By Amelia Brandt, MSW, MPH
Maternal & Child Health Specialist
I am a public health professional currently living in Sierra Leone and working on the Ebola response with an international non-profit organization. I arrived here in January and have had the opportunity to see our work transition from emergency response to recovery.
What comes to mind when you see the word ‘Ebola,’? For me, there is not just one image. There are the images that are splashed through the news of health care workers struggling to treat Ebola patients in cumbersome personal protective equipment (PPE), but outside of the view of the cameras, there are mothers and children struggling to stay healthy without primary health care. During my time in Sierra Leone, I have realized that Ebola has had far-reaching health impacts that we are only just starting to understand.
In addition to the massive loss of life, decimation of families, and lingering health issues for survivors, this epidemic has taken an already weak health system and brought it to its knees. The child mortality rate in Sierra Leone was the highest in the world before the epidemic (WHO, 2015) due in part to the weakness of the health system as well as the extremely high level of poverty. As we move forward to try to get to zero new infections, our attention is now turned to trying to pick up the pieces.
Before the epidemic started, health care service utilization was already quite low. Only 61% of births took place in a health care facility, and the majority of child deaths were caused by preventable and treatable diseases such as acute respiratory infections and malaria (WHO, 2015). As fear of infection gripped the country, the citizens of Sierra Leone began to avoid health care facilities at all costs. From June to December of 2014, overall primary health care utilization dropped by one third (ACAPS, 2015). The services most impacted were treatment for diarrhea and malaria, two of the top causes of death for children under five. Antenatal care service utilization dropped from 75% before the epidemic to 50% currently (ACAPS, 2015).
Restoring the public’s confidence in the health system – as we know – will be quite a challenge given that the fear of becoming infected with Ebola is present among both the public and health care workers. However several approaches have promise:
- The Sierra Leonean primary health care system is made up of Peripheral Health Units (PHUs) that offer basic preventive and curative services. These services, while low cost, can have an immense impact on reducing maternal and child mortality. We are working on increasing public confidence in PHUs, while also working on building capacity to ensure quality services. It is essential to engage the community in this endeavour, which we are doing through capacity building and support of Health Management committees made up of community members.
- The Care Group model is a complementary approach that can impact health behaviours, including care seeking behaviour. This is a multi-tiered model that uses Health Promoters and Care Group Volunteers (CGVs) from the community to educate and support mothers. Each CGV is part of a Care Group of 10 to 15 women who are trained by Health Promoters on different maternal and child health topics from malaria prevention to identification of malnutrition. Each CGV works with a group of 10 to 15 mothers in her community, sharing her knowledge and providing support in improving the health of each woman’s family. This approach ensures that all mothers receive consistent education and support, while also empowering CGVs to take a lead on improving health in the community.
Changing behaviour has never been an easy task. The challenge facing Sierra Leone is gargantuan, and recovery will take years, perhaps even decades. However, this epidemic has also created a unique opportunity. Given the country’s terrifying experience with Ebola, throughout the country there is heightened awareness of the importance of health systems and community health. Thus, even in the presence of other stressors such as lack of employment and persistent poverty, there is likely now greater appreciation and receptivity to health promotion and disease prevention. In the aftermath of this epidemic, I believe that the motivation to improve the health system will be strong, and we have the opportunity to leverage that motivation to create lasting change.
- ACAPS. (2015). Ebola Outbreak in West Africa: Impact on Health Service Utilisation in Sierra Leone, Retrieved from: http://acaps.org/img/documents/t-acaps_ebola_impact-health-service-utilisation-sierra-leone_25-march-2015.pdf
- WHO. (2015). Sierra Leone: WHO statistical profile, Retrieved from: http://www.who.int/gho/countries/sle.pdf?ua=1