Fighting For Survival in the Shadow of Covid-19

BOLGATANGA, Ghana — A nurse dressed in a white hazmat suit stands at a rickety wooden table folding surgical instruments into sheets of blue paper and placing them into a cardboard box on the floor. Next to her sits a white microwave-looking machine, one that is supposed to help sanitize scalpels and forceps, but is on the fritz — the door keeps popping open.

“We have to try and sanitize each tool individually ourselves,” she says. “Then we wrap it to save it for the next surgery.”

It’s hardly the ideal way of cleaning and storing tools, but it is the only option for the health care staff here at Kings Medical Center in Bolgatanga, located in the Upper East Region of Ghana near the border of Burkina Faso. The center, funded in part by the government and a consortium of Christian missionary organizations, is one of the only hospitals in the 140,000-person district. It treats patients from infancy to adulthood for a slew of health problems, including mild respiratory infections, malaria, diabetes and basic surgical cases. It is one of the most well-resourced facilities in the area, but it lacks basic tools needed to take care of people, doctors and nurses here say. They don’t have the necessary personal protective equipment, there’s only one light working in the surgical theater and the machine that administers anesthesia has to be used manually during procedures because it lost its automation feature.

Ghana, often cited as having one of the strongest health care sectors in sub-Saharan Africa, has in recent years experienced chronic underfunding. Health care workers here say Covid-19 completely depleted their facilities’ coffers, preventing doctors and nurses from being able to provide for patients with chronic, and often deadly health conditions. Now, staff in Bolgatanga, a region with one of the strongest public health offices in Ghana, and health care workers across the country are increasingly concerned about their ability to treat patients and save lives in the coming years, especially as some of the most well-funded hospitals in the country are taking on fewer cases in order to preserve resources. If new Covid variants cause cases to spike or there is another large-scale infectious disease outbreak, Ghana’s entire health system could collapse.

While the World Health Organization, the United Nations and various other global health organizations have tried to help low-income countries like Ghana build up their health care sectors over the last two decades, the investments have not met the need, health care workers here say. Without additional and sustained assistance from the international community and the Ghanaian government for equipment, medicines and additional staffing, doctors and nurses at the King’s Hospital worry they will never be able to catch up — putting millions of people at risk during the next pandemic. Without more help, they won’t have the resources they need to give tests, and administer shots and therapeutics — to save lives, they say. And if health care workers in Ghana are worried, so too are those working in other countries in the region where receiving any health care is seen as a luxury, such as Sierra Leone and Uganda.

Since the start of Covid, little funding has been put aside by the international community specifically to expand the scope of the world’s investment in health system strengthening as it relates to pandemic preparedness. In 2021, the World Bank, in coordination with the U.S., created the Financial Intermediary Fund — a pot of money set up to help low-income countries build the capacity of their health systems so that they can more quickly contain outbreaks.

The fund has only received $962 million in pledges, and it is still unclear how much of the money will go directly to governments to strengthen their public health infrastructure versus helping them pay for medical countermeasures such as vaccines and therapeutics. Governments and global health organizations have already pledged billions of dollars to invest in the development of those tools for the next pandemic. Investing in health care systems in low-income countries will take tens of billions more — a much higher expense than the development of medical countermeasures.

Even if the Financial Intermediary Fund were to dedicate significant resources to help countries respond to outbreaks by, for example, developing better surveillance networks, that still leaves facilities like Kings Hospital in Ghana vulnerable.

“We need quite a lot. We are trying to get space for the patients. We don’t have an intensive care unit. We don’t have the specialized staff. We need all the equipment, too,” says Wenceslaus Apungu, the medical director at Kings Hospital, adding that the hospital’s laboratory can only perform a few tests and that the facility lacks working ultrasound, X-ray and MRI machines. “They’ve broken down.”

A History of Underfunding

The G-20 estimates that $34 billion in public financing per year for five years is needed to help the world prepare for the next pandemic, including strengthening health systems in countries like Ghana.

However, it’s unclear if the world will ultimately take the risks of another pandemic seriously enough to stabilize the health care systems of low-income countries so they can adequately respond. Global Covid funding is beginning to run dry and health facilities in some of these countries are once again trying to figure out how best to manage the virus while also dealing with other systemic diseases. Global health organizations, governments and pharmaceutical companies are focusing on tests, therapeutics and vaccines. But the conversation about dedicating funds to help countries actually absorb and distribute them often has faded into the background.

