FREETOWN, 7 March 2008 (IRIN) - When people come to see Dr Dominic Weellah for anything more complicated than diarrhoea or malaria he often just gives them a placebo and sends them home.

"What else can I do?" he shrugged. "People just have to find their own way."

Weellah's clinic, in the remote centre of Sierra Leone, has no windows, just gaping holes in the walls and a rusty roof that has almost collapsed. There is no surgical equipment and a medical cabinet that is almost empty. He serves a community of over 10,000 people and the state-run clinic 17 km along unpaved roads is not much better.

"If you are really sick you either die or go to Freetown [more than 200 km west]," he said. "Even assuming patients can make it, facilities there are hardly brilliant."

Trip to nowhere

Indeed in Freetown the hospital facilities IRIN saw were shocking. Running water in the first floor of Princess Christian Maternal Health hospital is only on for an average of one hour every day, hospital staff said – usually in the dead of night.

"We all run around and fill as many buckets as we can before the pipes go dry again," said Sister Rugiatu Kanu, showing IRIN the plastic containers lined up along the walls of the hospital's surgery. Once that water runs out staff either do without or send patients' families out to fill more buckets.

"The most basic tools we need to do our work are not there," said Sister Hannah Mansaray, a nurse and midwife. "We can't even measure blood pressure." When any surgery is performed, patients need to provide their own gauze, bandages and sterilising equipment, she said .

The leading cause of death at the hospital is haemorrhaging, Mansaray said, yet the Princess Christian does not have a proper blood bank. Blood is provided on a "replacement donation basis" according to Philip Kamara, who guards a small fridge which on the day IRIN visited the hospital only contained blood type O+.

"If people need a different blood they will have to come with someone who can provide it," Kamara said.

The past

It was not always this way.

In the 1970s records show tens of thousands of people used the health system every year. Sierra Leone was renowned for having some of the best surgical training facilities on the continent.

Today, after the country's devastating civil war from 1991 to 2002, the average life expectancy is 41. In 2007 Sierra Leone slipped down from second to last into last place in the UN Development Programme's annual Human Development Index.

Medical doctors, administrators from the ministry of health, and UN officials were all unable to state how much the government commits to healthcare. "Even if a budget is published that is just on paper, it is not what we actually get – sometimes that is nothing," said Dr Peter Smart, a doctor at the Princess Christian.

A large part of the problem is corruption. A 2007 report by the Public Service Reform Unit showed salaries were being paid to 162 "ghost" or non-existent workers in the provincial branches of the health and agriculture ministries.

Cost recovery

The government's cost-recovery to fund the health system presents a further obstacle to getting people to use healthcare, according to doctors and experts.

"Healthcare payments are a substantial burden on households, they discourage [people] from seeking care and they create real risk of further impoverishment," according to the non-governmental health organisation Médecins sans Frontières (MSF).

An MSF survey in 2006 found that just one in three people in the country used the healthcare system when they got sick.

At the Princess Christian a tattered piece of paper taped to the wall in front of the surgery states the following: Notice to patients: 15,000 leones (US$5) – minor surgery; 45,000 leones (US$15) – major surgery. Those charges are formidable considering that the minimum wage is 41,000 leones (US$14) a month and many people earn even less.

In theory, those who genuinely cannot afford to pay for their healthcare are covered on an exemption system but MSF reported in 2006 that the "system is not working and the poorest still face exclusion".

Yet Dr Ibrahim Thorlie, Chief of Obstetrics at the Princess Christian hospital in Freetown, told IRIN he cannot oppose a cost recovery system. A government as cash-strapped and fragile as Sierra Leone's would never be able to deliver if it promised free healthcare for all, he said. "People seem to find money to spend on marriages, funerals and celebrations but not for health," he said.

Who will do the work?

Even if cash were forthcoming to rebuild the health infrastructure a further problem remains with the lack of health workers.

The UN estimates there are just 65 trained medical doctors in the country to serve a population of 5 million who are mostly rural dwellers. "What's the point of us having more drugs if there's no-one to administer them," said Thorlie. "Are patients going to treat themselves?"

UNFPA, with the Ministry of Health, is experimenting with incentives to retain staff, Thorlie said. The remoteness of many health facilitiess, the lack of adequate housing and the working environments are all deterrents, said UNFPA representative Barnabas Yiba."Water, electricity, environmental factors, transport, communications need to be functioning to lure trained health workers," Yiba said.

When new workers are trained, they tend to leave to join non-governmental organisations or move to other countries in the sub-region which have better facilities and provide better pay.

"So many trainings happen here, but there is so little to show for it," said Dr Jarrie Kabba, a programme officer at UNFPA. "Some stay in the system but the environment is so dysfunctional that many lose the skills they learned as there is no opportunity for them to practice."

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