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article imageAfrican-Canadian Consultant on Sierra Leone's Health Care System Special

By Gibril Koroma     Dec 11, 2012 in Health
Vancouver - Dr. Godwin Eni is a retired academic, health service provider, manager and adviser who has worked in Canada and has helped in the governance of many cultural and non-profit organizations, and consulted in many countries in Africa, Asia and Eastern Europe.
In a recent conversation I had with him at his home in Vancouver he emphasized that a person's true worth is not his academic qualifications or the extent of professional expertise, but what they have contributed, small or large, to better the conditions in the community or society in which they find themselves.
Indeed Dr. Eni who has lived and worked in Canada for over 40 years has demonstrably lived by this principle. He has faithfully served not only the Nigerian community in Canada and more recently in British Columbia, but many other communities in various capacities as president of the Multicultural Society, board member of provincial organizations , and chair of an accreditation commission on the health care profession. After retirement, Dr. Eni has been to places like India, Malaysia, Ukraine, Bangladesh, Malawi, Malaysia, Burkina Faso, Ghana, Nigeria, and so on.
Dr Eni (first from right) discussing a new health center in Tonkolili district  northern Sierra Leon...
Dr Eni (first from right) discussing a new health center in Tonkolili district, northern Sierra Leone, with the Paramount Chief (third from right, sitting) and some villagers.
In recent times Dr. Eni has turned his attention to the tiny West African country of Sierra Leone where he had been helping to put in place a viable and sustainable health care system. He has been and worked in this country twice; last year and this year. First he was in the southern part of the country, based in the country's second largest city of Bo, and this year he was in the capital city, Freetown, working with policy makers, senior administrators, and service providers in the Ministry of Health and Sanitation. Dr. Eni recently returned to Vancouver, British Columbia after eight months as an Advisor to the Ministry of Health in Sierra Leone.
I had a chat with him recently and he spoke expansively about the health care situation in that country while noting the prospects for a better future. He was very direct and frank on the country's health care system. He said:
Dr. Eni about to leave Kabala  northern Sierra Leone  after a capacity building workshop.
Dr. Eni about to leave Kabala, northern Sierra Leone, after a capacity building workshop.
“Let me put it in context. Sierra Leone has one of the lowest human development indices [HDI] in the world, a measure used by the United Nations to rank countries according to the level of social and economic development. This means that many indicators for health and well-being are very much higher than global averages on the negative side. It also means that many important health care issues ranging from governance, finance, management, human resource and service delivery issues are below world averages in terms of the capacity to deliver and achieve positive population health outcomes. “
A debilitating civil war that raged for 11 years ended in 2002 and practically brought the country to its knees, destroying the few structures and facilities that there were left behind by the British colonialists and the post-independence administrations that followed. Sierra Leone is a poor country according to many global financial institutions but has no business being poor with abundant natural resources including diamonds, iron ore, gold and now oil which has recently been discovered. Yet the country's health care situation is dire, to say the least. Here is Dr. Eni again:
Dr. Eni (second from right  second row)in Kenema  eastern Sierra Leone  after a workshop.
Dr. Eni (second from right, second row)in Kenema, eastern Sierra Leone, after a workshop.
“An examination of the health status of women and children over the last few years provides some understanding of the situation in the country. For example the country has the highest child mortality and maternal death rates in the world. In 2010 the death rate of children under 5 years of age in Sierra Leone is 217 per 1,000 live births according to a UNICEF Multiple Indicator Cluster Survey. In 2011, 185 children who are less than five years of age in Sierra Leone died for every 1,000 live births, and 890 mothers died for every 100,000. For the same year in Canada only 6 children under five years of age died for every 1,000 live births and 12 maternal deaths consistently per 100,000 each year since 2007. The UNICEF Multiple Indicator Cluster Survey conducted in 2010 shows a higher death rate among this group than indicated for 2011 by the World Health Organization’s report. It means that some progress has been achieved over a period of one year, between 2010 and 2011. In 2009, 46% of children less than 5 years of age showed severe or chronic evidence of malnutrition and/or stunting. Also in 2010, for every 1,000 Sierra Leoneans, there were 0.03 doctors, 0.05 nurses, and 0.2 midwives. “
He went on to say:
“The ratio for Canada is 2.0 physicians for every 1,000 Canadians. Access to the few available hospitals and health facilities is limited and constrained in Sierra Leone either by distance or by other forms of logistics including the scarcity of qualified health personnel and electricity supply.”
Chatting with him in his comfortable south Vancouver residence while watching MSNBC TV, Dr. Eni told me about intermittent electricity supply, lack of adequate public toilet facilities and unsanitary living conditions in slums in the capital city as well as the lack of basic hygiene in some communities including Freetown as some of the reasons for adverse health conditions and the emergence of periodic cholera epidemic in the country leading to deaths.
Eni is not an armchair or bureaucratic sort of person. While on assignment in any country he loves to go out and meet the common folks and try to listen to them and get their perspective on what really affects them rather than prescribe solutions himself. This strategy has helped him enormously in Africa and other so-called third world countries he has visited and worked.
