• TABLE OF CONTENTS
HIDE
 Front Cover
 Introduction
 The role of non-governmental organizations...
 Advantages of NGOs
 The essential message
 Background
 Women's reproductive health and...
 A total health care approach to...
 The staff
 Maintaining a commitment to high...
 Maintaining standards of quality...
 The importance of effective outreach...
 A humane program of cost recov...
 Clients' perceptions are the strongest...
 A life cycle approach to reproductive...
 A space for women that includes...
 Gaining the respect and trust of...
 Lessons learned
 Resume en Francais
 Resumen en Espanol
 Advertising
 Back Cover














Group Title: Quality/Calidad/Qualité
Title: Doing more with less
CITATION THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00088801/00001
 Material Information
Title: Doing more with less the Marie Stopes Clinics in Sierra Leone
Series Title: Quality = Calidad = Qualité
Physical Description: 28 p. : ill. ; 26 cm.
Language: English
Creator: Toubia, Nahid
Publisher: The Population Council
Place of Publication: New York N.Y
Publication Date: 1995
 Subjects
Subject: Maternal health services -- Sierra Leone   ( lcsh )
Birth control clinics -- Sierra Leone   ( lcsh )
Child health services -- Sierra Leone   ( lcsh )
Family Planning Services -- Sierra Leone   ( mesh )
Genre: non-fiction   ( marcgt )
Spatial Coverage: Sierra Leone
 Notes
Statement of Responsibility: by Nahid Toubia ; introduction by Grace Eban Delano.
 Record Information
Bibliographic ID: UF00088801
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 32940494
lccn - 96230201

Table of Contents
    Front Cover
        Front Cover 1
        Front Cover 2
    Introduction
        Page 1
    The role of non-governmental organizations (NGOs) in health and development
        Page 1
        Page 2
    Advantages of NGOs
        Page 2
    The essential message
        Page 3
    Background
        Page 4
    Women's reproductive health and family planning in Sierra Leone
        Page 5
    A total health care approach to family planning
        Page 6
        Page 7
    The staff
        Page 8
    Maintaining a commitment to high quality care: Challenges and rewards
        Page 9
        Page 10
    Maintaining standards of quality care while responding to demands for growth
        Page 11
        Page 12
    The importance of effective outreach and community involvement
        Page 13
    A humane program of cost recovery
        Page 14
        Page 15
    Clients' perceptions are the strongest advocate for quality services
        Page 16
        Page 17
        Page 18
    A life cycle approach to reproductive health
        Page 19
        Page 20
    A space for women that includes men
        Page 21
    Gaining the respect and trust of the community
        Page 22
        Page 23
    Lessons learned
        Page 24
        Page 25
    Resume en Francais
        Page 26
    Resumen en Espanol
        Page 27
    Advertising
        Page 28
    Back Cover
        Page 29
        Page 30
Full Text





















'.






Quality/Calidad/Qualitd, a publication of the Population Council, highlights
examples of family planning and reproductive health programs that are providing
unusually high quality care. This series is part of the Council's Robert H. Ebert
Program on Critical Issues in Reproductive Health and Population which, through
scientific and practical efforts, seeks to improve and expand the scope and quality
of reproductive health care. The philosophical foundation of the program, and of
this series, is that women and their partners have a fundamental right to respectful
treatment, information, choice and follow-up from reproductive health care
providers. The pamphlets reflect one of the four main thrusts of the program:
enhancing the quality of family planning programs.
Projects are selected for documentation in the Quality/Calidad/Qualite series
by an Advisory Committee made up of individuals who have a broad range of expe-
rience within the field of reproductive health and are committed to improving the
quality of services. These projects are making important strides in one or more of the
following ways: broadening the choice of contraceptive methods and technologies
available; providing the information clients need to make informed choices and bet-
ter manage their own health care; strengthening the quality of client/provider inter-
action and encouraging continued contact between providers and clients; making
innovative efforts to increase the management capacity and broaden the skills of ser-
vice providers at all levels; expanding the constellation of services and information
provided beyond those conventionally defined as "family planning;" and reaching
underserved and disadvantaged groups with reproductive health care services.
None of the projects documented in the series is being offered as a model for
replication. Rather, each is presented as an unusually creative example of values,
objectives and implementation. These are "learning experiences" that demonstrate
the self-critical attitude required to anticipate clients' needs and find affordable
means to meet them. This reflective posture is exemplified by a willingness to
respond to changes in clients' needs as well as to the broader social and economic
transformations affecting societies. Documenting the critical choices these pro-
grams have made should help to reinforce, in practical terms, the belief that an
individual's satisfaction with reproductive health care services is strongly related to
the achievement of broader health and population goals.







Publication of this edition of Quality/ Statements made and views expressed in
Calidad/Qualite is made possible by sup- this publication are solely the responsi-
port provided by the Ford Foundation ability of the authors and not of any orga-
and the Swedish International nization providing support for Quality/
Development Authority (SIDA). Calidad/Qualiti.


Number Seven 1995 ISSN 0-8734-057-2


Copyright @The Population Council 1995







Doing More with Less: The Marie Stopes

Clinics in Sierra Leone

by Nahid Toubia
Introduction by Grace Eban Delano

Introduction
In Africa, high fertility is known to be a major contributor to maternal mortality and mor-
bidity. Studies have shown that of every ten deaths to women of reproductive age, at least six are
caused by factors relating to pregnancy, child birth and related complications in the postpartum
period, most of which are fully avoidable. It has also been widely documented that when a woman
becomes pregnant too young, too soon (following a previous birth), or too old, she is likely to suf-
fer health problems with grievous complications.
The benefit of voluntary, health-oriented family planning programs in preventing the death
and illness of women and children cannot be over-emphasized. When a woman is able to have the
number of children she can adequately care for, at safe intervals, she is more likely to remain
healthy and to be able to pursue daily activities which contribute to her own and her family's
welfare. And because women play a major role in most agrarian economies of Sub-Saharan
Africa-tilling, planting and harvesting crops as well as caring for and supporting families and
children-they not only have a right to health but their well-being also has vital implications for
economic development.
The consequences of a combination of high fertility, mortality and morbidity among poor
women can also lead to a range of other problems.
Complications of childbirth can lead to long-term disabilities, general poor health and
even death for many women.
Attempts at unsafe and illegal abortion, often accompanied by complications, impair
women's health and sense of security.
Early childbearing interferes with the educational attainment of young girls who must
drop out of school, resulting in a lifetime of limited reproductive and productive choices.
The death of a mother through childbirth or unsafe abortion, or her inability to care for
her children due to ill health, can result in greater numbers of orphaned, abandoned or
abused children.
The Role of Non-Governmental Organizations (NGOs) in Health
and Development
In the period following independence, the provision of health care, in the African context,
was viewed primarily as the precinct of governments. But in recent years, political instability and
economic mismanagement, coupled with universal economic recession, has forced many African
governments to institute so called economic structural adjustment programs (SAP) to reduce their
external debt. Although the ultimate goal of these efforts is to improve the economy and thus cre-
ate better living conditions for everyone, the implementation of these policies has actually led, in
the near term, to a deepening socio-political crisis within African nations. This has had particu-
larly deleterious effects on women and children because one usual component of such programs
is reduced government spending on health and other social services. Already overburdened and
often under-developed, health care systems then either collapse altogether or are forced to limit
care to those who can afford service fees. Services that were once available free of charge now cost
money if, in fact, the services are even available.







Doing More with Less: The Marie Stopes

Clinics in Sierra Leone

by Nahid Toubia
Introduction by Grace Eban Delano

Introduction
In Africa, high fertility is known to be a major contributor to maternal mortality and mor-
bidity. Studies have shown that of every ten deaths to women of reproductive age, at least six are
caused by factors relating to pregnancy, child birth and related complications in the postpartum
period, most of which are fully avoidable. It has also been widely documented that when a woman
becomes pregnant too young, too soon (following a previous birth), or too old, she is likely to suf-
fer health problems with grievous complications.
The benefit of voluntary, health-oriented family planning programs in preventing the death
and illness of women and children cannot be over-emphasized. When a woman is able to have the
number of children she can adequately care for, at safe intervals, she is more likely to remain
healthy and to be able to pursue daily activities which contribute to her own and her family's
welfare. And because women play a major role in most agrarian economies of Sub-Saharan
Africa-tilling, planting and harvesting crops as well as caring for and supporting families and
children-they not only have a right to health but their well-being also has vital implications for
economic development.
The consequences of a combination of high fertility, mortality and morbidity among poor
women can also lead to a range of other problems.
Complications of childbirth can lead to long-term disabilities, general poor health and
even death for many women.
Attempts at unsafe and illegal abortion, often accompanied by complications, impair
women's health and sense of security.
Early childbearing interferes with the educational attainment of young girls who must
drop out of school, resulting in a lifetime of limited reproductive and productive choices.
The death of a mother through childbirth or unsafe abortion, or her inability to care for
her children due to ill health, can result in greater numbers of orphaned, abandoned or
abused children.
The Role of Non-Governmental Organizations (NGOs) in Health
and Development
In the period following independence, the provision of health care, in the African context,
was viewed primarily as the precinct of governments. But in recent years, political instability and
economic mismanagement, coupled with universal economic recession, has forced many African
governments to institute so called economic structural adjustment programs (SAP) to reduce their
external debt. Although the ultimate goal of these efforts is to improve the economy and thus cre-
ate better living conditions for everyone, the implementation of these policies has actually led, in
the near term, to a deepening socio-political crisis within African nations. This has had particu-
larly deleterious effects on women and children because one usual component of such programs
is reduced government spending on health and other social services. Already overburdened and
often under-developed, health care systems then either collapse altogether or are forced to limit
care to those who can afford service fees. Services that were once available free of charge now cost
money if, in fact, the services are even available.






