Living in Sierra Leone made me an angry woman

Sierra Leone is currently experiencing such a water shortage, that the human rights commission issued a worrying statement, saying that especially the capital Freetown is lacking water, largely unexplained and beyond the usual seasonal fluctuations. Fetching water from one of the community taps is usually task for the young children, who now have to get up as early as 4am to find a running tap or stay up late at night, roaming the streets for water. They are exposed to all manner of risks: drunkards, rape, injuries. At the same time, one of my international friends just excitedly announced that her swimming pool is up and running now. Disparities like this are part of everyday life in Africa, and they are difficult to digest, making ignorance a blissful alternative.

Or when the mid-level manager of a big UN agency, who regularly boasts of its humanity and printing posters of big-eyed black children receiving another dose of life-saving vaccination or food ratio, when that mid-level manager writes you in an email that you should really not put too much effort into this evaluation, as “in Sierra Leone, we don’t aim for perfection” and whatever effort you put in is “enough for this country”, after that manager has been in country for four months. A story, that the big-eyed black child on the poster could tell anyone who comes back after the intensive photo session, that actually there is no vaccination left at the clinic or the supposedly free food is sold on the market, because “in Sierra Leone, we don’t aim for perfection”. Sierra Leone should be more selective in what kind of people they allow to work on key development policies and programs, in the interest of their people.

Over dinner table with lots of food and wine, everyone complains about the inefficiencies and corruption within the UN system, a system that is immune of all national laws and can therefore not be audited. Money to the UN agencies is handed out based on political motives, not on performance, such as to give donors a bigger say in the UN. But yet, after dinner, we all gladly call our office sponsored drivers in white shiny SUV cars and let our alcohol-infused self be driven back home to our AC-powered bedroom. The next morning, in the office of our well-equipped NGO, we discuss again how to save Sierra Leone, having no idea how 90% of Sierra Leoneans actually live, because we remain in our little bubble, not willing to open our eyes and let go of white neo-colonialist privileges.

And in our nicely cooled down white shiny cars, we drive along nicely paved roads that were not built with our tax money, because internationals do not have to pay taxes here. We enjoy the roads, the best (even if still patchy) electricity supply of the country, pools filled with water from the public water company, but don’t feel like we should be paying for these public services. At the same time we rant about how government seems incapable to finance even basic social services, but we are not willing to contribute our own money to rebuild it. “Ah, they are too corrupt, you can’t give them any money”, is the standard excuse, turning a blind eye to the industrial corruption that is happening in the development world, where aid money is channeled through massively overpriced consultancies back to where it came from. Nobody questions an evaluation report about a big system change introduced by government that took the Western evaluator nearly two years to complete, who flew in and out of the country regularly, apart from the Ebola time, when it apparently was too dangerous to stay in luxury hotels and analyse data. Nobody questions the price tag of that lengthy analysis of secondary data, where everyone knows the quality thereof is questionable and primary data collection would have resulted in much more defined answers. Nobody questions that the outcome is a report where every page costs 3000 pounds and nobody in government is going to read it, even if they probably should. However interesting the findings are, does it justify the costs?

We also happily turn a blind eye to the privileges given to international staff because of “security reasons” or because “otherwise we wouldn’t be able to find good people”. Do we really want people to come and work in development who are primarily attracted by the prospect of an AC house with 24 hours electricity, a salary high enough to pay back the mortgage of a house in a year and a car with driver, sending back all the aid money he is living on to his international bank account? Or do we want to attract people who are willing to integrate into local communities, live like the ordinary middle-class Sierra Leonean with regular blackouts, the occasional water shortage, the joys of public transport and actually sharing the aid money that is financing all of that with its intended beneficiaries? I think the answer is a no brainer. Only if we live by example, we can claim to take part in the development process of this country. Actions speak louder than words, which is probably why the common man and woman on the street mainly associates NGOs in Sierra Leone with fancy cars, highly paid expats who are enjoying their weekends on the beach and the locals chance to get some job experience, even if only as support staff.

Their frustration for NGOs and the UN is only topped by frustration about the government. Understandably, when all they see government doing is putting flower pots in the middle of the street and installing traffic light signals, while the majority of them don’t have electricity, nor water, their housing is too crowded and not rain proof and there are no jobs. It explains what made one of my okada motorbike riders recently stop when he saw some government workers replenishing the flower pots, and shout at them that they are “pwel we moni”, misspending their (tax) money. I felt sorry and angry both for him and for the probably very low-level government workers, who were just doing their job. The people who took the decision, the people in power, hide in tainted glass vehicles with shaded number plates, they hide in their mansions on top of the hills of Freetown, or they hide in their relatives’ houses overseas, visiting their kids who go to school there. There should be a law that Minister’s children need to go to public schools and government officials have to use public health facilities – both would probably  improve in no time. The incentives that are set now are wrong and not encouraging progress.

