Project Hope: Improving Maternal Health in Sierra Leone

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This transcript is from a CSIS podcast published on March 21, 2024. Listen to the podcast here.  

Mvemba Phezo Dizolele: Welcome to Into Africa. My name is Mvemba Phezo Dizolele. I'm a Senior Fellow and the Director of the Africa Program at the Center for Strategic and International Studies. This is a podcast where we talk everything Africa: politics, economics, security and culture. Welcome!

Sierra Leone has known crises: coup, wars and Ebola epidemic. Despite its vast natural and mineral resources and despite the succession of elections, the country is still grappling with a spectrum of issues, including democratization, inequitable management of the said resources and the embedded inadequate public health service.

According to the United Nations Children's Fund, UNICEF, Sierra Leone ranks among the countries with the highest maternal mortality ratios, with 1360 mothers dying in every 100 000 live births. This crisis is attributed to poor healthcare practices, including substandard and inadequate healthcare facilities. These tragedies have been further exacerbated by the Ebola epidemic which also led to the loss of 21% of the country's entire health workforce. Further weakening an already fragile healthcare system struggling to recover from decades of civil war.

These numbers reflect a major crisis that has affected Sierra Leone for a long time. Joining me on Into Africa to discuss maternal, and of course, infant mortality in Sierra Leone, is Dr Uche Ralph-Opara, the Chief Health Officer at Project HOPE who recently returned from the country. Hello Dr Ralph-Opara and welcome to Into Africa.

Dr Uche Ralph-Opara: Hello Dizolele. Um, it's a pleasure to be here with you today.

Mvemba Phezo Dizolele: We are happy that you could join us today. Of course, we'll be talking about a topic that is very serious and, uh, close and dear to the hearts of a lot of Africans. You just returned from Sierra Leone, and you are the Chief Health Officer of Project HOPE. Could you tell us, first and foremost, what is Project HOPE? And then, lets talk about your visit, uh, to Sierra Leone.

Dr Uche Ralph-Opara: Yeah, thank you very much. So, Project HOPE is a global health and humanitarian NGO, headquartered in DC but providing program activities across various countries, including Africa, where we actually have our biggest portfolio. Project HOPE has been in existence since 1965, um, and most of our work has covered emergency response, disaster and, also, a lot of our portfolios, um, you know, covers, um, global health programs, um, including maternal, newborn and child health. We also do a lot around infectious diseases, focusing on HIV/AIDS, TB and malaria. We're doing a lot in the health security space, as well. Um, mental health, non-communicable diseases and, also, a lot, um, health security type of work.

Currently, in over 120 countries across about t five, six regions, Project HOPE has continued to, you know, grow our footprint and our portfolio across the countries where we, um, provide support.

Mvemba Phezo Dizolele: Uh-huh (affirmative). That's a lot of work and a lot of important work, 120 countries. In Africa in many... How many countries are you working in?

Dr Uche Ralph-Opara: Yeah, in Africa we're currently working, we have programs across about 13 countries. So, including Sierra Leone, which is the focus for this conversation.

Mvemba Phezo Dizolele: You talked about emergency medicine, emergency response, that you provide, uh, you just returned from Sierra Leone, what should we know about the situation there? What... The numbers I just read are pretty high.

Dr Uche Ralph-Opara: Yes. So I was gonna talk about the numbers which you mentioned because, just like you said, um, I returned from Sierra Leone about 2 weeks ago. Um, we have a couple of programs there. Project HOPE has been working in Sierra Leone since the Ebola crisis, um, like you mentioned. And we went into Sierra Leone at the time to support the government, um, through GIK donations in collaboration with some private sector partners we work with.

So, during the time, Project HOPE worked through the Ministry of Health and deployed some PPEs and medical supplies to support, um, the health system's response to the Ebola crisis, um, way back in 2014. And since then we've continued to provide support to the government of Sierra Leone through a lot of maternal, newborn and child health programs. And so our visit to Sierra Leone was basically to continue with our partnership conversations, stakeholder engagement and, also, meeting some of our programs, you know, in specific regions where we work.

So, in terms of the numbers, I hear you mentioned, you know, where Sierra Leone is at in terms of the maternal mortality. Um, and I'll be happy to say to you that, despite the fact that, you know, the country isn't where, um, they would love to be in terms of this maternal, newborn and child health indicators, the maternal mortality rate has actually fallen over the past couple of years.

So I know you mentioned the 1 300 but, as at 2018, Sierra Leone had brought down that number to 717 and by 2022 the country was at about 443 deaths per 100 000, sorry, live births. And the country has also set, um, some targets to get to less than 300 by 2025.

