By Haja Wurie
The aim of the WHO Ebola roadmap is to stop the transmission of the virus in affected countries within 6-9 months and prevent international spread. However, as of today, the Ebola outbreak continues to spread in alarming ways in Sierra Leone and Liberia and has now crossed international boundaries, with cases in Spain and the USA.
In Sierra Leone, the virus has spread to all 14 districts in the country, and the country is still struggling to control the escalating outbreak against a backdrop of severely weak health systems, and significant deficits in capacity. There are reports of five new cases per hour in Sierra Leone and an alarming prediction of 1.4 million people infected in both Sierra Leone and Liberia, if efforts to control the spread of the virus are fruitless.
If uncontained, the outbreak has the potential to cause a collapse of the affected countries, something that will take years to recover from. The only positive thing about the Ebola outbreak is that is has created a window of opportunity to prioritise health systems research and strengthening. Resilient and responsive health systems should be built, or rebuilt in this case, with concerted efforts needed by the Government, researchers, implementers and donors. Most importantly, long term solutions should focus on ensuring that universal health coverage becomes a reality. Resources, strategic planning and capacity development is needed to build to recover from this crisis.
Health systems in Sierra Leone
In Sierra Leone, the health sector is divided into six main pillars, governance, human resources for health, service delivery, infrastructure, drugs and technology and research and monitoring and evaluation. The current Ebola outbreak has highlighted the challenges in all the six pillars and the irresponsive nature of the current health sector, which contributed to the delayed response. In my opinion, the health sector needs to be completely reformed as it is just not working.
There are historical challenges regarding the implementation of policies the health sector in Sierra Leone, with a number of health policies on paper but not implemented. This might be a capacity issue which health systems research will shed some more light on. Systems within central government need to be reviewed, and possibly reformed, as the current practice causes inordinate delays.
The slogan ‘Health is Wealth’ can be seen everywhere at the Ministry of Health and Sanitation, Sierra Leone. Accordingly, the local leaders should ensure that sustainable investments are made in the health sector. This can range from investing in new or upgrading health facilities, diagnostic tools and technology, to investing in the health workers, the unsung heroes and heroines.
With only 2 medical doctors per 100,000 of the population, the human resources available for health are inadequate. Findings from the ReBUILD’s health worker incentive project in Sierra Leone, highlighted that building the capacity of health workers and developing a motivated health work force is an ongoing issue. Health workers in general are demotivated even before the outbreak. Health facilities are chronically understaffed by poorly trained, overworked healthcare personnel, with very little or no training on infection control practices. Working conditions are generally poor, lacking adequate logistics. The basics of sanitation, electricity and personal protective equipment to ensure the safety of health workers from infection are not always available when required. This has resulted in the majority of health specialists at the forefront of the outbreak being international experts flown in by international development partners, highlighting the heavy dependence on foreign expertise.
Attraction and retention of health workers in rural and remote areas of Sierra Leone is an on-going challenge, which has resulted in a mal-distribution of the health work force. Not having equitable access to health care services can influence one’s health seeking behaviour. With no health facilities within easy reach or poor quality of service delivered in the health facilities, service users might seek for health care services via the traditional route. This heavy dependence on traditional healers can only address by ensuring that universal health coverage is available to all. Hence, it is important for more health workers to be trained, that are motivated to work and stay in adequately functioning rural health facilities.
It is a common occurrence in recent weeks for health workers and burial boys – at the forefront in the fight against the virus – to go on strike, citing non-payment of risk allowances, inadequate supplies of PPEs and death of their colleagues. This implies that the health workforce feel both undervalued and ill equipped to do their job effectively, even during the outbreak. Health workers should be motivated and protected. A benefits package for health workers should be developed and their voices should be instrumented in the design. Thus investment is needed in the health workers in terms of remuneration and professional training/development and also in the health facilities in terms of improving the working conditions.
Sierra Leone faces a number of challenges in building its research for health systems, the greatest of which is the absence of national ownership of health systems research. Limited government commitment, inadequate funding, poor coordination and networking, a small number of health researchers who are typically combining multiple tasks or jobs, limited grants and research management skills, and very limited capacity in general, are some of the problems encountered in this country.
Sierra Leone’s research for health strengthening is mostly donor driven, which raises the issue of sustainability. Being heavily dependent on international aid, means that research initiatives are fragmented, and largely led by international researchers with little or no local capacity being built. This should be addressed as a matter of urgency.
The Government of Sierra Leone should make health systems research a priority and take national ownership. In the event of any further outbreak it will be necessary to ensure that local professionals adequately trained are on the ground, and local institutions are involved in health systems strengthening research.
Donor investment and coordination
There is an element of mistrust of the government’s role in how Ebola has come about and is spreading. Sierra Leone being a post-conflict country is still recovering from the effects of the conflict has definitely contributed to the spread of the virus. The eleven year conflict crumbled the health sector and fuelled social conflict and mistrust in the government. International donors should also consider supporting health civil society organisations, and tasking them with activities in health promotion and education, amongst other things.
Donors need to be coordinated to avoid fragmentation. There are reports of high profile meetings at central government, but so far coordination on the ground is ineffective. In the same vein gap between researchers and decision makers should be bridged to ensure that knowledge gaps are identified and incorporated into a tried and tested national health emergency response policy. This will have a ripple effect on leadership and governance systems in place.