Authors: Alex van Duinen MD, PhD Candidate, Nadia Cobb PA-C, PhD Candidate, Alieu Faylulu F Mansaray SACHO, Amadu Jawara SACHO, Seibatu Sia Kemoh SACHO in training
The Social Determinants of Health impact 80% of a patient’s health status, with medicine effecting the other 20%.1,2,3 Inequities in health stem largely from where patients are born, live, their ability to access education, their poverty level, where they work, as well as access to resources. Sir Michael Marmot’s startling comparisons of a girl born in Sierra Leone being halfway through her predicted life at the age of 17 years, if she has survived to the age of 5 years, as opposed to the Japanese girl who can readily expect to live to 80 years exemplify to stark disparities based on the social determinants of health (SDOH)4.
Photo credit; Maria Milland
Sierra Leone is a country in West Africa and is bordered by Guinea, Liberia and the Atlantic Ocean. Between 1808 and 1961 Sierra Leone was a colony under Great Britain. Civil war (1991-2002) took a heavy toll with ten of thousand killed and over 2 million people displaced.5 The country is rich in natural resources like diamonds, iron ore and gold, although it has not been able to utilize this potential resources and remains one of poorest countries of the world. Approximately 60% of the population work in agriculture, and 70% of the population are below the poverty line.5 The literacy rate in 2015 was estimated at 58.7% for males and 37.7% for females.5 The World Health Organization ranked Sierra Leone last of 191 nations in terms of their health system performance,6 with 1 of every 6 children dying before the age of 5 years, and a 1 in 21 chance of dying from childbirth in the life of women.7 (as compared to 1 in 4,900 in developed countries8) From a demographic survey it was reported that 1 in every 5 households has no sanitation facility; while 10% of households have an ‘improved, not shared sanitation facility’.9 It is estimated that >40% of infant deaths are secondary to sanitation and water borne diseases.
In 2014 the population of Sierra Leone was 5.9 million with fewer than 150 physicians and 1,100 nurses and midwives to care for the population.10 The first medical school was opened in 1988 (College of Medicine and Allied Health Sciences), but during the civil war was graduating approximately 5 physicians per year. Now approximately 30-40 graduate per year, however few go to the rural areas, and many migrate abroad.7 Narrow distribution (mainly urban) and specialization only add to the access issues for the majority of the country.
Wurie, et al (2016) explored the challenges of retention of health workers in rural and urban areas, citing unacceptable working conditions in the rural areas with no/limited electricity, clean water, supplies, medical resources; long hours, emotional and financial hardship as well as a health system not prepared to meet the needs of transportation/distances, clear referral lines, as well as poverty and communities with no/limited health literacy.
The Lancet Commissioners, 2010 explored health professional education as a way to start to shift the disparities. Their recommendations included aligning education and health systems, creating strong supportive networks, shifting to a more broad approach that included community and global input that were collaborative. The outcome of this transformative education being the production of ‘enlightened change agents’.11 The World Health Organization’s Human Resources for Health Strategy: Workforce 203012, as well as the United Nations High Level Commission on Health Employment and Economic Growth13 reinforce the vital necessity of an strong community-based health workforce that can include the external aspects (SDOH) in the care of the patient. Campbell, et al (2015) state “Maximizing the impact of community-based practitioners in the quest for universal health coverage”14 and call for a more clear understanding of the ‘front-line’ and community based health workforce, so as to integrate them fully into health systems, demonstrate the value of investment in them.14
The challenge in many countries, including Sierra Leone, has been political turbulence, violence, and a struggling health system on top of a weak/fragile infrastructure.
