A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002-2012

Background: It is recognized that decisions taken in the early recovery period may affect the development of health systems. Additionally, some suggest that the immediate post-conflict period may allow for the opening of a political 'window of opportunity' for reform. For these reasons, it is useful to reflect on the policy space that exists in this period, by what it is shaped, how decisions are made, and what are their long-term implications. Examining the policy trajectory and its determinants can be helpful to explore the specific features of the post-conflict policy-making environment. With this aim, the study looks at the development of policies on human resources for health (HRH) in Sierra Leone over the decade after the conflict (2002-2012). Methods. Multiple sources were used to collect qualitative data on the period between 2002 and 2012: a stakeholder mapping workshop, a document review and a series of key informant interviews. The analysis draws from political economy and policy analysis tools, focusing on the drivers of reform, the processes, the contextual features, and the actors and agendas. Findings. Our findings identify three stages of policy-making. At first characterized by political uncertainty, incremental policies and stop-gap measures, the context substantially changed in 2009. The launch of the Free Health Care Initiative provided to be an instrumental event and catalyst for health system, and HRH, reform. However, after the launch of the initiative, the pace of HRH decision-making again slowed down. Conclusions: Our study identifies the key drivers of HRH policy trajectory in Sierra Leone: (i) the political situation, at first uncertain and later on more defined; (ii) the availability of funding and the stances of agencies providing such funds; (iii) the sense of need for radical change - which is perhaps the only element related to the post-conflict setting. It also emerges that a 'windows of opportunity' for reform did not open in the immediate post-conflict, but rather 8 years later when the Free Health Care Initiative was announced, thus making it difficult to link it directly to the features of the post-conflict policy-making environment. 2014 Bertone et al.; licensee BioMed Central Ltd.sch_iih8pub3565pub

Boosting understanding of Lassa Fever virus epidemiology: Field testing a novel assay to identify past Lassa Fever virus infection in blood and oral fluids of survivors and unexposed controls in Sierra Leone.

BACKGROUND: Despite identification 50 years ago, the true burden of Lassa Fever (LF) across Africa remains undefined for reasons including research focus on hospitalised patients, lack of validated field-feasible tools which reliably identify past infection, and the fact that all assays require blood samples making large-scale surveys difficult. Designated a priority pathogen of epidemic potential requiring urgent research by the World Health Organisation, a better understanding of LF sero-epidemiology is essential to developing and evaluating new interventions including vaccines. We describe the first field testing of a novel species-neutral Double Antigen Binding Assay (DABA) designed to detect antibodies to LF in plasma and oral fluid. METHODOLOGY/PRINCIPAL FINDINGS: Paired plasma and oral fluid were collected in Sierra Leone from survivors discharged from Kenema Government Hospital Lassa Fever Unit between 1980 and 2018, and from controls recruited in Freetown in 2019. Epidemiological sensitivity and specificity of the DABA measured against historical diagnosis in survivors and self-declared non-exposed controls was 81.7% (95% CI 70.7%- 89.9%) and 83.3% (72.7%- 91.1%) respectively in plasma, and 71.8% (60.0%- 81.9%) and 83.3% (72.7%- 91.1%) respectively in oral fluid. Antibodies were identified in people infected up to 15 years and, in one case, 40 years previously. Participants found oral fluid collection easy and painless with 80% happy to give an oral fluid sample regularly. CONCLUSIONS/SIGNIFICANCE: Given the difficulties of assay validation in a resource-limited setting, including unexpected exposures and diagnostics of varying accuracy, the new assay performed well in both plasma and oral fluid. Sensitivity and specificity are expected to be higher when case/control ascertainment is more definitive and further work is planned to investigate this. Even at the performance levels achieved, the species-neutral DABA has the potential to facilitate the large-scale seroprevalence surveys needed to underpin essential developments in LF control, as well as support zoonotic investigations

Research on Emerging Infections Offers an Opportunity for Public Health Intelligence on Non-Communicable Diseases: Hypertension Prevalence in Volunteers for an Ebola Vaccine Trial in Northern Sierra Leone

