WORLD HEALTH ORGANIZATION
Health Update Sierra Leone
8 September 2000
Segbwema continue to drive people from
villages. Mike Von Swarray, humanitarian coordinator in Kenema, says all the six camps
have far more people than facilities to cater for
them, though the influx has slowed.
The town too is at bursting point with estimates
that at least as many new arrivals have been
absorbed into the community. Hygiene and
sanitation is the most pressing problem with rats
abounding and communicable diseases a
constant concern.
Displaced people
Security doesn’t assure health
Aid workers in the southern area of Sierra Leone
say health is still in emergency even in
apparently secure places.
According to Dr Sandra Simmonds, medical coordinator for Médicins sans Frontières Belgium,
her team were shocked by the level of illness
and malnutrition they found when they opened a
hospital into the southern town of Mattru Jong in
June this year.
“Mattru Jong has been one of the most secure
places since 1997. But if you saw what came
through the door when we opened the hospital,
you would almost say it is an emergency. Our
therapeutic feeding centre has 50 severely
malnourished children. Everyday we send an
ambulance to Bo Hospital with people in terrible
conditions. No one would declare an emergency
here because it is so secure, but it is an
emergency because these people have never
had access to health care.
Dr Adriana Zarrelli, head of health programmes
with UNICEF says having emergencies inside
the normal situation“ is a peculiarity of Sierra
Leone. “Even inside Freetown there are pockets
of crisis, so you have to have several different
approaches ranging from emergency activity
through to development and all the transition
activities in between,” she adds.
While WHO Representative to Sierra Leone, Dr
William Aldis says the fact that large numbers of
displaced people have been absorbed into the
community, and are relying on the help of family
and friends who are often little better off than
those displaced, adds to the effects of difficult
access due to transport or financial constraints.
“It is a misunderstanding if people believe that
the crisis has only caused problems for the
people in the camps,” says Dr William Aldis, who
believes solutions lie in a dual approach of
emergency response and health sector reform
(see page 11).
Kenema Camps
Aug 2000
Naiwama
Blama
Lebanese
Nyandeyama
Konia
Gofor
Registered
(ie. counted for food
& services)
26,000
12,996
10,487
9,589
916
780
Unregistered
(ie. not counted for
food & services)
931
2,052
1,860
2,850
400
325
Total
60,728
8418
Plans have been on the drawing board for
several months to expand the smallest camp at
Gofor, six kilometres east from Kenema Town
and about a kilometre beyond the last UNAMSIL
checkpoint, to take 5,000 more people. But a
WHO visit last week found inherent problems
including the lack of water on site and planting
on the planned expansion area.
…. and west
The problem is not confined to the east. Half an
hour’s drive from Freetown, the population of
Waterloo Camp run by the NGO ADRA has
more than doubled in the past month.
Assistant camp manager Samuel Hubbard told a
WHO assessment team last week the camp
currently has 12,854 “registered and verified”
people for whom food supplies are available,
and 13,100 who have been registered by the
camp process but not yet verified by the World
Food Programme and therefore cannot receive
food distribution.
“Some come to beg at the distribution lines or
from relatives, some sell firewood or make
gardens. If there is anything left over from the
official food distribution we give it to them and
sometimes we get donations of food from other
organizations.”
Accommodation is a major problem in the camp
built for a far smaller population. Some 2,600
are supposed to be in transit and have been
New influxes strain services east…
Displacement camps in the frontline town of
Kenema have swollen by almost 15% over the
past month as military and militia activities to the
east around the new RUF headquarters town of
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WORLD HEALTH ORGANIZATION
clustered in one big ‘booth’ since May, while
others are crammed several families per house.
There are 58 water taps and 10 pumps making
roughly one water source per 400 people.
At the ADRA medical centre, Argentinean
surgeon Dr Rubin Rostrand says the team is
now using 4000 chloroquine tablets a week
compared to 2000 a week last month. “We are
having serious trouble keeping up with
medicines and are talking to our medical coordinator about how we can increase supply.
Many of the new people coming in are sick with
malaria and infectious diseases.”
But, he adds, it is also very difficult to control
abuses of the system with trade going on in IDP
registration card. “We have pretty sharp staff
and used to be able to recognise most of the
faces but these new influxes make it more
difficult.”
“We found 60 to 70% of the population are sick.
You see diseases that you don’t see anywhere
else anymore, like scrofula because there has
been no attempt at TB control for 10 years.
Another example is the number of cases of
unexplained blindness.
“Our intervention has helped in Bonkolenken but
if it’s like this there, right on the edge of the
inaccessible area, what’s it going to be like
further north?”
Funded by the UK Department for International
Development (DfID), MRC Sierra Leone has
rehabilitated and equipped five clinics in
Bonkolenken, one of the few chiefdoms in
Tonkolili to remain loyal to the government and
therefore accessible.
This work follows a more extensive £400,000
programme rehabilitating a total of 15 health
units in Bo district over the past four years. All
are now manned by returned Ministry of Health
staff, are radio linked to the Bo base and have
access to an MRC ambulance.
“Every chiefdom in Bo district has at least one
health centre and we are now starting on the
maternal and child health posts,” says Mr
Downham, who has been in Bo since the late 60s.
The programme also helps villages set up health
development committees which with the district
health management team should gradually take
responsibility for the service. And it encourages
committees to set up small revolving credit funds
by charging minimal user fees, to help those
who find hospital care charges almost
impossible to raise.
A researcher with the British Medical Research
Council unit in Bo until it withdrew its staff eight
years ago, Mr Downham has spent much of
recent years helping local health staff run mobile
clinics to dispossessed and frightened people
wherever they are
“We set up by the side of the road or in deserted
villages and people appear, first one or two, then
crowds out of the forest, and then they disappear
again as quickly as they came,” he says.
Bo is now one of the most secure areas of
Sierra Leone with as many health units as
before the war. Mr Downham’s next mission
from DfID, if he chooses to accept it, is to try and
find away to get basic health services further
north to people who desperately need them.
Health promoters need protection
Work done by NGOs such as Oxfam, Care and
Action Contra La Faim to develop a cadre of health
promoters in each IDP camp is paying dividends in
some of them, but one year on from the start of the
initiative, volunteers say they desperately need
more tools to continue their work.
In Bo’s Splendid Camp, for example, Dominique
Lebbie, and over 80 colleagues are managing to
keep the nearly 8000-person camp surprisingly
neat. An unannounced visit by WHO found
common areas and huts swept clean, showers
scrubbed and water pump areas spotless.