Angri man nor get voice, angri man nor get choice. Emmerson, the Sierra Leonean social justice artist, sings about the fact that the man and woman on the street have no voice, because they either are not listened too or they are too scared to speak out. The song has become such a hit because it does exactly that: it gives a voice to the people, who sing along the song in the taxis, the cars, the streets. That also counts for me; I am an activist by nature, I want to move things, I want to change things, I want to be involved in politics and policy making, in moving and shaking. One of the statements that made me the most angry in the recent weeks, is when a Sierra Leonean man told me “you are not allowed to discuss politics, as you are not African”. How can I be silent, if I see the injustice staring at me everyday, either out of white shiny cars, or from the new traffic light, or from the neighbours’ house? How can anyone be silent and just ignore the water shortage, the power cuts, the housing and education problem, and keep swimming in the private pool?

My anger about the development sector is only topped by my anger about the Sierra Leonean police regulating traffic in the roundabout, stopping one lane, to let the other one pass for a while and vice versa. Don’t they know that roundabouts were built to be SELF-REGULATING and what they are doing is causing massive traffic jams?! Africa really made me a very angry woman. What gives me hope is that the best civil society movements started out of anger: anger about the treatment of blacks in the US, spurring women like Rosa Parks into action, anger about the prolonged detention of Nelson Mandela in South Africa was the beginning of the end of Apartheid, anger about the insufficiencies of the communist state of East Germany led into the falling of the wall. As long as there is anger, there is hope for movement and change, as soon as ignorance sets in, a blindness about injustice, the only hope remaining then is judgement day. Which also makes it very understandable that religion is opium for the people, keeping them calm and praising God for life, when what is needed is Sodom and Gomorrah. Sierra Leone is a very religious country, probably at least partly accounting for its peaceful and very friendly people. However, I also think it is part of the reason why civil society’s voice in politics is very quiet and a real quest for change missing. If all focus is put on life after death, heaven on earth becomes unnecessary. Which, again, makes me angry. We should never get to a point where we accept blatant injustice in front of our eyes. Never. Sierra Leone deserves better leaders, better international institutions and it also deserves, that I will be able to turn my anger into action, and not just ranting about it. I expect you to hold me to account for that!

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…di sun hot…

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When it is not possible to be ready to die

“People die here everyday, randomly and without good explanations.” I say this sentence in every longer conversation I have about Sierra Leone. It was always something very much matter of fact to me, just another statistic that I have saved in my head among the other key health indicators: maternal mortality 1165 per 100,000 live births, infant mortality 92 out of 1000, average life expectancy 48 years, GDP per capita 1500 USD per year, poverty rate 52%, 35% of pregnant women are teenagers, literacy rate among women 25%, ranking in the human development index: among the last 10 countries in this world. I am so used to these statistics, it doesn’t really move anything anymore in my mind, just some thoughts on how they were measured and if the right statistical approach was used. They are all screaming out that something is terribly wrong in Sierra Leone, that life years are wasted, families regularly hit with disaster and confronted with sickness and death.

I was never someone who was moved a lot by death. For me, the time of my and every one else’s death does not lay in our hands and is out of our control. I believe that we have a life after death and that death is just another milestone in this universal existence. In highschool, the best essay I wrote was titled “The aim of life is to be ready to die” and I lived according to it. The aim of life is to be ready to die. When it was someone’s time to reach that milestone, I normally thought that it was more or less justified and that life for us continues. Grandparents die after a long life, last stage cancer patients die after long treatment, only in rare cases are there exceptional deaths. My grandfather is receiving palliative care after few years of heavy medical interventions that kept him alive, including a bypass heart surgery ten years ago. His body has long been ready to die, but modern medicine wasn’t allowing this, giving his soul time to reach the point where he is ready to die. You do not get that time in Sierra Leone. There is no modern medicine, there is no working health system with heavy medical interventions and bypass heart surgery. You can be lucky if the clinic you are consulting with your pains has a qualified nurse who happens to be around and some painkillers in the shelf who are not expired or stocks just happened to have run out.

