Sierra Leone's Health Care System Becomes a Cautionary Tale for Donors

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FREETOWN, Sierra Leone -- The health statistics in this battered land, still scarred from a decade of civil war, are so alarming that for a decade, donors have opened their wallets to help improve some of the world's worst rates of maternal and infant mortality. This is the third-most dangerous place on earth to have a baby, and one of the most perilous to be a baby.

Millions of donor dollars later, health statistics show that the "crisis" for mothers and babies, as the British government called it, may be lessening. But one crisis appears to have spawned another: In a place where most of the population lives on less than a dollar a day, the incoming rush of health care aid has been dazzling.

Too dazzling, apparently.

Last month, the country's 29 top health officials found themselves indicted by Sierra Leone's anticorruption agency on charges of misappropriating a half-million dollars in grants from a global vaccine provider, GAVI Alliance, started by the Bill & Melinda Gates Foundation. The amount may not seem huge in some places, but in Sierra Leone, one of the least developed nations in the world, it looms particularly large, and the list of suspects is stunning.

The country's top doctor -- the chief medical officer, Dr. Kizito Daoh -- was among those indicted. So were the director of primary health care at the Health Ministry, the permanent secretary at the Health Ministry and the ministry's program manager for reproductive health. Much of the ministry's leadership, the key agency in tackling some of the continent's worst health outcomes, now finds itself charged with wrongdoing, including eight doctors.

"You have a ministry without a head," said the World Bank representative here, Francis Ato Brown. "It's virtually decapitated the ministry," he said of the indictments, adding that they had "the potential to virtually destroy the health care system."

The officials took money from the vaccine funds to hold workshops and training seminars, for instance -- and then could not prove that these sessions had been held, officials say. But that may have been just a piece of the problem. Investigators say they have found evidence of large houses and expensive cars not consistent with official salaries, as well as kickbacks from suppliers.

The vaccine alliance froze about $4.2 million in coming grants in November, as a country that had been a poster child for health care projects -- Britain and others have financed a free health care program for mothers and children that has reduced malaria rates -- suddenly became a cautionary tale.

Investigators have found nurses illegally selling drugs to patients in the free care program and doctors charging for services that were, according to the donor terms, supposed to be free.

Government auditors have found tens of thousands of dollars withdrawn from an internationally financed maternal and child health program, with no records for how the money was spent; at hospitals in the interior, and at the central medical store in Freetown, they have found no records to support the dispensing of drugs worth thousands of dollars; and they could not find records for 23 of the Health Ministry's 55 bank accounts. Record-keeping has been "abysmal," an anticorruption investigator wrote in a report.

The vaccine alliance first noticed problems in an internal review. And last week i t released an audit report that found tens of thousands of dollars in unjustified uses of finances and cash withdrawals, ambulances for which the Health Ministry paid almost twice as much as it should, and over a dozen motorcycles improperly distributed. The audit showed "very high exposure of this grant to misuse," the report concluded.

But Sierra Leone officials themselves, including the Anti-Corruption Commission and the auditor general, are the ones who are sounding alarms, motivated by the knowledge that outside aid represents 20 percent of national income.

"There is evidence of cash withdrawals, and we haven't seen what's been done with the cash," said Joseph F. Kamara, the head of the Anti-Corruption Commission, whose headquarters are in an old church office building next to the Anglican cathedral downtown. "They were claiming money for supervising work that was never done."

"We've seen a pattern," the misappropriation of health funds, "clearly being replicated elsewhere," he said.

Mr. Kamara has 161 people working for him, and they clamber up and down the narrow stairs of the old church building in this sweltering seaside capital. On the worn wooden door of his office is a sticker in the local Krio language exhorting that "corruption must be talked about."

The charges against the country's top physicians have also shocked the public in Sierra Leone.

"There's a perception that doctors are meant to heal wounds, not bleed them," Mr. Kamara said.

His predecessor obtained a corruption conviction against the former health minister, Sheiku Koroma. Health care "is an area that has long been corrupt," said Abdul Tejan-Cole, the former anticorruption commissioner, who resigned three years ago after receiving threats.

Top doctors, including at the Health Ministry, "refuse to go to the hospital" because "it's much more lucrative to manage a donor project," Mr. Tejan-Cole said. "Across the board in public-sector funds, a lot is going wrong. There's a lot of misappropriation and abuse."

Dr. Daoh, the chief medical officer who has been indicted, was sitting on the patio of his two-story house reading the Koran on a recent Saturday afternoon. He complained that the government kept putting off his day in court and said that "nobody has asked my side of the story," before declining to comment.

The anticorruption chief, Mr. Kamara, boasted about the speed with which he had obtained indictments, but doubts have been raised about whether they will hold up, and whether the volume of indictments was intended primarily to impress donors.

"The indictments were hurriedly done," said a knowledgeable former top government official, who spoke on the condition of anonymity.

Nonetheless, even the official, who was critical of Mr. Kamara, agreed that a crime had been committed with the missing vaccine funds.

"We can describe this as a reversal of a moral ethos," Mr. Kamara said. The doctors "should have been there for the victims, but it turns out that they are the perpetrators of the victims' predicament."

"It introduces a state of hopelessness in health security," he added. "You have nowhere to turn to."

world

This article originally appeared in The New York Times.


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