“It’s not good to self praise,” says Mr Lebbie,
“But I think we are doing a good job, and the
health of the people is much better than it was a
year ago when we had just arrived. We have no
excess of disease right now”
But, says Mr Lebbie, the team carries out the
often dirty work with no gloves or boots to protect
them, and cleaning groups in other camps echo
his plea for support.. Health promoters generally
receive no payment for their work.
Access to health
Sickness stalks rebel-held areas
Health workers fear populations still living in
Northern rebel-controlled provinces of Sierra
Leone are becoming sicker and sicker due to
virtually non-existent access to health care.
Mike Downham, director of the Bo-based
Medical Research Council of Sierra Leone
primary care centre rehabilitation programme
which has recently extended activities into the
newly accessible Bonkolenken chiefdom of
Tonkolili district, says he has been amazed at
the variety of sickness in the isolated rural area.
Clinic survives on Daru ‘island’
The only way to get secondary care in Daru is to
walk the 46 fraught miles to Kenema through
rebel-held territory or, if you are lucky – and very
sick – to get a lift in a UNAMSIL helicopter. Not
surprisingly in the past six months, only six
people have been referred to hospital.
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WORLD HEALTH ORGANIZATION
A UNAMSIL protected island in the middle of
rebel territory, uncomfortably close to the new
RUF headquarters town of Segbwema, the only
way in or out is by air, or taking a risk on the
footpath – the road itself has been cut. But if
secondary care is out of reach, primary care is
not, thanks to a dedicated bunch of local health
workers and the support of the International
Medical Corps.
Since July, Daru’s population has swelled from
around 1,500 people to almost 10,000 due to
conflict in the surrounding area, and according
to health statistics collected by the clinic, over
20% of this population has attended the clinic
with malaria in the past two months.
Dysentery, acute respiratory tract infections and
sexually transmitted diseases are the next most
common conditions in the clinic, which though
Spartan, has kept going throughout all strife and
is a lifeline for the population. Drugs and supplies
are flown in by IMC, ante natal clinics are held
twice a week and routine childhood immunization
restarted two months ago after UNAMSIL offered
to store vaccines in their fridge.
As well as the static services, the clinic team run
a mobile clinic to the village of Malema across
the river four times a week which serves people
who travel from 15 other villages outside the
UNAMSIL boundary – though mobile currently
means on foot since scarce fuel has pushed
prices beyond even OPEC’s wildest dreams.
But the main concern right now, say health
workers, is food supply. A rapid nutritional
screening exercise of 544 children carried by
British NGO Merlin last month, put global
malnutrition of 7.6 and severe acute malnutrition
at 3.7. But these figures hide higher rates for the
new arrivals with rates for children resident less
than six month reaching 9.6 global and 5.2
severe malnutrition.
IMC maternal and child health aide Marima
Kanneh fears things are going to go rapidly
downhill as the consequences of poor food kick
in. Already she estimates around 35% of
children are born sick in part due to their
mothers’ poor nutritional status.
Help may be at hand, however. The World Food
Programme, Merlin and IMC are meeting to try
and work out how, in spite of the logistic difficulties,
to start a programme of supplementary feeding to
target the most vulnerable.
Accessibility update
The security situation, particularly in the northern
provinces of Sierra Leone changes from day to day.
However, other areas of the country – including a
broad swathe of the south – are stable and are
accessible by various means.
“People think of Sierra Leone as a place where
nothing can be done, so secure places like Bo suffer,”
says Bo District Medical Officer, Dr Amara Jambai. “It
may look impossible from outside but there is a lot we
can do in these areas.”
Stable
Western Area: Freetown city and the rural suburbs
Lungi
Bo
Kenema
Pujehun
Unstable but accessible
Port Loko
Mile 91
Unstable and difficult to access
Kambia
Makeni
Kabala
Kono
Kailahun
Daru
The NGO pulled out international staff earlier
this year after they were taken hostage for a
day, but have supported national staff to
continue a skeleton programme, particularly
supplying essential drugs.
Medical co-ordinator Dr Sandra Simmonds said
they had hoped a newly arrived international
logistician would be able go into the area this
week after the area had been calm for almost
two months, but the renewed instability has put
plans on hold.
A recent WHO assessment visit to health
facilities in Kabala found the hospital functioning,
but in dire need of basic surgical equipment
including lighting – operations are being carried
out by flashlight. Training in the integrated
management of childhood diseases would also
be a priority when access is possible, the WHO
team said.
Reproductive health
Triple attack on maternal deaths
UN agencies are throwing their weight – and
more money than ever before – behind a new
assault on Sierra Leone’s tragic record of deaths
in childbirth.
The rate of maternal mortality in the country has
been stuck at more than 18 deaths per thousand
live births – one of the highest statistics in the
world – despite efforts over the years to reduce it.
Rebels delay Kabala efforts
Plans by Médicins Sans Frontières Belgium to
re-strengthen their support for six peripheral
health units in the Kabala region in coming weeks
received a set back when rebels again attacked
the town in late August.
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WORLD HEALTH ORGANIZATION
At this rate, a Sierra Leonean woman who gives
birth to six children has over a 10% risk of dying
in childbirth.
Now, after a major re-analysis of the root causes
of these figures, the three UN agencies involved
in the health of women and children – the United
Nations Population Fund, the United Nations
Children’s’ Agency and the World Health
Organization – have come together in a fresh
collaborative approach which they hope, this
time, will have a real impact.
“The trouble is,” says WHO representative to
Sierra Leone, Dr William Aldis, “that you can
train any number of traditional birth assistants in
how to make childbirth safer but if they don’t
have a hospital to refer to that is skilled and
equipped to deal with the complications of birth
that kill, TBA’s can’t make a difference to
maternal mortality.”
Training community birth assistants and
midwives does reduce risk factors such as
infection and can result in quicker reaction to
potential problems he says, “But once a
woman’s life is at risk, what she needs to save
her is beyond the skills of community workers.
What she needs is access to a functioning
hospital – and in Sierra Leone that means
solving some deep structural problems.”
Dr Abu Pratt, health project officer with UNICEF,
says the problem of maternal mortality is so big
no one agency can do it. “What we have done
with the other two agencies is divide the
responsibility for specific levels of care.
“In the new project, UNICEF is focusing on
raising skill levels for safe and clean birth in the
community while WHO and UNFPA have taken
on the task of improving the skills, equipment
and access to hospital care that can make the
difference between life and death once
complications set in. If we enable traditional birth
assistants to identify who needs hospital care in
time then the WHO role is to make sure that
they get safe care once they get there,” he says.
