By Poindexter Sama and Jessica McDiarmid
FREETOWN, Jun 20 2011 (IPS)

There is a brief bustle and then a woman wails as the small body is wrapped in cloth and set on a cot by the door of the paediatric ward. Nurses in pristine white uniforms continue to pad quietly around the large room at Ola During Children’s Hospital in Freetown, Sierra Leone’s capital city.

Infants are crammed two or three to a bed, sometimes more. Since the introduction nearly 14 months ago of free health care for pregnant women, lactating mothers and children under five, the number of people coming to seek treatment has shot up. Staffing and equipment has not risen to match, leaving health workers struggling to deal with the influx.

Sierra Leone’s ambitious plan to tackle one of the world’s highest rates of maternal mortality and infant death has garnered much praise from both international donors – who fund the majority of the program – and from within the country’s own borders.

In a country where one in five children dies before their fifth birthday, and one in eight women dies from complications of pregnancy or childbirth, free health care is seen as a huge step forward – and an enormous challenge.

According to a recent report by Sierra Leone’s ministry of health and sanitation, government-run hospitals saw about three times as many children under five – nearly three million – in the first 12 months of the program as in the preceding year. More than 126,000 women gave birth in hospital in the first year of the program, compared to about 87,000 in the previous year. The number of maternal complications treated in hospital increased from about 8,000 to over 20,000.

“Although the number of health staff has been increased since the launch of (free health care) it is still insufficient to match the service delivery demand,” said the report, entitled “The Free Health Care Initiative: 1 Year On.”

At Freetown’s largest public hospital for women and children, Dr. Mahmoud Idriss Kamara says the pressure on staff posed by the patient increase is wearing everyone down. Kamara sits behind a battered table, answering questions in between instructing staff, shuffling files, answering phones and signing the death papers for the child who’d just died. He has more than 24 hours left in his shift before he’d be able to get some sleep.

Across the ward, nurse Lucy Macauley says staff exhaustion leads to a poor standard of care for patients. She says they need help and the increase in workload should be accompanied by pay raises. “We’re working harder, but for the same pay,” says Macauley. Much of the equipment is obsolete and there are chronic shortages of supplies, she says, and the complex, which houses a maternity hospital and a children’s hospital, has an inadequate water supply – often, there simply isn’t any.

The hospital has been under scrutiny since an incident earlier this year when a woman died there from severe complications while the doctors scheduled to be on duty were absent. Those doctors have since been suspended.

The cost of the first year of free health care is estimated at 36 million dollars, the majority of which is put up by donors. But reports of corruption within the system are widespread. Patients recount being asked to pay for services and medications that should be free, or having to buy drugs when hospital supplies are said to have run out.

Umu Fofanah says she went for an ultrasound during her pregnancy because her doctor was concerned about the position of the baby. “When I went to do the scan, I was asked to pay 35,000 leones,” says Fofanah. “Not only me, but about 10 of us who were present.”

Other expecting mothers paid the roughly eight dollars for a scan that should have been free, says Fofanah. “But I had no money to pay, so I was sent home.”

Fofanah told a friend who happened to be the wife of Amnesty International’s Sierra Leone country director, Brima Sheriff. When he learned what had happened, he sent monitors with her to subsequent appointments or accompanied her himself to ensure she received free treatment.

“People are still paying for a lot of drugs and a lot of services,” says Sheriff. “This is not a secret. Everyone knows that people are still being asked for money, and it’s going into the private pockets of someone, at the expense of the women. The free health care was supposed to be for women but cost is still stopping them.”

Jonathan Abass Kamara, the public relations officer for the ministry of health and sanitation, says the government is always ready to react to reports of “the contravention of the principles of free health care.” Kamara cited several examples of medical staff being disciplined for extortion of patients or otherwise breaking the rules.

He says the initiative’s aim of reducing maternal mortality and infant death has been achieved, though exact figures are not yet available.

A 2009 Amnesty International report identified cost as the largest barrier to women and children accessing health services. In a country recovering from a decade-long war that ended in 2002, 70 percent of the population lives on less than one dollar a day. There are fewer than 100 doctors for some six million people and most health facilities are poorly equipped and lack basics like water supply and electricity.

While calling for better monitoring and accountability measures, Sheriff applauds the initiative and points out that there are a lot of positives to the free health care system. “But we need to recognise that it needs to be improved. We need to ensure that gaps are not left that allow some to defraud others.”

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By Poindexter Sama and Jessica McDiarmid
FREETOWN, Jun 16 2011 (IPS)

Bubble-wrapped pills are scattered across the crude table in a busy market beside crumpled boxes of lubricant, paracetamol and anti-fungal powder.

Regulators say many of the drugs sold on the informal markets in Sierra Leone are fake or substandard, posing a huge risk to the public. Credit: Poindexter Sama/IPS

A young man approaches and mutters a few words. The proprietor shuffles through the piles of sexual aids that cover the table – generic viagra, ‘man-woman’ cream (lubricant), dubious-looking condoms – before cutting a section containing two antibiotic capsules off a sheath. He hands them over, collecting in return 600 Leones, the equivalent of about 15 cents.

