Seven things we can learn from the Ebola epidemic in Uganda in 2000 – 2001

By Sarah Ssali, Senior Lecturer, School of Women and Gender Studies, Makerere University

Diseases such as Ebola highlight the importance of a holistic focus on health systems, as opposed to assuming that health is the preserve and concern of health professionals alone. This was the lesson Uganda learnt very quickly in managing the Ebola outbreak in 2001. Until the current epidemic in West Africa, Uganda held the unfortunate record for the greatest number of infections, with 425 recorded cases of Ebola, of which 224 people sadly died (Omaswa 2014, Kinsman 2012).

Gulu district, in the north of the country, bore the greatest brunt of the epidemic, with 393 people falling ill and 203 deaths (Kinsman 2012). But it was not the only affected district. Mbarara district in the south west, recorded five cases of people contracting Ebola of whom four died and Masindi district in the west recorded 17 deaths.

Ebola causes community panic and mistrust in the health system

Initially, the epidemic caused a lot of fear, panic, and anger within communities. As is the case in West Africa now, communities: stigmatized the sick; stormed Ebola isolation units (in Masindi) causing the unit to seek another site; and scared off relief burial teams, forcing them to abandon work (Kinsman 2012). Elsewhere in the country, fear and stigmatization grew, causing those who suspected that they had Ebola to hide and patients to flee hospitals once they knew Ebola treatment was being carried out there. In Kampala, religious leaders held prayer rallies against the epidemic, while in nomadic Karamoja anti-Ebola rituals were carried out.

Very quickly, the Uganda Directorate of Health Services learnt that they needed to do something to restore community trust if they were going to tackle the epidemic. Treatment alone was not enough. They needed the community to understand that those treating Ebola patients and burying the dead meant well and needed the community’s support.

Seven measures taken to tackle Ebola in Uganda

Measures were undertaken to gain the trust of the community and help them fight the epidemic. Okware et al (2002) and Omaswa (2014) provide a list of the interventions undertaken by Uganda’s Ministry of Health, which included the following:

1. Partnerships with communities

Upon realizing that they could not do everything by themselves, the Ministry of Health decided to build partnerships with other actors within the community, such as non-governmental organisations like the Red Cross and World Vision. These partnerships were crucial for mobilizing communities, information dissemination, and early case detection. Okware et al (2002) even state that anti government rebels stopped fighting and supported the anti-Ebola efforts

2. Community-based disease surveillance

The Ministry of Health trained community members to provide a network for surveillance and public information. These community members rapidly reported suspected cases from households, who were rapidly assessed using history of contact and clinical assessment. This strategy was important in that it was not very costly to manage.

3. Work with the Media

Realising the role of the media in informing and misinforming the masses, given their previous role in propagating myths and rumours about Ebola, the Ministry of Health learnt very quickly that they needed to partner with the media to provide prompt and factual public information. Information dissemination could no longer be the preserve of health workers. The media was trained in Ebola and barrier nursing to protect themselves, after which they were charged with providing factual updates about the disease on a daily basis. This way, the media helped curb rumours, myths and risks associated with the disease.

4. Technology for quick field diagnosis of new infections

Because there was no special laboratory for testing Ebola in the country, a field laboratory for spot screening was provided with help from the Centre for Disease Control (CDC) and the World Health Organization. The South African Institute of Virus Research helped customize certain procedures to make them simpler and less costly. This helped with early detection, while those suspected but found to be negative were able to return to their normal lives. This helped reduce stigma and re-build trust between the communities and the health facilities managing Ebola.

5. Infection control and hospital waste management

While health facilities should routinely manage waste professionally, this is not the case, especially in rural communities. Moreover, no one had been prepared for the kind of waste management that accompanied an Ebola epidemic. Sometimes, health workers thought that ensuring that isolating people with Ebola was all they needed to do. In addition, there was need to protect non-health workers in the Ebola response, such as drivers. The Ministry of Health developed a programme to promote infection control in hospital and health facility settings. However, this training was not restricted to health workers, but to others such as drivers who transported people to referral centres.

