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Sierra Leone: Election Madness and the Horror of Existence

20 August 2005 at 20:54 | 517 views

As this report from a study of the health sector in Sierra Leone conducted by the Campaign for Good Governance, an NGO in Fretown implies, the problems in that country are horrible criminal negligence, blatant robbery and lack of foresight in the government machinery. How else can one explain the loss of thousands of lives every year in this tiny country of 5 million with so many natural resources and international support?

With so many natural resources and international support?
Our research turned up many problems in the health sector. While we interviewed a wide-range of people we were struck by the consistency of the issues they identified. We highlight what appeared to us as the key ones. Many are inter-related and some are clearly more fundamental and cross-cutting than others. We begin by looking at the three most fundamental - a lack of resources, unclear and unrealistic policy, and a lack of equal access - and then consider more discrete, but nonetheless wide-reaching, problems. They all require urgent policy attention.

1. Lack of Resources: Drugs, Supplies and Salaries Most problems in the public health sector stem at least in part from a lack of resources. Though it is unhelpful and unimaginative to boil everything down to a lack of money, it is equally dangerous to underestimate this core problem. The shortage of resources manifests itself in a number of debilitating ways and costs thousands of Sierra Leonean lives each year. Public resources come from the Government of Sierra Leone, INGOs and donors. We examine each of these sources and highlight key effects of the resource shortage.

A. The Government of Sierra Leone The Government of Sierra Leone spends far too little on the health sector. The Ministry of Health and Sanitation’s total budget for 2002 is Le18.6b. This represents 3.12% of total government expenditure and lending, and 1.13% of GDP. It compares to Le36.4b for education. It amounts to Le3531($1.54) for every Sierra Leonean. An estimated 30% of the budget is spent on drugs, which works out to Le1069(46?)/person - i.e. not enough for a single course of anti-malaria tablets.

Shortages of Drugs and other Medical and non-Medical Supplies Public hospitals and clinics have extremely limited supplies of even basic drugs and medical equipment. More expensive drugs and items "are just not available" Patients, even those eligible for free treatment, die daily simply because there are not the, often basic, drugs or treatment they need. Patients with ongoing resource needs, such as drips, are particularly vulnerable. We heard scores of stories similar to the one on the left.

Supply shortages also affect the quality of health care in more subtle ways. A lack of everything from buckets to sterilising equipment means that sanitation in hospitals is generally poor with obvious implications for patients’ health. Also, shortages make work more difficult, increasing staff discontent and thus reducing the quality of service they provide and encouraging strike action.

Low Salaries: Discontent and Corruption The Government of Sierra Leone justifies paying medical staff low salaries - e.g. Le80,000 ($34.78)/mth for nurses and Le120,000 ($52.17)/mth for junior doctors - because of a lack of resources. In the case of doctors, low pay is the main reason for the acute shortage in the public sector (see section 4 below). More generally however, the problem is not so much shortages as the discontent and corruption which low salaries fuel. Pay has been at the centre of the recent industrial action by both nurses and doctors, which have severely disrupted services and resulted in loss of life. The widespread corruption by medical staff (see section 6 below) - e.g. privately selling medical supplies, overcharging patients - may also be a function of low pay. Hospital administrators told us that when INGOs provide "incentives", corruption drops significantly.

B. INGOs: The Pull-Out and the Resource Vacuum It is hard to overstate the role INGOs currently play in providing public health services. The scope and scale are disguised because many services are delivered through officially employed Ministry of Health and Sanitation staff and facilities. But from the surgical ward at Kenema hospital to Peripheral Health Units (PHUs) in Kambia to everything at Bo and Makeni hospitals, many services only exist thanks to INGO resources. In several districts, the only functioning public health facilities are those supported by INGOs. The only medical services provided for free in our country - e.g. to refugees or destitutes - are those funded by INGOs. Where INGOs work they tend to supply "everything" from generator fuel to drugs to staff "incentives" (i.e. salaries) to their own skilled employees.

The problem is what happens when the INGOs scale down their operations and leave. There is a real danger that many services will simply collapse, along with the financial and administrative structures that the INGOs put in place. Where services continue, prices are likely to skyrocket and free services disappear. These trends have already begun. Also, as INGO "incentives" for staff disappear, industrial action is likely to increase. It is no coincidence that nurses at Makeni Hospital have not been supporting their Freetown colleagues in the recent strike, since they receive "incentives" from MSF-Holland while nurses in Freetown do not get such INGO salary top-ups.

Ministry of Health and Sanitation officials are confident they will cope with the INGO pull-out, despite widespread concern among medical staff that the Ministry of Health and Sanitation is unable and/or unwilling to step in to fill the funding gaps that will soon begin to gape. In fact, one hospital administrator said, "there’s going to be a conflict" between hospitals and clinics on the one hand and the Ministry of Health and Sanitation on the other if the Ministry of Health and Sanitation does not take up the slack. He suggested that facilities may withhold payments to the Central Medical Stores unless the Ministry of Health and Sanitation provides the medical supplies to which it is committed. This conflict may take on a political dimension under decentralisation (see section 16 below) when health facilities will have more autonomy and both sides may claim that the failure to deliver services is the other’s fault.

C. Donors: Projects too Narrow; and the Question of Funding Salaries Donors - in particular the World Bank, the EU and the Islamic Development Bank - provide funding for public health projects in Sierra Leone far in excess of the Ministry of Health and Sanitation’s budget. While these resources are urgently needed, the narrowness of some projects and donors’ policies can undermine the long-term effectiveness of their assistance. Health workers cited many examples of donor-funded projects which failed to take into account key requirements - a major donor recently funded the construction of a new ward at Bo Hospital but did not provide the supplies needed for it to function, such as beds, so the ward lay idle (eventually supplies were forthcoming).

The most common missing element is skilled staff. Most donors have a policy not to fund salaries, which are needed to attract skilled staff. They argue that it is unsustainable since they cannot fund salaries ad infinitum. Yet it is futile to spend millions of dollars providing new facilities and equipment if they lie idle or are misused because salaries are too low to attract and retain qualified staff. Moreover, it appears equally unsustainable to dress up a health service with facilities and equipment and have it fall apart for lack of qualified staff to the point where INGOs (mostly funded by the same donors) come in with international staff (costing far more than decent local salaries would) to fill the personnel gaps.
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