World health leaders and advocates have for years argued that the international community needs to do more to consistently finance and prop up health systems in low-income countries, including those in Africa, by helping to hire and train staff, provide essential medical supplies and broaden access to supply chains. And in the course of the last several decades, through multiple infectious disease outbreaks, wealthy Western countries have promised to transform the way countries prepare for large-scale health disasters. But, health advocates say, that money is usually attached to emergency funding packages and the cash usually falls off after a few years.

During the 2014 Ebola outbreak, the U.S. was the largest single-country donor to respond to helping Liberia, Guinea and Sierra Leone get their health systems back to base — and then more. Congress appropriated $5.4 billion in emergency funding as part of its 2015 spending package through various agencies, many of which only had guaranteed funding for three years or until it ran dry. The next year, the Obama administration moved to repurpose some of the appropriated funds for the U.S. global Zika response.

U.S. funding continued to flow into the global response. But the international strategy changed, transitioning toward helping countries revamp their health systems and build their capacity to prevent, detect and respond to future outbreaks. Ebola cases decreased substantially. But in 2018, they reemerged in Congo. By 2019, the World Health Organization warned that it was running out of money to fight Ebola.

“African countries need a lot of support to build these [health] systems,” said Ernest Darkoh, the co-founder of BroadReach Group, a health care company working to expand Africa’s health system. “Everything from management and leadership skills to supply chains and HR systems, data, and IT systems.”

Over the last 20 years, Ghana has received hundreds of millions of dollars to establish programs to treat a range of diseases, including HIV, tuberculosis and malaria as well as a set of other more chronic health issues like child malnutrition and maternal mortality. The U.S. alone has allocated more than $120 million in Ghana’s HIV/AIDS response through the President's Emergency Plan for AIDS Relief. In the northern part of the country, where the land is less developed and communities are poorer, global aid organizations such as UNICEF and Oxfam have set up shop to try and assist the local health facilities with their work.

Some of Ghana’s internationally-funded programs have flourished — the country has significantly reduced its child mortality rate. And malaria cases have dropped, with treatment becoming more widely available. According to data from the World Health Organization, malaria-related deaths in Ghana dropped from 2,799 in 2012 to 308 by the end of 2020. But the country is still struggling with high HIV rates. Expanding treatment coverage is slow. Among children, malnutrition rates are consistently high — one in every 27 children will die before the age of one and about one in 19 will die before the age of five, according to a 2021 analysis by the U.S. Agency for International Development. These numbers have improved over the years, but malnutrition is still a prevalent condition, especially among children in the northern part of the country.

In addition, facilities throughout the country are underfunded — and have been underfunded for decades, with health care staff operating without essential medicines and equipment.

The country relies on Community Health Programs, launched by the government in 1999, as the first line of defense. The creation of these kinds of local health facilities was viewed in the global health world at the time as revolutionary — they significantly expanded access to care for millions of Ghanaians. Before their establishment, millions of people in Ghana had to travel far distances to find basic medicines. The centers, known as compounds, are small — just one or two rooms — and are located throughout each region. Now, many can walk or take a motorbike to seek care for things like colds, flu-like symptoms and even maternal care. Complicated cases are referred to a health center, a step above the CHPS compounds, where Ghanaians can access a higher level of care. Some of the health centers in the country include malnutrition programs and can keep patients overnight. The most complicated cases get referred to district hospitals and then regional hospitals that have trained surgical staff and other specialists.

But the facilities in Ghana are so strained that many are overwhelmed by normal, daily patient loads. They’re stretched to the brink when there’s an outbreak, for example, of yellow fever, or during the rainy season when malaria cases grow exponentially. The local health compounds, in particular, suffer from a lack of funding. While the Ghanaian government has propped up its health care sector by hiring more skilled nurses to work in the facilities, it has not dedicated enough money to ensure they have the goods needed to perform.

The Ministry of Health grew its health budget by 19 percent between 2015 and 2021, but funding from development partners decreased. In 2015, development funding accounted for about 23 percent of Ghana’s total health expenditure. In 2021, that number was just 10 percent. Of the money that the government of Ghana allocates to the health sector, almost 80 percent of it goes toward compensation, leaving little money for things like goods and services. In 2021, that goods and services line item accounted for less than 1 percent of the Ministry of Health’s overall budget.

