An Inside Look at How Policy Affects Practice in West Africa
08/13/2009
John Donnelly Looks Inside African Health Ministries
Journalist John Donnelly and photographer Dominic Chavez have spent the last two weeks traveling through Senegal and Sierra Leone to look inside Africa's health ministries and then going into the field to see how policy decisions are affecting the poor.
From Senegal:
Part 1: Looking Inside the Health Ministry
Part 2: Short Supply of Rural Health Clinics Brings Toll
In Sierra Leone:
Part 3: Health Ministry Under Budget and Asks How to Spend the Money
Part 4: Health Minister Re-evaluates Plan for Free Health Services
Part 5: A Day in the ‘Graveyard for Pregnant Women'
Part 6: What Happened to Isata Swaray?
Part 1: Senegal, Looking Inside the Health Ministry
July 30, 2009
DAKAR, Senegal - The second-in-command at the Ministry of Health in Senegal said he had many challenges, but one was easy to pinpoint: reducing the number of women dying during childbirth.
"There's a lot we have done but there's much more to this in reducing the deaths," said said Secretary General Moussa Mbaye. "Improving reproductive health is a central issue in the development of this country."
Senegal, which has had a strong record in several health initiatives from HIV prevention to vaccination rates, still has high maternal mortality figures - 410 deaths for every 100,000 births. A Senegalese woman's chance of dying while giving birth is one in 21 over her childbearing years.
I am traveling in Senegal and Sierra Leone over the next two weeks for an unusual look inside health ministries - as part of a project for the Ministerial Leadership Initiative for Global Health, or MLI. MLI, a project of Realizing Rights at the Aspen Institute in Washington, D.C., is one of the few non-profit groups aiming to improve performance in ministries, as opposed to funding specific programs.
Mbaye said the ministry has found two main problems in the country's efforts to reduce maternal mortality - not enough funding and too few women using existing health services. The government spends 10 percent of its budget on health, but just 2.5 percent of the health budget goes toward reproductive health programs.
He said women continue to give birth at home due to their "social and cultural backgrounds,'' in which families, and sometimes whole villages, decide to stick with traditional home-birth practices, despite the dangers; poor geographic distribution of health clinics and health posts; and some families not able to afford the cost of childbirth at clinics.
A visit to a small south Dakar hospital, Institut d'Hygiene Social, underscored the problem of lack of funding.
"It's a catastrophe - reproductive health is a neglected part of the health system," said Dr. Malick Ndiaye, who oversees the health center.
His colleague, Prof. Cheikh Tidiane Cisse, described reproductive health as "the nerve, or the heart, of the health system. Yes, HIV, malaria, TB, you're dealing with large populations affected. But 50 percent of the population is women. If you want long-term health programs to succeed, you need to take care of reproductive health first."
Striding through the small hospital's hallways, Ndiaye took me to the maternity ward, where dozens of women, all in various stages of labor, were sitting or lying down in corners or along the walls. He opened the door to one room where women were in the last stages before going into a small delivery room.
On three narrow beds lay five women.
"This is not busy," Ndiay said. "It you want busy, come in September or October, and you wouldn't believe it - women up and down the hallway, waiting to deliver. In December or January, we have colder weather, people stay inside, and nine months later you have an explosion of innocents."
Still, it was so crowded we couldn't move in the tiny room, which was shared now by four nurses and midwives, the five women, the doctor, my translator, photographer Dominic Chavez, and me. I was standing in a tiny baby factory: The center delivers 5,000 babies every year, more than 13 a day.
In Dakar, 100,000 babies are born each year mostly in five hospitals, including this one in south Dakar. In the last few years, two hospitals have closed, Ndiaye said, because of lack of funding for the service. Now, the remaining five hospitals were delivering more babies than ever before. The problem here wasn't that women weren't seeking services; the problem was the depleted health system was hard-pressed to keep up with demand.
At Ndiaye's hospital, women were being sent home an hour or two after birth as long as they had no complications; the hospital needed the space.
Ndeye Ba, 29, nursed her newborn son in a room near where she had given birth two days before. She had stayed longer than most because her blood pressure had been low. Now she was preparing to go home. "I'm very happy with my care here," she said.
"We have trained people here," Ndiaye told her. "In the rural areas, you have what they call the ‘lead woman' help deliver the babies. They have little training."
Ba's sister agreed. "There was a woman here yesterday. She said in her village they just hold onto a tree, bend their knees, and deliver their baby on a mat below," Khady Diop said. "I was so surprised that I repeated the question. She insisted it was true."
***
Next stop: rural Senegal, a place called Thiadiaye, about 140 kilometers southwest of Dakar. I had heard that the Thiadiaye's health centers' director of maternity services was so fed up with the difficulties of her job that she wanted to leave.
Part 2: Senegal, Short Supply of Rural Health Clinics Brings Toll
August 3, 2009
THIADIAYE, Senegal - The head of Senegal's reproductive health efforts in the Ministry of Health is an engaging doctor named Bocar Daff. He leans forward when he talks. He asks lots of questions. And when I asked for a meeting with him, he didn't want it one-on-one - he brought in six staff members so that I could hear other perspectives about what he considers the country's biggest health problem - maternal mortality.
