Freetown Blog

.. and home again

2010-05-02T10:32:00.004Z

My last few days here took pretty much the same hectic course as the previous 7 weeks. On Thursday, we found out that although salaries and back pay for health workers had been released by the Ministry of Finance a week ago, they hadn't been processed by the Central Bank as quickly as hoped. We had made a pretty big thing (too big with hindsight) of the fact that staff would be paid in time for the launch and by Thursday they were on third day of dealing with the post-launch increase in service demand without seeing their salaries. Late in the afternoon we heard that they were becoming suspicious that the government promise was not going to be kept and rumours of strike action were again beginning to circulate. There was an anxious couple of hours as we tried to find out if there was any reason for the hold-up and agreed a message to communicate to the Districts. But by Friday morning, I'm relieved to say, it was confirmed that the money had started to appear in staff accounts.

That was only one of the challenges that came up before I finally left the office on Friday, but that didn't mean that my colleagues were too busy to remember my departure. At one point during the rushing about on Thursday afternoon, I suddenly realised that HR team had all assembled in my office and took time to present me with a great card, and some Sierra Leonian clothes. The picture below was taken just afterward and I am wearing one of the shirts (but no-one going to see me wearing the trousers any time soon).

I'm really glad that we were so busy right up until I left, otherwise I think I would have choked up. I've had some great feedback from the Chief Medical Officer and others, which has been good for the ego, but, as ever, there is the worry about whether I have done anything that will make a sustainable difference. The good news on that front is that a new (Malawian) Technical Assistant will be occupying my desk from next Monday and we have had the last 2 weeks for a decent handover. He is very experienced (and, like me, an alumni of the health service management centre at Keele). He will be working in the Ministry of Health for the next 2 years and I feel I will be leaving the Technical Assistant role in good hands.

But my thoughts and feelings about leaving are not all about work...

Reading back through my blog entries since March, I am only too aware of all the things I haven't written about. This blog was never supposed to be only about my professional work here, but about a personal experience of living and working here at an extraordinary time. One of the most extraordinary things has been about being part of a great international team, all working together towards one goal with Ministry colleagues, but also having fun, supporting each other through the tough bits, drinking plenty of beers and (on one occasion) dancing under the stars until 3am. There are, you will be relieved to know, no pictures of the latter. The picture below is from the launch day celebration.

The second picture was taken at the Water Taxi terminal just before I set off for the airport. My reluctance to get on the boat very nearly resulted in me not making it at all, as they had more than a full boat load. Fortunately for us, they put on a second boat for just 3 off us. Speeding off across the bay, we soon overtook the other boat, and it was a great way to leave. Freetown even put on a great sunset for us.

And that I think, really is the end of the Freetown Blog. Written in jumble of emotions - of hope and best wishes for Sierra Leone as it faces it's next challenges; of that sad-to-leave/glad-to-be-home emotion that is difficult to describe; and of thanks for the fantastic people I have shared these months with - you know who you are!

Launch Day

2010-04-27T15:07:00.007Z

This free healthcare issue - we need to grasp it with both hands!

Yesterday was the last pre-launch Ministry Steering Group meeting, and there was much to discuss: have drug consignments reached all intended destinations? are they the right drugs? is all the equipment and renovation work completed? Are the monitoring arrangements in place? Have the messages been communicated properly? As far as HR is concerned, my boss was able to report that there are now 7077 health workers on the payroll and that all salaries (including new pay rates and back pay) have been sent from the Treasury to the banks. That is a huge achievement in itself and represents a lot of effort by a lot of people.

There is an artile about the launch on the BBC website today Sierra Leone gives new hope to mothers and children. I have just got back from the official launch by the President at the Childrens Hospital. It certainly looks like the Free Healthcare message has been communicated OK to women in Fretown.

Yes, those are queues. It was predicted that on launch day many would turn up, curious to see if free health care is a reality, rather than because they are in need of treatment. I think that one of the challenges for staff today is to pick out the needy patients from among them. I just spoke to my boss who is back in Pujehun to oversee the launch. He says that all is under control there and people are being cooperative, so we can hope that is the situation elsewhere as well.

Rob Yates from DFID is visiting this week. He has been involved with launching free healthcare initiatives in 9 countries and he has been very complimentary about the way the Ministry of Health here has prepared itself and in such a short time. He has also been talking about the strong evidence that even small user fees are a major barrier to very poor people accessing healthcare; and the strong correlation between proportions of people accessing health services and population health outcomes. It does seem blindingly obvious to me that making poor people pay because they are ill is a bad idea, so it has been interesting to hear how much resistance has had to be overcome from the World Bank to get to this point in Sierra Leone.

Today is the start of a journey, rather than the end of it, but it is definitely cause for celebration. I have allowed myself to be persuaded to celebrate by going to an Akon Concert at the National Stadium tonight (no, me neither, but according to Wikipedia he has had 6 Grammy award nominations and is one of the most successful R&B singers of the 21st Century). So tonight you can think of me, as probably the guy with the worst sense of how to move with the rhythm, among an audience of 30,000.

P.S. (pm Wed 28th). The concert got rained off! But there is a good positive article on the Guardian website today about the launch, which is worth a look.

Pujehun

2010-04-23T00:35:00.007Z

This week senior staff in the Ministry have been dispatched to Districts across the country to assess readiness for the expected big rise in demand for services next week. Dr Sandi (my boss) was allocated Pujehun District, which is in a remote area in the far South of Sierra Leone, near the Liberian border. And so it was that he, Margaret (the senior nurse midwife) Small (the driver) and I left Freetown on Monday afternoon, at the end of what had already seemed like a long day's work.

The first three hours to Pujehun town are on good road, but the last 2 are not so great and we were tired and hungry by the time we arrived in town. But that wasn't the end of the working day - I have met some formidable senior nurses in my time, but Margaret is right up there. After giving us just about time to eat some fish stew and rice, she decided we must do an evening tour of the maternity ward, to see what needed doing. This was about 10.30pm, but there is a hospital generator, so there was some light when we arrived on the ward - enough for me to catch sight of the ward statistics posted on the wall above the nurses desk: Stillborn - Feb, 3; March, 5; Maternal deaths - March, 1 (remember, this is not a large unit - it has only 12 beds). Margaret asked me what I thought of it all, and it was hard to comment. She certainly knew what she thought, and sent the staff scurrying to sort the things she wanted to see done before she came back.

Next morning, we made an early start to meet with the Distict Health Management team before setting off to visit the most remote facilities that have been designated as Basic obstetric emergency centres. In the rainy season the area is inaccessible from Pujehun town, but for the moment, the worst we had to deal with was 4 hours on rough roads and a river crossing.

The first facility we visited was Poturu Health Centre where the staff experienced the elemental force that is Margaret. Within 2 hours they had re-allocated rooms, cleaned and re-positioned equipment and committed to what they needed to do before we returned to check later in the day. I was rapidly coming to realise that many staff have simply not believed that such radical health service changes was really going to happen, as they haven't seen any practical evidence until now. It is not hard to understand that in a system as massively and chronically smashed as this, but, once given the impetus, the staff seemed up for the challenge.

One of the difficulties of delivering services in such remote areas is being able to refer complications to the District hospital. At the moment, they radio for an ambulance, which may or may not be able to reach them. However, new motor tricycles have recently been received at District level and they were dispatched to the obstetric centres earlier today.

We got back to Pujehun long after dark on Tuesday, but yesterday was another early start. On arrival at the hospital we found that the long awaited consignment of drugs had arrived from Freetown (after a protracted process of port customs clearance). It was clear that the sight of the lorry was converting many more sceptics, who had not believed that the free healthcare initiative would really happen.

Later in the day, we visited more centres, sorted equipment for delivery and watched the district and hospital stores, filling with supplies.

One of the things Margaret had decided on her first evening hospital visit, was that the maternity ward would function better if it was moved to the ward that was allocated for male patients. The Hospital Medical Superintendent agreed, and within 24 hours it had happened. The first picture below is the old ward yesterday morning and the second and third are the new ward and labour room (complete with new equipment), taken before we left this afternoon. The final picture is of the first resident of the new ward.

This morning, Dr Sandi and Margaret participated in a phone-in about Free Healthcare on local radio together with the District Medical Officer and hospital Matron. I was back at the hospital while they were broadcasting, but it was blasting out from a car radio on the hospital compound.

After that we had a meeting with the District Council and Hospital Management team to discuss our findings and agree actions to be taken. There was a lot to discuss, but there was also a lot of commitment to sort out practicalities - like accommodation for new staff who are starting to arrive for work (hooray for the fast-track recruitment process!)

It would have been good to have stayed longer and visited the remaining obstetric centres, but Dr Sandi had a call this morning to say that he was needed urgently back in Freetown, as the Chief Medical Officer needs to brief the President on progress. The President did a visit to all Districts 3 weeks ago and apparently he was particularly concerned about the situation in Pujehun, so wants to know what we found.

