Summary

The ongoing Ebola outbreak in the DRC faces significant challenges in response and recovery. Global policymakers, implementing partners, and donors must develop health information systems to address the major gaps in data and surveillance that are significantly hindering response efforts.

Key recommendations to scale up health information systems in the DRC include aligning local and national health information systems with global policies, integrating routine and active surveillance networks, fostering collaboration with communities, and investing in supporting health system infrastructure. This brief has major implications on both the DRC Ebola response and future health systems strengthening efforts. The consequences of delaying rapid scale up of surveillance and data capacities in the DRC will delay the control of Ebola and ultimately cost lives.

Introduction

In May 2018, scattered cases of Ebola were reported in the eastern part of the Democratic Republic of the Congo (DRC). Since then, over 1,300 cases have been reported and 900 lives have been lost, making this the second-largest Ebola outbreak in history after the 2014 outbreak in West Africa (1).

In light of the DRC’s vulnerable health system and continuing violence against Ebola responders, the World Health Organisation (WHO) expressed “deep concern” about a recent spike in cases and “emphasized the critical need to strengthen current efforts in both preparedness and response” (2).

With the 2014 West Africa Ebola outbreak still in recent memory, many are turning to lessons learned from previous health emergencies to inform an effective response. Particular strategies underscore the importance of resilient health systems, including “ongoing surveillance, a well-trained workforce, laboratory capacity, and emergency response capabilities” (3). These lessons are enshrined in global health policy, with major frameworks shaping how countries like the DRC prepare for and respond to outbreaks. These dominant approaches include global health security (preventing and responding to public health emergencies), universal health coverage (enhancing a broad spectrum of “essential, quality health services”) (4), and one health (working at the intersection of animal, human, and environmental health).

With global health stakeholders determined to integrate these key health policy agendas to maximize health systems improvements, major reforms have concentrated on interventions that improve health outcomes across all frameworks. Underpinning these cross-cutting reforms is the urgent scale-up of surveillance and health information systems to fill gaps epidemic data. In fact, experts argue that “increasing the capabilities of the surveillance system in the DRC is critical to health security in the DRC and the broader global community” (5). To achieve this, policy interventions are needed to scale up integrated health information systems in the DRC, aligned with ongoing global and national health reforms to achieve effective control of the Ebola outbreak.

Investing in timely and high-quality data systems that can accurately depict ongoing response efforts to fight Ebola in the DRC is paramount. Without a concerted effort to scale up health information systems, Ebola may quickly become a global epidemic.

Aim and focus

Aim

To provide evidence-based policy recommendations for scaling up health information systems to better guide the DRC’s ongoing Ebola response efforts. Recommendations will rely on important policy mechanisms to shape health information strategies, and will be synthesized through comprehensive analysis of previous and current related literature.

Focus

Using major studies and reports, this paper will identify the most important barriers and recommendations for scaling up health information systems to prevent, detect, and respond to disease outbreaks. Particular emphasis is placed on recommendations developed by responders and policymakers with experience in recent outbreaks, especially the 2014 West Africa Ebola outbreak, and those with expertise in health system capacity-building in fragile states, such as the DRC.

Because of the urgency to identify strategies with the highest chance of success in combatting DRC’s Ebola outbreak, solutions are tailored to policymakers and implementing partners influential in health policy for integrated health information systems and improved response coordination.

Key Messages

Major recommendations

• Align global policies on health systems strengthening to guide health information capacity-building in the DRC
• Integrate routine health information systems with Ebola response-related health information systems at all levels of governance
• Cultivate meaningful engagement with community stakeholders to develop sustainable surveillance and data networks
• Invest in foundational health systems infrastructure to support implementation and training on using digital health technologies

Major Implications

Global Policymakers

• Push for explicit inclusion of health information systems in major global policy documents that could influence DRC’s Ebola response, integrating efforts with current global health commitments
• Engage with impacted communities to develop trust through sustainable health information systems
• Champion policies that foster regional and global coordination for Ebola response through health infrastructure and data-sharing agreements

Implementing Partners

• Frame health information capacity-building as a core Ebola response strategy
• Develop and advocate for health information and surveillance systems that are inclusive and integrated at the local, national, and global levels
• Align Ebola response efforts with broader health systems strengthening activities, such as digital health capacity-building and health worker training

Global Health Donors

• Pledge to make rapid and sustainable investments in the DRC’s health information systems that foster collaboration at all levels
• Direct investments into strengthening the DRC’s routine health information systems to be responsive and resilient
• Commit to supporting key partners, such as local communities and civil society, in scaling up health information systems

Target audience

This brief is mainly intended for stakeholders in the DRC Ebola response that have notable policy or implementing authority. This audience may shift over time, as progress in controlling Ebola affects the role of stakeholders in ongoing response efforts.

These stakeholders can be classified into three primary clusters: global policymakers, implementing partners, and global health donors.

Global Policymakers

Decision-makers in global institutions, especially those that lead on global health security (GHS) or universal health coverage (UHC), such as the World Health Organisation (WHO), the Centers for Disease Control and Prevention (CDC), and key UN agencies, like the United Nations Organization Stabilization Mission in the Democratic Republic of the Congo (MONUSCO), UNOCHA, UNICEF, UNFPA, UNHCR, FAO, and OIE. Country missions that track and advise on global health emergencies may also be important to policy dialog.

Implementing Partners

Stakeholders with a prominent role in the day-to-day Ebola response efforts within the DRC. They include national actors and policymakers, such as the DRC’s Ministry of Health, Ministry of Defense, and Ministry of Education. Additionally, this cluster encompasses international civil society and humanitarian organizations, such as Médecins sans Frontiers (MSF) and the International Federation of the Red Cross and Crescent (IFRC), as well as health workers and local development organizations on the frontlines of DRC’s Ebola response who can advocate for the importance of health information systems in their work.

Global Health Donors

Actors that have adequate financial resources to significantly improve the DRC’s Ebola response through health information capacity-building. These include development agencies in high-income countries like the U.S. Agency for International Development (USAID) and the U.K. Department for International Development (DFID), development banks like the World Bank Group, private stakeholders like the Bill & Melinda Gates Foundation, and public-private partnerships like the Global Alliance for Vaccines and Immunizations (GAVI) and the Coalition for Epidemic Preparedness Innovations (CEPI).

Terms and definitions

• Health information systems (HIS) — includes surveillance systems, electronic health records, health databases, and epidemiological data
• Digital health technologies — digital resources used to collect novel personal or environmental data, including mHealth, social media, remote sensing technologies, GPS, nanotechnology and electronic management databases (6)
• Civil society organizations (CSOs) — all stakeholders that are outside formal government or official capacity, including non-governmental organizations (NGOs), private sector, academia, advocates, and health professional groups
• Fragile state — a country ‘facing particularly severe development challenges such as weak institutional capacity, poor governance, political instability, and frequently ongoing violence or the legacy effects of past severe conflict’ (7)
• International Health Regulations (IHR) — a legally binding instrument meant to assist countries to prevent and respond to global public health emergencies

Methods

The information synthesized in this policy brief was collected through a literature review of published academic studies and recent grey literature.

A search was conducted on three main platforms: PubMed, Google Scholar, and NEJM. Primary search terms included a combination of “health information systems” OR “HIS” OR “surveillance” AND “Democratic Republic of Congo” OR “DRC” or “West Africa” AND “Ebola.”

Because the DRC Ebola outbreak is a relatively new and ongoing crisis, there is limited formal literature on this specific context. Instead, previous global health and policy studies offer relevant information, contexts, challenges, and recommendations, especially those analyzing recent Ebola outbreaks like the 2014 outbreak in West Africa.

Articles were included if they discussed a combination of key concepts, including Ebola, health emergencies in the DRC, HIS in outbreaks, disease surveillance, health preparedness and response, and health systems in fragile states. Articles were excluded if they were based high-income or Western countries, as these wouldn’t be contextually relevant to draw reliable lessons. In addition, most articles published prior to 2013 were excluded to focus on recent outbreaks, though a few articles prior to 2013 were included to provide general concepts or definitions.

Major emerging themes included relevancy to health information capacity-building, health security preparedness and response, universal health coverage strengthening, or DRC health emergencies. Many studies touched on two or more themes, yielding important cross-cutting recommendations.

Finally, a broad search examined grey literature and general information through a variety of sources using similar search terms and criteria. This was necessary to incorporate recent developments in the DRC Ebola outbreak and authentic, experienced reflections from implementing partners and policymakers. This also had the added benefit of ensuring information was up-to-date and could yield the most politically feasible recommendations by providing urgent and candid reflections by those closest to response activities.

