Paul Pronyk | October 2015
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Presentation at the Global Maternal Newborn Health Conference, October 19, 2015

Sierra Leone was the worst affected country in West Africa’s recent Ebola epidemic. Prior to the epidemic, the status of the health system was poor. The most recent public expenditure on health was just $15 per person, with an additional $12 per person from external partners. The ratio of skilled health provider was 2/10,000 people – just 10% of WHO minimum acceptable thresholds. Not a single facility in the country was Basic Emergency Obstetric Care compliant, and levels of maternal and under 5 mortality are among the highest in the world (1,165/100,000 and 156/1000 respectively).

The conditions of the health sector served to accelerate Ebola transmission. Poor infection prevention and control (IPC) procedures resulted in 300 Ebola Cases among health workers, with 220 deaths. Ebola ‘holding centres’ were established due to insufficient isolation facilities.

Alongside this, the indirect effects of the epidemic were substantial. Quarantine reduced in food production and transport, potentially increasing levels of maternal and child undernutrition. An established community health worker program was suspended due to concerns regarding infection risk. Finally, widespread mistrust in the health system by local communities threatened the delivery of maternal child health services. A recent survey of primary health facilities conducted at during October 2014 and April 2015* demonstrated reductions in utilization of maternal-newborn services including immunization, antenatal care and skilled deliveries – leading to a substantial additional non-Ebola related burden of under 5 deaths

In response to these challenges, a number of strategies were employed. IPC training was conducted in all primary health facilities, including the provision of personal protective equipment for health providers. Prevention campaigns were implemented for malaria including mass-drug administration and bed-net distribution. ‘No-touch’ guidelines were developed and implemented to restore the community health worker program. A network of 46 Ebola Community Care Centres were deployed across 5 provinces to ‘decentralize’ the Ebola response and re-establish primary health care units as safe spaces for the delivery of maternal-child health services. While these may mitigate the short-term consequences of the epidemic, longer-term efforts to improve the resilience of the health system are essential.

*Sierra Leone Health Facility Assessment. UNICEF, Ministry of Health and Sanitation. June 2015.