Health systems in Sierra Leone and disaster risk reduction

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I visited Freetown, Sierra Leone, before the Ebola crisis, in January 2014, when the city was recovering from another hazard–cholera.  I was sent to Allen Town, a suburb outside Freetown, to write about its peripheral health unit (a peripheral health unit is a low level government clinic that provides basic front-line health services).   One of the outputs I produced was a short newspaper style article assessing the centre from a DRR perspective.  At the time Concern was looking to raise money to fix the centre; they ended up establishing the Send One Brick Campaign.

Freetown is interesting from a DRR perspective.  The city does not have a high exposure to natural hazards: storms are infrequent, as is drought, rainfall is moderate, and it is not located near any active fault-lines.  That said, services and infrastructure are incredibly poor, particularly health and sanitation in the peri-urban city outskirts and the slum areas within the city core (many are basically open sewers), and poverty is high.  In other words, hazards are low, but vulnerabilities are high.  Preventionweb has compiled various risk indices for the country as a whole that say as much:

Sierra Leone risk profile (source: preventionweb)
Sierra Leone risk profile (source: preventionweb… click on the pic for a clearer image)

The article I wrote is a qualitative example of low hazard/high vulnerability type of risk.  Visiting the health centre and talking with its staff reminded me that risk is fundamentally the result of human economic, social, and political practices and that no disaster is really natural.  It also served as an important reminder of the overlap between DRR and health- epidemics are a majour hazard, and health system strengthening is a key means of addressing health risk.  Today, the international aid community is starting to reflect on the Ebola crisis. With such poor health systems it’s no wonder Ebola spread the way it did.


Health workers in Sierra Leone describe their clinic as a “death-trap”

Aaron Clark-Ginsberg, disaster risk reduction documentation officer, Concern Worldwide

13 February, 2014

Allen Town, Sierra Leone—medical practitioners working at the government’s peripheral health unit (PHU) in Allen Town Sierra Leone recently described their clinic a “death trap” lacking the basic necessities for safe operation.

health centre
the clinic exterior

The government clinic provides the 22,000 residents of Allen Town, a suburb of Freetown, Sierra Leone’s capital, with basic services including immunisation, anti-natal care, general consultation, and HIV/AIDs counselling. It is also the frontline for emergency response to cholera and other epidemics and the link between local and national facilities. As a vital component of the area’s health system, the facility is overcrowded and lacks basic equipment and services including running water, toilet facilities, electricity, and security. Concern Worldwide, an international humanitarian organisation that has supported a number of health programmes across Sierra Leone, including Allen Town, is advocating for a new PHU to be built after Concern engineers assessed the building as structurally unsafe.



The PHU does not have enough space to provide appropriate services to the 120 patients a week PHU staff see.

the 5x7 foot HIV/AIDs room is so small the door cannot be fully opened
the 5×7 foot HIV/AIDs room is so small the door cannot be fully opened

HIV/AIDs is a growing challenge in Sierra Leone and the room for HIV/AIDS service delivery is 5×7 feet—so small that the door will not even fully open. Patients risk the potential stigma of HIV/AIDS if they want to use services, as the room is located right next to the waiting area.


Pre-natal, delivery, and post-post pregnancy services are housed in a single room with two beds. Patients have no privacy, and expectant mothers often see the entire birthing process.


The observation room is used to house patients in critical states—including mothers recovering from childbirth or patients suffering from cholera—and has only two beds. It is often at capacity during regular use, meaning that there is little hope for space during cholera epidemics. Staff state the room needs at least six beds.


Lacking equipment

The Allen Town PHU needs basic equipment to provide the patient support they are mandated to deliver. Unfortunately the PHU does not have funds to buy this equipment.


Nurses do not have scrubs or clamps for safely delivering babies. Health consultants do not have armbands to check for high blood pressure. More beds are needed in the observation room. A simple cloth divider separating mothers giving birth from expectant mothers is required for the maternal room. Freezers are needed to properly store vaccinations—they use an ice chest instead. Beds do not have protective mosquito nets and malaria is endemic in the area. The PHU’s first aid kits only contain gauze.


