A little summary of the CIA school project: how far have we come in four years?

HOW DID IT ALL START?

The Community Initiative Academy (CIA) was started in 2010 by the people of Nyandeyama, Kenema District, Sierra Leone, because there was no junior secondary school (JSS; comparable to Sekundarschule in Switzerland) in the town with more than 40,000 inhabitants. Pupils had to go to nearby Kenema (200,000 inhabitants), that had three secondary schools – also by far not enough to satisfy demand. Starting with 50 pupils in 2010, five years later the school had grown to 120 pupils but was struggling with finishing the school building with three classrooms, and paying the teachers. The Government of Sierra Leone had approved the school for assistance, but the ‘assistance’ had been limited to payment of one teacher. The infrastructural needs, the land, the other teachers, the books and uniforms were paid through a combination of community contributions (mostly in kind), the village chief’s contribution from his own pockets and small school fees levied on the pupils (25,000 per term, USD 2.70, or about USD 8 for a whole year of schooling).

In 2015, a proposal to collaborate landed on the desk of Noemi Schramm, who had by then spent nearly two years in Sierra Leone and was supporting different projects on an adhoc basis. She was employed by the Ministry of Health and Sanitation and was working as health economist on various projects to increase access and affordability of health services to the wide populace. However, one of the recurring key problems in her work stemmed from the lack of quality education – how are people supposed to know what to expect from a hospital, what an acceptable amount to pay for treatment is, or what basic prevention could help prevent Malaria? In a country with the world’s highest maternal mortality rate, and one of the worst child mortality rates,[1] interventions to drive those rates down needed to come from all sectors. The research is clear – if you want to save a child’s life, educate the mother[2].

The educational system in Sierra Leone was still rebuilding its infrastructure and human capital, after a decade of civil war, that destroyed a lot of the schools, and led to a generation missing out on education. While there was good progress being made in primary school enrolment, secondary schooling remained expensive and often simply not available[3]. Furthermore, the general outcomes of schooling were embarrassing for a country that used to be called ‘the Athens of West Africa’ for its high standard educational system, up until the 1970s, when it rapidly started declining. The literacy rates are still incredibly low, leaving more than half of the women and 4 out of 10 men not able to read or write a full sentence.[4] There was and still is a big case for investments in education – something that the recently newly elected government had recognized and therefore launched the Free Quality Education initiative, paying school fees and examination fees and school books for all government schools, encouraging partners to also prioritize investments in education.

Back in the office of the Health Financing Unit in Youyi Building, Freetown, Noemi was working on initiatives to provide cash to all 1300 public health facilities nationwide and evaluating the outcomes of the cash transfers. The outcomes clearly showed that solving locally identified problems had a much wider impact than a centrally imposed project. It was obvious – the communities and facility staff knew best what they needed to further improve service delivery. As soon as they were given the money, solutions were implemented cheaper and faster than a centrally led project ever could. It was these kind of experiences that shaped her belief that the most effective and efficient way to support communities is to identify strong, trusted leaders of those communities, and entrust them with the cash necessary to implement their home-grown projects. No NGO, no UN agency, and no government agency can identify, plan and implement projects better, faster and more cost-effective than an invested community with good leadership.

The letter for support to the Community Initiative Academy (CIA) was written by the board of the school, consisting of community members, and signed by the wife of the local chief, Madam Margaret Suwu. She is recognized in her community as a champion for women’s and girl’s advancement, and serves as a role model. She spent her time, resources and energy on building the school, and keeping it running. In 2015, it came to a meeting in Nyandeyama, five hours from Freetown, where it was agreed that Noemi, with support of her family and friends in Switzerland, would support the finishing of the three classrooms that the community had started constructing, as well as paying stipends to teachers, to serve as a part of the salary. Noemi and Margaret did not like the approach of sponsoring individual pupils, as this often overlooks the broader issues of lacking infrastructure, or lacking incentives for teachers to actually show up for their lessons. By paying a teacher’s salary, that teacher was able to teach several hundred pupils, having a much wider impact than sponsoring a single pupil alone. In short, we were paying teachers to teach a whole village.

 

…AND HOW DOES IT WORK?

 

The support was agreed to be time-limited, to incentivise the school to establish itself and provide schooling options to the thousands of primary school finishers, while working on getting more support from government. Having been approved as a government assisted school meant that the central and district government should provide teacher salaries, as well as books and learning materials. However, due to bureaucracy and political and ethnic differences, it can take several years (up to ten years) to enjoy the full assistance of government. The support of the Swiss friends should ensure that pupils can undergo secondary school in the meantime, and also help build a base of future supporters of the school (alumni who went to further education and then give back).

Inspired by Noemi’s lectures at the University of Zurich on behavioural economics, and recognizing the importance of setting the right incentive rewarding mechanisms, a performance bonus was instituted as part of the support. If the school would rank in the top three of the annual exams conducted nationwide at the end of junior secondary school, every teacher and the school in general would receive a bonus. The teachers were also monitored in terms of their punctuality, and monthly stipends are only paid if teachers appear to classes on time – usually a big issue in Sierra Leone.

The same studies and her experience in the health sector also taught Noemi that the most effective way to improve developmental outcomes are cash transfers. Inspired by programs in Mexico and pilots in India, she decided to setup the support with as little involvement of her as possible, leaving the main decision-making in the hands of the community, and applying the same principles of a conditional cash transfer program for households in Mexico to the CIA school in Nyandeyama, Sierra Leone.

