Abandoned: The Community Health Officer in Sierra Leone

27 August 2009 at 02:04 | 1276 views

Alhassan Fouard Kanu, London, United Kingdom.

The title of this article may bring to mind the civil fighters/hunters: the Kamajors, the Donsos, theTamaborohs and many others, who, during the height of the war, partnered the national security forces and the intervention forces (ECOMOG and UNAMSIL) to repel the rebels. They were lured into believing that their effort to end the war was principally to restore the deposed government of the SLPP and will see them taking charge of the security apparatus of the country. The war ended, the SLPP restored, but where are our civil fighters? Many dead, many disabled (physically and mentally) whilst the politically-connected few were enlisted into the army or police. The majority have been abandoned.

“The Abandoned Force” as applied here, is definitely not a fighting force but a force pivotal to the success of the primary health care delivery services in Sierra Leone. A force that can actualise the health-related MDG goals in Sierra Leone. I am referring to a force that can lift Sierra Leone from the bottom of the United Nations Human Development Index; if only our position in that table is due to our high infants and maternal mortality rates, as key indicators. This force is referred to as the Community Health Officers (CHO).


In response to international calls following the Alma Ata conference in 1978 for the improvement of Primary Health Care, Paramedical School was established in 1983 with funds provided by the EU. The school was mandated to train scientifically oriented and multivalent health workers, to replace the then dispensers and EDCU Assistants who were largely manning Peripheral Health Units (PHU) in the country. The training was for 3 years and graduates are referred to as Community Health Officer (CHO).

In Sierra Leone, the Peripheral Health Units (PHU) comprise of the Community Health Centre (CHC), which is headed by a CHO. The CHC is usually located at chiefdom headquarter and provides services to a population ranging from 5,000-10,000. Others include the Community Health Post (CHP) and Maternal and Child Health Post (MCHP); and both are usually located at smaller villages. They are manned by CHA/Dispensers and MCH-Aides respectively.

The CHO functions at the health centre largely include the treatment and appropriate referrals of medical, surgical and obstetric emergencies. He supervises the activities of other PHUs in the chiefdom and report to the District Health Management Team (DHMT).


The project document of 1977 for the training of CHO made provision for the progressive career advancement of the CHO in the civil service of Sierra Leone. Below are some of the proposed positions:

The Graduate CHOs enter the Civil Service as CHO grade 5. Their duty station is mainly the CHC level. They are directly responsible to the District Medical Officer (DMO).
After 6-8 years of practice, and /or a diploma in professional education, a CHO is promoted to the position of Senior CHO at grade 7. His/her duty station can be at a class “A” CHC or become member of the DHMT.
With a 10 year experience and /or postgraduate qualification, the Senior CHO can be promoted to the position of Principal CHO at grade 9.
The Principal CHO can be promoted to the position of Deputy Chief CHO, with duty station at national level and directly responsible to the Chief CHO.
At the top of the professional ladder for the CHOs is the Chief CHO, who is directly responsible to the Director of Primary Health Care. He actively participates in national health policy formulation among other responsibilities.
Also clearly stated on the document was the continuing professional development of this cadre. It requires the CHO to pursue mandatory 3 months refresher courses for every 5 years after qualifications, with funds provided by the Ministry of Health. In addition, CHOs who excel in their clinical practice were to be given the opportunity to qualify as Clinical Assistants with specialism in areas such as anaesthesia, surgery, obstetrics and the like.


Twenty-six years after the establishment of the CHO cadre, it remains the only health cadre who has no clearly defined wing in the MOHS organogram. The proposed scheme of service for this cadre has still not been implemented by the MOHS, despite its approval by an Act of Parliament.

Unlike the Nurses, who are automatically promoted to the position of District Health Sister (DHS), a CHO still remains a CHO after following the same course that leads to the promotion of a nurse to a DHS position.

Unlike the Nurses and the Medical Doctors, who have legitimate boards that oversee their practice, namely the Nursing Board and Sierra Leone Medical and Dental Association respectively, the CHO cadre, is yet to have a board after nearly 3 decades since its establishment.

Despite the frustrations, there are CHOs who have defied the odds and have gone ahead to capacitate themselves beyond what their detractors think of them. There are CHOs who are currently expatriates and consultants for International NGOs. Within Sierra Leone, there are CHOs who are programme managers and health coordinators and advisers to NGOs.

In terms of academic achievements, there are CHOs who are currently medical doctors practising abroad and locally. There are CHOs who are pursuing PhDs. There are CHOs who are holders of, or currently pursuing Masters Degrees, and most of these are self-funded. These CHOs are still considered as ordinary CHOs with no promotion, no defined roles in the MOHS and no difference in their salaries since graduations as CHOs.

Most frustratingly, the entrance requirements for the training as a CHO are the same as those for the entrance at the university and other institutions of higher learning. Yet after 10 years, a colleague who entered FBC or enlist in the army would have become a Permanent Secretary and a Colonel in the Army respectively, whilst a CHO remains a CHO regardless of his/her academic achievement.

This has led to the demotivation and demoralisation of this very important cadre in our health care delivery system, and it is threatening their retention in the MOHS. Up to 2004, the Paramedical School trained about 480 CHOs and only 40% of these are actually working for the MOHS.


Whilst the awkward predicament of the CHO as outlined above may stun patriotic individuals at the top, both in the MOHS and the leadership of the present regime, I would want to make it clear that, the health gains of any country is largely dependent on its health providers. The CHO is the team leader of Primary Health Care at the community level; the CHO provides basic health services to the underserved 75% rural population. Neglecting this very important cadre of staff would incapacitate the MOHS from scaling up intervention to achieve certain health goals including the MDGs, HIV/AIDS and TB, immunisation coverage and Maternal and Child health. The CHO is specifically trained to implement these activities at the community level and their absence means diminished technical input in the planning and implementation of these activities at that level.

The past governments and professional colleagues in the MOHS had failed to implement the Scheme of Service as outlined in the CHO project document of 1977. The ascendency of Alhaji Dr Kisito Sheku Daoh to the substantive post of Chief Medical Officer has, however, brought hope to the CHO cadre. There is no doubt about his determination to turn round the MOHS into an effective institution. He is a man that trusts the CHO cadre and who recognises their pivotal role in the health care delivery system in the country. On behalf of all CHOs sir, I congratulate you and wish you God’s guidance throughout your term as Chief Medical Officer.

To the APC administration, please be reminded that, the training of the CHOs who are currently the hub of the health care delivery in the country, was your initiation. Despite the failure by previous governments to translate your proposal into action, it is never too late and this important cadre is looking forward to you implementing the 1977 project document; especially to prevail on the MOHS and the Public Service Commission to expedite the implementation of the Scheme of Services for CHOs.

Health reforms are necessitated by the trends in the success of interventions to promote population health at the international level. The MOHS should emulate the success of health care delivery services in countries in the East of Africa. The Clinical or Medical Assistants, the contemporaries of the CHO, in countries like Tanzania, Uganda and Malawi performed the bulk of operations at the hospital level whilst carrying minor ones at the health centre. Considering the prevailing shortage of Medical doctors, the country would benefit immensely in terms of health gains by upgrading the skills of CHO to that of Clinical Assistance.

The CHO like the Medical Doctors and Nurses, need personal and social security in the form of professional regulations within the MOHS. The CHO needs a sense of belongingness such as established professional organisation that would seek their interest. The CHO need achievement in terms of promotion with commensurate earnings. The CHO needs professional self-actualization in which personal growth and achievement of professional goals are realised.