This says Dr Aldis, involves some fairly obvious
activities. Obstetric and surgical equipment has
been ordered, for example, and plans are being
made to update key staff in life-saving techniques.
But the harder task is the less obvious one of
reforming and revitalising hospitals that are
barely functioning due lack of resources, lack of
motivation and corrupt financial practices. “It
may seem a million miles from a mother’s life,
but without reforming hospitals, we cannot solve
the problem of maternal mortality,” says Dr
Aldis.
To back the new approach WHO is dipping deep
into its regular budget to put five times as much
money – some US$340,000 – into the pot as
last year, while UNFPA have committed $1.2
million and UNICEF over $250,000.
Despite this year’s crisis, some health sector
reform is in fact already taking place with the
introduction of cost recovery (see page 11). By
working with key NGOs and the Ministry of
Health, WHO hopes to promote this change of
culture more widely and through it reduce the
tragedy of maternal death.
Training for traditional birthers
UNICEF’s
reproductive
health
training
programme complete with a newly revised
manual for Sierra Leone started last month.
Participants are supplied with food during the six
week training but no per diem or incentive.
Despite this 40 women have recently completed
the six week training of trainers course.
At the end of the course each participant is
given a essential birthing kit and a unusual
record keeping device designed for the largely
illiterate assistants – a box with pictures of
different outcomes of labour with holes through
which small stones are posted to record the
event.
Sex for soap and kerosene
With women and children making up some 60 to
70% of displaced populations and around 10 per
cent having to perform sexual favours to get the
basic essentials for their family, setting up
dedicated reproductive health clinics in the camps
is an priority, according to International Medical
Corps medical co-ordinator Elizabeth Manga.
Mrs Manga takes her estimates from months of
carrying out interviews with women in the camps
while supervising IMC’s clinic activities which
are mainly in Port Loko, Lungi and Daru. But
one good thing about the camps, she says, is
that it provides an opportunity to reach women
with information on reproductive health.
“We shouldn’t be waiting until these women go
back to their area to help them with reproductive
health. They need it now – and they are in some
ways a captive audience.”
While most camp clinics do provide rudimentary
reproductive health care, Ms Manga, who was
herself displaced from Kono with four children
after her husband was killed, says most women
are too embarrassed to ask for help at general
clinics. She is advocating for camps to create
specific reproductive clinics where women can
be treated but more importantly educated about
protective and preventative measures.
Communicable diseases
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WORLD HEALTH ORGANIZATION
However he died on the journey, two days after
first reporting.
“We are not saying this patient could have been
saved – given the speed of his death. But it is
important that we establish a treatment unit in
Freetown so that cases can be started on the
treatment quickly,” says Dr Abdul Rahman
Wurie, WHO’s disease prevention and control
adviser..
The new isolation unit will be sited at the
ministry of health’s Waterloo Clinic in buildings
which used to house the Western District’s
health management team, now relocated to
Freetown.
A number of agencies have already come
forward to help provide the new unit with trained
staff and equipment.
Two ministry of health doctors and six nurses
from Freetown are to join the Lassa Fever
Treatment Centre in Kenema for an intensive
hands-on course on managing the disease. Run
by British health NGO Merlin, the centre is the
only specialist lassa fever unit in Africa and staff
are among those with the greatest experience of
treating the disease in the world.
While Merlin has agreed to sponsor training,
WHO will support the trainees financially during
the course, supplying transport and per diem.
WHO will also provide continued technical
assistance once they are established at the
Waterloo site.
To establish the unit itself, Médicins Sans
Frontières Belgium has agreed to provide beds,
mattresses and bedding, while UNICEF has
promised disinfectants and utensils and other
day-to-day equipment. WHO is to give the
protective equipment essential for barrier
nursing with extra gloves and other furniture
coming from the UN AIDS programme and Irish
NGO Goal is being approached to help set up
disposal facilities for clinical waste at the new
unit.
Action on yellow fever outbreak
Sierra Leone moved this week to build up its
defences against the potential spread of a
yellow fever outbreak from Liberia.
Disease control experts from the Ministry of
Health and WHO are carrying out crash training
in identifying and managing the disease with
health workers in the at-risk districts of Kenema,
Pujehun and Bo next week and NGOs such as
Médicins Sans Frontières Belgium and France,
Merlin, Goal and the International Medical Corps
who are supporting peripheral health units
clinics are disseminating guidance and
sensitising staff.
Meanwhile, WHO headquarters in Geneva has
despatched 180,000 doses to WHO Liberia for a
mass vaccination campaign due to start there
this week and is raising funds for at least further
50,000 doses to extend vaccination into Sierra
Leone.
The outbreak in Liberia, which was first reported
on August 16 in the coastal county of Grand
Cape Mount which flanks Sierra Leone’s
Eastern Province, has now spread into six of
Liberia’s 14 counties.
The risk of widespread transmission is high.
Both countries have a large unvaccinated
population, the area is notoriously insecure and
hard to access due to rebel activities, and there
are large numbers of displaced and weakened
people moving across the border.
One of the index cases – a four-year-old child –
is thought to arrived in Liberia from Sierra Leone
with fever but died before diagnosis could be
confirmed.
“We have to assume that it is already with us,”
says Dr Abdul Rahman Wurie, WHO Sierra
Leone’s Disease Prevention and Control Adviser
who, with the Ministry of Health, is leading the
response. “So we want to move fast to try and
prevent any further development.”
Health workers are being asked to immediately
report any suspected case with fever and yellow
eyes. The last outbreak of yellow fever occurred
in 1995 and caused 49 cases and four deaths.
Victims stay high despite rains
Lassa fever is continuing to cause concern in
Sierra Leone as the number of cases fail to drop
to normal rainy season levels.
Lassa is endemic in this area of the country but
cases normally peak in March, when rats
flourish with the dry season harvest, and drop
away with the onset of the rainy season. This
year, however, numbers have remained high.
In June and July, the Lassa Fever Treatment
Centre in Kenema treated 56 and 53 cases
respectively. compared to 12 and 22 in June and
July 1999, though these figures are also unusual
due to the conflict in the area.
One explanation for the high figures is the huge
influx of people into Kenema town and camps,
Death prompts new lassa unit
A lassa fever isolation unit is to be set up in
Freetown after the capital witnessed another
death from the disease in the last weekend of
August.
