Poor governance and Ebola worsen health system in Sierra Leone
By Silas Gbandia
Ali Bai Kamara, 35, took his pregnant wife to the Kissy Clinic in Freetown for delivery. The popular radio show host of east Freetown,the capital of Sierra Leone,was expecting their second child after 7 years of waiting. He left the clinic alone on August 24, 2014 in tears remembering only his wife’s goodbye message in the labour room to take care of their daughter. He lost the wife and the baby.
“I still read a text message I received from a friend during that difficult period. The text reads ‘If the healthcare facility was well equipped with the human resource and equipment, your wife wouldn’t have died,’”he recalled.
Many families have gone or are going through this painful experience of losing their loved ones during delivery. Children are dying of malaria and other preventable diseases.
Comparatively, Sierra Leone is one of the worst places in the world to carry a pregnancy and take care of a child.
The UNDP Human Development Index 2012 report states that for every 100,000 live births in Sierra Leone, 890 women die from pregnancy related causes including, for example, obstructed labour. This was almost twice the average for Sub-Sahara Africa of 475. The 2013 Sierra Leone Demographic Health Survey report states that 28 percent of adolescent women aged 15 – 19 are already mothers or pregnant with their first child and 46 percent of adolescent women with no education have begun childbearing.
“One in every 11 children die before reaching age 1, and 1 in every 7 does not survive up to his or her fifth birthday,” the 2013 Sierra Leone Demographic and Health Survey Key Findings states. Miatta Kargbo, former minister of Health and Sanitation said on Radio Democracy in Freetown in June 2014 that 2,400 women die every year of pregnancy related causes and 10,000 babies die every year before their fifth birthdays. This situation compounded with the Ebola outbreak that is killing hundreds of healthcare workers, paints a gloomy situation for the coming year.
“The disease [Ebola] has also worsened the already fragile situation of our women, children. In particular it eroded the gains achieved in the country’s healthcare services especially our flagship free healthcare initiative,” Dr. KaifalaMarah, minister of finance and economic development told lawmakers on November 14.
A fragile health system is a system that cannot withstand and contain an outbreak like Ebola because it lacks the personnel, equipment and infrastructure needed to address the health needs of the people without outside intervention, said Victor Koroma, director of Health Alert on December 17 in Freetown.
Prevailing corruption detected
On April 26, 2010, the country’s President Ernest Koroma declared a free healthcare initiative. The initiative aims to provide free treatment and free drugs to pregnant women, lactating mothers and children under the age of five to reduce maternal and infant deaths. This pronouncement was backed with a pay rise for doctors and nurses of about 200 percent.
Pay increases have not stopped petty and grand corruption in the health sector. The West African country’s Anti-Corruption Commission and the legal system have prosecuted doctors, nurses, ministers and other health workers relating to the stealing and selling of drugs and insecticide treated bed-nets meant for free distribution, breach of procurement rules and misuse of funds meant to support the health sector. The corruption commission dragged doctors to court over the misuse of $500,000 from the Global Alliance for Vaccine and Immunization (GAVI)fund. Some health workers have been caught demanding payments from pregnant women and parents of under-five children. These actions have resulted in the loss of lives. Those who cannot afford the bribe have gone home without receiving treatment and drugs.
Fatu [not her real name] took her sick son to a health facility in Freetown. She was asked to pay 10,000 Leones, (the equivalent of $2). “Because I could not afford it at the time, I went home with few drugs and my baby died later,” she said, choked up in tears on November 2.
Before the Ebola crisis hit the struggling health sector, there were only 5 ambulances across the country, so referrals were a major problem, Victor Koroma, national coordinator of the non-governmental organization Health Alert said in an interview in Freetown on November 10 and confirmed the same in another interview on December 17.“Motor bikes, the use of hammock are some of the ways pregnant women are rushed to the health facilities across long distances,” he said.
“We are not genuine about transforming our healthcare system,” Victor Koroma said.
Koinadugu, the largest district in the country now has two ambulances. This mountainous area with rugged, muddy and slippery roads in the jungles of northern Sierra Leone is difficult to movein from one village to the other. The journey from Neini chiefdom to Kabala is about 80 kilometers and lasts for about 5 hours one way. So 10 hours is needed to get a pregnant woman who is having an obstructed labour to the referral hospital in Kabala. Before the Ebola outbreak, the district had only one ambulance, Dr. Francis Moses, district medical officer and head of the primary healthcare hospital said in an interview in Kabala, the district headquarter town in November 2014.
“Before the outbreak, we had really good coverage for under-five and pregnant women. I used to do quite a lot of caesarean for obstructed labour and the maternity complex was almost always full. But now we are seeing less and less coming in,” Dr. Moses said.
An assessment done by the Ministry of Health and Sanitation shows that Sierra Leone needs 3,300 medical doctors but there are presently only 386 doctors including 9 dental surgeons for the whole country. The country also needs 8,615 nurses and midwives but only 1,365 are available to meet the demand of the country. The Ebola epidemic has killed over 100 healthcare workers including doctors and nurses. Some doctors regrettably have abandoned surgeries to take up administrative duties in the health ministry. Dr. Sas Kargbo head of the reproductive health division of the health ministry now doubles as head of the Ebola burial team. This is the extent to which the health system has been stretched. Dr. Kargbo is also involved in the discussions for the implementation of the phase 3 trial of two Ebola vaccines in Sierra Leone in January 2015.
