Thursday, 13 November 2014

Contracting out Ebola Hospital raises concerns in NGO community

MMU - Monrovia Medical Unit Ebola Training Tent - Monrovia, Liberia
Photo Credit: US Air Force (Maj. Adrien Adams) Oct 17, 2014
A slow moving, yet wide reaching crisis or catastrophic disaster event can easily overwhelm resources at the local and regional level. Resource management is a critical issue all emergency management agencies have. Preparation of logistics requirements for a wide variety of contingencies and events are analyzed, calculated and practiced. Gaps identified allowing crisis planners to document enhanced requirements and distributed for further consultation to all stakeholders, at all levels of responsibility. The volume of documents which chart and document each category of logistics support, for each type of disaster can accumulate into thousands of pages. At this level of planning, operations and command of resources often recognized during the real thing as hornets nest, stretched to the breaking point as the depletion of assets outstrip resupply of equipment and people available and what has yet to be anticipated. It is impossible to forecast every contingency that have the potential to occur once every 100 years.

In addition to local, regional, state and federal government response resources brought to a disaster zone, they can be augmented from every corner of a community including local, national and international NGO's. And if it is possible to establish, additional partners are sometimes right around the corner including community leaders, churches and the private sector. If the disaster is truly catastrophic, the United Nations and member nations offer assistance.

International assistance is a significant undertaking that entails complex planning and delivery roles that must be clearly understood. International experience is required to execute the mission and is paramount to achieve success. In most cases, several agencies or departments of the federal government are involved. The lead department is often resourced from the office of the Minister or Secretary of Foreign Affairs. In circumstances, such as broad coalition of international support, the United Nations is the lead organizer and resources are committed to the mission under U.N. responsibility and management. Navigating a disaster response inside the U.N. is a complex and difficult task depending on the nature of the event. The UN Office of Coordination of Humanitarian Affairs (UNOCHA) after decades of disaster responses has created an elegant and impressive response capability that has served the global community remarkably well and efficiently. Not every scenario has UNOCHA as the lead agency or Director of Operations. In some cases it might be the World Food Programme or World Health Organization. The participating government must be flexible and capable of working in multiple environments and do so with qualified personnel. In some cases, a donating nation may be approached directly by the government in need AND provide support services to other organizations such as WHO, or WFP simultaneously. U.N. agencies are always a work in progress. It isn't perfect either.

The mosaic of resources required for a response is immense, expensive and difficult to support. Each type of disaster requires different skillsets, equipment and expertise. It is not easily put into a template and put on a shelf until needed. Some elements are cookie cutter and can be simplified. Examples include aircraft specifications including payload, range and support requirements which can be factored into a response based on tonnage of cargo, flight distances and general planning information (airports, support services, technical requirements, etc.) that can be prepared in advance for any region of the world. Logistics templates can and have been designed and generated based on type of disaster and scale of response resources available or authorized for aid missions. Some agencies such as UNOCHA, USAID,  have prepared for multiple scenarios and update these plans regularly and are ready for implementation on a moments notice. It sounds simple. In today's world of computers, open data and access to technology, many argue that disaster planning should be a breeze. It isn't.

Most non-government organizations such as Save the Children, Oxfam, International Medical Corps, Doctors Without Borders/ Médecins Sans Frontières (MSF), IHS and many others are well organized, prepare for the worst and implement disaster response services knowing full well what kind of undertaking is before them, prior to deploying in the field. They understand the complexities involved in operating under difficult and some would argue, impossible conditions. In many cases, it is a collective effort working together to accomplish their goals. NGO's frequently deploy to the same disasters all over the world creating trusting and build lasting relationships. Along the way they find out what does and does not work in the field. There are still some rivalries between some of them, but certainly not all. Each are beginning to build new or revised operating procedures that take into consideration the strengths and weaknesses of each organization, creating improved operational capacity and expectations.

NGO's are not perfect organizations. Each has their strengths and specialized fields with burdens of flaws and weaknesses. Not all are welcomed in some parts of the world, including some UN entities and affiliated partners. Donors of NGO's are pushing for improved results and outcomes as funding is strangled during difficult economic times. As the complexity of a disaster increases the level of stress, performance and cost rise. There's never enough personnel, equipment, supplies or services.