The victim, a man from Kenema in Freetown for
a funeral, arrived in Freetown with fever. He was
rapidly diagnosed via examination and liver
function tests by doctors in the outpatient
department of Connaught Hospital but advised
to return to Kenema where Sierra Leone’s only
lassa fever treatment unit is sited for treatment.
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WORLD HEALTH ORGANIZATION
says Nichola Cadge, medical co-ordinator for
Merlin. But it’s also likely the intensive public
awareness work and training of health workers
done by Merlin, the ministry of health and WHO
in the wake of deaths of two expatriates and four
Sierra Leoneans from Lassa fever in Freetown
early this year is bringing more cases to light.
“There’s no doubt that the overcrowding and
poor sanitation not only in the camps but also in
Kenema Town where large numbers of people
have recently been absorbed into the
community, make ideal conditions for rats.,”
says Ms Cadge. “But we have been very
proactive in health education and have been
doing active case finding in previously
inaccessible areas.”
Roughly one in five patients who contract lassa
fever die from it and early diagnosis and
treatment is a key factor in survival. The 32-bed
centre, which was originally set up by the US
Centers for Disease Control and Prevention in
1994, is the only specialist lassa fever unit in
Africa and is now supported by Merlin with funds
from the European Community Humanitarian
Office, the US Office of Foreign Development
Aid (OFDA) and the Dutch Department for
International Development.
Its small local and expatriate staff have great
experience of treating the disease But Sierra
Leonean unit head, Dr Aniru Conteh, is
concerned about the unit’s future
“Merlin is an emergency relief programme and
this is a long term problem for us. I’m worried
about what will happen when they go.”
One of the problems in gaining long term
commitment to tackling the disease, says one
observer in the capital, is that the Lassa Belt is a
long way from Freetown. “The government only
really sit up and take notice when there’s a case
on their doorstep. So we are taking as much
advantage as possible of the attention raised by
the Freetown and expatriate cases to press for
long term public health activities.”
from WHO African Region, headquarters and
the Parisian communicable disease centre,
Epicentre helped identify the strain and
prompted training in management and
laboratory techniques. WHO also provided a
further 100,000 tablets plus $10,000 for the field
response and health education campaigns, oral
rehydration solutions and IV fluids.
MSF-France has closed the five temporary
isolation clinics it had opened in hard-to-access
areas close to the Liberian border, but it is
maintaining its Dauda isolation camp in Kenema
because of worrying levels of cholera and
typhoid fever, says MSF-France medical coordinator Ariane Bauernfeind.
“We saw around 100 cases of cholera in July,
which is enough to be worrying because the
town is extremely congested, latrines are full
and an epidemic could explode. We have also
had around 10 patients who we believe have
typhoid fever. But confirmation is difficult
because there is nowhere in Sierra Leone which
can culture blood for typhoid.”
Catching the diseases – early
Sierra Leone needs a fresh approach to disease
surveillance if it is going have a system that
really produces effective planning and action
against infectious outbreaks, according to WHO.
“Sierra Leone has a well developed system of
data collection,” explains Dr Abdul Rahman
Wurie, WHO’s disease prevention and control
adviser. “But very little analysis is done, so
trends and opportunities to act are missed. What
we need is data collection for action so that it’s
possible to shift from routine surveillance to
active surveillance and investigation when
epidemic threats are identified.”
Surveillance has suffered from the disruption of
the conflict but lack of analytical skills, data
equipment and motivation are also a major
problem. To remedy the situation WHO is
working with the ministry of health on a
programme that will improve skills at all levels.
In the community, the project involves refining
reporting forms so that health workers can
concentrate on fewer, high priority diseases. A
new surveillance manual is almost complete,
says Dr Wurie.
But speed of communication is also fundamental
to effective surveillance, and WHO is also
working to develop selected rural health facilities
as reporting centres, equipped with radios
through which smaller ‘satellite’ facilities can
report.
At district and ministry level, the focus is on
developing the analytical and computer skills
needed to turn data collection into an effective
early warning system
Shigella epidemic under control
Cases of shigella dysenterie type 1 have
dropped from epidemic levels seen at the turn of
the year, but some NGOs are now concerned
about the increases in other diarrhoeal diseases.
The Ministry of Health surveillance unit reported
1,856 cases of shigella in June for the whole
country compared to over 2,200 cases a month
reported between July 1999 and February 2000
by one NGO, Merlin. Médicins Sans Frontières
France in Kenema, where the outbreak was first
recognised, confirms their clinics are seeing
around three cases a week down from 150.
The outbreak was controlled after an
investigation in January by a combined team
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WORLD HEALTH ORGANIZATION
Dr Wurie says it is crucial to make a start
despite the fact that half the country is
inaccessible. “We will start in pilot areas “where
we are most likely to succeed and expand from
there.”
The first pilot sites are most likely Freetown,
Lungi, Moyambe, Pujehun, Bo and Kenema.
Much of the ground work, including the placing
of disease surveillance officers in each district
management team has been funded by WHO,
and the next stage will be supported with funds
from the Italian Government.
Dr Wurie says the new system will not just boost
disease
surveillance
but
by
improving
communications, will also improve other aspects
of care such as emergency referrals and the
ability of more isolated units to seek technical
support and advice.
Dr Sarian Kamara and WHO malaria focal point
Dr Abdul Rahman Wurie, the next two months
should see intensive activity to get national and
international health and community partners on
board, produce information kits and develop
district action plans.
Four districts have been selected to pilot the
programme scheduled to start in early 2001.
These are the Western district including
Freetown, Bo, Kenema and Port Loko.
WHO consultants were in Sierra Leone recently
to train ministry programme leaders and will
return in November to train the RBM taskforce in
driving the programme forward.
Sensitization workshops funded by WHO are
also starting up. In Bo last week some 40 district
health team staff, community health officers and
laboratory technicians were put through their
paces on current prevention, diagnosis,
management and investigation techniques.
The Roll Back Malaria created by WHO focuses
on the fact that most victims of malaria die
simply because they do not have access to
health care close to their home, or their cases
are not recognized as malaria by health care
workers.
Among its key principles are prevention using
impregnated bed nets and household protection,
improved supply of anti-malarials at local level
and improved skills for diagnosis and
management.
Blue flags wave for disease control
Disease prevention experts are to call on the
services of a Sierra Leone’s dynamic cadre of
community health workers known as Blue Flag
volunteers in their drive to get infectious
diseases under control.