However, Margaret has stayed in Pujehun, and I'm sure she will hit the remaining facilities with the same vigour for change and improvement. I was very interested to discover today that she was a vocal leader during the recent health workers strike. Seeing the commitment she is now giving to making Free Health Care a success makes me realise that the strike wasn't about an attempt to de-rail an initiative for political reasons, but was (at least for her) about a determination to see fundamental change in the way health professionals are supported to make a difference for patients.

Dr S and I arrived back in Freetown just before 10pm tonight, through torrential rain and a monumental Freetown traffic jam. And now, I'm finding it difficult to sleep. The experience of the last few days has left me feeling a bit wired (either that, or it's the tumbler of Jamesons!)

A bit of context

2010-04-14T17:09:00.002Z

Clinging on to the roller coaster of daily work in the Ministry it was good to be reminded of what it's all about, via an article posted on the Guardian website today. Dr Kargbo is a bit of an inspiration to a lot of us here - bringing huge energy to the task. It is reassuring to see his positive reference to the 'new kind of assistance' that they have been getting in Ministry this year and I hope I am playing at least a small part in that.

While I was looking at the article I also noticed a link to another Guardian article from last year which I hadn't seen before. This puts some context on the role of the UN, the British Government and Gordon Brown in the free healthcare initiative in Sierra Leone and elsewhere, and is worth a look.

Not about work at all

2010-04-10T15:58:00.003Z

A couple of weeks ago I had an email from someone who had got my contact through this blog and asked whether I could find out anything about the organ in Freetown Cathedral (not as odd as it might sound, as I did do a post on the Cathedral last November). Apparently, the organ began life in Siloh Presbyterian Chapel, Aberystwyth and was transferred out here when the Chapel closed. A couple of days ago I was in town so I called at the Cathedral and met the Canon, who confirmed the story. It is a very impressive 3 manual organ and was apparently built to specifications of a well known musician, Charles Clements, friend of Vaughan Williams and Bela Bartok. As you can see from the picture below, it looks very well in it's new home. The Cathedral staff unlocked the manuals and invited me to play it - a couple of chords were enough to confirm that it makes big noise (but unfortunately, under my hands, not very tuneful one).

My second non-work related experience took place earlier today, when I climbed the Sugar Loaf Mountain near Freetown. It is only 2,500' high, but with the climate here, and dense vegetation, it was a challenging enough undertaking for me. I had a headstart of a good 20 years on most of the others there (including some guys from the International Military Advisory and Training Team) but managed to keep up just about. Afterwards we went back to the IMATT base for a full English breakfast and swim in their pool. All in all, not my typical Sierra Leone day!

Some grounds for optimism

2010-04-08T20:13:00.004Z

We were scheduled to get back from Bo at lunchtime on Friday in time for the Easter weekend, but in the event, there were so many recruits to process that we got back at 10.30pm on Saturday night. The grand total for the tour was 755 new staff on the payroll and that figure is still climbing since we got back to Freetown. This is far more than we expected and the main reason is the scale of the pay increase, which is pretty substantial, though still modest by Western Standards.

	USD per month
Grade	Old	New
3	49	156	<< MCH Aide
4	55	183	<< State enrolled nurse
5	62	211	<< Community Health Officer

The figures above relate to the grades we were recruiting; the raises for senior medical grades are greater - e.g. Consultant pay goes from an average of $490 per month to over $4000 per month. It will be interesting to see what impact this has on motivation for exiled Sierra Leonians to return.

I felt like I deserved it by the time I made it to Lakka beach on Easter Monday. The Easter holiday is a big deal in Sierra Leone, with carnivals, dancing devils and a general exodus to the beach. The grilled snapper and chips washed down with some Star beers at sunset put a pretty good cap on a week that achieved more than we could have expected and set me up for another week that has brought a new set of challenges, of which more later.

Recruiting up-line

2010-04-02T13:22:00.004Z

The strike is over now, new salary levels have been communicated and everyone is back at work, but that doesn't mean there is any let up in the pace. It has been good to get out of the hot-house of the Ministry and come here to Bo to help the team who have been touring the regions to recruit new staff. The recruits are mostly qualified and already working as 'volunteers' - with salaries so low, and the recruitment process so long and dificult, many didn't bother to apply for posts and have just relied on informal user charges for their income. There are many professional reasons why this must not continue, but most critical at the moment is the pratical reason that in less than 4 weeks, charging user fees to a large proportion of users will be regarded as fraud. We therefore need to get as many staff as possible onto regular contracts so that they receive a legitimate salary.

We arrived in Bo yesterday at 9.30am after a 3 hour drive from Freetown to be greeted by queues of candidates outside the District Medical Office. The process involves checking qualifications and candidate suitability, getting medical clearance, registering bank details, getting photographed and finger-printed, getting appointment letters and registering acceptance, allocating PIN numbers,completing social security forms, taking copies, filing and recording. This normally takes months, but the team is trying to complete it in one hit and showing amazing energy and commitment to make it happen.

In the second picture above you can just about see the queue of candidates waiting to be processed in the background. As the time has gone on it has grown and grown. A lot of them have travelled a very long way to get here and we are not sure how many are still on the way. My job is to prepare and print appointment letteres. I'm not sure exactly how many I did yesterday, but by the time we stopped at 8pm it was over 130. There was enough generator power for the computer and printer, but not for light in the room where I was working, so I now have typing by headtorch to add to the skills on my cv!

I'm writing this in a quiet moment, as the morning scramble has calmed down as people queue for other parts of the process, though I am expecting it to kick off again at any time. The other guy I travelled up here with is a management consultant who only arrived from the UK on Wednesday night on his first visit to Sub-Saharan Africa. He is stepping in at short notice to cover for a colleague and is finding it quite a baptism by fire, I think.

On the Strike

2010-03-27T11:06:00.003Z

When you write a blog it's easy to forget that it's like writing a letter and nailing it to a tree - you have no idea who might read it or how they might interpret it. The volatility surrounding the healthworkers strike makes me wary of making any comment at all. But it has been a huge factor influencing everythingthat has been going on in the Ministry over the past 10 days, as youwill realise if you listen to yesterday's report from the BBC World Service or the report on the BBC website.

All I will say is that, unsurprisingly, this is all a massive distraction from the operational task of implementing the Free Health Care Initiative that should have been the focus of our work now. Making rapid changes from such a baselineof poverty and devastation was always going to painful, fraught with risks and with huge potential for mistakes to be made, so maybe none of this should be surprising. But deadlines are so tight now that there is no room for things to slip, and expectations relating to HR aspects of the plan are high.

On a personal note, I am pleased to report that I am writing this from the Simple Goal Guest House, that my bed is very comfortable. And that late last night, sitting at a beach bar with a cold beer, the pressures of work did not seem like too high a price to pay for being here.

http://africannewslive.com/?p=1788

The Simple Goal

2010-03-24T13:28:00.004Z

The pressure on the Ministry of Health and Sanitation to achieve the objective of launching free health care by 27th April is exposing how much work there is to do on fundamental organisational issues - communication, delegation, focus on execution etc etc (i.e. the challenges that face pretty much every government organisation and health system, only much more so).

Most days, something happens that give me a vertiginous feeling of just how close to the wind we are sailing: Yesterday, we were preparing for a team to go on a tour of Districts to validate payroll information and finalise recruitment of new staff, whose applications have been pending for months in the central office. The visits were due to start today, following an 8 day schedule, but yesterday at about 3pm we heard that the dates clash with National Immunisation Days over the weekend, which means that the staff we need won't be available. So there had to be rapid re-scheduling and all the related challenges of communicating that to Districts. That done, at that 5pm, we were still trying to track down the appropriate combination of drivers, vehicles and fuel for the trip. Under other circumstances, the visits could have been delayed, but if they don't happen now, then deadline of sorting out the payroll and recruitment of additional staff before 27th April will not be met.

On the subjct of deadlines, it looks like my (self-imposed) one of finding myself somewhere to live before the weekend will be met: The Simple Goal Guest House is a ten minute walk from work, in a quiet spot with water, electricity, aircon, and a small balcony from my room with an open view. I met the landlord this morning and am due to move in tormorrow. To maximise the chances of this happening, I am now using the estabished management technique of keeping my fingers crossed.

Trying to get sorted

2010-03-20T20:32:00.002Z

It's Saturday afternoon and I'm sitting in a bar (drinking ice tea - after re-acquainting myself with Star beer last night). The past week was pretty unrelenting and I have been in the office again this morning, but now intend to chill and re-charge the batteries again for Monday.

The week ended on a bit of a downer when the accommodation I thought I had found fell through last night. So it's back to square one and I'm trying to find other contacts to follow up. The friends from OTB that I'm staying with are being great about me staying until I find somewhere (I have rejected one option on the basis that it is $800 pcm for a pretty poky room in a shared house, with a rubbish mattress!) but if the pressure keeps on at this pace (which I suspect it will) then having my own space to chill will be a high priority.

Before I arrived back, people were emailing that the Ministry is a different place compared to last year, but I am still amazed to see how much it has transformed into a high pressure place of rapid decision-making and urgent action in only 3 months. Everything is focused on 27th April and it seems to me that one of the most important things is to avoid taking short terrm decisions that could create problems in the longer term - for example, in the rush to fast-track staff recruitment we need to make sure that only appropriately qualified staff are appointed and that they are appointed into the areas and roles where the need is greatest. You might think that is basic, but it is not so easy when you are trying to validate payroll records at the same time, and there is lack of information about where existing staff are actually working.