And so, I would say very specifically here, that Sierra Leone has a very responsive leadership at the Ministry of Health and they're very ambitious with ensuring that, you know, these goals are met. They've actually come up with a 5-point strategy to reduce maternal mortality from 443, where it's at, to less than 300 per 100 000 live births, um, by 2025, which is next year. And so they've put in place a lot of systems, structures and, also, with investments from donors, um, they're... We are optimistic that, you know, we would, um, be able to, as an organization, support Project HOPE to, um... support Sierra Leone government to- to meet these goals.

Mvemba Phezo Dizolele: This is much more encouraging than my numbers suggested so I stand corrected on those. Going from 1360 to 775 then to 443 and around, as the goal states here, to 300 or thereabout per 100 000 live births, that's very impressive. What has Sierra Leone done to get there?

Dr Uche Ralph-Opara: Yes. So I think over time and with, um, a very strong commitment from the leadership at the Ministry of Health, the- the Sierra Leone government has kind of approached or has- has been approaching the health system. You know, just trying to engage across all of the health systems, strengthening building blocks.

So, from ensuring that the health workforce is skilled and is able to deliver quality maternal, newborn and child health services across all the Primary Healthcare units where we work. To also ensuring that, you know, there's availability of the medical supplies and equipment. Um, you know, health information systems are strengthened and, you know, we are able to support service delivery from, um, emergency obstet- obstetric and newborn care across, you know, the Family Healthcare facilities. And also strengthening, you know, referral systems and the secondary and tertiary facilities to be able to respond to complications.

So I think the Sierra Leone government has been very intentional with strengthening the health system, um, to ensure that its responsive, um, towards, um, reducing, you know, maternal mortality and also child mortality. So, a lot has gone in into... including investments from, you know, various donors and to get support from implementing partners like Project HOPE and the others.

Mvemba Phezo Dizolele: Was the Ebola epidemic a wide issue?

Dr Uche Ralph-Opara: Oh, it definitely... it was. You- you did mention that, you know, over about 21% of the country’s healthcare workforce was kind of crippled, right? And we're looking at a health system that's already, kind of, fragile and broken. Also- also recovering from the country's long civil war. So that had a great impact on the health workforce.

So, the country is recovering, right? And trying to ensure that... You know, they're trying to address the health worker shortage, you know, that also resulted, um, post-Ebola. So, a lot more, you know, attention and even supporting and strengthening, um, health workforce at community levels. To ensure that, you know, services for mothers and children can be provided across, you know, communities, at the health facility levels all the way up to the tertiary, um, facilities as well.

Mvemba Phezo Dizolele: Yeah. So what a shared moment, also... you know there's big events, um, and big challenges, right? Uh, but those big events also present opportunities that, in any tough situation that a country, a community, an individual faces, it's about seizing the moment to do better. It sounds to me, from what you're describing, Sierra Leone was highly affected, losing 21% of the entire healthcare workforce. But at the same time, it seems like they seized on this moment as an opportunity to do better.

Dr Uche Ralph-Opara: Absolutely. So, even with Project HOPE's support post-Ebola, um, that was an opportunity for us to even support with resource-mobilization from- from private sector donors. To support, you know, beyond just the GIKs and PPEs for Ebola. We're able to come in with private sector resources to support maternal, newborn and child health programs.

For the longest time we did try to focus around strengthening the health workforce, so we did a lot of trainings at the adult level. So, from supporting, you know, Bachelor in Pediatric and Neonatal Nursing and Master programs for Neonatal, um, Nursing Education. You know, in very close collaboration with the Ministry of Health and, um, COMAHS, um, we are able to train a- lot more nurses in that field.

We also did support the system through capacity building for other health workers at the lower-level facilities and through, um, providing Helping Babies Breathe trainings, Helping Mothers Survive trainings. And just, basically, upskilling the existing health workforce at the facility level and also at the community level. Just so that we have more, um, you know, trained personnel who are able to, you know, provide quality of service to the mothers and the children when they present at the health facilities.

We also did help with some level of infrastructure support. So, we did, you know, support with setting up special care baby units at, um, Ola During Children's Hospital, I remember. And we've also continued to support that, um, facility and also, helping the hospital to purchase NICU equipment, that's Neonatal Intensive Care Unit equipment. We did establish Kangaroo Mother Care, um, Centers as well, um, and, you know, we have continued to support some level of infrastructure upgrades and support in the facilities.

So I think that that's, you know, with the Ebola crisis, you know, partners like Project HOPE, um, not just supported for that purpose, for the, you know, Ebola, but then we're able to do much more to strengthen the health system beyond, um, Ebola. And we continue to do that even up to this day.

