John Donnelly * - The Lancet - On April 27, 2010, Sierra Leone started free health care for pregnant women, new mothers, and young children. John Donnelly takes an in-depth look at how the war-torn nation managed it. At a dinner during the European Development Days events in Stockholm, Sweden, in October, 2009, Mary Robinson, the former President of Ireland, turned to the gentleman sitting next to her. He was President Ernest Bai Koroma of Sierra Leone. The gathering was full of chatter about the emerging global financial crisis and its effect on aid to countries like Sierra Leone, but Robinson, had something else on her mind. Sierra Leone was one of five countries supported by a programme that she had helped to start called the Ministerial Leadership Initiative for Global Health, and she wanted to talk about the country’s health system.
Secrets of success
The Ministry of Health and Sanitation, which was responsible for implementation of the initiative, was fortunate to have key leaders in technical positions, such as the chief medical officer, the director of reproductive health services, and the head of human resources. They took on additional responsibilities at a time when the ministry was without a minister.
- All involved—from the government to donors to development partners—operated under an organisational structure that forced them to work together and share responsibilities. Starting in January, 2010, representatives from the Ministry of Health and Sanitation and donor communities served on one of six committees and reported into one steering group, giving the effort an overarching organisation that had clear definable tasks and delivery dates for completion.
Key problems were tackled head-on. Troubles included exceedingly low salaries, a payroll bloated with phantom workers, a need to hire hundreds of new workers to meet the expected demand, and the logistical nightmare of securing and distributing huge amounts of essential drugs in a tight timeframe.
- The government committed substantial amounts of money to finance the initiative. Just 1 month before the launch of free health care, with health workers on strike, the government pledged its own funds to pay for increases in salaries. That was not lost on donors, and it later triggered more donor funds for the free health-care initiative.
The backdropSierra Leone was devastated by a civil war that started in 1991 and continued for 11 years. The war killed tens of thousands of people and displaced another 2 million (nearly a third of the population). The fighters’ signature act of brutality was the chopping off of the hands and feets of thousands of people, leaving a large group of people maimed for life. At that time, literacy rates were low (35%), fertility rates high (five children born per woman), and 42% of the population were younger than 14 years. The health system, like all public systems, was in tatters. One of its most shameful realities—especially in the eyes of President Koroma—was that Sierra Leone had one of the world’s highest rates of women dying during childbirth. After Koroma, who had been a longtime insurance executive, won the election in 2007, health care was near the top of his list of things to improve. First, he focused largely on revitalising trade and the economy. That did not stop the world from noticing the condition of the health-care system, though. On Sept 21, 2009, Amnesty International released a report called Out of Reach: The Cost of Maternal Health in Sierra Leone, bringing international attention to the fact that one in eight women died during pregnancy or childbirth. It called the situation a “human rights emergency”.President Koroma said he had already made up his mind to do something dramatic and he cited the same statistics to marshal support for his plan. “I inherited a health sector that was in shambles, a health sector that was giving us terrible health indicators, where one out of eight women were dying in childbirth, one out of every 10 children were dying before the age of 5 [years]”, Koroma said in an interview after the launch. “Our hospitals are not properly equipped and we have been lacking for the past 10 years in the human development health indicators.” Indeed, he saw problems everywhere. “There was a lack of motivation, the health infrastructure was far from being up to standards, and most of the contracts given out for construction were not completed. I decided that something had to be done about it. If we were to save this nation, if we want to build a healthy nation, if we want to have children with a future and families to be happy, there has to be a turnaround.”
