Dr. Godwin Eni return from Sierra Leone as Advisor on Primary Health (...)

Dr. Godwin Eni of Vancouver, British Columbia was in Sierra Leone from January to August 2012 as an Adviser on Primary Health Care in the Ministry of Health and Sanitation. He previously visited Bo District of Sierra Leone in 2011 to consult on District Health management. Although retired, Dr. Eni has just completed a second duty at the headquarters of the Ministry of Health and Sanitation in Freetown, Sierra Leone. The Patriotic Vanguard interviewed him upon his return to Vancouver, British Columbia.

PV: This is your second assignment in Sierra Leone having spent 6 months in 2011 in Bo District consulting on District Health Management. Why the second assignment?

GE: There were discussions about my returning to Sierra Leone at the conclusion of my work in Bo Health District in 2011 especially regarding possible assistance at the headquarters of the Ministry of Health and Sanitation in Freetown. My earlier assignment was limited to Bo district although I took the opportunity to assess the situation in two adjacent health districts Moyamba and Pujehun. However, what happens at the district and community levels in any national jurisdiction is impacted by government policies and directives from the headquarters especially how they are formulated, managed, supported, conveyed to the periphery, and coordinated to deliver health services to communities. My second trip was essentially to advice on health service management at the headquarters of the Primary Health Care Directorate although I fulfilled a variety of other responsibilities.

PV: What type of advice and other responsibilities did you provide and what were the challenges?

GE: Let me put it in context. Sierra Leone has one of the lowest human development indices [HDI] in the world, a measure used by the United Nations to rank countries according to the level of social and economic development. This means that many indicators for health and well-being are very much higher than global averages on the negative side. It also means that many important health care issues ranging from governance, finance, management, human resource and service delivery issues are below world averages in terms of the capacity to deliver and achieve positive population health outcomes. An examination of the health status of women and children over the last few years provides some understanding of the situation in the country. For example the country has the highest child mortality and maternal death rates in the world. In 2010 the death rate of children under -5 years of age in Sierra Leone is 217 per 1,000 live births. In 2011, 185 children less than five years of age in Sierra Leone died for every 1,000 live births, and 890 mothers died for every 100,000. For the same year in Canada only 6 children under five years of age died for every 1,000 live births and 12 maternal deaths consistently per 100,000 each year since 2007. The UNICEF Multiple Indicator Cluster Survey conducted in 2010 shows a higher death rate among this group than indicated for 2011 by the World Health Organization’s report. It means that some progress has been achieved over a period of one year. In 2009, 46% of children less than 5 years of age showed severe or chronic evidence of malnutrition and/or stunting. Also in 2010, for every 1,000 Sierra Leoneans, there were 0.03 doctors, 0.05 nurses, and 0.2 midwives. The ratio for Canada is 2.0 physicians for every 1,000 Canadians. Access to the few available hospitals and health facilities is limited and constrained either by distance or by other forms of logistics including the scarcity of qualified health personnel and electricity supply. Many of these issues depend on meagre resource availability and the government has to find ways to manage both resources and service delivery in an efficiently and effectively manner while planning for improvements.

In 2011, the health expenditure per capita in Sierra Leone is US$45 compared to US$63 in Nigeria, US$67 in Ghana, and US$5,222 in Canada. In 2008, the total public health expenditure in Sierra Leone per capita is 3.8% and government expenditure on health care as a percentage of Gross National Product is 5.6%. In 2010 the total health expenditure for health care in Sierra Leone increased to 11.3% which is relatively a significant increase but insufficient for taking care of the country’s health needs compared to 37.9% in Nigeria and 59.5% in Ghana. It is against this backdrop that Government must plan, manage and provide programs and services to a population of approximately 6 million people living mostly in rural communities. Given the scarcity of qualified and experienced health service planners and managers, my role was to provide advice and a measure of management capacity-building to some of the senior managers focussing on primary health care. My experience as a consultant in other developing countries in Africa and South-East Asia [Ghana, Malawi, Burkina Faso, Cote d’Ivoire, India, Malaysia, Sri Lanka and Bangladesh] came in handily in the context of Sierra Leone. I could envision some parallels in some of the governance and service delivery issues with other developing countries especially how resources and services are organized and managed to delivery programs to communities including associated impact on population health. Sierra Leone, like Bangladesh during the 90s depends heavily on donor or international support. They have made some progress. I was surprised to see a Bangladeshi NGO known as BRAC establish an office in Freetown and some communities in Sierra Leone. Perhaps Sierra Leone may one day fulfill a similar role in another developing country.

While there, I participated in supervision site visits to new community health facilities and projects I also gave presentations and workshops on leadership, medical rehabilitation, and health service management in some health districts including some hands-on restructuring activities at the Primary Health Care headquarters in Freetown. Much of the advice I provided were focused in Primary Health Care. As for the challenges, I have to say they were many challenges but they were also manageable under present post-civil war circumstances. The usual systemic constraints associated with bureaucracy in many developing countries appear to exacerbate issues of management, service coordination, productivity, and work ethic. Some structural reorganization may be required at the Ministry of Health in order to achieve positive outcomes under the decentralization policy. The input of many bosses in a defined area of responsibility is not always good for any organization.

PV: Are there any improvements you can identify and how is the government or the Ministry of Health handling things? In other words is there any hope for the future?

