Proposal on the Sierra Leone Health Sector

By Victor Ako Mengot

Government Plans for Improving Health Care Delivery—
Historical Perspective

The Ministry of Health and Sanitation published a National Health Policy document in October 2002. The policy document sets out the government’s plan for enhancing the health sector following a destructive civil war that caused major disruption to the health system in terms of damage to physical infrastructure and loss of skilled professionals. It also provides guidance on key interventions relating to human resources development, finance, distribution of medicines/drugs and the enhancement of the health management information system.

“Sierra Leone faces a number of major health problems. However, resource constraints (and in particular those related to availability of finance and health care professionals) mean that priorities have to be set as to the key health problems that the health sector will focus on. This does not imply that other health sectors will be ignored; but rather that they will not receive targeted national investment”. It is against this background that the Government is working with stakeholders such as private health service providers; international and national NGOs; faith groups (i.e. Christian Health Association of Sierra Leone (CHASL); and community organizations to identify options for redressing the balance.

Health Sector Initiatives in the Poverty Reduction Strategy Paper (PRSP)
The Government’s overall goal for health care is equitable access to affordable basic services, improving quality of service and restructuring delivery mechanisms, especially for the poor and vulnerable. Care will focus on maternal, infant and under- five mortality, malaria and communicable diseases, HIV/AIDS and other STDs. Devolution of health management will encourage community participation. Government plans to strengthen secondary and tertiary services where they support the basic level and to establish nursing training schools.

The focus of government’s health and sanitation policy in the medium term is to promote and enhance the supply of quality, sustainable and equitable health care services for all Sierra Leoneans. In this regard, the Government will expand and strengthen the decentralized network of reliable and quality facilities at the primary, secondary and tertiary levels with sufficient logistics to ensure functionality and enhance accessibility as well as to improve the supply of drugs and general sanitation in both rural and urban areas.

A cross cutting initiative within the PRSP is to develop the institutional and human resource capacity to manage change. This has resulted from the government’s own admission that “absorptive capacity problems have presented Sierra Leone from using some of the aid committed to date”. It is, therefore envisaged that capacity building will have a sharper, longer- term perspective. This is because Donors have already funded a series of strong capacity-building programmes and support is now shifting from technical assistance towards building indigenous human and institutional capacity.

World Health Day 2005 - Focus on Maternal and child Health
The World Health Organisation (WHO) launched World Health Day 2005 (WHD2005) with theme “Make every mother and child count” to focus on the plight of hundreds of million of women and children with no access to potential life-saving care at their time of need. The problem is more acute in developing countries “where progress in maternal and child health is slow, stagnating or has even gone into reverse in recent years”. According to the WHO “Make every mother and child count is a wide ranging study of the obstacles to health facing women before and during pregnancy, in child birth, and in weeks, months and years that follow for them and their children. It pays particular attention to the plight of newborns, whose specific needs have “fallen between cracks” separating maternal and child health programmes”.

Transaid , with support from the WHO Country Office in Freetown organized a national Symposium on 7 April 2005 to consider options for improving access to maternal and child health care. The Ministry of Health and Sanitation (MOHS) hosted the Symposium with participants drawn from multilateral and bilateral donors, international and local NGOs, other government ministries and professional health practitioners. In her keynote, address the Minister of Health & Sanitation Mrs. Abator Thomas called upon stakeholders to assist the government in its effort to strengthen the capacity of MOHS in order to deliver affordable and accessible system of primary health care services, particularly for women and children.

Following Transaid’s technical presentation on the role of transport in improving access to basic health care services in developing countries, MOHS and its donor partners agreed to support plans for developing an integrated health transport and logistics management unit for the Ministry of Health and Sanitation. The partners , after several meetings and consultations demanded the following:
· MOHS to work with Transaid to define a clear pathway for enhancing the transport and logistics management capacity of health care providers in Sierra Leone
· Transaid/MOHS should develop a project proposal/implementation plan, giving details of the financial and human resource costs of developing an integrated transport/logistics management system for the health sector in Sierra Leone
· Bilateral and multilateral donor agencies should provide the required financial resources after agreeing key deliverables and targets defined by the UN Millennium Development Goals (MDG)

Transaid Worldwide Services Ltd. (“Transaid”)
Transaid is an independent, not-for-profit non-governmental development agency committed to improving the contribution of transport and logistics in the development of poor countries. Experience has been gained working on many projects, usually related to delivery of basic services, with government and non-government organisations (NGOs). The first major involvement was in Ghana (1993 - 96), from which transport management system models have been developed, with further interventions in a good number of other African countries. Transaid has worked in the Republic of South Africa (RSA) with the Department of Health on a major Department for International Development (DFID) funded project since 1996. This project was reviewed by DFID and scored highly in meeting objectives with the final evaluation noting, “Transport is no longer a constraint to the delivery of health services in South Africa”. More recently, Transaid has worked to develop Transport Management Systems with the Ministry of Health and Population and Ministry of Education in Malawi, taking the initiative to complement other project activities with the development of a local institution as a long-term transport-training provider for the public sector. Transaid has developed a successfully proven training package backed by a comprehensive transport management manual and further `training of trainer’ methodology and materials.

Developing a Cost Effective Transport Management System for the Delivery of an Integrated Health Care Service
Existing Service Delivery Pattern
“In Sierra Leone, the health care delivery system is characterized by a plurality of health service providers with the government accounting for about 70%. The general population utilization rate of health care facilities is estimated at 0.5 contacts per capita per annum, implying that only one-half of the population attends a health facility once a year. Physical distance to health care facilities and the unavailability of drugs represent a major barrier to accessing health care”. More significantly, the number of physicians per 100,000 population is estimated at 9 and in the case of Kailahun in the eastern province, the ratio is about 25 times worse.

“There is a strong history of Primary Health Care within the health sector of Sierra Leone. The Government remains committed to this approach with an emphasis on primary care services and prevention as cost-effective strategies. As such, the delivery of health care will be based on the following principles:
· The development of an integrated health system which has a clear and inter-linked roles for primary, secondary and tertiary levels of care
· The strengthening of the referral system between the levels of care to ensure the efficient use of different levels of specialisms, and appropriate feedback between health professionals
· The importance of ensuring involvement of communities, and the voiceless within these communities in decisions about health
· An emphasis where appropriate on preventive strategies
· Collaboration between sectors.”

Structure of Primary Health Care Delivery System

The government is committed to the policy of decentralisation of public Services with a view to providing greater local determination of priorities and management autonomy to deal with issues such as health, sanitation and the environment. As part of the primary health care delivery plan, the Directorate of Primary Health care is responsible for the development and review of strategic policy based on nationally agreed targets for improving access to health care. Targets have been set for improving maternal health, reducing child mortality rates and activities that promote health education (i.e. HIV/AIDS awareness) and disease prevention. Additionally, the targets are designed to focus attention on effective delivery of services to the vulnerable community in isolated rural areas.

Communications and collaborative working are key elements in securing local ownership of service delivery targets. In this regard, the government has designed a delivery strategy that gives District Medical Officers the overall responsibility for interpreting and implementing national health policy at local district level. They are required to work in partnership with local authority representatives and health service providers in the private and not-for-profit sector to provide operational, technical and strategic support for community-based activities. The objective of this strategy is to develop effective stakeholder partnerships and to improve the flow of information (i.e. national health prevention priorities) between service providers and beneficiaries.

Considering the above, it is evident that transport plays an important part in the success implementation of a health care delivery strategy that focuses on preventive rather than remedial care.

Photo: HRH the Princess Royal, Transaid patron.