29th April 2010: Emily Spry on the launch of the free health care initiative

Yesterday was Independence Day in Sierra Leone, marking the start of the country’s fiftieth year since independence. It was also the launch of the President’s free health care initiative for pregnant and breastfeeding women and children under 5.

I previously shared with you my frustrations and grumbles as we got ready for the launch, specifically about problems with the allocation of drugs.

In the bigger picture, this is a really bold and important step by the President and by Sierra Leone as a whole.

Making health services accessible to those patients who need them most is a key weapon in the fight to reduce maternal and child mortality.

There have been nothing less than heroic efforts by the Ministry of Health and its funders and partners, who have been busting a gut for months to make this dream a reality.

The launch itself was held at our twin hospital, the Princess Christian Maternity Hospital and afterwards the President made a short tour of the two hospitals, visiting the therapeutic feeding centre, where malnourished children are cared for.

A huge throng of mothers, babies on their backs, had been queuing outside the Children’s Hospital since very early in the morning. Crowd control has been a bit of a challenge, but everyone pitched in with staff and volunteers making sweeps through the crowd to pick out emergency cases.

On Independence Day itself, we saw around 350 patients, around eight times our usual number of patients. There were a similar number today (Wednesday). All the doctors were working flat out in the outpatient department, apart from one in the emergency room and one in the neonatal unit. The wards are full to bursting – three-in-a-bed is now quite widespread. The drug supply problem is being taken seriously and we are expecting a quick re-supply, as many useful outpatient drugs have now run out.

Fingers crossed that the outpatient numbers will calm down fairly soon, as is expected. I’ll let you know how it goes.

22nd April 2010, Emily Spry: The free health care initiative in Sierra Leone

It is now less than one week until the launch of the free health care initiative in Sierra Leone when, as regular readers will know, government health facilities, such as my own dear Children’s Hospital, will be required to provide free healthcare to children under five, pregnant and breast-feeding women.

The big day is Tuesday 27th April, Independence Day, when the nation will celebrate 49 years since the end of colonial rule by Britain.
Clearly, this is a hugely complex project and myriad things need to come together to make it possible. A good deal of money is being spent by the UK Department for International Development (DFID), UNICEF, and several international non-governmental organisations.

One key step has been to increase health-worker salaries to a living wage, so that it is plausible to demand that they stop charging user fees. This has been done, though negotiations did involve a full-blown strike.

My sources now tell me that the strike was only ended by a secret meeting in which the President agreed to increase salaries further. This apparently will ensure that first year doctors take home $600 after tax, rather than being taxed heavily on a gross salary of that amount.

Of course, the salaries haven’t actually been paid yet and many beleaguered health workers prefer to reserve judgement “until we feel the money in our pockets”.

The second key issue is for the government to supply free drugs and consumables to the hospitals and clinics for the first time in many years.

I’m sure that UNICEF and the others had a strategy for this at some level. Certainly, they have brought several million dollars’ worth of drugs into the country.

For many months now, I have tried to find out which drugs we can expect at the Children’s Hospital, and how much thereof.

Just three days ago, the Hospital Pharmacist finally got a list.

Unfortunately (and AGONISINGLY predictably), whoever wrote the list clearly has no idea what the Ola During Children’s Hospital is (the clue is in the name) and what that might mean in terms of our drug needs.

According to this list, we are to be given the same drugs at the same quantity as if we were a small primary health unit.

Thus, we have been allocated inappropriate drugs and consumables (clotrimazole vaginal suppositories, anyone? Or would you like to have our allocation of drugs used only in childbirth?)

I can’t see any injectible anti-malarials on there, though I’m still hoping that I’m missing something.

And we have been allocated tiny quantities. In a really staggering disappointment, we have been allocated 13 intravenous cannulas. For a hospital that admits around 800 patients a month.

We are trying to engage the relevant people to make changes but, with three working days to go before the launch (and nothing yet delivered to the Hospital), it may well be too late.

Another key to all this is communication. A truck turned up at the Children’s Hospital today, pumping out music and blaring messages about free care.