6. Work on the legal, ethical and social issues

One of the biggest challenges in combating infectious diseases arises from people’s traditions and cultural norms. Such traditions, with respect to the Ebola epidemic, relate to burials in ancestral grounds, funeral ceremonies, and the handling of the dead. People were provided with information about the dangers of touching those who had died of Ebola and encouraged to leave burials to the specially trained burial committees.

In addition, there were issues of disclosure and confidentiality, which posed ethical challenges to medical workers, and the several children (about 500) orphaned by Ebola. To address these, the government enacted the Workman Compensation Act which entitled infected health workers and their close kin some form of compensation. Individual confidentiality was suspended for public information sharing and counseling services provided to the orphans. In addition, a Post-Ebola Association and a special clinic opened to provide services to survivors.

7. National and international collaborations

One thing that has been associated with Uganda’s success in combating epidemics such as HIV and Ebola is the leadership and commitment from government. With the suspicion of Ebola in Uganda, despite meager finances, the government embarked on a process of providing essential resources to help combat the epidemic. These essentials included but were not limited to; supplies, funding, expertise, communication, and information. Where resources became a challenge, the government called on the international community to help. Some of these, such as CDC, provided the expertise in field testing. All external actors were coordinated by the National Task Force. In addition, other tasks forces were established at the district (DTF) and between ministries (IMTF). These task forces included policy makers, such as district leaders, Members of Parliament, religious leaders, and the police along with people from the health sector.

References:

Kinsman John (2012), “A Time of Fear”: Local, National, and International Responses to a Large Ebola Outbreak in Uganda, in Biomed Central 8 (15), Pgs 1-12

Okware S. I et al (2002), An Outbreak if Ebola in Uganda, Tropical Medicine and International Health, 7(12), Pgs. 1068-1075

Omaswa Francis (2014), Regaining Trust: An Essential Prerequisite for Controlling the Ebola Outbreak, The Lancet Global Health Blog, 11th August 2014

Photo courtesy of Josh Zakary https://www.flickr.com/photos/joshzakary/6864103297

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Ebola emerges in fragile states: another ‘wake- up’ call?

By Kate Hawkins

Many ReBUILD researchers are also members of the Thematic Working Group on Health Systems in Fragile and Conflict-Affected States. Suzanne Fustukian (pictured), of the Institute for International Health and Development, Queen Margaret University, Edinburgh, is on the Steering Committee.

Along with Karen Cavanaugh who works at USAID she has just published a blog on Ebola for the Health Systems Global website. In it she argues:

In 2013 World Bank President Jim Kim stated that the lack of progress for many fragile states: “should be a wake-up call to the global community not to dismiss these countries as lost causes,” and that “timely and critical support [is needed] to improve the lives of people living in these fragile countries.”

If the global community has been sleeping on the job of supporting fragile and post-conflict settings, then the Ebola outbreak is certainly something to wake us up.

Read more…

What can we learn from health policy making patterns in post-conflict Sierra Leone for post-Ebola times?

By Kate Hawkins

I am a big fan of the IHP newsletter. It lands in the email every Friday and never fails to provide something to make you think, laugh, or get irritated. The editorials by Kristof Decoster are a must read and you can follow him on Twitter. What more could you ask for?

So a huge thanks to the IHP newsletter team for highlighting a blog by our colleague  last week. She argues that:

One of the unresolved challenges in post-crisis settings is the balance between humanitarian aid and the longer-term development approach to rebuilding the health system. We agree that decisions made in the early recovery phase could determine the long term development of the health system. But how, when, why and by whom are those decisions made? We know surprisingly little about that.

Drawing on evidence from a recent paper in Conflict and Health she outlines what happened with human resources for health reforms in Sierra Leone, from the end of the conflict in 2002 until 2012, and suggests some lessons that other countries can learn.

You can read all about it on the IHP website…

And subscribe to the newsletter, you won’t regret it!

