Over 6,000 people have died of Ebola since the outbreak began in West Africa early this year. While the outbreak appears to be subsiding in Liberia and Guinea, the situation in Sierra Leone is worsening. A recent New York Times article suggests that cultural practices are behind the depth and breadth of the outbreak in Sierra Leone.
While burial practices such as sleeping next to the deceased and handling the body spread infection, these practices do not fully explain the inability of Sierra Leone’s government to manage the outbreak. Why has Ebola been so difficult to control in Sierra Leone? Once the outbreak is brought under control, how can we prevent future outbreaks? The answer to both of these questions is better health care governance.
How Sierra Leone’s public health systems work (or don’t)
At the heart of the issue is the extremely unequal vertical and horizontal distribution of financial and human resources in Sierra Leone’s public health systems. Making sure that money and people reach the local government level (and are sent to the places they are needed most) will both strengthen the immediate response to this outbreak, and build long-term capacity to prevent the next one.
In 2011, the entire national health budget of Sierra Leone came to $46.8 million USD. In a country of more than 6 million people, Sierra Leone’s Ministry of Health was tasked with the daunting responsibility of providing health care at a cost of $8 per capita. In order to move health care decisions closer to the people, Sierra Leone’s Local Government Act of 2004 gives responsibility for primary health care (including public health and combating infectious diseases) to local councils, the lowest level of government.
In practical terms, local councils should be managing and maintaining clinics, hiring doctors and nurses, and coordinating health care within their jurisdictions. This localization should result in better, more tailored medical services. It should also facilitate tracking infectious diseases, monitoring patients, and identifying potential outbreaks before they explode.
In practice, all of these functions are still handled by the Ministry of Health, based in Freetown, the capital of Sierra Leone, far from the point of infection. In 2011, the national government allocated only $8.7 million to local governments for health care (or about $1.50 per person). It is patently unrealistic to expect local governments to provide a meaningful level of service on $1.50 per person, and “fixing” this unequal vertical distribution of resources may go a long way toward making Sierra Leone’s health systems more flexible and responsive.
An uneven distribution of resources
The first reported cases of Ebola in Sierra Leone occurred in Kailahun District, a rural district that shares borders with Guinea and Liberia. In 2013, the Urban Institute collected data on health care in Sierra Leone as part of a larger project to learn about local government service delivery. We found that the distribution of trained medical personnel was highly uneven across local governments.
In Freetown, there are approximately 14.8 trained medical professionals per 10,000 people. The World Health Organization (WHO) recommends at least 22 trained professionals per 10,000 people, but in Kailahun we recorded 1 health care professional per 10,000 people, the lowest ratio of the seven local councils able to provide us with data.
Our research shows that this uneven horizontal (across local governments) distribution of resources is the norm, rather than the exception in many developing countries. Working with the Ministry of Health to spread health care workers more equitably would strengthen the nation’s ability to identify and respond to health threats across the national territory.
Can we prevent the next outbreak?
The WHO is meeting next week in Geneva to discuss how to strengthen host country health systems in response to this outbreak. This is an important sign that international development partners are paying attention to the long-term challenge of improving health governance. If local governments in Sierra Leone, Liberia, and Guinea had the supplies, money, and trained personnel they needed to provide adequate health care, could they have stemmed the outbreak before it exploded into an epidemic?
More to the point, if the international community can help the governments of these countries develop stronger, more localized health care systems now, perhaps countries like Sierra Leone will be better positioned to prevent the next outbreak from occurring.
Photo: People carry food sent from Great Britain to aid communities fighting Ebola in Sierra Leone.