A separate bank account was opened for the school, in order to allow for full financial transparency and accountability. Noemi sends the stipends at the end of every month, and the school returns signed sheets for each payment. Once a year, a full financial statement is prepared, and a joint audit of school finances is conducted. In the first four years of the project, there has never been a financial mismatch, and every Leones (the local currency) was invested to maximize its impact.

The general day-to-day running of the school is in the hands of the principal, a well-trained and educated teacher, with experience running schools. He works under supervision of Margaret, the wife of the chief, who is the chairperson of the board. The board, which includes Margaret, village elders, religious leaders and parents’ representatives, governs the overall setup of the school and strategic direction. Noemi’s role is fundraising and setting financial incentives that improve the overall impact of the school. All support and all projects are co-financed, meaning the community has to contribute too. For infrastructural projects, that means the community is providing the land for free, some labor and some materials, while the financial support pays for the rest. For teachers, that means that they are all paid on performance and receive a smaller salary if they do not perform well. Co-financing projects ensures that only projects are implemented that have full community ownership and are a clearly prioritized need. It does slow down the pace of development, but it is a necessary step to ensure sustainability – given that maintenance has to be carried out by the school itself. They should only take on as much as they can handle.

In 2017, an opportunity arose to partner with a secondary school in Effretikon, Switzerland, and create a school partnership. This involves letter friendships between the pupils, who are paired up and exchange letters three times a year. The Swiss pupils raise funds once a year, to support the fitting of a new classroom, or the distribution of pens and notebooks to all before Christmas. The letters serve as a practice in English for both sides, as they are both non-native English speakers, and at a similar language level. It also provides fascinating insights into the lives of children on the other spectrum of the Human Development Index[5], raising the global awareness of how similar we all are, despite income differences. Especially the Swiss pupils have been deeply impressed by the exchange, and both sides are equally joyful when the letters arrive. It has created a human bridge between two countries, just by exchanging words on paper, and highlighting similarities in dreams and hopes for the future.

As part of the school friendship, a teacher during her sabbatical leave came for a month to teach the teachers of CIA school. She lived on campus, sharing the joys and frustrations of daily life with the boarding school kids, and talks about her experiences here: Ms Pia is telling us about life in Nyandeyama

Following this pilot project, the plan is to motivate at least one Swiss teacher a year to come and provide training to the teachers and serve as intercultural ambassador between Switzerland and Sierra Leone.

BUT, THIS IS ONLY ONE SCHOOL – ARE YOU REALLY HAVING A BIG IMPACT?

When the collaboration started in 2015, the school had 120 pupils. Due to the financial incentives that promote performance, the school was then able to not only finish its class rooms, but also started improving its performance at the annual exams, and has in the last three years consistently been ranked in the top three secondary schools in Kenema, and the best community school. The other two schools are private schools limiting enrolment to those who can afford higher fees. The increased quality of the school and excellent performance meant that the school has gone through rapid growth, now schooling 450 pupils. Its fame is known beyond the village, and pupils from across the district want to attend the CIA school.

From the monthly support for teacher’s salaries, a small part is retained for capital projects, which – together with one-off donations of Swiss friends – allowed for the school to add eight more classrooms, a library, solar-power across the school, and most recently a boarding house for ten girls and ten boys. The boarding school was established to allow for talented pupils from rural areas in the district with no access to secondary schools and no financial means to continue schooling. It is also a problem in Sierra Leone that children from rural areas are sent to relatives in urban areas for schooling but are then largely misused as housemaids and cheap laborers, which was a problem CIA wanted to address.

This implies that the impact expands beyond Nyandeyama, into rural villages of Kenema and even Kailahun (neighbouring) district. Talented pupils with no financial support by their families are given fee exemptions and school materials. The first set of CIA alumni are finishing university now, and will form a support circle to give back to the school and allow more pupils to benefit from secondary school. The graduates have gone into jobs with the government, the mining and agricultural sector as well as the health sector. They support their families back in Nyandeyama, thereby slowly improving the overall economic situation of the village.

In total, since the start of the collaboration, a total of 300 pupils finished three years of secondary school, and 450 are currently being schooled. This was possible with a total support of USD 29,440 as of the end of 2018, or USD 74 per graduated pupil – for the whole three years of secondary school! The cost-effectiveness is much higher than similar projects, due to the high commitment of the chief, his family and the whole community, and their contributions. It also meant the administrative efforts on the funding side is minimal – the project basically works as a plain cash transfer, just setting the structures and incentives in a way that ensures quality educational outputs.

 

MONEY BUSINESS – WHO PAYS HOW MUCH FOR WHAT?

Seven Swiss friends of the CIA school (shout out to Adi, Moni, Thomi, Edith, Corine & Maetthu) are currently supporting the project with in total USD 840 per month. USD 640 goes to the school every month, with USD 540 paying for teachers’ stipends, and USD 100 paying for the food of boarding school children (20 children in total). The remaining USD 200 are withheld for bigger infrastructural projects, and paid for specific projects, such as additional classrooms, a school garden, solar lights, a library, a fence or whatever is deemed necessary by the school board. All of the donations go fully to Nyandeyama, any administrative work involved is kept at a minimal level and done on a voluntary basis. With increasing interest of funders in Switzerland, and also recent successes in accessing more support from the Government of Sierra Leone (9 out of the 29 teachers are now paid by the Government), more of the support can be channelled towards a bigger project: the setting up of a sister school to the CIA school, in a remote village called Dia about one hour drive from Nyandeyama. It would bring secondary education to another chiefdom of Kenema district, an even more rural part than the one where CIA School is, and also lay the foundation for a network of secondary schools to be run in rural areas of Sierra Leone.

