By Sally Theobald, Liverpool School of Tropical Medicine
Ebola is threatening gains made in health systems strengthening in post conflict Sierra Leone. The ReBUILD consortium working in partnership with College of Medicine and Allied Health Sciences (COMAHS) in Freetown has been assessing the opportunities and challenges of the post conflict window(s) for health systems strengthening with a particular focus on human resources for health and health financing. Important gains have been made across the country in recent years with investment in health staff of all cadres and the roll out of the Free health Care Initiative for children under five and for pregnant women and breast feeding mums. With the recent outbreak of Ebola the landscape has changed dramatically. During our ReBUILD partners meeting in Liverpool in September we discussed health systems as complex adaptive systems and the implications of the latest shock, in the form of Ebola, to the Sierra Leonean health system. Haja Wurie from COMAHS, explained how the health system in Sierra Leone is divided into six pillars, and how the Ebola outbreak requires action and response across all areas. Examples discussed include:
1. Governance: there is need for a coordinated and swift response at all levels. In Sierra Leone the health system is decentralised but in reality this can lead to delays in response as district teams cannot act without decisions at national level. The situation is complicated by the influx of a number of international players. The methods deployed in ReBUILD (life histories) enable a long historical view and analysis of past relationships and experiences, which are also emerging in current responses to Ebola. In our ReBUILD question time panel, Alex Jones, ex-ODI fellow, highlighted how the international response reflects past political histories and relationships with UK largely supporting Sierra Leone; the USA Liberia and France, Guinea. This is turn brings challenges to the notion of a joint West African approach and strategic lesson learning about what works well in different contexts and why.
2. Human resources for health: Sierra Leonean health workers of all cadres need urgent support. Health workers across the board have limited supplies for infection control and are massively overworked. Training in and supplies for infection control in Sierra Leone is limited, exacerbating the infection spread. This has resulted in many of the health specialists at the forefront of the outbreak being much needed international experts flown in by international development partners, who in turn often get flown out to receive medical care if infected; an option rarely open to Sierra Leonean health care workers, who in many cases experience high levels of stigma amongst their communities because of the risks associated with their job.
3. There is need to develop robust systems and approaches for research and M&E. Sierra Leone’s research for health priorities are mostly donor-driven, with little ownership by the MOHS. There have been promising gains made in Ebola research in recent months and we can expect further research in this area in West Africa. Dr. Mohamed Samai from the MOHS in SL and ReBUILD colleague raised the importance of supporting the ethics committee in Sierra Leone to be able to respond quickly and appropriately to research protocols and ensure research meets national priorities.
4. Service delivery: Rebuilding trust with communities and ensuring health promotion messages get to those who need them is vital. Ebola is fuelling mistrust between health services and communities and in some cases health services are being abandoned by both health workers and communities. This has the potential to seriously undermine recent positive steps Sierra Leone has taken to increase health service utilisation and build trust between health systems and previously neglected rural communities. Sarah Ssali from the Department of Women and Gender Studies at Makerere University in Uganda, highlighted how lessons learnt from the HIV response were critical in addressing the Ebola outbreak in northern Uganda in 2001. Key to this was building trust and collaborative working relationships with different community groups and structures particularly community health workers; and developing effective multi-sectoral responses. Gender also matters. The links between gender and infectious diseases are well established and also sadly playing out in the latest Ebola epidemic; where the roles of women as girls as carers within households and communities means they are especially vulnerable to infection. In Liberia it is estimated that 75% of Ebola cases are female and in Sierra Leone women have comprised 55 to 60 percent of the dead. Within Sierra Leone the newly constituted Maternal Health Promoters are embedded in communities and have trusting relationships with women and could play an important and strategic role in spreading health promotion messages and support.
When I introduced our ReBUILD colleagues from Sierra Leone to my LSTM colleague Dr. Tim O’Dempsey who has recently returned from the WHO effort to address Ebola in Sierra Leone, I thought they would shake hands. Instead they bumped elbows in a comradely fashion – the ‘Ebola bump’ form of greeting amongst health professionals has evolved as a way to reduce cross infection; similarly health systems in Sierra Leone must adapt and respond to the latest shock faced in the form of Ebola. This means learning past lessons I order to build resilient and responsive health systems, strengthening governance and ensuring a coordinated response, investing in and protecting all cadres of health workers and working hard to support trusting relationships with diverse affected communities.