sierra leone's maternal health and health human resource situation, glenn benablo

8/8/2019 Sierra Leone's Maternal Health and Health Human Resource Situation, Glenn Benablo

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Theresa, Evelyn and Kayima:

The Journey of Three Modern Women of Sierra Leone

Written for VSO by:

Glenn Bede A. Benablo*

Volunteer and Programme Adviser (VPA)

VSO Bahaginan, Philippines

__________

Background

My trip to Sierra Leone in August 2010 was truly an eye-opener for me. It was my first ever trip

into the vastness of Africa and it was my very first sight of a real image of poverty. I have never

seen a country where beggars, slums, dirt roads, homeless children, hunger and sickness were

simply visible everywhere. Coming from another developing country, I must say that poverty inthis part of the world is just so overwhelming. As a health development professional myself, I

can see that health in Sierra Leone, among other

sectors, needs serious attention for equally very

serious reasons. Per WHO estimates in 2005, the

country has the highest maternal mortality rate in

the world (2,100 per 100,0001). The Sierra

Leonean government claims though that this

figure has dramatically reduced in 2010 as a

result of the implementation of the free healthcare for mothers and children. The enormous

shortage of human resources for the sector is

very alarming. Magburuka City of Tongkolili

1Maternal Mortality 2005, Estimates developed by WHO, UNFPA, UNICEF and the World Bank



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district, for example, has only one doctor for the 14,915 population. Unbelievably, apart from

his exhausting duty as a physician, he is also serving as the administrator of a poorly-equipped

and inadequately-staffed government hospital. Did I mention that this hospital is the central

referral facility for the entire district with 365,465 people? One does not need to look up and

calculate – it is a simple mathematical ratio: 1 doctor for 365,465 people equals impossible.

Like many other developing countries, Sierra Leone’s health system suffers from poor if not lack

of equipment, low levels of quality care, inadequately-staffed health facilities, the presence of

health personnel with low levels of motivation, and acute differences in access to health

services between the rural and urban population.

Sierra Leone’s population is currently estimated at 6.4 million yet there are only 3 physicians,

95 midwives and 245 registered nurses2

serving the entire nation. This is just too big a gaping

hole in its health care delivery system. This is a complete opposite in the Philippines, also a

developing country, where there are surpluses of doctors and midwives and overflowing supplyof nurses. There are over 200,000 unemployed yet skilled nurses in the Philippines to date

3. I

wonder if VSO as an organization did see this as an opportunity for Sierra Leone. Well,

apparently I did. As someone who takes a lead role with VSO Bahaginan’s partnership with the

Philippine Nurses Association, I see the potential of linking the two countries for targeted

volunteer placement programme for young Filipino nurses.

Maternal Health

On April 27 th

of this year, the country celebrated its 49th

year of independence. Pregnant women, breastfeeding

mothers and children under the age of five received free

health care services from government hospitals and clinics

for the first time. This free health-care-for-all scheme is an

initiative of the government in line with its 5-year (2010 to

2015) national health sector strategic plan. The

introduction of free services is a bold step for a country

where cost is the biggest barrier to accessing health services.

Sierra Leoneans have on average, only visited health facilities less than once a year, because of

the fees. In 2008, only one-quarter of all births took place in a health facility and just 42% of

2Figures from Government of Sierra Leone, Ministry of Health and Sanitation, National Health Sector Strategic Plan

2010 to 20153 Figures from Philippine Nurses’ Association 2010



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these births were performed by a skilled practitioner 4. Women in Sierra face the highest risk of

dying at childbirth than almost anywhere else in the world. And currently one in eight women in

the country die from pregnancy-related complications – 1,000 times more likely for any women

from developed countries.

After the free health care launch, demand for the service increased tenfold, and the already

stretched available facilities were further overstretched, drugs exhausted, doctors and nurses

were said to be working from 8 to 7 and patients who could not understand the situation blame

and insult health professionals5. I personally saw and heard these complaints from many Sierra

Leoneans and to think that my visit was already 4 months after the launch. The feeling of

dissatisfaction from amongst those who have availed and planning to avail of the free services

were just echoing. And this does not even involve the entire population yet because the free

health care programme has just been launched in key selected areas. There are glaring

evidences that the country’s health care delivery system is not fully prepared for this kind of

development at this point.

There were many health issues I have personally seen and discovered while in Sierra Leone for

10 days. Considering the maternal health concerns of the country, I decided to put faces to

women of Sierra Leone and provide a glimpse their health concerns – within the different

economic strata where they belong. I met several women in Sierra Leone, each of them had

stories to tell. During our formal and informal discussions, many of them talked about stories

that usually started at the time of war and mostly end up scrutinizing the health situation of the

country. They were trusting and engaging. I listened.

