Sierra Leone has long suffered from a weak health system, further exacerbated by the 1991-2002 civil war and, recently, the worst Ebola epidemic in history, affecting 14,124 people and killing 3,956, with 6.85% of the dead being health care workers.
In 2012, the King’s Sierra Leone Partnership (KSLP), a small NGO affiliated with King’s College London and the hospital collective of King’s Health Partners, embarked on a partnership with the main government hospital, Connaught Hospital, in Freetown, the College of Medicine and Health Sciences (COMAHS), and the Ministry of Health and Sanitation (MOHS) in order to support these institutions to build a stronger and more resilient health system.
The organization operates through international volunteers partnering with local leaders across a wide range of disciplines, of which emergency medicine is the key pillar. A UK-based voluntary team offers expert technical advice, and systems are strengthened through a four-pronged approach: policy development, clinical services, training, and—underpinning all of it—research, which not only evaluates the service, but also develops the individuals involved academically.
There is no formal emergency care system in Sierra Leone, so it was not uncommon at Connaught hospital to see patients lying for hours unconscious or in pain on trolleys in the waiting room. Because of the lack of free health care, priority would be given to patients that had ability to pay, or those with minor injuries that walked into hospital. Mortality rates are high and the A&E was neglected, so patients complained or stayed away. Progress in developing a new concept in this context has been highly challenging. For example, there exists a lack of information on the scale of the problem or what emergency care facilities could provide; the MOHS struggles to recognize or understand the need and therefore there is no funding; there is no post-graduate specialization in the country, other than in family medicine, so why and who should be interested in EM? However, working alongside our partners, we are pleased to report that several important steps in EM development have been made possible, giving the specialty more of a voice in Sierra Leone.
In May 2014, the Connaught Hospital, the MOHS, and KSLP collaborated to introduce a new triage system, the first of its kind in Sierra Leone. Amazingly, despite so much fear of health care worker deaths, the triaging continued throughout the Ebola epidemic, offering an additional level of security to the hospital, and which meant that Connaught Hospital was one of very few (<30%) hospitals that remained open. Not unsurprisingly, attendance rates to the hospital dropped during this period, but patients who did attend to hospital were more severely unwell with conditions unrelated to Ebola, highlighting the importance of effective emergency services with triage systems even during a humanitarian crisis. This evidence, and significant lobbying of the MOHS to maintain a resilient health system, resulted in the representation of emergency services in the government’s guidelines for a minimum standard of care, the Basic Package of Essential Health Services, and the MOHS has assigned a medical officer and four mid-level emergency care providers specifically to the Connaught Hospital Emergency Department. The Ebola epidemic resulted in funding for the complete refurbishment of the old Ebola isolation unit into a new A&E department, which is now capable of providing emergency services and includes a new fully functioning triage, resuscitation room, and trauma room.
Regular training, following the African Federation of Emergency Medicine signal functions, is being delivered to the 45 A&E nurses and clinicians at the Connaught Hospital. Unfortunately, there is still no recognized postgraduate training for these cadres. However, the medical school has for the first time included EM training within their curriculum, hopefully generating enthusiasm for the specialty amongst students who will hopefully be our future EPs.
Seventy-percent of Sierra Leone’s health system is financed through out of pocket payments, meaning that provision of emergency care is highly challenging. A pilot program for free emergency medication and a cost recovery scheme has resulted in patients receiving more timely care, and allows relatives time to mobilize funds for subsequent services. Data collected from this pilot program is helping us to produce advocacy documents to lobby the MOHS and donors for publicly funded free health care. In addition, bleakly, 75% of HCWs do not receive a salary. Through strong hospital management a financial incentive scheme has been introduced where staff receive a small proportion of the admission fee, which has helped to motivate and recognize their hard work.
Our resident Medical officer, Dr. Mark Sesay, comments: “The concept of Emergency medicine in Sierra Leone has started gaining momentum and its importance has been felt by many patients, especially those presenting acutely unwell with deranged physiology. It has been satisfying to see the transformation of the poorly managed outpatient department into a modern A&E department with appropriate equipment, along with improvement in the working environment. The consequences of these developments are that record keeping and patient flow have improved, staff are more motivated, and patients and relatives have more confidence in the service which has resulted in increasing hospital attendance.”
Dr. Mark does say, however, that in order to sustain progress and maintain momentum, emergency care centers will need to be developed and linked together across the country along with a prehospital ambulance service. In addition, there is a need for specialty recognition and curriculum development at the postgraduate training level. Some of this can be achieved through the initiation of the Sierra Leone Emergency Medicine Society, and improved collaboration with other West African Societies, and public and private EM providers. Ultimately, though, what the specialty really requires at this point is long term financial investment.