The contributing friends were initially asked to commit for about three years, until the government absorbs the teachers. Given this has happened recently for some of them, all donors were offered to stop contributing or reduce their payments. None of them agreed – they want to continue funding education in Sierra Leone, and have committed for another round of pupils to go through school.

There are enough plans that are waiting to be implemented: currently the school board has commenced the process to be accredited as Senior Secondary School as well (comparable to Gymnasium/Kantonsschule in Switzerland). This involves a different set of teachers, extra chemistry labs and equipment, and further investments in additional classroom space. The need for more schools is clear – there are currently only three such schools in the whole district, serving a population of close to 800,000. But in the usual slow yet sustainable pace of the CIA board and community, with financial support from Switzerland, this project will also be realized fully in the next three years – ‘inshallah’ or ‘by God in powa’, as they say here. Let’s make sure we achieve SDG 4 by 2030!


[1] WHO estimates the maternal mortality rate at 1,360 women dying out of 100,000 giving birth, and every 7th child does not survive its fifth birthday. To compare, in Switzerland, the rate is every 240th child doesn’t survive its 5th birthday, and 5 women die in childbirth out of 100,000 births.

[2] There is a large amount of literature spanning decades on the effect of mother’s education on child survival, for more recent studies, see for example Guenes, P. The role of maternal education in child health: Evidence from a compulsory schooling law. In: Economics of Education Review, 2015 (August), 47, p 1-16; or Grepin, K. and Bharadwaj, P. Maternal education and child mortality in Zimbabwe. In: Journal of Health Economics, 2015 (December), 44, p 97-117.

[3] According to the National Census 2015, net enrolment for Junior Secondary School is 21%, and more boys than girls attend JSS.

[4] According to the National Census 2015, the literacy rate for men is 59% and for women 43%.

[5] Switzerland is in the top ten countries, while Sierra Leone is in the bottom ten countries of the Human Development Index.

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To the hero of 2018: the nurse serving in rural Sierra Leone

Imagine yourself being a nurse, earning USD 110 a month, which makes you the main breadwinner of a family and extended relatives, married to a daily wage worker, who more often than not won’t find work. You have two children – a son and a girl, who you work hard for to keep in school, paying all formal and informal fees necessary. Then your employer, the government, posts you to a veryvery remote area, more than 8 hours from where your family lives, in an area with a different tribe and local language, with no warning, in the middle of a school year, and expecting you to resume work in your new duty station within two weeks. You are not given any relocation or transport money, but are expected to pay this out of your salary. You are also not given any salary increase – even though you could really use that, given you will have to continue to pay for your children’s home. You reach your new duty station via public transport and motorbike, and face a dilapidated staff quarter, barely any drugs available for treatment, and a community that is suspicious of this person from the capital. The chief sees you as his personal mistress, allowing him to sexually harass you, and given he is the local authority, who do you complain to?! The journey home to your family costs a third of your monthly salary, so you only go back once a quarter, and even though you wish you could bring your family to your new duty station, there are no schools in close reach – or the quality of the local school is not up to standards. Even to access your monthly salary, you have to travel 3 hours to the district capital, if you are lucky enough to be banking with a bank that has a local branch. To call your family, you have to walk 15 minutes to a spot that has network coverage. Once or twice a year a delegation from the district capital comes on supervision, and intimidates you with pages of checklists telling you a hundred things you need to change, of course with zero additional resources.
When you go back to visit your family, you know you are risking lives in the community where you serve, because no one is there to cover for you. Furthermore, when you finally see your children and husband again, you realize that he has found himself a mistress in the meantime, and you don’t appreciate the suspicious strangers walking in and out of your home, with vulnerable children being there.

Sounds grim, no? This is the reality for more than 500 nurses in Sierra Leone, serving in the most remote health facilities. 81% of all rural health workers are female – often having no other options but to comply to postings, as they lose their job otherwise.
I doubt anyone who is reading this post would agree to such work conditions, yet in Sierra Leone, these nurses still serve their communities in hard-to-reach, barely equipped health facilities, with small salaries and lots of demands placed on them. I have spent a lot of time in the last few months working with the government to better recognize, reward and motivate these health workers, and given that the majority of them are women, we spent time with communities, local authorities, health workers and policy-makers to discuss gender-specific issues. It is horrifying, and humbling, to hear all their stories, and to understand their struggle and their fight better. Female health workers in remote areas are my heroes of the year – and they deserve to be much more recognized for their sacrifice and service to this country. They are some of the strongest women that walk on this earth. I am sorry I have not seen your struggle earlier, and I salute you for your bravery and your service. You are heroes.