“I try not to impose knowledge or skill on anyone as a consultant or adviser. Rather, I do my best to learn from people in a given situation or context and assess how best to contribute to an ongoing effort in a collaborative manner. Very often, experts fail to ascertain how people have been doing things or solving problems before they exhibit their own expertise. Sometimes all it takes is an ability to incorporate local expertise with new knowledge to get the job done as people often cannot totally divest themselves of old habits in an environment that is different from that of the expert. It helps to be less critical of a situation in a different country. Your support must be perceived as genuine and accommodating. It is foolish to attempt to compare situations in a developed country such as Canada with that of a given developing country such as Sierra Leone. This method has always helped me in my work. Most times experts go abroad and prescribe all sorts of things that are most times not useful or relevant to the needs of the local inhabitants,” he told while sipping his tea on a Monday afternoon while his wife, a senior provincial government official, was at work.
Dr. Eni found his work at the Ministry of Health to be very challenging. He says there are many missing links to better planning and management of health services at the policy, managerial and technical levels. He was reluctant to go into details but says he has made his suggestions for improvement confidentially available to the Ministry.
“While there, I participated in supervision site visits to new community health facilities and projects. I also gave presentations and workshops on organization leadership, medical rehabilitation, and health service planning and management in some health districts including some hands-on restructuring activities at the Primary Health Care headquarters in Freetown. Much of the advice I provided were personalized and focused in the area of Primary Health Care. As for the challenges, I have to say they were many challenges but they were also manageable under present post-civil war circumstances. The usual systemic constraints associated with bureaucracy in many developing countries appear to exacerbate issues of management, service coordination, productivity, and work ethic. Some structural reorganization may be required at the Ministry of Health in order to achieve positive outcomes under the decentralization policy. The input of many bosses in a defined area of responsibility is not always good for any organization. “
But not everything is gloomy and hopeless in Sierra Leone's health care system, according to Dr. Eni. He is full of praise for the Sierra Leone government in its efforts, inspite of the enormous constraints to make things better for its people:
“I believe the government is aware of the challenges and moving in the right direction. Between my two placements in 2011 and 2012, I noticed incremental improvements in the areas of health system strengthening, maternal, neonatal, child health, immunization, and malaria control. It seems the political leadership is focused on achieving improvements in health indicators in these areas. Also, it seems the political leadership laid a very good foundation on which to build for the future. The government articulated a vision in a document entitled “Agenda for Change” as a guide for moving forward. As a result of this document and other policy-related pronouncements by the President, a national health sector strategic plan was developed to provide a systematic approach to strengthening the health system and addressing health inequities in order to achieve better health outcomes. It is a well-designed plan because it takes into consideration the five key elements of a viable health care system – governance, finance, human resource, drugs, and information system.”
He continued:
“The most important change is the implementation of a free health care policy for pregnant women, children under five years of age, and breast-feeding mothers. The free health care program offers free consultations, antenatal care, deliveries and postnatal treatment, x-rays, laboratory services, medicines, logistics support, and minor surgeries.”
The healthcare policy for pregnant women, children under five years of age and breast-feeding mothers Dr. Eni mentioned is funded largely by the British government and other international donors. In fact the country is run mostly from donor funds. The Sierra Leone government, had in existence an elaborate policy document called the Agenda for Change while Eni was there. Here is what he thinks about this document:
“Also a set of indicators have been established to promote the availability of basic emergency obstetrics and neonatal care in community peripheral health units and comprehensive emergency obstetrics and neonatal care for higher level health facilities. As a result of the free health care policy, there are noticeable increases in immunization coverage, enhanced nutrition intervention, and increased service utilization. The government is moving forward to link poverty with health care through the policy called “Agenda for Change”. The primary objective is to connect quality, accessibility, and affordability of health services to vulnerable populations especially the poor, women and children as a way to impact national development.”
The Agenda for Change came to an end in November this year just before the general elections that got President Ernest Bai Koroma re-elected for another five-year term. Now there is a new policy document called the Agenda for Prosperity which will consolidate the gains made by the Agenda for Change and move on to things like enabling the private sector to create and provide more employment for the teeming unemployed young people in the country. Of course the health sector, the education sector, and other service providers will not be forgotten according to statements made by the President and government officials. Indeed the future is bright for Sierra Leone, according to Dr. Eni, a man that does not praise easily. Though optimistic, he also points out some weaknesses in the system as this observation of his illustrates:
“Overall, the future is bright given current incremental improvements in health indicators if there is continuing willingness to undertake some strategic thinking and planning in key areas of health care. Also there is an urgent need to undertake efficient and effective management of hospitals and health institutions by qualified and experienced managers using existing resources. The lack of management expertise at many levels of the system is significant.”
In his final remarks, Dr. Eni has some praise for the former Health Minister Zainab Bangura with whom he worked while he was in the country (Zainab is now with the United Nations in New York as an Under-Secretary).
“The former Minister had significant presence in the Ministry. She was well organized and had clear idea of what she wanted to accomplish. She was very much involved in managing key aspects of the Ministry of Health. I found limitations in how the Ministry is organized and the high number of directorates available to do the work. As requested, and based on my observations, I have made some suggestions available to the Ministry.”
On the people of Sierra Leone themselves, here is what he has to say:
“The most important experience I cherish is the people’s hospitality, friendship and relaxed way of life. The matured and civilized level of coexistence, collaboration, accommodation, and acceptance of visitors and each other between the Muslim and Christian communities is an example to the world. I attended some weddings between Christians and Muslims and joint officiating by clerics from the two religions. I was equally surprised at the number of gifts I received from colleagues and acquaintances during my departure. I also learned that a Sierra Leonean does not consider being fed until he or she has eaten rice. “
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