House of Commons - Recovery and Development in Sierra Leone and Liberia

Recovery and Development in Sierra Leone and Liberia - International Development Committee Contents

5 Health

DFID's programme

66. DFID is investing £75 million up to March 2018 in health in Sierra Leone. This money will be used to strengthen Sierra Leone's health system through:

· human resources as there is a lack of key health professionals;

· drug procurement and management;

· essential laboratory services, and

· the generation of regular and reliable data.

DFID will also continue its support in providing direct services:

· for improved reproductive, maternal and newborn health, and

· to achieve universal coverage of bednets in households through the mass distribution campaign as malaria remains the lead cause of adult and child deaths.[96]

In Liberia DFID has also until recently focused on health. In this chapter we draw attention to a few key elements of DFID's work on health. Our report on Health System Strengthening takes a broader look at DFID's work on health and draws on our visit to West Africa.[97]

Free Health Care

67. Sierra Leone's maternal mortality rate is one of the highest globally at 1,100 deaths per 100,000 live births[98] and one in five children die before their fifth birthday (see Table 3). In an attempt to improve health outcomes the Government of Sierra Leone with support from DFID launched in 2010 A Free Health Care Initiative for pregnant and nursing women and children under five years. DFID said that in the first year of operation this resulted in the tripling of the numbers of children receiving consultations and the number of women delivering in a health facility although it acknowledged that the numbers had fallen back slightly. DFID said it was now working with the Ministry of Health & Sanitation to institutionalise the Free Health Care initiative.

68. In Liberia the National Health Policy, launched in 2007, introduced a package of health services available to all citizens free at the point of use. It was aimed at tackling communicable diseases as well as maternal and child health. DFID has contributed £20 million since 2008 to support the implementation of Liberia's Health Sector Strategy of which £12 million was committed to the Health Sector Pool Fund for 2010-13 to support the delivery of health services. Save the Children said that the Liberian Minister of Health had acknowledged that DFID's support had been integral to the success of the free healthcare initiative.[99]

69. Save the Children believed that the free health care initiatives in both countries had made significant improvements to health outcomes. It reported that the preliminary results from the 2013 Demographic Health Survey in Liberia suggested that real progress was being made and that Liberia might achieve the Millennium Development Goal 4 target of reducing child mortality by two-thirds by 2015.[100] It also noted that the preliminary results from the 2013 Demographic Health Survey in Sierra Leone had revealed a recent dramatic decline in child and newborn mortality.[101]

70. However, Save the Children is concerned about the future of free healthcare in both countries particularly, Liberia where DFID's support ended in March 2014. The Liberian Ministry of Health and Social Welfare is now proposing the reintroduction of user fees. One of the main reasons cited is a lack of predictable and long-term donor support.[102] We questioned the Minister on this who told us:

103

However, since the Ebola outbreak, funds have been given to health in Liberia to try to deal with the epidemic as we discuss later on in this chapter.

71. While there have been significant improvements over the last 12 years, the health indicators in Sierra Leone remain at emergency levels and it is still one of the most dangerous places to be born or to give birth.[104] Options, a Consultancy used by DFID to manage health programmes, informed us:

105

72. One of the key problems in Sierra Leone and Liberia is the lack of health care workers - the latest (2008) figures show just 57 doctors and 978 nurses and midwives in Liberia. Taking account relative populations, the UK has 200 times more doctors and 30 times more nurses and midwives. Sierra Leone had just 136 doctors and 1,017 nurses in 2010.[106] We were told on our visit that doctors were being trained both in Sierra Leone and in Ghana to a West Africa standard with the help from the Kings Partnership.[107] The Government was actively promoting work in the sector and promising senior management roles to attract more people in. In addition job adverts were being sent to the diaspora especially health workers in the UK and USA to attract health personnel back to Sierra Leone and Liberia. The UK Nursery and Midwifery Council have 103 nurses and midwives on its register that were trained in Sierra Leone. Equivalent to 10% of Sierra Leone's stock of domestic nurses are therefore working in the UK health system.Table 5 UK Nursery and Midwifery Council data on Sierra Leone and Liberian health personnel working in the UK

Liberia Sierra Leone

31/03/2013 3 105

Registered Midwife 1

Registered Nurse - Adult 3 103

Registered Nurse - Children 1

31/03/2014 3 104

Registered Midwife 1

Registered Nurse - Adult 3 102

Registered Nurse - Children 1

Source: Committee Correspondence with Nursery and Midwife Council

DFID's Health Adviser in Sierra Leone has excellent contacts with UK institutions and has worked to facilitate contacts between the UK and Sierra Leone, but she is moving to another post. We are alarmed that such a high percentage of nurses and midwives from Sierra Leone are working in the UK. In its response to us the Government should reassure us it is no longer recruiting clinical staff from Sierra Leone. We recommend that DFID facilitate relations between UK healthcare institutions and professionals and those in Sierra Leone and Liberia. This should be a part of the senior health adviser's job description and not simply left to that adviser's initiative. We also recommend that the UK Government facilitate contacts between the Sierra Leonean and Liberian diaspora health professionals in the UK.

