Launch Day

 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

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

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

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

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

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.