The soft underbelly of weak health systems in Africa

The Daily Nation
August 15, 2014

By Dr. Joachim Osur, Technical Director, Reproductive, Maternal and Child Health at Amref Health Africa in Kenya

The World Health Organisation has described the Ebola outbreak in West Africa as out of control and unstoppable.

In an expert committee meeting of the WHO this week, the organisation lamented that although protocols for controlling Ebola have previously worked, they broke down in the current outbreak.

As such, WHO approved a drug that has only been tested in monkeys to be used in humans with the hope that it treats the disease, a most rare occurrence in medical history give the strictness with which research in use of new drugs is conventionally applied.

But why is the current Ebola outbreak uncontrollable? The simple answer is that Africans lack faith in their health systems. As a result, affected people have ignored their health officials.

In the affected countries, people prefer to hide the sick at home than take them to hospital. They believe that it is those who go to hospital who die.

Some believe that herbalists and witch doctors have medicine for the disease. The result is that the health systems have failed to take charge.

The problem in West Africa attests to the bitter fact that African health systems are weak and have not responded to health problems appropriately. The people have lost faith in them.

Trying at this emergency time to reverse this historical fact is the reason behind the spread of Ebola.

At the centre of the weak health systems in Africa is the crisis of human resources. There are never enough health workers.


It is estimated that Sub-Saharan Africa needs 800,000 doctors, nurses and midwives. It is also estimated that to eliminate the shortage, $20 billion (Sh1.74 trillion) are needed.

The few health workers are concentrated in urban centres, are poorly remunerated, and are demoralised. Further, their skills are not continuously updated in rare conditions like Ebola so that when outbreaks happen, they are caught pants down.

The many problems that health systems in Africa face result from underfunding. For very good reasons, 189 African heads of states and governments met in Abuja, Nigeria, in 2001 and committed themselves to allocate 15 per cent of their national spending to health.

Ten years later, only six countries had kept the promise. They are Rwanda, Botswana, Niger, Zambia, Malawi and Burkina Faso.

Kenya, for example, allocated 10.5 per cent of the budget to the Ministry of Healt immediately after the Abuja Declaration. This figure dropped progressively and in 2005 it was 7.5 per cent; in 2011 5.9 per cent and last financial year it hit an all time low of about three per cent.

The counties have taken cue from the national government, with disadvantaged regions that need more allocation for healthcare setting aside even lower figures – Mandera and Wajir spent 3.6 per cent and 5.6 per cent on health this year.


It’s important to note is that even the 15 per cent agreed in Abuja is inadequate for Africa’s healthcare needs. The calculated health per capita expenditure in African countries ranges from Sh1,750 to Sh2,175. This is way below the Sh3,480 ($40) the WHO recommends.

Underfunding of healthcare in Africa has led to tragic consequences. Other than mistrust by populations, now obvious with this Ebola outbreak, the Africa Union indicates that the biggest health problem in the continent remains the big burden of preventable diseases.

This, according to Africa Union, is caused by weak health systems characterised by poor infrastructure, insecure supplies of equipment and commodities, inadequate human resources and weak management among others.

In this Ebola outbreak, the soft underbelly of the weak health systems in Africa is systematically being exposed.One patient entered Nigeria with Ebola and this has led to the death of at least two people including the doctor who treated her. Ten people are infected and more are being diagnosed by the day.

There is panic across Africa because if a sick person lands in any city the disease will spread unabated. Most countries have started screening passengers at the airport but again this may be in vain since Ebola takes 21 days to show symptoms. It is possible for an infected passenger to land at Jomo Kenyatta International Airport and travel to Turkana, Lamu and other parts of the country for days before getting symptoms.


The big question is whether our health systems are able to contain the epidemic should it happen. Having Kenyatta National Hospital prepare as it has done is good but it is also notable that Ebola is treated where the diagnosis is made.

If a diagnosis is made in Samburu it is not expected that patients will be transferred to Nairobi; Samburu must be able to contain the infection.

The greater fear also is that sick people could easily land in South Sudan, Somalia, Central African Republic or other parts of the continent where, because of instability, health systems have virtually collapsed. Many people could be wiped out.

While the risk of spreading the infection through air travel is very low, Africa is different and special in its own way and the global rules of the game may not apply.

While the US and Spain have confidently transported their sick citizens to their countries for treatment and ensured that nobody else got infected in those countries, this cannot be said of African countries.