There is a small team (i.e. 2) management consultants here helping with the payroll work and next week they are taking the validation and fast track appointment process out on tour to the regions (a first for a civil service appointment process that has always been cenralised in Freetown). I'm hoping to along myself for at least part of it to get a better understanding of what is going on, though it might only be possible to get away over the weekend.

...and back again

2010-03-17T21:56:00.003Z

When I left Sierra Leone last December, I did hope that I would be returning at some point, but never expected it to be this quick. What started as an email exchange with Faye from the Office of Tony Blair in Sierra Leone in January ended in my arrival back here 3 days ago, on contract with the Ministry of Health for 7 weeks.

The reason for the urgency is the Government of Sierra Leone is due to launch free health care for pregnant women, lactating mothers and children under 5 on 27th April. This is part of government efforts to work towards Millennium Development Goals and to end the reputation of the country as having the highest maternal mortality rates in the World.

To say that this is an enormous task is to understate the point: Ministry staff and partner agencies have been working flat out refurbishing facilities, ordering supplies, setting up supply chains and related infrastructure. But... at the heart of the challlenge is staffing. Health service provision here has long been associated with informal charging by health workers (and it was often the only way for them to keep functioning when salary levels were so appalling). The government knows that free health services must mean an end to informal charging and that big increases in salaries are required, but has been struggling to come up with rates that are both affordable and acceptable to staff.

If you know anything about the history of the health service in UK, you will know how much opposition there was from the professions when the free NHS was first launched in 1948 (when they realised the effect it would have on their private income) and you will also know how much bad will was generated by salary reforms over the past 5 years (never did so much new money create so much dissatisfaction). Well, translate that to a very resource poor environment and you might get a glimpse of what is happening here. Yesterday (Day 2 for me) the nurses went on strike in the main teaching hospital and when I left work today it seemed things were getting worse rather than better.

So, it is hard work at the moment, very hard. But I get a sense that underneath it, people know this is an important time, and they don't want to screw up. And busy though they are, they haven't been too busy to welcome me back with open arms. And that is great.

So that is work (and pretty much all I have been thinking about so far). On the domestic front, there is the slight matter of finding myself somewhere to live and related personal matters.I'm staying with friends at the moment (in a very nice house), but need to get it sorted, just as soon as I get time...

Going Home

2009-12-21T13:46:00.015Z

I am writing this just after midnight on the plane from Freetown to Heathrow. I have always found that flyingis like being in emotional suspended animation. Any excitement, or trepidation,or sadness, there might have been in the departures hall, switches off with the bumpof the wheels leaving the runway. In less than 6 hours, normal life will beresumed with the sound of seatbelts being released and overhead lockers beingopened, but for now, I am in a different place – 35,000ft above somewhere in North West Africa, feeling calm and clear-headed.

When I saw my boss last Friday, I told him that I had just had a great two months. He had just presented me with a big hand-woven blanket from hishome village, embroidered with my name and thanks from him and his family. I’m not exactly sure why my experience has been so good, but it hasworked for me on lot of different levels. Professionally, it has beeninteresting and challenging; socially it has been fun; and Laszlo’s obvious enjoyment and fearlesswillingness to get involved during his visit has been great.

One of the things that has surprised me most about my time here has been the way it has brought back stories about things that happened to me in my twenties, when Iwas a VSO in Uganda. Quite a few people have asked me about those days(including Ugandan VSO’s who are too young to remember them) and I have talked about the things that happened, including my experiences from the war there.

Many of the people I have met in Sierra Leone have experienced horrors in their lives that I hope I will never even dream of. Some of them will tell their stories freely, but others seem to be struggling to make senseof them. Even my most difficult experiences, of course, are absolutely nothing in comparison,but being here has made me realise how important it is to find a way to tell our stories – all the fragmented bits that add up to a life.

I don’t feel at all pessimistic about what I have seen and experienced. In fact my strongest impression is nothing to do with conflict, trauma or poverty, but about meeting people with a fundamental self-belief that would be the envy of many of us neurotic Brits (speaking for myself here, you understand). A friend of mineonce gave me a fridge magnet that said – “Sing as though no one is listening; danceas though no one is watching; live as though heaven is on earth”. It has beenmy privilege to live and work for a while alongside people who really seem to know howto do that. I know I will never be able to dance like a Sierra Leonian (and don’tworry, I won’t even try) but I do sort of hope a bit of that attitude mighthave rubbed off.

So that's it from the Freetown Blog, but please forgive me one last self-indulgence. One of the tasks that I would normally have been doing over the past two weeks is writing Christmas cards. It is a bit late for that now, so please accept this home-made one with my very best wishes for the festive season and the coming year.

A festive Freetown surprise

2009-12-19T09:45:00.007Z

I was lying on my bed under the mosquito net in the dark, sometime after 10pm. It was a very warm night (so no surpise there) and I was glad of the slight breeze blowing in through the open windows. Suddenly a sound started up outside that was as surprising as it was familiar.

Here in Freetown, I am quite used to late night West African music, but a brass band playing "See Amid the Winter Snow"? It turned out that it was the Freetown Police Band. I was brought up in a small village in Devonand every Christmas the village band would travel the parish playing carols at the outlying farms. The band often received refreshment at the places they visited. As the evening wore on, and more hospitality was received, the carol playing would increasingly become a triumph of enthusiasm over technique. As you can hear from the attached clip (which I recorded on my ipod recorder), I suspect the same tradition of hospitality operates here.

The Boat Pushing and Other Adventures

2009-12-17T00:27:00.083Z

We are now back in Freetown after 8 days of travelling down the coast and up-country. We set off last Wednesday with only a vague plan, deciding to travel light without much gear and hope for the best. And the best was, pretty much, what we got.

Our first stop was River Number 2 Beach. Before we left Freetown, I was unsure how easy it would be to get places to stay, but as it happened we were the only visitors there (and that continued to be our experience for the whole week). That evening on the beach we had a good chat with the only other person on the beach - a Bristolian, who first arrived 10 years ago on a government engineering project, and seems have all he wants for a happy life in his beachside house, with his Sierra Leonian wife and the gin bottle in the pocket of his shorts. We could certainly agree with him that as far as the setting is concerned, River Number 2 is hard to fault.

The next morning we crossed the river mouth by boat and walked three miles down the beach to Tokeh Village. Tokeh Beach was the site of the filming for the original Bounty Bar advert in the 1970's and you can see why the chose it -the sand is so white and so soft that it is more like walking on snow than on sand - it even squeaks like powder snow. Tokeh village is a fishing village and when we arrived they were just selling off the night's catch of lobster, makerel and small barracuda.

From Tokeh Beach got some transport a few miles south to Bureh Beach, where we were hoping to find some beach huts to stay in. In the event, we were over optimistic. However, we did find local lads who, from somewhere, found us a tent, which they hired to us, cooked us a supper of fantastic grilled fish, lit us a bonfire, and sat round the fire with us singing Sherbro songs and comparing the quality local gin and Hungarian Brandy (the the words of the songs, we later found out, would be enough to make a rugby team blush!)

One of the many remarkable things about the Freetown Penninsula is theway the sand colour changes in just a few miles. The sand at BurehBeach is a deep golden colour which almost looked like it was glowingin the early morning light.

We found that as we travelled down the coast, we were continually meeting up with the brothers and cousins of people we had previously been with and began to suspect that word was travelling ahead of us that there were two white guys on the way in need of assistance (mobile phones are a wonderful invention). From Bureh Beach, we were offered a boat trip across to the Banana Islands (which was our destination anyway). The starting price was $100, but we eventually settled on $30, and it seemed everyone was happy. And so it was that we arrived at the Islands, which are just three miles off shore from the Peninsula.

In the early 19th Century, the Banana Islands were used as a base by the Royal Navy in an effort to stop the slave trade, which was continuing at that time despite legislation in the UK to abolish it. The islands are now a place of complete quiet and peace, with only about 1000 inhabitants, but the traces of their military past are there to see, including a number of half buried cannons, one of which clearly shows a foundry mark of 1813.

We stayed 2 nights on the Islands and it was one of the most relaxing places I have ever visited. Before we left Freetown, I picked up a novel that was lying around in the house in anticipation of getting a bit of time to read on the beach. It was Jane Austen's 'Mansfield Park', and you might think that such a novel of 19th Century England would have little connection with the Banana Islands. However, as I read it, I discovered that it was written between the years of 1811 and 1813 - exactly the years when the Royal Navy was here on the Islands. One of the characters in the novel is a naval captain (and Jane Austen herself had two brothers in the navy), so it is not impossible that she had a fair awareness of what was going on here. One of the significant aspects of the first part of the novel is the prolonged absence of Sir Thomas Bertram, who travels to Antigua to attend to financial difficulties on his estate - problems we can assume were probably caused by the loss of the supply of cheap labour resulting from the efforts of the Navy here and elsewhere along the West African coast. It all brought home to me just how closely tied the history of this part of the world is to the great events of the 18th and 19th Century in the UK and Europe. The same events have had repercussions down the generations here and many argue they were a significant factor in the events that recently tore Sierra Leone apart.