Key sources of grey literature included published reports by international civil society partners, global and national work plans on GHS or UHC, press releases and speeches published by WHO, and blogs or articles from NGOs and advocates working in epidemic preparedness and response.

Main results

Lessons Learned

A landmark review characterized the 2014 West Africa Ebola outbreak as a wake-up call for the global health community and “a catalyst for innovative change and global action” (6). In its reflections on response efforts following the event, WHO outlined important lessons, including strengthening the IHR, building capacity for global surveillance and response systems, improving coordination through “seamless collaboration” (8), investing in preparedness and response systems that simultaneously strengthen national health systems, and fostering transparent and timely reporting (8). Similarly, a successful Ebola response in Uganda highlighted strong political support, effective coordination at all levels, active surveillance, robust community engagement, and timely laboratory capacity (9).

The DRC Context

When considering policy solutions to scale up health information systems in the DRC Ebola response, context cannot be overemphasized. In fact, this current outbreak represents “the first and the largest Ebola outbreak reported in an active conflict zone that includes multiple armed military groups spread out in the Ebola-affected area” (10). The expansion of Ebola into Congolese urban centers, poor existing health systems and infrastructure, and ongoing political instability and violence have led to substantial reporting delays, which can distort information on outbreak trajectory and misrepresent real-time Ebola response efforts (10).

The DRC’s health system is divided into national, regional, and local systems. At its most local level, this spans 8,266 health centers across 518 health zones, making coordination and collaboration particularly challenging (5). Furthermore, in areas like the DRC “with limited access to laboratory testing” and weak health infrastructure, surveillance systems are especially critical because they can promote “early detection and management of increased disease trends” to rapidly curb the spread of infection (11). In a systematic review of fragile states including the DRC, poor governance and political instability chronically led to weak routine health systems, limited diagnostic tools or surveillance networks, and inadequate training or data transmission (7). With an alarming average delay of five months before meaningful disease control (7), fragile states like the DRC must build context-specific, integrated HIS that rely on formal and informal sources of health information to ensure timely case detection and response.

Gaps in the DRC’s Surveillance Systems

Policy solutions must address notable weaknesses in the DRC’s current health information systems. A review of the country’s 2016–2020 National Health Development Plan laid out four key gaps in surveillance capacity to be prioritized by policymakers and responders, including poor quality and delayed data, inadequate data analysis capabilities, weak mechanisms to share and communicate health information, and overall poor facility or infrastructure support for digital health tools (5).

Key Challenges

Global health policies aligned with either GHS or UHC frameworks lead to siloed responses and fragmented priorities. In particular, there is noticeably poor collaboration and coordination between health and other national sectors, such as transportation, security, agriculture and education (12), despite the important role that these groups have on health emergency response in the DRC. Furthermore, chronic under-investment by donors and policymakers in local, provincial, and national capacities — “a critical element of UHC” (4) — leads to poorer health security and fractured data sharing mechanisms across borders, putting neighboring countries at risk.

Routine health information systems are not effectively integrated with Ebola-related health information systems. In fact, Ebola responders recorded “a high degree of unrecognized transmission in the community” (13), largely due to persistent pockets of Ebola in very rural or unsafe areas. To make matters worse, wide variance in data collection procedures and the lack of any “centralized organizing authority” for HIS means that timely data cannot be effectively shared, causing misalignment at the local, national, and global levels (14). As a result, HIS developed by policymakers in isolation from existing networks are likely to exacerbate coordination challenges and miss important data, particularly affecting vulnerable groups like pregnant women (15).

Communities often lack trust in responders and avoid seeking health care. As with most Ebola outbreaks, “community ostracism and resistance” (16) means that local communities occasionally foster negative attitudes toward both routine health workers and Ebola responders. As “one of the most important factors responsible for the sustained transmission and scale of the EVD outbreak in West Africa” (12), the lack of community engagement undermines data quality and management because “identified cases often refused to come forth with any personal information, reducing the accuracy of the information gathered” (6). Finally, local capacity-building is often ignored, with only “47% of community health workers [receiving] community-based surveillance training” (5).

Health facilities and supporting health infrastructure is glaringly under-financed and underdeveloped. In the DRC, electricity can be erratic and “computers and communication satellites are either not available or not well-functioning” (5). Furthermore, poor digital health means Ebola responders struggle to record data while wearing heavy protective suits and have even had to “shout data over a fence to someone outside the high-risk zone” to record vital information (14). This inevitably means that health workers must record data on paper and either call in or physically deliver crucial health information (5), significantly delaying response efforts.

Key Recommendations

Align policies that strengthen health information systems to ongoing global health security and universal health coverage initiatives at all levels.

Conflicting priorities in the Ebola response, often promoting GHS strategies at the expense of sustainable UHC strategies, can be addressed by focusing on “effective implementation of the IHR” (12). The 2014 Ebola outbreak in West Africa highlighted the importance of using “top level policy dialog […] to realign the provisions of the IHR” (12). This means that robust advocacy to DRC’s political leadership and national implementers must be intensified to “strengthen institutional arrangements required for implementation at the national and sub-national levels” (12).

Stakeholders, especially national and global policymakers, should develop HIS that are comprehensive, collaborative, and resilient for future outbreaks, in line with their global and national commitments to “strengthen the primary healthcare system” (16) and a one health framework. To ensure feasibility, policymakers must work in close partnership with advocates that can mobilize political will necessary to push for policy alignment at all levels of health systems.

Integrate routine health information systems with Ebola response-related health information systems to improve the efficiency of case reporting and speed up response efforts.

Uniting routine surveillance “by trained health care workers as they encounter cases during regular activities” with active surveillance “by the health care community to search for new cases of disease” is a proven strategy to promote early warning alerts and effective contact tracing (11).

Integrated Disease Surveillance and Response (IDSR) systems in the DRC, meant to “enable early detection of clinical symptoms and signs of epidemic potential” (11) should be better utilized to improve epidemic information for decision-makers. Studies have shown that IDSR, a routine HIS, “may be useful in early recognition” (11) of Ebola. Additionally, Uganda showed improved IDSR success by designating focal points at all levels to manage the integration of the surveillance system with other information networks, such as active epidemic surveillance and DHIS 2 (17).

Successful integration of IDSR into existing HIS in Uganda and Pacific Island countries suggests this is feasible in low-income countries (12). However, the uniquely complex context of the DRC demands close collaboration between community health workers, local CSOs, and national policymakers to scale up joint IDSR-HIS capacity.

Ensure strong community engagement is at the core of policies to scale up health information systems, both during and after the current the Ebola outbreak in DRC.

Poor community engagement during previous Ebola outbreaks led to detrimental health outcomes — delaying response and costing lives. Because Ebola response relies on the “identification and tracing of contacts of patients with confirmed or probable EVD” (18), robust partnerships with local communities is critical to “foster trust and acceptance between public health responders and communities” (18). With increasing attacks on health workers in the DRC, stakeholders must commit to robust engagement that can yield timely health information, identify early cases, and guide important cultural norms.

Past examples like the 2014 Ebola outbreak show that HIS scale up is most feasible when local buy-in is secured, especially with rural agro-livestock partners and community health workers (16).

Invest in partnerships that support digital health infrastructure and improve training on health information systems.

The DRC has well-documented gaps in health infrastructure, including lacking reliable electricity, Wi-Fi connectivity, and computers (19). Investments in digital health technologies, foundational to functioning surveillance and information systems, leads to a timely and more precise response (6). Additionally, stronger “integration into both citizen and health professionals’ communities is necessary to maximise the potential of digital technologies” (6). This includes training health workers in epidemiological surveillance and navigating new health technologies, as recent evidence shows an alarming lack of recent training in integral HIS capacities, such as IDSR (11).

Though securing new investments can be challenging, strong political support for health emergency response following recent severe outbreaks offers a window of opportunity for CSOs and vocal advocates to develop partnerships with key donors to transform HIS infrastructure in the DRC.

Key Implications

Global Policymakers

Policymakers must specifically include health information systems in all future GHS or UHC strategies and champion policies that foster local, national, and global coordination by prioritizing robust data transparency and improved health infrastructure. Institutions like the WHO and CDC have a special responsibility to invite impacted communities as key partners in crafting HIS policy.

Without the commitment of global policymakers, the DRC Ebola response will struggle to identify coherent strategies and powerful partners in mitigating the disease.

Implementing Partners

All partners on the frontlines of the DRC’s Ebola response should bring health information systems to the forefront of their strategy, developing and advocating for integrated surveillance systems that are closely aligned with broader health systems strengthening activities. In particular, organizations like MSF and IFRC can lead community outreach to strengthen ties with local NGOs and partners.

