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  • Nothing could have prepared me for Sierra Leone.

As Technical Advisor in the programming team based in Kenya, my work is to help design and implement programmes. It is to shape programmes in a way that gives them the best chance at succeeding in protecting children from poor health and other harm and giving them the best shot at not merely surviving but thriving and meeting their full potential. The bulk of our work is in Kenya and so, naturally, we work out of a lovely little office in Nairobi. Over the past year, the team has been working to develop a programme in Sierra Leone and as soon as I joined in January, we were planning a trip to Sierra Leone.
Nothing could have prepared me for Sierra Leone. My colleagues continually stressed that I should expect that the health system had taken a huge beating after the ebola outbreak of 2014-2016 and that it was some way to recovery. No one had warned me that I needed a separate bag for travel money, though. The local currency in SL is called ‘leones’ and the largest denomination note is 10,000 Leones which is worth a little over a dollar or just under a pound. A week’s travel money is therefore easily half a kilo of bundles of notes.  
Sierra Leone has been in the news in recent years over the civil war in which 50,000 people were killed between 1991 and 2001 and the Ebola outbreak of 2014 to 2016. I was later to learn that 7% of Sierra Leone’s healthcare workers died in the outbreak and left the health system with even deeper gaps in human resources. In 2015, the UN estimated that Sierra Leone had the highest maternal mortality in the world- 1.5% of all mothers died during pregnancy, in childbirth, or shortly after. 
Sierra Leone has a rich and chequered history: its landing beaches were once a slave trading outpost before becoming a refuge for those fleeing slavery and a focal point for naval forays against slave traders in the Atlantic. It has had more than its fair share of political upheavals and pestilences, promising economic booms and seasons of biting want. Its people were once dubbed the most resilient people in the world. And it is easy to see why. In a country where the scars of the civil war are not buried too deep under the surface and the poverty of the majority of the population is immediately apparent, people smile easily and talk openly. It is also probably one of the places where I have felt safest far away from home. People may ask for tips and bribes in roundabout ways but never with menace and an early morning or late evening beach run alongside the tossing Atlantic is always a sensible move when in Freetown. 
The most challenging circumstances I have seen
I have had the privilege of seeing health systems up close in different parts of the world. I left convinced that these were the most challenging circumstances in which to try to assure people’s health and wellbeing that I had ever seen. There are some things the country has got exactly right: the ambulance system under the National Emergency Services launched last year is working as designed; most women receive antenatal care and deliver in health facilities; cases of maternal deaths, child deaths, and stillbirths are investigated through the Maternal and Perinatal Death Surveillance and Response (MPDSR) programme. 



Significant challenges remain: the staffing follows some kind of rule of thirds- a third of the positions are substantively filled, a third of the positions are staffed by volunteers, and another third are not filled at all. Volunteers are drawn to work without pay for fear of losing their skills as practitioners to give them a good shot at landing an opportunity to work. They provide an essential service without a means to provide for themselves or their families and this creates the risk of some people seeking unofficial payment for services that should be free. Stocks and supplies required for provision of basic services are often inadequate. Laboratory and diagnostic services tend to be rudimentary even at regional hospital level. 


While it will take some time to change the narrative in Sierra Leone, it is by no means impossible. Parts of the health system that are working well already attest to the country’s potential to turn its health story around. There is an increasing investment by partners and interest in working with the people of Sierra Leone to improve the situation. is one of those partners and I, for one, look forward to visiting again and again, building friendships and collaboration, and learning from seasoned practitioners who continue on the trenches of the good fight to assure the survival of mothers and children and the health of a populace. 
PS: I did find a little spot of home away from home! Nathaniel, the hotel manager at the Barmoi hotel, is my compatriot and after a week out eating rice day after day, his chapati and ugali are a priceless culinary break- and taste awesome!


The photographs in James’ blog (apart from the last one) were taken at Yoni Community Health post, where has been collaborating with Makeni University on research into opportunities to improve quality of care.

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We would like to say a huge thank you to our friends at Festival Republic, who are funding our exploratory work in Sierra Leone.

To extend our work in Sierra Leone, need to grow our regular, unrestricted core funding. If you believe in James’ work – please support it. Join Core, or email us at to let us know how you can help. 



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