Struggling for survival under Covid-19 shadows

Pandemic preparedness means more to low-income countries than fighting the next virus. It's about building health system capacity.

A nurse in a white hazmat suit stands at a frail wooden table and folds surgical instruments into blue paper. Next to her is a white microwave-looking machine that's presumed to sanitize scalpels and forceps but its door keeps popping open.

She says, "We sanitize each tool individually and envelop it for the next surgery."

It's not ideal, but it's the only option for the staff at Kings Medical Center in Bolgatanga, Ghana, near Burkina Faso. The center is one of the only hospitals in the 140,000-person district. It treats infants to adults for diabetes, malaria, respiratory infections, and basic surgery. Doctors and nurses say it's one of the best-resourced hospitals in the area, but it lacks basic tools. They don't have the proper PPE, there's only one light in the operating room, and the anesthesia machine's automation feature is broken.

Ghana, which has one of sub-Saharan Africa's strongest health care sectors, has been chronically underfunded. Health care workers say Covid-19 exhausted their facilities' coffers, preventing them from treating chronic, often lethal conditions. Now, health care workers in Bolgatanga, a region with one of Ghana's most powerful public health offices, and across the country are worried about their capability to provide medical assistance to patients and save lives in the future years, especially as some of the best-funded hospitals in the nation take on fewer cases to conserve resources. If new Covid variants spike cases or there's another infectious disease outbreak, Ghana's health system could crumple.

World Health Organization, UN, and other global health organizations have tried to help low-income countries like Ghana build up their health care sectors over the last two decades, but the investments haven't met the need, health care workers say. Without international and Ghanaian government assistance for equipment, medicines, and staffing, doctors and nurses at King's Hospital fear they will never catch up, putting millions of people at risk during the next pandemic. Without more help, they won't have the resources to test, inject, and treat patients, they say. If Ghana's health care workers are worried, so are those in Uganda and Sierra Leone, where health care is a luxury.

Since Covid began, the international community has invested little in strengthening health systems for pandemic preparedness. In 2021, the World Bank and the U.S. created the Financial Intermediary Fund to help low-income countries build their health systems to contain outbreaks.

The fund has only received $962 million in pledges, and it's unclear how much will go to governments to strengthen their public health infrastructure versus helping them pay for vaccines and therapeutics. Governments and health organizations have pledged billions to develop pandemic tools. Investing in health care systems in low-income countries will cost tens of billions more.

Even if the Financial Intermediary Fund devotes significant resources to help nations react to outbreaks by creating better surveillance networks, facilities like Kings Hospital in Ghana remain vulnerable.

"We need much." We need patient space. No ICU here. We lack specialists. We need all the equipment,” says Wenceslaus Apungu, the medical director at Kings Hospital. The facility lacks working MRI, X-ray, and ultrasound, machines. "They broke."

Underfunding in Ghana healthcare system

The G-20 projects $34 billion per year for five years is needed to prepare for the next pandemic, including strengthening health systems in Ghana and other countries.

It's unclear if the world will take the danger of another pandemic seriously to stabilize low-income countries' health care systems. Global Covid financial allocation is running out, and health facilities in some countries are trying to manage the virus while also treating other systemic diseases. Health organizations, governments, and pharmaceutical companies focus on tests, therapies, and vaccines. Discussions about allocating funds to help nations absorb and distribute them have faded.

World health leaders and proponents have argued for years that the international community should do more to finance and prop up health systems in low-income nations, including Africa, by hiring and training staff, providing essential medical supplies, and expanding supply chain access. In recent decades, wealthy Western nations have promised to change how nations prepare for large-scale health catastrophes. Health advocates say the money is usually tied to crisis funding parcels and disappears after a few years.

During Ebola outbreak in 2014, the U.S. was the largest single-country donor to Sierra Leone, Guinea, and Liberia. Congress appropriated $5.4 billion in crisis allowance as part of its 2015 spending package through various agencies, many of which only had three-year funding guarantees. Obama repurposed some Zika funds the following year.

U.S. aid continued to flow. The international strategy shifted to helping nations revamp their health systems to detect and respond to future outbreaks. Ebola infections fell. Ebola reemerged in Congo in 2018. By 2019, the WHO cautioned that it was going dry on funds to fight Ebola.

