Dr. Samuel A.S. Kargbo is the director of reproductive health in Sierra Leone's Ministry of Health and Sanitation. He recently attended the International Conference on Global Health in Washington, DC, as part of the Ministerial Leadership Initiative. Kargbo was instrumental in helping launch Sierra Leone's free healthcare strategy for women and children. He spoke with AllAfrica about health worker migration and the importance of education for good health.
I started medicine in Europe. One of the things that lead me to go back home when most of my colleagues found their way to America and Europe was the fact that Sierra Leone is a poor country and that country invested so much in me. Since seventh grade I've been on government money, to this day, through graduate school. So I thought the only thing I can do to pay back that country is go back and serve. The second thing is that my father comes from a very small village; he was the only one that was lucky to go to school simply because he was the last child.
When all the elder children went to the farm the missionaries came there and they wanted some of the children to go to school. After he finished he saw the need for it and sent all his children to school. That is how I became educated.
And now going back to his village two generations later one thing I see when I see so many poor people I start to think, 'Why was my father removed from this and why did I become educated?' I could have been like one of them and it must have been for a purpose. It didn't happen by chance that we were removed in my family. Divine intervention - it must have been for a purpose. We all became educated. I have a brother who is a lawyer. If I have been removed this way it means I have to give back.
This is why when I went back to this community I saw to it that they have a health facility that they never had before, a school for the kids. Through providing teaching materials I tried to support this school. One thing that I see is the kids that go to school are happy, and this is what I want to do for every village in the country. I have the opportunity to see that every child goes to school and see that suffering be a thing of the past. If I have a chance to do that for every village in the country because I think that's where I would've been.
Education is vital. When you look at prevention, you don't find many maternal deaths among educated women. You find them among the uneducated women - they are the ones that take the risk. The educated women know the signs to seek help earlier. And because of their education they know where to go. Even in the outcome of the health of the children there is evidence that the education of the woman plays a part. In fact, it doesn't matter the level of education, even a woman with primary education has children with better health outcomes. And it is not what they learn in school, it is what they learn from each other.
The way I see things, for instance, you have proximal causes of disease, then you have the intermediate and then you have the distant causes. These distant causes are the factors of education, it is women's empowerment - this is where education comes in. What actually kills the woman is the bleeding, the hemorrhage, they all go to the cause of maternal mortality. But the intermediate can be the lack of transport... all of them need to be put into place. But say you solve the distant aspect, you educate the woman, for example, but you don't get the blood bank in the hospital, you don't have the doctors with the skills. Then you end up with the same thing.
[Health worker migration] is not getting better. As long as the inequalities in the economic base of the country exist, it will never get better. People will always migrate. It will only improve because the more you have Africans in the United States the more there are chances for them to send [money] to ones [in Sierra Leone]. It will never improve. The more the economies of our countries get weaker and weaker, the more our colleagues want to migrate out of our countries. The only way that can [change] is that if we put policies that can attract health workers to our countries ... sent to work there for a period of time. It can be an exchange program, in terms of aid for instance, that the United States gives to my country. What can happen is say, 'I want a 100 doctors to go and work in Sierra Leone but I will continue to pay them for this period.' That can make them want to go because the reason why they came [to the United States] was because of [better pay]. If you can give the same conditions - just like Peace Corps - why not send other doctors? It will make a change in the healthcare delivery system of the country. If you send Peace Corps [workers] to live in my country for two or tree years why not send doctors?
Another thing that can help to support our countries is [producing doctors]. Right now we are producing very few doctors but if you can up that to five or 10 times what we produce now. Right now we are producing 30 or so doctors - 20 leave and only 10 remain. But if you produce 200 or 300 more will stay. If we can do that and get other doctors from [the United States] and send them to my country they will help in teaching in the school, they will help in working.
The reason health workers are migrating is because they need an increase in salaries, but doing that is not enough. Each salary increase can de-motivate you ... you need more. You need the continual education; you need the other non-cash benefit, so those structural things need to be put in place. And even in our health facilities, the provision of drugs alone is not all. You need the environment to be there - how can you work without electricity? You become de-motivated. How can you work without running water when, for instance, with free healthcare now we have a huge influx of patients into the facilities. So where as in the past when you had one or two patients coming in now you have 20 or 30, which means you have to come in the night and so there is need for electricity. When you have one or two patients you can just wash your hands in a bucket. Now, because you have 20 or 30, you must have running water!
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These things need to be put in place if you want to have a system to work. The other thing, to get this to work is finance. If you look at the financing of the health system, we are spending something like nine or 10 U.S. dollars per capita (government expenditure) now, which is insufficient to achieve the MGDs (Millennium Development Goals). If we actually want to be on course to achieve the MGDs we need something like six dollars more to around $15 or $16. That will allow for putting some of those structural things in place.
The main reason free healthcare in Sierra Leone succeeded is due it being country-led and country-driven. Even the origin of it all - it was not something that was brought down to us. It led to greater commitment on all sides.
