Mile 91, Sierra Leone – The morning sun has yet to spill through the clinic windows and Dr. Peter Koneh reviews the patient registry by the light of his cell phone. The fear of Ebola has subsided, despite new cases of in July that put this district in the global spotlight, and patients are returning to the five-bed Hinistaas Community Health Center. The facility doesn’t have electricity, water or even a toilet, yet it remains the best hope of survival for many of the 84,000 people living in Tonkolili, Sierra Leone’s rural core.
Ebola brought international attention to the country’s fragile health system, which had an upside for this clinic. After three months of lobbying district officials for Ebola relief, the facility now has a surplus of drugs for the first time in years. But the biggest hurdles to providing quality care remain, and Koneh doesn’t see that changing anytime soon.
“It has been very difficult, even with the donor partners,” he said. “They will come and tell us that power and water are the government’s responsibility. Then you go the to the district medical officer and they will say it’s a funding issue and we have to deal with the problem. People are dying here because of these things.”
The 2013 Mo Ibrahim report ranked Sierra Leone’s health system as the fourth-worst in Africa, despite large-scale investments from the international community after the country’s 11-year civil war. Government officials, civil society groups and health workers say missteps in development strategies paved the way for Ebola to overrun the country, and if efforts are not reevaluated, Sierra Leone will forever remain vulnerable to catastrophe.
“The truth came out when Ebola arrived,” said Victor Koroma, director of the civil society group Health Alert. “Everyone was in pandemonium, helter skelter. NGOs were criss-crossing, and the government officials were saying conflicting things. There was no coordination because health has not been seen as a priority in this country.”
While local and international efforts grappled with containing Ebola, other health issues went unchecked as people’s fears of the virus compelled them to avoid hospitals and clinics. A recent study by the Liverpool School of Tropical Medicine showed a 30 percent increase in maternal mortality rates during the outbreak and the number of stillbirths in the country rose by 24 percent. Children treated for malaria dropped by 39 percent, according to ministry of health data, and HIV and tuberculosis are on the rise as well.
Sierra Leone has the highest maternal mortality rate in the world, according to 2013 WHO figures. But some progress was made after a Free Health Care initiative was adopted in 2010. It provides pregnant women, new mothers and children under 5 with free access to health services.
Foreign aid paid for most of the initiative, but funding doesn’t solve everything. Free Health Care’s implementation has been rocky. Some health workers have been caught demanding payment from those covered by the initiative to make up for poor salaries, and others have had to turn patients away because of drug and equipment shortages.
“That was the mistake during the launch of Free Health Care,” said Alhassan Bakarr Kamara, project manager of the Health for All Coalition. “Some schools of thought figured removal of fees was the only issue, neglecting the quality of care aspect of it, which is as critical as the removal of fees themselves. ”
UNICEF volunteered to handle drug procurement and distribution through the initiative’s first three years, after which responsibility would be turned over to a newly designed government agency. Still, distribution problems lingered.
Drugs were distributed based on population rather than consumption patterns, and many communities with higher illness rates complained to the Ministry of Health and Sanitation that they did not receive enough medicine to combat their area’s health issues. Other less disease-prone areas reported having a surplus of drugs for which there was no need.
UNICEF handed procurement and distribution responsibilities over to the newly formed National Pharmaceutical and Procurement Unit (NPPU) in April 2014. Sierra Leone began recording Ebola cases a month later and the fledgling system was quickly overwhelmed.
By November, the U.N. was reporting large disparities in the availability of essential drugs across the country. Only 9 percent of facilities had access to chlorine and 87 percent reported a lack of protective gear. Ministry officials blame NPPU’s failures on a lack of coordination among the ministry and development partners and say they are currently in the process of overhauling the entire system.
Dr. Abu Bakarr Fofanah, Sierra Leone’s minister of health and sanitation, told lawmakers in June that the greatest threat to the post-Ebola recovery effort was not a lack of funding or foreign partners, but the ministry’s inability to coordinate the numerous players in a way that caters to local and national priorities. Ministry officials believe this largely stems from a lack of transparency surrounding foreign aid.