During our second day on the islands, we were shown a boat, which had just been completed after 9 months of manual labour and was due to be launched the following day. The site where the boat was built was in the middle of Dublin Village, and getting it to the water involved pushing it several hundred metres down to the beach. We were invited to the ceremony, and duly turned up next morning at the appointed hour. The ceremony began with us all being asked to gather round the boat and recite the Apostles' Creed; then sing Now Thank We All Our God ("first verse only"); then The Doxology; then we had the tossing of Kola Nuts to seek the blessing of the ancestors; the sprinkling of palm oil and palm wine; the throwing of food into the boat (which was eagerly grabbed by the children). Then, amid much chanting and general hilarity, the Boat Pushing began, and we joined in.

When the boat eventually got in to the water, it floated with perfect balance, but that was not enough to stop us being alarmed when it was decided that the maiden voyage of the boat should be the one that took us back to the mainland. If I look nervous in the photo below, and as if I have just grabbed one of the only two available life jackets, it's because I was, and I did.

Our arrival point back on the mainland was Kent Beach, at the slave wharf where John Prescott madea speech on the 200th Anniversary of the abolition of slavery ("from such an idyllic place, so vile a trade"). It was yet another stunning place that we had to tear ourselves away from after only one night to travel up-country.

The day we left Kent, we travelled up to Mile 91 to meet with my VSO friend Jayne, and the following day, travelled on north on a dusty 8 hour round trip to visit the Bumbuna Falls. As you can see from the photo below, the road, particularly the last bit, was not all easy going.

When we parked the car, we couldn't actually see the Falls, but could hear a rumbling, more like a jet plane accelerating down a runway than a waterfall, and when we got down the path in front of the Falls, the sound was almost too deep to be audible - more like being thumped on the chest by the force of the water. The driver of the vehicle we hired to get there had lived in Sierra Leone all his life without seeing the Falls and was as mesmerised as we were.

By the end of our trip we were pretty comprehensively dust covered. The sort of dust which, I fear, will not get extracted from every orifice until long after I get back to Cardiff!.

And so, it's back to noisy, dirty old Freetown. I arrived back this afternoon, to a phone message from my boss, saying he has a lot of things he needs to finish by Friday and really needs my help. I find that I am really pleased about that - to be busy and involved right up until my last day is how I would want it. So tomorrow, Laszlo will be off to negotiate Freetown on his own. Hopefully, we will meet up again tomorrow evening..

Institute for Healthcare Improvement

2009-12-08T20:50:00.004Z

Over the past 20 years, I have been involved in a lot of different health service quality improvement projects and my experience has generally been that they promise more than they offer. It was therefore surprising for me to find that the IHI approach to quality improvement that is guiding the 1000 Lives patient Safety Campaign in Wales has sustained my enthusiasm for so long.

My interest has continued since I have been here, as it soon became clear to me that the challenges of connecting front line clinical staff with other organisational levels, and making change and improvement sustainable, are faced here just as much as they are anywhere else (as my VSO friend and erstwhile Matron from the Royal London puts it: " the thing is Tim, it's the same old shit, just a very different scale!")

Last month, I made contact with IHI and discovered that they have been working on a large scale project for child health improvement in Ghana. They have been supporting the testing of small scale change ideas to discover which ones result in measurable improvement and are now spreading and scaling up successful ideas. This is probably even more radical in a developing country context than in the UK, as donor-led development projects tend to be very long on high level strategy and very short on how to actually go about sustainable implementation.

Over the past two weeks, it has been great to put Dr Kargbo, the Director of Reproductive and Child Health in Sierra Leone, into direct contact with Nana Twum-Danso, who is leading the IHI project in Ghana. I have been talking to Dr Kargbo about the IHI approach for a while and he was interested to find out more. It now sounds like the IHI is very positive about the potential to support progress in Sierra Leone - an opportunity to work on health service improvement across the full spectrum from the very top of the UN Development Index to the very bottom. It may be that it takes a while before anything comes of it, if it ever does, but if I have done anything to help it come about, I will be well pleased.

First day of the holiday

2009-12-05T15:31:00.000Z

As it happened, the rendezvous at the airport went without a hitch. After an evening beer with the Kenyan VSO's, I had a comfortable and low stress helipcopter trip over to the aiport with windows, seats and even ear protectors. Laszlo's flight was more or less on time and I booked a room at the airport hotel (not so grand) so all in all the whole thing was pretty straightforward.

Yesterday morning we had a leisurely breakfast before strolling down to the water taxi jetty at the beach. The sailing schedules depend on flight arrivals so we weren't exactly what time we would leave, but the beach makes a pretty good waiting area. Soon after we got there, some local lads identified Laszlo as in need of some intensive football coaching (they obviously spotted that I was a lost cause in that department). So Laszlo spent his first morning in Sierra Leone engaged in a vigorous game of footie.

When the boat arrived, a team pic was requested with 'Laz', and I was happy to oblige.

Getting to the airport

2009-12-03T12:13:00.001Z

Freetown has the third largest natural harbour in the World. The city itself is on one side of the harbour, while the airport is way over on the other (think Penarth to Western Super Mare). This is not great if you need to get to the airport as the transport options are not very inspiring - rusty old car ferry, rusty old helicopter, or small water taxi (a bit hairy if it is dark or rough). However, things are looking up - a new helicopter has recently come into service, which has glass in the windows and individual seats; and a new foot passenger ferry started three days ago.

This is all of particular interest to me today, as I need to get over to the airport tonight to meet Laszlo. I have ruled out the car ferry, as even getting to the terminal at the Freetown end can take hours. The passenger ferry fare is half the cost of the helicopter, so about an hour ago, I phoned the ferry office to find out about their schedule and booking arrangements. They just said I should turn up around 2300 tonight and they should be leaving around 2330. This would probably be fine, but it is such a new service that it is difficult to tell whether it is reliable and I found myself considering a worst case scenario which involved me stuck at midnight in the City Centre, and Laszlo at Lungi airport, facing the scrum in Arrivals on his own. So I have decided to go by helicopter, which leaves from much nearer to where I live. I just hope that I get the one with the windows, and the seats.

Tying things up at work

2009-12-01T11:36:00.002Z

It's my last few days at work now, and I'm trying to finish things off and spend time talking to others about their plans for next year. One of the things that keeps surprising me is when I find people with great skills who just need a bit of support to help focus their efforts. There is one man, Dennis, in the department who is Rwandan and initially came to Sierra Leone to help with monitoring elections. He later had to leave SL because of the war, but subsequently had to leave Rwanda for the same reason and returned here. He has been working in the Ministry for a while, though without a salaried contract.

Dennis is fantastic on Microsoft Access and Excel. By sitting down with him and talking about the sort of questions we need the staff headcount database to answer, he is well able (far more able than me) to generate the reports required.Some of the answers are shocking, but they really help the Ministry to state its case to the Government and to donors.

One of the issues we have picked up is that around 50% of the newly qualified Enrolled nurses appointed this year did not take up their posts. It is not difficult to see why when you understand that transport to get to their base could easily be $10, and basic accommodation could be $50 per month, and compare that with the salary scales:

Grade	Monthly salary
14	$ 359	«Consultant
13	$ 276
12	$ 195	«Medical Specialist
11	$ 151
10	$ 90
9	$ 69	«Medical Officer
8	$ 52
7	$ 40	«Nursing Sister
6	$ 28
5	$ 22	«SRN
4	$ 18	«SEN
3	$ 16
2	$ 14
1	$ 12	«Nursing Aide

The only way anyone is able to keep functioning at work at all is through making informal charges for basic services. But with general poverty rates as high as they are, that means that many people simply cannot afford to access basic health services at all.

So you see what I mean about the scale of the challenges here.When you work with people who have seen services decline through the years of conflict, and are still struggling to get things moving back in the right direction, you can only admire the tenacity that keeps them going.I'm starting to wonder how all this might make me view the problems and constraints of the Health Service in Wales on my return...

St George's Cathedral

2009-11-29T02:58:00.024Z

Travelling into the city centre for pleasure has not been high on my priority list until now, but yesterday, Jayne, Becky and I (VSO colleagues) took off into town to explore. As well as the government wharf and market area, we visited St George's Anglican Cathedral. Walking through the door into the whitewashed nave was like suddenly being back in Britain, a world apart from the streets outside. But on closer examination, the memorials that line the walls give glimpses of the unique history and geography that have shaped this place. I was so taken with some of the inscriptions that I wrote them down on a scrap of paper. One of the first plaques I came across was at the back of the building, just inside the door:

Sacred to the memory of Robert Corley, RAC Corps, who survived the Battle of Waterloo and perished in this unhealthy climate, June 16th 1837, in the 39th year of his age.