 

Sofa-Geschichten von den Lion Mountains

Was oder wie wurdest du erwachsen? Wann und wie hast du die Jugend hinter dir gelassen? Was war das Uebergangsritual? Fuer mich war das Zeichen von “Erwachsensein” immer ein grosses, schweres Sofa. So etwas macht dich traege, es wird schwieriger umzuziehen, es ist eine finanzielle Investition, es braucht noch mehr Moebel um richtig benutzt zu werden. Kurz: es macht das Leben komplizierter. Einige von meinen Freunden investierten schon mit 18 in grosse, teure Sofas – Ich mag mich noch gut an das Panikgefuehl in meinem Magen erinnern, wenn ich daran dachte, mich so niederzulassen. Ich habe daher im letzten Jahrzehnt entweder kein Sofa besitzt, oder das guenstigste Ikea-sofa gekauft (100 Franken, ein echtes Schnaeppchen), oder einfache Bamboo-sofas besitzt (weniger als 200 Franken fuer drei Sofas, auch ein echtes Schnaeppchen). Das Bamboo-sofa, das ich die letzten fuenf Jahre in Sierra Leone benutzt habe, hat Abel hergestellt. Er wurde ueber die Jahre ein guter Freund, und ich habe ihn an einige andere Leute weiterempfohlen. Er hat mir dafuer gedankt, in dem er eines seiner Kinder nach mir benannt hat. Es wurde aber ein Junge, also musst Naomi umgeaendert werden in die maennliche Form – was anscheinend “Nami” ist. Nami bedeutet auf Krio auch “Das bin ich”. Wenn ihn also jemand fragt, wie er heisst, dann antwortet er “Nami / das bin ich”. Etwas verwirrend, aber es scheint ihn nicht zu stoeren!

SOFA EINWEIHUNG

Also, zurueck zu Sofas. Nami’s Vater hat mein erstes wunderschoen farbiges Sofa hergestellt, das ich nun fuenf Jahre lang benutzt habe, und drei Mal gezuegelt habe. Ich habe kuerzlich herausgefunden, dass ich nochmals fuer mindestens vier Jahre in Sierra Leone sein werde, die Gruende dafuer erklaere ich euch sonst mal. In dem Moment habe ich auch realisiert, dass ich soweit bin – ich getraue mich nun in ein grosses Sofa zu investieren, mich niederzulassen (zumindest fuer vier Jahre), offiziell meine Jugend hinter mir zu lassen und das Gewicht eines Sofas auf mich zu nehmen. Eine Aethiopische Freundin hat ein grosses graues Sofa kreiert und zusammen mit Sierra Leonischen Schreinern hergestellt.
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Photo 1: Blen, die Sofadesignerin mit meinem neuen Sofa. 
 
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Photo 2: Die offizielle Sofa-Einweihungs-Sonnenuntergang-Snack-&-Drink Feier.
Ich habe gestern eine kleine Einweihungsfeier organisiert, mit Sonnenuntergang Cocktails, um diesen Anlass gebuehrend zu feiern. Jayne’s Kommentar: “Ah super, die letzte Einweihungs-feier die ich hatte war fuer einen Kirchenaltar – das Essen hier ist besser!”

JUNGE DAME

Obwohl ich den Eindruck habe, dass ich aelter werde (in weniger als einem Monat werde ich 30!), gibt es da auch andere Meinungen – vor allem an meinem Arbeitsort, im Gesundheitsministerium. In den letzten Wochen haben mich verschiedene Leute auf dem Gang mit “Guten Morgen, junge Dame” begruesst. Das passt mir aus verschiedenen Gruenden gar nicht, und ich habe diesen Leuten jeweils gesagt, ich bin nicht mehr so jung, und ueberhaupt sei mein Name Madam Naomi, was ja bekannt sei. Am Freitag habe ich mit anderen Leuten auf ein Meeting mit dem Gesundheitsminister gewartet. Der Vize-Gesundheitsminister kommt dazu und begruesst mich mit “Guten Morgen, junge Dame”. Ich blieb freundlich, aber habe auch ihm erklaert ich sei nicht mehr so jung, und er wisse ja meinen Namen. Er lachte und meinte “du kannst ja noch nicht 40 sein” – was ich zustimmen musste. Anscheinend sind alle unter 40-jaehrigen offiziell noch jung in Sierra Leone. Wenige Minuten spaeter laufen wir in das Buero des Gesundheitsminister, und er begruesst mich mit “Guten Morgen, grosse Dame”. Ich sag ihm, dass ich das besser finde als “junge Dame”, worauf er lacht und sagt “du kannst ja nicht aelter als 37 oder 38 sein, oder?”. Nachdem ich ihm erklaert habe, dass ich noch nicht ganz so alt bin, meinte er: “na, das heisst du bist noch ein Baby – ich habe gedacht du bist mindestens 37, mit der Arbeit, die du leistest”. Was ist so schwierig daran, mich mit Madam Naomi anzusprechen?! Mein Gesicht muss ihm deutlich gemacht haben, dass ich nicht sonderlich erfreut darueber war, “Baby” genannt zu werden. Als ich nach der Sitzung mich verabschiedete, sagte er “Auf Wiedersehen, schlaue Dame”. Besser!

