Thanks to your donations: More Oxygen for Sick Children

Thanks to our generous supporters, Welbodi Partnership has been able to buy four smart new oxygen concentrators, which arrived at the Hospital earlier this month.

These fantastic machines provide essential oxygen for up to four sick children at a time and are undoubtedly saving lives every week, if not every day. Prior to this, the Hospital had only four machines and babies and kids who needed oxygen often went without.

Other work-in-progress includes adding four extra water tanks, which will store water for when the mains supply is interrupted (as it often is).

We are also incredibly excited this month to have employed an Associate Professor of Paediatrics from Nigeria, Prof Abiodun, who is charged with guiding the hospital towards teaching hospital standards, so that it becomes the place where Sierra Leone’s future Paediatric doctors and nurses can be properly trained.

Reaching our vision of a centre of excellence for Paediatrics in Sierra Leone is going to take a lot more time, money and effort, with many challenges along the way. But the Hospital and its partners are committed to making it happen, bit-by-bit (or “Small small” as they say in Krio).

Happy New Year

Dr Emily Spry, Medical Coordinator at the Welbodi Partnership, is writing about her experiences at the Children's Hospital for the BMJ. Her latest blog is below.

http://blogs.bmj.com/bmj/category/emily-spry/

It’s a new year at the Children’s Hospital and everyone is cheerful. The figures from the last months of 2009 suggest that inpatient mortality has decreased substantially, compared to the equivalent period in 2008. We are also more popular; the number of inpatient admissions has tripled over the past six months.

The Children’s Hospital is fortunate to have substantial support from Cap Anamur (German Emergency Doctors), who pay attendance-based monthly incentives to staff and provide free drugs and consumables to all inpatients. But this is not a long-term project and may end as early as July this year. The Welbodi Partnership, which I volunteer for, does not yet have the resources to step in and take over this expensive project, though we are doing our best to seek other options.

The staff rightly dread going back to the dark days of previous years, when children died for lack of drugs that their parents couldn’t afford and staff attendance was much less. As I have said in a previous blog, the junior nurses are paid only 120,000 LE (around 30 USD) monthly by the Government, meaning that, prior to the incentives scheme, many of them had other jobs to make ends meet.

In fact, there are big changes afoot in the whole health care system in 2010. With considerable encouragement from donors and NGOs, the President has announced that health care will be provided free for all pregnant women and children under 5 years old from 27th April 2010, the country’s Independence Day.

We do not yet know how this will work on the ground. Can we hope for an increase in healthcare workers’ Government salaries? Can we expect a regular supply of drugs and essential consumables (e.g. gloves, cannulas etc) to the Hospital?

One thing that seems fairly certain is that the Government intends to eradicate the informal user fees charged in all healthcare facilities.

There’s no doubt that user fees are a barrier to healthcare and everyone agrees that they need to go. The challenge is how to deliver quality healthcare for free in a system that currently relies on those user fees.

At present, a consultation fee (15,000 LE; 3.8 USD) supplements the Hospital running costs and doctors’ wages. The Hospital management faces a long and difficult procedure to get funds or resources from the Ministry and has not had any drug supplies from the Ministry since 2006.

The Government, donors and NGOs are meeting regularly in the coming weeks to devise a plan that we hope will make the President’s promise come true on 27th April 2010. I will keep you updated!

Emily Spry is a doctor from London who has taken a year out of her General Practice Specialty Training Programme to live and work in Sierra Leone, West Africa. She is working for the Welbodi Partnership, a charity which supports the main government Children’s Hospital in a country where more than one quarter of children die before their fifth birthday.

Improving child mortality

Our Medical Coordinator, Dr Emily Spry, is writing for the BMJ about her experiences at the hospital...

http://blogs.bmj.com/bmj/category/emily-spry/

A relatively newly-posted medical officer told me how she resisted returning to the children’s hospital after her three month stint here as a house officer last year. “It was so awful when the children died, and they died all the time. I went home and cried every night.”

If you believe the stats (which are certainly not bulletproof but hopefully skewed in a fairly consistent way), the inpatient mortality rate has fallen from 15-20% in previous years to less than 7% last month. A large part of the credit must go to German charity Cap Anamur, which has implemented free drugs and basic disposables for all children admitted as inpatients. I’m hoping for further improvement this first month of our Emergency Room, though there are also seasonal variations; we should expect less mortality now that the rains have finished.

