May 16, 2014


Interview with Dr Brima Kargbo, Chief Medical Officer



The WHO released its maternal health review (Trends in Maternal Mortality, 1990 to 2013) recently and Sierra Leone was placed last with maternal mortality of 1,100 per 100,000 live births ( http://www.natinpasadvantage.com/essays/Sierra_Leone_Last_in_Maternal_Mortality.htm ). We spoke to Sierra Leone’s Chief Medical Officer, Dr Brima Kargbo, at his Youyi Building office. Excerpts:



Natinpasadvantage (NPA): Dr Kargbo, how do you view the recent WHO report with regards to maternal mortality in Sierra Leone?


Dr Brima Kargbo (BK): Well, I am satisfied and also not satisfied. Satisfied in the sense that we have reduced the maternal mortality ratio from 2,300 (per 100,000 live births) to 1,100 over the period, about 23 years. Why I'm not satisfied is because we still have one of the highest in the world. As I was saying, if you look at the 1990 maternal mortality ratio it started with 2,300 per 100,000 live births; and in 1995 you had about 2,400; then in year 2000 we had about 2,200, then in 2005 we had 1,600. And now we have 1,100. It means we have actually reduced the maternal mortality ratio over the years. It's very good thing for Sierra Leone , but at the same time we are still at the bottom and also we have key indicators that has proven that we have done well. Take for instance the number of pregnancies attended by skilled birth attendants. Initially we had about 41% of births attended by skilled birth attendants. Now we have up to 61%. For institutional delivery, we have more pregnant women now delivering in health care facilities. It has increased from 26% to 61%. And also the case fatality rate of pregnant women dying in our hospitals has reduced from 7.8% to 1.6%.  And now we are currently conducting a maternal death review in Lunsar to actually determine the causes of these deaths and see whether more pregnant women are dying. So you can actually see the ministry has done very well. That is why in fact when we had our audited negotiations with the Islamic Development Bank to support the ministry we asked them to support us to establish a midwifery school in Kenema, in the eastern part of the country just to actually increase the number of midwives, because currently we have less than 400 And what we require is about eight hundred. We are short of that. That is why the ministry has established a school of midwifery in the north, in Makeni, and now we are trying to establish another one in Kenema. Also we continue to do on the job training to ensure that health workers have the requisite skills for them to deliver these pregnant women safely.


NPA: What are the problems militating against you achieving this your objective which would drastically reduce the maternal mortality to the World Health level?


BK: The problem is even at the World Health level they said much progress has been done, based on what I've just highlighted. Mind you, for maternal death we have three key factors that are actually hampering our activities. One is the delay at home by the pregnant woman to decide whether she should go to the health facility or to deliver at the community, and when you delay it will have effect on the life of the baby and the life of the pregnant woman. And the second delay is on the transportation. How do they transport the pregnant woman to the nearest health facility. That is beyond the control of the Ministry of Health. And the third delay is the delay at the health facility, because when you go there is the health worker available to provide the services. Are there drugs or equipment? So these are three great factors inhibiting our progress in achieving this goal. But notwithstanding that 52% is a very big reduction, and also another most important thing as I was saying the case fatality rate on the maternal death review it has reduced from 7.8% to 1.6%. And when we conducted the maternal death review we find that 33 percent of pregnant women who died are teenagers. 33 percent! And this is beyond the control of the Ministry of Health. That is why I always say this is a multisectoral affair, that all sectors need to come together. Agriculture, Education so that women will become educated, Social Welfare - our cultural beliefs. So it's a whole range of MDAs should come together if we want to see a reduction in maternal death in this country. Ministry of Health alone we can provide the service yes, but how about the teenagers who become pregnant, less than 15 years, when they are not physically strong to carry the pregnancy. So these are the deaths that we actually see in this country. But to us as I said, we are satisfied and not so satisfied because we want to move away from that bottom, but when you look at it as a trend the Ministry of Health has made so much progress in that.


NPA: Is the mortality spread evenly across the country and is it also spread evenly between rural and urban areas?


BK: Well of course I actually would not give you the current statistics on that except we go through the DHS for us to be able to know exactly. I'm taking the broader picture. Except maybe I check I'll be able to tell you exactly whether it's the urban or the rural area. I'm actually looking at the broader perspective, because at the end of the day one death is a concern. Even if they die more in the urban or die more in the rural it's a concern for the government, because we don't want any pregnant woman should die during delivery. That is our goal as a ministry.


NPA What do you intend doing to get the average man in the street understand that you've reduced this thing so drastically?


