Donors like the World Bank and the World Health Organization often urge developing countries to invest in national health systems. But while rushing to construct clinics and other medical facilities in even the remotest regions may seem like a straightforward approach to ensuring universal health coverage, that has not turned out to be true.
The recent Ebola epidemic in West Africa highlighted the urgent need for stronger, more efficient, and more resilient health-care systems in developing countries. But when countries rush to build more clinics, the resulting facilities tend to be hastily constructed and lacking in the equipment, supplies, and staff needed to deliver vital health services effectively.
In my frequent visits to rural areas of my native Sierra Leone, I have seen more than a few health facilities that communities could do without. A newly refurbished facility in Masunthu, for example, had scant equipment and no water in the taps. The facilities in nearby Maselleh and Katherie had cracked walls, leaky roofs, and so few cupboards that supplies like syringes and medical registers had to be stacked on the floor.
This situation is the direct result of a piecemeal and hurried approach to investment in health-care infrastructure. At the end of the civil war in 2002, Sierra Leone had fewer than 700 health facilities, according to the 2004 Primary Health Care Handbook. In 2003, the cash-strapped government decided to “decentralize” various public services to the district level, fueling fierce competition for limited resources.
Local councils, seeking to grab the biggest possible slice of the pie, began to push forward new projects, leading to rapid and uncontrolled expansion of the health system. Today, Sierra Leone – with a population of just seven million – has nearly 1,300 health facilities. The Ministry of Health has been unable to equip all of these new facilities and cover staff and operational costs, as its budget has not risen to match the system’s expansion. In fact, very few (if any) of the African countries that signed the 2001 Abuja Declaration to allocate 15% of their budget to health have been able to do so.
Last September, Sierra Leone conducted an assessment of the distribution of public-health facilities and health workers in the country, in order to guide discussions on the Human Resources for Health Strategy 2017-2021. The results were stark: only 47% of the country’s health facilities employed more than two health workers, including unsalaried workers and volunteers. Seven percent of health facilities had no health workers assigned to them at all – an empty promise in physical form.
This situation is not unique to Sierra Leone – or to Africa. In Indonesia, the government invested oil revenue in the massive and rapid expansion of basic social services, including health care. But today an insufficient number of doctors plagues many of these facilities, particularly in remote areas, where absenteeism also is high. There are many nurses, but most are inadequately trained. Still, they are left to run remote facilities on their own.
Beyond personnel, remote health facilities in Indonesia lack adequate supporting infrastructure: clean water, sanitation, reliable electricity, and basic medicine and equipment. Decentralized local governments, which have little authority over remote clinics, cannot supervise their activities. Small wonder that Indonesia has one of the highest rates of maternal mortality in East Asia.
An excess of poorly equipped health facilities is not only ineffective; it can actually make matters worse, owing to factors like poor sanitation and weak emergency referral systems. During the recent Ebola crisis, underequipped facilities caused even more deaths, not just among patients, but also among the health workers committed to helping them.
Rather than continuing to pursue the uncontrolled proliferation of poorly equipped and operated health-care facilities, policymakers should consider a more measured approach. Of course, people living in remote areas need access to quality health care, without having to navigate rough and dangerous roads that can become virtually inaccessible during some periods of the year. But outreach services and community health workers could cover these areas much more effectively. The value of such an approach has recently been demonstrated in Ethiopia, where health outcomes have improved.
While most of the Sierra Leone facilities were built with donor funds, the government has gone along with plans to accelerate the construction drive. The government and donors have a joint responsibility to pursue a more cautious approach that guarantees quality service delivery.
At the WHO’s World Health Assembly this month, participants should shine a spotlight on this responsibility and begin to rethink current strategies for achieving universal health coverage. With a more measured approach, it will take longer to build the same number of clinics. But more lives will be saved. And that’s the only indicator that should count.