Without the participation of implementing partners, response efforts won’t be guided by timely or relevant health data, potentially exacerbating the outbreak.

Global Health Donors

Major donors should pledge rapid and sustainable investments in the DRC’s health information systems and support key civil society and community partners in training and capacity-building. Additionally, investments through donors like the World Bank and DFID should enhance integration between routine and active HIS.

Without adequate financial resources, the DRC Ebola response could come to a halt altogether, costing the global community far more in economic impact down the line.

Conclusion

Timely solutions to scale up health information systems in the DRC are vital to inform Ebola control measures. Global policymakers, implementing partners, and donors must make concerted efforts to develop health information and surveillance systems that are collaborative, integrated at all levels, and well-financed. Without these crucial investments to address glaring gaps in data, many more lives will be lost, placing the world at risk for a devastating global health emergency.

References

1. Digitalizing the Ebola response [Internet]. PATH. [cited 2019Apr29]. Available from: https://www.path.org/articles/digitalizing-ebola-response/

2. World Health Organization. World Health Organization; [cited 2019Apr29]. Available from: https://extranet.who.int/sph/news/statement-meeting-international-health-regulations-2005-emergency-committee-ebola-virus-disease

3. Marston BJ, Dokubo EK, Steelandt AV, Martel L, Williams D, Hersey S, et al. Ebola Response Impact on Public Health Programs, West Africa, 2014–2017. Emerging Infectious Diseases. 2017;23(13).

4. World Health Organization. World Health Organization; [cited 2019Apr29]. Available from: https://extranet.who.int/sph/uhc-health-system

5. Stolka KB, Ngoyi BF, Grimes KEL, Hemingway-Foday JJ, Lubula L, Magazani AN, et al. Assessing the Surveillance System for Priority Zoonotic Diseases in the Democratic Republic of the Congo, 2017. Health Security. 2018;16(S1).

6. Bempong N-E, Castañeda RRD, Schütte S, Bolon I, Keiser O, Escher G, et al. Precision Global Health — The case of Ebola: a scoping review. Journal of Global Health. 2019;9(1).

7. Bruckner C, Checchi F. Detection of infectious disease outbreaks in twenty-two fragile states, 2000–2010: a systematic review. Conflict and Health. 2011;5(1).

8. WHO leadership statement on the Ebola response and WHO reforms [Internet]. World Health Organization. World Health Organization; 2016 [cited 2019Apr29]. Available from: https://www.who.int/csr/disease/ebola/joint-statement-ebola/en/

9. Mbonye A, Wamala J, Nanyunja M, Opio A, Makumbi I, Aceng J. Ebola Viral Hemorrhagic Disease Outbreak in West Africa- Lessons from Uganda. African Health Sciences. 2014;14(3):495.

10. Tariq A, Roosa K, Mizumoto K, Chowell G. Assessing reporting delays and the effective reproduction number: The Ebola epidemic in DRC, May 2018–January 2019. Epidemics. 2019;26:128–33.

11. Ashbaugh HR, Kuang B, Gadoth A, Alfonso VH, Mukadi P, Doshi RH, et al. Detecting Ebola with limited laboratory access in the Democratic Republic of Congo: evaluation of a clinical passive surveillance reporting system. Tropical Medicine & International Health. 2017;22(9):1141–53.

12. Olu OO. The Ebola Virus Disease Outbreak in West Africa: A Wake-up Call to Revitalize Implementation of the International Health Regulations. Frontiers in Public Health. 2016;4.

13. Nuzzo JB, Inglesby TV. Ramping Up the Response to Ebola. New England Journal of Medicine. 2018;379(26):2490–1.

14. Jobanputra K, Greig J, Shankar G, Perakslis E, Kremer R, Achar J, et al. Electronic medical records in humanitarian emergencies — the development of an Ebola clinical information and patient management system. F1000Research. 2016;5:1477.

15. Time to Deliver: New Ebola Findings Highlight the Need to Improve Evidence and Interventions for Pregnant Women [Internet]. Center For Global Development. [cited 2019Apr29]. Available from: https://www.cgdev.org/blog/time-deliver-new-ebola-findings-highlight-need-improve-evidence-and-interventions-pregnant

16. Tambo E, Ugwu EC, Ngogang JY. Need of surveillance response systems to combat Ebola outbreaks and other emerging infectious diseases in African countries. Infectious Diseases of Poverty. 2014;3(1).

17. Building Capacity for Resilient Health Systems [Internet]. [cited 2019Apr29]. Available from: https://www.measureevaluation.org/resources/publications/tr-17-158/at_download/document

18. New Tools in the Ebola Arsenal | NEJM [Internet]. New England Journal of Medicine. [cited 2019Apr29]. Available from: https://www.nejm.org/doi/full/10.1056/NEJMp1811751

19. Macdonald PD, Cressman G, Mckay M, Loo S, Mcclure E, Macguire E. Real-time surveillance and response system for Ebola and other emerging infections. Online Journal of Public Health Informatics. 2017;9(1).

According to the World Health Organisation, “pandemics, health emergencies and weak health systems not only cost lives but pose some of the greatest risks to the global economy and security faced today.”[1] Health emergencies have no doubt risen to the top of global health discourse, but what do they say about the state of global health policy, both today and moving forward?

This paper will seek to argue two interrelated claims about the influence of recent health emergencies on the state of global health policy: First, that recent health emergencies have cemented a securitized approach to global health, serving as a dominant paradigm through which global health policy will continue to be framed. Second, that health emergencies continue to involve an increasingly diverse array of stakeholders which are constantly molding global health governance to reflect shifting balances of power.

These two claims, this paper will further assert, are inextricably linked to develop a continuous cycle of securitization in health, as the increasing reliance on a global health security paradigm attracts an ever-evolving cast of characters in global health, while this multitude of stakeholders commits to the health security paradigm — indicating that global health policy at large is becoming ever-more securitized the more it perpetuates a global health security approach. This analysis will explore these two closely tied claims together as they have evolved over key health emergencies, underscoring their increasingly co-dependent progression, and will conclude with their influence on recent developments in global health policy.

Defining Global Health Security

Elbe characterizes “securitization” as “the political process through which an issue is ‘presented as an existential threat requiring emergency measures […] justifying actions outside the normal bounds of political procedure.’”[2] This draws the important distinction that securitization relies on the presence of an existential threat. Wenham supports this, asserting that “the referent object of threat [may] be the state (national security threat), the population (human security threat), or economic interests (socioeconomic threat).”[3] This line of logic has led to infectious diseases becoming “the latest in a long line of non-military issues to be securitized in such a manner.”[4] This analysis will approach the rise of health security responses to health emergencies through this lens of securitization.

Health security is defined by Heymann as “the protection from threats to health.”[5] He further distinguishes between collective health security that reduces “the vulnerability of societies to infectious disease threats that spread across national borders” and individual health security that ensures “access to safe and effective health services, products, and technologies.”[6] This distinction between collective health security and individual health security is critical, as this paper will allege that a securitized approach to health emergencies have slowly merged these two realms of health security. This distortion of boundaries will also suggest that previously specialized actors will increasingly play larger roles in the global health governance (GHG) of each other.

The Evolution of Global Health Security

Heymann et al. chronicles “a series of international treaties and conventions” that quelled the spread of key infectious diseases since the 14th century — primarily plague, cholera, smallpox, and yellow fever.[7] Though this description suggests a steadily increasing focus on health emergencies, a deeper analysis indicates short bursts of focused attention on addressing these specific diseases, followed by longer periods of inaction, and eventually culminating in the creation of the World Health Organisation (WHO) in 1948.[8] The establishment of WHO as a new coordinating authority for infectious diseases — and central stakeholder in GHG — proved to be integral in generating necessary political will to address health emergencies, particularly for disease outbreaks.

HIV/AIDS

A complex web of actors, many with broader implications on human security, was critical in pressuring governments to respond accordingly, thus increasingly viewing themselves as equal stakeholders in global health policy. This became apparent when experts widely agreed that “existing regulations contained no answer, either in disease surveillance or response, to the growing international HIV/AIDS crisis.”[9] In a milestone for global health security, the UN Security Council adopted a resolution on HIV/AIDS in 2000 to address widespread “concern at the potentially damaging impact of HIV/AIDS.”[10] The involvement of the UN Security Council marked “the first ever by the Council on a health issue” — a significant departure from longstanding norms in what the body viewed as security matters. This participation by one of the most powerful forces in international security undoubtedly opened the door to blurring the lines between security and health globally.