Budget reductions can also mean that medical personnel are frequently unpaid, sometimes
for months at a time, resulting in frequent strike actions which then create increasing distrust
among health providers and, ultimately, further chaos within the public health sector. And despite
the austerity rhetoric of SAP, official corruption continues to flourish, further impoverishing peo-
ple who are politically powerless, illiterate, and poor-people who have no understanding of the
long-term, macro level economic problems SAP is meant to address.
In Africa NGOs have a long history of providing health care, especially family planning ser-
vices. Therefore, it is not surprising that given the unpredictability of governments' response
to meeting people's health needs, many NGOs have intensified their efforts in an attempt to fill
the void.
NGOs have generally approached the provision of family planning as an integral part of
reproductive health care programs associated with primary health care. Such programs:
Provide an opportunity for child spacing and fertility choices.
Prevent unwanted pregnancies and provide an environment that is supportive of women's
reproductive health needs.
Provide services that ensure a woman's access to quality medical care during pregnancy,
childbirth and the postpartum period, (i.e. safe motherhood).
Inform, educate and counsel the larger community on socio-cultural barriers that con-
tribute to unsound reproductive health practices and the effects of such practices on
mothers, children, families, and society.
Advantages of NGOs
Because they are generally smaller in size and enjoy more flexible management structures,
many NGOs have been able to institute and sustain innovative approaches to meeting clients'
reproductive health goals despite the waxing and waning fortunes of government services.
1. Lack of Bureaucracy. NGOs tend to have fewer levels of management and less rigid
regulations-that is, less red tape. Timeliness and the personal touch in the implementation of
programs tend to lead to greater trust between provider and client as well as, in most cases,
greater overall effectiveness and efficiency.
2. Innovativeness. The size, structure and nature of NGOs put them in a better position to
more rapidly test alternative approaches to service delivery and then to adopt those innovations
that have proved successful.
3. Accountability. While most NGOs operate out of a deep social consciousness, neverthe-
less they must manage within limited budgets and are accountable for the quality of care they ren-
der. Therefore, they tend to pursue service delivery in a business-like manner which is at the same
time client-centered and result-oriented.
4. Maximizing Scarce Resources. Most NGOs, despite some degree of competition, are will-
ing to work together. In the best cases, the diverse expertise of a number of organizations can thus
be combined to provide clients with a system of referral and support.
5. Challenging Convention. With aware and committed leadership, NGOs are often able to
advocate change and challenge many cultural and even legal barriers that hinder the spread of
reproductive health information and services. Thus they are able to open doors where larger, gov-
ernment programs can subsequently follow.
The operations of NGOs, however, are not free from problems. Because in Africa local
resources are often limited, their funding must come from international (private and governmen-
tal) donor agencies. This leaves them susceptible to country-to-country vagaries. Support may also
be predicated upon the political situation in the receiving country and thus may be vulnerable to
a changing political climate or civil turmoil. Uncertain political environments in many African
nations can lead to frequent delays in receipt of funds or commodities which, in turn, can have a
significant negative effect on the delivery of services.
Even through they usually charge something for services, NGOs still must wrestle with how
to balance client affordability with self-sufficiency. Because most of their clients are poor, the






Budget reductions can also mean that medical personnel are frequently unpaid, sometimes
for months at a time, resulting in frequent strike actions which then create increasing distrust
among health providers and, ultimately, further chaos within the public health sector. And despite
the austerity rhetoric of SAP, official corruption continues to flourish, further impoverishing peo-
ple who are politically powerless, illiterate, and poor-people who have no understanding of the
long-term, macro level economic problems SAP is meant to address.
In Africa NGOs have a long history of providing health care, especially family planning ser-
vices. Therefore, it is not surprising that given the unpredictability of governments' response
to meeting people's health needs, many NGOs have intensified their efforts in an attempt to fill
the void.
NGOs have generally approached the provision of family planning as an integral part of
reproductive health care programs associated with primary health care. Such programs:
Provide an opportunity for child spacing and fertility choices.
Prevent unwanted pregnancies and provide an environment that is supportive of women's
reproductive health needs.
Provide services that ensure a woman's access to quality medical care during pregnancy,
childbirth and the postpartum period, (i.e. safe motherhood).
Inform, educate and counsel the larger community on socio-cultural barriers that con-
tribute to unsound reproductive health practices and the effects of such practices on
mothers, children, families, and society.
Advantages of NGOs
Because they are generally smaller in size and enjoy more flexible management structures,
many NGOs have been able to institute and sustain innovative approaches to meeting clients'
reproductive health goals despite the waxing and waning fortunes of government services.
1. Lack of Bureaucracy. NGOs tend to have fewer levels of management and less rigid
regulations-that is, less red tape. Timeliness and the personal touch in the implementation of
programs tend to lead to greater trust between provider and client as well as, in most cases,
greater overall effectiveness and efficiency.
2. Innovativeness. The size, structure and nature of NGOs put them in a better position to
more rapidly test alternative approaches to service delivery and then to adopt those innovations
that have proved successful.
3. Accountability. While most NGOs operate out of a deep social consciousness, neverthe-
less they must manage within limited budgets and are accountable for the quality of care they ren-
der. Therefore, they tend to pursue service delivery in a business-like manner which is at the same
time client-centered and result-oriented.
4. Maximizing Scarce Resources. Most NGOs, despite some degree of competition, are will-
ing to work together. In the best cases, the diverse expertise of a number of organizations can thus
be combined to provide clients with a system of referral and support.
5. Challenging Convention. With aware and committed leadership, NGOs are often able to
advocate change and challenge many cultural and even legal barriers that hinder the spread of
reproductive health information and services. Thus they are able to open doors where larger, gov-
ernment programs can subsequently follow.
The operations of NGOs, however, are not free from problems. Because in Africa local
resources are often limited, their funding must come from international (private and governmen-
tal) donor agencies. This leaves them susceptible to country-to-country vagaries. Support may also
be predicated upon the political situation in the receiving country and thus may be vulnerable to
a changing political climate or civil turmoil. Uncertain political environments in many African
nations can lead to frequent delays in receipt of funds or commodities which, in turn, can have a
significant negative effect on the delivery of services.
Even through they usually charge something for services, NGOs still must wrestle with how
to balance client affordability with self-sufficiency. Because most of their clients are poor, the





amount NGOs can recover from client fees is usually insufficient to sustain their programs. And
because the programs of most NGOs are relatively small, they frequently have to limit their cov-
erage to poor, densely populated peri-urban communities while in sub-Saharan Africa, most of the
unmet need is in dispersed rural areas which are far more difficult to serve.

The Essential Message
The success story of the Marie Stopes Society of Sierra Leone (MSSL) is particularly strik-
ing in the face of the economic and political turmoil that has faced Sierra Leone. It is just short of
amazing that MSSL has not only been able to continue providing quality care, but has also been
able to continually expand its services. MSSLs experience demonstrates how the flexibility of an
NGO can result in the provision of a constellation of services within the same environment that
make it easy for clients to meet their diverse needs in the same place and at the same time.
Primary credit goes to MSSL's remarkable staff and to the flexibility and steadfastness of
their primary founder and technical resource, Marie Stopes International in the United Kingdom.
However, to be able to surmount the obstacles in its path, MSSL has been able to establish posi-
tive relationships with a variety of local agencies, public and private, that have enabled the orga-
nization to reach a diverse clientele in a variety of service settings. And, of vital importance, MSSL
has established a strong base of support within the community.
For NGOs in sub-Saharan Africa to continue bridging the gap between the demand for
reproductive health care and scarce resources, they will continue to need, as an adjunct to strong
local initiative and sheer hard work, committed and flexible support from national and interna-
tionial donor agencies. Both are essential if reproductive health goals are to be attained.

Grace Delano would like to express her thanks to Ms. Christy Laniyan, Association for
Reproductive & Family Health's Program Development Coordinator for her contribution to this
Introduction.








N, I
































Background
Located on the west coast of Africa,
between Guinea and Liberia, Sierra Leone
("lion mountain") is the home to some 18 eth-
nic groups, as well as the descendants of freed
slaves from the British Empire and North
America. Known locally as Creoles, the former
slaves settled in Sierra Leone, then a British
colony, in the late eighteenth and early nine-
teenth centuries. The nation's capital,
Freetown, gained its name as the site where
these Africans returned from exile. The major-
ity, cut off from their own lands and traditions
by the experience of slavery, chose to remain in
Sierra Leone.
Sierra Leone is a country rich in natural
resources. With a wide coastal front on the
Atlantic Ocean and lush inland of hills and
plains covered by rain forests and savannah,
Sierra Leone has the potential to feed itself.
Before the outbreak of civil strife in 1991, min-
ing of diamonds, rutile and other minerals was
the primary source of the country's foreign
exchange. However, Sierra Leoneans watched
their economy go from bad to worse in recent
years, as mineral prices dropped and the cost of
imports such as oil rapidly escalated. This eco-


nomic decline, coupled with rampant corrup-
tion, government instability and the spillover of
political turmoil from neighboring Liberia, has
left the country in a precarious condition. In
1992 the military ousted the long-standing gov-
ernment of 24 years in a bloodless coup d'etat.
Now under military rule, Sierra Leone is in a
period of "revolution" in an attempt to turn
things around.
Today, Sierra Leone's economy is in a des-
perate state, suffering from rampant inflation
and corruption. By 1993, per capital annual
income was just U.S. $240; the economy has
registered zero growth in the gross domestic
product since 1980. Today petty trading and
subsistence farming are the most common
means of support for most Sierra Leoneans.
The meager salaries of government workers
and other professionals have forced many to
either abandon their professions or take up
some form of trading to make ends meet. As a
result, the public sector can no longer provide
anything but minimal services. The situation
has been further exacerbated since many inter-
national development programs withdrew from
Sierra Leone in recent years due to high levels
of political and economic instability.






