Local and international staff at the Makeni Ebola treatment centre, Sierra Leone Local and international staff at the Makeni Ebola treatment centre, Sierra Leone Photo credit: Jessica Seldon/DFID
Training on the frontline in the Ebola response
by Clara Hawkshaw June 2015

The Ebola crisis has generated an unprecedented need for training during an emergency response. The rapid scaling up of the response during September–December 2014 saw the construction of six UK-funded treatment centres (ETCs) across Sierra Leone, in Kerry Town, Port Loko, Makeni, Moyamba and Freetown, bringing the number of UK-supported beds to over 700. In October 2014 Save the Children took over the running of the largest of these centres, in Kerry Town. The maintenance of each centre requires a large number of staff. Unlike previous disasters such as the Indian Ocean tsunami, which had huge influxes of international aid workers, the Ebola response has had a much smaller international presence on the ground, and the majority of staff have been recruited locally. In February 2015, Save the Children employed 600 national and 100 international staff to run the Kerry Town centre.

As non-medical international NGOs such as Save the Children have taken on responsibility for building and running treatment centres, staff training has had to adapt to incorporate technical and clinical training. It is imperative that training on humanitarian principles, how to operate in an Ebola context and how to wear Personal Protective Equipment (PPE) is successfully delivered to every staff member. As such, the goal of Save the Children’s training strategy is to ensure that all national, regional and international staff working at the Kerry Town centre receive a comprehensive induction and specialist training that enables them to manage their own health and safety, maximise team cohesion and minimise reputational risk.

Staff diversity

Staff recruited for the treatment centre fall broadly into two categories: health and water, sanitation and health (WASH). The health team comprises doctors, nurses and community health officers seconded primarily from the UK National Health Service, the Sierra Leone Ministry of Health and the Cuban Medical Brigade, as well as Save the Children consultants. Laboratory technicians are seconded from Public Health England to analyse patients’ blood samples at the onsite laboratory. The majority of health staff have not worked in an emergency context before.

The WASH team is the largest at the ETC and their tasks vary from site cleaners and PPE dressers to incinerator engineers and dead body hygienists, arguably one of the most dangerous tasks in this context. As the majority of WASH staff do not have any previous work experience of their role, the induction training is therefore longer and more comprehensive than the clinical induction, taking five days to cover the basics of the role and a familiarisation with hygiene protocols and PPE procedures. In comparison, the clinical induction takes three days to cover clinical protocols and the PPE procedure and focuses less on the day-to-day tasks. Transforming local labourers into infection control personnel is testament to the high level of training and capacity-building which can be achieved even during an emergency response.

Background of the training curriculum

As the majority of centre staff have not worked in an emergency before, induction training includes information on basic humanitarian principles and the values of Save the Children. PPE training for health staff ensures that they are protected from health risks. Historically, PPE training has been delivered by Médecins Sans Frontières (MSF), the only INGO treating Ebola cases in Sierra Leone before the scaling up of the response. In an unprecedented move the agency invited other INGOs to its training centre in Brussels, as well as opening a training centre in-country in Bo.

Save the Children followed MSF’s lead in designing its Ebola response. Treatment centre protocols were based on MSF protocols, although these have been modified since by new clinical experts to ensure that they are specific to the context of the centre. For example, if a piece of PPE kit changes or is modified the protocols need to be amended accordingly, and staff are continuously retrained on the updated equipment.

Ongoing capacity-building

The speed of the scale up was a huge challenge. Whilst construction was being completed at the treatment centre, local staff were trained by Save the Children in nearby school buildings and community centres. Since then, the training has become much more sustainable by incorporating Training of Trainers programmes. PPE training is delivered by seven full-time trainers who joined the centre as hygienists but who previously worked as teachers. The team has the capacity to deliver training which goes beyond the initial humanitarian inductions and PPE training, and it has incorporated a strong capacity-building approach and a commitment to creating a strong and sustainable workforce for the centre. Training ranges from one-hour knowledge-sharing lectures to three-day leadership courses.

Knowledge sharing has largely been organised and run from within the health team. During the response there were fluctuations in patient numbers and the team has used the quiet times to deliver knowledge-sharing and capacity-building lectures. International clinicians have given lectures on various clinical topics at the request of national medical staff, and the training plans for each module have been assessed to ensure that the model is contextually relevant for the country, and will cover topics that will be useful after the Ebola response has scaled down.

Refresher training has been delivered throughout the response, ensuring that all staff are up to date on the protocols. To reach all staff refresher training is increasingly delivered through a training of trainers model whereby certain individuals within each team are trained to deliver the training to the rest. This ensures that the centre can promptly address issues raised by ongoing quality assurance monitoring.

The training of trainers model highlights the well of talent within the 600-strong national team. Leadership training has been introduced for senior WASH team members to help them move into management roles. Although it is uncertain how the expertise of the WASH teams will be used after the outbreak, leadership training aims to create professional individuals and teams that can be deployed to deal with infection prevention and control (IPC) issues in the future.

Future plans and lessons learnt

The training delivered at the treatment centre shows what can be achieved in capacity-building programmes during a humanitarian response. The team has grown from two international trainers in November 2014 to three international and seven national trainers in February 2015, supported by two administrators. A key lesson here is that training needs to be properly planned for and resourced from the outset, ensuring that the training effort has sufficient planning and coordination capacity to assist in both identifying the need and delivering the required quality of outcome.

INGOs deliver training as a means to meet their wider capacity-building targets. However, there is limited analysis on the impact of this training, or the number of external staff who receive it. INGOs spend their resources building the capacity of their own staff, rather than people in local communities or within national NGOs. However, with such high short-term local recruitment, the Ebola response has challenged the status quo and pushed NGOs to train local non-skilled workers who will not necessarily be employed by them in the long term.

In one sense it is difficult to use the Ebola context as a model for future crises, not least because the high level of local recruitment in the response was only made possible because of high unemployment in the country as a result of school closures and other special measures by the government. However, we should not ignore the success of this level of training and the sector should consider how greater numbers of local staff can be trained to respond to local emergencies in the future. Instead, we should scale up the capacity to deliver high-quality training at the beginning of a response and dedicate resources to realise the potential of all staff.

Clara Hawkshaw is the Training Officer at the Save the Children Ebola Treatment Centre in Kerry Town, Sierra Leone. She tweets as @ClaraHawkshaw.