Sierra Leone is one of the poorest countries in the world, with one of the highest maternal and child mortality rates. The country has been shattered from 1991 to 2002 by a dreadful civil war and soon after, just when the country was trying to recover from the trauma of the war, by a widespread ebola epidemic which has costed almost 4000 lives. Many of these lives were those of highly committed - and largely uncelebrated - Sierra Leonean health care workers which fought until the end to try to contain the epidemic and sacrificed themselves providing care to the sick ones. Today the country has a health workforce (doctors, nurses, midwives) of 1.4 per 1000 population, compared to the most recent sustainable development goals threshold of 4.5.
But why do I say this? Not actually to introduce my post with the “classic” list of sorrowful datas that are often used to count introduce the discourse about African countries, but rather to highlight the tremendous challenges and the remarkable successes that these countries registered in recent years. Indeed, if we manage to keep calm in front of absolute numbers, which still mark an unbearable distance from those of western countries, and we analyze the situation from an historical perspective, we can see that from 2000 to 2017 the maternal mortality rate in Sierra Leone has more than halved, passing from 2.480 to 1.120 cases/year; and this improvement is made even more remarkable in the light of the historical facts depicted above.
I have spent my last 9 months working as a doctor in Sierra Leone with Doctors without Borders (MSF). Due to my position of “Outreach doctor”, I had the opportunity to work inside the facilities of the Sierra Leonean Health System and work side by side with local primary care workers, namely Community Health Officers and Nurses. Even though sometimes faced with the shortcomings of the local Health System (from the regular supply of essential drugs, to the lack of referral systems or qualified specialists, just to mention few examples) I was amazed and surprised by the resilience of their Primary Health Care strategy and, more specifically, by the comprehensiveness of their inter-professional approach.
At least two fundamental factors drove many African countries toward an inter-professional approach to primary care:
lack of doctors, all over the continent (WHO forecasts that the shortage will further worsen between 2013 and 2030)
An extremely wide and sparse territory, with more than 58% of the population still living in rural settings in Sierra Leone.
To answer these challenges (and more), African countries like Sierra Leone developed innovative health professionals that are today the backbone of the Primary care System. One of them, and perhaps the most important one, are the Community health officers (CHO). The CHO is a qualified health professional that has completed a three-years academic course and is proficient in the clinical diagnosis and care of common conditions, from infectious diseases to pediatric care, maternal care and so on. In the three Community Health Centers I was working with, MSF provided an extra health professional, the so-called “health promoter” (HP) which is a person with communicational skills in charge of delivering health education on common topics, like nutrition, hygiene measures, sexual and reproductive health etc. The main objective of the health promoter is to fill the communication gap that is frequently present between the clinician and the user, especially in a resource-deprived contexts where professionals frequently lack time for health education. Last but not least, the Community Health Workers (CHW). The CHW is a person without a medical background, frequently a community leader, which lives inside the community or in the surrounding areas and act as a “sentinel” for the health system and report to the attention of the nearest Center all those cases susceptible to be seen be a qualified health professionals. In countries like Sierra Leone, where access to health care facilities is limited, CHWs are also demanded to provide first line treatment for very common and deadly conditions like malaria, pneumonia and diarrhea. The impact of this last professional has been more deeply studied than the former two, and evidence suggests that its importance in reducing childhood mortality in developing countries has been remarkable.
This background information is relevant to understand how African countries developed original approaches which putted inter-professional collaboration and task shifting at the core of a resilient Primary Health Care strategy, able to face the many shortages which chronically affects African countries.
To foster dialogue, I think that these question are relevant for the European context today:
what lessons can we learn from the African experience?
Do we have all the competencies (and the respective professionals) needed to deliver equitable, accessible and quality PHC?