Women's Reproductive Health
Sierra Leone's calamitous economic situa-
tion has serious repercussions for women's
reproductive health. Although the 1985 census
reported a literacy rate for adult females of 21
percent, current observations suggest that this
is an overestimate and that the situation is
worsening, as the educational system has been
steadily collapsing. For the majority of unedu-
cated women, learning about what it means to
be a woman comes during their initiation cere-
mony into the traditional secret societies com-
mon in Sierra Leone. These initiation training
and rituals take from two weeks to three
months and occur under the supervision of an
elderly woman who takes the young girls away
from their families. The content of this training
is a mixture of useful knowledge and the harm-
ful practice of circumcision.
Since agricultural production in Sierra
Leone does not meet the food requirements of
its population, the lives of mothers and children
are constantly threatened by inadequate nutri-
tion, as well as poor living conditions and insuf-
ficient medical care. Both child and maternal
mortality rates in Sierra Leone are among the
highest in the world: 150-200 per 1000 and
2,500 per 100,000, respectively. The average
woman bears six to seven children during her
lifetime and complications of pregnancy and
childbirth are a major cause of death among
women. The high incidence of maternal mor-
tality is compounded by rapidly growing num-
bers of teenage pregnancies, with the attendant
problems of birth complications, unsafe
abortions, abandoned babies and disrupted
schooling.
This situation is further exacerbated by
very low literacy rates, the effects of boredom
caused by unemployment and limited access to
family planning. Many areas are without any
medical or family planning care whatsoever and
less than 3 percent of the country's 750,000
women of childbearing age use effective con-
traception. Most people rely on traditional
methods, which are at best uncertain, and at
worst dangerous. The need for low-cost, effec-
tive maternal and child health and family plan-
ning services is, therefore, overwhelming.


Family Planning in Sierra Leone
Prior to the establishment of a National
Population Policy in 1988, Sierra Leone had
very few family planning services. Around the
time the policy was being developed, 14 non-
governmental organizations (NGOs) were pro-
viding some family planning services. However,
given the service and management difficulties
unique to Sierra Leone, few have survived.
UNICEF is now executing the National
Family Planing/Maternal Child Health (MCH)
Project, funded by United Nations Population
Fund (UNFPA). This program operates
through government health centers and posts
and also assists NGOs like Marie Stopes
Sierra Leone (MSSL) and the Planned
Parenthood Association of Sierra Leone
(PPASL). Both MSSL and PPASL receive some
assistance, including contraceptive supplies,
from this project.





Marie Stopes International (MSI)


Marie Stopes International is a registered
charity in the United Kingdom (UK) that works
in both the developed and developing world to
help men and women plan their families and
avoid unwanted pregnancies. The organization
was named for Dr. Marie Stopes (1880-1958),
the founder of Britain's first birth control clinic.
Dr Stopes, a paleobotanist,fervently advocated
contraceptive choice and the elimination of the
fear of unwanted pregnancy.
In the UK, MSI runs a successful net-
work of clinics for women's reproductive
health and vasectomy and provides services on
a fee-paying basis to nearly 50,000 men and
women annually. Income generated by these
programs helps to defray some of the adminis-
trative costs of MSI's overseas activities. Marie
Stopes International provides technical and
financial assistance to a wide range of innova-
tive and low-cost service delivery, social
marketing and educational projects in the


A Total Health Care Approach to
Family Planning

Family planning is not easy. You have to be
patient and learn what people want, instead
of dragging them along. Education is about
understanding people and getting them to
take the initiative and responsibility, so that
even when you are not there they will get
what they want somewhere else.
Sylvia Wachuku King

This statement, by the director of the
Marie Stopes Society of Sierra Leone (MSSL),
summarizes the operational philosophy of this
group of clinics. From the beginning, MSSL's
emphasis has been on women's health, includ-
ing reduction of reproductive mortality and
morbidity, assisting women in child spacing and
fertility choices and preventing problems asso-
ciated with unwanted pregnancy. To attain such
a goal is indeed a challenge in a country where
the economic and service infrastructure is col-
lapsing.
To serve as many people as possible,
MSSL has adopted an integrated approach to
reproductive health care that includes family
planning, treatment of sexually transmitted dis-


maternal and child health and family planning
fields in developing countries which operate
either through existing NGOs or MSI helps
concerned local individuals establish an orga-
nization specifically geared to provide family
planning. The goal is to assist those individu-
als and families most vulnerable to the hazards
of unwanted pregnancy, unsupervised preg-
nancies and deliveries, sexually transmitted
diseases (STDs), and other reproductive
health problems.
Marie Stopes International itself receives
funding from the British Government's
Overseas Development Administration, the
European Economic Community (EEC), volun-
tary trusts and foundations, businesses and
individual donors. Projects are funded by
grants for a predetermined period (usually
three years), and service delivery programs
operate on a cost-recovery basis with the aim of
achieving self-sufficiency.


eases, prenatal care and simple gynecological
surgical procedures. General health services,
especially for children under age five, are also
available. A compelling reason for providing
such a broad range of services is that medical
care in Sierra Leone has become very expen-
sive, beyond the reach of middle and low-
income people: The average income of a school
teacher, for example, has averaged about US
$10 a month, or U.S. $120 per year, since the
early 1990s. Therefore it seems inappropriate
to MSSL to provide only reproductive health
care to clients and then abandon them when
they are suffering from malaria or other
endemic diseases. Further, by providing more
than just family planning or even comprehen-
sive reproductive health care, MSSL has been
able to gain clients' satisfaction and confidence.
On March 1, 1988, the first Marie Stopes
Sierra Leone Clinic opened on Collegiate
School Road in Freetown. Demand for services
increased steadily during the first year of oper-
ation and, by the end of 1988, the clinic regis-
ter showed that 2,424 clients (men, women and
children) had come for 10,046 consultations-
an average of four to five visits by each client
per year. Women who visit the clinic are pri-
marily low-income petty traders, mostly in their






mid to late twenties. As the majority of clients
are illiterate and unable to report their ages
accurately, MSSL staff have devised an effec-
tive method to estimate their ages so they can
maintain reliable client records.
As the number of clients increased, more
staff was recruited and services added. A nutri-
tion clinic for under-fives was established and
later extended to include malnourished preg-
nant women. MSSL is also a center for the
Extended Program of Immunization, which
provides free immunization to mothers and
children.
MSSL gradually introduced laboratory
tests into its service and the clinic now takes
Pap smears for cervical cancer and high vaginal
swabs to test for sexually transmitted diseases.
These are sent to outside laboratory facilities
for analysis. Routine testing for pregnancy,
urine tests for sugar and protein and blood
hemoglobin samples are performed on the
premises. Initially only female clients came
for treatment of sexually transmitted diseases;
they were given an extra supply of drugs for
their male partners. However, because the
clinic's open-door policy does not exclude men,
infected male partners started coming and have
gradually begun to feel more comfortable using


MARIE STORES SOCIETY SIERRA LEONE
SUMMARY CLINIC DATA
January-December 1994
OTHER REPRODUCTIVE HEALTH CARE TOTAL
Gynecological Consultations 9,254
Sexually Transmitted Diseases 2,100
Antenatal Care 4,874
Postnatal Care 169
Deliveries 238
Other Operations 18
TOTAL OTHER REP HEALTH 16,653
Children Under Five Medical 8,163
Adult Medical 9,135
GRAND TOTAL CLIENTS 56,378
Pregnancy Tests 2,436
Laboratory Tests 6,851
New Family Planning Acceptors 5,786
TOTAL CONSULTATIONS 61,634


the clinic. A few bold clients occasionally vol-
unteer to take an HIV test; however, the clinic
does not advise clients whether or not to be
tested for HIV and does not routinely perform
the procedure.
Next a dispensary/accounts section was
added to the reception area. Here clients pur-
chase contraceptive supplies and medicines
and pay their fees. Clients come from all parts
































of Freetown, despite high transportation costs,
because MSSL charges fees that are within a
range most Sierra Leoneans can afford. If a
client is unable to pay, fees can be waived but
fortunately such occasions do not often occur.
By mid-1989, MSSL had leased a build-
ing in a centrally located area of the city to
house the Society's headquarters and a small
clinic. By the end of 1991, the main clinic in
Freetown had to be moved to a larger site to
accommodate the rising number of clients. In
mid-1992, MSSL realized a goal it had held
since 1988-to offer good quality obstetric ser-
vices to low-income women living far from a
hospital. An obstetric unit was established at
14a Aberdeen Ferry Road which serves as a
Safe Motherhood Center. It offers a full range
of prenatal, maternity and postnatal services
and the ten-bed unit is open for deliveries 24
hours a day. Clients are provided with three
meals daily during their stay. By October 1993,
a laboratory and an operating theater had been
opened so that Caesarian sections and treat-
ment of other obstetric complications can now
be performed on site. Blood needed for opera-
tions is obtained from the Red Cross or the
government hospital.


The Staff
The first clinic started with eight full-time
and three part-time staff, including medical
consultants. By the end of the first three years,
there were twelve full-time and five part-time
staff. In recent years, staff turnover has less-
ened-down to only about 5 percent since
1992-3 because fewer people are now leaving
the country. Currently MSSL employs 89 full-
time and three part-time staff, including non-
medical personnel.
Most staff training is undertaken in-house
and includes not only training and assessment of
technical competence but also an orientation to
the goals and ethics of MSSL. This orientation
is considered an important component in ensur-
ing continued high levels of client care and
in promoting staff harmony. At MSSL, child
clinics, prenatal care and family planning (with
the exception of sterilization) are provided by
nurses, as are simple STD diagnosis and treat-
ment. Physicians diagnose and treat general
medical problems and are called upon for advice
in difficult maternal and child health cases.
MSSL currently is receiving assistance from the
United Nations Population Fund (UNFPA) for
staff training both locally and abroad.






