West Africa, in the throes of a calamitous Ebola epidemic, missed out on significant health investment during the past decade or more because it had low rates of HIV, a detailed survey of the changing health of Africa and Asia reveals.

A major project called Indepth, which has looked at the causes of death of more than 110 000 people in 13 countries, shows that health improved generally in those given substantial international aid to try to turn around the HIV epidemic.

But West Africa, with severe poverty and low healthcare standards but relatively little HIV, did not benefit.

“In most parts of Africa, health systems have been strengthened by the external funding of HIV,” said Dr Jimmy Whitworth, the head of population health at the Wellcome Trust, which funded the project. Pepfar (the United States President’s Emergency Plan for Aids Relief) and other agencies invested in health clinics and staff in order to make it possible for thousands of Africans in HIV-hit countries such as Kenya to be tested and given antiretroviral drugs to keep them alive and well.

“There was a view at one stage that HIV care would crowd out other illnesses and they would get worse,” said Whitworth, but that did not happen.

Instead, healthcare became a higher political priority in countries such as Rwanda and Kenya and improved across the board over time.

But no such improvement occurred in Sierra Leone, Liberia or Guinea.

Civil war

“In West Africa it is most stark,” said Whitworth. “I used to work in Sierra Leone in the late Eighties. The health services were pretty poor at that time. Since then, they have gone through civil war with everything collapsing.

“They have been rebuilding since the civil war ended so some improvement has been made, but I don’t think the health systems have been strengthened very much.”

Just as Aids focused minds and money 15 years ago, so Ebola should now.

Whitworth said he hoped that, as healthcare in West Africa now had the world’s attention, it could keep it. “Otherwise we’re left as a global community with a real Achilles heel with inadequate services,” he said.

The Indepth project is an unprecedented exploration of the causes of death in communities where no records are kept. Hundreds of researchers carried out interviews over two decades to establish how people died. They conducted verbal autopsies, interviewing family members in a structured way about the illness and last days of the deceased. The data, collected at 22 sites, each containing about 100 000 people, was then processed to establish the likely cause of death.

Missed deaths

Most studies that publish death rates from diseases around the world use official figures from hospitals, but deaths in rural villages are missed and there are no death certificates issued in certain parts of rural Africa.

The data comes to similar conclusions to the Global Burden of Disease study on the toll taken by malaria, tuberculosis, HIV and maternal and child mortality. But it shows a great deal of variability between one region and another, and investment in healthcare appears to be a factor.

Deaths of women in pregnancy and labour and child deaths are consistently high in Africa and Asia. Children’s drownings in Bangladesh and homicide among adult men in Eastern and Southern Africa are also causes for concern, the authors say. – © Guardian News & Media 2014