BOOTSTOUR

Meine Abenteuerlust ist ungebremst, ob ich alt oder jung bin. Wir sind kuerzlich auf Besuch in den Distrikten, um unsere Distrikts Personalangestellten zu unterstuetzen und coachen. CHAI (wo ich arbeite) hat der Regierung geholfen, diese Reform einzufuehren, und das Personalwesen im Gesundheitswesen mehr zu dezentralisieren, naeher zu den Kliniken zu bringen, und damit die Transparenz und Rechenschaft zu foerdern, und gleichzeitig bessere Gesundheitsdienstleistungen anzubieten. Ich bluehe auf auf diesen Reisen ins Landesinnere, einerseits weil es sehr motivierend ist, die Veraenderung vor Ort zu sehen, und andererseits weil immer mehrere Abenteuer auf mich warten.
Auf unserem Trip vor ein paar Wochen mussten wir mit dem Boot auf die Bonthe Insel fahren, wo das oeffentliche Spital ist. Bonthe ist einer der entferntesten und am schlechtesten entwickelten Distrikten. Ich habe diese Bootsreise vor ein paar Monaten schon gemacht, aber immer nur mit einem eigens gemieteten Schnellboot, fuer 200 Franken, hin und zurueck, je 45 Minuten. Dieses Mal haben wir uns entschieden, die “Faehre” zu benutzen, die nur LE 15,000 kostet pro Person – weniger als 2 Franken, fuer die 90-120 Minuten Ueberfahrt, mit zwei Haltestellen auf anderen Inseln. Die richtige oeffentliche Faehre wird nicht betrieben und rostet vor sich hin, da die Betriebskosten zu teuer sind. Dafuer benutzt man ein hoelzenes Boot, das einmal pro Tag hin und zurueck faehrt. Die Regeln auf dem Boot sind klar angeschriben, und Bussen definiert. Ich mochte diese Regel am meisten: “Ich will kein Geschwaetz – Busse LE 50,000 (ungefaehr 6 Franken)”.
Wir sind also auf unsere Bootstour mit einer Ziege, einem Motorrad, 30 Passagieren und viel Gepaeck. Zwischendurch haben wir an einer “Raststaette” Halt gemacht – und konnten geraeucherte Shrimps, Nuesse oder Fische kaufen. Neben mir war ein junger Mann, dessen einzige Aufgabe war, das Wasser auszuschoepfen, das konstant stieg im Boot. Jede halbe Stunde war er wieder fuer zehn Minuten mit Wasser schoepfen beschaeftigt – meine Fuesse wurden kein einziges Mal nass, und wir kamen heil an.
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Photo 3: Am warten auf die Faehre in Yargoi. 
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Photo 4: Einsteigen! Das Motorrad ist auf dem Dach. 
 
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Photo 5: Ich will kein Geschwaetz – Busse 50,000. 
 
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Photo 6: Haltestelle, und Verpflegung mit geraeucherten Shrimps. 
 
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Photo 7: Auf der Bonthe Insel. 
 
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Photo 8: Am Schweizer Apfel essen, waehrend dem ich auf die Autofaehre nach Mattru warte!
 
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Photo 9: Das Team in Mattru. 
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Photo 10: Das Team mit dem Vize-Buergermeister in Bonthe.  
Ein weiteres Merkmal von Erwachsen-werden ist Weihnachten ohne Familie zu feiern. Wegen voellig ueberteuerten Fluegen, und anderen geplannten Reisen, werde ich dieses Jahr nicht fuer Weihnachten in die Schweiz kommen. Es wird mein erstes Mal ohne meine Familie sein – und ich spuere zu gleichen Teilen Respekt und Aufregung darueber, in Sierra Leone zu sein ueber Weihnachten und Silvester. Weihnachten hier sind viel weniger kommerzialisiert, was sicher erfrischend sein wird. Ich habe eine Woche frei, also falls mich jemand im garantierten tropisch warmen Wetter besuchen kommen moechte, nur zu – ich wuerde mich freuen!
Danke, an euch alle, dass ihr Teil meines Erwachsen-werden seit und Geduld mit mir habt!

Sofa-stories from the Lion Mountains

What is your own sign of growing up? What was the step that made you feel like you have left youth behind and moved into a new sphere? Like an initiation into adulthood – how does or did this look for you? For me, the symbol of settling down is a heavy, expensive sofa. It will make you want to move around less, it is a financial investment, it requires some other furniture to go with it. Some of my friends had the guts to get a sofa at the age of 18 – I remember the feeling of panic that grew in my stomach when I imagined having to buy a sofa myself back then!
So for the past decade, I have either not had any sofa, bought the cheapest and smallest Ikea sofa that was available (100 bucks, a real catch) or have lived off cane furniture the last five years (a whole sofa set for under USD 200, also a real catch). The latter is made by the apt Sierra Leonean Abel – Abel and Cain/cane, rings a bell? He has become a friend over the years, and I have recommended him and his business to many other people, to which he thanked me by naming his child after me. It was a boy though, so the name Naomi wasn’t fitting – he turned it into Nami (which in Krio means “this is me”). Nami is now nearly three years old, and he is talking, a conversation that goes like this:
Someone: “Hi little man, how are you?”
Nami: “fine, tell god tenki”
Someone: “and what is your name?”
Nami: “Nami”
Someone: “yes, but what is your name?”
Nami: “Nami!”
Someone: “yes, I know this is you, but what is your name?!”
Nami: “Mi name Nami!”
Someone: ??
I really feel sorry for inflicting this confusion on Nami – but he seems to grow up strong and healthy, so I am confident he will fight off any confusion easily.

SOFA INAUGURATION

So, back to sofas. Nami’s father made me the first beautifully colourful sofa in Sierra Leone, which has lasted me five years. I have recently found out that I will be in Sierra Leone for another four years – for reasons I cannot explain to you yet – and that was the moment I realized that I am ready. I am ready to invest in a sofa, to settle down (at least for four years), leave youth behind me and carry the weight of a heavy sofa around my neck (figuratively). An Ethiopian friend of mine designed and built a massive grey sofa with storage unit and colourful pillows together with talented Sierra Leonean carpenters and upholsterers.
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Photo 1: Blen, the designer, on the new sofa. 
 
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Photo 2: Snapshot from the official sofa inauguration sunset drinks and snacks event.
I had a little inauguration event of the sofa, to mark this significant event – to which Jayne commented: “Ah nice, the last inauguration event I have been part of was for a church altar – food is better here!”