Wikipedia defines an NGO as;

A non-governmental organization (NGO) is the term commonly used for an organization that is neither a part of a government nor a conventional for-profit business. Usually set up by ordinary citizens, NGOs may be funded by governments, foundations, businesses, or private persons. Some avoid formal funding altogether and are run primarily by volunteers. NGOs are highly diverse groups of organizations engaged in a wide range of activities, and take different forms in different parts of the world. Some may have charitable status, while others may be registered for tax exemption based on recognition of social purposes.

NGOs are difficult to define, and the term 'NGO' is rarely used consistently. As a result, there are many different classifications in use. The most common focus is on 'orientation' and 'level of operation'. An NGO's orientation refers to the type of activities it takes on. These activities might include human rights, environmental, or development work. An NGO's level of operation indicates the scale at which an organization works, such as local, regional, national or international.

The term "non-governmental organization" was first coined in 1945, when the United Nations (UN) was created. The UN, itself an inter-governmental organization, made it possible for certain approved specialized international non-state agencies—i.e., non-governmental organizations—to be awarded observer status at its assemblies and some of its meetings. Later the term became used more widely. Today, according to the UN, any kind of private organization that is independent from government control can be termed an "NGO", provided it is not-for-profit, non-criminal and not simply an opposition political party.

One characteristic these diverse organizations share is that their non-profit status means they are not hindered by short-term financial objectives. Accordingly, they are able to devote themselves to issues which occur across longer time horizons, such as climate change, malaria prevention or a global ban on landmines. Public surveys reveal that NGOs often enjoy a high degree of public trust, which can make them a useful - but not always sufficient - proxy for the concerns of society and stakeholders.

By all accounts, disaster response NGO's fit the definition as described above. Support of their programs are often funded national governments and United Nations agencies such as World Food Program (WFP) or World Health Organization (WHO). The role and value of an NGO's in disaster response is their neutrality during response and recovery operations. NGO's follow local customs, recognize and respect indigenous laws and do not discriminate in how they deliver support aid. Some conditions do apply.

And like legal fine print in contract terms and conditions, there are numerous historical examples where NGO and International Government aid has not always been successful. Beginning with the 2004 Tsunami that struck Banda Aceh, Indonesia, a significant shift how international relief missions began. The use of the Internet, commercial satellite services and mobile phones allowed cooperation between multiple agencies, NGO's and foreign government assistance aid while working on the ground in extreme conditions in real time without having to attend meetings that could take hours to figure out where it was, let alone when. This was a time of monumental innovation in terms of technology, and mutual support services. International disaster management had entered a new era. These new capabilities evolved and were tested several times during subsequent large scale disasters including the 2004 Khyber Pakhtunkhwa, Punjab,Sindh, Balochistan and Gilgit-Baltistan floods in Pakistan and 2010 Earthquake in Haiti. During these two disasters, numerous lessons learned were collected, culminating into several critical reviews in how NGO's not only worked separately and together, but what important improvements were needed. The information age powered by the Internet generated new areas of accountability, forcing NGO's to opened up to ever increasing demands of transparency. Social media broadcast in real-time status every mistake and success in addition to recovery operations gaps and needs.

Typhoon Haiyan (Yolanda) was a global response effort that engaged every corner of the globe. It is still in the reconstruction phase and continues to this day. When the Category 5 Typhoon hit Micronesia, the Philippines, Southern China and Vietnam, it was the most devastating Typhoon ever recorded with winds speeds that recorded between 230 to 315 kmph, killing over 6,500 with over 1,000 still declared missing. The scale of the disaster and impact on the population triggered one of the largest disasters response operations in recent history. It is the largest international humanitarian military intervention recorded since the Berlin airlift in 1949 with over a dozen nations participating. Every major U.N. relief agency and all the major NGO's. The way in how disaster response aid had improved and developed with new techniques, process and delivery mechanisms. Military Navy, Air Force, Army and Coast Guard units filled valuable roles with direct non-integrated military to military operations as NGO organizations prepared long term recovery support to affected areas. At times, this technique ruffled some feathers as complaints of what supplies were assigned different priority than that of the donating military nation's aid supplies. Sharing information continued to be a significant barrier in an era where Open Data is considered to a necessity. Nonetheless, the disaster response capabilities implemented demonstrated continued emergency management improvements across every segment including communications, transportation & logistics, access to power, computer information tools and transparency.

