This Piece was shortlisted for the Haller Prize for Development Journalism

The Health Systems Strengthening Game


Her name could be Halima, or Hanna or Salaymatu. She could be from urban or rural Freetown; perhaps from the main town in the provinces or from a remote village. She could be between the ages of 15 – 49. She may have no education, some education, or be very educated. Yet, as long as she plans to deliver in a health facility in Sierra Leone, she can also easily become a statistic: One out of 2400 women die every year in Sierra Leone due to pregnancy related causes. Unfortunately, in the midst of myriad health systems challenges such statistics can easily become a needle in a haystack. It is therefore paramount for Government and development partners to act with urgency in asserting systematic changes to save the lives of women.

I come from a country that was ranked in 2014 by WHO as having one of the worst maternal mortality ratios (MMR) in the world. Sierra Leone, prior to our recent Ebola Virus Disease (EVD) outbreak, was already struggling to strengthen its health systems to save the lives of more mothers and babies. The international development sector in Sierra Leone was demoralized by the WHO findings, and yet, remained relatively silent about them.  The scapegoat excuse was the yet unreleased government Demographic Health Survey (DHS) figures that outline maternal and newborn health figures, meaning we had to wait to see what government’s figures would say. The failure of development partners to vocalize their frustrations – or at the very least create public space for constructive dialogue to re-address the gaps and fault lines – while forging tangible outcomes for moving forward made us all complicit in sustaining weak accountability systems in Sierra Leone.

It is now September 2014 and Sierra Leone, a nation of about six million people, is grappling with the largest Ebola outbreak in West Africa to date. Since the first confirmed case in May, we are now 4 months in; we have only managed to implement two Ebola treatment centres in the entire country with two more treatment centres said to be functioning in the near future. The rate at which the epidemic continues to spread is insidiously disproportionate to the rate at which systems are put in place to contain the disease. The outbreak so far has effectively claimed the lives of more than 50 medical professionals, including senior doctors like Dr. Sheik Umar Khan, Dr. Modupeh Cole and Dr. Buck. The epidemic has taken a great toll on the economy, with the World Bank estimating growth reduction from 11.3 % to 8%, precipitating complex strains on food security and quality of life.

The shift in priorities across all ministries towards boosting the capacity of the Ministry of Health and Sanitation (MoHS) to contain the spread of the disease has in effect significantly lessened attention towards other prominent health issues like maternal and newborn health. The lack of a comprehensive emergency response plan that not only addresses tackling Ebola but also other health issues in an already heavily burdened health system, will cost lives. In 2013 when the MoHS conducted its innovative transparent seeking and solution focused Facility Improvement Team Assessments (FIT) findings, there were 8 functioning emergency obstetric and newborn care (EmONC) facilities nationwide. The July 2014 FIT assessments results reveal that Sierra Leone currently has zero functioning EmONC facilities available to provide life saving care – meaning the country has no safe clinics for quality service delivery for mothers and babies meaning more women will continue to become maternal death statistics.

We cannot talk about weak health systems in a vacuum; the conduit for sustainable development is a strengthened and transparent government which Sierra Leone lacks. For example, Sierra Leone has yet to reach its Abuja target of 15% spending on health. Even though the percentage spent on health has increased significantly today standing at 11.2%, there still remain challenges with getting prompt and accurate data on health spending, disbursement of funds to the health sector and budget allocation lines that specify spend on health issues. To talk about Sierra Leone’s weakened health care system is to also talk about its weakened educational system. It is to address the country’s high rate of illiteracy coupled with majority of the populations’ lack of trust in the effectiveness of government social policies supported by development partners. We know this because even with effective Ebola sensitisation messaging, many continue to believe Ebola outbreak to be a conspiracy theory. These are all interrelated issues that play a pivotal role in not only containing a deadly disease like Ebola but also saving the lives of mothers and babies. Combating health issues requires both a strengthened health system and an empowered populace with health care seeking practices and trust in their leadership to effectively translate knowledge into practice and changes in behaviour.

It is therefore quite hypocritical for the dominant narrative on the table, by government and development partner’s alike, to now centre-around health systems strengthening when seven months ago (prior to Ebola outbreak) we were snail pace about enacting systematic change to a weak health care system. My real concern is what the results will show when we tally lives lost to Ebola as compared to lives lost due to the lack of provision of quality health care services. What will moving forward for Sierra Leone look like for the Government, development partners, the international community and for regular Sierra Leoneans? How will our statistics or the death of Halima, Hanna or Salaymatu and many others influence Government actions in the future, if at all they do? What if we had acted a little faster, held one another accountable to the people of Sierra Leone without fear of backlash just a little earlier and a little quicker? Would we be in the lion’s den negotiating between life and death? Sierra Leone deserves better, as does its people and especially its women and newborns.