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Rebuilding Trust in Health Systems in Sierra Leone, Post-Ebola

the need for more welcoming facilitIES

A lack of running water. Leaking roofs. A dearth of essential drugs and basic vaccines.

It’s no wonder in communities throughout Sierra Leone, many people do not think of the local health facility as the first place to go for routine health care or for issues like illness or giving birth.

In turn, nurses and doctors are frustrated that community members do not visit health facilities regularly, making it more challenging for them to spread the word about potential health risks, preventative measures and healthy behaviors.

The good news is that change is afoot.

Communities across the country have been meeting – including health providers – to discuss how they can address the health issues in their community and build a bridge between the community and the facility. These dialogues are the first step in a series of activities involving the entire community to improve the quality of health care facilities and services. Led by the USAID-funded Health Communication Capacity Collaborative (HC3) program in Sierra Leone, 75 communities throughout Northern Province and Western Area have been participating in community engagement activities that culminate with a facility “makeover.”

Recently, people in Roruks and Leicester and many other communities have met to discuss addressing these issues in their community and build a bridge between the community and the facility.

Community engagement, by the numbers


honing in on key improvements

In the facility makeover process, the community is engaged through dialogue, collaboration and outreach. The process begins with a series of dialogues to identify barriers to accessing health services at the facility and the repairs, renovations and improvements that can be done as part of the makeover to address these barriers. These initial dialogues take place first with community members, traditional leaders and leaders of groups within the community, separately from dialogues with facility staff and providers, and then the two groups are brought together to agree on the makeover priorities.

In addition to discussing the facility makeover, the community dialogues raise awareness about the health issues affecting the community and the importance of attending the facility, as well as motivate the participants to act in ways that help them, their families and their communities to become and remain healthy. The community dialogues follow the nine module Journey to a Bright Future (JBF) guide developed by HC3 and implemented by partner GOAL.

Dialogue at Mamanoh, Tonkolili district
Dialogue in Koso Village D., Western Area Rural
Dialogue in Kissi Town, Western Area Rural
Dialogue in Kanikay, Bombali district
Dialogue in Magborognor, Port Loko District
Dialogue in Makarankay, Port Loko district
Dialogue using the Journey to a Bright Future toolkit, in Maborie, Tonkolili district
Dialogue at Looking Town, Western Area Urban
Dialogue at Femkebaia village, Tonkolili district

Rapid Makeovers: The Before

Many clinics throughout the country are in such a state of disrepair that they are not able to adequately serve the population within the catchment areas. With a lack of funding, facility staff previously had little hope for any repairs or improvements to be done. Due to the poor condition of the facilities, community members choose not to go to a there for their health needs or opt to travel longer distances even in the case of a health emergency.

By coming together to discuss these challenges and issues, the community and the facility staff and providers are able to overcome misunderstandings and conflicts related to the facilities. The community dialogues also help both sides recognize the importance of cooperation to reach their common health goals for themselves, their families and the community.

Involvement in these initial discussions builds community ownership over the makeover process and for the continued upkeep of the facilities.

Window in Tonkolili Petifu before rehabilitation.
Inside the Kambia Community Health Post, Bombali district
The outside of Musaia Community Health Post, Port Loko district
A bed at the Makarie Community Health Post, Bombali district
Outdoor space between buildings at the Roruks Community Health Post, Tonkolili district
Old walkway over drainage at MacDonald Maternal and Child Health Post, Western Area Rural
Medicines and supplies on the ground at Iscon Community Health Post, Western Area Urban
Poor drainage system at Malama Maternal and Child Health Post, Western Area Urban
Latrines blocked at Nikikoro Community Health Post, Tonkolili district

The "during"

The makeovers are completed largely by members of the community and the facility staff, with everyone contributing what they can. The paid laborers, including carpenters, masons and plumbers, are mostly members of the community. People contribute sticks for the fencing and tools to complete the work. Others climb up on ladders to repair roofs and ceilings and give a fresh coat of paint to the inside and outside of the facility, or grab a broom to clean the grounds and common areas of the facility. Community members also bring food and water for the workers and help with tasks such as fetching more water and mixing the cement.

Light repairs as well as a ‘freshening’ of the Health Post as well as the surrounding grounds are the basis of the makeover. Typical activities include repairs to the roof and ceiling, improving drainage systems, interior and exterior painting, renovation of rooms to better utilize available spaces, repairs to windows and doors, replacing concrete floors, fixing or installing solar electricity systems and refrigerators for vaccine storage, as well as an overall cleaning of the facility.