Lacking water, bathrooms, electricity, and security

Conditions at the PHU have deteriorated drastically since the building was constructed in 1992. The building used to have running water but the water tower fell into disrepair and collapsed; today the janitor delivers water by hand. Bathrooms were shut down a few years ago after they were vandalised leaving staff and patients to rely on a nearby private residence to use the toilet. Solar panels were stolen a few years ago, and today the building is without electricity.


wash basin out of use due to lack of water storage.  A bucket is used instead
wash basin out of use due to lack of water storage. A bucket is used instead
Particle board doors are easily broken
Particle board doors are easily broken

Security is all but non-existant: the building lacks a wall to keep out vandals and thieves and doors and windows can be easily broken down. The government only provides the facility with a limited supply of drugs because they fear they will be stolen. The last item stolen was a small battery powered clock, which was stolen last year and has not yet been replaced.


Unsafe building

Concern engineers have described the building as structurally unsafe. Massive cracks run across the structure, from its walls to its foundations. They have been developing over the last five years, and staff are worried that the building might collapse at any time.


The building has roof damage and massive cracks running across it.  Also note the lack of guard rails and the toilets, on the left, which have been shut down
The building has roof damage and massive cracks running across it. Also note the lack of guard rails and the toilets, on the left, which have been shut down
Green mould, caused by water damage, is found throughout the building
Green mould, caused by water damage, is found throughout the building

The rainy season runs from May to October and whenever it rains water pours in off the street and from the disintegrating roof. Patients and staff are forced to evacuate during these floods and staff have to use buckets to remove the water before resuming use. The water destroys equipment, damages the floors, ceilings, and walls, can spread illnesses including cholera, and has caused dark green mould to grow many of the rooms.


The building is also host to numerous smaller problems. Windowpanes are broken and many windows cannot be opened or closed. The incinerator used to dispose medical waste including used needles and blood soaked bandages, has separated from its foundation and is close to collapse. Steps and walkways do not have railings. These problems create an unsafe environment for everyone using the building.


Appeals go unheard

Staff at the PHU have been looking for support to improve the facility for years. They have appealed to the government, the UN, international charities including Goal, Action Against Hunger, and Concern, but have had yet to get any support. While the poor condition is acknowledged, these organisations do not have the funds to build a new facility.


The future of Allen Town’s PHU?
a few of the PHU staff with their patients in the waiting room.
a few of the PHU staff with their patients in the waiting room.

Despite these challenges, Allen Town staff have a vision of a facility where they can provide high quality health services and are hopeful that their vision will be realised soon. They see a new secure building with strong foundations and walls and with enough space and equipment for treating patients. Such a building would have a fence for protection, solar panels, a water tank, and toilets for basic services, and a good roof to keep out the rain and prevent flooding and mould. Such a clinic would give staff the ability provide patents with a full range of services in a safe, dignified, and comfortable manner.


Staff currently have the tools to run the facility but need support to achieve their wider vision. They are committed to providing high quality healthcare to their patients and they are all well trained in their fields. As government workers they are embedded within a strong local healthcare system, and have the support of community health workers, local officials, and the community of Allen Town as a whole.

Concern Worldwide wants to support this vision of a clean, safe, and well functioning health facility. The international humanitarian organisation has been working in Sierra Leone since 1996, with a key focus on health system strengthening. It has been working in Allen Town since 2009 and has supported the health system by providing PHU staff and Allen Town residents with medical equipment and job aides, medical trainings, and supportive supervision and mentoring. It has worked toward improving relationships with community structures in national health campaigns and in community sensitisation on maternal and child health behaviours. It played a critical role in the 2012 cholera epidemic, mobilising and training 70 volunteers toward sensitisation and surveillance.


In 2012 Concern, with the support of Irish Aid, built a PHU in Kuntorloh, a neighbouring community located in Freetown, and found that clinic birth deliveries increased from 1-2 a month to over 52 a month. Concern now wants a similar facility in Allen Town; one that is safe, secure, and resilient to future shocks and stresses.


Allen Town needs a functioning PHU. It has a right to a safe PHU. It can have a high quality PHU with the right support.


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