YOUNG LADY

While I think I am growing up and growing older (less than a month to go before the big #THREEZERO hits me), clearly the folks in the Ministry of Health think differently. Several people have greeted me with “Good morning, young lady” in the corridor the last few weeks. Something about this really works me up, and I have replied quite harshly to all of them that I am actually not that young anymore and anyway, my name is Madam Naomi, in case they have forgotten.
On Friday, I was waiting with a group of other people for a meeting with the Minister, when the deputy Minister of Health came out and greeted me with “Good morning, young lady”. I tried to remain friendly, but also told him that I am actually not that young anymore. He laughed and said but I can’t be 40 yet – which I had to agree to. Seems like anyone below 40 is considered young in Sierra Leone. Few minutes later we are walking into the Minister’s office, and he greets me with “Good morning, tall lady”. I told him this is better than “young lady”, to which he laughed and said but I can’t be more than 37 or 38? When I told him I haven’t reached there yet, he said “well, that means I should call you baby – I just thought because of the kind of work you do you must be at least 37”. What is wrong with just calling me Madam Naomi?! My face must have clearly told him that I do not approve of “baby” – when I left he said “Good bye, smart lady”. Small victories.

BOAT TRIP

No matter if I am young, deemed young, or old, my thirst for adventures is never quenched. We recently went on supervision, to support district Human Resource Officers and assistants across the country to better manage and motivate the health workforce. CHAI (where I work) have helped government implement this reform to further decentralize the health system, and increase transparency and accountability, as well as improve service delivery.
I thrive on these trips, not just because it is very rewarding to see the change on the ground, but also because there are all sorts of adventurous experiences that make me feel alive. On our recent trip, we had to cross to Bonthe Island, which is where the government hospital is for Bonthe district, a very remote and challenging district for service delivery.
I have made this journey before, but always in chartered speedboats, which take you across in 45 minutes, but also cost about 100 dollars, one way. This time, we decided to take the “ferry”, which costs LE 15,000 per person – less than 2 dollars, for the 90-120 minute journey, with two stops on other islands in between. The actual government ferry is not used, as the fuel costs of running it are too expensive – so a wooden boat is used instead. The rules are clearly indicated on the top, with fines attached to it. My favourite one was “I don’t want palava – fine 50,000” / “I don’t want any gossip/big talks – the fine is LE 50,000 (about 6 dollars)”.
We headed off on our journey with a goat, motorbike, 30 people and bags on board. We stopped at a “service station” and were offered smoked shrimps, fish and nuts for sale. Right next to me, there was a guy solely responsible for draining the water that filled the boat in regular 30-minute intervals – whenever the water was just about to reach my feet, he started pouring it out again. I thoroughly enjoyed it.
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Photo 3: Waiting for the ferry at Yargoi. 
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Photo 4: getting on the ferry. Note the bike on top of it. 
 
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Photo 5: I dont want palava – fine 50,000. 
 
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Photo 6: pit stop on the way, to buy smoked shrimps. 
 
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Photo 7: On Bonthe Island. 
 
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Photo 8: Eating Swiss apples waiting for the ferry to Mattry, sponsored and delivered by Rachel!
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Photo 9: Team in Mattru, at the District Health Management Team offices. 
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Photo 10: team with the deputy Mayor on Bonthe Island. 
The other part of growing up is not celebrating Christmas with family – because of expensive flight prices, and other planned trips, I will not come to Switzerland over Christmas this year. It will be my first time celebrating without my family, and I am dreading it, while at the same time being excited to be in Sierra Leone for this celebratory season. I have some time off, so feel free to come join me here over Christmas! Beautiful warm weather guaranteed 🙂
All of you – thanks for bearing with me while I am growing up!

Presidential-stories from the Lion Mountains

What story would you like to hear today:
a) how I ended up being followed with a photographer and a journalist for week; or
b) how I spent four hours sitting at a table with the President of Sierra Leone, worrying about my hair; or
c) why I started making chocolate; or
d) how I got stuck for half a day in the jungle close to the Liberian border?
I’ll leave d) for another blog post, as it is a beautiful little story – but that still leaves you with three choices, so choose well! Sierra Leone is in the election fever – presidential and parliamentary elections were on 7th March, the run-off is on the 27th March, and the current president – Ernest Bai Koroma – can’t stand for another term after 10 years or ruling, so there will be a change of leadership. Politics in Sierra Leone have been largely dominated by two parties – a green one and a red one (no connection with what we assign with these colours), the one from the South-East and the one from the North of the country. Party membership is often based on tribes and origin, and not so much on policies. It is always funny asking strong party members about the main difference to the opposition party and guess what – both would say “we are less corrupt than the other”. But that is the only perceived difference, making political discussions here very interesting. However, this time around, a third party emerged, with a very eloquent, charismatic and smart leader (guess where my sympathies lay…), who has forced the conversation into a bit more of “what actually needs to happen to move this country forward, and who has the best ideas for that?”. For the first time in history, there was a presidential debate with the six major candidates, which was streamed live on all radio stations, TVs and internet – and I had a (very emotional) blast listening to the various candidates’ ideas for speeding up development of Sierra Leone. One candidate seriously promised to improve the whole health system within three weeks – that sounds like a task for superman and wonderwoman.
There was also this ‘obama’-moment, when the same eloquent, charismatic and smart candidate gave his closing remarks – giving me goosebumps with “you touch one, you touch all”. For those of you who understand Krio, enjoy it here: (well spent 3 minutes, trust me).

