Today we first drove to Tambaima to visit a Community Health Clinic (CHC). We met with 4 CHWs who have been working since 2012 and a peer supervisor who has been a part of the Ministry of Health’s (MOH) program for 10 years. The CHWs stated that they have a lot of love and passion for the work that they do, and said that over the years they have learned that “health is wealth.” One of the challenges they face is changing the mindset of their community members. Most of them do not go to the clinic to treat their illnesses, or rely on traditional medicine. The CHWs are trying to change this by educating them on modern medicine and the importance of disease screening.

They also gave us some insight on how their CHW training works. For learning how to test for malaria, they first have a lecture on background information. The teacher then gives a demonstration. After, the CHWs all role play with each other, performing the tests on each other.

Pictured: the CHWs we interviewed

After speaking with the CHWs and peer supervisor, we met with the nurse in charge. She was a little reluctant to talk to us, and give us little insight. She said they constantly are delivering babies at this clinic (about 20 births per month). Because of this, there is often a lack of delivery supplies. They have to use their cell phone light as lighting in the delivery room. She also told us that STIs are a lot more common than UTIs.

Pictured: This is where they do the screening for patients.

After visiting Tambaima clinic, we drove to Masongbo CHC. When we arrived, a nurse immediately took our temperature and made us wash our hands before entering. This is the first clinic that has made us do this. We first spoke to a nurse in charge who told us how there are no medical residents here, most of the staff are volunteers, therefore it is hard to assist patient needs on a regular basis.

Pictured: a nurse and the nurse in charge (the one interviewed)

She said this clinic also delivers a lot of babies on a monthly basis. The most common birth complications are preeclampsia and PPH. The most common diseases are malaria and STIs, specifically HIV. She suggested that our refresher training has to be very well structured and clear that if CHWs do not perform their job properly, they will lose their position.

Later we talked to two CHWs who have been working since 2016. The challenges they face are the lack of education about diseases that their community members have, denial of medication from community members and transportation. They stated that community members are used to free healthcare so they will likely not pay for screening. They hopefully will pay when sensitized to the issue, or through community outreach programs.

pictured: a nurse and the two CHWs

Today we drove about an hour to Rokulla, a very rural area. Most of the roads there were not paved and therefore took us a lot longer to navigate all the bumps and ditches. Our drive William, however, is an excellent driver!

When we got there, we were greeted by the CHO and nurse in charge of the Community Health Post. Both spoke a good amount of English which made the conversation feel a lot more personable and well understood.

They took us to a room where 6 local CHWs and 1 peer supervisor were seated. All of them have been working since 2013 and had been trained for UTIs already by Gabi. They stated that their main challenges as a CHW are transportation/travel time, the referral process, having to make calls and care for people in the night and their stipends not being paid in full. Most stated that they are peasant farmers.

A super helpful insight to us was that stated that their community members will not pay for a UTI screening because they already get malaria and TB for free. They will not understand why they have to pay 1000 Leones for a cup of their urine. So in order for our business model to work in this this community, we need to focus our efforts on sensitization so people understand the importance of screening. The CHWs said that their villages are not educated and so most will not understand, and therefore not pay. Some of the CHWs felt uncomfortable with the idea because they don’t want to enforce a financial burden on their community members.

The common diseases that the CHWs come in contact with the most are Tuberculosis, elephantiasis, river blindness and gonorrhea. It was important for us to visit this CHP because of how different it was compared to the other places we went to. The needs of the CHWs, villages and community members are a lot different.

Charts and informational posters hanging in the clinic

Outside the clinic

Today we traveled to Kambai to meet up with 115 CHWs who were gathering to receive their stipend and learn proper breastfeeding techniques to combat child malnutrition.

We first met with a midwife who has been working in Kambai clinic for 6 years. She described to us that more women are coming into the clinic for STIs rather than UTIs. This gave us some insight on what disease to focus our test strips on next, after we have launched UTI strips. She stated that her main challenge was the tools she’s given to work with and how difficult it is to get women to come to the clinic to give birth. Her goal is to encourage more women to give birth in the clinic. She also said that more women give birth in the dry season, rather than the wet. Therefore, we hope to have Ukweli up and running before the next dry season.

At the same clinic, we then met with 9 peer supervisors. Most of them were in charge of managing 7 CHWs. Some were from extremely rural areas and reported to Community Health Posts (CHPs). Others came from more urban areas, reporting to Community Health Units (CHUs). They told us that their main challenge was communication to other CHWs (they have to travel so far just to reach them). They stated that they do monthly meetings with CHWs to make sure they are performing their job duties correctly and efficiently.

When we asked them about how much CHWs should charge people of their community for test strips, they said about 1,000 leones ($0.13).

Our translator Hassan and the 9 peer supervisors.

We later toured the lab facilities to see how test strips are stored at a clinic. The lab technician showed us they all stored in a small cabinet. He then showed us where the medicine for patients is stored, shown in the picture below.

After, the CHO of the clinic took us to a bench where about 60-70 CHWs were gathered. It was extremely intense because we were not expecting that big of crowd to present in front of. Most stated that their challenges as a CHW are transportation, late stipend payment, lack of equipment (no lights to help deliver babies in the night), lack of communication with peer supervisor and having to leave their daily work/tasks (ex: farmer leaving for long period of time=food gets spoiled) to treat members of their community. They all agreed that 1,000 Leones was what they should be charging community members, but they would have to consider the current season (wet or dry).

Sage, Cassidy and Naakesh with the CHWs.