Who is going to tell an expectant public that it’s only basic healthcare that is free? (if your child needs a second-line antibiotic, you will need to go out and buy it or go without). Who is going to tell them that the 13 cannulas have run out?

I found out today that the President is going to launch free health care at the Children’s Hospital. I’m not sure if that will be a blessing or a curse.

8th April 2010, Emily Spry: Emily Spry is back in Freetown

If you blinked, you probably missed it, but I’m back in Freetown after a short Easter jaunt to the UK to see my family and a few friends. I was surprised but delighted to be snowed on in the mountains in Wales; at least I can say that I experienced the legendary winter of 2009-2010, no matter how briefly.
When I left, the Children’s Hospital was entirely empty of patients; the doctors and nurses were nearly two weeks into a strike over pay. Several of the administrative staff were beside themselves, as they milled around the empty corridors; they hated seeing the Hospital that way. The only silver lining was that the Environmental Health people got to spray the wards to their hearts’ content, hopefully banishing unwanted insects.

However, the day after I left, the president issued a statement that all those not back at work by the Monday morning would be fired. Frantic meetings followed and eventually the associations agreed; they would go back to work.

It seems that ultimately, the nurses will get around 150 USD per month, with more for very senior nurses, whilst the house officers (i.e. newly-graduated doctors) will get around 600 USD, pre tax. Paying the highest rate of tax plus national insurance, the house officers will take home around 300 USD per month.

The mood seems to be cautiously optimistic. “It’s not what we wanted, but it’s better than nothing,” several people have said to me.

The focus is now moving to the looming day (27 April) when user fees for pregnant and lactating women and children under 5 will be abolished. I would love to say that the Children’s Hospital is ready but it’s not. They are currently trying to create an appropriate store for the free drugs and a dispensary.

For me, triage is the scary part. We expect a huge influx of people coming to get whatever free stuff they can while it’s there, not yet believing that the programme is to continue. The danger is that the emergency cases will be hidden in the crowd.

The great thing about going back to work today was appreciating again the incredible warmth of the people that I work with here. I was only away for a week but everyone welcomed me with huge smiles and hugs and asked me about my holiday, my family, my journey and everything else. It’s so different from the working culture in the UK, where a brief nod would probably have done. After very mixed feelings leaving family and friends at home, today I felt really glad to be back.

26 March 2010, Emily Spry: The Strike Continues

After 11 days, the total strike of all government healthcare workers in Sierra Leone has finally been elevated to a BBC World Service African news headline.

Yesterday, the President called all the doctors and nurses to a meeting in a room at the Stadium.
I was also indirectly invited, but decided that it would be better to stay away.

As you know, I’m entirely sympathetic of the doctors and nurses, although I do very much regret the suffering the strike is inflicting on those poor people who rely on public healthcare. The Welbodi Partnership has always said that staff must be paid appropriately as an essential part of any attempt to improve healthcare here. It’s common sense that nurses cannot work for the Government in any meaningful way when they are not paid enough to cover their transport costs to and from work.

At the same time, we are only able to work in a Government Hospital because of the approval and cooperation of said Government. I was very keen to avoid being asked to come out for one side or the other in a public meeting!

The meeting took things back to square one. The President’s exhortations and promises did not impress the health workers; they did not even applaud him, which seems like quite a statement in a country where people respect their elders. They rejected his pleas to call off the strike and go back to work.

The strike has apparently also spread “upline” (a lovely phrase left over from the days of the railway, decades ago) to the towns and villages outside of Freetown.

The good news is that yesterday we managed to transfer the last three babies from our bizarre temporary ward at the private hospital. These children were those left behind in Children’s Hospital after the strike was called. They were too sick to go home, so a few volunteers ended up looking after them.

Yesterday, I once again prevailed upon the professionalism and humanity of the wonderful Lieutenant Colonel Foday Sahr, who runs the Military Hospital in Freetown. Although packed to the rafters with those who would normally be treated in the public hospitals, he and his staff agreed to take the three babies and one very anaemic mother.

