Birth of Sierra Leone's health miracle

THE paramedic's eyes were bloodshot, his features drawn. Pregnant women jammed into the darkened concrete bunker, just as they had yesterday and would tomorrow. The increase in patients had been fivefold, or tenfold. The exhausted paramedic had lost count in a blur of uninterrupted examinations and deliveries.

The word was out: it was no longer necessary to give birth at home and risk losing a baby or dying in childbirth.

Hadiatou Kamara, 18, waited in the crowd. She had already lost a baby boy and girl. "They both died," she said quietly. Now, for her third pregnancy, she was at this rural health clinic outside Freetown, the capital. The government of Sierra Leone has eliminated fees for pregnant women and children, and Kamara, like thousands of women in a country where surgery has been performed by the light of mobile phones and flashlights, could afford trained medical staff to oversee her pregnancy for the first time.

At the Waterloo Community Health Centre the women were spilling out of the door, as they have done consistently since the fees were lifted last year.

Sierra Leone is at the vanguard of a revolution - heavily subsidised for now by international donors - that appears to be substantially lessening health dangers in one of the riskiest countries in the world for pregnant women and small children.

Lives are being saved, providing an early and concrete lesson about the impact of making health care free for the very poor and vulnerable.

By waiving the requirement for payments - which sometimes amount to hundreds of dollars and clearly represent the main barrier to using health facilities - the government appears to have sharply cut into mortality rates for pregnant women and deaths from malaria for small children.

The results have been "nothing short of spectacular", said Robert Yates, a senior health economist in from the UK's Department for International Development, which is paying for almost 40 per cent of the 21 million programme, with most of the rest coming from donors such as the World Bank. Since waiving the fees, Sierra Leone has seen a 214 per cent increase in the number of children under five receiving care at health facilities, a 61 per cent decrease in mortality rates in difficult pregnancy cases at health clinics, and an 85 per cent drop in the malaria fatality rate for children treated in hospitals.

Still, the hurdles loom large. In Sierra Leone, health minister Zainab Bangura says her country needs 54 gynaecologists but has only four. And there are only two paediatricians in a nation of over four million people."We lost 10 years" to civil war, Bangura said of the impetus behind increasing access to health care. "We needed to embark on a drastic measure."

But donors will not finance the programme forever, and the hope is that revenues from the mining of diamonds and minerals, shaky for now, will replace them. Beyond that, Unicef recently discovered that drugs equivalent in value to 14 per cent of what it had donated were missing. The agency has demanded an investigation.

Given how recent, untested and strained some of the efforts to provide free health care are, some researchers are reluctant to make an automatic correlation between better access and better health. But Sierra Leone, still scarred by a brutal decade-long civil war hovered at or near the bottom in the world's maternal and infant mortality tables.

It had nowhere to go but up, which may be why there appears to have been an immediate benefit from the lifting of fees. The nihilistic rebels of the Revolutionary United Front deliberately took aim at health care facilities, as symbols of government authority.

"This was about stopping it from being the worst place in the world," said Dominic O'Neill, a British official. "It's an emergency response to what was a humanitarian crisis. It was about stopping people dying."

On a recent morning at Freetown's main maternity hospital, about 80 women crowded into the prenatal examination waiting room, filling benches that doctors said had been sparsely populated in the past. Most of the women raised their hands when a nurse asked how many had been able to come to the hospital simply because the fees had been eliminated. The mood was upbeat. In unison they sang, "We are the pregnant women, and we are saying good morning."

Up in the spartan wards of the 1920s hospital, with its whitewashed walls and rolling metal-frame cots, there was little nostalgia for home births. "They don't take proper care of you at home," said Fatamatou Touray, 39, who had previously lost three children.

And doctors said that while they were swamped, the more patients they saw, the bigger the difference they made. "I'm the only surgical hand here, seven days a week, and nights as well," said Dr Ibrahim Bundu, chief medical officer at the hospital in Makeni, northeast of Freetown. "It's only patriotism that keeps me going."