GE: I believe the government is aware of the challenges and moving in the right direction. Between my two placements in 2011 and 2012, I noticed incremental improvements in the areas of health system strengthening, maternal, neonatal, child health, immunization, and malaria control. It seems the political leadership is focussed on achieving improvements in health indicators in these areas. Also, it seems the political leadership laid a very good foundation on which to build for the future. The government articulated a vision in a document entitled “Agenda for Change” as a guide for moving forward. As a result of this document and other policy-related pronouncements by the President, a national health sector strategic plan was developed to provide a systematic approach to strengthening the health system and addressing health inequities in order to achieve better health outcomes. It is a well-designed plan because it takes into consideration the five key elements of a viable health care system – governance, finance, human resource, drugs, and information system. The most important change is the implementation of a free health care policy for pregnant women, children under five years of age, and breast-feeding mothers. The free health care program offers free consultations, antenatal care, deliveries and postnatal treatment, x-rays, laboratory services, medicines, logistics and minor surgeries. Also a set of indicators have been established to promote the availability of basic emergency obstetrics and neonatal care in community peripheral health units and comprehensive emergency obstetrics and neonatal care for higher level health facilities. As a result of the free health care policy, there are noticeable increases in immunization coverage, enhanced nutrition intervention, and increased service utilization. The government is moving forward to link poverty with health care through the newly articulated policy called “Agenda for Prosperity”. The primary objective is to connect quality, accessibility, and affordability of health services to vulnerable populations especially the poor, women and children as a way to impact national development.

In general, there is a lot going on to develop a new direction for Sierra Leone health care which deteriorated during the civil war. Over the last two years the country has experienced improvements in under-5 mortality rates [2.5%], child mortality [7%], child immunization [34%], nutrition [20%] and declining child-case fatality in hospitals. The list goes on. However, the country is facing considerable challenges in attracting, training, and retaining qualified health care professionals in all categories. There is some reliance on foreign contributions from Cuba, Saudi Arabia and other countries regardless of language difficulties but it barely scratches the surface of what is required at the minimum. Some form of cross-national exchange program with Canada, the United States, Australia and other English-speaking countries may contribute. Also there is considerable reliance on donor contributions and logistic support from international and non-governmental organizations. I am particularly impressed with the contributions of Canadian University Services Overseas [CUSO] and Volunteer Service Organization of Sierra Leone [VSO-SL]. They provide critical volunteer support in the key areas of doctors, nurses, health educators, health managers, and financial experts among others. However, this type of human resource support should not be a substitute for training and capacitating local personnel.

It seems to me that some programs are donor driven and dependent. It also seems that some large international donors influence program development in accordance with their organizational objectives because they have the funds. Key activities and programs are focused on women and children under five years of age. However, the rest of the population, for example adolescent care, do not receive noticeable attention. Overall, the future is bright given current incremental improvements in health indicators if there is continuing willingness to undertake some strategic thinking and planning in key areas of health care. Also there is an urgent need to undertake efficient and effective management of hospitals and health institutions by qualified and experienced managers using existing resources. The lack of management expertise at many levels of the system is significant.

PV: What district or districts in Sierra Leone need the most urgent attention health-wise and why?

GE: I did not spend time in all twelve districts of Sierra Leone. I made presentations or participated in workshops or project supervision in nine of the twelve districts including the Western Area of the capital city. They include Bo, Koinadugu, Port Loko, Moyamba, Kenema, Bombali, Pujehun, Tonkolili, and Kenema districts. From available information, there is no apparent difference in population or district health needs. However, the Western Area seems to be doing reasonably well comparatively probably because of the capital city and location of the headquarters of the Ministry of Health. Bo and Bombali districts seem to be doing fairly better that other districts. Bonthe district has accessibility difficulties due to difficult terrain and so do some areas in the northern districts. The 2009 Sierra Leone District Health Services Survey did not show significant differences in health and service indicators for the twelve districts.

PV: The former Minister of Health (Zainab Bangura) has taken up a position at the UN. What advice can you give to the incoming Minister of Health?

GE: I am not a politician and hardly qualified to give advice on political leadership. I can only comment on what I observed in my area of expertise. The former Minister had significant presence in the Ministry. She was well organized and had clear idea of what she wanted to accomplish. She was very much involved in managing key aspects of the Ministry of Health. I found limitations in how the Ministry is organized and the high number of directorates available to do the work. As requested, and based on my observations, I have made some suggestions available to the Ministry.

PV: What is your personal opinion of Sierra Leone?

GE: The country is rich with natural resources. There is progress in the public sector and infrastructure development. More roads are paved compared to the situation during my earlier visit. Freetown has fairly regular electricity supply. The Chinese are helping to construct alternative entry road to Freetown to ease traffic congestion. However, I was astonished to find a Chinese enclave with all the modern facilities in the mining town of “Bumbuna” with fenced enclosure separating the town from the enclave. The rainy season is very demanding because of flooding in some areas of Freetown. The slums of the city are an eyesore to visitors. I was not surprised at the emergence of Cholera periodically every year. The town of Makeni is becoming a beautiful city and a rival to Bo City. However, the most important experience I cherish is the people’s hospitality, friendship and relaxed way of life. The high, matured and civilized level of coexistence, collaboration, accommodation, and acceptance of each other between the Moslem and Christian communities is an example to the world. I attended some weddings between Christians and Moslems and joint officiating by clerics from the two religions. I was equally surprised at the number of gifts I received from colleagues and acquaintances during my departure. I also learned that a Sierra Leonean does not consider being fed until he or she has eaten rice.

Top photo: Dr. Eni addressing the audience at the launching of the Physical Medicine and Rehabilitation policy in Freetown, Sierra Leone.

Dr Eni discussing a new health center in Tonkolili district, northern Sierra Leone, with the Paramount Chief (third from right, sitting) and some villagers.