In the future, it seemed clear that emergency management teams on the ground would continue to see significant improvements when a catastrophic event impacts a community, a large metropolitan city or an entire province covering thousands of square miles. Evidence suggests that cooperation and collaboration tools and services are dramatically improving how organizations can deliver effective and timely disaster relief. And then, Zaire ebolavirus infected a 2 year old boy in Gueckedou Guinea in December of 2013.

Ebola outbreaks in themselves are not unusual in Africa. Prior to 2013, between 1976 and present day there has been 9 outbreaks, 3 of those as regional epidemic events. The World Health Organization monitors the region in cooperation with local and national governments in all three nations currently affected, Guinea, Liberia and Sierra Leone. In all the previous 9 outbreaks since 1995, the fatality rate never exceeded 224. In the past twelve concurrent months, over 5,000 have died. This epidemic spread out of control before local resources could react to contain it. It is estimated over 15,000 are currently infected. The virus has a 70% mortality rate.

The international response was initially very slow, if not downright sluggish. There are several reasons why this occurred and are beyond the scope of this article. The World Health Organization upon recognizing the disaster activated every resource required in response. It engaged the International community including NGO's in support of the disaster across three countries that spans 170,000 square miles with a combined population of just over 20 million people.

According to the Center for International Disaster Information, 61 NGO's are engaged in Ebola Disaster Response initiatives, including U.N. Agencies. Not all of them are directly on the ground. Only three military organizations are on the ground; China, United States, and the United Kingdom.

10 International Government Foreign Assistance Agencies (USAID, UKAID, CIDA, etc) have also committed some or all of the following items;

  • Personnel (Medical Staff, Logistics Support Experts)
  • Financial support 
  • Medical supplies (including PPE and Medical equipment)
  • Airlift  and Logistics Support (Shelters, Supplies, Equipment)
  • Technology (Communications, Computers, Devices, etc.)

In some cases, funding is being directed to NGO's already deployed. The United Nations also tracks funds donated by governments through the Central Emergency Response Fund managed by UNOCHA.

In addition to these assets being deployed, other institutions and organizations have contributed. These include the private sector that vary from large multi-national corporations to Foundations and small organized volunteer teams that span across the world. These include the Thompson - Reuters Foundation, Gates Foundation, Facebook, and many others. Informal volunteers technical also help through the United Nations such as Digital Humanitarians, Open Street Map, Crisis Mappers and the Standby Task Force. These services are critical in Ebola response efforts. Without them, the fabric of support weakens, threatening to tear the security blanket apart. According to the U.S. Chamber of Commerce, over 44.4 Million (USD) in cash or equivalents in equipment has been donated by U.S. corporations alone.

Private sector participation, in particular large corporate organizations, tend to engage in disaster response using one of two methods, direct funding to an agency or NGO (or blend of equipment and funding) or directly under the authority of a Government Agency such as USAID or their respective equivalents around the world. Using this model has significant advantages by offering support to a country in need without:

  • Specific knowledge or expertise in how to deliver disaster relief
  • Extensive knowledge of the area in need
  • Understanding specific requirements, laws and regulations
  • Exposure to unforeseen risks  and liability

It is one thing to help during a disaster on home territory, but supporting relief operations in a country that is facing an epidemic or where they have never been before would be irresponsible behavior by the company and potentially be damaging over the short and long term. Government agencies like CIDA, UKAID and USAID have worked with the private sector for decades, building unique disaster support mechanisms and forums to engage when assistance is needed. In most cases, Government agencies act as facilitators and managers for the response effort and direct how and where these services can be best used either through cooperation with another government agency or with the recipient host government. Corporations routinely operate under government oversight and management as required and necessary. DHL routinely acts as air transport agent for German Government aid delivery when military transports are not available and do so all over the world. Communications manufactures including Cisco, Motorola and Alcatel provide engineers, equipment and expertise as required, under the supervision of government oversight of their representative country and host nation.

In a disaster where infrastructure is severely damaged, civilian engineering company's are often contracted by governments (including the UN) to assist in rebuilding a region after an earthquake, flood or other catastrophic event. This process often takes months of planning and assessments prior to entering this phase of recovery. Depending on the type of disaster, it is simply not possible to allow or risk civilian engineering providers to enter a dangerous area. This gap is often filled by their military counterparts such as the U.S. Corp of Engineers, currently in Liberia.

