Nurses as integral to health systems strengthening in post-conflict countries
By: Hanan Moalim
Multiple factors have led to deteriorating health systems in various countries. During conflict, health systems are often weakened. Whether that be through health professionals leaving the country, lowered investment in health systems, or attacks on hospitals or health workers, conflict has a massive effect on the health of populations living in conflict or post-conflict states.
Liberia, Rwanda, and Sierra Leone are three countries that Partners in Health (PIH) works in and each of them has dealt with violent conflict in the previous years. Liberia has experienced two civil wars spanning fourteen years, with the first beginning in 1989 and the second ending in 2003. Rwanda faced civil war and a brutal genocide in 1994. Sierra Leone also experienced civil war for ten years. Currently, many countries are embroiled in civil war or have transitioned into post-conflict states, making health systems strengthening an important area of global health work.
Conflict has placed an immense burden on the health systems of these countries. During the civil war years in Liberia, many health workers left the country, training was delayed, and medical equipment was stolen, weakening the medical education capacity. Prior to the wars, there were about 293 functioning public health facilities and 242 of the facilities were considered inadequate after the war. In Rwanda, health workers also left the country during and after the genocide. There was lack of willingness to invest in Rwanda’s health care system and Rwanda received the least amount of foreign health assistance in Africa in 1995, despite this being the time when support was much needed. There was a rise in infectious disease during the war years, leading to further burdens on the weakened health system. In Sierra Leone, civil war increased the number of unattended birth deliveries, contributing to the highest maternal mortality rates globally. Liberia and Sierra Leone were also epidemic countries in the 2014 Ebola outbreak in West Africa, placing further strain on their health systems. These are only some of the ways the health systems in these countries were weakened during and following conflict.
Health systems building or strengthening has become an integral aspect of global health work. Generally, among other important benefits, strengthening health systems allows for improved health outcomes and better distribution of health professionals globally. Additionally, increasing the capacity of health systems by focusing on local health workers can allow the health needs of patients to be addressed in a more nuanced and context-informed manner.
Nurses and midwives are integral to health systems strengthening. However, there are a shortage of nurses in low-income countries (including post-conflict countries). Nurses in low-income countries are overworked, receive low pay, and poor training, further pressuring already weakened health systems. Still, nurses make up the majority of the health workforce in post-conflict countries and thus investing in training and educating nurses could help bolster the health systems of their respective countries.
Much can be learned from PIH’s involvement in post-conflict countries. PIH works on multiple fronts and through various programs to build health systems in such countries, including through nursing. Nurses and midwives make up 84% of PIH’s clinical workforce and hence are central to PIH’s work in post-conflict countries.
In Rwanda, PIH worked alongside Rwanda’s Ministry of Health to introduce the Mentoring and Enhanced Supervision at Health Centers (MESH) program in 2010. The program is aimed at helping train rural nurses by connecting them to nurse mentors.
An important feature of the MESH program is the gap identification process as described by a journal article in Nursing Outlook. The mentors of the program identify gaps in the health centres in Rwanda to support MESH quality improvement interventions. For example, mentors found that there was poor monitoring of women in early labour and post-partum periods. Correspondingly, the MESH intervention added labour and post-partum care forms to record patient care and improve patient monitoring. Mentors also highlighted that there was inadequate screening for opportunistic HIV infections. The MESH program then implemented teaching sessions in which important screening questions for opportunistic infections were taught. These are a few of the gaps that were identified and how they were dealt with, which is key to helping improve health care provision in Rwanda.
In Liberia, PIH helps improve nursing education. PIH experts and professors at Harvard School of Public Health serve as technical advisors at Tubman University in Liberia. The university provides the only public nursing program in the country. In 2015, ten students from Tubman University took and passed the national nursing exam with other nursing students from private universities, a rarity. The group of students passed the exam, making them the first public university graduates to be licensed in decades. In 2017, the university graduated the first cohort of students from the nursing program. With the university located in southern Liberia, populations in Maryland County have access to more trained nurses. This is just one of the ways PIH works to improve access to health care in Maryland County.
During the Ebola outbreak, nurses were central to mitigating the spread of the virus in Sierra Leone and Liberia. In Liberia, PIH supported Ebola treatment units and community care centres while also providing training on how to reduce spread of infection. PIH also staffed the Maforki Ebola Treatment Unit, community care centres, and Port Loko Government hospital in Sierra Leone. Many of the staff were volunteer nurses who took time away from their regular jobs to work at Ebola treatment units. On his experience as a volunteer nurse in Sierra Leone, Justin Mast wrote, “I learned much during my trip — specifically that nurses are uniquely positioned and trained to lead the EVD [Ebola virus disease] response.” PIH continues to support the efforts started during the Ebola outbreak to build the capacity of the health systems in Liberia and Sierra Leone.
Supporting nurses in post-conflict countries is crucial to improving health outcomes. PIH’s efforts in Liberia, Rwanda, and Sierra Leone are critical to strengthening their health systems. PIH’s efforts to improve nursing can set a precedent for other efforts that seek to strengthen health systems in post-conflict countries.