So-called “drug peddlers” ply the streets of cities and villages across Sierra Leone and much of West Africa, selling pharmaceuticals, often counterfeit or substandard, at reduced rates.

Strides have been made over the past few years to ensure drugs are safe and effective, but medical practitioners still cite these drugs as one of the largest obstacles in their fight to save lives. In Sierra Leone, still struggling to overcome the devastation of an 11-year war that left the nation in ruins, efforts remain beset by hurdles such as weak infrastructure, a lack of regulatory regimes in neighbouring countries, and few resources stretched in many directions.

Pharmacies in Sierra Leone are regulated under its Pharmacy and Drugs Act. Enforcement has been stepped up substantially in recent years, but what to do about those peddling on the streets remains elusive.

Drug peddler Abubakarr Keai says the majority of his supply comes from Guinea, where drugs are sold at cheaper prices and easily smuggled in over West Africa’s infamously porous borders. Other times, he buys them from local pharmacies.

He’s been selling since the war – when the formal healthcare system disintegrated and peddlers were the only option – and says he’s never had a complaint about his products. He recommends drugs and describes how to take them, though he can’t read most of what’s written on the packaging.

Keai says police frequently harass drug peddlers. Occasionally, authorities seize his drugs and arrest him. Sometimes he even goes to jail for a while.

“But there are no job opportunities, so even if we are arrested, we’ll start selling the drugs again when we are released,” says Keai. “We are doing this to survive.”

The registrar of the Pharmacy Board of Sierra Leone, Wiltshire Johnson, tasked with regulating drugs in the country, says about half the drugs sold in Sierra Leonean pharmacies three years ago were fake or substandard. Now, Johnson estimates more than 95 percent of products from pharmacies tested by the board are real.

Johnson says Sierra Leone is left vulnerable, however, because while it has beefed up its monitoring and enforcement of the formal sector, the country imports all its pharmaceuticals – some 30 to 40 million dollars worth a year. A crackdown on formal imports has been largely successful.

“The people involved in the formal sector realise you can no longer bring bad drugs to Sierra Leone,” says Johnson. “Our big challenge is the informal sector, the illegal sector, the drug peddlers.”

Liberia and Guinea, which neighbour Sierra Leone, have virtually non-existent drug regulations. The borders between countries are porous, allowing traffickers to move supplies in with relative ease, and customs and border officials are poorly paid. It doesn’t take a large percentage of profits from a lucrative drug trade to convince someone to overlook a few cartons of packages of – supposedly – penicillin.

Johnson says the pharmacy board works with police and the judiciary to enforce the pharmacy act, but argues that tougher punitive measures are needed to deal with drug peddlers.

The current law tops the time in prison at two years and the fine at five million Leones, about 1,200 dollars.

But the actual punishments meted out are usually far lower – between 100,000 and 300,000 Leones, or 20 to 60 dollars – doing little to discourage the practice, says Johnson.

“It’s a mafia, they just pay the monies and go back to the street and sell,” he says. “Tougher penalties are the only way we can really change.”

The regulatory laws on pharmaceuticals are currently under review.

Umaru Kamara, a pharmacy technician at Connaught Hospital in Freetown, says many, if not most, of the drugs for sale on the streets are substandard or fake.

It’s a regular occurrence in the hospital for staff to notice that medication – which patients will buy outside for cheap prices instead of at the hospital pharmacy where drugs are sold on a cost-recovery basis – isn’t working. Investigations reveal that the drugs the patients bought aren’t what they should be.

The dangers of substandard and counterfeit drugs are many, says Kamara. For example, fake antibiotics lead to worsening infections and complications, while substandard antibiotics cause drug resistance.

“(Drug peddlers) either give the wrong dose, give the insufficient dose so it will have no effect, or give an overdose,” says Kamara. “They can kill thousands of people.”

While education campaigns seek to inform the public of the risks of fake or substandard drugs, poverty gets in the way. Drug peddlers often offer lower prices and will sell a single dose, rather than having to buy a course of treatment all at once.

“Drug peddling is directly poverty related,” says Johnson. “It’s a social issue of survival.”

From the peddlers on the street to the patients buying their products to the people smuggling cartons of weak amoxicillin through the jungle, crippling poverty – some 70 percent of Sierra Leoneans live on less than one dollar a day – means there are few other options.

In April of last year, Sierra Leone introduced free health care for pregnant and nursing women, and children under five, including free medicines, in a bid to improve one of the world’s highest rates of maternal mortality and infant death. The ambitious program has seen a huge rise in the number of women and children accessing treatment, but drug supply remains a challenge, driving many to the streets to find medicines even when they’re covered by the program.

“You can have all the doctors, all the free health care, but if you don’t have the medicines, people are still going to die,” says Johnson.

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