Rosalind McCollum is a PhD student with the REACHOUT Consortium at the Liverpool School of Tropical Medicine who has recently returned from Sierra Leone where she had been working with Concern Worldwide to train health workers and community members in infection protection control. In her blog, she reflects on her time back in Sierra Leone and on some of the weaknesses in the health system that have affected the progress of the Ebola outbreak and the response to it, and some actions that could improve the resilience of the health system for this outbreak and future shocks.
Returning to Sierra Leone to join with former colleagues from Concern Worldwide working together in the Ebola response is a rare privilege, allowing me to reflect on some of the weaknesses within the health system which enabled the outbreak and have the potential to derail future recovery.
Ebola has revealed weaknesses within the health system, bringing to the surface gaps and inadequacies as highlighted previously by researchers in Sierra Leone such as Dr Haja Wurie. The delayed recognition of Ebola as a threat and subsequently slow response to the outbreak, allowed Ebola to spread throughout the country. Thankfully the international community has now mobilised to provide support. However, Sierra Leone’s health system is severely understaffed and under-resourced with too few trained health staff and a lack of trust between community and the health system.
Shifting priorities and multiple tasks
As the response has scaled up this has created huge pressure on existing health workers particularly community health officers (CHOs), who are clinical staff with five years training and who under normal circumstances provide and supervise health activities within their chiefdom, under overall direction of the district medical officer. As a range of different implementers have entered the districts seeking to provide a full range of interventions to tackle Ebola – from case investigation, to Infection Prevention Control (IPC) training at Peripheral Health Units (PHUs), training and mentoring for community care centres, running holding centres, working at Ebola treatment units etc. Each intervention has needed to draw on the same pool of trained health workers (particularly CHOs) within the district. As a result the most qualified staff in the district are at times seconded from District Health Management Team (DHMT) to work on various interventions, sometimes concurrently and often changing on a weekly or even daily basis as priorities change within the district. All the while these Ebola related activities are in addition to their regular activities supervising and directing routine health activities within their chiefdom.
Changing priorities within the district happens on a daily basis as new players, with new funding, and reporting to different donors with differing degrees of influence, arrived. While expansion in the response was undoubtedly positive a lack of coordination among donors could at times create confusion, since one priority would be replaced with a seemingly conflicting intervention now taking precedence. This also created challenges in ensuring coherence between so many stakeholders within such a rapidly changing situation. For example, the introduction of community care centres occurred at such a rapid pace that decisions regarding testing and referral of patients were still being determined when the first patient was admitted creating confusion for staff and patients.
The community response
As a PhD student studying community health workers (CHWs), I am particularly interested in the vital role volunteers have played so far in the response. Volunteers are working in a wide variety of roles from burial team members, to contact tracers and screeners. One question this raises is to what extent has the response engaged with existing CHWs? Concern has been seeking to engage with Health Management Committees and CHWs they have previously trained, who are keen to respond and to help their communities. However, there are also stories of trained CHWs being neglected during selection of contact tracers. What will be the future consequence of this? For CHWs who previously have worked for small incentives, to be ignored while others take on the role and allowances associated with contact tracing must undoubtedly be demotivating. For any CHW recruited into a contact tracing or screening role he/she will bring with them skills, experience and community acceptance. In addition there is the future benefit for strengthening the health system associated with training and experience gained by CHWs through Ebola response roles. As a country where cholera is endemic these are skills which could be modified and put to use in a variety of ways in the future.
While the number of people acquiring Ebola has reduced dramatically in Liberia, that number remained high in Sierra Leone for much longer, and has only recently shown significant reduction. This raises many questions as to the reasons behind the differing outbreak trajectory within these neighbouring counties. Why did Liberia manage to reduce the number of cases so significantly? And what lessons can Sierra Leone learn from this? Have there been significant differences in the EVD response or is it due to underlying contextual and health systems factors? Liberia has a longer history of working with established CHWs compared with Sierra Leone, who introduced their CHW programme in the last few years. Has this longer established CHW network mobilised more effectively in recent months in Liberia, contributing to their reduction of cases?
In order to ensure eradication of Ebola and strengthen Sierra Leone’s health system for greater resilience beyond this outbreak it is vital that actions taken now contribute towards health systems strengthening both now and in the future such as:
- Long-term commitment to fund health systems strengthening, including training of health workers
- Strengthened governance, coordination and accountability at district and national level
- Strengthened coordination and reporting, building on lessons learned through case investigation and contact tracing from community level through to national level
- Permanently improved IPC standards within all health facilities in the country, through regular ongoing mentoring following IPC training
- Health workers empowered to demand salaries, supplies and equipment which they need for their work and protection, through strengthened supply chains and improved human resource systems which also efficiently accommodate the many volunteers working on the Ebola response to ensure their timely payment of risk allowances as well as health worker salaries
- Integration of rapid diagnostic tests for Ebola (when available) within existing community care centres to provide early access to safe testing relatively close to patients homes for earlier diagnosis, contributing to earlier isolation and management when linked with early onwards referral to Ebola treatment unit
- Engagement and discussions with communities and health management committees through IPC trainings and mentoring at PHU level to build trust again in their health system and promote utilisation of health facilities for non-Ebola related illnesses.
Concern Worldwide, a member of the Ebola Response Consortium (led by the International Rescue Committee), has worked in Sierra Leone since the civil war in 1996, initially providing humanitarian response before transitioning to development. Concern Worldwide has provided a range of humanitarian response actions to the current Ebola outbreak in Sierra Leone and Liberia https://www.concern.net/ebola . Rosalind temporarily left her studies with the REACHOUT Consortium to work together with Concern Worldwide in Sierra Leone to train health workers, volunteers, support staff and community members in IPC. This enables them to identify people suspected to have Ebola, to isolate them in an area separate from others, to safely don and doff Personal Protective Equipment (PPE) when entering the isolation area and how to clean safely.
Involving community stakeholders during the training helps to ensure community participation in monitoring screening, construction of isolation spaces and other IPC activities. In addition, these community leaders can share knowledge about the training with their communities so that people know that the clinic is a ‘safe zone’ therefore encouraging attendance. We hope this will contribute to improvement in utilisation rates in the future.