Dr. Godwin Eni left his native Nigeria over 40 years ago to study in Canada. After his studies he diligently worked as a public health specialist in his adopted country while raising a family and contributuing significantly to the progress and development of the African-Canadian community in British Columbia, Western Canada. Even though he is officially retired, Dr. Eni continues to work on a volunteer basis in various parts of the world, from Europe to Asia and his beloved Africa. He has been to Nigeria several times where he shared his expertise with students and faculty in some of the universities there. He was recently in Bo, southern Sierra Leone, where he spent six months. In this interview with PV CEO/Publisher Gibril Koroma, Dr. Eni shares some of his experiences in Sierra Leone:
Gibril Koroma: You have just spent six months in Sierra Leone where you had the opportunity to observe and help resolve some of the country’s serious challenges in the health sector. What are your impressions?
Godwin Eni: I was primarily concerned with helping to build planning and management capacity of health care providers and managers in the area of maternal and child health services in Bo Health District. I had the opportunity to observe health services delivery and programs in government hospitals, rural health posts, and community health centers in different administrative Chiefdoms. I visited a couple of health posts in Pujehun and Moyamba Districts, just to see how they compare in terms of common challenges. Overall, all of the health districts seem to struggle with issues associated with the immediate causes of sickness and death; the determinants of health such as inadequate water supply, food security, poor sanitation and hygiene; inefficiencies associated with the delivery of health services; and infrastructure and management problems relating to personnel, equipment, planning, disease surveillance, and supervision.
Dr. Eni at a community event, southern Sierra Leone. Top photo: Dr. Eni, right and Dr. Kargbo of the Pujehun hospital.
Infant mortality and maternal death rates are very high. It is sad to see women and children die almost on a daily basis from preventable diseases or lack of drugs, adequate treatment and care. In one district, there are five doctors serving a population of about 550,000 people, two of the five doctors are engaged in administrative responsibilities. I met a lone doctor in another district hospital assisted by a volunteer doctor from the Philippines, courtesy of VSO or the Volunteer Services Organization. The good news is that Non-Governmental Organizations are making valuable contributions in health care especially in the area of maternal and child health. CUSO Canada and VSO Sierra Leone collaborate to provide doctors, nurses and other health personnel in some districts but not nearly enough given the scarcity of medical volunteers. I was happy to see six CUSO and VSO volunteer doctors as well as some nurses in isolated rural communities.
Left to right: Honourable Moijue Kaikai, resident minister, southern region, Chief Medical Officer Dr. Daoh and Child Health Director Dr. S.A.S. Kargbo.
The key challenge however is to reduce high morbidity and mortality rates to acceptable levels. There are issues associated with drug supply, access, and mobility in rural communities. Underlying these factors are governance issues relating to infrastructure, organization, planning, management and service delivery. Although many Non-Governmental Organizations are contributing their efforts in different parts of the country, however, they are subject to their own bureaucracies and mandates. There is some need for better coordination of NGO contributions to health care in Sierra Leone in support of Government’s efforts. The Government is somewhat severely limited by the terms that govern the use of grants from major donors such as the World Bank and UNICEF. In spite of the limitations, the Ministry of Health and Sanitation continues to explore several options to achieve better health outcomes for the population. I am impressed with the Government’s “Basic Package of Essential Health Services for Sierra Leone” [BPEHS] which is mandatory for all health districts and which spells out the criteria and processes for health services delivery through a network of urban and rural health facilities.
With Dr. Rudolf at Bo hospital.
Developed in partnership with donors and key development partners, BPEHS targets high disease burden in Children less than five years of age in the areas of malaria, acute respiratory infection, diarrhea, and malnutrition. BPEHS is also linked to the Government’s Poverty Reduction Strategic Plan [PRSP] that articulates an agenda for change. These developments, along with free health care for lactating mothers and children under five years of age, have led to some improvements in some of the health indicators but not nearly enough due to meager resource, inadequate work force, and deficiencies in organization, service coordination, and management capacity. To address the challenges of inadequate workforce, as well as improve productivity at the community health posts, the Government introduced a reward system under the Performance-Based Financing Initiative. Overall, much is being done, and much more needs to be done to meet the health sector challenges of Sierra Leone especially in the effective organization, planning and management of current health system given the shortages in personnel and financial resources. The country’s “District Health Services Baseline Survey” in 2009 provides a good foundation for improving the system.
