Dr. Kisito Sheku Daoh is the chief medical officer in Sierra Leone's Ministry of Health. He acts as the chief liaison between the ministry and the health partners and the lead advisor on all health-related issues. Daoh recently attended the International Conference on Global Health in Washington, DC, as part of the Ministerial Leadership Initiative. He spoke to AllAfrica about Sierra Leone's free healthcare for pregnant women, lactating mothers and children under five, and advances in bringing down the country's high rates of child and maternal mortality.
I am trained gynecologist and so naturally I feel the need to address the issue of child mortality very, very strongly. I worked as a program manager, first as a clinician and then as head of reproductive health, for years in Sierra Leone. I was there right through all of the conflict. I stayed because if we all went out, who is going to take care of the issues?
Our young people, for instance, the last two groups we have trained, I can easily say 90 percent have not gone out of the country, which is the complete opposite of what we have seen in the past. If you go back five years and see all of the doctors that were trained in the country, 90 percent left. The increase of salary is actually one of the things that motivated health workers to stay. People did not see the need to move out, so it really says that if you provide the right environment and the right incentives it will serve as a deterrent for people to move out. We even have young doctors, they want to come home, but these people have been out for many years. If you are paying for your kids in any university in a developed country and you also want to have decent accommodation, then you may not easily get a [sufficient] salary back at home. So what we ask is to even have a short-term engagement with your country, come in briefly, provide something, and this is happening.
I have a strong bond not only to the country but to the objectives of the profession I chose to carry on - that is why any challenge we have in health is not something I can run away from. That is something that gives me a lot of hope, that I'm sure a lot of us can make a difference by being champions of some of these issues. When I was a clinician in Sierra Leone in the 1980s [we had] such a high mortality rate. If you see a strategy that is going to bring that down then of course that is something that keeps you going. We also have a very strong, committed team in the ministry. Free healthcare actually put everyone together in one boat with a very strong commitment, a very strong drive to succeed. And that keeps you going as chief medical officer. You can rely on colleagues, you can rely on ministers and you can talk to people.
[Providing free healthcare for women and children] was a big challenge in 2010. We were at the very bottom of the human development index, especially in regards to maternal health and child health. We had the highest maternal mortality rate and the highest infant mortality rate. So, for years, it was something somebody had to do something about.
Getting close to 2010, a few articles actually came out to say if you took away the fees for service you are definitely going to get more utilization of the service. That very strong information was a basis for the commitment by the head of state that this was the right way to go, that we should provide free healthcare for these three groups that were actually affected most by paying the cost of services. That's pregnant women, lactating mothers and children under five. That's taking care of the Millennium Development Goals (MDGs) numbers 4 and 5.
In 2010, there was always the realization that we were not prepared. That was clear. We did not have the right numbers of competent health workers in the field; we didn't have the facilities. We didn't have the drug supplies. All the health financing was not good enough. Even the government support to health was far below the minimum requirement for countries: 15 percent of expenditure overall. We actually brought our partners here and said, 'Now look, this is for all of us. You continue to say the situation is unacceptable, just like we do; therefore, let us all go into this boat and see if we can save these three groups.'
We started by having a very strong government structure where on a regular basis we would discuss with the partners [about] having big themes where we have committees. We [established] if a chair in a committee was a government person the co-chair would be a partner. So we had a committee that looked at leadership and governance. We had one that looked at service delivery. We had one that looked at health financing, one [regarding] the drug supply chain. For each of these we didn't just want to identify the problems but the cost of them. During the whole process we had a fairly good idea of what it was going to cost to actually get a successful free healthcare program. These discussions proved to be very fruitful.
If you look at the results that started coming in right at the day of the [program] launch, you see a utilization that was incredible - we didn't know such patients existed and needed care at the time. In the first week, we saw four times the numbers that were seen in the children's hospital. We began to see a lot of women come in with complications that need cesarean sections and they were being done. Of course, you imagine from that there was a reduction of infant deaths. Everything that had to do with pregnancy was free! It was a very big achievement.
The challenge is we need to build on that. We need more resources from the government and to talk to our partners to support us where it's not always easy, especially about drugs and human resources. Human resources are a very serious issue where you cannot always depend on partners. You have to train your own people. We set up a community midwifery school.
By the end of this year we should have close to 100 midwives that would be used in the small facilities. So, again, this is extremely important for the success of the program because generally we have a health worker per population that is extremely low. You're talking two health workers for 1,000 citizens. Only 70 percent of the health facilities have more than one health worker. So if you have an increase of utilization then you can't expect these health workers to work 24 hours. But those are the challenges we have. The good thing is that there is good community support for this initiative, among civil societies as well.
In terms of health-related MDGs ... we will make progress by 2015 but we will not achieve the targets by 2015 for any of the MDGs because of human resource challenges. ... A lot of the young doctors, they didn't see any hope of ever specializing in a specific field and becoming specialists. We didn't have accreditation and we didn't provide post-graduate training. Now we have partial accreditation in the area of surgery, in the area of obstetrics and gynecology, and were trying to get one especially for pediatrics. So if doctors now know they can go in and become specialists then they believe they can make sacrifices along the lines of accepting lower salaries. There is a lot of light down the tunnel.
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If it were possible to have more institutions supported to provide training for nurses and community health workers [to establish] a very strong base across the country in the rural areas it would reduce the burden that goes into hospitals. Now what we see in hospitals are cases that can be treated at a very much lower level. But because we do not have human resources they cannot be treated at the appropriate level.
Civil society groups are actually doing a lot of work at the community level. The other aspect in Sierra Leone is decentralization. With decentralization you're actually saying to the communities that you're in charge of your health, education and agriculture. It's no longer at a central level. There is a growing improvement in all of this. Then, of course, people are taking a leadership role, and its not just community leaders, but you're also seeing the religious leaders are coming in and this is very, very strong. Sierra Leone is one country where you don't know which a Christian is and what a Muslim, because even in a session there is always a Christian prayer and a Muslim prayer. There is a lot of working together at a community level.
The whole issue of immunization of vaccines is a huge priority in Sierra Leone. Our gross domestic product is very, very low. We do not have enough revenue to look at the whole issue of vaccines and the development of it. If you can get all of the vaccines, you are reducing deaths among children by 60 percent. So vaccines are the key area of investment. There is also the whole area of drugs, and supply chain management, which is extremely important.