The small Paediatric ward and Maternity unit at the Military Hospital left a strong impression. The nurses and doctors are present, proactive and communicative; the wards are clean, tidy and organised.

I’m sure that there are many factors contributing to this; the Hospital is resourced directly by the Ministry of Defence, the staff organised in the strictly hierarchical command structure of the military etc. But they also have a great leader – knowledgeable, kindly and determined to improve the services the Hospital provides.

I am going back to the UK tonight for a week. It seems a rather frivolous jaunt in some ways but after 8 months away, it is also very welcome. I’m going to meet my first godson (born in September – he has been patient, as have his parents!), read a decent newspaper, drink real milk and help my sister celebrate her 30th birthday. And I’m going to bring back a lot of parmesan.

“Wi go si back Freetong” (See you later Freetown).

March 23rd 2010, Emily Spry: Sierra Leone doctors still on strike

Despite my best efforts, I seem to have ended up with four sick babies and a mother with an infected Caesarian wound, all of us stranded in an unused wing of the fanciest hospital in Freetown.

It all started on Wednesday when the doctors and nurses went on strike across the capital. As I have noted before, doctors here are paid around $100 per month and nurses around $50 per month, not enough to live on in Freetown. After the strike was called, there was a flurry of phone calls and between myself, two German NGO nurses, the VSO doctor and an experienced neonatal nurse, who also volunteers almost full-time with me for the Welbodi Partnership.
The gut reaction was for us to step into the breach at the Hospital. At least to review those who were too sick to be discharged and field the Emergency cases. To be heroes.

But there were lots of questions. Safety for one; VSO ordered its volunteers to stay away from the Hospitals, as there could be risks in a situation with angry staff and patients. In fact, no trouble
materialised, but it wasn’t an outlandish concern.

Secondly, and more complicated, the question of whether we should interfere with the healthcare workers’ decision to shut the Hospital down. Who were we to go against their decision? The healthcare workers know the implications of what they are doing; patients will die. But they feel strongly enough that the upcoming abolition of user fees (the President’s Free Healthcare Initiative) cannot and will not work if their conditions of service are not improved to fill the
gap left by user fees. They feel that this is their only chance to force the Government to meet their demands.

This also leads on to what our role should be here. The Welbodi Partnership’s approach is to form a long-term relationship with the Hospital that will bring slow but, hopefully, sustainable improvement. Breaking a strike is a strategy that could seriously damage important relationships and raise questions about our role.

After long discussions and advice from my boss, all of this led to me staying away on Wednesday and I had a prior engagement speaking at a conference on Thursday. But by Friday, I felt that it was time to go and have a look at what was going on.

In retrospect, it seems that the best way to deal with an insoluble ethical dilemma is to stay as far away from it as possible. As soon as I got into the Hospital, I was sucked right back in.

When the strike was called on Tuesday evening, the staff had discharged most of the children, with only the sickest remaining. By Wednesday, there were less than 30 patients left, gathered in the ICU. Somehow, the German nurses and another volunteer ended up caring for these patients between them, with an occasional doctor review. The Military sent a nurse to relieve them on Thursday night. The Head of the Hospital forbade further admissions (not that the skeleton team
could have handled it) and all patients were turned away at the gate.

By the time I arrived on Friday morning, they were exhausted. Some senior nurses were also murmuring about why the Hospital was still open three days after the strike started. So, with the Prof’s help, we swung into action, reviewing, discharging and ringing around to try to find Hospitals that would take some of them.

The Military Hospital generously accepted some patients and we discharged several more. But we were left with four sick babies, all on IV drugs, two of whom were dependant on oxygen. The manager of a private hospital offered us a room with some beds, but had no extra staff; he had already taken around 15 surgical patients from the main Hospital in town. There was talk of a general strike at the Children’s Hospital, so the security and porters would be gone by Monday.