Work is conducted while the facility remains open and serving patients. Completing the makeovers during the rainy season adds to the challenge, yet community members and facility staff eagerly and excitedly pitch in.

Repairing windows and exterior cracks at Blessed Mokaba CHP, Western Area Urban
Replacing the mesh on the labor room window at Bath Bana MCHP, Tonkolili district
Making and installing new doors at Mamalikie MCHP, Port Loko district
Installing a new drainage system at Kagboray MCHP, Bombali
Children look on as a carpenter works on building new benches for Leicester CHP, Western Area Rural
Reaching the last spot with a fresh coat of paint at Makarie CHP, Bombali district
Repairing the roof at Maborie MCHP, Tonkolili district
Fabricating aluminum shelving for Iscon CHP, Western Area Urban
Improving the area around the water pump, Rothatha CHP, Bombali district

Taking action together

As the makeover activities near completion, it draws the attention of other community members who come to see the work being done. Some are then inspired to contribute in their own way and, at many facilities, the communities’ work has gone beyond the initial makeover plan.

Building a new drainage system and ramps into the facility at Warima MCHP, Port Loko district.
Replacing floor and preparing for tiling at Maborognor MCHP, Port Loko district
Work being done all around at Kanikay MCHP, Bombali district
Constructing a new waiting area at Leicester CHP, Western Area Rural
Building a ramp over drainage at Makarankay MCHP, Port Loko district
Building new approach to Looking Town MCHP, Western Area Urban
Repairing exterior walls at Malama PHU, Western Area Urban
Improving burning pit for refuse at Roruks CHP, Tonkolili district
Taking stock of repair materials including cement, paint and new roofing, at Kissi Town CHP, Western Area Rural

The "after"

After the makeovers are completed the entire community will gather to celebrate their hard work in fixing up and tidying up the facility. However, the work doesn't end with the facility makeover. Additional community dialogues will be held to help communities understand when they should go to the facility and emphasize the importance of doing so. These messages will also be promoted through a nationwide campaign that includes a radio drama, radio spots that highlight the main message and themes, as well as community-level events. The campaign, called Get Kol Art, Pik Welbodi, focuses on reproductive, maternal, newborn and child health (RMNCH) to not only improve the current health in communities across the country but also support a healthier future for Sierra Leone.

Window with glass replaced and curtains at Petifu Mayepoh CHP, Tonkolili district.
New benches, chairs and tables in a room with floor re-paved and walls and ceiling repainted, Bathbana MCHP, Tonkolili district
Waiting area improved with new cement floor and roof at Leicester MCHP, Western Area Rural
New tiling, fresh coat of pain and plumbing repaired at Magborognor MCHP, Port Loko district
Newly repainted building with doors replaced, Makarie CHP, Bombali district
Latrines cleaned up, fixed up and repainted at Nikikoro CHP, Tonkolili district
Drainage system repaired, walkways over drainage built and facility repainted at Warima MCHP, Port Loko district
Exterior walls repaired and repainted at Lookingtown MCHP, Western Area Urban
Facility repainted, fencing built and drainage system repaired at Maborie MCHP, Tonkolili district

Celebrating the improvements

After the makeovers are complete, communities celebrate the cooperation and contributions that made possible the repairs and improvements. They also pledge to continue working together to keep their facility clean and in a good state. Additional "after" photos will be posted as well as stories from the celebrations!

Enthusiastic staff, Community Champion and Chief, plus community members at Maborognor Maternal and Child Health Post (Port Loko district)
The in-charge (center) at Warima MCHP is known for her warm heart and passion for the community
Women celebrating the improvements at Petifu Mayepoh CHP, Tonkolili district
Young and old participate in the makeovers as seen here at Magborognor MCHP, Port Loko district
Facility staff, makeover committee members and community leaders working together at Slims CHP, Western Area Urban
Makeover workers and leaders at Makarie CHP, Bombali district
Town chief and health staff at Nikikoro CHP, Tonkolili district

see for yourself

Watch the exuberant end of a community engagement event which took place in Kanikay in Sierra Leone.

HC3 throughout the mano river region

HC3 is working to improve service uptake in the two other countries hit hardest by the Ebola outbreak, Guinea and Liberia (along with Sierra Leone, these countries make up the Mano River Region). In Guinea, similar makeovers have taken place. In Liberia, HC3 is working to build the capacity of Community Health Volunteers (CHVs) who are an essential link between the community and the health facility as well as promote compassion for health care workers through a mass media campaign.

Footnote: Photos courtesy of the HC3 team in Sierra Leone.
Sierra Leone