30 seconds of fame

So, I had my own 30 seconds of fame, as I suddenly appeared on the cover page of the Schweizer Familie, as well as the article about Sierra Leone being chosen as one of 12 best articles of the year 2018. If you speak German, enjoy:

Artikel in Schweizer Familie: “Ich will hier bleiben”

19.01.2018 : Freetown (Sierra Leone): Noemi Schramm.

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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.

 

Spital Geschichten von den Lion Mountains

“Weniger Drama als in 2016”, war Monika’s und mein Neujahrsvorsatz fuer 2017. Na, 10 Tage ins neue Jahr lag ich zuhause am Boden mit schlimmsten Rueckenschmerzen und brauchte 20 Minuten um mich Millimeter fuer Millimeter zurueck zum 2 Meter entfernten Mobiltelefon zu robben. Die Ambulanz des besten Privatspitals in Freetown kam innerhalb von 20 Minuten mit der erloesenden Morphiumspritze, mein Freund Elias und der Schlosser waren auch innerhalb von 15 Minuten da um die Tuer zu oeffnen – die 10 Meter zur Tuere haette ich beim besten Willen nicht geschafft. Ich verbrachte die naechsten drei Wochen liegend und mit gluecklichmachenden Mengen von Opiumhaltigen Schmerzmitteln, bevor in die Schweiz geflogen wurde um meinen Bandscheibenvorfall konservativ zu behandeln. Viele Physiotherapien spaeter und einige glueckliche Wochen zurueck in Sierra Leone kamen die naechsten Schmerzen, diesmal war etwas mit der Niere nicht in Ordnung, ich solle das in der Schweiz mal abklaeren bei einem Spezialisten, wurde mir greaten. Long story short, ich hatte mittlerweile drei vollnarkotisierte Eingriffe im Spital und schreibe auch dieses Email aus dem Spital. Wegen medizinischen Risiken darf ich momentan nicht in Sierra Leone sein, das Risiko fuer lebensgefaehrliche Komplikationen ist zu gross.

Ihr seht, ich hatte gute Gruende, mich so lange nicht mehr zu melden, da ich mit meiner Gesundheit und den ungewollten Unterbruechen meines Lebens in Sierra Leone beschaeftigt war. Bin ich zwar immer noch, aber ich habe gedacht, das waere doch ein gute Zeitpunkt, mal ein paar Spitalgeschichten zu erzaehlen, davon habe ich mittlerweile genug!

Krankenhaus Fakten

Dank meines Arbeitsgebers habe ich eine sehr grosszuegige Krankenversicherung, die mir Zugang zum besten Privatspital in Freetown ermoeglicht. Das kann man aber doch nicht ganz mit unseren Spitaelern vergleichen, der einzige Arzt (ein Nierenspezialist, der meine akute Nierenentzuendung nicht diagnostizieren konnte) ist ein sehr netter und umgaenglicher Typ, schlaegt aber fuer jedes Leiden sofort eine medizinische Evakuierung vor – er kennt seine und Sierra Leone’s Grenzen. Ich war mittlerweile genug oft im Spital (und habe in allen vier Patientenzimmern schon mal geschlafen), dass ich das Personal gut kenne und sie mich auch. So war ich im Maerz wieder einmal da und verbrachte die Wartezeit damit, allen in ihren Bueros und Zimmern Hallo zu sagen. Wieder im Wartezimmer kommt ein Patient auf mich zu und sagt “Sie, ich haette noch ein paar Fragen zu den Unterlagen, die ich fuer meine Behandlung benoetige – Sie arbeiten doch hier, oder?”. Ich habe eindeutig zu viel Zeit im Spital verbracht dieses Jahr!

Being fed delicious Lebanese food and lots of Morphine during my back problem in the hospital in Freetown.

Waehrend meinem Bandscheibenvorfall im Spital in Freetown wurde ich regelmaessig mit leckerem Libanesischem Essen und viel Morphium gefuettert.

Ich habe ausgerechnet: in 2017 habe ich gleich viele Abende im Spital verbracht, wie in Restaurants, und insgesamt 42 Spritzen/Infusionen erhalten. Diese werden besonders in Afrika gerne verteilt, die Regel ist: egal welche Krankheit, damit du wirklich gesund wirst, brauchst du Infusionen und Spritzen, am besten in mehrere Koerperteile. Die Krankenschwestern waren immer sehr freundlich, bis auf eine, die auch nach 20 Minuten herumstechen meine Vene immer noch nicht gefunden hatte. Als ich ihr sagte, das sei jetzt doch etwas unangenehm, meinte sie “so wehleidig kannst du nie ein Kind kriegen, du bist viel zu schwach fuer eine Geburt”. Einen Spruch, den man als kinderlose Frau in Sierra Leone oefters hoeren muss.