Naakesh and Sage outside the clinic (it is undergoing construction).

Later, we interviewed a Travel Birth Attendant (TBA). She has been working a TBA for 6 years and has had no casualties (such an amazing woman!). She said that she was inspired to become a TBA when she was giving birth to her own children. Two people would sit down on the stomach and pound on it while she was in labor, to try and get the baby out. She said this method led to many of her friends and their unborn children to pass. Because of how awful this method was, she became inspired to make a difference and improve maternal and infant mortality rates. She got certified by the red cross to become a TBA and has been working ever since.

Today we first met with the head of the PHUs of Kambai. His name is Abdul K. Kamara, and have gave us a good amount of insight on to how to develop and integrate our venture in Bombali and Kareneh districts. He was familiar with Ukweli, and stressed that maintaining patient confidentiality should be well emphasized in the training that we provide CHWs. He told us a lot about how medicine and supplies are distributed to different clinics that he manages. This helped us get a bit of insight on how we will distribute our test strips and the distribution chain as a whole.

After interviewing Mr. Kamara, we headed out to Binkolo PHU to meet with 5 CHWs. They were all very open and interested in the idea of Ukweli because a lot of women in their villages complain of abdominal pain. The challenges faced the most as a CHW were transportation, communication, 2-3 month delay in stipend pay, and worn out equipment/rain gear. Most travel on foot to meet with a patient, and that can be around 6 miles.

They suggested that we conduct refresher trainings every three months so new ideas and concerns can be talked about or added to the program. We gave them a sheet that described their role and responsibilities if they were to be involved in Ukweli. All of them responded positively to what we mentioned.

We later set out to meet with 4 more CHWs at Kambai. They have been working as CHWs for 1-5 years. They described similar challenges that the Binkolo CHWs faced: far distance to travel, poor communication, late stipend payments and expenses for traveling.

They explained to us how their is a stigma against CHWs created by members of their village. Many don’t understand that CHWs are volunteers, and assume that when CHWs go into other villages for training and meetings, they are going to get funding from outsiders. We hope that Ukweli can eliminate this stigma by giving CHWs screening equipment, showing the community members that the CHWs are working and getting money from them, not from outside sources.

They thought that the best way to launch Ukweli was through community engagement. This is critical in order to get women and people to pay the CHWs for strips. They must be sensitized to the problem and recognize the signs and symptoms of a UTI.

Pictured is the 4 CHWs and our translator, Huson.

On our way back to World Hope we stopped at a beautiful rock formation to take pictures!

Naakesh and Cassidy.

Naakesh and our driver, William.

Sage + rocks = happy Sage

This morning we finalized and printed out The CHW Ukweli job responsibilities sheets. We planned on giving these sheets to CHWs and other clinic workers, asking their opinion and advice on how to improve them. Our goal of these sheets is to inform CHWs on the role they play in the Ukweli business model. CHWs are our primary distributer to women, therefore they must know what we expect of them.

We first visited Binkolo Community Health Centre, Safroko Limba Chiefdom. Here we met with Sister Marieta, who spoke on behalf of her boss (a CHO). We showed her the sheet we created and asked for her opinion. She provided extremely helpful insights, informing us of the major causes of maternal mortality that she witnesses.

An Ukweli created poster used outside of the clinic (shown top right).

Sister Marieta gave us a tour inside the clinic. Shown is a bed where pregnant women get checkups.

After speaking with Sister Marieta, she took us to meet three different community health workers, that are located in a much more rural areas (Kathala, Makenkita and Bombali Bona). The three were all men around the age of 30. They spoke a good amount of english, and therefore were able to understand some of what we were asking them and our translator. Overall, they also provided us a good amount of insight. For example, they told us that they are very eager and willing to be trained by Ukweli and are open to the idea of making money through selling. They do know their limits and role as a CHW, and do not want to overstep or try to do the job of a CHO or nurse in charge.

This is a picture of what the surrounding areas look like when visiting the communities.

The first two days in Sierra Leone we worked in World Hope International’s conference room developing a game plan for our venture and what it will take to get it on the ground. At first it was difficult for us to understand the different healthcare sectors and people that are present in Makeni (CHC, PHU, CHO, NIC, CHW). Our translator, Hasan, helped us a lot by drawing out the chains that follow who is in charge of who, and how they interact with each other.

Hasan and Sage working out Makeni healthcare system pathways on poster paper.

The mushroom team that is traveling us have been doing construction outside and gathering the materials needed to build from nearby markets. We are often quite jealous that they get to be exploring and working outside, because the past two days we have worked all day in the conference room.

This is the conference room we have been working in. It is air conditioned which we are incredibly grateful for!

Pictured left to right: Isabel, Marc and Rachel (the 3 members of the mushroom team), Jwara (current employee in SL for mushroom team), Naakesh and Sage.

Documents we have been working on in the conference room:

-Employment contracts for two people

-Job duties for hospitals, clinics, pharmacies, CHWs, PHUs, CHOs and CHCs for working with an Ukweli product

-Training protocols for hospitals, clinics, pharmacies, CHWs, PHUs, CHOs and CHCs

-End user selling plans

-Quality control instructions for test strips

The resort we are staying at is really great, a lot nicer than we all expected it to be. The six of us all share a bed with one other person. The rooms also include a desk, dresser, mosquito net, shower, sink and toilet.

Heres what the hotel compound look like. The houses with the red/pink roofs have four rooms in them, and all of the students are living in house 5.