BackgroundFragmentation across governance structures, funding, and external actor engagement in Sierra Leone continues to challenge the efficiency and coherence of health sector activities and impedes sustained health system strengthening. Three examples are discussed to highlight the extent, causes, and impacts of health sector fragmentation in Sierra Leone: the community health worker programme, national medical supply chain, and service level agreements.ResultsIn these examples we discuss factors contributing to fragmentation, the impact on efficiency of systems and sustainability of interventions, and persistent barriers to achieving sustainable improvements in health system performance. Prolonged external dependence and a proliferation of partner and donor involvement tending towards vertical programming and funding have contributed to this fragmentation.ConclusionAlignment of policy and planning initiatives, investment in proactive (to reduce need for reactive) policy and plan development, strengthened partnerships, and strengthened governance and accountability mechanisms offer opportunities for greater health sector integration.

Background Most children with epilepsy reside in resource-limited regions such as sub-Saharan Africa, where the majority of studies have been conducted in rural areas with limited investigations. Medical records from children with epilepsy seen at an urban hospital in Kenya were examined to provide a comprehensive description of epilepsy in children from this hospital.   Methods A retrospective observational study was conducted which involved reviewing medical records of 426 epilepsy patients (260 males and 166 females) aged 0 - 18 years, seen at Aga Khan University Hospital, Nairobi, Kenya between February 2011 and December 2014.   Results The most frequent age at presentation; documented in 29% was in infancy. Generalized seizures due to structural brain abnormalities were the most common form of epilepsy (28%). Lennox-Gastaut Syndrome was the most common electroclinical syndrome (7%). Focal seizures and focal seizures with loss of awareness were identified in 12% of the population. There were no cases of childhood absence epilepsy in this group. Brain atrophy was the most common MRI finding, occurring in a fifth of the population (20%), while cystic encephalomalacia occurred in 13%. Half (50%) of all EEG recordings performed for this cohort were abnormal. Generalized seizures due to structural brain abnormalities and Lennox-Gastaut Syndrome (LGS) were significant predictors of a treatment history of three or more AEDs. At the conclusion of the review period, 16% of the patients had not visited the clinic for more than 12 months and were considered to be lost to follow-up.   Conclusion The highest frequency of epilepsy cases was documented in children less than one year of age. Generalized seizures due to structural abnormalities and Lennox-Gastaut syndrome were the most common seizure type and syndrome. Improvement of public awareness of different types of seizures in children may increase identification of children with childhood absence epilepsy.

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Illness is not in itself a sufficient ground either for admission to hospital or for continued stay in hospital. A patient should be admitted for the purpose of receiving specific medical attention, and when treatment is completed he should be discharged to the care of his general practitioner as soon as he no longer requires nursing care which can be provided only in hospital. A simple checklist procedure is described for rapidly and objectively assessing a patient's daily state of dependency on nursing care. A patient-nurse dependency chart is designed primarily to assist the attending doctor in determining the earliest time at which his patient is ready for discharge; in addition, the charts for all patients in a ward together provide the ward sister with a rapid measure of the total nursing load which must be met by her staff. In a study of uncomplicated dilation and curettage cases, it was estimated that the average stay of 5.5 days could have been safely shortened by 1–2 days if patients had been discharged as soon as they required only light nursing care such as could be provided by domiciliary services. The need for closer integration of all health services is stressed and the employment of district nurses on a fee-for-service basis is advocated.