 

I might not have a child, but I had a goat! His name was Nyandeyama and he sadly died at my birthday.

Ich bin zwar kinderlos, aber hatte dafuer eine Ziege! Er hiess Nyandeyama und ist leider an meinem Geburtstag gestorben.

Alternative Behandlungen

Alternative Medizin gibt es auch in Sierra Leone, einfach vielleicht noch etwas alternativer als unsere alternative Medizin. So hat mir eine Krankenschwester bei meinem dritten Aufenthalt innerhalb kurzer Zeit beim Spritzen verabreichen geraten, es waere jetzt wirklich an der Zeit, mal ein Huhn zu opfern, das ist ja kein Zustand, dass ich immer so krank sei. Sie koenne mir sonst jemanden empfehlen, mit hoher Erfolgsrate. Oder sie koenne auch ihren Pastor mal herbitten, der betet auch fuer Kranke. Schoen, Alternativen zu haben!

We don't really use chickens for medical treatment - but for Hen's nights! Jayne is starring here with cockerel Nathan.

Fuer medizinische Behandlungen brauche ich Huehner eher weniger, dafuer mehr fuer Junggesellenabschiede/Polterabende, hier Jayne & Hahn im Korb ‘Nathan’.

Mein Spital, meine Informationsquelle

Ich versuche, alle meine Besuche im Spital auch zur Erweiterung meiner Gesundheitsfachkenntnisse zu nutzen, als sogennante “Fieldtrips”, die mir dann bei der Arbeit im Gesundheitsministerium helfen. So erkundige ich mich gerne nach den Kosten fuer Geraete, Eingriffe und Medikamente, und bin echt immer wieder erstaunt, wie gut und wie teuer das Gesundheitssystem in der Schweiz ist. Fuer einen Nierenfunktionstest wird eine Maschine benutzt, die eine Million Schweizerfranken kostet – damit koennen in Sierra Leone 5700 Krankenschwestern fuer ein Jahr bezahlt werden (also 5400 mehr als sie jetzt angestellt haben).

Mit den Krankenschwestern in der Schweiz spreche ich auch gerne ueber meine Arbeit – die sind dann immer gleichzeitig fasziniert und auch froh, in der Schweiz zu sein. Mit einem Monatslohn von CHF 175 ist es auch in Sierra Leone nicht einfach, eine Familie durchzufuettern.

Seit knapp vier Jahren arbeite ich im Gesundheitsministerium in Sierra Leone daran, die Regierung bei der Gesundheitssystemstaerkung zu unterstuetzen. Ich kenne die Nummern, die Fakten, die Theorien, und doch ist es fuer mich immer wieder traurig und schockierend, zu sehen wie inexistent die Gesundheitsversorgung ist. Waere ich Sierra Leonerin, wuerde ich mit dem gleichen Nierenproblem sehr wahrscheinlich vor 35 an Nierenversagen sterben – einfach weil es nicht richtig diagnostiziert und behandelt werden koennte in Sierra Leone.

Women's March in Freetown: affordable care for everyone.

Frauenmarsch in Freetown: zahlbare Krankenversorgung fuer alle!

Hospital-stories from the Lion Mountains

“Less drama than in 2016”, was Monika’s and my New Year’s resolution for 2017. Ten days into the new year and I was laying on the floor in my house in Freetown with the worst back pains of my life. It took me 20 minutes to move back inch by inch to the mobilephone that laid 2 meters away. The ambulance of the best private hospital in Freetown came within 20 minutes with the relieving morphine injection. Elias came to the rescue and called a welder to break the door – I wasn’t able to move at all, the 10 meters to the door felt like an ocean. The following three weeks were spent laying down and with lots of opium containing painkillers, that kept me happy and hallucinating every now and then. I had to fly back to Switzerland to treat the disc hernia properly and was allowed back after many hours of physiotherapy. Some happy weeks in Salone later, the next set of pains started, this time something was wrong with my kidney. To keep the long story short: I have spent the last three months in Switzerland with several surgeries under full anesthetics and a very slow recovery process.  The risk of life threatening complications was big enough to keep me grounded in Europe!

