SIERRA LEONE

Just under half of Sierra Leone’s urban population is projected to live in Freetown by the year 2028. During the civil war of 1992-2002, the capital experienced a high influx of internally displaced people from the provinces. Coupled with natural population growth and the continued shift from rural areas to the cities, the proliferation of informal settlements poses a major health challenge.

Health and social issues

In Freetown, most of the official health statistics and surveys do not adequately capture the range of health problems experienced by poor people living in informal urban settlements. The lack of disaggregated data on different informal communities indicates that appropriate policies may not be in place. No known study has been conducted to bring together perspectives on the range of problems, contexts and approaches.

Many informal urban settlement dwellers face a variety of risks related to their environment, including those associated with overcrowding, poor housing, poor waste disposal systems and air pollution (including the burning of waste), poor sanitation and inadequate water supply. These fuel the rapid spread of communicable diseases. The health system’s capacity for disease control is poor. Poor and marginalised communities are affected more severely by these health hazards. Poor nutrition, high rates of maternal mortality, teen pregnancies and sexually transmitted infections (STIs) disproportionately affect poor households living in informal settlements. The burden of disability is high. Largely as a result of poor drainage, flooding has become nearly an annual event in Freetown in the last four years, leading to the collapse of houses, deaths, injuries, destruction of toilets and contamination of water sources. Because data are limited on the scale of risks faced by informal urban settlement dwellers, the government and NGOs have struggled to plan and coordinate effective responses to improve health.

Studies identify a range of barriers faced by people in informal settlements in accessing formal health care, including costs (direct and indirect), limited geographic accessibility, socio-cultural obstacles, distance, long waiting times and limited availability of services.

Governance

Despite efforts to build effective, inclusive and accountable governance in the post-conflict era, the recent Ebola epidemic illustrated the weakness of the health system as well as lack of trust between citizens and the state. Most people have to pay for services from a mix of public and private suppliers. The country faces considerable challenges in training and retaining health workers.

SLURC conducted a review of government policies from the perspective of informal settlements. They found that because the health sector has been slow to realise the particular problems posed by rapid urbanisation to health care delivery in urban areas, the health policy framework is general, with no specific reference to urban health. Policies not only ignore informal communities’ specific health problems and needs, but also their role in health care delivery. Only a few policies, such as the community health worker policy, are open to community inclusion in health care delivery. A number of policies do not refer to environmental health, including the potential for communities and their groups to work with the government (central and municipal) to mitigate environmental health risks. It is not clear to what extent people living in informal settlements are aware of relevant policies. This knowledge could, however, enable them to hold health organisations accountable, and shape interventions to meet community needs.

According to SDI, some informal settlement dweller organisations exist in Freetown. A stakeholder workshop identified over 13 organisations that are currently active in informal settlements. Apart from the Ministry of Health and Sanitation and its key agencies, nearly all the other actors — mostly NGOs and a few community-based organisations (CBOs) — operate at the subnational level. These organisations’ responses are uncoordinated and duplicated, and rarely informed by evidence. Most health interventions focus on cholera and diarrhoea, nutrition and child health and wellbeing, the promotion of safer sex and treatment of STIs. Few interventions deal with environmental health threats, health education, mental health and occupation-related health problems at the community level.

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Annie Wilkinson & James Fairhead (2017) Comparison of social resistance to Ebola response in Sierra Leone and Guinea suggests explanations lie in political configurations not culture, Critical Public Health, 27:1, 14-27

SDI Know your city website