The organisation is the brain child of UNICEF
and the Ministry of Health who originally
recruited and trained people from communities
in the mid 1990s to detect cholera and
administer oral rehydration solutions. The
volunteers identify their house in the village with
a blue flag and agree to be available day and
night.
Now the Ministry and WHO hope to add
surveillance of other diseases to the skills of the
volunteers, many of whom have also now been
involved in both polio immunization days and
watching out for acute flaccid paralysis, the
marker sign for potential polio virus.
At a recent meeting in Pujehun to explain the
plan,
volunteers
received
the
idea
enthusiastically, though they pointed out the
biggest problem for them was simple getting
from A to B with the information.
Dr Abdul Rahman Wurie, WHO disease
prevention adviser, says the new approach will
counter this problem by setting up local radiolinked networks to cut travelling distances.

Nets and information are key tools
Malaria is the number one cause of reported
illness in Sierra Leone. District medical offices
report an average of 30-40% of visits to health
facilities are prompted by malaria.
Merlin is one of the organizations distributing
bed nets and training local people in
impregnation in displacement camps in Sierra
Leone. The nets are distributed on a cost
recovery basis and after six months there has
been a 95% retention rate in the three Kenema
camps they have supplied.
Merlin outreach teams have also been
promoting prevention messages to camp and
town populations. “We have been concentrating
on child to child activities, on reaching women’s
groups and on training health volunteers on the
community-based management of childhood
fevers,“ says Nichola Cadge, Merlin medical coordinator.
A knowledge, attitudes and practices survey
carried out by the team in February showed
there is plenty of need for education. “For
example, a large number of women don’t know
that it is mosquitoes that transmit malaria, many
thought it was a stomach disorder,” says Ms
Cadge, noting that Merlin is currently planning to
Malaria
Kick start for Roll Back Malaria
After two years of piecemeal activities disrupted
by conflict and erratic funding, health players in
Sierra Leone are determined to get the Roll
Back Malaria programme, agreed upon in 1998,
back on track this year.
According to the new plan of action, drawn up by
Ministry of Health national programme director
7
WORLD HEALTH ORGANIZATION
extend its activities to Newton Camp near
Freetown in collaboration with the Ministry of
Health and Oxfam.
Other myths common even among medical
professionals, according to Dr Abdul Kargbo, a
malariologist and WHO’s co-ordinator for the
East and Southern districts, are that drinking
beer, palm wine or orange juice, and the
presence
of
menstruation
increases
susceptibility to malaria.
three of 11 chiefdoms in Tonkolili. Kono and
Koinadugu are better covered two thirds of
Vaccine virus in Kono shows reach
Proof that polio vaccine has reached the
remotest corners of Sierra Leone came earlier
this year with the recovery of a vaccine-related
virus from a child in the diamond-mining district
of Kono.
Double the number of children were vaccinated
against polio in national immunization days in
1999 compared to 1998 simply because all
political entities committed themselves to getting
vaccinators into every part of Sierra Leone.
President Kabbah, Revolutionary United Front
chairman Foday Sankoh, Lt Col. Johnny Paul
Koroma, head of the Armed Forces Ruling
Council and Brigadier General Maxwell Khobe,
Chief of Defence Staff not only gave their
support to the campaign but even posed
together for the poster picture.
The three 1999 rounds reached 76, 85 and 84%
of the almost 822,000 children in the target age
group compared to only 45% in 1998 when only
seven out of Sierra Leone’s 13 districts could be
reached.
Results of a prevalence and knowledge, attitudes and
practices survey for the Kenema camps/district should
be available from Merlin in mid September, ph: 232
22 231 738, email merlin@serratel.sl
Surprise sensitivity results
Doctors from the United Nations Mission in
Sierra Leone’s Jordanian battalion (UNAMSIL)
are reporting high cure rates for malaria using
chloroquine, a therapy thought to be ineffective
due to increasing resistance. In recent weeks,
medics say 50 of 50 cases treated with
chloroquine as first line therapy have achieved
full cure.
This supports several chloroquine resistance
studies carried out by WHO in 1998 and 1999
which found resistance to be under the threshold
of 30%. WHO continues to support sentinel site
surveillance of resistance patterns in the
Western District,
the chiefdoms with assured access at present.
Polio co-ordinators from Guinea and Sierra Leone
are meeting this week to see whether closed
areas may be accessed from across the border.
Thirty-two cases of acute flaccid paralysis have
been investigated so far this year. Two samples
– one from the Port Loko area, the other from
Kenema – have proved to be wild polio virus
with another reported as an non-polio
enterovirus.
“The defining characteristic of the last place on
earth to have a case of wild virus polio is that it
will be a complex emergency,” says Dr William
Aldis. “We don’t want that place to be Sierra
Leone.”
Polio eradication
Partners will make or break it
Partners in the campaign to rid Sierra Leone –
and the world – of the polio virus are concerned
that, with just two months to go to planned
national immunization days, vaccinator access to
large areas of the countries is still not assured.
Last year, Sierra Leone achieved what many in
the outside world believed impossible – the
agreement and support of all the conflicting
parties and a coverage rate of 84%.
But the breakdown of the Lomé Accord has
removed contact points on the rebel side and
despite the appointment of new RUF leader
General Isa Sesay, the lack of agreement is
forcing international organizations to raise the
alert that Sierra Leone may again slip to the
bottom of the polio league.
So far, intensive negotiations with health and
local authorities have assured access to most of
the Western and Southern districts plus Kenema
town where immunisation will be carried with a
combination of house to house and static sites.
But WHO medical officer for the expanded
programme of immunization Dr Mekonnen
Admassu says the team has had no contact in
either Bombali or Kambia and can reach only
HIV/AIDS
Survey to pin down HIV impact
The US Centers for Disease Control and
Prevention are to carry out a customised
seroprevalence survey to try and pin down the
real impact of HIV/AIDS in Sierra Leone.
The survey – funded by the World Bank – will
extend beyond normal target groups to include
groups such as child combatants and displaced
people.
“Past figures suggest that Sierra Leone is at 810% seroprevalence which is about the level at
which cases start to grow exponentially,” says
WHO representative, Dr William Aldis. ”But
figures are unreliable and we really need solid
8
WORLD HEALTH ORGANIZATION
areas of lowest coverage,” said one officer
involved who did not wish to be named.
information if we are to target activities
effectively.”
Sierra Leone’s emergency situation is a “lethal
mix for HIV transmission” according to the
Ministry of Health national programme manager.
