International Health Regulations: implications to the healthcare system in Uganda

Danny Gotto

My recent visit to Geneva, Switzerland to attend the 69th World Health Assembly (thanks to Wemos who enabled me attend) was such an eye opener. I learnt in that short time how the Global Health system functions with its players who mastermind the Global Health Agenda. I also gained insight in the implication of these agendas to my local context as a person living in a developing country like Uganda. Here, I want to address one interesting area within the global health agenda, the International Health Regulations (IHR).

The IHR are an international law framework intended to help countries work together to save lives and livelihoods caused by the international spread of diseases and other health risks. Their coming into force nine years ago has somehow offered guidance to countries on how to prevent, protect against, control and respond to the international spread of disease while avoiding unnecessary interference with international traffic and trade.


Ebola and other epidemics
These regulations were meant to establish a set of rules to support the global outbreak alert and response system and to require countries to improve international surveillance and reporting mechanisms for public health events. Also strengthening their national surveillance and response capacities was at stake. Had these goals been achieved, the IHR would have become central in ensuring global public health security. However, the recent Ebola epidemic in West Africa and prior similar emergencies in Uganda have clearly demonstrated inconsistencies in the IHR.


Like West Africa, Uganda in the recent past has had her share of struggles with episodic epidemics like Cholera, Marburg, Ebola, and Yellow Fever. Although contained a little faster than in West Africa, these epidemics have shown ability to always bounce back even when least expected and taking enormous lives especially the most vulnerable bottom of the population pyramid.


One must confess that due to the episodic nature of these epidemics, Uganda has developed internal capacities to manage the epidemics. For instance, there is the Uganda Public Health Emergency Operation Center, a coordinating body established in 2007. It has been instrumental in overseeing coordination and planning in situations like the wake of the Ebola crisis, when the world, and especially WHO, overtly failed in offering leadership and effective coordination. Some health workers from Uganda lost their lives in the early days of the epidemic in Liberia.


Shortcomings of the healthcare system
However, this capacity has its shortcomings, especially when compared with best practices from the developed world. For example, Uganda has one of the least funded healthcare systems in Africa with only 4 percent of her total annual budget dedicated to health. The doctor-patient ratio is 1:25,000, while the nurse-patient ratio is 1:11,000 (the WHO standard is 1:439). Only 23 percent of the population lives less than 5 km from a functional health facility. Just like other developing countries, Uganda has had her share of brain drain with most of her well-trained health workforce migrating to destinations where pay is better. Therefore, preparedness for epidemics as a key requirement for the IHR is farfetched in a non-functioning healthcare system like the one of Uganda.


Challenges to global health security
The most recent Global Health Security Agenda assessment (2007) revealed glaring gaps in Uganda’s preparedness to emergencies. There was lack of adequate funding, human resources were inadequate and surveillance is limited. Also challenges in information and data systems and laboratory capabilities were evident.


This is a clear indictment to all who design international frameworks like the IHR, because mostly these frameworks mean nothing to the poor people surviving with poor resourced healthcare systems in developing countries.


As a representative of a grass-root organization in Uganda, I applauded the new Health Emergencies Program that designed a single line of authority and accountability. However, the need to bypass incompetence and lack of accountability, in particular of the WHO-Africa Regional Office, in relation to emergencies only underlines the importance of strengthening regional and country capacities in responding to emergencies.


Needs of developing countries
Lessons from West Africa revealed a clear failure of the healthcare systems in Liberia, Sierra Leone and Guinea. It is therefore wishful thinking that Africa, and Uganda in particular, will be ready to meet her obligations as stipulated by the IHR to control future emergencies with her current weak healthcare system.


There is a need for a focused, consistent and well-meaning plan that will enable the country and global community to work together to address the existential threat from future global epidemics. This means building a well-trained health emergency workforce and prioritizing core emergency capacity building under the IHR. It means also ensuring adequate international financing for epidemics (like operationalizing the WHO Contingency Fund for Emergency) and better communication and community engagements.


But the most important change especially in developing countries would be overhauling the healthcare systems holistically. Emergencies are not isolated occurrences. Therefore, it makes little sense to tackle them otherwise than within the healthcare system of the place where they occur.


Read more about the role of IHR in Dutch global health strategy (Kaleidos Research)

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