“We know how much money comes in for Ebola because it was announced, but if you go to the beneficiaries on the ground and try to account for what actually entered, you’ll never be able to get to the bottom of how and where each penny was spent,” said Dr. Samuel Kargbo, director of health systems, policy, planning and information at the Ministry of Health and Sanitation. “If we’re not allowed to put their contributions under the microscope, it may not end up in the right place.”
Koroma agreed with Kargbo’s assessment, adding that foreign agencies tend to bring in their own experts, staff and consultants, with the bulk of funds donated by individuals going to maintaining the agency’s presence in the country. The biggest flaw in their methods, he said, is a lack of community input and ownership in the projects donors are financing.
“Donors have their own plans, designs and goals,” he said. “They go implement these projects themselves while leaving the community out, and sustainability becomes a problem. Because at the end of the day, the project ends and nobody continues the project.”
Community engagement was critical in tracking Ebola contacts. Tracking squads were ineffective once they moved out of their home communities. It wasn’t until teams began hiring local youths exclusively that their respective districts were able to reign in missing contacts and fleeing patients.
“Community ownership is critical and we saw that in the fight against Ebola,” Kamara said. “As long as donors continue to force large, blueprint projects on the people of this country, they will continue to be white elephant activities. It has to be a holistic engagement with the government and local community people. Otherwise those projects will continue to be unsustainable and the people will not continue to support them.”
The Ministry of Health recently began adopting what they call Service Level Agreements in an effort to encourage further donor-community engagement. These agreements require donor agencies to first have a dialogue with community members to outline their needs before designing a project, scouting out local workers to assist with implementation.
After the project is approved by community leaders, the plan is sent to the Ministry of Health, where it is evaluated by a finance team and then a team of ministry directors. If both teams endorse the plan, it is sent to the minister for final approval. Only then can donors begin to implement the project.
Kargbo says the new process “will go very fast and no one will ever complain that their proposals are slow because they go through us.” But bureaucratic hold-ups are endemic on all sides of the Sierra Leonean health sector.
Dr. Koneh has three nurses working along side him at the Hinistaas Community Health Center but only one has ever been paid. The other two have worked for years without pay, caught in limbo while they wait for their titles to be officially filed with the ministry. Koneh himself only began receiving his salary in 2009 after waiting nearly five years for his position to be officially documented.
Although he makes little more than $100 a month, Koneh regularly shares with the other staff to encourage them to keep working. He says it’s his patriotic duty to make sure the clinic stays staffed and that despite the lack of incentives, he has a personal obligation to press on.
“The first health worker to die of Ebola in this country was my own sister, Messi Koneh,” he said. “She died in abject poverty because she did not have gloves to treat patients with. Those who went to the burial, who took part in the ceremony, all of them died. … The aim is to never do harm to any patient, but in these conditions you just can’t help everyone. Health can’t be about money.”
Messi Koneh was one of 152 health workers killed by the virus in Sierra Leone. Before the outbreak the Ministry of Health estimated that approximately 400 doctors and 1,300 nurses were working in the country – a far cry from the 3,300 doctors and 8,000 nurses it would need to meet international health standards.
“We have nurse and midwife training centers, some by the government and some by development partners, all across the country,” Kamara said. “But recruiting those people who have been trained is a big problem, bringing them into the mainstream and retaining them.”
Post-graduate education for health workers is nonexistent in Sierra Leone and few return after getting specialist training elsewhere. There are two cardiologists, one psychiatrist and one orthopaedic surgeon living in the country, all of whom work in Freetown.
The Ministry of Health says the human resource deficit stems from a lack of funding, and in September Kargbo wrote an op-ed for the Irish Examiner requesting an additional $896 million in Ebola relief aid. But the national health budget was reduced from 10.2 percent to 9.2 percent in 2015 and Kargbo, Koroma and Kamara agree that a large portion of funds allocated are never disbursed.
Sierra Leone gives away three times the health sector’s budget in tax exemptions for mining companies each year and neither the government nor donor partners can say for sure how much Ebola relief money came into the country. Kargbo advocates for a donor fund-monitoring scheme, but Kamara thinks there’s more to it than that.
“It is critical that we hold donors accountable for what they do for the people of this country,” he said, “but it does boil back to government’s intention of having that done. … Ebola taught us that we need a better-equipped health system. If things don’t drastically change in the 2016 budget, we will know that they didn’t learn their lesson.”