There was a programme on the BBC World Service recently about the digital recording and broadcasting of life stories, and their significance for bringing closure and communicating about traumatic events to future generations. Walking down the side aisle, it occurred to me how digital stories are only the latest way of doing something that memorial inscriptions have been trying to do for generations. Another plaque records words that appear to have been written by angry, grieving parents, far away in Britain, telling the story of their son's death:

This memorial was erected at the desire of the afflicted parents of John Mansfield, mate aboard HMS The Scout, in token of their untimely and irreparable loss from the effects of a season sickly beyond example, in a climate pre-eminently fatal to the health and life of Europeans.

May 6th 1833.

Some of the memorials read like references addressed to St Peter, leaving no good deed undeclared, but others choose their words with care, leaving stories untold. Half way down the south aisle, there is a small memorial stone, high on the wall.163 years on, I wonder about the circumstances of his life, and the grief he left behind.

To the memory of William McCauley, his manliness and generosity, the true friend of the poor in this colony. He died on 24th September 1846, aged 38 years.

This stone was erected by a friend who loved him well.

A request from VSO

2009-11-26T22:22:00.016Z

VSO London has been in touch today, wanting feedback on my experience of being here. The demand for health managers is greater than their ability to recruit and they are looking for case studies to use for publicity and advice for others who might be considering applying. As with a lot of things here, I find it difficult to comment without sounding contradictory: it is one of the most challenging things I have ever done, but being here does not feel like a hardship; I feel like I'm working as part of a team with my Sierra Leonian colleagues, but I am not sure whether I have made any difference at all; daily life in Freetown is exhausting and frustrating, but nearly every day I have experiences that make me laugh and put a spring in my step. However, I'm aware that such ramblings might not be of much use to VSO, so I have tried to answert their questions as best I can:

· What expectations/preconceptions did you have of Sierra Leone before you arrived and how far have they been met or challenged?
Before I arrived, the only things I really knew about SL were that there had been a war here; that it was very poor; and had the highest infant mortality rates in the World. All that is true, but so is the huge optimism and commitment to work for change among my colleagues, the easygoing friendliness of the people and the stunning coastline and scenery.I think that living in Freetown is probably tougher than I expected, though it is a vibrant and fascinating place.

· When you arrived in Sierra Leone, what was the situation in its hospitals? What challenges were they facing?
My job is working in the Ministry of Health, so I’m not based directly in a hospital. However, I have spent some time with the hospital manager at the teaching hospital in Freetown, who did a health management Master’s degree in the UK . Many of the challenges are recognisable to a UK HS manager, but the scale of the problems and the constraints on resolving them are of a completely different magnitude.

· What does your day-to-day work involve?
I share an office with my boss, which has been great for learning fast about the range of challenges and priorities he faces. SL has recently published a health sector strategic plan and there is now a huge amount of work in progress to bring the plan to life and set operational objectives. During my time here we have been analysing HR data; preparing for next years operational plan; and thinking through the HR implications of the proposed establishment of the Health Service Commission. (see blog 18th Nov).

· What positive changes have you seen as a result of your work?
It is difficult to say whether I have had any impact in such a short space of time, but people tell me they have appreciated having some more energy around to get on with the practicalities. Today, my boss and I were discussing a problem together and he commented that “two heads are better than one”. He is a very committed and experienced man, and I take that as a great compliment on the way we have worked together.

· Looking back at your work, what are you most proud of?
I am proud to have been seen as a valued colleague by senior people in the Ministry of Health for whom I have great respect (See blog 20th Nov).

· Can you tell me about any skills you have gained or enhanced as a result of volunteering? For example, would you say you're a better leader/communicator/decision maker / influencer/problem solver/strategic thinker/innovator etc?
Since I have been here, I have sat in many meetings having to work from first principles to consider questions like ‘what is going on here?’; ‘what behavior would be most useful in this setting?’. ‘What contribution would be most useful to get where we want to go? ’. ‘How might my presence and behavior be impacting on others?’ These are issues we confront daily in all management settings, but we make assumptions when operating in a familiar cultural context that we probably shouldn’t. Working outside your cultural comfort zone really brings these issues to the surface and tests your skills of perception and judgement.

· How far would you recommend volunteering to others?
I’m lucky to have been part of the Welsh Assembly scheme, as my two month placement has always been understood primarily as a learning opportunity. I think that anyone doing this sort of thing should be under no illusion that that it is going to be easy. It is not like an extended holiday, or an external management consultancy. You will be right in amongst it. So don’t do it if you aren’t prepared to be challenged on pretty much every level. But if you are, then I think the experience is hard to beat.

Learning Krio (small, small)

2009-11-24T20:16:00.004Z

Last Thursday I had a barb, although I wasn't aware of the fact at the time. I only realised the next morning, when I arrived at the office with my shorn head, to be greeted by the comment "Eh, nice barb, Tim!" (It's obvious when you think about it - what else would a barber do?)

Alhough English is the main spoken language in the office, many conversations soon move into Krio and exchanges on the street, with the neighbours or in the taxi are almost always in Krio. According to my Bradt Guide, the language started as a trading language for tens of thousands of freed slaves across West Africa, Europeans and other merchants, and uniquely blends words from different sources. There are many recognisable words from English, but the grammar and vocabulary make it a language in its own right.

People sometimes comment that I should know more Krio by now, and Iwish I did, because judging from the laughter, conversations in Krio have the best jokes. As it is, I can manage greetings: "Ow di bodi?" ("How are you?"); reply: "A tel God tenke" ("Can't complain"). Given my short time here, I'm never going to be fluent, but I have realised that just trying will often crack a smile on even the most serious face.

A Sunday stroll - via Leicester and Gloucester

2009-11-22T18:02:00.005Z

Today Becky (VSO colleague) and I have been for a great walk in the hills behind Freetown. We had been told where the route began, so just decided to take a taxi up there (near the American Embassy) and see if we could find our way. As it happened, it was easy - a very quiet and shady lane winding through Krio villages back down towards the city.

The villages in the area were originally set up by Christian missionaries as communities for freed slaves and some of the sights had a hint of English village about them. In the village of Leicester (below), we passed the Anglican church, complete with stained glass windows, from which a packed congregation, in their Sunday best, was giving a hearty rendition of 'All Things Bright and Beautiful'.

On a day like today, it is hard to imagine the hardships the early settlers endured, both freed slaves and missionaries. Of the 70 adult missionaries sent out by the CMS from 1804, by 1824 38 had died in the harsh conditions of climate and disease they found here

In addition to the British heritage of the missionaries, there are also signs of the US heritage of the freed slaves. Many of the house designs are reminiscent of the US, where many of the returnees would have previously worked as domestic staff.

Although it is quite high above the city, it was still hot, and we stopped off for a welcome cold 'soft' at a roadside shop, before the urban sounds and smells started to rise up through the trees to meet us.

On arriving back among the hot throng, we jumped straight in a minibus taxi. For 40p and in 40minutes we were on the beach and able to cool our feet and have a beer.

And here is one last picture. It adds nothing at all to the flow of the narrative and I am only including it because I can..

A shocking lunch

2009-11-20T17:01:00.007Z

It is Friday again and I was disappointed this morning when Dr Sandi turned up in a rather conventional shirt on the very day I took in my camera to catch the Friday dress code. Even Margaret and Hannah were not quite as colourfully dressed as usual (yes, I know the white guy looks a bit out of place, but he is trying).

Shortly after this photograph was taken, Dr Sandi produced, as he sometimes does, a big plate of fried chicken from under his desk and he and I sat down to eat it and to chat.

I have often thought to myself how little people mention the war here. In the six weeks we have shared an office, the subject has rarely been raised, except in the most general terms. I knew he had been in Sierra Leone until 2001, when he went to London to study for a year, but had assumed that prior to that he had been working in the Ministry in Freetown. But as we chewed our chicken bones and swigged our coke, he told me things that shocked me more than anything I have heard since I arived, telling the story in such matter of fact terms that he might have been telling about what he did last weekend.

In 1997, he was posted as Medical Superintendent of the Government hospital in the Eastern town of Kenema (see A Long Way Gone - Memoirs of a boy soldier for a feel for the war in the Eastern Region). He stayed there for the next four years, trying to keep the hospital functioning. On one occasion, he and one other doctor received 1200 maimed and injured in 24 hours, triaging and treating as best they could, and spending 12hours per day, 6 days per week in theatre. There were very frequent attacks on the town, and he was a target for capture by the militia - a surgeon would have been particularly valuable to the rebels in the bush.

He explained how his extended family, originally from that area, had been scattered by the conflict, and how his brother had been killed in an ambush. At one point he was offered evacuation from Kenema, but the offer did not extend tohis wife and sons, so the decision to stay was not difficult. As a contingency, in case they found themselves alone, he gave each of his teenaged sons 100,000leones and told them that if ever there was an attack, they should on no account go home, but should run into the bush and go to a prearranged place where he would find them. I asked him if they had ever had to use the rendezvous point. "Many, many times", he said.

When we got up to go back to our desks, he said "Tim, those were bitter times. One day when I retire, I will write a book". That makes me feel better for writing this, because I haven't asked his permission to share his story. It would have seemed trite to finish our conversation by asking "do you mind if I write about this in my blog?" I just hope that if he ever does read it, he will understand the sense of respect with which I wrote it.

