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The health workforce as a crucial bottleneck in containing Ebola

By Remco van de Pas
on January 17, 2015

Remco Van de  Pas  (ITM) is currently for a research assignment in Guinea, one of three countries in West Africa affected by Ebola. Together with the national research center for training and promotion of rural health (CNFRSR) of Maférinyah, Conakry, the Institute of Tropical Medicine will explore policies and possibilities to strengthen the public health system in Guinea during the ongoing Ebola outbreak and afterwards.  During his visit, Remco  keeps a journal.  Below you find the third episode (15/1/2015).

Our research here focuses on the health workforce gap and the possibilities to improve the availability, quality and distribution of health workers required to quell the current Ebola outbreak. We would also like to explore how a  critical mass of health personnel could be put in place to provide essential health services. When speaking with the health authorities and health workers at different levels, we learned many things in the past days.

One key issue is employment. There are many nurses, auxiliary nurses and some midwives in this region that are not employed as government staff. Some of them have temporary contracts, but the local revenues for such contracts are largely non-existing. The government of Guinea is highly centralized, with limited decentralization of budget autonomy. Also, the government of Guinea spends 3% of its national budget on health prevention and medical services. This is low compared with neighboring countries. In 2001 African countries agreed to spend at least 15% of their national budget on health, in the so- called ‘Abuja agreement’.  In reality, many health workers work on a voluntary basis in public health centers. As they don’t receive a salary, they often ask for informal user fees from the people they care for. Another option for them is to open a small private consultation at home.  The demand for these services is mainly in (small) towns, which means that in the majority of rural villages there is no midwife or (auxiliary) nurse. It was in these settings, with a scarcity of tools, frequent medicine stock disruption and no protection material, that the Ebola virus could thrive so well. With the consequences we know by now.

147 health workers have been infected with the virus till now; 78 of them have passed away. Many  of them were working in non-regulated informal private settings, often in their own homes. During the initial phase of the outbreak (December ’13 – February ’14), people were looking for services who could deal with this new disease in the health centres around Gueckedou, and later in the district hospital of Macenta. The doctor in charge in Macenta told us “In the beginning we didn’t know what to do, we were overwhelmed with the patients and  their dramatic symptoms and eventual deaths. I have tried to reanimate the first patient when he arrived here. I didn’t use any gloves or other protection material, because it was not available. I am lucky that I didn’t get infected.” Others were not so fortunate. In total, 9 persons of this hospital got infected and 8 of them passed away, including the hospital director. It was then that the health authorities realized that something was very wrong.

The hospital had in fact become a site of transmission. People recognized that the hospital lacked the basic medical equipment and protection, and started to avoid its services. The attendance rate for different medical services dropped by about 70%.  The people retreated to their communities to find alternative care or  searched for treatment via  informal private providers. Indeed, most of the health clinics and hospitals that I visited here are empty. Both people and even (some) staff avoid to go to the hospital and get health services there. People are still afraid to get infected. This has amongst others an impact on the skilled birth attendance. A much lower proportion of deliveries are followed up. Complications during delivery are currently not dealt with at  the health centers. It is likely that the maternal mortality rate will increase substantially in the coming year. Vaccination coverage has also considerably decreased (from 80% to about 15%). In some sub-districts measles infections have returned as a result.

A group discussion with several directors of health centers in the district of Gueckedou  shed some more light on the structural deficiencies already existing in health centers before the Ebola outbreak. In the forest region, where there are many different ethnic groups, and analphabetism is about 50-60 %,  the dialogue between the government, health authorities and communities is limited. Trust is, consequently, fragile. This area had a large influx from refugees during the Sierra Leone war in the 90s, as well as people who migrated from other parts of Guinee to seek business opportunities. The autochthone ethnic groups feel that they are being ‘encroached’ upon by these newcomers . A certain form of resistance against the state that enforces its policies (including health) on the population has existed for quite some time.

The Ebola outbreak has aggravated this already existing distrust. The autochthone population has the impression that the government doesn’t take them seriously. There are many stories about communities that defy requirements by the state to have ‘safe’ burials (without the customary rituals like washing the body) or call for an ambulance to take a suspected case to a treatment center. There is even the sad case of Womey, about 50 km from N’Zerekore, where earlier in the year 8  health and governmental officials were murdered when they tried to inform the village of the dangers of the Ebola Disease.

When the Ebola outbreak will, eventually, be over, there will be much technical and organizational work to do. For instance training of existing (community) health workers to conduct regular surveillance and assess policy options to increase recruitment of health workers. There is much talk about decentralizing the services and have the local communities participating in allocation and accountability of the available health workers.

In my opinion, there is also an urgent need for some sort of  reconciliation process, both at the village and regional level. During such a process the communities of Ebola victims could share their grievances with the authorities. The government health responsibilities could explain their regrets, acknowledging committed errors and their willingness to evaluate and learn from the Ebola outbreak and its response. Dialogue and introspection seem required as a first step to rebuilding the health system in Guinea.