"Mortality is much higher in the rural area," he said. "It's connected to many factors - and one of the biggest ones is accessibility to health services. The roads are bad, telephones aren't working, people are too poor to pay for a taxi to the health post. For many, it comes down to a choice of do I spend my money for a checkup with a doctor or buying rice for my family? You know what a mother will do."
Khady Sy, national coordinator for the bureau of adolescent health, told the story of a director of a maternity clinic in Thiadiaye and how fed up she was with the lack of funds and support from donors and the government. Sy said the director didn't know how much longer she could stay in her job.
I decided to go find her. I've been traveling in Senegal for the past several days; next week I go to Sierra Leone. In both trips, I'm spending time in Health Ministries and in the field - looking at linkages between policies/funding choices and what happens in the field. It is part of a project with the Ministerial Leadership Initiative for Global Health, a four-year effort based at the Aspen Institute that seeks to strengthen the leadership capacity in five countries - Ethiopia, Mali, Nepal, Senegal and Sierra Leone. One of its major issues is improving reproductive health.
The drive to Thiadiaye took just three hours. I arrived with photographer Dominic Chavez and our translator Aziz Hane just as the director of maternal health walked into the Thiadiaye Health Center.
Even though we arrived unannounced, Diop Khady Sao, 44, a midwife by training, welcomed us and immediately launched into her struggles.
"I have so many obstacles," she said. "Number one is staff. We delivered 2,671 births last year. I should have seven midwives. I have two. Number two is that we are a referral center for the entire district. We have a surgical center, but we have no gynecologist, so we have to refer all women with complications to another hospital 75 kilometers away."
Sao remembered the date the gynecologist left: Feb. 17. Days afterward, she had organized several hundred women to protest publicly the lack of funds to hire a replacement, but Thiadiaye's new mayor promised he would find funds for a new gynecologist if they didn't protest. Sao is still waiting.
The government, she said, has frozen spending for health staff since 2005. She said she was fed up with the hardships of the job and living more than 400 kilometers away from her husband, but that she would stay for now. One of her reasons was if she left, the center's services would further erode.
In Senegal, an estimated 410 women die for every 100,000 births - which translates into a lifetime risk of death of one in 21 for women. At Thiadiaye Health Center, Sao recorded just three maternal deaths last year, but she said that was misleading. She said "as many as 12, maybe more" died after being referred to a hospital 75 kilometers away.
The figure also doesn't tell the story of the center's vulnerability. Last year, she said, a woman gave birth to twins and then started hemorrhaging blood. The woman died soon after. Sao felt helpless in trying to save her - she needed a blood bank, but the nearest one was 29 kilometers away.
"That really shocked me," she said. "That woman didn't have to die. I needed just one liter of blood to save her."
Two doors down, three women rested on their mattresses alongside their newborns - all girls. All mothers were in great moods.
Seynabou Sene, 40, had just delivered her tenth baby - her last, she hoped. She had delivered her first six at home, the last four at the health center. "It's better to deliver here," she said. "Here you are assisted, and it's safer."
Sene had arrived the night before on a horse-pulled cart - an hour-long trip she bore in agony on the flat wooden surface.
Marie Faye, 35, had just delivered her sixth baby, the third in the hospital. She, too, said the experience was far better at the center. Tening Faye, 18, had delivered her first baby four days earlier - and then promptly slept for three days, her mother said. The mother, Amy Ndour, had 11 children, and all but Tening were delivered at home.
"I belong to the old generation," Ndour said. "We didn't know better so we delivered at home. I advised my daughter to come here."
A taxi cab pulled up sharply to the center. Out walked a woman carrying a newborn. Sao, the director of the maternity ward, and a nurse brought the baby and mother into the delivery room.
The mother, Sokhna Sene, 42, told Sao that she was at a private clinic for a checkup, stood up, and promptly delivered the baby at her feet. It was her eighth. A nurse cut the umbilical cord, prepared her to travel, and accompanied Sene to the center.
Sao asked Sene where she lived. "Domb," she said.
"Domb?" the midwife said. "A year ago there was an accident in that village. A woman delivered at home, hemorrhaged, and died. I was not happy. I went to your village and said next time I hear that a woman delivers a baby at home, I will take the whole village to the police. Do you remember?"
Sene remembered. She said she remembered it so well that she feared coming to Sao's health center.
But she said, the message worked: In Domb, no woman has delivered at home since.
***
Next stop, Sierra Leone, for a look at issues that may be quite different - or perhaps not.
Part 3: Sierra Leone, Health Ministry Under Budget and Texas Expat at its Helm Asks How to Spend the Money
August 5, 2009
FREETOWN, Sierra Leone - Every few hours here, surprises get me thinking.
On a run, I watched several young, one-legged men on crutches - surely victims of a civil war in which rebels cut limbs as a signature terror tactic - racing down the beach for their morning exercise, almost keeping pace with me. In the middle of a rundown downtown sidewalk, I bought warm French bread piled high in tall baskets. And after I paid a taxi driver for a short ride, he pushed for an extra dollar so hard that he started getting bug-eyed.
I thought being inside the Ministry of Health and Sanitation for a few days would be a respite - a bunch of meetings in conference rooms and hours going through piles of documents.
Then I met the Minister.