Meanwhile, HIV/AIDS advocates and civil society organizations (CSOs), inspired and emboldened by the elevation of HIV/AIDS through its framing as a collective security threat, began focusing on the individual health security aspects of the disease. Heymann et al. notes this shift led to the rise of new partnerships like “the Global Drug Facility, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and UNITAID […] to provide medicines to low-income countries at no cost.”[11] This method of framing HIV/AIDS as a threat to both collective and individual health security was profoundly effective. Katz and Fischer went on to argue that the “catastrophe of HIV/AIDS catalyzed a transformation in development assistance for health,”[12] evidenced by the tripling of global health investments during the period, as well as the introduction of new private stakeholders in GHG such as the Bill and Melinda Gates Foundation (BMGF).[13] The surprising appetite for CSOs to integrate health security narratives into their HIV/AIDS programs and the impact this head on attracting new stakeholders would foreshadow a growing trend in the coming decades.

Impact of the Global War on Terrorism

In 2001, the September 11th attacks placed the world on high-alert, with countries reacting to the heightened climate of fear in the United States and its allies by ushering in an intense era of national security capacity-building. Levich recalls the tangible impact this pressure had on health policy, noting that “it wasn’t long before worldwide alarm about bioterrorism provided an opportunity to link together two previously separate fields: health and national/international security.”[14] Rubenstein further highlights that for policymakers, framing “health as a national security intervention married the intrinsic value of health and its instrumental use, with benefits for both health and security.”[15]

Meanwhile, Levich asserts that “coincident with the U.S. ‘global war on terrorism,’ [GHG] rapidly rose to the top of the worldwide public health agenda.”[16] With this rise of GHG came a plethora of nonstate actors, seeing this as an opportunity to advocate for inclusion in the evolving GHG structure. As a result, CSOs eagerly adopted securitized language, agreeing with governments that “cross-border travel, urbanization, and trade has made emerging infections inevitable and potentially catastrophic.”[17] This nascent relationship between health and national security meant that traditional global health partners — foundations, NGOs, and advocacy groups — could potentially serve in a mutually “reciprocal” relationship in national security.[18]

Cementing a Global Health Security Paradigm

On the heels of 9/11 and — importantly — set within this backdrop of heightened national security and a gradual acknowledgement of the political benefits of securitizing health, a series of health emergencies forced global actors to face the spread of infectious diseases head-on, by now commonly framed as “security threats.”[19] It was, as Wenham asserts, the “outbreaks of SARS (2003), H5N1 (2005), H1N1 (2009) and Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (2012–15)” that underscored “global mutual vulnerabilities to infectious disease” and led to infectious diseases “being framed as a collective security threat.”[20]

SARS 2003 Outbreak

The 2003 SARS outbreak significantly shaped global health policy, not only because the security paradigm surrounding the event emphasized just how susceptible a globalized world was to infectious diseases, but because of its impact on the role of WHO. During the response to SARS, WHO “assumed a new position of authority and respect” by coordinating epidemic intelligence in real-time, performing the role of a “real-time policy adviser,” acting as a “government assessor,” and serving as a “government critic.”[21] In doing so, WHO was bold in its assertion of power. The organization garnered widespread praise for effectively curtailing the emergency and was hailed as “the point at which a new governance paradigm for global infectious disease threats truly came of age.”[22] The climate of fear at the height of the SARS outbreak was ripe to employ a securitized response, a condition that was foundational to providing WHO valid justification to assume such powerful new roles.

However, WHO’s autonomy and swift response also ruffled many feathers in the global health community. Several governments were “uncomfortable with the ease with which the Secretariat acted” during SARS, particularly in its sole discretion to declare a public health emergency as a ‘worldwide health threat’ and its broad authority over coordination and response.[23] Accordingly, the member states moved to “decisively […] reign in the Organization’s powers.”[24] This backlash by governments to what would otherwise have been regarded as a successful health emergency response accentuates the complexity in GHG that arises by operating within a health security paradigm: On one hand, the “uncertainty inspired by SARS’ international spread”[25] boded well for WHO to efficiently respond during globally uncertain times by utilizing a security lens that granted it necessary authority. On the other hand, this encroachment by a single institution into national sovereignty disturbed many governments that were uneasy relinquishing their own autonomy, leading to accusations that WHO overextended its mandate by behaving “like the ‘international health police’”[26] during its response to SARS. In short, the 2003 SARS outbreak highlighted the noteworthy impact that prioritizing health security approaches has on global health governance.

Revision of IHR (2005)

The global health policy implications of the concurrent success of a health security response to SARS and the simultaneous fallout in GHG from WHO’s perceived power grabs were reflected in the updated International Health Regulations (IHR) in 2005. The IHR requires WHO member states to “develop public health capacities to detect and respond to public health emergencies of international concern (PHEIC), with states required to cooperate in building these capacities.”[27] The SARS outbreak served as an impetus to greatly strengthen previously outdated regulations. In fact, Wenham notes that “SARS acted as a catalyst for the updating of the IHR in 2005,”[28] while Katz and Fischer underscore that in the “immediate wake of the SARS outbreak, sudden fear of the consequences of a single nation’s failure to report an emerging infection — whether due to lack of will or capacity — overcame many of the concerns […] that had previously stalled the IHR revision process.”[29]

Many scholars regard SARS as a “global health disrupter”[30] that catalyzed IHR revision. Moon expanded on this visible shift, saying that SARS “redefined WHO’s identity as not only a technical organisation supporting its members, but also a political actor with decision making power that could have global consequences”[31] — highlighting just how influential this health emergency was on GHG. However, Kamradt-Scott pushed against this, pointing out that the revised IHR actually required WHO to convene an emergency committee with representatives from affected countries to come to consensus on issuing PHEICs, a departure from previous standards that allowed WHO to make such declarations independently.[32] This could be interpreted as underscoring “the subservient nature of the WHO”[33] to national authorities post-SARS.

In hindsight, both perspectives are true — the revised IHR, spurred by the SARS outbreak, can be considered a tool that provides “the world with a system of checks and balances to ensure that no one, including the WHO Director-General, has unfettered power when making decisions.”[34] As Kamradt-Scott reflects, this showed that the “emerging system of global health governance has been shaped and then re-shaped in the aftermath of SARS and the IHR revisions.”[35] This push-and-pull of powers and resultant expectations of evolving global health stakeholders, as symbolized by governments post-IHR seeking to retain a level of autonomy during health emergencies that was originally entrusted to WHO pre-SARS, suggests a recurring pattern in the state of global health policy: that health emergencies employing a health security response are particularly susceptible to dramatic shifts in GHG due to the heightened pressures that a national security discourse places on issues of sovereignty, power, and threat mitigation. As Kamradt-Scott rationalizes, given the history of recent health emergencies, “it is likely that when a new threat emerges, whether from an entirely new pathogen or a well-recognised one, the WHO’s response will adapt again to suit the circumstances surrounding the diseases’ emergence and the political environment.”[36]

West Africa Ebola Outbreak

A decade after SARS, the outbreak of Ebola in West Africa provided one of the most telling examples of just how dominant the health security paradigm had become in global health — and its influence on attracting nontraditional actors that perpetuate a cycle of securitization in health. Gostin and Friedman’s assessment at the height of the 2014–2015 epidemic warned that the virus “will take hundreds of thousands of lives if the current trajectory is not reversed,”[37] while the Defense Minister of Liberia described the virus as “spreading like wild fire and devouring everything in its path.”[38] Even global leaders utilized this emotionally-charged rhetoric, a tell-tale sign of health security responses. WHO Director-General Chan called the outbreak “the largest, most severe and most complex that we have ever seen”,[39] while MSF President Liu referred to the Ebola response as “lethally inadequate.”[40] Applying a global health security approach to Ebola, Chancellor Merkel equated the threat posed by Ebola “along the same lines as global issues such as terrorism and forced migration,”[41] while President Obama spearheaded a UN Security Council resolution calling the Ebola virus outbreak “a threat to international peace and security,”[42] marking the second time in its history that the Security Council responded to a health crisis. This created the sense of urgency necessary to the fight Ebola, while further cementing the health emergency as a global health security threat and attracting a diverse array of actors to heed the call to action.