BK I think we actually need to engage the media as we are now doing, to actually sensitize our community members to know that yes, we are bottom but we have done so much.  We've already begun. About two days ago I was on the SLBC, I was over some other radio station trying to explain to them as we did in the case of the Ebola ...I think we should now go on the offensive so that we go over the media for people to actually fully understand that yes, it's high but we've done much to them. Because if they say we've reduced by 75 percent and we have reduced 2 percent, if you translate that 2 over 75 times hundred it will actually give you about seventy something percent reduction which to me I think means the country has done well.  But the ordinary man in the street would not understand that. That is why I said

 we need to actually improve our community sensitization activities.


...Because mind you, even if you look at the number of deliveries, it has increased tremendously in our health facilities. The Free Health Care has done so much for us. Cost was the barrier for pregnant women to come. The President has already addressed that in April 2010 by giving us the Free Health Care Initiative. Free of cost to pregnant women, under-fives and lactating mothers. So that is why we see an increasing uptake. And even the TBAs who used to deliver, now we only use them to refer pregnant women to the nearest health facility, so that is why we have seen an increase in institutional delivery.


NPA: Doctor Kargbo, we are particularly interested in the Maternal and Child Health Aides. I notice that you haven't mentioned them. You've mentioned midwives and TBAs.


BK Well of course they are also midwives. Midwives is just a general term. Because we have the State Enrolled Community Health Nurse, Midwives and MCH Aides. In fact they are doing most of the deliveries now Because if you go to our districts about 60, 70% of the effort is the Maternal and Child Health Aides.


NPA: How many of them do you have?


BK: I would not be able to give you off head the total, but as I say the entire midwifery employed force in the country is less than 400. Because we have about 1222 peripheral health units in the country. Some of them, about 60% of them are manned by these MCH Aides. Even when I was a District Medical Officer myself in Port Loko I had about 79 peripheral health units and about 60% of them were manned by MCH Aides, and they are doing a very good job. In fact that is why as I said the Liverpool School of Tropical Medicine is actually helping us to mentor these people,  also helping us to reduce this maternal death in this country, to actually mentor them during their on the job training for them to actually have the requisite skills for them to actually deliver these pregnant women. So when I say midwives it's a broad term. The MCH Aides are part of it.


NPA: We have received reports Dr. Kargbo, complaints from the MCH Aides to the effect that the class that entered in 2010 and finished in 2012, they have still not been absorbed into the ministry.


BK: That is the problem. Even when I was District Medical Officer in Port Loko in 1994 I knew of MCH Aides who were working without being paid almost eight years. What happened was that most of them they engaged them at district level without getting proper documentation. The Ministry of Health do not employ. It is the Public Service Commission and now the Health Service Commission. Most of the time our colleagues recruit these people without doing the necessary procedures in bringing them to the civil service workforce. That is the biggest challenge. Now as I am talking to you we have about 825 applicants - nurses - to come to the service and what is available, space, is about 100, but now we are going to negotiate with them to see whether they can increase-


NPA: This is SECHN you're talking about?


BK: Yes it's SECHN. So, with MCH Aides, because they don't come through - because they're short of health personnel at the district level, they engage these midwives without bringing their papers up to the central office for us to process their papers. We have a lot of these cases, and I gave you my example as a District Medical Officer, the same thing. When I was posted to Port Loko in 1994 I found out that there were MCH Aides who were working for eight years, they had not been paid, because what happened their papers were never brought to Freetown for them to be processed, for them to be absorbed into the civil service. So what we have decided is to actually ask the DMOs to let them submit all MCH Aides or SECHN who are working in these places that have not been absorbed so that prompt action could be taken for them to be absorbed into the civil service.



NPA: Dr Kargbo, who trains these people, who pays for their training? How are they trained? Because they go through this course of training. Our understanding is there is some funding from overseas


BK: No it's not funding from overseas. It's the Ministry of Health that is supporting training of these MCH aides. We need them. Because for them it's automatic, because we train them. Unlike the SECHN who actually go to some of these private...As I was telling you if the doctors - and there is no way you can go to payroll if you don't follow the established procedures, getting a pin code number, a NASSIT number. That's why we have asked them to submit all the list of workers who may have been - in fact it's wrong for them to have actually recruited them in district without the proper documentation.


NPA: Well this is not even in other districts. We're talking about the Western Area. There are a large number in the Western Area


BK: It's the same thing-


NPA: But here we have the highest maternal mortality rate in the world, and then we have all these MCH Aides who have been trained in exactly this area, and they have not been absorbed by the government. They are not being paid.


BK: If their papers are brought to the attention of the Human Resources for Health in the ministry, I'm sure appropriate action will be taken. I know of somebody who came here, he has been working for over one year...it's only now that he's bringing her papers.