Well, you see that I have been a bit busy the last few months taking care of my health and dealing with my interrupted life in Salone – apologies for all the silence this created! I thought this might be a good moment though to tell some of my hospital stories…

 

Hospital facts

I have a very generous health insurance, thanks to my employer. That means I can access the most expensive and supposedly best private hospital in Freetown – sounds good, but can’t really be compared to hospitals in Europe. The leading doctor (a kidney specialist who couldn’t diagnose my kidney infection properly) is a very nice and kind man, but recommends medical evacuations for basically any illness – he knows his’ and Sierra Leone’s limitations. Thanks to my regular hospital stays (I have slept in all four patient rooms already), I know the staff and they know me. When I was back in March for another visit and spent my waiting time saying hi to the nurses, I was approached by another patient who waited for his term and he said “Sorry, I have some questions around the documents that I need for my treatment – you work here, nottoso?”. I knew then that I have definitely spent too much time in hospitals this year.

Being fed delicious Lebanese food and lots of Morphine during my back problem in the hospital in Freetown.

Being fed delicious Lebanese food and lots of Morphine during my back problem in the hospital in Freetown.

It made me calculate: I have spent the same number of evenings in hospitals, as in Restaurants in the first five months of 2017. I have also received in total 42 injections – they are liked a lot in Africa, where the rule is: no matter what sickness, to get better, you need as many injections as possible, in as many different body parts as possible. The nurses are all very friendly, apart from one, who after 20 minutes of bloody failures to get my vein was as frustrated as I was. I told her that this is not very comfortable anymore, to what she replied: “pull yourself together, if you can’t take this pain, you will never be strong enough to give birth to a child”. Something that childless women hear every now and then in Salone!

 

I might not have a child, but I had a goat! His name was Nyandeyama and he sadly died at my birthday.

I might not have a child, but I had a goat! His name was Nyandeyama and he sadly died at my birthday.

Alternative medicine

Alternative medicine does exist in Salone as well – just maybe a tad more alternative than our alternative medicine. During my third visit within few weeks, one of the nurses recommended that “it really is time now to sacrifice a chicken, it just isn’t normal that you keep being sick”. She also told me she can recommend someone, with high success rates. Or she can also ask her pastor to come and pray, he also prays for the sick. Nice to have options!

We don't really use chickens for medical treatment - but for Hen's nights! Jayne is starring here with cockerel Nathan.

We don’t really use chickens for medical treatment – but for Hen’s nights! Jayne is starring here with cockerel Nathan.

My hospital, my source of information, my work experience

I am trying to use all my visits in the hospitals to expand my knowledge of health systems, and see them as “field trips” – hopefully helpful in my work at the Ministry of Health. I like asking for costs of equipment, medicines and procedures and it is shocking to realise how expensive the health system in Switzerland is. The machine used for a kidney function test costs one million Swiss franks (about 1.1 million USD) – with that money you could pay 5700 nurses in Salone for a year (therefore hiring 5400 more than what they have now). There have also been lots of interesting discussions with the nurses about my work and Sierra Leone – the nurses in Switzerland are usually fascinated, but also thankful to be working in Switzerland. Even in Salone it isn’t easy to feed a family with an average monthly wage of USD 180, that a nurse earns.

It has been nearly four years now that I have worked in the Ministry of Health in Sierra Leone, working on projects to strengthen the health system. I know the facts, numbers, the theories and reports, but it still hits me at the core how inexistent and incapable the health care is. If I would be a Sierra Leonean with the same kidney problem, I would probably have died before the age of 35 of kidney failure – just because Salone is not able to diagnose and treat it.

Women's March in Freetown: affordable care for everyone.

Women’s March in Freetown: affordable care for everyone.

An update on the Sierra Leone Social Health Insurance

  • Overview of Sierra Leone Social Health Insurance

 

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

  • SLeSHI: Progress and achievements

 

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

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

  • SLeSHI: Outlook and recommendations

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

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

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

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

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

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

  • Overview of Performance Based Financing

 

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

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

 

  • PBF light

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

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

 

  • PBF PLUS

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

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

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

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

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

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

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

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

PBF Verification in Makeni

PBF Verification in Makeni

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

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

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

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

SUMMARY OF RESULTS OF NATIONAL HEALTH ACCOUNTS 2013

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

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

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

RECOMMENDATIONS FOR HEALTH SECTOR IN SIERRA LEONE

Key recommendations for senior decision-makers are:

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

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

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

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

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

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

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

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

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

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

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

[2] MoHS, Sierra Leone National Health Accounts 2013

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

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

  1. Introduction

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

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  1. Interview questions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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