I came to Freetown as part of a two-week trip to Senegal and Sierra Leone on a project for the Ministerial Leadership Initiative for Global Health (MLI), a program of Realizing Rights at the Aspen Institute in Washington, D.C. MLI seeks to build up health ministries' capacity to carry out their responsibilities: helping ministers and their staff to put their financial houses in order; building better relationships among the ministries and donors; and improving core missions such as maternal and child health.
Sierra Leone, as the world knows, is world-worst at so much, according to indicators that the international community and reporters love to quote. There's being last in the Human Development Index (179th out of 179); an under-five mortality rate of one in four; adult literary at 37 percent; and life, that on average, ends at 41 years.
Those figures give context - but not much else. They don't give any indication, for instance, on what the government is trying to do to fix the problems. And the figures don't give any insight as to whether the situation is hopeful or not.
The Minister is Sheiku T. Koroma, who was an engineer in Dallas, Texas, until taking the job last February.
In a meeting with financial advisers from PricewaterhouseCoopers, hired by MLI to study the ministry's financial management system, Koroma not only welcomed them warmly, he also made a plea for help. "Why do we have $39 billion leones (US $117 million) budgeted for the year, and now we're seven, eight months into it and we've only spent around $12 billion? Something is wrong,'' Koroma said. "There is money there, but how to best spend it?''
Part of the problem, he said, was that he inherited a system in which the ministry has been putting money into multiple accounts. The Finance Ministry holds all its money, and Koroma said the Health Ministry needed to steam-line its own financial system. "The system is broken, and we want you to help us," he told the financial consultants.
His candid assessments didn't stop there. At a meeting later in the day with the major donors of the Ministry, Koroma said that he was thinking about announcing late this week a plan for free health care for all pregnant women and children under five years. He said he wanted to announce it even if all the final details weren't worked out; his staff, led by Dr. Samuel A.S. Kargbo, the dedicated head of the Reproductive and Child Health Program, was working late into the night to put together the plan.
"I wake up at 3 o'clock in the morning, worried about maternal mortality and young children dying," Minister Koroma said. "If we offer free medical treatment for women and children under five, everything is going to change. Let's jump into this water. Let's get into this water and learn how to swim!"
He received support in principle from several of the donors. Geert Cappelaere, UNICEF representative for four-and-a-half years in Sierra Leone, told the Minister:
"Let me express my big appreciation of the bold step you are making here. It's been under discussion for the last many years - to ensure that health care for pregnant women and children will be effectively implemented is to be complimented."
Still, there was the not-so-small, unresolved matter of who will pay, and whether the district health services could handle a large influx of new patients. The government didn't seem to be in any position to pay - although Koroma said later that the government was prepared to pitch in.
The Minister also had another idea to increase demand - specifically in persuading more pregnant women to deliver at health facilities. Sierra Leone has one of the highest maternal mortality rates in the world: an estimated 857 per 100,000 live births.
"Let's go to the radios," he told the donors. "Let's go all over this country and say that anyone delivering at home will go to jail. I know everyone will stop delivering at home then! I was asked if we had to pass a law for this, and I said no. We will just scare them. That will work."
Several donor representatives laughed, in a kind way. It made me think back to last week in Senegal when the head of a maternal ward in Thiadiaye, Diop Khady Sao, drove to a village where a woman had died in her home while giving birth. She, too, had threatened them she would call police if any woman delivered at home again. Since then, none have.
Some people - ministers and midwives - are so fed up by these preventable deaths, they're ready to scare people if it means saving lives.
Part 4: Sierra Leone, Health Minister Re-evaluates Plan for Free Health Services
August 10, 2009
FREETOWN, Sierra Leone - For a moment last week, Health and Sanitation Minister Sheiku T. Koroma was so optimistic - he would usher in an era of free health care for pregnant women and children, battling head-on the world's worst rates of maternal mortality and under-age five deaths. He planned to make a big splash in a press conference in a few days.
But then donors started blasting holes in the Ministry's plan - it wasn't well-thought through, they said, and it could unleash a wave of mothers and children upon health clinics that weren't ready for them.
And so the Minister punted. He asked a technical committee of donors and Ministry staff to revisit the issue starting today (Aug. 10) and then left Freetown for the weekend. I never had a chance to talk to him about the turn of events.
I've been in Senegal and Sierra Leone for the past two weeks as part of a project with the Ministerial Leadership Initiative for Global Health, or MLI. The group's mission is to do something that very few donors groups focus on: paying attention to the inner workings of a Health Ministry and lending a helping hand in issues from money flows to improving reproductive health. It is a program of Realizing Rights, housed in the Aspen Institute in Washington, D.C.
Along with photographer Dominic Chavez, my role was to learn about the challenges and opportunities inside these Ministries and then to tell stories. That was how I found myself at an emergency meeting last Monday (Aug. 3) that included the Minister, his top staff, and a dozen donor representatives.
Minister Koroma said then that the country had to do something dramatic to reduce maternal mortality and the deaths of young children. He said reinstituting a government promise in 2004 - but never followed through - to provide free health care was the right choice. Several donor representatives at the meeting applauded but also on the sidelines quietly began to raise questions.
Those whispers turned into a forceful donor statement on Wednesday that advised against a public announcement of free health care.
Late last week, Dr. Samuel A.S. Kargbo, the Ministry's director of reproductive and child health services, said the Ministry still planned to go forward with a free health-care plan, but would likely start it with a couple of hospitals and health clinics and then build it gradually nationwide.