I was never someone who was moved a lot by death. I realised that people attend funerals regularly here in Sierra Leone, I realised that people tend to die younger than what I know from Switzerland. However, when one of the uncles of my closest friend died of Ebola or when the father of my night guard suddenly had to be rushed to hospital, dying of unknown causes and making my strong young guard crying out loud, I didn’t feel a lot. I didn’t feel a lot when the father of one of my best friends here died and avoided going to the funeral (it was Ebola times, after all, is what I told myself). I didn’t feel a lot when people kept commenting on the fact how lucky I was to still have both of my parents alive (why should they be dead, they are only in their fifties anyway?!). I just had my wake up call, literally. I woke up at 4am this morning to a text message from Kapry, saying that his sister in law has passed away. She was the wife of Lansana, whom I know well, the mother of an 18 month old girl who likes to dance to Nigerian music and she was my age. She was not ready to die and she shouldn’t have. Sierra Leone let her down and Sierra Leone also let the other 3500 women down who died during the last year in childbirth of preventable causes. Sierra Leone also let the 25,000 children down who die every year before they reach their 5th birthday. We let the 4000 people down who died because of Ebola, but a similar epidemic (even worse – as it is endemic) is happening in Sierra Leone in the front of all our eyes, written in all statistics. People are dying here all the time, randomly and without good explanations. And they are not given the time to be ready to die, they have not lived their life to the fullest of their possibilities, they have not had time to accept their fatal illness or had time to note down how they would like their funeral to happen. Sometimes, it is not possible to be ready to die – and it is up to us to change that, for everyone, especially in Sierra Leone.

I apologise for my ignorance so far. I apologise that it took me two years of living here to be shocked at a message of death. I apologise to all Sierra Leoneans and Africans for not giving you the time to be ready to die. Rest in peace, Madame Marie Kabbah, and thank you for waking me up from my ignorance. Let us hope and pray that your daughter will reach her 5th birthday and live way beyond that, enough long to be ready to follow you to where you are now.

Wachet auf, freie Schweizer, wachet auf!

Liebe Schweizerinnen und Schweizer,

Ein Leben ohne Leidenschaft ist nur eine leere Huelle. 

In meinen Ferien in der Schweiz wurde meine Leidenschaft fuer die Schweizer Politik wieder geweckt – wir leben in so einer spannenden Zeit, wo Aengste ueberhand nehmen, elitaere Gruppierungen brainwashing machen und die Komplexitaet der Probleme dazu fuehrt, dass viele Personen einfach sich ausklinken aus den Diskussionen und aus dem Leben. Das Leben ist um einiges einfacher und ueberschaubarer wenn ich mich nur um das Ablaufdatum der Milch im Kuehlschrank kuemmern muss und nicht um die Asylanten im naechsten Dorf. Aber wart mal – lass mich das nochmals formulieren: Das Leben ist um einiges einfacher und ueberschaubarer wenn ich mich nur um das Ablaufdatum der Milch im Kuehlschrank kuemmern muss und nicht um die Mitmenschen im naechsten Dorf.

Got it? Geschnallt? Wer hat sich ausgesucht, in der Schweiz geboren zu werden? Wer hat Sierra Leone gewaehlt? Wer Syrien?  Ich zumindest habe nicht gewaehlt – ich wurde einfach so privilegiert, weil ich im 1988 am ersten Schneetag im Jahr im Aargau geboren wurde. Wir haben ein Geburtsprivileg, dass uns dazu befaehigt, anderen weiter zu geben und zu teilen. Die Schweiz bietet uns politische Mitspracherechte, die absolut aussergewoehnlich sind. Wir schulden es unseren Mitmenschen in Syrien, Lybien und Tschad, dieses Recht wahr zu nehmen und die Schweiz verantwortungsvoll mitzufuehren. Lass uns eine offene und warmherzige Schweiz sein, die weniger privilegierte Menschen aufnimmt und von unserem Grundschatz abgibt. Wir wollen mehr sein als einfach nur ein reiches Land, wir wollen reich sein an Mitgefuehl, Grosszuegigkeit und Akzeptanz. Wir wollen eine Schweiz, die wach ist und am Geschehen der Welt mitfuehlt und Teil der Loesung ist. Wir wollen eine Schweiz sein, die sich auf ihre humanitaeren Wurzeln stuetzt, die Arme ernaehrt, die Waisen schuetzt und Obdachlose aufnimmt.

Wir wollen freie Schweizer sein: frei von Vorurteilen, frei von Fremdenhass, frei von Aengstemachern. Wachet auf, freie Schweizer, wachet auf!

Das ist meine Leidenschaft. Was ist deine?

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An update on the Sierra Leone Social Health Insurance

  • Overview of Sierra Leone Social Health Insurance

 

The Sierra Leone Social Health Insurance Scheme (SLeSHI) is about sustaining Free Health Care in Sierra Leone and ultimately reaching Universal Health Coverage. Beneficiaries of any of the free health care initiatives (pregnant and lactating mothers, children under five and people suffering from Malaria, TB or HIV/AIDS) will all be exempt from premiums. However, the financing structures to pay for their treatment can be part of the wider financial structure for Government provision of public health care. In this way, the scheme should both help Government raise money for health care and create the unified structures necessary for Government to buy into health care that is currently largely donor funded.

