Vacancies

Storm clouds gather over the city, forks of lightning flash in the night sky and rumbles of thunder roll across the estuary like distant drums, a warning of the approaching rains.  As the dry season comes to an end, the damns remain low and power shortages add frustration to the daily grind; the humming of generators are heard across the city each evening bringing electricity to those that are able to afford fuel.  

As the dry season ends, so too does the first year of the President’s post-Ebola Recovery Programme, launched last July.  The first nine months were focused on getting to and maintaining zero cases, restoring access to basic healthcare, re-opening schools, providing social protection support and revamping the economy.  Many of these objectives have been achieved, some are still a work in progress.  The next phase has begun; the 10 to 24-month period which is about re-invigorating the private sector, creating jobs and improving infrastructure.  There is also a major focus on building a resilient health system.  This will be a herculean task and there are some promising early signs but there is much hard work to be done.  All this also comes at a time when the World Health Organisation has launched the Sustainable Development Goals (SDGs) to end poverty and ensure prosperity for all.  Goal 3 focuses on good health and well-being including universal health coverage and access to quality health services.  Goal 3c specifically aims to “increase health financing and the recruitment, development, training and retention of the health workforce in developing countries”.

Here are a few facts that illustrate the health situation currently.  Sierra Leone has a population of 7 million, sixty percent of whom live below the poverty line, living on less than $1.25 per day with a 40% literacy rate.  According to World Bank data, for every 100,000 live births, 1,360 mothers die of pregnancy related causes in Sierra Leone whereas in the UK the figure is 9.  Similarly, for every 1000 babies born 120 will die before the age of 5.  There has been progress here as the figure was 150 per 1000 four years ago.  In the UK, the child mortality rate is 4 per 1000.  Maternal health is a good indicator of the functioning of the healthcare system as a whole as they are dependent on services from the community level through to specialist care.  Social and cultural factors also play a part in this; gender inequality and education impact on whether a woman is able to seek appropriate antenatal and emergency obstetric care.  Although Sierra Leone is towards the bottom of the UN development rankings, these problems are shared by many other low income countries across Africa and Asia.

The estimated expenditure on health is $86 per capita, of which 60% is met by the patient. In comparison, the UK spends just under $4000.   There are only around 200 doctors in the whole of Sierra Leone and 288 midwives, the majority of whom are based in the Western Area close to the capital. 64% of skilled health worker posts are vacant across the country and there is a major shortage of more highly-skilled nurses.  It is estimated that just under half the workers are currently unsalaried.  This means that not only are they not payed, but many are unregulated. 

Human resources forms one of the WHO core components of health systems and a workforce that is motivated and adequate for the population it serves is an essential part of a health system strengthening strategy.  This blog post stems from my recent attendances at a Health Ministry summit on human resources and the annual West African College of Physicians Scientific Meeting where many of these issues have been highlighted and discussed in depth.  The government and senior medical figures are well aware of what the problems are and are working hard to improve the situation.  

      

So what is the country doing to address some of these problems and what are the potential solutions?  It will be necessary to increase the number of staff on the payroll, training will need to be improved at all levels, across all cadres of health worker and stronger governance and regulatory systems will need to be introduced.  Task shifting, whereby less skilled workers are utilised to provide certain services, will be important in this process.  Community Health Officers are already being trained to conduct surgical procedures in certain health facilities.

Strong leadership will be required and partnership working will be essential to achieve the targets set.  Health workers will also need incentivisation to stay in the system and not leave the country to work elsewhere.  This will not only require adequate remuneration and supervision but also defined career pathways, professional development and the resources and facilities to enable them to do their jobs properly.  Adequate infrastructure is required in terms of clean water, electricity and a supply chain to ensure that clinics can function effectively.  The discrepancy between urban and rural staffing levels will need to be ironed out and recruitment streamlined and decentralised so that workers may be employed more quickly.  

In the last 6 months, a teaching hospital bill has been passed by parliament which will give hospitals like Connaught more autonomy in governance.  They will be able to recruit and manage their own staff and have more independent decision making over how the organisation is run.  Post-graduate medical training is developing; several months ago I mentioned that the hospital had an accreditation visit from the West African College of Surgeons.  This was successful and the hospital is now able to provide basic surgical training.  The long term goal will be to have doctors that are able to complete speciality training without having to work abroad in all the major specialities.

It will take years and significant investment to train the extra health workers required but I have noticed positive changes even in the last nine months.  King’s is in a fortunate and privileged position to be able to contribute to these changes.  By working with the Ministry, teaching hospital and college of medicine and allied health sciences, we are able to contribute towards policy development discussions, training and the support of post-graduate specialisation.  It is a time of great change and transition.  My time here is short and KSLP are currently recruiting for an emergency physician to take my place, I would encourage anyone reading this with the requisite skills to apply and be part of the journey to recovery and prosperity.     

Healthcare workers at Connaught.  Without adequately trained staff, a health system will not function effectively.