Pic: the APC party rallying today.
Pic: us standing for the arrival of the President, in the middle of the table. I am the pale woman on the very left.
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!
“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.
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?
Oldie, but goldie: Mein Jahr 2012 war ein wildes Abenteuer.
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.
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 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.
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.
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.
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.
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.
Die Oecnews hat in ihrem Alumni-teil einen Einblick in mein Leben hier in Sierra Leone veröffentlicht: