Often donors, such as the World Bank and the World Health Organization, urge developing countries to invest in national health systems. But while rushing to build clinics and other medical facilities in the most remote regions might seem like a logical approach to ensuring universal health coverage, it has actually been proven that this is not the case.
The recent Ebola epidemic in West Africa highlighted the urgent need to develop more resilient, robust and efficient health systems. But when countries rush to build new clinics, the facilities that are set up tend to be hastily built and lack the equipment, supplies and personnel needed to deliver essential health services effectively.
The rural areas of Sierra Leone have more than a few health facilities that are of no use to the communities. A newly refurbished clinic in Masunthu, for example, was poorly equipped and had no tap water. The facilities in nearby Maselleh and Katherie had cracks in the walls, leaks from the roofs, and so few cabinets that syringe stocks and medical records were piled on the floor.
This situation is the result of a fragmented and hasty approach in the construction of new medical and health infrastructures. In 2003, the government, in severe economic difficulty, decided to “decentralize” the various public services at the circumscriptional level, however, thereby fueling a ruthless competition for the few resources available.
Local councils, in an effort to grab the biggest piece of the pie, have begun carrying out new projects leading to a rapid and uncontrolled expansion of the healthcare system. Today Sierra Leone, with a population of only seven million people, has around 1,300 health facilities.
The Ministry of Health was unable to equip all of these facilities and cover operational and staff costs as the budget did not increase adequately to cover the expansion of the health system. In fact, very few African countries that signed the Abuja declaration in 2001, which provided for the allocation of 15% of their budget to the health system, were able to do so.
In September, Sierra Leone conducted an analysis of the distribution of public health facilities and health workers in the area to guide the discussion on the Human Resources Strategy in the Health Service for 2017-2021. The results of the analysis highlighted strong contrasts, i.e. only 47% of the country’s health facilities have employed more than two health workers, including voluntary workers and non-salaried workers, while 7% of health structures have no health workers.
Doctors and Medical Staff
This situation is not confined to Sierra Leone or Africa. In Indonesia, the government has invested oil profits in a rapid process of expanding basic social services, including health care. But today the insufficient number of doctors puts many of these health facilities at risk, especially in remote areas where absenteeism is very high. There are many nurses, but most are not adequately trained and are still left alone to manage the facilities in the most remote areas.
In addition to staff, health facilities in remote areas in Indonesia lack adequate infrastructure support, namely clean water, sanitation, reliable electrical services, and basic equipment and medicine. Decentralized local administrations, which have limited authority over health facilities in remote areas, cannot supervise their activities. It is therefore not surprising that Indonesia has one of the highest maternal mortality rates in all of East Asia.
An excess of poorly equipped health facilities is not only ineffective, but can actually worsen conditions due to factors such as poor sanitation and weak emergency referral systems. In fact, during the recent Ebola crisis, poorly equipped facilities caused a greater number of deaths not only among patients, but also among health workers who should have helped.
Rather than continuing to pursue the uncontrolled expansion of poorly equipped and understaffed health facilities, policymakers should consider a more measured approach. Certainly people living in remote areas need access to quality health care without having to travel down the winding and dangerous roads that can become inaccessible at certain times of the year. But social services and community health workers could cover these areas much more efficiently. The value of this approach was recently demonstrated in Ethiopia where health outcomes have improved.
While most of Sierra Leone’s facilities have been built with donor funds, the government has pursued programs aimed at accelerating the momentum for the construction of new facilities. Both the government and the donors therefore have a shared responsibility to pursue a more cautious approach capable of guaranteeing quality services.
At the next World Health Assembly sponsored by the World Health Organization, participants should highlight this responsibility and begin reviewing current strategies for achieving universal health coverage. With a more measured approach it will undoubtedly take more time to build the same number of clinics, but more lives can be saved and this is the only indicator that should count.