Community Health Officers
Taking the lead from other sub-Saharan countries that had developed an accelerated medically trained clinician health15 workforce to increase access to care where there were shortages of physicians, the Ministry of Health & Sanitation established the Medical Assistant (now Community Health Officer) in 1980.10 The Community Health Officer (CHO) training consists of 3 years condensed medical education. They work in the rural areas in Sierra Leone, serving as the front line primary care. They are in all 149 chiefdoms in Sierra Leone. Most of the CHOs are born and raised in the districts. This gives them an unplanned ability to fully ‘understand’ the SDH the communities struggle with, and consider them when providing care for the patients. Although after enrolment with the government, CHOs can be placed anywhere in the country, many will serve in the area where they come from originally or communities that are similar.
Photo credit; Maria Milland
For many from the districts, the medical school in Freetown is not accessible in terms of financial capacity and entry requirements and the CHO training is seen as the best alternative.
During the civil war the training was suspended. In late 2016 over 1,000 CHOs have been trained. Most are in charge of the Community Health Centers (CHC), providing primary care and treatment of common diseases within the community like: HIV, TB and Malaria. CHCs have a catchment population of 10,000 to 30,000 and usually located in a chiefdom headquarter. All CHCs should be able to provide full basic emergency obstetric and neonatal care, per their training. The CHO is the in-charge in the facility supported by nurses, midwifes and maternal and child health aides. The CHC receives referrals from community and maternal and child health posts and can refer cases to the district hospitals.
Based upon a nation-wide survey from all health facilities providing surgery in 2012, it was concluded that in total about 24,000 surgical procedures were performed in the governmental and private sector combined. This is estimated to be only 8% of the total need for surgery in the country.9 There was a 30-fold difference between access to surgeries in the least served district and the capital Freetown. This is in the same proportions as the access to surgery between the poorest and the richest parts of the world.10
As a result of the lack of medical doctors, and needed skills mix, some of the CHOs are employed to work in the outpatient department and wards in district and regional hospitals. Literature has shown task –sharing/skills-mix-expansion to increase quality access to care in a cost effective manner.11
In 2011 a program was started to train CHOs in basic lifesaving surgery and obstetrics. For enrolment in the surgical training program completion of the CHO training and 3 years of working experience is required. The program takes 3 years. In the beginning of the training the focus is on basic surgical skills follow by more on the job training after completions of 2-3 internships in NGO and governmental hospitals the students are examined by the obstetric and surgical specialist in the capital. The last year of the training are the housemanship in the referral centers in Freetown where they are assessed by the specialist before postings in the districts.12
Currently 12 students have graduated in the program and 30 are in training. The graduates of the program are called surgical assistant CHOs (SACHOs). Although the acceptation from both the doctors and the patients has grown based upon the positive experience, there are unfortunately still struggles with remuneration, regulation and supervision. Although there is progress, the political machine is slow and this has impact on the motivation of the graduates of the program
In 2014 Liberia, Sierra Leone and Guinea were overcome with the Ebola virus. Sierra Leone had 14,124 cases (suspected, probable and confirmed) and lost 3,956 to it.21 Overall the three countries suffered over 11,000 deaths and 28,616 total cases (suspected, probable and confirmed). Stability and economic growth/recovery that Sierra Leone had started to emerge post civil were shattered. The devastating time of the Ebola virus heightened the world’s awareness of the already fragile health system, and the stretched and challenged skills mix needed to be able to respond. The mostly rural CHO’s were not equipped with the resources, or training to manage the rapidly moving Ebola virus. As they were on the frontlines, the lack of infrastructure in national highly communicable epidemic became increasingly evident, with CHOs working unendingly to care for patients, but lacking in gloves, protective gear, not receiving information on the transmission aspects, being overwhelmed with the clinical aspects and not able to communicate with the communities to help inform them of the nature of transmission only added to the devastation. With a rapidly crumbling infrastructure barriers such as transportation, water, electricity, health literacy, basic medical supplies, proper burial material highlighted the already weak health system.
It is estimated that 7% of the health workforce of Sierra Leone was lost.22 The first CHO (Aruna Kallon) age 45 years, was the second health worker in the country to die from the Ebola virus. He had treated the index case. He was working at the Daru CHC, Kailahun District, in the Eastern Province. Two of the CHO students died after caring for patients. Not only health care workers were at risk but also family members of health care workers (see text box).