Ernest Darkoh, co-founder of BroadReach Group, a health care company expanding Africa's health system, said African countries need a lot of assistance to build resilient systems from management to IT, data, supply chains, HR systems, and leadership."

Ghana has received hundreds of millions of dollars in the last 20 years to treat maternal mortality, child malnutrition, malaria, tuberculosis, and HIV. Through the President's Emergency Plan for AIDS Relief, the U.S. has contributed more than $120 million to Ghana's HIV/AIDS response. In the north, where the land is less developed and neighborhoods are more impoverished, UNICEF and Oxfam have set up shop to help local health facilities.

Ghana's internationally-funded programs have reduced child mortality. Malaria cases have dropped with better treatment. Malaria-related deaths in Ghana dropped from 2,799 in 2012 to 308 by 2020, according to the WHO. Nevertheless, high HIV rates persist. There is slow coverage expansion. One in 27 children die before their first birthday and one in 19 die before their fifth birthday, according to a 2021 USAID analysis. Malnutrition is still common, especially among children in the country's northern region.

Health care staff in underfunded facilities across the country lack essential medicines and equipment.

First line of defense is the government's 1999 Community Health Programs. Local health facilities were revolutionary at the time, expanding access to care for millions of Ghanaians. Millions of Ghanaians had to travel far to find basic medicines before their opening. The one- or two-room compounds are found all over each region. Many can now walk or ride a motorbike to get care for colds, flu-like symptoms, and pregnancy. Complex cases are directed to a health center, which is a measure above CHPS compounds. Some health centers can keep malnourished patients all through the night. Complex cases are directed to district and regional hospitals with trained specialists includig surgical staff.

Many Ghanaian hospitals are overwhelmed by daily patient loads. Yellow fever outbreaks or rainy season malaria cases strain them to the limit. Local health compounds are underfunded. The Ghanaian government has bolstered its health care sector by hiring more nurses, but it hasn't given them enough money to perform optimally.

The Ministry of Health's budget grew 19% from 2015 to 2021, but development partner funding fell. In 2015, 23 percent of Ghana's health spending was for development. That figure was just 10 percent in 2021. Almost 80% of Ghana's health budget goes toward compensation, leaving little for goods and services. In 2021, this line item made up less than 1% of the Ministry of Health's budget.

“This low allotment severely constrains the ability to provide critical services,” a 2020 UNICEF report about Ghana's health care sector says.

USAID has helped Ghana's Ministry of Health improve its public health sector by procuring equipment and medicines for chronic health issues.

"Improving the health system means improving care," Janean Davis, acting USAID mission director in Ghana, says. "Quality saves lives. Nobody wants to go to the CHP compound if it's collapsing, unstaffed, or lacking lab tests and supplies. No, you can't call that a health system. That's a run-down building."

'It gets dicey sometimes'

After Covid-19, severe problems in health care delivery became untenable, say workers.

Ghana's Covid-19 cases and deaths are among the least in the world and Africa, with 161,370 cases and 1,445 mortalities. Health care workers say the infection counts are much higher because people aren't tested unless they're hospitalized. Even though the numbers are low compared to other African countries, the surges overpowered the health care system as the government hurried to repurpose funds to contain the spread and treat patients.

At one of Ghana's best-resourced newest and hospitals, the Univerity of Ghana Medical Center, the ICU was understaffed. Ready machines and medicines were in the waiting but beds lacked qualified nurses. In smaller facilities, doctors had to decline patients seeking maternal care, hypertension medication, or routine vaccinations. Health care workers were testing for Covid, treating it, and deciding patients that needed ventilator.

Doctors and nurses must stretch limited resources in the health care system. One of the main doctors at the King's Medical Center in Bolgatanga, famously called Bolga, said staff have performed procedures for months with almost no light.

One bulb works in the operating room's overhead lighting system. There is malfunctioning anesthesia machine. Surgical gowns and gloves are needed. A half-finished concrete maternity ward is idle due to lack of funds.

King's finances will worsen. Even though Covid cases have fallen, the regional hospital has stopped receiving minor cases from district hospitals and local health centers to ensure it has enough resources to handle its current caseload. That means the medical staff at Kings Hospital will soon deal with more patients when it's already struggling.

The financial distress of this district hospital and lack of life-saving equipment and medicines are common in Ghana.

