A health worker treats a child with ebola in Sierra Leone. Photo: Francisco Leong/AFP/Getty Images
Show Hide image

Warnings over collapse of health system in the wake of ebola in Sierra Leone

Prior to the outbreak there were signs of progress in the country’s public health operation, which are now under threat.

Sierra Leone’s health system is showing worrying signs of collapse in the face of ebola, as the epidemic puts exceptional pressure on already weak systems in West Africa. This is a hugely frustrating and sad situation as the country had started to make progress in public health in the years prior to the outbreak. Despite the progress, however, the health system was not strong enough to absorb a shock on this scale and rebuilding infrastructure and trust will require major investment in the post-ebola period.

Taking Sierra Leone as an example, bearing in mind that the health system performance in Guinea Conakry and Liberia are somewhat comparable to their neighbouring country, we can see how the impact has been felt across all aspects of health.

In 2013, for the first time since the end of the war, Sierra Leone succeeded in eliminating the deficit of its country balance sheet, leaving no doubt that the country was in a period of recovery for the first time since the end of the war in 2002. Nevertheless, in 2014, Sierra Leone was still ranked amongst the poorest countries in the world. In 2013 the per capita expenditure on health was a mere $7.60, far short of the recommended $54. It is anticipated that the short-term impact of the ebola outbreak will affect the economy in Sierra Leone by a reduction in growth of GDP from 11.3 per cent to 8 per cent, which may mean that the government’s contribution to health activities outside of ebola will reduce in real terms. As campaigners mark the first-ever Universal Health Coverage Day on 12 December, this serves as a serious blow to the chances of bringing quality healthcare to all as a basic human right.

Signs of progress in public health prior to the ebola outbreak included the fact that between the periods assessed in the 2008 and 2013 Demographic and Health Surveys, the proportion of births taking place in a health facility has doubled (from 24.6 per cent to 54.4 per cent) and the proportion of women receiving a postnatal check-up within two days of delivery increased to more than two thirds (from 58.0 per cent to 72.7 per cent).

Despite these achievements, Sierra Leone still faces one of, if not the highest level of maternal and child mortality in the world.  The maternal mortality ratio shows no sign of improvement at 1,165 maternal deaths per 100,000 live births; the under-five mortality rate is 156 deaths per 1,000 live births; and the neonatal mortality rate is 39 deaths per 1,000 live births, which remain unchanged since 2008. The increases in health service uptake between 2008 and 2013 have not resulted in improvements in health outcome indicators, reflecting issues related to poor quality of health services.

Health workers are overstretched with an ever-growing burden of ebola cases, and the ebola-related fatalities of 101 of the 128 health workers infected impacts not only the workforce numbers but also morale, further reducing capacity of the health system to provide adequate care.

Facilities are under-equipped with essential infrastructure and equipment to provide even basic essential health services. Based on the Ministry of Health and Sanitation’s recent Facility Improvement Team (FIT) assessment, the pressure of ebola on the healthcare system is resulting in the closure of health facilities and a drop in those that are equipped to provide emergency obstetric and neonatal care.  Further, Government data shows that since the ebola outbreak, fewer people are attending public health facilities for essential health services; between May and July 2014, the proportion of women attending for their first antenatal care visit dropped by 17 per cent; for their first postnatal visit, fell by 18 per cent; and for a delivery, fell by 16 per cent. In terms of child health, over the same period, the proportion of children who received oral rehydration solution and zinc treatment for diarrhoea within the first 24 hours fell by 33 per cent and those receiving full immunisations dropped by 12 per cent.

The trust in health services has been further eroded by inadequate communication with, and involvement of, community members in the first few months of the outbreak. Serious misconceptions about ebola persist; a third of survey respondents in a survey believed that ebola was airborne and one out of every five people believed that ebola could be cured by traditional healers. With a case fatality rate estimated to be at least 70 per cent, health facilities are perceived as places where one catches the disease and dies.  Further, anecdotal reports appear regularly in the media about pregnant women being triaged out of care due the level of ebola transmission risk they are perceived to present to health workers.

The collapse of the health system demonstrates Sierra Leone’s poor resilience to absorb shocks. The focus of everyone is rightly on bringing the ebola epidemic under control, but at what cost? The impact of the drop in service utilisation on morbidity and mortality from other preventable illnesses is yet to be seen. An estimated 382,000 women will become pregnant over the next 12 months in Sierra Leone. Based on the pre-ebola levels of care without any consideration of the health system collapse, 2,400 women per year die due to preventable conditions related to pregnancy and childbirth. Malaria accounts for a quarter of all deaths in the country, and is the leading cause of death among under 5s. Measles outbreak is another risk for all three countries, which will be difficulty to contain if current resources do not broaden their focus to redress the gap in providing basic essential health services.