Faces of Women of Sierra Leone:

Theresa. As the VPA for Voluntary Service Overseas

(VSO) Sierra Leone’s health programme, I have been

virtually communicating with Programme Manager

Theresa Bagrey for two years now mostly about official

VSO-related matters. It was a heartwarming

opportunity to have spent 10-privileged days with her in

her own country where we talked about VSO, health

development, poverty around Sierra Leone, and about

our roles in delivering a VSO Health Programme in her

country. She is a very feisty but sensible woman and within the short period of time we shared

4A study conducted by Amnesty International in 2009

5Excerpts from the After-Shave Notion by VSO Volunteer Roberto Alaban, the Editor of VSO Sierra Leone’s

newsletter, the Kushe-o.



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“There are a few international hospitals in

Freetown but the cost of its services is way

too high that is almost unaffordable for a

middle-income woman like me.”

“A hospital cannot survive with just one

doctor working. It needs skilled and properly

educated nurses and midwives as well.”

together, I have decided to add her in my list of ‘favorite people in the world’ . I thought that

her story is interesting and integral to her role as a health programme manager in Sierra Leone.

Auntie Tee, as she wants to be called, is a nurse and a single mother of two grown-up children.

She had to work while raising her two kids alone and at the same time study to become a

qualified professional nurse. She believes that as a woman, it is very difficult to find a place in

Sierra Leone. As a woman of reproductive age she knows that getting quality health services for

herself and for her kids whether from government or private health facilities is always a tricky

process. She remembered vividly how his son almost died of pneumonia when he just entered

the university. She struggled with health payment issues. Based from her own experience, she

could easily emphatize with the people from the community that VSO serves. She hurdled

challenges of providing for her kids and felt proud that both of them have already graduated

from the university. A new goal unfolds – she is now pursuing a graduate study on public

health. She is tireless and committed to learn more for Sierra Leone’s health . Her hope is that

one day; Sierra Leone could take care of

the health of its people. Even at this stage

in her life when she is relatively financially

stable, she still experiences difficulty in

getting quality health care. She knows very

well how tough it is for others who are

poor or destitute. Government hospitals’

equipment and facilities are still

substandard with almost no qualified

health professionals.

Tee is grateful that she is working with VSO in Sierra Leone and be of service to her fellow Sierra

Leoneans. She sees VSO’s programme goal in health human resource development and valuing

health workers as key approaches in delivering quality health care services.



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“Sister Evelyn is one of the few Sierra Leoneans with high degree of integrity. She is verystraight-forward and a very modern woman. She wants to keep in trail with the world

trends. I admire her as a counterpart and as a friend. Working with her is one of the

greatest things that happened to me in Makeni.” Anita Aguila, VSO Nurse Volunteer

Sister Evelyn. Tee and I visited the Northern

Polytechnic School of Nursing in Makeni where

I met Sister6

Evelyn Bangura, the head of the

nursing department. Like Tee, Sister Evelyn is

also a Nurse and has two kids. She is new in theposition as head of the department and she

works really hard to improve the quality of

nursing education of the school and literally the

entire nation. The challenge is made even

bigger with the complexities on undoing the

mismanagement and irregular transactions

made by the previous management

I was so surprised to learn that there is only one stethoscope and one sphygmomanometer in

the skills laboratory being used by many nursing students. For a learning institution it was also

surprising to learn that the school does not keep academic records of previous students. An

alumnus/a will never ever see his/her records again if he/she has lost her original copy. Sister

Evelyn said that an IT VSO volunteer with experience in management information system (MIS)

would greatly help the school. There is just one old computer for the entire school that is

locked somewhere; but that’s the least of the problem as there is no regular power supply

anyway and the teachers are not computer literate. So it doesn’t really matter if they only have

one computer.

It was uncomfortable to see more than 150 students packed in one room without ventilation,

without textbooks, and teachers without a sound system to ensure that they are heard by

everyone. Teachers make do with an old blackboard and limited supply of chalks. The most

surprising of all is that the school has no water supply. I cannot believe a nursing school without

running water. I reckon hand-washing technique would have been a big challenge to teach.

6Nurses in Sierra Leone are also called sisters.



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These are some just of the many challenges that Sister Evelyn is facing. But she is a very

determined and empowered woman who doesn’t accept no for an answer. She wants to build

an auditorium for students, a fully-equipped skills laboratory, and an IT room with power supply

and internet access – and, yes, buy more stethoscopes. Sister Evelyn would like to produce

quality nurses but she said that it would only happen if the school hires qualified nurse teacherslike Annette Aguila, a VSO volunteer. VSO’s

contribution in health human resource includes

strategic placement of VSO volunteers in medical

and nursing colleges.