“Population displacement, rape, occupying
troops, women in desperate circumstances,
insecure blood supplies, drug abuse, unsafe sex
practices and insufficient control activities all add
up to a disaster,” says Dr Patrick Moses, who
spends most of his time on the road
evangelising about prevention.
Substantial funding – over US$1.3 million has
been allocated by the World Bank to developing
the AIDS programme in Sierra Leone and a
further US$100,000 has been promised by the
US Bureau for Population, Refugees and
Migration to establish safe blood transfusions
services in all government hospitals. This
supplements the US$150,000 start-up grant
provided by UNAIDS earlier this year.
Schools in – worms out
Over 250,000 children in the Southern district
appearing for their first day of school on 11
September will also receive their first treatment
to banish worms in a campaign that is part of a
UNICEF project to rebuild school health
services.
Over the past two years, the agency has worked
to revive the programme in Freetown and the
Western Area, and it is now expanding into the
Southern District, targeting schools in Bo,
Bonthe and Pujehun.
So far 250 teachers have attended training
courses on first aid, use of oral rehydration
solutions and de-worming as well as how to
promote health messages in areas such as
hygiene and protection from AIDS/HIV.
Mental Health
Child Health
Culture can help child soldiers
Care givers working with former child
combatants and abductees do not need to be
inundated with psychological training, according
to the International Rescue Committee’s new
field co-ordinator. But what they do need is
support to discover how they can tap their own
cultural resources to the benefit of the children
and to themselves.
Over 1800 children have passed through the
demobilisation, disarmament and rehabilitation
process this year and almost all stay some
period of time in the interim care centres set up
to be a home while the possibilities of family
reunification or other solutions are explored.
Here local people trained by various NGOs care
for the children and help them readjust to normal
life. Some have suggested that the strain on the
relatively unskilled caregivers, many of whom
have
themselves
experienced
violence
perpetrated by children, makes it impossible for
both the child combatants and the caregivers.
But IRC psychologist Dragan Markovic who
directs the psychosocial care programme for five
interim care centres in Bo and Kenema believes
with the right support, the experience can be
beneficial to both.
“We need to reinforce for local staff that it is not
us – the outsiders – who bring the solutions but
them and their own culture that has the tools to
deal with what is happening with these children,”
he says
IRC caregivers receive a basic training in
counselling, but more important than days of
concepts and techniques in workshops, says Mr
Markovic, is having a system of day to day
Immunization at rock bottom
Routine childhood immunization has almost
completely collapsed in some areas of Sierra
Leone and even the best performing districts are
managing to vaccinate less than 30% of all
eligible children - a far cry from 1991 when with
coverage of over 75% the country was an
example to the region.
Latest figures from UNICEF show that while
around a quarter of children in districts like Bo,
Kenema and Bonthe have had BCG vaccination,
and between 13% and 33% received DPT 3 and
measles, the Western District which covers
Freetown and its rural surround has among the
worst coverage – down to single figures for both
DPT 3 and measles and as low as 6% for BCG.
This coverage is as bad as the frontline conflict
districts of Kambia, Bombali and Port Loko.
Despite these figures, a national campaign
funded by the Christian Children’s Fund which
completed its second round last month, has
drawn substantial criticism. This is partly
because the campaign was sprung on partner
agencies with little warning and both
undermined vaccine supplies for normal
immunization activities and strained human
resources, since health workers were pulled out
of clinics to carry out the campaign, but also
because of its questionable effect.
“The trouble with a campaign like this is that it
can raise the coverage, but it does nothing to
keep it up. The money and effort spent on the
campaign would have been better spent on
strengthen routine immunization activities in the
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WORLD HEALTH ORGANIZATION
support which allows care-givers to talk through
the issues their work throws up.
“This kind of close support enables people to
understand and develop their knowledge of the
cultural patterns and their knowledge of the
children and themselves. If this system is in place,
I don’t see it as at all tragic to have a person
dealing with a child combatant who may have had
their own experiences with them in the conflict.”
What is more disturbing, says Mr Markovic, is
the lack of continuity in the DDR process. “It’s
possible for a child to be dealt with by five or six
agencies from demobilisation to interim care
centre. We plant to reassess all the 90 children
in the Bo and Kenema houses to try to build a
more coherent strategy for each one.”
Other critics say that the real gap is lack of
follow-up for those children who do return to the
community. “We talk to them about things like
returning school but when they get home, who’s
going to pay their school fees,” noted one
international worker at the Lungi transit centre,
while others say there’s little help for ex
combatant children who face community hostility
if tensions start to rise again in the area
Official estimates around 5,400 children have
been involved in combat by the rebels, though
some dealing with the children believe there are
many more.
There are growing concerns about the impact of
the ‘amputees camp’ in Murraytown and future
of its inhabitants.
Set up by the NGO ADRA in early 1999, the
camp was meant to be a temporary solution for
the overflow of patients undergoing surgery for
violent injury in Connaught Hospital, who
needed care post-surgery, but had nowhere to
live and no relatives to care for them.
However, efforts to reintegrate its inhabitants
back into the community are proving difficult for
a number of reasons not least the high level of
care they receive in the camp and the fact the
site has become a lucrative ‘business’ in itself
with residents making substantial amounts of
money from both official and unofficial donors.
The compound currently houses 200 amputees,
200 war wounded and 600 relatives, all of whom
receive food rations from the World Food
Programme. A number of other organizations
are providing vocational training and other
services including a dedicated health clinic run
by Médicins Sans Frontières France.
However, though most of the residents have
now been fitted with prostheses by Handicap
International, many refuse to use them
particularly in the presence of visitors. Residents
have also refused attempts to relocate some of
their number to Grafton to ease overcrowding or,
where it has become possible, to return to their
villages.
Médicins Sans Frontières France, which took
over management of the camp from ADRA, last
month handed over responsibility for it to the
National
Committee
for
Rehabilitation,
Redevelopment and Reconstruction which
received it reluctantly. But says MSF-France
medical co-ordinator Ariane Bauernfeind the
amputees really need to be part of a
reintegration process that MSF does not have
the capacity to offer. “It has to be done by the
government,” she says.
MSF also hopes to pull out of operating the onsite clinic as soon as alternative care can be
arranged. “The clinic is serving only 1000 people
and we think there are more urgent needs
elsewhere.
Colleagues for lone psychiatrist
The US Bureau of Population, Refugees and
Migration has donated US$50,000 to improve
services for the mentally ill in Sierra Leone.
