A community celebrating the building of their new health clinic

Community-led solutions to maternal health in Sierra Leone

Sierra Leone is one of the most dangerous places to give birth in the world. In this blog, Joanna from our health team, explains how our adaptive and participatory approaches to programming are saving lives, by reducing the cost of building clinics and improving maternal healthcare. 

By Joanna Tom-Kargbo, senior programme health officer, Christian Aid Sierra Leone

In my country, Sierra Leone, where we have seven million people, improving maternal health is a critical issue to be tackled:

1 in 17

...mothers have a lifetime risk of death associated to childbirth

(2015 estimates)

1 in 9

...children do not reach their fifth birthday


...of the country’s health workers were killed in the Ebola crisis


Christian Aid Sierra Leone works with 22 communities in the Pujehun district in the southern province to improve maternal health, working in partnership with local partners, communities and the authorities, to improve outcomes.

The district has a population of over 340,000 people, yet there is just the one ambulance. To try to tackle these challenges, we adopted a Participatory Vulnerability and Capacity Assessments (PVCA) approach to bring lasting change to the communities.

PVCA is a process we use that empowers people to analyse their own problems and suggest their own solutions. The approach begins with each community meeting to identify and map out their issues and vulnerabilities as well as the resources needed to address these challenges.

Working together we consider:

  • What are the challenges the community faces, what are its needs? 
  • Where does the community want to get to, what are their goals? 
  • What resources are needed, what can people contribute themselves?  

Community Development Action Plans are then created on sheets of flip chart paper and importantly, left with the community, where they can be regularly reviewed.

We find that for some, this is a unique experience, as it is the first time that an NGO has come to their community and hasn’t led the activities.

a community action plan

A community action plan is key to the PVCA approach

Participation in practice

In Sawula, a community who desperately needed a new health facility, as part of the PVCA process, they were able to offer their time, their labour and some basic building materials such as sand and stone.

What they needed in addition were items such as wheelbarrows and shovels, which were provided through our partner Rehabilitation and Development Agency (RADA), along with remaining building materials such as cement, zinc for roofing and solar panels.  

As the local Ministry of Health officials were also involved in the process from the beginning, they committed to providing the necessary staff and equipment as well as maintaining a regular supply of medicines. Therefore, there was a three-way division of responsibilities – community, NGO and local authorities.

As a result, the cost of building the clinic was reduced by approximately 30%, which not only made it more financially viable, it also gave the community a far greater sense of involvement and ownership.

Building the clinic involved the whole community

Building the clinic involved the whole community

Gender model families

As part of the PVCA, we also created 'gender model families' to help highlight some of the issues. Ten influential couples were chosen from each community, often having some leadership responsibility within the local mosque or church. 

Each husband and wife were asked to write down and share with their community what the other did over a 24-hour period, so they could start to better understand the division of family responsibilities. 
In this way, others in their community could also see how these families addressed issues such as how men were often dominant in decision making and gender-based violence, as well as examples of how to share-out parental responsibilities, especially during pregnancy.

What we found

We found that this process highlighted the fact that women were shouldering the vast majority of the tasks, often starting their day at 3am and not finishing until 9 or 10pm.

It also showed the gender inequality that exists between girls and boys, for example the fact that girls were expected to collect water for washing, while the boys were able to attend school.  

Through PCVAs, we can work together with communities to develop action plans and using this process, we can review progress and adapt them as necessary.

Men and women sharing household duties

It's important for men to take their share of the household duties

Taking an adaptive approach

Adaptive Programming is another tool we use which allows us to review and reflect in context, both in terms of budget priorities and planned activities. We are able to test the strength of our strategy, to see if there has been real behavioural change. 

To put this into context, we know from experience that to reduce cases of malaria, pregnant women must sleep under mosquito nets, but this was also well known within the communities.

The challenge was that this knowledge wasn’t being put into practice. Therefore, rather than just focusing on education, we recognised that the programme needed to quickly adapt to create household volunteers, trained to check-in on pregnant women to ensure they were using the nets and also to refer them to the health facilities if necessary. In this way, maternal health became the collective responsibility of the whole community and cases of malaria reduced significantly as a result.

This has been a ground-breaking project for Sierra Leone and the success is down to a combination of many factors but for me, the key point is that for once, the communities have been given a real sense of ownership and have been able to contribute towards the outcomes themselves, whilst the project implementation has been able to adapt in the background to their changing needs.  

Find out more

This project is the focus of Christian Aid Week 2019. You can also find out more about our overall work in Sierra Leone