Maintaining a Commitment to
High Quality Care: Challenges
and Rewards
In a hot and humid climate with temper-
atures of 90-1020F, managing to keep morale
high, while maintaining the dignity and self-
respect of both staff and clients is a real chal-
lenge. Raising people's interest in preventive
health measures such as family planning is not
easy when they can barely secure sufficient
food and must constantly fight acute illnesses.
Yet Marie Stopes Sierra Leone has risen to the
challenge and arrived at some, if not all of the
answers. Each day new solutions must be found
to endlessly vexing problems.
The precarious balance between obtain-
ing the supplies necessary to run the clinics and
attending to the demands of each service has to
be addressed on a month-to-month, and some-
times day-to-day, basis. Keeping an adequate
stock of supplies is in itself a formidable task,
extending beyond contraceptives and drugs to
antiseptics, soap, office supplies, and imported
goods. In the early years, MSSL also faced fre-
quent shortages of gasoline and replacement
parts for equipment. However, this situation
has recently improved.
For clients to have confidence in the clin-
ic's program, they need to know that they will
always be able to obtain the contraceptive of
their choice or the drug prescribed for them,
and that they will be provided with clean sheets
and towels during their visit. Inconsistencies in
any of these areas can result in a loss of faith in
the clinic. Thus the staff responsible for pro-
curement are trained to be resourceful in the
face of an unstable market. MSSL stresses that
having adequate supplies is vital to sustaining
the quality of its services.
For some time, just maintaining commu-
nications with the outside world, particularly
during emergencies or periods of acute short-
ages, posed a real problem. Telephones were
constantly out of order and frequently there
was no electricity. However, throughout these
hard times, MSSL managed, to the best of its
ability, to maintain its high standards.
In the early years, MSSL faced other
unforeseeable difficulties on an almost routine
basis. For example, in late 1989 there was a
constant shortage of water in Freetown. Since


keeping clinics clean is impossible without
water, each of MSSL's main clinics was fitted
with a large tank to hold a supply of water for
use when it was not available from the tap.
Despite such precautions, the following situa-
tion was not uncommon.

It is 2:00 p.m. on a Wednesday. There has
been a water shortage since Monday, exhaust-
ing the supply in the tank. The afternoon ses-
sion in the operating theater is scheduled to
begin, and the doctor and the women are wait-
ing. Buckets and plastic gallon containers are
brought from the storeroom. Staff members
then go around town by car until they have
secured sufficient water so that the clients
awaiting surgery need not be turned away-
something MSSL tries to avoid at all costs. In
addition, the clinic will need to be washed down
in preparation for reopening at 8:30 a.m. the
next day. In such a crisis the entire staff helps
out, and usually the situation is successfully
resolved. However, if all efforts fail and water
cannot be secured, every possible compensation
is made to the clients (such as payment of trans-
portation fees) and their procedures are
rescheduled.
































Another problem created by conditions
of extreme economic hardship is the increased
threat of burglary and violence. All MSSL
buildings must be constructed with this threat
in mind. Therefore, the openness and feeling
of welcome that are an important part of the
image of MSSL clinics must sometimes be
compromised for the sake of security, at least
in the capital city. In Freetown, strong wire
mesh surrounds the dispensary and accounts
payable sections where money is handled.
Unfortunately, this creates barriers between
clients and providers at these points in the
clinic routine, but staff members try to com-
pensate for this seeming unfriendliness with
increased emphasis on personal warmth and
affectionate gestures made at other times dur-
ing client visits.
Increased security also entails extra cost.
In 1990, burglars drilled through the clinic
windows and stole the electric generator. The
generator had to be replaced immediately
(fortunately, donors came to the rescue), and a
new room had to be built to house it more
securely. In addition, the clinic has also had to
employ a guard at night.


Despite these hardships, staff still try to
cut costs by reducing consumption-something
they have learned to do in their own homes,
since no one in Sierra Leone can afford to be
wasteful. Under such conditions of scarcity,
conscious efforts at preservation, recycling and
careful use of resources are not just an ideolog-
ical exercise but a daily necessity. For example,
the office secretary never discards a piece of
paper that can be reused!
In poorly managed services, where
employees are dissatisfied with their jobs, waste
and misappropriation often occur. But MSSL's
staff strongly identifies with the organization.
They feel that the clinics belong to them and
thus are as respectful of the clinics' property as
they are of their own. Thus a fine balance is
always kept between what is needed to sustain
quality and what can be cut back on to prevent
waste. What started as a philosophy has now
became a daily habit for all the administrative,
nursing and cleaning staff.
Most difficult of all unseen crises is a sud-
den devaluation of the currency and the accom-
panying change in the exchange rate. Besides
raising prices (thus forcing increased charges






for services), this creates a formidable account-
ing burden. For example, with each devalua-
tion the staff must recalculate and average
the costs of supplies purchased before and after
the devaluation, as well as prices of items still
in transit. Balancing the books, therefore,
becomes a very difficult exercise. Computeri-
zation would simplify the process, and it is
hoped that with the continuing improvement in
Sierra Leone's power supply this can be a real-
istic option in the not-too-distant future.
Maintaining Standards of
Quality Care While Responding
to Demands for Growth
Despite all the difficulties, MSSL's ser-
vices have not only survived but expanded. By
the end of 1991, Marie Stopes Sierra Leone
boasted two main clinics that provide a full
range of services (including an operating the-
ater in each) and eight satellite clinics.
The main clinics are located on Aberdeen
Ferry Road in Freetown and in Port Loko, a
town 76 miles north of Freetown. At the
Aberdeen Ferry Road Clinic, a physician and
nurse are available every day. Another full ser-


vice clinic in Freetown on Adelaide Street lacks
only an operating theater.
Access to all MSSL clinics is on a walk-in,
first-come-first-serve basis. Although follow-up
appointments are scheduled, clients can come
in anytime between appointments if they feel
the need. The main clinics are open Monday
through Friday from 8:30 a.m. to 4:00 p.m., and
on Saturday from 8:30 a.m. to noon to accom-
modate office workers. Clinic hours at satellite
clinics vary with physicians attending on a rota-
tional basis, since one physician may serve
more than one satellite clinic.
Clinic hours and schedules are clearly
posted at each site. Signposts identifying the
location of the clinic are also strategically locat-
ed in the streets surrounding each site. In addi-
tion, newspaper articles and radio programs
frequently cite the location of MSSL services so
that it not difficult for anyone in Freetown to
know where to go for reproductive health care.
MSSLs eight satellite clinics offer limited
services in different combinations, referring
clients to the main clinics for services or con-
traceptive methods not available locally.
Satellite clinics are located at strategic sites to






facilitate client access, including employment-
based health centers and employees' residential
neighborhoods.
Employment-Based Services. Employ-
ment-based sites are important for two reasons:
linking family planning to employment benefits
gives a legitimacy to the services and, because
employers pay a contribution to the cost of ser-
vices, contraception is made affordable to low-
income employed families. In most cases, the
employer also provides space for the clinic and
covers maintenance and utility costs.
Currently, MSSL is collaborating with
two major employers, the Port Authority and
the police force. In a small, agriculturally-based
country like Sierra Leone, with a long and
accessible coastline, the Port Authority is the
nation's single largest private enterprise,
employing about 2,000 workers. Besides pro-
viding space for the family planning clinic, the
Port Authority also covers most of the cost of
services for its employees.
The police force clinics are located either


near the main police health clinics or in the
police housing barracks. The clinic buildings and
all amenities are provided by the police force,
but there is no reimbursement of client costs.
Today three police clinics are in operation.
Services to Refugees. Recently, be-
cause of the rising problem of refugees fleeing
from insurrections in neighboring Liberia, as
well as within Sierra Leone, refugee camps
managed by the Sierra Leone Red Cross have
been set up. In response to the emergency,
Marie Stopes Sierra Leone opened a tent in the
camps to provide family planning and gyneco-
logical services. Since the Red Cross provides
general health care, MSSL limits its work with
refugees to family planning and STD and AIDS
counseling and prevention. MSSL considers its
work with refugees to be a long-term invest-
ment, since providing them with high quality
services makes family planning a more attrac-
tive option. In addition, responding to a national
emergency gives the organization visibility
and respect.
































The Importance of Effective
Outreach and Community
Involvement


Because MSSL considers unplanned/
unwanted pregnancies and excessive childbear-
ing to be a root cause of high morbidity and
mortality among women of reproductive age in
Sierra Leone, an important initial objective has
been to generate awareness of family planning
among the women of Freetown. A second
objective has been to build a women's health
program that could provide a platform from
which to reach out to the women of Freetown
with basic preventive medical care that
includes an emphasis on child spacing.
Before the first clinic went into operation,
traditional birth attendants (TBAs) and tradi-
tional social leaders, such as chiefs and "mama
queens," were called together and informed
about the Society's goals and objectives. MSSL
staff explained how good reproductive health
care can improve the quality of life for both
women and men. Two weeks before the first
clinic opened, MSSL placed advertisements in
local newspapers and held meetings with
women in marketplaces and bus stations to


make them aware of the services that would be
available.
On the day of the opening, there was a
city-wide parade, with songs and banners intro-
ducing the clinic to the Freetown community.
A special inaugural football gala was held at the
National Stadium and a popular local newspa-
per published an article about Dr. Marie
Stopes. An art competition on the theme "bet-
ter health for all" was organized for college and
senior secondary school students. Senior sec-
ondary school students also participated in an
essay competition on the roles of women and
men in family welfare. Similar activities contin-
ued throughout the year, including a theatrical
production called "Sister Marie," staged by the
Freetown Players, which emphasized the
importance of family planning.
Initially three family planning pamphlets
developed by the Marie Stopes organization in
Kenya were reprinted for use in Sierra Leone.
However, it was decided that too many ended
up unread. Since then, advertising for the clin-
ics and information about services have been
printed on the covers of the exercise books sold
to secondary school students and many stu-
dents have subsequently come to the clinics as






a result. The following information is printed in
the books:
MARIE STORES CLINICS OFFER
THE FOLLOWING SERVICES:
1. Comprehensive family planning
2. Pregnancy tests
3. Pathological tests
4. Maternal and child health
e.g. Prenatal care
Immunization
Growth monitoring
Nutrition education
Oral rehydration therapy
5. Gynecological consultation
6. Treatment of sexually transmitted diseases
7. Counseling
8. General health advice
VISIT THE CLINIC IF YOU
1. Have problems with irregular periods
2. Need education on the various family planning
methods and guidance in making a choice
3. Are going through the hazards of an unwanted
pregnancy and need guidance and counseling
4. Need information on maternal and child health:
e.g. Vaccinations
Growth monitoring
5. Need treatment for sexually transmitted diseases
6. Are frustrated due to lack of communication
MESSAGES
1. If possible avoid sex before marriage
2. Seek advice from Marie Stopes Clinic if sexually
active and need advice on contraceptives
3. Protect yourself from unwanted pregnancy
4. Avoid multiple sexual partners
5. Be aware that AIDS is around and is a killer disease
6. Be sure to immunize your child against the childhood
killer diseases
7. Discuss all problems with trained youth leaders, coun-
selors or visit the clinic