 

Pic: my living room, just before the presidential debates started! The TV belongs to Elias, in case you wondered.
Being the President of Sierra Leone is a multi-million dollar job (a year…) and a way more influential position than we know it from our countries, so it is no wonder that the campaigns are fought hard and with whatever the candidates have. It is common practice to pay people money and give them a t-shirt with the party colours and symbols to go out on the street and rally for a certain candidates. So the strength of the different rallies are a good indicator of how much money each party has. See here for some insights from my balcony:

​Pic: the APC party rallying today.
 
Anyway. I am sure you’d like to hear about b) how I ended up sitting at a table with the President of Salone for 4 hours, worrying about my hair. Well, the very next day after the presidential elections, I went to the same venue where the debates were held, attending the launch of the social health insurance scheme of Sierra Leone. You probably know that I have worked on this extensively in my first two years in Sierra Leone, but then Ebola changed everything and other people took over. However, the President wanted to launch this before the end of his term, to leave it as one of his legacy projects. There were about 500 invited guests in the Bintumani conference center, with a big stage and high table at the front, including a red satin chair for the President.
Pic: the Bintumani conference center with the high table, for the launching of the Social Health Insurance. 
​Now, quick explanation – Sierra Leonean events or programs or workshops or trainings or birthdays or award nights or anything that is significant in life should have a high table, where distinguished dignitaries sit and give speeches, before the beginning of the actual program. This can easily take half of the total assigned time of the program, or even most of it. Without it, a program is not deemed ‘official’ enough and lacking ‘the appropriate weight’. So, high tables it is.

Well, sitting at the very back, I enjoyed watching all the paramount chiefs (there are 144 nationwide, and they are the key leaders on the ground) walking in their fabulous outfits, enjoying the feeling of being where just 12 hours before, the presidential candidates were for their debates. The program starts and Ministers are called up to the high table, leaving the red seat for the president. I suddenly hear my name being called “Naomi” and a finger being pointed at me, with several hundred heads turning to watch the white woman turning red. The lack of alternatives led to me being called up to the high table, supposedly giving a speech on behalf of development partners and observing the etiquette required around a head of state. Needless to say, I was not prepared and worried about what I would say and do and how to not get kicked out of the country by the President because I could tell him I actually don’t think that Social health insurance is a good idea now. Apart from worrying about my hair (I didn’t wash it in the morning, shame on me…) and worrying about my posture (all the TV cameras make nervous), I tried to get the message across the chairman, that I can’t give a statement, due to non-preparedness.

Pic: us standing for the arrival of the President, in the middle of the table. I am the pale woman on the very left. 
 
You won’t believe how many nerves it cost me, to be sitting at that table for four unexpected hours – do you pretend you are taking notes, when they make inappropriate jokes about the opposition party? Do you smile when they all clap for the president, can you clap as well – even though you represent all health development partners? What face are you supposed to make on a high table, when the President says something you completely disagree with? You can see the dilemmas and mind battles I was having, while on a bigger adrenaline rush that any caffeine or similar pill could give you. I did say “Congratulations for a bold initiative” to him afterwards, and left it at that. Time for a glass of wine…
I think I have rambled on enough and we will leave story a) and story c) for another post…

Praesidenten-geschichten von den Lion Mountains

Welche Geschichte moechtest du gerne lesen?
a) wie ich eine Woche lang von einem Fotographer und einem Journalisten auf Schritt und Tritt begleitet wurde; oder
b) wie ich vier Stunden lang an einem Tisch mit dem Praesidenten von Sierra Leone sass und mich um meine Frisur sorgte; oder
c) warum ich angefangen habe, Schokolade zu produzieren; oder
d) wie ich einen halben Tag lang im Regenwald festsass nahe der Liberianischen Grenze?
Ich spare d) fuer ein anderes Update, weil es eine nette kleine Geschichte ist. Aber das heisst, du hast immer noch drei zur Auswahl! Sierra Leone ist auch im Wahlfieber, es waren Praesidenten und Parlamentswahlen am 7. Maerz, und eine zweite Runde am 27. Maerz. Der amtierende Praesident – Ernest Bai Koroma – kann nicht mehr antreten, weil er schon zwei Amtszeiten hinter sich hat.
Sierra Leone’s politische Landschaft wird durch zwei grosse Parteien dominiert – eine gruene und eine rote (hat keine Verbindung mit was wir unter diesen Farben kennen), die Eine vom Suedosten und die andere vom Norden des Landes. Die Parteimitglieder unterscheiden sich oft in hauptsaechlich durch den Geburtsort der Mitglieder, und die Stammeszugehoerigkeit. Ich finde es immer wieder erheiternd, nach dem Unterschied zwischen rot und gruen zu fragen, und beide Parteien ruehmen sich darauf als “die weniger korrupte”. Sonst gibt es kaum Unterschiede. Fuer diese Wahlen hat sich eine neue Partei gegruended, unter einem eloquenten, charismatischen und erfahrenen Praesidentschafskandidaten, der die Diskussionen etwas mehr Richtung “Was ist wirklich noetig in diesem Land um die Entwicklung voran zu treiben und wer hat die besten Ideen dazu?”. Das erste Mal in Sierra Leone’s Geschichte gab es eine landesweit ausgestrahlte und uebertragene Debatte mit den sechs Hauptkandidaten fuers Praesidialamt. Ich verbrachte einen auesserst emotionalen und leidenschaftlichen Abend damit, den verschiedenen Kandidaten zuzuhoeren (und zuzuschreien, in gewissen Situationen). Ein Kandidat hat versprochen, das Gesundheitssystem innerhalb drei Wochen komplett zu revolutionieren – klingt nach einer Aufgabe fuer Superman und Wonderwoman.
Es gab aber auch einen echten “Huehnerhaut”-Moment, als der selbe eloquente, charismatische und erfahrene Kandidat seine Schlussrede hielt.
Fuer Leser, die Englisch (und Krio) koennen, hier kann man sich die Rede anschauen:
Foto: Mein Wohnzimmer, kurz bevor die Debatte startete! Der grosse Fernseher gehoert uebrigens Elias, falls ihr euch wundert…
Das Amt als Praesidenten von Sierra Leone lohnt sich – neben dem omnipraesenten Einfluss des Praesidenten, verdient er auf legale und weniger legale Weise jaehrlich mehrer Millionen Dollars. Das erklaert auch, wieso mit allen Mitteln um das Amt gekaempft wird. Es passiert oft, dass Leute bezahlt werden und mit einem Parteien-Tshirt bekleidet auf die Strasse los gesendet werden, um Werbung zu machen. Die Anzahl Leute, die an den verschiedenen Strassenmaersche teilnehmen, ist ein guter Indikator dafuer, wie reich eine Partei ist.  Vor zwei Wochen war der wohl groesste Umzug – hier sind einige Eindruecke von meinem Balkon:

