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!)