To date the most successful publicity and
educational program sponsored by MSSL is a
15 minute weekly radio program in the local
language, Krio, called "You en You Well Bodie"
("You and Your Health"). Produced by the
Sierra Leone Broadcasting Service, the pro-
gram presents discussions of important health
and social topics such as: "The nature and causes
of stress due to unplanned family size" and
"Myths, misuse and abuse of contraceptives,"
by prominent women and leading health care
providers in the community. Each program also
provides information on various services
offered at the MSSL clinics. At the clinics,
tapes of these programs are played for clients in
the waiting areas.
Grassroots leaders, both women and men,
also participate in IE&C activities. Indigenous


elders and traders from selected areas of
Freetown have been recruited and trained. For
example, in Port Loko 300 men and women
received intensive education in family plan-
ning, prenatal care, child care, STDs (including
AIDS), personal hygiene, environmental sani-
tation and counseling and now act as field moti-
vators. Their work is monitored by MSSL staff.
In addition, MSSL, in collaboration with
the Department of Health, has provided train-
ing to traditional birth attendants (TBAs) in
western Freetown. This area is far from the
government hospital and most deliveries are
performed by "grannies," as the TBAs are
known locally. Twenty-five grannies came to
the new obstetrics unit for three weeks in early
1993, to learn how to maintain good hygiene
during delivery, when to refer a woman to
the hospital and how to keep records. The
"grannies" learned songs about the preparation
of oral rehydration solution and the importance
of immunization, and, through role playing,
dealt with how to handle irresponsible fathers
and call on the authority of the chiefs when
necessary. The training program ended with an
elaborate closing ceremony attended by local
chiefs and health care officials as well as the
trainees' family and friends. The TBAs were
then presented with training certificates and
a delivery kit. MSSL staff are now holding
monthly follow-up sessions in which the TBAs
can discuss any problems they encounter.

A Humane Program of Cost
Recovery
All MSSL clinics aim to be self-sufficient,
an important step toward achieving eventual
independence from donor agencies. But in
some locations, such as Port Loko, there is no
way local people can afford the full cost of
health care. In such situations, preventive mea-
sures such as family planning get pushed down
to the bottom of clients' list of priorities. Thus
donor contributions are still necessary to sus-
tain the clinics. Grants from donors in interna-
tional currencies also help to purchase supplies
and spare parts from abroad. Local currency,
primarily raised from clinic charges, can then
be used to pay staff salaries and cover operating
costs and procurement of local supplies.

































Currently, some MSSL clinics are 50 per-
cent co-funded by the European Economic
Community, with MSSL covering 35 percent of
the costs and Marie Stopes International the
remaining 15 percent. Several other clinics
receive support from the British Overseas
Development Administration.
Almost all of MSSL's contribution comes
from clinic fees. The Society has tried other
means of fund raising, but these have proven
not only to be time consuming but ineffective
as local people simply do not have extra money
to spend. However, while many of the social
events organized by Marie Stopes may have
failed as fund raising mechanisms, they were
successful tools for publicizing the clinics' ser-
vices. MSSL also supports services such as
family planning and child nutrition by charging
more for curative health care. The highest
charges are for adult medical consultations
(other than family planning) at a cost of 700
Leones (US$1.20). However, curative services
for children are provided at half the adult rate.
Thus by adjusting fees between curative care
and preventive care-raising the former to
subsidize the latter-and by stressing efficient
use of resources, the organization has been


able not only to sustain but actually improve
the quality of its services. MSSL's experience
has shown that clients are willing to pay a little
more when they perceive that the services ren-
dered are of high quality and constantly
improving.
In an effort to encourage use of contra-
ception, clients already registered for family
planning could until very recently, get their
general medical consultations free of charge.
However, the Society has not been able to sus-
tain this policy due to the rising costs of ser-
vices. Currently, family planning clients pay
only half the regular fee for general medical
consultations.
As a not-for-profit organization, Marie
Stopes tries to keep women's interests as its
central goal despite the need for cost recovery.
To cut costs and keep fees low, MSSL pur-
chases most of its supplies from abroad through
Marie Stopes International. However, this
requires placing orders well in advance so sup-
plies of contraceptives do sometimes run out.
Every effort is made to restock the item imme-
diately-even if this means purchasing
commodities at a higher price in the local
marketplace.






Schedule of Fees and Charges (US $1 = 585 Leonnes)


Service


Family Planning (yearly) Adults
Students
STDS (per month)
Antenatal (monthly) per visit
(throughout pregnancy)
Gynecological Consultation
General Health Consultation Adult
Student
Under 5


Card Fee 90 .15
Note: There is a Special Medical Treatment Fund for the severely ill, under-fives and for clients with chronic STDs who cannot afford to
pay for drugs.


When such a problem arises, the impor-
tance of the flexibility and trust that character-
ize the relationship between MSSL and the
Marie Stopes headquarters in London becomes
apparent. For example, when a large influx of
new clients coincided with an acute shortage of
oral contraceptives, the project director acted
immediately and bought whatever pills were
available on the local market. She later con-
tacted the Marie Stopes office in London and
explained the situation to them. Within a short
period of time, MSI was able to provide funds
from donors to cover the added cost. This level
of mutual trust allows MSSL to act swiftly in a
crisis-often the only way to handle the volatile
conditions that result from a very unstable
economy. In the context of Sierra Leone, com-
plicated bureaucratic procedures and undue
caution could easily bring a program such as
MSSL's to an immediate halt.
Given the state of Sierra Leone's eco-
nomy, the support of foreign donors remains
critical. Without their assistance, MSSL would
have to become a private for-profit company
and charge much higher fees (estimated at a
minimum of ten times the current rates) to
cover all costs, including imported contracep-
tives and drugs. If this were to happen, MSSL's
fees would be well beyond the reach of most
Sierra Leoneans. Thus there would be fewer
clients-probably not enough to even keep the
organization in business.


Clients' Perceptions Are the
Strongest Advocate for Quality
Services
My friend said, "It [the clinic] is so good I
cannot explain. Go ahead and you will see
for yourself." As soon as I enter, the place
feels like a clinic. It is tidy, neat and clean.
You are seen by several people, reception,
general checkup and then your family plan-
ning person. There is no waste of time, and
you are constantly cared for
31 year old primary schoolteacher,
on her first visit to the clinic.
At the main clinic in Aberdeen, women
start arriving at 8:00 a.m. It is still cool in the
reception veranda overlooking the lush tropical
surroundings and scattered banana fields. By
8:30 a.m., when the clinic opens, all the benches
are filled. One of the nursing staff greets the
women and gives them a 30 minute talk on the
day's health or family planning topic. In the
smaller clinics, a battery-run tape recorder
takes the place of the nurse, since it can play
throughout the day as the clients come and go.
After clients are registered, their clinic
cards are retrieved or a new card filled out.
Everyone gets a general checkup to measure
their temperature, pulse and blood pressure;
children have their weight and height recorded.
Clinic staff believe strongly that such simple
measurements help them to monitor their


Charges
in Leonnes
LE 180
70


500
5000
400
700
400
300


Equiv
in US$
$ .31
.12
.41
.85
8.55
.68
1.20
.68
.51

































clients' health. For people who get little med-
ical care, every opportunity should be taken to
check their general health. This simple screen-
ing has proven to be lifesaving for many with
undiagnosed high blood pressure and diabetes
(which causes loss of weight). For family plan-
ning clients, these routine checkups help
exclude contraindications to certain contracep-
tive methods.
Up until this point, all clients move in a
single stream through the clinic. Family plan-
ning and other clients are in the general flow to
ensure confidentiality. During the checkup,
clients explain their reason for attending the
clinic and are channeled to the appropriate ser-
vice. STD treatment, family planning and gen-
eral medical services are all provided in private
rooms with doors that lock so that the client is
ensured complete privacy.
The prenatal clinic has its own waiting
area and an examination area separated by cur-
tains. The immunization clinic is in a separate
building at the far end of the back yard. Here
mothers gather to cook for the under-five nutri-
tion program. The waiting and recovery areas
for surgical clients are impeccably clean, with
five beds, armchairs, curtained windows, ther-


mos flasks full of cold water and a rotating fan.
Next to the operating room is an immaculately
clean treatment area for dressings, injections
and other minor procedures.
All MSSL clinics have their own steriliza-
tion equipment. In the small clinics, the nurs-
ing staff has been trained to operate portable
kerosene-fueled autoclaves for sterilizing metal
instruments and toweling. With the advent of
the AIDS epidemic, the Society has employed
more rigorous training in how to avoid cross
infection, especially since needles and related
items must be reused given the clinics' limited
resources.
Before leaving the clinic, clients are
directed to their last stop, the joint dispensary
and cashier area. Here, prescribed drugs and/or
contraceptives are dispensed and a cashier
receives the payment for both the consultation
and the dispensary fees. The accounting and
bookkeeping is kept up-to-date, with an atten-
tion to detail comparable to that of commercial
bankers. In the smaller clinics, the nursing staff
are trained to fill prescriptions and perform the
accounting functions.
Family planning counseling takes place in
a closed room on a one-to-one basis. All meth-

































ods are offered, as long as supplies are avail-
able. Most women already have an idea of what
method they want to try when they come to the
clinic and this is the method they receive, if
there is no contraindication. Throughout the
consultation, both married and unmarried
women are treated the same way; no consent
from a husband or parents is required.
The pill is the method most commonly
used by MSSL clients, followed by the
injectable Depo-Provera. Only a one-month
supply of pills is provided to the client after her
first visit. Subsequently, she receives a two-
month supply and then a three-month supply is
provided with each follow-up visit.