An update from the frontline of health systems research in Sierra Leone by Dr Haja Wurie

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.

Research priorities

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.

What should the Australian government be doing about global health threats like Ebola?

By Kate Hawkins

ABC radio in Australia interviewed one of our colleagues Barbara McPake to get her views on what the national response to Ebola and other health crises should look like.

She explained how the response is a broad church from lab based scientists to social scientists looking at the social determinants of ill health. The Nossal Institute is currently meeting to discuss health security and the Australian aid for health.

She suggested that the global health community is responding fairly poorly to health threats. Ebola should be quite an easy disease to control given that there is a fairly small period when people are infectious but the symptoms are invisible. In places like Syria and Iraq it is difficult to prioritise health systems when there are so many other emergencies and crises. But both their health systems have been very seriously damaged by events there.

National health systems weaknesses underpin the problem. But there have also been two major global health systems failures:

  1. The lack of sufficient investments in health systems over a long period which has left them vulnerable to shocks like Ebola
  2. A lack of investment in global emergency disease control measures

“The World Health Organisation has acknowledged the failures in its response, but longer term there has been a failure to invest in the World Health Organisation…Budget costs there have meant that it has lost a lot of Ebola experts in the last few years.”

Barbara explained how a lot of health aid has been targeted at specific health conditions over the last decade. This has had positive results and been quite effective for the particular illnesses which received support. But the ability of the health system to respond to a range of health problems in many settings is weak because of under-investment.

Both Bird Flu and SARS are threats to Australia as they emanate in the region. Countries like China have significantly strengthened their health system since the SARS outbreak. But other countries have very weak health systems.

Barbara went on to state that Australian aid has made some really good investments in the past, for example in Cambodia. The current administration continues to emphasise health and education. Health systems should be part of that. There are simple and effective investments that can be made in this area and there is also a need to innovate and find new mechanisms for the delivery of health care. Barbara is hoping that the Government will focus on these innovations in the health system as well as investments in general development as part of the mix. Weak health systems rely significantly on people paying out of their pockets for health care. There is a need to get that balance right and see these things as mutually supportive.

Listen to Barbara on ABC Radio or download the sound file…

A view from Australia on Ebola

This week our Director Barbara McPake has been in the news in Australia talking about Ebola:

Global Health’s Professor Barbara McPake, speaking ahead of a conference on global health security in Melbourne on Wednesday, said although it is likely we will see the Ebola within our borders, Australia is well placed to deal with an outbreak.

“As the epidemic gets larger and larger in west Africa the likelihood of the odd case emerging in Australia is quite high, but I do think Australia will deal with it very well,” she said. “If anybody dies in Australia it’s likely to be somebody who has come already at a fairly advanced stage of the infection.”

Read the full article…

In a second article in the West Australian she explains:.

“Australia has a very strong health system.” 

“I think what Australians need to be worried about is if future outbreaks like this are being adequately prepared for and prevented by the strengthening of health systems in countries in the region.”

Read the full article…

I’m an expert in healthcare in developing countries and conflict zones, AMA

As part of the Nossal Annual Forum Barbara McPake is taking part in a Reddit “IAmA”. This is an online forum where users post “AMAs” (for “Ask Me Anything”) and others can ask questions on a particular topic. Anyone can join in, you just need to register with Reddit (which takes seconds).

Barbara is a health economist specialising in health policy and health systems research in low- and middle-income countries. She is Director of the Nossal Institute for Global Health and heads the ReBUILD Consortium (along with Tim Martineau).

So far Barbara’s fielded a range of questions:

  • How much should the USA worry about the Ebola virus? Does it have the potential to spread like in other parts of the world?
  • In a perfect world – assuming everything was to run perfectly! – how should emergency responses to health crises function?
  • How often and in what ways does superstition get in the way of you and yours trying to help?

Join in the conversation by following this link http://nr.reddit.com/r/IAmA/comments/2jq70t/im_an_expert_in_healthcare_in_developing/

Go on, ask her anything…