John F Kennedy Referral Hospital situated in the southern end of the capital.
Currently, the Liberian government is struggling to ensure basic services like electricity supply and piped water at Soniiwien where the labs too are not fully equipped. “Our head has written to the country health team on several occasions for power and water supply as well as additional equipment, but these are still not available,” says Nathaniel B Witherspoon, senior laboratory assistant at the clinic. Even officer incharge Irene Sherman Isiri admits there are challenges. “We no longer receive supplies that we used to get during the Ebola outbreak. We lack soap and chlorine. Our personal protective gear is also in limited supply and at times we run out of gas for ambulances,” Isiri says.
Disappearance of aid money
Such a desperate situation at Soniiwien is despite the fact that during Ebola, millions of dollars flowed into the country to support recovery and build a resilient healthcare system. According to the World Bank’s Global Ebola Response Resource Tracking, the United States channelised US $9,71.3 million to tackle Ebola. The amount was part of a larger sum of $2 billion committed to fight Ebola in West Africa. Further, $1.6 billion was raised by the World Bank to support recovery in Liberia, Guinea and Sierra Leone. The United Kingdom provided $1 billion, followed by the European Union which raised $940.9 million, and the African Development Bank which contributed $825.4 million for recovery in Liberia and other Ebola-hit countries. But now pertinent questions arise over how the funds were spent.
In November 2017, the International Committee of the Red Cross based in Geneva confirmed that more than $5 million of aid money was fraudulently skimmed off in West Africa during the Ebola epidemic. An investigation by Red Cross auditors revealed that in Liberia, close to $2.7 million disappeared as a result of overpriced supplies and for paying the salaries of non-existent health workers. In Sierra Leone, Red Cross staff apparently colluded with local bank employees to pocket over $2 million, according to auditors, while in Guinea, where investigations are going on at present, around $1 million disappeared in fake customs bills.
In January this year, two Ebola survivors sued the government of Sierra Leone in the ECOWAS Court of Justice in Abuja, Nigeria, alleging that the lack of government accountability allowed the disappearance of almost a third of the aid money during the early months of the Ebola outbreak in 2014. The survivors claimed this led to violation of survivors’ rights to health and life. In one case, health officials were meted out punishment. In June 2016, two senior members of the Guinean National Ebola Coordination Committee were sentenced to prison for periods extending from five to 18 months for embezzling $67,405 granted by the World Health Organization (WHO). The fund was meant for educating traditional healers on the danger of Ebola.
“The aid money was not well managed. Our health system is bleeding and there is a chronic shortage of medical supplies and equipment,” says George Poe Williams, president of the National Health Workers’ Association of Liberia. However, he acknowledges that there has been improvements in training and capacity building of health workers post Ebola.
At the height of Ebola, Liberia’s Finance and Development Planning Minister Amara Mohamed Konneh announced that anyone who pockets Ebola money would go to jail. But in sharp contrast, former President Ellen Johnson Sirleaf said the emergency situation warranted making decisions that violated the country’s public procurement and other laws in the interest of saving lives. According to critics, this was a public defence of corrupt officials.
Determined not to have a rerun of the 2014 Ebola outbreak, the Liberian government established the National Public Health Institute of Liberia (PHIL) in December 2016 with a mission to prevent and control public health threats. Mosoka P Fallah, the deputy head of the institute, who also serves as a visiting scientist at the Harvard T H Chan School of Public Health in the US, praised Liberia’s current capacity to detect early outbreaks and respond to them adequately. “Immediately after the official end of Ebola in May 2015, we had three subsequent outbreaks that we were able to contain quickly,” he says. Fallah adds that prior to the 2014 Ebola outbreak, Liberia lacked the capacity to test for highly contagious diseases such as lassa fever. Samples of suspected cases were usually transported to other countries for confirmation. But things have changed. According to Fallah, since the beginning of January 2018, Liberia has identified and responded to 42 outbreaks ranging from lassa fever to monkey pox.
After Ebola ended, the government launched a six-year national plan (2015-21) to build a resilient healthcare system to restore public trust in the government’s ability to ensure quality services. Then there is also the National Health Plan (2011-2021) of Liberia. The cost of implementing it is estimated at $2.8 billion from 2015 when the decision to build a resilient health system was taken, but the total projected allocation based on current levels is estimated at $416.9 million, thus leaving a gap of $2.4 billion over the same period. According to WHO, budgetary allocations in the health sector in the past 12 years has risen from $10,913 in 2006 to $48,999 in 2012 in the country. But Liberia’s recent allocations fall below the annual allocation target of $466,666 needed to implement the six-year plan. The Liberian government hopes that domestic resources and external aid would help execute it.
Absence of a strong healthcare system in many West African countries often results in high out-of-pocket expenditure for people. For example, in Nigeria, out-of-pocket payments can be higher than 72 per cent of the total health cost. For 70 per cent of Nigerians, who are extremely poor, out-of-pocket payments can exacerbate their level of poverty. In 2016, researchers Obumneke Obieche and Valentine Odili based in Benin City in southern Nigeria, stated that on an average, Nigerians spend a minimum of $13.5 to treat a single bout of malaria. The government’s Roll Back Malaria programme provides insecticide-treated nets, artemisinin-based combination therapy and rapid diagnostic tests, but these are not available. Allegation is rife that these drugs and nets are sold in the open market.
Hannah Fadekemi had to admit her septuagenarian uncle to a private hospital in Lagos in August this year for septicemia. “I have spent $980 on antibiotics in less than two days,” she says. Her uncle is a retired worker of the Nigerian railways and Fadekemi is not sure if he could repay her. The cheaper option would have been to take him to a public hospital. Though the cost in government hospitals is about 10 per cent of the total amount charged at private units, they are full of patients and it takes a long time to find doctors. Those who can afford prefer private hospitals.
People find it so difficult to pay that often there are instances when patients stay back in hospitals and work to pay for their bills. “Sometimes a few patients are rescued by philanthropists or charity organisations during Christmas or Easter on the recommendation of the hospital welfare committee. Those strong enough are allowed to work to pay their bills,” says a staff of the University of Benin Teaching Hospital, a multifacility provider about 300 km from Lagos. Lack of funds has hit rural clinics too. In Ahiazu Mbaise in South-East Nigeria, nurse Chinyere Okoro, in charge of the local health facility, says, “The centre has not received malaria drugs or rapid diagnostic kits since 2017 under the Roll Back Malaria programme.”
Strengthening primary healthcare is at the root of achieving universal health coverage mentioned under Goal 3 of the Sustainable Development Goals (SDGs). But the health scenario in West African countries is not likely to improve anytime soon due to declining budget even after the 2001 Abuja Declaration when African countries agreed to allocate at least 15 per cent of their annual budget in health. Since the declaration, the highest allocation for Nigeria’s health sector has been 5.95 per cent in 2012, which is far below the WHO recommendation of 13 per cent of the country’s annual budget. Liberia launched the SDGs on January 26, 2016. But with fund crunch, hopes of building a resilient health system by 2030 remain faint.
(This article was first published in the 1-15th December issue of Down To Earth under the headline 'Healthcare in a shambles'. It is part of a series on healthcare in Africa).
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