The medical officer was pleasantly surprised by how the hospital has changed in the past year, but it’s still tough on those days where several children die. She was particularly frustrated and upset the other morning, when it emerged that a child with meningitis who “passed off” had not been given his antibiotics overnight.

We discussed the different ways of addressing how this had happened and how to prevent future mistakes. Partly as a result, we’ll be restarting the lapsed “medical meetings” next week, which will look at difficult or troubling cases.

But when it came to the issue of trying to establish the details of who had done what on this particular night, she drew back. “I don’t believe in it myself,” she said, “but there are some people here who have special powers. There are people in this side of town where you can pay just ten thousand Leones [less than 2 GBP] and have a curse put on someone. I don’t want someone to have a reason to hate me.”

She related a tale of a friend who developed a severe skin condition that no conventional doctor could diagnose or treat. When she sought the traditional healers’ opinion, he was able to diagnose a curse and cure it with a special potion.

“As I say, I don’t really believe in it myself, but you have to be careful in this country.” She seems to believe it enough to avoid causing problems for a nurse whose neglect or mistake contributed to this child’s death.

Is this a cultural expression of something rather more familiar? No one wants to be seen to rock the boat, to point a finger of blame, because of the potentially dramatic social consequences.

Somehow we need to create an environment and a process through which we can examine what happens and raise the standard of care. It’s just, as always, a bit more complicated than I thought.

Emily Spry is a doctor from London who has taken a year out of her General Practice Specialty Training Programme to live and work in Sierra Leone, West Africa. She is working for the Welbodi Partnership, a charity which supports the main government Children’s Hospital in a country where more than one quarter of children die before their fifth birthday.

Recruiting: Voluntary Medical Coordinator 2010-2011

Voluntary Position Available – Medical Coordinator
Location: Freetown, Sierra Leone
Assignment Length: One year
Application Deadline: 31st January 2010
Starting – July 2010 (start date may be somewhat flexible)

Job Description

The Medical Coordinator (MC) will provide technical leadership and contribute to the development and implementation of ongoing and new project activities aimed at improving the quality of paediatric health care in Sierra Leone, starting at the country’s only specialist paediatric facility, Ola During Children’s Hospital (ODCH).

Responsibilities

The Medical Coordinator (MC) is responsible for the design and implementation of all medical project work. This includes:

1. Needs assessment and planning: Work with partners in the Ministry of Health and Sanitation (MoHS) and Ola During Children’s Hospital (ODCH), to identify barriers to the delivery of timely and effective healthcare for children and develop ongoing plans to address these barriers.

2. Implementation: Take joint responsibility with ODCH management and staff for implementing medical project work. This may include coordinating and delivering in-service training for healthcare workers, promoting improved clinical standards and supporting the introduction of new technologies and techniques.

3. Monitoring and evaluation: Together the Welbodi Directors and local partners, design and implement systems to monitor the process, effectiveness, and impact of activities on desired outcome measures.

4. Relationships: Work closely with doctors, nurses and other staff in the hospital to ensure good communication between ODCH and the Welbodi Partnership on all issues. Periodically meet with donors, international and local NGOs, and MoHS to update them. Where appropriate, you may develop collaborations and partnerships within broader efforts to reduce child mortality in Sierra Leone.

5. Fundraising: Help the Welbodi Partnership fundraisers to identify funding needs and provide appropriate technical information as necessary in the development of fundraising materials and proposals.

6. Clinical Work. Engage in direct patient care in order to maintain clinical skills and gain first-hand knowledge of the realities of patient care within this environment.
Qualifications

1. Medical or nursing degree is essential with at least two years experience working in health care. Additional postgraduate qualification in international development, public health or public policy is highly desirable.
2. Professional experience of healthcare in Africa.
3. In-depth, substantive knowledge of healthcare policy in developing countries.
4. Excellent people skills and a demonstrated ability to work collaboratively with people from diverse backgrounds in a dynamic and constantly-shifting environment.
5. Excellent written and oral English communication skills.
6. Flexibility, focus, and the presence of mind to work in sometimes difficult and chaotic circumstances.
7. Commitment to the goals and principles of the Welbodi Partnership.