Somewhat reluctantly, Kargbo acknowledged the donors' argument to go-slow had some merit. An announcement for free health care now "would show that we have very good intentions, but ultimately such a move could have a negative affect," he said. "If you have a party with just 10 cents in your pocket, you will create trouble."
Sierra Leone has more than 10 cents in its pocket, but it doesn't have a functioning system to do something as simple as track the money.
Now, more than seven months into the year, Minister Koroma said the Ministry has spent less than one-third of the year's allocated budget. The Ministry has 70 separate bank accounts, he said. It has received from UNICEF and World Bank alone in the past year 47 four-wheel drive vehicles, 272 computers, and 467 motorcycles - but if you asked for an accounting of it, as I did, good luck getting an answer.
Geert Cappelaere, UNICEF's country representative for the past four-and-a-half years who is leaving soon for a post in Yemen, told me that he applauded the Minister for announcing the free-services program, but understands why the idea was pulled back.
"Free health care doesn't exist," he said. "Someone is going to have to pay for it. It will be a huge step forward when the country does offer free health care. But I very much agree a word of caution is critical. If you announce this, and there is no staff or no drugs available, it will be even more discouraging for people. People will very quickly feel betrayed."
Cappelaere said the Ministry was desperately in need of stronger leadership; he said that leaders have failed to set priorities, and seemed unable to distinguish among small and large issues. But he also the Ministry also desperately needed donors to work better with them, instead of often making their work more difficult.
"Rather than doing things in a coordinated way, we approach the Ministry individually for one thing or other," he said. "The donor partners should have one voice, and let the people in the Ministry do their jobs."
He remained hopeful. "This country has a future, but it will take a long time to get there," he said. "We need to be committed for a long time - 20, 30 years. We need to have the guts to say this could take two or three generations. But if we help them to make the right decisions over the next 10 to 15 years, then we will get past all of this."
Still, there was a feeling in and around the Ministry last week of an opportunity missed, and skepticism whether it would be recaptured soon. As one outside observer told me, donors in neighboring Liberia have been pushing that government to initiate a free health care plan, but the government has resisted.
Here, a Minister and his staff were out in front for free health care - only to be pushed back.
***
Next: A look inside a hospital in Freetown that a newspaper called a ‘graveyard' for women giving birth.
Part 5: Sierra Leone, A Day in at the ‘Graveyard for Pregnant Women'
August 12, 2009
Two days after I arrived in Sierra Leone, one of the newspapers here referred to the Princess Christian Maternity Hospital (PCMH) in Freetown as a `graveyard' for pregnant women. So I had to go - even if the report itself seemed incredibly shaky (it relied on anonymous reports and had no comment from the hospital).
PCMH is the country's main referral center for complicated pregnancies. It sees the most difficult cases - the ones that other hospitals and clinics decide they can't handle. And so it shouldn't be surprising to see higher maternal mortality rates than anywhere else in the country. But then I looked at the figures. In 2007, 1,279 women gave birth here. Of them, 141 died. That works out to a 11 percent fatality rate.
Put another way, for every 10 pregnant women who enter here, one will die.
Countrywide, Sierra Leonean women's chances of dying during her reproductive lifetime are about one in eight, compared to one in 4,500 for women in the developed world.
I'm finishing a two-week trip in West Africa - Senegal and Sierra Leone - for the Ministerial Leadership Initiative for Global Health (MLI), a program of Realizing Rights based at the Aspen Institute in Washington, D.C. I have had access inside health ministries, meeting with ministers on down, and then going into the field to see how policy decisions affect the poor. During this time, I've looked at a wide range of issues, but the ministries themselves are pinpointing what they're most concerned about - and both have said they desperately need to do a better job at maternal and child health.
That has been one of the surprises of the trip. African Ministries of Health have always seemed to me to be mostly impenetrable bureaucracies - places so bogged down that little appeared to have happened.
But I'm finding something different. I've seen two relatively new ministers - Senegal's determined Therese Coumba Diop and Sierra Leone's talkative Sheiku T. Koroma - push maternal health protections. And I've seen those responsible for executing maternal and child health plans to be working long hours to find creative ways to save lives. I felt like I found the sparkplugs with people such as Drs. Bocar Daff in Senegal and Samuel Kargbo in Sierre Leone, who were trying to develop systems and policy choices that would help women and children. These people, unfortunately, are largely anonymous to the West, because who takes the time to look inside Ministries of Health? And who inside the Ministries takes the time to present their work to the world? Some do, but not enough.
Back to PCMH, the so-called graveyard hospital - a hospital that the Sierra Leone Minister of Health and Sanitation is trying to assist. The hospital is their last safety net in Freetown and beyond for women experiencing difficulties in pregnancy.
Photographer Dominic Chavez and I spent a long day in its three delivery wards. For an afternoon, we put on sterilized gowns and hats to enter the operating theater and watch doctors perform two Caesarian-section deliveries.
The conditions were difficult. A generator provided electricity, but only one of the four bulbs in the operating table spotlight worked; doctors didn't have enough suturing material, and the needle they used for stitching was crude - a far cry from the round-body needle that made clean stitches.
One C-section was pre-scheduled; the other became an emergency.
I was most worried about the emergency. The woman, Henittor Koroma, had spent long hours in difficult labor, screaming, "WHY? WHY? WHY?" in the one of the maternity wards.
