Photo Above: Women and Children Attending Antenatal and Under-Five Clinic in a Health Centre,
Bumpe Chiefdom, Sierra Leone (circa, 1980)
Bumpe Chiefdom, Sierra Leone (circa, 1980)
Resources
Education
Sierra Leone has one of the lowest adult literacy rates in the world. According to the UNDP, "the country has a Gender Inequality Index-GII value of 0.644, ranking it 153 out of 162 countries in the 2018 Index." Eleven years of civil war between 1991 and 2002 stalled progress. The Ebola crisis and COVID-19 set back efforts to strengthen the education sector. Nevertheless, the current government is strongly committed to educational improvements and has set ambitious targets for its youth as outlined in its plans for gender equality and the education sector. The Medium Term National Development Plan for Sierra Leone (2019-2023) is titled "Education for Development". In March, 2020, the government lifted the discriminatory ban that did not allow girls to attend school if they were pregnant. Secondary school retention rates remain lower for girls than boys.
In March, 2021, The "National Policy on Radical Inclusion in Schools" was implemented. This policy provides "a roadmap for the day-to-day operations of schools and the Ministry of Basic and Senior Secondary Education to ensure inclusion and positive experience for all students regardless of their status in society. Radical Inclusion, as defined by the Minister of Basic and Senior Secondary Education, Hon. Dr. David Moinina Sengeh, is “the intentional inclusion of persons directly or indirectly excluded (from education) due to actions or inactions by individuals, society or institutions. Sometimes silence and infrastructure added to other intentional actions exclude. Radical inclusion means that these silent exclusionary policies, moral stances, formally stated actions, institutional regulations, national laws and systemic frameworks should be removed intentionally and with urgency to achieve inclusion.” . . .The policy particularly emphasizes the inclusion of historically marginalized groups: pregnant girls and parent learners, children with disabilities, children from rural and underserved areas, and children from low-income families."
https://www.undp.org/sierra-leone/speeches/developing-undp-sierra-leone-gender-equality-strategy-2021-2023-levelling-playing-field-gender-actions?utm_source=EN&utm_medium=GSR&utm_content=US_UNDP_PaidSearch_Brand_English&utm_campaign=CENTRAL&c_src=CENTRAL&c_src2=GSR&gclid=Cj0KCQjwjbyYBhCdARIsAArC6LKcigatuhR1X3Sf962yJq2ri_NNkXRKNKaT7QCsYXL_OgvCU2yPrm4aAvisEALw_wcB
European Commission. Gender Action Plan III - 2021-25. Country Level Implementation Plan - CLIP Sierra Leone.
https://mbsse.gov.sl/wp-content/uploads/2020/02/Educational-Sector-Plan-2018-2020.pdf
https://mbsse.gov.sl/wp-content/uploads/2021/04/Radical-Inclusion-Policy.pdf
https://education-profiles.org/sub-saharan-africa/sierra-leone/~inclusion
https://www.cgdev.org/blog/sierra-leone-has-made-big-bet-free-education-poor-children-so-long-they-can-pass-exams
Sierra Leone has one of the lowest adult literacy rates in the world. According to the UNDP, "the country has a Gender Inequality Index-GII value of 0.644, ranking it 153 out of 162 countries in the 2018 Index." Eleven years of civil war between 1991 and 2002 stalled progress. The Ebola crisis and COVID-19 set back efforts to strengthen the education sector. Nevertheless, the current government is strongly committed to educational improvements and has set ambitious targets for its youth as outlined in its plans for gender equality and the education sector. The Medium Term National Development Plan for Sierra Leone (2019-2023) is titled "Education for Development". In March, 2020, the government lifted the discriminatory ban that did not allow girls to attend school if they were pregnant. Secondary school retention rates remain lower for girls than boys.
In March, 2021, The "National Policy on Radical Inclusion in Schools" was implemented. This policy provides "a roadmap for the day-to-day operations of schools and the Ministry of Basic and Senior Secondary Education to ensure inclusion and positive experience for all students regardless of their status in society. Radical Inclusion, as defined by the Minister of Basic and Senior Secondary Education, Hon. Dr. David Moinina Sengeh, is “the intentional inclusion of persons directly or indirectly excluded (from education) due to actions or inactions by individuals, society or institutions. Sometimes silence and infrastructure added to other intentional actions exclude. Radical inclusion means that these silent exclusionary policies, moral stances, formally stated actions, institutional regulations, national laws and systemic frameworks should be removed intentionally and with urgency to achieve inclusion.” . . .The policy particularly emphasizes the inclusion of historically marginalized groups: pregnant girls and parent learners, children with disabilities, children from rural and underserved areas, and children from low-income families."