“This low allocation severely constrains the ability to deliver key services … which can adversely impact Ghana’s drive to achieve universal health coverage,” according to a 2020 UNICEF report about the country’s health care sector.

USAID has tried to step in to help Ghana’s Ministry of Health improve the way it invests in its own public health sector, helping it procure medicines and equipment for the most chronic health issues.

“For us, improving the [Ghanaian] health system means you're improving the quality of care. It's the quality that saves lives,” says Janean Davis, acting mission director of USAID in Ghana in a recent interview. “Nobody wants to go to the CHP compound if it's falling apart and there's no one there to staff it or they don't have lab tests and don't have supplies. That's not a health system. That's just a dilapidated building.”

'Sometimes it can get a bit dicey’

Problems in health care delivery that were severe before Covid-19 became completely untenable afterward, health care workers here say.

Ghana’s overall Covid-19 numbers — both cases and deaths — are among the lowest in the world and the lowest in Africa, with about 161,370 infections and 1,445 deaths, according to an analysis by Reuters. But health care workers on the ground say the infection numbers are much higher — that people often do not get tested unless they need to be admitted to the hospital. And, they say, even though the overall numbers are relatively low in comparison to other African countries, the surges overwhelmed the health care system as the government rushed to repurpose funds to go toward containing the spread and treating patients.

At one of the country’s newest and best-resourced hospitals, the University of Ghana Medical Center, staff could not fully staff the intensive care unit. The machines and medicines were ready. But there were not enough qualified nurses to man the beds. At other, smaller facilities across the country, doctors had to turn away patients who showed up for normal visits — wanting routine vaccinations, hypertension medication or maternal care. But health care workers were focused almost primarily on Covid — testing for it, treating it and trying to sort referrals for those who needed ventilators.

The health care system is still playing catch up, with doctors and nurses needing to stretch their limited resources. Inside the surgical theater at the King’s Medical Center in Bolgatanga, also known here as Bolga, one of the main doctors — who requested to remain anonymous to speak freely about the hospital’s shortages — said staff have for months performed procedures with virtually no light.

There’s only one bulb that still works in the overhead lighting system that sits above the bed in the operating room. The anesthesia machine is malfunctioning. And the team needs more surgical gowns and gloves. Down the hall and through a red doorway, there is a half-finished concrete maternity ward that sits idle due to lack of sufficient funds.

The financial situation is set to get even worse at King’s. Even though Covid cases have fallen precipitously, the regional hospital has stopped receiving what it defines as minor cases from the district hospitals and local health centers because it wants to ensure it has enough resources to handle its current caseload. That means the medical staff at the Kings Hospital are going to soon have more patients at a time when it is already struggling to provide services. 

This district hospital’s financial situation — and its lack of life-saving medicines and equipment — is emblematic of the straitened circumstances of many health care facilities in Ghana.

At a health compound in a small neighborhood outside Accra, funded in part by the Salvation Army, a team of seven nurses and midwives are trying to find new ways to get funding so they can provide better treatment and accommodations for people living in the area. To the left of the small pink building lies a dirt and gravel patch of land on which the health care workers hope to put a small waiting room so patients that need blood and IVs do not have to sit in plastic chairs in the sun. Inside the small, five-room building, the director of the center lifts a bedsheet off a table, unveiling the facility’s only laboratory machine. It’s small and white and can run just a few tests.

“We have to send the rest of the tests to the hospital,” she says. “It is about a 45-minute drive from here.”

In the room down the hall, a large, singular maroon doctor’s chair sits in the dark. It’s duct-taped together, torn from years of overuse. An empty oxygen tank sits in the corner. This is where women in this community give birth — several of them now lie in the room next door, recovering. There’s space for just six people here.

“We do not have a permanent sonograph,” says Olivia Koduah, the physician's assistant who helps treat patients on a day-to-day basis. “Sometimes it can get a bit dicey.”

Koduah says the facility also lacks an electrocardiogram machine and a generator — and the lights often go out. When that happens, the health care workers use flashlights to see.

The staff at this facility is committed to filling the resource gaps whenever and however they can. Last week, a woman from the community came in for an appointment. She needed medication for high blood pressure — it had been weeks since she’d taken it because she did not have money. One of the nurses here used her own, limited cash to help pay.

Doctors and nurses have learned to adapt to their situation, but the pang of wanting to provide quality for their patients has not dissipated.