  • SLeSHI: Progress and achievements

 

The Government has constituted a Technical Committee comprising of representatives from both Government institutions and partners to design SLeSHI. A blue print has been developed, pilot districts selected (Bo and Koinadugu), institutional arrangement approved whilst the benefits package is being designed. Additionally, preparatory work is at an advanced stage for an impact evaluation that will not only assess willingness and ability to pay for the scheme, but will also provide the baseline that will be used to assess the impact of the scheme after the pilot. A pre-pilot was conducted in rainy season and the questionnaire was administered to health workers, communities and patients. Furthermore, it was planned to use mobile credit vendors as a distribution channel for the insurance policies. The method was tested at some vendors and their feedback obtained. The premium is yet to be defined, but if there could be found a way to pay smaller amounts regularly, the system using the mobile credit vendors could be a success.

A facility assessment is being planned in order to provide an overview on the situation of the facilities in the two pilot districts. The assessment will include public, private and faith-based facilities and also hospitals, laboratories and community-led referral system. The general infrastructure of the district (transport, communication, human resources) shall be analyzed too. The facility assessment could also be done through desk analysis, using existing findings.

  • SLeSHI: Outlook and recommendations

SLeSHI was paused due to the Ebola outbreak. The President assigned the lead of the project to the Ministry of Labour and Social Security to re-commence progress.

Another option that has come up during the pre-pilot in the field, was to make it a two step process and change the design slightly. In a first step and to encourage people to use the facilities again, all drugs at primary care level could be made free. Apart from the free health care drugs, the amount of drugs distributed at primary level was USD 200,000 in 2013. It would probably be possible to make all drugs free for a cost of less than USD 1,000,000, which could be a very cost-effective way to increase trust into government facilities again. However, another approach would be to redesign the Free Health Care Initiative slightly to target the poor. This could work through the Performance-Based-Financing PLUS scheme, which would pay higher subsidies for vulnerable patients. Making all drugs free could on the contrary be regressive (anti-poor) again.

In a second step, secondary care could be included in an insurance scheme. During the pre-pilot, it became clear that a lot of people go directly to hospitals or are referred to hospitals because they can’t be treated in PHUs. There is a need to cover this cost.

In the academic discussion, a voluntary insurance scheme which SLeSHI would most resemble in its current design, is regarded as not effective, nor efficient. Administrative costs are high and in the case of SLeSHI would have constituted more than 100% of the premium for each insured. That means that SLeSHI would create additional administrative structures but not address the issues on the ground of quality of care. Furthermore, the effect of health insurance in Africa is currently at the heart of the debate and results from existing insurance schemes are discouraging. The current SLeSHI design as it stands has to be reviewed carefully in order for it to achieve its target of better and wider access to care and protection against health risks.

A review is planned to take place in 2015 to assess the feasibility and options for a National Health Insurance in Sierra Leone. The advice of the technical personnel being involved so far is to hold on for now and focus on other ways to strengthen the health sector. In essence, SLeSHI would cost more than raise for Government and likely fail to reduce poverty.

An update on Performance Based Financing of health facilities in Sierra Leone

  • Overview of Performance Based Financing

 

Performance Based Financing (PBF) was introduced in all 1200 public health clinics and selected private clinics in 2011. It is funded through the Reproductive and Child Health Project from the Worldbank and has so far sent about 15 Million US Dollars directly to facilities, who have invested 40% of that money in upgrading and maintaining the facility and the remaining 60% as incentive for staff performance. The project was externally verified through Cordaid in 2013/2014, who found increased motivation of staff and that small investments were being done, but also large disparities in data collected, weak financial management structures and generally low knowledge and capacity in the scheme.

With support of Cordaid, the Ministry has now developed a plan to move towards PBF PLUS as a first step to strengthen the health system in the Ebola recovery phase. PBF PLUS is addressing the weaknesses of the existing scheme and aims to increase transparency and governance, as well as ownership of the Ministry in the health sector. It addresses some of the key issues of the ministry such as low quality of services, under-financing of the health sector, weak coordination and decentralization and low transparency.

 

  • PBF light

The current scheme is called PBF light, as its design is not fully reflecting PBF standards. It resembles more a payment scheme with some pay-for-services elements. It has been administrated from national level, with verifications being done by the DHMTs. The scheme will be upgraded slightly in 2015 to prepare the health system for the move towards the PBF PLUS.

The PBF light scheme is an integral part of service deliveries at PHU level. Health workers motivation is highly linked to PBF payments and the direct cash flow has allowed basic maintenance and investments. The World Bank has been funding the PBF scheme through the Reproductive Child Health Project 2, which runs until October 2016. From the beginning, the idea has been that Government buys into the PBF scheme and starts contributing to service delivery at primary level using the PBF. However, the World Bank remains the only funding source and the scheme is now running out of money. RCHP2 allocation is enough to pay incentives up until the end of March 2015, which means that facilities will receive money up until about October 2015, as payments are done after delivery of services. There is an urgent need to raise 2.1 million US Dollars to keep paying the facilities or find another solution for the future of the PBF light.