https://www.undp.org/sierra-leone/speeches/developing-undp-sierra-leone-gender-equality-strategy-2021-2023-levelling-playing-field-gender-actions?utm_source=EN&utm_medium=GSR&utm_content=US_UNDP_PaidSearch_Brand_English&utm_campaign=CENTRAL&c_src=CENTRAL&c_src2=GSR&gclid=Cj0KCQjwjbyYBhCdARIsAArC6LKcigatuhR1X3Sf962yJq2ri_NNkXRKNKaT7QCsYXL_OgvCU2yPrm4aAvisEALw_wcB
European Commission. Gender Action Plan III - 2021-25. Country Level Implementation Plan - CLIP Sierra Leone.
https://mbsse.gov.sl/wp-content/uploads/2020/02/Educational-Sector-Plan-2018-2020.pdf
https://mbsse.gov.sl/wp-content/uploads/2021/04/Radical-Inclusion-Policy.pdf
https://education-profiles.org/sub-saharan-africa/sierra-leone/~inclusion
https://www.cgdev.org/blog/sierra-leone-has-made-big-bet-free-education-poor-children-so-long-they-can-pass-exams
Tuberculosis (TB)
TB, or dry cough as it was called among the Mende people with whom I worked, remains a significant health threat in Sierra Leone. According to WHO's Global Tuberculosis Report (2021), Sierra Leone is one of 30 countries with the highest rates of TB in the world. When I lived in the country, the estimated prevalence rate in our rural area was 3%. That was before HIV and AIDS hit this West African country. The current incidence rate is estimated to be over 500 per 100,000. This compares to Canada's rate of less than 10 per 100,00. There are important efforts underway in Sierra Leone to tackle the disease including addressing multi-drug resistance, setting up a dedicated treatment centre for multi-drug resistance, and testing patients newly-diagnosed with HIV for TB. But TB is a disease of poverty that remains steeped in stigma. These are more intransigent causal factors must also be addressed to meet the goals set out in WHO's End TB Strategy.
https://www.who.int/publications/digital/global-tuberculosis-report-2021
https://www.who.int/publications/digital/global-tuberculosis-report-2021/tb-disease-burden/incidence
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00045-6/fulltext
Kamara RF, Sanders MJ, Sahr F, et al. Social and health factors associated with adverse treatment outcomes among people with multidrug-resistant tuberculosis in Sierra Leone: a national, retrospective cohort study.
Lancet Glob Health. 2022; 10: e543-e554
The End TB Strategy. https://tbfacts.org/end-tb/#:~:text=To%20reduce%20TB%20deaths%20by,catastrophic%20expenses%20due%20to%20TB
TB, or dry cough as it was called among the Mende people with whom I worked, remains a significant health threat in Sierra Leone. According to WHO's Global Tuberculosis Report (2021), Sierra Leone is one of 30 countries with the highest rates of TB in the world. When I lived in the country, the estimated prevalence rate in our rural area was 3%. That was before HIV and AIDS hit this West African country. The current incidence rate is estimated to be over 500 per 100,000. This compares to Canada's rate of less than 10 per 100,00. There are important efforts underway in Sierra Leone to tackle the disease including addressing multi-drug resistance, setting up a dedicated treatment centre for multi-drug resistance, and testing patients newly-diagnosed with HIV for TB. But TB is a disease of poverty that remains steeped in stigma. These are more intransigent causal factors must also be addressed to meet the goals set out in WHO's End TB Strategy.
https://www.who.int/publications/digital/global-tuberculosis-report-2021
https://www.who.int/publications/digital/global-tuberculosis-report-2021/tb-disease-burden/incidence
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00045-6/fulltext
Kamara RF, Sanders MJ, Sahr F, et al. Social and health factors associated with adverse treatment outcomes among people with multidrug-resistant tuberculosis in Sierra Leone: a national, retrospective cohort study.
Lancet Glob Health. 2022; 10: e543-e554
The End TB Strategy. https://tbfacts.org/end-tb/#:~:text=To%20reduce%20TB%20deaths%20by,catastrophic%20expenses%20due%20to%20TB
Climate Change
The impact of climate change is being seen in Sierra Leone as well as other West African countries. In August, 2017, a mudslide in Freetown killed more than 1,100 people. Increased rates of urbanization, torrential rain, and deforestation were contributing factors (https://blogs.worldbank.org/sustainablecities/preventable-disaster-landslides-and-flooding-disaster-freetown-sierra-leone).
