‘They are out, we are not.’ How overseas aid has changed child health in Sierra Leone
The loss of funding because of the ODA cuts has stalled a valuable programme: Dickya Labicane, Dr Alexandra Pledge and Dr Andrew McArdle speak about the impact that programmes funded by overseas aid can have for infants, children and young people in developing countries, as well as how that impact carries back to the NHS.
“We were given two- or three-weeks’ notice before the funding stopped,” says Dickya Labicane. He is the Country Lead for Global Links in Sierra Leone, a programme run by the Royal College of Paediatrics and Child Health. Like many others working in health and development, Dickya saw the funding stream for Global Links suddenly disappear. In March 2021, the Sierra Leonean programme was deprioritised because of the government’s decision to reduce Official Development Assistance (ODA) from 0.7% to 0.5% of Gross National Income, a saving of about £4bn per year.
With the pandemic the economy of the whole world is really suffering but people will suffer more here because this lifesaving programme has come to its end.
ODA is government aid that promotes and specifically targets the economic development and welfare of developing countries. The cuts are a U-turn; historically the UK has moved resources including money, materials and manpower to developing countries around the world. In 2015, the Government Aid Strategy stated: “We firmly believe that spending 0.7% of Gross National Income (GNI) on international development — alongside our commitment to spend 2% on defence — means our country walking taller in the world.” This commitment was retained in the Conservative Party’s 2019 General Election Manifesto.
Now, programmes like Global Links that provide essential services to those who need it most, have their funding stream significantly reduced or stopped completely. “We understand that with the pandemic the economy of the whole world is really suffering but people will suffer more here because this lifesaving programme has come to its end,” says Dickya. The response of development aid projects during the pandemic, and the robustness of funding such as ODA to support it, is critical in the global battle against Covid-19, most urgently so in those countries facing the harshest impacts of all from the crisis. Restoring the UK’s overseas aid budget is crucial to the global recovery from the pandemic.
“ETAT+ impacts the whole healthcare system because it doesn’t just focus on human capacity development and human resources,” says Dickya, “it is a quality improvement tool that also develops how the hospital is run.”
Global Links in Sierra Leone
RCPCH’s Global team started delivering Emergency Triage Assessment and Treatment Plus (ETAT+) training and system strengthening in the context of a health system still recovering from the Ebola outbreak in 2014–2015. Global Links teams work with local doctors, nurses and midwives to help build the quality of clinical knowledge, skills, infrastructure and service delivery systems to improve the quality of care provided to infants, children and young people, working with the with the low resources in these settings. The programme has grown from a single hospital pilot to a national programme, adopted by the Ministry of Health and Sanitation, and rolled out in all regional and district government hospitals in the country. Partnership is at its core, whether at a ministry level or peer-to-peer support; that is what makes this programme robust and sustainable. “ETAT impacts the whole healthcare system because it doesn’t just focus on human capacity development and human resources,” says Dickya, “it is a quality improvement tool that also develops how the hospital is run.”
Alexandra Pledge and Andrew McArdle both participated in Global Links in 2016, at Ola During Children’s Hospital in Freetown, the capital of Sierra Leone. “We worked as clinicians. We did ward rounds, we managed patients, we also did systems strengthening work to contribute to the hospital systems for better care,” says Alexandra. “I worked on the children’s intensive care unit, the cardiology clinic, and delivered ETAT+ training to upwards of 30 house doctors who rotated through the hospital,” says Andrew, “I worked harder than I ever have in any year in my life, and it was probably the most satisfying year I’ve had.”
Impact
In 30 months of the ETAT+ programme, Dickya estimates almost 1,300 health workers were trained in Sierra Leone, 85% of whom are nurses. Dickya noted the significance of building this capacity: “In Sierra Leone the big issue is there’s less than 500 doctors for a population of 7 million. Patients have to wait hours and hours to be seen by a doctor and given treatment.” Developing the skills and confidence of nurses and midwives through ETAT+ has empowered nurses to lead emergency assessment and treatment intervention. The programme has significantly impacted hospital care, reducing delays between triage and treatment times from 215 minutes to eight. The programme has contributed to a 38% reduction in child mortality across the regional and district hospitals between 2016 and 2020.
You come back and work in the NHS and contribute hugely to the fabric of the NHS in so many ways.
Andrew could see the change in perception of Ola During Hospital in the year he was there: “When we arrived, it was early post-Ebola, house officers didn’t want to come to that hospital — it was busy and stressful.” The presence of Global Links doctors, aside from the ETAT+ training delivered, meant more support and practical mentoring. “Most of this was about coming as extra people. Our presence meant greater access to senior support on ward rounds, ad hoc advice. We placed ourselves as part of the team,” Andrews recalls. Then, house officers started to ask to go to Ola During because they knew they would get training and clinical support. “A handful of extra doctors was enough to shift the perception of the hospital.”
It demonstrates the benefit for health workers based in Sierra Leone but both Alexandra and Andrew emphasised the mutual benefits too. According to Andrew, for the UK clinicians, working in these communities broadens the mind: “When you work in a setting where an awful lot of things are available to you, you default to using them. Working in a setting where a lot of the things you want are not available to you and you have to do your best without it.” There is also the opportunity to improve core clinician skills. Andrew recalls a one-year-old boy who came into hospital with black lesions covering his whole body. “It looked like cigarettes had been put out on him,” Andrew recalls. The boy was very sick, needed respiratory support and antibiotics, and had been brought in by his grandmother. They learnt that his mother had HIV. “His diagnosis was ecthyma gangrenosum, which I will never forget. As an infectious disease clinician in the UK, I learned something of great importance to my career.” Alexandra emphasises how working in low resource settings breeds innovation: “People are creative when they have limited resources,” she says, “it gives you so many skills and tools. You come back and work in the NHS and contribute hugely to the fabric of the NHS in so many ways.”
Looking to the future
The sharp sudden hit of the cuts left Global Links in Sierra Leone without the supports for volunteers and training material to deliver ETAT+ training in the 14 hospitals. “The nurses felt demoralised,” says Dickya. “I wasn’t even able to meet them in person to the 14 hospitals because I don’t have the funding to go. I had do it by letter. We have a high risk to our reputation right now, people feel we have abandoned them.”
The NHS will be poorer for the lack of these kinds of opportunities for its staff to go out and do that
The sharp contrast to the government’s ambitions brings the perception of these cuts on a global level into question. “It says that this partnership is flaky- the UK is not a reliable partner,” Andrew believes. “The place that this comes from is the wrong starting point, which is let’s save some money- its pennies in their overall budget.” adds Alexandra, “The NHS will be poorer for the lack of these kinds of opportunities for its staff to go out and do that,” Alexandra reflects, “The cuts really impact on the knowledge exchange in both directions. That makes everybody poorer.”
Despite the ODA cuts, RCPCH and the Global Links team continue to work on quality of care provided to infants, children and young people in Sierra Leone. Though the programme has been interrupted, the ‘whole of hospital’ approach to the programme could mean all is not lost. “On the brighter side of things,” Dickya says, “despite the cuts from budgets, we’re very glad that our small successes really matter in terms of how we worked with the local people, making sure that they own the process, and they own the success of it.” There is the hope that through local trained staff, ETAT+ can continue. Dickya feels positive about this possibility; “they are out, we are not; we’re still in the game, we remain committed and willing to continue what we are doing.”