Applications

The Welbodi Partnership (WP) is a UK-registered charity established to support the provision of paediatric health care in Sierra Leone and in particular to support the Sierra Leone Institute for Child Health (SLICH). SLICH is a joint project between the Sierra Leone Ministry of Health and Sanitation, the Ola During Children’s Hospital, and the Welbodi Partnership to create a centre of excellence in paediatric care. It forms part of the Government of Sierra Leone’s Strategic Plan for Reproductive and Child Health.

Ola During is Sierra Leone’s only specialist children’s hospital, located on Fourah Bay Road in the poor and densely-populated eastern part of Freetown. More than 15,000 patients are treated at the hospital each year, spread across two inpatient wards, an outpatient department, emergency room, ICU and a therapeutic feeding centre. The hospital is extremely under-resourced, however, and providing adequate care is still a challenge.

To learn more about us, please visit our website at www.welbodipartnership.org.

We are seeking an individual to fill the role of Medical Coordinator described above, who will work alongside the two Welbodi Partnership Directors in Freetown and in the UK, our Fundraisers and a network of local and international partners.

Interested candidates should please send a CV and cover letter by 31st January 2010 for the attention of: Matthew Clark

info@welbodipartnership.org



Further Important information for applicants

The Welbodi Partnership is a small organisation with limited financial resources. To keep our overheads low, this position has been filled on a voluntary basis over the past 2 years.

We are willing to contribute towards cost of travel, visas, and medical insurance, but you would need to cover your own living expenses.

In order for you to decide whether or not you can do so, we want you to know what to expect in terms of the cost of living. Although Sierra Leone is a very poor country, it is surprisingly expensive to live an expatriate lifestyle. You can get a relatively simple self-contained local-style flat for around $3,000 per year, but it may not have running water (instead you'd find someone to bring you buckets of water each day), frequent electricity (you could buy and fuel a private generator), or modern appliances.

In contrast, a room in a larger, higher-end house in one of the nicer areas of town will likely run you upwards of $400 per month, plus $200-300 more for electricity, water, a cleaner, internet, etc. Likewise, it is possible to by a local meal of rice and sauce for just a few dollars, but an individual pizza in one of the more upmarket Western-style restaurants costs $12. And taking local shared taxis back and forth to the hospital would cost about $1-2 / day, while chartering an individual taxi could run $10-15 per day and buying and fuelling a private vehicle is similar.

As the Medical Coordinator of the Welbodi Partnership, you would have a direct and significant impact on the quality of care provided to children both at ODCH and throughout the paediatric healthcare system. You would be part of building a relatively new organization from the ground up, of identifying and implementing high-impact interventions -- including quality training for Sierra Leone's young doctors and nurses -- and of building a foundation for lasting change. You would join a committed core team and would be responsible for leveraging the contributions of a wider network of volunteers and partners to bring significant and lasting change to ODCH.

The devil is in the detail

Our Medical Coordinator, Dr Emily Spry, is writing for the BMJ about her experiences at the hospital...

http://blogs.bmj.com/bmj/category/emily-spry/

The devil is in the detail

It might seem odd that the most challenging folk to work with here are not the Sierra Leonean ones. Sometimes the toughest part is dealing with the endeavours of my fellow “whiteman”.

“Development” can be a painful business. It’s painful because of the contrast between what is promised and what is possible, what is dreamed versus what is ever implemented or achieved.

In a country as poor as Sierra Leone, it is so easy to “see” solutions, so easy to make big promises - so much could be fixed with so little, everywhere you turn. Or so it seems.

The truth is, of course, that if it were easy, someone would have done it long ago.

The devil is in the detail, every time. And the details are messy, dirty, tiresome and impossible to uncover from the sanctity of an air-conditioned office.

A classic example is the two giant generators sitting quietly in a building at the back of the Children’s Hospital. Installed during the “rehabilitation” of the Hospital in the early 1990s, just after the war, these were paid for by an African Development Bank loan.

Despite the fact that the regular power cuts leave the hospital operating by candlelight, they have never been used. Why?

