By Michael Murphy and Alan Ricks
A rendering of Redemption Pediatric Hospital. Image Courtesy of MASS Design Group.
The aftermath of the world’s worst Ebola outbreak in history provides an important opportunity to reflect on the response; but most importantly, to acknowledge we have much more to do.
Thanks to the bravery of local and international aid workers and nurses, among others, new cases dwindle in the single digits. However, our great fear is that the international community will declare Ebola’s containment a victory and move on, without addressing the reasons the outbreak was so devastating in the first place. The crisis is the canary in the mine, indicating a broader problem that long existed.
An unfortunate reality that plagues development assistance worldwide is what we call “short-termism.” It’s the tendency to mobilize health infrastructure resources only in crises. This is a reactive and costly strategy that prioritizes temporary stabilization without considerations for long-term security. While short-term needs must be addressed, without a simultaneous long-term view, we risk repeat disasters and repeat outbreaks, rendering vulnerable places increasingly vulnerable.
Perpetuated emergency response and disaster relief in vulnerable regions is an expensive, reactionary strategy when not coupled with efforts to strengthen institutions, infrastructure, and human capacity within countries to end the undignified cycle of dependence.
Following the earthquake in Haiti and subsequent cholera outbreak, billions were invested, but very little in permanent infrastructure. In Haiti, only 5.6 of the 9.2 billion dollars pledged for recovery was ever issued; more striking is that less than one percent went to the Haitian government. Five years later, the Haitian government’s capacity to invest in long-term infrastructure and grow its economy is thwarted by this over-prioritization of humanitarian relief funding. Liberia’s President Ellen Johnson Sirleaf fears similar consequences in Liberia: “We need long-term infrastructure [not] military field hospitals. They would not be needed if adequate health-care services [had been] in place.”
Can we truly build back better in West Africa after Ebola? The answer is definitely yes. But first, we need to think about investing in physical infrastructure differently, and debunk four myths that mislead public opinion..
MYTH 1: It costs too much.
Temporary structures are viewed as quick and cheap solutions. However, costs are often exorbitant and, more often than not, these shelters are forced to last longer than they should. The WHO estimates that it takes roughly $5.7 million to set up and operate a 50-bed Ebola treatment center for six months, though the average lifespan is 7 years. As a comparison, we built a 150-bed hospital with the Rwandan Ministry of Health and Partners In Health in three years that cost $4.5 million, and will perform, with standard upkeep, for decades. We were able to do this because we engaged local partners and experts, plus employed local labor and materials, so also funneled nearly half a million dollars into the local economy. Our understanding of “cost” must evolve from a static number to an understanding of the lifecycle value of infrastructure capital and its benefits to populations.
MYTH 2: Any building will do.
Prefab buildings are flat packed, quickly assembled and easily deployed. But, prefabrication solves the wrong problem. Prefab is a strategy in the US and other developed markets to reduce the cost of labor on-site, which is often the most expensive part of the process. But in emergency response we need to maximize labor and locally sourced materials to build back economies simultaneously with infrastructure. We don’t need prefab; we need local fab. We call this idea Lo-Fab, a strategy to better maximize donor funding, economic stimulus and the overall maintainability of the buildings because you can train the technicians during the build.
MYTH 3: It doesn’t have to look nice.
Beautiful buildings dignify communities and strengthen public confidence of health care quality; we just have to invest in them. The 150-bed hospital previously mentioned has become a symbol of national renewal and pride in post-genocide Rwanda. Beautiful buildings may be one of the surest forms of sustainability because they engender pride and ownership in the constituents they serve. One doctor recently told us it was the cleanest hospital she had ever worked in, that nurses work hard to keep it in top condition, that patients take their shoes off before entering as if it were their own homes and that people come and volunteer on the grounds to maintain them. Author Eric Klinenberg has written extensively about how these social ties strengthen communities to weather the next disaster.
MYTH 4: There is a lack of capacity.
After the civil war ended in 2003, Liberia spent much of its time investing in proper planning for strong health infrastructure and a national plan to deal with its weak central health system. In 2011, under the leadership of Minister of Health Walter Gwenigale, the Ministry of Health and Social Welfare (MOHSW) developed an ambitious 10-year plan—the National Health and Social Welfare Policy and Plan 2011-2021—that would serve as a roadmap to develop such a robust and resilient system.
Working with the Director of Infrastructure at the MOHSW, David Jallah, we recommended development of 48 new primary health clinics, 90 new health centers, and 2 hospitals built over the subsequent decade. The MOHSW then developed comprehensive National Infrastructure Standards and Guidelines to ensure that all facilities would be resilient, safe and high quality.
This planning has prepared the MOHSW to build out the health infrastructure system. However, lack of capital delayed implementation and then was completely stymied by the Ebola outbreak, revealing that even more significant systems need to be developed. The MOHSW is now calling for five new regional hospitals, 10 county hospitals, 30 health centers, and 90 health clinics at a cost of $600 million—a seemingly ambitious scope. But this would constitute just 5% of the total amount pledged for post-Ebola recovery. The massive resource influx into West Africa by international donors provides momentous opportunity to build a strong and resilient health system. Long-term infrastructure is possible, cost-effective and imperative, and it will be transformative for nations crippled by shocks and dependent on relief funding.
What will Liberia look like in 5 years? Will it look like Haiti, with the only artifact of billions of dollars of aid the decaying shells of temporary tent hospitals? Or will Liberia be provided the funding to lead its own robust infrastructure strategy?
To balance investment in short- and long-term responses, the international community and local governments should call for a 1-for-1 program. For every dollar invested toward donor-led emergency response, a dollar must be invested into locally led long-term projects. For example, a field hospital for healthcare workers in Liberia who contracted Ebola cost $10 million dollars—it’s also a tent. In contrast, the Liberian Ministry of Health and Social Welfare has been waiting 5 years for the same $10 million of funding to construct a high-designed 150-bed children’s hospital that is shovel ready and desperately needed, and will last for generations. Rather than pin their merits against each other, a 1-for-1 approach would ensure that over-priced, time-sensitive but mandatory expenses are coupled with smart, strategic permanent investments.
We do need ample emergency response, but also the long-term foresight to identify and spend resources effectively in partnership with local governments, ensuring that what is built is high quality and will weather future outbreaks. We must make more efficient the massive collective investments of an empathetic but hasty aid infrastructure, and engender greater collaboration and shared vision between all parties involved in building.
In West Africa, we have nothing left to do but get started.
Michael Murphy and Alan Ricks are co-founders of MASS Design Group. MASS Chief of Staff Annie Moulton contributed to this piece. Learn more about MASS at www.massdesigngroup.org