During the outbreak elective surgical activity was reduced to a minimum. For emergency surgeries such as caesarean sections, most facilities continued to provide these services, although there were big differences between the governmental and private sector. While in the private sector there was a clear drop in number of caesarean sections, the governmental hospitals were able to maintain the level compared to before the crisis.23
Pregnant women are uniquely vulnerable to the effects of Ebola, and it is extremely difficult to distinguish the disease’s symptoms from routine pregnancy complications. Performing a caesarean section is considered as a risk full procedure as the potential body fluid can transmit the virus to the surgeon or the assistant when not fully protected by special clothing.24
During the peak of the crisis, both the CHOs in the surgical training program doing their housemanships and the newly graduated SACHOs together with the medical doctors were in the frontline performing part of the caesarean sections. Two of the trainees (CHOs) and two of the trainers (medical doctors) of the surgical training program contracted the Ebola virus and died.
All training facilities were asked to stop training.21 During the Ebola outbreak a >50% reduction in health services occurred because health workers were shifted to deal with the virus. Health Center avoidance was also noted, decreasing care for HIV, NCDs, TB, nutrition, and vaccinations. It is estimated that there was a measles vaccine decrease of 25% during Ebola.24
As transmission methods came to light challenges with sharing the message became very clear. In Moyamba: 36 Ebola cases and nine deaths might have been prevented had the pharmacist had a safe, medical burial. Of the 36 cases 75% touched corpse, 57% had direct contact prior to death, 37% contact with the patient alive and dead.25 Calls for markets closing, social gatherings to stop, burials to be medical rather than traditional, staying away from the sick, isolation forced through quarantine were culturally not handled well, leading to distrust, violence and avoidance/hiding of reporting. As part of the Ebola virus response new community based personnel were developed. Community engagement officers worked with contact tracers, social mobilizers, ambulance drivers and burial teams on compassionate communication skills to diffuse the resistance, anger and distrust. These cadres directly were directed at the SDOH at the community levels, as it became increasingly evident that a much broader structure was needed, to be able to support the care being provided by the CHO’s and the physicians.
Other sectors were affected. Schools closed, in Sierra Leone is was on average 39 weeks, however students were out longer because of increased poverty and need to help provide for families. Farmers missed 2 harvesting seasons, causing repercussions in the economy, food safety, and nutrition.
Sierra Leone was declared Ebola free in November 2015, after 22 months of enduring seemingly endless tragedy. The front line heroes, communities, global communities all had lessons to share and build from as Sierra Leone not only rebuilds a country, but a model health system for future outbreaks.
The sequelae of Ebola leave survivors often with ocular complications (some leading to blindness), auditory symptoms, arthralgias, fatigue, abdominal pain, skin disorders, back pain and alopecia.27,28 The mental health aspects are complex amongst survivors as well as with those not sickened by Ebola. Training the current and future health workforce requires a shift, as rebuilding will take time.
Some of the most noted lessons learned were from well meaning outside aid workers coming into communities and ‘working on, rather with’ the communities. “Community structures were not empowered to manage a post-Ebola situation. It is important to build capacity and empower community structure so that they can serve as first line of support... There has to be a sense of ownership”.25 Post Ebola there has been great effort to build capacity within the health care settings in communities, training doctors, CHO’s, nurses in mental health management and psychosocial support, promotion of Minimum Standards in Mainstream Facilities (screening, triage, quality assurance), as well as harmonization of the care needed for survivors. Continued vigilance with training health workers and community members in infection control, disease surveillance, and preparedness is critical. Specific survivor clinics were opened, with outreach services based from them. Strengthening the existing clinic systems, empowering community based procedures and building trust are all part of the processes needed moving ahead. 29,30 The CHO and SACHO’s continues, with a new appreciation of the work that they do, and the ‘connector’ role they provide between the many new layers of community health workers cadres and the physicians in the district and city hospitals.