Mvemba Phezo Dizolele: How is the infrastructure? You mentioned... There's the software, by software here I mean, training the nurses, getting the skills to the doctors and so on. That knowledge-type, uh, capacity building. But then there is the infrastructure, so the physical infrastructure. You talked about some of the centers that you helped raise. How is Sierra Leone doing in expanding access to those physical infrastructures, um, that exist or not?

In other words, we have urban, we have rural, we have, you know, often road access is always a challenge in a lot of, um, African countries. They're working hard, they're trying but it's not always... even in a country as developed as the United States, sometimes it's not always easy.

Dr Uche Ralph-Opara: Yeah, so, um, are you referring to infrastructure in terms of hospital infrastructure or rural infrastructure? Because I hear, I hear both.

Mvemba Phezo Dizolele: In terms of, in terms of hospital infrastructure, right?

Dr Uche Ralph-Opara: Okay.

Mvemba Phezo Dizolele: So, we have areas where there're more hospitals, typically, urban areas seem to have more of those. Then we have rural areas. And rural areas not only struggle with the physical structure, as in hospitals, but then even access to those places where hospitals are.

Dr Uche Ralph-Opara: Yeah. So for the hospital infrastructure, like I mentioned, you know, we have supported, you know, the NICUs. So you have the Newborn, um, Intensive Care Units and you don't have sufficient equipment. So we did, um, support with expanding that and I do know a couple other partners are doing the same.

We also did note, um, you know, other things. Even things like electricity. We also tried to install some solar panels to support whereas, you know, just making sure that there's some kind of electric supply to some of the facilities where we worked. And, you know, that kind of hard infrastructure support.

So I know that the Sierra Leone government as well, on the other hand, is also doing a lot with infrastructure. You know, they're trying to properly renovate a couple new hospitals, expand staff as much as possible and just ensure that, you know, when, you know, the mothers and the children do get to those hospitals they find, you know, the services that are needed. The equipment, the devices and the medical supplies are available.

But we know what's happening in... what happens in real life, in terms of the rural and the urban divide so, of course, we still have those challenges of inadequate or insufficient number of, you know, equipment and devices. You know, to be able to, um, provide these services.

Mvemba Phezo Dizolele: You have worked in many countries in Africa. You have worked in Nigeria, in other countries, how do you see Sierra Leone comparing with its peers? Countries in the region, countries in the same category?

Dr Uche Ralph-Opara: Yeah, I think, um... Yeah, that's- that's a... that's- that's one I have to think about, really, because, um, I have worked, um, quite a bit in the Western Africa, um, region. Like you mentioned, Nigeria and Sierra Leone and also Ghana, as well. And... all of these countries are struggling in terms of the health system, right? And this not just speaks to maternal, newborn and child health, but, you know, the health system generally. In terms of, you know, availability of infrastructure, services, health information system, even governance.

Um, but where would, where would Sierra Leone sit? Sierra Leone still has, you know, a huge burden in terms of, you know, maternal, newborn and child health outcomes not looking really great. And, um, is still struggling to get there. Um, but, like I said, they do have a very responsive leadership and, you know, they're working towards meeting, you know, those- those goals of, you know, zero maternal and infant deaths.

Um... I don't know whether I wanna, you know, compare because it's not apples and apples. So it's tough to do a comparison of, you know, Nigeria and Sierra Leone or Ghana and Sierra Leone because everyone has their unique, you know, challenges, um, you know, they're dealing with as a country. Which, you know, whether it's economic- economy-related, it still kind of trickles down to the health system.

So, you know, all of these countries are at different levels and, you know, wherever they find themselves, you know, is pretty much based on the bigger picture things. So it's hard to do a comparison of apples to apples. Um, I think that's where I'll leave this here. But they're all struggling, absolutely.

Mvemba Phezo Dizolele: No, absolutely Dr, uh, Ralph-Opara. I think what I'm interested in and that may be of interest to those, uh, listening to you, is what kind of trend do you see? Perhaps that's the best way to ask the question. What kind of trend do you see in the future within this space?

Dr Uche Ralph-Opara: Yes, so in the region, and pretty much what I had described earlier in terms of, you know, maternal, newborn and child health rates are declining across Africa. So maternal, newborn and child health rates are declining across the board but maybe not declining to the levels we want to see it, you know, based on investments that have gone in. So I think that a lot of the governments and the health system is doing a lot more consolidation of investments to make sure, you know, the impact is felt.

