It is easy to blame the governments of Liberia, Sierra Leone and Guinea for their failure to contain the spread of ebola. Some have argued that they should have put more resources into developing their health-care systems – but these are resources the countries of West Africa don’t have and that the international community has been unwilling to provide. At the same time, the severe shortage of medical staff in these countries is not simply a result of failures in government planning. One major contributing factor is the high demand for trained health personnel in rich countries.
Around 30 per cent of NHS doctors and 40 per cent of nurses were born outside the UK. Some medical schools and nursing colleges, particularly in India and Pakistan, have aligned their training and degree programmes with UK requirements. The NHS has direct recruitment systems in place that ensure special access to British citizenship. In 2013, 6,000 foreign nurses were recruited. At the same time, despite receiving 226,400 nursing applications that year, the NHS cut the number of nursing training places to 17,219, down from 20,829 in 2010. The UK is not alone in raiding health personnel from developing countries: many other rich countries behave in the same way.
Not only does this mean that poorer countries end up with too few health staff, as we have observed in Sierra Leone and Liberia. They also end up, in effect, subsidising richer countries by training nurses, doctors and other health technicians. Local medical education is distorted as a result. To give an example, I once travelled to Malawi on a UN mission in which one of our aims was to look at how to improve nurse training for HIV/Aids. The UN suggested that it would be cost-effective to develop a two-year in-service nursing diploma, yet this was instantly ruled out, in large part because the existing nurse training had been developed to meet international recruitment needs. Malawi needs more staff to address a growing HIV epidemic and other diseases but instead it is training nurses who tend to migrate.
Efforts to contain ebola have also been hampered by changes to global policymaking. In 2002, members of the G8 group of advanced nations launched a new international agency, the Global Fund to Fight Aids, Tuberculosis and Malaria. The fund has an annual expenditure of about $4bn, with 94 per cent of funding coming from the usual donor governments: the UK, France and US.
At the same time, the World Health Organisation’s (WHO)budget has been more or less frozen in monetary terms since 2006-2007. In its budget for 2013-2014, WHO expenditure for communicable diseases has been cut by 8 per cent; its allocations for emergency responses has been reduced by 51 per cent; funding for research into tropical diseases has fallen by 52 per cent. The Global Fund and WHO now have a similar budget but the WHO’s remit is much broader. The result? While there have been welcome advances in the response to malaria, HIV, Aids and TB, the international community diverts fewer resources to tackling epidemics such as ebola and other emerging global health problems.
To prevent a future ebola crisis, the health-care systems of countries such as Sierra Leone and Guinea need to be strengthened. But that also requires carrying out reforms closer to home: reducing rich countries’ dependence on medics trained in poorer countries and increasing funding to the WHO.
Desmond Cohen is a former director of the HIV/Aids programme at the United Nations Development Programme