Portal de Periódicos da CAPES

West African countries focus on post-Ebola recovery plans

2016; Elsevier BV; Volume: 388; Issue: 10059 Linguagem: Inglês

10.1016/s0140-6736(16)32219-x

1474-547X

Andrew Green,

Global Public Health Policies and Epidemiology

Guinea, Sierra Leone, and Liberia have mapped out strategies for the recovery of their respective health systems and other sectors after the Ebola outbreak of 2013–16. Andrew Green reports. It has been more than 6 months since the last diagnosis of Ebola virus disease (EVD) in Guinea, Sierra Leone, or Liberia. The three west African countries suffered nearly all of the more than 28 600 diagnosed cases and 11 300 deaths during the outbreak that began in December, 2013, in a Guinean village. Although the outbreak has ended, the scale of the epidemic collapsed these countries' health systems, while unleashing new medical crises. The capacity to treat even basic illnesses is now limited, while health needs of EVD survivors stretch the services that do remain. With EVD having killed health workers at a disproportionate rate, the years-long efforts to rebuild the health systems are only just beginning. Officials in all three settings acknowledge that the task ahead is immense. “For a long while, especially where the outbreak was going on, we were left to just count the loss—the economic, human resource, numbers of deaths”, said J Soka Moses, a Liberian physician who worked in the public system throughout the crisis. However, with the outbreak over, he said, there is also an opportunity. “What it did for us, it was able to highlight the gaps.” Now, with the support of an international community awakened to the global security threat posed by disease outbreaks, there is the chance to begin filling those gaps. The three governments have seized on the opportunity. Each has introduced strategic plans calling for not just health system fixes, but improvements to all of the conditions that facilitated Ebola's explosion. There is also outside support, including the US National Institutes of Health's (NIH) recently announced plan to strengthen viral research in the region. “It was a global wake-up call about how we need to make sure all of our health systems and health protection services are robust enough to deal with Ebola, Zika, or whatever other outbreak we don't know is coming”, said Joanna Nurse, the head of health at the Commonwealth Secretariat, which is helping to redesign Sierra Leone's health system. On June 9, Liberia was the last of the three countries to be declared free of Ebola virus. By then, the health systems were already grappling with how to care for the survivors of EVD. WHO puts the number at more than 10 000 people, but Moses said any estimates are probably low. In Liberia, “during the worst days of the outbreak, there was no proper documentation”, he said. This lack of data makes it difficult for the countries to apportion funding or design interventions for the survivors. Meanwhile, health officials are still trying to document all of the after effects. WHO has registered complaints that include musculoskeletal pain, especially in joints; eye problems—including sensitivity to light and blurry vision; tinnitus and hearing loss; and neurological problems that range from headaches to tremors. However, patients are being referred to a health system that still has little capacity to help them. This situation is both a bid to reduce stigma by not segregating survivors, but also the result of a shortage of specialised services. The absence of such services has created additional problems for survivors, said Audrey Crawford, the country director in Liberia for the non-profit Danish Refugee Council. “They think no one knows how to treat them”, said Crawford, whose organisation focuses on building community resilience. “They're not getting the health care, because no one knows how to do it. I think that leads to more isolation, to feeling alone.” This isolation, combined with the gaps in registers of survivors, also poses serious risks to the countries' efforts to prevent a recurrence of Ebola virus. Even after blood tests register negative for EVD, the virus can lurk in reservoirs that are isolated from the immune system, including the testes. That allows for the sexual transmission of the disease, in some cases more than 20 months after a negative blood test, according to Moses. Still, there are signals the situation is improving. The emergency medical organisation Médecins Sans Frontières (MSF)—one of the first groups to alert the world to the severity of the outbreak—is operating dedicated survivors' clinics in all three countries. The group announced in October that it felt comfortable ending its medical and mental health care for survivors by the end of the year, and transitioning any remaining patients over to local health teams or other organisations. However, that does not mean the situation has returned to normal, cautioned Mit Philips, an MSF health policy adviser. There are still mental health and stigma needs to address and “the countries also need catch-up plans for services that lapsed during the epidemic, such as treatment for HIV and tuberculosis, as well as preventative services, for which coverage remains low”. Alongside the survivors, one of Ebola's other legacies is that it may have left the three countries more prone to future outbreaks. Jonathan Suk, a researcher and public health practitioner with the European Centre for Disease Control and Prevention, investigated a measles outbreak in Lola, a prefecture near Guinea's southern border with Liberia. Regular measles vaccination was interrupted when Ebola reached the area and a follow-up campaign scheduled for the second half of 2014 was also cancelled. That created the conditions for an outbreak. The country's Direction Préfectorale de la Santé reported 702 measles cases in Lola between the beginning of January and the end of June, 2015, but no deaths. There are still places throughout the region where routine vaccinations have not restarted and an ongoing shortage of health staff is making it difficult to resurrect, not just immunisation efforts, but all pre-Ebola services. “The major challenge is the inadequate human resource”, said Brima Kargbo, Sierra Leone's chief medical officer. A WHO analysis from mid-2015 found health workers were 21 to 32 times more likely to be infected than the general population during the outbreak, resulting in substantially higher death tolls. Even before the epidemic, Sierra Leone had only 3·4 skilled providers for every 10 000 people (the recommended level is 25 to 10 000). Then Ebola swept through, killing more than 220 health workers—including 11 specialised physicians—by January, 2015, according to the country's Ebola recovery strategy. The situation was similar in Liberia and Guinea. WHO recorded 157 health