Then she started addressing her Savior. "Jesus, deliver me! WHY? Jesus, deliver me! Set me FREE!" Her screams echoed through the hospitals' wards.
Nurses determined that her unborn baby was turned around in the womb; she would need a C-section.
The second woman, Isata Swaray, by contrast, was calm. Her C-section, an elective, was set for this date. She was overdue by perhaps a week.
But in the operating room, precursor had no relation to reality.
For Henittor Koroma, now blissfully silent from a spinal tap anesthetic, doctors took four minutes to scoop out her baby boy. He emerged with a healthy scream, nowhere near as loud as his mother's earlier shouts, but forceful nonetheless. Mother and child emerged in good shape.
But for Isata Swaray, it wasn't so simple. The surgeon, Dr. S. Nial Koroma, had to deal with a complication - a baseball-sized fibroid on the woman's belly, next to her uterus. The baby also was large, and when he pulled her out of the womb and held her upside down by the feet she didn't make a sound.
Midwives snatched her from the doctor's hand, and brought her to a table, immediately suctioning out fluid from her mouth. One woman slapped the baby's behind, and she let out a soft cry.
And then she was silent.
One midwife started moving the baby's legs - nothing.
Then they took turns pushing on the newborn's tiny chest.
"WAAAAA," the baby cried.
More pushing. More crying. More pushing, and more pushing, and finally the baby's heart kept beating. She would make it.
But on the operating table, her mother not only had to be sewn up, but the doctor also had to remove the fibroid. The operation, normally 30 or 40 minutes for a C-section, stretched to two hours. The woman lost more than a liter of blood; it spilt all over the operating room floor, forming red puddles underfoot of the doctors and nurses.
Nurses, leaving the operating theater, said they were concerned about whether the woman would be OK.
Surgeon Koroma emerged. He said she would be fine. She had lost a lot of blood, he said, but they would giver her a transfusion.
I decided to return and find out what had happened to her.
***
Next: What happened to Isata Swaray?
Part 6: Sierra Leone, What Happened to Isata Swaray?
August 13, 2009
I approached the Princess Christian Maternity Hospital (PCMH) in Freetown with wariness. Only a few days before, I watched surgeons perform a Caesarian section operation on Isata Swaray - and it hadn't gone well. She lost more than a liter of blood, and the operation took two hours to first deliver a baby girl and then to remove a large fibroid lodged next to the woman's uterus.
The surgeon had said she should be fine. Nurses weren't so sure. They worried about all the blood she lost.
Entering the maternity wing, I saw a nurse whom I had met a few days before. I asked her about Isata.
"Follow me," the nurse said. "She's right in here - she's very, very lucky."
Lying down in bed, Swaray beamed. Her baby girl was asleep in a bassinet next to her. The mother said she was in still a great deal of pain, but otherwise felt relieved to have made it through the surgery.
The girl, not yet named, was her second. Swaray, 39, had one other child - a 19-year-old girl. In between births, she said she had two miscarriages. She never thought she would give birth again.
She said she worked as a trader - selling soap in the back of a small shop. In a good week, she said she earned 2,000 leones, less than $6. Her husband, she said, worked "small jobs." How much did he earn? "I have no idea," she said.
I asked her about the cost of the operation. Her face drained.
She said it would be about 800,000 leones, or more than $260. How would she pay it?
Her husband, upon her insistence, made a 500,000 leone down payment to the hospital so she would be admitted.
"He gave me that 500,000 leones to save my life," she said. "It saved my life and my daughter's life."
The high cost of health care for Sierra Leone's poor is the largest barrier to access to care, say Health and Sanitation Ministry officials and donors. Everyone here knows of a story of someone dying because they didn't have the money necessary for health care.
The roots of the problem lay in poor pay for health care workers. Doctors earn about $200 a month, nurses around $70 a month. In every hospital ward that I visited, several `volunteers' were working for free - hoping that someday it would lead to a job. Because the pay is so low, the government allows doctors to moonlight in private practice to earn more money.
In addition, at hospitals and clinics, corruption is rampant. Patients almost always pay higher than the published prices. Nurses purchase drugs on the black market and then sell to patients - often at a steep markup. Doctors charge extra for surgeries. All must be paid upfront.
So what will Isata Swaray do now to meet her bill?
She still owes 300,000 leones, about $100.
"I don't have the money - not yet," she said in her hospital bed. "I apologized to the doctor that I couldn't pay him right now. But I will find the money - somehow, someway."
I left feeling so happy that Isata had survived - but also worried about the financial burden she now carries.
John Donnelly, a former staff reporter for The Boston Globe, where he covered global health issues based from Africa and Washington, D.C., is now an independent writer.
is just very interesting to know just what is happening in Africa, just what are Africa’s’ ministries of health doing to combat this problem, please what’s the situation in Nigeria on this issue
— chimere may on 2009-07-30
The case of Senegal is particularly interesting because the country has such a large pool of very educated and very smart leaders. The health policy guidelines are generally pretty uptodate and well written but their implementation inadequate. It would be very beneficial to get an insight on why progress on surmounting the many socio-cultural challenges has been so slow…
— pape Gaye on 2009-07-31
In reply to Pape Gaye’s comment:
It’s a great question and I’m sure there’s no simple answer. One of the answers may be the results of a study of funding distribution in Senegal. It found that areas that set up official structures (councils etc.) received much higher levels of funding than areas that didn’t. And so remote rural areas without representation received far less funding and attention on issues across the board, including health. The reason those areas received less funding likely has something to do with a truism worldwide: Politicians respond to those who help get them elected. I heard several people in the Ministry of Health talk about a more equitable distribution of funds. They are very focused on reducing maternal and neonatal mortality, and they know the areas of the highest mortality rates.
