Without people this hospital is just an empty house … people depend on us, people [need to] trust us.”
Elizabeth Skargo, state-enrolled community health nurse, Port Loko, Sierra Leone.
I met Elizabeth when I was in Sierra Leone this summer measuring the impact of the Free Health Care Initiative (FHCI). Introduced by the president of Sierra Leone in 2010 and funded by the Department of International Development (DFID) and other donors, FHCI abolished health fees for pregnant women, lactating mothers and children under five years of age, providing much-needed medicines to women and children in one of the most dangerous places in the world to give birth.
Elizabeth, like many of the remarkable people I encountered, was also at the heart of the Ebola response in 2014-15. When I arrived at Port Loko hospital to meet her, she was leading the women and children waiting for the weekly vaccination clinic in song; the hospital was bustling. But she explained that this was not always the case.
Last week marked one year since Sierra Leone was declared Ebola free, but to many in the country, hospitals and ambulances are still talismans of death, closely associated with the trauma of the epidemic. “Everything was focused on Ebola” says Elizabeth. “There was a decrease in people coming to the hospital as they were afraid to catch it”.
Even before the epidemic, recurring medicine shortages stopped many from bothering to go to hospitals. Elizabeth and her colleagues have worked hard to draw people back by reaching out to communities and regaining trust. Part of that is ensuring that essential medicine shortages are a thing of the past, and delivery is accountable so that no one goes away empty-handed.
As part of the UK’s response to Ebola, Crown Agents in partnership with the International Procurement Agency under the CAIPA banner, established a series of emergency treatment centres, equipping them to respond to the crisis within just 72 hours. But the truth is that effective supply chains are not just about effective processes, it’s also about people. People like Elizabeth.
The most remarkable part is that Elizabeth, and many other nurses, worked on a voluntary basis throughout the crisis. “I went into nursing to save lives – money or no money” she tells me matter-of-factly. Now she continues her work aided by the FCHI.
Reform and recovery
One positive legacy of the international Ebola response is that hard-to-reach locations benefit from FHCI because an effective supply chain has been established, getting drugs to where they are needed regardless of obstacles.
When I met patients Hawa Sankoh and Moses Larkoh, they were quietly waiting for the nurse’s attention at the Lunsar Basic Emergency Obstetric and Newborn Care Centre (BeMONC) in Port Loko district. Moses has joined his wife and infant son Musal at the clinic every month since his son’s birth. On this occasion Hawa and Moses were not in for a routine check-up, but to get urgent treatment for pneumonia, a condition that tragically claimed their first child. Today, the nurses at the medical centre were able to offer Musal treatment for free, preventing this young couple from enduring another needless and heart-breaking loss.
Some barriers to effective healthcare remain. The nurse treating Musal told me that post-Ebola, stock-outs of basic medicines needed for child health have at times returned. Some parents cannot afford the price even of their baby’s health passport, a barrier at the very start of the healthcare journey .
Bustling health centres
Alhaji Sidaway is a distribution driver for the FHCI. He spends his days delivering free drugs to the districts of Sierra Leone, and the rest of the time operating a cab around the capital, Freetown. He tells me that he sees daily improvements from FHCI. Stores are no longer empty, health centres are full of people, and vehicles bearing the CAIPA logo can be seen moving goods throughout Sierra Leone. Alhaji told me about his first distribution to Koinadugu District, where in one village they were surprised to see him as no vehicles had delivered healthcare in almost a year. Medical professionals used to get access to essential drugs by hiring drivers from larger towns, but some districts were too remote to receive drugs at all. In others, medication went missing before reaching end-users.
Salaries for overworked medical staff are also an issue. In every district Alhaji visits he meets nurses and staff who have not been paid in months or, due to their volunteer status, not at all. The illegal selling of medical drugs in Sierra Leone has been linked to an over-dependence upon unpaid workers (pdf); “if healthcare workers are not being paid, some of them resort to stealing to survive”, he explains. In order to be sustainable, these individuals, the backbone of Sierra Leone’s recovery, must start to see fair remuneration.
“I pray that the Free Health Care Initiative continues - without this we will continue dying of common sickness and no progress will be made”
Alhaji Sidaway.
Alhaji also wants to see continued capacity-building to enable Sierra Leone’s health system to stand on its own feet. “Every day we are learning … and gaining new experiences,” he said. This must be the aim of all our work with Sierra Leone’s health system, to allow the system to stand on its own.
I saw positivity and commitment from everyone I encountered in Sierra Leone working to rebuild the healthcare system. It is a country that has emerged from the ashes of a global disaster, with a stronger, more equitable health system. What’s needed is continued investment and support.
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