As researchers noted, “the 2014 Ebola outbreak in west Africa blurred the lines between a public health emergency and humanitarian crisis.”[43] As Fidler states, though this rhetoric elevated Ebola from “an exotic tropical disease to a priority for global health security,”[44] before long, the responses became more reminiscent of wartime rather than disease outbreak. Several developed countries, such as Australia, issued temporary visa restrictions on all travelers and immigrants from Ebola-affected countries, while several airlines refused to fly to affected nations.[45]

Following suit, more countries imposed trade and travel restrictions as a way to assuage public fears of contracting the disease. In response to an overly-cautious WHO that grossly delayed designating the Ebola outbreak as a PHEIC, the UN “stripped WHO of leadership in creating the UN Mission for Ebola Emergency Response (UNMEER).”[46] It can be deduced that the “fear and dread”[47] of Ebola and the subsequent overly-securitized response, rather than a conventional health governance decision, forced the UN to create this duplicative mechanism and essentially sideline the role of WHO in order to maintain international credibility.

Kamradt-Scott et. al reflected that “several challenges arose from how the Ebola crisis was initially framed as a health emergency instead of a humanitarian crisis.”[48] This sparked an “Ebola hysteria,” offering the chance for organizations to be praised for humanitarian action and supported by the ensuing influx of “disaster fundraising.”[49] Conversely, organizations risked damage to their reputation by continuing to neglect the crisis. This led to firms like Firestone receiving favorable press for providing protective equipment to health workers, MSF raising over twice its annual operating budget from Ebola-related appeals, and public figures like supermodel Naomi Campbell and Facebook founder Mark Zuckerberg supporting the cause.[50] Notably missing from in this publicized narrative was the harm caused by poor accountability of these actors. Firestone grossly underpaid its workers while evicting Ebola victims’ families, and much of the money raised by celebrities went to Western-based institutions suspected of having ulterior motives. Levich argued that even the $50 million pledge provided by the Bill and Melinda Gates Foundation to combat Ebola, “was geared, not to assisting local health-care systems, but to advancing the foundation’s broader agenda.”[51] As Wenham states, during the response “each actor made a rational calculation of their interests in and responsibility for disease control and of whom they felt accountable to for this responsibility.”[52]

Finally, the participation of the military during the Ebola response is one of the most potent signs of the dominance of a health security paradigm, as well as its involvement of previously excluded national security actors. As researchers lamented, “no common framework was established for how different militaries operated during the Ebola crisis.”[53] Though the international and domestic military assistance played a key role in providing order to the chaotic response, concerns were raised for the future of civil-military cooperation in global health, for which the west African Ebola outbreak can be considered a precedent.[54] The deployment of 5,000 foreign military personnel from mainly Western nations was “key to convincing several non- governmental organizations to maintain or establish operations in the affected countries.”[55]

Civil society organizations, usually quick to participate in such health emergencies, were forced to flee due to the amplified fear and complexity of Ebola (in many ways exaggerated by the ultra-securitized framing) and only returned once militaries were deployed and provided a sense of personal safety and security for responders. However, Levich suggests that the lack of a common framework for civil-military cooperation during Ebola “offered useful cover for a substantial escalation in U.S. military presence” in the region, more than doubling its military presence in Africa and establishing a new military base in Monrovia,[56] while ironically, the widely anticipated Ebola Treatment Units provided by the US military went largely unused, with only 28 Ebola patients treated at the 11 ETUs built and 9 ETUs going untouched.[57] The military personnel deployed by various participating nations were blatantly uncoordinated due to differing mandates and operational structures. For example, the US military mainly supported Liberia’s Ministry of Health and Social Welfare in coordination with USAID, while the British military operated partially through DFID and an integration with Sierra Leone’s military.[58] These fractured responses by overlapping stakeholders are emblematic of, as Wenham puts it, “global shared responsibility for (their own) national health security.”[59]

Zika Outbreak

While the West African Ebola outbreak was “unprecedented”[60] in its integration of military actors, symbolizing the most tangible influence of securitization in health until that point, it was the outbreak of Zika in 2016 that truly cemented this as a new reality in global health. President Obama regularly held meetings “with national security advisors to strategise on Zika,” while the country’s Secretary of Health declared that “Zika has a significant potential to…affect national security or the health and security of US citizens”.[61] This securitized framing from the start wasn’t unique to developed nations in the Global North. Gostin and Hodge reported that Brazil Ecuador, and Cuba had already “deployed the military to fight the outbreak.”[62] The rapid reliance on the military as a key responder in health emergencies, having only been utilized for the first time less than two years prior, strengthens the assertion that health security and securitized actors fuel the rise of each other in an increasingly apparent cycle in global health.

Recent Expansion of Global Health Security Applications

The expansion of PHEICs in the 2005 IHR to “include any event that would constitute a public health emergency”[63] allows a variety of health issues to warrant a “health security” response. This has also been reflected in the way health emergencies are portrayed, with language and framing more conventionally reserved for military zones being employed in health emergencies to spur action. Recent pushes by global health advocates and policymakers have shown the bleeding of global health security into other areas of global health — and their willingness to embrace this as the dominant paradigm. As Chen and Takemi put it, “individual security sums up to collective security, and collective security means enhanced individual security.”[64]

Many of these links were strengthened following Ebola. For example, Heymann et al. argues that access to effective vaccines and drugs posed a major challenge to ensure the health security of communities facing Ebola, while, Chen and Takemi draw on the UN Commission on Health Security to underscore that health security must be “people-centered.”[65] Further uses of health security include the urge to “broaden the framing of health security to include non-communicable diseases” drawing on a health and human rights framework, and that universal health coverage is an effective strategy to strengthen health security while also improving economic and national security.[66] These framings strongly suggest that actors across the global health community are increasingly exhibiting a broader application of health security, weaving collective and individual health security to advance their health agendas.

Another key element of this is to look at the new types of partnerships and commitments that have been made following careful reflections of the health emergencies chronicled in this paper. Tappero et. al welcomed the creation of the Global Health Security Agenda (GHSA) to provide “clear targets and milestones to accelerate progress”[67] in complying with the IHR — a clear sign of the new mechanisms being developed and non-traditional stakeholders being included in the name of global health security. Civil-military partnerships like AFRICOM’s conference on Medical Support Operations feature modern health security stakeholders, including NATO and the Spanish Armed Forces.[68] Public-private partnerships like the Coalition for Epidemic Preparedness Innovations, highlight that it will only become more common to rely on “non-state actors’ resources, innovation and expertise as both necessary and desirable” to make strides in global health security.[69] The creation of a Coordinator for the Foreign Policy Dimension of Global Health Issues in Germany’s Ministry of Foreign Affairs at the height of the Ebola epidemic[70] and the designation by President Obama of an “Ebola Czar”[71] proves the extent to which governments will provide the capacity to create concrete, high-level government positions within global health governance that align with health security interests. In fact, as recently as December 2018, United States unveiled a plan to appoint an official global coordinator for global health security,[72] serving as a window to engage in broader commitments to global health and health systems strengthening. During the 71st World Health Assembly, member states committed to a “five-year global strategic plan” on health security and a commitment to “better protect one billion people from health emergencies by 2023.”[73] Finally, a review led by Moon et. al. following Ebola in West Africa all for “the creation of a Global Health Committee as part of the UN Security Council to expedite high-level leadership and systematically elevate political attention to health issues.”[74] Such a concrete involvement by the leading authority on international security would vastly serve to further securitize the principles and implementation of global health for years to come.

Conclusion

Global health security has become a staple of global health policy, with a series of health emergencies suggesting an apparently endless appetite to securitize health for political and social reasons. But by elevating health as a security issue, new stakeholders and partnerships have emerged, further linking security and health. This has also yielded a variety of commitments, including the IHR and targets set by global institutions to solidify health security as an expected strategy to achieve broader health successes. This cycle of health security, shaping global health governance to further perpetuate a health security paradigm, will make it increasingly difficult for stakeholders to disentangle themselves from securitizing health should they want to — as health security has become a norm rather than an occasional pattern in global health. With the ink barely dry from new commitments in global health security as a response to recent health emergencies, one thing is clear — this self-fulfilling cycle of global health security doesn’t show signs of slowing down any time soon.

References

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Connolly, G. (2018). Connolly and Chabot Introduce Bipartisan Global Health Security Act. https://connolly.house.gov/news/documentsingle.aspx?DocumentID=1528.

Cross, R. (2017). Global health spending good for U.S. security and economy, National Academies say. Science Magazine. https://www.sciencemag.org/news/2017/05/global-health-spending-good-us-security-and-economy-national-academies-say.

