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.