worker deaths in Liberia between January, 2014, and March, 2015, and 109 deaths in the same period in Guinea. The shortage of trained doctors and nurses does not necessarily mean the country will not be able to recover, at least on the immunisation front, Suk said. “It is probably the case that nationally coordinated public health initiatives, such as vaccination catch-up campaigns, can be re-established fairly quickly in most parts of Guinea, since these do not rely too heavily on regional capacities”, he said. Any health gains will depend on several other factors, however, including rebuilding community trust in a system that was unable to identify and then stem Ebola and improving the quality of local health-care services. Other concerns linger, as well, including the threat of food insecurity in some areas of the three countries. The outbreak interrupted planting and harvesting seasons and forced countries to close borders, disrupting key trading routes. Thomas ten Boer, the Liberian country director for the private German aid organisation Welthungerhilfe, was working in southeastern Liberia when the Ebola virus struck. He said people there “could not sell their vegetables or their cassava or their rice. They were eating it themselves.” And they are now in the dangerous position of not having anything to plant or to trade. The international community is continuing to monitor and provide emergency support, aware of the potential strain any rise in food insecurity could put on the already overstretched health system. Each of the three countries has mapped out post-Ebola strategies for recovering not just their health system, but also other sectors that contributed to the rapid spread of the disease and prevented its quick containment. They will be aided by the recently announced NIH grants, initially totalling US$200 000. The funding will allow four US institutions to partner with academic centres in Liberia and Sierra Leone to improve research on emerging viral diseases, but also to evaluate vaccines and develop new tests and treatments. These are planning grants, ahead of longer-term funding to develop more robust programmes, which should dovetail with the strategies the countries have individually developed. In Guinea, the government has put together a $2 billion post-Ebola recovery plan, with 63% of the funding slated for health, nutrition, and hygiene. Already one of the poorest countries in the world before the epidemic, the government has also allocated money to improving education and child services and to jump-starting the socioeconomic recovery. The plan underscores that poverty and illiteracy contributed to the disease's spread. Guinea sees the post-Ebola period as an opportunity for “strengthening the country's economic, social, and institutional resilience”. In neighbouring Sierra Leone, where the government had already prioritised achieving universal health coverage, the Commonwealth is helping them to take advantage of the window offered by the post-Ebola planning period to reach it. Nurse said they have positioned an adviser within the ministry of health, to assist with drafting policies aimed at coordinating government and donor activity, strengthening the systems for addressing communicable diseases and emergency responses, and smoothing synchronisation with international systems. “Through the recovery plan and work with donors, we want to ensure they're able to come through this with a better health system than they went into it”, she said. In Liberia, the government is focusing on three “big ticket” priorities: an improved health workforce, better infrastructure, and strengthened surveillance and response. These are also part of a broader package of socioeconomic interventions. The health portion, alone, comes with an estimated cost of $489 million through the next fiscal year. In the rush to implement these plans, though, Sjoerd Postma—the chief of party in Liberia for Management Sciences for Health (MSH) and a health systems strengthening expert—urged the governments and donors to consider how the outbreak was able to devastate the existing systems so quickly. “It's for me really astounding that before Ebola, in the last 10 years, about $0·5 billion was invested in the health sector [in Liberia]. You would think you would have a robust health system, but as soon as Ebola hit, everything crumbled down.” He pointed to problems the government had hiring and retaining health workers, but also to the infrastructural issues, including poor roads, that made it difficult to deliver medicines or to roll out public awareness campaigns. For the health system to hold during another crisis, he said, it is critical the governments to follow through on the pledged improvements to these issues. Lisa Denney, a researcher with the UK's Overseas Development Institute, who has spent substantial time in Sierra Leone, said the outbreak also exposed how poorly integrated other health-care options—including customary authorities and traditional healers—were into the national system. That began to change in the first year of the EVD response in Sierra Leone, she said, as officials began to recognise their importance as a conduit to communities. “It's a precedent that could be built on”, she said. “If you isolate these sorts of actors, it's just not helpful.” This increased community involvement is a key component of phase 3 of the WHO's Ebola response, which aims to keep the disease at bay. On the opposite end of the spectrum, there is also an awareness of the need for stronger links to regional and global clinical and surveillance systems—both to provide support to poorer countries, like Guinea, Sierra Leone, and Liberia, but also to keep pace with a disease's spread. Though the Ebola outbreak was centred in west Africa, cases reached North America and Europe. The World Bank recently approved $110 million in International Development Association financing to help build a disease surveillance system in west Africa. Beginning in Sierra Leone, Guinea, and Senegal, the plan is to extend the Regional Disease Surveillance Systems Enhancement Program across all 15 countries that make up the Economic Community of West African States. Experts said this range of proposals—from the local to the global—is indicative of how much work needs to be done to prevent future health crises in west Africa. “It's a myriad of problems that continue to exist”, MSH's Postma said. “There's not a short solution in sight. It's 10, 20, 30 years before the system is up and running again.” Except the countries may not have that long. As the end of the outbreak started to come into sight last year, UN Secretary-General Ban Ki-moon held an International Ebola Recovery Conference, which raised $3·4 billion to put toward the recovery plans in the three countries. That brought the global total to $5·2 billion.