The country has about 1,200 Peripheral Health Units (PHUs) that provide primary healthcare services to remote rural communities and slum communities in the city. Some of these PHUs are manned by nursing aides as professionals are not available to venture into remote areas.
These circumstances put lives at risk waiting to add to the maternal and infant mortality rates. In a report published by Health Alert-Sierra Leone a local NGO in December 2014 titled Assessment Report on the Impact of Ebola on the Free Health Care Service Delivery, the publication stated that during Health Alert’s visits to Peripheral Health Units (PHUs) and Community Health Centers around the country, it realized “most PHUs were found empty with no Nurse whilst there are other communities that still do not have health facility.” The report presents pictures of closed health facilities. The Koquima Community Health Center in Kono for instance was closed. Some community health centers in Koinadugu District because of the roads have just a nurse doing general treatments and deliveries.
“The non-Ebola illnesses are adding to the toll of death and suffering as clinics and hospital staffs are hesitant to attend to other patients for fear of contagion of this dreadful disease. Our doctors and nurses are the main victims with lose of lives in several cases,” Kaifala Marah said.
There has been a drop in the number of children coming forward for vaccination for diseases like measles. Some people have been shouting that vaccines are meant to infect people with Ebola and reduce fertility rates, Dr. Moses Said.
Sierra Leone, a country of 6 million, experienced an 11-year civil war that ended in2002 leaving 50,000 people dead. At a time when the country is rebuilding its battered economy and labelled since 2012 as one of the fastest growing economies in the world mainly on iron ore exports, Ebola has lowered the country’s growth prospect making a difficult healthcare situation worse. Many private hospitals since the outbreak in May remain closed. Some government-run health facilities have been shut down from time to time when a case of Ebola is identified.
The Abuja declaration of 2001 stated that 15 percent of the national budgets of West African countries should be allocated to the health sector but Sierra Leone has not complied. The 2014 national budget allocated 10.5 percent to health, according to Mathew Dingie, director of the budget bureau in the Ministry of Finance and Economic Development. With civil society groups like Health Alert coming out, the supplementary budget raised it to 11.4 percent, Victor Koroma said. It is hoped that the 2015 budget will take into consideration the declaration.
The World Bank gave a US$5.7 million grant to Sierra Leone to incentivize health workers working on the free healthcare initiative to reduce infant and maternal deaths.
At the Koribundo Health Centre in Bo District, the provision of incentives for nurses and Traditional Birth attendants (TBAs) saw an increase in the number of deliveries done in the health facility from 197 in 2010 to 229 in 2011. In 2012 it rose to 337 and in 2013 rose again to 468. Antenatal care saw a steady rise from 1,080 in 2010 to 3,326 in 2012 in the health facility. Since 2013, no maternal death has been recorded in the facility. Vandy Kabba, the community health officer associates the success to the $5.7 million World Bank grant known as the Performance-Based Fund. Not all public hospitals and clinics are part of the performance based fund and late disbursement of the funds has been a serious issue. Some health facilities have still not received disbursement for the third quarter of 2013.
Tiange Koroma a suckling mother living in Koribundu said that she had been visiting the health facility from the time she got pregnant. She stressed that she had never paid for drugs and services offered at the health center. Her stories vary from others in other districts.
Transforming a healthcare system weakened by an 11-year war and burdened with an Ebola outbreak is herculean with the low level of education and rising poverty level. Less than 40 percent of the population is literate and a greater percentage of the people live in abject poverty.
The demographic health survey shows that 10 percent of households have an improved, not shared sanitation facility while one in every 5 households have no sanitation facility. About 40 percent of infant deaths in Sierra Leone have to do with water borne diseases and sanitation.
“More than 7 in 10 women report having at least one problem accessing health care for themselves. Two thirds of women were concerned about getting money for treatment. About 40 percent of women were concerned about distance to the health facility,” according to the Demographic Health Survey report.
Those financially strong can pay for healthcare in private hospitals but the vast majority depends on public run facilities. Many of the public-run health facilities have several concerns to address and Ebola has overshadowed all other health issues.
The Ministry of Health and Sanitation runs Sierra Leone’s healthcare system with the minister Dr. Abu Bakarr Fofanah as the political head. He is assisted by two deputies. The technical head is the chief medical officer and Dr. Brima Kargbo is holding that position at the moment.
There is a huge challenge with health governance, Victor Koroma said. Senior doctors in the health ministry are heading programmes leaving junior doctors to handle their traditional role to take care of sick people. “All senior doctors are managers and directors of projects. Every project has its own account and they are all signatories,” he said.
“Let doctors go back to their traditional work of treating patients and government employs managers to man the programmes,” Victor Koroma stressed.
But the programmes for malaria, polio etc are where the money is and therefore require a strong sense of integrity to leave the air-conditioned office with a cheque book in pocket to going into the operating theatre and keep the oath of saving humanity.
“Before the Ebola outbreak as we know, we had seen tremendous improvement but this was not enough for us to be able to achieve the Millennium Development Goals which says we should have reduced maternal deaths by two third,” Dr, Sas Kargbo said in an interview in Freetown on December 18.
Sierra Leone is therefore a long way off from saving more pregnant women and babies.
This report was produced by Silas Gbandia, with support from Partners for Democratic Change and from the Institute for War&PeaceReporting. It is part of the Access Nigeria/ Sierra Leone program funded by the US Department of State’s Bureau of International Narcotics and Law Enforcement.