Currently Sierra Leone has just one psychiatrist
who manages the country’s only mental hospital
together with an almost completely untrained
staff. Kissy Mental Hospital itself is severely run
down
and
overflowing
with
mentally
handicapped patients.
Lack of skilled staff at district hospital level
means many patients who could be managed
outside of hospital are referred to the
overburdened hospital while the trauma of the
war tends to increase the risk of sub-clinical
illness becoming manifest.
The BPRM programme, managed by WHO, will
focus on developing the skills of ministry of staff
at the eight district hospitals. Nurses will be
selected to train in community-based psychiatry
and the facilities are to be supported with basic
equipment and supplies for psychiatric care as
well as specialised drugs.
A consultant psychiatry is currently being
recruited to work alongside the Ministry of
Health, particularly to support the development
of case management protocols
Nutrition
Pockets of hunger cause concern
Levels of nutrition are generally under control in
displacement camps, say international experts,
but there are still concerns over vulnerable
groups that require emergency action.
A survey in Bo District early in the rainy season
by French NGO Action Contra La Faim found
4% of children were globally malnourished and
1% were severely malnourished.
Better solutions needed for amputees
10
WORLD HEALTH ORGANIZATION
This is not an ‘alarming’ level nor dissimilar to
the circumstances prior to the war, says
UNICEF head of health programmes and
nutritionist Dr Adrianne Zarrelli. But she warns
that even if district figures seem normal, they are
likely to hide ‘pockets’ of hunger that must be
taken seriously.
“In Bo, for example, there were at the same time
as the survey 140 children in the therapeutic
feeding centre – and the situation is likely to be
worse in rebel-held or hard to access areas like
Bombona or Bonthe.”
The ideal, says Dr Zarrelli, is for health workers
to be supported by a system of rapid links with
humanitarian food agencies such as the World
Food Programme so that they can call for
targeted food supplementation when they
identify need.
food
aid
and
supplementary
feeding
programmes, says Merlin medical co-ordinator
Nichola Cadge But, she cautions, this survey will
not indicate the level of malnutrition among new
arrivals to the camps.
For further information, please contact Nichola
Cadge, medical co-ordinator Merlin on +232 22 23 17
38 or email:
Health financing
Cost recovery in action
A new cost recovery scheme now has three
months worth of fees in its bank account.
The first thing you see of Bo Government
Hospital are two large boards listing the fixed
patients fees for public and private sector
services. Inside the hospital similar lists are
displayed in every department and, at the
cashiers’ booths, uniformed staff collect the fees
and dispense triplicated receipts – one for the
patient, one for the hospital, one for the
management board – in return.
The fee scales are visible evidence of an
experiment in cost recovery that has evolved
arduously over 18 months against a background
of
changes
of
government,
conflict,
displacements and evacuations. Since starting
in June, it has returned some 22 million leones a
month (US$11,000) to the hospital coffers.
Key players in the development have been the
20-person management committee of the
hospital – itself a new concept with its 50:50 split
between hospital staff and external members
and Médicins Sans Frontières-Belgium, the
international NGO with support from WHO and
the Ministry of Health.
Cost recovery and an emergency NGO like MSF
may seem odd bedfellows but, explains MSF-B
medical co-ordinator Dr Sandra Simmonds,
“working in the hospital we started to realise that
it was okay for those who could pay because
they went privately, and it was okay for the
destitute or displaced because we looked after
them, but there was this huge group of ‘normal’
people in the middle who had no access to
health services. Our own MSF staff couldn’t get
medical care. Since so many people were
outside our target group but still needed help,
we had to think about whether we would leave
or stay and really support the hospital to serve
its population.”
The only way to do that, says Dr Simmonds,
was to try and bring in a system which
redirected the money changing hands into the
hospital itself.
Now, fees for public and private, inpatient and
outpatient care, laboratory investigations and
drugs are all fixed. Patients from displacement
camps and the destitute are excluded because
Kenema influx fills feeding station
Roughly 25% of the 450 children being fed by
Merlin’s therapeutic feeding centre and 2500
attending its supplementary feeding programme
in Kenema are from the town itself.
Kenema town has absorbed an unknown
number of displaced people in waves over the
months since the May crisis. The most recent
influx came in July when almost 10,000 are
thought to have flooded into the town over a few
days after Operation Khukri took place to free
captured UNAMSIL troops.
Mrs Millicent Juana, the state enrolled
community health nurse who now runs the
centre with support from Merlin nutritional and
outreach co-ordinator Alison Day, has first hand
experience of displacement, having had to
escape to the bush herself several times as
conflict overwhelmed the hospital. She says they
are coping with the influx, but often have to feed
mothers as well as children.
The ‘temporary’ centres – now four years old –
are housed in three large booths of grasses,
plastic sheeting and corrugated iron in a
compound in the grounds of Kenema Hospital.
One is given over to therapeutic feeding, one to
supplementary feeding clinics while the third is
currently ‘invaded’ by over 300 recuperating
children who are overflow from the Merlinsupported paediatric unit, where admissions
have tripled from 200 to 600 a month since May.
Despite the huge numbers who pass through, the
compound with its kitchen, toilets, washing area
and small isolation ward for cases of severe
diarrhoea are spotless – the combined work of
the 32 ministry of health staff and the mothers.
Merlin is currently awaiting results of a 2000child nutritional survey carried out in July which
targeted families in the camps since June last
year. This will allow analysis of the impact of
11
WORLD HEALTH ORGANIZATION
they
are
covered
by
MSF-Belgium’s
humanitarian mandate All emergency patients
also get the first 24 hours care free.
In reality, private fees are still open to
negotiation but regardless of the price settled
on, private patients are supposed to pay the
whole amount to the hospital cashiers who
deposit 60% for the doctor involved and 40%
into the hospital finances. Doctors also receive
30% of the income generated from public patient
fees as an end of the month bonus while other
staff receive a percent of the combined public
and private income as a salary top-up.
While observers hail the hospital as a model for
the country, there are not surprisingly still some
teething problems. For example, says hospital
superintendent and consultant gynaecologist Dr
Samuel Sidique, current income is around 50%
of what it should be.
“The workers and nurses are on the side of cost
recovery because they benefit in a way they
didn’t before but doctors are losing money keen
and 10 to 20% are not co-operating with the
scheme. Some are not contributing at all, some
are not contributing the whole fee they negotiate
with the patient. We have to find ways to
penalise them for this. What we really need is for
the ministry of health to step in and make it clear
to them that they must co-operate.”