Dr. Eni (fourth from right) in a village in Moyamba district.
GK: What, in your opinion are the most urgent issues to resolve in the country’s health services?
GE: Although many NGOs and international organizations are contributing their effort to reduce infant and maternal deaths and improve morbidity statistics in communities, it is my view that better coordination of these efforts is required to supplement Government’s health service delivery to populations. A starting point is to review delivery of key health programs with a view to undertaking some reforms. There is an urgent need to improve the management capacity of key health personnel with responsibility for implementing important government policies such as free health care to lactating mothers and children under five years of age and the decentralization or devolution of responsibility to city and district councils. The absence of qualified medical and other essential health personnel in hospitals and community health centers, and the increasing use of locally trained Community Health Officers [CHO] and State Enrolled Community Health Nurses [SECHN] to perform certain medical functions, necessitate a thorough review of management capabilities currently existing in the health facilities.
There are serious gaps in the delivery of health services in hospitals especially in coordinating referral services between community health posts and secondary care hospitals. Although there is a theoretical coordination mechanism on paper, however not much effectiveness of the process is observed in practice. Perhaps, the most important issue in need of resolution pertains to the training of more medical personnel and specialists including concerted effort to attract those who left the country during the civil war. Many health workers at different levels of responsibility are concerned about low or static wages, conditions of service, opportunities for promotion and recognition. These issues are affected by the level of poverty in the country and high unemployment rate sometimes resulting in apathy. Some incremental progress has been achieved over the past five years. Some of the limiting factors need to be addressed incrementally over in order to achieve significant progress under the current Health Sector Strategic Plan that was implemented in 2010.
GK: You have lived among and worked with Sierra Leoneans for a couple of months. What immediately comes to mind when you think about the country and its people?
Dr. Eni, Dr Rudolf and a nurse at Bagbo Health Centre.
GE: I was very apprehensive about going to Sierra Leone because of the country’s recent history of civil war and associated aftermath. However, living, working and travelling within the country gave me another perspective of the people, their life, and activities of daily living. Sierra Leone is a rich and beautiful country with the potential to develop beyond its current standard. Its agricultural land is very fertile and there are many valuable mineral resources. The people are friendly and very accommodating of strangers. The most important attribute of the country, in my view, is their post war tolerance of each other, and the ability of ethnic groups to live peacefully in spite of religious differences. I was amazed at the high degree of collaboration and mutual understanding between Christians and Moslems. I attended a traditional wedding where a Christian Priest and a Moslem Imam jointly performed the wedding ceremony for the couple who belonged to different religious beliefs. This gesture is unheard of in some countries in the region where religious conflict is prevalent. I was invited to the consecration ceremony of the first Roman Catholic Bishop of the new Diocese of Bo where I learned that the new Bishop came from a Moslem Family and converted to Christianity. The Anglican Bishop of Bo Diocese was invited to the consecration ceremony. What a lesson for other countries where violence and intolerance tend to define allegiance to religious beliefs.
Some Sierra Leonean colleagues exposed me me to rural life in villages. We sat around with elders, ate, drank “puyo”, and engaged in conversations. I was amazed at the warmth of social interactions. I was practically overfed either at the villages or by some of my colleagues at the health district office. However, I was equally surprised that virtually all Sierra Leoneans appear to eat rice and cassava or potato leaves on a daily basis, sometimes three times a day! I could not obtain something different to eat at lunchtime in cafeterias and hotels in Bo, the second largest city, except “chips” or French Fries. In addition, the people are very generous. Before my departure to Canada, I received several gifts from colleagues, friends and acquaintances – clothing and artwork – during an impromptu farewell gathering. Many of them have kept in touch with me. In general, I think of Sierra Leone as a seemingly poor but peaceful country that is rich in human and natural resources, whose people have accommodating disposition, and a country with development potential that transcends its current state of affairs. I also see a country with long and difficult access from the capital city of Freetown to its international airport at Lungi .
Dr. Eni at a community immunization campaign.
GK: . In our conversations you always stressed the need for people in a place like Sierra Leone to work with what is available or within their budget. Could you please elaborate on this concept for the benefit of our readers?
