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.

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.