© UNICEF Sierra Leone – The UNICEF-supported Kania Community Care Centre, in Kambia District, Sierra Leone. At the height of the Ebola crisis, 46 UNICEF-supported CCCs provided services throughout the country; 17 remain in operation.
By Indrias G Kassaye
By bringing isolation facilities to the village level and making it easier for people to seek treatment, Community Care Centres in Sierra Leone have made a critical contribution towards getting to zero Ebola transmissions. They have also helped build public trust in the medical system, critical for a healthier future.
KANIA, Sierra Leone/ HONG KONG, 19 October 2015 – After two days suffering severe headaches, Mamadu Sesay thought he might have contracted the Ebola virus.
Fearing the worst, Mamudu made his way to the Kania Community Care Centre (CCC) in Sierra Leone’s Kambia District, operated by the District Health Management Team, with support from UNICEF and the UK Department for International Development (DFID).
“I walked here by myself, because I felt really bad,” says Mamadu. “I was afraid I might have Ebola.”
Seeking professional medical help is not a reflex for everyone who gets sick in Sierra Leone, and trust in the public health system was undermined by the Ebola epidemic, which severely stretched resources.
Ebola also had a heavy impact on health workers themselves: Between January 2014 and March 2015, more than 325 were infected by the virus, and more than 150 died, in a country that before the epidemic had fewer than 140 doctors for its 6 million population, according to the World Health Organization.
Historically, villagers have been more inclined to seek the help of traditional healers when they fall ill. But herbs and home remedies don’t work against Ebola, and they even contributed to its spread by keeping people out of quarantine and not following standard infection prevention and control guidelines.
Breaking down barriers
Within this context, the CCCs were set up by UNICEF, with support from DFID, in Bombali, Tonkolili, Kambia and Kono districts. Two more CCCs were later added in Western Area. The CCCs didn’t just bring isolation facilities to the village level – essential in containing local outbreaks; they also broke down barriers to people seeking care.
At the height of the Ebola crisis, 46 UNICEF-supported centres were providing services throughout the country. Staff received training on infection prevention and control (IPC), and protocols were put in place before they opened. In addition to practicing correct use and disposal of Personal Protective Equipment (PPE) and reviewing IPC principles, there were role plays involving different patient scenarios.
“CCCs bridged the gap between the community and the health system,” says Liya Aklilu, UNICEF Health Specialist and UNICEF CCC Coordinator for the Ebola Response. “The UNICEF CCCs alone screened 33,391people – and we’re still counting. They cast a very wide net, which is what you need to do in order to proactively identify suspected cases. Their location in the community and accessibility were also crucial, as our data show that people came to the CCCs early, when symptoms presented, making early isolation a possibility and helping to reduce possible transmission in the community.”
The idea was go beyond the notion of ‘Build it and they’ll come’ and instead invest actively in making sure communities used the facilities and put aside misplaced fears about Ebola. One of the ways this was carried out was by engaging people as liaisons between villagers and the CCC.
Dauda Kamara is the community focal point working with the Kania CCC. “When the CCC started, people in the community were afraid, saying that the CCC staff are going to give something that is going to kill all of the community,” he says. “That is why UNICEF got together with the paramount chief, the section chief and the head of town and engaged some of us to take responsibility – to work with the CCC and the community members.
“I would go to the community and discuss with them, telling them the importance of the CCC and inform them of the advantage of the CCC. Now a lot of them are coming to the CCC before going to the Peripheral Health Unit [PHU].”
Procedures in place
When Mamadu arrived at the CCC feeling sick, he was met by Amara Kamara, a security guard who Mamadu knows from his village. Amara assisted him with the precautionary procedures taken when entering the health facility.
“I am the security guard protecting life and property,” Amara says. “When a patient comes, my responsibility is to tell the patient to do the handwashing and take his or her temperature. After that, I will show him or her where to go for triage.”
The CCCs employ staff from the community like Amara in order to foster good relations, community ownership and utilization. Day-to-day operations such as screening and providing care are led by nurses from the District Health Management Teams. Hygienists, cleaners and security staff responsible for safety and decontamination staff are also recruited from the community.
After checking Mamadu’s temperature and interviewing him, including asking whether he has other symptoms of Ebola, the attending nurse determined that Mamadu did not meet the case definition for admission to the CCC and referred him to the nearby PHU for further tests. The CCCs supported the existing health system not just by isolating suspected cases, but also ensuring referrals were exchanged between the two.
Leaving the CCC, Mamadu appeared visibly relieved at the good news that the pain he had been experiencing over the past two days was probably not Ebola. At the PHU, located a short walk from the CCC, a rapid diagnostic test kit was used to diagnose that Mamadu had instead contracted malaria, another potentially deadly disease that shares some symptoms of Ebola but is far more easily treated. Mamadu was provided free medication and sent home.
A lasting lesson
Today, as progress to zero Ebola transmissions continues, 17 CCCs remain in operation in Sierra Leone. The centres, housed in tents within carefully designed compounds, are temporary emergency measures, and, in time, all will be shut down. As CCCs close down, efforts are made to enable the local health system to prepare for a resilient zero by transferring staff, supplies and knowledge from CCCs to PHUs.
If there’s a lesson from the outbreak, it is the importance of community engagement. Long after the Ebola outbreak has passed, winning the trust of communities to use health systems will have a lasting benefit. In the fight against the numerous and largely preventable causes of childhood and maternal deaths, which in Sierra Leone occur at some of the highest rates in the world, this trust will be a fundamental advantage.