A nurse at Sister Agnes Clinic in Gardensville, Liberia with the correct IPC materials. Photo: Abbie Trayler-Smith/Oxfam

The Ebola crisis has drawn attention to the state of health care systems in West Africa. Oxfam is calling for long-term investment in health from governments and donors.

Jessica Skinner is the Policy Adviser for Response and Resilience Team for Oxfam Great Britain.  A version of this blog was originally posted on Oxfam Great Britain’s Policy and Practice site.

Liberia’s Bardnesville district in Montserrado County has never had excellent health care, but when Ebola struck last year, it further deteriorated as four of its five health clinics closed down out of fear of infection. For more than 7,000 people, the Sister Agnes Memorial Maternity Clinic became the only place to seek care.  A few days ago I was there, listening to one midwife, Mary,1 talk about the year of Ebola – and her hope of a future in which everyone in Liberia can reach decent health services.

Mary is kind, open and inspiring. Throughout the Ebola outbreak, she and her staff kept the clinic open, continued to deliver babies, and meet the needs of sick pregnant women and children – many with malaria.

At the beginning of the crisis, Mary was given only a raincoat and gloves to protect herself from infection. One day during a delivery, she got blood on her face and in her eyes. She was so scared she immediately washed her face with heavily chlorinated water; she still suffers from pain in her eye today.

During those early days of the outbreak, Mary wanted to give up, as she was so fearful of Ebola. But one of her friends encouraged her to keep going, to protect pregnant women and their unborn babies from the everyday illnesses and complications that did not stop and wait for Ebola to end.

Over the year, only two cases of Ebola were identified at the clinic, and were successfully referred. Thanks to the quick action of staff at Sister Agnes, both these people survived.

The four other health clinics in the area were forced to close, not because they were not brave, like Mary, but because they did not have the facilities to effectively provide infection control to protect their staff and patients. Without infection control, the clinics could have turned into hotspots for the spread of disease.

In fact, it was only luck that prevented that happening in Sister Agnes. Like many other health clinics in Liberia, it does not have running water or a solid waste disposal system to safely dispose of medical waste. That is why Oxfam has been renovating Sister Agnes’s water and sanitation system to ensure that it not only has access to water, but running water that can be used to flush toilets and keep the clinic clean. Oxfam is also providing an incinerator to dispose of infectious and dangerous waste.

Across Liberia, the great majority of health facilities fail to meet national standards for water, sanitation and hygiene. Less than half have hand-washing facilities close to their toilets. Only 50% have year-round access to water and 20% do not have a source of water on site. In one clinic in Gardnersville, Montserrado, the caretaker has to walk for 15 minutes to collect water. Incinerators are vital for infection control, but only 37% of health facilities have one and even more fail to meet medical standards for safe disposal. This means that medical waste is left lying around or dumped in rivers.

Sister Agnus is better than most, but it comes at a cost. The clinic is run by the church and requires patients to pay minimum fees to cover salaries and medicines. Only 7% of Montserrado’s community health facilities are government run, and they often have poorer standards of care. People rely heavily on non-state health facilities because they are often closer to hand and have supplies such as medicines.

Across both private and public facilities, more needs to be done to support them to rapidly get up to standard; ensuring people can confidently access safe health care. Liberia’s government must have the oversight, to monitor and support facilities to meet such basic standards. But raising standards will not happen without determination and resources.

However, evidence has shown that even the smallest fees will deter people, especially the poorest, from accessing health care, and will push countless more into poverty. Investments in health care need to work towards a public health system that is free at the point of use.

In Never Again-Building Resilient Health Systems: Learning from the Ebola Crisis, Oxfam draws attention to the weak state of healthcare systems in West Africa and calls on Governments and donors to provide long-term financial and technical investment to build free and resilient health systems that are better equipped to prevent the spread of infectious diseases, and offer protection to courageous health workers like Mary and the communities she seeks to serve.

As World Bank spring meetings get underway in Washington this week, recovering from the impacts of the Ebola crisis will be firmly on the agenda. International donors must stand by Liberia – and the other countries affected by Ebola – and offer the vital support that is needed.

Read more at: www.oxfam.org.uk/ebolabriefings.