Trouble at the ministryBefore anything could happen, Koroma had to get his house in order. Earlier in 2010, the country’s Anti-Corruption Commission was investigating his health minister, Sheiku Tejan Koroma (no relation to the president), for allegedly influencing a procurement contract in favour of a friend. Minister Koroma, who had been an engineer in the USA for many years, had almost impulsively announced in August, 2009, in a meeting with donors that he was about to start a free health-care plan.In November, 2009, several events unfolded in rapid succession: police arrested health minister Koroma and he was indicted on three corruption-related counts, to which he pleaded not guilty; President Koroma appointed his vice president, Samuel Sam-Sumana, as caretaker of the health ministry; ministry officials unveiled its new health strategic plan in the capital Freetown, a framework within which the free health-care initiative would fit; and during the third week in November, the president made the free health-care announcement. The president turned the public spotlight from internal issues and focused on getting health care to women and children in order. “We had to do something for the children, mothers, and pregnant women”, he said.President Koroma knew his announcement in London would set everything, and everyone, into motion. “We had to make a commitment to it”, he said. “We had to announce it internationally and we had to do something to capture the attention of the donors and the people of the country.”The Ministry of Health and Sanitation offices are housed on the fourth floor of the Youyi Building, a poorly lit, dusty building on the fringes of Freetown’s urban centre. Change had moved slowly through the hallways here. And that was true immediately after the president’s announcement. Many at the ministry and some donors were surprised and only a few started work on it.But after Jan 1, 2010, the pace picked up and a sense of urgency filled the offices as the London deadline approached, said Faye Melly, a technical adviser to the ministry from the Africa Governance Initiative, an effort started by former British Prime Minister Tony Blair. She said one thing drove the process then: an organisational structure of committees that attacked pieces of the work. “The committees were critical”, she said. “With the committees, we now had many people working toward the same goals, with one steering group that would be led by a government leader.”The six groups oversaw human resources; drugs and logistics; finance; monitoring and evaluation; infrastructure and communications. Each committee was co-chaired by a representative of the ministry and by someone from the donor community. Each met weekly, and attendance, from the start, was high. “I think having a co-chair from a donor organisation was really important”, Melly said. “Having that donor there made the ministry people feel less that it was doing all the work. The meetings also added transparency to the whole process. Before, what struck me was how some donors would have their own meeting and talk among themselves and then come back and tell the ministry, ‘Why isn’t it done?’ But now there was more of the feeling that here are the five things to do, this is more of a joint activity, and we need each other’s support to do this.”She added, “People were tough with each other in those meetings. There was no place to hide.” Susan Mshana, the human development team leader and health adviser for DfID in Sierra Leone, said the committees were “the first time all the partners—not just the funders and the United Nations, but the NGOs [non-governmental organisations], and service providers—all came together around one solid plan. And they were committed to go live on April 27 for this initiative, as the president said. That was the key thing—that date actually galvanised people.”
Health leadersIn the ministry, underneath the president and vice president, several key leaders guided the process. Among them were two who stood out: Kisito S Daoh, the then acting chief medical officer, and Samuel A S Kargbo, director of reproductive and child health. “The chief medical officer (Dr Daoh) and Dr Kargbo were kind of the encyclopedia of the ministry”, President Koroma said. “They motivated people. It was just what I needed.”Daoh’s office, in the absence of a minister, became the centre of activity. He was locked into meetings all day long, playing the role of a health diplomat to the long line of visitors from inside and outside the ministry.“He was always knowing quite well what he wanted to do, but he did not adopt a direct nature of leading. It was conciliatory and warm and friendly. It was, ‘Do you think we could do this?’ instead of ‘Why the hell has this not happened?’” said Melly, who along with Mohamed Massaquoi served as a top aide to Daoh during this period.Across the hallway, Kargbo, known to everyone as SAS for the initials of his first three names, was a study in contrast. More than a decade younger than Daoh, Kargbo was more impatient and excitable. Sometimes, the chaotic atmosphere got him down, and he would raise his voice and then punctuate his loud messages with laughter. Kargbo also took on the role of ministry spokesperson for free health care. Kargbo became quite adroit at this job. “One consultant came to me after an interview and he said, ‘SAS, are you an evangelist?’” One of the first jobs was to rid the payroll of phantom workers and then hire additional staff. Anthony Sandi, the human resources manager for the health ministry, oversaw the entire process. A 2007 country report found Sierra Leone had 67 medical officers and 225 nurses for a population of more than 5·5 million; with that population, according to WHO indicators, the country needed at least 300 doctors and 600 nurses. Additionally, doctors were paid US$200 a month and nurses $100 