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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Cabinet audit: what does the appointment of Andrea Leadsom as Environment Secretary mean for policy?

The political and policy-based implications of the new Secretary of State for Environment, Food and Rural Affairs.

A little over a week into Andrea Leadsom’s new role as Secretary of State for Environment, Food and Rural Affairs (Defra), and senior industry figures are already questioning her credentials. A growing list of campaigners have called for her resignation, and even the Cabinet Office implied that her department's responsibilities will be downgraded.

So far, so bad.

The appointment would appear to be something of a consolation prize, coming just days after Leadsom pulled out of the Conservative leadership race and allowed Theresa May to enter No 10 unopposed.

Yet while Leadsom may have been able to twist the truth on her CV in the City, no amount of tampering will improve the agriculture-related side to her record: one barely exists. In fact, recent statements made on the subject have only added to her reputation for vacuous opinion: “It would make so much more sense if those with the big fields do the sheep, and those with the hill farms do the butterflies,” she told an audience assembled for a referendum debate. No matter the livelihoods of thousands of the UK’s hilltop sheep farmers, then? No need for butterflies outside of national parks?

Normally such a lack of experience is unsurprising. The department has gained a reputation as something of a ministerial backwater; a useful place to send problematic colleagues for some sobering time-out.

But these are not normal times.

As Brexit negotiations unfold, Defra will be central to establishing new, domestic policies for UK food and farming; sectors worth around £108bn to the economy and responsible for employing one in eight of the population.

In this context, Leadsom’s appointment seems, at best, a misguided attempt to make the architects of Brexit either live up to their promises or be seen to fail in the attempt.

At worst, May might actually think she is a good fit for the job. Leadsom’s one, water-tight credential – her commitment to opposing restraints on industry – certainly has its upsides for a Prime Minister in need of an alternative to the EU’s Common Agricultural Policy (CAP); a policy responsible for around 40 per cent the entire EU budget.

Why not leave such a daunting task in the hands of someone with an instinct for “abolishing” subsidies  thus freeing up money to spend elsewhere?

As with most things to do with the EU, CAP has some major cons and some equally compelling pros. Take the fact that 80 per cent of CAP aid is paid out to the richest 25 per cent of farmers (most of whom are either landed gentry or vast, industrialised, mega-farmers). But then offset this against the provision of vital lifelines for some of the UK’s most conscientious, local and insecure of food producers.

The NFU told the New Statesman that there are many issues in need of urgent attention; from an improved Basic Payment Scheme, to guarantees for agri-environment funding, and a commitment to the 25-year TB eradication strategy. But that they also hope, above all, “that Mrs Leadsom will champion British food and farming. Our industry has a great story to tell”.

The construction of a new domestic agricultural policy is a once-in-a-generation opportunity for Britain to truly decide where its priorities for food and environment lie, as well as to which kind of farmers (as well as which countries) it wants to delegate their delivery.

In the context of so much uncertainty and such great opportunity, Leadsom has a tough job ahead of her. And no amount of “speaking as a mother” will change that.

India Bourke is the New Statesman's editorial assistant.