So the countries are not where they want to be, in terms of, you know, maternal, newborn and child health outcomes but if we're comparing to where we were, you know two decades ago, we- we definitely can see that the trend... There's definitely a decline, I've given you the Sierra Leone example. And that's what we're seeing across all of the African countries where we work. There's that steady decline.

But is it dropping to the rates where we're comfortable? The answer might be no. Are we doing things to get it to where we want it to be? The answer would be yes. So you have some countries that are still kind of stagnating. You have some countries declining, you know, rapidly. You have others that are just... have... on that really slower, small, steady decline. So it's still different at different levels. The reductions we're seeing but not to the levels where we want, um, those countries to be at. So I think that that would be my response.

Mvemba Phezo Dizolele: Any other services that you, from your experience on the ground in Sierra Leone, that need to be promoted in terms of supporting obvious trackers, that country, like Sierra Leone?

Dr Uche Ralph-Opara: In terms of solutions or services we would want to see scaled up, one of the things that's very near and dear to the Minister's heart, for example, is integration, right? So we want to see more integration of services so that when these mothers, for example, come to the facilities for antenatal, right? We're doing... giving them all, the mothers and the children, we're giving them all of these services at one go. So whether it's family planning or it's nutrition or it's malaria, right? We're not just providing only services for, you know, her and the pregnancy and the baby, eventually, but we're also ensuring that there's integration. So it's a one-stop-shop.

We're also looking at reducing fragmentation of programs. So she doesn't... this woman doesn't have to go to this spot to receive this and then to another facility to receive something else. It's... she can receive everything in one place. So that's the service integration, trying to minimize fragmentation and also, approaching maternal, newborn and child health, and even general, global health programs, through a person-centered approach. So, you are catering to the needs of that, you know, individual.

So, for the mother, we are looking at the mother-baby pair, right? Because most times in this kind of setting, we’re kind of examining both and treating both at the same time. We're managing both mother and child where that, the baby is still in uterus or the baby is, um, you know, has already been born. We want to ensure that all the services the mother and the baby needs, to get it under one roof as much as possible.

So, also very importantly is, kind of, using the Life Stages Approach. So, from birth to adolescence to when they become mothers to when they become, you know, even geriatrics. So, I think the Sierra Leone government specifically has come up with a Life Stages Approach to their general health system trending intervention. So I think that's also very critical.

One also core piece, as well, is, you know, how we're engaging with the communities, because at the end of the day, we have these women come to the hospitals for services but then they're going to go back home to their communities. There are also those harmful practices, you know, across, you know, cultures and traditions that might also, you know, worsen, you know, these maternal and newborn, child morbidities. So, how are we engaging with the communities to, maybe, dispel myths and misconceptions. How are we engaging with the community to ensure that, you know, pregnant women are getting to the hospitals rather than having home births, which kind of puts them more at risk. How are we, you know, kind of facilitating the access at all levels and having these conversations.

So, one of the things we had done on one of, um, our Sierra Leone projects was set up mother care support groups. So we have a group of, say, 20 mothers who come round to meet. Most of them are at same gestational age or, if they've already had their babies, their babies are within the same age. And we use that platform to educate them, you know, empower them with knowledge they need to be able to take care of themselves and their newborns. And also let them know how to identify, even danger signs where they're feeling, you know, out of sorts and they are able to... They know when to go to the hospital, to access care. So that has also been a very important and helpful piece, you know, at the community level and a way of engaging the mothers outside of the health facilities.

Mvemba Phezo Dizolele: And that will take... that, uh, certainly takes a lot of coordination.

Dr Uche Ralph-Opara: Yes, absolutely. So that we do, for the most part... So, um, Project HOPE doesn't work in isolation, like I said. If you notice, most of what I'm saying, we're collaborating with the government, right? So even at the district and the community level, we are working very closely with the District Health Management Teams, for example, or the community leaders and, you know, those relevant stakeholders. Just so that there's some kind of sustainability of the interventions and there's the ownership, you know, post-, you know, partner support.

So there's a lot of trying to entrench, you know, sustainability across the programs we do. So we never do it in isolation but always in collaboration with the government, across all levels of care.

Mvemba Phezo Dizolele: Collaboration with the government, uh, collaboration with your peers, other NGOs?

Dr Uche Ralph-Opara: Absolutely. Just so that we don't duplicate effort because we find that, you know, there's all sorts of investments going towards the health system in every country, right? So, that coordination and collaboration and engagement across, you know, uh, the different partner levels has also been helpful. So if a particular partner is doing something, already has existing resources, rather than duplicate, you know, we leverage on those existing, you know, structures or mechanisms. So that coordination piece is also very important. I know iit's not... We're not where we want to be, in terms of coordination, but I think it's something that programs are prioritizing.

