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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The UK is dangerously close to breaking apart - there's one way to fix it

We must rethink our whole constitutional settlement. 

When the then-Labour leader John Smith set up a report on social justice for what would be the incoming government in 1997, he said we must stop wasting our most precious resource – "the extraordinary skills and talents of ordinary people".

It is one of our party’s greatest tragedies that he never had the chance to see that vision put into practice. 

At the time, it was clear that while our values of equality, solidarity and tolerance endured, the solutions we needed were not the same as those when Labour was last in power in the 1970s, and neither were they to be found in the policies of opposition from the 1980s. 

The Commission on Social Justice described a UK transformed by three revolutions:

  • an economic revolution brought about by increasing globalisation, innovation and a changing labour market
  • a social revolution that had seen the role of women in society transformed, the traditional family model change, inequality ingrained and relationships between people in our communities strained
  • a political revolution that challenged the centralisation of power, demanded more individual control and accepted a different role for government in society.

Two decades on, these three revolutions could equally be applied to the UK, and Scotland, today. 

Our economy, society and our politics have been transformed even further, but there is absolutely no consensus – no agreement – about the direction our country should take. 

What that has led to, in my view, is a society more dangerously divided than at any point in our recent history. 

The public reject the status quo but there is no settled will about the direction we should take. 

And instead of grappling with the complex messages that people are sending us, and trying to find the solutions in the shades of grey, politicians of all parties are attached to solutions that are black or white, dividing us further. 

Anyone in Labour, or any party, who claims that we can sit on the margins and wait for politics to “settle down” will rightly be consigned to history. 

The future shape of the UK, how we govern ourselves and how our economy and society should develop, is now the single biggest political question we face. 

Politics driven by nationalism and identity, which were for so long mostly confined to Scotland, have now taken their place firmly in the mainstream of all UK politics. 

Continuing to pull our country in these directions risks breaking the United Kingdom once and for all. 

I believe we need to reaffirm our belief in the UK for the 21st century. 

Over time, political power has become concentrated in too few hands. Power and wealth hoarded in one corner of our United Kingdom has not worked for the vast majority of people. 

That is why the time has come for the rest of the UK to follow where Scotland led in the 1980s and 1990s and establish a People’s Constitutional Convention to re-establish the UK for a new age. 

The convention should bring together groups to deliberate on the future of our country and propose a way forward that strengthens the UK and establishes a new political settlement for the whole of our country. 

After more than 300 years, it is time for a new Act of Union to safeguard our family of nations for generations to come.

This would mean a radical reshaping of our country along federal lines where every component part of the United Kingdom – Scotland, Wales, Northern Ireland and the English regions – take more responsibility for what happens in their own communities, but where we still maintain the protection of being part of a greater whole as the UK. 

The United Kingdom provides the redistribution of wealth that defines our entire Labour movement, and it provides the protection for public finance in Scotland that comes from being part of something larger, something good, and something worth fighting for. 

Kezia Dugdale is the leader of the Scottish Labour party.