On the beat with a community health worker in Sierra Leone

BOMBALI DISTRICT, Sierra Leone – Osman Koroma is on a mission to save lives. Like almost everyone else in the village of Kathirie in Sierra Leone’s Bombali District, Osman is a farmer. But four years ago, he added a new set of skills when he was trained to join the ranks of Sierra Leone’s cadre of Community Health Workers (CHWs).

Osman visits Abou Kargbo and his 19-month-old daughter Aisata, who has not been feeling well. Osman checks Aisata for malnutrition using a mid upper-arm circumference (MUAC) tape. ©UNICEF Sierra Leone/2015/Kassaye

Today, Osman is on the front lines of efforts to protect the lives of children and women in a country that has the highest levels of maternal mortality in the world, and one of the highest rates of child mortality.

“I do this community work early in the morning before going anywhere, and also at times I do it in the evening hours,” says Osman, who knows everyone in the village, which has a population of close to 500 people.

He works alongside the village Mothers’ Support Group and Village Development Committee (community organizations that support the needs of the village) to identify pregnant women, breastfeeding mothers and children under 5 years old, whom he then visits on a regular basis.

Critical advice

On this day, Osman’s first stop is at the home of Rahmatou Sesay, who is sitting outside as she nurses her one-month-old baby, Mariatu Kamara.

“I came to Rahmatou the morning after she delivered to see how she and the baby were doing,” Osman says. “I gave her advice on how to take care of her baby and not to put native medicines on the umbilical cord. She must wash her hands with soap before touching the baby. I advised her to breastfeed exclusively for six months.”

After filling out Rahmatou and Mariatu’s details on his CHW register, Osman makes his way to the home of 25-year-old Margaret Sesay, who is nine months pregnant with her third child. Margaret and her mother were busy peeling cassava recently harvested from her family’s farm.

Rahmatou Sesay and her one-month-old baby, Mariatu Kamara © UNICEF Sierra Leone/2015/Kassaye

Osman used the illustrated ‘National Counselling Cards for Community Workers’, developed by UNICEF and the Ministry of Health and Sanitation, to advise Margaret about what, how and when she should be eating during pregnancy.

They are soon joined by Kadiatu Tarawalie, leader of the Kathirie Mothers’ Support Group. Together they continued the discussion on what Margaret should do when the time comes for her to give birth and how she should feed and care for the new baby. Osman advises her to deliver at the Binkolo Peripheral Health Unit (PHU), and to start preparing money for transport, food and clothing and other things she will need.

“I am happy with the work that Osman is doing,” says Margaret, who has developed a good rapport with him. Osman counselled and followed up on her during her previous pregnancies. His advice was critical to her decision to give birth at the PHU rather than at home, and all her pregnancies have gone well.

“Today we discussed the things that I should be eating while I am pregnant and when I am breastfeeding, including bananas, cucumber and chicken,” Margaret says. “The pregnancy is going well. I have been to the PHU four times for check-up. I have also been vaccinated. I delivered my first two children at the PHU, and my plan is to give birth there this time as well.”

Making the difference

Margaret’s decision to give birth at a health facility, where trained health professionals can provide appropriate care, is essential for improving her chances of safely delivering her new baby. In Sierra Leone, only one out of two pregnant women deliver at a health facility, which is one of the contributing factors in the country’s high rate of maternal mortality.

Community Health Workers like Osman, working in collaboration with the Mothers’ Support Groups, provide direct and continuous counselling to expecting mothers. Even in remote rural areas, creative community action facilitated by CHWs like Osman is making the difference.

Osman makes a visit to Margaret Sesay (centre), 25 years old and nine months pregnant with her third child. Kadiatu Tarawalie, leader of the Kathirie Mothers’ Support Group (left) also joins them to help Margaret prepare for the birth. © UNICEF Sierra Leone/2015/Kassaye

“The nearest PHU is four miles away, which is far for a pregnant woman who is about to deliver to walk,” Osman says. “So we mobilize the community to volunteer to take her using a hammock.”

Moving on through Kathirie village, Osman reaches the home of Abou Kargbo, whose daughter Aisata Kargbo, 19 months old, has not been feeling well. After talking to the concerned father, Osman pulls out some of the simple tools he uses to diagnose various potentially life-threatening conditions among children under 5.

“I check for pneumonia if the child has difficulty breathing,” Osman says. “I use this timer to check how fast a child is breathing. If a baby 2-11 months breathes 50 or more times a minute, that will tell me that the baby could have pneumonia, and I refer them to the PHU.  Also for malaria, if the baby has fever I refer them. If a child is refusing to breastfeed, I refer. I also refer diarrhoea cases. I check for malnutrition using the MUAC [mid upper-arm circumference] tape, and if the child shows signs of moderate malnutrition, I give advice on how to improve feeding, and if the tape reading is red for severe malnutrition, I refer to the PHU.”

Aisata’s examination does not set off alarms, and after counselling her father Abou about appropriate child feeding practices and advising him to continue monitoring her situation, Osman puts his pneumonia timer back around his neck and moves on to his next visit.

Changing behaviour

As Sierra Leone emerges from the devastating Ebola epidemic, which had a particularly harsh impact on the health sector, many challenges remain, such as deploying sufficient and qualified health workers, building facilities for them near communities like Kathirie Village, and – critically – building community trust in the health sector and fostering behaviour to seek health care.

Osman visits Abou Kargbo and his 19-month-old daughter Aisata, who has not been feeling well. Osman checks Aisata for malnutrition using a mid upper-arm circumference (MUAC) tape. © UNICEF Sierra Leone/2015/Kassaye

“We faced many challenges doing this work during Ebola,” Osman says. “People were afraid of us. And we, too, were afraid of them. But because it was our job, we continued to do it, even though it was a risk to our lives. We were still visiting newborns and screening under-5s for malnutrition – but we didn’t touch. I would give the tape to the mother and show her how to do it…. Now, we have no problem. Whatsoever you want to do, they will allow you.”

As Osman makes his way through the village, all the people he meets greet him effusively. At the young age of 22, Osman’s role as the key link with the health sector has earned him the respect of his fellow villagers, giving him the motivation to continue his volunteer position.

“I don’t get paid to do this work,” Osman says. “I make my living farming, growing cassava, potatoes and rice. My level of education is SS3 [high school graduate], and in the future I would like to study to be a medical professional.  I was not thinking about doing medicine before, but now, because I am enjoying my work as a CHW, I want to learn more.”

Working with the Government of Sierra Leone to reduce child and maternal mortality is one of the priority areas for UNICEF’s programmes in the post-Ebola recovery period. More than 10,000 CHWs have been trained and equipped with the necessary job aids to provide high-impact maternal and child health services. In 2015 alone, more than 296,500 children under 5 were assessed by CHWs, of whom 32,000 were referred to PHUs for further treatment. Close to 90,000 pregnant women received home visits by CHWs and more than 60,840 mothers and their babies received post-natal home visits within 48 hours of delivery. UNICEF, with the support of donors, including the UK Department for International Development (DFID), the Government Canada, the European Union and National Committees for UNICEF, is working at the community level to train and deploy additional CHWs to ensure all rural communities have equitable access to lifesaving health and nutrition services.

By Indrias G. Kassaye