A team of seven nurses and midwives at a Salvation Army partly-funded health compound outside Accra is examining for new ways to get funding so they can deliver better treatment and lodgings for locals. Left of the small pink building is a dirt and gravel patch where health care workers hope to build a small waiting room so patients don't have to sit in plastic chairs in the sun. The center's director raises a bedsheet to reveal the facility's only laboratory machine. It's small, white, and runs a few tests.

She says, “We must send the remaining tests to the hospital which is 45 minutes away"

A large, dark maroon doctor's chair sits down the hall. Overused, it's duct-taped and torn. Cornered is an empty oxygen tank in a room for maternity. Several women from this community are recovering in the next room. Six people can fit.

"We don't own a permanent sonograph," says physician's assistant Olivia Koduah. Sometimes it's dicey.

Koduah says the facility lacks an ECG machine, generator, and lights. Then, health care workers use flashlights when the lights go out.

This facility's staff fills resource gaps whenever possible. A local woman had an appointment last week. She needed high blood pressure medication, but she hadn't taken it in weeks because of lack of money. One nurse paid with her own money.

Doctors and nurses have learned to adapt, but they still want to provide quality care.

King's Hospital's medical director Apungu says, "We're doing our possible best."

Finding a solution

The WTO, World Bank, World Health Organization, and other global health supporters want more investment in low-income countries' health systems to ready for the next pandemic. No central funding mechanism exists.

ACT-Accelerator, formed in 2020 to fast-track Covid-19 tests, therapeutics, and vaccines, has committed $120 million to strengthening international health systems. The Global Fund to Fight Malaria, Tuberculosis, and AIDS, one of the largest nonprofits that strengthens health systems, is asking donors to invest $18 billion this year to cut HIV, TB, and malaria deaths and prepare the world for the next pandemic. About $6 billion would go toward strengthening health systems, ensuring countries have staff and resources.

The World Bank's Financial Intermediary Fund may have the most money. The U.S. has pledged $250 million since last week making it the only donor. At the Biden administration's second Global Covid Summit on May 12, several more countries promised money, bringing the total to $962 million — far below the $10 billion a year the U.S. and other health officials have called for to help low- and middle-income countries plan for the next pandemic.

The fund was initially created to help countries build surveillance systems and expand their health care workforce. A year later, it's unclear how much of the fund's money will go toward low-income health systems.

Global health leaders debate what to give preference in the coming years. Some proponents want the bulk of the fund to go toward vaccines and therapeutics. Others say more must be done to ensure that bolstering health systems doesn't fall behind vaccine and therapeutic development in global health priorities.

"Africa has the highest disease burdens and lowest per capita resources. Even simple challenges are difficult," Darkoh said. "When you multiply the complexity of the challenges with poverty and civil war, you can imagine how much harder it is on the continent ." It's impossible."

Rich countries may move on from the pandemic, depleting international funding. Despite rising case counts in the U.S., China, and Europe, governments are relaxing public health restrictions.

As the international community left the pandemic's emergency phase, it cut Covid funding.

The U.S. Congress authorized $10 billion in supplementary Covid funding for Health and Human Services in April, billions less than the agency requested. USAID and the White House urged lawmakers to approve an additional $5 billion for the administration's global Covid response. At the second Global Covid summit, participants pledged $3.1 billion for the fight against the virus, but tens of billions more are required for vaccinations and therapeutics distribution.

Tom Frieden, former CDC director and CEO of Resolve to Save Lives, said, "You need people, not stuff. That's a big issue in some discussions. Staff who can manage, run programs, and analyze data are needed."

Frieden has proposed an "accountability framework" and "swift quality refinement mechanism" to prepare for the next pandemic. The matric called 7-1-7 encourages countries to notice a presumed infectious disease outbreak in seven days, notify public health authorities and begin an investigation in one day, and respond in the next seven days.

Frieden: "We've partnered with African countries to look back at past outbreaks to see if they met the 7-1-7 criteria and, if not, why not and what can be done. It helps nations improve quickly."

If countries continue to cut funding for the global Covid fight, money for strengthening health systems may also disappear, says Darkoh. It's unclear if it will reappear before the next pandemic, at least in sufficient quantities. He says the global health community must rethink how it prepares low-income countries.

Darkoh further said, "We need to innovate radically if we're going to survive and get this right, especially for Africa. The traditional approach of 'We'll train more doctors'... We're stuck on how to approach this. But it won't do."