Climate change impact reports and adaptation efforts in Sierra Leone can be found here:
https://www.irishaid.ie/media/irishaid/allwebsitemedia/20newsandpublications/publicationpdfsenglish/Country-Climate-Action-Reports-Sierra-Leone-FINAL.pdf)
World Bank Report: https://climateknowledgeportal.worldbank.org/country/sierra-leone
https://www.unido.org/stories/fostering-climate-adaptation-through-entrepreneurship-sierra-leone
Monkeypox
I recall hearing rumours about an outbreak of human monkeypox when I lived and worked in Sierra Leone in the early 1980s. However, there were no official reports of the disease in Sierra Leone at that time. We were in the midst of rolling out immunization campaigns. Having witnessed the eradication of smallpox through vaccination programs, village elders were encouraging mothers to bring their children for essential vaccines. Our public health team was concerned that reports of monkeypox might derail the uptake of immunizations, but they didn’t. Measles, neonatal tetanus, tuberculosis, and polio took the lives of many children. Families continued to seek protective immunizations for these diseases. No official cases of human monkeypox were reported in Sierra Leone between 1970 and 2014. However, serological antibody studies undertaken in Sierra Leone in the late 1970s, indicated that there had been unreported cases of monkeypox. Heymann et al’s article from the British Medical Bulletin (1998), traces the early history of human monkeypox in Africa and makes for an interesting read.
Rural Water Supplies
Access to potable drinking water remains a challenge in many lower-income countries. Sierra Leone has recently reported improvements in access to safe drinking water for more than 700,000 people in rural areas: https://www.environmental-expert.com/news/sierra-leone-improves-access-to-safe-drinking-water-for-more-than-700000-people-in-rural-areas-1075564. But this is only the start. Sierra Leone's government must commit ongoing funding to maintain the vital infrastructure for safe drinking water. Hope et al. (2020) provide a thoughtful economic analysis describing the complex dimensions of sustainable safe water supplies in rural areas of Africa. They outline economic policy parameters we must rethink to achieve the Sustainable Development Goal for universal and safe drinking water. The article by Hope et al. can be found here: https://academic.oup.com/oxrep/article/36/1/171/5696680.
Traditional Birth Attendants (TBAs)
Descriptions of TBAs' roles and practices, the effectiveness of TBA training programs, and government policies regarding TBAs' midwifery practices can be found in many documents, some dating back to the 1960s. These recent resources are also relevant.
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1691-7
https://pubmed.ncbi.nlm.nih.gov/29375881
https://pubmed.ncbi.nlm.nih.gov/34582455
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6591059/
https://amref.org/position-statements/amref-health-africas-position-on-the-role-and-services-of-traditional-birth-attendants/
See a discussion about the debate on banning TBAs from doing deliveries in Sierra Leone that was published in The Guardian: https://www.theguardian.com/global-development/poverty-matters/2012/jan/17/traditional-birth-attendants-sierra-leone
An update on how the roles of TBAs are changing in Sierra Leone is available here:
https://www.globalcitizen.org/en/content/innovating-to-help-mothers-and-babies-in-sierra-le/
The following chapter by Margaret MacDonald (York University, Toronto) provides an excellent review of policy shifts that have shaped and shifted the role of TBAs in many countries over the last few decades: https://link.springer.com/chapter/10.1007/978-3-030-84514-8_6
Health Systems Fragility and Strengthening
There are lessons to be learned about health systems fragility and strengthening from resource poor countries. The qualitative studies listed below shed light on system challenges in Sierra Leone in both urban settings (e.g. Connaught Hospital) and rural Chiefdoms during the Ebola outbreak:
https://www.sciencedirect.com/science/article/pii/S027795362100592X?dgcid=raven_sd_via_email
https://www.sciencedirect.com/science/article/pii/S0277953621005414#bbib42
https://www.sciencedirect.com/science/article/pii/S0277953621005414?dgcid=raven_sd_via_email
Health Human Resources
Although there are nursing shortages across the globe, the health human resource crisis is particularly acute in the African Region of WHO. As the WHO 2020 World Nursing Report (https://www.who.int/publications/i/item/9789240003279) describes, while nurses make up 66% and 56% of health professionals in the WHO African and Americas regions, respectively; the density of nurses per 10,000 population is enormously different in these two regions: 8.7 per 10,000 in the African region versus 83.4 per 10,000 in the Americas. Investing in education, jobs, and leadership for nurses is essential to meet targets set out in the Sustainable Development Goals for health, education, gender, and decent work and economic growth.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458571/
The impact of climate change is being seen in Sierra Leone as well as other West African countries. In August, 2017, a mudslide in Freetown killed more than 1,100 people. Increased rates of urbanization, torrential rain, and deforestation were contributing factors (https://blogs.worldbank.org/sustainablecities/preventable-disaster-landslides-and-flooding-disaster-freetown-sierra-leone).
