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  • We also thank Kate Mandeville and Adamson Muula for their


    We also thank Kate Mandeville and Adamson Muula for their letter and agree with the need to ensure resources are available to fund salaries for newly trained doctors and other health workers to allow these workers to be absorbed into the under-resourced Malawian health system. The doctors\' salary cap in Malawi is intended to increase macroeconomic stability. However, recruiting staff will improve capacity for service delivery, ensuring better health, and thus enhancing economic growth. If health workers have been trained—using scarce resources—they need to be hired. Austerity is unlikely to lead to a financially sustainable (or effective) public sector now, or in the long term, because it will prevent a prosperous Malawi in future. The International Monetary Fund needs to learn the lesson the World Bank did with user fees 10 years ago and reverse its public sector wage cap edicts. The Government of Malawi should also increase its spending on health to 15% of gross domestic product in line with the Abuja target to help ensure the funds are available to hire all health workers who have been trained, and develop a sustainable health financing strategy to address the new ambitious health-related Sustainable Development Goal targets and the Global Strategy for Women\'s, Children\'s, and Adolescents\' Health.
    Sierra Leone has one of the highest rates of female genital mutilation (FGM) in the world. Before the Ebola virus disease (EVD) outbreak, according to the Sierra Leone Demographic and Health Survey of 2013, FGM had been performed on 89·6% of girls and women.
    The scarcity of skilled nurses has been identified as one of the greatest obstacles to achieving an effective health-care system. Strengthening paediatric nurse training has been recommended as a primary strategy to reduce mortality in children younger than 5 years in both South Africa and Malawi.
    A year into the protracted and increasingly bloody conflict in Yemen, a sharp decline in coverage of measles and rubella CM-272 poses a substantial threat to population health. Falls to around 54% coverage nationally by late 2015 have been noted elsewhere, but data available to us from sources in Yemen indicate that coverage might in fact have fallen to as little as 41%. This represents a sharp fall in a very short time period, to a level well below the herd immunity threshold, and in marked contrast to national rates that had hovered fairly consistently between 70% and 80% for the preceding decade or more despite periodic instability in Yemen (especially in the far north) and long-standing access difficulties, especially for rural communities. Vaccination shortfalls have yet to translate into spikes in case reports, but we believe the risk of a large-scale outbreak is greater than at any time in recent years for two reasons. First, indiscriminate attacks on civilian areas, health facilities, and health workers, combined with movement restrictions imposed by all sides, make comprehensive vaccination delivery and appropriate case management extremely difficult. In December, 2014, 32% of the Yemeni population were without access to basic health care; that figure is now 54%. Efforts to improve coverage through outreach work continue, but WHO estimates that 230 000 children younger than 12 months missed out on routine vaccinations last year. Second, rates of malnutrition—high pre-conflict, and a well-recognised marker for poor outcomes from infection—are worsening. The UN Office for the Coordination of Humanitarian Affairs estimates that 14·4 million people are food insecure (58% of the population); 60% of households are using coping strategies, including meal size reduction to manage shortages. The effect has been particularly pronounced for children younger than 5 years. The number of children with severe acute malnutrition now stands at 320 000 compared with an immediate pre-conflict figure of 160 000. The conflict has undone important progress made in reducing the number of children with severe acute malnutrition in Yemen, which had stood at 280 000 in early 2014.