— John Donnelly on 2009-08-01
Very interesting blog, especially since Senegal has seen many successes in other areas. Do you happen to have more information on the study of funding distribution in Senegal? I would be very interested in learning more. Many thanks - great blog!
— Jamie Anderson on 2009-08-04
Thank you John for the illuminating report.Your observations in Senegal apply in varying degrees to most of the sub-Saharan African countries,including oil-rich countries like Nigeria.In virtually all the countries affected,the underpriviledged communities bear a disproportionate burden of maternal and neonatal mortality.Maternal health in most of these countries is compromised by numerous infections, and more importantly ,by severe ,chronic malnutrition (particularly micronutrient deficiencies ).Very regretably,health care policy makers have not addressed the issue of maternal nutrition adequately.Worse still,many health practitioners lack basic understanding of nutrition in relation to outcome of pregnancy.
— C.O.Enwonwu on 2009-08-05
sustainable follow-up strategies in Congo; can we partner with Dr.? (Gbangi’ sister), to expand her services to a reproductive and child health clinic. This will require seeking funding as well as human resources in Congo as well the U.S. This is a theoretical question that can be used for brain storming at our next meeting.
— yvonne brooks-little on 2009-08-06
Hello John! I’m happy to catch up with you after your Boston Globe days. mothers2mothers continues to grow at lightening speed…we now have 550 sites in 7 countries and employ more than 1,500 HIV-positive moms. I’d love to catch up with you one of these days. Warmest regards, Robin Smalley, Co-founder/International Director, mothers2mothers
— Robin Smalley on 2009-08-10
I spent several months in East Africa and noted the heroic and successful efforts to decrease maternal and infant mortality on the part of the MOH of Eritrea. For all of the assistance offered to developing nations, much comes earmarked for certain “silos” of care such as HIV, TB, malaria, malnutrition. A more effective approach would be to offer assistance for strengthening the health care delivery system across the board, that in turn could address all of the issues which in turn, impact maternal/child health. This would include funds for education of health professionals, making health care an attractive option with better pay, and other strategies that would result in sustainable and self-directed health care systems.
Angela Albright, RN, PhD
— Angela on 2009-08-17
Thanks for some very interesting pieces on Sierra Leone. I am myself enganged there in a project to strengthen the health information system. I would like comment on the question regarding free health services. When data showed that Western Area district (Freetown) had the country’s lowest institutional delivery rate, the District Medical Officer there himself took the initiative, and placed an ad in the newspaper explaining that such services were indeed free in Western Area. So local action by concerned professionals is taking place to address this. The key is of course reliable information and transparent use of funds, both hard to come by in Sierra Leone.
— Johan Saebo on 2009-08-18
My piece of advice that Sierra Leone needs from other countries, the health system need to be restructured to have a more effective approach for strengthening the health care delivery system across the country in order to enhance maternal/child health, more funding for health care providers, better pay for professionals ,and also for a better sustainable health care system
— Dr Manso Dumbuya on 2009-08-18
I wonder whether the contributions of the general practitioners/ family physicians to the maternal and child mortality reduction in Senegal has been looked into. They are a forgotten cadre of health professionals in Africa, combined with Community Based health Insurance, they are a formidable force for change in health indices in Africa. More of them need to be trained, encouraged and supported all across the continent. This is the way Nigeria is Taking
— Olayinka Ayankogbe on 2009-08-18
I’ve met John Donnelly and greatly admired his writings at the Globe. This is a great blog. I hope everyone reads Nick Kristof’s and Sheryl Wudunn’s book to come out Sept 8. Half the Sky talks about gender inequality and tells stories from all over the world. It also gives hope by showing how women overcome terrible difficulties. 34 Million Friends of UNFPA of which I am cofounder is a nice part of Chapter 8.
— Jane Roberts on 2009-08-18
Thank you John for your great blog.
As you note - seldom does anyone really get “inside the Ministry of Health” and see the realities that patients, health workers and health managers see everyday.
— Joseph Dwyer on 2009-08-19
Thank you for once again bringing this tragic reality about maternal and child mortality into print. As a board member of the Birthing Kit Foundation (Australia) we have long acknowledged that providing a clean birthing environment improves maternal and child health surrounding childbirth. Giving birth with a midwife at a clinic or hospital is always the best option to aspire to, however, as noted in developing countries, many women because of extreme remoteness (no roads or transport) or for cultural reasons, can never get to a hospital or clinic. Supplying a small transportable clean birthing kit in a snap lock bag, comprising a sheet of plastic, soap, gloves, cord ties, a sterile scalpel blade and gauze, with directions on how to properly use it, given by a health provider to a birth attendant is often all that is needed to stop infection and potentially save life. The foundation has supplied over 650,000 clean birth kits since 2004 to 26 countries. We have also trained over 5000 birth attendants/village nurses in midwifery, hygiene, nutrition and health in Vietnam and Kenya. Ideally we would like to see all women give birth with a midwife in a hospital or clinic, however, until then we will supply our kits for women giving birth at home in developing countries. The project to date has been part funding by AusAID (Australian government overseas aid) and predominantly by Zonta clubs in Australia. The kits are assembled at Assembly Days where Zonta Clubs organise 40 - 60 volunteers to gather to make up kits, with directions from a manual. The kits are then posted overseas and distributed through reputable organisations and individuals. Ultimately we work towards sustainability of kit production and training programs in country. The BKFA foundation’s work is only limited by funding, with the demand for our kits and training programs exceeding our ability to supply. http://www.birthingkitfoundation.org.au Once again, thanks for the excellent article.