 

  • PBF PLUS

The PBF PLUS scheme is implementing a full PBF structure with clear separation of functions, higher autonomy of the facilities while having regular supervision, a comprehensive indicator list and feasible prices being paid for services and quality at facilities. The payment structure is going to be simplified in order to decrease payment delays. Clear separation of functions (Verification, service delivery and payment) leads to greater governance and transparency. The Ministry can easily take ownership of the indicator list and quality checklist and guide the health service delivery in the direction it wants. At the same time, results are clearly visible and can be tracked.

The PBF PLUS will be piloted in Bombali in the second half of 2015 before being evaluated and rolled out nationwide. The idea is that Government is flowing part of their budget for health through the PBF and strengthen primary and secondary care services through a clear performance approach, where facilities who perform better also receive more money. The total funding needed is 24 Million US Dollars, where among other donors the World Bank is willing to contribute, if the Government buys in as well.

(Un)happy birthday, Ebola! How a financing scheme can restore the health system of Sierra Leone

A year after the declaration of Ebola in Sierra Leone, we are looking back and reflect on our lessons learnt, while fighting the last few remaining cases. It is simple to explain why Ebola could get out of control so easily in Sierra Leone. The reasons range from underfinanced health system, lack of medical education, not having enough staff to weak governance and coordination. We recognised that Ebola was spread and fought in communities. Being plain honest: I have been thinking a lot that we probably wouldn’t have ended up in such a chaos if more money would have flown directly to health facilities and therefore communities. They could have protected themselves as much as possible and would have had incentives keep providing essential health services, while feeling protected. There is an example of a Maternal and Child Health Post in Gbongboma who constructed a holding center out of palm trees, to the best of their abilities. Initiatives like these finally allowed the spread of Ebola to slow down – interventions at community level. They need to be at the heart of any recovery strategy.

As part of the post-Ebola recovery plan, Sierra Leone is implementing a performance financing scheme. The Performance Based Financing (PBF) scheme is paying incentives to health workers and investments for health facilities based on its number and quality of services provided. It is more than “just” financing: it is a systems approach, improving quality and quantity of services through regular supervision and agreed targets. Service provision, verification, supervision and payment function are clearly separated, hence increasing accountability. The reputation of Sierra Leone’s Ministry of Health and Sanitation has been questionable before Ebola and the unaccounted one third of Ebola funds as highlighted in a recent audit report did the rest. Donors are not trusting the Ministry, which meant that a large part of the Ebola fight was outsourced to more reliable partners. The Performance Based Financing scheme is an opportunity to restore trust in the supervising Ministry as well as providing much needed funds for essential health services. A results-based approach means that monthly updates will be provided on the indicators covering a comprehensive package of health services, only paying for actual services delivered. The performance framework guarantees that health workers who work harder and better, also earn more.

Maybe the most important aspect of the scheme is its strong voice for patients and communities: patient satisfaction surveys are essential part of the scheme and will influence the incentive payments. This is a much needed addition in the Sierra Leone health sector, where it generally is a challenge to get patients adequately represented and listened too – even though they are the main stakeholders in the health sector. Community committees are part of the designing of business plans of health facilities. Let them decide, what they need and want from their health service provider. This way, they can prepare themselves for other epidemics and do not need to wait on the central level Ministry to intervene.

The PBF is restoring trust of patients in the health system through increasing its quality and social marketing strategies. It also motivates and equips health staff again to do their work, while leaving them the autonomy to manage their own facility. Cash injections into the community through the health facilities increase local ownership and also have economic multiplier effect: the local carpenter can pay the school fees of his daughter with the profit he makes from fixing a delivery bed, for example.

The total funding needed for the next five years of recovery in Sierra Leone is up to 1 Billion US-Dollars. Spending money through a results-based approach like PBF is four times as efficient as traditional input financing, which means that any dollar raised to help Sierra Leone recover from Ebola is best spent through PBF, making it equivalent to four dollars otherwise spent. In a pilot PBF scheme running now, 1.2 Million US-Dollars are sent over six months directly to 110 health facilities. Small money relating to the overall recovery strategy, big money for the receiving facilities. Bringing market approaches to the health sector doesn’t make it evil: it is a necessary move to make it work more efficient, effective and transparent. All attributes are much needed in the Sierra Leone context.

PBF Verification in Makeni

PBF Verification in Makeni

The hospital secretary and the financial officer of Princess Christian Maternity Hospital in Freetown

The hospital secretary and the financial officer of Princess Christian Maternity Hospital in Freetown

The 10 commandments of health financing following the results of the National Health Accounts 2013

The results of the 2013 National Health Accounts are drawing a picture of funds in the Health Sector in Sierra Leone: where do they come from, how do they flow to which provider and end user. 10 commandments can be drawn from that survey as recommendations for the health sector.