GE: Sierra Leone is the twentieth developing country I have worked, consulted or visited. Each country has unique characteristics but collectively similar in some respects especially in matters associated with development. By definition, developing countries are “poor” compared to Western standards. Many developing countries, especially in Africa have difficulty overcoming the burden and aftermath of colonialism especially in economic terms. As a result, a dependency mentality gradually emerged. Financial grants and voluntary work from developed nations became important factors in development. Yet, progress has been slow and painful for the citizens. Over time we are beginning to realize that marginal gains achieved with grants, donations, and volunteer work from abroad are not sustainable without built-in local foundation. I believe that building the skills and capacity of people living in the country, with respect to various areas of development, is one of the tools that lead to sustained growth and development as well as less dependency.
GK: What role do you think Africans in the Diaspora and the international community can play in tackling the enormous problems facing the continent?
GE:Africans in the Diaspora constitute a diverse group of individuals with different and sometimes unique experiences from their home countries. Some Africans travel abroad for educational purposes. They may choose to live abroad after completing their education based on political and/or economic conditions in their home countries. Some Africans living abroad are refugees from brutal civil wars who are afraid to return home. Africans who are established, especially those with professional qualifications, are leery of not being allowed to use their expertise in appropriate ways because of question of ethics and corruption. Sometimes, their knowledge and expertise are not valued compared to those of Caucasians who possess the same level of competence and experience. In some African countries, there is the specter of kidnapping and murder. Sierra Leone had a good supply of indigenous medical and health professionals before the civil war. This included a good complement of medical specialists. One district hospital with seven or eight doctors from different specialties before the civil war now depends on one full time and one part time doctor, no nurses, and malfunctioning equipments to attend to the treatment and care responsibilities of a secondary care institution.
Africans in the Diaspora certainly have a role to play in the development of Africa, but at what cost, given their apprehensions, economic and political environment. Those who developed an acceptable work ethic may find it difficult to work under certain conditions that supplant professional expertise with socio-cultural norms and corruption. Regardless of these impediments, many Africans have returned to their countries of origin in Africa to live and contribute to development. Some of them are in positions of responsibility with the potential to effect change. However, their number is quite small.
Dr. Eni with Dr. Kargbo at Pujehun hospital.
My forty-one years experience in North America discussing, interacting and sometimes leading African organizations informs me that a different strategy is needed to attract competent African professionals to return to home countries for the purpose of assisting in national development. I suggest that the African governments should take proactive steps to attract them and establish conducive environments in the work place based on the rule of law and good governance rather than ethnic affiliation. The governments should also live up to their promises and commitments.
In 2007/08, I was invited by an African government as a Visiting Professor to provide advice on accreditation standards and build local faculty capacity in a medical school department under a policy designed to attract Africans in the Diaspora. From the beginning, the government officials had difficulty fulfilling their end of the contract, as I received no compensation for the first three months despite repeated reminders. I completed my end of the contract with very satisfactory outcomes. To date, I have yet to receive the remaining portion of my compensation despite the acknowledgement that I am being owed and several requests from me. That is the nature of what happens in many African countries, as corruption becomes the norm.
The international community has continued to fill the gaps, albeit temporarily in key areas of need in African countries. Many international development organizations are reexamining their roles and how best to attract and utilize qualifies Africans in the Diaspora for the development of their home countries. Recently, CUSO-VSO Canada is exploring ways to encourage Africans in the Diaspora to volunteer for services in their home countries. CUSO-VSO has a long history of providing volunteers to assist in vulnerable communities. They send hundreds of Canadians to work on collaborative development projects in 40 countries including Africa. The organization is keen to invite Africans in the Diaspora to participate as volunteers in development work. However, the work that international organizations undertake in developing countries through volunteers may not achieve full benefits on the long term if they depart. Concerted effort on the part of developing countries and their governments is needed to plan for the sustainability of programs supported by international organizations. Unsustainable, short-term projects tend to promote the dependency of recipient nation on the donor. The transfer of skills from Africans in the Diaspora to those in home countries, especially their “know-how”, as well as the assumption of role and responsibilities associated with aspects of development by qualifies Africans in the Diaspora, can go a long way towards “tackling the enormous problems facing the continent”.
Child immunization in Bo.
Dr. Eni discussing preventive care with youth in Bo City
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