by Dr. Mary Hodges, Country Director, Helen Keller International – Sierra Leone
The following article was published on The Guardian Global Development Professionals Network on June 24, 2014. It was originally commissioned as part of the Development Progress series.
Despite poverty and a recent civil war, Sierra Leone has rapidly expanded treatment for NTDs. What can other countries learn?
The Lancet recently published a report on gains made towards reaching the 2020 neglected tropical disease (NTD) elimination goals set by the 2012 London declaration. Despite being one of the world’s poorest countries, Sierra Leone, in particular, has made incredible strides.
Before the current NTD control programme, approximately half of the districts saw over 50% of their children infected with schistosomiasis (snail fever) before they reached 14. By 2010 mass drug administration had reached, and has since maintained, 100% geographic coverage of those at risk of NTDs, outperforming neighbouring countries.
This rapid progress has been unexpected in the post-conflict setting. By the end of the rebel war in 2002, most health facilities were damaged, ill-equipped and their staff and communities traumatised. Many health professionals had been evacuated during the war and had little opportunity or incentives to return.
While sustained funding from USAid is one explanation behind the country’s success, other countries like Nigeria, with strong funding and better resourced health sectors and public communications systems, have not made the same level of progress. So why has progress in NTD control in Sierra Leone been so swift? Here are some key lessons behind Sierra Leone’s success.
1. Size matters
While infrastructure remains a challenge, especially during the rainy season, Sierra Leone is small and most communities can be reached in a sturdy four-wheel drive within a day’s travel from Freetown. This makes implementing, and evaluating a nationwide NTD programme much more manageable.
2. Invest in country-specific research
There has been a long-standing academic interest in tropical diseases in Sierra Leone. This can be traced back nearly a century to what is now known as the Liverpool School of Tropical Medicine, where research commenced in diseases contracted by sailors returning from the country.
In addition, Glasgow University has contributed to building human resource and research capacity since the 1980s with two local universities and a local NGO. These have all provided broad foundations of understanding and operational experience which have been used in the development of post-war control programmes.
3. Decentralise healthcare to reach marginal populations
The Local Government Act in 2004 called for the active participation of communities in public policy discourse and decision making to improve the delivery of basic services. The adoption of community-based approaches, and the decentralisation of health care delivery services, has had a significant impact. This is particularly evident in vulnerable and resource-constrained settings in rural communities where the NTD burden is most prevalent.
4. Provide adequate training to health leaders
Traditionally in Sierra Leone healthcare was delivered by people without formal education. After the war, medical officers that lead the district teams have been sponsored by WHO for a public health masters degree at Leeds University, giving rise to a new generation of health leaders better positioned to provide service with accountability.
5. Don’t underestimate the power of community
The high NTD burden has been a key motivating factor. Local community drug distributors volunteer to go from home to home to conduct village censuses, provide information and administer NTD drugs. The motivation of the 29,000 volunteers and that of the 1,500 health workers that train and supervise them come from the obvious improvement they see in the health and wellbeing of their communities.
6. Harness the power of technology
In 2010 mobile technology and independent monitors were introduced to facilitate the tracking of mass drug administrations in real time, enabling the NTD programme team to see progress and challenges immediately, as well as to validate results. This has been crucial in the post-conflict setting where rapid internal migrations and urbanisation occurs.
7. Tailor communication to local needs
Tailoring messages for opinion leaders, health workers, volunteers and the public in the context of local culture and traditional beliefs has been key to controlling the diseases. Frequently asked questions must be extensively pre-tested, regularly revised, and aired on radio programmes that encourage listener participation. Public phone-in and SMS messages help keep the dialogue relevant and the concerns of the public swiftly addressed. Facebook and other internet resources have dramatically helped ensure messages get to even the most hard-to-reach communities in remote locations.
There is still much to be done if we are to reach the 2020 global elimination goals, but learning from countries like Sierra Leone, who have succeeded against all odds, is a step towards saving and improving the lives of millions.
Dr. Mary Hodges has served as the Sierra Leone Country Director for Helen Keller International since 2008. She is a pediatrician and co-founded the St. Andrew’s Clinics for Children which established clinics in Sierra Leone and four other sub-Saharan countries. Mary has also worked as a Training and Research Advisor for the Health Sector Support Programme in Sierra Leone and as a Medical Advisor to various embassies, as well as a Lecturer in the University of Sierra Leone and as a Honorary Senior Research Fellow for the University of Glasgow. She has lived on and off in Sierra Leone since 1984.
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