The current research piece outlined the problems that contributed to Sierra Leone's high death rates. Furthermore, problems affecting public health were examined, including the state of the healthcare system, national health priorities, traditional medicine, and human resources in the healthcare industry. According to UNICEF, the mortality rate among 5 year old male and female children was 190 and 173, respectively. Infant mortality among one-year-old children was 117, and neonatal mortality was 50 (UNICEF, 2017), while the average life expectancy was 51.4 years.
Sierra Leone is located on the African continent's western coast. The country has land borders with Liberia and Guinea. Freetown is the commercial capital and the center of the government of Sierra Leone. The country experiences varied weather such as dry winters between December and April and rainy summers between May and December (Central Intelligence Agency (CIA), 2017).
Population
In 2009, the total population of Sierra Leoneans was 6.4 million, and the mean growth rate was 2.28 percent (Central Intelligence Agency (CIA), 2017).
Government
Sierra Leone became a constitutional democracy and a presidential republic after attaining independence from Britain in 1961. However, simple regionalized administrative structures were in place since 1462 when the country was discovered by Pedro de Sintra – a Portuguese explorer. The state has three provinces namely the north, south, and east. Ernest Bai Koroma heads the executive arm of the Sierra Leonean government. The legislature is composed of 124 members of parliament (Central Intelligence Agency (CIA), 2017).
Economy
Sierra Leone’s GDP was modest compared to other developing countries in Africa and Asia. The World Bank pegged its GDP and gross national income per capita at $3.67 billion and $490, respectively. It was ranked number 41 in Africa (based on GDP) and 165 globally (The World Bank Group, 2017a). Therefore, the country was among the least developed countries. The GDP of Sierra Leone was expected to grow by an average of 5.93 percent up to 2019 according to the latest estimates (The World Bank Group, 2017c). Subsistence agriculture and iron mining were some of the key economic activities in the country. Given that the nation had a coastline of over 400 km, fishing was one of the typical commercial activities undertaken by local communities.
The protracted civil war between 1991 and 2002 adversely affected the economic performance of critical sectors of the economy such as mining, agriculture, and tourism. Apart from the ravages of prolonged conflict, the mining economy in the country was impacted by the fluctuating commodity prices in the international market (Central Intelligence Agency (CIA), 2017). Additionally, the Ebola disease in West Africa had negatively affected the country’s economy. Thus, the government was reliant on foreign aid to sustain its budgetary expenditures.
The State of Health
The state of health in Sierra Leone was affected by accidents, violence, and disease. The WHO – African Health Observatory observed that Sierra Leone had made remarkable strides in reducing adult and infant mortality. Immunization against BCG, Polio, MCV, and Tetanus was at 97, 81, 80, and 87, percent respectively (UNICEF, 2017). The UN noted that infant mortality per 1000 live births had reduced from 222 to 83.3 between 1960 and 2016 (The World Bank Group, 2017b); representing a 62.5 percent decrease in half a century.
The WHO-African Health Observatory noted similar trends in adult mortality in the country. For instance, it was pointed out that adult mortality in 2008 was 393 per 1000 Sierra Leoneans (African Health Observatory-WHO, 2014b). The adult mortality rates were higher compared to its neighbors Liberia and Guinea at 340 and 336, respectively. Besides, the adult mortality rate in Guinea was slightly higher than Africa’s average (392 per 1000 people). Additionally, gender disparities in adult mortality prevalence were also noted. In particular, adult mortality was higher among men compared to women (422 versus 368); the same trend was observed in Africa. Nonetheless, the continental male mortality ratios were lower while the female mortality ratio was higher compared to Sierra Leone’s adult mortality (African Health Observatory-WHO, 2014b).
The pie chart in Figure 1 below depicted the leading causes of mortality in Sierra Leone. Diarrhea, Pneumonia and other diseases resulted in 60 percent of the mortality cases among young children. HIV/AIDs, injuries, neonatal sepsis, birth asphyxia, prematurity, malaria, and measles combined resulted in 40 percent of the mortality cases in Sierra Leone (African Health Observatory-WHO, 2014b). Mortality among young children in the country was quickly preventable; however, the high incidence of poverty, low access to standard healthcare and pure drinking water, illiteracy, and unhygienic practices were cited as some of the factors that contributed to the high mortality cases among infants and adults (African Health Observatory-WHO, 2014a). Besides, it was noted that lifestyle changes among the adult population resulted in higher diabetes and hypertension cases among the Sierra Leoneans.