a month—so low that it had become regular practice in Sierra Leone for them to charge patients for services in hospitals and clinics, even if the services were prominently advertised as free.Going into the planning of the free health-care initiative, Sandi acknowledged that he “had many nervous moments”. But Sandi, who had long felt a lack of support in the ministry in terms of staffing and even basic supplies, finally had some help to do his job. A consultant from Booz & Company did an extensive analysis of the ministry’s payroll of more than 7000 workers, which included all employees, even those who worked in remote health posts throughout the country. The analysis found more than 850 phantom workers, who were mostly retirees still receiving their salaries, however paltry. Those people were removed from the payroll, allowing the ministry to add 1000 new workers.This process was easier said than done. It could take months to add someone to the ministry’s payroll. But the ministry did not have months—or even weeks. Sandi instituted a fast-track process for hiring. Most of the new hires, it turned out, were already working as volunteers in district hospitals or clinics. Instead of waiting months for approval, Sandi instituted a new process in which people could be hired in a day. 6 weeks before the initiative was to begin, the country’s health workers went on strike for better pay and benefits. From the start, negotiations were difficult. The government had always assumed the health workers’ salaries would be substantially increased. But unresolved was who would pay for it. After more than 10 days of stalled negotiations, President Koroma authorised the Finance Ministry to use government funds to pay the increase in salary. The government offered a range of increases, which included doubling and tripling salaries. That act had a carry-on effect: donors, seeing the government commitment, increased their funding. DfID led the way, committing $16 million over 5 years, and $8 million for drug and supplies over the first year.In the days before the launch, the teams stepped up their work. Kargbo, chief spokesman for the launch, began to go on radio shows and hold press conferences. Key leaders in the ministry were assigned districts and each travelled to the areas a couple of days before the launch.
New era beginsAt dawn on April 27, 2010, mothers and their young children began forming lines outside hospitals and clinics around Sierra Leone. They were anxious to receive medical attention that had been out of their reach.At the Ola During Children’s Hospital in Freetown, President Koroma told a crowd in English and the local Krio language that pregnant women, breastfeeding mothers, and children younger than 5 years will no longer have to pay for health care in government facilities. When he said the words in Creole, people in the crowd shouted out in joy. “For many years, many, many pregnant women, breastfeeding mothers, and children under 5 [years] have suffered and died because they simply could not pay fees for consultations, drugs and other services”, Koroma said. “Today we are taking the biggest step ever to end this unenviable position.”Just minutes before President Koroma spoke, a 30-year-old woman named Marie Smart, delivered a baby boy by caesarean section in an operating theatre that was only 15 metres from where he spoke. Mother and child were healthy. She said later that she would name him Sallieu after her father. Asked about free health care, she said, “Thank God”.Her 22-year-old niece Ramatu Fofanah said it would have been hard for Smart to pay the hospital fees for delivery. “It’s a very important thing that the country has done”, Fofanah said. “People are too poor here. We know of women who have died giving birth in homes. One neighbour lost her life, and lost the baby, too, when she gave birth in her home. With this free medical care, so many lives will be saved.” In the month before free health care, an average of 170 000 children received care from Sierra Leone’s hospital facilities each month. In the months after free health care, the number exceeded 340 000, or double. “It’s a very clear indication that there were major barriers accessing health care”, DfID’s Mshana said. “For treatment of malaria in children, we’re seeing a three-fold increase. It’s quite stunning, staggering even.”The effort to bring free health care to Sierra Leone was not easy or simple, and ministry officials readily admit to making wrong decisions at points. In order to pull it off, scores of people worked long hours for months toward a single goal that they believed in. President Koroma, who now is looking at extending access to health care through health insurance, said believing in the mission was key. “You have to get people to go along with you”, he said. “After all, this was serious business that we were doing, this was not business as usual, where a pronouncement is made and they do things at the same pace. We set a deadline and we would meet a deadline.” He was not the only person encouraged by the results. Health-care workers, now earning a living wage, also expressed admiration for the broad effort, even as they struggled to keep with the demand.On that first day of free health care, the pharmacy at Ola During Children’s Hospital had run out of antibiotics, among other things. Yet, Matthew Barnes, a pharmacy technician, motioned out to the line of people waiting for him and said, “It is an incredible day—all these people are getting care, many for the first time.”* JD’s reporting was sponsored by the Ministerial Leadership Initiative for Global Health (MLI), based in Washington, DC, USA, and a programme of Aspen Global Health and Development. MLI supports the priorities of five ministries of health in the developing world, including Sierra Leone.
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