— Julie Monis-Ivett on 2009-08-19
Interesting and engaging pieces—thanks for covering such important issues. Although I realize you’re focused on ministries, I’m intrigued as to why you did not mention family planning as one of the most important interventions for lowering maternal mortality rates. It is critical that ministries invest in family planning and reproductive health initiatives to help women and their families.
At Pathfinder, we believe access to sexual and reproductive health care is a fundamental human right and partner with local communities and ministries to ensure all women have options for contraceptives and maternal care. Our programs reflect the fact that using contraception to delay, space, or limit the number of children a woman bears is the most effective way to protect women and newborns from the health risks caused by early and frequent childbearing. To learn more, please visit http://www.pathfind.org.
— Jaime-Alexis Fowler on 2009-08-19
Thanks to everyone for their great comments and questions.
Let me answer a few of them. Jaime-Alexis, you raise a very good question on why family planning wasn’t covered much in these postings. It clearly is a huge issue in these countries, but my reading of it was that both Ministries were focused primarily on the more urgent priority of making sure women delivered babies in clinics or hospitals. I think they believe they needed to stabilize the situation and reduce home births before moving to other key issues, such as integrating family planning into maternal mortality strategies. You can bet, though, that both these ministries would welcome any assistance that Pathfinder or other outside technical experts could give them.
Olayinka, I agree that general practitioners can be key partners in efforts to save mothers’ lives, but the problem in these countries, especially Sierra Leone, is that there aren’t enough of them! Or enough nurses, or enough trained midwives. The low numbers are astounding. In Sierra Leone earlier this year, after a horrible explosion/fire from people trying to take fuel from a pipeline, the Ministry’s Chief Medical Officer, the top administrator for public medical services, became an emergency room surgeon for a couple of days. They simply do not have enough medical professionals.
Dr. Dumbuya, your point that a restructuring of the health system may be needed is an interesting one. Obviously, something dramatic needs to be done to reduce maternal mortality in both Senegal and Sierra Leone (and many other countries), and both places could benefit from experts such as yourself to work in partnership with them to closely analyze what would make the system make better.
Johan, great point on the district medical officer in the Western area (which includes Freetown) taking out an ad in the newspaper saying that the services are free. But in practice, that’s not true—people are paying huge fees in hospitals, with many health professionals in hospitals getting paid under the table. Transparency is part of the solution. But it won’t work alone.
Prof. C.O.Enwonwu, great to have your comment on the importance of nutrition. As someone who has studied this in West Africa over the years, you know this point better than anyone I know. Policymakers should incorporate your important findings in their strategies. Many have—and many more should.
Jamie—still looking for the Senegal funding information; will try to report back soon.
Angela, your experiences in Eritrea sound amazing. Next time you do a trip like that, blog!
And thanks to Joseph, Jane, Robin—wonderful to get comments from the three of you.
I also have a question that I’d like to throw out. Another of my findings on this trip was the Ministries’ poor use of communications to get their messages across both internally (inside the government) and externally. It seemed a no-brainer to me that a well-thought-out strategic communications campaign would be vital to any rollout of a strategy to reduce maternal mortality. My question: Does anyone know of a great example where a Ministry of Health’s communications strategy helped boost the overall effort to save women’s lives? Perhaps other examples could help both of these countries. Thanks.
John Donnelly
— John Donnelly on 2009-08-22
John, I don’t know of a great MoH communication strategy but I have been speaking with several African First Ladies who very much want to speak out on behalf of maternal health and have not had the platform to do so successfully. While some are in the decidedly unenviable position of being half of unpopular political regimes, others are perfectly positioned to be role models and spokespeople for the women of their countries and are actively looking for ways to become involved. Empowering women is a critical component of a successful womens health program and the First Ladies, when they find their voices, should be encouraged to work in partnership with the MoH to communicate national maternal health strategies. It’s wonderful John, that you are inspiring this kind of dialogue!
Robin Smalley, Co-founder/International Director, mothers2mothers
— Robin Smalley on 2009-08-22
John, join the Gates funded http://www.maternalhealthtaskforce.org
Communication is absolutely key. Maybe you could find answers there or ask (JavaScript must be enabled to view this email address) Say I sent you.
— Jane Roberts on 2009-08-22
Hi John, thanks for the blog. As with so many blogs, it induces thinking, and of course, more questions than answers. Reproductive Health and Maternal and Child Health is the forgotten stepchild in the HIV/AIDS epidemic, and I completely agree that we need more emphasis on this. The DOH in South Africa does see this as a critical issue, and is putting concerted efforts to strengthen MCH through focusing on 18 priority districts. Too soon to see the fruits of the labour, but I am hopeful.