Introduction: The West African Ebola outbreak of 2014–2016 necessitated clinical trials in communities with limited health data. The EBOVAC-Salone Ebola vaccine trial is ongoing in the largely rural Kambia District in northern Sierra Leone. To gain a baseline insight into our local noncommunicable disease (NCD) epidemiology, we examined screening blood pressure (BP) measurements in trial volunteers. Methods: BP involved taking multiple readings using an Omron M6 sphygmomanometer in rested individuals. We classified BP by the European 2018 ESC/ESH guidelines: optimal BP, normal or high-normal BP, or hypertension (systolic ≥ 140 mmHg ± diastolic ≥ 90 mmHg) with Grade 1, 2, or 3 (G1HT, G2HT, G3HT) severity levels. Results: Of 870 volunteers, 220 (25.3%) had optimal BP, 236 (27.13%) had normal BP, and 250 (28.7%) had high-normal BP. The remaining 164 (18.9%) were hypertensive. By gender, 16.5% (109/668) of males and 27.2% (55/202) of females were hypertensive. Among hypertensives, 62.2% had G1HT, 18.3% had G2HT, and 19.5% had G3HT. Twenty-two (13.4%) were previously diagnosed, with eight on treatment. Forty-one had isolated systolic hypertension. The prevalence significantly increased with age (p < 0.0001), with 5.3% (27/514) in the age-category 18–29 y, 18.6% (29/156) in 30–39 y, 49.4% (84/170) in 40–59 y, and 80% (24/30) in ≥60 y. The severity also increased with age, with 54.9% of G1HT, 76.7% of G2HT, and 90.7% of G3HT being aged ≥ 40 y. In total, 36.6% (60/164) of hypertensives were overweight or obese. Discussion: In an economically disadvantaged, Ebola-affected rural West African community where NCD might not traditionally be thought prevalent, almost one in five adults were found to be hypertensive and were mostly unaware. Additionally, nearly one in three had high-normal BP. Together, these findings portend a potent, largely silent, and potentially growing NCD threat, and illustrate that infectious disease (ID) studies could provide opportunities for pragmatic NCD data. As both ID and NCD are putatively promoted by overlapping pro-inflammatory and poverty-driven factors, a cross-paradigmatic “multiplex” approach, whereby ID studies prospectively incorporate NCD-related sub-studies (and vice versa), might optimize limited research resources for enhanced public health benefit

Changes in catastrophic health expenditure in post-conflict Sierra Leone: an Oaxaca-blinder decomposition analysis.

BACKGROUND: At the end of the eleven-year conflict in Sierra Leone, a wide range of policies were implemented to address both demand- and supply-side constraints within the healthcare system, which had collapsed during the conflict. This study examines the extent to which households' exposure to financial risks associated with seeking healthcare evolved in post-conflict Sierra Leone. METHOD: This study uses the 2003 and 2011 cross-sections of the Sierra Leone Integrated Household Survey to examine changes in catastrophic health expenditure between 2003 and 2011. An Oaxaca-Blinder decomposition approach is used to quantify the extent to which changes in catastrophic health expenditure are attributable to changes in the distribution of determinants (distributional effect) and to changes in the impact of these determinants on the probability of incurring catastrophic health expenditure (coefficient effect). RESULTS: The incidence of catastrophic health expenditure decreased significantly by 18% from approximately 50% in 2003 t0 32% in 2011. The decomposition analysis shows that this decrease represents net effects attributable to the distributional and coefficient effects of three determinants of catastrophic health expenditure - ill-health, the region in which households reside and the type of health facility used. A decrease in the incidence of ill-health and changes in the regional location of households contributed to a decrease in catastrophic health expenditure. The distributional effect of health facility types observed as an increase in the use of public health facilities, and a decrease in the use of services in facilities owned by non-governmental organizations (NGOs) also contributed to a decrease in the incidence of catastrophic health expenditure. However, the coefficient effect of public health facilities and NGO-owned facilities suggests that substantial exposure to financial risk remained for households utilizing both types of health facilities in 2011. CONCLUSION: The findings support the need to continue expanding current demand-side policies in Sierra Leone to reduce the financial risk of exposure to ill health