By Laura Dean (and Haja Wurie)
In preparation for our stakeholder meeting in Liberia detailed in our previous blog I spent some time interviewing Haja Wurie. Haja is based at the College of Medicine and Allied Health Sciences in Sierra Leone and works as part of the ReBUILD Consortium focusing on health systems research in post-conflict countries. Interviewing Haja, allowed time for reflection on the impact Ebola has had in Sierra Leone and enabled us to begin to strategize how best to move forward to build back more ‘responsive and resilient’ health systems. The interview will be used at our stakeholder meeting in Liberia to spark debate and encourage cross-country lesson learning.
The impact of Ebola in Sierra Leone
Haja believes that Ebola has exposed weaknesses across all pillars of the health system from service delivery to human resources for health and beyond. Haja describes the health workforce as ‘victims’ both during the conflict in Sierra Leone and during the Ebola crisis. During conflict health workers were targets of kidnap, and during Ebola they have become targets of a virus which they were ill-equipped to avoid due to lack of training and resources, at the onset of the outbreak. Ebola has impacted on health programmes through a decrease in service use because of mistrust and fear between service users and providers. Where vertical programmes, such as the Neglected Tropical Disease programme, had begun to establish themselves, Ebola has resulted in them taking ‘three steps back’. Haja believes there is ‘no more time for excuses’ and we need to address the systemic problems that allowed such a crisis to develop. There is a need for the health system to be prepared as future outbreaks of Ebola are likely once one has already occurred.
Building back better: What’s next for Sierra Leone’s health system?
Haja believes that we have to look toward strengthening all six pillars of the health system simultaneously to be able to build back better. It is too simplistic to argue for better training of staff or more available equipment without looking at all underlying factors that caused weaknesses in the system. For example, instigating infection prevention and control training is unlikely to be effective when most health workers are in facilities where there is no running water or electricity. Just as it is unproductive to have numerous donors and NGOs operating in an uncoordinated manner. So we need to think about how we strengthen systems in a holistic and unified way at a pace where no building blocks are left behind. This can be a hard thing to swallow as an academic with your own personal research interests in a specific disease area, or as the implementer of a vertical programme only concerned with a particular disease. The reality however is that unless we all start to think about the health system as a whole we are unlikely to be able to respond in a resilient manner to crisis.
What does building back better really look like?
Rebuilding trust between the health system and the communities which it is designed to serve is a critical first step in moving forward from Ebola. Haja believes that health education and health promotion are a crucial and that close-to-community providers play an essential role in their delivery. The Ebola crisis meant that there were travel restrictions within affected countries, as a result close-to-community providers had to be selected from within communities to ensure that health services did not cease altogether. Haja believes that it is these very close-to-community providers that present an opportunity for rebuilding trust. As ‘sons of soil’, they are trusted by their communities and the messages they share are respected. Driven by willingness and pride, often supported by minimal incentives (~three dollars every three months for community health workers), it is critical that community health workers are well supported by the health system they are serving.
Vertical disease programmes, such as those for the control of neglected tropical disease are essential health services. However strengthening them in isolation from the rest of the system is unlikely to contribute to a stronger health system. Through the delivery of essential health services vertical health programmes present a potential platform to strengthen another elements of health care. These health programmes should therefore look at ways to support and strengthen human resources for health through the cadre of community health workers and integrate this within their programmes. Vertical programmes could then promote co-ordination between strengthening building blocks and avoid contributing to fragmentation.
Internationally there is the scope for learning between all Ebola affected countries, specifically, Liberia, Guinea and Sierra Leone. Haja believes in the recent crisis, opportunities were missed to learn from systems in place in Uganda and this should not continue in rebuilding the health system. Countries have the opportunity to share their post-crisis action plans and ideas regarding their implementation. National ownership of health system strengthening is critical however, and it is essential that countries are given the opportunity to work together to harness donors to provide strategic support that is in line with nationally identified action plans building on countries strengths and developing their weaknesses.
Finally, Haja believes that health systems research is critical, but it has to be context relevant and led from within. There needs to be national ownership of research that incorporates community (service users and service providers) voices. Health systems research needs to be co-ordinated and directed in collaboration between policy makers, academics and health staff to ensure successful policy generation and implementation. It should not only focus on issues directly related to Ebola but explore issues across all sectors and all levels of the health system.
As I embark on a new area of research in an Ebola affected country, I will continue to ask myself; how can our research contribute to a stronger health system so that we build back better?