Late on Friday night, we ended up cramming four cots, an oxygen concentrator, boxes of drugs and equipment, four babies, mums, aunts and grandmas and all their stuff into two cars. A friendly local policeman agreed to lead our strange convoy through town on his police motorbike, haring down the middle of the traffic, flashing and beeping (we have no oxygen cylinder, so we needed a quick transfer for the babies dependent on oxygen). I have never crossed traffic-clogged Freetown at such a pace.

I also never quite imagined myself in this situation, especially in my non-clinical role with the Welbodi Partnership. I tentatively think that we have done the right thing. We made sure that the children already admitted to the Hospital were cared for appropriately, though we didn’t accept any new cases.

There is no doubt that sick children will die because of this strike. But I am not here to break the strike of the Sierra Leonean doctors and nurses whose duty it is to care for those children. I believe that I am here to try to help them build a system whereby all children have a better chance at life-saving healthcare. And paying doctors and nurses properly is a must for that to happen.

But it’s a bit of a minefield, to say the least. As I write this, I do wonder if it will sound insane or just plain wrong from another perspective. Do please let me know.

March 18th 2010 Emily Spry: Doctors and Nurses on Strike

Here in Freetown, both the doctors’ and nurses’ associations have decided to go on strike with immediate effect.

The strike has been precipitated by the Free Healthcare Initiative, which is due to remove user fees for healthcare for pregnant and nursing women and children under 5 years old on the 27th April 2010, Sierra Leone’s Independence Day.
The issues behind it have, however, been brewing for a lot longer.

In the Children’s Hospital, user fees are low compared to many other Hospitals, although still prohibitive for most of the poor families who live in the slums around the Hospital.

Thanks to the contribution of Cap Anamur (German Emergency Doctors) and other partners, patients at the Children’s Hospital pay a one-off consultation free of 15,000 LE (3.8 USD). If they are admitted, drugs and other consumables (IV lines, dressings etc) are free, though many laboratory tests and blood transfusions are still charged for.

The Free Healthcare Initiative was announced by the President in November 2009 and is supported by donors and NGOs including DFID, Save the Children and various UN agencies. Since the announcement, a progressively more frenetic atmosphere has been building up at the Ministry of Health and Sanitation, the Ministry of Finance and in all health-related organisations across the capital. With six weeks to go to the launch, major decisions are still to be taken and many crucial issues are still to be resolved.

The plan is that all user fees for the three vulnerable groups are to be abolished. Huge consignments of drugs and consumables are being shipped in and will (inshallah) be distributed to the patients who need them. Salaries are to be raised for all staff, with incentives for hard-to-fill rural posts. Performance-based incentives are to follow next year.

So, what on earth are the doctors complaining about?

Firstly, doctors and nurses are extremely poorly paid, even by the standards of neighbouring countries, such as Liberia. Junior doctors, when they are fortunate enough to be “absorbed” onto the Government payroll after graduation, are paid around 100 USD per month.

I am paying 550 USD per month for a bedsit. Even taking into account the fact that I have the luxury of relatively constant light and water, and the inevitable “whiteman tax”, it is clear that living in Freetown is not cheap.

Moreover, the user fees actually contribute significantly to the doctors’ income at present. The consultation fees are put into a pool and shared out according to seniority. The Children’s Hospital medical officers get up to 200 USD per month from the user fees pool.

So, using this example, to avoid an income loss with the Free Healthcare Initiative, these doctors will need to be paid roughly three times as much as they are at present.

Moreover, it is the intention of this policy to substantially increase access to healthcare. In other words, there will be more patients and therefore more work. For a doctor who sees 40 or 50 patients a day in outpatients, this is not a very appealing prospect, especially if combined with a loss of income.

The whole initiative is brave and fascinating. There is consensus among those involved in the planning that it has already forced a lot of progress in the healthcare sector here that might never have happened otherwise. For example, cleaning the payroll of “ghost” workers and improving the process for absorbing new staff (previously many worked as “volunteers” for years, awaiting laborious process at various Ministries).

However, it is also a risky strategy and there is a lot of work still to be done, prior to 27th April and after the launch. The drugs may have started arriving in Sierra Leone, but if the doctors and nurses aren’t satisfied, I am not sure what will happen.