Figure 1 Diseases causing mortality among < 5-year-old children (African Health Observatory-WHO, 2014)
Apart from diseases, other causes of mortality in Sierra Leone were accidents and violence. Violence in Sierra Leone was varied; for instance, it was noted that child marriages, female genital mutilation were still common practices at 39 and 90 percent, respectively. Besides, about 45 percent of Sierra Leonean women were exposed to physical or sexual abuse by an intimate partner at some point in their lifetime while 29 percent of the female population were exposed to violent situations annually (UN Women, 2016). Besides, approximately 70,000 fatalities were reported during the 1991-2002 civil war and close to 3 million people were displaced (Kaldor & Vincent, 2006).
Accident information (statistics) in Sierra Leone was insufficient. Available statistics from the Open Data for Africa (an initiative funded by the African Development Bank) reported 128 deaths out of every 100,000 people due to gun violence in Sierra Leone (Gusev, 2017). The WHO estimated that road accidents caused 28.3 fatalities out of 100,000 Sierra Leoneans while data from the Sierra Leone Road Transport Authority indicated that 275 deaths were reported in 2009 (WHO, 2017).
Traditional Medicine
Herbal medicine practitioners in the country were governed by the Medical and Dental Surgeons Act, which established provisions for herbal medicine administration. Drugs committees complemented government efforts in regulating traditional medicine at the regional level. The administration of herbal medicines was undertaken in line with the Traditional Medicine Act of 1996. The practitioners were allowed to treat patients in the mainstream health sector as long as there was no threat to human life (WHO, 2001). Traditional medicines in Sierra Leone were extracted from various sources such as wild plants, pangolin skin, and body parts. Boakye et al. (2014) noted that the use of pangolin extracts in traditional medicine was a common practice in Sierra Leone. However, unregulated poaching of pangolins was posing a threat to the future sustainability of the vital conventional medicine source (Boakye, Pietersen, Kotzé, Dalton, & Jansen, 2014).
Healthcare System and Delivery
The healthcare system was regulated by MoHS at the federal level while district health management teams were in charge of health at the grassroots in partnership with organizations such as WHO and Hope Medical Mission. Other health regulatory organizations included the Public Health Ordinance, Sierra Leone Pharmacy Board, Nursing Board and the Medical and Dental Council of Sierra Leone (African Health Observatory-WHO, 2014). The country had 80 public and private hospitals (such as the BlueShield and Choithram Hospitals) (Commonwealth Network, 2017). Operations in healthcare facilities were governed by the Hospitals Board Act of 2007. Statistics from the UN indicated that the entire country had 136 doctors only; the doctor to population ratio was 0.2: 1000 (200:100,000) (Ighobor, 2017) while the nurse to population ratio was 0.3 per 1000 people (300:100,000) (The World Bank Group, 2017). The National School of Midwifery and Nursing and College of medicine at the University of Sierra Leone were the only specialized training facilities for doctors and nurses. Graduate nurses were accredited by the Nursing and Midwifery Board (King’s Sierra Leone Partnership, 2017; Kruth, 2013).
A study conducted by Groen at al. (2012) established that the scarcity of healthcare facilities had made it difficult for ordinary citizens to access quality healthcare in Sierra Leone. In particular, the researchers noted that a significant segment of the population across the country had untreated surgical conditions (Groen et al., 2012). The findings by Groen et al. (2012) validated the observations made by Kingham et al. (2009) who noted that pronounced inadequacies in medical supplies, personnel and infrastructures inhibited the delivery of quality surgical care to Sierra Leoneans. Given the budgetary constraints, it was deduced that enhancing the delivery of healthcare in public hospitals was highly unlikely in the short-term. Nonetheless, tangible progress could be made with the training of additional medical personnel (Kingham, Kamara, & Cherian, 2009).
Health Priorities
Given that, the country was experiencing high levels of mortality due to preventable ailments such as diarrhea and malaria. The current health priority in the country was to reduce the high mortality cases among adults and infants and to improve the doctor and nurse ratios.
Conclusion: Nursing Implications
The present research paper highlighted the fundamental health challenges affecting the health sector in Sierra Leone. The underlying problems included lack of human resources, insufficient funding from the government, high rates of communicable diseases, few medical, and nursing (and midwifery) schools. Diseases such as Pneumonia and Diarrhea and others accounted for 60 percent of the total disease fatalities among young children. Injuries, birth asphyxia, neonatal sepsis, prematurity, HIV/AIDS, malaria, and measles combined accounted for at least 40 percent of the mortality cases in Sierra Leone. The challenges were further compounded by the low national GDP and the history of civil strife. The difficulties impeded the ability of nurses to provide better care to the patients. Besides, they enhanced exposure to contagious diseases such as Ebola. Nonetheless, the country had made significant improvements in suppressing mortality rates among infants and adults in the last 50 years. Western medicine was complemented by herbal medicine whose use was in line with the Traditional Medicine Act. Herbal medicine was permitted as long as it posed no risk to the safety of the patient.
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