EU health sector funding in Liberia

73. On our visit we examined what other donors were doing in the health sector; and, in particular, which donors would take over DFID's role in the health sector in Liberia. We were shocked to hear at our meeting with the Liberian Deputy Minister of Health and her team that the EU's $30 million sector support to the Health Ministry had last year only partially been passed through ($3.9 million) from the Liberian Ministry of Finance and none of this year's $30 million funding had been passed on at all. As a result of this, the Deputy Health Minister told us that services were beginning to slide backwards and they were losing the gains that had been made on the country's health outcomes.

74. From questioning both DFID and EU officials in country it seemed very little was being done in response to the Ministry of Finance's decision. We found it hard to understand why the EU had continued to channel funding for health through the Ministry of Finance knowing it was not being passed on for its intended purpose. We questioned EU officials in Monrovia but were not given any satisfactory answers.

75. We followed the matter up with the Minister on our return and we are deeply concerned that she had not even been briefed on the matter saying "It is not something I am particularly aware of".[108] DFID Sierra Leone and Liberia's Acting Head of Office told us it was:

109

Surprisingly, the European Commission in its submission, although mentioning that the health sector budget support had been the subject of 'some debate' in Liberia, did not mention the failure of the funding to be passed on only saying:

110

Considering that DFID contributes considerable funds to the EU (approximately £1.23 billion each year approximately 16% of the UK's total aid budget)[111] and that DFID has played a significant role in improving health services and outcomes in Liberia, we would have thought that this should be a matter of serious concern to DFID Ministers. If this money does not reach the Ministry of Health, DFID's investments in the Liberian health system to date are put at risk. The dangerous result of recipient governments not prioritising health system spending is evident from the spread of Ebola currently in Liberia which is widely being blamed by international commentators on the country's weak health system.

76. We recommend that, as a matter of urgency, working with EU officials, DFID actively pursue what has happened to the EU sector support to health which has not been passed on by Liberia's Ministry of Finance and has resulted in the weakening of an already strained health system.

Comparison of outcomes in Liberia and Sierra Leone

77. It is striking that Liberia has made considerably better improvements to its health outcomes than Sierra Leone. In 1990 both countries had similar levels of newborn and child mortality and yet since its Civil War Liberia has demonstrated one of the largest reductions (57%) in child deaths.Table 6

Under 5 mortality rate
(deaths per 1,000 live births)
Newborn mortality rate
(deaths per 1,000 live births)
Maternal Mortality (death per 100,000 live births)

1990 2000 2012 1990 2000 2012 1990 2000 2012

Liberia 248 176 75 51 N/A 27 1,200 1,100 640

Sierra Leone 257 234 182 59 N/A 50 2,300 2,200 1,100

Note: For newborn mortality, there are no figures for 2000.

Source WHO Health Statistics 2014

78. In response to questions about Liberia's better progress the Minister informed us:

· Regarding maternal mortality, Sierra Leone started from a significantly lower base following the war compared to Liberia for example in 2000, the maternal mortality rate in Sierra Leone was almost double that of Liberia, at 2,200 per 100,000 live births compared to 1,100;[112]

· immediately post-war there was a large, sustained injection of funding for the health sector in Liberia;

· the leadership of the sector had been consistently much stronger in Liberia than it had been in Sierra Leone for example there has been one health minister since 2008 in Liberia and four different health ministers in Sierra Leone;

· the strategic approach had been very different in both countries. In Liberia, there had been a parallel NGO-led health service delivery model as opposed to delivering service through a decentralised public health system in Sierra Leone;

· free healthcare services had been introduced earlier in Liberia in 2008 than in Sierra Leone in 2010 and in Sierra Leone, only 30% of the population was eligible for free healthcare;

· the status of women which was a key indicator for improved family health was higher in Liberia, with 67% of females with some schooling compared with 57% in Sierra Leone, and

· access to improved drinking water was higher in Liberia at 75% than in Sierra Leone, at 57%.[113]

79. The Acting Head of DFID Sierra Leone and Liberia thought that while health outcomes had been better in in Liberia, the system established might not be sustainable

114

The Minister expected that when the current statistics on health in Sierra Leone were published they would demonstrate substantial improvement of outcomes as a result of the free healthcare initiative.[115]

80. We recommend that DFID assess why Liberia has made much faster progress in reducing child mortality than its neighbour Sierra Leone. DFID should also facilitate greater collaboration between the two countries and the sharing of best practices.