Dr. Vandy, the dean of Eastern Polytechnic School of

Nursing in Kenema District agrees with Sister

Evelyn. He is also working with a VSO volunteer and

expresses his genuine gratitude for VSO’s support to

the school.

Kayima. On my fourth day in Sierra Leone, I had to go back to the

airport to claim my lost luggage. While waiting for my luggage, I

wandered around. I saw a young woman in a beautiful dress

carrying a basin of goods on her head. She looked so comfortable

despite the noticeable weight of the goods. I approached her and

bought a pair of flip plops. Let me call her Kayima7.

Kayima at an early age had already two pregnancies but has never

visited a health facility the entire time that she was twice pregnant.She said that it was difficult for her to visit a clinic because of its

distance from where she lived and her husband, a construction

worker, had no money to pay for transportation and clinic bills. She said that it was also useless

7 Kayima means ‘by the Kayi river’. I have not asked the girl’s permission to use her real name for this article.

“We lack clinical instructors here in the school. There are also no instructors based in the

hospital to guide the students during practical application. There seems to be a disconnect

between the school where students learn the theories and the hospital where students do

their related learning experience. Our school does not need expert VSO volunteers only.

We can even accept volunteer nurse-teachers with minimal experience as long as they

know how to teach the basics of nursing.” Dr. Vandy



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to visit a clinic because they do not have medicines and doctors. Kayima delivered both her

pregnancies at home. After giving birth to her youngest kid, she started selling goods on the

street to help augment her husband’s income. She was so happy that I bought a pair of slippers

because she needed some money to buy medicines for her sick boy. She said that if only the

government can provide free medicines and free services to poor people, she would have notleft her kids who were sick and all alone at home.

Kayima dreams of becoming a nurse but because of financial reasons, she was not able to

follow her dream. She got married instead. Her husband wants to have more kids.

Commonalities

Tee, Sister Evelyn and Kayima are not totally different from each other. They share

commonalities as they are all in reproductive age, they are working mothers, they all have twokids each, they experienced two pregnancies and they are all nurses. Well, Kayima dreams of

becoming one.

Their individual experiences being a woman in Sierra Leone had confronted them with many

realities around the health situation of the country. The three of them wished to see Sierra

Leone with improved health care delivery system in the future – where quality standard health

services are accessible, where doctors are available in the clinics and where education in health

is at par with the rest of the world.

For Kayima, health human resource is an issue at the community level. For Sister Evelyn, humanresource is an issue within the health education system. And for Theresa, human resource is an

issue around all levels of health care. These women from different walks of life speak one voice

on behalf of all women in Sierra Leone.

Ways Forward

The stories and the issues raised by Tee, Sister Evelyn

and Kayima were validated by the stakeholders in

Tongkolili District. I was very privileged to be part of

the first ever stakeholders’ consultative meeting

conducted in the district attended by more or less

thirty very passionate citizens. Mr. Jalloh, the director



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of Medical Research Center8

(MRC) was kind enough to quickly organize the said meeting at the

time when Tee and I suggested it during our visit to his office in Freetown. It was an amazingly

good experience to see the MOHS authorities, district health management team, chiefdom

leaders, representatives from local and international NGOs9, health professionals, Christian and

Muslim groups, teachers and some members of the community gather together to share storiesof successes and disappointments. It was also a venue to discuss the plans to address

challenges, to discuss issues and to plan enthusiastically.

Just outside the conference room I saw hundreds

of people queuing patiently in the hope of getting

some health services. It is a usual daily sight

according to Chief Kholifa Rowalla, who was

seated right next to me. It was heartbreaking to

hear the leaders begging for support from VSO

and MRC. They were begging for things that they

rightfully should have. They altogether begged for

VSO to send more volunteer doctors,

ob/gynecologists, nurses, laboratory technicians –

the list was just endless. The stories of the three women, the begging of the stakeholders, the

information from the MOHS and the reports written by experts from around the world all say

one thing: Sierra Leone’s health system is failing.

VSO’s health programme is contributing enormously to the improvement of the country’s

health system. Partners have been truly grateful and appreciative of the impact of theinternational volunteers’ hard work.

The visit and interactions with the programme office, government and NGO partners brought

me to thinking about these:

There is a case for strategic scaling up of our health programme in Sierra Leone. We

bring our resources to where they are needed most.