Climate change impact reports and adaptation efforts in Sierra Leone can be found here:
https://www.irishaid.ie/media/irishaid/allwebsitemedia/20newsandpublications/publicationpdfsenglish/Country-Climate-Action-Reports-Sierra-Leone-FINAL.pdf)
World Bank Report: https://climateknowledgeportal.worldbank.org/country/sierra-leone
https://www.unido.org/stories/fostering-climate-adaptation-through-entrepreneurship-sierra-leone
Monkeypox
I recall hearing rumours about an outbreak of human monkeypox when I lived and worked in Sierra Leone in the early 1980s. However, there were no official reports of the disease in Sierra Leone at that time. We were in the midst of rolling out immunization campaigns. Having witnessed the eradication of smallpox through vaccination programs, village elders were encouraging mothers to bring their children for essential vaccines. Our public health team was concerned that reports of monkeypox might derail the uptake of immunizations, but they didn’t. Measles, neonatal tetanus, tuberculosis, and polio took the lives of many children. Families continued to seek protective immunizations for these diseases. No official cases of human monkeypox were reported in Sierra Leone between 1970 and 2014. However, serological antibody studies undertaken in Sierra Leone in the late 1970s, indicated that there had been unreported cases of monkeypox. Heymann et al’s article from the British Medical Bulletin (1998), traces the early history of human monkeypox in Africa and makes for an interesting read.
Rural Water Supplies
Access to potable drinking water remains a challenge in many lower-income countries. Sierra Leone has recently reported improvements in access to safe drinking water for more than 700,000 people in rural areas: https://www.environmental-expert.com/news/sierra-leone-improves-access-to-safe-drinking-water-for-more-than-700000-people-in-rural-areas-1075564. But this is only the start. Sierra Leone's government must commit ongoing funding to maintain the vital infrastructure for safe drinking water. Hope et al. (2020) provide a thoughtful economic analysis describing the complex dimensions of sustainable safe water supplies in rural areas of Africa. They outline economic policy parameters we must rethink to achieve the Sustainable Development Goal for universal and safe drinking water. The article by Hope et al. can be found here: https://academic.oup.com/oxrep/article/36/1/171/5696680.
Traditional Birth Attendants (TBAs)
Descriptions of TBAs' roles and practices, the effectiveness of TBA training programs, and government policies regarding TBAs' midwifery practices can be found in many documents, some dating back to the 1960s. These recent resources are also relevant.
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1691-7
https://pubmed.ncbi.nlm.nih.gov/29375881
https://pubmed.ncbi.nlm.nih.gov/34582455
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6591059/
https://amref.org/position-statements/amref-health-africas-position-on-the-role-and-services-of-traditional-birth-attendants/
See a discussion about the debate on banning TBAs from doing deliveries in Sierra Leone that was published in The Guardian: https://www.theguardian.com/global-development/poverty-matters/2012/jan/17/traditional-birth-attendants-sierra-leone
An update on how the roles of TBAs are changing in Sierra Leone is available here:
https://www.globalcitizen.org/en/content/innovating-to-help-mothers-and-babies-in-sierra-le/
The following chapter by Margaret MacDonald (York University, Toronto) provides an excellent review of policy shifts that have shaped and shifted the role of TBAs in many countries over the last few decades: https://link.springer.com/chapter/10.1007/978-3-030-84514-8_6
Health Systems Fragility and Strengthening
There are lessons to be learned about health systems fragility and strengthening from resource poor countries. The qualitative studies listed below shed light on system challenges in Sierra Leone in both urban settings (e.g. Connaught Hospital) and rural Chiefdoms during the Ebola outbreak:
https://www.sciencedirect.com/science/article/pii/S027795362100592X?dgcid=raven_sd_via_email
https://www.sciencedirect.com/science/article/pii/S0277953621005414#bbib42
https://www.sciencedirect.com/science/article/pii/S0277953621005414?dgcid=raven_sd_via_email
Health Human Resources
Although there are nursing shortages across the globe, the health human resource crisis is particularly acute in the African Region of WHO. As the WHO 2020 World Nursing Report (https://www.who.int/publications/i/item/9789240003279) describes, while nurses make up 66% and 56% of health professionals in the WHO African and Americas regions, respectively; the density of nurses per 10,000 population is enormously different in these two regions: 8.7 per 10,000 in the African region versus 83.4 per 10,000 in the Americas. Investing in education, jobs, and leadership for nurses is essential to meet targets set out in the Sustainable Development Goals for health, education, gender, and decent work and economic growth.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458571/