81. The impression we gained on our visit was that there was a much stronger and committed leadership in health in the Liberian health ministry than in the Sierra Leonean. We are concerned that this reflected national priorities The horrors of the Ebola outbreak show the importance of a well-functioning health system. We trust that the Government of Sierra Leone will now give a higher priority to health.

Ebola outbreak

82. Ebola emerged in Guinea earlier this year and has since spread across the border into Sierra Leone and Liberia where it is having devastating consequences and the death toll is still rising. President Obama told a summit of African leaders in July that the blame for the spread of Ebola lay on the weak health systems of West Africa.[116] Peter Piot, the Belgian scientist who co-discovered the virus in 1976, described the current outbreak as a "perfect storm". He said it was "exploding in countries where health services are not functioning, ravaged by decades of civil war," and "in addition, the public is deeply suspicious of the authorities. Trust must be restored. Nothing can be done in an epidemic like Ebola if there is no trust."[117] The outbreak has demonstrated how critical DFID and other donors' support for strengthening and supporting health systems in Sierra Leone and Liberia is.

83. DFID has announced that the UK would provide £5 million to strengthen health systems in Sierra Leone and Liberia to help contain the spread of Ebola.[118] The funding will include:

· £1.25 million to help the governments of Sierra Leone and Liberia strengthen their national health systems. This will focus on improving their capacity to deliver health care and better coordinate activities;

· £1 million to a consortium of NGOs, including the International Rescue Committee and Save the Children, allowing them to expand the investigation, monitoring and tracing of new Ebola cases in Sierra Leone;

· £500,000 to provide support to families and communities affected by Ebola, including counselling for up to 150 children and help for those who have been orphaned. This funding will also increase and improve radio messaging on the outbreak in eight local languages so communities better understand the disease and can take steps to prevent its spread, and

· £250,000 to help Médecins Sans Frontières scale up specialist clinical care to Ebola patients.

In addition DFID says that it is filling critical gaps in the front-line response by providing technical staff including epidemiologists, clinicians, information managers and logistics managers for six months. It is also improving public understanding of the disease through direct engagement with communities, including women's groups. In Liberia the UK has provided chlorine and other materials for hygiene and sanitising. DFID has also launched a £6.5 million research initiative co-funded by the Wellcome Trust to look into the spread of Ebola.[119]

84. The World Health Organisation (WHO) has been seriously criticised for its lack of response to the developing epidemic. David Heymann of the London School of Hygiene and Tropical Medicine who was on the team which first recorded the virus close to the River Ebola in Democratic Republic of Congo, then Zaire, said he was disappointed with the WHO response to the Ebola outbreak.[120] Brice de la Vigne, Head of Operations for medical charity Medecins sans Frontieres (MSF), said in a news interview that the slow pace at which the WHO reacted to the rapidly-escalating Ebola epidemic in West Africa was like boiling a frog:

121

In April, MSF said the current outbreak needed urgent international action but WHO accused the medical charity of causing panic. It was not until August that WHO declared Ebola a public health emergency of international concern and people were sent to help with contact tracing, disease surveillance, laboratory work, logistics, information-sharing and social mobilisation—but no doctors, nurses or equipment.[122] We have heard accounts from Sierra Leone that there are not even enough rubber gloves to help protect health workers from the virus. Nurses in both Liberia and Sierra Leone have been striking, demanding better equipment to protect them.[123] WHO has now pulled out its team from the eastern Sierra Leonean city of Kailahun. WHO's representative was reported as saying that the team was exhausted and the added stress caused by one of their colleagues contracting Ebola risked increasing the chances of mistakes being made. Canada also announced it was evacuating a laboratory team.[124] Ebola threatens the ability to move in specialist staff from the international community and the diaspora to work in Sierra Leone and Liberia.

