Executive Summary

As it slowly emerges from a decade of civil war, Sierra Leone is struggling to repair its ruined economy, the basic infrastructure and the state’s provision of essential services. Despite the relative political stability, the population’s health status has not improved from the disastrous levels of five years ago. Mortality and morbidity numbers remain incredibly high. The healthcare system barely functions and there are huge deficits of staff and skills. MSF, which has been working in the country since 1994, is trying to fill some of these gaping holes.

This report documents MSF’s experience in three critical areas of healthcare: malaria treatment, mother and child health, and the impact of user fees. It sets out the problems as recorded by our medical statistics and it contains substantial patient testimonies, which speak of the suffering regularly endured by people who have very limited access to what is normally inadequate care. Those personal histories also point to the difference that can be made by some relatively simple changes, which are already being implemented in MSF’s projects.

In malaria treatment, the vital, missing component is Artemisinebased Combination Therapy (ACT). The Sierra Leone government agreed in July 2004 that it should become the new first-line treatment for uncomplicated malaria. MSF has been using it successfully in the country for two years. Despite public commitments and international funding the drugs have yet to reach patients in Ministry of Health facilities. Instead, chloroquine, to which the malaria parasite is widely resistant, is still being prescribed. A mother, whose son has just been successfully treated by MSF with ACT, describes how she had lost a daughter to what she believes was the same fever when she was given different pills at an MoH clinic that did not work.

In maternal and child health, the innovation that MSF is proposing is the provision of maternity “waiting houses” attached to district hospitals, where pregnant women can spend the last few weeks before delivering. One of the cruelest and most common causes of death amongst new born babies and their mothers is the difficulty of getting to a place where trained care can be given. The case histories record what a difference in life chances can be made by coming early to a “waiting house”. MSF’s own medical records suggest that despite the fact that many pregnant mothers are referred to the houses because they have high risk factors, mortality figures amongst women and children are much better than at hospitals which do not have them. They are also cheap and easy to run.

The cost of medical care and the impact this has on the ability of people to access that care is also a theme running through the patient stories. In late 2005 MSF conducted a survey in four rural districts of Sierra Leone 1 to look at the effect of various levels of charges and at the socio-economic condition of the population.

The study showed that there is a significant under use of health services in the formal system in Sierra Leone. Only one out of three households declared using the nearest health centre during their last episode of illness. The present healthcare payments are a substantial burden on households, they discourage them from seeking care and they create real risk of further impoverishment. Although in theory sick people who are unable to pay should be protected by an exemption system, the system is not working and poorest face exclusion. MSF’s attempts to use a low, flat rate system of charges, rather than the tariff method applied in many MoH facilities, made some difference. However, the clearest evidence of the connection between charges and health seeking behaviour came when MSF removed charges in some of its clinics and saw a doubling of patient numbers. The elderly man who tells his story of a long term struggle with disabling pain would not have been able to afford in an MoH hospital the treatment he received free from MSF. He probably would have died as a result.

MSF is aware of the complex deficits in the country’s health sector, which will take decades to reform. However the three recommendations covered by this report show that reducing malaria deaths, as well as those among mothers and babies, and increasing people’s access to medical care can already be achieved with relatively simple changes. The Sierra Leonean people should not have to wait for all of the structural reforms to make the final difference; things can be done to cut those unnecessary deaths rates now.