Working hard

2009-11-18T10:41:00.002Z

I really wasn't expecting to be working quite as intensively as I have been. This is great, as I feel like I am in among it, though it is also tiring. It is now clear that the formation of the Health Service Commission is a contentious issue, and not all government departments are as enthusiastic about it as the Ministry of Health. Last Saturday there was a special meeting in the Ministry to consider how to stengthen the case and a lot of the work I have been doing with my boss was central to the discussion, which was good to know (I was supposed to be there, but was unable to attend for reasons previously explained).

One thing that is very much in my mind now is the fact that I have less than 3 weeks of working time left here. Bloke flies in, works hard, flies out, leaves no trace, doesn't seem like a good recipe for sustainable development on the face of it. However, I have come to the conclusion that just being here, showing a bit of enthusiasm, helping to get some work out the door and giving positive feedback on the commitment of good people who keep going under constraints that, frankly, would make most of us give up in despair, is not such a bad thing.

And I am, of course, a very small cog in a wheel: DFID is sending in Technical Assistants in the New Year, and the Office of Tony Blair also has a consultant here supporting the Ministry, so there are others giving support and continuity.

So I'm not beating myself up about whether I am doing any good or not and for the next 2 weeks I will keep grafting. After that, Laszlo arrives and we will be heading down the Freetown penninsula. And there will be photographs of tropical beaches, oh yes, there will.

Freetown Sounds

2009-11-16T11:24:00.005Z

One thing I haven't mentioned much so far, and which you obviously can't get through a picture, is what this place sounds like. It is rarely quiet and often loud; sometimes very loud.

The sounds of the morning generally start around 5am, when the pans and buckets start clattering in the kitchen next door. The building is very close to ours so you can easily hear the morning greetings and conversations as people get up to start the day. Early yesterday morning, the conversation was punctuated by a sound that I first thought was the croak of an old person with a bad throat, but then realised was a goat. Later in the day, the household had a big family meal and, for some reason, I can no longer hear the goat.

By about 7am, cars have begun moving along the lane outside. They travel very slowly and the creak and crack of suspension being tested to its limits is generally louder than the sound of the car engine itself. This is all very calm compared to the roaring engines, hooting and shouting that you get up on Wilkinson Road.

During the day, there is sometimes quite a bit of amplified music in the area around the house. There is a small and very poor looking compound out the back that is a major contributor. On one occasion, the music stopped and was followed by that jingle you get when Microsoft Windows closes down. It shouldn't still surprise me, but it does, when I realise that someone in that tiny, poor, house, has got laptop, and has been downloading music. You might think that a power cut would be a relief under such circumstances. However, if the power does go down, you get the additional sound of various diesel generators.

In the evenings we frequently get another sound which is very common in this football-obsessed country: Beside our house is a long tin shed that is quiet for most of the day, but if you look inside, you will see 3 large TV screens in front of rows of wooden benches. When you hear them turn on the sets in the evenings for the pre-match commentary, you just have to brace yourself for the eruption. Watching football on TV is not done half heartedly here.

There is just one other night sound that I need to mention: If you are Disney fan, you may remember that in the film "101 Dalmations", there is a bit where all the dogs bark to eachother to communicate that the puppies have been stolen. Well there must be a lot of puppy theft here (there are certainly a lot of dogs). Sometimes you can hear it start far away over the hill, and then approach like a wave until you are surrounded by howling and barking before it passes off in the other direction.

The odd thing is that noise that would drive me mad in Cardiff is somehow less of a wind-up here. It may be that I'm still in the honeymoon period. If so, I just hope it lasts until December!

On communicating by email

2009-11-14T11:41:00.001Z

I've got the runs. Apologies if that is too much information, but I did say I would use my blog to keep people udpated with my movements (bad joke, sorry). It's nothing serious, I think; it is usually self-limiting within 4 days, and prevalence is about 50%, so I would have been lucky to avoid it. But for today, I have decided to allow myself to lounge round the house, groaning gently.

There is something about feeling off colour that makes you want cool; and Lucozade; and home. It brings back a lot of memories for me about my various tropical illnesses as a young VSO. In those days there was no prospect of emailing or skyping for a bit of instant sympathy. Communicating with home involved air mail - usually an aerogram - a single piece of paper that folded to make its own envelope. It took around 3 weeks for my letters to get home, and a similar time for the response to get back in the other direction. I wrote most weeks and got used to the experience of receiving letters responding to things that I had written 6 weeks and several letters before.

Today, in my fragile state, I think email is The Best. But, although I know it is a cliche, there was something about a letter that I suspect has gone for good. In 1982, I remember the first letter that arrived from my Dad and thinking how I had never really seen his hand-writing before, apart from his signature, or a note to the Vet or the AI man. But looking at it, I could imagine him coming in from the farm, cleaning himself up, and sitting down to write to me. It was probably only the usual news of family and village and weather, but the collection of blue and red envelopes that grew month by month was like having a physical bit of home there with me. You just don't get that with email.

Comparing notes

2009-11-12T11:57:00.002Z

In my previous experience of VSO in Uganda, the organisation was very strongly British. Almost all of the volunteers were British; the Country Director was British; as was his Assistant (me). There were Ugandans on the staff, but they worked as secretaries, drivers and junior support staff. Twenty five years on, the staff in the VSO office here are all Sierra Leonian, with the exception of the Country Director, who is Eritrean. But more remarkable is the fact that the British Volunteers are significantly in the minority, as the majority are from other African countries. For me, the presence of 4 Ugandan VSO's here, sharing their very considerable skills, is the most remarkable of all. For some reason I can't quite explain, that makes me want to cheer.

One effect of this internationalism is happy events like the one that took place in our house last night. In the picture below, there is (from L-R), a Kenyan VSO who works up-country and was staying with us overnight; my Kenyan VSO housemate, who did his accountancy training in India, and has also worked as a aVSO in Indonesia; our Sierra Leonian nieghbour (and boyfriend of the photographer); me; and a VSO ex-publican and business-woman from North Yorkshire. It was a good reminder for me of thedimensions and diversity of Africa - Freetown is closer to London than to Nairobi.We were discussing and comparing the bizarreness of local cultural practices (and you have to admit, the scenes on St Mary Street on a Saturday night must get a pretty high bizarreness rating as a cultural practice!)

During the course of the evening, there was a spectacular rainstorm, and another topic of conversation was the question of just how heavy the rain would have to be before it is reasonable for a Manchester United fan to walk home under an Arsenal umbrella (Answer: there is no rain of sufficient intensity for this even to be considered as an option).

Street life

2009-11-10T16:37:00.007Z

I spend quite a bit of time on the street, at least it feels like it. Last night, for the first time, I actually wondered whether I was ever going to get home. To catch a taxi when it's busy you really need to have your wits about you. They often just swing by the crowd waiting on the pavement and you have to call out where you want to go. Sometimes it also helps to offer a fare that is slightly over the odds, say 1000le (16p), rather than the standard 800le(13p). When it gets dark, the task gets trickier, as the lack of streetlights makes it diffiicult to see which vehicles are taxis and which are just cars crawling along in the traffic.

The good thing is that there is no extra hassle for a white guy, but there is no extra preference either, at least not much. After about 40 minutes on the kerbside last night, a woman who had been standing next to me, called out very insistently in Krio to a passing taxi. As he pulled up, she grabbed my arm and bundled me in, without a word to me. As we drove off, the taxi driver was chuckling when he said "So, how do you like our Freetown, brother?" He then took me right to the end of my road for the standard fare. When things like that happen, the frustration just tends to evaporate.

Despite all the exotic chaos of the streets, when you look at the street signs themselves, the names are more than slightly resonant of their British colonial history. There is, unsurprisingly, given Freetown’s origins as a home for freed slaves, both a street and an area called Wilberforce (if you want to go there, you need to call out "Ba-foss!, Ba-foss!"). There is also a Liverpool Street, Gloucester Street, Victoria Street, Regent Street and an area called Aberdeen ("Abba! Dabba! Dabba!"). You can just imagine the colonial administration meeting to discuss naming the streets: Given the strength of the British desire to limit French colonial influence in West Africa, the naming of Waterloo Street and Wellington Street probably had unanimous support!

However, there is one area of Freetown on the hill above where I live that bucks the colonial naming theme: It is called “Bottom Mango”. I have rather been hoping that, somewhere in Freetown, there is also an area called “Top Banana”. Unfortunately, this does not seem to be the case.

Mile 91

2009-11-08T19:51:00.003Z

It has been good to get out of Freetown this weekend. We left early yesterday morning and chartered a taxi across the city to a place where we could pick up a minibus taxi. You can't rely on exactly when they will leave, because they just wait until they fill up, but we weren't sitting in the sun too long before there was a full load (which is a about 5 people more than I would judge as a full load). On the way, we noticed that every time we stopped a remarkably similar looking lad appeared outside and pulled the side door open to let people in and out. It was only when we saw vans coming the other way with passengers tucked among the luggage on the roof that we realised how he was managing it. In contrast to the hot traffic jam that is Freetown, the main road up-country is a joy. If only the standard of the vehicles could match it..