Generators of that size use 16 gallons per hour of fuel such that running them would cost 240,000 Leones (around 40 pounds) per hour.

This fuel cost per hour is around the price of employing a full-time nurse for a month. Even if the Hospital received its meagre budget from the Ministry (which it has not so far in 2009), the generators are useless.

Who on earth would buy such a thing with money meant to get the hospital back on its feet? And why are they not held accountable?

In fact, these generators were paid for by Western tax payers. Even more painfully, they are paid for by the ordinary Sierra Leonean who should have got rather more development bang for their aid buck. Every dollar wasted is not just a dollar wasted. It’s a dollar that should have been spent on something better.

Being white here, and particularly British, bring great benefits to one’s self-esteem. Many Sierra Leoneans credit the British army with ending their decade-long war and we are often joyfully hailed as “IMATT” (the remaining British military representatives here) as we drive our old Landrover around town. Strangers regularly thank us for our work, without ever asking what we are actually doing in Freetown.

But when I look at how often the “whiteman” has stood so proud and magnanimous and then failed to deliver, I feel acutely ashamed.

Emily Spry is a doctor from London who has taken a year out of her General Practice Specialty Training Programme to live and work in Sierra Leone, West Africa. She is working for the Welbodi Partnership, a charity which supports the main government Children’s Hospital in a country where more than one quarter of children die before their fifth birthday.

Emergency Room Progress

Our Medical Coordinator, Dr Emily Spry, is writing for the BMJ about her experiences at the hospital...

http://blogs.bmj.com/bmj/category/emily-spry/


Emily Spry on ER in the Pikin Hospital

Pikin HospitalI am happy and exhausted at the end of the first week of the new Triage system and Emergency Room at the Children’s Hospital. Around 80 children present to the hospital each day and Triage nurses now briefly assess them and rush those with Emergency signs to the new 3-bedded ER. There they are assessed and given emergency treatment by a team of specially-trained nurses and the Medical Officer on call.

After 4 days of training last week, the nurses are showing great enthusiasm. I have seen several cases where their prompt intervention bought the child crucial time, allowing a happy outcome instead of a tragic one. This is particularly the case with the hypoglycaemia associated with malaria and malnutrition. It is hard to describe the buzz you get when a grey, clammy, barely-breathing child wakes up after their dextrose infusion and starts screaming. The nurses had most of the skills and knowledge before, but the ER seems to allow everyone to focus their attention on the sickest children for the crucial first half hour or so after they arrive.

That’s not to say it’s all been plain sailing. It quickly emerged that, despite recent payments to the hospital electricians to renovate the room, none of the plugs in the ER work. Our brand new oxygen concentrator tubing now stretches across from another bay and is trampled on every few minutes. The concentrator also has a two-pin plug; the nurses do a hair-raising trick with a pair of scissors to jam it into the three-pin sockets.

There is no precise system for sharps collection or disposal. Although this part of Africa has a relatively low HIV prevalence, this is clearly still breath-takingly dangerous for all involved. As far as I have been able to ascertain, the standard method of waste disposal in Freetown is to chuck it over the nearest wall, which doesn’t give me great confidence about where our lovely mixed clinical waste is going.

But it’s one day at a time… this weekend I’m buying some plastic buckets so that water for hand-washing can be fetched when the taps go off. Maybe I’ll buy an extension cable and a plug adapter too. At some point in the next few months, I’ll spend a day following the cleaners and pondering how to make a sharps bin that has no resale value (else it will undoubtedly be emptied and recycled somewhere along the chain).

Staffing the new ER was in its first week was complicated somewhat by it coinciding with the Sierra Leone Medical and Dental Association annual conference, in which several of our Medical Officers played a role.

Amazingly for a country of 6 million people, there is only one fully-trained Paediatrician in Government Service in Sierra Leone, Dr David Baion, who is the Acting Medical Director of the Children’s Hospital. The Ministry also allocates 10 other doctors, including 5 newly-graduated doctors on three month placements. The five Medical Officers, two of whom work part-time elsewhere, are the more experienced and mostly hope to stay in Paediatrics, although there is as yet no formal Postgraduate Training available to doctors in Sierra Leone. The Medical Officers graduated between 1 and 5 years ago and some have special roles in treating TB and HIV.