Mvemba Phezo Dizolele: It remains, it remains important. Because we spoke about trends earlier, you, uh, yourself, uh, Dr Uche Ralph-Opara, you've worked in a few countries, um, now of course, you're at the headquarters therefore you've seen the trends, you've seen how they all work together, sometimes not. Have you also seen, uh, or advocate for, collaboration between countries, as well? Especially with cross-border?

Dr Uche Ralph-Opara: Absolutely. So, it's... I think that's also very important. The cross-learnings across countries. And, even as an organization, I think that's one thing we've been, you know, very... we've been advocating for and we've actually started doing, in Africa specifically. So, I would use, you know, our immunization project in Ethiopia, which has been very successful. And one of the things, uh... A lot of the learnings we have learnt from that Ethiopia Immunization Program, we're kind of cross-fertilizing with, you know, Nigeria, for example. Working with partners to say, "Here's what we've found. Um, is this something that's applicable that you can contextualize and, you know, run with on your own program?"

So we find that we are very intentional about, you know, even collection of data because, of course, our data would speak to, you know, our learning or what... our program effectiveness, for example. And for, um, the best practices we are able to identify, we are able to roll it out, scale them up across, you know, that particular country and, you know, also package for roll-out or pilot, to begin with, in other countries. So there's always that opportunity to cross-learn and cross-fertilize, you know, best practices and lessons learnt across projects and countries.

Mvemba Phezo Dizolele: Serious work with, uh, serious, uh, impact on- on livelihoods and, uh, and … and the progress of the country. Considering that health is the backbone of the economy, backbone of survival and productivity and so on. People have been saying to us... people are wondering what else should be done. People may say, "You've done a lot already in a place like Sierra Leone," the international community, "As you have supported Sierra Leone in the transition, particularly post-Ebola." Um, you talked about good leadership that they have that is making a difference. What else?

Dr Uche Ralph-Opara: I think I alluded to the fact that, you know, with health outcomes are very much tied to, you know, the economic situation of any country or any context. So, as much as, you know, our focus is around, you know, improving health outcomes, we do, um, acknowledge the social determinants of health, which, if you don't address, you know, would kind of impact on these outcomes at the end of the day.

You mentioned livelihoods and economic empowerment, for example. If, um, for whatever reason, a woman isn't economically empowered enough, even accessing care, getting medications, going to the hospital to even deliver would be a problem. So we're finding that, as part of program integration, increasingly there's, you know, an additional economic strengthening, um, component to it.

So it's not necessarily just handing down cash or doing cash transfers, but also building the capacity of the... Most of these, most of these, um, economic empowerment programs we're seeing within the global health portfolio, um, you know, is kind of targeted at women and adolescent girls for obvious reasons we know about. So, one of the things, you know, programs are also trying to integrate within, whether it's maternal, newborn and child health programs or HIV programs, is that eco- economic strengthening. Where this woman is, or this young girl, is empowered to be, you know, economically stable and self-sufficient to be able to earn.

And this is not a hand-down things or a cash transfer only but even starting with financial literacy training. Starting with engaging them or linking them to income-generating activities like think... teaching them how to, you know, make their own, you know, cash, right? So that way, you know, they're not... that's the poverty or the economic deprivation, which would affect their ability to access and utilize services, would be kind of minimized.

So I think, you know, just ensuring that our programs are not just very, hyper-focused on the health outcomes and not, kind of, examining or integrating those other social determinants, which, you know, directly or indirectly affect the health outcomes. So I think we kind of look at all of that. You know, so we are looking at this human being in a more holistic way, versus just addressing a specific disease condition or a specific issue that maybe brought them to the hospital or, uh, got them enrolled onto our programs.

Mvemba Phezo Dizolele: In other words, it's really about what you mentioned earlier, integration and that, of course, is looking, uh, holistically at these-

Dr Uche Ralph-Opara: Comprehensive.

Mvemba Phezo Dizolele: Women and their families, which really comprehensively, in how they fit in as pillars of societies and communities.

Dr Uche Ralph-Opara: Absolutely.

Mvemba Phezo Dizolele: And so that will make it, uh, to make public health systems work, uh, for everyone. This has been really enlightening, uh, Dr Uche Ralph-Opara. I started by talking about some numbers that were pretty dismal. Now that we are talking, it's obvious that Sierra Leone is making major strides, big strides, moving forward and we hope that will continue and we'd like to thank you for your work and please come see us in years ahead.

Dr Uche Ralph-Opara: Thank you very much, Dizolele. It was a pleasure speaking with you today.

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