As you can see below, the welcoming committee were out to meet us at Mile 91. Jayne, the VSO we were visiting, has only been there for 2 weeks and the arrival of 3 more white faces was a big deal for some.

Jayne works for the Sierra Leone Youth Empowerment Organisation, which is doing great work with young people. This area was very badly affected during the war, when much of the fighting was done by young people. We also met several of the other staff, some of whom have been working in the organisation since its inception 10 years ago.

I'm now back in Freetown and feel I can set the city in a bit better context than before. The weekend was a tiring one in some ways, but it was also energising for me, just observing the way people get on with life when they don't have any of the 'essentials' we take for granted. On the way back we were in a car sized taxi, and paid for an extra seat, so that were only three of us in the back. As you can see, the guys in the front could not afford such luxuries.

Having a bit more space, I was able to take some pics of the roadside scenes as we drove by. There was just one view that was alarming, and I really, really hope some artistic wag was just having a laugh, though I can't be sure..

White Man's Grave

2009-11-06T13:47:00.005Z

It was not for nothing that in the 19th Century, the area that is now Sierra Leone was known as the “White Man’s Grave”. A traveller to the area at the time wrote: “When you have made up your mind to go to West Africa, the very best thing you can do is to get it unmade and go to Scotland instead; but if your intelligence is not strong enough to do so, abstain from exposing yourself to the direct rays of the sun, take 4 grains of quinine every day ....and get an introduction to the Wesleyans; they are the only people on the Gold coast who have got a hearse with feathers“.( ref)

Things are not quite like that now of course, but compared to my experience of East Africa, this is certainly not a place to take a cavalier attitude to health and hygiene (especially while you are still getting the hang of bathing in a bucket, which, incidentally, I am now excellent at). In East Africa, moquito nets were often regarded as optional, but here they are definitely not. It may be that I am acting on the cautious side (being here for such a short time, I really don’t want to waste any of it being ill) but every morning before I leave the house, I check that I have mosquito repellent (useful for when you get diverted to an outdoor bar for a sundowner on the way home – like every night), drinking water, antiseptic wash and sunblock.

This weekend I am off up-country to Mile 91 (no prizes for guessing how far it is from Freetown) to visit a VSO who lives there. I am going with two other VSO friends, one of whom is an Australian nurse working in the office of the CNO. The other is also a nurse lecturer at the Teaching Hospital, whose previous job was Matron of the Emergency Unit at the Royal London. Considering the total number of qualified nurses in the whole of the country, I think my health care risks for the trip will be pretty well managed!

I have been asked to go easy on the beach shots, so this is my health related picture for the day - my mosquito netted bed. Just be relieved that I have spared you the shot of me demonstrating my bucket bath technique.

Never a dull moment

2009-11-05T16:06:00.003Z

The office gossip can be high quality here. The Ministers office is just up the corridor and the news that is now on the link below has been been flying around as a possibility for a while. The President launched the Health Sector Strategic plan this morning and, remarkably, all seemed to go off without a hitch.

Reuters, Africa - top news

At first sight.the headline might look dramatic, but when you think about it (for those of us who have been around the UK NHS for a while) it's not like we have never come across a situation where a contract has been favourably awarded to a relative, is it? The dominant view round here seems to be that sacking and arrest is not such a disproportionate reaction. Maybe we have something to learn...

Just like Wales (in some ways)

2009-11-04T09:35:00.002Z

Every Monday morning there is an 8.15 meeting of the Directors in the Ministry of Health (which I and two VSO colleagues get to go along to) where the issues for the week are discussed. This week is busy: on Tuesday the President opened a telemedicine facility at the Connaught Hospital, and tomorrow he is attending the launch of the Health Sector Strategic Plan, so there was a lot talk about.

Immediately after the meeting I was asked to go with my boss to a meeting at the office of the Cabinet Secretary about the formation of the Health Service Commission. Although I was only there as an observer, this was definitely a jacket and tie job, as we sat around a very shiny table while my boss and colleagues were roundly berated for the quality of ministerial briefings and recommendations. In the car on the way back to the office, I told them how similar it all was to Wales, so we all had a good laugh about that!

As it is shaping up, my job is about helping my boss at a practical level to get on top of his huge agenda. It is proving a lot easier to help than I feared before I started, although that is probably more to do with his skill in knowing how to work with me, rather than the reverse. He did his medical training in the Ukraine, a Masters Degree at the LSE, was in Sierra Leone during the war and has more life experience than I will ever get.

There are loads of things I would love to photograph here – at work, on the way to work, around home. But you have to be very sensitive about using a camera, particularly away from the beach. So though I am now in city work mode, here are some more gratuitous beach shots, this time of Lakka beach. Getting there requires a bit of walking and taxi hopping, but I got there in about an hour last Sunday, at a total cost for the round trip of about 70p. The sand here is very yellow and, once again, the whole scene is stunning.

Slogans, shopkeepers and comedy

2009-11-01T10:06:00.004Z

The minibus taxis that ply the streets of Freetown invariably have slogans painted on their body work. They can vary from the positive :“ We Are All Blessed”, to the unsettling: “My business is washed in the blood of Jesus”. Some slogans assume people know their Bibles pretty well - I saw one yesterday that said “1 John 3v10”. But not all of them are religious; there is one that I have read about, and am looking out for, which declares :“Still with my paddle, nevertheless”!

Although Christian culture is very visible, there are also many Moslems here. Last night, as I was walking back to the house along the back lane, I stopped at a shop to buy some oranges (think small tin shack with open front). As I approached , I saw the shop-keeper standing inside with his back to me, looking at the shelves of provisions. “Hello”, I said, to attract his attention. But he ignored me and I realised he was talking quietly to himself. Then he knelt down on what I suddenly realised was a prayer mat, so I moved away. But I did really want some oranges, so I waited until he had finished and went back. When I apologised for disturbing his prayers, he flashed a smile at me and said “No problem, brother”.

It seems to me that religious beliefs here are generally held with a fair degree of tolerance and humour. Yesterday, I went to some auditions for the national cultural festival, which takes place at the end of November. There were a very wide range of acts – from traditional dance and plays, to sketches and stand-up comedy. One of the comedians told a joke that was linked to the words of the Lords Prayer. Unfortunately, I can only pick out the odd word in Krio, so didn’t understand it. However, judging from the gusts of laughter that shook the hall, it was side-splittingly hilarious for the large and varied audience.

Dress down Friday

2009-10-30T23:53:00.001Z

Actually, 'dress up Friday' would be a more accurate description. A lot of the Ministry staff dress very smartly on every day of the week, but on Fridays the style steps up a pace and the corridors are colourful with shirts and long dresses, very often with matching head gear. And yes, I did have a genuine Sierra Leonian shirt myself- not made to measure, but a very nice one of fine cotton, dyed in indigo. I'm not sure if I paid over the odds for it, but I enjoyed doing the deal in the Big Market.

Today has been a really good day at work. The President gave assent to the creation of a Health Services Commission last Wednesday, which is something the Ministry of Health has been wanting for a long time. At the moment, everybody who works in publicly funded healthcare facilities (and that includes drivers, porters and cleaners in the remotest rural areas) is classed as Ministry staff, with hiring and firing done at national level. The Commission would separate the HR arrangements for health workers, including regulation and standards, from central civil service arrangements. The President wants the Commission in place by next March, which is a huge task. I can't quite believe how lucky I am to have arrived at a time when my UK background and experience is so relevant. I am also amazed at the calibre and commitment of colleagues I am working with - techincally sharp, politically savvy, but very open to discussion and ideas.

I really wanted to get a picture today of our department in Friday dress mode. My boss was very keen on the idea, but then the day took flight and there wasn't a good moment, so that one will have to wait. Instead, this is a gratuitous beach shot of Lumley beach in Freetown, taken from my chair at a beach bar last Sunday afternoon. Think bath-warm sea...

Around Home

2009-10-28T20:34:00.001Z

I'm trying to find a way to describe what the immediate environment of the house is like without it sounding contradictory. Here on the West side of Freetown, living conditions are generally much better than in the East and in relative terms it is by no means a poor area. The house has a balcony and although the next house is built so close to ours that part of the view is obscured, in one direction we do have a clear view of the sea, which is a very pleasant sight in the evening.

In another direction the view is not quite as easy on the eye:

And in another, there is a more gritty reality:

I could tell you that a couple of hundred metres away on the tarmac road there is a lebanese bakery and a supermarket; a bit further up the road there is an Italian restaurant; and that about a kilometre in the other direction is a patisserie. All these things would be true, but somehow, I think the impression that gives would be misleading. It doesn't really feel like rich and poor, North and South; the chaotic mix here is far more exotic than that.

Tonight we have had a plumber here, to try to sort out the problem of our lack of water. However, it seems the problem is not in the house - the pipes are not buried very deep and it seems that it has been cut and turned into an impromptu stand-pipe somewhere further up the road.