SUMMARY OF RESULTS OF NATIONAL HEALTH ACCOUNTS 2013

The government of Sierra Leone allocated 11.2% of the national budget to Health in 2013, the highest percentage in the 6-year period beginning in 2008 and an increase from only 8.5% in 2012.[1] Total health expenditure (THE) in Sierra Leone in 2013 amounted to Le 2.5 trillion, or the equivalent of approximately USD $590 million. Of this amount, the government contributed 6.8% of those funds. Donors contributed 24.4% of this spending, and NGOs 7.2%. Out of pocket (OOP) expenditures by utilizers of the health system (households) made up the vast majority of spending, at 61.6%. THE per capita in 2013 was USD $95.10, with donors contributing USD $23.20, GoSL and NGOs $6.50 and $6.80 respectively, and OOP again contributing the greatest share at $58.60 per capita. Out of pocket health expenditures are a heavy burden on household finances, and catastrophic unanticipated health care expenses are a driver of continuing poverty for households in the country.

The greatest amount of expenditures in 2013 went into public hospitals, follow by PHUs (37% and 28% respectively) – combined, the two levels of public health service delivery capture over two thirds (65%) of total health expenditures. Private health facilities captured 9%, pharmacies 4%, and only 3% supported administration / government health administration agencies. This reflects the reality that the majority of health care is provided by the public sector. 85% of all expenditures went into care seeking – 65% going to outpatient curative care and 20% to inpatient services. 10% went to information, education, counseling, and other preventive care programs, with only 2% supporting administration.

While government and NGOs spent around 40% of their contributions on children under 5, Donors spent over half (60%). In contrast, only 20% of OOP expenditures went to under-5s. This reflects the implementation of the Free Health Care Initiative, which is supported largely by donors and is intended to reduce the burden of health care costs for women and children on households. This picture indicates that FHCI is reaching its goals in reducing household expenditure on health care for the target groups, and releasing funds for treatment of older children and adults. However, the high overall OOP expenditures also indicate that households are still struggling despite the reduced burden, and the majority of Sierra Leoneans are not covered under FHCI.[2]

RECOMMENDATIONS FOR HEALTH SECTOR IN SIERRA LEONE

Key recommendations for senior decision-makers are:

1) The high Out-Of-Pocket expenditures show the need for further reductions of user fees, which is also in line with government strategy as stated in pillar 3 of the Agenda for Prosperity.

2) Government expenditures on health as percentage of total government expenditures need to be increased from currently 11% to 15% in order to comply with the Abuja target.

3) In 2013, GoSL was contributing less than Donors and NGOs to total health expenditures. In order to increase sustainability, Government is advised to take ownership and increase their contribution to the health sector.

4) In order to increase cost-effectiveness, it is advisable to spend more on primary care than secondary and tertiary care. Currently, 60% of funds are flowing into hospitals, while 40% are spent on primary care clinics.

5) Every tenth Leone is spent in a private facility. Government is encouraged to invest in public-private partnerships to yield some of the benefits of the private sector while satisfying demand of people.

6) In 2013, epidemiological surveillance and disaster and emergency preparedness were hardly financed, which explains the weaknesses encountered during the fight against the Ebola virus. In order to mitigate that risk in the future, financial investment in that area is needed.

7) Only 3662 Leones (approx 60 cents) per capita were spent on capital investments, such as infrastructures, buildings or similar. Capital investments are the foundations for stronger and more robust health systems for future generations and should be invested more.

8) Both NGOs and Donor organisations are contributing significantly to the Free Health Care Initiative. Maintain the good relationship between NGOs, Donors and GoSL for the continued implementation of the Free Health Care Initiative.

9) National Health Accounts are an annual event to inform Government and key stakeholders about the state of the health sector from a financial perspective. Government can draw part of the Health Financing Strategy and Policy out of this document and should ensure the regular occurrence of the NHA.

10) A large proportion of Government expenditures on health are spent on staff, however, there is still a shortage of health workers, especially in the higher cadres. Government is to invest additional funds into training of health care workers and develop retention strategies both to keep workers in country and at their work station. Make sure to not pay workers who are not showing up at their work station and provide incentives for hard working and well-performing staff (e.g. through Performance Based Financing).