In addition acute staff shortages means there is
one doctor on staff to screen public patients and
the resulting long queues can make ’choosing’
public care an unrealistic option – a situation borne
out by the fact that in June paying ‘customers’
outnumbered public patients two to one.
There are also other problems. Outside
agencies referring to the hospital say money still
changes hands for public care despite
assurances from hospital management that
patients should not pay above the printed rates.
Others say the charges set by the community
may be reasonable for townsfolk but they are
entirely beyond the reach of country folk.
“Bo’s charges are too expensive for people in
the villages,” says Mike Downham, head of the
UK Department for International Development’s
primary care rehabilitation project in Bo district.
“Village people delay first hoping they won’t
have to go, then again while they to try and get
the money together. As a result we are losing
about 30% of the people we transfer to hospital.”
Doctors in Bo also question why their incomes
should be in the firing line before anyone else.
But while this is a legitimate complaint, says Dr
William Aldis of WHO, the answer is to get cost
recovery moving in more places. The bottom line,
he adds, is that health facilities need to start
changing the culture and create an income flow
while they have international support to underpin
them.
Full fee lists are available from the Bo Hospital
management team or Médicins Sans FrontièresBelgium in Freetown, msfbfreetown@sierratel.sl
Directing money back to health
District hospitals are receiving increasing
attention in terms of both financial viability and
concrete structures.
Sierra Leone has had health sector reform on
paper for many years, says Dr William Aldis of
the World Health Organisation, but the crisis has
given it a boost. “People are realising that the
only way to sustain the level of care and
incentives currently being provided with the help
of international agencies is to take the money
people typically pay to individuals to obtain
health care in Sierra Leone and redirect it into
the healthcare facilities.”
Involvement of the community is one of the keys
to success, says Dr Aldis. “The need for
payments has to be brought into the open and
debated with the community. If you pretend that
care is going to be free for everyone, nothing
can change. There will still be people who
cannot pay and the system can be designed to
provide full care for them. But a solution will
never be found under the old system of irregular
practices and hidden fees.”
Another essential feature of introducing cost
recovery in Sierra Leone is the support of NGOs
willing to give the day to day support and
supervision essential to making the new system
work, while WHO and the Ministry of Health
work to extend standardised practices gradually
across the country.
Kenema, Lungi Hospital and Sierra Leone’s
main tertiary hospital, the Connaught in
Freetown are likely to be the next focus of
attention for cost recovery in secondary care. In
primary care some NGOs are also trying to
prepare units and their community for the
introduction of low level fees later this year.
One problem, however, is the dearth of clear
guidance and standards from central level, while
another is the entrenched level of ‘business’
activities, particularly in hospitals such as
Connaught where very little free care is
available, say NGOs
In addition to moves to strengthen viability,
district hospitals are also due to get a structural
boost from the US Bureau for Population,
Refugees and Migration which has allocated
US$100,000 to WHO to help strengthen and
rehabilitate buildings and equipment.
Human resources
To pay or not to pay?
12
WORLD HEALTH ORGANIZATION
The dilemma of ‘incentives’ and whether they do
more damage than good is becoming acute in
Sierra Leone.
Government salaries are erratic and when they
arrive, very low. Junior doctors at Connaught
Hospital, for example, earn less than US$50 a
month and senior specialists around US$100.
Nurses and other health workers earn even less.
As a result many NGOs supporting health
facilities are paying incentives to their staff
ranging from US$25 to $100 a month.
Not only, says one NGO co-ordinator, does this
improve motivation but it also brings ministry of
health staff earnings closer to the amounts
earned by the staff directly employed by the
NGO.
However, well meaning though incentives might
be, there are problems looming.
Top-ups are breeding a reluctance among
MoHS staff not connected to NGOs to do
anything to extend their activities unless it is
accompanied by an incentive, says District
Medical Officer for the Western District Dr PAT
Roberts who notes that while there are plenty of
displaced people on the MoHS role to staff reestablished clinics, many refuse to work unless
the clinic is supported by an NGO.
In addition, some donors believe the levels of
incentives being paid are too high and are
demanding a drop. This means some NGOsupported community health workers, for
example, are likely to see their incentives fall
from around 150,000 leones (US$75) to 90,000
leones ($45) by the end of the year which is
likely to cause dissatisfaction.
While moves towards cost recovery may be one
way for both primary care clinics and hospitals to
sustain the extra payments to staff when NGOs
leave, low income levels for the majority of the
population means this may prove difficult.
regulate what is called in Sierra Leone doctors’
‘intramural private practice’ (see page 11) – a
problem that will remain an issue until the
ministry manages to standardise the scheme
throughout the country.
Contact WHO in Sierra Leone
WHO Office Freetown
21A/B Riverside Drive, off Kingharman Road
Ph:
+232 22 24 12 59 or 22 31 88
Fx:
+232 22 22 73 13
Email: who@sierratel.sl
WHO representative
Dr William Aldis
Mobile: +232 23 50 05 63
Email: aldisw@yahoo.com
Disease Prevention and Control Adviser
Dr Abdul Rahman Wurie:
Mobile: 232 23 50 10 73
Email: wuriefs@hotmail.com
Emergency and Humanitarian Action Adviser
Dr Bona Hora
Health Economist
Mr Ade Renner
Human Resources
Mr Sebora Kamara
Health Information and media liaison
Mr Rod MacJohnson
Northern Provinces Co-ordinator
Dr Jalloh
Bo Sub-office
Southern & Eastern Provinces Co-ordinator
Dr Abdul Kargbo
Skill drain hurts districts
District hospitals are suffering from acute
shortages of senior specialist medical staff
“It’s been a problem since 1994,” says Dr
Samuel Sidique, medical superintendent of Bo
Hospital. “But is getting worse. Some doctors
have left the country while others who have run
to Freetown for safety and new medical officers
being trained there are reluctant to come to the
districts because of the security situation.”
Bo Hospital itself Iacks specialists in
paediatrics, internal medicine and ENT and is in
dire need of extra generalist doctors to man its
admissions department which.
Erratic payment of hospital staff is another
problem and Bo’s situation may also be
exacerbated by its leading role in an innovative
cost recovery programme part of which seeks to
This update was researched and written by Hilary
Bower, information officer with the Department of
13
WORLD HEALTH ORGANIZATION
Emergency and Humanitarian Action, WHO Geneva.
The opinions expressed do not necessarily reflect
official WHO policy. For further information, phone
+41 22 791 3451, mobile +41 79 249 3528, email
bowerh@who.ch or hbower26hotmail.com.
14