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[1] World Health Organization, 2018

[2] Elbe, 2010

[3] Wenham, 2016

[4] Elbe, 2010

[5] Heymann et. al., 2015

[6] Heymann et. al., 2015

[7] Heymann et. al., 2015

[8] Katz & Fischer, 2010

[9] Katz & Fischer, 2010

[10] United Nations, 2000

[11] Heymann et. al., 2015

[12] Katz & Fischer, 2010

[13] Katz & Fischer, 2010

[14] Levich, 2015

[15] Rubenstein, 2015

[16] Levich, 2015

[17] Levich, 2015

[18] Levich, 2015

[19] Heymann et. al., 2015

[20] Wenham, 2016

[21] Kamradt-Scott, 2011

[22] Kamradt-Scott, 2011

[23] Kamradt-Scott, 2011

[24] Kamradt-Scott, 2011

[25] Kamradt-Scott, 2011

[26] Kamradt-Scott, 2016

[27] Gostin & Friedman, 2014

[28] Wenham, 2016

[29] Katz & Fischer, 2010

[30] Moon, 2018

[31] Moon, 2018

[32] Kamradt-Scott, 2011

[33] Kamradt-Scott, 2011

[34] Katz & Fischer, 2010

[35] Kamradt-Scott, 2011

[36] Kamradt-Scott, 2016

[37] Gostin & Friedman, 2014

[38] Kickbusch et. al., 2017

[39] Levich, 2015

[40] Levich, 2015

[41] Kickbusch et. al., 2017

[42] Gostin & Friedman, 2014

[43] Kamradt-Scott et. al., 2016

[44] Heymann et. al., 2015

[45] Heymann et. al., 2015

[46] Heymann et. al., 2015

[47] Heymann et. al., 2015

[48] Kamradt-Scott et. al., 2016

[49] Levich, 2015

[50] Levich, 2015

[51] Levich, 2015

[52] Wenham, 2016

[53] Kamradt-Scott et. al., 2016

[54] Kamradt-Scott et. al., 2016

[55] Kamradt-Scott et. al., 2016

[56] Levich, 2015

[57] Levich, 2015

[58] Kamradt-Scott et. al., 2016

[59] Wenham, 2016

[60] Levich, 2015

[61] Gostin & Hodge, 2016

[62] Gostin & Hodge, 2016

[63] Katz & Fischer, 2010

[64] Heymann et. al., 2015

[65] Heymann et. al., 2015

[66] Heymann et. al., 2015

[67] Heymann et. al., 2015

[68] Levich, 2015

[69] Puyvallee et. al., 2018

[70] Kickbusch et. al., 2017

[71] Cross, 2017

[72] Connolly, 2018

[73] Burci & Qurin, 2018

[74] Moon et. al., 2015

I first met Angela as part of the Emerging Voices for Global Health fellowship, where she opened up to me about her experiences as a young, female researcher in Uganda. One story stood out because it perfectly portrayed the complex web of barriers that prevent the world’s most vulnerable communities from accessing essential primary health services, the foundation for universal health coverage (UHC), as well as the importance of intersectionality among health professionals as stewards of UHC.

During a visit to a rural clinic in northeast Uganda, she arrived to find a long queue of patients frustrated that the health worker on duty was nowhere to be found. After tracking him down, Angela was shocked to discover that the man the entire community depended on for healthcare was listed as the clinic’s security guard. Investigating further, she learned that for weeks no health workers had showed up at the clinic. Seeing this, the security guard took it upon himself to act, diagnosing each patient with malaria and sending them home with a dose of Coartem.

His explanation for this? “Well, what else could I do?”

On the heels of the Astana Declaration on Primary Health Care, Angela’s story uncovers some hard truths about just how far we are from realizing the vision of UHC. Here are three ways civil society partners can strengthen primary health care to ensure no one is left behind:

Step 1: Value the key role of frontline health workers by supporting their needs.

Without frontline health workers, UHC is impossible to achieve. But simply employing health workers doesn’t yield adequate primary health care either. Angela’s story highlights the countless barriers that prevent health workers from effectively doing their jobs. Programs must consider their needs too — including sufficient compensation to improve motivation, providing decent facilities to prevent rural to urban emigration, and promoting effective management to combat absenteeism, following examples from organizations like IntraHealth International. Furthermore, strong data systems are needed to gauge gaps in health worker cadres, plan for essential health services, and train health workers as leaders of UHC in their own communities.

Step 2: Empower community voices, particularly those of women and youth.

Health systems are most successful when we put people at the center. But civil society organizations (CSOs) have a spotty track record of doing this, largely because we fail to engage those who have been marginalized the most. Because her supervisors empowered Angela, a young female researcher living close to the communities she serves, root causes of human resources for health (HRH) gaps often overlooked were brought to the fore during her explorations. And by empowering local communities to speak up themselves, Angela could more effectively determine sustainable, people-centric solutions.

The voices of those that are young, female, impoverished, and/or living in rural areas are far too often left out of decision-making, ultimately leading to massive fractures in health systems. Men, particularly those in power, have a big role to play in passing the mic; an important first step can be making commitments with groups like Women in Global Health. By spotlighting less-visible voices at all levels, CSOs will progress much faster on achieving UHC.

Step 3: Commit to an intersectional approach. Always.

A paradigm shift is needed to ensure CSOs understand that their impact on all UN Sustainable Development Goals (SDGs) impacts progress for UHC. For example, it’s not enough to develop reproductive health programs for women if they continue to sideline LGBT+ communities or ethnic minorities. Health worker training programs must meaningfully engage the growing youth population and those in poverty with decent jobs and employment. An immunization campaign partnering with pharmaceutical companies that pollute the environment or discriminate against women in leadership is simply not sustainable.

It can be challenging to advocate for multiple issues at once, but being committed to intersectionality accelerates progress on all global goals, particularly in the provision of primary healthcare. And if we don’t develop programs that highlight intersectionality in health systems, we cannot expect policymakers to develop holistic solutions either.

The vision of UHC is ambitious, and the SDGs go even further. But the right to health for all hinges on these shared global goals.

Recognizing that diverse teams of trained and supported health workers are the bedrock for UHC is paramount. And by placing those long removed from decision-making at the center of the table, whether young and female like Angela or rural and poor like the security guard, we can learn vital lessons that accelerate progress toward UHC. Combined with an intersectional lens that truly commits to leaving no one behind, and we actually have a shot at meeting our targets by 2030.

As we barrel toward the UN High-Level Meeting on Universal Health Coverage and reflect on commitments made during the 40th Anniversary of the Alma-Ata Declaration, let’s keep these important lessons in mind. Universal health coverage is possible, but the status quo we’ve relied on will no longer work. And it will take an army of young, female leaders like Angela and forward-thinking civil society partners that support her to make it happen.

Arush Lal is a Master’s student in Health Policy, Planning and Financing at the London School of Hygiene and Tropical Medicine and the London School of Economics. A Gates Foundation Goalkeeper and Primary Health Care Young Leader, he currently serves on the Board of Directors for Women in Global Health, where he is helping push for gender equality in leadership positions. Arush recently completed fellowships with Global Health Corps and Emerging Voices for Global Health.

Global Health Corps (GHC) is a leadership development organization building the next generation of health equity leaders around the world. All GHC fellows, partners, and supporters are united in a common belief: health is a human right. Want to get involved? Check out these great opportunities to support the health equity movement and consider joining us as a fellow — applications are open through January 16, 2019! And don’t forget to connect with us on Twitter / Instagram / Facebook.

A Reality Check on UHC: Where do we go from here? was originally published in AMPLIFY on Medium, where people are continuing the conversation by highlighting and responding to this story.

The attendees, a passionate and vocal conglomeration of 2,100 health systems researchers, clinicians, policymakers, educators, administrators, and advocates, spent the week focusing on issues ranging from health service gaps in fragile and conflict-affected states to global health security to engaging the private sector in managing noncommunicable diseases.

What was clear from just about every session I attended was the critical role frontline health workers play in making healthcare possible in all communities and contexts. Whether it was coping with the migration of health workers from rural to urban areas in search of better-supported jobs, ensuring sustainable and quality health services in vulnerable communities, or addressing pervasive power dynamics that perpetuate harmful gender imbalances in healthcare, health workers were a foundational aspect of much of the research and recommendations being shared throughout the week.

And a unifying theme emerged — well-supported frontline health worker teams made up of multiple cadres that are diverse and qualified to provide a full range of care are a catalytic component of achieving universal health coverage and the triple billion targets set by the World Health Organization.

The Alma-Ata declaration, which boldly committed to “health for all” forty years ago, has unfortunately been sidelined over the past decades as health systems prioritized vertical approaches that focused on treating specific diseases rather than ensuring access to health services through robust primary healthcare. Today, over eight million die annually in LMICs due to “inadequate access to quality care,” resulting in over $6 trillion in economic losses yearly.