— Celicia Serenata on 2009-08-24
Robin, I noticed that several First Ladies from Africa had some recent events in the US (LA and Washington) and wonder if you were involved in that. Obviously, First Ladies have the potential to be great advocates/communicators. For those really committed to the issue, I would advise them to have a series of talks with key MoH people (including one-on-ones with the mid-level person in charge of the maternal mortality issue) to fully understand the problem, and not to focus at first on a couple of press events. They should be strategic and figure out how they can push ahead the MoH experts’ agenda. I see so much opportunity for them internally and internationally.
Jane, great ideas. I’ll look at the website and send an email, saying you sent me.
And Celicia, great to hear from you. You raise one of the big issues out there because of all the funding for HIV/AIDS: how to expand/target those services to help build reproductive health and maternal and child health programs. I would love to read an on-the-ground assessment of what’s happening in South Africa’s 18 priority districts as it is happening; it would be a great story for a South African journalist—or a foreign correspondent, who could tell the broader story on this renewed focus in maternal and child health initiatives.
— John Donnelly on 2009-08-24
Hi John, I agree. It is important to have an “evaluation” component to the efforts to ensure that it is having an impact of maternal and child health outcomes. Apologies for doing this in a public forum, but I do not have your email address, and wanted to tell you how much I loved the TB book you gave me in Windhoek. I have loaned it out to a few people in the TB world here.
— Celicia Serenata on 2009-08-24
I am happy for the mothers and babies in your report from PCM Hospital, Freetown, but as you know many are not that lucky in developing countries. The fundamental problem to health delivery and financing, is that the cart comes before the horse. One does not jump into a pool and then figure out how to swim, or enter a tennis competition and them learn how to bat a ball. The scenario in most health ministries is how to utilize the budgetary allocations whether funded solely by government or donor support. There is usually no medium or long term plan or strategy on implementation or concise health policy. Health ministries need pro-poor health promoting policies, strategies and plans of implementation, then budget allocated to finance them. The donors should impress on health ministries the need for policies and plans to address maternal child health, free health care, HIV/TB control and so on before offering financial support.
— Martin A-Williams on 2009-08-30
I remember visiting a joint UNFPA-government RH clinic in the Tambacounda province of Senegal. There was a distinct lack of laboratory facilities, testing for anemia etc. The middle chapters of Nick Kristof’s and Sheryl Wudunn’s new book (Half the Sky: Turning Oppression into Opportunity for the World’s Women) are centered on reproductive health, maternal mortality etc. Shamelessly I am thrilled to say that the second half of chapter 8 is Jane Roberts and Her 34 Million Friends. You can read my review of the book in GLOBAL HEALTH magazine bit.ly/O3UfQ. We have to get the grassroots in every country demanding RH for women. Only then will governments prioritze women’s health. Think of it, EVERY HUMAN BEING EVER BORN HAS COME OUT OF THE WOMB OF A WOMAN. Gender inequality is the moral scourge of the age.
— Jane Roberts on 2009-08-30
This realy captured some of the major issues in health system strenthening in Africa generally.In Nigeria MSH is on the top gear building the capacity of health care providers and Health institutions in the area of leadership for sustainability of partners effort to mitigate the impact of HIV and AIDS.In most states we have govt seconding health personel to PHC for better services.Interms of internal communication related to patient care MSH has piloted a model called PCT (Patient care team meeating)which is now adopted by most of the facilities where MSH intervened.The meeting provide fora where new innovations were shared and challenges brainstorm for next plan of action e.g issues of tracking of defaulters for ARV and many more.
— Nura on 2009-08-31
I read the observation you made in Senegal and Sierra Leon. I appreciate you very much for your concern to show the world what is happening to African rural women’s reproductive health.
The information that you released to the world is one part of it, may be your objective is this one. I think it is also good to observe other problems that may help to alleviate the the problem of reproductive health. I think they go together. There are many problems the African women are facing which is a challenge not only to Africa it is also a challenge to the world. Some of the problems facing the African rural women are reproductive health, commicable diseases, HIV AIDS, Malaria,Tuberculosis and others. The rural women are suffering from communicable diseases that can be prevented easily. Just by educating the rural women how to prevent it. Power imbalance and harmful traditional practices play a major role affecting the health and life of the rural women. If you go to some other African rural countries and observe how the rural women are living you may not believe your eyes, they are leading a miserable life.
It does not mean that the governments and other concerned groups are not working I think it is becoming out of their control, it needs the concerted effort of every one, particularly those educated groups have to find the solution by giving more emphasis to research.
Mentioning all the ill points do not solve the problems. I think finding the root cause may give a root answer for the problem that you mentioned.
I know that your are asking comment for reproductive health, I think, what I mentioned above go together to alleviate the reproductive health in Africa.
Gebeyehu
— Gebeyehu W. Bogale on 2009-09-23
Thanks these findings, as they are quite interesting. It has added some impetus to my curiosity as research student. I am also about to estimate what women and households pay when they develop obstetric complications…perhaps later by the end of the year some preliminary finding can surface. this could bring some of queries I am interested in; direct and indirect cost whence user feee for MCH services have been abolished in my country..The GAMBIA. I’ll be keen and interested to get inputs on or about issues in other parts of the world related to cost to pay for EMOC.
— B.Njie on 2010-03-01