[1] Preliminary expenditure report, Budget 2009-2014, MoFED

[2] MoHS, Sierra Leone National Health Accounts 2013

Some Q&A at the height of the Ebola outbreak in Sierra Leone

Interview of Maria Bertone held in November 2014 with the Directorate of Policy, Planning and Information of the Ministry of Health and Sanitation in Freetown

  1. Introduction

Noemi Schramm, Acting Unit Head & Health Economist, Health Financing Unit, DPPI, MoHS, GoSL

https://www.linkedin.com/profile/view?id=112471512&trk=nav_responsive_tab_profile

  1. Interview questions

From our offices in Europe, reading daily Ebola updates and news, we tend to imagine that nowadays a city like Freetown, the capital of one of the countries most affected by the outbreak, Sierra Leone, would look like as a barren, empty, post-apocalyptic town. Perhaps our perceptions shaped by the footage of the “lockdown” (http://vimeo.com/106806835) – when a three-day curfew was imposed on the entire country of Sierra Leone to allow volunteer to go house by house to sensitize the population and track down suspect Ebola cases (LINK). For those who know Freetown and West Africa in general, it was shocking to see empty roads and such eerie quietness.

How does the city look like today? What is the dominant atmosphere? Is everything close down or are shops and markets open and people fill the streets as usual and report regularly to work?

Life is going on as normal – with some small limitations. People are not shaking hands anymore, taxis and poda-podas (mini buses used for public transport) are less crowded and clubs are closed at night. However, people are still selling, buying, going to work, organizing their lifes, visiting family and friends and catching up with the latest football news. As most of the small cinemas showing football games are closed now, people with TVs in their house have become popular! Churches and Friday prayers are still allowed to happen and people spend significant times following religious services. As schools are closed, there are more children on the street either playing or selling things. So yes: life is bustling as normal during the day, but probably a bit quieter in the evenings. However, this obviously also depends on what community you live in. There have been isolated disturbing scenes in the East of Freetown, but the city never collapsed as much as Monrovia did. There were no public riots, no panicking public. Sierra leoneans are very resilient.

What are the main challenges for people’s daily life in Freetown?

Paying for food. Food prices have gone up and combined with less jobs or less secure jobs available, providing for the daily needs is even more of a challenge now. Furthermore, the situation in some rural parts of Sierra Leone is devastating and people are asking their family members in the city for increased help, which puts further pressure on people’s already limited financial resources.

This is a song circulating on the web (http://www.youtube.com/watch?v=0bo8s98t_g8). Have the information and community awareness efforts on Ebola improved people’s knowledge of the precautions? And if so, what were key determining factors (community health workers, social media, media, …)? Did the “lockdown” play an important role?

Everyone has heard of Ebola. However, the level of knowledge differs, as well as the level of belief in the messages. People still think that bushmeat is one of the major sources of transmission, even though there has only been one confirmed case of animal to human transmission. People are hearing the Ebola messages all day long, but sometimes it is just not possible to implement them – they might live in very crowded places, sharing latrines (if even available), eating food out of one pot or not having enough water to wash (hands) regularly.

The lockdown was called a success, but infection rates are still soaring. My impression is that a lot of people know some facts, but if it comes hard to hard, if your husband or your mother or your child is screaming in pain in your house and the free toll line 117 is not answering your calls for help for hours, everyone is a human. There are not enough treatment beds, so people are being sent home with very basic instructions on how to take care. Often, there is no other option than to touch the patient, with limited protection possible.

What do people in Freetown think of the international response? Too little, too late, or …? How do they see the international and domestic health workers with their PPE space suits, etc.? Is trust in the health system increasing or not, or is it too early to tell?

There is a general sense of disappointment. The British response is very slow, of the six treatment centers promised only one is opened and only working on a 10% capacity – three weeks after the opening. It is not understood what takes them so long to build treatment centers and what makes them turn away patients. There is a sense of a two-class treatment – with international workers getting evacuated quickly and being provided medical care (on board of the Argus, the military ship), while Sierra Leoneans are left to die in their houses. All Sierra Leonean doctors that got infected with Ebola died so far (one still fighting for his life at the time of writing). It is also not understood how the UK can invest so much money into fighting the disease here and at the same time cancel flights – the cancellation of the British Airways flight beginning of August started a whole chain of panic that probably cost the Sierra Leonean economy more than what is given every year in aid money.

The PPE space suits are scary and are carrying a message of death. People know that when somebody like this is carrying away your loved one, chances are high that you might not see that person again.

Trust in the health system has been weak pre-ebola and was still recovering from the civil war, when the outbreak hit. It will take time to rebuild and continue to strengthen the health sector. However – this time around the whole health sector is hit, including traditional healers. So instead of previously choosing traditional healers over public health care, people are now choosing no health care over the possibility of being infected with Ebola.

Some argue that the presence of urban slums and their mobile populations play a role in the spread of the Ebola epidemic (http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70339-0/fulltext). Which factors do you think allowed Ebola to spread so fast and widely in Sierra Leone?

Part of it is the dense population and uncontrolled movements, but also the lack of organization on community level. Poor areas were just left on their own with limited interventions from top-level. There is a need for way more community-based Ebola response centers, which can actually track each individuals.