NPA The facility at Cline Town, is that not under the ministry? There's an MCH facility at Cline Town.


BK: At Ross Rd?


NPA: No at Cline Town. There was a Dr Kandeh in charge. I understand he's been transferred.


BK: Yes, he was the District Medical Officer


NPA: But he was in charge of the MCH program


BK: Yes, he brings these documents here. But the recruitment process is not automatic. It's not automatic.


NPA: Do you want them? Because these people are reporting to the MCH posts. They've been reporting for the past two years. In fact I understand another batch has finished now. Do you want them? If you want them why don't you-


BK: I don't recruit. I am the Chief Medical Officer. I am the professional officer. But the way we get these papers, we take them to the HRH, then we take them to the HRMO, ok, before then the Public Service Commission. That is why the government in its wisdom constituted the Health Service Commission so that the Ministry of Health is responsible for the recruitment of health workers. I can show you, these are all ...would-be employees ... (getting up to go to a table with a collection of papers) who were supposed to...they will send them to the Health Service Commission....so that we don't have to go again through the general civil service Public Service Commission. We will be doing it on our own. As long as their papers are here...I'm sure right now if I call the HRM they'll tell you they don't have any document of an MCH Aide. If you've written to them, you bring the list, then they'll process them then they'll recruit them.


NPA: Dr Kargbo these people are being supervised or were being supervised by Dr Kandeh, who is an employee of this ministry-


BK: That's what I'm telling you-let's forget about Dr Kandeh. Even me, when I was a District Medical Officer I knew of MCH Aides who were working without documents. I had to come to Freetown, to be sent to the HRMO office, and then they were absorbed.


NPA: So what's the position now? Are they going to be absorbed, or is it uncertain.


BK: I would not know the number. Let me just ask the Human Resources for Health whether they have a case or whether they have documents for MCH Aides who are currently working and have not been absorbed. I would not give you now, because that's why we have the Human Resource department of the ministry. I'm just the professional head. Whatever you bring to my table I will tell you I will just sign it, but the issue of recruitment it has to go through the Human Resource Management office, the Health Service Commission before they are being recruited.


NPA: Okay


BK: Because this is what we are now trying to do. Even this 800 we are talking about, we will see whether they are going to increase the number so we will get more staff in the field. Here again ...We have a lot of nurses training schools, who we are not sure of the quality of nursing that they do produce. So what we have proposed as a ministry is for them to take a written examination. You have so many of them, about 13 or 11 of them, private nursing schools, apart from the military and the college of medicine. And that does not mean that all of them are good enough.


NPA: You're going to Geneva, we understand. Are you going to discuss this report there?


BK: Of course. These things, it's not only Sierra Leone, it cuts across. Even Asia countries. In fact we have done better than South Africa, Zimbabwe...if you look at the report, if you look at it very critically, you'll see the remarks column that most progress-because we started from a very high maternal mortality ratio. You don't just drastically reduce it overnight. It is gradual. It's a mathematical model that they actually use. You see, if we would have had a very good vital registration system we would have noted all the deaths and births in this country, but no, we depend on this mathematical model they give us, but the only good thing is we did our Demographic Health Survey, and it's almost about the same thing and it's consistent with what WHO actually published....


NPA: So you don't have any problems with the actual numbers WHO published?


BK: No. we don't have any problems. The statistical model they use they look at the GDP of the country, the literacy rate of women in the country, the number of deliveries done ex facility, the percentage done by skilled birth attendants, you know it's a whole range of parameters that they use that they came to that. And when they're actually computing they find that we have done progress, because we started from a very high 2300. But of course the ordinary man would not understand that, but for us as professionals we know we have done so well. That is why as I said earlier we are now engaging in training doctors, more midwives, equipping our basic facilities to ensure that we provide the services that are required...The Ministry of Health can not do it alone. It's a multisectoral approach. I've told you the delays, the challenges. As I told you the teenage pregnancy. The Ministry of Health has no control on the 33% of death of pregnant women. That is the Ministry of Social Welfare who should be able to address the issue of traditional cultural beliefs, norms, laws about early marriage, you understand. The issue of roads - it is the Ministry of Works. The issue of education - educating the girl child - it is the Ministry of Education. But when people die they say Ministry of Health, but for us as a ministry all our output indicators have been improved, and it takes time for us to reach a certain level where we  say, 'ha, we are fine'. For us as professionals we have reduced by 52%, and it is clear, it is there.


NPA: Dr Kargbo, we want to thank you very much for granting us this interview. Thank you.