Saturday, September 01, 2007

Scrap Sierra Leone health fees

As Sierra Leone prepares to elect a new president on Saturday 8 September, Sarah Jacobs from aid agency Save the Children writes that scrapping fees for health care should be a priority for whoever becomes the country's new leader.

Sitting in her house in Koindu, a town in eastern Sierra Leone, 10-year-old Margaret finds it difficult to look to the future. She can't even think beyond a few hours.

"I can't go to school or go out with my friends because the urine will just come out. It happens about four times a day, and people take empty tins and start knocking them behind me."

Margaret (Photo: Charly Cox/Save the Children) Margaret still hopes to have a brilliant future .

If I see a patient who I think has money, I will charge them extra 

Jonathan Hai
Health worker

In 2002, when Margaret was just five, she was raped by three men in a camp in neighbouring Guinea, where her family was seeking refuge from the vicious civil war that raged for 10 years in Sierra Leone.

Five years on and she has never seen a doctor. She is incontinent, and sometimes has trouble walking because she is in pain and bleeding.

'Nothing I can do'

"They messed me up," she says, her chin pressed down into her chest as she sits in front of her house. "I was unhappy then and I am unhappy now."

Her parents returned home from Guinea with 11 children - five their own and six whose parents could no longer look after them - whom they now try to support through begging.

Around her, the dilapidated houses and bombed out mosque show clearly the ravages of war.

Margaret's father, 75-year-old Samuel Fartoma Foryoh, is furious.

"I feel very sorry for this child but I can't afford to take her to the health clinic. Every time I go they demand money, even though I tell them I don't have any.

"We tried to cross the border into Liberia to go to hospital because we thought it might be free, but the hospital was closed. If any of my children fall ill, there's nothing I can do."

But for many in Sierra Leone, this is a time of possible hope.

If the elections pass off peacefully, perhaps the country will at last start to move on from the legacy of violence left by a civil war that killed 50,000 and mutilated 100,000 others, and show the world that it is, finally, stable.

Optimists say that professionals and businessmen who fled during the atrocities may be drawn back, or tourists could come to explore the country's beautiful landscape.

Yet for Margaret, her family, and the hundreds of thousands of people living below the poverty line in Sierra Leone, the feeling is one of desperate frustration.

Many have sick relatives, and what they want most is the chance to get treatment.

And with a system of health fees imposed across the country, getting help even for the most common of diseases - pneumonia, malaria, diarrhoea - is impossible.

Rice and chickens

Jonathan Hai, 45, is a health worker at a clinic an hour's drive along pot-holed mud roads from Margaret's home.

He knows about the official government guidelines, which state that the very poorest and most vulnerable, such as children under five and pregnant women, should get free treatment.  

A two-year-old being treated for malnourishment at Kailahun hospital (Photo: Anna Kari) One in four Sierra Leone children die before their fifth birthday

But, he says, he is always forced to charge them.

"We have many constraints at the clinic. No money for the upkeep of the building, no money to repair the bike we use to get to patients in the community.

"I'm supposed to give 60% of the drugs we receive from the government pharmacy away for free to people who can't pay for them. I can't afford to do that."

It is a story repeated across the country. Like many of Sierra Leone's clinics and hospitals, Mr Hai's clinic functions thanks to health workers volunteering their services.

It is estimated that around 40 to 50% of the country's nurses and midwives are still waiting to be added to the government's payroll.

"With the money we get from patients," says Mr Hai, "I pay volunteers who work here, I pay for equipment, and I pay for my children to go to school.

"Sometimes, if I see a patient who I think has money, I will charge them extra. That means if a patient is really needy I can give them drugs for cheap, or in return for rice or chickens."


For a population where the average income is 12 US cents a day, the price list pinned on the wall of his clinic is intimidating. Consultation: 200 leones (8 cents); treatment for diarrhoea: 2,000 leones (66 cents); treatment for malaria: 2,500 (80 cents).

The result is a country that still relies heavily on the herbal potions of traditional healers and sorcerers, often with catastrophic results.

Graffiti on the wall of a building which reads, 'I need drugs for my hospital' (Photo: Aubrey Wade) The government demands free care for the poor and vulnerable, but clinics struggle to provide anything

"Since the war ended life for many in Sierra Leone has significantly improved," says Jeanetta Johnson, health manager for Save the Children.

"But having to pay for treatment is crippling the country. Thousands of children are dying every year from diseases that are easily preventable.

"The next government must look hard at ways of removing health fees, and international governments need to give them the financial support to do so."

Despite having most of its debt scrapped, Sierra Leone is still the second poorest country in the world and has the highest rate of child mortality, with one in four children dying before the age of five.

The country has a long way to go before children like Margaret can be sure of getting help. But there's no doubt of the possibilities that would bring.

"If I get better I want to be a driver and have a small car," says Margaret. "In the future I want to be brilliant."

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