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How post-Ebola health system support needs to change

Written by Lisa Denney

​The International Development Committee released its report last month on the response to the Ebola crisis in West Africa. The report recognises the UK’s significant assistance prior to and following the Ebola outbreak in Sierra Leone and sets out lessons to inform future health support and emergency response.

Critically, the IDC report highlights two messages that came out strongly in the Secure Livelihood Research Consortium’s research on capacity support to the health sector in Sierra Leone (this research is cited here and here).

First, the role of communities and their leaders in emergency response should be acknowledged and engaged from the outset. And second, the UK should continue to invest in health systems strengthening as the first line of defence in any health emergency.

Community leaders are vital to success – even after the Ebola crisis

The slow response of the international community to the Ebola outbreak overlooked the critical role of community leaders. While some international media depicted customary beliefs, for instance surrounding traditional healers, as backward, this failed to appreciate how they are a rational response to a state that does not function in the interests of citizens.

If your experience of the health system is one in which you arrive at a clinic only to be treated badly by staff, charged informal fees for services meant to be free, and find no medicines available due to drug stockouts, then it is not surprising that you don’t trust this system in a crisis.

The Ebola response taught us the value of customary practices and leaders within communities. Once community leaders enforced by-laws and promoted supporting messages, Ebola contact tracing became easier and adherence to restrictions to stem its spread increased.

Employing these pathways of communication could also be used to address other challenges confronting communities. For instance, Sierra Leone experienced an upsurge in teenage pregnancy during Ebola – it is estimated that over 14,000 girls got pregnant. This was partly the result of girls being out of school for ten months and thus both more available to engage in sex, and vulnerable to rape and transactional sex.

If the problem of teenage pregnancy is to be addressed, it will require the collaboration not only of government and civil society, but also of community leaders, to ensure that girls are kept safe, family planning is available (and not feared), pregnant teenagers are not stigmatised and more opportunities for girls are provided. The IDC findings on the importance of community leaders are thus as important for addressing post-Ebola challenges as they were for ending Ebola.

Building a functioning health system takes more than new clinics and staff training

The second message in the IDC Report – that the UK should continue to invest in health systems strengthening as the first line of defence in responding to health emergencies – is welcome.

Beyond the lessons for the humanitarian community, there are also lessons for the development community about wider health sector support. Currently there is much talk of ‘building back better’, but there is a danger that the phrase becomes meaningless rhetoric.

For example, the new Ebola death in Sierra Leone in mid-January was not diagnosed when the victim presented at a clinic. The healthcare worker who took her blood did not wear appropriate protective equipment that became mandatory during Ebola. This was despite substantial support and training during the outbreak. And while temperature checks along highways and at building entrances are still common, my temperature readings ranged from 31-47 degrees: none prompted any reaction from those taking the readings.

These are examples of ‘form over function’ that characterises so much capacity building – whereby the trappings of healthcare are put in place but don’t actually function to deliver better health. Clinics are built, staff trained, temperatures checked – but these don’t add up to a functional health system. What part of this is ‘building back better’?

We need to learn the lessons not just of the crisis, but of what came before it. Tellingly, when asked about the history of health assistance a health advisor in an intergovernmental organisation launched into an explanation of how things had evolved from six months ago. The influx of international staff new to Sierra Leone aren’t always aware of the history, which is crucial to ensuring post-Ebola support lives up to its ‘building back better’ rhetoric (ideas for how to do this are set out here).

Of course, it’s early days since the Ebola epidemic was declared over and rebuilding a health system is a very long-term endeavour. But if we are to take seriously the IDC’s recommendations, then we need to interrogate our ways of working, learn lessons from past assistance, and trial new approaches to address shortcomings. Otherwise, we fall at the first hurdle.