​Foto: die APC Partei war auf der Strasse heute. 
Wie auch immer – ich bin sicher, ihr wollt etwas ueber die Geschichte mit dem Praesident und dem Tisch und meinen Haaren erfahre. Einen Tag nach der Debatte ging ich zum gleichem Konferenzzentrum, um an der offiziellen Lancierung der Nationalen Krankenkasse von Sierra Leone teilzunehmen. Ihr magt euch wahrscheinlich erinnern – ich habe viel Zeit in meinen ersten zwei Jahren mit der Entwicklung der Krankenkasse verbracht, aber dann kam Ebola und andere Leute uebernahmen die Ausarbeitung der Details. Nun wollte der Praesident die soziale Krankenversicherung launcieren bevor seine Amtszeit fertig ist, und das Projekt als sein Erbe hinterlassen. Es waren etwa 500 Leute eingeladen ins Konferenzzentrum, mit einer grossen Buehne und einem Ehrentisch, inklusive rotem Samtstuhl fuer den Praesidenten in der Mitte..
Foto: das Bintumani Konferenzzentrum mit Ehrentisch, bereit fuer die Lancierung der nationalen Krankenversicherung. 
​Kurze Erklaerung: Jeder Anlass in Sierra Leone, sei es Workshops, Ausbildungstage, Geburtstage, Preisverleihungen, oder was auch sonst im Leben wichtig ist, hat einen Ehrentisch, an dem hochstehende Gaeste Platz nehmen, und das Programm mit Reden eroeffnen. Diese Ehrentische und Eroeffnungszeremonien koennen gut und gerne den grossen Teil des Programmes ausmachen. Ohne diese Zeremonie wird ein Program als nicht offiziell genug, oder nicht mit der passenden Wichtigkeit empfunden. Die Ehrentische und Zeremonien muessen sein.

Ich sass also im Konferenzzentrum ganz hinten, und genoss das Beobachten der Gaeste. Alle 144 Chiefs waren da in praechtigen Gewaendern, und ich dachte gerne daran zurueck, dass vor 12 Stunden alle Praesidentschafskandidaten im gleichen Raum waren. Das Program beginnt und die Minister (Bundesrat) werden an den Ehrentisch gerufen, da hoere ich auf einmal meinen Namen – “Naomi” und einen Finger, der auf mich zeigt, sowie mehrere hundert Personen, die sich nach mir umdrehen. Eine Reihe von verschiedenen Umstaenden fuehrte dazu, dass ich aufgefordert wurde, am Ehrentisch teilzunehmen und eine Rede zu halten, im Namen der Entwicklungspartner. Schockiert und leicht ueberfordert gehe ich auf die Buehne und denke fieberisch daran, was wohl die Benimmregeln sind, wenn man den Praesidenten eines Landes trifft. Und was sagt man an einem Anlass, wenn man die Idee der Krankenkasse unausgereift findet und schlecht umgesetzt? Kann man das sagen, ohne den Praesidenten zu beleidigen (ich hab es nicht gesagt, keine Angst…). Ich hatte also vier Stunden lange Zeit um zu bedauern, dass ich am Morgen meine Haare nicht gewaschen habe, und auf meine Haltung zu achten, vor den Fernsehkameras. Darf man lachen, wenn sich die Ministers ueber die anderen Parteien lustig machen? Soll ich vortaeuschen, ich mache mir Notizen, wenn alle fuer den Praesidenten applaudieren und ich aber nicht mag, was er gesagt hat? Ihr seht – so unter Beobachtung hat jede Gestik auf einmal viel mehr Bedeutung. Ich habe mich dann freundlich geweigert, eine Rede zu halten, aber hatte die Moeglichkeit, dem Praesidenten spaeter zu sagen “Gratulatiere zu einer mutigen Initiative” – und dann brauchte ich wirklich ein Glas Wein.

​Foto: Stehend den Praesidenten begruessen, der sich in der Mitte gerade hinsetzt – ich bin die blasse Frau ganz links aussen. 
Ich glaube, ich habe genug erzaehlt fuer heute, und wir lassen Geschichten a) und c) fuer ein anderes Update…

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…

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.