Although I know the women have already
been told how to use the pill or the medica-
tion, I know they may not remember all the
information. They have too much on their
minds and this is new to them. I make sure I
explain the use of all medications I dispense
and confirm that the client absorbed it. It
does not take that much time really.
Nurse/pharmacist at the
Aberdeen Clinic


MARIE STORES SOCIETY SIERRA LEONE
SUMMARY CLINIC DATA
January-December 1994

FAMILY PLANNING METHOD TOTAL
Pill 9,256
Depo Provera 7,177
IUD 730
Condom 2,472
Foaming Tablets 484
Tubal Ligation 44
Other Family Planning Related Visits 2,264
TOTAL 22,427


If the woman has any questions regarding
side effects or possible complications, she can
come back to the clinic at any time, without an
appointment, and she will be given the neces-
sary attention.
By August 1991, MSSL clinics were see-
ing about 4,000 clients per month. For many
MSSL clients, general health issues-particu-
larly acute illness-is their entry point to the
service. But when they come, they learn about
reproductive health, family planning, STDs and
AIDS, prenatal care, and the importance of
good nutrition for children and pregnant moth-
ers. MSSL believes that family planning is







Marie Stopes Society Sierra Leone
Yearly Family Planning Figures 1988-1994

Thousands

22,427
20,155

16,956


1I 7I

7,844

-----------------------
3,223
563 1


1988


1989


1990


1991


1992 1993 1994


important for the health and well being of indi-
viduals and families, and that the best way to
promote it is by increasing people's general and
reproductive health awareness.

Reproductive health is a woman's right but
we cannot yet pose it in these terms in our
community. If you say "right" they will want
to know who is wrong, who you are blaming
and a fight will start.
Sylvia Wachuku King


A Life Cycle Approach to
Reproductive Health
Young People. It is MSSL's goal to meet
the reproductive health needs of Sierra
Leonean women throughout their life cycle.
Although not all the links are yet in place, they
continue to move ahead one step at a time. For
youth, there are educational and awareness
campaigns. Through radio programs, talks and
by showing videos in schools (using a portable
generator), MSSL brings a discussion of sexual-
ity to young people and advises them to try to
postpone sexual activity until they feel they are
ready. However, if they are already sexually


active, they are encouraged to come to a MSSL
clinic to talk about contraception and STDs and
to get services.
There is now a network of eight MSSL
Youth Clubs in the police barracks, with mem-
bership open to women and men between the
ages of 16 and 24. In these clubs, they talk
about contraception as well as prevention of
STDs and AIDS. Having adolescents enrolled
as members helps MSSL to follow up with
young people who drop out of the clinics. The
Society also organizes workshops, plays and
singing groups for young people.
Largely because of the efforts of MSSL
and other NGOs, AIDS and STDs have ceased
to be taboo subjects in Sierra Leone and are
now discussed openly. In the refugee camp, a
youth singing group supported by MSSL popu-
larized a song about the prevention of AIDS as
part of its contribution to the International
AIDS Day in December 1991.
The Youth Forum of the Fifth African
Regional Conference held in Dakar, Senegal in
1994 stressed the need for special health ser-
vices for youth. MSSL has always been aware of
the these special needs. Unfortunately, at
MSSL today young people still have to use the
same clinics as adults; and although the clinics







Sylvia Wachuku King comes from a mod-
est middle-class Sierra Leonean family. She fin-
ished her high school education in Freetown. In
1969, she was awarded a grant to study at the
State University of New York in the United
States. She lived in New Paltz, in upstate New
York, for the next seven years, finishing her BSc
and MA in biology and working as the director
of a residence hall at the women's dormitories.
During these years Sylvia gave much
thought to issues of women's social and health
problems and started to develop her skills as a
counselor In the residence hall where she
worked, many women were experimenting with
drugs and sex, and some of them became preg-
nant and were seeking abortions. Abortion had
just become legal in the U.S. and was covered
by college insurance plans. For Sylvia, it was
good to see that women need not risk damaging
their health when seeking abortion. By helping
the students, she developed a deep interest in
women's health and realized that, apart from


drug use, youth problems in the U.S. were not
all that different from those in Sierra Leone.
Upon returning to Sierra Leone, Sylvia
became a high school teacher with a goal of
becoming a program director for a youth-ori-
ented program. She reconnected with her soci-
ety and deepened her understanding of its
social and economic issues. She also continued
to develop her counseling skills within her own
community. But by 1987 she had become tired
and felt confined by the school system curricu-
lum. Besides, a school teacher's salary was hard
to live on.
It was then that she answered an adver-
tisement for a director of a women's health
clinic. An EEC grant would cover the cost of
establishing the clinic as well as staff salaries
and operating costs for three years. Within
weeks, Sylvia had the job. She had found what
she was looking for.
However it did not take long for her to
realize what a challenge she faced. Sylvia set to
work immediately, before initial support from
Marie Stopes in London even arrived. "One can
imagine being a project manager in Freetown
in 1987 without an office, people and funds to
manage!" Her first hurdle was just to find a site
for the new clinic. One day while returning
from a visit to a possible landlady, she fell into
a hole hidden by a pool of water "The scars on
my knees can still be seen."
Despite the obstacles, and the skepticism
of many friends and colleagues, Sylvia per-
sisted. By December 1987 the new organization
was registered with the Ministry of Social
Welfare and by January 1988, six staff members
had been hired. And that was just the begin-
ning. When a friend likened her task to trying
to fit a square peg into a round hole, she replied
that with modern technology it is possible to do
just that-to smooth the sides of the peg to fit
the hole and then use what is left to fill in the
gaps. "I may have been a square peg in a round
hole, but I spared no time to fill in the gaps
through training, learning from everyone no
matter what their level, setting short and long-
term goals, having a mind of my own and,
above all, getting tremendous support from my
family."






have no age restrictions, many young people
are still too shy or intimidated to attend. Sylvia
King dreams of creating a youth center that will
provide popular music, inexpensive food,
games and a counselor who would be available
for consultation. There would also be a room
with a nurse who could provide services. As
Sylvia notes, "This would be a great place for
the kids who now stand bored in the streets."
And judging by what the organization has
already achieved, this dream may not be too far
out of reach.
Meeting the Broader Needs of Re-
productive Age Clients. When a woman
becomes sexually active, she needs other gyne-
cological services besides family planning. In
addition to treatment of infections, the clinic
provides Pap smears and treatment for infertil-
ity. Because there are few technologies avail-
able in Sierra Leone to investigate and treat
infertility, the service concentrates on screen-
ing for simple problems, particularly infections,
and treating them. For the more complicated
cases, much effort is put into explaining the
limitations of the infertility services available in
Sierra Leone and in attempting to stop couples
from falling prey to profit minded doctors, who
push repeated and costly tests which offer little
hope of tangible results.
The clinic provides counseling, offers
support, and directs infertile couples, when-
ever possible, to other services. Unfortunately,
some clients feel disappointed that they did not
receive a miracle drug. "The most painful situ-
ation is when you suspect that it is the man who
needs a sperm count," explains one of the
nurses, "but it is very difficult to get the men to
test their sperm." Dealing with the man in
cases of infertility calls for tact and subtle per-
suasion. But sometimes it is impossible to con-
vince him; instead, he keeps trying to prove his
fertility by continually entering into relation-
ships with new girlfriends.
Services for Menopausal and Post-
Menopausal Women. The clinic nurses are
also very effective in providing counseling for
menopausal women, but sometimes they need
to refer them to MSSL's female gynecologist


who has devised a special counseling technique
for this situation. She helps the woman "flash-
back" to menarche and remember all the
changes that happened to her then. In this way,
she can see that menopause is only a returning
to her original state, after she has completed
her child-producing period. In the gynecolo-
gist's experience, much of the sadness associ-
ated with menopause actually comes from
women's concern that their husbands will seek
younger partners. Through counseling, MSSL
staff try to make them aware that their days of
sexual activity are not over and that it is cultur-
ally acceptable to continue having sex.

A Space for Women That
Includes Men
Although MSSL's vision is to create a
space where women feel at ease, they are very
aware that women's lives are closely tied to both
their children and their male partners. The
organization's policy includes men and encour-
ages them to be involved in the welfare of their
partners and children. The decision to operate
employment-based clinics was one step in that
direction.
At employment-based clinics, each male
employee is allowed to bring one woman and
her children to the clinic, regardless of his mar-
ital status. (No more than one woman is
allowed for each employee in order to safe-
guard against abuse.) To inaugurate the first
such clinic, a big football match was organized
to make the men feel involved. In addition, a
drama group frequently visits the employment
sites and performs for the men. Recently a
drafts tournament (a table game similar to
chess that is popular with men in Sierra Leone)
was organized.
"We try to befriend the men so they are
familiar with us," says Sylvia. "On any given day,
at least one-third of the people in any of the
clinics will be men. They bring their children,
their mothers or accompany their wives. So
although male contraceptive methods are not
yet popular, many men have already been won
over to the idea of family planning."






In a further effort to increase men's
knowledge of and participation in reproductive
health care, MSSL recently opened its first
Male Health Care Centre on Collegiate School
Road in Freetown. Services offered at the
men's clinic include: family planning (including
vasectomy), general health care, counseling
and treatment of STDs, counseling on
HIV/AIDS and condom promotion and distrib-
ution. The clinic also stresses social responsibil-
ity and preventive health care by encouraging
men to: learn about family planning and their
role in making informed choices about family
size and contraceptive methods; use condoms
for both prevention of unwanted pregnancy
and STDs; become more receptive to and
understanding of maternal and child health
issues; take advantage of both preventive and
curative health care services available at the
clinic; and recognize and accept responsibility
for their roles in the family and community.