85. The problem Sierra Leone and Liberia is now facing is the collapse of their ability to treat people with non-Ebola-related diseases such as malaria and typhoid as well as complications from child birth as hospitals and clinics are forced to close. Immunisation programmes have also come to a halt. People are not going to the hospitals or clinics because they are frightened of catching Ebola; some hospitals have been totally taken over by Ebola patients;[125] Other centres are without any staff due to their fear of turning up to work where protective clothing is in short supply. Health workers have been hardest hit by the disease as they are at increased risk of contracting the disease due to their proximity to patients. To date, the WHO has reported more than 240 of them developing Ebola in Guinea, Liberia, Sierra Leone and Nigeria. More than half of that number have died. In addition three leading Ebola doctors have been killed by the disease.[126]Box 6: WHO and reasons for spread of Ebola

The World Health Organisation has cited a number of reasons for the deadly toll of this outbreak of the Ebola virus on medical staff:
- In many cases, medical staff are at risk because no protective equipment is available - even in dedicated Ebola wards, the correct equipment is often scarce. The affected countries, especially Sierra Leone, Liberia and Democratic Republic of Congo, are among Africa's poorest.
- Even where the correct equipment is available, it can have a negative impact on staff's work. The equipment is hot to work in and some members of staff attempt to work beyond their physical limits, meaning they are more likely to make mistakes and further increase their own risk of infection.
- The Ebola virus's long incubation period (2 to 21 days) means that risk of infection is increased because the host has more time to inadvertently infect others.
- Several infectious diseases endemic in the affected part of West Africa, such as Malaria and typhoid fever, mimic the initial symptoms of Ebola. The medical staff who treat patients displaying these symptoms may not suspect Ebola and may fail to take the correct protective measures.
- Past outbreaks have been mostly limited to remote rural areas, but this latest outbreak has affected capital cities too. These densely populated areas allow the disease to quickly spread as busy areas allow closer contact between hosts of the disease and lead to higher infection rates.
- The loss of so many doctors and nurses has made it difficult for WHO to secure support from sufficient numbers of foreign medical staff, leading the African Union to launch an urgent initiative to recruit more health care workers from among its members.

Source "Why is this the worst ever outbreak of Ebola?" Telegraph 26 August

86. The Ebola epidemic is also beginning to have serious consequences for the countries' economies with internal travel restricted, borders sealed, the closure of businesses and markets. Farmers are unable to trade and fears are rising about food shortages. The Minister of Finance in Liberia has already reported a 2% fall in revenue and that projected GDP for 2014 would need to be revised down from the current forecast.[127] Moody's investor services has warned that Ebola could lead to "significant" economic and fiscal damage to the economies of Sierra Leone and Liberia.[128] Sierra Leone's economy is already reported to have deflated by 30%.[129]

87. It has been suggested that the secret societies (see Box 4), superstition and traditional medicine have made the epidemic far worse-one traditional healer has been blamed for 365 deaths from Ebola[130] in the far east of Sierra Leone on the border with Guinea; she had claimed to have powers to cure Ebola but instead spread the disease and it passed to many more women at her funeral attributed in part to the custom of touching the corpse during traditional funeral rites. This outbreak has demonstrated how between them these factors threaten the entire development potential of the area.

88. As the Financial Times has reported:

131

89. The horrific Ebola outbreak has spread for many reasons, but the weakness of health systems has played a part. The outbreak indicates the continuing need for the governments of Sierra Leone and Liberia and for donors to give a high priority to health. Both countries are also going to need support from the international community on the long-term effects of the crisis in rebuilding the health systems and economies. We question whether the World Health Organisation is really on top of the epidemic and whether the international community are providing enough funds to manage the spread of the disease.

96 DFID (SLL05)para 44 Back

97 International Development Committee, Fifth Report of Session 2014-15, Strengthening Health Systems in Developing Countries, HC 246 Back

98 WHO et al 2014 Back

99 Save the Children (SLL07) Back

100 Save the Children (SLL07), p 2 Back

101 Save the Children (SLL07), p 2 Back

102 Save the Children (SLL07) Back

103 Q103 Back

104 International Rescue Committee (SLL12), para 17 Back

105 Options (SLL15), para 28 Back

106 WHO Global Health Observatory Data Repository Back

107 The King's Sierra Leone Partnership was established in 2011 by the King's Centre for Global Health, King's College London, the lead for King's Health Partners, an Academic Health Science Centre,that includes three NHS Foundation Trusts (Guy's and St Thomas', King's College Hospital and South London and Maudsley). The vision of King's Health Partners is to 'create a centre where world-class research, education and clinical practice are brought together for the benefit of patients' with physical and mental health care problems, internationally and locally. Back