Sunday Service

2009-10-27T20:37:00.005Z

On Sunday it was the annual medical and health services Sunday service, which was held at the Methodist Church in Central Freetown. My colleague VSO who works in the Chief Nurses Office had been involved in the organisation, so three of us went along to what turned out to be very lively and enjoyable event - with the congregation cheering the preacher when he spoke about the scandal of low pay for health workers, and with great singing and dancing up the aisle for the offertory (not by me, you understand). After the service everybody formed up to march through Freetown to a reception. In the picture below, you can see the famous Freetown Cotton Tree in the background.

I had a special reason to feel thankful at the service, as it is where I met up with the delegation from ABMU Health Board in Wales who have come to do some training in the Childrens' Hospital over the next week. They were carrying with them my laptop from UK (thank you Julie and Lisa!). So this week I'm a bit better placed to support my boss and get on with some of the things he wants me to do. And also, of course, it now means that I have a way to upload some pics to my blog.

Checking out the beach

2009-10-27T20:36:00.006Z

Well it did rain on Friday night - and it was heavy rain. So heavy that you could really feel the weight of it on your umbrella. I now realise why all the unmetalled side roads (i.e most of the roads) are like rocky river beds. It is because that is what they quickly become. However, by Saturday morning it had cleared up and four of us decided to hire a taxi for the day (which worked out at about £7 each) and go down to River Number 2 Beach. The road was terrible, but the beach is jaw-dropping.

It was almost deserted but the community there has formed a development association and built some simple lodges for overnight accommodation. They will also cook meals (baracuda kebabs and chips), provide cold beers, and they pool their takings for village development. Apparently, during the war, when the rebels were approaching they buried their generator and other valuables and took to the sea in boats, where they were safe from harm.

Friday afternoon

2009-10-23T17:28:00.002Z

It's been a good week and I'm learning a lot. There are some aspects of the job that seem very familiar at first sight, but then turn out to be quite different (like the staff appointment process) and there are other things that are surprising, but then turn out to be very recognisable after all (like arriving at work today and finding everyone in traditional dress - it turns out that it is dress down Friday). The secretary has offered to take me to the tailor to have a shirt made for next week..

The Ministry of Health is under great pressure to reduce the time between a job advert being placed and someone taking up the post. It can currently take years, by which time newly qualified staff have often gone elsewhere. I've been doing a process map with the personnel staff this week and it's not hard to see why it takes so long, with approval of every appointment involving 2 Ministries plus the Public Services Commission. I'm not sure how possible it might be to change yet. It seems the controls were put in place to reduce the risk of corruption so there are a lot of concerns about losing central control.

In general feel I'm finding the groove now. Each day gets a bit easier; the journey to work is simply a matter of timing, and there's plenty of good natured banter to make the time pass (I shared a taxi this morning with someone whose son lives in Arabella Street in Cardiff). The humidity has also dropped and the weather today has been great. I've arranged to meet with some others for a beer at the beach in a while, though from where I'm sitting, I can see some grey clouds in the distance, so we may be rained off. This is just the tail end of the rainy season so its quite changeable - Sierra Leonians, seem to talk about both traffic and the weather, just as much as the Brits!

Finding a routine

2009-10-20T17:24:00.001Z

Well, I definitely haven't found a routine yet, although at one level, I'm living the commuters office life. I go to work by taxi; they can take up to 6 people (4 in the back, 2 in the front) and they pick up and drop off as they ply the main routes round the city at a cost of around 15p per person. Yesterday, I left home at 6.45 and was at the office by 7.15 (about an hour too early), so today I left home at 7.15 and got in at 8.45 (a bit too late). It would actually be possible to walk in about an hour, but it is rather hot for that, and also feels a bit dangerous to me - mainly because of the large holes that suddenly appear at the roadside.

I work in the main Ministries Building (the "Youyi Building" - its marked on Google Earth)and I have to walk up to the 4th floor. Needless to say, I'm pretty sweaty by the time I get there.

My actual office (which I share with my boss) has a great view and was my second culture shock here: There is air conditioning and it's positively icy. Luckily I brought a jacket and tie with me from UK. I am keeping it in the office, so that I can put it on if needed to warm up! The Ministry staff are all being very welcoming and my boss clearly has an overwhelming workload, so I hope it won't be hard to find ways to support him.

I'm living in the West of Freetown, just off off Wilkinson Road at the Murray town end (try the street name function on Google Earth). I share a first floor flat with a Kenyan VSO, who is a great source of practical advice. The flat is basic but OK - we have electricity (and a fan, but no aircon)and no running water. We pay a guy to wash clothes, bring water cans to the ground floor hall, and clean the house. (I know some would argue that my judgement of character isn't great when it comes to cleaners - but this guy really does seem good!)

I've been to the beach once so far - a great place to unwind from the city stresses. It's quite possible to get there by taxi after work to drink a cold beer in a beach bar if you time it right. Working that out is my next transport challenge!

A couple of people have texted about whether I am picking up emails. Well I am, and it is good to get them - you can email via a link if you click on "my profile" opposite, so no excuses!

Starting work

2009-10-16T11:16:00.012Z

I'm in an internet cafe (sort of). I met my boss on Tuesday have spent the last 2 days with him at a workshop on the role of Community Health Workers. The workshop was trying to work through defining roles and supervision structures. These workers are community members at village level and the Ministry of Health is looking for ways to train, support and reward them without undermining qualified staff, who are often unsupported themselves and not paid reliably.

I've also met more of the other VSO health volunteers. As well as the one in the CMO's office, there is one working with the CNO, and one working as a clinical instructor in the main teaching hospital. At one level, the structures are recognisable and familiar to me; it is just what you see in the street (and apparently in the hospitals) that is the shock. Last week, the latest global UN Development index was published and Sierra Leone has only moved up 2 places from bottom position.

At a practical level, one thing that has surprised me is just how widespread the use of mobile IT is - even by people who don't look they could afford much else. At the Ministry workshop all the presentations, breakout group notes and feedback was done electronically, without a flipchart in sight! You can see the sense of it - when paper is expensive and photocopiers unreliable, "flashing" documents round by email and memory stick is practical and quick. In the light of that, my discovery that my laptop only works on broadband(which doesn't exist here)and that the USB ports are disabled was more than a slight annoyance (yes, I know, I should have prepared more carefully!)

First impression

2009-10-13T08:31:00.001Z

Walking across the tarmac to the terminal building at Lungi airport was like stepping into a well heated bathroom where someone has recently had a shower. I was booked on the 4th helicopter shuttle trip across to Freetown, so I had time to chat to my fellow travellers : a couple returning from UK to live in Sierra Leone, the Freetown University Registrar, and a woman from the UN, who wanted to know if I played Bridge...

I'm now in the VSO office, which overlooks the bay and is a very calm place, compared to the bewildering chaos that is my impression of Freetown at the moment.

It is going to take a while for me to get to grips with the basics of daily life, I think. The VSO staff here are all Sierra Leonian, and seem great. There is also a very international group of volunteers, including 3 Ugandans, who have been telling me about how well developed and well organised Kampala is these days!

Last night, I was talking to another VSO who recently started work in the CMO's office. It sounds like things will be even more challenging than I thought.

Time to go

2009-10-11T10:25:00.002Z

Well, my passport and visa finally arrrived by courier yesterday morning, which is just as well, because otherwise I wouldn't be sitting here in Heathrow Terminal 1 Departures. Laszlo just left to head back down the M4 for his late shift, and the bit of this whole adventure that I was least looking forward to is over. 'You'll be fine', he said, and I will be, but I'm still rubbish at leaving. The departures hall is quiet this morning, very British sunday morning with coffee and newspapers. It is still pretty hard to imagine Freetown, less than 7 hours beyond the departure gate.

A bit of background

2009-09-24T17:07:00.004Z

I know we sometimes complain about staff shortages in Wales, but I just got hold of a copy of the Sierra Leone Health workforce Development Plan 2006 - 2010. Here are a few comparisons for directly employed staff:

	Wales	Sierra Leone
Doctors	5,500	308
Registered nurses	21,400	1,375
Total Trained health workers	49,000	3,736
Health workers : population	1 : 63	1 : 1,705

As I understand it, urban hospitals in Freetown lose their staff to hospitals abroad; District hospitals lose their staff to Freetown; community clinics can't find any trained staff so are staffed by assistants who have little training, supported by volunteers, who have virtually none. Add to that the lack of basic infrastructure and supplies, and may be I can start to glimpse the scale of the challenge.

Three weeks to go

2009-09-19T19:25:00.006Z

On 12th October, I will be going to Sierra Leone to work in the Ministry of Health for two months. The picture behind the blog heading is apparently of a beach near Freetown and I find it difficult to reconcile with what I am reading about the challenges facing a country that was so badly butchered in a civil war that finished only seven years ago. It is, by all accounts, a friendly, safe and beautiful place, but it struggles at the very bottom of the UN Development Index (ranked 179 out of 182). About 3 times bigger than Wales, and with a population around twice the size, health services are non-existent in many areas with hospitals and clinics struggling with an almost total lack of trained staff. My role (I think) will be to support the development and implementation of a plan for training and supporting the staff they need. I just hope I can find a way to make myself useful.