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

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A general election means Jeremy Corbyn's euroscepticism is finally an asset

The Labour leader's track record means he can connect with Remain and Leave voters alike. 

The first anti-establishment party leader to offer true ideological opposition and alternative to the Thatcher consensus in a generation is staring down the barrel of a 20 point polling deficit at the start of this snap election race. This leader has filled halls; galvanised hundreds of thousands and consistently voted on the side of freedom, progress and justice. So just why has he been abandoned by those who should support him?

While Jeremy Corbyn’s leadership has rightly been held to account, the criticisms have been, at times, unfairly amplified both by hostile MPs and a condescending press. With the election just over 40 days away, the left must now realise the severity of the task at hand, and question whether its constant attacks are helping to create the monstrous Tory landslide we all so fear. In the run-in, Corbyn will need unified backing by all those who oppose austerity, inequality and injustice, in a way he’s so far failed to receive.

The votes for Brexit and Donald Trump show the sheer disillusionment with the extreme centre governments of the last decades, that have given rise to mass inequality, caused global instability and brought terrorism to our doors. While Corbyn’s policies – on nationalising railways, foreign intervention, supporting the NHS, tuition fees, and more – are overwhelmingly supported by the public, he has so far lacked the communicative edge to ride the wave of this new age of populism. Whereas policy-lite Trump romped home with the mere repetition of eight syllables, Corbyn often misses opportunities to sell the bright, inclusive future needed to inspire the British public. He needs to create the punchy soundbite that sells his vision, in one, short sentence what a future Britain can look like, and how it stands in stark contrast to that of the Tories.

Throughout his spell at the helm of the Labour Party, Corbyn’s style has constantly been ridiculed; from his dress sense to tone of voice. So what do we really value in a leader and how should they act?

As PM, David Cameron regularly hit home in Parliament, brashly mocking opponents with quips and digs. He stood smug and unrepentant as deeply damaging cuts were enforced. But while he was once considered a strong and stately leader, history now judges him quite differently. For inflicting austerity, and leaving behind a heavily divided Britain, he’s now recognised as one of the worst. Theresa May’s brief stint at leadership has already seen a humiliating u-turn, dodged live debate and false election date promises, all while cruelly playing with the lives of millions of EU nationals.

Meanwhile, Corbyn, who at times has been unfairly lambasted for his approach has consistently displayed personal and professional dedication to championing pro-people politics for over 30 years, undeterred by spin and political games. Compassion, equality, fairness - surely these leadership traits hold equal worth.

In an election based primarily on Brexit, Corbyn can take real and emboldened ownership. A lifelong eurosceptic, Corbyn has the chance to offer a people-led Brexit that works for the majority, reaching out to Leave and Remain voters alike.

Much of the Remain protest movement and post-referendum activism revolves around fears of Britain becoming racist, hostile and isolationist in its approach to would-be migrants, and EU nationals. In negotiations, if a deal on immigration is to be struck, Corbyn’s historically compassionate views on migrants and refugees could create the most fair, humane solution possible. In his move today, he’s sought to reassure EU nationals of a future far removed from May’s brutal nationalistic games. And in Corbyn’s lifelong championing of workers’ rights, and redistribution of wealth, he can at last speak to the working-class heartlands freely of an inclusive and beneficial post-Brexit future.

While there can be shortcomings in Corbyn’s communication, and occasionally muted approach; criticisms can frequently seem unbalanced. His inability to shout about recent budgetary u-turns, for instance, made headlines over the actual climbdown itself. The time has surely come to focus on the severity of the alternative.

Throughout his leadership, Corbyn has been targeted by all corners of the press, with focus poured on his character over providing a real and important platform to explore his policies. When he refused mass media engagement he was dubbed cranky and weak, yet we’ve largely let May off the hook for dodging much-needed live debate. Written off by Westminster, mocked and condemned by the media. A principled voice fighting for equality, inclusion and fairness. Not much has changed in 30 years.

While we must hold his leadership to account, there is a sense that we, on the left are at times helping to fuel the massive Tory victory we apparently dread. So now is the time to remind ourselves, and others, who and what we’re up against. The "go-home illegal immigrants" vans circulated, and then pulled by May; her election u-turn, reinvention and uncompromising hard-Brexit approach. A party of callous, brutal decisions that have caused despair and plunged many into poverty. A snapshot of their comparative voting records alone should be enough to put the choice ahead of us into stark perspective.

And just to reiterate Corbyn’s largely swallowed, forgotten record during his rebranding as meaningless, lost and ineffectual. He was right on sad, regrettable wars; he passionately protested apartheid, championed workers rights and equal pay, and has consistently stood up for the NHS – against party line.

That’s a name, record and leader many will be proud to put an inked endorsement by on 8 June 2017. 

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