What Can Donors Learn from HIV in Responding to Ebola?

This is a joint post with Alan Whiteside, CIGI Chair in Global Health Policy, BSIA and Professor Emeritus, University of KwaZulu-Natal.

Since the first case of Ebola appeared last year, the virus has infected nearly 10,000 people.  The epidemic is concentrated in Liberia, Sierra Leone, and Guinea — post-conflict countries with incredibly weak health systems. It stands to have severe health, social, and economic consequences and is arguably the most pressing challenge to global health security the world has faced in decades.

But despite the scale and spread of this devastating disease, the international response has been slow and inadequate.  If Ebola is to be contained it requires massive mobilization of significant new resources and these resources will need to come in the form of foreign aid.  To date, approximately $500 million in funding has been made available, and an additional $200 million has been pledged. However, there is little evidence that these resources are yet doing much to bend the curve of the epidemic.

Although HIV and Ebola are very different, the scale-up of foreign aid to address the HIV epidemic was among the most important achievements of global health, but it was not without its growing pains. We believe important lessons can be drawn from AIDS to inform donor responses to the current Ebola outbreak. However, these lessons, which were learnt over many years for HIV, need to be applied over weeks for Ebola.

First, donors should not assume they know what works or how their resources are best spent.  Early in the response to HIV, donors wasted money on large-scale prevention activities that did little to prevent the spread of the virus, rather than targeting high-risk populations. Treatment models were based on Western experiences, but  were hard to implement in low-resource settings.   

In all previous outbreaks of Ebola, a rapid response that included the isolation of patients, case management in treatment centers, safe burial practices, extensive contact tracing, and behavior change were effective at stopping the disease in its tracks.  This outbreak is different – it has spread across national boundaries and into urban areas, the response has been slow, and it is larger than all previous outbreaks combined.  The expansion of health infrastructure required to implement these same strategies at scale in West Africa seems largely implausible.  It would require immediately doubling or tripling capacity in the health system and then allowing it to grow in an exponential manner for as long as the virus continues to spread.   

Donors need to allow for experimentation and to develop new models of prevention and care that are accepted and can be implemented by local communities. One of the key innovations in the response to the HIV epidemic was the realization that a multi-sector response would be required to address the epidemic.  Treatment was not initially available or affordable, so the early emphasis was on prevention. This too must be the case with Ebola.

Donors like to give aid in kind, as was done for HIV and is now being done for Ebola in the form of protective equipment, ambulances, and other supplies. While these are important inputs, if countries are given cash they can usually more efficiently procure these supplies and can also flexibly fund their own pressing needs.

Second, we also learned from HIV that the most precious resource, and the one most difficult to scale-up rapidly, is human resources.  As treatment for HIV expanded across Africa, it became increasingly clear people, rather money, was the main constraint. Medicines and supplies can be bought on international markets, but human resources take time to produce, or are costly to import.  Engaging non-health system actors and deploying alternative strategies that require less human input per case are likely to be key.  A new ‘Ebola corps’ is needed.

There are signs that the global response to Ebola is starting to achieve scale, but we will be playing catch up for some time. While it is astonishing to see such selfless volunteerism, the current response has been largely uncoordinated.  As the HIV response taught us, coordinated responses were much more effective and efficient and all partners must fit within a single country operational plan.

The global response to the HIV epidemic was exceptional, as arguably it should have been, due to the complex challenges that virus posed to societies in Africa.  Ebola demands a similarly exceptional and nimble response. Both of these epidemics have taught us that it is investments in health systems that are key to prevent and control infectious disease outbreaks.

Funding for Ebola needs to be rapidly increased but these increases should not come from current commitments to other global health programs. If anything, investments in health systems must be seen as a key part of maintaining global health security and should become an even bigger priority. AIDS transformed global health, Ebola will do the same: we need to make sure it does so in a constructive way.

Karen A. Grépin is an Assistant Professor of Global Health Policy, Robert F. Wagner Graduate School of Public Service, New York University and Non-Resident Fellow at the Center for Global Development (@KarenGrepin)