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BackgroundSierra Leone has faced a shortage and maldistribution of staff in its post-conflict period. This long-standing challenge is now exacerbated by the systemic shock and damage wrought by Ebola. This study aimed to investigate the importance of different motivation factors in rural areas in Sierra Leone and thus to contribute to better decisions on financial and non-financial incentive packages, here and in similar contexts.MethodsThis article is based on participatory life histories, conducted in 2013 with 23 health workers (doctors, nurses, midwives and Community Health Officers) in four regions of Sierra Leone who had worked in the sector since 2000. Although the interviews covered a wide range of themes, here we present findings on motivating and demotivating factors for staff, especially those in rural areas, based on thematic analysis of transcripts.ResultsRural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities, etc.). Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive. Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected.By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general.ConclusionsThis study provides important policy-focused insights into motivation of health workers and can contribute towards building a resilient and responsive health system, incorporating the priorities and needs of health workers. Their voices and experiences should be taken into account as the post-Ebola landscape is shaped.

BackgroundTKM-130803, a small interfering RNA lipid nanoparticle product, has been developed for the treatment of Ebola virus disease (EVD), but its efficacy and safety in humans has not been evaluated.Methods and FindingsIn this single-arm phase 2 trial, adults with laboratory-confirmed EVD received 0.3 mg/kg of TKM-130803 by intravenous infusion once daily for up to 7 d. On days when trial enrolment capacity was reached, patients were enrolled into a concurrent observational cohort. The primary outcome was survival to day 14 after admission, excluding patients who died within 48 h of admission.After 14 adults with EVD had received TKM-130803, the pre-specified futility boundary was reached, indicating a probability of survival to day 14 of ≤0.55, and enrolment was stopped. Pre-treatment geometric mean Ebola virus load in the 14 TKM-130803 recipients was 2.24 × 109 RNA copies/ml plasma (95% CI 7.52 × 108, 6.66 × 109). Two of the TKM-130803 recipients died within 48 h of admission and were therefore excluded from the primary outcome analysis. Of the remaining 12 TKM-130803 recipients, nine died and three survived. The probability that a TKM-130803 recipient who survived for 48 h will subsequently survive to day 14 was estimated to be 0.27 (95% CI 0.06, 0.58). TKM-130803 infusions were well tolerated, with 56 doses administered and only one possible infusion-related reaction observed. Three patients were enrolled in the observational cohort, of whom two died.ConclusionsAdministration of TKM-130803 at a dose of 0.3 mg/kg/d by intravenous infusion to adult patients with severe EVD was not shown to improve survival when compared to historic controls.Trial registrationPan African Clinical Trials Registry PACTR201501000997429

The unmet operative need in Sierra Leone is very high. The 30-fold difference in operative output between districts also is very high. As the main training institution, operative services within the governmental sector need to be strengthened. An understanding of the existing operative platform is a good start for expanding operative services.

Background: The indirect effects of the Ebola epidemic on health service function may be significant but is not known. The aim of this study was to quantify to what extent admission rates and surgery has changed at health facilities providing such care in Sierra Leone during the time of the Ebola epidemic. Methods: Weekly data on facility inpatient admissions and surgery from admission and surgical theatre register books were retrospectively retrieved during September and October. 21 Community Health Officers enrolled in a surgical task-shifting program personally visited the facilities. The study period was January 6 (week 2) to October 12, (week 41) 2014. Results: Data was retrieved from 40 out of 55 facilities. A total of 62,257 admissions and 12,124 major surgeries were registered for the study period. Total admissions in the week of the first Ebola case were 2,006, median 40 (IQR 20-76) compared to 883, median 12 (IQR 4-30) on the last week of the study. This equals a 70% drop in median number of admissions (p=0.005) between May and October. Total number of major surgeries fell from 342, median 6 (IQR 2-14) to 231, median 3 (IQR 0-6) in the same period, equal 50% reduction in median number of major surgeries (p=0.014). Conclusions: Inpatient health services have been severely affected by the Ebola outbreak. The dramatic documented decline in facility inpatient admissions and major surgery is likely to be an underestimation. Reestablishing such care is urgent and must be a priority.

Pilot testing of SOSAS showed that a population-based survey measuring the prevalence of surgical disease could be undertaken in a low income country. It is recommended that SOSAS be used with a larger sample size to calculate the prevalence of surgical disease in low income countries.

BackgroundIt 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).MethodsMultiple 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.FindingsOur 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.ConclusionsOur 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.

Objective Despite the tremendous disability and mortality caused by traumatic injuries worldwide, there is a relative dearth of information on the burden of injuries in developing countries. In an effort to document the surgical burden of disease in Sierra Leone, a nationwide survey was conducted utilizing the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool. Here, we report the injury data from this study with the aim to (1) provide an estimate of injury prevalence, (2) determine the mechanisms of injury, and (3) evaluate the degree of injury related deaths. Methods A population-based household survey was conducted in Sierra Leone in 2012. Participants were selected using a two-stage random sampling method, which generated a target population of 3750 participants across the 14 districts of Sierra Leone. Frequency distributions of mechanisms of injury based on age, sex, and urban versus rural residence were computed, and bivariate logistic regression models used to determine associations between sociodemographic factors and injury patterns. Results Data was analyzed from 1,843 households and 3,645 respondents, representing a response rate of 98.3%. Four hundred and fifty-two respondents (12.4%) reported at least one traumatic injury in the preceding year. Falls were the most common cause of non-fatal injuries, accounting for over 40% of injuries. The extremities were most commonly injured (55% of injuries) regardless of age or sex. Although motor vehicle related injuries were the 4th most common cause of injury overall, they were the leading cause of injury related deaths, accounting for almost 6% of fatal injuries. Conclusion This study provides baseline data on the burden of traumatic injuries in one of the world's poorest nations. In addition to injury prevention measures, immediate strategies to address current healthcare deficits are urgently needed in these resource poor areas. This report is an Original Article with Level I evidence.