There is a strong case for international volunteering as a practical and strategic

approach in addressing the health sector’s shortage of human resources.

8MRC is one of the very strong partners of VSO in Sierra Leone. The organisation is running a new midwifery

school in Makeni where 3 VSO volunteers are currently placed. It also supports the referral system of Tongkolili

District by providing 2 vehicles that are used as ambulance.9

Concern Worldwide and ACT were also present in the meeting.



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We can bring in more doctors. GPs, gynecologists, surgeons. The partnership with the

Royal College of Pediatricians in the UK can be enhanced to include Sierra Leone as a

regular destination.

We can develop a project concept that can create venues for the 200,000 unemployed

nurses from the Philippines and let them volunteer in Sierra Leone. They can volunteer

in teams in each health facility. Teams of clinical nurses for the hospitals; teams of

clinical instructors for the schools; and teams of nurse managers for the district

management teams of MOHS.

Dr. Vandy and many of the partners have confirmed that they just don’t need volunteer

experts. They will welcome volunteers with minimal experience and qualifications. Dr.

Vandy even said that he can accept fresh graduates if the latter are difficult to find.

Revisiting and reconsidering our recruitment criteria not to accept applicants below 25

years old and with less than 3 years professional experience is not a bad idea either.

Women in reproductive age and children under five are the ones directly affected by the

uncontrollable imbalance of Sierra Leone’s health care delivery system. There is a need

for VSO (in partnerships with local and international organisations) to establish focused

and complementing approaches to contribute to the reduction of children and maternal

mortality/morbidity rates. The complementing approach is already happening in

Tongkolili District where the MRC, the district health management team and VSO are

simply coordinating their initiatives and activities to produce a bigger impact.

The focused and complementing approaches should be balanced with strong andappropriate advocacy efforts.



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Quezon City, Metro Manila, Philippines

2010

______

* GLENN BEDE A. BENABLO is a Registered Public Health Nurse and currently finishing up a post-graduate degree on Master in

Development Management. He has 16 years of experience in the field of reproductive health and 12 years experience in the

field of health volunteering. He is also a VSO Returned Volunteer (RV) and a former Health Programme Manager of VSO in

Mongolia. He now works with VSO Bahaginan in the Philippines as Volunteer and Programme Adviser (VPA) for the VSO health

programmes of Sierra Leone, Mongolia and Zimbabwe.



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APPENDIX

VSO Sierra Leone Health Programme Area

VSO Sierra Leone (VSO SL) developed a Program in Health in October 2007 to respond primarily to and identified

need for more human resources for health in Sierra Leone. To this end, international volunteers were placed withintraining institutions to train most cadres of health care workers including State Enrolled Community Health Nurses,

(SECHNs), State Registered Nurses (RN), BSN, Community Health Officers (CHO), Community Health Assistants

(CHA) and Midwives. In addition, volunteers were also based in a government hospital to deliver in-service training

and ongoing mentoring and supervision (Clinical education) to facilitate the improvement of quality nursing education

and prepare Nursing students in their critical role in the promotion of health, prevention and treatment of illnesses to

address the pressing overall health problems in Sierra Leone.

Following the Health Program Area review in March 2009 it was clearly seen that training and increasing human

resources for health itself cannot meet the numerous challenges in the health sector, especially so when the

government cannot readily absorb the health workers after graduation.

Programme Objectives:

1. Strengthen Human Resources for Health in Sierra Leone through increasing the number of trained and

retained State Enrolled Community Health Nurses, Community Health Officers, Community Health

Assistants, State Registered Nurses and Midwives.

2. Raise standards of nursing care in four district hospitals through supporting improvement in wards and

hospital management.

3. Support District Health Management teams in four district hospitals to manage the delivery of improved and

more inclusive Primary Health Care to vulnerable communities.

4. MOHS at central level shows increase capacity in key aspects of management; HIMS, HR management,

health service coordination.

List of key skills that VSO sends to Sierra Leone

1. Doctors – General Practitioners, Pediatricians, Ob-gynecologists, Surgeons for government hospitals and

clinics

2. Medical Lectures – Doctor lecturers, nurse teachers and midwife tutors for government and private medical,

nursing and midwifery schools.

3. Nurses/Midwives – Hospital nurses/midwives and nurse/midwife clinical instructors for government hospitals

4. Health Managers – Doctors, Nurses and other allied health professionals with management experience to

work with the ministry and district level management teams.

5. IT/MIS Specialists – IT experts with MIS experience for the schools and health facilities

6. HR Advisers – HR professionals to work with the ministry and district level management teams

sierra leone's maternal health and health human resource situation, glenn benablo

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