Gaining the Respect and Trust of
the Community
Central to MSSL's mission is to hold a
respectable position in Sierra Leonean society


It is Friday afternoon on a mildly hot and
humid November day. Brima Mansaray (age
27), who is a chargei" or petty trader, arrives at
the clinic with his wife, Fatima Kama (age 20).
Brima sells local goods or food to the sailors on
their boats in the port in exchange for imported
goods like soap or toothpaste. Fatima sells fried
food in the market. They have been married for
eight years and have three children, ages nine,
five and two. One child died in his first year.
They are Muslims and live in Cline Town, about
six miles outside of Freetown. The two older
children are in school and Brima is taking care
of the two-year old girl.
Fatima and Brima married young. They
know they do not want any more children because
life is becoming very hard for them; and, although
they are both working, they are bringing less home
every month. They have heard a little about family
planning but are not quite sure about it.
Fatima wanted a girl after having three
boys, one of whom died. She was fortunate to


and to become part of everyday life. Articles on
MSSL activities appear frequently in the daily
newspapers, such as a recent issue of the New
Citizen that featured a half-page article about
MSSL winning the prize for the best monthly
narrative report to its parent body, Marie
Stopes International in London, while the
Week End Spark reported on MSSL's activities
in observation of International Women's Health
Day. MSSL was instrumental in instituting May
28th as Women's Health Day Sierra Leone, in
response to the call of the Women's Global
Network for Reproductive Rights in
Amsterdam. Many local women's organizations
now participate in this annual celebration. For
the first Women's Health Day Campaign, 12
women formed a committee to work on every
aspect of women's health. They wrote to health
providers and policy makers about their
concerns. They also visited local markets with
placards and talked to other women, individu-
ally or in small groups. Their message was:
Remember the 28th of May is the day
when every woman should sit down and
reflect on her health. If she needs help she
must go and get it.


have a girl in her fourth pregnancy. But then
she got pregnant again, and both she and Brima
decided they could not afford to have any more
children. They asked around for ways to deal
with their situation. Someone directed them to
the MSSL clinic in Cline Town, where they
were referred to the clinic in Freetown.
While at the clinic, both Brima and
Fatima had a long talk with the family planning
nurse about different contraceptive methods.
Today Fatima will leave with a packet of pills.
She will then report to the Cline Town clinic for
follow-up and refills so that another unplanned
pregnancy can be avoided. When Brima was
asked if he would use a method himself, he
paused awhile, then responded, "Well, I would
not mind. In fact, maybe I will prefer to use a
method myself in case I am tempted to have a
girlfriend. Then she cannot tie me down with a
child or tell on me." (This conversation took
place while Fatima was being attended to by
MSSL staff)
































In the month following the campaign,
MSSL's clinic intake rose by 40 percent. Some
of those coming for the first time were market
women who had never seen a health profes-
sional before. Routine checkups identified
some of these women as having advanced
hypertension. Their lives had been in danger
because they were taking so many painkillers to
relieve the headaches resulting from the high
blood pressure. Thus, the 28th of May cam-
paign may have saved their lives.
MSSLs community activities and its daily
presence in people's lives are apparent every-
where. A few examples include: an annual
Christmas party for clients and their families;
designing and selling greeting cards; sponsor-
ing essay and art competitions; holding a street
parade to mark the fifth anniversary of the
opening of the first clinic; a variety show for
youth; raffle drawings; and sponsoring a police
force football club that competes in league
matches-it won the trophy in 1991.
The creative minds of MSSL's staff will


keep generating new ideas to make health and
family planning interesting, exciting and fun
subjects for the people of Sierra Leone.
Working closely with TBAs, local chiefs and
opinion leaders (who serve as resource persons
and motivators and provide services at strategic
locations within the community), they will con-
tinue to seek ways to offer hope for the people
of their country at a time when daily life is a
constant hardship and the future is uncertain.
For MSSL, the rewards are worth all of the
hardships.
MSSL clinics have been pace setters in
shaping the family planning program of Sierra
Leone and will be held up as the standard by
which all future services will be measured.
Through MSSL, the people of Sierra Leone
have been given a window of hope, a feeling
that they can at least control some aspects of
their lives and look forward to a healthier
future. For those who work in the clinics,
MSSL gives a purpose to their lives and creates
a sense of pride in their work.






Lessons Learned
My experience as author of this edition of
Quality/Calidad/Qualite on the Marie Stopes
Sierra Leone organization was both stimulating
and inspiring. The organization pursues its
goals with an astonishing amount of compas-
sion and ambition, despite seemingly insur-
mountable economic hardships. In fact, I found
it difficult to evaluate and summarize the orga-
nization's programs because of the momentum
and velocity with which they expanded and
evolved, even during the short period of my
observation. Although Sierra Leone's political
and economic problems create hardships and
instability, the extent and quality of the MSSL's
work nonetheless remains extraordinary. My
work with the Sierra Leone clinic was educa-
tional at a variety of levels, but several particu-
larly important lessons emerged.
1). While severe economic hardship seri-
ously affects the ability to maintain quality
health care services, creative, skillful man-
9 agement, well-organized and flexible
financial administration, and human moti-
Svation and perseverance can enable an
organization to overcome financial diffi-
culties and achieve remarkable goals.
2). Family planning is an integral part
of people's reproductive and general
health concerns. Therefore, in places where
general health care services are scarce, a com-
prehensive, integrated program of reproductive
and general health care services is essential to
meeting the needs of the community.
3). A wide choice of fertility regula-
tion services need not be compromised by
scarcity of supplies. A staff that is trained to
act creatively and flexibly in offering the widest
variety of choices available can almost always
provide people with services that allow them to
be comfortable, safe and healthy.
4). Concern for reproductive health
can dovetail with concern for development
in useful and practical ways. Health service
personnel can be important agents of social
change. Because of their status as knowledge-
able caregivers, their attitudes hold a great deal
Sof influence, and they are in a position to dis-
seminate information widely.
T3
































5). Men appreciate being involved in
the care of their children and their female
partners. Including men in the process of
family planning and educating men about
reproductive health care-their own and their
partners-encourages better communication
around fertility choices and more successful


family planning programs.
6). A woman-centered reproductive
health care service can help empower
women to care for and value themselves. It
can also act as a comfortable venue for the
introduction and discussion of women's rights
issues in a non-threatening environment.






R6sumb en Frangais


A travers l'Afrique, une des principles causes
de mortality et de morbidity maternelle, est un taux
de fertility 6lev6. Pour la Sierra Leone, un 6tat de
l'Afrique de l'Ouest, la situation est encore plus pr6-
caire a cause du declin 6conomique, de l'instabilit6
politique, et du retrait d'une grande parties de l'assis-
tance international au d6veloppement. Le taux
d'alphab6tisation baisse et de nombreuses regions
du pays n'ont pas de services m6dicaux et encore
moins de services de planification familiale.
Marie Stopes Sierra Leone (MSSL) a ouvert
sa premiere clinique dans la capital, Freetown, en
mars 1989. Sous la direction dynamique de son
directeur, Sylvia Wachuku King, MSSL s'est
d6velopp6e et comprend maintenant deux bureaux
principaux et huit cliniques satellites. MSSL a 6gale-
ment mis des services cliniques A la disposition de
plusieurs grands employers du pays (tels que 1'
Autorit6 Portuaire et la Police), et offre des soins aux
r6fugi6s fuyant la guerre civil qui se d6roule dans le
pays voisin, le Liberia.
Concernant la sant6 g6n6sique, m&me les
soins primaires ne sont pas disponibles ou ne sont
pas A la port6e de la plupart des Sierra Leonais; ainsi
MSSL a adopt une approche int6grant la planifica-
tion familiale, le traitement des maladies sexuelle-
ment transmissibles, les soins pr6natals et les proc6-
dures gyn6cologiques simples ainsi que les soins
g6n6raux de sant6, en particulier pour les enfants de
moins de cinq ans. Cet int6r&t pour la sante g6narale
des individus a permis A MSSL de satisfaire ses
clients et de gagner leur confiance: le client moyen
visit une clinique environ quatre A cinq fois par an
pour divers services.
De plus, les homes ne sont pas exclus par
MSSL. Au d6but, ceux-ci sont venus surtout pour
accompagner leurs partenaires ou des membres de
sexe f6minin de leur famille. Ult6rieurement, A
cause de l'acceuil positif qu'ils ont recu, ils sont
venus tout seul pour le traitement des maladies sex-
uellement transmissibles et de l'infertilit6. En fait,
MSSL est devenue tellement efficace a repondre
aux besoins des hommes qu'elle a recemment ouvert
sa premiere clinique "pour hommes seulement" a
Freetown.
Le champ des services offers par les cliniques
de MSSL continue A s'6largir en function des
besoins des clients. Au d6but, une classes ayant pour
sujet la nutrition des enfants de moins de cinq ans a
6t6 organisee, peu a pros, elle comprenait 6galement
la nutrition des femmes enceintes et malnourries.
L'introduction d'examens de laboratoire permet
maintenant A MSSL de faire des Pap smears et des
tests pour les maladies sexuellement transmissibles.
Les m6dicaments et les contraceptifs sont
disponibles a des prix tres modestes. Les clients qui
ne peuvent pas payer ne sont jamais renvoy6s ou