The West Africa Ebola epidemic has created hardships that few could predict or forecast. This has created fears and the implementation of policy's many still do not understand why. In turn, emergency management resource planners are faced with limited access to available experts because of the perceived health risks and stigma attached. Some nations have prevented civilians from volunteering in any capacity, including Australia and Israel. These policies have had a chilling effect that has sent shock waves in and outside disaster management response community. On October 3rd, those that know MSF's modus operandi, this news did not sit well and publicly condemned Australia's actions to the point it refused Australian government financial aid. Peers cringed as Doctors without Borders lashed out at one of its biggest supporters over the past decade. Emotions run high when the largest NGO's on the ground in West Africa is operating around the clock in harsh conditions.

Australia's response was silence until last week (except in Canberra in Parliament where the controversy ignited fierce debate), when it announced on November 5th, that Aspen Medical, a global medical company based Deakin (Canberra), ACT had been awarded as sole source contract to construct, operate, manage and support a 100 bed Ebola Hospital in Sierra Leone. It will be responsible for every aspect of the hospital including medical staff. Upon learning this news, Antony Loewenstein of the Guardian Newspaper published an editorial suggesting the Ebola crisis had become a profit center for corporations. Company's supplying materials used in disasters have always had profit margins embedded into them - for over 50 years. This is not new and nor should it come as any big surprise. The scale and singularity of the contract may be unique, but not the awarding of a commercial contract for services required during a disaster.

Loewenstein asserts that NGO's could have delivered the same services for a lower cost. But when MSF refused any part of Australia's 18 million dollar aid package, it was rerouted to Aspen, and then adding fuel to the fire, the government added another 2 million. Even if we make the assumption that the extra 2 million is defined as 'profit', it is a slim one at best. In fact, it is likely Aspen will be lucky to break even, 18 or 20 million. Given the scope and scale of the project, where it is to be placed and the extent to which Aspen will be responsible for its operation, making a profit will be challenging. 20 Million for a hospital is relatively inexpensive. The U.S. is spending over 1 billion dollars, of which 700 million is for the construction and logistics support of 20 Medical Hospital units, each with 100 beds. These units will not include medical personnel costs required to operate them, but does include specialists and facilities to operate four medical labs, installed by a 22-member team from the expeditionary 1st Area Medical Laboratory unit.

There will be significant concerns the company has to address, despite past experience with NGO's and understanding the medical requirements;

  • It has never operated in Sierra Leone
  • It does not have an existing relationship with the Sierra Leone government
  • It is in cooperation with the United Kingdom's aid program (who is in control?)
  • Governance and oversight on the ground will prove difficult if Australia does not send government representatives to supervise the program
  • It does not have a ready to deploy team in place with previous large scale disaster experience

But these barriers should not be reasons this experiment should not be attempted. In fact, it is long overdue. Privately operated companies have strong advantages that could serve them and the community well.
  • Clear ownership of end to end responsibilities
  • Streamlined project management, protocols and management systems
  • Established procurement and service delivery organization
  • Quality control mechanisms
  • Cost containment (unless it is delivered on a cost - plus basis
  • Knowledge transfer
Commercial vendors always have potential roles in disaster response. They have management skill sets that are desperately needed in some scenarios. It may have negative optics to many and it certainly has the potential to go wrong if mismanaged and terms and conditions (T&C's) are not clearly identified or transparent - one of Loewenstein's primary concerns. But ultimately the authority that is responsible, in this case, is the Australian Ministry of Foreign Affairs and Trade and ultimately, the Prime Minister. There can be little doubt this program will be under the microscope given the nature and type of disaster this is. Loewenstein also suggests that MSF believes this program will be inflexible and uncoordinated. It takes both sides to have that result. Non-profits have quarreled with each other, let alone the private sector over far less complex issue than this one raises. Many NGO's have learned valuable knowledge and expertise from the private sector and this should not be an area of friction that is put in place before it has a chance to be tried. 

We may learn very little from this particular deployment because Sierra Leone's Ebola epidemic is currently trending lower and has a lower infection rate than Liberia. In fact, by the time Aspen completes negotiations with the Australian government, gets clearance and agreement with the U.K. Government and establishes a relationship with Sierra Leone's, and builds the hospital, the need for it may have diminished or eliminated. The U.S. has already announced that it is not deploying all 4,000 military personnel to West Africa as originally planned and cutting it by 25% to a maximum of 3,000, of which 75% of those are now in theatre. 

Before passing judgement, Australia's contract with the private sector should be welcomed, observed and analyzed with an open mind. 

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