By Alpha Bedoh Kamra
Sierra Leone – The Auditor General of Sierra Leone 2014 report has blamed the ministry of health for major deficiencies in tackling public health issues in the country, stating “The review revealed that the sector is in deep trouble. There are major deficiencies in the Ministry, hospitals and other responsible bodies that need urgent attention and increased support from the government and other stakeholders. Truly appalling conditions abound”.
The review was carried out because during the recent EVD crisis the weaknesses in the health sector brought the country to its knees, devastated families and around 4,000 people died. For many years, predating the crisis, we have highlighted concerns about poor management practices, internal control deficits and significant under-resourcing in MOHS, individual healthcare institutions and across the board in the sector. We saw little evidence of improvement and a general failure to act on our recommendations.
Much has been written and reported, largely by outsiders, about components of our health system. We thought it timely to look for ourselves from a Sierra Leonean perspective, obtain an overview and understanding of the issues and convey this to parliamentarians, civil society and all stakeholders to try to kick-start reform.
We found shameful panoply of dysfunction including the following:
Gross underfunding impeding delivery of quality health care services to the population;
Overlapping or conflicting legislation governing the health sector, creating bottlenecks reducing effective and efficient service delivery;
Hardly a single international health standard for medical staff to population ratio is met;
Shortages of nurses and specialist doctors everywhere with none available in some institutions;
Eight medical specialists working at MOHS headquarters when field needs go unmet;
A lack of basic equipment in hospitals, operating theatres, laboratories and wards and even some
cases of obsolete and defective equipment in use;
Deplorable conditions prevailing in stores, wards and kitchen;
General waste management and cleanliness so poor as to pose a threat to the health of already
sick patients, health workers and visitors;
Medical waste disposal so poor as to risk infection and disease to staff and public alike;
Such meagre resources as are available not judiciously utilised to achieve value-for-money aggravated by breaches of procurement procedures, poor control over revenue and disbursements, unmanaged assets and poor to near-non-existent record keeping in critical areas;
A drug distribution system from the Central Medical Stores that pushed shipments to hospital and other locations with no consultation on actual needs;
“The review revealed that the sector is in deep trouble. There are major deficiencies in the Ministry, hospitals and other responsible bodies that need urgent attention and increased support from the government and other stakeholders. Truly appalling conditions abound. We found a shameful panoply of dysfunction …”
Government investment in training programs for practising health workers is particularly insufficient; in fact, most in-service training is delivered by development partners with little or no coordination with or by the MOHS; and
Some hospital boards have not been established but, alarmingly, the government is allocating funds to the board secretariats even though there is no board.
In the prevailing circumstances the drug distribution regime in place at present has contributed to estimates of out of date drugs running as high as 20% with storage facilities, not fit for purpose, dating in some instances, we were told, from the 1940s. The NPPU, an independent agency charged with drug procurement and distribution under its enabling legislation, is funded by MOFED but through MOHS. The relationship between the NPPU and MOHS management seems to have descended into a classic turf war characterised as beyond tense by one interviewee. The managing director suggested that NPPU does not yet have the full staff complement to effectively manage all the drug stores across the country. It is collaborating with the DHMT/DMOs to supervise the stores and to distribute the drugs to the PHU level. Internal studies suggest the NPPU needs 175 staff to carry out its full functions. At the moment, the unit only has 10 full-time staff.
On the procurement front the acquisition of 123 ambulances stands out as being a doubly reprehensible event. A 60% advance – rather than the legally permissible 30% – was paid. Only 90 vehicles were delivered and as warranties and performance bonds were allowed to expire by MOHS rights of action against the supplier for non-performance or contract abandonment are limited. In addition, the 90 vehicles delivered, notwithstanding the critical need for them across the country, have never been deployed but were stored in the open at the Youyi building for about one month initially and were then transferred to the Military Headquarters at Wilkinson Road.
“In the prevailing circumstances the drug distribution regime in place at present has contributed to estimates of out of date drugs running as high as 20% with storage facilities, not fit for purpose, dating in some instances, we were told, from the 1940s.”
“… 90 vehicles delivered, notwithstanding the critical need for them across the country, have never been deployed …” Ambulances parked at Military HQ
Story adapted by the Auditor General Report 2014