refuses des m6dicaments et, parce que les prix sont
si bas, cette situation arrive tres rarement.
Au milieu de 1992, MSSL a 6tabli une unit
ost6tricale dans sa clinique principal a Freetown.
Cette clinique servait 6galement de centre pour le
programme "Maternit6 sans risque". Une game
complete de services pr6natals, maternels et postna-
tals 6tait offerte, et une unit de dix lits ouverte
vingt-quatre heures sur vingt-quatre pour les
accouchements. En 1993, une salle d'op6ration fut
ajout6e pour que les Caesariennes et autres proce-
dures chirurgicales puissent Otre faites sur place.
MSSL a 6galement adopt une approche relative au
"cycle de vie" afin de r6pondre aux besoins des
femmes en sant6 g6ensique, approche incluant les
services pour les adolescents et les femmes h la
menopause.
Tout ceci a ete accompli en d6pit de la crise
6conomique, des devaluations fr6quentes de la mon-
naie, et de toutes sortes de crises. Le staff de MSSL
est devenu 6tonnemment ing6nieux dans sa deter-
mination a donner des soins de quality dans un envi-
ronnement ou seul maintenir un stock ad6quat de
fournitures est une tache formidable: des contracep-
tifs et des m6dicaments aux antiseptiques, savons et
fournitures de bureau.
MSSL a toujours travaill6 tres pres de la com-
munaut6: les leaders d'opinion et les membres influ-
ents de la soci6t6 participent a de nombreuses activ-
it6s; de plus elle s'est serve des m6dias de mani&e
efficace pour 6duquer les membres de la commu-
naut6 sur la sant6. MSSL a 6galement de bonnes
relations de travail avec les minist res du
Gouvernement et les groups civiques.
Bien que toutes les cliniques MSSL ont pour
but d'&tre ind6pendante financiirement, le recouv-
rement des d6penses ne sera pas possible pour
longtemps A cause de la pauvret6 de la plupart des
clients. Peut etre il ne le sera jamais. MSSL depend
de l'assistance financiere des bailleurs de fonds
internationaux qui pourvoient les devises don't elle a
besoin pour acheter, a l'6tranger, les fournitures et
pieces d6tach6es. Les frais de clinique, en monnaie
locale, servent a payer les salaires et a couvrir les
couts d'operation. Le support positif et flexible que
MSSL regoit de son bailleur de fonds principal,
Marie Stopes International de Londres, a 6t6 crucial
pour aider l'organisation a traverser les fr6quentes
crises qui arrivent dans un milieu 6conomique aussi
instable. Qu'ils aient pu continue non seulement a
fonctionner, mais a offrir des soins de quality, tout
en 1largissant la game de leurs services selon les
besoins des clients, est tout simplement stup6fiant.
Marie Stopes Sierra Leone a 6tabli un standard que
bien des programmes, 6voluant dans un environ-
nement ou les resources sont rares, pourraient
chercher A 6muler.






Resumen en Espahol


En Africa, el alto nivel de fecundidad es uno
de los factors que mis contribute a la mortalidad y
morbilidad materna. Las mujeres de Sierra Le6n, en
el oeste africano, cargan ademis con las consecuen-
cias del deterioro econ6mico, la falta de estabilidad
political, y la reciente desaparici6n de casi todo el
apoyo international para el desarrollo. Los niveles
de alfabetizaci6n de Sierra Le6n estln en descenso,
y muchas de sus regions han quedado sin atenci6n
m6dica alguna, ni hablar de servicios de planifi-
caci6n familiar.
La organizaci6n Marie Stopes Sierra Le6n
(MSSL) inaugur6 su primera clinic en Freetown, la
capital del pais, en marzo de 1989. Bajo la dinamica
direcci6n de Sylvia Wachuku King, la MSSL ha creci-
do a tal punto que opera dos oficinas principles y
ocho clinics satelite. La MSSL tambi6n prove servi-
cios clinicos para various grandes empleadores en Sierra
Le6n-entre ellos la administraci6n de puertos y la
policia-ademis de suministrar atenci6n medica para
refugiados de la guerra civil en Liberia, un pais vecino.
Dado que los servicios de salud basicos no
existen o estan fuera del alcance de la gran parte de
los habitantes de Sierra Le6n, la MSSL ha adoptado
un system integral de atenci6n que incluye planifi-
caci6n familiar, tratamiento para enfermedades de
transmisi6n sexual (ETS), atenci6n prenatal y pro-
cedimientos ginecol6gicos simples. Estos servicios
complementan una base de atenci6n m6dica gener-
al, especialmente para nifos menores de cinco afios.
Como consecuencia de esta preocupaci6n por el
bienestar total del individuo, la MSSL ha logrado
satisfacer y ganar la confianza de sus clients, que
tipicamente visitan la clinic entire cuatro y cinco
veces por ano.
Es mis, la MSSL no excluye a los varones. Al
principio 6stos venfan principalmente para acom-
pafiar a sus parejas o parientes. Pero a media que
vieron que eran bien recibidos, muchos hombres
empezaron a venir por su cuenta para recibir
tratamiento para las ETS o problems de infertili-
dad. De hecho, la MSSL ha respondido tan bien a
las necesidades de los hombres que recientemente
abri6 su primera clinica "s61o para varones" en
Freetown.
La gama de servicios ofrecidos por las clinics
de la MSSL sigue creciendo en reconocimiento de
las necesidades de los clients. Casi desde el princi-
pio se ofrecieron classes sobre la nutrici6n de niios
menores de cinco afios; mis tarde 6stas fueron
ampliadas para incluir mujeres embarazadas que
padecen de desnutrici6n. La introducci6n de prue-


has de laboratorio ahora permit que la MSSL
ofrezca exAmenes Papanicolau y pruebas para las
ETS. Una pequefia farmacia provee medicamentos
y anticonceptivos a bajo precio. A los clients que no
pueden pagar nunca se les niega un servicio, pero
dado que los honorarios son tan econ6micos, esta
situaci6n casi nunca se present.
Para mediados de 1992, la MSSL estableci6
una unidad de obstetricia en su clinic principal de
Freetown que tambien sirve como Centro Para la
Maternidad sin Riesgos. Esta unidad, que funciona
24 horas por dia y cuenta con una sala de parts con
diez camas, ofrece una gama complete de servicios
prenatales, maternos y posnatales. En 1993 se
agreg6 una sala de cirugia para la ejecuci6n de par-
tos por cesarea y otros procedimientos quirurgicos.
La MSSL tambi6n ha adoptado un filosofia de servi-
cios orientada hacia el ciclo entero de la mujer, en el
cual se incluyen services tanto para adolescents
como para mujeres que atraviesan la menopausia.
Todo esto se ha logrado en un entorno de cri-
sis econ6mica, frecuentes devaluaciones en la mon-
eda national, y la falta continue de abastecimientos
bAsicos como el jab6n, los antis6pticos y el papel,
ademas de anticonceptivos y remedies. A pesar de
todo, el personal de la MSSL ha encontrado man-
eras de mantener su compromise con la provision de
servicios de alta calidad.
La MSSL siempre ha trabajado estre-
chamente con la comunidad entera, solicitando el
apoyo de personajes influyentes y utilizando los
medios de comunicaci6n para educar al ptiblico
sobre la salud. La MSSL tambi6n cultiva buenas
relaciones con los ministerios del gobierno y con var-
ios grupos civicos.
Aunque todas las clinics de la MSSL tratan de
ser autosuficientes, la pobreza de la mayoria de sus
clients hace casi impossible la recuperaci6n total de
los gastos. La MSSL depend de donantes extran-
jeros para comprar suministros importados. Los hon-
orarios que las clinics reciben de los clients son uti-
lizados para pagar sueldos y cubrir los gastos de
operaci6n. El apoyo positive y flexible que la MSSL
recibe de su donante principal, Marie Stopes
International en Londres, ha sido indispensable
para la supervivencia en un ambiente de crisis
econ6mica. El que la MSSL no s61o haya logrado
seguir operando, sino que lo esta haciendo con altos
niveles de calidad y una ampliaci6n continue de los
servicios, es poco menos que incredible. La MSSL ha
establecido una modelo de servicio que muchos pro-
gramas en pauses mas ricos deberfan tratar de imitar.





































Other Issues of Q/C/Q Currently Available

1. Celebrating Mother and Child on the Fortieth Day: The Sfax
Tunisia Postpartum Program (English; text in Spanish and
French available in typewritten format)
2. Man/Hombre/Homme: Meeting Male Reproductive Health Care
Needs in Latin America (English and Spanish.)
3. The Bangladesh Women's Health Coalition (English)
4. By and for Women: Involving Women in the Development of
Reproductive Health Care Materials (English)
5. Gente Joven/Young People: A Dialogue on Sexuality with
Adolescents in Mexico (English)
6. The Coletivo: A Feminist Sexuality and Health Collective in
Brazil (English)






About the Authors
Nahid Toubia is a physician from Sudan. As a practitioner in her country
for 15 years, she has also experienced many similar hardships of operating under
deteriorating economic conditions, as those she witnessed in Sierra Leone.
Formerly an Associate for Women's Reproductive Health at the Population
Council, she is currently a professor in the School of Public Health at Columbia
University and director of a new NGO, Rainbb, focusing on issues of women's
reproductive health and rights.
Grace Delano is a Nigerian nurse-midwife. As Principal Nursing Officer in
the Department of Obstetrics and Gynecology at the University College Hospital in
Ibadan, she was involved in numerous research and training programs in the areas
of family planning and reproductive health. Currently she is Vice-President and
Executive Director of the Association for Reproductive and Family Health in
Ibadan, Nigeria.





Quality/CalidadlQualite Advisory Committee


Ian Askew
Karen Beattie
George Brown
Judith Bruce
Ethel Churchill
Adrienne Germain
Joan Haffey
Margaret Hempel
Ann Leonard
Magaly Marques
Margaret McEvoy
Kirsten Moore







Design:
Cover Photo:
Typography:
Printing:


Nancy Newton
John Paxman
Geeta Rao Gupta
Debbie Rogow
Jill Sheffield
Cynthia Steele Verme
Lindsay Stewart
Kerstin Trone
Nahid Toubia
Gilberte Vansintejan
Beverly Winikoff
Margot Zimmerman







Ann Leonard
Nahid Toubia
Line & Tone Group
Graphic Impressions


We invite your comments and your ideas for projects which might be included
in future editions of Quality/Calidad/Qualite. If you would like to receive copies of
prior issues or be included on our mailing list, please write to Ann Leonard,
Quality/Calidad/Qualitd, The Population Council, One Dag Hammarskjold Plaza,
New York, N.Y. 10017, U.S.A.














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