Yet it was evident at the Health Systems Research symposium that the tides are shifting. Experts and policymakers are putting the focus back on community health — and that means ensuring we have robust frontline health workers who can deliver care at the center of primary healthcare programs.

During several panels and workshops throughout the week, there were strong appeals to better commit to milestones set forth in the Global Strategy on HRH: Workforce 2030, urgent calls to prioritize investments and funding in the health workforce to support frontline health workers in underserved communities, and countless examples of how training health workers in competency-based education yields massive gains in health outcomes for patients.

So as we look ahead to the 40th Anniversary of the Alma-Ata at the Global Conference on Primary Health Care next week, it’s important that we translate the mountains of evidence and recommendations on supporting frontline health workers into tangible action through national and global policies and financial commitments.

I sincerely hope that with the incredible momentum being generated around robust primary health systems, the voices of frontline health workers are not just valued in discussions and policy outcomes, but prioritized. Their role as stewards of health services at all levels places them as the primary guardians of healthcare — and they should be valued as such.

Our progress in achieving universal health coverage and building resilient primary healthcare systems hinges directly on how we empower frontline health workers to do their jobs effectively. From Liverpool to Astana, how we respond to the needs of health workers will either make or break our vision of a world where equitable, quality health services are accessible to all. Let’s make sure to get it right this time.

Arush Lal was a 2017–2018 Global Health Corps U.S.A. fellow at IntraHealth and is currently pursuing an MSc in Health Policy, Planning and Financing at the London School of Hygiene and Tropical Medicine/London School of Economics. Supported during #HSR2018 in part by IntraHealth International and the Frontline Health Workers Coalition, Arush was selected as an Emerging Voice for Global Health during the recent HSR Symposium and a PHC Young Leader for the upcoming Global Conference on Primary Health Care.

From Liverpool to Astana: Frontline Health Workers Are a Catalyst for Universal Health Coverage was originally published in AMPLIFY on Medium, where people are continuing the conversation by highlighting and responding to this story.

Arush Lal recently served as the Global Policy and Advocacy Associate at IntraHealth International and the Frontline Health Workers Coalition and a Global Health Corps fello. He supported strategic refinement and expansion of advocacy and policy efforts to support health workforce development and health systems strengthening, serving as a key liaison to partners in U.S. government, officials in Congress, multilateral agencies, country offices, and civil society/private sector organizations.

The Women in Global Health team sat down with Arush to ask him his opinions on gender equity and how men can engage in the conversation.​​

Women in Global Health: In what ways have you noticed gender inequality at the leadership level during your career in global health?

Arush Lal: As a young professional in global health, one thing has been clear to me from the start — gender inequality is just about everywhere. It doesn’t take years of experience in the field to notice the inexcusable juxtaposition between women who constitute a vast majority of the health workforce and men who hold a vast majority of the leadership or management roles in the same areas. I’ve caught myself more than once asking, where did all these males in leadership positions come from, and where did all my female colleagues disappear to?

I’m fortunate to already have worked in a number of healthcare settings, both as a health worker and when training health workers in six different countries. It really is striking that across all contexts, spanning continents, cultures, languages, and income, one constant always remains — men are usually in power. From NGOs in Haiti, to government health centers in Peru, to hospitals in the Dominican Republic, to mobile clinics in rural Albania, I’ve worked closely with women — who comprise a majority of the workforce as nurses, midwives, educators, and physicians — and men who were calling the shots, as directors or managers of the programs we served.

Many times, when we talk about gender inequality at the leadership level in global health, we often tend to ignore the system of inequality that surrounds the health system as well. Not only are men often head physicians or directors of their programs, men are also more likely to be heads of households, policymakers in the government, renowned academics, and respected donors and philanthropists. In my view, this tends to foster a world that inevitably favors the advancement of men, while women continuously face an uphill battle building their careers.

WGH: Where do you see opportunities to improve the inequality? Are there strategies you’ve seen implemented or used yourself that have helped?

AL: Because gender inequality is so ingrained within our health and societal systems, I believe it can only be improved one way — boldly and intentionally. It’s been proven time and time again that women often get passed over on leadership roles despite equal or better qualifications and face significant renumeration disparities, despite equal work. Until purposeful steps are taken to ensure women in global health are as valued at the highest levels as they are at the lowest, progress will simply remain at a standstill.

There are several strategies I’ve seen and used myself that I feel have helped turn the tide on gender inequality in global health, even if in smaller and more nuanced ways.

I think initiatives like Women in Global Health’s pledge to only participate in panels with gender parity are a great example of cementing women as equal voices in the health workforce. Pledges like this, however, need to be accompanied by tireless commitment and engaged colleagues. For example, on a recent high-level forum I was helping plan, I referenced the pledge and noted early on that we must all commit to having gender parity in each and every event. Another example is partnering with other groups that are often marginalized to join forces for increased impact. This means intentionally collaborating with underrepresented groups like youth associations and local health workers from rural communities, especially across the Global South.

Finally, it’s critical to focus attention on this issue through any and all skills and resources available. As a fellow with Global Health Corps, I’ve been working with IntraHealth International and the Frontline Health Workers Coalition to better support and recognize the impact of female health workers, as well as the impact that investing in health systems has on empowering women. Through policy recommendations including our new fact sheet, we are pushing this issue in as many venues as possible, including in briefings to government leaders at high-level events like the Fourth Global Forum on Human Resources for Health, the G7/G20, and the World Health Assembly.

WGH: What do you do to get people around you interested in working with gender equality? (i.e. in your workplace, personal life, etc.)

AL: As a younger voice in global health, I feel fortunate to be focused on gender inequality early on, so I can ensure I am addressing the issue in all aspects of my personal and professional life moving forward — such a pervasive issue really does take a lifelong commitment.

One way I am working with gender equality is to listen often and openly to all women speaking out about the issue. Keeping an attentive ear toward what marginalized voices in this community are saying ensures I’m aware of the most severe barriers that hinder the progress of women, as well as enabling a better understanding of how I can promote their voices and empower their growth as equal partners in global health.

Furthermore, I try my best as a male in the room to see that female colleagues receive the equal opportunities and recognition they deserve, from encouraging them to contribute to discussions, to asking their opinions on key initiatives, to highlighting their impact on organizational missions. Finally, I make it a point to push for gender parity wherever I have power, and publicly point out where we fail to deliver on this promise. This includes assembling teams with gender parity, featuring women voices wherever possible, especially female voices that are underrepresented, in addition to vocalizing support for gender equality through social media, blog posts, and high-level events. I am constantly pushing my team and my peers to think about how intersectional issues in gender inequality affect our own projects, and that we must be firm in our commitment to realizing the change we need.

WGH: Solving inequality requires an ‘all hands on deck’ response, we need all genders to address and engage in the issue. Therefore, what role do you think men can play in addressing this inequality?

AL: It really is on all of us to address gender inequality, both in global health and across society. Men have a pivotal role to play in this, as we often carry the power of privilege — and the responsibility to use it wisely. For too long men have been comfortable sidelining or undermining the role of women in leadership positions. This is an especially painful truth in global health, where we fight inequities daily while ironically continuing the dark legacy of gender inequality in our own workplace.

All men should commit to basic steps to address this — listening to female colleagues and women voices on the frontlines, vowing to only participate in events or panels that achieve gender parity, pushing for the inclusion of gender inclusive practices that value the contribution of women (who make up to 70% of the health workforce and $3 trillion into the health system), and committing to fight against systemic barriers that prevent women from reaching their full potential in their careers and in society.[VB1] As men, we need to be a lot more comfortable passing the mic, rather than taking it. The world advances when we truly listen to those who haven’t been heard.

WGH: From a societal perspective, what changes and adaptations do you think are necessary to highlight this issue and address it as a community?

AL: First, I think a key change must be made in the way we in global health look at ourselves as a field. I feel many times, as a sector that is devoted to fighting global inequalities of all forms, we falsely believe that we can do no wrong ourselves. This “holier-than-thou” mentality has allowed some profound injustices to quietly continue, including the grave issue of gender inequality. Admitting this is as a sector is a critical first step. Next, we must be open to change, and embrace the recommendations of women who have been voiceless and powerless for so long. Finally, we should focus our efforts on truly committing to the issue as a core tenet of all programs and strategies we undertake. Not only does this make sense economically — with a $28 trillion increase in global GDP possible if women were able to participate equally in the economy — it’s quite simply the right thing to do.

We must be steadfast and not lose momentum, re-framing gender equality as an unquestioned expectation, not a lofty goal.

