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Skip to 0 minutes and 14 seconds MELISA MARTINEZ-ALVAREZ: Before the epidemic the health system in all three countries was already very fragile. They had huge human resource shortages, poor infrastructure, badly performing information systems. So the situation was already very dire even before the outbreak. At the initial response, the health system became overwhelmed very quickly. There was a lack of leadership and capacity from the national government. So, for instance, in Sierra Leone, the Ministry of Health did not respond in time. There was little cross-sector communication and information, but recently the Ministry of Defence has taken over the response. And there are reports that now the response is much better coordinated and much better organised. Before the epidemic there were acute human resource shortages.

Skip to 1 minute and 9 seconds So for instance, Sierra Leone only had 136 doctors, Liberia had 90, and Guinea had 1,000. But the epidemic has taken a huge toll on health workers. So there has been about 600 health workers infected out of which 340 have died. Many people are not using the health service due to fear, due to the fact that some facilities have been overwhelmed, or have closed down. They have also been turning patients away, which has fuelled rumours in the community. And there was already a quite high level of mistrust in the national and international governments.

Skip to 1 minute and 51 seconds And therefore many people have actually stayed at home, or have kept their relatives at home and cared for them at home, which has also helped spread the Ebola epidemic. The three countries, Liberia, Sierra Leone, and Guinea all had a very high burden of disease. And because people are not using the health service for other diseases, such as malaria or maternal health, even though we don’t have any figures as of now, the estimates are very worrying. The whole of the West African region has about 100,000 death of malaria every year. There are worries that the number of deaths could quadruple this year if people are not accessing the health service for treatment.

Skip to 2 minutes and 38 seconds All three countries already had very high levels of maternal mortality. So for example, Sierra Leone had a maternal mortality of 890 deaths per 100,000 live births, but there had been huge improvements in recent years with free health care delivery for mothers, for children under five. And the use of traditional birth attendants had hugely decreased. And there are now reports that this situation is reversing. And there is an increase in the use of traditional birth attendants, and a decrease in the use of hospital services. And one hospital has actually reported a 25% decrease in deliveries in the month of July. So this will have a huge impact on both maternal and newborn mortality.

Skip to 3 minutes and 29 seconds And UNFPA has released figures and they estimate that it will be 800,000 births in the three countries this year, out of which they estimate that 120,000 will be complicated and will need some assistance, which means that in the worst case scenario where no assistance is given it could result in an increasing maternal mortality of 15%. There is also worries because all routine immunizations have stopped. So there are real concerns about some of those diseases coming back.

Skip to 4 minutes and 4 seconds YASMIN JUSI-SHERIFF: One of the biggest issues is about health care for non-Ebola cases.

Skip to 4 minutes and 17 seconds One of the early stories was about a young student, I think she was a sickle cell sufferer. And she went into a crisis. And she was taken to two hospitals and the health workers refused to treat her because they said they couldn’t confirm that she didn’t have Ebola and she eventually died. And there was a lot of publicity on the radio and all over talking to her family. And I remember particularly people were talking about one of the answers when the asked the dead girl’s sister, what is your advice to people of the country? And she said, don’t get sick. Because if you get sick there’s nobody going to take care of you and you’re going to die.

Skip to 5 minutes and 4 seconds There were cases that were reported of people who had complications in their pregnancy and went to the maternity hospital, and the health workers wouldn’t touch them, wouldn’t treat them and they died of totally preventable deaths.

Skip to 5 minutes and 23 seconds REGINA BASH-TAQI: I know that from our work with maternal health, for instance, that people accessing antenatal care have gone down. And this is what we’ve spent a lot of our time doing, trying to raise demand for services of people to access antenatal, postnatal, and delivery. All of those have, at the last count I knew, was kind of about almost 25% down. People are not coming forward to use the health service. And it’s not rocket science. They’re quite scared. And rightly so because in the patch where I work, three health workers have died in routine delivery of their work. So all it takes is for one sick Ebola patient to turn up at a health centre.

Skip to 6 minutes and 11 seconds And those health centres, how prepared can you be to actually triage and to treat every patient who comes in as if they have Ebola? It’s not easy at all. And so, of course, you’re getting near misses and you’re getting those, if you want to call them accidents, happening. And all of those things need to be strengthened. I know that there’s training out there, but where the system is weak already, where people already don’t have a very strong culture of prevention, it’s really hard. And one of the things that I think is really, really paramount now because our maternal mortality was one of the worst in the world and one of the reasons why we’re so low in the human index.

Skip to 6 minutes and 59 seconds We really need to work on that. We need to have safe clinics where women can go and under fives. All of those things are very scarce right now. So, in fact, right now people are almost sure that people are dying from other conditions more than they are of Ebola.

Skip to 7 minutes and 18 seconds PEARLYN MAMULU: If I go to a clinic or a hospital to seek treatment, I might not get that treatment because they’re concerned with Ebola. And they’re not going to want to treat me. So, I mean, I don’t want to put all my family’s business out there, but I know of family members who do have conditions and they need medical help, but they can’t get it at this point in time because that’s not what the mandate is for the health care system in Liberia. The mandate is Ebola.

Skip to 7 minutes and 46 seconds MELISA MARTINEZ-ALVAREZ: Aid programmes before the epidemic have essentially stopped. Most of the assistance is now focused on Ebola, which is of great concern for continuity of programmes. I think it’s also important to highlight that many aid programmes were vertical disease oriented programmes. And Ebola has highlighted the need to invest in health systems, which investment in health systems was lacking prior to the epidemic. There has been a lot of investment in treatment and care centres for Ebola, but there have also been some concerns that they may not benefit the health system because some of them, or most of them, will be burned after the epidemic for obvious reasons of infection control.

Skip to 8 minutes and 29 seconds And they have not been very well integrated in the health sector. That is changing now, however, with efforts focusing on the rehabilitation of primary care centres in Sierra Leone and Liberia. But certainly the response has not been very well integrated within the health system of the three countries. There’s going to be an impact to the closure of schools, particularly medical schools. All medical schools have been closed in all three countries. So there will be no new doctors or nurses for at least for the next one or two years, which will obviously have an impact on human resource availability. There will be a two year gap. We were starting from very low levels.

Skip to 9 minutes and 14 seconds Also many health workers have now died because of the disease. So the results on human resources for the health sector is catastrophic.

Immediate health system consequences of Ebola in West Africa

Health systems that were already weak prior to the Ebola outbreak have all but collapsed during it. The numbers of doctors and nurses, again very low prior to the outbreak, have been further reduced by Ebola deaths. This has a devastating effect on services and many health centres and hospitals are closed. Some people stay away from those that are functioning due to fear. The impact on illness and deaths from other preventable and treatable illnesses is expected to be huge, but is largely unknown at this time.

The video, recorded in December 2014, highlights examples of this impact. Maternal mortality was already very high in Sierra Leone, and recent progress that was being made to reduce it will have been undermined. Malaria deaths could rise 4-fold. Routine immunisation programmes have stopped. Aid programmes have stopped, and the money that is being spent now is Ebola-specific and will have few long-term benefits. The Ebola outbreak has highlighted the need to invest in health systems, not just vertical programmes.

The longer term consequences on health and development are considered in a later step.

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Ebola in Context: Understanding Transmission, Response and Control

London School of Hygiene & Tropical Medicine