“We are doing the best we can,” Apungu, the medical director at King’s Hospital, says.

Seeking a solution

Top officials at the World Health Organization, the World Bank, the World Trade Organization and other global health advocates are pushing for more investment in low-income countries’ health systems in order to help prepare for the next pandemic. But there is no central funding mechanism for the task.

The World Health Organization’s ACT-Accelerator, originally formed in 2020 to fast-track Covid-19 tests, therapeutics and vaccines, has dedicated some funding — $120 million — to strengthening global health systems. And the Global Fund to Fight AIDS, Tuberculosis and Malaria, one of the largest nonprofits that dedicates significant funds to strengthening health systems, is asking donors this year to invest $18 billion to cut the death rate for HIV, TB and malaria while helping to prepare the world for the next pandemic. About $6 billion of those funds would go directly toward strengthening health systems — ensuring countries have the necessary staff and resources.

Perhaps the best chance for a specific pot of money lies within the World Bank in the Financial Intermediary Fund. As of last week, the U.S. was the sole contributor — pledging $250 million. At the Biden administration’s second Global Covid Summit May 12, several more countries pledged money, bringing the total to $962 million — far less than the $10 billion a year the U.S. and other world health officials have called for in order to adequately help low and middle-income countries prepare for the next pandemic.

The fund’s original purpose was to raise money with the specific focus of helping countries stand up new surveillance systems and expand their health care workforce. Now, a year later, It’s unclear what percentage of the fund’s money will go toward strengthening health systems in low-income countries.

There is a debate among leaders in the global health community about what to prioritize over the next several years. Some advocates are calling for large portions of the fund to be put toward research and development of vaccines and therapeutics. Others say more needs to be done to ensure the issue of strengthening health systems does not once again fall to the bottom of the global health priority list behind vaccine and therapeutic development.

“The African continent is in a position where we have the largest burdens of disease and vastly lowest per capita resources. On a good day, it's difficult to address even simple challenges,” Darkoh said. “When you multiply the complexity of the challenges in the context of poverty and in some cases civil war ... you can just imagine how much more difficult it gets on the continent [with Covid]. The capacity is just not there.”

But international funding could yet run dry as rich countries begin to move on from the pandemic. Across the world, governments are beginning to roll back public health restrictions despite case counts increasing in Europe, China and the U.S.

As the international community has shifted away from the emergency phase of the pandemic, so too has it rolled back Covid funding.

In April, the U.S. Congress approved $10 billion in supplemental Covid funding for the Department of Health and Human Services to continue to prop up its response to the pandemic — billions less than what the agency said it needed. But lawmakers did not approve any supplemental funding for the administration’s global Covid response despite USAID and the White House urging Capitol Hill to consider an additional $5 billion. And at the administration’s second Global Covid summit, participants pledged $3.1 billion in new funding for the world’s fight against the virus — but tens of billions more are needed, including for disbursement of vaccinations and therapeutics.

“What you need is not just stuff, but staff,” said Tom Frieden, the former director of the Centers for Disease Control and Prevention and CEO of the company Resolve to Save Lives. “I think that's a really big problem in some of the discussions. There's a huge need for staff — people who are good at managing, who are good at running programs and who know how to analyze data.”

Frieden has proposed what he describes as an “accountability framework” and “rapid quality improvement mechanism” that countries can use to prepare for the next pandemic. The metric, known as 7-1-7, pushes countries to detect a suspected infectious disease outbreak in seven days, notify public health authorities and start an investigation within one day and respond in another seven.

“We've partnered with countries in Africa to first look retrospectively on past outbreaks, and determine [whether] they meet the 7-1-7 criteria and when they don't, to understand why they didn't and what can be fixed,” Frieden says. “It gives countries a way to rapidly improve progress.”

If countries continue to roll back cash for the global Covid fight, it’s likely the money for strengthening health systems, although minimal, will also disappear, Darkoh says. And it's not clear whether it would surface again before the next pandemic — at least not in the amount that’s needed. The global health community needs to completely rethink how it approaches helping low-income countries prepare, he says.

“I think first and foremost we need acknowledgment that we need to innovate very radically if we're going to survive and if we're going to actually get this right, particularly for the African continent,” Darkoh says. “Trying to keep pursuing this traditional approach of ‘Well, we're going to train more doctors’ … We're locked into that schema of how this needs to be addressed. But it's just not going to get us there.”