Photo credit; Maria Milland
The training of CHO’s and SACHO’s has expanded to an increased focus on community engagement, mental health/psychosocial support, disease surveillance, case management, prevention of exposure for patients as well as safety for health workers, strengthening of essential health services, as well as systems coordination/planning and emergency preparedness. As part of the post-Ebola time frame training current health workers as well as trainees in the immunization acceleration plan to prevent devastating outbreaks from missed vaccines over the 22 months of the Ebola crisis.30
There is clearly an increased focus on infection prevention and control. In most of the hospital facilities you will still need to wash your hands and get your temperature checked before allowed to enter. Even though, coming to one year after the declaration of the country Ebola-free, the attention is dropping and falling back to the situation as before the outbreak. The threat of Ebola might be over, the risk for health workers to attract other diseases is even more relevant.31
There is a greater emphasis on mapping the health workforce, including geographic distribution, and skills sets to better strategize maximizing access to care, as the health system rebuilds and scales up. Sierra Leone is in the process to start resident training for doctors in surgery, obstetrics and internal medicine. This will increase the number of specialist in the future. The College of Medicine and Allied Health Sciences has increased the intake of medical students to 50-60 per year. The challenge globally is the cost effectiveness of the lengthy physician training, distribution primarily in the main cities, as well as the migration abroad. Health workforce shortage are still the norm with 245 doctors, no radiologists, no practicing psychiatrists, 2 anaesthesiologists, and 1 ophthalmologist in country, but through this crisis it has been highlighted that the community based health workforce is vital. They are being recognized as a strength within health system, and the CHO’s and SACHO’s are key members in the skills mix team of health workforce that serve the ‘health’ of the population.
The Ebola crisis demonstrated the vulnerabilities of Sierra Leone’s health system, yet ultimately highlighted the vital health workforce based in the communities, and the resilient, responsive, economically viable model of the CHO and SACHO. The expansion of cadres, engaged with the most basic of the SDOH, as well as the strengthening of the CHO, SACHO training in these areas serves as models for other regions in the world.
In Dr Margaret Chan’s reflections on the Ebola crises at the 2015 Princeton- Fung Global Forum in Ireland, she concluded “the first priority must be to get well-functioning health systems in place, especially in fragile or vulnerable countries” The UN Commission Report for Health Employment and Economic Growth stresses ‘health is an investment, not a cost’ as the world seeks to meet the needs of the current and future populations.
Samuel Batty SACHO
Photo credit; Maria Milland
Samuel Batty was one of the first students that entered in the Surgical Training Program. He came with a lot of experience and became a role model for many of the students. His friendliness and patients were inspiring for all around him. During the Ebola Crisis, Samuel Batty was posted together with two of his colleagues in the maternity referral hospital in Freetown, where they did most of the surgeries.
One day, at around 19:00, a pregnant woman came through the outpatient department. She was accompanied by 2 well-dressed women. Although she was seriously sick, she did not have fever, although patients use Paracetamol to supress fever. She denied exposure to Ebola patients or having had fever and after examination by Samuel Batty, she was sent to the ward for observation. Within 2 hours after admission, the patient vomited a large amount of blood, and died. The following day the lab-results came back positive for Ebola.
A few days later Samuel developed fever and was taking Paracetamol to be able to continue the work. His colleague observed red eyes and flu and became suspicious. He advised him to go to the centre to get tested for Ebola but Samuel denied. He preferred to go back home to his family. The following day he went to his family in the south and slept the night in the same room as his wife and son. The following morning the situation was deteriorated further and he was tested positive for Ebola. Unfortunately both Samuel and his wife died in the Ebola centre. Their son was also tested positive but survived.
Samuel Batty is one of the many brave health workers that were active in the front-line during the Ebola crisis. Where some might have tried to avoid patient contact, others took their responsibility risk their lives by caring for patients.