One of the Medical Officers, Dr Freddie Coker, is on permanent night shifts. If you can imagine it, this means that Freddie works every night of the year, except when he can get a colleague to cover for him. What would the European Union have to say about that? With Freddie on nights, that leaves two full-time and two part-time doctors to cover the ER, Wards and Outpatients by day, with the help of the House Officers. When I collapse in a heap after a morning in the ER, I do wonder how they do it.

Emily Spry is a doctor from London who has taken a year out of her General Practice Specialty Training Programme to live and work in Sierra Leone, West Africa. She is working for the Welbodi Partnership, a charity which supports the main government Children’s Hospital in a country where more than one quarter of children die before their fifth birthday.

Emergency Room Opened

At the end of October, the Welbodi Partnership trained 20 nurses in Triage and Emergency Care, with help from colleagues from VSO, Abertawe Bro Morgannwg NHS Trust Link and Cap Anamur.

The programme was a great success and the staff are now working well in the new Triage and Emergency Room, which opened on the 1st of November.

This is the first time that the Hospital has had an Emergency Room and a robust Triage process for prioritising the treatment of the sickest kids who come to the hospital. The new facilities and equipment, combined with the new skils of the staff, should help give the Emergency cases a better chance of survival.

Emily Spry, our Medical Coordinator, is writing about her experiences at the Children's Hospital on the BMJ website and here are her reflections on the training and nursing at the Children's Hospital from the BMJ site.

http://blogs.bmj.com/bmj/category/emily-spry/

Emily Spry on nursing in Sierra Leone

The nurse steps forward into the circle, putting her hands together. She prays aloud, “in Jesus’ name,” asking that our four day workshop at the Children’s Hospital be blessed, “so that we might put everything that we have learnt into practice.” After a rousing Christian song, we proceed directly to the Muslim prayer. Nearly every nurse who clapped, sang and loudly proclaimed “Amen” now turns her palms to the ceiling and intones in Arabic. Quietly atheist, I vaguely join in with the gestures; luckily no one expects me to know the words.

Such religious tolerance is the norm in Sierra Leone, though I do wonder if my faithlessness would be as well accepted, if I were more open about it. Either way, I’m sure that this society has much to teach, as well as to learn. Someone told me that life is so hard here that the wise hedge their bets; mosque on Friday and church on Sunday. A nurse whose birthday it was told me that she would spend her special day praying that she will see another one next year. With average life expectancy in the 40s, it is perhaps unsurprising that people in their 30s are nervous.

The last day of our Emergency Assessment and Treatment workshop for the nurses this week coincided with pay day. The junior nurses receive 120,000 Leones (around 20 GBP) per month from the government for working a six day week. It’s not enough even to buy rice for an average family for the month, though many nurses are the only breadwinner. At the Children’s hospital, a charity provides a monthly top-up of a further 50,000 Leones (around 8 GBP), still little more than the average monthly spend on getting public transport to work.

Nurses’ neglecting to come to work at all is a major problem at the Children’s Hospital, particularly at night. To make ends meet, staff often take part- or even full-time jobs in private healthcare facilities, on top of their government jobs. The Ministry of Health and Sanitation has central control of staffing, making it hard for the Children’s Hospital to replace those who do not attend.

But, as I consider the small pile of tatty bank notes that the nurses are taking home for the month, I wonder about things the other way around. While some do not attend, most are there, many working longer than their hours rostered. Why do they come to work at all? The Children’s Hospital is trying hard but is chronically under-resourced and treating a poor and sick population; around 1 in 10 children who are admitted die.

As I see it, these nurses are no different to healthcare professionals elsewhere. Yes, they want to be paid; they need to eat and they have families to support. But that’s not the only reason they work here. They are here because of the respect that they get from their community for their skills, even if that means being woken in the night by a neighbour with a sick child. They are here because of the gratitude of parents when a child recovers. They are here because they enjoy the camaraderie with colleagues who have also seen life and death and everything in between.

Emily Spry is a doctor from London who has taken a year out of her General Practice Specialty Training Programme to live and work in Sierra Leone, West Africa. She is working for the Welbodi Partnership, a charity which supports the main government Children’s Hospital in a country where more than one quarter of children die before their fifth birthday.