Reconstructing the health system in the post-ebola period will require significant investments in every aspect of the health system. Additional human resources for health will be needed not only to compensate the deaths of health professionals during the epidemic but also to fill the pre-existing gaps to be able to deliver the quality of services needed to improve health outcomes, and restore trust in the health system. In the meantime, authorities including the World Health Organisation, donors and implementing agencies must address the routine health needs of people in these affected countries, particularly those conditions that require simple interventions to prevent death and morbidity in areas such as malaria, vaccine-preventable diseases and the needs of pregnant women and their newborns.

Karl Blanchet is Lecturer at the London School of Hygiene and Tropical Medicine and a member of the Public Health in Humanitarian Crises Group. Sara Nam is a Technical Specialist in Reproductive and Sexual Health with Options Consultancy Services Ltd.

Getty
Show Hide image

MPs should follow Emmanuel Macron's example and stand up to the far right

Where does a liberal centrist's victory fit into your narrative of inevitable decline? 

“Après le #Brexit, le printemps des peuples est inévitable !” wrote the far-right Front National leader Marine Le Pen, days after Brexit. Well, the blossom is on the trees, and Le Pen is through to the second round of the French presidential elections, so presumably we’re bang in the middle of that inevitable “people’s spring”. 

After all, a referendum that left Britain’s metropolitan elite weeping into their EU flags was swiftly followed by the complete overturning of US political and ethical traditions. Donald Trump defied polling and won the Presidency, all the while proclaiming he was “Mr Brexit”.  

Then, in December, the Italian Prime Minister Matteo Renzi held a referendum on constitutional changes and lost. Both Europhiles and Eurosceptics read the runes. Ukip’s on and off leader Nigel Farage crowed of 2016: “First we had the Brexit deliverance, then the Trump triumph, then the Italian rebellion. Democracy and the rebirth of the nation state!”

As this illustrates, the far-right want you to believe all these results are linked, and that they represent a popular, democratic movement. In the UK at least, the liberal left has drunk the English champagne. Labour is agonising over how to reconnect with “traditional” voters Ukip is apparently so in touch with – which don’t seem to include ethnic minorities, young people and those living in cities. Being “tough on immigration” is the answer to modern woes, and globalisation is a dirty word that can only represent multinational interests and not, say, cheaper food on the table. 

There are debates to be had about globalisation, of course, and the lingering impact of the 2008 financial crash, and the fact wages haven’t risen, and public services have been cut, and that in some northern towns, people from different ethnic backgrounds live segregated lives. But if the first round of the French presidential election can do us one favour, it’s to dispense with the narrative that there is something inevitable about the end of liberalism. 

Emmanuel Macron, an unapologetically pro-EU social, economic and political liberal, led the way in the first round of the French presidential election. The polls put him on course to become President.

If he wins, perhaps it’s time to revisit the narrative of decline. To remind ourselves that Hillary Clinton, now written off, won the popular vote in the United States, and among growing demographics of voters too. That a far-right  Austrian presidential candidate was defeated in 2016. That as recently as March, the Dutch mainstream prevailed against the far-right original Trump, Geert Wilders, and that the left-green leader Jesse Klaver enjoyed a surge instead. And that, although it’s now commonplace to assume Canada is just “nicer” in electing a liberal, Justin Trudeau, his party actually overturned nearly a decade of tar sands Conservative rule. 

Should liberals start to join these dots, voters should have the right to ask why both Labour and the Conservatives have jumped on the populists' bandwagon so eagerly. Why, among previously economically liberal Conservatives, are Nicky Morgan, Ken Clarke and Anna Soubry left as lone voices on the back benches. And why, in Labour, is patchy research linking depressed wages and immigration now exhalted as long-established fact? 

Liberalism may be out of fashion, but it’s not dead yet, as any of the Tory MPs in south-west marginal seats know too well. By the time Farage’s “independence day” on 24 June arrives, the narrative may have changed again. 

 

Julia Rampen is the digital news editor of the New Statesman (previously editor of The Staggers, The New Statesman's online rolling politics blog). She has also been deputy editor at Mirror Money Online and has worked as a financial journalist for several trade magazines. 

0800 7318496