Furthermore, there are lots of really bad decisions being done on the politics side of the ebola response. Unnecessary power fights (in government, between national and international partners, etc) do not help containing the outbreak.

We understand that new Ebola cases are now diminished in the provinces where the epidemic started (Kailahun, Kenema, ..), but there are increasing in other provinces (Port Loko, Bombali, …). Do you have an idea of the situation in the remote villages of those provinces? DO you have a sense that a ‘turning point’, the peak of the epidemic has been reached somewhere, and the worse is to come elsewhere? What about Freetown?

Some villages in the original epicenters are now starting to rebuild their communities. Fields have been abandoned, family structures changed, market situations are deteriorated. Some villages have come up with their own recovery strategy and are working towards rebuilding their communities. However, my impression is that the new epicenters are still very much in a panic mood. The turning point has not yet been reached. Especially in Freetown – it is difficult to see the light at the end of the tunnel.

What is happening at the Ministry of Health and Sanitation (MoHS)? Is everyone regularly reporting to work? Is staff screened for fever or other symptoms?

Staff is coming to work regularly and a lot are working hard to contain the disease. People are generally tired after having been fighting for more than half a year.
Security measures have tightened, there are chlorine buckets everywhere and thermometers that are used sporadically.

I read that a new National Ebola Response Center (NERC) has been established on the premises of the former Special Court for Sierra Leone (10-15 minutes drive from the MoHS in Youyi building), in order to ensure coordination in the efforts to fight Ebola. Have some staff or Departments of the MoHS been seconded or moved there? What is the role of the MoHS in the Ebola response? What is the role of the major international organizations (UNMEER, WHO, CDC/USAID, DfID, NGOs, Global Fund, GAVI, etc.)? How is the coordination/cooperation happening in practice?

Yes, some staff has been seconded to the NERC. Some staff has been seconded to the call center as well. MoHS was told by the president to focus on our usual work and continue with the previous projects as much as possible. This is good, as it is important to keep providing other services as well, however, it led to power fights as the doctors and MoHS feels undermined. A lot of money is channeled through the UN agencies now, after some initial problems with GoSL structures. UNFPA is responsible for contact tracing, Unicef is a logistics hub, World Bank is paying hazard pay to health workers, Red Cross and World Vision is responsible for the burial teams. The burial teams were previously managed by the Directorate of Reproductive and Child Health of MoHS, which obviously didn’t make sense at all. It was outsourced now through a contract. NGOs in cooperation with Ministry of Social Welfare is taking care of orphans and survivors. Coordination and cooperation is happening at NERC.

I noticed that the new MoHS website (http://health.gov.sl/) is very much focused on the Ebola response, and there is little on the other programs. The DPPI is usually quite busy with the management of the health information system (HMIS) on the one hand, and with the planning and managing of numerous health financing issues – you manage the country-wide Performance-Based Financing (PBF) system, you are preparing the National Health Accounts report, discussing the future of health financing in Sierra Leone, etc. What is the DPPI working on today?

We have been pushing hard to keep existing projects going, especially the PBF scheme. It is of utmost importance to 1) get money to clinics which they can use for general Ebola protective gear for example and 2) incentivize treatment of non-ebola diseases. However, it was difficult to persuade donors and partners that it makes sense to not stop all non-ebola activities. But up till now the PBF scheme is running, which is a success in itself. Furthermore, the NHA report is in its final stages and was just verified in a validation workshop with stakeholders, data validation was done on the HMIS, etc. The data system is important now, as it tells us about utilization of public health facilities. We have done some analysis and found no significant differences up until September, where utilization started dropping significantly. We are still completing October data. DPPI is very busy and also involved in the post-ebola strategy. Field missions have been completed and ideas are now being thrown around on how to rebuild the system.

There are many calls in blogs and discussions not to forget the importance of broader health system strengthening efforts in the fight of Ebola. Some estimate that the excess non-Ebola related deaths are substantial as people decide not to seek treatment in health facilities (LINK). What do you think are the main issues and challenges for the health system in this emergency? Are there health systems strengthening efforts that can be taken while addressing the Ebola emergency? What could be done / you are doing to support health system strengthening at the moment, and what should be done in the future?

Keep existing programs going – look at the PBF scheme. Inform policy makers on the health system now with all data available to allow for thorough planning of post-ebola strategies.

What do you think will be crucial to end this Ebola outbreak?

Behaviour change. I hope that the continued soaring of Ebola is a wake up call and people finally start being responsible for their families and neighbours and stopping the transmission change! Furthermore, I feel like the huge inflow of humanitarian emergency money has spoilt the health workers. More patriotism is needed and a higher sense of duty and responsibility for Sierra Leone. For the international community: stop looking in your own four walls and start thinking globally – this disease has to be defeated here. Panicking and stopping flights are not helpful. Stop the stigmatization of West Africa(ns) and send any help you can.