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SIERRA LEONE: Bold Plan for Maternal Health

FREETOWN, Apr 30 2010 (IPS) - A woman alone: Josephine Bangali fetches water from the well to set to boil over a wood fire so she can sterilise her instruments.

At a government hospital in Makeni, Sierra Leone. Credit:  Nancy Palus/IRIN

At a government hospital in Makeni, Sierra Leone. Credit: Nancy Palus/IRIN

The clinic is built of mud. In one of its three rooms stands a rickety bed where she can admit in-patients; it is also the room where Bangali delivers babies. She relies on a kerosene lamp at night – supplemented with a torch when she can afford batteries.

“The underlying causes of maternal and infant mortality are far-reaching and enormous,” says Bangali. “For government to address these problems, they really need to start at the roots.”

And those roots are here in Bellentin village, where Bangali is the solitary nurse serving 15 villages – 3,000 people – in Bumpeh chiefdom, in Sierra Leone’s southern Moyamba district.

When the rains come, the water digs deep gullies in the roads. Bangali told IPS there has not been a regular supply of drugs to meet the needs of her patients, especially pregnant women and children under five.

Care too costly?

Patricia Kargbo a nurse at the Princess Christian Maternity Hospital, government’s central facility in Freetown, a large number of women simply refuse to come to the hospital to deliver their babies, or even go to clinics during their pregnancies, preferring to go to traditional birth assistants (TBAs).

"The TBAs - unqualified, mostly illiterate midwives - some women prefer to go to them for deliveries, and sometimes they even ended paying more to these TBAs than they would have spent in clinics or hospitals. In all of these cases when there are complications they cannot handle it and they then run to the hospitals, but most times they would have been too late for help" said Kargbo.

"We are afraid of the cost involved at the big hospitals," said Sentho Sesay, who gave birth to four of her six children at home with help from TBAs. "They ask you to pay for everything and if you don’t pay they will not attend to you, unlike the traditional birth attendants. They will help you deliver your baby even if you do not have money at that particular time."

“Most times, I have to buy my own drugs in the big town and sell it to my patients on a cost recovery basis, which they most times are unable to pay for and that means that I am unable to recover my money. The government had only been giving me stipend of about 150,000 leones (35 dollars) a month, said Bangali.

Bangali sometimes runs out of gloves, and must attend to patients with her bare hands, putting herself at risk in an area where few people know their HIV status.

When she’s faced with a case that needs to be referred to the hospital in Moyamba, 65 kilometres away, she has to walk to the next village, 1.5 km away to get mobile phone coverage to call for the ambulance. The vehicle takes an age to come, struggling over the bad roads; sometimes a patient’s family will be asked to pay for fuel so the ambulance can make the trip back.

According to the U.N. Human Development Index, one in eight women in Sierra Leone risks dying during pregnancy or childbirth. One in 12 children die before their first birthday. These are some of the highest maternal and infant death rates in the world.

On the 49th anniversary of Sierra Leone’s independence from Britain, the government in Freetown announced it is extending free medical care to all pregnant women, breastfeeding mothers and children under five.

The plan is to cover 230,000 pregnant women and nearly one million children.

Nearly 71 million dollars has been committed to the project by development partners – including Irish Aid, the UK’s Department for International Development, the United Nations Population Fund, UNICEF, the World Health Organisation and the World Bank.

Abass Kamara, the public information officer at the national health ministry, said the ambitious programme still faces a funding gap of just over 20 million dollars.

And yet… is it ambitious enough?

Brima Sheriff, the director of Amnesty International in Sierra Leone, says to address maternal and child mortality, it’s necessary to widen the focus.

“Despite these huge resources pumped into free health care, what government should focus on is improving the road conditions. Because we can buy many ambulances, but if the roads are not accessible the ambulances are worthless,” he told IPS. “And women and children will continue to die because they will be unable to access the free care.”

Amnesty International’s 2009 report, “Out of Reach: the cost of maternal health in Sierra Leone”, states that high maternal mortality rates arise from a combination of factors including lack of access to healthcare due to high cost (and fear of cost) poor referral networks, lack of trained medical staff and insufficient drugs and medical equipment.

In addition, the report cited “discrimination against women and social factors that contribute to undermining women’s right to health and the lack of accountability at different levels of the health care system to ensure availability, accessibility, acceptability and quality of health care services”.

“I believe we will begin to see considerable impacts in the capital, but the gap in realisation of the free health care will be widening in the districts, towns and villages if the government does not progressively provide roads, electricity and water to every part of the country,” said Sheriff.

The question of trained personnel is a serious one. Health ministry spokesperson Kamara told IPS there are only 825 state registered nurses in the country; the country needs 1,175 more. He also revealed that there are just five obstetrician/gynaecologists – just 75 medical doctors in total – in government service in the whole country.

“Government is unable to attract these professionals because of the poor salary structure in the country,” Kamara said.

“Imagine: a qualified doctor was being paid less than 400 U.S. dollars a month,” Sulaiman Conteh a medical doctor at Connaught Hospital, Freetown’s largest, said. “It is really pittance and many of our colleagues could not work in the country for such meagre sums, so they are leaving for other African countries and Europe.”

A recently-concluded strike has paid off, though. Government increased the health sector wage bill to about 125 million dollars per annum, representing six percent of total domestic revenues collected.

The benefits of the new attention to the country’s health needs are beginning to be felt in places like Bellentin, where Josephine Bangali is upbeat.

“The government has regularised my services very recently in preparing for the free health care (programme). Now I am expecting to receive my first salary at the end of the month after almost a year without salary,” said Bangali. “It is a good sign that they are ready for this (programme) to work.”

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