WGH: What advice do you have for young men regarding gender equality and moving forward?

AL: Young men — we are in a unique and special place in history to truly make gender inequality a thing of the past. We have countless years of evidence and mountains of data proving that our world only moves backward when women hold unequal footing in society. It’s crucial we make it a point to dismantle barriers that hold women back from achieving their full potential as partners in global health, hearing what our female colleagues, friends, and family have to say and applying these lessons to foster a world that finally engages all of us. Without 50% of our population fully empowered to make the change we want to see, we will struggle to achieve global goals, including the most critical targets in public health. Mentor and encourage each other in this initiative, support leaders who are like-minded in pushing for gender equality, and never be afraid to speak up when you witness an injustice to our female counterparts. Our entire generation suffers without this.

WGH: In your opinion, how will we reach gender equality?

AL: Untangling the mess of gender inequality from cultural norms, societal pressures, status quo, and expectations is extremely difficult. Gender inequality is so complicated because it’s not simply a black and white issue — it’s rooted deep within our collective, and ingrained throughout our childhood and early careers. Leaders who fail to make the necessary, intentional, maybe even controversial changes required to tip the scales to equilibrium perpetuate this cycle. In my opinion, we can only hope to reach gender equality when men reflect intentionally and seriously on their role in levelling the playing field once and for all. We have to train the next generation, especially young men, in a world of uncompromising gender equality. We must empower our female colleagues, and bring out the most marginalized of voices to the forefront, so we can learn where we have made mistakes and how we can revise our programs to be inclusive for everyone. And we must always be open to the profound, sometimes uncomfortable changes that gender equality requires for the good of our future. Because I have found, as many others have as well, that when we invest in women and gender equality, the world moves forward and so do we. It is time we commit to this once and for all.

This interview was originally posted on Women in Global Health’s website as part of their ongoing series highlighting male champions in the push for gender equality in the health workforce.

Global Health Corps is a leadership development organization building the next generation of health equity leaders around the world. All GHC fellows, partners, and supporters are united in a common belief: health is a human right. Want to get involved? Check out these great opportunities to support the health equity movement and consider joining us as a fellow or partner when applications open later this year! And don’t forget to connect with us on Twitter / Instagram / Facebook.

Engaging Men in the Gender Equality discussion: a conversation with Arush Lal, IntraHealth… was originally published in AMPLIFY on Medium, where people are continuing the conversation by highlighting and responding to this story.

Today, I remember Gabriel, a Panamanian boy half my age who first taught me how a fractured health system fails people. I met Gabriel in the waning hours of our fourth clinic day, where our team of passionate doctors and volunteers was visibly exhausted after treating hundreds of patients in the remote islands along Panama’s rugged coastline. I vividly recall watching him bear the sweltering heat as he waited to be examined, and felt proud when I saw him leave with a much-needed bottle of Albendazole and a bag of nutritional supplements for his sister back home.

As I instructed the team to wrap up for the day, I suddenly noticed Gabriel running the winding path back to the clinic, stopping in front of me wide-eyed and out of breath. He urgently explained that his disabled grandmother needed medications to control her diabetes, but no health workers reached their part of the island. I asked him if he could bring her to the clinic before we left, but he informed me she was too weak to make the hour-long journey to meet us.

I desperately wanted to help, but we were short-staffed, facing a surge of patients and a setting sun. As the leader of the group, I was faced with an impossible decision: provide the medication without an examination or send the boy home empty-handed. I was forced to choose the latter.

Gabriel is one of 400 million people who lack access to health workers, and that number grows every day. In fact, it’s estimated that the world will face a shortage of 18 million health workers by 2030, meaning a shameful rise in stories like Gabriel’s.

Where someone lives should never determine if they live, but although illness is universal, healthcare isn’t. As a vocal advocate for UHC, I now focus on health workers, because without them, health doesn’t happen.

Where someone lives should never determine if they live, but although illness is universal, healthcare isn’t. As a vocal advocate for UHC, I now focus on health workers, because without them, health doesn’t happen. Frontline health workers are the first and only point of contact for many marginalized populations, often facing unsafe conditions with limited training, equipment, and resources needed to perform their lifesaving duties.

Investing in health workers isn’t just a cost-effective solution (the UN Secretary-General’s Commission on Health Employment and Economic Growth estimates a 9 to 1 return on investment), it’s essential to achieving the Sustainable Development Goals (SDGs) — eliminating poverty, fueling economic growth, reducing gender inequalities, and saving millions from preventable diseases.

In many ways, Gabriel reminded me of myself. Just as I, one of the youngest team leads at Volunteers Around the World, was busy overseeing our clinic operations to ensure rural populations had access to lifesaving care, so was he, a compassionate nine-year-old, spending his day scouting medications for his family rather than, well, being a kid. But where healthcare is scarce, everyone, including our youngest, must step up to the plate.

With the support of Global Health Corps and IntraHealth International, I recently attended the Fourth Global Forum on Human Resources for Health, convened by the World Health Organization and several partners in Dublin, as a youth delegate and panelist. Along with 1,000 policymakers and advocates, we discussed possible solutions to the health workforce crisis and the pivotal role young people play.

Youth aren’t just the leaders of tomorrow; they’re leaders today, as young doctors, policymakers, and researchers. Bold, innovative, and visionary, my peers are making noteworthy advances in the way we pursue global public health. Youth must be empowered to push for greater accountability, stronger policies, and sounder investments to improve access to frontline health workers and resilient health systems. Without over three billion of us at the table, world leaders will continue to struggle to achieve their global health targets.

Over half the world’s population is under 30, and young people have woefully untapped potential as crucial advocates and partners in achieving UHC. Youth aren’t just the leaders of tomorrow; they’re leaders today, as young doctors, policymakers, and researchers. Bold, innovative, and visionary, my peers are making noteworthy advances in the way we pursue global public health. Youth must be empowered to push for greater accountability, stronger policies, and sounder investments to improve access to frontline health workers and resilient health systems. Without over three billion of us at the table, world leaders will continue to struggle to achieve their global health targets.

Innovative Education

As the next health workforce, young people must be actively involved in planning their future, and we should push for academic programs that cultivate students who are well-versed in the SDGs and UHC. This includes expanding models like the UN Regional Centers of Expertise, one of which I recently helped create in Atlanta, to bring the global goals onto college campuses. Similarly, there is a need to create effective education programs, like an undergraduate degree in global health systems and technology I proposed at Georgia Tech, aligning interdisciplinary curriculum with the goal of achieving UHC.

Taking Action

Young people should work with local governments and NGOs as implementers in the fight for UHC, because youth are effective at reaching vulnerable populations. IntraHealth is a shining example of how to mobilize young people as frontline health workers. Through its CS4FP Plus program, IntraHealth has trained 92 youth ambassadors to lead family planning campaigns, featuring advocates like 16-year-old Nina Kone of Burkina Faso, who pushes for gender equality while de-stigmatizing sexual education, and Abou Diallo, who ensures that young people have access to contraceptives and reproductive health services in Guinea.

A Voice for Change

Few things are more effective than a passionate young person with a platform and a voice to cut through cynicism and question the status quo. Youth can and should advocate globally, ensuring governments commit to the policies they enact.

The Dublin Declaration and an accompanying Youth Call to Action are promising examples of youth engagement in UHC done right. For the first time, “youth” appears as a key stakeholder in the Dublin Declaration — and for good reason too. Youth perspectives are catalytic in achieving the SDGs, and our fluency in social media to push our messages far and wide make us an asset to governments trying to drive change. The first generation faced with climate change and an innately powerful imagination for new technology, we apply innovative solutions to health systems gaps, creating database and information systems, training health workers online, and improving telemedicine.

Young people: Be proactive and vocal advocates for change in achieving UHC, building relationships with diverse stakeholders and holding leaders accountable when they fail to deliver.

Established leaders: Engage youth more meaningfully, as key partners and not as an afterthought or disconnected silos. Mentor us, empower us, give us a platform.

For me, the story of Gabriel regularly reminds me of two truths we simply can’t ignore:

Emboldened youth today are our future — it’s time we start recognizing it.

Our world needs more health workers — it’s time we start showing it.

Arush Lal is a 2017–2018 Global Health Corps fellow at IntraHealth International.

All GHC fellows, partners, and supporters are united in a common belief: health is a human right. There is a role for everyone in the movement for health equity. Join the movement — applications for our 2018–2019 class are open through January 17, 2018.

Why UHC Day is a Call to Action for the World’s Youth was originally published in AMPLIFY on Medium, where people are continuing the conversation by highlighting and responding to this story.